Inspection Reports for
Brandywine Dresher Estates
1405 Limekiln Pike, Dresher, PA 19025, United States, PA, 19025
Back to Facility Profile17 Reports
Inspection Report — Mar 16, 2026
Complaint Investigation
Date: Mar 16, 2026
Visit Reason
The inspection was a partial, unannounced complaint and incident investigation conducted on 03/16/2026 to review compliance with regulations following complaints and incidents at Dresher Estates.
Complaint Details
The inspection was complaint and incident driven, investigating allegations of improper incident reporting, abuse, mishandling of resident belongings, and discharge violations. The report does not explicitly state substantiation status.
Findings
The inspection identified multiple deficiencies including failure to timely and accurately report incidents, breaches of resident record confidentiality, abuse and mishandling of resident belongings, inadequate medication administration, improper discharge and transfer procedures, and failure to secure doors with electronic locking systems. Plans of correction were accepted with training and ongoing audits scheduled.
Citations (10)
16c - The home failed to report an incident within 24 hours and submitted an incident report with incorrect date, time, and circumstances.
17 - Resident records confidentiality was breached when the Narcotic Count book containing personal information was left unlocked and accessible.
42b - Abuse: Resident's belongings were discarded and their former room rented to another resident before the 30-day discharge period ended, causing mental anguish.
42l - Personal Clothing: Resident's personal belongings were discarded without proper opportunity for retrieval after discharge.
102h - Toilet Paper: Toilet paper was not provided in the bathroom by the dining room at the time of inspection.
182c - Medication Administration: The home failed to observe a resident ingest medications during administration despite resident being unable to self-administer.
223b - Service Procedures: The home issued a 30-day discharge notice that did not comply with the required 30-day period and omitted required information such as discharge location and appeal rights.
228b - Discharge or Transfer: The home did not provide an actual 30-day notice period, rented the resident's apartment early, discarded belongings, and mailed notice to a former address.
228e - Discharge and Transfer: Resident's record lacked the destination of discharge and documentation supporting the discharge decision was inadequate.
233d - Electronic/Magnetic System: Doors to memory care exits C1 and C2 were not secured with electronic or magnetic locks; a gate lock was malfunctioning at inspection.
Report Facts
Residents Served: 55
Residents Served in Dementia Care Unit: 16
Current Hospice Residents: 10
Residents Age 60 or Older: 55
Residents with Mobility Need: 27
Total Daily Staff: 82
Waking Staff: 62
Refund Check Amount: Refund amounts issued to residents were redacted.
Inspection Report — Sep 11, 2025
Follow-Up
Date: Sep 11, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident review to verify the implementation of a submitted plan of correction.
Complaint Details
The visit was complaint-related and incident-related, as indicated by the inspection reason and findings involving failure to report an incident and other compliance issues.
Findings
The facility was found to have multiple deficiencies including failure to submit a required incident report, improper handling of leftover food, lack of notation for resident refusal to sign support plans, and delayed completion of admission support plans. All deficiencies had accepted plans of correction with training and ongoing monitoring implemented.
Citations (4)
Failure to submit an incident report to the Department after a resident alleged staff attack.
Unlabeled, undated, uncovered bowl of sherbet ice cream found in memory care kitchenette fridge.
No notation made regarding resident's inability to sign the support plan.
Admission support plan was not completed within the required 72 hours after admission to the secured dementia care unit.
Report Facts
Residents Served: 60
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 11
Residents Age 60 or Older: 60
Residents with Mobility Need: 26
Total Daily Staff: 86
Waking Staff: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in relation to training and monitoring corrective actions for deficiencies. | |
| Director of Nursing | Named in relation to training and monitoring corrective actions for deficiencies. |
Inspection Report — Jun 26, 2025
Monitoring
Date: Jun 26, 2025
Visit Reason
The visit was an unannounced partial inspection conducted for monitoring purposes to review the facility's compliance with regulations and the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies including incomplete criminal background checks, inadequate staff training, unsafe storage of poisonous materials, sanitary condition issues, maintenance problems with bathrooms and lighting, food safety violations, medication labeling and storage issues, incomplete medical evaluations, and incomplete preadmission screening and assessments. The facility submitted plans of correction for all deficiencies, many of which were implemented by the time of the report.
