Inspection Reports for
Overlook Green Senior Living
5250 Meadowgreen Dr, Pittsburgh, PA 15236, United States, PA, 15236
Back to Facility Profile19 Reports
Inspection Report — Apr 9, 2026
Complaint Investigation
Date: Apr 9, 2026
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements and verify the submitted plan of correction.
Complaint Details
The visit was complaint-related as indicated by the inspection information. The complaint involved an allegation of neglect investigated by the local Area Agency on Aging. The incident was found to have been reported late to the Department.
Findings
The facility was found to have multiple deficiencies including failure to timely report an incident, incomplete medical evaluations, incomplete preadmission screening, incomplete resident assessments, missing support plan signatures, and missing operational postings for key-locking devices. All deficiencies had plans of correction implemented by June 11, 2026.
Citations (6)
Regulation 2600.16c: The home failed to report an incident involving neglect to the Department within 24 hours as required.
Regulation 2600.141b1: Resident's annual medical evaluation did not include a determination that the resident's needs can be safely met by the home.
Regulation 2600.224a: Resident's preadmission screening form lacked documentation that the resident's needs can be met by the home.
Regulation 2600.225a: Resident's initial assessment did not include dental or dietary needs, leaving these sections blank.
Regulation 2600.227g: Resident's support plan was not signed by the resident and lacked documentation of resident participation or refusal to sign.
Regulation 2600.233c: Directions for operating the home's locking mechanism were not conspicuously posted near the secured dementia care unit courtyard gate.
Report Facts
Residents Served: 65
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 8
Resident Support Staff: 65
Total Daily Staff: 143
Waking Staff: 107
Residents Age 60 or Older: 64
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Re-educated on incident reporting requirements | |
| Director of Health & Wellness | Re-educated on incident reporting and responsible for audits and reviews | |
| Executive Director | Provided re-education and conducted audits related to incident reporting and staff education |
Inspection Report — Oct 16, 2025
Monitoring
Date: Oct 16, 2025
Visit Reason
The inspection was a monitoring visit conducted on 10/16/2025 to verify the implementation of a previously submitted plan of correction and continued compliance with regulatory requirements.
Findings
The facility was found to have fully implemented the plan of correction with compliance maintained. Several deficiencies were identified related to staff orientation, training, medication management, storage of poisonous materials, resident records security, and documentation of support plans, all of which were addressed with corrective actions and retraining.
Citations (12)
Regulation 2600.65a: Direct care staff person A did not receive orientation on fire safety topics including designated meeting place, smoking safety, fire extinguisher use, and smoke detectors.
Regulation 2600.65b: Direct care staff person A did not receive training within 40 hours on emergency medical plan, mandatory abuse reporting, and reporting of incidents.
Regulation 2600.65g: Direct care staff persons B and C did not receive annual training on fire safety and emergency preparedness during the 2024 training year.
Regulation 2600.65i: Training records for staff persons B and C lacked documentation of course lengths for several trainings.
Regulation 2600.82c: Poisonous materials were found unlocked and accessible to residents in the housekeeping closet, posing safety risks.
Regulation 2600.183b: A treatment cart containing medications was unlocked and unattended in the wellness office.
Regulation 2600.186a: Resident had medication without a current prescription order, causing uncertainty about correct dosage.
Regulation 2600.187a: Medication record for a resident showed inconsistent frequency of administration compared to prescriber order.
Regulation 2600.187b: Medication administration times were not recorded accurately at the time of administration for a resident.
Regulation 2600.187d: Medication was not administered timely due to family not supplying refill; follow-up orders were obtained.
Regulation 2600.227d: Resident's support plan did not include specific hospice services or frequency of services.
Regulation 2600.254c: Approximately 21 resident records were found unlocked and accessible in the wellness office.
Report Facts
Residents Served: 71
Secured Dementia Care Unit Residents Served: 8
Hospice Current Residents: 7
Resident Age 60 or Older: 70
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Inspection Report — Aug 12, 2025
Follow-Up
Date: Aug 12, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies involved failure to report an allegation of neglect within 24 hours and failure to provide timely assistance with activities of daily living (ADLs). Staff member A was suspended and terminated, and staff education and monitoring measures were implemented.
Citations (2)
Failure to report an allegation of neglect to the Department within 24 hours as required by regulation 2600.16c.
Failure to provide timely assistance with changing a resident's brief despite multiple call bell requests, violating regulation 2600.23a.
