Senior Commons at Powder Mill

A resident was forcefully shoved to the ground by another resident, resulting in a hip fracture and hospitalization.

The most current LIS and a copy of the 2600-chapter regulation were not conspicuously and publicly posted in the home.

Suspected resident abuse incidents occurring on 12/11/24 were not reported to the local Area Agency on Aging via the mandatory ACT 13 form.

The resident's assessment was not updated to reflect a significant change in condition, specifically the transition from independent ambulation to using a walker and wheelchair.

A staff member used manual restraint by applying pressure to a resident's shoulders to force them to sit down during an episode of physical aggression.

A container of Sani Wipes labeled with poison control instructions was left unlocked and accessible to residents in the SDCU kitchenette.

Insufficient number of staff trained in CPR and First Aid were present during overnight shifts on multiple dates in May 2024.

Wooden cabinet doors in the dining room kitchenette were covered with a sticky film.

A staff member used profanity and verbally intimidated a resident, causing the resident to become emotional and sob.

A courtyard gate in the Rosewood Court Secure Dementia Care Unit was locked with a padlock because the electronic locking system was inoperable, obstructing the egress route.