Inspection Reports for
Brandywine Upper Providence
1133 Black Rock Rd, Phoenixville, PA 19460, United States, PA, 19460
Back to Facility Profile14 Reports
Inspection Report — Mar 25, 2026
Renewal
Date: Mar 25, 2026
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and incident reasons.
Findings
The inspection identified multiple deficiencies related to resident confidentiality, training records, resident personal equipment, medical evaluations, menu postings, medication storage and administration, and support plan documentation. All deficiencies had accepted plans of correction with implementation dates and ongoing quality improvement monitoring.
Citations (14)
2600.17 Resident records confidentiality was violated when an unlocked narcotics control binder was found unattended on a medication cart.
2600.65i The home’s annual staff fire safety training records lacked dates of completion and training source.
2600.81b A bedside mobility device in resident bedroom 315 lacked a cover, posing an entrapment risk.
2600.141a Resident 1’s medical evaluation form had no indication whether the resident’s needs could be met in the home.
2600.141b1 Resident 4’s initial and annual medical evaluations were incomplete or missing documentation.
2600.162c The home’s posted menus used a four-week cycle without specific dates, making it unclear which weeks were current.
2600.183e A Lispro insulin pen for Resident 2 was stored with an opened date of 2/17/26, exceeding the 28-day discard period.
2600.185a Resident 3’s glucometer readings were inaccurately documented and inconsistently recorded on the glucose log.
2600.187d Resident 3 was prescribed sliding scale insulin but did not receive insulin corresponding to a glucometer reading of 291.
2600.225c Resident 8’s assessment inaccurately identified needs for irritability, agitation, or aggression.
2600.227c Resident 1 and Resident 5’s support plans lacked documented descriptions and plans for identified needs.
2600.227d Resident 6’s support plan failed to address the intended use, risks, and safe use of a halo bar mobility device.
2600.234d Resident 7’s support plan was not updated after a physical altercation to reflect needs related to physical aggression.
2600.251c Resident 5’s medical evaluation was completed on an Assisted Living Residence form instead of a Personal Care Home form.
Report Facts
Residents Served: 88
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 9
Resident with Mobility Need: 56
Residents Age 60 or Older: 88
Inspection Report — Feb 24, 2025
Complaint Investigation
Date: Feb 24, 2025
Visit Reason
The inspection was conducted due to a complaint and incident at the facility.
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: 78
Secured Dementia Care Unit Residents Served: 25
Hospice Current Residents: 5
Residents Age 60 or Older: 78
Residents with Mobility Need: 47
Residents with Physical Disability: 1
Inspection Report — Jan 7, 2025
Renewal
Date: Jan 7, 2025
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the facility.
Complaint Details
The inspection included a complaint investigation as indicated by the inspection reason and findings related to medication and resident care issues.
Findings
Multiple deficiencies were identified including issues with resident refunds after death, missing posted telephone numbers, incomplete staff training, sanitary conditions, trash management, hot water temperature violations, food storage, smoking area fire hazards, medication record inaccuracies, medication storage, and medication administration errors. Plans of correction were accepted and implemented by February 20, 2025.
Citations (12)
Resident refund after death was not issued timely according to regulations.
Telephone numbers of regulatory and complaint offices were not posted conspicuously.
Two staff members did not complete required training within 40 scheduled work hours.
A staff member did not receive annual training in resident rights and falls prevention.
Ice cream freezer next to kitchen was dirty with spilled ice cream and stains.
Trash, including a blue mattress and armchairs, was found outside the home near smoking area.
Hot water temperature exceeded 120°F in kitchen and bathroom sinks.
Opened and unsealed food items found in dry food storage area.
Fire hazards present near designated smoking area including trash and furniture.
Resident medication list was incomplete and medications were not properly documented.
Opened eye drop medication was not dated and stored improperly.
Errors in transcription of resident blood glucose levels in medication administration record.