Report Facts
Residents Served: 68
Secured Dementia Care Unit Residents Served: 8
Current Hospice Residents: 8
Residents Diagnosed with Mental Illness: 16
Residents with Mobility Need: 11
Residents Age 60 or Older: 67
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in findings related to neglect and failure to assist resident with ADLs; suspended and terminated. |
Inspection Report — May 21, 2024
Complaint Investigation
Date: May 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements at the facility.
Complaint Details
The visit was complaint-related. The plan of correction was accepted on 07/02/2024 and implemented on 07/03/2024.
Findings
The submitted plan of correction was found to be fully implemented. A deficiency was noted regarding a resident being undressed and covered only with a sheet while being transported through common areas to the shower room, which did not respect the resident's dignity.
Citations (1)
Resident was undressed in bedroom and covered with only a sheet while being propelled in a wheelchair through common areas to access the shower room, violating dignity and respect requirements.
Report Facts
Residents Served: 55
Residents Served in Dementia Care Unit: 10
Hospice Residents: 3
Resident Mobility Need: 26
Residents Age 60 or Older: 55
Inspection Report — Feb 1, 2024
Follow-Up
Date: Feb 1, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted on 02/01/2024 for complaint and monitoring purposes, including a follow-up on a previously submitted plan of correction.
Complaint Details
The visit was complaint-related and monitoring in nature. The submitted plan of correction was reviewed and found fully implemented. No substantiation status explicitly stated.
Findings
The facility was found to have implemented the submitted plan of correction fully. Deficiencies related to medication administration documentation were identified, including missing entries on medication administration records (MAR) and improper documentation of blood glucose monitoring, but no resident suffered ill effects.
Citations (2)
Failure to enter blood glucose readings on the resident’s January medication administration record (MAR) as ordered.
The January 2024 MAR for multiple residents was not initialed by staff for numerous medications on multiple dates and times.
Report Facts
Residents Served: 53
Secured Dementia Care Unit Residents Served: 9
Resident Support Staff: 0
Total Daily Staff: 74
Waking Staff: 56
Residents with Mobility Need: 21
Residents with Physical Disability: 1
Residents Diagnosed with Mental Illness: 1
Residents 60 Years or Older: 53
Inspection Report — Nov 30, 2023
Renewal
Date: Nov 30, 2023
Visit Reason
The inspection was conducted for renewal, complaint, and incident reasons as part of a full, unannounced licensing inspection.
Findings
Multiple deficiencies were identified including inadequate first aid/CPR trained staff coverage, incomplete direct care staff training, sanitary condition violations, hot water temperature exceeding limits, fire drill record issues, incomplete medical evaluations, and improper storage procedures for medical equipment. Plans of correction were accepted with specified completion dates.
Citations (12)
At least one staff person for every 50 residents trained in first aid and certified in CPR was not present at all times.
Direct care staff provided unsupervised ADL services without completing required training and competency tests.
Direct care staff did not receive required annual training topics including care for dementia, infection control, safe management, emergency preparedness, resident rights, and falls prevention.
Enabler bar on resident's bed was not well-secured, posing entrapment and fall hazard.
Resident's glucometer was used improperly and insulin was administered without cleaning site with alcohol wipe.
Hot water temperature in resident-accessible bathrooms exceeded 120°F.
Fire drill records lacked indication of AM or PM for drill times.
Alternate exit routes were not consistently used during fire drills.
Fire drills were routinely held at the end of the month, not varying days and times as required.
Medical evaluation for resident did not include ability to self-administer medications.
Annual medical evaluations for residents in secured dementia care unit were incomplete or missing attachments.
Resident's glucometer was not calibrated to the correct date and time.
Report Facts
Residents served: 53
Staff daily total: 75
Waking staff: 56
Residents with mobility need: 22
Residents age 60 or older: 53
Residents with mental illness: 1
Residents with physical disability: 1
Residents in hospice: 6
Hot water temperature: 132.1
Hot water temperature: 131.9
Inspection Report — Apr 21, 2023
Date: Apr 21, 2023
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, on 04/21/2023.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Report Facts
Residents Served: 63
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 12
Residents Age 60 or Older: 63
Residents with Mobility Need: 33
Inspection Report — Apr 4, 2023
Follow-Up
Date: Apr 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation and a follow-up to verify the implementation of a previously submitted plan of correction.
Complaint Details
The visit was complaint-related as indicated by the inspection information. The plan of correction was fully implemented as of the follow-up review on 04/04/2023.
