Inspection Reports for
Brandywine Haverford Estates
731 Old Buck Ln, Haverford, PA 19041, United States, PA, 19041
Back to Facility Profile21 Reports
Inspection Report — Mar 5, 2026
Complaint Investigation
Date: Mar 5, 2026
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance and verify the submitted plan of correction.
Complaint Details
The inspection was complaint-related and incident-driven, involving substantiated violations including staff abuse, failure to report incidents, and resident treatment issues.
Findings
Multiple deficiencies were identified including failure to report an incident timely, resident treatment issues, incomplete staff training, maintenance hazards, smoking policy violations, and incomplete resident support plans. The submitted plan of correction was accepted and fully implemented.
Citations (7)
16c - Written Incident Report: The home failed to report an incident involving staff overhearing inappropriate comments about a resident within 24 hours as required.
42c - Treatment of Residents: Staff called a resident a derogatory name after the resident touched the staff member, violating dignity and respect requirements.
65b - Rights/Abuse 40 Hours: Staff member C did not complete required training on emergency medical plan and reporting of incidents after 40 scheduled work hours.
88a - Surfaces: The drain cover in the first floor men's public restroom was unsecured, creating a tripping hazard.
95 - Furniture and Equipment: A dining room chair had a left front leg not securely attached, causing it to buckle when sat upon.
144d - Smoking Outside: A resident repeatedly smoked in their room, which is not the designated smoking area, violating facility policy.
227d - Support Plan Medical/Dental: The resident's support plan did not document how identified personal care needs would be met.
Report Facts
Residents Served: 85
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 3
Inspection Report — Oct 3, 2025
Follow-Up
Date: Oct 3, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was found to be fully implemented. Multiple deficiencies related to incident reporting, food storage, preadmission screening, resident assessments, support plans, and standardized forms were corrected with re-education and audits in place to ensure sustained compliance.
Citations (7)
2600.16c The home failed to report an incident to the Department within 24 hours as required.
2600.103d Food was stored on the floor in the food pantry, violating storage requirements.
2600.224a The resident's preadmission screening form was completed after admission, not within 30 days prior.
2600.225c Resident assessment did not include mental health needs despite awareness of the condition.
2600.227d Resident support plan did not document how mobility device needs would be met.
2600.227g Resident participated in support plan development but did not sign the plan.
2600.251c Resident medical evaluation was not completed on the Department’s current standardized form.
Report Facts
Residents Served: 78
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 1
Residents Diagnosed with Mental Illness: 21
Residents Diagnosed with Intellectual Disability: 4
Residents with Mobility Need: 45
Residents with Physical Disability: 8
Residents Age 60 or Older: 78
Inspection Report — Jun 18, 2024
Complaint Investigation
Date: Jun 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Complaint Details
The visit was complaint-related, triggered by a complaint. The report does not explicitly state substantiation status.
Findings
The inspection found multiple deficiencies including failure to report medication incidents timely, breaches of resident record confidentiality, failure to follow prescriber's medication orders, failure to report medication errors to the prescriber, and failure to provide resident records timely to the designated person. Plans of correction were accepted and implemented by July 19, 2024.
Citations (5)
Failure to report medication incidents to the Department within 24 hours as required.
Breach of resident record confidentiality by having multiple residents' private medical information found in a resident's belongings.
Failure to follow prescriber's orders for medication administration, including missed and partial doses.
Failure to immediately report medication errors to the resident, designated person, and prescriber.
Failure to provide resident records timely to the resident's designated person upon request.
Report Facts
Residents Served: 62
Secured Dementia Care Unit Residents Served: 23
Residents Age 60 or Older: 61
Residents with Mobility Need: 40
Inspection Report — Apr 4, 2024
Complaint Investigation
Date: Apr 4, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Brandywine Living at Haverford Estates on 04/04/2024.
Complaint Details
The complaint involved alleged physical abuse by Staff Person A and neglect by Staff Person B. The abuse was substantiated with evidence of bruising and resident report. Immediate suspension and termination of Staff Person A followed, along with staff training and policy reinforcement.
