Merrill Gardens at West Chester.

“The Health Services office area was unlocked, unattended, and accessible with 3 binders containing resident information including 24-hour communication reports, task logs, and medical evaluations exposed to unauthorized access.”

“A long hose was sprawled on the ground in front of the courtyard exit, posing a tripping hazard.”

“The left side of double doors in the Main Dining Room would not open, creating a choke point if multiple residents were attempting to escape simultaneously and blocking egress.”

“A resident with dementia entered another resident's apartment and touched the resident inappropriately on the chest, body, and between legs while the resident was asleep. The incident caused the victim resident significant distress including loss of sleep and relocation from the home.”

“Two direct care staff persons (Staff A and B) do not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, failing to meet required qualifications.”

“The home's staff list does not include employees of healthcare agencies (Staff Persons B, C, D, and E from outside provider) who are working in the home caring for a resident.”

“Two residents participated in development of their support plans but did not sign the support plans as required.”

“The home did not report an incident involving one resident pushing another resident down onto the floor causing injury to the department within 24 hours as required.”

“A resident was pushed down onto the floor by another resident, causing serious injury. This incident constitutes physical abuse and neglect as residents were not adequately supervised or protected from harm.”

“Staff Person A does not have a Pennsylvania Criminal Background check through PATCH. Additionally, two contractors installing carpet were left unsupervised in a resident room without current Pennsylvania Criminal Background checks on file.”

“The Memory Care unit was staffed with only one staff person during overnight shifts (10 pm to 6 am) with a census of 17 residents. Additionally, no qualified staff were available to administer PRN medications to Personal Care residents during certain overnight periods, as the only medication-qualified staff was working alone on the Memory Care Unit.”

“Multiple direct care staff members did not meet the minimum 12 hours of annual training requirement during training year 2023: Staff person A received 4.5 hours, Staff person C received 6 hours, Staff person D received 5 hours, and Staff person E received 4.75 hours.”

“Direct care staff persons A, C, and D did not receive required training in medication self-administration and care for residents with dementia and cognitive impairments during training year 2023.”

“Staff persons A, C, and D did not receive required annual training in fire safety, emergency preparedness procedures and crisis response, resident rights, the Older Adult Protective Services Act, and falls and accident prevention during training year 2023.”