Findings
The report found a medication safety violation involving an unlocked pill accessible in a resident's room. The facility implemented corrective actions including removal of the medication, notification of involved parties, staff training, and auditing procedures to ensure compliance.
Citations (1)
Unlocked, unattended, and accessible medication found in resident #1's bedroom, violating medication security requirements.
Report Facts
Residents Served: 64
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 11
Residents Age 60 or Older: 64
Residents with Mobility Need: 39
Total Daily Staff: 103
Waking Staff: 77
Inspection Report — Mar 2, 2023
Complaint Investigation
Date: Mar 2, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with multiple on-site visits between 03/02/2023 and 03/09/2023 to review compliance and the submitted plan of correction.
Complaint Details
The visit was complaint-related, triggered by allegations of abuse/neglect and an incident involving suspected theft of an Amazon Alexa device. The plan of correction was fully implemented and compliance maintained.
Findings
The facility was found to have deficiencies including failure to report incidents to the Department, incomplete annual medical evaluations for residents, and improper narcotic storage and documentation procedures. The submitted plan of correction was determined to be fully implemented by April 10, 2023.
Citations (3)
Failure to report incidents of alleged abuse and theft to the Department within 24 hours as required.
Residents did not have annual medical evaluations completed timely as required.
Failure to properly document and report discrepancies in narcotic inventory counts according to facility policy.
Report Facts
Residents Served: 59
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 8
Number of Residents Age 60 or Older: 59
Residents with Mobility Need: 36
Inspection Report — Jun 6, 2022
Routine
Date: Jun 6, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 06/06/2022, 06/08/2022, and 06/10/2022.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report — Apr 19, 2022
Renewal
Date: Apr 19, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility Overlook Green on 04/19/2022 through 04/21/2022.
Findings
The inspection identified multiple deficiencies including failure to post the current license inspection summary, lack of privacy locks on bedroom and bathroom doors, sanitary condition issues such as lack of hand-drying methods in bathrooms, lack of operable ventilation fans in bathrooms, inadequate lighting at bedside for a resident, obstructed emergency egress, missing exit signage, incomplete support plan signatures, unsecured confidential resident records, and unsigned resident contracts. Plans of correction were accepted and implemented with specified completion dates.
Citations (10)
Current licensing inspection summary, dated 4/22/21, was not posted in a conspicuous and public place.
Shared resident bedroom door and bathroom door not equipped with locks, preventing resident privacy.
Shared resident bathrooms in rooms 220 and 224b lacked paper towels, mechanical air dryers, or other sanitary hand-drying methods.
Bathrooms in rooms 220, 223, and 239 did not have operable ventilation fans or windows.
Resident #2 did not have a source of light that can be turned on/off at bedside.
Emergency exit door in lower level laundry room was blocked by garbage and a gas can, obstructing egress.
No exit sign posted above the exit door in the staff break room.
Residents #1 and #4 participated in support plan development but did not sign the support plan.
Several boxes of confidential files of former residents were unlocked, accessible, and unattended in an unlocked storage room.
Resident #1's home contract was not signed by the resident; repeat violation from 4/22/2021.
Report Facts
Residents Served: 48
Secured Dementia Care Unit Residents Served: 15
Hospice Residents: 5
Staffing Hours - Total Daily Staff: 80
Staffing Hours - Waking Staff: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to corrective actions for privacy locks, sanitary conditions, ventilation, lighting, exit signage, and audits. | |
| Executive Director | Named in multiple findings related to corrective actions, retraining staff, and ensuring compliance. | |
| DRC | Named in findings related to support plan signatures and corrective actions. | |
| Business Office Manager | Named in findings related to securing confidential records and key control. | |
| Marketing Director | Named in corrective action related to contract signature audits. |
Inspection Report — Oct 6, 2021
Routine
Date: Oct 6, 2021
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report — Jun 25, 2021
Renewal
Date: Jun 25, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Jun 11, 2021
Renewal
Date: Jun 11, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — May 26, 2021
Renewal
Date: May 26, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Apr 22, 2021
Renewal
Date: Apr 22, 2021
Visit Reason
The inspection was conducted as a renewal inspection along with complaint and provisional reasons, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The inspection included complaint-related reasons; however, substantiation status is not explicitly stated.
Findings
The facility was found to be in compliance overall but had several deficiencies including unsigned resident contracts, wheelchair repair needs, sanitary condition issues with urine odor, hot water temperature exceeding limits, furniture and equipment hazards, emergency procedures not posted, medication administration errors, and incomplete resident assessments. Plans of correction were accepted and implemented for all deficiencies.
