Inspection Reports for
AHAVA Memory Care
200 JHF Dr, Pittsburgh, PA 15217, United States, PA, 15217
Back to Facility Profile20 Reports
Notice — Aug 7, 2023
Date: Aug 7, 2023
Visit Reason
The document serves to notify the facility that their request to waive 55 Pa.Code § 2800.104(b) regarding dining utensils has been granted to comply with Kosher dietary requirements.
Findings
The waiver permits the limited use of plastic and paper plates, utensils, and cups for serving, eating, and drinking Kosher food. The Department will review compliance with this waiver annually during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Harman | Bureau Director, Human Services Licensing | Signed the waiver approval letter |
Inspection Report — May 4, 2023
Complaint Investigation
Date: May 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 05/04/2023.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and the follow-up was not required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 28
Current Hospice Residents: 4
Residents Diagnosed with Mental Illness: 5
Residents Aged 60 or Older: 28
Residents with Mobility Need: 28
Total Daily Staff: 56
Waking Staff: 42
Inspection Report — Feb 1, 2023
Complaint Investigation
Date: Feb 1, 2023
Visit Reason
The inspection was conducted as a complaint investigation at the AHAVA Memory Care Residence.
Complaint Details
The inspection was complaint-driven and the findings indicate no deficiencies or citations.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 27
Current Residents in Hospice: 4
Residents Age 60 or Older: 27
Residents with Mental Illness: 2
Residents with Mobility Need: 27
Inspection Report — Jun 29, 2022
Renewal
Date: Jun 29, 2022
Visit Reason
The inspection was a renewal, provisional licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing, to evaluate compliance with 55 Pa. Code Ch. 2800 relating to Assisted Living Residence.
Findings
The facility was found to be in compliance after the inspection and corrections were made. Several deficiencies were identified related to resident contracts, locked poisons, window screens, bedside tables, unobstructed egress, preadmission screening, and key-locking devices, all of which had plans of correction implemented and accepted.
Citations (7)
Resident #1 does not have a resident-home contract in place.
An unlocked, accessible, and unattended 4oz. tube of WeCare CalaSoothe Cream was found in the common bathroom next to the sunroom.
Right window screen in bedroom #M02 is in disrepair with frayed and pulled corner; right window screen in bedroom #M09 has two small holes approximately 1 inch in diameter.
Resident #2's bedside table measures approximately 56 inches from the resident's bedside with a chair between the bed and table.
Emergency exit door from activity room into secured courtyard was unable to be opened due to a yellow hose obstructing the door.
Resident #1 was admitted without a written cognitive preadmission screening completed within 72 hours prior to admission.
No codes were posted at the locking mechanisms keypads at the gates on the left and right side of the secured courtyard.
Report Facts
Residents Served: 26
Staffing Hours: 52
Staffing Hours: 39
Current Residents: 6
Residents Age 60 or Older: 26
Residents with Mobility Need: 26
Inspection Report — Jun 28, 2022
Renewal
Date: Jun 28, 2022
Visit Reason
The inspection was conducted as a licensing inspection for the AHAVA Memory Care Residence to determine compliance with 55 Pa. Code Chapter 2800 relating to Assisted Living Residences and to issue a regular license.
Findings
The facility was found to be in compliance with the applicable regulations after the inspection and corrections made. A regular license was issued to the facility.
Inspection Report — Oct 20, 2021
Monitoring
Date: Oct 20, 2021
Visit Reason
The inspection was a monitoring visit conducted on 10/20/2021 to assess compliance with licensing requirements at AHAVA Memory Care Residence.
Findings
The inspection identified multiple medication-related deficiencies including incorrect labeling of insulin pens, discrepancies in blood glucose documentation versus glucometer readings, and failure to follow prescriber orders for insulin administration. Plans of correction were accepted or directed to address these issues with staff education, audits, and updated medication orders.
Citations (6)
Insulin pens were not labeled correctly according to pharmacy labels, causing potential medication errors.
