Inspection Reports for Brandywine Longwood
301 Victoria Gardens Dr, Kennett Square, PA 19348, United States, PA, 19348
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Inspection Report
Complaint Investigation
Census: 55
Capacity: 92
Deficiencies: 15
May 5, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to a complaint and incident at the facility.
Findings
Multiple deficiencies were found including resident treatment issues, privacy violations, unsafe storage of poisonous materials, maintenance problems such as lack of ventilation and water-stained ceiling tiles, improper medication labeling and storage, and failure to complete additional resident assessments after behavioral changes. Plans of correction were accepted and implemented by July 16, 2025.
Complaint Details
The visit was complaint-related, triggered by incidents involving resident aggression, privacy violations, and other regulatory concerns. Substantiation status is not explicitly stated.
Deficiencies (15)
| Description |
|---|
| Resident was treated without dignity and respect, including aggressive behavior and threats toward other residents. |
| Residents' right to freely associate and communicate was restricted by door alarms on bedroom doors. |
| Residents had door alarms on bedroom doors that alerted staff, violating privacy rights. |
| Poisonous materials (Colgate toothpaste) were left unlocked and accessible in the memory care unit. |
| Bathrooms lacked operable windows or ventilation fans. |
| Two ceiling tiles near a resident's room were water stained. |
| Exit sign hanging from ceiling with exposed wires. |
| Unlabeled and undated leftover food items found in memory care refrigerator. |
| A recliner chair blocked an exit in the memory care dining area. |
| Weekly menus were not posted in advance as required. |
| Discontinued medication was found in the medication cart. |
| Medication blister pack was damaged and taped. |
| Incorrect directions on pharmacy medication labels without direction change stickers. |
| Failure to implement positive interventions for residents exhibiting aggressive behaviors. |
| Failure to complete additional resident assessments after significant behavioral changes. |
Report Facts
Residents Served: 55
License Capacity: 92
Residents Served in Secured Dementia Care Unit: 20
Current Hospice Residents: 7
Residents Age 60 or Older: 55
Residents with Mobility Need: 28
Total Daily Staff: 83
Waking Staff: 62
Inspection Report
Follow-Up
Census: 56
Capacity: 92
Deficiencies: 4
Feb 12, 2025
Visit Reason
The inspection visit on 02/12/2025 was a partial, unannounced follow-up review triggered by a complaint and 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 addressing deficiencies related to treatment of residents, staff training, and locking of poisonous materials. Staff training deficiencies were corrected, and safety measures for poisonous materials were improved with new locks and monitoring procedures.
Complaint Details
The visit was complaint-related, triggered by an incident involving inappropriate treatment of a resident by staff person B, who was subsequently terminated. The complaint was investigated and found substantiated with corrective actions implemented.
Deficiencies (4)
| Description |
|---|
| Resident was not treated with dignity and respect when staff person B responded inappropriately to resident's nonverbal cue for a drink. |
| Direct care staff person A did not receive required training in medication self-administration and care for residents with dementia during 2024. |
| Poisonous materials (Wood Polish and TB Cide Quat) were unlocked and accessible to residents in the Memory Care unit. |
| Direct care staff persons A and C had insufficient dementia care training hours during 2024. |
Report Facts
Residents served: 56
License capacity: 92
Capacity of secured dementia care unit: 22
Residents served in secured dementia care unit: 19
Current hospice residents: 7
Residents aged 60 or older: 56
Residents with mobility need: 29
Direct care staff total daily hours: 85
Waking staff hours: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Named in treatment of resident deficiency and subsequent termination | |
| Staff person A | Named in treatment of resident incident and staff training deficiencies | |
| Staff person C | Named in dementia care training deficiency |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 92
Deficiencies: 8
Dec 19, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial review of the facility on 12/19/2024.
Findings
Multiple deficiencies were found including unlocked narcotics logbook and assignment sheets, unsecured bedside mobility devices, unlocked poisonous materials accessible to residents, damaged walls and ceilings, use of prohibited portable space heaters, outdated medical evaluations, unlocked medications, and missing conspicuous posting of keypad operation instructions.
Complaint Details
The inspection was triggered by a complaint, as indicated by the inspection reason. The plan of correction was accepted and fully implemented by 02/20/2025.
Deficiencies (8)
| Description |
|---|
| Narcotics logbook and assignment sheets for residents in the Secure Dementia Care Unit were unlocked, unattended, and accessible. |
| Bedside mobility devices were not secured to beds and moved easily when pulled. |
| Poisonous materials such as nail polish remover, isopropyl alcohol, deodorant, and toothpaste were unlocked and accessible to residents. |
| Ceiling corner peeling away exposing drywall and stained ceiling tile in resident bedrooms. |
| A large plug-in portable space heater was in use in the Secure Dementia Care Unit activities area. |
| Medical evaluation for a resident was completed over 60 days prior to admission. |
| Prescription medications and syringes were unlocked, unattended, and accessible on top of the medication cart. |
| Directions for operating the home's locking mechanism were not conspicuously posted near the first-floor door exiting to the patio in the Secure Dementia Care Unit. |
Report Facts
Residents Served: 54
License Capacity: 92
Capacity of Secured Dementia Care Unit: 22
Residents Served in Secured Dementia Care Unit: 19
Current Hospice Residents: 4
Residents Age 60 or Older: 54
Residents with Mobility Need: 27
Total Daily Staff: 81
Waking Staff: 61
Inspection Report
Renewal
Census: 61
Capacity: 92
Deficiencies: 13
Nov 20, 2024
Visit Reason
The inspection was conducted as a full, unannounced review for renewal and complaint reasons at Brandywine Living at Longwood.
