32 Reports
Inspection Report — Apr 7, 2026
Follow-Up
Date: Apr 7, 2026
Visit Reason
This visit was an unannounced partial inspection conducted as a follow-up to verify the implementation of a previously submitted plan of correction for the facility.
Findings
The inspection found repeated violations related to sanitary conditions, medication storage and administration, and resident assessments. The facility has implemented corrective actions including retraining staff, conducting audits, and updating resident records to ensure compliance.
Citations (8)
85a Sanitary conditions were not maintained as a resident room had a strong pungent odor. The housekeeper cleaned the room and audits were scheduled to ensure ongoing compliance.
101o Bedrooms had walls, floors, and ceilings that were not clean and in good repair as a resident room had an overflowing trashcan with food items and debris on the floor. Maintenance cleaned and audits were established.
103e Leftover food items in the 400 hall kitchenette refrigerator were unlabeled and undated. The dining director removed the food and staff were retrained on labeling requirements.
183b Prescription and OTC medications were found unlocked, unattended, and accessible in multiple resident rooms. Medications were removed, staff retrained, and weekly audits initiated.
183f Discontinued and expired medications were found in a resident room. The expired medication was removed and staff retrained on proper disposal procedures.
185a The facility failed to have certain prescribed PRN medications available in the home. Medications were obtained and staff trained on medication availability policies.
187a Medication records did not include special administration instructions for some residents. Records were corrected and staff trained on documentation requirements.
225c Resident assessments lacked accurate documentation of dietary needs, personal care needs, and supervision requirements. Assessments were corrected and staff retrained.
Report Facts
Residents Served: 86
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 7
Inspection Report — Jan 28, 2026
Renewal
Date: Jan 28, 2026
Visit Reason
The inspection was conducted as a renewal and complaint investigation to review compliance and verify the submitted plan of correction.
Complaint Details
The inspection included a complaint investigation regarding alleged staff abuse of Resident #1, which was substantiated with findings of physical abuse and improper restraint use. Staff members involved were suspended and no longer employed.
Findings
The inspection identified multiple deficiencies including failure to timely report incidents, breaches of resident record confidentiality, improper use of restraints, medication errors, and safety hazards such as obstructed egress and unlabeled carbon monoxide alarm batteries. Plans of correction were accepted and implemented with ongoing monitoring.
Citations (14)
16c - Written Incident Report: The home failed to report an allegation of staff to resident abuse to the Department within 24 hours as required.
17 - Record Confidentiality: Resident personal information and evacuation lists were found unlocked and accessible in unsecured areas.
18 - Compliance With Laws: Carbon monoxide detectors were labeled with unclear dates, failing to meet labeling requirements.
42b - Abuse: Staff used a wheelchair to restrict Resident #1's movement against policy and the resident was subjected to taunting and physical aggression.
100b - Removal Snow/Obstructions: Snow and ice accumulation obstructed exterior walkways and stairwell exits near the Secure Dementia Care Unit.
121a - Unobstructed Egress: Ice and snow blocked the stairwell exit door near the Secure Dementia Care Unit, preventing door opening.
132c - Fire Drill Records: Fire drill records lacked documentation of evacuation times for multiple drills.
171b5 - First Aid Kit: The first aid kit in the home's transport van was missing a thermometer.
183b - Meds and Syringes Locked: Prescription medications and ointments were found unlocked and accessible in common areas and resident rooms.
184a - Resident's Meds Labeled: Resident #1's medication label instructions conflicted with the prescribed dosage and administration time.
185a - Implement Storage Procedures: Resident #7's blood glucose readings were inaccurately documented due to glucometer time calibration errors.
187a - Medication Record: Resident #7's medication administration record documented incorrect insulin doses on multiple dates.
202 - Prohibitions: Staff used a wheelchair as a mechanical restraint on Resident #1, restricting movement contrary to policy.
225c - Additional Assessment: Resident #7's assessment was not updated to reflect a change in mobility needs; Resident #8's assessment lacked updates for behavioral and cognitive changes.
Report Facts
Residents Served: 86
Secured Dementia Care Unit Residents Served: 24
Current Residents in Hospice: 8
Carbon Monoxide Alarms: 33
Medication Rooms Audited: 14
Medication Rooms Audited Weekly: 7
Medication Audit Charts: 5
Inspection Report — Mar 13, 2025
Complaint Investigation
Date: Mar 13, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a review by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, on 03/13/2025.
