Inspection Reports for
Celebration Villa of South Hills
5300 Clairton Boulevard (Route 51), Pittsburgh, PA 15236, Pittsburgh, PA, 15236
Back to Facility Profile28 Reports
Inspection Report — Jul 14, 2026
Complaint Investigation
Date: Jul 14, 2026
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and fine reason.
Complaint Details
The inspection was triggered by a complaint and fine, but no deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified during the inspection conducted on 07/14/2026 and 07/16/2026.
Report Facts
Residents Served: 60
Current Hospice Residents: 11
Residents Age 60 or Older: 60
Residents with Mental Illness: 2
Residents with Intellectual Disability: 1
Residents with Mobility Need: 21
Inspection Report — May 20, 2026
Complaint Investigation
Date: May 20, 2026
Visit Reason
The inspection was conducted as a complaint, provisional, and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 69
Current Hospice Residents: 4
Residents Age 60 or Older: 69
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 12
Inspection Report — Jan 5, 2026
Renewal
Date: Jan 5, 2026
Visit Reason
The inspection was conducted as a renewal inspection combined with complaint and incident investigations at Celebration Villa of South Hills.
Complaint Details
The inspection included complaint investigations with substantiated findings of medication administration errors, incident reporting errors, and infestation issues.
Findings
Multiple violations were found related to contract signatures, staffing and support plans, staff orientation, medication storage and administration, fire drill records, sanitation, and resident assessments. The facility was issued a second provisional license with a plan of correction and fines pending if violations are not corrected.
Citations (19)
2600.25b The resident-home contract was not signed by the resident until after admission.
2600.60a Staffing did not meet resident needs; call bell alerts were repeatedly unanswered for extended periods.
2600.65a Direct care staff did not receive orientation in general fire safety and emergency preparedness prior to or during first work day.
2600.65b Staff orientation records lacked dates for completion of required training topics.
2600.85d Trash receptacles in kitchens and bathrooms were uncovered, allowing penetration of insects and rodents.
2600.100b Snow and icy slush were not removed from outside walkway near main laundry exit.
2600.103f Refrigerator freezer temperatures exceeded required limits, reaching 20°F and 14°F.
2600.132c Fire drill records had incorrect or missing evacuation times and durations.
2600.183e Medication storage lacked dates on pharmacy labels for insulin pens and other medications.
2600.184a Prescription medication labels did not match physician orders or contained incorrect instructions.
2600.185a Procedures for safe storage, access, security, and use of medications and equipment were not fully implemented; resident glucometer sharing occurred.
2600.187a Medication records did not accurately reflect medication administration, including dose and timing errors.
2600.187b Medication administration times were not recorded as required; doses were missed or not documented.
2600.190a Annual medication administration training was incomplete; staff administered medications without required training.
2600.225a Resident initial assessments were incomplete or unsigned within 15 days of admission.
2600.226a Resident mobility assessments were incomplete or inaccurate regarding use of wheelchair and walker.
2600.16c Incident reports were submitted to incorrect email addresses despite prior technical assistance.
2600.85b Evidence of infestation was found including flying insects, dead cockroach, and live cockroach in resident rooms.
2600.65a Substitute agency staff did not receive required orientation in fire safety and emergency preparedness.
Report Facts
Residents Served: 86
Fine Per Day: 240
Total Daily Staff: 110
Waking Staff: 83
Residents Served: 80
Total Daily Staff: 87
Waking Staff: 65
Inspection Report — Dec 1, 2025
Complaint Investigation
Date: Dec 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance and verify the submitted plan of correction.
Complaint Details
The inspection was complaint-driven. The submitted plan of correction was accepted and fully implemented, with ongoing monitoring planned.
Findings
The facility was found to have a repeat violation related to incomplete resident assessments, specifically failing to document formal home health supports and special health or dietary needs for wound care. The submitted plan of correction was fully implemented and compliance was maintained.
Citations (1)
Regulation 2600.225c requires additional resident assessments if the resident's condition significantly changes before the annual assessment. The resident's significant change assessment failed to identify Gallagher Home Health Services as a formal support and did not document special health or dietary needs for wound care.
