Inspection Reports for Silver Springs at East Norriton
2101 New Hope St, East Norriton, PA 19401, United States, PA, 19401
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Monitoring
Census: 70
Capacity: 245
Deficiencies: 11
Jul 2, 2025
Visit Reason
The visit was an unannounced partial inspection conducted for monitoring purposes to review compliance and the implementation of a plan of correction.
Findings
The inspection identified multiple deficiencies including failure to report an incident timely, lack of signed resident contracts, disrespectful treatment of a resident by staff, incomplete staff lists, incomplete training records, unsecured poisonous materials, unsanitary conditions, uncovered trash receptacles, lack of bedside lighting, obstructed emergency exits, and outdated resident photographs. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (11)
| Description |
|---|
| Failure to report an incident to the Department within 24 hours as required. |
| Resident-home contract was not signed by the administrator or designee. |
| Resident was treated without dignity and respect; staff spoke rudely and removed shower sign. |
| Staff list did not include staff persons in training until they received their first paycheck. |
| Training record did not include length of training. |
| Poisonous materials (toothpaste) were unlocked and accessible to residents not assessed as safe to use them. |
| Soiled incontinence brief found on floor of resident shower. |
| Trash outside home was kept in uncovered dumpster with debris nearby. |
| Resident bedroom lacked an operable lamp or source of lighting at bedside. |
| Emergency exit door had inappropriate signage obstructing egress. |
| Resident record did not include a photograph less than 2 years old. |
Report Facts
Residents Served: 70
License Capacity: 245
Capacity of Secured Dementia Care Unit: 50
Residents Served in Secured Dementia Care Unit: 27
Hospice Current Residents: 4
Residents Age 60 or Older: 70
Residents with Mobility Need: 40
Total Daily Staff: 110
Waking Staff: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in disrespectful treatment of resident and failure to report incident | |
| Staff Person B | Administrator | Named in maintaining incomplete staff list |
| Director of Wellness | Responsible for re-education, audits, and corrective actions related to multiple deficiencies | |
| Executive Director | Reviewed and signed resident contracts and educated staff on compliance | |
| Business Office Manager | Updated staff list and responsible for training record audits | |
| Maintenance Director | Responsible for corrective actions related to lighting, emergency exits, and trash area | |
| Front Desk Concierge | Responsible for updating resident photographs and auditing compliance |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 245
Deficiencies: 10
Apr 28, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial inspections on April 28 and May 8, 2025, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The inspection found multiple violations including failure to suspend a staff member suspected of theft, delayed reporting of abuse incidents, resident abuse, lack of safeguarding resident property, incomplete medical evaluations, missing support plan signatures, inaccurate support plan needs, and outdated resident photographs. A provisional license was issued due to these violations.
Complaint Details
The inspection was complaint-driven, triggered by allegations including theft of residents' credit cards and money, abuse incidents between residents, and failure to report incidents timely. The complaint was substantiated with multiple violations found.
Deficiencies (10)
| Description |
|---|
| Failure to immediately suspend or supervise staff member involved in alleged theft of residents' credit cards and money. |
| Delayed reporting of an incident involving resident abuse to the Department beyond the required 24 hours. |
| Resident abuse observed where one resident hit another in the secured dementia care unit. |
| Lack of a system or policy to safeguard residents' money and valuables, resulting in thefts. |
| Resident medical evaluation did not include medication list. |
| Resident's most recent medical evaluation was not completed annually as required. |
| Resident's preadmission screening form did not include determination that needs could be met by the home. |
| Resident participated in support plan development but did not sign the support plan. |
| Support plans did not correctly identify residents' needs for agitation and aggression. |
| Resident record did not include a photograph no more than 2 years old. |
Report Facts
License Capacity: 245
Residents Served: 70
Secured Dementia Care Unit Capacity: 50
Residents Served in Secured Dementia Care Unit: 24
Staffing Hours: 111
Waking Staff: 83
Residents with Mobility Need: 41
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents Receiving Hospice: 5
Residents 60 Years or Older: 70
Inspection Report
Monitoring
Census: 75
Capacity: 245
Deficiencies: 13
Mar 20, 2025
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of the facility's compliance with licensing requirements.
