Inspection Report
Complaint Investigation
Census: 75
Capacity: 120
Deficiencies: 4
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.
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.
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.
Deficiencies (4)
| Description |
|---|
| 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
License Capacity: 120
Residents Served: 75
Secured Dementia Care Unit Capacity: 30
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
Renewal
Census: 73
Capacity: 120
Deficiencies: 13
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.
Deficiencies (13)
| Description |
|---|
| 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
License Capacity: 120
Residents Served: 73
Secured Dementia Care Unit Capacity: 30
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
Complaint Investigation
Census: 64
Capacity: 120
Deficiencies: 0
Nov 5, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint and incident; no deficiencies or citations were found.
Report Facts
License Capacity: 120
Residents Served: 64
Secured Dementia Care Unit Capacity: 30
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
Follow-Up
Census: 52
Capacity: 120
Deficiencies: 2
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 120
Residents Served: 52
Secured Dementia Care Unit Capacity: 30
Residents Served in SDCU: 21
Current Hospice Residents: 5
Resident Support Staff: 0
Total Daily Staff: 79
Waking Staff: 59
Inspection Report
Renewal
Census: 50
Capacity: 120
Deficiencies: 15
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.
Deficiencies (15)
| Description |
|---|
| 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
License Capacity: 120
Residents Served: 50
Secured Dementia Care Unit Capacity: 30
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
Renewal
Census: 48
Capacity: 120
Deficiencies: 26
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.
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.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for visit and review of submitted plan of correction.
Deficiencies (26)
| Description |
|---|
| 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
License Capacity: 120
Residents Served: 48
Capacity of Secure Dementia Care Unit: 30
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
Deficiencies: 0
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
Routine
Deficiencies: 0
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.
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