Report Facts
Residents Served: 84
Current Residents in Hospice: 3
Residents Age 60 or Older: 84
Residents with Mobility Need: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Completed audit of residents to identify formal support and care needs | |
| Director of Nursing | Educated staff on regulation 2600.225c and involved in ongoing review of assessments | |
| Resident Care Coordinator | Educated on regulation 2600.225c | |
| Regional Director of Clinical Services | Provided education on regulation 2600.225c |
Inspection Report — Oct 30, 2025
Complaint Investigation
Date: Oct 30, 2025
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on October 30, 2025, December 16, 2025, and December 17, 2025, to review compliance and the submitted plan of correction.
Complaint Details
The inspection was complaint-driven with multiple follow-up submissions and reviews. The plan of correction was found not implemented as of the last review on December 17, 2026.
Findings
The facility was found to have multiple violations related to hospice care, abuse, medication records, medication administration timing, follow prescriber's orders, additional assessments, and support plan revisions. The submitted plan of correction was determined not to be implemented as of the last review.
Citations (7)
29a.a Hospice Care: The home failed to provide services related to eating, drinking, turning, positioning, call bell responses, medication administration, and wound care when hospice staff were not physically present.
42b Abuse: Resident #1 experienced neglect and inadequate care related to wound treatment, medication administration, and feeding assistance, culminating in discharge due to a sacrum wound and other care failures.
187a Medication Record: The medication administration record (MAR) was not updated to reflect changes in medication frequency and instructions for Resident #1.
187b Date/Time of Medication Administration: Medication administration times were not properly recorded, and medications were not administered as ordered on multiple occasions.
187d Follow Prescriber's Orders: The home failed to follow prescriber orders accurately, including medication administration and documentation for Resident #1.
225c Additional Assessment: The resident's assessment did not accurately reflect the need for staff assistance with eating, drinking, turning, and positioning.
227c Support Plan Revision: The support plan was not updated to include important physician orders and care needs related to turning and positioning.
Report Facts
Residents Served: 82
Hospice Current Residents: 3
Residents Age 60 or Older: 82
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 28
Inspection Report — Jun 5, 2025
Complaint Investigation
Date: Jun 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations and incidents at the facility.
Complaint Details
The complaint investigation included allegations of medication errors, inadequate supervision, unsanitary conditions, and failure to follow prescribed care plans. Multiple repeat violations were noted.
Findings
Multiple violations were found including unsecured medication records, hazardous resident equipment, unlocked medications, expired medications, inaccurate medication documentation, inadequate staff qualifications and training, deficient resident assessments and support plans, unsanitary conditions, and safety hazards such as obstructed egress and fire drill deficiencies.
Citations (38)
Unlocked and unattended narcotic count logs on medication cart containing confidential resident information.
Bed enablers without covers posing limb entanglement risk to residents.
Unlocked, unattended, and accessible medications on medication cart.
Expired medications present in medication cart.
Resident's glucometer not set to current date and time; inaccurate blood glucose documentation.
Medication record contained discontinued medication and inaccurate medication orders.
Blood glucose readings missing from resident glucometer and inaccurate documentation on MAR.
Inadequate staff qualifications: direct care staff without high school diploma or GED.
Inadequate staffing for emergency evacuation and fire drills exceeding maximum evacuation time.
Staff not trained or certified in first aid and CPR present at all times.
Administrator has not completed Department-approved competency-based training test.
Direct care staff missing required annual training on infection control, safe management, and emergency preparedness.
Staff training plan incomplete, missing names, positions, duties, and scheduled training dates.
Trash outside home not kept in covered receptacles.
Food stored on floor in emergency food and water storage closet.
Fire drill records incomplete or missing evacuation times and exit routes.
Evacuation times exceeded maximum allowed by fire safety expert.
Resident medical evaluations incomplete or missing required information.
Resident annual medical evaluations not completed timely.
Resident medication labels incorrect or inconsistent with physician orders.
Inaccurate documentation of blood glucose readings on medication administration records.
Medication administration records missing staff initials for administered medications.
Staff administering medications without current Department-approved medication administration course.
Staff administering insulin injections without current Department-approved medication administration and diabetic education.
Resident preadmission screening forms incomplete and unsigned.
Resident assessments not completed timely or missing diagnoses and functional assessments.
Resident support plans not completed timely or missing required signatures.
Resident-home contract not completed timely and services not provided as contracted.
Carpet and surfaces stained and unclean in resident rooms.
Emergency exit door hardware malfunctioning requiring excessive force to open.
No operable lamp or lighting source at resident bedside.
