The Province of Southampton.

“Staff person A failed to report within 24 hours an alleged incident where staff person B slapped a resident's hand in the dining room. The incident occurred at approximately 12:00 pm but was not reported until the following day at approximately 1:00 pm.”

“Staff person C physically and verbally abused a resident by shouting accusations while pointing a finger in the resident's face while the resident was on the toilet, and then grabbing the resident's right arm, causing pain and leaving bruise marks. This occurred after the resident had refused assistance from staff person C with colostomy care.”

“Staff Member A did not receive training in instruction on meeting the needs of the residents as described in the preadmission screening form, assessment tool, medical evaluation and support plan during the 2024 training year.”

“Staff Member A did not receive training in emergency preparedness procedures and recognition and response to crises and emergency situations, resident rights, or The Older Adult Protective Services Act during the 2024 training year.”

“A resident's most recent medical evaluation was overdue; the resident did not have an annual medical evaluation as required.”

“Medications were not stored in compliance with manufacturer's instructions and proper conditions. A loose pill was found in the medication cart, and multiple eye drops were stored beyond their manufacturer-recommended discard dates.”

“Medications belonging to a discharged resident were stored in the Reflections laundry room, which is not an approved method of destroying medications according to Department of Environmental Protection and Federal and State regulations.”

“The list of staff persons maintained by the administrator does not include agency staff and the health care director. This was a repeat violation from 4/29/2024.”

“Resident-home contracts were not properly signed. One contract for resident 1 was not signed by the administrator or designee, and one contract for resident 2 was not signed by the resident. This was a repeat violation.”

“Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, violating qualification requirements.”

“Inadequate first aid and CPR certified staff present during evening and overnight shifts. On 2/1/2025 from 3 PM to 11 PM, and on 2/2/2025 from 3 PM to 7 AM on 2/3/2025, only 1 staff person certified in first aid was present for 82 residents (requiring at least 2).”

“Torn off tops of three medication blister packs containing resident medication information were observed unlocked, unattended, and accessible on top of a second-floor medication cart, violating record confidentiality requirements.”

“Resident record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures.”

“On at least 10 occasions during summer 2024, a resident repeatedly refused to leave another resident's room when invited to watch television, and staff failed to provide appropriate assistance to enforce the resident's right to privacy during bedtime preparation.”

“Direct care staff person A, hired on an unspecified date, began providing unsupervised ADL services before completing and passing the Department-approved direct care training course and competency test.”

“Direct care staff person A's annual training hours could not be determined because the home did not document the length of trainings for the review period.”

“A resident eloped from the secured dementia care unit by entering the posted code on magnetic door locks, exiting through main doors and proceeding onto a four-lane busy road (45 mph speed limit) for approximately 1/4 mile until entering a 7-11 parking lot where police located them. The elopement exposed the resident to significant safety risks including traffic hazards.”

“A resident assessment and support plan was not signed by the resident and did not include any indication whether the resident was unwilling or unable to participate in the care plan.”

“The Chart Room door was propped open, leaving approximately 45 resident medical records and a whiteboard with resident information (names, room numbers, bathing schedules, assistance needs) unlocked, unattended, and accessible to the public.”

“The facility failed to consistently provide a resident with assistance with activities of daily living, specifically overnight incontinence checks and changes as outlined in the resident's night shift task assignment prior to the resident being hospitalized.”

“A resident's Residency Agreement was not signed by the resident at the time of admission.”

“A resident's record did not contain a statement signed by the resident acknowledging receipt of information regarding resident rights and complaint procedures.”

“A resident was being physically restrained to their bed by a wooden chair and a large pillow that ran the full length of one side of the bed, with the other side against a wall.”

“Resident 1 was prescribed wound care twice weekly and as-needed care for soiled bandages, but the home failed to provide adequate wound care. When the resident refused care on one occasion, staff did not attempt to provide care at a later time. Soiled bandages were not changed timely, and staff did not escalate to the nurse on call. The home lacked trained staff to provide wound care during weekends and did not ensure wound care was provided as prescribed.”

“Resident 1 was prescribed wound care twice weekly and as-needed care, but the home failed to follow the prescriber's orders. The resident did not receive prescribed wound treatment on a scheduled date, and staff made no attempt to provide the treatment at another time. Wound treatment was not provided until several days later.”

“Medication narcotic count book was unlocked, unattended, and accessible on top of medication cart on the second floor, creating a confidentiality and security violation regarding resident records.”

“Carbon Monoxide detector in the kitchen was only ten feet from the gas grill, in violation of the Care Facility Carbon Monoxide Alarms Standards Act which requires detectors to be installed not less than 15 feet from any fossil-fuel burning device or appliance.”

“Resident #1's resident-home contract was signed by the legal representative on 01/20/24 but was not reviewed with and signed by the resident until 02/21/24, which is after the required 24-hour window from admission.”

“The resident-home contract for resident #2 was not signed by the resident, in violation of contract signature requirements.”

“The resident-home contract for resident #2 was not signed by the resident, in violation of contract signature requirements.”

“Medication narcotic count book was unlocked, unattended, and accessible on top of medication cart on the second floor, creating a confidentiality and security violation regarding resident records.”

“Carbon Monoxide detector in the kitchen was only ten feet from the gas grill, in violation of the Care Facility Carbon Monoxide Alarms Standards Act which requires detectors to be installed not less than 15 feet from any fossil-fuel burning device or appliance.”

“Resident #1's resident-home contract was signed by the legal representative on 01/20/24 but was not reviewed with and signed by the resident until 02/21/24, which is after the required 24-hour window from admission.”

“On the inspection date, 92 hours of direct care was required, but only 67.5 hours (73 percent) were provided during waking hours. The regulation requires at least 75 percent of personal care service hours to be available during waking hours.”

“The facility was required to provide 79 hours of direct care, but only 58 hours (73 percent) were provided during waking hours. The regulation requires at least 75% of personal care service hours to be available during waking hours.”