The Manor at Market Square.

“A reportable incident involving a resident was not reported to the Department within the required 24-hour timeframe. The home failed to timely notify the Department's personal care home regional office or complaint hotline as required by regulation.”

“A resident with a documented need for assistance with wheelchair mobility was not provided safe mobility assistance as specified in the resident's support plan. Staff member handled the resident's wheelchair inappropriately, including aggressive 180-degree turns and free rolling the wheelchair while disregarding safe mobility practices.”

“A resident was not treated with dignity and respect. Staff member ignored the resident's repeated refusal and requests to remain with other residents, then positioned the resident's wheelchair in an inappropriate location and addressed the resident in an inappropriate tone.”

“A direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, as required for direct care staff qualifications.”

“The home failed to follow prescriber's orders.”

“A portable space heater was found in use in the administration office of the home, which is prohibited.”

“A resident missed a prescribed blood glucose check and medication administration due to being out of the home, resulting in a medication error. The home failed to report this medication error to the Department within 24 hours as required.”

“Three residents did not have access to a source of light that could be turned on or off at bedside. All three residents had lamps at bedside that could only be operated by wall switches not within reach of their beds.”

“A resident missed a prescribed blood glucose check and medication administration due to being out of the home, resulting in a medication error. The home failed to report this medication error to the Department within 24 hours as required.”

“Three residents did not have access to a source of light that could be turned on or off at bedside. All three residents had lamps at bedside that could only be operated by wall switches not within reach of their beds.”

“A portable space heater was found in use in the administration office of the home, which is prohibited.”

“A resident who self-administers medications had several unlocked, unattended medications in their bedroom. The resident shared a room with another resident who is not assessed to self-administer medications, creating a security and safety concern.”

“An inhaler in the medication cart had no date indicating when it was removed from the tray for use. According to manufacturer's instructions, the inhaler should be discarded six weeks after removal from the tray.”

“Multiple medication storage and administration procedures violations were identified: blood glucose readings documented but not saved in glucometer, required medications not available in medication carts when needed, blood glucose readings documented incorrectly, and a PRN medication not available in the medication cart. This is a repeat violation.”

“A resident who self-administers medications had several unlocked, unattended medications in their bedroom. The resident shared a room with another resident who is not assessed to self-administer medications, creating a security and safety concern.”

“An inhaler in the medication cart had no date indicating when it was removed from the tray for use. According to manufacturer's instructions, the inhaler should be discarded six weeks after removal from the tray.”

“Multiple medication storage and administration procedures violations were identified: blood glucose readings documented but not saved in glucometer, required medications not available in medication carts when needed, blood glucose readings documented incorrectly, and a PRN medication not available in the medication cart. This is a repeat violation.”

“Two residents were not administered prescribed medications as they were out of the home without medications. The home did not report these medication errors to the Department within 24 hours as required.”

“A resident-home contract was not signed by the resident. No documentation of the resident's refusal to sign was present in the record.”

“The facility's administrator had not successfully completed the Department-approved orientation program or the Department-approved competency-based training test prior to initial employment.”

“Sanitary conditions were not maintained. A bathmat in a resident's bathroom contained orange stains and a black substance on the underside around the suction cups.”

“A resident did not have access to a source of light that could be turned on and off at bedside.”

“Food storage violations were found: three packs of American cheese, an opened bag of broccoli, and 18 loaves of bread in the kitchen were unlabeled and undated. This was a repeat violation.”

“Food was not stored in closed or sealed containers. A container of chocolate chips was found open and unsealed in the kitchen storage area.”

“Outdated or spoiled food was found in storage. A pack of 12 hot dog buns with apparent green mold was located in the kitchen storage area.”

“A resident prescribed medication at 7:00 a.m., 1:00 p.m., and 7:00 p.m. was not administered the medication at the scheduled times on at least one occasion.”

“A resident reported that a bruise on their arm was caused by a staff person. This allegation of abuse was not reported to the Area Agency on Aging in a timely manner.”

“A staff person was suspended pending investigation of an allegation of abuse, but the home did not submit notice of suspension or a plan of supervision to the Department's personal care home regional office in a timely manner.”

“An allegation of abuse was not reported to the Department's personal care home regional office or complaint hotline within 24 hours as required.”

“A staff person issued a 30-day discharge notice to a resident and informed the responsible party that 1:1 service is required immediately with billing to the responsible party, without providing proper 30-day advance written notice of the contract change.”

“A resident was discharged and moved out of the home, but the home failed to issue a refund of the security deposit held by the home within 30 days of discharge.”

