Inspection Reports for Merrill Gardens at Glen Mills

52 Baltimore Pike, Glen Mills, PA 19342, PA, 19342

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Inspection Report Follow-Up Census: 64 Capacity: 120 Deficiencies: 5 Aug 7, 2025
Visit Reason
The inspection visit was a partial, unannounced follow-up review conducted on 08/07/2025 to verify the full implementation of the submitted plan of correction for the facility.
Findings
The facility was found to have fully implemented the plan of correction addressing multiple deficiencies including record confidentiality, fire safety orientation, trash receptacle coverage, food protection, and support plan revisions. Continued compliance is required.
Deficiencies (5)
Description
A card with resident emergency contact information was posted on a magnet attached to a lamp outside the resident's room.
Staff person A did not receive orientation on fire safety and emergency preparedness topics until after the first day of work.
There was a partially full, uncovered, unattended trash can in the 2nd floor public bathroom.
Four uncovered carafes of water were stored in the 2nd floor Bistro refrigerator.
A resident's support plan was not revised to reflect exhibited aggressive behaviors towards other residents and staff.
Report Facts
License Capacity: 120 Residents Served: 64 Secured Dementia Care Unit Capacity: 20 Secured Dementia Care Unit Residents Served: 19 Hospice Current Residents: 5 Residents Age 60 or Older: 84 Residents with Mobility Need: 63 Residents with Physical Disability: 37 Total Daily Staff: 127 Waking Staff: 95
Inspection Report Follow-Up Census: 87 Capacity: 120 Deficiencies: 3 May 14, 2025
Visit Reason
The visit was a partial, unannounced inspection conducted due to an incident at the facility on 05/14/2025, followed by review of submitted plans of correction.
Findings
The inspection found deficiencies including lint accumulation in a dryer lint trap, failure to follow prescriber's medication orders for a resident, and incomplete cognitive preadmission screening documentation for a resident admitted to the secured dementia care unit. Plans of correction were submitted and accepted, with full implementation verified by 06/20/2025.
Deficiencies (3)
Description
Approximate 1/2 inch accumulation of lint in the lint trap of the dryer on floor 2.
Resident was not administered prescribed medications as ordered on a specific date.
Resident admitted to the Secure Dementia Care Unit did not have written cognitive preadmission screening completed within 72 hours prior to admission.
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License Capacity: 120 Residents Served: 87 Secured Dementia Care Unit Capacity: 20 Secured Dementia Care Unit Residents Served: 19 Current Hospice Residents: 3 Total Daily Staff: 107 Waking Staff: 80
Inspection Report Renewal Census: 71 Capacity: 120 Deficiencies: 20 Feb 25, 2025
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 02/25/2025 and 02/26/2025 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including medication administration errors, contract signature issues, training deficiencies, sanitary condition lapses, and medication storage problems. The facility submitted plans of correction which were accepted and later determined to be fully implemented.
Deficiencies (20)
Description
Resident 1 was not administered their Eye Multivitamin Tab Sodium at 5:00 pm on 2/9/2025 and the incident was not reported to the Department.
Resident-home contract for resident 2 was not signed by the resident.
Resident 2's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures.
Staff person A did not have a criminal background check completed until after hire; Staff person B did not have a criminal background check completed.
On 2/17/2025, no staff certified in CPR/first aid were present during a shift with 71 residents.
Direct care staff persons C and D did not receive required training in medication self-administration, care for residents with mental illness or intellectual disability, safe management techniques, and other required topics during training year 2024.
Direct care staff persons D and E did not receive required annual training in fire safety, emergency preparedness, resident rights, and other mandated topics during training year 2024-2025.
Resident 3 had a bedside mobility device that was not secured to the bed frame on 2/26/2025.
An unlabeled washcloth was found in a shared bathroom on 2/26/2025.
Residents 4 and 5 did not have operable lamps or sources of light at bedside.
No thermometer was present in the Activity kitchen refrigerator.