Complaint Details
The visit was complaint-related, triggered by allegations of neglect and abuse. The complaint was substantiated based on findings of resident neglect, failure to secure hazardous areas, and failure to report incidents.
Findings
The inspection found multiple deficiencies including failure to report an incident of a resident found unattended and injured, neglect and lack of supervision leading to resident harm, unsecured hazardous areas, improper medication administration, and failure to maintain trash receptacles properly. Plans of correction were accepted and implemented with ongoing monitoring.
Citations (4)
Failure to report an incident of a resident found unattended on the floor with injuries to the Department within 24 hours.
Neglect and failure to provide supervision and assistance devices to a resident found unattended in an unsecured utility room.
Trash outside the home was kept in uncovered receptacles allowing penetration of insects and rodents.
Failure to properly observe and ensure ingestion of prescribed medications by a resident.
Report Facts
Residents Served: 75
Residents Served in Dementia Unit: 21
Hospice Residents: 4
Residents Age 60 or Older: 75
Residents with Mobility Need: 28
Residents Receiving Supplemental Security Income: 1
Inspection Report — Dec 3, 2024
Renewal
Date: Dec 3, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements on 12/03/2024 and 12/04/2024.
Findings
The facility was found to have multiple deficiencies including lack of carbon monoxide detectors near gas dryers, unsecured enabler bars posing hazards, odors in resident rooms, hot water temperature exceeding limits, stained floors, medication storage and labeling issues, and incomplete resident assessments. Plans of correction were submitted and implemented with ongoing audits and staff retraining to ensure compliance.
Citations (13)
No carbon monoxide detector/alarm observed near gas-powered commercial dryers.
Enabler bar partially covered with an opening posing entrapment and fall hazards.
Resident bedroom had an odor of urine.
Hot water temperature in resident bathroom measured 132.8°F, exceeding 120°F limit.
Resident bedroom floor heavily stained and covered in debris.
Medications not kept in original labeled containers; blue pill box found in hall medication cart.
Prescription medications and syringes not kept locked; medication bottle found unsecured in resident's room.
Discontinued medications found in medication carts.
OTC medications and CAM not labeled with resident's name.
PRN medication not available in the home as prescribed.
Medication record did not reflect correct dose and frequency for a resident's medication.
Medication not administered as prescribed due to unavailability.
Resident assessment did not reflect specific need, risks, or proper documentation for bedside mobility device.
Report Facts
Residents Served: 73
Secured Dementia Care Unit Residents Served: 23
Current Hospice Residents: 6
Residents with Mobility Need: 30
Residents Age 60 or Older: 73
Supplemental Security Income Recipients: 1
Total Daily Staff: 103
Waking Staff: 77
Inspection Report — Nov 5, 2024
Complaint Investigation
Date: Nov 5, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Complaint Details
The inspection was triggered by a complaint and incident; no deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 64
Secured Dementia Care Unit Residents Served: 22
Current Hospice Residents: 6
Residents with Mobility Need: 30
Residents 60 Years or Older: 64
Residents Receiving Supplemental Security Income: 1
Inspection Report — May 29, 2024
Follow-Up
Date: May 29, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, to review the submitted plan of correction for previous deficiencies.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies related to support plan signatures and preadmission screening for the secured dementia care unit were addressed with staff retraining and audits to ensure compliance.
Citations (2)
Resident assessment and support plan did not include required staff member or resident signatures indicating participation in the development of the support plan.
Resident's written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit.
Report Facts
Residents Served: 52
Residents Served in SDCU: 21
Current Hospice Residents: 5
Resident Support Staff: 0
Total Daily Staff: 79
Waking Staff: 59
Inspection Report — Jan 17, 2024
Renewal
Date: Jan 17, 2024
Visit Reason
The inspection was conducted as a full, unannounced review for renewal, complaint, and incident reasons at the facility.
Findings
The inspection identified multiple deficiencies including failure to report suspected resident abuse timely, incidents of resident abuse, privacy violations, unsecured poisonous materials, uncovered trash receptacles, equipment hazards, improper food storage, failure to submit emergency procedures annually, incomplete medical evaluations, missing menus, medication availability issues, and incomplete preadmission screenings. Plans of correction were accepted and implemented with ongoing monitoring.
Citations (15)
Failure to immediately report suspected resident abuse to the local area agency on aging.
Failure to report a physical altercation incident to the Department within 24 hours.
Resident abuse incidents involving physical altercations resulting in bruises.