“Staff person A was observed shaking a resident's chair and telling them to get up, and on another date sprayed residents with a water gun upsetting them. These incidents were not reported to protective services until after discovery by staff person B.”

“Staff person A remained working in the home after being observed shaking a resident's chair and spraying residents with a water gun. No plan of supervision was developed and implemented, and the staff person was not suspended pending investigation.”

“No plan of supervision was submitted to the department regarding staff person A who remained working in the home after being observed shaking a resident's chair and spraying residents with a water gun.”

“Staff person A was observed shaking a resident's chair and telling them to get up, and on another date sprayed residents with a water gun upsetting them. These incidents were not reported to protective services until after discovery by staff person B.”

“Residents and their designated persons were not immediately notified of suspected abuse involving the residents, specifically incidents where staff person A shook a resident's chair and sprayed residents with a water gun.”

“The facility failed to report suspected abuse incidents to the Department's personal care home regional office within 24 hours. Incidents involving staff person A shaking a resident's chair and spraying residents with a water gun were not reported to the department until after discovery.”

“Residents were not treated with dignity and respect. Staff person A sprayed residents with a water gun causing them to become upset and curse at staff, and shook a resident's chair while telling them to get up, requiring staff to calm the resident afterward.”

“Staff person A remained working in the home after being observed shaking a resident's chair and spraying residents with a water gun. No plan of supervision was developed and implemented, and the staff person was not suspended pending investigation.”

“No plan of supervision was submitted to the department regarding staff person A who remained working in the home after being observed shaking a resident's chair and spraying residents with a water gun.”

“Residents and their designated persons were not immediately notified of suspected abuse involving the residents, specifically incidents where staff person A shook a resident's chair and sprayed residents with a water gun.”

“A resident caused another resident to fall resulting in injury requiring surgery following a physical altercation in the dining room. The incident involved one resident punching another resident on the left cheek. The resident with the injury was transported to the hospital for evaluation.”

“Staff persons A, B, and C did not complete annual fire safety education by a fire safety expert or person trained by a fire safety expert for the training year 2023.”

“The phone located in the main lobby area did not have the required emergency numbers posted on or near the phone.”

“The main kitchen freezer contained a 10-pound box of sausage links with an open bag of sausage that was not dated when opened, in violation of food labeling and dating requirements.”

“Fire drills conducted on 10/19/23, 11/30/23, 12/26/23, and 1/9/24 indicated more residents were in the home than were evacuated. The record did not indicate why all residents were not evacuated.”

“On 10/17/24 at approximately 9:30am, the medication cart located in the nursing office was unlocked and unattended. The nursing office door was also unlocked.”

“Insulin pens for Residents #1, #2, and #3 were located in the medication cart at room temperature. The pens were labeled with instructions to refrigerate until opened and had not been opened.”

“Narcotic counts were inaccurate for Resident #5. Staff D signed medications out on the Medication Administration Record but did not sign the controlled drug record. Additionally, the home did not properly maintain the Medication Administration Record (MAR) of Resident #6 due to staff incorrectly transcribing blood glucose test results from the glucometer.”

“Resident admitted to secured dementia unit experienced multiple falls between admission and a subsequent date, including incidents where resident was found wedged between bed and nightstand/wall, resulting in a fractured hip requiring hospitalization. Another resident was found with hands down the front of another resident's pants on at least three documented occasions. The home only documented precautions of keeping the room uncluttered and properly lighted, with no other documented interventions or additional supervision despite the high frequency of falls.”

“Resident's medical evaluation completed on 12/13/2023 does not include a medical professional's name, signature, or medical license number as required for admission to a secured dementia care unit.”

“Resident admitted to secured dementia unit on 8/11/2023 did not have a signed cognitive preadmission screening prior to admission, as required by Department regulations.”

“Multiple residents experienced numerous falls that were not documented in their assessments and support plans. The assessment and support plan was not updated to include safeguards for residents experiencing high-frequency falls, and one resident's increased supervision following an incident was not documented in their support plan.”

“Resident medical evaluation documentation was incomplete. The section for Medical Information Pertinent to Diagnosis and Treatment was blank with no indication it was reviewed during the evaluation process. This deficiency was cited for two residents.”

“Rodent feces were found on the floor of a chemical closet located inside the kitchen with no evidence of cleanup despite traps being present.”

“An ongoing rodent infestation was documented in multiple areas including the kitchen, dining rooms, resident rooms, break room, atrium, and offices. Despite a 6/8/2023 incident report stating pest control would visit 2-3 times weekly, there was no evidence this was occurring.”