Meadow Glen at Phoebe Richland.

“Staff person B did not receive orientation on telephone use and notification of emergency services on their first day of work, which is required orientation content for all direct care staff.”

“The home's written emergency procedures have not been reviewed, updated, and submitted annually to the local emergency management agency since July 1, 2024.”

“Staff person D transports residents from the facility alone but has not completed the required initial new hire direct care staff person training.”

“Lorazepam 0.5 mg blister pack was improperly stored with punctured slots held in place with tape, and Calazime Intensive Paste expired on 5/23/2025 was kept on the medication cart, violating proper medication storage requirements.”

“A resident was administered a psychotropic medication (¼ tablet as needed for agitation) on multiple occasions to control behaviors related to agitation and confusion, but there was no documentation of attempted non-pharmacological interventions prior to administering the medication. This constitutes use of a drug for the specific purpose of controlling acute or episodic aggressive behavior, meeting the definition of a chemical restraint, which is prohibited.”

“A resident was admitted to the home, but the preadmission screening form was not completed within the required 30 days prior to admission.”

“Direct care staff person A received only 1.75 hours of annual training in training year 2023, failing to meet the requirement of at least 12 hours of annual training relating to job duties.”

“Direct care staff person A did not receive required training in medication self-administration, meeting resident needs per preadmission screening and assessment, dementia and cognitive impairment care, infection control and hygiene/immobility prevention, personal care service needs, and safe management techniques during training year 2023.”

“Staff person A did not receive required annual training in emergency preparedness procedures and crisis response, resident rights, the Older Adult Protective Services Act, and falls and accident prevention during training year 2023.”

“A resident's bedside mobility device (13" wide x 20" high) was not secured to the bed frame, creating a potential safety hazard.”

“Sani Cloth disinfectant wipes and DG Home Disinfectant Spray, both labeled with poison control warnings, were unlocked, unattended, and accessible to residents in Memory Care Wing B nurse station. Not all residents were assessed as capable of safely using or avoiding poisonous materials.”

“A resident did not have access to an operable lamp or other source of lighting that could be turned on/off at bedside.”

“Staff member recorded a resident without consent and removed the resident's wig without permission, violating the resident's right to dignity and respect. The video was subsequently shared on social media.”

“Staff member set up a cellphone to record a resident without consent and removed the resident's wig without obtaining permission, violating the resident's right to privacy. The video was later shared outside the home and on social media.”

“A dietary staff member began employment without having a completed background check on file prior to their first day of work.”

“Staff persons A, C, D, and E did not receive annual fire safety training completed by a fire safety expert or trained staff person during training year 2022.”

“Emergency telephone numbers including the nearest hospital and fire department were not posted on or by the telephone in Memory Support A kitchen.”

“Three refrigeration units had improper temperatures: Memory Support B freezer was 10°F, Memory Support A refrigerator was 46°F (above the 40°F requirement), and 2nd floor activities room freezer was 10°F.”

“The home had no documentation of submitting emergency procedures annually to the local emergency management agency.”

“The fire drill record for the drill conducted on 10/31/22 at 12:15pm does not include the exit route used.”

“During the fire drill on 10/31/22 at 12:15pm, the home exceeded the maximum safe evacuation time of 15 minutes, completing evacuation in 45 minutes.”