Cut lemon was found opened and unsealed in the refrigerator.
Two unlabeled, undated desserts were found in the activity refrigerator.
Two individuals were observed smoking outside the designated smoking area on 2/25/2025.
Resident 2 had medications (Advil and pain-relieving gel) not included on the medication administration record.
Resident 6 had a Wixela Inhaler without an open date, which should be discarded 30 days after opening.
Resident 1 and Resident 4 had medications in their rooms despite not being able to self-administer them.
Resident 3 was administered Zyrtec 10 mg tablet instead of prescribed chewable form from 2/5/2025 to 2/25/2025.
Medication error involving Resident 1 not being administered prescribed eye multivitamin Tab Sodium on 2/9/2025 and failure to report the error.
Resident 2 has not been educated on the right to refuse medication if a medication error is suspected.
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License Capacity: 120 Residents Served: 71 Secured Dementia Care Unit Capacity: 20 Residents Served in Dementia Unit: 16 Hospice Residents: 5 Residents Age 60 or Older: 71 Residents Diagnosed with Mental Illness: 18 Residents with Mobility Need: 48 Residents with Physical Disability: 31 Total Daily Staff: 119 Waking Staff: 89
Inspection Report Follow-Up Census: 68 Capacity: 120 Deficiencies: 12 Sep 16, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident, as part of a follow-up to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including failure to provide immediate access to requested records, unsigned resident contracts, abuse related to improper denture removal, incomplete criminal background checks, inadequate staff qualifications and training, insufficient waking hours staffing, unsecured poisonous materials, expired medications stored improperly, and incomplete resident support plans and signatures. All deficiencies had plans of correction accepted and were implemented by 01/16/2025.
Deficiencies (12)
Description
Failure to provide immediate access to the agency staff list upon request by Department agent.
Resident-home contract was not signed by the resident.
Staff person forcibly and improperly removed resident's dentures causing distress.
Criminal background check for staff person was incomplete at time of hire.
Direct care staff person lacked required high school diploma, GED, or active nurse aide registry status.
Less than 75% of required personal care service hours were provided during waking hours (49% provided).
Staff person did not receive required fire safety and emergency preparedness orientation on first day of work.
Staff person did not complete required orientation on resident rights, emergency medical plan, mandatory abuse reporting, and incident reporting within 40 scheduled work hours.
Poisonous denture cleanser was unlocked and accessible to residents not assessed as capable of safe use.
Expired medication was present in the home's medication cart.
Resident support plan did not document how assessed needs for transportation, bowel management, and memory would be met.
Resident participated in support plan development but did not sign the support plan.
Report Facts
License Capacity: 120 Residents Served: 68 Secured Dementia Care Unit Capacity: 20 Secured Dementia Care Unit Residents Served: 14 Total Daily Staff: 81 Waking Staff: 61 Direct Care Hours Required: 82 Direct Care Hours Provided During Waking Hours: 40
Employees Mentioned
NameTitleContext
Staff person ANamed in findings related to abuse, criminal background check, staff qualifications, orientation, and training deficiencies.
Business Office DirectorNamed in findings related to contract audits, criminal background check process, staff training, and orientation compliance.
General ManagerNamed in findings related to staff training, plan of correction implementation, and oversight of compliance.
Resident Care DirectorNamed in findings related to staff in-service on proper dental care and dignity/respect during resident care.
Health Service DirectorNamed in findings related to staff training, medication cart audits, and securing poisonous materials.
Regional Director of Health ServicesNamed in findings related to support plan audits, staff training, and compliance oversight.
Garden House DirectorNamed in findings related to securing poisonous materials and medication cart audits.
Inspection Report Follow-Up Census: 54 Capacity: 120 Deficiencies: 8 Jun 13, 2024
Visit Reason
The inspection was an unannounced partial review conducted due to an incident at the facility.
