Merrill Gardens at West Chester

The Health Services office area was unlocked and unattended, leaving resident binders and medical evaluations accessible.

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

A stuck double door in the dining room blocked egress and created a choke point.

A staff member engaged in a verbal altercation with a resident and moved their walker out of reach in a way that felt like taunting.

A resident reported being physically pushed, verbally threatened, and having medication doses withheld by a staff member.

The home failed to interview medication technicians after being made aware of an allegation involving a resident's walker being moved out of reach.

During the overnight shift, only one staff member was present who was certified in first aid, obstructed airway techniques, and CPR.

An insulin pen was found in use without an open date, violating manufacturer instructions regarding disposal after 28 days of opening.

Poisonous materials, including toothpaste, shampoo, and antifungal cream, were left unlocked, unattended, and accessible to residents.

A resident's bedside mobility device was not securely attached to the bed and could easily slide out from under the mattress.

A resident was subjected to inappropriate touching and distress when another resident entered their apartment while they were asleep.

Two direct care staff members lacked a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.

The facility's staff list failed to include employees from healthcare agencies working within the home.

Two residents who participated in the development of their support plans did not sign the documents.

The home failed to report a resident incident involving a resident being pushed to the floor within the required 24-hour timeframe.

A resident was physically pushed to the floor by another resident, resulting in a serious injury.

The facility did not have current Pennsylvania Criminal Background checks on file for two contractors installing carpet.

Staffing levels in the Memory Care unit were insufficient during overnight shifts, leaving no qualified staff available to administer medications.

A jukebox was placed in a manner that blocked the egress from the home's patio door.

The door leading from the patio to the outdoor area was not properly latched, causing the alarm to fail during a resident elopement.

A resident eloped through an improperly latched gate without triggering the alarm, and staff did not immediately notice the resident was missing.

Resident #1's most recent assessment did not include the required 2-hour overnight checks mandated by the hospice order.