The first documented incident occurred February 16, 2025, when the resident opened a dining room window and climbed out into the courtyard.
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The resident required emergency department treatment for these injuries.
The resident in question had been prescribed 50 milligrams of Seroquel daily for agitation.
State inspectors cited violations under multiple sections of the Pennsylvania Code, indicating systemic issues that required immediate attention.
Resident 208's morning medications, scheduled for 7:30 AM and 9:00 AM, were not administered until after 10:20 AM.
On July 13, 2024, at 5:24 a.m., the resident complained of pain extending from his groin down to his thigh.
Inspectors documented soiled surfaces, contaminated equipment, and improper food storage that violated fundamental food safety protocols.
This cross-contamination scenario represents a fundamental breach of infection control protocols.
However, inspectors found no physician's order authorizing the transfer in the medical record.
The dietitian recommended **Arginaid, an amino acid supplement essential for wound healing**, twice daily for 30 days in December 2024.
According to inspection records, the resident first reported abdominal discomfort on July 22 at 9:45 PM and received antacid medication twice without relief.
Scores typically range from 0-28, with scores above 10 indicating significant fall risk requiring immediate interventions.