Findings
The inspection found multiple deficiencies related to contract signatures, signed statements, medical evaluations, medication storage and administration, resident rights education, and documentation for secured dementia care unit admissions. Plans of correction were accepted and implemented by May 30, 2025.
Deficiencies (13)
| Description |
|---|
| Resident-home contracts were not signed by residents. |
| Resident records lacked signed statements acknowledging receipt of resident rights and complaint procedures. |
| Resident medical evaluation did not include medication regimen, contraindicated medications, and medication side effects. |
| Blood sugar reading recorded on medication administration record but missing on resident's glucometer. |
| Medication administered but not recorded on narcotic control log. |
| Medication administration records missing blood sugar readings and insulin administration details. |
| Blood sugar check not performed as prescribed. |
| Medications not administered as ordered at prescribed times. |
| Residents not educated on right to refuse medication if medication error suspected. |
| Medical evaluation for secured dementia care unit resident did not include diagnosis. |
| Preadmission cognitive screening for secured dementia care unit resident lacked completion date and behavior documentation. |
| No objection statement documentation for secured dementia care unit admission missing. |
| Resident without primary dementia diagnosis residing in secured dementia care unit. |
Report Facts
License Capacity: 245
Residents Served: 75
Secured Dementia Care Unit Capacity: 50
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 5
Residents Age 60 or Older: 75
Residents with Mobility Need: 41
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in relation to education and oversight of contract signing, resident rights education, and admission documentation. | |
| Director of Marketing | Responsible for ensuring contracts and resident rights acknowledgments are signed and present in files. | |
| Director of Wellness | Responsible for medication administration oversight, staff education, audits, and medical evaluation corrections. | |
| Administrator | Responsible for auditing new admissions to ensure resident rights education and documentation compliance. | |
| Staff Member A | Named in medication administration and narcotic log documentation deficiency. |
Inspection Report
Follow-Up
Census: 32
Capacity: 50
Deficiencies: 3
Aug 15, 2024
Visit Reason
The inspection was a follow-up review conducted on 08/15/2024 to determine if the previously submitted plan of correction was fully implemented and compliance was maintained.
Findings
The facility was found to have deficiencies related to compliance with the Clean Indoor Air Act, operable lighting at bedside, and window coverings. Each deficiency had a directed plan of correction which was implemented by early October 2024.
Deficiencies (3)
| Description |
|---|
| No 'Smoking' or 'No Smoking' signs posted at the designated smoking area on the front porch. |
| Resident does not have access to a source of light that can be turned on/off at bedside; lamp was placed near foot of bed. |
| Window in bedroom has bottom 1/5th of blind slats broken and/or missing. |
Report Facts
Residents Served: 32
Total Capacity: 50
Staffing: 97
Staffing: 129
Inspection Report
Follow-Up
Census: 78
Capacity: 245
Deficiencies: 3
May 6, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident at the facility to review the submitted plan of correction.
Findings
The facility was found to have implemented the submitted plan of correction related to abuse and positive intervention violations. Staff Member B was removed and terminated following an incident involving physical abuse of a resident. Staff received training on abuse prevention and positive interventions, with ongoing reviews planned.
Deficiencies (3)
| Description |
|---|
| A resident was physically abused by Staff Member B, who struck the resident forcibly in the chest. |
| Failure to use positive interventions to modify or eliminate behavior that endangers the resident or others. |
| Resident's record did not include a reportable incident report. |
Report Facts
License Capacity: 245
Residents Served: 78
Secured Dementia Care Unit Capacity: 50
Secured Dementia Care Unit Residents Served: 30
Hospice Current Residents: 9
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 48
Residents Age 60 or Older: 78
Inspection Report
Complaint Investigation
Census: 76
Capacity: 245
Deficiencies: 2
Mar 6, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Brandywine Senior Living at Senior Suites.