Blood glucose readings documented on medication administration records (MAR) did not match glucometer readings for residents, including failure to document 'HI' readings properly.
Resident #1's medication administration record did not include additional insulin doses required when blood glucose was less than 100 mg/dl at meals.
Resident #1 was administered incorrect amounts of insulin on multiple occasions, not consistent with prescribed orders.
Resident #2's blood glucose checks and insulin administration were inconsistently documented and did not always follow prescribed sliding scale orders.
Resident #3's blood glucose monitoring was incomplete with missing glucometer readings despite prescribed twice daily checks.
Report Facts
Residents Served: 29
Total Daily Staff: 58
Waking Staff: 44
Hospice Residents: 6
Blood Glucose Readings Discrepant: 8
Inspection Report — Jul 7, 2021
Renewal
Date: Jul 7, 2021
Visit Reason
The inspection was conducted as a full, unannounced renewal inspection of the AHAVA Memory Care Residence on 07/07/2021 and 07/08/2021.
Findings
The inspection identified multiple deficiencies related to medication administration and equipment use, including sharing of glucometers between residents, unlabeled medication pens, glucometers not set to the correct time, and discrepancies in medication administration records. The facility submitted an acceptable plan of correction addressing these issues.
Citations (5)
Resident #1’s glucometer was used to test resident #2’s blood glucose.
Resident #2’s Humalog Kwik pen does not have a pharmacy label.
Resident #1 and resident #3's glucometers are not set to the current time.
Resident #1's medication administration record (MAR) indicates incorrect sliding scale blood glucose range.
Resident #2 is prescribed insulin but no glucometer was present in the residence for this resident.
Report Facts
Residents Served: 27
Current Hospice Residents: 6
Total Daily Staff: 54
Waking Staff: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN, Infection Control | Conducted glucometer audits from July 12 through July 26, 2021 | |
| RN, Director of Resident Care | Conducted audits of glucometers and medication carts; responsible for ongoing monitoring and training |
Inspection Report — Jan 7, 2021
Follow-Up
Date: Jan 7, 2021
Visit Reason
The visit was a follow-up review to verify the implementation of a previously submitted plan of correction related to an incident of resident abuse and failure to report.
Complaint Details
The visit was triggered by an incident reported involving resident #1, diagnosed with Alzheimer's dementia, who was abused by staff on 12/21/2021. The complaint was substantiated as the facility failed to report the abuse timely and did not immediately suspend the staff involved.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing the abuse incident involving resident #1. Staff were reeducated on abuse reporting, and the staff member involved was terminated and prohibited from returning to the facility.
Citations (5)
Failure to immediately report suspected abuse of resident #1 in accordance with the Older Adult Protective Services Act.
Failure to immediately develop and implement a plan of supervision or suspend the staff person involved in the alleged abuse incident.
Failure to immediately notify the resident and the resident’s designated person of a report of suspected abuse.
Resident #1 was subjected to abuse including being forcibly restrained in a reclined chair, dragged down the hall, and left alone in a room with the door closed.
Prohibited procedure of seclusion by involuntary confinement of resident #1 in a room from which the resident was physically prevented from leaving.
Report Facts
Residents Served: 22
Current Residents in Hospice: 3
Residents Age 60 or Older: 22
Residents with Mobility Need: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Involved in abuse incident; terminated and prohibited from returning to the facility | |
| Jason Williams | Signed the letter confirming plan of correction implementation |
Notice — Oct 2, 2020
Date: Oct 2, 2020
Visit Reason
The document serves as a license renewal notice and informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Jan 30, 2020
Routine
Date: Jan 30, 2020
Visit Reason
The Department’s Bureau of Human Services Licensing Representatives conducted an inspection of the Ahava Memory Care Residence facility.
Findings
No regulatory citations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Inspection Report — Oct 30, 2019
Complaint Investigation
Date: Oct 30, 2019
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection to review compliance at Ahava Memory Care Residence.