Findings
The report details multiple deficiencies related to resident abuse reporting, incident reporting, compliance with laws, contract signatures, staff training, resident personal equipment, labeling and storage of medications and clothes, additional resident assessments, and support plan documentation. Plans of correction were accepted and implemented by 01/09/2025.
Complaint Details
The visit included complaint investigation related to suspected resident abuse and failure to report incidents appropriately. The complaint was substantiated with findings of failure to report suspected abuse to the local Area Agency on Aging and Department.
Deficiencies (13)
| Description |
|---|
| 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. |
| Influenza Awareness Poster was not present in the home as required. |
| Resident home contract was not signed by the resident. |
| Staff training plan did not include dates and times of scheduled training for each staff person. |
| Bedside mobility device was not securely attached to the bed, creating entrapment hazards. |
| No system to safeguard resident laundry from loss; clothes were unlabeled and misplaced. |
| Staff transporting residents had not completed required initial direct care staff training. |
| Improper storage of medications; resident's medication punctured and covered with tape. |
| Medication pen not labeled to identify the resident. |
| No additional assessment completed addressing exhibited inappropriate behaviors despite incidents. |
| Resident's assessment and support plan did not indicate need for bedside mobility device present. |
| Resident participated in support plan development but did not sign the support plan. |
Report Facts
Residents Served: 61
License Capacity: 92
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 8
Residents Age 60 or Older: 61
Residents with Mobility Need: 30
Total Daily Staff: 91
Waking Staff: 68
Inspection Report
Renewal
Census: 64
Capacity: 92
Deficiencies: 0
Sep 11, 2023
Visit Reason
The inspection was conducted as a renewal of the facility's license.
Findings
No regulatory citations or deficiencies were identified during this licensing inspection.
Report Facts
Residents Served: 64
License Capacity: 92
Residents Served in Secured Dementia Care Unit: 20
Capacity of Secured Dementia Care Unit: 23
Current Hospice Residents: 2
Residents 60 Years or Older: 64
Residents with Mobility Need: 35
Total Daily Staff: 99
Waking Staff: 74
Inspection Report
Complaint Investigation
Census: 60
Capacity: 92
Deficiencies: 0
Feb 28, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection on 02/28/2023 and 03/01/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related with no deficiencies found; substantiation status is not explicitly stated.
Report Facts
License Capacity: 92
Residents Served: 60
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 20
Resident Mobility Need: 30
Total Daily Staff: 90
Waking Staff: 68
Inspection Report
Follow-Up
Census: 59
Capacity: 92
Deficiencies: 1
Jan 18, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to a resident abuse incident involving fraudulent use of a resident's debit cards by a staff member. Continued compliance and staff training on Resident Rights and abuse prevention were emphasized.
Deficiencies (1)
| Description |
|---|
| Resident 1 was subjected to financial abuse involving fraudulent transactions on debit cards by a staff member. |
Report Facts
License Capacity: 92
Residents Served: 59
Fraudulent Transactions: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Signed the Licensing Inspection Summary letter |
Inspection Report
Renewal
Census: 56
Capacity: 92
Deficiencies: 11
May 16, 2022
Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 05/16/2022 and 05/17/2022 to review compliance and licensing status of Brandywine Living at Longwood.
Findings
The inspection identified multiple deficiencies including sanitary conditions, hot water temperature exceeding limits, refrigerator temperature violations, obstructed egress routes, incomplete menu postings, medication record errors, storage and administration issues, and lack of documentation for resident admission objections. All deficiencies had plans of correction accepted and were implemented by the facility.