Findings
The investigation found a violation related to the treatment of residents involving disrespectful language by a staff member, resulting in suspension and termination. Another violation involved a non-dementia diagnosed resident residing in the secured dementia care unit without proper diagnosis documentation, which was subsequently corrected with updated assessments and training.
Complaint Details
The visit was complaint-related, investigating disrespectful treatment of a resident and inappropriate placement of a non-dementia resident in the secured dementia care unit. The disrespect incident was substantiated leading to staff suspension and termination.
Deficiencies (2)
| Description |
|---|
| Staff Member A was overheard using disrespectful language towards a resident during care, violating dignity and respect requirements. |
| A resident without a primary diagnosis of Alzheimer's or dementia was residing in the secured dementia care unit without proper documentation; diagnosis was updated and staff trained accordingly. |
Report Facts
License Capacity: 245
Residents Served: 76
Secured Dementia Care Unit Capacity: 50
Residents in Secured Dementia Care Unit: 32
Hospice Residents: 10
Residents with Mobility Need: 50
Residents 60 Years or Older: 76
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Follow-Up
Census: 74
Capacity: 245
Deficiencies: 3
Feb 7, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction related to resident assistance and incident reporting.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing deficiencies related to failure to assist a resident with activities of daily living and failure to timely report an incident. Staff person A was suspended and terminated due to noncompliance. Ongoing staff training on abuse, neglect, and resident assistance was documented.
Deficiencies (3)
| Description |
|---|
| Failure to report an incident to the Department within 24 hours as required by regulation 16c. |
| Failure to provide assistance with activities of daily living (transferring, toileting, bladder management) as indicated in the resident’s support plan. |
| Failure to treat a resident with dignity and respect, including refusal to assist with toileting and transferring. |
Report Facts
License Capacity: 245
Residents Served: 74
Secured Dementia Care Unit Capacity: 50
Residents Served in Dementia Unit: 32
Hospice Residents: 11
Resident Mobility Need: 43
Staffing Hours - Resident Support Staff: 117
Staffing Hours - Waking Staff: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to refusal to assist resident and incident reporting; suspended and terminated due to noncompliance | |
| Wellness Director | Involved in staff training and review of care plans related to deficiencies | |
| Executive Director | Involved in staff training and review of care plans related to deficiencies |
Inspection Report
Renewal
Census: 77
Capacity: 245
Deficiencies: 0
Apr 25, 2023
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 04/25/2023, with the reason noted as a fine.
Findings
No regulatory citations or deficiencies were identified during this licensing inspection.
Report Facts
License Capacity: 245
Residents Served: 77
Secured Dementia Care Unit Capacity: 41
Secured Dementia Care Unit Residents Served: 31
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 51
Residents 60 Years of Age or Older: 77
Inspection Report
Census: 76
Capacity: 245
Deficiencies: 0
Mar 28, 2023
Visit Reason
The inspection was a partial, unannounced visit 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: 245
Residents Served: 76
Secured Dementia Care Unit Capacity: 50
Secured Dementia Care Unit Residents Served: 41
Hospice Current Residents: 11
Resident Support Staff: 0
Total Daily Staff: 124
Waking Staff: 93
Residents Age 60 or Older: 76
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 48
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 76
Capacity: 245
Deficiencies: 9
Mar 22, 2023
Visit Reason
The inspection was conducted as a renewal and provisional review of the facility's compliance with licensing requirements on 03/22/2023 and 03/23/2023.
Findings
The inspection identified multiple deficiencies related to resident privacy, trash management, medical evaluations, menu posting, following prescriber's orders, additional assessments, support plans, and legibility of record entries. Plans of correction were accepted and implemented with ongoing monitoring and in-service training scheduled.
