Brookdale Grayson View.

“Resident assessment did not document that the resident utilizes a rollator for movement, despite medical evaluation evidence showing rollator use.”

“A medication error occurred on 06/08/2025 for Resident 6, but the home did not report this incident to the department until 06/11/2025, failing to meet the 24-hour reporting requirement. This was a repeat violation from 10/30/2024.”

“The floor of a bedroom occupied by Resident 1 was covered with papers, discarded cups, reading material, food crumbs, and other debris, creating a slip/fall risk and violating cleanliness and safety standards.”

“A prescription medication (Rosuvastatin Calcium 20 mg) was found on the floor of a bedroom occupied by Resident 1, indicating that medications were not properly secured in a locked container as required.”

“For Resident 4, the Medication Administration Record indicated a 300MG dosage of Gabapentin, but the medication label stated a 100MG dosage (3 capsules), creating a discrepancy between the prescribed order and the labeled medication container.”

“For Resident 6, a straight order for Lactobacillus tablets to be administered twice daily was not given on 06/08/2025 because the pharmacy did not deliver the medication. The home failed to follow the prescriber's orders. This was a repeat violation from 8/27/2024 and 10/30/2024.”

“Violation related to regulatory compliance noted during inspection with calculated fine of $228 per day based on 76 residents at $3 per resident per day.”

“Violation related to regulatory compliance noted during inspection with calculated fine of $380 per day based on 76 residents at $5 per resident per day.”

“License revoked and downgraded to First Provisional status based on violations with 55 Pa Code Ch. 2600. Original license dated July 2, 2024 to July 2, 2025 was revoked. First Provisional license valid from December 27, 2024 to June 27, 2025.”

“Staff Member A did not follow the prescriber's orders when administering medication on 9/23/2024 at 8pm.”

“An unwitnessed fall resulting in a laceration requiring stitches was not reported to the Department within 24 hours as required. The incident was reported more than 24 hours after it occurred.”

“Three residents did not have annual medical evaluations completed as required. One resident's medical evaluation was more than one year and 15 days overdue from the previous evaluation. This was a repeat violation from 10/11/2023.”

“Staff Member A administered Lorazepam 0.5mg belonging to Resident #3 to Resident #2 instead of the resident's prescribed Oxycodone 2.5mg. The staff member did not properly identify the correct resident before administering the medication.”

“An unwitnessed fall resulting in a laceration requiring stitches was not reported to the Department within 24 hours as required. The incident was reported more than 24 hours after it occurred.”

“Three residents did not have annual medical evaluations completed as required. One resident's medical evaluation was more than one year and 15 days overdue from the previous evaluation. This was a repeat violation from 10/11/2023.”

“Staff Member A administered Lorazepam 0.5mg belonging to Resident #3 to Resident #2 instead of the resident's prescribed Oxycodone 2.5mg. The staff member did not properly identify the correct resident before administering the medication.”

“Staff Member A did not follow the prescriber's orders when administering medication on 9/23/2024 at 8pm.”

“Violation related to regulatory compliance noted during inspection with calculated fine of $228 per day based on 76 residents at $3 per resident per day.”

“Violation related to regulatory compliance noted during inspection with calculated fine of $380 per day based on 76 residents at $5 per resident per day.”

“License revoked and downgraded to First Provisional status based on violations with 55 Pa Code Ch. 2600. Original license dated July 2, 2024 to July 2, 2025 was revoked. First Provisional license valid from December 27, 2024 to June 27, 2025.”

“Resident #1's Resident Assessment and Support Plan (RASP) does 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) does not include the resident's signature or indicate if the resident is incapable of signing or refused to sign the RASP.”

“A resident's credit card was stolen from the facility and fraudulent charges of approximately an unspecified amount were incurred. The facility was informed of the theft by Pennsylvania State Police. Resident funds and property must only be used for the resident's benefit.”

“A resident's photograph and name were published in the facility's December 2023 monthly newsletter without consent. The resident and their Power of Attorney had signed a photograph authorization form at admission specifically stating 'not authorized for pictures.'”

“A resident's support plan/RASP did not document the resident's known visual impairment and associated dietary needs (cut up food, no pasta) that were communicated at admission by the resident's physician or medical representative.”

“The outdoor vents for the memory care laundry room dryers were clogged with a buildup of lint, creating a fire hazard.”

“The exit door located near the library was stuck and did not open without excessive force applied to the panic bar, obstructing egress.”

“A pair of green pants were found behind dryer #1 in the memory care laundry room, storing combustible materials near a heat source.”

“Resident #1 does not have a completed annual Documentation of Medical Evaluation (DME). The prior DME was completed at an unknown prior date.”

“Staff member A was witnessed yelling and cursing at Resident #1, telling the resident there were no cameras present, and forcefully grabbing and dropping the resident on the bed. The resident was found in a fetal position on the bed following the incident.”

“Poisonous materials were not kept locked and inaccessible to residents. A cup of denture cleanser was left in a resident's room on 6/14/2023, creating a risk of accidental ingestion.”

“The support plan (RASP) for a resident was not updated to reflect that the resident was receiving Physical Therapy services, as required when a resident's condition changes or services are initiated.”