Inspection Reports for Brandywine Dresher Estates
1405 Limekiln Pike, Dresher, PA 19025, United States, PA, 19025
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Inspection Report
Follow-Up
Census: 60
Capacity: 112
Deficiencies: 4
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.
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.
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.
Deficiencies (4)
| Description |
|---|
| 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
License Capacity: 112
Residents Served: 60
Secured Dementia Care Unit Capacity: 25
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
Monitoring
Census: 62
Capacity: 112
Deficiencies: 24
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.
Deficiencies (24)
| Description |
|---|
| 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
License Capacity: 112
Staffing Hours - Total Daily Staff: 96
Staffing Hours - Waking Staff: 72
Secured Dementia Care Unit Capacity: 25
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
Follow-Up
Census: 80
Capacity: 112
Deficiencies: 3
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.
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.
Complaint Details
The visit was complaint-related and included incident investigation. The plan of correction was accepted and fully implemented.
Deficiencies (3)
| Description |
|---|
| 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
License Capacity: 112
Residents Served: 80
Secured Dementia Care Unit Capacity: 25
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
Census: 90
Capacity: 112
Deficiencies: 0
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
License Capacity: 112
Secured Dementia Care Unit Capacity: 25
Residents Served in Secured Dementia Care Unit: 21
Hospice Residents: 7
Residents 60 Years or Older: 90
Residents with Mobility Need: 42
Inspection Report
Census: 87
Capacity: 112
Deficiencies: 0
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
License Capacity: 112
Residents Served: 87
Secured Dementia Care Unit Capacity: 25
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
Renewal
Census: 86
Capacity: 112
Deficiencies: 24
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.
Deficiencies (24)
| Description |
|---|
| 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
License Capacity: 112
Secured Dementia Care Unit Capacity: 25
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
Census: 86
Capacity: 112
Deficiencies: 0
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
License Capacity: 112
Residents in Secure Dementia Care Unit: 22
Secure Dementia Care Unit Capacity: 25
Hospice Residents: 5
Total Daily Staff: 122
Waking Staff: 92
Residents with Mobility Need: 36
Residents Age 60 or Older: 86
Inspection Report
Renewal
Capacity: 112
Deficiencies: 0
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
Maximum capacity: 112
Secure Dementia Care Unit capacity: 25
Inspection Report
Renewal
Census: 77
Capacity: 112
Deficiencies: 17
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.
Deficiencies (17)
| Description |
|---|
| 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
Total licensed capacity: 112
Residents in secured dementia care unit: 19
Capacity of secured dementia care unit: 25
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 |
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