Narcotic shift change forms not completed for multiple shifts and medication counts inaccurate.
Medications not administered as prescribed and inaccurate medication administration documentation.
Resident left home unattended without supervision as required by support plan.
Resident call bell response times excessive and call bells not answered timely.
Toilet paper not provided in resident bathroom.
Obstruction in egress route by flag and flagpole.
Walls, floors, ceilings in resident rooms damaged, stained, or unclean.
Report Facts
Residents Served: 80
Staffing Hours: 85
Waking Staff: 64
Deficiency Count: 38
Fine Amount: 430
Fine Amount: 258
Residents Served: 86
Total Daily Staff: 110
Waking Staff: 83
Residents Served: 86
Total Daily Staff: 112
Waking Staff: 84
Inspection Report — Mar 25, 2025
Complaint Investigation
Date: Mar 25, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations and assess the submitted plan of correction.
Complaint Details
The inspection was triggered by a complaint and included review of staffing adequacy, medication storage and administration, and adherence to prescriber orders. The complaint was substantiated by findings of multiple deficiencies.
Findings
The inspection found multiple deficiencies including inadequate direct care staffing hours for residents with mobility needs, insufficient staffing during night shifts affecting emergency evacuation, unlocked medication carts accessible to residents, and multiple medication administration documentation errors including missing initials, incorrect or missing blood glucose readings, and failure to follow prescriber's orders. The submitted plan of correction was accepted and fully implemented.
Citations (6)
Direct care staff hours were insufficient to provide at least 2 hours per day of personal care to residents with mobility needs.
Staffing during the 11:00pm-7:00am shift was inadequate to evacuate all residents in an emergency.
Medication cart near ground floor elevator was unlocked, unattended, and accessible containing numerous medications.
Blood glucose readings for several residents were not documented or incorrectly documented on medication administration records (MAR).
Medication administration records lacked initials of staff administering medications on numerous occasions.
Prescriber's orders for blood glucose checks were not consistently followed as documented by resident reports and MAR discrepancies.
Report Facts
Residents served: 79
Residents with mobility needs: 10
Direct care hours required: 85
Direct care hours provided: 82.5
Staff present during night shift: 2
Total daily staff: 84
Waking staff: 63
Resident hospice: 6
Residents diagnosed with mental illness: 2
Residents diagnosed with intellectual disability: 1
Residents with mobility need: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michaela McCutcheon | Med Tech | Named in medication cart locking deficiency and corrective action |
Notice — Mar 13, 2025
Date: Mar 13, 2025
Visit Reason
The document is a response to a facility's request for a waiver of Pennsylvania Code § 2600.190(b) to allow unlicensed direct care staff to administer subcutaneous injections of GLP-1 agonist medications.
Findings
The waiver outlines the training requirements for direct care staff administering GLP-1 agonist injections, including completion of a Department-approved medication administration course, in-person training by licensed health professionals, and annual training hours. The facility must have policies and clinical contacts in place to monitor and support medication administration.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Feb 10, 2025
Complaint Investigation
Date: Feb 10, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations and assess the submitted plan of correction.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The submitted plan of correction was fully implemented and compliance was maintained.
Findings
The inspection found deficiencies related to incomplete medical evaluations lacking legible provider information and inaccurate resident assessments regarding supervision needs and hearing aid use. The facility submitted and implemented plans of correction addressing these issues.
Citations (2)
The medical evaluation for a resident did not include a legible name or medical professional license number of the provider who completed the exam.
The resident's assessment indicated minimal supervision needs but did not reflect unsteady gait and additional supervision required; also failed to indicate hearing aid use.
Report Facts
Residents Served: 81
Current Residents in Hospice: 5
Residents Age 60 or Older: 81
Residents Receiving Supplemental Security Income: 1
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 1
Residents with Physical Disability: 0
Total Daily Staff: 82
Waking Staff: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in plan of correction training and audit activities related to medical evaluation and resident assessments | |
| Director of Nursing | Named in plan of correction training and audit activities related to medical evaluation and resident assessments | |
| Regional Director of Clinical Services | Provided training on regulations 2600.141a and 2600.225c |
Inspection Report — Sep 20, 2024
Complaint Investigation
Date: Sep 20, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 87
Current Residents - Hospice: 11
Residents Age 60 or Older: 87
Residents Diagnosed with Mental Illness: 13
Residents with Mobility Need: 10
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 1
Residents Receiving Supplemental Security Income: 1
Inspection Report — Sep 5, 2024
Complaint Investigation
Date: Sep 5, 2024
Visit Reason
The inspection was conducted as a complaint investigation and incident review at Celebration Villa of South Hills on 09/05/2024.
