Senior Commons at Powder Mill.

“A resident was forcefully shoved to the ground by another resident in the Secured Dementia Care Unit, resulting in a hip fracture. The resident was hospitalized for 6 days and subsequently transferred to a skilled nursing facility for rehabilitation.”

“Licensing inspection identified violations related to prescription medication administration (section 182b incomplete in provided text).”

“Residents #8 and #9 did not have access to a source of light within reach that can be turned on/off at bedside.”

“The most current Licensing Inspection Summary (LIS) dated 12/9/24 and a copy of the 2600 chapter regulation were not conspicuously and publicly posted in the home.”

“Three incidents of alleged resident abuse were not reported to the local Area Agency on Aging via the mandatory ACT 13 form: (1) On 12/11/24 at 9:30am, resident #1 with hand in resident #2's pants; (2) On 12/11/24 at 5:49pm, resident #1 with hand in resident #3's shirt and resident #3 with hand in resident #1's pants; (3) On 2/23/25 at 5:00pm, resident #5 struck resident #4 with a cane.”

“Resident #7's bed had a Halo ring mobility device that was not securely attached and able to fully spin, creating a potential entrapment hazard. Additionally, a second Halo ring device was partially removed with an uncovered pole posing risk of injury.”

“Staff applied manual restraint by placing hands on resident's shoulders and applying pressure to force the resident to sit down, which restricts the resident's ability to move freely. This is prohibited as a hands-on physical means of restraint.”

“Resident's assessment dated 7/29/2024 indicated independent ambulation with no assistive device, but on the inspection date the resident was observed using a walker and staff referenced wheelchair use in incident documentation, indicating a significant change in condition that was not documented through an additional assessment.”

“The facility did not maintain the required minimum number of CPR and First Aid certified staff during overnight shifts (11:00PM-7:00AM) on multiple dates in May 2024. With 104 residents present, the regulation requires at least 3 certified staff; only 2 were on duty on 05/13, 05/14, 05/15, and 05/18/2024.”

“A container of Sani Wipes labeled as poison control if swallowed was left unlocked, unattended, and accessible to residents in the Secure Dementia Care Unit kitchenette on 05/22/2024 at approximately 10:35AM.”

“Upper and lower wooden cabinet doors in the kitchenette of the dining room were covered with a sticky film on 05/23/2024 at 10:14AM.”

“No thermometer was located in the freezer or refrigerator sections of the stainless steel refrigerator in the PC dining room kitchenette on 05/23/2024 at 10:12AM.”

“The home's written emergency procedures were not reviewed and submitted annually to the local emergency management agency in 2023.”

“A resident-owned feline named Abby was present at the facility without a current rabies vaccination certificate. The vaccination had expired on 01/11/2024. This was a repeated violation from 02/15/2023 and earlier.”

“There was no fire extinguisher in the attic of the home on 05/23/2024 at 9:40AM.”

“A staff member verbally abused a resident by making an inappropriate profane comment, telling the resident "Where do you think you're going? You're not allowed to be in here. Get the fuck out of here." The resident was observed sobbing and emotional afterward.”