Citations (9)
Resident #1's resident-home contract was not signed by the resident.
Resident #1's resident-home contract statement acknowledging receipt of information was not signed by the resident.
Vinyl on the arm rests of resident #3’s wheelchair was cracked and missing, posing a laceration hazard.
Strong, pungent odor of urine in resident rooms #173 and #174, with wet bedsheet and urine puddle observed.
Hot water temperature in the secure dementia care unit kitchen sink measured 125.2°F, exceeding the 120°F limit.
Metal edging on PTAC unit in resident bedroom #431 was separated and sharp, posing a hazard; exhaust fan knob in shared bathroom was missing.
Emergency preparedness plans were not posted in a public and conspicuous place.
Medication error: Resident #6 received incorrect dose of Olanzapine from 4/16/21 to 4/23/21.
Resident #1’s initial assessment was not updated to include diagnoses of diabetes mellitus, glaucoma, and muscle spasms.
Report Facts
Residents Served: 45
Residents Served in Secure Dementia Care Unit: 14
Current Hospice Residents: 8
Waking Staff: 56
Total Daily Staff: 75
Hot Water Temperature: 125.2
Urine puddle size: 18
Urine puddle width: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary | Signed licensing letter and certificate of compliance. |
| Executive Director | Named in plan of correction audits and contract signing compliance. | |
| Maintenance Director | Repaired wheelchair, PTAC unit, exhaust fan knob, and coordinated hot water temperature correction. | |
| Director of Maintenance | Responsible for ongoing inspections of wheelchairs, PTAC units, exhaust fans, and water temperature. | |
| Director of Resident Care | Responsible for grievance reviews, medication audits, resident care plan meetings, and assessment audits. | |
| Business Office Manager / Designee | Ensures contracts are signed and emergency plans are posted. | |
| Maintenance Assistant | Completed audit of PTAC units and exhaust fan knobs. | |
| Staff person A | Provided information about medication administration process. |
Inspection Report — May 21, 2020
Monitoring
Date: May 21, 2020
Visit Reason
Monitoring inspection conducted to review compliance with regulations and follow-up on previous deficiencies at Overlook Green.
Findings
The inspection found multiple violations related to medication administration, staff qualifications, safety hazards, and record confidentiality. Plans of correction were submitted but some were not fully implemented by the follow-up date.
Citations (18)
2600.17 Resident records were not kept confidential; two unlocked and unattended medication administration records were found on medication carts outside the Florida room.
2600.18 Carbon monoxide detectors were missing in the basement near gas dryers and hot water heaters; batteries in the dining room detector were undated.
2600.51 No Pennsylvania criminal background check was completed for direct care staff person B hired on 10/21/19.
2600.54a Direct care staff person B hired on 10/21/19 lacked a high school diploma, GED, or active nurse aide registry status.
2600.65a Direct care staff person A hired on 5/26/19 did not receive orientation on fire safety, evacuation, or emergency procedures.
2600.65b Direct care staff person A did not receive orientation on resident rights and mandatory abuse reporting within 40 hours of hire.
2600.81b Resident #3's enabler was not securely attached to the bed and moved approximately 2 inches in both directions.
2600.85a No sanitary means of hand drying was present in the bathroom of bedroom 426; resident #4's glucometer was used to check resident #1's blood glucose.
2600.88a Rust and peeling paint were present on exit doors next to bedrooms 230 and 344 and the exit door leading to the common living area.
2600.100a Uneven cement pad and asphalt near exit doors posed tripping hazards; metal cords near exit route posed hazard.
2600.103g Unsealed food items including a veggie burger, vanilla container, French toast slices, and ice cream were found in the walk-in freezer.
2600.105g Approximately half-inch lint accumulation was found in the dryer located in the secured dementia care unit.
2600.121a Exit door near bedroom 437 was locked with keypad and did not allow immediate egress; exit door near bedroom 344 could not be opened by department agent.
2600.125a Seven 5-gallon buckets of paint were stored near the gas hot water heater; boiler certificate was taped to the heater.
2600.133.2 Exit sign at main entrance was not visible in the library and lacked indication of travel direction; home served 88 residents on inspection day.
2600.185a Resident #1's blood sugar readings were inaccurately transcribed on the medication administration record (MAR).
2600.187a Medication records for residents #2 and #3 lacked documentation of insulin units administered for multiple dates in May 2020.