Complaint Details
The complaint involved an incident where a resident was found on the floor with a laceration above the eye and a skin tear to the left elbow. The facility did not report this incident to the Department as required by regulation.
Findings
The facility failed to report an incident involving a resident found on the floor with injuries to the Department within 24 hours as required. The submitted plan of correction was accepted and fully implemented by 10/23/2024.
Citations (1)
Failure to report an incident involving a resident injury to the Department within 24 hours.
Report Facts
Residents Served: 85
Current Hospice Residents: 11
Diagnosed with Mental Illness: 15
Residents 60 Years or Older: 85
Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 3
Residents with Physical Disability: 1
Inspection Report — Jul 11, 2024
Follow-Up
Date: Jul 11, 2024
Visit Reason
The inspection visit on 07/11/2024 was conducted as a complaint investigation and incident review, with a follow-up type of Plan of Correction (POC) submission to verify correction of previous deficiencies.
Complaint Details
The visit was complaint-related, involving allegations of neglect and failure to provide timely care to resident #1. The complaint was substantiated, leading to suspension and termination of staff member A, staff training, and ongoing monitoring.
Findings
The inspection identified multiple deficiencies including neglect related to failure to respond to a resident's call bell, uncovered trash receptacles, incomplete resident assessments, and missing signatures on support plans. The facility submitted plans of correction which were determined to be fully implemented by the follow-up date.
Citations (5)
Resident #1 was neglected when staff failed to provide incontinence care and did not respond to call bell requests for assistance.
Trash outside the home was not kept in covered receptacles preventing insect and rodent penetration.
Resident #1's initial assessment did not accurately reflect the resident's need for assistance with toileting and use of adult briefs.
Resident #2's support plan did not indicate a plan to meet the service need, frequency, or responsible party for assessed medical needs.
Resident #2's support plan was not signed or dated by the assessor.
Report Facts
Residents Served: 71
Current Residents in Hospice: 6
Residents Age 60 or Older: 71
Residents with Mobility Need: 20
Residents Diagnosed with Intellectual Disability: 1
Inspection Report — Feb 28, 2024
Complaint Investigation
Date: Feb 28, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 02/28/2024.
Complaint Details
The inspection was complaint-driven and included a follow-up on the submitted plan of correction.
Findings
The inspection found deficiencies related to fire drill compliance and medication record keeping. The facility failed to conduct an unannounced fire drill in January 2024, had incomplete fire drill records, and did not conduct fire drills during sleeping hours as required. Additionally, a medication administration record error was identified and corrected.
Citations (4)
An unannounced fire drill was not held during the month of January, 2024.
The fire drill record for the fire drill conducted on 6/17/23 at 11:10 does not indicate if the fire drill was held in the AM or PM.
The home’s most recent fire drill conducted during sleeping hours was held on 11/29/23 at 11:58pm; however, the previous fire drill during sleeping hours was held on 4/5/23 at 5:20am, not meeting the 6-month requirement.
Medication administration record indicated a resident was prescribed a capsule by mouth twice daily for 7 days; however, the February 2024 MAR showed continued administration beyond 7 days.
Report Facts
Residents Served: 63
Total Daily Staff: 71
Waking Staff: 53
Current Hospice Residents: 4
Residents with Mobility Need: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator reeducated Maintenance Director and Assistant on fire drill regulations and medication record regulations. | |
| Director of Nursing | Director of Nursing corrected medication order and conducted audits of medication records. | |
| Maintenance Director | Maintenance Director responsible for conducting fire drills and reviewing fire drill records. |
Inspection Report — Jul 13, 2023
Complaint Investigation
Date: Jul 13, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations following concerns raised about medication administration and resident care.
Complaint Details
The visit was complaint-related as indicated by the inspection information on page 2, with the reason stated as 'Complaint'.
Findings
The inspection found multiple deficiencies related to medication storage, administration, documentation, and follow prescriber's orders, including unsecured medications accessible to residents and missed or improperly documented medication doses for resident #4. Plans of correction were submitted and accepted with ongoing monitoring and education.
