Country Meadows of York.

“A physical altercation between two residents on 11/17/23 involving one resident pushing another, resulting in a fall, was not reported to the local area agency on aging despite being reported to staff. This was a repeated violation from 9/27/23.”

“A bed side mobility device used by Resident 2 for positioning and transferring was not securely fastened to the bed on 8/28/24.”

“A 1 oz bottle of Weaver Eye Associates lens cleaner labeled "harmful if swallowed" was unlocked, unattended, and accessible in Resident 2's room on 8/28/24. Not all residents in the home have been assessed capable of safely recognizing and using poisons.”

“Oxycodone (5mg) prescribed for Resident 3 was found in the home's controlled substances lock box on 8/28/24, but the medication was discontinued on 3/30/24 and should not have been kept in the home.”

“Resident 1's blood sugar reading of 185 documented on 8/25/24 in the medication administration record was not recorded in the resident's glucometer. Additionally, Resident 3 is prescribed Lisinopril with parameters to hold if systolic pressure is <110 or diastolic pressure is <60, but the home did not document the resident's blood pressure readings.”

“An alleged sexual abuse incident occurred and was observed by staff. Although reported to another staff member immediately and subsequently to DHS, an Act 13 Mandatory Abuse Report was not timely filed with the local area agency on aging.”

“An alleged sexual abuse incident occurred on the premises. The home failed to report this incident to the Department within the required 24-hour timeframe.”

“Resident #1 was observed performing a sexual act on Resident #2 (who is adjudicated totally incapacitated) and subsequently on Resident #3. Despite prior notifications to the physician and family regarding concerning sexual behaviors, and despite orders for private duty supervision, adequate supervision was not maintained to prevent these incidents of sexual abuse.”

“Resident #1 received physician orders for medications at bedtime for 'behaviors' and daily for a 'preventative measure.' According to staff, these medications were administered to lower the resident's sexual drive and behaviors toward others, constituting use of drugs for the specific purpose of controlling behavior, which may constitute chemical restraint.”