Inspection Reports for Grace Manor at North Park
9565 Babcock Blvd, Allison Park, PA 15101, PA, 15101
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Census: 48
Capacity: 67
Deficiencies: 0
Sep 11, 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 as a result of this inspection.
Report Facts
Total Daily Staff: 77
Waking Staff: 58
License Capacity: 67
Residents Served: 48
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 13
Residents Age 60 or Older: 48
Residents with Mobility Need: 29
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 1
Inspection Report
Census: 44
Capacity: 67
Deficiencies: 0
Jul 18, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 67
Residents Served: 44
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 12
Residents Age 60 or Older: 44
Residents with Mobility Need: 28
Residents with Physical Disability: 1
Total Daily Staff: 72
Waking Staff: 54
Inspection Report
Complaint Investigation
Census: 46
Capacity: 67
Deficiencies: 4
Mar 28, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at Grace Manor at North Park on 03/28/2025.
Findings
The inspection found multiple deficiencies including missing narcotic medications due to improper storage and handling, failure to follow prescriber's orders resulting in delayed medication administration, incomplete resident assessments, and inaccurate support plans. Plans of correction were implemented and staff were re-educated on policies.
Complaint Details
The visit was complaint-related, investigating missing narcotic medication and medication administration issues. The complaint was substantiated with findings of missing medication and policy violations.
Deficiencies (4)
| Description |
|---|
| Failure to implement procedures for safe storage, access, security, distribution and use of medications, resulting in missing narcotic tablets. |
| Failure to follow prescriber's orders, with a resident not receiving a prescribed medication dose until late. |
| Failure to complete additional assessments when resident's condition changed, with diagnoses not reflected in the most recent assessment. |
| Support plan did not accurately document resident's medical and behavioral care needs, inconsistent with assessments. |
Report Facts
License Capacity: 67
Residents Served: 46
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 18
Residents Age 60 or Older: 46
Residents with Mobility Need: 28
Residents with Physical Disability: 1
Total Daily Staff: 74
Waking Staff: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Received narcotic medication delivery and transferred medication to Staff person B. | |
| Staff person B | Failed to place medication in medication cart, was terminated after investigation for policy violations. | |
| Director of Wellness | Identified missing medication, notified Executive Director, and reordered medication. | |
| Executive Director | Notified police regarding missing medication, added steps to medication policy, and provided education. | |
| Assistant Executive Director | Provided education on medication policy changes and support plan corrections. |
Inspection Report
Follow-Up
Census: 42
Capacity: 67
Deficiencies: 1
Feb 21, 2025
Visit Reason
The inspection visit was conducted as a follow-up to review the submitted plan of correction related to an incident at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction regarding medication storage and narcotic count procedures. Continued compliance is required.
Deficiencies (1)
| Description |
|---|
| Failure to properly count and reconcile controlled substances during shift change, including missing narcotic flow sheets and incorrect medication labeling. |
Report Facts
License Capacity: 67
Residents Served: 42
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 18
Residents Age 60 or Older: 42
Residents with Mobility Need: 22
Residents with Physical Disability: 1
Total Daily Staff: 64
Waking Staff: 48
Inspection Report
Complaint Investigation
Census: 45
Capacity: 67
Deficiencies: 4
Jan 10, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation regarding allegations of financial abuse and other regulatory compliance issues at Grace Manor at North Park.
Findings
The investigation found that a direct care staff person, who was also the Power of Attorney for a resident, misused the resident's funds for personal expenses. The facility failed to immediately suspend or supervise the staff involved and delayed reporting the incident to the Department. Additionally, the facility's website improperly advertised assisted living services without proper licensure. Corrective actions including staff education, termination of the involved staff, and changes to reporting and monitoring procedures were implemented.
Complaint Details
The complaint investigation substantiated allegations that direct care staff person B, also the Power of Attorney for a resident, misused the resident's funds for personal expenses including travel, shopping, and gambling. The facility delayed reporting the abuse and failed to suspend the staff promptly.
Deficiencies (4)
| Description |
|---|
| Failure to immediately suspend or supervise staff person involved in alleged financial abuse. |
| Failure to report the incident of financial abuse to the Department within 24 hours. |
| Advertising assisted living services without proper licensure as required by Act 56 of 2007. |
| Resident was subjected to financial abuse by a staff person who was also the Power of Attorney. |
Report Facts
Residents Served: 45
License Capacity: 67
Memory Care Capacity: 25
Memory Care Residents Served: 19
Total Daily Staff: 70
Waking Staff: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Direct Care Staff and Power of Attorney | Named in financial abuse violation and termination |
| Staff person A | Activity Director | Reported allegations of financial abuse |
| Staff person C | Executive Director | Involved in investigation and corrective actions |
| Assistant Executive Director | Assistant Executive Director | Led staff education and training on abuse reporting and compliance |
Inspection Report
Census: 46
Capacity: 67
Deficiencies: 0
Sep 18, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 67
Residents Served: 46
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 17
Resident Have Mobility Need: 28
Residents Age 60 or Older: 46
Residents Have Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 46
Capacity: 67
Deficiencies: 5
Feb 14, 2024
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 02/14/2024.