Citations (24)
Criminal background check for staff person A was incomplete at date of hire.
Direct care staff persons B and C did not receive required training in 2024 on resident needs and care for mental illness or intellectual disability.
Staff person B did not receive training in falls and accident prevention during 2024.
Unsecured poisonous materials (sandbag) accessible to residents in memory care courtyard.
Feces observed in multiple resident bathrooms; ice cream lids in freezer were smeared and not sealing properly.
Bathrooms lacked operable exhaust fans or windows for ventilation.
Non-operable lighting in stairwell exit near resident room.
Ceiling water stains in resident room.
Smoke detector hanging from ceiling in resident room; prep refrigerator out of order.
Residents lacked operable bedside lamps within reach.
Toilet paper not provided in resident bathroom.
Food contamination risk: trays of hotdogs and cabbage on serving plates inside food warmers.
Food stored unsealed: rice, pasta, and beans in pantry were opened and unsealed.
Outdated food items and unlabeled/undated frozen food found in pantry and freezer.
Emergency water supply insufficient for resident census; no 24-hour bottled water contract.
Blocked egress: dining chair placed in front of exit during meal time.
Resident missing medical evaluation within required timeframe.
Resident missing annual medical evaluation for 2025.
Pharmacy labels for resident medications did not include change of order stickers.
Medications prescribed as needed were not available in the home when required.
Blood sugar checks not completed as prescribed; medication not administered due to unavailability.
Resident preadmission screening form lacked determination that resident needs can be met by the home.
Resident initial assessment not completed within 15 days of admission.
Direct care staff person B had only 4 hours of dementia care training instead of required 6 hours in 2024.
Report Facts
Residents Served: 62
Staffing Hours - Total Daily Staff: 96
Staffing Hours - Waking Staff: 72
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 9
Residents Age 60 or Older: 62
Residents with Mobility Need: 34
Emergency Drinking Water Supply (gallons): 45
Emergency Drinking Water Required (gallons): 180
Inspection Report — Feb 28, 2024
Follow-Up
Date: Feb 28, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to verify the implementation of a previously submitted plan of correction.
Complaint Details
The visit was complaint-related and included incident investigation. The plan of correction was accepted and fully implemented.
Findings
The submitted plan of correction was found to be fully implemented with continued compliance required. Deficiencies involved privacy concerns related to video monitoring signage, medication storage procedures, and medication record accuracy, all of which were addressed with corrective actions and staff training.
Citations (3)
Privacy violation due to signage warning of video monitoring in resident living space.
Failure to have prescribed medications available in the home at the time needed.
Medication record did not accurately reflect the strength and dose of a resident's medication; family brought wrong dosage.
Report Facts
Residents Served: 80
Secured Dementia Care Unit Residents Served: 20
Hospice Residents: 11
Residents Age 60 or Older: 83
Residents with Mobility Need: 41
Total Daily Staff: 121
Waking Staff: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in corrective actions related to removal of signage and audits for privacy compliance. | |
| Assistant Wellness Director | Involved in auditing medications and contacting family regarding medication dosage issues. | |
| Regional Support Nurse | Audited residents prescribed PRN medications to verify all medications were in-house. | |
| Corporate Support Nurse | Checked remainder of resident medication to ensure proper dosages were in-house. | |
| Regional Director of Clinical Services | Conducted staff training on medication regulations. | |
| Wellness Director | Responsible for auditing PRN medications monthly and reviewing regulations at quality improvement meetings. |
Inspection Report — May 4, 2022
Date: May 4, 2022
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 90
Residents Served in Secured Dementia Care Unit: 21
Hospice Residents: 7
Residents 60 Years or Older: 90
Residents with Mobility Need: 42
Inspection Report — Apr 19, 2022
Date: Apr 19, 2022
Visit Reason
The inspection was conducted as a partial, unannounced licensing inspection due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 87
Secured Dementia Care Unit Residents Served: 22
Total Daily Staff: 127
Waking Staff: 95
Residents with Mobility Need: 40
Residents 60 Years or Older: 87
Inspection Report — Mar 28, 2022
Renewal
Date: Mar 28, 2022
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 03/28/2022 and 03/29/2022 to review compliance with licensing requirements.
