The Residence at Chadds Ford.

“Aqua Fresh Extreme Clean toothpaste with poison control warning label was unlocked, unattended, and accessible to all residents in the secured dementia care unit, who have not been assessed as capable of recognizing and using poisons safely.”

“Feces was smeared on top of and on the sides of an activity table in the secured dementia care unit, and a nearby chair had smeared feces on the seat, creating unsanitary conditions.”

“Food items including a box of pasteurized homogenized liquid whole eggs with citric acid in the walk-in refrigerator and multiple boxes (Nabisco crackers, soup, coffee, tuna, muffin mix) in the freezer were stored on the floor instead of on shelving.”

“Multiple unlabeled and undated food items were found throughout the facility including chocolate sauce, cream in pastry bag, ice cream containers, cereal containers, pies, sausage patties, and a 25lb bag of rice, making it impossible to determine if they are outdated or spoiled.”

“Two residents' medical evaluations were incomplete: one did not include health status and another did not include the resident's need for body positioning and movement stimulation.”

“The home's weekly menu was not posted in the secured dementia care unit one week in advance; only specials from a limited date range were posted.”

“Residents' records did not include current medication lists. One resident's record contained outdated medications the resident no longer takes, and another resident's record was missing medications the resident is currently taking.”

“Oxycodone 5 mg prescribed to Resident 1 was not administered on 4/22/2025 at 9:00 PM due to medication not being in stock. The home did not report this medication error to the Department as required within 24 hours.”

“A bottle of Trader Joe's lemon kitchen hand soap marked "External use only" and "Keep out of reach of children" was unlocked, unattended, and accessible to residents in secure dementia care unit room 412. Not all residents have been assessed as capable of recognizing and using poisons safely.”

“A small brown uncovered trash can in the cafe area on the first floor contained food wrappers and empty soda bottles, violating the requirement that trash in kitchens and bathrooms be kept in covered receptacles.”

“One open box of pecan crunch tilapia filets and one box of McCain signature frites were stored on the floor in the walk-in freezer, violating the requirement that food be stored off the floor.”

“The home's written emergency procedures did not include contact information for each resident's designated person as required.”

“A large red stop sign was adhered to the emergency exit door to stairwell 2, obstructing the egress route which must be unobstructed.”

“A resident's most recent medical evaluation did not include medical information pertinent to diagnoses and treatment, and immunization history as required for annual medical evaluations.”

“Narcotic control record for a resident's prescribed medication contained a documentation error that was not corrected properly. This is a repeated violation of medication storage and documentation procedures.”

“Medication Administration Records for multiple residents contained pre-printed ranges of times (e.g., 7am-12pm, 8pm-12am) for medications instead of documenting actual specific administration times as required.”

“A resident prescribed a medication to take with each snack had no documented administrations from 11/12/24 through 12/9/24 and was not receiving the medication as prescribed. Another resident's prescribed medications were not administered as prescribed on 11/23/24.”

“Narcotics control log for a resident contained multiple cross outs and write-overs of administration times and dates, making documentation illegible and not in compliance with permanent record requirements.”

“The home's menu was not posted in a conspicuous place. Weekly menus must be posted one week in advance in a conspicuous and public location.”

“Medication storage and security procedures were not properly followed. Resident 1 had 29 Lorazepam syringes but the count was documented as 19. Resident 2's glucometer did not have the correct date and time, causing glucose readings to not match the Medication Administration Record, with documented readings (399 on 4/30/2024 and 385 on 4/02/2024) not matching actual meter readings.”

“Narcotic medication administration was not properly documented. Resident 3's Narcotic Medication count log for Zolpidem Tartrate 10 mg and Resident 4's Narcotic Medication count log for Temazepam 7.5 mg did not have signatures from the person administering the medications.”

“Resident 1 was discharged but did not receive a refund within 30 days of discharge as required. The home did not issue the refund until after the 30-day deadline.”

“Staff member A and Staff member B began work before their criminal background checks were completed, in violation of criminal history check requirements under the Older Adult Protective Services Act.”

“Sanitary conditions were not maintained. A nurse shared a glucometer between two residents due to missing test strips, resulting in cross-contamination. Additionally, there were transcription discrepancies between glucometer readings and resident glucose logs.”

“Emergency telephone numbers including the nearest hospital and fire department were not posted on or by a telephone in a resident room on 3/6/23 at 3:08 PM.”

“Resident 4 did not have access to a source of light that can be turned on/off at bedside on 3/6/23 at 2:15 PM. The lamp was on the dresser rather than accessible at the bedside.”

“Food was not stored in closed or sealed containers. On 3/6/23 at 3:00 PM, uncovered cheesecake was found in the Secure Dementia Care Unit refrigerator. This is a repeated violation dating back to 8/31/21.”