Complaint Details
The inspection was complaint-driven and unannounced. The violation regarding the annual medical evaluation was identified and a plan of correction was submitted and fully implemented.
Findings
The report found a violation related to the annual medical evaluation requirement, specifically a resident's most recent medical evaluation was outdated. The submitted plan of correction was fully implemented and approved.
Citations (1)
2800.141b Annual medical evaluation requirement was violated as a resident's most recent medical evaluation was dated 8/20/18, despite admission on 10/16/17.
Report Facts
Residents Served: 26
Current Residents in Hospice: 5
Total Daily Staff: 52
Waking Staff: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Reno Becker | Administrator | Named in facility information on inspection report |
| Amy Dukes | Interim Executive Director | Signed plan of correction |
Inspection Report — Sep 12, 2019
Annual Inspection
Date: Sep 12, 2019
Visit Reason
The inspection was an annual licensing inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2800 relating to Assisted Living Residence.
Findings
Multiple violations of the assisted living residence regulations were found, including deficiencies in staff training, emergency telephone postings, lighting in resident rooms, unobstructed egress, emergency procedures posting, menu postings, medication storage and administration, resident rights education, and keypad exit signage. Plans of correction were submitted with partial implementation status.
Citations (11)
65h Direct care staff persons did not receive 16 hours of required annual training related to their job duties during the training year 1/1/18 to 12/31/18.
65i Direct care staff person did not receive training in any of the required training topics during the training year 1/1/18 to 12/31/18.
65j Direct care staff persons, ancillary staff, substitutes, and volunteers did not receive required annual training in fire safety, emergency preparedness, resident rights, protective services, and falls prevention during 1/1/18 to 12/31/18.
91 Emergency telephone numbers for nearest hospital, police, fire department, ambulance, poison control, local emergency management, and assisted living complaint hotline were not posted on or near the phone in the home's private dining room.
101j Lighting operable lamp: Resident #4 did not have access to a lamp or other source of light that can be turned on/off at bedside in resident room #2.
121a Stairways, hallways, doorways, passageways and egress routes from living units and building were obstructed by items including a bunched up green outdoor carpet, a grey plastic storage bin, a red and white folded umbrella, plastic fencing, and a rolled up blue padded mat.
123b Emergency preparedness procedures for the home and local municipality were not posted in a public and conspicuous place in the home.
162c Menus posted did not include the week in advance menu for 9/16/19 to 9/22/19 as required.
185a Medication storage procedures: Resident #1 was prescribed LiquiTears 1.4% with no open date on the label and pharmacy order filled on 7/28/19, exceeding 28 days after opening.
191 Resident right to refuse medication: Residents #1, #2, and #3 were not educated on their right to question or refuse medication if they believed there may be a medication error.
233c Key-locking devices: Codes or instructions to operate keypad and override magnetic locks were not posted conspicuously near the device or gates.
Report Facts
Residents Served: 30
Current Hospice Residents: 4
Staff Total Daily: 60
Waking Staff: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mindy Dean | Administrator | Named as administrator responsible for plans of correction and signature on all violation pages |
Inspection Report — Jul 16, 2019
Renewal
Date: Jul 16, 2019
Visit Reason
The document is a renewal notification and license issuance for Ahava Memory Care Residence, confirming the facility's renewal application to operate an Assisted Living Home under Pennsylvania regulations.
Findings
The Department of Human Services has approved the renewal application and issued a license for the facility to operate with a maximum capacity of 30 residents. The Department will conduct an onsite inspection within the next twelve months as required by state code.
Report Facts
Inspection Report — Sep 25, 2018
Renewal
Date: Sep 25, 2018
Visit Reason
The inspection was conducted as a renewal inspection of the Ahava Memory Care Residence under 55 Pa. Code Ch. 2800 for Assisted Living Residences on September 25 and 27, 2018.
Findings
Multiple violations were found related to fire drill documentation, medical evaluations including tuberculin skin tests, medication storage and administration, resident education on medication rights, and pre-admission screening documentation. Plans of correction were submitted and partially implemented for all deficiencies.
