Colonial Courtyard at Tyrone.

“Resident demonstrated physically aggressive behavior towards another resident on the Secure Dementia Care Unit. At 3:30 pm, staff witnessed resident push another resident, causing them to fall and sustain an injury to the back of the head requiring medical attention.”

“Resident #1 was prescribed ABH (ativan, benadryl, haldol) topical gel for anxiety to be administered 1ml every 8 hours as needed. However, the medication was administered twice on 4/10/24 at 2:05 PM and 3:58 PM, which violated the prescriber's directions.”

“Resident #1 was prescribed Quetiapine TAB 25MG twice daily for agitation, which may constitute a chemical restraint as defined by the prohibition against use of drugs for the specific and exclusive purpose of controlling acute or episodic aggressive behavior.”

“The home did not complete a significant change assessment when Resident #1 was moved to the secure dementia care unit, as required when a resident's condition significantly changes prior to the annual assessment.”

“Resident #1 was unable to participate in the development of the support plan and could not sign it. The home did not document a notation regarding the resident's inability to sign.”

“The resident-home contract was not signed by the resident as required by regulations.”

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

“An enabler bar attached to a bed had an uncovered opening measuring 7½ inches by 11¾ inches, creating a potential entrapment hazard to the resident.”

“Resident-home contracts for two residents were not signed by the residents as required.”

“Staff member B lacked a Pennsylvania State Police clearance within 1 year prior to hire and within 30 days after hire, as required by the Older Adult Protective Services Act.”

“The home with 41 residents lacked a staff member with current training in first aid and CPR during specified weekend hours, when at least one staff person trained in first aid and certified in obstructed airway techniques and CPR must be present at all times.”

“Staff member A was observed placing a cup containing medications beside a resident and walking away without placing the medication in the resident's hand or mouth as required by medication administration procedures.”

“Multiple prescription and OTC medications were observed unlocked, unattended, and accessible in resident bedrooms, including medicated creams in bathrooms and bedroom areas.”

“Resident #2's preadmission screening form does not include a determination that the resident's needs can be met by the services provided by the home, as required within 30 days prior to admission.”

“Resident #1 was transferred from memory care to senior care with a RASP completed for the significant change, but the personal care need for supervision and mental health need of wandering were not updated on the RASP. Resident #2 had documentation to initiate hospice services, but no additional RASP was created for this significant change; the most recent RASP remained the initial one from admission.”