Findings
The facility was found to have multiple deficiencies including issues with posting licenses and emergency procedures, medication storage and administration errors, incomplete resident documentation, and safety concerns such as unlocked poisonous materials. Plans of correction were accepted and implemented with ongoing monitoring.
Citations (24)
The home's most recent license inspection summary and a copy of 55 Pa.Code 2600 were not posted in a conspicuous and public place.
An influenza awareness poster was not posted as required by the Influenza Awareness Act.
Resident funds exceeding $200 were held without offering an interest-bearing account.
Resident 2 did not receive required assistance with toileting on multiple days.
Resident-home contracts for residents 3 and 4 were not signed by the residents.
Resident 3 and 4 records lacked signed statements acknowledging receipt of resident rights and complaint procedures.
Resident 2 was told by staff not to ask for anything after 8:00 pm, violating dignity and respect.
Staff member hired without timely criminal background check and orientation.
Ancillary staff person did not have general orientation to job functions prior to working.
First aid kit on first floor lacked a thermometer.
Hole in the wall in bedroom of room 256 reopened after previous patch.
Undated and unlabeled leftover food found in kitchenette and storage areas.
Emergency procedures were not posted in a conspicuous and public place.
Unannounced fire drills were not held in January and February 2022 due to COVID-19 outbreaks.
Medication cart was unlocked, unattended, and accessible; resident's medication was kept unlocked in room.
Blood glucose readings for resident 8 were not consistently recorded on the glucometer or blood glucose log.
Medication prescribed as needed for resident 7 was not available in the home on 3/29/22.
Medication record for resident 8 lacked dosage information for sliding scale insulin.
Resident 2 was not administered prescribed medication on 3/28/22 due to unavailability.
Resident 8 was administered 0 units of insulin despite blood glucose readings requiring dosage.
Residents 3 and 4 were not educated on their right to refuse medication if they believed there was an error.
Resident 9's initial support plan was completed after admission to the secured dementia care unit.
Poisonous materials including toothpaste and soap with warning labels were unlocked and accessible to residents not assessed as safe to use them.
Resident 5's most recent medical evaluation was not completed within the required annual timeframe.
Report Facts
Residents Served: 86
Residents Served in Secured Dementia Care Unit: 20
Hospice Residents: 2
Residents with Mobility Need: 39
Total Daily Staff: 125
Waking Staff: 94
Inspection Report — Sep 10, 2021
Date: Sep 10, 2021
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, triggered by an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 86
Residents in Secure Dementia Care Unit: 22
Hospice Residents: 5
Total Daily Staff: 122
Waking Staff: 92
Residents with Mobility Need: 36
Residents Age 60 or Older: 86
Inspection Report — Jun 22, 2021
Renewal
Date: Jun 22, 2021
Visit Reason
The document is a renewal license issued in response to the March 9, 2021 renewal application to operate Brandywine Senior Living at Dresher Estates, a Personal Care Home. The Department advises that an onsite inspection will be conducted within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It serves as a notification of license renewal and outlines the Department's intent to conduct an inspection within the next year.
Report Facts
Inspection Report — Mar 22, 2021
Renewal
Date: Mar 22, 2021
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations at Brandywine Senior Living at Dresher Estates.
Findings
The inspection identified multiple deficiencies including failure to provide quarterly financial statements to residents, insufficient CPR trained staff during overnight shifts, incomplete staff orientation and training, unsecured poisonous materials accessible to residents, hot water temperatures exceeding allowed limits, missing emergency telephone numbers, incomplete resident medical evaluations and support plans, and missing first aid kits in transport vehicles. Plans of correction were accepted and implemented for all deficiencies with ongoing monitoring.
Citations (17)
Residents are not provided a quarterly account of financial transactions.