Findings
The report details multiple violations related to resident abuse reporting, supervision of staff involved in abuse allegations, timely incident reporting, treatment of residents with dignity and respect, privacy violations, incomplete support plans, and missing medical evaluation details. The facility submitted a plan of correction which was accepted and implemented.
Deficiencies (8)
Description
Failure to immediately report suspected abuse of a resident as required by law.
Failure to immediately suspend staff involved in alleged abuse.
Failure to report incident to the Department within 24 hours.
Staff member took and showed photos of a resident without consent.
Resident was not treated with dignity and respect; staff used inappropriate language and behavior.
Violation of resident privacy by taking unauthorized photos.
Support plan for a resident missing key information on care needs.
Medical evaluation did not include resident's need for secured dementia care unit.
Report Facts
License Capacity: 120 Residents Served: 54 Secured Dementia Care Unit Capacity: 20 Secured Dementia Care Unit Residents Served: 14 Current Hospice Residents: 6 Residents 60 Years or Older: 54 Residents with Mobility Need: 22 Residents with Physical Disability: 1
Inspection Report Renewal Census: 66 Capacity: 120 Deficiencies: 19 Feb 26, 2024
Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to review compliance and verify the submitted plan of correction for Merrill Gardens at Glen Mills.
Findings
The inspection identified multiple deficiencies including contract signatures not signed by residents, insufficient direct care staffing hours, sanitary condition issues, improper food storage, medication labeling and storage problems, incomplete medical evaluations and assessments, and missing signatures on support plans. Plans of correction were accepted and implemented by April 4, 2024.
Deficiencies (19)
Description
Resident-home contracts for Resident 1 and Resident 2 were not signed by the residents.
Insufficient direct care staff hours provided for residents with mobility needs; 74 hours provided instead of required 92 hours.
Only 73% of required personal care service hours were provided during waking hours instead of the required 75%.
Strong odor of urine and soiled incontinence pad found in Resident 3's apartment.
Food stored on the floor in multiple locations including boxes of water bottles and dry food items.
Unlabeled and undated leftover food items found in walk-in freezer.
Food items in walk-in freezer were opened and unsealed.
Lint accumulation of approximately 1 inch found in lint traps of clothes dryers in laundry rooms.
Resident 4's medical evaluation did not include immunization history.
Weekly menus for current and upcoming week were not displayed in a conspicuous and public place.
Pharmacy label for Resident 5's inhalation aerosol powder did not include prescribed dosage and instructions.
Several prescription medications were not available in the home for Residents 1, 4, 6, and 7.
Medication administration records for Residents 1, 2, and 4 did not include initials of staff who administered medications at specified times.
Resident 4’s annual assessment was late and previous assessment date was not current.
Resident support plans did not document medical, dental, vision, hearing, mental health or behavioral care services adequately for Residents 4, 5, 6, and 7.
Support plans for Residents 1, 2, 5, and 8 were not signed by the residents or assessor as required.
Resident 1's medical evaluation was not completed within 72 hours prior to admission to the Secure Dementia Care Unit (SDCU).
Resident 1 and Resident 2's written cognitive preadmission screenings were not completed within 72 hours prior to admission to the SDCU.
Resident 1's initial support plan was completed four weeks post admission to the SDCU.
Report Facts
License Capacity: 120 Residents Served: 66 Secured Dementia Care Unit Capacity: 20 Secured Dementia Care Unit Residents Served: 14 Residents with Mobility Needs: 26 Direct Care Hours Required: 92 Direct Care Hours Provided: 74 Direct Care Hours During Waking Hours: 67 Total Daily Staff: 92 Waking Staff: 69
Inspection Report Renewal Census: 55 Capacity: 120 Deficiencies: 21 Mar 22, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements on 03/22/2023, 03/23/2023, and 03/24/2023.
Findings
The facility was found to have multiple deficiencies including lack of ServSafe certification for kitchen staff, unsigned resident contracts, insufficient staffing levels, incomplete staff training, medication errors, unsafe storage of poisonous materials, unsanitary conditions, missing documentation for fire department notification, and lack of written approval for locking systems. Plans of correction were accepted and implemented by 05/17/2023.