Deficiencies (9)
| Description |
|---|
| Staff administered medications to a resident in a common area with other residents present, violating privacy rights. |
| Trash outside the home was not kept in covered receptacles, allowing penetration of insects and rodents. |
| Resident medical evaluations were incomplete, missing body positioning/movement, general physical examination, immunization history, and ability to self-administer medications. |
| Menus were not posted for the following week as required. |
| Medication prescribed to resident was not administered as ordered, with documentation issues noted. |
| Resident assessment did not include all current diagnoses. |
| Resident support plan did not document how identified needs would be met. |
| Medical evaluation for a resident admitted to the secured dementia care unit did not document the need for secured care. |
| Resident record entries were illegible, including preadmission screening date and medical evaluation/order. |
Report Facts
Residents Served: 76
License Capacity: 245
Secured Dementia Care Unit Capacity: 50
Residents Served in Secured Dementia Care Unit: 30
Current Hospice Residents: 12
Residents with Mental Illness: 3
Residents with Mobility Need: 48
Residents 60 Years or Older: 76
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Counseled staff person A regarding medication administration privacy violation. | |
| Wellness Director | Conducted in-service trainings, updated medical evaluations, led audits, and oversaw correction plans. | |
| Assistant Wellness Director | Participated in in-service trainings and nursing team education. | |
| Dining Services Director | Updated menu board and ensured compliance with menu posting regulations. | |
| Environmental Services Director | Removed uncovered trash bin from outside the facility. |
Inspection Report
Plan of Correction
Census: 76
Capacity: 245
Deficiencies: 1
Feb 1, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted on 02/01/2023 with the reason noted as 'Fine'. The document also includes follow-up and plan of correction submissions related to the inspection findings.
Findings
A deficiency was found related to failure to follow the prescriber's orders for insulin administration for Resident #1, involving a transcription error where insulin was documented as administered incorrectly. The plan of correction was accepted and implemented with staff training and ongoing audits.
Deficiencies (1)
| Description |
|---|
| Failure to follow prescriber's directions for insulin administration for Resident #1, involving a transcription error. |
Report Facts
License Capacity: 245
Residents Served: 76
Secured Dementia Care Unit Capacity: 40
Secured Dementia Care Unit Residents Served: 25
Current Hospice Residents: 13
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 48
Residents with Physical Disability: 1
Resident Age 60 or Older: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Director | Coached nurse responsible for transcription error and conducted staff in-service trainings related to insulin administration and prescriber directions |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 245
Deficiencies: 4
Oct 19, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review compliance and verify the submitted plan of correction for the facility.
Findings
The inspection found multiple deficiencies related to incident reporting, locking poisonous materials, positive interventions for resident safety, and support plan revisions. The submitted plan of correction was accepted and fully implemented by the dates specified.
Complaint Details
The visit was complaint-related as indicated by the inspection information section stating 'Reason: Complaint'.
Deficiencies (4)
| Description |
|---|
| Failure to report an incident of a resident rolling out of bed to the Department. |
| Poisonous materials were unlocked, unattended, and accessible to a resident. |
| Failure to implement safety interventions to modify or eliminate a resident's behavior that caused falling out of bed. |
| Support plan did not indicate that resident was a fall risk or include interventions to assist with falling. |
Report Facts
License Capacity: 245
Residents Served: 87
Secured Dementia Care Unit Capacity: 50
Residents Served in Dementia Care Unit: 27
Current Hospice Residents: 16
Residents Age 60 or Older: 84
Residents with Mobility Need: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maxanne Crawford | Wellness Director | Named in relation to training on reporting potential fall risks and resident safety concerns. |
Inspection Report
Follow-Up
Census: 89
Capacity: 245
Deficiencies: 8
Jul 15, 2022
Visit Reason
The inspection was an interim, unannounced partial inspection conducted on 07/15/2022 as a follow-up to verify correction of previous deficiencies.
