Inspection Reports for Greystone Country Estates
424 DELAWARE ROAD,, FREDONIA, PA, 16124
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
32% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
78% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 35
Capacity: 45
Deficiencies: 4
Apr 10, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The submitted plan of correction was determined to be fully implemented. Several deficiencies were noted including missing intended use of rent rebate in resident contract, incomplete criminal background check for a staff member, lack of required qualifications for direct care staff, and improper food storage. All deficiencies had accepted plans of correction with completion dates and were implemented by the time of the report.
Deficiencies (4)
| Description |
|---|
| The rent rebate addendum for resident #1 does not include the intended use of the home's portion of the rent rebate. |
| Staff person A did not have a Pennsylvania background check completed. |
| Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| At 10:36 AM there was a case of wax beans stored on the floor in the pantry. |
Report Facts
License Capacity: 45
Residents Served: 35
Current Residents in Hospice: 5
Residents Receiving Supplemental Security Income: 5
Residents 60 Years or Older: 34
Residents Diagnosed with Mental Illness: 5
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 2
Residents with Physical Disability: 0
Total Daily Staff: 37
Waking Staff: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to missing Pennsylvania background check, lack of required qualifications, and high school diploma verification |
Inspection Report
Renewal
Census: 25
Capacity: 45
Deficiencies: 8
May 2, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review the facility's compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including uncovered trash receptacles, insufficient water pressure in bathroom sinks, unlabeled personal hygiene items, outdated fire safety inspections and drills, incomplete resident preadmission screening forms, and incomplete resident assessments. Plans of correction were submitted and determined to be fully implemented by the follow-up date.
Deficiencies (8)
| Description |
|---|
| Partially full, uncovered and unattended trash can in the shared Jack and Jill style bathroom in bedroom #106. |
| Insufficient water pressure at the 2 bathroom sinks in the shared shower room; one sink was out of order and the other had no hot water. |
| Seven unlabeled bottles of bodywash and shampoo on the shelf inside shower #1 and four unlabeled bottles plus one container of shaving gel on the shelf inside shower #2 in the shared bathroom. |
| The last fire drill and fire safety inspection by a fire safety expert was conducted on 9/19/23, with the prior one on 4/19/22, not meeting annual requirements. |
| During fire drills conducted April to August 2023, the home exceeded the evacuation time of 2 minutes 30 seconds specified by a fire safety expert. |
| Resident #1 was admitted without a completed preadmission screening form. |
| Resident #1's initial assessment did not include diagnoses of Vitamin D Deficiency and Degenerative Joint Disease Right Knee as indicated on medical evaluation. |
| Resident #2's assessment did not include diagnoses of Joint Disorder, Magnesium Deficiency, Hypo-Osmolality and Hyponatremia, Muscle Weakness, Symbolic Dysfunctions, and Dysphagia as indicated on medical evaluation. |
Report Facts
License Capacity: 45
Residents Served: 25
Staffing Hours: 27
Waking Staff: 20
Residents Receiving SSI: 9
Residents Age 60 or Older: 23
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 2
Residents with Physical Disability: 0
Fire Drill Dates: 2
Inspection Report
Census: 25
Capacity: 45
Deficiencies: 0
May 1, 2023
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 during this inspection.
Report Facts
Total Daily Staff: 26
Waking Staff: 20
Residents Served: 25
License Capacity: 45
Residents Receiving Supplemental Security Income: 4
Residents Age 60 or Older: 25
Residents with Mobility Need: 1
Inspection Report
Renewal
Census: 32
Capacity: 45
Deficiencies: 6
Mar 9, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license to ensure continued compliance with regulatory standards.
Findings
The inspection found multiple deficiencies including lack of window screens, combustible storage near furnace, improper smoking area location, missing posted menus, incomplete preadmission screening forms, and unsigned support plans. The facility submitted plans of correction which were determined to be fully implemented.