Lack of written notification for use of voice-controlled Alexa device in common area.
Unsecured poisonous materials accessible to residents in the secured dementia care unit.
Full, uncovered, unattended trash can in the main dining room.
Exposed gas pipe posing a tripping hazard in room 304.
Walk-in freezer temperature above required level (9-10°F instead of ≤0°F).
Uncovered tubs of ice cream in the bistro freezer.
Failure to review and submit written emergency procedures annually to local emergency management agency.
Resident medical evaluation missing medication regimen and medical professional's signature, date, and license number.
Resident medical evaluations not completed annually as required.
Menus not posted one week in advance as required.
Medications prescribed to residents were not available and thus not administered.
Resident's written cognitive preadmission screening not completed within 72 hours prior to admission to secured dementia care unit.
Report Facts
Residents Served: 50
Residents Served in Secured Dementia Care Unit: 21
Current Hospice Residents: 4
Residents Age 60 or Older: 50
Residents with Mobility Need: 23
Freezer Temperature: 10
Freezer Temperature: 9
Inspection Report — Feb 22, 2023
Renewal
Date: Feb 22, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation to review compliance with licensing requirements and verify the submitted plan of correction.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for visit and review of submitted plan of correction.
Findings
The inspection identified multiple deficiencies including staff qualifications, training, medication administration, sanitary conditions, safety issues, and documentation errors. Plans of correction were accepted and implemented with ongoing audits and retraining scheduled to ensure compliance.
Citations (26)
Direct care staff persons hired did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
No staff working on certain dates were trained in first aid and certified in obstructed airway techniques and CPR.
Direct care staff persons did not complete training on Resident Rights and Reportable Incidents within 40 scheduled working hours.
Poisonous materials were unlocked, unattended, and accessible to residents in the Secure Dementia Care Unit.
Soiled adult diaper found behind the toilet in the public bathroom in Secure Dementia Care Unit activity room.
Cabinet doors in the Secure Dementia Care Unit kitchenette/dining area contained sticky dried food residue; bathroom floor had dried fecal matter.
Hot water temperature in resident accessible area exceeded 120°F (measured 125°F).
Emergency telephone numbers were not posted on or by telephones in the Secure Dementia Care Unit and 400 hallway.
Carpet in room 405 had various liquid stains and food particles.
No toilet paper in the public bathroom in Secure Dementia Care Unit activity room.
Accumulation of lint in the lint trap of the dryer in the 500 hallway.
No current certificate of rabies vaccination for cats belonging to two residents.
An unannounced monthly fire drill was not documented for November 2022; fire drill records lacked evacuation details.
Resident medical evaluations were not current for several residents.
Staff member transporting residents alone did not have direct care training certification.
Resident medication administration record did not include all current prescribed and over-the-counter medications.
Resident repackaged medication into an unoriginal container.
Medication packaging was torn, exposing medication.
Expired medications were found in resident's room.
Resident medication was not administered due to unavailability in the home.
Preadmission screening forms were missing for several residents.
Resident support plan did not include required assistance information.
Resident support plans were not signed or dated by staff who completed them.
Directions for operating key-locking devices were not conspicuously posted; exit code did not unlock doors.
Resident record did not have a current photo no more than 2 years old.
Laptop computer on medication cart was left unsecured, exposing resident medication information.
Report Facts
Residents Served: 48
Residents in Secure Dementia Care Unit: 16
Current Hospice Residents: 7
Residents Age 60 or Older: 48
Residents with Mobility Need: 31
Staff Total Daily: 79
Staff Waking: 59
Notice — Jul 13, 2021
Date: Jul 13, 2021
Visit Reason
The document serves to notify that a waiver request to delay completion of administrator training requirements was granted for Brookdale Grandon Farms.
Findings
The waiver is granted under specific conditions including attendance at a department-approved orientation course and documentation of training to be maintained by the facility. Non-compliance may result in termination of the waiver or other licensing actions.
Report Facts
Scheduled orientation date: Aug 18, 2021
Inspection Report — Apr 8, 2021
Routine
Date: Apr 8, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — Dec 3, 2020
Date: Dec 3, 2020
Visit Reason
This document serves as a license renewal notification and certificate of compliance for Brookdale Grandon Farms Personal Care Home. It informs the facility of the Department's requirement to conduct an annual onsite inspection within the next twelve months.
Findings
The document confirms issuance of a regular license in response to the renewal application. It advises that if non-compliance is found during the upcoming inspection, enforcement actions will be taken.
