The Devon Senior Living.

“A resident who is wheelchair dependent and unable to transfer independently was found confined to their locked room without the ability to exit independently and without staff having immediate access to provide assistance in an emergency situation. The resident's door was locked and could not be opened without a key, violating the requirement that residents not be neglected or confined.”

“Poisonous materials including Zinc Oxide paste, Zoltaren (pain relief cream), and mouthwash—all bearing labels indicating risk of poisoning—were found unlocked, unattended, and accessible to residents in various rooms. Not all residents of the home have been assessed as capable of recognizing and using poisons safely.”

“A resident room door in the Secured Dementia Care Unit is equipped with a key-locking device that can only be unlocked from the hall with a key. Not all staff on the unit have a key to the door, preventing immediate egress. The home does not have written approval or a variance from the Department of Labor and Industry, Department of Health, or local building authority for use of such a lock.”

“Weekly menus for the week were not posted in the home in a conspicuous and public place. The menus posted were from December 2025, not current menus prepared one week in advance.”

“Medications were found in residents' rooms for which the residents do not have current orders. Only current prescriptions, OTC, sample and CAM medications for individuals living in the home may be kept in the home.”

“Staff member B verbally abused residents by shouting at them, yelling at a sick resident for asking for help, and making residents afraid to request assistance. Multiple residents and staff reported witnessing verbal abuse and intimidating behavior.”

“Staff member B disrespected residents by turning off lights and televisions against residents' wishes, taking remote controls, and telling residents to go to bed without regard for their preferences or dignity.”

“The home could not provide verification that a new staff member received required first-day fire safety and emergency preparedness orientation, including evacuation procedures, staff duties during emergencies, designated meeting places, smoking safety, fire extinguisher use, smoke detectors and fire alarms, and emergency notification procedures.”

“An unlocked housekeeping cart containing poisonous cleaning materials (Ecolab cleaners and Clorox Healthcare Hydrogen Peroxide Disinfectant) was left unattended in the memory care unit, accessible to residents who had not been assessed as capable of safely using or avoiding poisonous materials.”

“An as-needed medication prescribed for a resident was not available in the home. The facility failed to implement proper procedures for safe storage, access, security, distribution and use of medications by trained staff.”

“An as-needed medication prescribed for a resident was not available in the home. The facility failed to implement proper procedures for safe storage, access, security, distribution and use of medications by trained staff.”

“A resident was not secured with a seatbelt while being transported in a vehicle by staff. During an abrupt stop, the resident was ejected from their wheelchair, striking their head and sustaining injuries including a skin tear, abrasion, and tibial fracture.”

“A resident was not secured with a seatbelt while being transported in a vehicle by staff. During an abrupt stop, the resident was ejected from their wheelchair, striking their head and sustaining injuries including a skin tear, abrasion, and tibial fracture.”

“Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. This was a repeat violation from 8/27/24.”

“During transportation, a resident was not secured with a seatbelt while the vehicle was in motion, violating requirements for occupants to be in appropriate safety restraints at all times.”

“A resident discharged from the hospital with a significant change in condition did not receive an updated assessment until 9/4/2025, exceeding the 5-day requirement for assessments following significant changes. This was a repeat violation from 8/27/24.”

“A resident and assessor did not sign and date the support plan after the resident participated in its development.”

“Resident records and medication information were left unlocked, unattended, and accessible at the nurses' station and on the medication cart, violating confidentiality requirements.”

“A resident-home contract was not signed by the resident, in violation of contract signature requirements. This was a repeat violation.”

“The home does not have an established and implemented quality management plan.”

“Direct care staff persons B and C did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. This was a repeat violation.”

“Staff persons E and F did not receive required first-day fire safety and emergency preparedness orientation, including evacuation procedures, staff duties during emergencies, designated meeting places, smoking safety procedures, fire extinguisher use, smoke detectors and fire alarms, and emergency notification procedures. This was a repeat violation.”

