44 Reports
Inspection Report — Jul 7, 2026
Complaint Investigation
Date: Jul 7, 2026
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance with regulatory requirements and to verify the submitted plan of correction.
Complaint Details
The inspection was complaint-related and incident-driven. The incident of a fractured wrist was substantiated as not reported timely. Staff member A was suspended and terminated following the DHS visit on 7/7/2026.
Findings
The facility was found to have multiple deficiencies including failure to timely report an incident, inadequate assistance with activities of daily living, incomplete resident assessments, and unsigned support plans. The submitted plan of correction was accepted and fully implemented by August 12, 2026.
Citations (4)
16c - The home failed to report a resident's fractured right wrist incident to the Department within the required 24-hour timeframe.
23a - The facility did not provide required physical assistance to transfer a resident as indicated in the resident's assessment and support plan.
225c - Resident assessments did not include numerous diagnoses indicated in the most recent medical evaluations.
227g - Support plans were not signed by assessors or residents, and did not indicate if residents were unable or declined to sign.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 8
Total Daily Staff: 102
Waking Staff: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Suspended and terminated after incident reporting failure and DHS visit on 7/7/2026. |
Inspection Report — May 12, 2026
Complaint Investigation
Date: May 12, 2026
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Complaint Details
Inspection was triggered by a complaint and incident. No deficiencies or citations were found, indicating no substantiated violations.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 12
Inspection Report — May 9, 2025
Date: May 9, 2025
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, with the reason noted as 'Incident'.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 66
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 10
Residents Age 60 or Older: 66
Residents with Mental Illness: 1
Residents with Mobility Need: 30
Inspection Report — Apr 16, 2025
Complaint Investigation
Date: Apr 16, 2025
Visit Reason
The inspection was conducted as a complaint investigation at THE PINES OF MT. LEBANON facility on 04/16/2025.
Complaint Details
The inspection was triggered by a complaint, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this complaint investigation inspection.
Report Facts
Residents Served: 66
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 13
Residents Age 60 or Older: 66
Residents with Mobility Need: 33
Residents with Physical Disability: 1
Inspection Report — Sep 17, 2024
Complaint Investigation
Date: Sep 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 51
Secured Dementia Care Unit Residents Served: 9
Hospice Current Residents: 6
Resident Age 60 or Older: 51
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Total Daily Staff: 67
Waking Staff: 50
Inspection Report — Mar 18, 2024
Renewal
Date: Mar 18, 2024
Visit Reason
The inspection was conducted as part of a renewal and provisional exit conference to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Complaint Details
The April 2024 and July 2024 inspections were complaint-related, investigating incidents including abuse of resident #2 by staff, failure to assist resident #1 with transfers, and other regulatory violations. The abuse allegation was substantiated by APS following investigation.
Findings
The facility was found to be in compliance overall but had multiple deficiencies including failure to post current license inspection summaries, confidentiality breaches of resident records, lack of influenza posters, inadequate first aid/CPR trained staff, insufficient annual training for direct care staff, heat source safety issues, ventilation problems in bathrooms, improper food storage, missing emergency procedures postings, inadequate fire alarm signaling for hearing impaired residents, medication packaging violations, outdated service descriptions, incomplete preadmission screenings, unsigned support plans, delayed medical evaluations, missing directions for key-locking devices, incomplete resident records logs, and abuse incidents.
Citations (25)
Failure to post current license inspection summaries in a public and conspicuous place.
Resident records were unlocked, unattended and accessible, violating confidentiality requirements.
No influenza poster posted in a public place as required by the Influenza Awareness Act.
Insufficient number of staff trained in first aid and certified in obstructed airway techniques and CPR present during shifts.
Direct care staff did not receive required annual training hours related to job duties.
Direct care staff did not receive required training on specified topics including medication self-administration, dementia care, infection control, and others.
Direct care staff did not receive required annual training on fire safety by a fire safety expert.
Heat sources exceeding 120°F accessible to residents were not equipped with protective guards or insulation.
Bathrooms without operable outside windows lacked exhaust fans for ventilation.
Food and emergency water stored on the floor in kitchen storage room.
No thermometer present in special needs kitchen drink refrigerator.
Food stored in open and unsealed containers in walk-in freezer and cooler.
Emergency preparedness plans not posted in a conspicuous and public place.
Residents with hearing impairment lacked approved signaling devices in common areas to alert fire alarms.
Medications repackaged into small bags not in original labeled containers.
Written description of services inaccurately indicated transportation was provided when it was not.
Preadmission screening forms incomplete, unsigned, or missing for several residents.
Resident support plan not signed by resident and lacked documentation of refusal or inability to sign.
Medical evaluation for secured dementia care unit resident completed after admission date.
No directions posted for operating key-locking devices at secured dementia care unit exit door.
Resident records destruction log missing birthdates and admission dates.
Resident #1 not assisted with transfers due to inoperable Hoyer lift.
Resident #2 subjected to inappropriate and non-consensual kissing by staff, causing fear and distress.
