Inspection Report Summary
The most recent inspection on August 25, 2025, found three deficiencies related to record confidentiality, exterior hazards, and unobstructed egress, all of which were promptly corrected. Earlier inspections showed a pattern of deficiencies involving resident safety, medication management, staff training, and abuse incidents, with some substantiated complaints including physical abuse by staff and residents. Inspectors cited issues such as unsecured poisonous materials, incomplete support plans, insufficient staffing and training, and medication storage problems. Complaint investigations were mostly substantiated when related to abuse or incident reporting failures, though some complaint inspections found no deficiencies. The facility has addressed many prior deficiencies through accepted plans of correction, but recent findings indicate ongoing attention is needed to maintain compliance.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
183% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
79% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 74
Capacity: 94
Deficiencies: 3
Date: Aug 25, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection found three deficiencies related to record confidentiality, exterior hazards, and unobstructed egress. All deficiencies were corrected promptly with plans of correction accepted and fully implemented by the dates specified.
Deficiencies (3)
Health Services office area was unlocked and unattended with resident information accessible.
A long hose was sprawled on the ground in front of the courtyard exit posing a tripping hazard.
A stuck door blocked egress from the home’s dining room, creating a choke point.
Report Facts
License Capacity: 94
Residents Served: 74
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 4
Total Daily Staff: 112
Waking Staff: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Named in plan of correction for confidentiality deficiency and conducting in-service with care staff. | |
| Garden House Director | Named in plan of correction for confidentiality and tripping hazard deficiencies and conducting rounds. | |
| General Manager | Named in plan of correction conducting random rounds to ensure compliance. | |
| Director of Maintenance | Named in plan of correction for fixing stuck door deficiency. | |
| Executive Chef/Maintenance Director | Named in plan of correction conducting weekly checks on dining room doors. |
Inspection Report
Follow-Up
Census: 78
Capacity: 94
Deficiencies: 9
Date: Jun 12, 2025
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of the submitted plan of correction related to prior complaints and incidents at the facility.
Complaint Details
The visit was complaint-related and incident-driven, involving allegations of medication withholding and physical abuse by staff, which were substantiated by resident interviews and observations.
Findings
The submitted plan of correction was determined to be fully implemented. Several deficiencies were identified and addressed, including incident reporting, abuse prevention, resident treatment, first aid/CPR staffing, sanitary conditions, food storage, refrigerator/freezer temperature monitoring, menu posting, and medication storage.
Deficiencies (9)
Failure to interview med techs after an incident where a resident's walker was moved out of reach.
Staff withholding prescribed medication and physically abusing a resident, including pushing to the floor and verbal threats.
Staff member taunted resident by moving walker out of reach after a verbal altercation.
Only one staff person certified in first aid and CPR was present during a night shift for 78 residents.
Bathroom in resident room had strong odor of feces and visible feces and brown substances on shower bench and curtain.
Food stored on the floor in the main kitchen's food storage room.
No thermometer in the freezer of the 2nd floor activity room.
Weekly menu was not posted for the following week in memory care.
Blister pack for prescription medication had tears with pills still inside.
Report Facts
Residents Served: 78
License Capacity: 94
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 2
Residents Diagnosed with Mental Illness: 21
Residents with Mobility Need: 38
Residents Age 60 or Older: 78
Residents with Physical Disability: 1
Total Daily Staff: 116
Waking Staff: 87
Inspection Report
Monitoring
Census: 81
Capacity: 94
Deficiencies: 8
Date: Dec 5, 2024
Visit Reason
The visit was an unannounced partial inspection conducted for monitoring purposes to review compliance and verify the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies including unsecured bedside mobility devices, unlocked poisonous materials accessible to residents, improper medication storage and documentation, and incomplete support plans. The facility submitted and implemented plans of correction for all deficiencies, with ongoing audits and staff training scheduled to ensure compliance.
Deficiencies (8)
Resident has a bedside mobility device that is slid under the mattress and is not securely attached to the structure of the bed; the device slides out from under the mattress with minimal effort.
Colgate Optic White Toothpaste was unlocked, unattended, and accessible to resident; not all residents assessed capable of safely using or avoiding poisonous materials.
Head & Shoulders Clinical Strength Shampoo was unlocked, unattended, and accessible to resident; not all residents assessed capable of safely using or avoiding poisonous materials.
Baza Antifungal Cream was unlocked, unattended, and accessible to resident; not all residents assessed capable of safely using or avoiding poisonous materials.