Report Facts
Residents Served: 81
Residents Served in Dementia Unit: 24
Hospice Residents: 6
Staffing Hours - Total Daily Staff: 131
Staffing Hours - Waking Staff: 98
Number of Medications Found: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Clinical Services | Director of Clinical Services | Involved in medication record correction, staff training, and medication audits. |
| Assistant Director of Clinical Services | Assistant Director of Clinical Services | Assisted in staff training and medication audits. |
| Executive Director | Executive Director | Reviewed regulations, implemented plans of correction, and responsible for ongoing compliance monitoring. |
| Dining Service Director | Dining Service Director | Responsible for food storage corrections and sanitary condition audits. |
| Maintenance Director | Maintenance Director | Removed trash and fire hazards, responsible for daily perimeter checks. |
| Regional Director of Plant Operations | Regional Director of Plant Operations | Adjusted hot water temperature to comply with regulations. |
| HR Director | HR Director | Implemented staff training and orientation compliance. |
Inspection Report — Sep 24, 2024
Date: Sep 24, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 09/24/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 122
Waking Staff: 92
Residents Served: 76
Secured Dementia Care Unit Residents Served: 25
Residents Diagnosed with Mental Illness: 6
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 46
Residents with Physical Disability: 1
Residents Age 60 or Older: 76
Residents Receiving Supplemental Security Income: 0
Inspection Report — Aug 21, 2024
Complaint Investigation
Date: Aug 21, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation, as indicated by the reason for the visit and the partial, unannounced inspection type.
Complaint Details
The visit was complaint-related, investigating allegations of abuse and other compliance issues. The complaint was substantiated as abuse was confirmed and staff member D was terminated.
Findings
The inspection identified multiple deficiencies including abuse of a resident, incomplete criminal background checks for staff, medication administration documentation errors, and failure to revise a resident's support plan following a significant change in condition. Plans of correction were accepted and implemented by 09/20/2024.
Citations (4)
Resident was physically abused by a caregiver who forcibly removed the resident from the toilet, resulting in bruising on both forearms.
Criminal background checks were not completed in accordance with the Older Adult Protective Services Act for staff member D.
Medication administration record lacked initials of staff and reasons for omitted medications when resident was hospitalized.
Resident's support plan was not revised within 30 days following a significant change in condition and new treatment orders.
Report Facts
Residents Served: 77
Secured Dementia Care Unit Residents Served: 25
Hospice Current Residents: 6
Residents Age 60 or Older: 77
Residents with Mobility Need: 45
Repeat Violation Date: 2024
Inspection Report — Feb 12, 2024
Renewal
Date: Feb 12, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies related to resident personal equipment, medication self-administration assistance, medication storage, and medication administration documentation. Plans of correction were submitted and accepted, with ongoing monitoring and training scheduled.
Citations (6)
Resident 1 had an enabler bar secured to a board under the mattress and not to the bed frame, posing a safety hazard.
Resident 2 did not receive needed assistance with self-administering medications, resulting in missed and incorrect medications being kept in the resident's room.
Loose orange pill found in medication bin for resident 1 and medication with tape on blister pack for resident 3.
Resident 1 was missing prescribed as needed medications on the day of inspection.
Resident 4 borrowed medication from resident 5, which is against policy.
Resident 6's narcotic medication administration record lacked initials and signature of administering staff.
Report Facts
Residents Served: 79
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 8
Residents Age 60 or Older: 79
Residents with Mobility Need: 38
Residents with Intellectual Disability: 1
Inspection Report — Feb 22, 2023
Date: Feb 22, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 95
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 10
Residents Age 60 or Older: 95
Residents with Mobility Need: 52
Residents with Intellectual Disability: 1
Residents with Physical Disability: 1
Inspection Report — Aug 16, 2022
Renewal
Date: Aug 16, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license to ensure compliance with regulatory requirements.
Findings
The inspection identified multiple deficiencies related to record confidentiality, staff training, medication management, medical evaluations, food safety, and medication storage. Plans of correction were submitted and determined to be fully implemented by the follow-up dates.
