34 Reports
Inspection Report — Jan 21, 2026
Follow-Up
Date: Jan 21, 2026
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident, followed by a plan of correction submission and review.
Findings
The submitted plan of correction was fully implemented and compliance was maintained. A specific deficiency involved a resident assessment that did not document the use of a rollator for mobility, which was corrected promptly with staff re-education and audits.
Citations (1)
225c - Additional Assessment: A resident assessment did not include that the resident utilizes a rollator for movement. The facility corrected this by updating the RASP and re-educating staff on mobility regulations.
Report Facts
Residents Served: 74
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 6
Residents Age 60 or Older: 73
Residents with Mental Illness: 1
Residents with Mobility Need: 21
Inspection Report — Aug 20, 2025
Date: Aug 20, 2025
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Report Facts
Residents Served: 80
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 8
Residents Age 60 or Older: 80
Residents with Mobility Need: 24
Inspection Report — Jul 24, 2025
Date: Jul 24, 2025
Visit Reason
The inspection was an unannounced partial licensing inspection conducted as an interim review of the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 77
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 5
Residents Age 60 or Older: 77
Residents with Mobility Need: 27
Inspection Report — Jun 10, 2025
Renewal
Date: Jun 10, 2025
Visit Reason
The inspection was conducted as a renewal and complaint investigation to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance after corrections were made following the inspection. Several deficiencies were identified including medication reporting errors, cleanliness issues, medication storage, labeling discrepancies, failure to follow prescriber's orders, preadmission screening, admission support plans, and incomplete resident records. All deficiencies had plans of correction implemented and verified by follow-up.
Citations (8)
Failure to report a medication error incident to the department within 24 hours.
Bedroom floor covered with papers, discarded cups, food crumbs, and debris creating slip/fall risk.
Prescription medications and syringes not kept locked; pill found on bedroom floor.
Medication label dosage did not match prescribed dosage for Gabapentin.
Medication not administered as prescribed due to pharmacy action required.
Cognitive preadmission screening not completed within 72 hours prior to admission to secured dementia care unit.
Support plan not developed within 72 hours of admission to secured dementia care unit.
Resident records missing eye color, hair color, and identifying marks.
Report Facts
Residents Served: 67
Residents Served in Secured Dementia Care Unit: 13
Current Hospice Residents: 5
Residents Age 60 or Older: 67
Residents with Mobility Need: 22
Total Daily Staff: 89
Waking Staff: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the licensing letter and certificate of compliance. |
| Health & Wellness Director | Named in multiple findings related to medication reporting, staff re-education, audits, and compliance. | |
| Executive Director | Named in multiple findings related to staff training, audits, and compliance. | |
| Health & Wellness Coordinator | Involved in staff training and compliance activities. |
Inspection Report — Jan 14, 2025
Date: Jan 14, 2025
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, on 01/14/2025, with the reason noted as 'Fine'.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 79
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 4
Resident Count Diagnosed with Mental Illness: 1
Resident Count with Mobility Need: 34
Residents Age 60 or Older: 79
Inspection Report — Oct 30, 2024
Complaint Investigation
Date: Oct 30, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation with multiple inspection dates from August 27, 2024 through October 30, 2024, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The inspection was complaint-driven with incidents including medication errors, abuse related to fall management, and failure to comply with medical evaluation and secured dementia care unit requirements. The complaint was substantiated as violations were found.
Findings
The inspection found multiple violations including delayed incident reporting, incomplete annual medical evaluations, medication administration errors, failure to follow prescriber's orders, abuse related to inadequate fall response, unsafe storage conditions, fire drill documentation issues, and deficiencies in secured dementia care unit documentation. A provisional license was issued due to these violations.
Citations (13)
Incident report was not submitted within 24 hours after an unwitnessed fall resulting in a laceration.
Residents had medical evaluations that were not completed annually or were incomplete.
Medication administration error where a resident was given medication prescribed for another resident.
Failure to follow prescriber's orders regarding medication administration times and availability of emergency medications.
