Brandywine Living at Haverford Estates.

“The drain cover in the first floor men's public restroom is not secured to the drain and pops off when stepped on, creating a tripping hazard.”

“Staff member C completed 40 scheduled work hours in February 2025 but had not completed required training in emergency medical plan and reporting of reportable incidents and conditions. This is a repeat violation.”

“A dining room chair in the private dining room had a left front leg that buckled inward and was not securely attached to the frame, creating a safety hazard.”

“A resident was observed smoking in their room on several occasions, which is not the home's designated smoking area. Housekeeping staff found evidence of smoking including ashes in sink and cigarette butts in a cup with water.”

“A resident's assessment identified needs for transferring in/out of bed/chair, toileting, ambulating, and managing health care, but the support plan did not document how these needs would be met. This is a repeat violation.”

“Resident was admitted to the home, but the preadmission screening form was completed after the 30-day prior-to-admission requirement. The screening date was recorded as 7/26/2025 instead of the correct date of 6/26/2025 due to a typographical error.”

“A resident's assessment did not include the resident's mental health needs, even though the home became aware of the resident's mental health needs. The assessment was not updated to reflect significant changes in the resident's condition.”

“A resident's assessment indicated a need for a mobility device, but the resident's support plan did not document how this medical need would be met. This is a repeat violation.”

“A resident participated in the development of their support plan but did not sign the support plan. This is a repeat violation.”

“A resident's medical evaluation was not completed on the Department's current standardized form.”

“Facility failed to report medication errors to the Department within 24 hours. Resident 1 did not receive Atorvastatin 10 mg and Quetiapine Fumarate 75 mg on 12/4/2023 at 8:00 pm, and did not receive Quetiapine Fumarate 75 mg on 12/5/2023 and 12/6/2023 at 8:00 pm. None of these incidents were reported to the Department.”

“Resident records were not kept confidential. A handwritten task log containing multiple residents' names and confidential medical information including blood pressures, weights, medications, medication refusals, information about deceased residents, and hospital visits was found in Resident 1's belongings.”

“Facility failed to follow prescriber's orders for medication administration. Resident 1 was not administered Atorvastatin 10 mg and Quetiapine Fumarate 75 mg on 12/4/2023 at 8:00 pm because the medications were not available. On 12/5/2023 and 12/6/2023, Resident 1 received only 25 mg of Quetiapine Fumarate instead of the prescribed 75 mg.”

“Facility failed to immediately report medication errors to the prescriber. Resident 1 did not receive prescribed Atorvastatin 10 mg and Quetiapine Fumarate 75 mg on 12/4/2023 at 8:00 pm, and received only 25 mg of Quetiapine Fumarate on 12/5/2023 and 12/6/2023. None of these medication errors were reported to the prescriber.”

“Facility failed to make resident records available timely to the resident's designated person. The designated person requested access to Resident 1's records in writing on 2/19/2024, but records were not provided until May 8, 2024.”

“Staff Person A forcefully grabbed a resident by the arm causing bruising, shoved them onto a rollator, and pushed them aggressively into the bathroom on 3/23/2024 at approximately 4:45 am. Staff Person B subsequently refused to provide the resident access to their cell phone when requested. The resident required assistance with bathroom use and could not walk without assistance.”

“The home failed to report three incidents to the Department within 24 hours as required: a missing jewelry box from a resident's dresser, a resident's hospital admission, and an incident involving residents.”

“Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry as required.”

“Direct care staff persons B and C did not receive required annual training topics during 2022, including medication self-administration training, instruction on meeting resident needs, care for residents with dementia and cognitive impairments, infection control and hygiene, personal care service needs, safe management techniques, and care for residents with mental illness or intellectual disability.”

“A resident's record did not include a current list of prescription, CAM, and OTC medications required for residents who are self-administering medication.”

“A resident's initial assessment, completed within 15 days of admission, did not include assessment for required behavioral or cognitive needs including orientation to time, place, and person, irritability, judgment, agitation, aggression, and short and long-term memory.”

“Staff member referred to resident by room number instead of name, violating dignity and respect requirements. Resident expressed disappointment at being called 'room #9' instead of by their name.”

“Posted contact information for ombudsman office contained an incorrect name on the poster board provided by the Ombudsman Agency.”

“Front door alarm system device was not in good repair, creating an unsecured entrance. The door was swollen and did not close properly. Additionally, the lock in the mailbox unit was broken.”

“Approximately 1/4 inch accumulation of lint was found in the lint cavity of the clothes dryer, creating a fire hazard.”

“A bottle of OTC medication belonging to a resident was found in the medication cart and was not labeled with the resident's name.”

“A resident who participated in the development of their support plan did not sign the support plan at the time of development, signing it at a later date instead.”

“A resident was pushed by a family member visiting another resident. The incident was observed by staff and reported to the Wellness Director, but was not reported to the local area agency on aging as required.”

“A resident was pushed by a family member visiting another resident. The incident was observed by staff and reported to the Wellness Director, but the home did not report the incident to the Department within 24 hours.”

“A resident was screamed at and pushed by a family member visiting another resident. The incident was observed by staff but not properly reported or investigated. The family member's actions constituted physical abuse of the resident.”

“A visitor screamed at a resident. The incident was observed by staff but not properly investigated or reported by the Wellness Director to whom it was disclosed.”