Elm Terrace Gardens

A staff member treated a resident with disrespect by threatening not to provide dinner after the resident used the call bell.

A direct care staff member did not receive required training regarding meeting resident needs as described in assessment tools and support plans.

Staff failed to identify the correct resident during medication administration, resulting in the resident receiving the wrong medication and requiring hospital treatment.

Assignment sheets were found on top of an unlocked and unattended 4th floor medication cart, making them accessible.

Medication administration records did not include the initials of the staff person who administered narcotics, despite the narcotic sheet being signed out.

A resident's medication was held due to low blood pressure/heart rate without consulting the prescribing doctor.

The home failed to report an incident to the Department regarding a resident not receiving prescribed medication as intended.

A resident was neglected medication administration, missing 63 doses of Ibrance, and medication was stored in an unlocked cabinet.

Five direct care staff members lacked a high school diploma, GED, or active status on the Pennsylvania nurse aide registry.

The home failed to report a resident's missing property (wallet) to the local area agency on aging.

Staff failed to provide and document required supervision and wander guard checks as outlined in the resident's support plan.

A resident was left unattended and subsequently found on a stairwell landing with skin tears after a wander guard alarm triggered.

Binders containing resident hospice, Accu-Chek, and lab information were found unlocked, unattended, and accessible to visitors on the nurses station counter.

A resident requiring extensive supervision due to elopement history eloped from the SDCU because required safety checks and a wander pendant were not in use.

A staff member used physical force by grabbing a resident's pants to lower them into a wheelchair and responded to a resident's physical aggression with a retaliatory tap.

A medication blister pack was found punctured in one slot and taped over.

The facility failed to implement required positive interventions and redirection techniques for an agitated resident during care.