Saint Benedict Manor, Inc..

“Staff member A was employed but a Pennsylvania State Police clearance was not requested until more than 30 days after employment, violating the requirement that criminal history checks be completed within 30 days of hire.”

“Staff member A did not receive orientation on fire safety and emergency preparedness topics including evacuation procedures, staff duties during emergencies, designated meeting places, smoking safety, fire extinguisher use, smoke detectors/fire alarms, and emergency notification procedures on their first work day.”

“Resident #3's bed enabler bar had an uncovered opening measuring 12 inches by 6 inches, creating a potential entrapment risk. Wheelchairs, walkers, and other apparatus must be clean, in good repair and free of hazards.”

“Three residents (Residents #1, #2, and #3) were observed using bed rails or enabler bars, but their assessments did not indicate a need for these devices and their support plans did not document how these needs would be met, violating the requirement to document medical needs in support plans.”

“Resident #1 was admitted to the Secure Dementia Care Unit but the written cognitive preadmission screening was not dated and the doctor did not provide verification that the resident requires admission to an SDCU. A written cognitive preadmission screening must be completed within 72 hours prior to admission.”

“A resident prescribed anti-seizure medication to be administered twice daily at 9:00 AM and 8:00 PM did not receive the medication from 8:00 PM to 4:00 PM, resulting in a breakthrough seizure and hospitalization at 4:06 PM.”

“The home failed to follow prescriber's orders for two residents' medications. One resident's medication prescribed twice daily was not administered on multiple dates and times due to medication unavailability. Another resident's medication prescribed twice daily was only administered on select dates and times during the inspection period.”

“A medication error involving missed doses of prescribed medication was not reported to the prescriber by the home, as required. The resident did not receive the medication on multiple dates and times, but this error was not communicated to the prescriber.”

“The resident-home contract for resident #1 was not signed by the resident.”

“The home's quality management review dated 1/4/24 did not address reportable incident and condition reporting procedures, complaint procedures, staff person training, licensing violations and plans of correction, or resident or family councils.”

“Staff person B did not receive orientation on the first day of work regarding staff duties and responsibilities during fire drills, designated meeting place outside/interior fire safe area, location and use of fire extinguishers, and smoke detectors and fire alarms.”

“There was no thermometer in the refrigerator located in the kitchen.”

“The last fire drill completed during sleeping hours was on 11/17/23 at 12:45 AM, which was more than 6 months prior to the inspection date.”

“Emergency procedures were not posted in a conspicuous and public place in the home.”

“An insulin pen in the medication cart was not labeled with the date and staff initials of the person who opened it.”

“A tube of cream belonging to Resident #3 and a small bottle of solution of unknown resident assignment were in the medication cart and not labeled with the resident's name.”

“Three residents (Residents #1, #2, and #3) have not been educated on the resident's right to refuse medication if the resident believes there may be a medication error, and documentation of this education was not kept.”

“Resident #2 was admitted to the Secure Dementia Care Unit, but the written cognitive preadmission screening was not completed within 72 hours prior to admission as required.”

“Resident #1 was admitted to the Secure Dementia Care Unit, but the initial support plan was not developed, implemented, and documented within 72 hours prior to or following admission.”