Poisonous materials left unlocked and accessible in secured dementia care unit storage room.
Sanitary conditions not maintained; red sticky substance found on freezer drawer bottom.
Report Facts
Residents Served: 54
Residents Served: 51
Residents Served: 50
Residents Served in Secure Dementia Care Unit: 8
Residents Served in Secure Dementia Care Unit: 5
Residents Served in Secure Dementia Care Unit: 7
Total Daily Staff: 70
Waking Staff: 53
Total Daily Staff: 67
Waking Staff: 50
Total Daily Staff: 66
Waking Staff: 50
Gallons of Emergency Water Stored on Floor: 137
Open Hot Dogs: 7
Open Box of Corn Kernels: 30
Open Bag of Cookie Pieces: 0.5
Open Bag of Sugar: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Roser | Lead Inspector | Lead inspector for multiple inspections including March 18, 2024 and April 18, 2024. |
| Eric Ambrose | SMD | Responsible for conducting fire safety training and monitoring compliance. |
| Staff person A | Involved in abuse incident with resident #2; suspended and terminated. |
Inspection Report — Jan 18, 2024
Follow-Up
Date: Jan 18, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit to verify the implementation of a previously submitted plan of correction related to medication storage, labeling, changes, and administration documentation.
Findings
The facility was found to have repeat violations regarding medication storage, labeling, changes in medication orders, and documentation of medication administration. The submitted plan of correction was determined to be fully implemented as of the follow-up inspection.
Citations (4)
Medication eye drops were opened, undated, and filled beyond the manufacturer's 28-day discard requirement.
Several residents' prescription medications lacked pharmacy labels on the original containers.
Medication changes were not properly documented in writing; a medication was omitted without a discontinuation order.
Medications were administered by staff but not documented in the medication administration record (MAR) with no exceptions noted.
Report Facts
Residents Served: 49
Memory Care Residents Served: 8
Hospice Residents: 12
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Total Daily Staff: 65
Waking Staff: 49
Inspection Report — Aug 14, 2023
Complaint Investigation
Date: Aug 14, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by multiple complaints and incidents, including allegations of mistreatment, abuse, failure to submit and comply with plans of correction, and other regulatory concerns at The Pines of Mt. Lebanon.
Complaint Details
The complaint investigation involved multiple allegations including resident abuse, neglect, medication errors, failure to report abuse, and inadequate care. The investigation found substantiated violations and repeat deficiencies. The facility was issued a second provisional license and directed to correct all deficiencies.
Findings
The inspection identified multiple deficiencies including breaches in resident record confidentiality, failure to prevent resident elopement, medication administration errors, incomplete or untimely resident assessments and support plans, inadequate staff training, and failure to report and respond appropriately to allegations of abuse. Several repeat violations were noted. Plans of correction were directed but many were not implemented as of the last follow-up.
Citations (17)
Resident records were left unsecured and accessible without proper authorization.
Resident #5 left the home unattended and unsupervised, triggering safety concerns.
Medications were not current; discontinued medications were found in the home.
Exit doors were not properly labeled with exit signs.
Resident medical evaluations and assessments were incomplete, untimely, or missing required information.
Medication administration records lacked documentation of administration times and doses.
Medications were administered late or not available when scheduled.
Allegations of resident abuse were not reported timely to appropriate authorities.
Staff failed to immediately suspend or supervise staff involved in abuse allegations.
Residents and their designated persons were not notified of abuse allegations.
Incident reports were not submitted timely to the Department.
Residents did not consistently receive assistance with activities of daily living as indicated in their plans.
Residents were subjected to neglect and verbal/physical abuse by staff.
Medications and syringes were left unlocked and accessible.
Medication carts contained discontinued medications that were not removed timely.
Resident support plans and assessments were incomplete, unsigned, or missing required documentation.
Glucometers were not set to the correct date and time.
Report Facts
Residents Served: 66
Residents Served in Secured Dementia Care Unit: 14
Staffing Hours: 86
Waking Staff: 65
Fine Amount Per Violation: 310
Number of Violations with Fines: 10
Resident Wait Time for Assistance: 72
Resident Wait Time for Assistance: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in multiple abuse and neglect findings involving rough handling of residents and failure to follow care plans. | |
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters. |
Inspection Report — Mar 27, 2023
Renewal
Date: Mar 27, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of The Pines of Mt. Lebanon facility to assess compliance with Pennsylvania Department of Human Services regulations.
Findings
Multiple violations were found related to resident confidentiality, contract completion, staff training, sanitary conditions, emergency preparedness, medication management, fire safety, and record keeping. Many corrective actions were directed with specified completion dates, but several were noted as not implemented as of July 24, 2023.
Citations (32)
Resident privacy coding document containing names of multiple residents was posted in a public area.
Resident-home contracts were not completed timely for certain residents.
Telephone number of the Department’s personal care home regional office was not posted in a conspicuous and public place.
Staff trained in first aid and CPR were not present at all times as required.
Direct care staff did not receive required annual training hours.