Findings
The investigation found that Staff Person A physically abused a resident by forcefully grabbing and pushing them, causing bruising. Staff Person B refused the resident's request for their cell phone. The facility took immediate corrective actions including suspension and termination of Staff Person A, staff training on resident rights and abuse prevention, and ongoing compliance monitoring.
Citations (1)
Staff Person A forcefully grabbed and pushed a resident causing bruising and left the resident in a room with lights off. Staff Person B refused resident's request for cell phone access.
Report Facts
Residents Served: 62
Residents Served in Dementia Unit: 23
Staffing Hours - Total Daily Staff: 102
Staffing Hours - Waking Staff: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emmanuel Afia | Completed RELIAS training on Resident Rights, Preventing, Recognizing, and Reporting Abuse, and Effective Communication |
Inspection Report — Jan 8, 2024
Follow-Up
Date: Jan 8, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 01/08/2024 to review the submitted plan of correction related to an incident.
Findings
The facility was found to have multiple deficiencies including failure to report incidents timely, direct care staff lacking required qualifications and training, incomplete resident medication records, and incomplete resident assessments and support plans. The submitted plan of correction was determined to be fully implemented as of 04/05/2024.
Citations (8)
Incidents involving residents were not reported to the Department within required timeframes.
Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Direct care staff persons B and C did not receive required annual training on medication self-administration, resident needs, dementia care, infection control, personal care, safe management, and care for residents with mental illness or intellectual disability.
Resident medication record did not include a current list of prescription, CAM and OTC medications for a resident self-administering medication.
Resident initial assessment did not include evaluation of behavioral or cognitive needs such as orientation, irritability, judgment, agitation, aggression, and memory.
Resident initial support plan did not indicate plans for behavioral or cognitive needs including orientation, irritability, judgment, agitation, and memory.
Resident support plan did not document how medical, dental, vision, hearing, mental health or other behavioral care services needs would be met.
Support plans were not signed by the assessor despite resident participation.
Report Facts
Residents Served: 61
Memory Care Unit Residents Served: 21
Hospice Residents: 7
Residents 60 Years or Older: 60
Residents with Mental Illness: 1
Residents with Mobility Need: 40
Total Daily Staff: 101
Waking Staff: 76
Inspection Report — Oct 11, 2023
Complaint Investigation
Date: Oct 11, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that a resident was pushed by a family member visiting another resident, which was not properly reported by staff.
Complaint Details
The complaint involved an incident where Resident 1 was pushed by a family member visiting Resident 2. The incident was observed by staff but was not reported to the appropriate agencies in a timely manner. The complaint was substantiated and led to staff retraining, changes in reporting protocols, and banning the visitor from the community.
Findings
The investigation found that a resident was pushed by a visitor, the incident was observed by staff but not reported to the appropriate agencies. Staff training and new reporting protocols were implemented to prevent recurrence. The visitor was banned from the community. Additional deficiencies related to record keeping and resident treatment were also identified and addressed.
Citations (5)
Failure to immediately report suspected abuse of a resident to the local area agency on aging.
Failure to report the incident or condition to the Department’s personal care home regional office or complaint hotline within 24 hours.
Resident was physically abused by a family member visiting another resident.
Resident was treated without dignity and respect when a visitor screamed at the resident.
Use of correction fluid on a resident’s record entry.
Report Facts
Residents Served: 64
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 2
Total Daily Staff: 98
Waking Staff: 74
Inspection Report — Aug 30, 2023
Renewal
Date: Aug 30, 2023
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 08/30/2023 to review compliance with licensing regulations.
Findings
The inspection identified several deficiencies including improper treatment of residents by staff, incorrect ombudsman contact information posted, furniture and equipment not in good repair, lint accumulation in dryer vents, unlabeled OTC medications, and delayed support plan signatures. All deficiencies had plans of correction accepted and were implemented by 12/04/2023.
Citations (6)
Staff referred to a resident by room number, not treating the resident with dignity and respect.
Ombudsman name was incorrect on the posted telephone number board.
Alarm system device on the door was not in good repair, creating an unsecured entrance; mailbox lock was broken.