Report Facts
Inspection Report — Oct 30, 2019
Renewal
Date: Oct 30, 2019
Visit Reason
The inspection was a renewal/settlement review conducted on October 30 and 31, 2019, to assess compliance with licensing requirements at Brookdale Grandon Farms.
Findings
The submitted plan of correction was accepted, fully implemented, and in compliance. One deficiency was identified related to missing signage for key-locking devices at the secured dementia care unit exit door.
Citations (1)
Regulation 2600.233(c): The operation code for the door to the courtyard in the secure dementia unit was not posted at the exit. The facility corrected this by reposting the code and implementing ongoing audits.
Report Facts
Residents Served: 71
Memory Care Residents Served: 17
Current Hospice Residents: 9
Resident Support Staff: 71
Total Daily Staff: 173
Waking Staff: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Weidman | Administrator | Named as facility administrator and signed plan of correction |
| Michael Showers | On-site department representative during inspection | |
| Michael Palermo | On-site department representative during inspection | |
| Brett Swanger | Human Services Licensing Supervisor | Signed letter accepting plan of correction |
Notice — Oct 15, 2019
Date: Oct 15, 2019
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home facility Brookdale Grandon Farms. It informs the facility that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It is a license renewal notice confirming the issuance of a regular license and outlining future inspection requirements.
Report Facts
Inspection Report — May 14, 2019
Complaint Investigation
Date: May 14, 2019
Visit Reason
The inspection was conducted as an incident investigation following a complaint or allegation at Brookdale Grandon Farms.
Complaint Details
The inspection was an incident investigation triggered by a complaint. The violation involved a missing resident signature on a contract.
Findings
A violation was found related to the resident-home contract not being signed by the resident. The facility was required to correct this citation and maintain compliance with 55 Pa.Code Ch. 2600.
Citations (1)
Regulation 2600.25.b: The resident-home contract dated 3/15/19 for Resident #1 was not signed by the resident.
Report Facts
Residents Served: 69
Residents Served in Dementia Care Unit: 15
Current Hospice Residents: 6
Resident Support Staff Total Daily Staff: 96
Waking Staff: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Weidman | Administrator | Named as the facility administrator in the violation report. |
Notice — Jan 16, 2019
Date: Jan 16, 2019
Visit Reason
The document communicates the Department of Human Services' decision that a waiver for direct care staff qualifications is not needed based on submitted educational documentation.
Findings
The Department reviewed the waiver request and confirmed that the staff member meets educational qualifications for direct care staff without needing a waiver.
Report Facts
Pa.Code section: 2600.54
Pa.Code subsection: 54
Pa.Code paragraph: 2
Waiver request count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the waiver determination letter |
Inspection Report — Dec 17, 2018
Renewal
Date: Dec 17, 2018
Visit Reason
The inspection was a renewal licensing inspection conducted on December 17 and 18, 2018, to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Findings
Violations were found related to confidentiality of resident records, carbon monoxide detectors, staff training in infection control, fire safety, and falls prevention, cleanliness and maintenance issues, prohibited portable space heaters, smoking area safety, transportation staff training, and first aid kit contents. Plans of correction were submitted and partially or fully implemented by January 2019.
Citations (9)
Regulation 2600.17: Resident records containing confidential information were found unsecured in an unlocked drawer accessible to residents and visitors.
Regulation 2600.18: Gas burning PTAC units in resident rooms lacked required carbon monoxide detectors.
Regulation 2600.65(f): Staff Member B did not receive infection control training during 2017.
Regulation 2600.65(g): Staff Member C did not receive fire safety and falls prevention training during 2017.
Regulation 2600.88(a): Kitchen ductwork was covered in grease and dust; ceiling above food prep area was stained.
Regulation 2600.127(a): A portable space heater was found in the home's mechanical room, which is prohibited.
Regulation 2600.144(c): The designated smoking area contained a red upholstered chair not made of fire resistant material.
Regulation 2600.171(b)(4): Staff Member D providing resident transportation had not completed required direct care training as of 12/12/18.
Regulation 2600.171(b)(5): The first aid kit in the home's bus lacked eye coverings.
