Glen Mills Senior Living.

“Direct care staff person A, hired on 2/4/25, began providing unsupervised ADL services without dated documentation of completing and passing the Department-approved direct care training course and competency test.”

“Tide Clear and Fresh Pods with poison control label were unlocked, unattended, and accessible in a room in the Secured Dementia Care Unit. Not all residents of the home, including a specified resident, were assessed capable of recognizing and using poisons safely.”

“On 9/3/2025 at 2:06 pm, a cleaning cart blocked egress from the top of the home's 2nd floor stairwell leading to the 1st floor.”

“Medication blister packs were torn on multiple pill slots with pills remaining in place, not stored in accordance with manufacturer's instructions for proper conditions of sanitation, temperature, moisture and light.”

“The pharmacy label for a resident's medication does not include the prescribed dosage and instructions for administration.”

“The home reported suspected rough handling of a resident but failed to report this allegation of abuse to the local area agency on aging as required by the Older Adult Protective Services Act.”

“A resident home contract was not signed by the resident as required by regulation.”

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

“The home's secured dementia care unit (SDCU) typically has only two Resident Wellness Associates scheduled for the 3:00 PM to 11:00 PM shift for 12 residents, which is inadequate given that one resident requires feeding assistance, two residents require 2-person assist for bathing and dressing, up to three residents require Hoyer lift assistance, and at least two residents need total care. Staff reported insufficient staffing to handle all duties and inconsistent availability of additional help from personal care.”

“A lamp in a resident's room had a broken light switch that was not operational, creating a potential hazard.”

“A resident was not treated with dignity and respect. Staff member responded in a nasty tone to the resident's privacy request, and later engaged in a profane verbal altercation with the resident, telling the resident to leave and continuing to yell and curse at the resident.”

“A resident did not have privacy during dressing and toileting. The resident requested the apartment door be closed for privacy, but the door remained open while the resident was naked from the waist down after using the bathroom, exposing the resident to anyone in the hallway.”

“Staff member C, hired in 2021, did not have a completed criminal background check on file at the facility.”

“The designated smoking area for staff located off the back dock in the parking lot had spent cigarettes littered on the pavement and grass. An open, uncovered household trash can filled with spent cigarettes and other trash with burn markings inside was stored next to red gasoline containers, trash and rusted paint cans. The receptacle was not fireproof. Proper safeguards must be provided to prevent fire hazards involved in smoking, including fireproof receptacles and ashtrays.”

“A laminated picture of a stop sign was hung on the emergency exit by the laundry room, obstructing the egress route. Stairways, hallways, doorways, passageways and egress routes from rooms and from the building must be unlocked and unobstructed.”

“A dirty rag and an open bottle of sealant were stored on top of the home's boiler, a heat source. Combustible and flammable materials may not be located near heat sources or hot water heaters.”

“A gas propane tank was unlocked, unattended, and accessible to residents on the patio outside of the dining room. Combustible materials shall be inaccessible to residents.”

“The fire alarm and sprinkler systems have not been functioning in full since 1/23/2025 when a sprinkler pipe burst in the foyer. On 3/5/2025 the fire panel was beeping and indicated water flow in the 1st floor mechanical room was disabled. Multiple water-based fire protection system failures were noted including dry pipe system valve failures, sprinkler head deficiencies, anti-freeze system failures, and waterflow alarm failures. The home's emergency procedures shall indicate procedures immediately implemented until fire alarms are operable.”

“Medications prescribed for residents were not available in the home at the time of inspection, including a medication prescribed for loose stools and a medication prescribed for anxiety.”

“Discontinued prescription medications were found in the home's medication cart, including tablets prescribed for one resident (discontinued on an unspecified date) and a topical medication prescribed for another resident (discontinued on an unspecified date).”

“Two medications in the medication cart had expired pharmacy labels at the time of inspection and were not stored according to manufacturer's instructions.”

“A prescribed suppository medication present in the home was not included on the resident's January 2025 medication administration record.”

“Multiple instances of prescribed medications not being administered as directed: insulin was held without documented parameters; another medication was held without documented parameters; glucose checks were not performed at prescribed times (multiple instances); and eye drops were not administered on multiple dates either because the medication was not available or with incorrect documentation that it was not due, when no such holding parameters existed.”