Accumulation of lint in the lint cavity of the dryer, posing a fire hazard.
A bottle of OTC medication belonging to a resident was not labeled with the resident's name.
Resident participated in support plan development but did not sign the plan within the required timeframe.
Report Facts
Total Daily Staff: 97
Waking Staff: 73
Residents Served: 64
Residents in Secured Dementia Care Unit: 22
Current Hospice Residents: 2
Residents 60 Years or Older: 64
Residents with Mobility Need: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Corrected staff behavior, provided training, and monitored compliance for multiple deficiencies | |
| Maintenance Director | Repaired door and mailbox lock, removed lint, and monitored equipment compliance | |
| Wellness Director | Labeled OTC medication and conducted cart audits | |
| Assistant Wellness Director | Assisted with OTC medication labeling and audits |
Inspection Report — Feb 1, 2023
Follow-Up
Date: Feb 1, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to medication administration records and support plan documentation. Specific deficiencies involved missing diagnosis or purpose for medication and missing staff initials on medication administration records, as well as incomplete dietary needs documentation in a resident's support plan.
Citations (3)
Resident 1's medication administration record does not indicate the diagnosis or purpose for the medication.
Resident 1's January 2023 medication administration record does not include the initials of the staff person who administered medications on a specific date and time.
The assessment for Resident 1 does not indicate the need for a diet with low cholesterol and no added sodium or how this need will be met.
Report Facts
Residents Served: 69
Secured Dementia Care Unit Residents Served: 19
Current Hospice Residents: 3
Residents Age 60 or Older: 69
Residents with Mental Illness: 1
Residents with Mobility Need: 43
Inspection Report — Sep 7, 2022
Follow-Up
Date: Sep 7, 2022
Visit Reason
The inspection visit on 09/07/2022 was a partial, unannounced follow-up to review the implementation of a previously submitted plan of correction related to an incident involving resident elopement.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing the elopement of Resident #1 from the secured dementia care unit. The plan included staff retraining, increased staffing, installation of cameras, use of two-way radios, and enhanced monitoring protocols. Continued compliance and ongoing monitoring were emphasized.
Citations (4)
Resident #1 eloped through a stairwell emergency exit door that was a delayed release door with audible and visual alarms. Staff were unaware the door could release and did not adequately monitor the resident, who was missing for approximately 45 minutes before being found unharmed.
The home's elopement drills were conducted annually instead of monthly as required by policy.
The facility did not employ an elopement monitoring system for Resident #1 despite the resident being at risk.
Staffing levels during the incident were insufficient, with only two staff members assigned to 12 residents in the secured dementia care unit, and no additional staff to assist during two-person transfers.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 24
Hospice Residents: 3
Staffing - Total Daily Staff: 115
Staffing - Waking Staff: 86
Residents with Mobility Need: 45
Residents 60 Years or Older: 70
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 0
Staff Assigned to SDCU: 2
Resident #1 Absence Duration: 45
Temperature: 80
Staffing Plan: 21
Licensed Nurses Planned: 5
Additional Staff Planned: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Signed the letter confirming plan of correction implementation |
Inspection Report — May 3, 2022
Renewal
Date: May 3, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection found deficiencies related to direct care staff qualifications, incomplete first aid kits, and medication storage procedures. The facility submitted a plan of correction which was determined to be fully implemented.
Citations (3)
Direct care staff person does not have a US high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
The first aid kit in the wellness office does not include adhesive bandages, gauze pads, a thermometer, scissors, breathing shield or eye coverings.
Resident #1 was prescribed medication as needed, but on 5/4/22, the medication was not available in the home.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 3
Resident Mobility Need: 45
Total Daily Staff: 115
Waking Staff: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ian Monteith | Administrator | Named as the facility administrator. |
Inspection Report — Mar 14, 2022
Follow-Up
Date: Mar 14, 2022
Visit Reason
The inspection visit on 03/14/2022 was a partial, unannounced follow-up to review the submitted plan of correction related to a previous incident.