Report Facts
Residents Served in Secured Dementia Care Unit: 18
Total Daily Staff: 69
Waking Staff: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Weidman | Administrator | Named in violation report signature and plan of correction |
| Staff Member B | Did not receive infection control training in 2017 | |
| Staff Member C | Did not receive fire safety and falls prevention training in 2017 | |
| Staff Member D | Did not complete required direct care training for transportation staff as of 12/12/18 |
Inspection Report — Nov 15, 2018
Enforcement
Date: Nov 15, 2018
Visit Reason
The inspection was conducted as a complaint and incident investigation with multiple on-site visits on November 15, 2017, November 20, 2017, and December 18, 2017, related to violations found at Brookdale Grandon Farms.
Complaint Details
The inspection was complaint-related involving allegations of abuse, neglect, failure to report incidents, medication errors, and recordkeeping deficiencies. The substantiation status is implied by the enforcement action and license revocation.
Findings
The facility was found to have multiple violations including failure to provide immediate access to resident records, failure to report suspected abuse, neglect and abuse of residents, medication administration errors, incomplete resident records, and unsanitary conditions. The Department revoked the facility's license and intends to assess fines unless corrections are made.
Citations (12)
Regulation 55 Pa.Code §2600 2600.5(a)(1) - The administrator failed to provide immediate access to resident records upon request on 11/20/17.
Regulation 55 Pa.Code §2600 2600.15(a) - The home failed to report suspected abuse of a resident by Resident #1 to the local area agency on aging as required.
Regulation 55 Pa.Code §2600 2600.16(c) - The home failed to submit reportable incident reports to the Department for sexual assaults by Resident #1.
Regulation 55 Pa.Code §2600 2600.42(b) - The home failed to protect female residents in the Secure Dementia Care Unit from abuse by Resident #1.
Regulation 55 Pa.Code §2600 2600.182(b) - Direct care staff members A, B, C, D, and E administered medications without completing required medication administration training.
Regulation 55 Pa.Code §2600 2600.252 - Resident #1's record did not include the date of discharge, destination, or reason for discharge.
Regulation 55 Pa.Code §2600 2600.16(c) - The home failed to notify the Department of a resident ingesting a poisonous material on 1/27/18 resulting in hospitalization.
Regulation 55 Pa.Code §2600 2600.420(b) - Resident #1 was found to have physically abused female residents in the Secure Dementia Care Unit.
Regulation 55 Pa.Code §2600 2600.54(a) - Direct care staff person B lacked a high school diploma or active registration on the Pennsylvania Nurse Aide Registry.
Regulation 55 Pa.Code §2600 2600.82(c) - The home failed to maintain sanitary conditions; a blue plastic container in the Secure Dementia Care Unit was unlabeled and undated.
Regulation 55 Pa.Code §2600 2600.184(a) - The home failed to properly label medication containers with required pharmacy information.
Regulation 55 Pa.Code §2600 2600.225(c) - Resident #1's assessment and support plan was not updated timely to address fall prevention and safety interventions.
Report Facts
Fine per day: 485
Number of violations: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Hofsass | Executive Director | Named as legal entity representative signing plans of correction and involved in retraining and corrective actions |
| Jacqueline L. Rowe | Director | Signed enforcement letter regarding license revocation |
| Shivani Patel | Enforcement Manager | Named in enforcement letter for appeal contact |
Inspection Report — Nov 6, 2018
Date: Nov 6, 2018
Visit Reason
The inspection was conducted by the Department’s Bureau of Human Services Licensing on November 6 and 7, 2018, related to compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
A citation was found for a direct care staff member lacking a high school diploma, GED diploma, or active registration on the Pennsylvania Nurse Aide Registry. The facility submitted a plan of correction and later provided documentation meeting educational qualifications.
Citations (1)
Regulation 55 Pa.Code §2600.54(a) requires direct care staff to have a high school diploma, GED diploma, or active registration on the Pennsylvania Nurse Aide Registry. Direct care Staff Member A did not meet these qualifications at the time of inspection.
Report Facts
Number of Residents Served: 69
Number of Residents Served in Secured Dementia Care Unit: 17
Number of Current Hospice Residents: 7
Number of Hospice Residents in Past Year: 10
Number of Residents Age 60 or Older: 67
Number of Residents with Mental Illness: 3
Number of Residents with Intellectual Disability: 0
Number of Residents with Mobility Need: 40
Number of Residents with Physical Disability: 1
Number of Residents Receiving Supplemental Security Income: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judith Carrabbia | Administrator | Named as facility administrator |
Notice — Aug 7, 2018
Date: Aug 7, 2018
Visit Reason
This letter responds to a waiver request submitted by Brookdale Grandon Farms related to qualifications for direct care staff persons under Pennsylvania Code Chapter 2600.