“The facility's copy of 55 Pa Code Chapter 2600 was not posted in a conspicuous and public place in the home.”

“The facility did not have a required influenza poster posted in a public place year-round as required by the Influenza Awareness Act (HB 1785).”

“A staff member's criminal background check was not obtained and placed in their employee file prior to their hire date, in violation of requirements under the Older Adult Protective Services Act. This was a repeat violation.”

“The facility failed to provide sufficient direct care staffing hours. On two dates reviewed, the facility was required to provide 94 hours of direct care service but only provided 74 hours and 77.5 hours respectively.”

“A staff person completed their 40th scheduled work hour but had not received required orientation training on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents and conditions.”

“The facility's copy of 55 Pa Code Chapter 2600 was not posted in a conspicuous and public place in the home.”

“The facility did not have a required influenza poster posted in a public place year-round as required by the Influenza Awareness Act (HB 1785).”

“A staff member's criminal background check was not obtained and placed in their employee file prior to their hire date, in violation of requirements under the Older Adult Protective Services Act. This was a repeat violation.”

“The facility failed to provide sufficient direct care staffing hours. On two dates reviewed, the facility was required to provide 94 hours of direct care service but only provided 74 hours and 77.5 hours respectively.”

“A staff person completed their 40th scheduled work hour but had not received required orientation training on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents and conditions.”

“The home failed to submit an incident report to the Department within 24 hours when a resident was taken to the hospital and received six sutures for a laceration to the left ankle.”

“A resident requiring assistance with ambulation, personal hygiene, and transferring suffered neglect when staff person A did not follow the resident's support plan requiring use of walkers first for transfers and two-person assistance if resident cannot stand. During an improper transfer, the resident's foot was caught under a wheelchair, causing a laceration requiring six sutures.”

“The home did not have a Pennsylvania State Police criminal background check on file for staff person A at the time of inspection.”

“Direct care staff person C does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. The home obtained a credential evaluation report for overseas education but never applied to the Department for a waiver.”

“Staff persons D and E were not included on the facility's current staff list of names, addresses, and telephone numbers.”

“A resident-home contract was not signed by the resident. This was a repeat violation from 02/16/24.”

“A resident-home contract was not signed by the resident. This was a repeat violation from 02/16/24.”

“A resident's record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures.”

“Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.”

“Staff person B completed their 40th scheduled work hour in June 2024 but did not complete training in reporting of reportable incidents and conditions. Staff person C completed their 40th scheduled work hour in May 2024 but did not complete training in reporting of reportable incidents and conditions.”

“Direct care staff person A received only 11.50 hours of annual training in training year 2023, which is below the required 12 hours of annual training relating to their job duties.”

“Staff person A 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 training year 2023. Staff person D 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 training year 2023.”

“A resident's record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures.”

“Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.”

“Staff person B completed their 40th scheduled work hour in June 2024 but did not complete training in reporting of reportable incidents and conditions. Staff person C completed their 40th scheduled work hour in May 2024 but did not complete training in reporting of reportable incidents and conditions.”

“Direct care staff person A received only 11.50 hours of annual training in training year 2023, which is below the required 12 hours of annual training relating to their job duties.”

“Staff person A 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 training year 2023. Staff person D 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 training year 2023.”

“The home's record of direct care staff training does not include the length of each course for staff persons D and E's completed modules.”

“The home's procedures for physical site accommodations and equipment necessary to meet the health and safety needs of a resident with a disability were not described in the inspection report.”

“The home's record of direct care staff training does not include the length of each course for staff persons D and E's completed modules.”

“The home's procedures for physical site accommodations and equipment necessary to meet the health and safety needs of a resident with a disability were not described in the inspection report.”

“The portable smoke detector in the 1st floor visitor's bathroom did not have an operable battery installed.”