Deficiencies (21)
Description
No staff present in the kitchen were ServSafe certified as required by the PA Department of Agriculture Food Employee Certification Act.
Resident home contracts for residents #1, #2, #3, and #4 were not signed by the residents.
Residents 1, 2, 3, and 4's records did not contain a signed statement acknowledging receipt of resident rights and complaint procedures.
Multiple cameras on the property lacked signage indicating surveillance, and staff could not verify if cameras were recording or monitored.
Staffing levels were insufficient to meet the needs of residents, particularly in the secured dementia care unit and personal care areas.
Direct care staff person A provided unsupervised ADL services without completing required Department-approved training and competency test.
Direct care staff persons B, C, and D did not meet the required minimum hours of annual training in 2022.
Direct care staff persons B, C, and D did not receive required training in medication self-administration, dementia care, infection control, safe management, and other specified topics during 2022.
Direct care staff persons B, C, and D lacked training in fire safety, emergency preparedness, resident rights, and other required annual training topics during 2022.
Multiple poisonous materials were unlocked and accessible to residents who were not assessed as capable of safely using them.
Unsanitary conditions were found including soiled mattress and urine-stained carpet in resident rooms.
Resident #3's bed handrail had a large opening presenting a hazard.
The home lacked documentation of written notification to the local fire department regarding the home's address, bedroom locations, and evacuation assistance.
Resident #1's most recent medical evaluation was not completed annually as required.
Staff person E regularly transporting residents had not completed initial new hire direct care staff training.
Medication audit revealed a discrepancy in narcotic medication count for resident #3.
Resident #4 did not receive prescribed medication for five days due to unavailability.
Staff persons C and D did not complete Department-required medication administration annual practicums.
Residents 1, 2, 3, and 4 were not educated on their right to refuse medication if they believed there was an error.
The home lacked written approval for magnetic locks used on exit doors from the secured dementia care unit.
Direct care staff persons B, C, and D did not complete required dementia care training hours in 2022.
Report Facts
License Capacity: 120 Residents Served: 55 Secured Dementia Care Unit Capacity: 20 Secured Dementia Care Unit Residents Served: 15 Hospice Current Residents: 5 Staff Total Daily: 87 Staff Waking: 65 Medication Discrepancy: 1 Unsigned Resident Contracts: 4 Unsigned Resident Statements: 4
Inspection Report Complaint Investigation Census: 44 Capacity: 120 Deficiencies: 6 Jun 27, 2022
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 06/27/2022.
Findings
The inspection identified multiple deficiencies including a medication error where a resident was given the wrong dose of Klonopin and the incident was not reported timely, incomplete fire safety orientation for a new staff member, incomplete rights and abuse training within 40 hours for a staff member, missing annual medical evaluation documentation for a resident, failure to follow prescriber's medication orders, and a staff person administering medications without completing the required medication administration course.
Complaint Details
The inspection was triggered by a complaint and included a follow-up on a Plan of Correction submission.
Deficiencies (6)
Description
Failure to report a medication error incident to the Department within 24 hours.
New staff member did not receive required fire safety orientation on the first day.
Staff member did not complete required training on resident rights, emergency medical plan, abuse reporting within 40 scheduled work hours.
Resident's most recent annual medical evaluation was not completed as required.
Resident was administered a higher dose of Klonopin than prescribed.
Staff person administered medications without completing Department-approved medication administration course.
Report Facts
License Capacity: 120 Residents Served: 44 Residents in Secured Dementia Care Unit: 17 Residents in Hospice: 5 Residents with Mobility Need: 23 Staffing Hours - Total Daily Staff: 67 Staffing Hours - Waking Staff: 50
Inspection Report Complaint Investigation Census: 42 Capacity: 120 Deficiencies: 6 Feb 16, 2022
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Findings
The inspection found multiple deficiencies including failure to report a resident incident to the Department, failure to assist a resident with medication self-administration, incorrect medication labeling, lack of safe medication storage procedures, absence of a system to document medication errors, and failure to revise a resident's support plan after medication changes and health status changes.