Findings
Multiple medication-related deficiencies were found including presence of discontinued medication, incomplete medication administration records, medication administration timing errors, medication errors not reported, and improper medication storage. The facility was issued a first provisional license due to these violations and was required to implement corrective actions.
Deficiencies (8)
| Description |
|---|
| Discontinued medication (Ipratropium Bromide) was found in the medication cart. |
| Medication administration record did not include all administered insulin dosages for Resident #2 and Resident #5. |
| Medication administration times were inaccurately recorded; medication given later than recorded for Resident #1. |
| Medication errors were not reported to the resident, designated person, or prescriber for Residents #1 and #2. |
| Resident #1 was given Morphine Sulfate later than ordered; staff signed off medication as given but did not administer it at the time. |
| Medication storage procedures were not properly implemented; narcotic count discrepancies and missing blood sugar readings on MAR. |
| Failure to follow prescriber's orders regarding insulin administration for Residents #1 and #2. |
| Incomplete and inaccurate documentation of medication administration and blood sugar readings. |
Report Facts
License Capacity: 245
Residents Served: 89
Secured Dementia Care Unit Capacity: 50
Residents Served in Dementia Care Unit: 30
Hospice Residents: 12
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 445
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the letter regarding license revocation and provisional license issuance. |
| Staff person A | Named in findings related to medication administration timing errors and narcotic count discrepancies. | |
| Wellness Director | Responsible for removing discontinued medication and auditing medication administration records. | |
| Executive Director | Prepared incident reports for medication errors. | |
| Wellness Nurse Staff Person #1 | Addressed via performance counseling for delay in medication administration. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 245
Deficiencies: 7
Jun 1, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspection on June 1, 2022, to assess compliance with regulations at Brandywine Senior Living at Senior Suites.
Findings
Multiple violations were found related to medication administration errors, failure to report incidents and refusals, inadequate assistance with activities of daily living, and improper medication storage and documentation. Plans of correction were proposed but not yet implemented as of the report date.
Complaint Details
The inspection was complaint-driven, with findings substantiated by multiple violations related to medication errors, refusal reporting, and care plan adherence.
Deficiencies (7)
| Description |
|---|
| Failure to report medication error involving Resident #1's missed administration of Simethicone 125 mg and Olopatadine Drops 0.1%. |
| Resident #2 did not receive assistance with personal hygiene as indicated in the support plan, receiving only four showers instead of two per week. |
| Failure to implement safe storage, access, security, distribution and use of medications and medical equipment by trained staff. |
| Failure to report refusals of medication to prescriber for multiple residents on multiple dates. |
| Failure to follow prescriber's orders for medication administration and blood glucose checks for Residents #1 and #2. |
| Medication error reporting failure for Resident #1's missed medication administration and failure to notify resident, responsible party, and prescriber. |
| Medication record did not indicate units of insulin administered for Resident #3 with sliding scale insulin order. |
Report Facts
License Capacity: 245
Residents Served: 91
Secured Dementia Care Unit Capacity: 50
Residents Served in Dementia Unit: 29
Hospice Residents: 10
Residents 60 Years or Older: 90
Residents with Mobility Need: 33
Residents with Physical Disability: 2
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 445
Inspection Report
Complaint Investigation
Census: 85
Capacity: 245
Deficiencies: 2
Feb 28, 2022
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident involving resident care and safety concerns at Brandywine Senior Living at Senior Suites.
Findings
The inspection found violations related to inadequate personal hygiene care and supervision of a resident, resulting in neglect and an accidental death due to environmental hypothermia. The facility failed to provide required toileting, hygiene, and fall risk monitoring, and door alarms were not properly responded to, leading to the resident's exposure to the elements.