Findings
The submitted plan of correction was determined to be fully implemented. The deficiency involved a resident not signing their support plan and the facility failing to document the resident's inability to sign. The facility marked the appropriate box indicating the resident was unable to sign and implemented care plan audits to ensure compliance.
Citations (1)
Resident did not sign the support plan and the home did not make a notation regarding the resident's inability to sign.
Report Facts
Residents Served: 68
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 4
Total Daily Staff: 114
Waking Staff: 86
Residents with Mobility Need: 46
Inspection Report — Oct 26, 2021
Complaint Investigation
Date: Oct 26, 2021
Visit Reason
The inspection was conducted due to a complaint regarding the facility's handling of resident refunds following deaths.
Complaint Details
The visit was complaint-related concerning delayed refunds after resident deaths. Specific violations involved refunds not issued timely for three residents.
Findings
The facility failed to issue timely refunds to the estates of deceased residents as required by regulations. A plan of correction was accepted to ensure refunds are processed promptly and documented properly.
Citations (1)
Failure to issue refunds to the estates of deceased residents within the required timeframe.
Report Facts
Residents Served: 62
Residents in Secured Dementia Care Unit: 20
Hospice Residents: 8
Inspection Report — Jun 16, 2021
Follow-Up
Date: Jun 16, 2021
Visit Reason
The inspection was a full, unannounced review conducted on 06/16/2021 and 06/17/2021 to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including unlocked poisonous materials accessible to residents, uncovered trash dumpsters, disrepair of outdoor surfaces, unlabeled over-the-counter medications, improperly calibrated glucometers, missing prescribed medications, incomplete resident assessments, and unsigned support plans. The submitted plan of correction was determined to be fully implemented.
Citations (8)
Unlocked and accessible poisonous materials (Listerine Mouthwash) in resident #1's bathroom in the Secure Dementia Care Unit.
Trash outside the home was kept in uncovered dumpsters with lids open, allowing penetration of insects and rodents.
Outdoor surfaces including gazebo shade and rails were in disrepair and the laundry area vent was clogged with lint creating a hazardous situation.
Over-the-counter medications (Centrum Vitamins, Tylenol, Vitamin D3) found unlabeled in medication cart.
Resident #2's glucometer was not calibrated to the correct date and time and glucose log readings did not match meter readings.
Resident #4's prescribed Vitamin B12 medication was missing from the medication cart.
Resident #1's assessment did not address needs for eating, drinking, transferring, toileting, nor indicate level of need.
Residents #5 and #6 participated in support plan development but did not sign the support plans.
Report Facts
Residents Served: 65
Residents Served in Secure Dementia Care Unit: 20
Current Residents Receiving Hospice: 11
Residents Age 60 or Older: 65
Residents with Mobility Need: 37
Total Daily Staff: 102
Waking Staff: 77
Notice — Apr 30, 2021
Date: Apr 30, 2021
Visit Reason
The document serves as a response to the renewal application submitted on February 9, 2021, for the operation of Brandywine Living at Haverford Estates, and notifies that a regular license is being issued. It also informs that an onsite annual inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it is a licensing renewal notice confirming issuance of a regular license and outlining future inspection requirements.
Report Facts
Inspection Report — Mar 5, 2020
Renewal
Date: Mar 5, 2020
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations at Brandywine Living at Haverford Estates.
Findings
The inspection identified multiple violations including lack of annual fire safety training, broken furniture, tripping hazards outside the memory care unit, outdated food items, lint accumulation in dryers, improper medication storage, and unsecured medication carts. Plans of correction were submitted and fully implemented as of July 17, 2020.
Citations (7)
65g - Annual Training Content: Staff persons A, B, and C did not receive fire safety training completed by a fire safety expert or a trained staff person during 2019.
95 - Furniture and Equipment: A light cover in the southwest stair tower between the first and second floors was broken and in disrepair.
100a - Exterior - Free of Hazards: The walkway from the first floor memory care unit exit was littered with household items presenting a tripping hazard.
103i - Outdated Food: An unlabeled, undated bag of ciabatta bread and pita bread was found in the walk-in refrigerator.
