01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-09-13 | 2 | 2024-09-13 | 7 |
| Cycle 2 | 2023-10-20 | 1 | 2023-10-20 | 7 |
| Cycle 3 | 2022-12-08 | 2 | 2022-12-08 | 5 |
CMS CCN 3960622026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Inn At Freedom Village,The
35 Freedom Boulevard · West Brandywine, PA 19320 · Chester County
Certified beds60CMS provider file
Recent citation rows24current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
24 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2024-09-13 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-10-102024-09-13 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2024-10-102024-09-13 · FIREK0225Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Correction field: Deficient, Provider has date of correction · 2024-11-112024-09-13 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2024-11-112024-09-13 · FIREK0324Severity C · widespread; potential for minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-11-112024-09-13 · FIREK0363Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2024-12-202024-09-13 · FIREK0712Severity C · widespread; potential for minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2024-11-112024-09-13 · FIREK0754Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Provide properly sized and located linen or trash receptacles.
Correction field: Deficient, Provider has date of correction · 2024-11-112024-09-13 · FIREK0918Severity C · widespread; potential for minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2024-11-112023-10-20 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2023-11-242023-10-20 · FIREK0100Severity C · widespread; potential for minimal harm
Construction Deficiencies
Meet other general requirements.
Correction field: Deficient, Provider has date of correction · 2023-12-112023-10-20 · FIREK0345Severity C · widespread; potential for minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2023-12-112023-10-20 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2023-12-112023-10-20 · FIREK0355Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2023-12-112023-10-20 · FIREK0531Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have elevators that firefighters can control in the event of a fire.
Correction field: Deficient, Provider has date of correction · 2023-12-112023-10-20 · FIREK0761Severity C · widespread; potential for minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2023-12-112023-10-20 · FIREK0914Severity C · widespread; potential for minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Correction field: Deficient, Provider has date of correction · 2023-12-112022-12-08 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2023-01-152022-12-08 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2023-01-152022-12-08 · FIREK0291Severity C · widespread; potential for minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2022-12-232022-12-08 · FIREK0293Severity C · widespread; potential for minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2022-12-232022-12-08 · FIREK0353Severity C · widespread; potential for minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2022-12-232022-12-08 · FIREK0918Severity C · widespread; potential for minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2022-12-232022-12-08 · FIREK0929Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Correction field: Deficient, Provider has date of correction · 2022-12-2303 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CCRC OPCO VENTURES LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 03/19/2026
- CCRC OPCO VENTURES LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 03/19/2026
- HCP MA3 GP HOLDING, LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 03/19/2026
- HCP VENTURES II TRS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 03/19/2026
- HEALTHPEAK OP LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/10/2023
- JANUS LIVING TRS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 03/19/2026
- OCEAN ACQUISITION I LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 03/19/2026
- BRANDYWINE PROPCO 1, LLCOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 03/19/2026
- CHENG, PATRICKIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/31/2022
- RUSSO, FRANKIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/31/2022
- MALAWI, LORNAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/06/2023
- LIFE CARE SERVICES LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2020
- GEYER, DANIELLEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/09/2022
- MALAWI, LORNAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/06/2023
- ULICHNEY, ANDREWIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2025
- HCP MA3, LPOrganization · LIMITED PARTNERSHIP INTERESTNOT APPLICABLE · since 03/19/2026
- HCP PARTNERS LPOrganization · LIMITED PARTNERSHIP INTERESTNOT APPLICABLE · since 03/19/2026
- BLACKROCK INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/19/2026
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.65per resident day
RN hours1.15per resident day
Weekend nurse hours4.28per resident day
Staff turnover38.6%CMS reported field
06 / LOCAL RECORDS
Open the Pennsylvania ledger →Other published facilities nearby
No second facility in the same city met the directory rule.