The Residence at Fitz Farm.

“A resident was punched twice on the left cheek/eye area by another resident. Staff observed redness and applied an ice pack. Redness was still present approximately 2 hours and 41 minutes later. Another resident reported feeling scared from witnessing the incident.”

“Staff member yelled at a resident accessing a trash can and responded with disrespectful language ("bite me") when the resident yelled back. This violated the resident's right to be treated with dignity and respect.”

“The support plan for a resident in the Secured Dementia Care Unit had not been updated to reflect changes in the resident's condition and care needs, as documented in caregiver notes.”

“From 11:00 PM to 7:30 AM on multiple dates, 70 residents were present in the home with no staff person certified in CPR and First Aid, and on other dates with only 1 certified staff person present. At least one staff person for every 50 residents must be trained in first aid and certified in obstructed airway techniques and CPR at all times.”

“The home's most recent Licensing Inspection Summary from the partial inspection on 6/25/2024 and the full inspection on 11/1/2023 and 11/2/2023 were not posted in a conspicuous and public place in the home.”

“One resident bed was equipped with a partial bedrail that is 6 inches away from the mattress, posing an entrapment risk. Another resident bed was equipped with a bed enabler that has an opening of 9.5 inches wide and 7.5 inches high, posing an entrapment risk. Wheelchairs, walkers, prosthetic devices and other apparatus used by residents must be clean, in good repair and free of hazards.”

“At 9:55 AM on 11/13/2024, the door to the spa room in the Secure Dementia Care Unit was standing open with a can of Penetrating Liquid (labeled "May be fatal if swallowed") in plain view and a can of Off Insect Repellent in a cabinet. The residents in the SDCU have not been assessed to be safe around poisonous or hazardous materials, and poisonous materials must be kept locked and inaccessible.”

“Three electric fireplaces in the facility produce heat resulting in surface temperatures exceeding 120 degrees Fahrenheit near the top. The guards at the fireplaces do not sufficiently cover the area where the heat is dispensed to prevent a resident from coming in contact with the hot surface.”

“During the initial walk through at 9:45 AM on 11/13/2024, resident rooms in the Secure Dementia Care Unit were locked and residents were unable to access their rooms. A key fob by staff was needed to unlock these rooms, violating the requirement that residents shall have access to their bedrooms at all times.”

“The home's written emergency procedures have not been reviewed, updated and submitted annually to the local emergency management agency. The last submission was completed prior to the home's opening and has not been completed since.”

“Fire drill records show evacuation times recorded in minutes only, with no seconds indicated. Written fire drill records must include the date, time, the amount of time it took for evacuation, the exit route used, the number of residents in the home at the time of the drill, the number of residents evacuated, the number of staff persons participating, problems encountered and whether the fire alarm or smoke detector was operative.”

“The facility failed to report an incident of abuse to the Department within 24 hours. Staff Member A grabbed Resident #1 by the arm and hit them on the back of the head on an unspecified date during day shift, observed by Staff Member B, but the facility did not report this to the Department until a later date.”

“Two incidents of abuse were substantiated. First incident: Staff Member A grabbed Resident #1 by the arm and hit them on the back of the head during day shift. Second incident: Staff Member B yelled progressively louder and verbally berated Resident #1, using profanity and calling the resident selfish and narcissistic.”

“Resident #1 was admitted to the Secure Dementia Care Unit on an unspecified date, but the required medical evaluation was not completed within 60 days prior to admission as required.”

“Resident #1's support plan did not identify or include support plans for the resident's documented physical, medical, social, cognitive and safety needs, specifically failing to address the resident's documented anxiety, disorientation, confusion, and sadness.”

“Glucometers and Medication Administration Records were switched between two residents. Resident 1's glucometer was used to measure Resident 2's blood glucose and vice versa, indicating unsanitary conditions and cross-contamination of medical equipment.”

“Staff did not correctly record or administer insulin orders. Sliding scale and routine insulin orders were inputted onto the Medication Administration Record as a combined order, causing confusion and resulting in medication administration errors for multiple residents.”