Complaint Details
The visit was complaint-related due to an incident where resident #1 was found deceased outside the facility after failing to receive required supervision and care. The death was ruled accidental with environmental hypothermia as a contributing factor. The facility failed to respond to door alarms and did not adequately monitor the resident overnight.
Deficiencies (2)
| Description |
|---|
| Failure to provide toileting and routine hygienic care for resident #1 as indicated in the resident’s assessment and support plan. |
| Resident #1 was neglected, resulting in accidental death due to environmental hypothermia after leaving the facility unsupervised. |
Report Facts
License Capacity: 245
Residents Served: 85
Secured Dementia Care Unit Capacity: 50
Residents Served in Dementia Unit: 23
Residents 60 Years or Older: 84
Residents with Mobility Need: 40
Staffing Hours - Total Daily Staff: 125
Staffing Hours - Waking Staff: 94
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 445
Census at Inspection: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the enforcement letter regarding license revocation and provisional license issuance |
Notice
Capacity: 245
Deficiencies: 0
May 14, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Brandywine Senior Living at Senior Suites, a Personal Care Home, following receipt of the renewal application dated February 16, 2021.
Findings
The Department advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations. No findings or deficiencies are reported in this document.
Report Facts
Total licensed capacity: 245
Secure Dementia Care Unit capacity: 50
Inspection Report
Renewal
Census: 68
Capacity: 100
Deficiencies: 14
Mar 31, 2021
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements for Meadow Glen at Phoebe Richland.
Findings
The inspection identified multiple deficiencies related to safety, medication management, documentation, and resident involvement in care planning. Plans of correction were submitted and determined to be fully implemented by the follow-up dates.
Deficiencies (14)
| Description |
|---|
| Poisonous materials (fluoride toothpaste) were unlocked and accessible to residents not assessed as capable of safe use. |
| Emergency telephone numbers were not posted on or by the telephone in resident room #112. |
| First aid kit in the 2nd floor medication room did not include a thermometer. |
| No system to safeguard resident laundry from loss; residents reported lost bed sheets and blankets. |
| Resident #2's medical evaluation did not include ability to self-administer medications and health status. |
| Menus posted in the secured dementia care unit dining area were for past weeks, not current or upcoming week. |
| Medications in med carts lacked open date labels as required by manufacturer instructions. |
| Pharmacy label for resident #3 did not reflect changed medication order (no direction change sticker). |
| Resident #5's prescribed medication for chest pain as needed was not available in the home on 04/01/2021. |
| Resident #6's glucometer reading was not logged as required. |
| Resident #3's twice daily medication was not administered on 04/01/2021 due to unavailability; staff initialed MAR without administration. |
| Resident #5's March MAR lacked staff initials for medication administration on 03/13/2021 at 07:30 AM. |
| Resident #7 was administered a chemical restraint medication to control behaviors on multiple dates without appropriate indication. |
| Resident #8's support plan was finalized without involvement of the resident or designated person. |
Report Facts
License Capacity: 100
Residents Served: 68
Secured Dementia Care Unit Capacity: 38
Secured Dementia Care Unit Residents Served: 32
Hospice Residents: 4
Residents 60 Years or Older: 67
Residents with Mobility Need: 38
Total Daily Staff: 106
Waking Staff: 80
Inspection Report
Follow-Up
Census: 61
Capacity: 245
Deficiencies: 16
Feb 3, 2021
Visit Reason
The inspection was conducted as a renewal and incident review of Brandywine Senior Living at Senior Suites to verify compliance and implementation of the submitted plan of correction.
Findings
The inspection found multiple deficiencies related to resident dignity and respect, privacy violations, training deficiencies, unsafe storage of poisonous materials, sanitary conditions, medication storage and administration errors, and failure to implement positive interventions. The submitted plan of correction was determined to be fully implemented with ongoing monitoring and training scheduled.
