Frederick Living - Aspen Village.

“A resident's bedroom did not have a bedside table or shelf.”

“A resident with exit-seeking behavior and a requirement for 24-hour direct supervision exited the secured dementia care unit and was found on the ground outside in approximately 15-degree Fahrenheit weather with snow. The resident's support plan did not include specific interventions to prevent elopement beyond daily monitoring.”

“The initial staff list provided did not include one staff person who was working at the facility. A corrected staff list that included this staff person was not provided until over two hours later.”

“A resident did not have access to a source of light that could be turned on or off at bedside.”

“A resident's assessment documented they require 24-hour direct supervision and are independent with mobility, but their support plan did not reflect exit-seeking behavior or behaviors such as irritability, agitation, and aggression that were documented in progress notes. The resident also eloped from the home, but no additional assessment was completed to address these changes in condition.”

“Staff Member B did not receive training in fire safety completed by a fire safety expert or by a staff person trained by a fire safety expert during the 2024 training year.”

“The administrator could not provide a current list of substitute personnel for the home, including their names, addresses, and telephone numbers as required.”

“The home's staff training plan does not include estimated dates for each training to be completed as required.”

“Medication cards with punctured blister foil containing medications were observed, exposing them to contamination or improper sanitation. Additionally, a roll pack of medications was found with discontinued medications that had been taped shut rather than properly handled.”

“A resident-home contract was not signed by the resident as required.”

“A resident was physically abused when staff forcefully pulled back the resident's blanket, raised their voice, and struck the resident's hand and forearm during an altercation over incontinence care.”

“Staff failed to use positive interventions and de-escalation techniques when a resident refused incontinence care and became combative, instead using physical force and raised voices contrary to the resident's support plan.”

“A resident admitted to the Secure Dementia Care Unit lacked documentation that the resident and their designated person have not objected to the admission.”

“No staff person on the schedule was ServSafe certified. The PA Department of Agriculture Food Employee Certification Act requires one supervisory employee per food facility to obtain food safety certification and be available during all hours of operation.”

“A contractor painting a resident room did not have a criminal background check completed. This is a repeated violation from 1/9/2024.”

“During multiple shifts on October 3, 5, and 6, 2024, there was inadequate coverage of staff trained in first aid and CPR. Specifically, on October 5, 2024 from 7pm to 6:30am there was no staff person trained in first aid present, and other shifts had only one trained staff member for more than 50 residents.”

“During the fire drill on September 27, 2024, the home's evacuation time was 11 minutes and 32 seconds, exceeding the maximum safe evacuation time of 8 minutes and 30 seconds as specified in writing by the fire safety expert on August 12, 2024.”

“A resident's support plan did not adequately document details regarding a bedside mobility device, including the intended use, associated risks, the resident's ability to use it safely, identification of the specific device, and whether a cover is required to meet FDA guidelines.”

“A resident's support plan was developed without the resident's signature and there was no notation documenting why the resident was unable to sign.”

“Direct care staff did not receive annual fire safety training completed by a fire safety expert or by a staff person trained by a fire safety expert during the training year January 2023 to December 2023.”

“The administrator does not maintain a current list of staff persons that includes substitute or agency personnel. Employee information was available through various systems but not compiled into a single accessible list.”

“The home does not have a system to safeguard resident laundry from loss. Unlabeled folded clothes were found in the activities room with a sign asking residents to identify items, rather than ensuring proper labeling and return within 24 hours.”

“Multiple resident support plans do not identify residents' physical, medical, social, cognitive and safety needs. Specifically, support plans failed to address irritability, agitation, aggression, orientation, and communication of needs.”

“Resident records do not include an inventory of the residents' personal property as required by regulation.”

“The home does not have the criminal background check for staff person A.”

“The exit door leading to the outside area of the memory care unit malfunctioned and prolonged the closing of the door.”

“Resident 1 rammed a walker into an unnamed resident, and this allegation of abuse was not reported to the local area agency on aging. Additionally, resident 2 was heard screaming and witnessed leaving resident 1's room holding their thigh and saying 'ow' repeatedly; this allegation was also not timely reported to the local area agency on aging.”

“Two incidents involving resident 1 were not reported to the Department within 24 hours: one incident where resident 1 rammed a walker into an unnamed resident, and another incident where resident 2 was heard screaming and witnessed leaving resident 1's room with apparent injury.”

“Resident 2 sustained a bruise on the left thigh after an incident in resident 1's room involving screaming and witness observations of resident 2 in pain. Resident 1 had a documented history of aggressiveness toward staff and other residents, but the resident's most recent assessment and support plan was not updated to address behavioral needs or create a plan to manage aggressive behavior.”

“Staff person A did not receive required first-day fire safety and emergency preparedness orientation on evacuation procedures, staff duties and responsibilities during fire drills and emergency evacuation, designated meeting places, smoking safety procedures, location and use of fire extinguishers, smoke detectors and fire alarms, and telephone use and emergency services notification. This is a repeat violation from 9/13/22.”