Citations (9)
Resident records were unlocked, unattended, and accessible on the medication cart in the hallway.
Insufficient number of staff certified in first aid, obstructed airway techniques, and CPR during night shift with 82 residents present.
Agency staff did not receive orientation on fire safety and emergency preparedness topics prior to or during first work day.
Resident #1's medication record did not include a current list of medications and contained errors.
Resident #2's medical evaluation did not indicate the need for secured dementia care unit placement.
Open, unlabeled, and undated food items found in reach-in freezer #2.
Resident #1 had self-administered medications that were not currently prescribed.
Resident #1 was prescribed a medication as needed, but the medication was not available.
Resident #1's medication orders were not followed; medication was not available as prescribed.
Report Facts
Residents Served: 88
Secured Dementia Care Unit Residents Served: 24
Hospice Residents: 8
Residents with Mobility Need: 47
Residents 60 Years or Older: 88
Total Daily Staff: 135
Waking Staff: 101
Staff Certified in First Aid/CPR: 1
Agency Staff Used: 7
Inspection Report — Jul 27, 2021
Complaint Investigation
Date: Jul 27, 2021
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The complaint triggered a partial unannounced inspection on 07/27/2021.
Findings
The inspection identified multiple deficiencies including failure to have a signed resident statement acknowledging receipt of resident rights and complaint procedures, lack of resident education on the right to refuse medication, incomplete documentation in the resident support plan regarding medical and behavioral care services, and an undated cognitive preadmission screening for a resident in the Secure Dementia Care Unit.
Citations (4)
Resident 1's record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures.
Resident 1 has not been educated to the resident's right to refuse medication if the resident believes there may be a medication error.
The assessment for resident #2 was not updated to address the resident's increase in falls including nine falls from January 2021 through July 2021; the resident's support plan does not document how this need will be met.
Resident #1’s written cognitive preadmission screening was completed but not dated.
Report Facts
Residents Served: 71
Residents Served in Secured Dementia Care Unit: 22
Current Hospice Residents: 2
Residents with Mobility Need: 24
Falls: 9
Staffing Hours - Resident Support Staff: 95
Staffing Hours - Waking Staff: 71
Inspection Report — Jun 9, 2021
Renewal
Date: Jun 9, 2021
Visit Reason
The document is a renewal license issued in response to the facility's renewal application to operate the Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a certificate of compliance and license renewal for the facility.
Report Facts
Inspection Report — May 20, 2021
Follow-Up
Date: May 20, 2021
Visit Reason
The visit was a full, unannounced inspection conducted to review the submitted plan of correction and verify its full implementation.
Findings
The inspection found multiple deficiencies related to sanitary conditions, food storage, outdated food, fire extinguisher inspection, medication management including prescription accuracy, labeling, storage, and following prescriber's orders. The submitted plan of correction was determined to be fully implemented with ongoing monitoring by the Wellness Director and other staff.
Citations (9)
Shared glucometers leading to inaccurate blood sugar readings for residents.
Uncovered coffee ice cream container found in the ice cream freezer.
Outdated or undated food items including donuts, bagels, fries, breaded chicken, and pasta found in kitchen and storage.
Fire extinguisher in the 2015 Ford Bus had not been inspected since April 2019.
Medications on cart not reflected on Medication Administration Record (MAR) for Resident #4.
Discrepancies between medication labels and MAR instructions for residents' MAPAP 500MG tablets.
Medications prescribed but not available in the home or resident rooms; transcription errors and inaccurate glucometer readings documented.
Failure to follow prescriber's orders for insulin administration for Residents #1 and #3.
Resident #2's preadmission screening form lacked determination that resident's needs can be met by the home.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 23
Staffing Hours - Total Daily Staff: 95
Staffing Hours - Waking Staff: 71
Current Residents Receiving Hospice: 4
Residents Age 60 or Older: 70
Residents with Mobility Need: 25
Residents with Physical Disability: 1
Inspection Report — Feb 26, 2020
Renewal
Date: Feb 26, 2020
Visit Reason
This document is a renewal license issued to Brandywine Living at Upper Providence to operate a Personal Care Home. The Department of Human Services received the renewal application and will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a certificate of compliance and renewal license for the facility.