Deficiencies (16)
| Description |
|---|
| Staff person took a picture of a resident during incontinent care and posted it on social media without consent. |
| Resident privacy was violated during bathing and medical procedures. |
| Direct care staff did not receive required annual training on medication self-administration and infection control. |
| Poisonous materials (fluoride toothpaste) were unlocked and accessible to residents not assessed as safe to use them. |
| Bathroom lacked hand drying options and had pink mold stains. |
| Trash cans in kitchen were uncovered. |
| Residents' bedroom doors were locked, restricting access. |
| No thermometer in ice-cream freezer. |
| Food stored uncovered or unsealed (ice cream tub uncovered, rice bag open). |
| Expired eye drops found in medication cart beyond manufacturer recommended discard date. |
| Medication labeling did not reflect updated dosage instructions. |
| Medication administration records showed discrepancies and missing signatures. |
| Resident was not redirected or de-escalated during behavioral episode, resulting in injury. |
| Preadmission screening form lacked determination that resident's needs could be met. |
| Resident's condition changed significantly but additional assessments were not completed timely. |
| Resident record entries were illegible and improperly altered without notation. |
Report Facts
License Capacity: 245
Residents Served: 61
Secured Dementia Care Unit Capacity: 40
Secured Dementia Care Unit Residents Served: 17
Staff Total Daily Staff: 92
Staff Waking Staff: 69
Number of Residents with Mobility Need: 31
Number of Residents Age 60 or Older: 60
Medication Discrepancy: 1
Trash Cans Uncovered: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Reviewer | Signed letter regarding plan of correction implementation |
| Wellness Director | Responsible for auditing training records, medication administration, and monitoring compliance | |
| Executive Director | Ensured removal of inappropriate social media post and staff training | |
| Dining Service Director | Responsible for ensuring trash can lids and food storage compliance | |
| Reflections Coordinator | Performed daily and monthly checks for locked poisonous materials and unlocked doors | |
| Care Manager | Involved in behavioral incident; suspended and terminated |
Inspection Report
Renewal
Census: 61
Capacity: 245
Deficiencies: 15
Feb 3, 2021
Visit Reason
The inspection was conducted as a renewal inspection and incident review for Brandywine Senior Living at Senior Suites.
Findings
The inspection identified multiple deficiencies including violations related to resident dignity and privacy, training deficiencies, unsafe storage of poisonous materials, sanitary conditions, medication administration and documentation errors, and failure to implement positive interventions. Plans of correction were accepted or directed with specified completion dates.
Deficiencies (15)
| Description |
|---|
| Staff person took a picture of resident during incontinent care and posted it on social media without consent. |
| Poisonous materials (fluoride toothpaste) were unlocked and accessible to residents not assessed as safe to use them. |
| Bathrooms lacked sanitary conditions including no hand drying options and pink mold stains. |
| Trash cans in kitchen were uncovered. |
| Residents' bedroom doors were locked, restricting access. |
| No thermometer in ice-cream freezer. |
| Food stored uncovered or unsealed. |
| Expired eye drops found in medication cart. |
| Medication labeling did not reflect updated dosage instructions. |
| Medication administration records had discrepancies and missing signatures. |
| Resident's insulin dose units not documented on medication administration record. |
| Failure to use positive interventions to manage resident behavior resulting in injury. |
| Resident preadmission screening form lacked determination that needs could be met. |
| Resident assessments not updated after significant condition changes. |
| Resident record entries were illegible and altered without proper notation. |
Report Facts
License Capacity: 245
Residents Served: 61
Secure Dementia Care Unit Capacity: 40
Secure Dementia Care Unit Residents Served: 17
Staffing Hours: 92
Waking Staff: 69
Residents with Mobility Need: 31
Hospice Residents: 3
License Capacity Revision: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Gonzalez | Administrator | Named as facility administrator. |
| Jamie Buchenauer | Deputy Secretary | Signed licensing approval and correspondence. |
| Marla Nadelstumph | VP of Organizational Development & Program Excellence | Correspondence author regarding capacity revision. |
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