Resident abuse due to failure to properly assess and report a fall resulting in a head injury and subsequent death.
Kitchen floor was discolored, cracked, broken, and sticky, posing a hazard.
Lint accumulation behind a natural gas dryer posing a fire hazard.
Fire drill records were inaccurate and fire drills were not held at varied times and days.
Residents did not evacuate properly during fire drills.
Medical evaluations for residents in the secured dementia care unit did not document the need for secured care or diagnosis of dementia.
Cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit.
Expired medication found in medication cart.
Blood glucose readings were not properly recorded or taken as prescribed.
Report Facts
Residents Served: 76
Residents in Secured Dementia Care Unit: 18
Staffing Hours: 76
Waking Staff: 57
Fine Amount: 228
Fine Amount: 228
Fine Amount: 380
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Heeter | Administrator | Named as facility administrator in inspection summary. |
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed enforcement and licensing letters. |
Inspection Report — Jun 28, 2024
Complaint Investigation
Date: Jun 28, 2024
Visit Reason
The inspection was conducted as a complaint and incident follow-up survey to review compliance and the submitted plan of correction for the facility.
Complaint Details
The visit was complaint-related and included an incident follow-up. The plan of correction was accepted and fully implemented as of August 23, 2024.
Findings
The facility was found to have deficiencies related to the resident's support plan documentation, specifically lacking indication of how the facility meets the resident's need to go outside with supervision and missing resident signatures on support plans. The submitted plan of correction was accepted and fully implemented by August 23, 2024.
Citations (2)
Resident #1's Resident Assessment and Support Plan (RASP) did not indicate how the facility will meet the resident’s need to go outside with supervision.
Resident #1's Resident Assessment and Support Plan (RASP) did not include the resident’s signature or indicate if the resident is incapable of signing or refused to sign the RASP.
Report Facts
Residents Served: 75
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 1
Residents Age 60 or Older: 75
Residents with Mental Illness: 1
Residents with Mobility Need: 21
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Updated Resident #1’s Support Plan/RASP to reflect recent strategies and reviewed with resident | |
| Executive Director | Retrained Health and Wellness Director and Coordinator regarding community policy on support plans and signatures | |
| Health and Wellness Coordinator | Assisted with audits and reviews of support plans for compliance and signatures |
Inspection Report — May 22, 2024
Follow-Up
Date: May 22, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit related to a complaint and incident involving the facility, conducted to verify the implementation of a previously submitted plan of correction.
Complaint Details
The visit was complaint-related involving a stolen resident credit card and fraudulent charges. The complaint was investigated, and the staff person under investigation is no longer employed. No other residents reported missing valuables.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The investigation involved a resident's stolen credit card and fraudulent charges, with no other residents affected and the implicated staff no longer employed.
Citations (1)
Resident credit card was stolen from the facility and fraudulent charges were incurred.
Report Facts
Residents Served: 77
Secured Dementia Care Unit Residents Served: 17
Hospice Residents: 2
Residents with Mental Illness: 1
Residents with Mobility Need: 23
Residents 60 Years or Older: 77
Inspection Report — Feb 21, 2024
Complaint Investigation
Date: Feb 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 02/21/2024.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The submitted plan of correction was fully implemented and compliance was maintained.
Findings
Two deficiencies were identified: a privacy violation involving unauthorized publication of a resident's picture, and a failure to document a resident's food preferences related to visual impairment in the support plan. Both deficiencies had plans of correction implemented by 04/01/2024.
Citations (2)
Privacy violation due to publishing a resident's picture without consent in the December 2023 newsletter.
Resident's support plan did not document food preferences related to visual impairment and dietary restrictions.
Report Facts
Residents Served: 78
Secured Dementia Care Unit Residents Served: 15
Hospice Residents: 4
Residents Age 60 or Older: 78
Residents with Mobility Need: 26
Inspection Report — Oct 11, 2023
Renewal
Date: Oct 11, 2023
Visit Reason
The inspection was a renewal and incident inspection survey conducted on 10/11/2023 to assess compliance with licensing requirements and investigate an incident.