2600.187d Resident #1's physician was not notified of a high blood sugar reading of 343 on 5/14/20 as required by prescriber's order.
Report Facts
Residents Served: 71
Residents Served in Secured Dementia Care Unit: 18
Current Hospice Residents: 13
Resident Support Staff: 0
Total Daily Staff: 94
Waking Staff: 71
Residents Age 60 or Older: 71
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 23
Residents with Physical Disability: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Moran | Executive Director | Named in multiple plans of correction and findings related to medication administration and compliance. |
Inspection Report — Jan 22, 2020
Renewal
Date: Jan 22, 2020
Visit Reason
The inspection was a full, unannounced licensing inspection conducted as part of the renewal process for the Overlook Green facility.
Findings
The inspection identified multiple violations related to record confidentiality, compliance with laws, criminal background checks, staff qualifications, orientation, resident personal equipment, sanitary conditions, surfaces, exterior hazards, food storage, lint removal, egress, combustible storage, exit signs, storage procedures, medication records, prescriber orders, key-locking devices, admission support plans, and record content. Plans of correction were accepted and implementation dates were provided.
Citations (21)
Regulation 2600.17: Resident medication administration records were left unlocked and unattended outside the Florida room.
Regulation 2600.18: Carbon monoxide detectors were missing in the basement and batteries in detectors were not verified as replaced within the past year.
Regulation 2600.51: No Pennsylvania criminal background check was completed for direct care staff person B hired on 10/21/19.
Regulation 2600.54a: Direct care staff person B hired on 10/21/19 lacks a high school diploma, GED, or active nurse aide registry status.
Regulation 2600.65a: Direct care staff person A hired on 5/26/19 did not receive orientation on fire safety and emergency preparedness topics.
Regulation 2600.65b: Direct care staff person A hired on 5/26/19 did not receive orientation on resident rights and mandatory abuse reporting.
Regulation 2600.81b: Resident #3's enabler is not securely attached to the bed and moves approximately 2 inches in both directions.
Regulation 2600.85a: No sanitary means of hand drying was present in the bathroom of bedroom 426 and resident #4's glucometer was used to check resident #1's blood glucose.
Regulation 2600.88a: Rust and peeling paint were present on exit doors next to bedrooms 230 and 344 and the exit door leading from the common living area.
Regulation 2600.100a: Uneven cement pad and asphalt near exit doors and metal cords posed tripping hazards outside the building.
Regulation 2600.103g: Unsealed food items including a veggie burger, vanilla container, French toast, and ice cream were found in the walk-in freezer.
Regulation 2600.105g: Approximately half-inch lint accumulation was found in the dryer located in the secured dementia care unit.
Regulation 2600.121a: The exit door near bedroom 437 was locked with a keypad and required significant force to open, blocking immediate egress.
Regulation 2600.125a: Seven 5-gallon buckets of paint were stored near the gas hot water heater and the boiler certificate was taped to the heater.
Regulation 2600.133.2: The exit sign at the main entrance was not visible and lacked indication of the line of travel to the front exit.
Regulation 2600.185a: Resident #1's glucometer was not calibrated to the current date and time; medications for residents #5 and #7 were not available in the home.
Regulation 2600.187a: Resident #3's January 2020 medication administration record did not include route or strength for Humalog and Zinc Sulfate; blood glucose readings were inaccurately transcribed.
Regulation 2600.187d: Resident #3 was administered only 5 units of insulin instead of the prescribed sliding scale dose; physician was not notified.
Regulation 2600.233c: Directions for operating the home's locking mechanism on the entrance door to the secured dementia care unit were not conspicuously posted.
Regulation 2600.234a: Resident #2's initial support plan was not completed within 72 hours of admission to the secured dementia care unit.
Regulation 2600.252: Resident #1's record did not include a current photograph of the resident that is no more than 2 years old.
Report Facts
Residents Served: 88
Residents Served: 18
Current Residents: 9
Total Daily Staff: 134
Waking Staff: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Moran | Executive Director | Signed multiple plans of correction and referenced in report |
Notice — Dec 31, 2019
Date: Dec 31, 2019
Visit Reason
Issuance of a new license certificate for the Personal Care Home facility Overlook Green, confirming compliance with applicable regulations.
Findings
The facility was found to be in substantial compliance with regulations set forth in 55 Pa. Code Ch. 2600 relating to Personal Care Homes. The license is granted with a maximum capacity of 128 persons.
Report Facts
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