“Medication errors involving eye drops that were not administered (either because unavailable or falsely documented as "not due") were not reported to the resident, the resident's designated person, or the prescriber.”

“Resident #1 requires a Hoyer lift and three-person assist to transfer according to their assessment and support plan dated 12/12/2024. On 12/23/24 at 9:07 pm, the resident was transferred from chair to bed by only one staff person using the Hoyer lift, violating the required assistance level.”

“Resident #2, admitted to the Secure Dementia Care Unit with severe wandering and elopement risks, eloped from the facility on 12/22/24 at approximately 7:35 pm. The resident was discovered missing after approximately 43 minutes behind the home's dumpster at 8:18 pm, having traveled about 100 yards in cold weather without a coat. The resident had a history of multiple incidents of physical aggression and elopement attempts starting 11/7/24, indicating inadequate supervision and safety measures despite known risks.”

“Resident did not receive required assistance with toileting and bladder/bowel management during three quarantine periods in August, September, and October 2024, as indicated in their assessment and support plan.”

“Resident 1 experienced neglect during three isolation periods (August, September, October 2024) including failure to maintain sanitary conditions, irregular personal hygiene care, unsanitized medication administration, cold meals, and refusal to warm food. The home charged the family for a private room during isolation despite facility policy of not charging for private rooms during isolation, and initially refused to readmit the resident without family payment for private room.”

“Sanitary conditions were not maintained during quarantine periods for resident 1. Housekeeping did not clean the room regularly, food trays and items were not removed timely resulting in trash overflow, and the facility failed to follow infection control policy regarding daily thorough cleaning of room surfaces.”

“The memory care emergency exit fire tower on the first floor south does not have adequate lighting, with inoperable lights observed at 10:30 AM on April 23, 2024.”

“The ceiling above the second set of doors at the entrance is in disrepair with missing ceiling tiles, indicating a leaking issue observed at 9 AM on April 23, 2024.”

“Resident #4 and Resident #5 do not have access to a source of light that can be turned on/off at bedside. This is a repeat violation from August 23, 2023.”

“Staff member D's training record does not include the number of hours trained on the training transcript.”

“The home's staff training plan does not include the name, position and duties of each direct care staff person, and does not include the dates, times and locations of scheduled training for each staff person for the upcoming year.”

“Fire drill records for October 31, 2022, December 22, 2022, February 28, 2023, and December 26, 2023 do not include the location, the number of residents in the home, and the amount of time to evacuate. This is a repeat violation from September 28, 2022.”

“The home routinely holds fire drills at the last week of the month (December 26, 2023, January 31, 2024, February 27, 2024, and March 29, 2024), which violates the requirement to conduct drills on different days of the week and at different times.”

“The designated smoking area does not have fireproof receptacles for safe cigarette disposal, consists of only a wooden bench, chair, and table, and lacks a sign indicating it is a designated smoking area.”

“Resident #4, who is prescribed a mechanical soft diet, was served a cheesesteak on a roll and tater tot potatoes, which do not meet the prescribed dietary needs.”

“Multiple violations of 55 Pa Code Chapter 2600 resulted in revocation of the certificate of compliance and issuance of a FIRST PROVISIONAL license.”

“Multiple violations of 55 Pa Code Chapter 2600 resulted in revocation of the certificate of compliance and issuance of a FIRST PROVISIONAL license.”

“Staff member D's training record does not include the number of hours trained on the training transcript.”

“The home's staff training plan does not include the name, position and duties of each direct care staff person, and does not include the dates, times and locations of scheduled training for each staff person for the upcoming year.”

“The memory care emergency exit fire tower on the first floor south does not have adequate lighting, with inoperable lights observed at 10:30 AM on April 23, 2024.”

“The ceiling above the second set of doors at the entrance is in disrepair with missing ceiling tiles, indicating a leaking issue observed at 9 AM on April 23, 2024.”

“Resident #4 and Resident #5 do not have access to a source of light that can be turned on/off at bedside. This is a repeat violation from August 23, 2023.”