Findings
The inspection identified multiple deficiencies including lint buildup in dryer vents, obstructed egress doors, combustible storage near heat sources, incomplete annual medical evaluations, medication administration training lapses, medication storage and labeling issues, missing PRN medications, incomplete resident support plans, and missing exit instructions for key-locking devices. Plans of correction were accepted and implemented by 12/08/2023 with ongoing audits and staff retraining scheduled.
Citations (11)
Outdoor vents for the memory care laundry room dryers were clogged with lint buildup.
Exit door near the library was stuck and did not open without excessive force applied to the panic bar.
A pair of green pants were found behind dryer #1 in the memory care laundry room.
Resident #1 did not have a completed annual Documentation of Medical Evaluation (DME).
Annual practicums for two medication technicians were completed more than 12 months apart.
A prescription bottle was stored in the cart for resident #2 without a current order.
Resident #2's medication bottle contained tablets cut in half and crumbled bits, not stored properly.
Medication label for resident #2 did not match the order on the Medication Administration Record (MAR).
Resident #2 did not have PRN medications on hand as ordered.
Resident #3 had an enabler bar attached to their bed not addressed in the support plan.
Memory care exit door lacked posted code and instructions for key-locking device operation.
Report Facts
Residents Served: 59
Residents Served in Dementia Unit: 15
Residents with Mobility Need: 18
Total Daily Staff: 77
Waking Staff: 58
Inspection Report — Aug 23, 2023
Follow-Up
Date: Aug 23, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, to review the submitted plan of correction for a prior statement of deficiency.
Complaint Details
The visit was complaint-related due to an incident involving abuse of Resident #1. The allegation was investigated, with interviews and assessments conducted. Staff member involved was suspended and no marks or reddened areas were noted on the resident during assessment. The complaint was addressed through training and monitoring.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The deficiency involved abuse where staff were witnessed yelling, cursing, and physically mishandling a resident. Appropriate staff training and investigations were conducted, and corrective actions including staff suspension and training were completed.
Citations (1)
A resident was neglected, intimidated, verbally and physically abused by staff, including yelling, cursing, and forcibly grabbing and dropping the resident on the bed.
Report Facts
Residents Served: 80
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 1
Residents Age 60 or Older: 80
Residents with Mental Illness: 1
Residents with Mobility Need: 19
Residents with Physical Disability: 2
Inspection Report — Jul 6, 2023
Complaint Investigation
Date: Jul 6, 2023
Visit Reason
The inspection was conducted as an incident investigation related to a complaint or incident involving the facility.
Complaint Details
The visit was an incident inspection survey triggered by a complaint or incident. The submitted plan of correction was determined to be fully implemented.
Findings
Two deficiencies were identified: one involving unsecured poisonous materials left in a resident's room, and another involving failure to update a resident's support plan to reflect physical therapy services. Plans of correction were accepted and implemented.
Citations (2)
Poisonous materials were not kept locked and inaccessible; a cup of denture cleanser was left in Resident 1's room despite the resident not being assessed as safe around poisonous materials.
The support plan for Resident 1 was not updated to show that the resident is receiving Physical Therapy services.
Report Facts
Residents Served: 80
Residents Served in Secured Dementia Care Unit: 17
Current Hospice Residents: 1
Residents Age 60 or Older: 80
Residents with Mental Illness: 1
Residents with Mobility Need: 19
Residents with Physical Disability: 2
Inspection Report — Jul 26, 2022
Renewal
Date: Jul 26, 2022
Visit Reason
The inspection was conducted as a renewal survey of the facility's license on 07/26/2022 and 07/27/2022.
Findings
The inspection identified multiple deficiencies related to staff training in First Aid/CPR, medication administration and labeling, storage procedures, medication records, preadmission screening, and posting of key locking device instructions. The facility submitted plans of correction which were accepted and implemented.
Citations (9)
No staff person present was currently certified in first aid, obstructed airway techniques and CPR during specified shifts.
