Allied Services Meade Street Residence.

“A resident with a history of exit-seeking behavior was taken from the Secured Dementia Care Unit to the first floor for a birthday party and subsequently eloped from the facility, found approximately 1 block away after 30 minutes. The resident was not properly supervised during this activity despite known elopement risk.”

“The resident's support plan indicated a need for supervision for outings outside the SDCU; however, the resident was taken outside the SDCU for a party and was able to elope from the facility, demonstrating the support plan was not adequate or properly implemented.”

“A resident entered another resident's room and smashed the resident's television, violating the resident's right to privacy and possessions.”

“A staff member dropped a pill on an unsanitary medication cart and picked it up with their fingers to place it back in the bottle, creating a sanitation concern.”

“Resident #3 did not have access to an operable lamp or other source of lighting that can be turned on/off at bedside.”

“Four chairs blocked an egress from the home's courtyard entrance, obstructing emergency exit routes. This is a repeat violation from 11/06/24.”

“Resident #4 self-administers medications and stated they do not have a locked storage location for medications and do not lock their door when leaving their room.”

“Bottles of Ocuvite, fish oil, calcium, and vitamin C belonging to resident #6 were in the medication cart and were not labeled with the resident's name.”

“Resident #5's medication record listed B-12 500mcg tablet as Cyanocobalamin rather than B-12, creating inconsistency in medication documentation.”

“Two staff members had incomplete training records: Staff person B's form did not document any completed medication record reviews or medicine administration observations but was marked as requalified; Staff person C's form documented only one of two required medication record reviews and one of two required observations but was marked as requalified without a completion date.”

“Two residents placed on the secure dementia unit were able to manipulate their way out of the home and walked to a nearby residence before being located by emergency services at 3:40 P.M. This constitutes neglect as residents were not properly supervised and secured doors were accessible to residents.”

“Carbon monoxide monitors installed in the lobby fireplace area and Terrace level gas-fired boiler system were not labeled with installation dates. These monitors have 10-year battery life expectancy and should be labeled to indicate replacement dates.”

“Staff person A did not receive required annual training in two areas: Older Adult Protective Services Act and resident rights for the 10/1/23 to 9/30/24 training year.”

“The shower room in the secure dementia care unit near the laundry room was unlocked and propped open, with poisonous materials accessible including anti-fungal powder and antiperspirant bottles labeled with warnings to seek medical attention if swallowed.”

“The refrigerator in the 2nd floor kitchenette area did not have a thermometer to monitor temperature for food requiring refrigeration.”

“The front door used by residents and visitors requires a keypad to unlock and has a 15-second delayed egress system, but lacked signage indicating residents can push the door to open after 15 seconds. Additionally, the exit door in the Lehigh wing stairwell (not in the secure dementia unit) had a keypad lock with a 30-second panic bar release but lacked any signage indicating how to exit.”

“Resident #1's medication label indicated 2 sprays in both nostrils daily for 14 days, but the physician order was for 1 spray in both nostrils one time daily. Resident #2's medication label indicated nightly use but did not reflect the "as needed" instruction from the physician order.”

“Resident #3's glucometer was not calibrated to the correct date, creating unsafe conditions for accurate blood glucose monitoring.”

“A staff member accepted monetary gifts (check and cash) from a resident in June 2024 despite knowing the facility's no-gift policy. This acceptance disregarded the resident's financial wellbeing and violated the facility's financial management requirements.”

“A resident was placed in the SDCU activity area without proper admission paperwork and waivers. The resident could not independently operate the exit door code, which constitutes a mechanical restraint violation as the resident was unable to freely exit the secured area.”

“A resident was admitted to the SDCU without waiting for the Primary Care Physician to return the signed Detailed Medical Evaluation indicating approval for admission to the unit. The required medical evaluation documentation was not obtained prior to admission.”

“A resident was admitted to the SDCU without completing the Statement of Objection Form, which documents that the resident and designated person have not objected to admission to the locked secure unit accessed by coded door locking system.”

“The resident's support plan (RASP) dated 4-24-24 did not document information about the resident's specific need for the bedside mobility device, intended use, associated risks, ability to use it safely, the specific device to be used, or whether a cover was required to meet FDA guidelines.”

“Training logs did not document the specific dates that staff members were trained. Logs indicated training was conducted "by 3-21-24" rather than recording the actual dates when individual staff members completed training on regulation 58a Awake Staff Persons, Proper Medication Administration, and OAPSA.”

“An uncovered bedside mobility device was attached to the left-hand side of a resident's bed with an opening of approximately 12 inches by 8 inches, creating a potential injury hazard that required a cover.”

“Staff member A was suspended following an allegation of mistreatment of a resident, but no plan of supervision was submitted to the Department prior to the staff member's return to work, as required.”

“An incident involving staff member A and a resident occurred around 6:30 AM but was reported greater than 24 hours after the incident occurred. Additionally, when a resident left the facility at 1:20 AM and was returned by Emergency Services at 3:10 AM, no incident report was created.”

“A resident who required 2-hour safety checks and was to be accompanied in unfamiliar surroundings walked out of the facility at 1:20 AM and was not discovered missing until returned by Emergency Services at 3:10 AM. The required 2:30 AM bed check was not completed.”

“Staff Member B was found sleeping during shift at approximately 3:10 AM on the date of a resident elopement. This is a repeated violation from 7-27-23.”

“On multiple dates, Staff Member B arrived late for the 11-7 PM shift, leaving only 2-3 staff to potentially evacuate 52 residents. On the date of the resident elopement, Staff Member B did not arrive until 12:30 AM, leaving only 3 staff for one hour to manage 52 residents. This is a repeated violation from 7-27-23.”

“The home's menu for the week of 11/19/23 to 11/25/23 was not posted in the secured dementia unit. Weekly menus must be posted 1 week in advance in a conspicuous and public place.”

“Staff person used foul language regarding a resident's behavior within earshot of the resident. This was a repeat violation from 9/14/22. The violation involved failure to treat the resident with dignity and respect.”

“Staff persons C and B were observed sleeping on overnight shift by other staff members. Video evidence was provided. The home serves 55 residents, 14 of whom reside in a secure dementia care unit, requiring all direct care staff to remain awake at all times.”

“The facility serves 55 residents with 14 in secure dementia care unit requiring evacuation assistance. On 7/27/23, only 2 staff members were present on the 11pm-7am shift. With 8 internal fire safe areas and 10-minute safe evacuation time, the facility would not be able to meet residents' needs per their assessment and support plans during emergencies between 11pm and 7am.”

“Fire drills were not conducted on 3/9/23 and 6/20/23. Instead, employee training on fire procedures was held on these dates. The facility failed to conduct unannounced fire drills at least once a month with all residents evacuated to fire safe areas.”

“Fire drill documentation from May 2022 to present was incomplete and inaccurate. Records listed only evacuation time for affected area, not total time for all residents to reach internal fire safe area. Exact exit routes used were not documented. Logs incorrectly documented drills on 3/9/23 and 6/20/23 that did not actually occur.”

“A fire drill during sleeping hours was not conducted from March 2023 to present. Staff training on fire procedures was held on 3/9/23 and 6/20/23 instead of actual sleeping hour fire drills required once every 6 months.”

“Fire drills conducted from May 2022 through September 2022 were all held in the middle of the month between the 13th and 18th, failing to meet requirements for drills on different days of the week and at different times of day and night.”