Findings
The Department determined that a waiver is not needed because the submitted documentation meets the educational qualifications for a direct care staff person. The facility is advised to keep a copy of the educational documentation in personnel files.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the waiver response letter. |
Inspection Report — Jul 3, 2018
Complaint Investigation
Date: Jul 3, 2018
Visit Reason
The inspection was conducted as an unannounced incident investigation related to violations of 55 Pa.Code Chapter 2600 for Personal Care Homes.
Complaint Details
The inspection was triggered by an incident complaint. Specific violations were substantiated as described in the violation report.
Findings
Violations were found related to confidentiality of resident records and medication storage. Specifically, an unattended medication cart and an unlocked tube of Lidocaine ointment were observed. A plan of correction was submitted addressing these issues.
Citations (2)
Regulation 2600.17 requires resident records to be confidential and accessible only to authorized persons. On 7/3/18, the medication cart was unattended with a bin containing narcotic count books and confidential resident documents left accessible.
Regulation 2600.183(b) requires medications and syringes to be kept locked in the resident's room. On 7/3/18 at 4:30 PM, a tube of Lidocaine Ointment USP 5% was unlocked and accessible in Resident 1's nightstand.
Report Facts
Number of Residents Served: 79
Number of Residents Served in Secured Dementia Unit: 25
Number of Current Hospice Residents: 12
Number of Hospice Residents in Past Year: 10
Number of Residents Age 60 or Older: 78
Number of Residents with Mobility Need: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Samantha Sipe | Administrator / Executive Director | Named as the legal entity representative and executive director who signed the plan of correction |
Notice — May 30, 2018
Date: May 30, 2018
Visit Reason
The document is a response to a waiver request related to qualifications for direct care staff persons under Pennsylvania Code Chapter 2600 for a personal care home.
Findings
The Department determined that a waiver is not needed because the individual’s Bachelor of Science degree meets the educational qualifications for a direct care staff person. The facility is advised to keep a copy of the educational documentation in the personnel file.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the waiver determination letter. |
Inspection Report — Apr 9, 2018
Enforcement
Date: Apr 9, 2018
Visit Reason
The inspection was conducted due to complaint and incident investigations on multiple dates between November 15, 2017 and April 9, 2018, resulting in violations and enforcement actions including license revocation, admission ban, and fines.
Findings
The Department found multiple violations related to resident abuse, failure to report incidents, medication administration errors, and incomplete resident records. The facility's license was revoked, new admissions were banned, and fines were imposed due to negligence and misconduct.
Citations (5)
Regulation 55 Pa.Code §2600.5(a)(1) requires immediate access to residents and records; the home failed to provide access to the business office on 11/20/17.
Regulation 55 Pa.Code §2600.16(a) mandates reporting suspected abuse within 24 hours; the home failed to report sexual assaults by Resident #1 to the local agency and Department.
Regulation 55 Pa.Code §2600.42(b) prohibits neglect and abuse; Resident #1 physically and sexually abused female residents, and the home failed to protect residents from this abuse.
Regulation 55 Pa.Code §2600.182(b) requires medication administration by qualified staff; several direct care staff administered medications without proper training or supervision.
Regulation 55 Pa.Code §2600.252 requires complete resident records; Resident #1's record lacked discharge date, destination, and reason for discharge.
Report Facts
Fine per resident per day: 5
Calculated Fine Per day: 485
Total Daily Staff: 120
Walking Staff: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Hofsess | Executive Director | Named as administrator and legal entity representative on violation reports and plan of correction |
| Shivani Patel | Enforcement Manager | Named as enforcement manager in enforcement letter |
| Cynthia A. Haines | Attorney | Attorney for appellant Brookdale Grandon Farms, named in appeal and correspondence |
Notice — Jan 30, 2018
Date: Jan 30, 2018
Visit Reason
Response to a request for a waiver of qualifications for direct care staff persons under 55 Pa.Code § 2600.54(a).
Findings
The Department determined that the submitted Haitian high school part II diploma meets the educational qualifications for a direct care staff person and that a waiver is not needed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the waiver determination letter. |
Inspection Report — Jul 26, 2017
Renewal
Date: Jul 26, 2017
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections on July 26 and July 27, 2017, for renewal of the facility license.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found, including issues with staff qualifications, training, medication administration, and safety protocols. Plans of correction were submitted and partially implemented as of August 2017.