Resident #1 was not assessed to self-administer medications; unauthorized medications were found in resident rooms.
Medications found in the home were not current prescriptions for the residents.
Medication labels did not match current physician orders for several residents.
Over-the-counter medications were not labeled with the resident's name.
Medications prescribed to Resident #2 were not available in the medication cart.
Medication records for Residents #2 and #3 were incomplete or inaccurate regarding dosages and administration directions.
Resident #4's preadmission screening form did not include a determination that the resident's needs could be met by the home.
Directions for operating key locking devices in the secured dementia unit and main entrance were not conspicuously posted.
Report Facts
Residents Served: 48
Residents Served in Secured Dementia Care Unit: 13
Current Hospice Residents: 1
Inspection Report — Mar 23, 2022
Follow-Up
Date: Mar 23, 2022
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction related to incidents and deficiencies identified at the facility.
Findings
The inspection found that the submitted plan of correction was fully implemented, including retraining staff, updating medical evaluations and support plans, and addressing incidents of resident abuse. The facility demonstrated ongoing efforts to comply with regulatory requirements and maintain resident safety.
Citations (3)
Resident #1 pushed Resident #2 to the ground, resulting in Resident #2's right humerus fracture; incidents of non-consensual contact between Resident #4 and Resident #3.
Resident #3's medical evaluation did not include the resident's level of cognitive functioning.
The incident involving Resident #1 and Resident #2 was not documented in Resident #2's assessment and support plan; Resident #3 and Resident #4's support plans were not updated to reflect behavioral incidents.
Report Facts
Residents Served: 35
Residents Served in Dementia Unit: 14
Resident Support Staff: 14
Total Daily Staff: 63
Waking Staff: 47
Follow-Up Date: Apr 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Graziano | Executive Director | Retrained staff on regulations and community policy regarding resident safety and medical evaluations. |
Inspection Report — Jan 19, 2022
Renewal
Date: Jan 19, 2022
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.
Inspection Report — Sep 2, 2021
Renewal
Date: Sep 2, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing licensing inspections on 09/02/2021 and 09/13/2021 for the facility Brookdale Grayson View.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — Jun 30, 2021
Date: Jun 30, 2021
Visit Reason
This document serves as a certificate of compliance and notification of license renewal for the Personal Care Home facility Brookdale Grayson View. It informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
The Department has issued a regular license in response to the renewal application and advises that an annual inspection will be conducted to ensure compliance with applicable regulations. No findings or deficiencies are reported in this document.
Report Facts
Inspection Report — Jun 9, 2021
Renewal
Date: Jun 9, 2021
Visit Reason
The inspection was a renewal inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 06/08/2021 through 06/10/2021 to review the facility's compliance and licensing status.
Findings
The facility was found to have several deficiencies related to incident reporting, annual medical evaluations, menu posting, medication storage procedures, and following prescriber's orders. Plans of correction were accepted and implemented, including staff retraining, audits, and new checklists to ensure compliance.
Citations (5)
Failure to report incidents to the department within 24 hours as required, including missed medication doses and resident injuries.
Failure to complete annual medical evaluations for residents in a timely manner.
Menus were not posted one week in advance as required.
Medication storage procedures were not properly followed; glucometer was not calibrated correctly and medication administration records were inaccurately transcribed.
Failure to follow prescriber's orders, including missed medication doses due to unavailability of medications.
Report Facts
Residents Served: 44
Secured Dementia Care Unit Residents Served: 12
Hospice Residents: 1
Resident with Mobility Need: 12
Inspection Report — Dec 16, 2020
Routine
Date: Dec 16, 2020
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.
Inspection Report — Nov 5, 2020
Routine
Date: Nov 5, 2020
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Oct 21, 2020
Follow-Up
Date: Oct 21, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The plan of correction related to a resident-to-resident altercation involving dignity and respect was fully implemented. Staff were retrained, behavior plans updated, and monitoring increased to prevent further incidents.
Citations (1)
Regulation 2600.42(c): A resident yelled at and pushed another resident to the ground and called her useless. The facility implemented behavior plans, increased monitoring, and retrained staff on dignity and respect.
