Arbor Terrace Willistown.

“The facility did not submit an incident report to the Department within the required 24 hours. A resident was administered medication prescribed for another resident at 8am, but the incident report was not submitted until 6:19pm.”

“Staff person A was hired but no criminal background check had been completed as of the inspection date. Staff person B was hired with a Pennsylvania criminal background check completed, but did not have a required FBI clearance completed as of the inspection date.”

“A bedside mobility device observed on a resident's bed was not securely attached to the frame of the bed. Bedside mobility devices that slide under the mattress and are not securely attached can move and create entrapment zones, and are not permitted under any circumstance.”

“Spray cleaner with warnings to keep out of reach of children and wash hands thoroughly was stored on a shelf above fresh produce. An additional spray bottle of the same cleaner was observed next to silverware on the server station. Poisonous materials must be stored separately from food, food preparation surfaces, and dining surfaces.”

“Dial antibacterial soap labeled "Contact poison control if swallowed" was unlocked, unattended, and accessible in the memory care kitchenette. Crest detoxifying toothpaste and Secret deodorant with poison control warnings were unlocked and accessible in resident bedrooms. Not all residents have been assessed capable of recognizing and using poisons safely. Poisonous materials must be kept locked and inaccessible to residents.”

“Two electrical cords were observed laying across the floor from bed to wall in a resident bedroom, creating a tripping hazard. Floors and other surfaces must be free of hazards.”

“Resident records were unlocked, unattended, and accessible in the second-floor wellness center room. Resident medication information was unlocked, unattended, and accessible in the Secure Dementia Care Unit resident services office. An empty medication blister pack with resident's name and medical information was unlocked, unattended, and accessible on top of a medication cart in the SDCU.”

“Two staff persons (A and B) were permitted to work in the home without current criminal background checks completed within one year prior to hire, in violation of criminal history check requirements under the Older Adult Protective Services Act.”

“The administrator's list of staff persons does not include agency staff and substitute staff with their names, addresses, and telephone numbers.”

“Poisonous materials including Aloe hand sanitizer, Home Bright Disinfectant Spray, and Amaya home laundry detergent were unlocked, unattended, and accessible to residents in the SDCU resident services office and in a resident's room. Not all residents have been assessed as capable of recognizing and using poisons safely. This is a repeat violation.”

“Resident 1 does not have access to a source of light that can be turned on/off at bedside because the bedside lamp was not functioning.”

“A red stop sign shaped sticker was placed on the emergency exit door in stairwell 2 leading to the SDCU courtyard. This universal stop sign image presents an obstruction to the exit in an emergency as it may deter a person from using the exit.”

“Staff member observed bruising on a resident's arm and lower back area. The facility did not report this incident to the Department within the required 24-hour timeframe.”

“Direct care staff person A did not receive training in medication self-administration during training year 2024. All required annual training topics must be provided to direct care staff.”

“Colgate toothpaste and Head and Shoulders shampoo with poison control warnings were unlocked, unattended, and accessible to residents in a secured dementia unit room. Poisonous materials must be kept locked and inaccessible to residents.”

“A controlled medication was signed out at 11:00 PM but not administered to the resident until 1:55 AM, exceeding the 2-hour window before scheduled administration.”

“A discontinued medication was found in the home's medication cart. Only current prescriptions, OTC, sample and CAM medications for individuals living in the home may be kept in the home.”

“A medication bottle did not include a pharmacy label with required information including resident name, medication name, prescription date, dosage, administration instructions, and prescriber name and title.”

“Multiple medication administration and storage issues were identified: a controlled substance was administered but not signed out on the controlled drug record, and PRN medications prescribed to residents were not available in the home. The home must develop and implement procedures for safe storage, access, security, distribution and use of medications.”

“A controlled substance was signed out on the controlled drug record, but the medication administration record does not include the initials of the staff person who administered the medication. Date and time of medication administration must be recorded at the time the medication is administered.”

“Multiple prescribed medications were not administered to residents on scheduled dates and times because the medications were not available in the home. The home must follow the directions of the prescriber.”

“The home's Pennsylvania Chapter 2600 regulation book was not posted in a conspicuous and public place in the home.”

“The home's quality management plan does not include the required topics: reportable incident and condition reporting procedures, complaint procedures, staff person training, licensing violations and plans of correction, and resident or family councils.”

“Two residents had bedside mobility devices (enabler bars) that were not attached to the bed frame, were uncovered, and had openings approximately 11 inches wide by 21 inches high presenting a risk of entrapment. The devices were slide under the mattress and not securely attached, creating moveable entrapment zones.”

“Trash outside the home was not kept in covered receptacles. On inspection, there was an uncovered trashcan filled to the top, and a tied bag of trash in the parking lot away from the dumpster area, along with a washing and drying unit, wheelchair, and plastic shelves outside.”

“The toilet paper holder in bedroom 119 in the Memory Care Unit was broken with a protruding section that could catch clothing or assistive devices such as a walker, presenting a hazard.”

“Resident #3's medication record did not include a current list of medications. The record contained medications the resident was no longer taking (hycoscyamine and albuterol) and was missing over-the-counter medications being taken (CVS Health Stool Softener Docusate Sodium 100 mg and Care One Allergy Relief Loratidine 10 mg).”

“The facility's policy prohibited residents from using recording devices in their apartments without the Community Executive Director's express written consent, and the facility posted signs on apartment doors indicating video recording devices were in use. Residents have the right to privacy and to possess recording devices without facility knowledge or consent.”

“A resident's assessment plan did not indicate the resident's need for ambulation assistance with a rolling walker or how this need would be met, in violation of requirements for annual assessments that must document resident needs and plans to address those needs.”

“The home submitted an initial incident report but failed to submit a final report to the Department immediately following the conclusion of the investigation.”

“A staff member verbally abused a resident by stating 'There is nothing wrong with you' and 'we are not doing this tonight' when the resident requested blood pressure and pulse checks and hospital transport. The staff member dismissed the resident's medical concerns and closed the door, leaving the resident to trigger a fire alarm to access emergency services.”

“A resident requested assistance accessing health services (blood pressure check, pulse check, and hospital transport) but was denied assistance by staff member A, who told the resident there was nothing wrong and to contact their children instead.”

“The home failed to provide assistance in accessing health services to a resident as contracted for in the resident-home contract.”

“A resident's medical evaluation did not include a list of medications. The evaluation indicated 'see attached' but no attachments were provided.”

“Medication administration records for residents did not document the name and initials of the staff person administering medications on multiple dates (7/7/2024 and 7/22/2024).”

“A resident was not treated with dignity and respect. During an incident in the memory care unit, a staff member began yelling at a resident, and another staff member held the resident's hands to restrict movement after the resident became verbally aggressive.”

“The facility's communication system (walkie-talkies) was not utilized by staff during an emergency incident in the Secured Dementia Care Unit, preventing immediate contact for assistance.”

“A resident's prescription medication pharmacy label did not include the correct day of administration. The label indicated Monday administration while the prescriber's order specified Sunday.”

“A prohibited restraint procedure was used on a resident. Staff member held a resident's hands in their own lap to restrict the resident's movement during an incident in the Secured Dementia Care Unit.”

“A resident's support plan was not revised following a change in the resident's condition. The plan indicated no needs in the area of aggression, but the resident subsequently attempted to kick staff members, and the plan was not updated.”

“A resident fell forward out of their wheelchair, hitting their head on the floor and sustaining a bruise to the forehead. The resident was hospitalized, but the home failed to report this incident to the Department within 24 hours as required.”