Citations (8)
Regulation 2600.81 - Staff Person A was not a resident of Pennsylvania for 2 years prior to employment and the home did not obtain an FBI criminal background check for this staff person.
Regulation 2600.84(a) - Direct care staff persons A and B did not have a high school diploma, GED diploma, or active registration status on the Pennsylvania nurse aide registry.
Regulation 2600.85(a) - Direct care staff persons A and B did not receive required training within the first 40 working hours on resident rights, emergency medical plan, and reportable incidents and conditions.
Regulation 2600.85(f) - Direct care staff persons A and B did not receive required annual training in medication self-administration, resident needs, personal care, and infection control during training years 2014 and 2016.
Regulation 2600.85(g) - Ancillary staff person E did not receive training in fire safety, emergency preparedness, resident rights, OAPSA, falls, and accident prevention during training year 2016.
Regulation 2600.82(c) - Three bottles of Ecolab hand sanitizer were unsecured and accessible to residents in the secured dementia care unit.
Regulation 2600.85(d) - Trash receptacles in the bathroom and shared bathrooms were not covered.
Regulation 2600.183(f) - Expired medications were stored in the medication cart, including Spectrace Vials expired in May 2017 and Bayer Tylenol expired in March 2016.
Report Facts
Number of Residents Served: 95
Total Daily Staff: 137
Walking Staff: 103
Number of Residents Served in Secured Dementia Care Unit: 29
Number of Current Hospice Residents: 8
Number of Hospice Residents in Past Year: 10
Number of Residents Age 61 or Older: 94
Number of Residents with Mental Illness: 3
Number of Residents with Mobility Need: 42
Number of Residents with Physical Disability: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Hofsass | Executive Director | Signed plans of correction and referenced in multiple findings and corrective actions. |
Inspection Report — Jun 9, 2017
Renewal
Date: Jun 9, 2017
Visit Reason
The document is a renewal application and license issuance for Brookdale Grandon Farms Personal Care Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Apr 21, 2017
Complaint Investigation
Date: Apr 21, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving alleged abuse and medication administration issues at Brookdale Grandon Farms.
Complaint Details
The complaint involved an allegation of abuse against Resident 1 and improper medication administration to control behavior. The home did not report the abuse allegation to the local area agency on aging. The complaint was substantiated by the findings.
Findings
The inspection found violations related to failure to immediately report suspected abuse and improper use of medication to control resident behavior. Plans of correction were submitted addressing staff retraining and policy compliance.
Citations (2)
Regulation 2600.15(a): The home failed to immediately report suspected abuse of a resident as required by law. An allegation of abuse against Resident 1 was reported to staff but not reported to the local area agency on aging.
Regulation 2600.202: The facility prohibited procedures including seclusion, aversive conditioning, and mechanical restraints. On 3/17/2017, a half tablet of Benadryl 25 mg was administered to Resident 1 to control behavior, violating these prohibitions.
Report Facts
Number of Residents Served: 93
Number of Current Hospice Residents: 7
Number of Residents Served in Secured Dementia Care Unit: 27
Number of Hospice Residents in Past Year: 20
Number of Residents 60 Years or Older: 92
Number of Residents with Mobility Need: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Hotsass | Executive Director | Signed plan of correction documents related to deficiencies |
Inspection Report — Aug 15, 2016
Annual Inspection
Date: Aug 15, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections on August 15 and 16, 2016, including renewal and complaint investigation.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found, including fire hazard risks, emergency procedure deficiencies, medication record issues, and training requirements. Plans of correction were submitted with varying implementation statuses.
Citations (8)
Regulation 2600.105(g)(1): Heavy accumulation of lint was found in the lint trap of the commercial dryer, posing a fire hazard.
Regulation 2600.107(d): The home's written emergency procedures had not been reviewed, updated, and submitted annually to the local emergency management agency.
Regulation 2600.127(a): A freestanding electric fireplace producing heat was located in room 616, violating the prohibition of portable space heaters.
Regulation 2600.132(g): Fire drills were not routinely held at different days and times, with some drills held during sleeping hours and staffing levels higher than normal.
Regulation 2600.187(a): Medication administration records lacked diagnosis or purpose for certain residents' medications.
Regulation 2600.187(c): Medication refusals for residents #5, #6, and #7 were not reported to the prescriber as required.
Regulation 2600.236: Direct care staff in secured dementia care unit did not receive the required 6 hours of annual training related to dementia care and services during 2015.