A prescribed medication pen was found in the home marked with an open date exceeding manufacturer’s disposal recommendation of 28 days.
Medication administration was not documented in the resident's November 2024 medication administration record (MAR) for several doses of a controlled substance prescribed as needed.
Resident support plan assessment lacked description of service needs or plan for managing finances, securing and using transportation, and shopping.
Resident participated in the development of support plan but did not sign it, nor was there documentation explaining the absence of signature.
Report Facts
Residents Served: 81
License Capacity: 94
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 16
Total Daily Staff: 119
Waking Staff: 89
Inspection Report
Complaint Investigation
Census: 84
Capacity: 94
Deficiencies: 4
Date: Oct 7, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Merrill Gardens at West Chester.
Complaint Details
The visit was complaint-related and involved substantiated abuse of a resident with dementia by another resident, resulting in trauma and relocation of the victim.
Findings
The inspection found multiple deficiencies including abuse of a resident with dementia, unqualified direct care staff, incomplete staff contact lists, and unsigned support plans. The submitted plan of correction was determined to be fully implemented as of the follow-up.
Deficiencies (4)
Resident was physically abused by another resident in the secure dementia care unit, causing trauma and relocation.
Direct care staff persons A and B did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
The home's staff list did not include employees of healthcare agencies working in the home.
Residents participated in the development of support plans but did not sign them as required.
Report Facts
License Capacity: 94
Residents Served: 84
Capacity of Secure Dementia Care Unit: 23
Residents Served in Secure Dementia Care Unit: 20
Current Hospice Residents: 7
Residents with Mobility Need: 36
Residents Age 60 or Older: 84
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 82
Capacity: 94
Deficiencies: 13
Date: Aug 6, 2024
Visit Reason
The inspection was conducted as a renewal and incident review of the facility Merrill Gardens at West Chester on 08/06/2024 and 08/07/2024.
Findings
The facility was found to have multiple deficiencies including delayed incident reporting, abuse incidents, lack of criminal background checks for contractors, insufficient staffing during overnight shifts, inadequate staff training hours and topics, unsafe resident equipment, unsecured poisonous materials, routine fire drills scheduling issues, medication storage discrepancies, missing consent documentation for secured dementia care unit admission, and lack of dementia care training for staff. All deficiencies had plans of correction accepted and were implemented by December 2024.
Deficiencies (13)
Delayed reporting of an incident where a resident pushed another resident causing injury.
Resident abuse incident involving pushing causing serious injury.
Lack of Pennsylvania Criminal Background checks for contractors left alone in the facility.
Insufficient staffing in Memory Care unit overnight; no qualified staff to administer medications during certain shifts.
Direct care staff persons received less than the required 12 hours of annual training in 2023.
Direct care staff persons did not receive required training in medication self-administration and care for residents with dementia and cognitive impairments during 2023.
Direct care staff persons did not receive required training in fire safety, emergency preparedness, resident rights, Older Adult Protective Services Act, and falls prevention during 2023.
Resident had unsecured enabler bars on bed that were not properly secured or covered.
Poisonous materials (shaving cream) were unlocked and accessible to residents not assessed to safely use them.
Fire drills were routinely held during the same week and time each month, not varying days or times.
Medication storage procedures had discrepancies in prescription numbers and documentation.
Missing documentation that resident and designated person did not object to admission to secured dementia care unit.
Direct care staff working in secured dementia care unit had zero hours of dementia care training during 2023.
Report Facts
Residents served: 82
License capacity: 94
Residents served in secured dementia care unit: 17
Current residents in hospice: 5
Residents 60 years or older: 82
Residents with mobility need: 38
Residents with physical disability: 2
Total daily staff: 120
Waking staff: 90
Residents in Memory Care unit overnight shift: 17
Training hours received by staff person A: 4.5
Training hours received by staff person C: 6
Training hours received by staff person D: 5
Training hours received by staff person E: 4.75
Medication tablets in home: 60
Inspection Report
Complaint Investigation
Census: 83
Capacity: 94
Deficiencies: 0
Date: Sep 21, 2023
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 09/21/2023.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 83
License Capacity: 94
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 16
Resident Support Staff: 0
Total Daily Staff: 101
Waking Staff: 76
Inspection Report
Follow-Up
Census: 73
Capacity: 94
Deficiencies: 4
Date: Apr 24, 2023
Visit Reason
The inspection was an unannounced partial review conducted due to an incident involving a resident eloping through an improperly latched gate.