Report Facts
Residents Served: 51
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 1
Total Daily Staff: 64
Waking Staff: 48
Inspection Report — Jul 29, 2020
Follow-Up
Date: Jul 29, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to a resident dignity and respect violation. The incident involved inappropriate touching by a resident and staff conduct issues, which were investigated and addressed with staff re-education and reassignment.
Citations (1)
42c - Treatment of Residents: Resident #1 attempted to touch two female residents inappropriately on 07/20/20. Staff person A raised her voice and got very close to Resident #2's face during a disagreement, failing to treat the resident with dignity and respect.
Report Facts
Residents Served: 51
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 1
Inspection Report — Jul 1, 2020
Routine
Date: Jul 1, 2020
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.
Inspection Report — Jun 4, 2020
Renewal
Date: Jun 4, 2020
Visit Reason
The inspection was conducted as part of licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, covering multiple dates in June 2020.
Findings
No regulatory citations were identified as a result of the inspections conducted on 06/04/2020, 06/05/2020, 06/24/2020, and 06/26/2020 at the facility.
Inspection Report — Mar 31, 2020
Complaint Investigation
Date: Mar 31, 2020
Visit Reason
The inspection was conducted as a complaint investigation and incident follow-up related to a resident treatment violation.
Complaint Details
The inspection was triggered by a complaint and incident. The plan of correction was approved on 5-13-2020 and fully implemented. The associate involved was suspended pending investigation and later resigned.
Findings
The investigation found that on 3/9/2020, a staff member smacked a resident in the face to rouse her while she was sleeping in a common area. The facility submitted a plan of correction which was approved and fully implemented.
Citations (1)
42c - Treatment of Residents: On 3/9/2020, staff person A smacked resident #1 in the face to rouse her while she was sleeping in a common area of the home.
Report Facts
Residents Served: 65
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lennie Boop | Executive Director | Named in plan of correction and signature on report |
Notice — Mar 13, 2020
Date: Mar 13, 2020
Visit Reason
The document serves as a renewal notification for the Personal Care Home license for Brookdale Grayson View and informs 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 confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Dec 20, 2019
Complaint Investigation
Date: Dec 20, 2019
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations related to resident care and safety.
Complaint Details
The inspection was triggered by a complaint/incident involving Resident #1 who suffered multiple falls, including an unwitnessed fall resulting in a skull fracture. The complaint included concerns about neglect and inadequate supervision. The findings substantiated these issues.
Findings
The facility was found to have multiple deficiencies related to failure to report incidents, inadequate supervision leading to resident falls, incomplete medical documentation, and outdated support plans. The submitted plan of correction was fully implemented as of February 2020.
Citations (5)
Regulation 2600.16.d: The home failed to report that Resident #1 suffered a skull fracture after a fall and did not submit a follow-up incident report to the department.
Regulation 2600.42.b: Resident #1 suffered multiple falls due to inadequate supervision, and the home failed to provide necessary supervision to prevent falls.
Regulation 2600.141.a: Resident #1's medical evaluation form was missing health status and pulse information, and changes on the form were not properly authorized or documented.
Regulation 2600.141.a: Resident #1 no longer resides at the home and a new medical evaluation could not be obtained; audits and staff retraining were conducted to ensure compliance.
Regulation 2600.234.d: Resident #1's support plan was not updated to reflect fall risk and combative behaviors, and interventions during the 2nd shift were not addressed.
Report Facts
Residents Served: 64
Residents Served in Secured Dementia Unit: 14
Current Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lennie C. Boop | Executive Director | Named in plan of correction signatures and retraining related to deficiencies |
Inspection Report — Jun 17, 2019
Complaint Investigation
Date: Jun 17, 2019
Visit Reason
The inspection was conducted as a complaint investigation at Brookdale Grayson View on June 17, 2019.
Complaint Details
The inspection was triggered by a complaint. The report does not explicitly state substantiation status.