Regulation 2600.252: Resident records for #1, #2, and #3 were missing eye color, hair color, and identifying marks.
Report Facts
Number of Residents Served: 93
Number of Residents Served in Secured Dementia Care Unit: 29
Number of Current Hospice Residents: 7
Number of Hospice Residents in Past Year: 20
Number of Residents Age 60 or Older: 93
Number of Residents with Mental Illness: 4
Number of Residents with Mobility Need: 35
Number of Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Cox | HWD, PCHA | Signed as Legal Entity Representative on multiple violation report pages. |
| Jacqueline L. Rowe | Director | Signed cover letter as Director of Department of Human Services. |
Inspection Report — Jul 1, 2016
Renewal
Date: Jul 1, 2016
Visit Reason
The document is a renewal application and license issuance for Brookdale Grandon Farms Personal Care Home, confirming the facility's authorization to operate and noting the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of future inspection requirements.
Report Facts
Inspection Report — Jan 29, 2016
Date: Jan 29, 2016
Visit Reason
The inspection was a document review conducted as an interim inspection related to enforcement of licensing regulations for a personal care home.
Findings
The facility was found to be in violation of Pennsylvania Code 55 Pa.Code § 2600.18 for advertising as an assisted living residence without proper licensure. The violation concerns the use of the term 'assisted living' in written materials and on the facility's website.
Citations (1)
55 Pa.Code § 2600.18 requires compliance with applicable laws and regulations. The facility advertised assisted living services without being licensed as an assisted living residence.
Report Facts
Fine per resident per day: 3
Calculated Fine per day: 282
Mandated Correction Date: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew J. Jones | Director | Signed enforcement letter regarding violation and plan of correction |
| Jacob Herzing | Enforcement Manager | Contact for submission of plan of correction and off-site inspection |
Inspection Report — Jan 29, 2016
Enforcement
Date: Jan 29, 2016
Visit Reason
The Department of Human Services issued a notice of intent to assess a fine for regulatory violations related to advertising an unlicensed assisted living residence. The inspection was a document review conducted off-site.
Findings
Brookdale Grandon Farms was found to be advertising assisted living services without being licensed as an assisted living residence. The facility was assessed a Class III fine totaling $4,230 for continuing to advertise as an assisted living residence.
Citations (1)
55 Pa.Code § 2600.18: The facility advertised assisted living services without being licensed as an assisted living residence. Brookdale Grandon Farms is not a licensed assisted living residence but continued to advertise as such.
Report Facts
Fine Amount: 4230
Fine Per Resident Per Day: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Selden M. Granahan | Executive Director | Signed Plan of Correction and training documentation |
| Matthew J. Jones | Director | Signed enforcement letter |
| Jacob Herzing | Enforcement Manager | Listed as contact for appeals and inspection |
Inspection Report — Jan 8, 2016
Follow-Up
Date: Jan 8, 2016
Visit Reason
The inspection was a follow-up visit triggered by an incident to verify correction of previous deficiencies at Brookdale Grandon Farms.
Findings
Mental Health Nursing Services were provided to Resident 1 by an outside nursing agency following an incident on 11-1-15, but these services were not documented in the resident's support plan. A plan of correction was submitted to update the support plan and retrain staff.
Citations (1)
Regulation 55 Pa.Code 2600 requires documentation of medical and behavioral services in the resident's support plan. Mental Health Nursing Services provided to Resident 1 by an outside agency after an incident on 11-1-15 were not documented in the support plan.
Report Facts
Number of Residents Served: 91
Number of Residents Served in Secured Dementia Care Unit: 26
Number of Current Hospice Residents: 8
Number of Hospice Residents in Past Year: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S. Denny Granahan | Executive Director | Signed plan of correction and named in corrective action |
Document — August 6, 2018
Date: August 6, 2018
Visit Reason
This document set includes a settlement agreement and correspondence regarding the issuance and rescission of a first provisional license for Brookdale Grandon Farms personal care home, addressing regulatory compliance and licensing status.
Findings
The Department of Human Services rescinded a previously issued provisional license due to inaccuracies and issued a new first provisional license under a settlement agreement. The agreement outlines corrective actions, staff training, and compliance requirements to resolve regulatory issues.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the letter rescinding the first provisional license and the settlement agreement. |
| Darlene Klamerus | District Director of Operations | Signed the settlement agreement on behalf of Brookdale Grandon Farms. |
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