105g - Lint Removal and Duct Cleaning: Accumulation of lint was found in the lint trap of the clothes dryer on the second floor memory care unit.
183e - Storing Medications: On 03/06/2020, an opened and undated NovoLog FlexPen and Lantus SoloStar insulin injection pens were observed on the medication cart.
185a - Implement Storage Procedures: Loose pills were observed on the secured dementia unit medication cart and the third floor medication cart.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ian Monteith | Executive Director | Signed Plan of Correction documents related to multiple violations |
Notice — Jan 21, 2020
Date: Jan 21, 2020
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Brandywine Living at Haverford Estates to operate as a Personal Care Home. It informs the facility that an onsite annual inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It is a licensing and renewal notification letter with an enclosed certificate of compliance.
Report Facts
Inspection Report — Sep 12, 2019
Date: Sep 12, 2019
Visit Reason
The inspection was a partial, unannounced interim visit conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
Multiple violations were found related to resident confidentiality, safety, medication management, food labeling, fire drill records, and support plan documentation. Plans of correction were submitted and partially implemented with ongoing monitoring.
Citations (8)
2600.17 Resident records were not kept confidential; a laptop on the 3rd floor was unlocked and unattended with resident information visible.
2600.88a The delayed egress door on the 1st floor secured dementia care unit did not open within 15 seconds when pressed.
2600.103e Food served and returned from an individual's plate was not labeled or dated; unlabeled food items were found in the freezer and refrigerator.
2600.132c Fire drill records from June 24, 2019, documented 17 staff participating, but only 4 staff signed in as participating.
2600.183b Medication cart on the 3rd floor was unlocked and unattended; pills were found on the hallway carpet and nightstand, and a resident unable to self-administer medications was involved.
2600.184b OTC medication Vitamin C was not labeled with the resident's name.
2600.227d Resident #1's support plan did not provide direction on how staff will meet the need for assistance with personal hygiene.
2600.227g Resident #2 did not date his support plan as required.
Report Facts
Residents Served: 79
Residents Served in Dementia Unit: 20
Total Daily Staff: 104
Waking Staff: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ian Montieth | Executive Director | Named in multiple findings and signed plans of correction |
Inspection Report — Aug 12, 2019
Complaint Investigation
Date: Aug 12, 2019
Visit Reason
The inspection was a complaint investigation conducted on August 12, 2019, at Brandywine Living at Haverford Estates.
Complaint Details
The inspection was conducted due to a complaint. The report does not explicitly state substantiation status.
Findings
The inspection identified multiple medication-related violations including improper medication administration, missing medication documentation, lack of accountability for PRN pain medications, and failure to document medication refusals. The facility submitted a plan of correction which was fully implemented by July 24, 2020.
Citations (10)
182c - Medication Administration: On 08/12/2019, resident #1 was left with 3 pills to self-administer after bathing, which the resident did not take.
183d - Prescription Current: Medications for resident #1 were found in the medication cart but were not listed on the current medication administration record.
184a - Labeling OTC/CAM: Resident #1 had morphine bags without dates of prescription issuance on the medication cart.
185a - Implement Storage Procedures: Tylenol 325 mg tablets ordered for resident #1 were not available in the home on 08/12/2019.
185b - Medication Procedures: PRN pain medications were signed out but many lacked staff initials documenting administration.
187a - Medication Record: Resident #2 did not receive medication at prescribed time; staff did not bring medication at 1:00pm as required.
187b - Date/Time of Medication Admin.: Multiple residents had missing staff initials on narcotic sign-out sheets for medication administration dates in July and August 2019.
187c - Refusal of Medication: Several residents refused medications but the home did not notify prescribers of these refusals.
187d - Follow Prescriber's Orders: Resident #6's elevated blood pressure was not reported to cardiologist; multiple medications were not signed out properly.
188d - System to Document Medication Errors: The home lacked a system to identify and document PRN pain medication errors and staff were unable to describe such a system.