“Fire drill records for October 31, 2022, December 22, 2022, February 28, 2023, and December 26, 2023 do not include the location, the number of residents in the home, and the amount of time to evacuate. This is a repeat violation from September 28, 2022.”

“The home routinely holds fire drills at the last week of the month (December 26, 2023, January 31, 2024, February 27, 2024, and March 29, 2024), which violates the requirement to conduct drills on different days of the week and at different times.”

“The designated smoking area does not have fireproof receptacles for safe cigarette disposal, consists of only a wooden bench, chair, and table, and lacks a sign indicating it is a designated smoking area.”

“Resident #4, who is prescribed a mechanical soft diet, was served a cheesesteak on a roll and tater tot potatoes, which do not meet the prescribed dietary needs.”

“The home failed to submit incident reports to the Department within 24 hours for two reportable incidents: an unwitnessed fall requiring hospital admission and a missed medication administration.”

“The home did not have a copy of the hospice license for Accent Care Hospice, which was providing services to a resident.”

“A resident did not receive required repositioning services as specified in their assessment and support plan due to lack of available direct care staffing.”

“With 46 residents present, no staff persons certified in first aid, obstructed airway techniques, and CPR were present in the home during a specific time period.”

“Direct care staff person A received only 8.75 hours of annual training in training year 2022, failing to meet the required 12 hours minimum.”

“Staff persons A and B did not receive required training in emergency preparedness procedures and recognition and response to crises and emergency situations during training year January 2022 to December 2022.”

“A bathroom in a resident bedroom had a stain on the ceiling that appeared to be mildew or mold from a water leak, constituting unsanitary conditions.”

“A bathroom in a resident room lacked both an operable window and a functioning exhaust fan for ventilation, violating ventilation requirements.”

“The Prep Refrigerator was out of order, constituting equipment in poor repair.”

“Prescription medications and syringes were found unlocked, unattended, and accessible in a resident room.”

“The home failed to report two incidents to the Department within 24 hours as required. On 10/13/23, resident #1 had an unwitnessed fall and was hospitalized, but the home did not report until 10/15/23. On 11/02/23, resident #2 was sent to the hospital but the home did not report this incident to the Department.”

“Resident #1's medical evaluation (DME) was incomplete. Section (4) Special Health or Dietary Needs was blank and section (8) Body Positioning/Movement had a box checked for 'Listed Below:' with no additional information provided.”

“Resident #1's assessment was not completed in accordance with annual assessment requirements. The previous assessment was completed in 2021 and the current assessment in 2023, with an apparent gap in the required annual assessment schedule.”

“Resident #1's mobility assessment was inconsistent between documents. The assessment listed the resident's mobility need as Moderate (Immobile) while the DME listed it as Total (Immobile).”

“Multiple residents' support plans (RASP) had discrepancies with their DME documentation regarding medical needs. Resident #1's RASP and DME conflicted on mobility status, dietary needs, and transfer assistance. Resident #2's RASP and DME conflicted on body positioning/movement needs and transfer assistance, and Resident #2's RASP lacked documented physical and psychological diagnoses.”

“There were no mattresses in bedrooms 104 and 109.”

“There were no chairs in bedroom 109.”

“There is no bedside table or shelf in bedroom #109.”

“The distance between fossil fuel burning equipment and the door leading out of the enclosed space was less than 15 feet, and a carbon monoxide detector was not installed outside the door.”

“Bathrooms in bedrooms #115, 117, and 120 do not have an operable window or ventilation fan. The fan is inoperable and there is no ventilation in the bathroom.”

“A patio was available for residents, families, and visitors, but there was no furniture available to accommodate them.”

“There were no pillows, bed linens, or blankets that were clean and in good repair in bedrooms #104 and 109.”

“There was no storage area for clothing that included a chest of drawers or wardrobe space accessible to the resident in bedroom #109.”

“There was no access to a source of light that could be turned on or off at the bedside in bedroom #109.”

“There was no toilet paper for the toilet in the bathroom for bedrooms #104 and 109.”

“There were unlabeled and undated food items including 8 packs of jam, 1 pack of meat, two bags of carrots, one chocolate cake, one pound cake, and at least 5 bags of bagels.”