The Highlands at Wyomissing Personal Care Facility.

“Resident's urostomy appliance was not changed as ordered by the prescriber on Monday. The prescribed schedule was every Monday and Thursday, but the order was not followed.”

“A resident in the secured dementia unit exited the facility when a visitor failed to ensure the door locked behind them. Staff did not follow roam alert protocols or complete a head count when the alarm sounded. The resident was found near the parking lot with a displaced proximal humerus fracture requiring hospitalization.”

“Resident's medication administration record was incorrectly initialed to indicate a urostomy appliance was changed on a date when it was not actually changed. The date on the appliance bag showed it had not been changed as documented on the MAR.”

“Staff person failed to properly count prefilled syringes upon receipt from pharmacy, relying instead on an incorrect pharmacy label that indicated 32 syringes when only 30 were actually delivered. The discrepancy was not caught because the staff person did not remove syringes from the storage bag to individually count them.”

“Resident #1 has a PRN prescription for sublingual tablets that was not available in the home at the time of inspection, failing to ensure safe storage, access, and availability of medications.”

“The green dumpster located outside of the home near the mechanical room had an inoperable lid which would not close, failing to prevent the penetration of insects and rodents.”

“The home's emergency exit door located near room 708 in the Meadow Memory Care Unit did not have an exterior light, failing to ensure safe evacuation for residents including those with vision impairments.”

“Resident #1's Resident Assessment Support Plan did not document whether a cover was required for an enable bar used for bed transfers to meet FDA guidelines.”