Findings
The inspection found violations related to the facility's fire alarm system activation and evacuation procedures. The administrator acknowledged issues with the fire alarm system and the process for evacuating residents during alarms.
Citations (1)
Regulation 2600.132h requires residents to evacuate to a designated meeting place during fire drills. The administrator and staff failed to document the date of fire alarm activation and did not properly manage evacuation procedures during a false alarm.
Report Facts
Residents Served: 67
Secured Dementia Care Unit Residents Served: 11
Current Hospice Residents: 2
Resident Support Staff: 67
Total Daily Staff: 148
Waking Staff: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lennie Boop | Administrator | Named in relation to fire alarm system violation and plan of correction |
Inspection Report — May 9, 2019
Renewal
Date: May 9, 2019
Visit Reason
The inspection was an unannounced full renewal inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2600 for Personal Care Homes.
Findings
The inspection identified multiple violations related to posting of licenses, fire drills, medical evaluations, smoking area guidelines, prescription medication documentation, medication labeling, refusal of medication, support plan updates, and key-locking device signage. Plans of correction were submitted with partial implementation status.
Citations (10)
Regulation 2600.3.c requires posting the current license and inspection summary in a conspicuous public place. License inspection summaries dated 8/3/2018 and 5/9/2018 were posted behind the home’s license and not visible to the public.
Regulation 2600.132.g requires fire drills on different days and times, not routinely held only when staff are present. Fire drills were consistently conducted on or near the last day of the month or last week for the past 11 months.
Regulation 2600.141.a requires a medical evaluation form including immunization history. The form dated 3/19/19 for resident #1 was incomplete as the immunization section was left blank.
Regulation 2600.144.c requires written fire safety policies for smoking areas. Approximately 8 cigarette butts were found in mulch next to the designated smoking area gazebo.
Regulation 2600.182.b requires documentation of medication administration training. Annual practicum sheets for several med techs for 2018 were incomplete or not signed, and some 2019 practicums were overdue.
Regulation 2600.183.d requires only current prescriptions be kept in the home. Resident #2 had Advair inhalers with two different 'date opened' entries and expired medication at the time of audit.
Regulation 2600.184.a requires prescription medications be labeled with pharmacy labels matching physician orders. Resident #3’s Flomax medication label did not match the current physician order.
Regulation 2600.187.c requires documentation and notification of medication refusals. Resident #4 refused Valsartan medication on multiple dates and the physician was not notified as required.
Regulation 2600.227.d requires support plans to reflect current medical and hospice services. Resident #5’s support plan and RASP were not updated to reflect mechanical soft diet and hospice services.
Regulation 2600.233.c requires conspicuous posting of key-locking device codes. Codes posted near the memory care unit courtyard exit doors were incomplete and did not indicate the need to press an asterisk.
Report Facts
Residents Served: 64
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 3
Resident Mobility Need: 15
Total Daily Staff: 79
Waking Staff: 59
Cigarette Butts Found: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lennie Boop | Senior Executive Director | Named as legal entity representative and signer of plans of correction |
Notice — Apr 9, 2019
Date: Apr 9, 2019
Visit Reason
The document serves as a renewal notification for the Personal Care Home license and informs the facility of the Department's requirement to conduct an annual onsite inspection within the next twelve months.
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 — Feb 1, 2019
Complaint Investigation
Date: Feb 1, 2019
Visit Reason
The inspection was conducted as a complaint investigation at Brookdale Grayson View on February 1, 2019.
Complaint Details
The inspection was triggered by a complaint. The report does not specify substantiation status.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 related to medication administration and documentation were found. The facility submitted a plan of correction addressing issues such as self-administration of medications, glucometer calibration, medication record keeping, and medication error reporting.
Citations (4)
55 Pa.Code §2600.181(c) - Resident #1 was permitted to store medications and self-administer medications without proper assessment by a physician or certified nurse practitioner.
55 Pa.Code §2600.185(a) - Glucometers for residents #2 and #3 were not calibrated to the correct date or time, resulting in inconsistent glucose readings.
