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Broad Mountain Health: Resident Escapes Unattended - PA
Twelve residents at the facility had been identified as being at risk for wandering....
Latest reports, citations, and penalties from CMS data
Twelve residents at the facility had been identified as being at risk for wandering....
Arlington Gardens Care Center sent Resident 1 to the placement facility despite knowing she required assistance going to the bathroom to prevent falls....
Resident #11 had been prescribed Vitron-C, an iron-vitamin C supplement for anemia, to be taken every other day since May....
The resident's physician had issued specific orders on April 24, 2024, requiring staff to check residual stomach contents before each tube feeding....
Federal inspectors discovered the investigation failure during an October 2025 complaint inspection....
Resident 16 died on a recent evening at 7:30 PM....
While a bath towel covered the front of his body, the resident's uncovered buttocks hung through the chair and remained visible to anyone in the hallway....
Staff D, the Resident Care Manager, confirmed receiving the telephone order for the urine test from the urologist....
She said the touching felt sexual and that the nurse was violating her....
Resident #12 had been equipped with an electronic monitoring device designed to prevent exactly this type of dangerous wandering....
The incident at Princeton Manor Healthcare Center occurred between 11:30 p.m....
The violation occurred at Presidential Post-Acute during an October 16 wound care session involving Nurse #494 and Wound Nurse #474....
The dangerous reading occurred on September 16, 2025, at Ossian Care Center....
She returned six minutes later carrying a box of medication....
The September incident involved a complex antibiotic regimen prescribed by a nurse practitioner to treat the UTI....
The October 15 incident involved treatment of a resident's "very large deep unstageable wound" covered with yellow slough on their lower back....
The discovery occurred during Resident #681's respite stay at Austintown Healthcare Center....
The resident's family filed a complaint on September 9 with the state agency, expressing concerns about their loved one's wounds and care....
Her care plan, updated October 16, specifically requires a mechanical aid sling and full mechanical lift for transfers....
But the plan contained no section addressing the pacemaker or directing staff how to ensure it was working properly....