Only one staff person certified in first aid, obstructed airway techniques and CPR was present during overnight shifts for approximately 77 residents.
Staff person A did not receive orientation on fire safety and emergency preparedness topics on their first day.
Staff person A did not complete required training on resident rights, emergency medical plan, mandatory abuse reporting, and incident reporting within 40 scheduled working hours.
Direct care staff person B received only 9.75 hours of annual training in 2019, less than the required 12 hours.
Direct care staff person B did not receive required training on medication self-administration and meeting resident needs as described in assessment tools during 2019.
Poisonous materials were unlocked and accessible to residents in the secured dementia care unit.
Hot water temperatures at multiple bathroom sinks in the Reflections unit exceeded the maximum allowed 120°F, measuring between 122.3°F and 128.3°F.
Emergency telephone numbers were not posted on or by the telephone in a resident's room.
Resident #1's annual medical evaluation was not completed timely; the most recent was for a status change.
No first aid kit was present in the Lincoln Town Car used to transport residents.
Resident #2's discontinued medication was still listed on the March 2021 medication administration record.
Resident #3 did not have a written initial assessment completed within 15 days of admission.
Resident #3's initial support plan was not completed within 30 days of admission.
Directions for operating key-locking devices on emergency exit doors in the Secure Dementia Care Unit were not conspicuously posted.
Direct care staff person B had only 1.75 hours of dementia care training during the 2019 training year, less than the required 6 hours.
Resident #3's record did not include the initial intake assessment or a support plan.
Report Facts
Residents served: 77
Residents in secured dementia care unit: 19
Hot water temperature readings: 124.3
Hot water temperature readings: 122.3
Hot water temperature readings: 128.3
Hot water temperature readings: 125.6
Staff training hours: 9.75
Staff training hours: 1.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Wellness Director | Provided CPR re-certification training and involved in compliance monitoring |
| Assistant Wellness Director | Checked apartments for poisonous materials compliance and monitored locked doors | |
| Maintenance Director | Instituted weekly water temperature checks and ensured emergency telephone numbers were posted | |
| Business Office Manager | Updated resident fund accounts and sent quarterly financial statements | |
| Chauffer | Responsible for checking first aid kit in transport vehicle weekly |
Notice — May 5, 2020
Date: May 5, 2020
Visit Reason
This document serves as a renewal notification and license issuance for Brandywine Senior Living at Dresher Estates, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is a license renewal notice with a certificate of compliance.
Inspection Report — Jan 2, 2020
Follow-Up
Date: Jan 2, 2020
Visit Reason
The visit was a follow-up review conducted by the Pennsylvania Department of Human Services on January 2, 2020, to verify that the submitted plan of correction was fully implemented following a prior incident.
Findings
The submitted plan of correction was found to be fully implemented and compliance was maintained. The report details resolution of violations related to resident treatment, prohibited procedures, and additional assessments.
Citations (3)
42c Treatment of Residents: Staff Member A was rude to Resident #1 during assistance on 11/11/19, witnessed by the resident's daughter. The staff member was suspended and later cleared to return to work with reminders on appropriate care.
2600.202 Prohibitions: Resident #2 was administered Ativan 0.5mg for agitation on 12/11/19 without proper diagnosis documentation. The Wellness Director ensured proper diagnosis audits and monthly reviews of psychotropic medications.
225c Additional Assessment: Resident #2's assessment dated 11/22/19 lacked documentation of aggression or agitation needs. The Reflections Coordinator updated the RASP and noted the resident passed away before inspection.
Report Facts
Residents Served: 90
Dementia Unit Residents Served: 23
Hospice Residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ian Yannuzzi | Executive Director | Signed plan of correction documents and named as administrator |
Inspection Report — Apr 8, 2019
Annual Inspection
Date: Apr 8, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an annual inspection of Brandywine Senior Living at Dresher Estates on April 8, 9, and 10, 2019 to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The inspection identified multiple violations related to staff training, maintenance, medication storage and administration, and documentation. Plans of correction were submitted and partially implemented as of June 25, 2019.