Deficiencies (11)
| Description |
|---|
| Medication administration record for resident #3 had readings that appeared to be shared between residents, indicating sanitary condition issues. |
| Hot water temperature in resident accessible areas exceeded 120°F, with readings of 123.1°F and 127°F. |
| Refrigerator temperature on 2nd floor Reflections unit was 46°F, exceeding the required maximum of 40°F. |
| Multiple chairs blocked exit path to courtyard gate and stairwell 1 exit was locked, obstructing egress routes. |
| Menu for the week of 5/22/22 to 5/28/22 was not posted as required one week in advance. |
| Discontinued medication was found in the medication cart for Resident #1. |
| Number transposed on Medication Administration Record for Resident #2. |
| Medication administered to Resident #2 was not included on the medication administration record. |
| Medication prescribed for Resident #1 was not administered due to unavailability at the facility. |
| Resident #2 was administered medication but electronic documentation on the MAR was incorrect. |
| No documentation that Resident #1 and Resident #4 or their designated persons objected to admission or transfer to the secured dementia care unit. |
Report Facts
License Capacity: 92
Residents Served: 56
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 14
Hospice Residents: 2
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Total Daily Staff: 72
Waking Staff: 54
Hot Water Temperature: 123.1
Hot Water Temperature: 127
Refrigerator Temperature: 46
Inspection Report
Census: 51
Capacity: 92
Deficiencies: 0
Oct 7, 2021
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted 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: 92
Residents Served: 51
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 19
Hospice Residents: 1
Resident Support Staff: 70
Waking Staff: 53
Residents Age 60 or Older: 51
Residents with Mobility Need: 19
Inspection Report
Annual Inspection
Census: 51
Capacity: 92
Deficiencies: 2
May 28, 2021
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing, to determine compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall, but two deficiencies were noted: an unlocked medication cart accessible on the second floor, and the absence of a carbon monoxide detector in the basement near fossil-fuel burning appliances. Both issues were addressed with corrective plans and follow-up audits.
Deficiencies (2)
| Description |
|---|
| Medication cart located on the second floor was left unlocked, unattended, and accessible. |
| No carbon monoxide detector in the basement near the natural gas fueled boiler and clothes dryer, not meeting compliance with Pennsylvania Statutes Title 35 P.S. Health and Safety § 7243.(a)(1). |
Report Facts
License Capacity: 92
Residents Served: 51
Secured Dementia Care Unit Capacity: 23
Residents Served in Secure Dementia Care Unit: 20
Current Hospice Residents: 6
Total Daily Staff: 83
Waking Staff: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary | Signed the licensing inspection letter and certificate. |
Inspection Report
Follow-Up
Census: 50
Capacity: 92
Deficiencies: 1
Mar 29, 2021
Visit Reason
The visit was a provisional, unannounced partial inspection conducted to review the submitted plan of correction for a previously identified deficiency.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The deficiency involved a late report of an unwitnessed resident fall, which was corrected with staff training and process improvements.
Deficiencies (1)
| Description |
|---|
| The home did not report an unwitnessed resident fall to the Department within the required 24 hours, submitting the report one day late. |
Report Facts
Residents Served: 50
License Capacity: 92
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 5
Residents Age 60 or Older: 54
Residents with Mobility Need: 30
Residents with Physical Disability: 4
Inspection Report
Complaint Investigation
Census: 65
Capacity: 92
Deficiencies: 1
Jul 21, 2020
Visit Reason
The inspection was conducted as a complaint investigation following incidents reported involving resident abuse at Brandywine Living at Longwood.
Findings
The investigation found that Staff member A engaged in a sexual relationship with Resident #1, including inappropriate sexual activity and misconduct over approximately one year. Staff member A was terminated and the police were notified.
Complaint Details
The complaint was substantiated based on evidence that Staff member A engaged in sexual abuse of Resident #1 over an extended period, despite the resident's requests to stop. The police were notified and Staff member A was fired.
Deficiencies (1)
| Description |
|---|
| Staff member A persuaded Resident #1 into a sexual relationship and engaged in sexual misconduct including masturbation in the resident's room. |
Report Facts
License Capacity: 92
Residents Served: 65
Secured Dementia Care Unit Capacity: 23
Residents Served in Secured Dementia Care Unit: 19
Current Hospice Residents: 5
Total Daily Staff: 98
Waking Staff: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paola Fusaro | Executive Director | Named in relation to the incident report and investigation |
| Jennie Heinberg | Lead Inspector | Conducted the inspection and investigation |
| Susan Smith | On-site inspector during the investigation | |
| Shawn Parker | Lead Reviewer | Reviewed follow-up documentation and submissions |
| Jamie Buchenauer | Deputy Secretary | Signed official correspondence regarding licensing and enforcement |
Inspection Report
Plan of Correction
Census: 67
Capacity: 92
Deficiencies: 1
Jun 12, 2020
Visit Reason
The inspection was conducted as a follow-up review of the submitted plan of correction related to an incident at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing deficiencies in resident assessments, specifically related to behavioral issues of a resident. Continued compliance must be maintained.
Deficiencies (1)
| Description |
|---|
| Resident #1's initial and annual Resident Assessment Support Plan (RASP) did not address aggressive, irritability, and agitation behavior issues for staff to direct resident appropriately. |
Report Facts
License Capacity: 92
Residents Served: 67
Staffing Hours - Total Daily Staff: 101
Staffing Hours - Waking Staff: 76
Residents with Mobility Need: 34
Residents with Physical Disability: 3
Residents 60 Years or Older: 67
Residents in Secured Dementia Care Unit Capacity: 67
Residents Served in Secured Dementia Care Unit: 21
Hospice Current Residents: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Wooters | Human Services Licensing Supervisor | Signed letter confirming plan of correction implementation |
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