“Direct care staff person working in the Secure Dementia Care Unit had only 1 hour of training in dementia care during the 2023 training year, falling short of the required 6 hours of annual dementia-specific training.”

“The resident-home contract for a resident was not signed by the resident as required.”

“The resident-home contract for a resident was not signed by the resident as required.”

“Following a ceiling collapse and flooding incident in which a resident fell and sustained a head injury with neck pain, the home failed to secure medical care or hospital evaluation for the affected residents, despite the traumatic nature of the event.”

“Following a ceiling collapse and flooding incident in which a resident fell and sustained a head injury with neck pain, the home failed to secure medical care or hospital evaluation for the affected residents, despite the traumatic nature of the event.”

“Resident medical evaluation did not include medical information pertinent to diagnosis and treatment in case of emergency, medication regimen, contraindicated medications, medication side effects, and body positioning and movement stimulation for residents, if appropriate.”

“Resident record does not include race, height, weight, color of hair, color of eyes, or a record of incident reports for the individual resident.”

“Resident #2's Pen medication was found in the medication cart without an 'opened on' date listed. Per manufacturer's instructions, the medication must be used within 42 days of opening and unused portion must be discarded 28 days after first opening.”

“A narcotic medication prescribed for individual #1 was found in the home's medication cart; however, the medication was discontinued on 04/05/23 and has not been destroyed according to the home policy or in a safe manner according to DEP and Federal and State regulations.”

“Resident #2's glucometer was not calibrated to the correct date and time. This was a repeat violation from 11/30/22. The glucometer was determined to be malfunctioning and unable to have its date and time set.”

“Resident #2's Pen medication was found in the medication cart without an 'opened on' date listed. Per manufacturer's instructions, the medication must be used within 42 days of opening and unused portion must be discarded 28 days after first opening.”

“A narcotic medication prescribed for individual #1 was found in the home's medication cart; however, the medication was discontinued on 04/05/23 and has not been destroyed according to the home policy or in a safe manner according to DEP and Federal and State regulations.”

“Resident #2's glucometer was not calibrated to the correct date and time. This was a repeat violation from 11/30/22. The glucometer was determined to be malfunctioning and unable to have its date and time set.”

“Resident #3 and Resident #4 were not administered their medications at the prescribed times. Residents were asleep during medication pass and staff did not wake them to administer medications as prescribed.”

“Resident #5's assessment and support plan does not include documented dietary needs. The resident has a doctor's order for mechanical soft diet that was not reflected in the support plan.”

“Resident #1 was admitted to the Secure Dementia Care Unit on 5/22. The resident's medical evaluation completed on 5/22 does not indicate a need for the resident to be served in a secured dementia care unit.”

“Resident #1 was admitted to the Secure Dementia Care Unit on 5/22 and Resident #6 was admitted to the SDCU on 5/23. The home has no documentation that the residents and their designated persons have not objected to the admissions.”

“Resident #6 was admitted to the Secure Dementia Care Unit on 5/23; however, the resident's initial support plan was completed on 5/23, failing to meet the 72-hour requirement prior to or at admission.”

“Resident #3 and Resident #4 were not administered their medications at the prescribed times. Residents were asleep during medication pass and staff did not wake them to administer medications as prescribed.”

“Resident #5's assessment and support plan does not include documented dietary needs. The resident has a doctor's order for mechanical soft diet that was not reflected in the support plan.”

“Resident #1 was admitted to the Secure Dementia Care Unit on 5/22. The resident's medical evaluation completed on 5/22 does not indicate a need for the resident to be served in a secured dementia care unit.”

“Resident #1 was admitted to the Secure Dementia Care Unit on 5/22 and Resident #6 was admitted to the SDCU on 5/23. The home has no documentation that the residents and their designated persons have not objected to the admissions.”

“Resident #6 was admitted to the Secure Dementia Care Unit on 5/23; however, the resident's initial support plan was completed on 5/23, failing to meet the 72-hour requirement prior to or at admission.”