Citations (5)
Medications and syringes were found unlocked and accessible on the medication cart, violating storage requirements.
Failure to implement storage procedures for medications, including missing medication in the home for resident #4.
Medication administration documentation was incomplete or missing for resident #4, including injections not properly recorded.
Failure to follow prescriber's orders for resident #4, including missed medication doses and lack of administration due to no nurse availability or resident refusal.
Additional assessments for resident #4 were not updated to reflect current care needs and services.
Report Facts
Residents Served: 66
Current Hospice Residents: 5
Residents 60 Years or Older: 65
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 9
Residents with Physical Disability: 1
Inspection Report — Aug 26, 2022
Complaint Investigation
Date: Aug 26, 2022
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial licensing inspection.
Complaint Details
The inspection was complaint-related; however, no deficiencies were found and no substantiation status was explicitly stated.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 64
Staffing Hours - Total Daily Staff: 70
Staffing Hours - Waking Staff: 53
Residents in Hospice: 5
Residents Age 60 or Older: 63
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 6
Notice — Aug 31, 2021
Date: Aug 31, 2021
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home 'Atria South Hills' following receipt of the renewal application dated July 13, 2021.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter and certificate of compliance. |
Inspection Report — Jul 1, 2021
Renewal
Date: Jul 1, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license to ensure compliance with applicable regulations.
Findings
The inspection identified multiple deficiencies including improper placement of carbon monoxide detectors, unsigned resident contract, unsanitary conditions in the smoking area, uncovered trash receptacles, lack of operable bedside lamps, improper food storage, lint accumulation in dryers, incomplete medical evaluations, uncalibrated glucometers, and delayed resident assessments and support plans. Plans of correction were submitted and implemented for all deficiencies.
Citations (11)
Carbon monoxide detector was not placed within 15 feet of fossil fuel burning device as required.
Resident-home contract for resident #1 was not signed by the resident.
Approximately 25 extinguished cigarette butts found on ground and under table in designated smoking area.
Partially full, uncovered 40 gallon trash can found in kitchen.
Resident #2 did not have a source of light that could be turned on/off at bedside.
Uncovered and undated small white ceramic bowl of vanilla ice cream found in freezer.
Approximate 1/8 inch thick lint accumulation in lint trap of 3rd floor laundry room's right dryer.
Resident #3's initial medical evaluation did not include resident's height.
Resident #4 and #5 glucometers were not calibrated to current date and time.
Resident #6's initial assessment was not completed within 15 days of admission.
Resident #6 and #7 initial support plans were not completed within 30 days of admission.
Report Facts
Residents Served: 75
Extinguished cigarette butts: 25
Trash can size: 40
Lint thickness: 0.125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in multiple findings and plans of correction including carbon monoxide detector placement, contract signature compliance, smoking policy retraining, bedside lamp compliance, food storage, lint removal, medical evaluation, glucometer calibration, resident assessments, and support plans. | |
| Maintenance Director | Involved in carbon monoxide detector placement, smoking area monitoring, trash receptacle compliance, bedside lamp audits, lint removal, and glucometer calibration. | |
| Director of Culinary Services | Involved in smoking area retraining, trash receptacle compliance, and food storage and labeling. | |
| Resident Services Director | Responsible for audits and corrections of medical evaluations, glucometer calibration, resident assessments, and support plans. | |
| Community Business Director | Instructed to ensure resident contract signatures and compliance. |
Inspection Report — Jun 28, 2019
Renewal
Date: Jun 28, 2019
Visit Reason
The document is a renewal application and license for Atria South Hills Personal Care Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as part of the renewal process.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of upcoming annual inspection requirements.
Inspection Report — Mar 28, 2019
Renewal
Date: Mar 28, 2019
Visit Reason
The inspection was conducted as a renewal inspection of the Atria South Hills Personal Care Home to assess compliance with 55 Pa. Code Chapter 2600.
Findings
The inspection identified multiple violations related to direct care staff training, fire safety drills, equipment maintenance, and medication administration documentation. Plans of correction were submitted addressing these issues with partial implementation noted.
Citations (9)
Regulation 2600.65(d) - Direct care staff person A hired on 5/12/17 provided unsupervised ADL services until completing required training and competency test on 6/8/18.
Regulation 2600.65(g) - Direct care staff persons did not receive annual training on fire safety and emergency preparedness as required for 2018.