Citations (6)
Regulation 2800.132(c): The fire drill record did not include the exit route(s) used at the time of the drill conducted on 7/30/18 and 8/28/18.
Regulation 2800.141(a): Resident #1, admitted 11/27/17, did not have a tuberculin skin test as required by medical evaluation standards.
Regulation 2800.183(b): Barrier cream was unlocked, unattended, and accessible to residents in unit #4 and unit #29.
Regulation 2800.187(d): Resident #2 was ordered Atorvastatin 20mg but the medication was not administered on 9/19/18, 9/20/18, and 9/24/18.
Regulation 2800.191: Residents #1, #2, #3, and #4 have not been educated on their right to question or refuse medication if they believe there is a medication error.
Regulation 2800.231(c)(1): The preadmission screening form for Resident #1, dated 11/24/18, did not indicate if the resident's needs can be met by the residence.
Report Facts
Number of Residents Served: 28
Number of Current Hospice Residents: 7
Number of Hospice Residents in past year: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rena Becker | Administrator | Named in multiple findings and plans of correction |
Notice — Jul 11, 2018
Date: Jul 11, 2018
Visit Reason
The document serves as a renewal notification and license issuance for Ahava Memory Care Residence, an assisted living facility, following receipt of the renewal application.
Findings
The Department confirms issuance of a regular license for the facility with a capacity of 30 residents. The Department will conduct an annual onsite inspection within the next twelve months as required by regulation.
Report Facts
Inspection Report — Apr 13, 2018
Renewal
Date: Apr 13, 2018
Visit Reason
The inspection was conducted due to an increase in capacity at the Ahava Memory Care Residence.
Findings
Two violations were found: fire extinguishers lacked inspection tags, and exit doors were not properly marked with exit signs. Plans of correction were submitted and partially or fully implemented by April 25, 2018.
Citations (2)
Regulation § 2800.131(f): Fire extinguishers did not contain tags indicating annual inspection and approval by a fire safety expert. Missing tags were noted near bedroom #21 and the elevator machine room.
Regulation § 2800.133: Exit doors from the breezeway to the porch area and from the dining room to the enclosed courtyard were not marked with exit signs. These doors do not provide a means of egress and are not marked as 'not an exit.'
Report Facts
Number of Residents Served: 16
Number of Current Hospice Residents: 5
Number of Hospice Residents in past year: 5
Notice — Nov 13, 2017
Date: Nov 13, 2017
Visit Reason
The document is a response to a request for a waiver of specific Pennsylvania Code regulations related to application, admission, medical evaluation, and initial assessment for the Ahava Memory Residence assisted living facility.
Findings
The waiver request was granted under specified conditions, including the use of alternative documentation for medical evaluation and preadmission screening forms. The waiver remains effective as long as conditions are met and will be reviewed annually during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the waiver approval letter. |
Inspection Report — Sep 27, 2017
Original Licensing
Date: Sep 27, 2017
Visit Reason
The inspection was conducted as a licensing inspection for the new assisted living facility, Ahava Memory Care Residence, which was not yet serving four or more residents at the time.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the licensing inspector was unable to complete a full inspection due to the facility being new and not yet serving four or more residents.
Document — October 14, 2021
Date: October 14, 2021
Visit Reason
The document includes a certificate of compliance granting operation of the Ahava Memory Care Residence and a letter acknowledging receipt of a renewal application for the assisted living home license.
Findings
No inspection findings or deficiencies are reported; the letter states that an annual inspection will be conducted within the next twelve months and enforcement action will be taken if noncompliance is found.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal application acknowledgment letter |
Notice — July 7, 2023
Date: July 7, 2023
Visit Reason
This document serves as a renewal notification and license issuance for Ahava Memory Care Residence, an assisted living home, following receipt of the renewal application dated April 7, 2023. It also advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and states that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the renewal notification letter |
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