Complaint Details
The visit was complaint-related, triggered by a complaint received by the Department. The complaint involved failure to report a resident incident and other medication-related deficiencies. The plan of correction was accepted and fully implemented as of the inspection date.
Deficiencies (6)
Description
Failure to report a resident incident involving a fall and injury to the Department within 24 hours.
Failure to provide assistance with medication ordering for self-administration, resulting in medications not being available.
Incorrect pharmacy labeling on medications for residents, including dosage and start date errors.
Failure to implement safe storage procedures for medications, resulting in prescribed medications not being available in the home.
Lack of a system to identify and document medication errors and patterns of errors.
Failure to revise a resident's support plan to reflect medication changes and health status changes.
Report Facts
License Capacity: 120 Residents Served: 42 Residents in Secured Dementia Care Unit: 16 Staffing Hours: 58 Waking Staff: 44 Deficiency Count: 6
Inspection Report Renewal Census: 33 Capacity: 120 Deficiencies: 21 Oct 20, 2021
Visit Reason
The inspection was an unannounced full renewal inspection conducted to assess compliance with licensing regulations and verify the implementation of a previously submitted plan of correction.
Findings
Multiple deficiencies were identified including unsigned resident contracts, delayed resident refunds, missing signed statements acknowledging resident rights, lack of CPR certification among staff during a night shift, sanitary issues, missing emergency phone numbers, incomplete first aid kits, outdated food items, medication management errors including discontinued and mislabeled medications, incomplete medication records, failure to follow prescriber's orders, lack of resident education on medication refusal rights, missing directions for key-locking devices, and unsecured narcotics logs. All deficiencies had plans of correction accepted and were reported as implemented or ongoing.
Deficiencies (21)
Description
Resident-home contract for resident #3 was not signed by the administrator or designee.
Resident #4 was discharged but refund was not issued within 30 days.
Resident #2's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures.
On 10/15/21, during night shift with 33 residents present, 2 staff members were present but neither was certified in CPR or obstructed airway techniques.
Spilled sticky substance found on bottom of freezer in memory care unit.
Emergency telephone numbers for nearest hospital and fire department were missing on or by telephones in resident rooms 408 and 212.
First aid kit at 2nd floor nurses station missing eye coverings and thermometer.
First aid kit in bus used for resident transport missing antiseptic, thermometer, eye coverings, and tweezers.
Outdated food items found including potato salad, grape jelly, and rice past their use-by dates.
Discontinued medication found in medication cart for resident #1 not listed on medication administration record.
Medication labels for residents #1 and #5 did not match prescribed instructions.
OTC medications in medication carts not labeled with resident's name or room number.
Medication prescribed for resident #1 was not available in the home as required.
Resident #1's medication administration record did not include diagnosis for prescribed Aspirin.
Resident #2's medication was documented as given but was not administered; discrepancies in medication administration documentation for resident #6.
Resident #1 was not administered prescribed doses as ordered on multiple dates.
Resident #2 was not administered prescribed medication on 10/20/21 due to unavailability.
Resident #2 was not educated on the right to refuse medication if a medication error is suspected.
Directions for operating locked doors in Secure Dementia Care Unit were not conspicuously posted; posted codes did not unlock exits.
Resident #1's record did not include an incident report dated (redacted).
Narcotics log for 2nd floor medication cart was left on top of unattended medication cart and accessible to anyone.
Report Facts
License Capacity: 120 Residents Served: 33 Residents Served in Secured Dementia Care Unit: 15 Capacity of Secured Dementia Care Unit: 19 Total Daily Staff: 61 Waking Staff: 46 Residents with Mobility Need: 28
Inspection Report Follow-Up Census: 32 Capacity: 120 Deficiencies: 4 Oct 18, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 10/18/2021 to review the submitted plan of correction related to prior deficiencies, specifically regarding an incident and abuse allegations.
