Mifflin Court.

“Resident records containing names were found in an accessible binder at the main entrance without proper confidentiality protections. Privacy coding pages with resident identifiers had not been removed from Licensing Inspection Summaries.”

“A medication foil pack was tampered with and resealed with tape, with pills 18, 19, and 20 punched out and the packet subsequently resealed, failing to maintain proper medication storage integrity.”

“Multiple narcotic and medication documentation deficiencies were found, including incorrect tablet quantities recorded on narcotic logs compared to medication cards, incomplete narcotic count book entries lacking required dates/times/signatures, and a glucometer reading that was incorrectly documented on the Medication Administration Record.”

“A resident's initial assessment indicated the resident could not self-administer medications, but the medical evaluation indicated the resident could self-administer medications; the assessment did not reflect that the resident chooses to have staff administer them.”

“A resident's annual assessment did not include information regarding current ongoing wound care service that had begun.”

“A resident admitted to the Secured Dementia Care Unit did not have a support plan completed within 72 hours of admission; the plan was completed more than 72 hours after admission.”

“Violations cited during inspection on July 9, 2025 at Mifflin Court facility. Specific violations documented in the Licensing Inspection Summary.”

“Violations cited during follow-up inspection on July 17, 2025 at Mifflin Court facility. Specific violations documented in the Licensing Inspection Summary.”

“Resident #1's Eliquis 5 mg medication was not administered on 4/8/25 at 9:00 p.m. and 4/9/25 at 9:00 a.m., and this medication error was not reported to the Department within 24 hours as required.”

“Resident #2 was self-administering Butenafine cream but had not been assessed by a physician to do so. The resident's medical evaluation dated 9/10/24 notes the resident is unable to self-administer medications.”

“Medication administration staff were not following proper procedures. Staff were administering all residents' medications and then completing the Medication Administration Record (MAR) by initialing all medications at once rather than individually as required, and this improper practice was observed on-site.”

“Resident #3's medication labels were incorrect. Potassium CL ER 20 MEQ label noted Sunday take 3 tablets but MAR showed Saturday take 3 tablets. Prednisolone AC 1% eye drops label was also incorrect, not reflecting the dosage change from four times daily to twice daily ordered on 4/4/25.”

“Resident #1's Eliquis 5 mg medication was not administered on 4/8/25 at 9:00 p.m. and 4/9/25 at 9:00 a.m., and this medication error was not reported to the Department within 24 hours as required.”

“Resident #2 was self-administering Butenafine cream but had not been assessed by a physician to do so. The resident's medical evaluation dated 9/10/24 notes the resident is unable to self-administer medications.”

“Medication administration staff were not following proper procedures. Staff were administering all residents' medications and then completing the Medication Administration Record (MAR) by initialing all medications at once rather than individually as required, and this improper practice was observed on-site.”

“Resident #3's medication labels were incorrect. Potassium CL ER 20 MEQ label noted Sunday take 3 tablets but MAR showed Saturday take 3 tablets. Prednisolone AC 1% eye drops label was also incorrect, not reflecting the dosage change from four times daily to twice daily ordered on 4/4/25.”

“Resident #1's Eliquis 5 mg medication was not administered on 4/8/25 at 9:00 p.m. and 4/9/25 at 9:00 a.m., and this medication error was not reported to the Department within 24 hours as required.”

“Resident #2 was self-administering Butenafine cream but had not been assessed by a physician to do so. The resident's medical evaluation dated 9/10/24 notes the resident is unable to self-administer medications.”

“Medication administration staff were not following proper procedures. Staff were administering all residents' medications and then completing the Medication Administration Record (MAR) by initialing all medications at once rather than individually as required, and this improper practice was observed on-site.”

“Resident #3's medication labels were incorrect. Potassium CL ER 20 MEQ label noted Sunday take 3 tablets but MAR showed Saturday take 3 tablets. Prednisolone AC 1% eye drops label was also incorrect, not reflecting the dosage change from four times daily to twice daily ordered on 4/4/25.”

“Medications were administered to a resident at 5pm but were not initialed as administered on the Medication Administration Record (MAR). This included multiple medications that lacked proper documentation of administration.”

“Pharmacy labels for resident medications contained incorrect information: one label showed wrong dosing frequency (twice daily shown as morning and evening only), another showed incorrect sliding scale blood sugar threshold, and two medications were missing required hold parameters for blood pressure and heart rate.”

“Medication administration records (MAR) were not properly initialed by staff. Multiple residents had scheduled medications not marked as administered, and one resident's MAR showed an end date for a medication that is still being actively administered.”

“Resident morning medications were not administered on 8/2/24 because the MAR indicates the medications were not available for administration, resulting in failure to follow the prescriber's orders.”

“The grounds surrounding the concrete patio areas of the memory care courtyard were overgrown with grass and weeds approximately one foot tall.”

“During a fire drill conducted on 5/20/24 at 9pm, Resident #1 was not evacuated during the fire drill.”

“During the medication cart audit, the medication Divalproex Sodium 125mg was found in the cart for resident #4, who does not have a current order for this medication.”

“The Novolin insulin pen belonging to resident #2 and the Novolog insulin pen for resident #3 were not dated and initialed when the pens were opened for use.”

“Resident #2 has an order for Novolin insulin 20 units twice daily, but the pharmacy label states 12 units in the morning and 14 units in the afternoon. Resident #5 has an order for Lantus insulin 14 units every morning, but the pharmacy label states 15 units every morning. This is a repeated violation from prior inspections.”

“The grounds surrounding the concrete patio areas of the memory care courtyard were overgrown with grass and weeds approximately one foot tall.”

“During a fire drill conducted on 5/20/24 at 9pm, Resident #1 was not evacuated during the fire drill.”

“During the medication cart audit, the medication Divalproex Sodium 125mg was found in the cart for resident #4, who does not have a current order for this medication.”

“The Novolin insulin pen belonging to resident #2 and the Novolog insulin pen for resident #3 were not dated and initialed when the pens were opened for use.”

“Resident #2 has an order for Novolin insulin 20 units twice daily, but the pharmacy label states 12 units in the morning and 14 units in the afternoon. Resident #5 has an order for Lantus insulin 14 units every morning, but the pharmacy label states 15 units every morning. This is a repeated violation from prior inspections.”

“Resident 1's most recent annual medical evaluation was dated 3/31/2022, which was overdue at the time of inspection on 5/25/2023.”

“Resident 1 self-administers medications but had not been assessed in the past year to self-administer medications; the last assessment was completed 4/14/2022.”

“An expired medication was found on the medication cart that expired in 7/2022.”

“Resident 2's prescribed medication had a pharmacy label that had faded and no longer displayed the required dosage, administration instructions, or prescriber's information legibly.”

“Resident 3's medication administration record was incomplete; staff member failed to identify the amount of insulin given. This was a repeat violation from 3/22/2022.”

“Resident 4's RASP was not updated to reflect their current diet of soft and ground foods.”

“Resident 5's RASP was not signed by the assessor.”

“Resident 6 was admitted to the secured dementia unit but there was no completed cognitive screening found in the record at the time of inspection. This was a repeat violation from 3/22/2022.”