Report Facts
Inspection Report — Feb 19, 2020
Renewal
Date: Feb 19, 2020
Visit Reason
The inspection was an unannounced renewal visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing to review compliance at Brandywine Senior Living at Upper Providence.
Findings
The facility had multiple deficiencies related to compliance with health and safety laws, contract signatures, signed statements, mattress condition, bed linens, food protection, outdated food, medication discontinuation, storage procedures, medical evaluations, resident rights, key-locking devices, evacuation diagrams, and admission support plans. All plans of correction were approved and fully implemented as of August 12, 2020.
Citations (17)
2600.18 - The home did not have the required Influenza Information poster as required by the PA House Bill 1785 Influenza Awareness Act of 2015.
2600.25b - The resident-home contract for resident 1 was not signed by the resident and lacked documentation of attempts to obtain the signature.
2600.41e - Resident 1's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures.
2600.101j - The mattress in room 335 was sagging and did not support the resident.
2600.101j - The bed pad in room 335 for resident #2 was soiled with a brown stain.
2600.103c - An uncovered container of fresh fruit was found on the kitchen counter, risking contamination.
2600.103i - A dented can of mandarin oranges was found on the kitchen rack.
2600.183f - Medications discontinued for resident #5 were still in the medication cart without current prescriptions.
2600.185a - Glucometer readings for residents 6, 7, and 8 were not properly recorded or calibrated in the Medication Administration Record.
2600.186a - The prescription medication Dulcolax was discontinued but remained on the physician order record for resident 5.
2600.187a - Medication administration records for resident 4 did not indicate diagnoses for prescribed medications.
2600.191 - Resident 1 was not educated on the right to refuse medication and documentation was lacking.
2600.123c - Emergency evacuation diagrams did not include a line of travel to evacuate the building.
2600.231b - Medical evaluations for residents admitted to the Secure Dementia Care Unit were incomplete or not timely.
2600.231e - Resident records lacked documentation that the resident and designated person had not objected to admission to the Secure Dementia Care Unit.
2600.233c - Directions for operating the home's locking mechanism were not posted near the exit to the Secure Dementia Care Unit.
2600.234a - Admission support plans were not developed, implemented, or documented within 72 hours of admission to the Secure Dementia Care Unit.
Report Facts
Residents Served: 83
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 4
Residents Age 60 or Older: 83
Residents with Mobility Need: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Cianfrani | Executive Director | Named in multiple plans of correction and signature on documents |
Inspection Report — Apr 4, 2019
Original Licensing
Date: Apr 4, 2019
Visit Reason
The inspection was conducted due to a change in legal entity operating the facility and to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
The facility was found to be in substantial compliance with applicable regulations. Three violations were identified related to poisonous materials accessibility, sanitary conditions, and lack of bedside lighting, all of which had plans of correction fully implemented.
Citations (3)
Regulation 2600.82(c): Poisonous materials shall be kept locked and inaccessible to residents. Toothpaste labeled 'poisonous if swallowed' was unlocked and accessible in secured dementia unit bedrooms #235 and #237.
Regulation 2600.85(a): Sanitary conditions shall be maintained. On 4/4/19, eight unlabeled toothbrushes were observed in a shared bathroom in room #235 posing a contamination risk.
Regulation 2600.101(j)(7): Each resident shall have a lamp or other source of lighting at bedside. The bed in room #338 lacked a source of light that can be turned on/off from bedside.
Report Facts
Number of Residents Served: 79
Number of Residents Served in Secured Dementia Care Unit: 23
Number of Residents Age 60 or Older: 79
Number of Residents with Mobility Need: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Cianfrani | Administrator | Signed plan of correction documents related to violations |
| Sabrina Freeman | Licensing Inspector | Conducted on-site inspection on 04/04/2019 |
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