Regulation 2600.95 - On 3/28/19, a 5 x 2.5 foot puddle of standing water was found under the hot water tank in the first floor electrical room.
Regulation 2600.132(c) - Fire drill records lacked indication if drills were conducted in the am or pm for multiple dates in 2018.
Regulation 2600.132(d) - Fire drills on 9/25/18 and 12/30/18 exceeded the home's maximum safe evacuation time of 8 minutes.
Regulation 2600.132(g) - Fire drills were not conducted with minimum staff scheduled at different times and days as required; only 3 staff present for drills in past year.
Regulation 2600.185(a) - On 3/29/19, the glucometer for resident #1 was not calibrated to the correct date and time.
Regulation 2600.185(a) - Medication administration record for resident #2 showed conflicting blood glucose readings at the same time on 3/24/19.
Regulation 2600.187(b) - The March 2019 medication administration record for resident #1 lacked initials of staff who administered prescribed insulin dose on 3/7/19 at 4:30 pm.
Report Facts
Total Daily Staff: 82
Waking Staff: 62
Number of Residents Age 60 or Older: 75
Number of Residents with Mental Illness: 3
Number of Residents with Mobility Need: 7
Number of Hospice Residents in Past Year: 10
Fire Drill Duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle M. O'Donnell | Executive Director | Named as Administrator and signer of plans of correction related to multiple deficiencies. |
| Lauren Spagna | Department representative conducting the inspection on 3/28/19 and 3/29/19. | |
| Barbara Barone | Department representative conducting the inspection on 3/28/19 and 3/29/19. |
Notice — Jul 3, 2018
Date: Jul 3, 2018
Visit Reason
The document is a renewal application approval and license issuance for Atria South Hills Personal Care Home, confirming the facility's authorized capacity and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of future inspection requirements.
Report Facts
Inspection Report — Mar 26, 2018
Renewal
Date: Mar 26, 2018
Visit Reason
The inspection was conducted as a renewal and complaint investigation for Atria South Hills Personal Care Home on March 26 and 27, 2018.
Findings
Violations of 55 Pa. Code Chapter 2600 were found related to direct care staff training and food storage. Plans of correction were submitted and partially implemented as of July 2018.
Citations (2)
55 Pa.Code §2600.65(d) direct care staff person A began providing unsupervised ADL service without completing required training and competency test.
55 Pa.Code §2600.103(d) a 25 pound bag of toasted panko crumbs was stored unsealed on the kitchen floor.
Report Facts
Number of Residents Served: 82
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 5
Notice — Jul 7, 2017
Date: Jul 7, 2017
Visit Reason
The document serves as a renewal approval for the Personal Care Home license for Atria South Hills and notifies the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Mar 16, 2017
Renewal
Date: Mar 16, 2017
Visit Reason
The inspection was a renewal licensing inspection conducted on March 16, 2017, March 21, 2017, September 22, 2017, and September 26, 2017, to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations were found related to financial transaction documentation, criminal background checks, staff training, sanitary conditions, fire safety inspections, medical evaluations, medication administration, and resident care documentation. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (15)
Regulation 2600.20(b)(8): The home failed to provide residents #1 and #2 and their designated persons with itemized accounts of financial transactions made on their behalf quarterly.
Regulation 2600.51: Staff person A lacked documentation of an FBI background check prior to hire, and the record was not on file at the time of inspection.
Regulation 2600.65(f): Direct care staff person B did not receive required training in medication self-administration and related topics during the 2016 training year.
Regulation 2600.85(a): Resident #3's glucometer was used to check resident #4's blood glucose levels on multiple dates.
Regulation 2600.132(b): The home did not conduct the next fire safety inspection and drill until 7/7/16, after the annual requirement date.
Regulation 2600.132(c): The home's fire drill documentation did not coincide with the home's fire alarm monitoring company records, showing discrepancies in dates and times.
Regulation 2600.132(d): The home exceeded the safe evacuation time of 8 minutes during a fire drill on 2/17/17 with an evacuation time of 9 minutes and 3 seconds.
Regulation 2600.141(b)(1): Residents #6 and #7 did not have timely medical evaluations completed as required annually.
Regulation 2600.181(f): Resident #6's medication record lacked an accurate list of medications for self-administration, including discontinued medications.
Regulation 2600.183: Resident #8's medication container of eye drops was open 28 days after being opened, exceeding the allowed time.