Findings
The facility was found to have fully implemented the submitted plan of correction. Deficiencies related to resident abuse reporting, verbal abuse by staff, criminal background checks, and staff qualifications were addressed with staff removals and in-service training. Continued compliance must be maintained.
Complaint Details
The visit was related to an incident complaint involving alleged verbal abuse of a resident by staff. The allegation was substantiated as staff verbally abused a resident and failed to report the abuse timely. The plan of correction was accepted and implemented.
Deficiencies (4)
Description
Failure to immediately report suspected resident abuse to the local area agency on aging as required.
Resident was verbally abused by staff during care and left unattended for an undetermined amount of time.
Criminal background check for a staff member was not completed timely.
Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Report Facts
License Capacity: 120 Residents Served: 32 Secured Dementia Care Unit Capacity: 20 Residents Served in Dementia Unit: 15 Total Daily Staff: 49 Waking Staff: 37 Residents with Mobility Need: 17
Notice Capacity: 120 Deficiencies: 0 Aug 31, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Merrill Gardens at Glen Mills, a Personal Care Home, following receipt of the renewal application dated July 6, 2021.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 120
Employees Mentioned
NameTitleContext
Jamie L. BuchenauerDeputy SecretarySigned the renewal notification letter and certificate of compliance.
Inspection Report Complaint Investigation Census: 27 Capacity: 120 Deficiencies: 1 Jul 16, 2021
Visit Reason
The inspection was conducted as a complaint investigation on 07/16/2021 at Merrill Gardens at Glen Mills.
Findings
A violation was found related to criminal background checks where an agency aide's background check was older than one year prior to their start date. The plan of correction was accepted and fully implemented by the follow-up dates.
Complaint Details
The visit was complaint-related as explicitly stated. The plan of correction was accepted and fully implemented with follow-up submissions on 07/27/2021, 08/02/2021, and final document submission on 08/09/2021.
Deficiencies (1)
Description
Criminal history background check on file for an agency aide was dated more than 1 year prior to the staff person's start date.
Report Facts
License Capacity: 120 Residents Served: 27 Secured Dementia Care Unit Capacity: 20 Secured Dementia Care Unit Residents Served: 12 Hospice Current Residents: 3 Staff Total Daily Staff: 47 Staff Waking Staff: 35
Document Capacity: 120 Deficiencies: 0 Apr 5, 2021
Visit Reason
The document serves to issue a new license due to the facility's recent name change from The Summit at Glen Mills to Merrill Gardens at Glen Mills.
Findings
No inspection findings are reported; the document confirms the issuance of a new license under the authority of 55 Pa. Code Chapter 2600 with unchanged expiration date.
Report Facts
Maximum capacity: 120 Secure Dementia Care Unit capacity: 20
Employees Mentioned
NameTitleContext
Jamie BuchenauerDeputy SecretarySigned the certificate of compliance and the license issuance letter
Inspection Report Monitoring Census: 17 Capacity: 120 Deficiencies: 2 Jan 28, 2021
Visit Reason
The inspection was a partial, unannounced monitoring visit to review compliance and the implementation of a submitted plan of correction.
Findings
The facility was found to have deficiencies related to medical evaluations and preadmission cognitive screenings for residents admitted to the Secure Dementia Care Unit. The submitted plan of correction was determined to be fully implemented as of the review date.
Deficiencies (2)
Description
Resident #1's medical evaluation was not completed within 60 days prior to admission to the Secure Dementia Care Unit.
Resident #1's written cognitive preadmission screening was not completed within 72 hours prior to admission to the Secure Dementia Care Unit.
Report Facts
License Capacity: 120 Residents Served: 17 Secured Dementia Care Unit Capacity: 20 Secured Dementia Care Unit Residents Served: 8 Current Hospice Residents: 1 Residents with Mobility Need: 11 Residents Age 60 or Older: 17

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