Findings
The inspection identified multiple deficiencies including failure to timely report an incident, unsecured medications in resident rooms, improper documentation of medication administration times, failure to follow prescriber's orders, and incomplete resident assessments. Plans of correction were accepted and implemented by 03/05/2024.
Complaint Details
The inspection was complaint-driven, as indicated by the reason 'Complaint' and the unannounced partial inspection on 02/14/2024. The plan of correction was accepted and fully implemented.
Deficiencies (5)
| Description |
|---|
| Failure to report an incident to the Department’s personal care home regional office or complaint hotline within 24 hours as required. |
| Prescription medications and syringes were found unlocked, unattended, and accessible in resident rooms. |
| Medication administration times were not documented at the time of administration for multiple residents. |
| The home did not follow prescriber's orders for medication administration and wound care treatments. |
| Resident assessments were not updated to reflect significant changes in care needs and home health services. |
Report Facts
License Capacity: 67
Residents Served: 46
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Unit: 18
Current Hospice Residents: 9
Total Daily Staff: 71
Waking Staff: 53
Resident Mobility Need: 25
Resident Physical Disability: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Executive Director | Named as responsible for submitting incident reports, conducting education, reviewing reportables, and auditing medication administration records. | |
| Wellness Directors | Responsible for auditing resident rooms for medication security and educating staff and agencies on medication regulations. | |
| Executive Director | Conducts random audits on medication logs to ensure accuracy. |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 67
Deficiencies: 0
Jan 8, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 67
Residents Served: 48
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 4
Residents Age 60 or Older: 48
Residents with Mobility Need: 35
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 49
Capacity: 67
Deficiencies: 0
Jun 22, 2023
Visit Reason
The inspection was conducted as a complaint investigation at Grace Manor at North Park on 06/22/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this complaint inspection.
Complaint Details
The inspection was complaint-driven and no deficiencies were found, indicating no substantiated issues.
Report Facts
Total Daily Staff: 74
Waking Staff: 56
License Capacity: 67
Residents Served: 49
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 10
Residents Age 60 or Older: 48
Residents with Mobility Need: 25
Inspection Report
Complaint Investigation
Census: 51
Capacity: 67
Deficiencies: 0
Dec 28, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial licensing inspections on 12/28/2022 and 12/29/2022.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and unannounced. No deficiencies or regulatory citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 67
Residents Served: 51
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 22
Current Hospice Residents: 7
Residents Age 60 or Older: 50
Residents with Mobility Need: 38
Inspection Report
Renewal
Census: 42
Capacity: 67
Deficiencies: 12
Nov 8, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance with licensing regulations and to review the submitted plan of correction.
Findings
Multiple deficiencies were identified including breaches in record confidentiality, sanitary conditions, medication procedures, evacuation times, and incomplete resident medical documentation. The facility submitted plans of correction which were accepted and later determined to be fully implemented.
Complaint Details
The inspection included a complaint investigation component; however, the report does not explicitly state the substantiation status of the complaint.
Deficiencies (12)
| Description |
|---|
| Resident records were unlocked, unattended, and accessible in public areas, exposing confidential medical information. |
| No soap or sanitary hand drying means were present at sinks in the 3rd floor common dining room and activities room. |
| An uncovered and unattended trash can was found in the kitchen, approximately 3/4 full of trash. |
| A 14 inch crack was present along the entire left side of the countertop at the 2nd floor common restroom sink. |
| Numerous operable windows lacked screens, including windows in bedrooms #301, #302, and #307. |
| Fire drill evacuation time exceeded the maximum allowed time by 40 seconds. |
| Resident #6's medical evaluation did not include the resident's temperature. |
| Discrepancies in controlled drug records and medication administration records for resident #6, including missing Lorazepam tablets and undocumented administration. |
| Medication administration records for resident #1 lacked staff initials for multiple doses of Hydrocodone/APAP. |
| Resident #1 was not administered prescribed oxygen for approximately one week. |
| Resident #1's support plan did not document oxygen use, responsible persons, or administration frequency. |
| Resident #7's cognitive preadmission screening did not include diagnoses. |
Report Facts
License Capacity: 67
Residents Served: 42
Residents in Secured Dementia Care Unit: 22
Current Hospice Residents: 5
Staffing Hours: 67
Waking Staff: 50
Evacuation Time: 565
Maximum Allowed Evacuation Time: 525
Medication Discrepancy: 2
Inspection Report
Routine
Deficiencies: 0
Dec 9, 2021
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report
Renewal
Census: 39
Capacity: 67
Deficiencies: 19
Oct 12, 2021
Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to assess compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies related to facility maintenance, resident care, medication management, and documentation. Several deficiencies were corrected during the inspection or through plans of correction, with follow-up reviews scheduled. Some violations were repeated from prior inspections.