55 Pa.Code §2600.187(a) - Resident #4's medications were administered by an outside agency nurse without proper documentation in the electronic Medication Administration Record (EMAR).
55 Pa.Code §2600.188(b) - A medication error involving Resident #1 was not immediately reported to the resident, designated person, or prescriber as required.
Report Facts
Number of Residents Served: 86
Total Daily Staff: 103
Waking Staff: 77
Number of Residents Age 60 or Older: 86
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Need: 17
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lennie Boop | Senior Executive Director | Named as the legal entity representative who signed the plan of correction. |
| Amy Deluca | Department representative on-site during inspection. |
Inspection Report — Nov 27, 2018
Complaint Investigation
Date: Nov 27, 2018
Visit Reason
The inspection was conducted as a complaint investigation at Brookdale Grayson View personal care home.
Complaint Details
The inspection was complaint-driven. The complaint involved neglect and inadequate supervision of Resident #1, resulting in multiple falls and injuries. The complaint was substantiated as violations were found.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found related to incident reporting, resident neglect, and documentation of resident support plans. Plans of correction were submitted and partially implemented as of May 8, 2019.
Citations (3)
Regulation 2600.16(d): The home failed to submit a final report for a June 2018 incident involving Resident #1 with cervical fractures. Staff were retrained and ongoing reviews were planned.
Regulation 2600.42(b): Resident #1 was neglected and suffered multiple falls and injuries between February and August 2018. The home failed to provide adequate supervision and services to prevent harm.
Regulation 2600.227(d): The Personal Service Plan was not updated to reflect the resident's declining cognitive status and increasing exit-seeking behavior. Staff were trained and plans to update the plan were ongoing.
Report Facts
Number of Residents Served: 85
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 22
Number of Residents Served in Secured Dementia Care Unit: 15
Residents Age 60 or Older: 85
Residents with Mobility Need: 19
Residents with Physical Disability: 1
Residents with Mental Illness: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lennie Boop | Senior Executive Director | Named as the legal entity representative signing plans of correction and administrator of the facility. |
Notice — Sep 28, 2018
Date: Sep 28, 2018
Visit Reason
Notification of a revised Personal Care Home license due to regional office realignment and issuance of a new Certificate of Compliance number.
Findings
The document confirms the issuance of a revised license with an unchanged expiration date and specifies the maximum capacity of the facility.
Report Facts
Inspection Report — Aug 3, 2018
Complaint Investigation
Date: Aug 3, 2018
Visit Reason
The inspection was conducted as a complaint investigation at Brookdale Grayson View on August 3, 2018.
Complaint Details
The inspection was complaint-driven. The facility was found to have failed to timely report suspected abuse incidents involving resident #1 and failed to properly manage discontinued medications.
Findings
Violations of 55 Pa. Code Chapter 2600 related to resident abuse reporting and medication management were found. The facility failed to timely report suspected abuse incidents and improperly stored discontinued medication for a resident.
Citations (3)
Regulation 55 Pa.Code §2600 requires immediate reporting of suspected resident abuse to the Department of Aging and compliance with staff restrictions. The facility failed to timely report multiple incidents of resident #1's inappropriate sexual and physical contact and abuse between 2/8/18 and 8/3/18.
Regulation 55 Pa.Code §2600.16(c) requires reporting incidents to the Department's regional office or complaint hotline within 24 hours. The facility failed to timely report the same incidents to the NE Regional licensing office as required.
Regulation 55 Pa.Code §2600.183(f) requires discontinued or expired medications to be destroyed safely. The facility stored prescribed Mupirocin ointment for resident #1, discontinued by the physician effective 6/1/18, in the medication cart.
Report Facts
Number of Residents Served: 82
Number of Residents Served in Secured Dementia Care Unit: 16
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 16
Residents 60 Years or Older: 82
Residents with Mental Illness: 1
Residents with Mobility Need: 18
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lennie C. Boop | Senior Executive Director | Named as the legal entity representative who signed the plan of correction and was involved in management staff training related to violations |
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