Inspection Report
Census: 80
Capacity: 95
Deficiencies: 0
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
License Capacity: 95
Residents Served: 80
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 8
Residents Age 60 or Older: 80
Residents with Mobility Need: 24
Inspection Report
Census: 77
Capacity: 95
Deficiencies: 0
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
License Capacity: 95
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 5
Residents Age 60 or Older: 77
Residents with Mobility Need: 27
Inspection Report
Renewal
Census: 67
Capacity: 95
Deficiencies: 8
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.
Deficiencies (8)
| Description |
|---|
| 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
License Capacity: 95
Residents Served: 67
Secured Dementia Care Unit Capacity: 24
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
Census: 79
Capacity: 95
Deficiencies: 0
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
License Capacity: 95
Residents Served: 79
Secured Dementia Care Unit Capacity: 24
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
Enforcement
Census: 76
Capacity: 95
Deficiencies: 11
Oct 30, 2024
Visit Reason
The inspection was conducted due to complaints and incidents, including a renewal inspection and enforcement actions related to violations found during multiple inspection dates from August to October 2024.
Findings
Multiple violations were found including failure to report incidents timely, medication errors, incomplete medical evaluations, unsafe storage of medications, fire safety deficiencies, and failure to secure timely medical care for residents. The facility's license was revoked and a provisional license was issued with fines pending correction of violations.
Complaint Details
The inspection was complaint-related, triggered by incidents including resident falls, medication errors, and other compliance concerns. Specific substantiation status is not stated.
Deficiencies (11)
| Description |
|---|
| Incident report was not submitted within 24 hours after an unwitnessed fall resulting in injury. |
| Residents did not have annual medical evaluations completed within required timeframes. |
| Medication administration error where a resident was given medication prescribed for another resident. |
| Failure to follow prescriber's orders regarding medication administration times and accuracy. |
| Resident sustained head injury from fall; medical care was not secured timely, resulting in death. |
| Expired medication found in medication cart. |
| Medication storage procedures not properly followed; missing emergency medication kits and inaccurate blood glucose records. |
| Fire drill records were inaccurate and drills were not held on varied days and times as required. |
| Residents did not evacuate properly during fire drills; some refused or hid during drills. |
| Medical evaluations for residents in the Secure Dementia Care Unit did not document required diagnosis or need for secured care. |
| Cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit. |
Report Facts
License Capacity: 95
Residents Served: 76
Secure Dementia Care Unit Capacity: 24
Residents Served in Secure Dementia Care Unit: 18
Staffing Hours: 76
Waking Staff: 57
Fine Amount Per Day: 228
Fine Amount Per Day: 380
Census for Fine Calculation: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julie Heeter | Administrator | Named as facility administrator in relation to inspection and compliance. |
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed enforcement and licensing correspondence. |
| Staff Member A | Involved in medication administration error and failure to follow prescriber's orders. | |
| Staff Member B | Failed to document and communicate resident fall and injury; was terminated. | |
| Health and Wellness Director (HWD) | Health and Wellness Director | Involved in retraining staff and overseeing compliance with medical and medication regulations. |
| Executive Director (ED) | Executive Director | Responsible for retraining staff and reviewing compliance audits. |
| District Director of Clinical Services (DDCS) | District Director of Clinical Services | Conducted audits and retraining related to resident assessments and support plans. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 95
Deficiencies: 13
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.
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.
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.
Deficiencies (13)
| Description |
|---|
| 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
License Capacity: 95
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
Complaint Investigation
Census: 75
Capacity: 95
Deficiencies: 2
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.
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.
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 95
Residents Served: 75
Secured Dementia Care Unit Capacity: 24
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
Follow-Up
Census: 77
Capacity: 95
Deficiencies: 1
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.
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.
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.
Deficiencies (1)
| Description |
|---|
| Resident credit card was stolen from the facility and fraudulent charges were incurred. |
Report Facts
License Capacity: 95
Residents Served: 77
Secured Dementia Care Unit Capacity: 24
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
Complaint Investigation
Census: 78
Capacity: 95
Deficiencies: 2
Feb 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 02/21/2024.
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.
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 95
Residents Served: 78
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 15
Hospice Residents: 4
Residents Age 60 or Older: 78
Residents with Mobility Need: 26
Inspection Report
Renewal
Census: 59
Capacity: 95
Deficiencies: 11
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.
Deficiencies (11)
| Description |
|---|
| 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
License Capacity: 95
Residents Served: 59
Secured Dementia Care Unit Capacity: 24
Residents Served in Dementia Unit: 15
Residents with Mobility Need: 18
Total Daily Staff: 77
Waking Staff: 58
Inspection Report
Follow-Up
Census: 80
Capacity: 95
Deficiencies: 1
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.
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.
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.
Deficiencies (1)
| Description |
|---|
| 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
License Capacity: 95
Residents Served: 80
Secured Dementia Care Unit Capacity: 24
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
Complaint Investigation
Census: 80
Capacity: 95
Deficiencies: 2
Jul 6, 2023
Visit Reason
The inspection was conducted as an incident investigation related to a complaint or incident involving the facility.
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.
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 95
Residents Served: 80
Secured Dementia Care Unit Capacity: 24
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
Renewal
Census: 48
Capacity: 95
Deficiencies: 9
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.
Deficiencies (9)
| Description |
|---|
| 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
License Capacity: 95
Residents Served in Secured Dementia Care Unit: 13
Capacity of Secured Dementia Care Unit: 24
Current Hospice Residents: 1
Inspection Report
Follow-Up
Census: 35
Capacity: 95
Deficiencies: 3
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.
Deficiencies (3)
| Description |
|---|
| 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
License Capacity: 95
Residents Served: 35
Secured Dementia Care Unit Capacity: 16
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
Renewal
Deficiencies: 0
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
Renewal
Deficiencies: 0
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
Capacity: 95
Deficiencies: 0
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
Maximum licensed capacity: 95
Secure Dementia Care Unit capacity: 16
Inspection Report
Renewal
Census: 44
Capacity: 95
Deficiencies: 5
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.
Deficiencies (5)
| Description |
|---|
| 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
License Capacity: 95
Residents Served: 44
Secured Dementia Care Unit Capacity: 16
Secured Dementia Care Unit Residents Served: 12
Hospice Residents: 1
Resident with Mobility Need: 12
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