Findings
The inspection found multiple deficiencies including a resident eloping due to a faulty gate latch and alarm, blocked egress by a jukebox, incomplete medical evaluation documentation for a resident, and furniture/equipment not in good repair. Plans of correction were accepted and implemented by July 3, 2023.
Deficiencies (4)
Resident #1 exited through a gate that was improperly latched and alarm failed to sound, leading to an elopement incident.
The door leading from the patio to the outdoor area was not properly latched causing the alarm to fail to sound when a resident eloped.
A jukebox blocked egress from the home's patio door.
Medical evaluation for resident #1 did not include the resident's height and weight.
Report Facts
License Capacity: 94
Residents Served: 73
Secured Dementia Care Unit Capacity: 23
Residents Served in Secured Dementia Care Unit: 17
Hospice Current Residents: 10
Residents Age 60 or Older: 73
Residents with Mobility Need: 17
Residents with Physical Disability: 1
Total Daily Staff: 90
Waking Staff: 68
Inspection Report
Complaint Investigation
Census: 67
Capacity: 94
Deficiencies: 1
Date: Mar 13, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at Merrill Gardens at West Chester.
Complaint Details
The visit was complaint-related and incident-based. The submitted plan of correction was accepted and fully implemented.
Findings
The submitted plan of correction was fully implemented and compliance was maintained. One deficiency was noted regarding a resident's assessment not including the need for 2-hour overnight checks as ordered by hospice, which was corrected with updated support plans and monthly audits.
Deficiencies (1)
Resident #1’s most recent assessment did not include the need for 2 hour checks overnight from the hospice order.
Report Facts
License Capacity: 94
Residents Served: 67
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 9
Residents Age 60 or Older: 67
Residents with Mobility Need: 15
Residents with Physical Disability: 1
Total Daily Staff: 82
Waking Staff: 62
Inspection Report
Complaint Investigation
Census: 73
Capacity: 94
Deficiencies: 2
Date: Dec 1, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation at Merrill Gardens at West Chester.
Complaint Details
The complaint involved an accusation of sexual assault reported by resident #1 that occurred the previous evening in the home's movie theatre. The home notified the Local Area Agency on Aging by phone but failed to submit required Act 13 paperwork within 48 hours.
Findings
Two deficiencies were identified: failure to submit Act 13 paperwork within 48 hours after a resident reported a sexual assault, and failure to complete a medical evaluation within the required timeframe for a resident. Plans of correction were accepted and implemented.
Deficiencies (2)
Failure to submit Act 13 paperwork within 48 hours after a resident reported a sexual assault.
Medical evaluation for a resident was not completed within 60 days prior to admission or within 30 days after admission.
Report Facts
License Capacity: 94
Residents Served: 73
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 11
Residents Age 60 or Older: 84
Residents with Mobility Need: 40
Residents with Physical Disability: 1
Inspection Report
Original Licensing
Census: 76
Capacity: 76
Deficiencies: 9
Date: Jun 30, 2022
Visit Reason
The inspection was conducted due to a change in legal entity and as part of the initial licensing inspection for the newly licensed personal care home facility.
Findings
The facility was found to be in substantial but not complete compliance with applicable regulations. Multiple deficiencies were cited related to storage and locking of poisonous materials, sanitary conditions, food labeling, refrigerator temperatures, emergency procedure submissions, unobstructed egress, medication cart security, and electronic locking systems.
Deficiencies (9)
Unlabeled spray bottle of yellow liquid in an unlocked kitchenette area.
Poisonous materials not locked and accessible to residents in the Gardenhouse SDCU kitchenette service area.
Accumulation of wet coffee grounds and brown liquid in the bottom of an unused ice cream freezer chest.
Unlabeled and undated opened bottle of orange juice and plastic container of cookies and butter in the coffee bistro mini fridge; unlabeled frozen brown liquid in walk-in freezer.
No thermometer in the refrigerator in the bistro area.
Written emergency procedures not submitted to local emergency management agency since 5/19/2021.
Sign posted on emergency exit door considered obstructed egress due to wording and image that could cause hesitation in emergency.
Medication cart on 2nd floor unlocked, unattended, and accessible in hallway.
Door leading from Gardenhouse SDCU to courtyard unlocked; courtyard gate not locked with magnetic lock allowing unsupervised resident access.
Report Facts
License Capacity: 76
Residents Served: 76
Secured Dementia Care Unit Capacity: 23
Residents Served in Secured Dementia Care Unit: 17
Current Hospice Residents: 11
Total Daily Staff: 115
Waking Staff: 86
Residents with Mobility Need: 39
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