Deficiencies (19)
| Description |
|---|
| 55 Pa. Code Chapter 2600 was not posted in the home. |
| Push lock removed from bedroom #314 door, leaving a hole posing a hazard. |
| Floor deterioration in second-floor hallway near bedroom #207 causing hazard. |
| Concrete ramp at front entrance deteriorating and crumbling, posing trip/fall hazard. |
| Bedroom #201 had two residents but only one chair available. |
| Pillow on resident #1's bed lacked a pillow case. |
| Unlabeled, used bar soap found in shared bathroom of bedroom #201. |
| Open and unsealed food items found in kitchen pantry and refrigerator. |
| Resident #2's medical evaluation missing height, immunization status, and attachments. |
| Menus in memory care unit lacked dates to identify current week. |
| Discontinued medication (Lorazepam) still stored in medication cart for resident #1. |
| Medication label for Albuterol incomplete, missing second order details. |
| Glucometer for resident #1 lacked coding strips and batteries; blood glucose readings inconsistently documented. |
| Blood glucose readings for resident #3 and #4 were inconsistently documented or missing. |
| Medication administration records not initialed or medications not available for resident #3 on multiple dates. |
| Resident #2's support plan inaccurately documented mobility needs, not reflecting total immobility. |
| No lock on door of single use common bathroom with shower in memory care east wing, compromising privacy. |
| Emergency telephone numbers not posted near cordless phone in third-floor medication room. |
| Broken towel rack in private bathroom of bedroom #314 in memory care east wing. |
Report Facts
Licensed Capacity: 67
Current Census: 39
Residents in Secure Dementia Care Unit: 17
Hospice Residents: 7
Staffing Hours: 67
Waking Staff: 50
Residents 60 Years or Older: 38
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Himes | Administrator | Named as facility administrator. |
| Jon Kimberland | Reviewer | Reviewer of plan of correction and document submissions. |
| Karen Georgoulis | Lead Inspector | Lead inspector conducting the on-site inspection. |
| Alexis Martini | Vice President of Operations | Named in correspondence regarding inspection results. |
Inspection Report
Follow-Up
Census: 32
Capacity: 67
Deficiencies: 1
Jul 6, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 07/06/2021 to review the Plan of Correction submission related to a previous deficiency.
Findings
The inspection found that door locks on shared bathrooms in semi-private rooms within the Secured Dementia Care Unit were disabled, violating resident privacy rights. A Plan of Correction was accepted and implemented to re-enable the locks and educate staff.
Deficiencies (1)
| Description |
|---|
| The door locks were disabled on numerous shared bathroom doors located in semi-private rooms in the Secured Dementia Care Unit, including the bathroom doors in bedrooms #302, #307, and #316. |
Report Facts
License Capacity: 67
Residents Served: 32
Secured Dementia Care Unit Capacity: 25
Residents Served in Secured Dementia Care Unit: 12
Completion Date: Jul 12, 2021
Inspection Report
Follow-Up
Census: 26
Capacity: 60
Deficiencies: 3
May 21, 2021
Visit Reason
The inspection was conducted as a partial, unannounced incident review related to emergency medical and health information availability and response.
Findings
The facility was found deficient in providing current emergency medical and health information to EMS during a 911 call, and issues with staff access to the elevator and building entry for EMS were noted. The submitted plan of correction was reviewed and accepted with monitoring steps.
Deficiencies (3)
| Description |
|---|
| Failure to have current emergency medical and health information available and provided to EMS for resident #1 during an emergency. |
| EMS was unable to access the elevator due to no staff having a key to unlock the key locking device. |
| EMS had difficulty accessing the building and required staff assistance to enter. |
Report Facts
License Capacity: 60
Residents Served: 26
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 8
Hospice Current Residents: 2
Resident Mobility Need: 15
Residents Age 60 or Older: 26
Total Daily Staff: 41
Waking Staff: 31
Notice
Capacity: 60
Deficiencies: 0
Feb 3, 2021
Visit Reason
The document serves as a renewal certificate and letter confirming the receipt of the renewal application to operate the Personal Care Home and informing that an annual inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported; the document confirms issuance of a regular license following the renewal application and outlines the requirement for an annual inspection.
Report Facts
Maximum capacity: 60
Secure Dementia Care Unit capacity: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal letter |
Notice
Capacity: 60
Deficiencies: 0
Jan 25, 2021
Visit Reason
The document serves as a notice of approval for a revised license capacity following a request to adjust the use of physical space to add a secured dementia care unit at the facility.
Findings
The Department approved the capacity revision request for the addition of a secured dementia care unit with a capacity of 18, while the overall license expiration date remains unchanged.
Report Facts
Total licensed capacity: 60
Secured dementia care unit capacity: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the approval letter for the revised license |
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