Regulation 2600.185(a): Glucometers for residents #5, #6, #7, and #8 were not calibrated to the current date and time.
Regulation 2600.16(c): The home failed to report an allegation of verbal abuse involving resident #1 within 24 hours as required.
Regulation 2600.141(b)(1): Resident #1's next medical evaluation was not completed until after the required date.
Regulation 2600.181(f): Resident #2's medication record did not include an accurate list of medications for self-administration.
Regulation 2600.183(d): The community did not properly dispose of expired medications found in resident #4's possession at the time of inspection.
Report Facts
Number of Residents Served: 87
Total Daily Staff: 98
Walking Staff: 74
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nichole Mitcham | Executive Director | Named as legal entity representative and involved in plans of correction |
Inspection Report — Sep 23, 2016
Complaint Investigation
Date: Sep 23, 2016
Visit Reason
The inspection was conducted as a complaint investigation at Atria South Hills Personal Care Home.
Complaint Details
The inspection was complaint-driven. The violation involved failure to timely report a resident death as required by regulation.
Findings
Violations of 55 Pa.Code Chapter 2600 were found related to failure to report a resident's death to the Department's personal care home complaint hotline within 24 hours. A plan of correction was submitted to ensure compliance with reporting requirements.
Citations (1)
55 Pa.Code §2600.16(c) requires the home to report incidents to the Department's complaint hotline within 24 hours. The home failed to report the death of Resident #1 until 09/21/16.
Report Facts
Number of Residents Served: 87
Total Daily Staff: 97
Waking Staff: 73
Number of Current Hospice Residents: 6
Number of Hospice Residents in past year: 10
Residents Age 60 or Older: 86
Residents with Mobility Need: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nichole Mitcham | Executive Director | Named in Plan of Correction and signature on violation report |
Notice — Jul 1, 2016
Date: Jul 1, 2016
Visit Reason
The document is a renewal notice and license issuance for the Personal Care Home 'Atria South Hills' following receipt of a renewal application dated June 30, 2016.
Findings
No inspection findings are reported. The letter states that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Inspection Report — May 10, 2016
Renewal
Date: May 10, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections on May 10 and May 11, 2016, for renewal and incident reasons.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found, including issues with direct care staff training, heat source safety, facility maintenance, emergency telephone numbers, and exit signage. Plans of correction were submitted addressing each violation with partial implementation progress noted.
Citations (6)
2600.65(d) - Direct care staff persons hired after April 24, 2006 may not provide unsupervised ADL services until completing required training and passing competency tests. Documentation was missing for two direct care staff providing unsupervised care.
2600.84 - Heat sources accessible to residents must have protective guards or insulation to prevent contact. A fireplace face plate measured 160.5 degrees Fahrenheit with an opening allowing access.
2600.88(a) - Floors, walls, ceilings, windows, doors, and surfaces must be clean, in good repair, and free of hazards. Holes were found by the light plate in the bathroom and in the bathroom doorway of bedroom #334.
2600.91 - Telephone numbers for emergency management and personal care home complaint hotline must be posted on or by each telephone with an outside line. Numbers were not posted on or by the telephone in bedroom #330 but were later removed at resident's discretion.
2600.95 - Furniture and equipment must be in good repair, clean, and free of hazards. The towel rack behind the bathroom door of bedroom #330 was not secured and pulled approximately 1 inch away from the door.
2600.133(a)(1) - Homes serving nine or more residents must have exit signs with legible letters posted at all exits. The exit door from the living room to the courtyard was not labeled as an exit.
Report Facts
Number of Residents Served: 85
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 8
Number of Residents Age 60 or Older: 83
Number of Residents with Mobility Need: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ron Gardner | Administrator | Named as facility administrator on page 2. |
| Patricia Bartlett | Department of Human Services inspector present on inspection dates. | |
| Deb McConnell | Department of Human Services inspector present on inspection dates. | |
| Brent Sutherland | Department of Human Services inspector present on inspection dates. | |
| Michelle Mitcham | Executive Director | Signed plans of correction on multiple violations. |
Notice — September 9, 2020
Date: September 9, 2020
Visit Reason
This document serves as a certificate of compliance and notification of license renewal for the Personal Care Home 'Atria South Hills'. It 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 receipt of the renewal application.
Report Facts
Report — October 26, 2020
October 26, 2020
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