Inspection Reports for
Celebration Villa of South Hills
5300 Clairton Boulevard (Route 51), Pittsburgh, PA 15236, Pittsburgh, PA, 15236
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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 |
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. |
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