Citations (5)
2600.65(g) Direct care staff did not receive required annual fire safety training during 2018.
2600.65(i) The home's training records for staff members A and B lacked documentation of the length of fire drill courses.
2600.95 The home failed to follow PTAC manufacturer instructions for monthly maintenance, resulting in equipment not being clean and free of hazards.
2600.185(a) Resident #3's glucometer was not calibrated with the correct date, and Resident #2's glucometer readings did not match medication administration records on multiple dates.
2600.187(d) Resident #1 was administered Alprazolam instead of the prescribed Lorazepam from March 5 to March 9, 2019.
Report Facts
Residents Served: 79
Residents Served in Dementia Unit: 22
Current Hospice Residents: 6
Residents Age 60 or Older: 77
Residents with Mobility Need: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ian Yannuzzi | Executive Director | Signed plans of correction and referenced in report |
Inspection Report — Feb 7, 2019
Routine
Date: Feb 7, 2019
Visit Reason
The Department's Bureau of Human Services Licensing representatives conducted an inspection of Brandywine Senior Living at Dresher Estates to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
No regulatory citations were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Human Services Licensing Supervisor | Signed the inspection report letter. |
Inspection Report — Jan 10, 2019
Complaint Investigation
Date: Jan 10, 2019
Visit Reason
The inspection was conducted as a complaint investigation regarding violations of 55 Pa. Code Chapter 2600 related to Personal Care Homes.
Complaint Details
The complaint was substantiated as the facility failed to provide resident records in a timely manner. The resident had not lived at the home for 6 months and the request was made by an attorney due to a lawsuit.
Findings
The facility was found to have violated resident record availability requirements. The resident in question did not reside at the facility for 6 months and the requested records were sent to the resident's attorney after the inspection.
Citations (1)
Regulation 55 Pa.Code §2600 requires resident records to be available to the resident or designated person during normal working hours. The home did not make the records available as requested by the resident's attorney until after the inspection.
Report Facts
Number of Residents Served: 80
Number of Residents Served in Secured Dementia Care Unit: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ian Yannuzzi | Executive Director | Named in relation to the plan of correction and violation report |
Inspection Report — Oct 30, 2018
Original Licensing
Date: Oct 30, 2018
Visit Reason
The inspection was conducted as a licensing inspection for a new legal entity operating the Personal Care Home facility.
Findings
The facility was found to be in substantial compliance with regulations but had violations noted on the License Inspection Summary. A provisional license was issued based on substantial but incomplete compliance.
Citations (1)
Regulation 55 Pa.Code 2600.85(a) requires sanitary conditions to be maintained. On 10/30/2018, a strong odor of urine was detected in the hallway next to fire exit door #4.
Report Facts
Number of Residents Served in Secured Dementia Care Unit: 20
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 18
Total Daily Staff: 128
Waking Staff: 96
Number of Residents 60 Years or Older: 83
Number of Residents with Mobility Need: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ian Yannuzzi | Executive Director | Named as Administrator and Legal Entity Representative in relation to inspection and plan of correction |
| Jennie Heinberg | Licensing Inspector | Conducted inspection on 10/30/2018 |
| Shawn Parker | Licensing Inspector | Conducted inspection on 10/30/2018 |
Inspection Report — Jul 12, 2018
Complaint Investigation
Date: Jul 12, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving alleged theft by a staff person.
Complaint Details
The complaint investigation was substantiated by findings of theft by a staff person and inadequate support plan documentation.
Findings
Two violations of 55 Pa. Code Chapter 2600 were found, including theft of resident credit cards by a staff person and failure to clearly define support plan assistance for a resident managing finances.
Citations (2)
Regulation 55 Pa.Code §2600.42(b): A staff person stole two credit cards from a resident and made fraudulent charges totaling $1448.58.
Regulation 55 Pa.Code §2600.227(c): The support plan was not clearly defined regarding how the home would assist a resident in managing finances.
Report Facts
Number of Residents Served: 75
Total fraudulent charges: 1448.58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ian Yannuzzi | Executive Director | Named as facility administrator and signer of plan of correction |
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