Grace Manor at North Park.

“Administrator received only 9 hours of in-person training during 2024 training year, but required 24 hours of annual training relating to job duties.”

“Prescription medications not properly stored with required dating and conditions. Open and undated insulin pen was present in medication cart exceeding 28-day use timeframe; two open and undated Methotrexate vials exceeded 30-day use timeframe per manufacturer instructions.”

“Resident medication tube did not contain current pharmacy label with required information including resident name, medication name, date issued, dosage, instructions, prescriber name and title. Medication was stored in bag with incomplete labeling. This is a repeat violation.”

“Resident's prescribed allergy medication was not indicated on December 2025 medication administration record (MAR) despite being prescribed. This is a repeat violation.”

“Medication storage procedures were not properly followed. Narcotic medication (30 tablets) delivered to the facility was given to direct care staff who failed to place it in the medication cart, resulting in the medication going missing and unaccounted for. Additionally, narcotic medications were not counted during required shift changes on multiple occasions, violating the facility's policy requiring daily counts before and after each shift.”

“Resident prescribed medication to be taken every 12 hours did not receive a dose until 9:00pm on 3/11/25 because the medication was not properly stored in the medication cart upon delivery, causing a delay in prescribed medication administration.”

“Resident's assessment did not include diagnoses that were documented in the resident's most recent medical evaluation, failing to reflect a significant change in the resident's condition requiring an additional assessment.”

“Direct care staff failed to properly count controlled substance pill bottles during shift change as required by facility procedure. Two bottles containing tablets were not counted, and the narcotic flow sheet for these medications had been missing for an unknown period with staff failing to sign or reconcile the count sheet.”

“An allegation of financial abuse was reported against direct care staff person B on 12/31/2024 at approximately 4:37 p.m., but the staff member was not immediately suspended or placed on an approved plan of supervision. The staff member returned to work on 1/2/2025 at 7:00 a.m. and continued to provide unsupervised direct care services until approximately 11:00 p.m.”

“An allegation of financial abuse against a resident was reported to direct care staff person C (administrator) on 12/31/2024 at approximately 4:30 p.m., but was not reported to the Department's personal care home regional office or complaint hotline within 24 hours. The incident was not reported to the Department until 1/10/2025 at approximately 10:55 a.m.”

“On an unspecified date at approximately 10:00 a.m., the facility's website advertised assisted living services. Act 56 of 2007 prohibits use of the term 'assisted living' without licensure as an assisted living residence under 55 Pa Code Chapter 2800.”

“A resident death incident was not reported to the Department's personal care home regional office or complaint hotline within 24 hours as required. Direct care staff was notified of the resident ceasing to breathe, but the incident report was not submitted until a later time.”

“Prescription medications, OTC medications, and syringes were found unlocked, unattended, and accessible in resident rooms instead of being kept in locked medication carts.”

“Direct care staff administered medications to multiple residents but failed to document the date and time of administration on medication administration records at the time the medications were given. Five instances were cited involving medications administered in December 2023 and January 2024.”

“The home did not follow prescriber's orders in two instances: (1) a topical medication prescribed to be applied every shift was documented as needed and not administered on every shift during specified date ranges, and (2) wound care supplies required by prescriber orders were not available in the home to administer prescribed care on specified dates.”