Deficiencies (6)
| Description |
|---|
| No screen on the functioning window in bedroom #. |
| Furnace paperwork was stored directly on top of the furnace. |
| The home's designated smoking area is located directly in front of the rear door. |
| The home's menu for the week of 3/9/23 was not posted. |
| Resident #1’s preadmission screening form does not include a determination that the needs of the resident can be met by the services provided by the home. |
| Resident #2’s current support plan was not signed by the resident nor does it indicate inability or refusal to sign. |
Report Facts
License Capacity: 45
Residents Served: 32
Total Daily Staff: 33
Waking Staff: 25
Residents Receiving Supplemental Security Income: 4
Residents 60 Years or Older: 32
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 1
Residents with Physical Disability: 0
Inspection Report
Renewal
Census: 31
Capacity: 45
Deficiencies: 7
Mar 17, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection identified several deficiencies including lack of carbon monoxide alarms near fossil fuel devices, inadequate overnight staffing, missing emergency telephone numbers, outdated fire safety inspection and drill, medication storage and administration issues, and incomplete resident assessments. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (7)
| Description |
|---|
| No carbon monoxide alarms near the gas furnace on the 3rd floor and gas dryers in laundry rooms. |
| Only one staff person regularly works overnight, which is inadequate to meet resident needs in an emergency. |
| No emergency telephone numbers posted on or near the cordless phone in resident #4's bedroom. |
| Last fire safety inspection and fire drill conducted by a fire safety expert was on 6/4/2019, overdue for annual requirement. |
| Medication storage and administration errors found for residents #4 and #5. |
| Staff person administering medications had not completed required Department-approved medication administration annual practicum course. |
| Resident #3 and #7 had incomplete or untimely additional assessments. |
Report Facts
License Capacity: 45
Residents Served: 31
Total Daily Staff: 32
Waking Staff: 24
Completion Date: May 5, 2022
Completion Date: May 18, 2022
Fire Drill Completion Date: Apr 19, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| General Manager | Registered to take Medication Train the Trainer course and responsible for staff medication training. | |
| Administrator | Responsible for oversight of plans of correction, documentation, and monitoring compliance. |
Notice
Capacity: 45
Deficiencies: 0
Apr 30, 2021
Visit Reason
The document serves as a notification of receipt and approval of the renewal application to operate the Personal Care Home, Greystone Country Estates, and informs that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it is a license renewal notice confirming issuance of a regular license and advising of future inspections.
Report Facts
Total licensed capacity: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter and Certificate of Compliance. |
| Monica Shoup | Administrator | Recipient of the renewal notification letter. |
Inspection Report
Renewal
Census: 30
Capacity: 45
Deficiencies: 6
Feb 3, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 02/03/2021 through 02/05/2021 to assess compliance with licensing requirements.
Findings
Several deficiencies were identified including improper glucometer use, unfinished wall surfaces with lint accumulation, snow and ice obstructions on emergency exits, blocked egress routes, incomplete emergency evacuation diagrams, and inaccurate blood glucose documentation. Plans of correction were directed or accepted with completion dates ranging from 02/05/2021 to 04/30/2021. Weekly and monthly monitoring and staff reeducation were implemented.
Deficiencies (6)
| Description |
|---|
| Resident #1’s glucometer was used to measure resident #2’s blood glucose levels on 1/26/21 and 2/1/21. |
| The lower wall behind 2 dryers in the 100 hall laundry is unfinished, exposing pink wall insulation covered with dryer lint. |
| Outside landing and steps leading from the side driveway emergency exit doors were covered with 2" of snow and ice from 2/3/21 to 2/4/21. |
| Emergency exit double doors off the lounge had a handwritten sign taped stating 'This is not an exit' and egress was blocked by a chair and other items on 2/3/21 and 2/4/21. |
| Emergency evacuation diagram posted in the 200 hallway did not include the line of travel to the exit doors off of the lounge. |
| Blood glucose readings documented on Resident #1 and Resident #2's medication administration records were not found on the glucometer. |
Report Facts
License Capacity: 45
Residents Served: 30
Current Residents in Hospice: 5
Staffing Hours - Total Daily Staff: 30
Staffing Hours - Waking Staff: 23
Snow/Ice Obstruction Duration: 1.5
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