Report Facts
Residents Served: 74
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 5
Resident Age 60 or Older: 73
Residents with Mobility Need: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ian Monteith | E.D. | Signed plan of correction and named in relation to medication administration violations |
Inspection Report — May 29, 2019
Complaint Investigation
Date: May 29, 2019
Visit Reason
The inspection was conducted as a complaint investigation of Brandywine Senior Living at Haverford Estates on May 29, 2019.
Complaint Details
The inspection was complaint-driven, focusing on supervision and reporting failures related to resident #1. The complaint was substantiated by findings of unattended resident and failure to report injury.
Findings
Violations of 55 Pa. Code Ch. 2600 related to personal care home regulations were found, including failure to report incidents, inadequate supervision, failure to provide contracted services, and maintenance issues. Plans of correction were submitted addressing these violations with timelines for implementation.
Citations (5)
2600 16c: The home failed to report an incident involving a resident with a head laceration to the Department within 24 hours as required.
2600 23b: The resident's assessment indicated need for regular supervision, but the resident was found unattended outside on the driveway.
2600 42v: The home failed to provide supervision to a resident as contracted in the resident-home contract, allowing the resident to be outside unattended.
2600 101j7: Bedside lamps in resident bedrooms #12 and #227 B were not working, failing to provide operable lighting at bedside.
2600 231e: The home lacked documentation that the resident and designated person had not objected to admission to the Secure Dementia Care Unit.
Report Facts
Residents Served: 66
Residents Served in Dementia Unit: 16
Resident Age 60 or Older: 65
Residents with Mobility Need: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ian Monteith | Executive Director | Named in multiple plans of correction and signature on documents related to findings. |
Inspection Report — Apr 8, 2019
Complaint Investigation
Date: Apr 8, 2019
Visit Reason
The inspection was conducted as an incident investigation related to violations of 55 Pa. Code Chapter 2600 for Personal Care Homes.
Complaint Details
The inspection was triggered by an incident complaint. Specific medication errors involving Resident #1's Prednisone administration were investigated and substantiated.
Findings
Multiple violations were found related to medication administration, storage, documentation, and error reporting. The facility failed to maintain proper medication records, administer medications as prescribed, and document medication errors appropriately.
Citations (7)
Regulation 55 Pa.Code §2600.183(d): Only current prescription, OTC, sample and CAM medications for residents may be kept in the home. Resident #1 had medications on the med-cart not on the medication administration record.
Regulation 55 Pa.Code §2600.185(a): The home must have procedures for safe storage, access, security, distribution and use of medications by trained staff. Resident #2's prescribed medications were not available on site on 4/8/19.
Regulation 55 Pa.Code §2600.187(a): A medication record must include resident's name, drug allergies, medication name, strength, dosage form, dose, route, frequency, administration times, duration, special precautions, diagnosis or purpose, date/time of administration, and staff initials. Resident #1's medication administration record lacked diagnosis or purpose for Prednisone.
Regulation 55 Pa.Code §2600.187(d): The home must follow prescriber's directions. Resident #1 was administered incorrect dosage of Prednisone on 3/24/19 with no documentation of the error.
Regulation 55 Pa.Code §2600.188(c): Documentation of medication errors and prescriber's response must be kept in resident's record. There was no documentation of the medication error involving Resident #1's Prednisone administration.
Regulation 55 Pa.Code §2600.188(e): The home must identify and document medication errors and the home's pattern of error. The medication policy and error reporting system did not comply with regulations.
Regulation 55 Pa.Code §2600.188(e): The home failed to provide documentation of follow-up action taken to prevent future medication errors related to Resident #1's Prednisone administration.
Report Facts
Number of Residents Served: 75
Number of Current Hospice Residents: 4
Number of Residents Served in Secured Dementia Care Unit: 25
Number of Hospice Residents in Past Year: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ian Monteith | Administrator / E.D. | Named as Administrator and signatory on plan of correction documents related to medication violations. |
| Sabrina Freeman | Department representative on-site during inspection on 4/8/2019. |
Inspection Report — Apr 2, 2019
Original Licensing
Date: Apr 2, 2019
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 applicable regulations, but the licensing inspector was unable to complete a full inspection due to the newness of the legal entity.
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