Direct care staff did not receive required training in infection control, personal care needs, and safe management techniques.
Sanitary conditions were not maintained; freezer in secure dementia care unit kitchen had large splatters of sherbet and vanilla ice cream.
Emergency telephone numbers for nearest hospital, police, fire department, etc. were not posted in the secure dementia care unit kitchen.
No operable lamp or other source of lighting that can be turned on/off at bedside for residents #1 and #2.
No grab bar, hand rail or assist bar in unlocked employee bathroom in main hallway.
Food was stored uncovered in the freezer in the secure dementia care unit kitchen.
Outdated or unlabeled food was found in the freezer in the secure dementia care unit kitchen.
Residents #5 and #6 unable to hear fire alarm system; no approved signaling device installed.
Unannounced fire drills were not held monthly as required.
Fire drill records did not indicate time or exact evacuation times for multiple drills.
Fire drill during sleeping hours was not conducted as required.
Fire drills were not held on different days and times as required.
Residents #2 and #7 medical evaluations lacked required clinical details and documentation.
Discontinued medications were found in medication carts for resident #4 and #8.
Medication labels did not match prescribed dosages for residents #2 and #4.
Blood sugar readings did not match documented medication administration records for resident #2.
Certain prescribed medications for resident #4 were not available in the home.
Resident #4's medication administration record indicated incorrect dosing for acetaminophen and oxycodone.
Resident #4's medication administration record was not updated with correct prescriptions.
Resident #2 was prescribed multiple medications that were not administered on 3/11/23.
Resident #8's prescribed medications were not available in the home on 3/27/23.
No preadmission screening was completed for residents #4 and #8.
Resident #4 and #5 initial assessments were incomplete or missing required diagnoses and medical information.
Resident #8's medical evaluation was not completed within 60 days prior to admission as required.
Resident #8 did not have a completed cognitive preadmission screening within 72 hours prior to admission.
Key-locking devices and directions for operating the home's locking mechanism were not posted near the door leading from the secure dementia care unit courtyard.
Multiple resident records were destroyed in 2023 without including required resident identifying information.
Report Facts
Residents served: 57
Staff total daily: 80
Waking staff: 60
Fine per day: 285
Fine per resident per day: 5
Inspection Report — Jan 4, 2023
Complaint Investigation
Date: Jan 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation with multiple unannounced visits on January 4, 5, and 19, 2023, to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Complaint Details
The inspection was complaint-driven with multiple unannounced visits on January 4, 5, and 19, 2023. The complaint involved failure to report incidents, medication errors, and other regulatory violations. The complaint was substantiated based on the findings.
Findings
The facility was found to have multiple violations including failure to report incidents, medication administration errors, confidentiality breaches, incomplete resident contracts, inadequate staff training, sanitary issues, and failure to maintain required emergency procedures. Many corrective plans were directed but not implemented as of the last follow-up.
Citations (33)
2600.16c The home failed to report multiple incidents including smoke detection and medication errors to the Department within 24 hours as required.
2600.187b Medication administration records for multiple residents lacked initials of staff administering medications.
2600.187d The home did not follow prescriber's orders for multiple residents, resulting in missed medications.
2600.17 Resident privacy was breached when confidential resident information was publicly displayed.
2600.25a Resident-home contracts were incomplete or missing for admitted residents.
2600.44g The telephone number for the Department’s personal care home regional office was not posted in a conspicuous place.
2600.63a No staff certified in first aid and CPR were present during multiple inspection times.
2600.65e A direct care staff person received only 4.5 hours of annual training instead of the required 12 hours.
2600.65f A direct care staff person did not receive training in infection control, personal care needs, and safe management techniques.
2600.65g Staff and volunteers did not receive required training in fire safety, emergency preparedness, and falls prevention.
2600.85a The freezer in the secure dementia care unit kitchen was unsanitary with large splatters of sherbet and vanilla ice cream.
2600.91 Emergency telephone numbers were not posted in the secure dementia care unit kitchen.
2600.101j Residents did not have operable lamps or lighting sources at bedside as required.
2600.102d Grab bars or handrails were missing in the unlocked employee bathroom.
2600.103g Food was stored uncovered in the freezer in the secure dementia care unit kitchen.
2600.103i Outdated and unlabeled food was found in the secure dementia care unit kitchen.
2600.130e Residents with hearing impairment lacked approved signaling devices for fire alarms.
2600.132a Monthly unannounced fire drills were not held during January and December 2022.
2600.132c Fire drill records lacked exact times and duration for evacuation drills.
2600.132e Fire drills during sleeping hours were not conducted as required.
2600.132g Fire drills were not routinely held at different days and times as required.
2600.141b.1 Resident medical evaluations lacked documentation of vital signs, immunizations, and cognitive functioning.
2600.183d Only current prescriptions may be kept in the home; discontinued medications were found in medication carts.
2600.184a Prescription medication containers were not properly labeled with pharmacy information and dosage instructions.
2600.185a The home failed to properly store medications and medical equipment; discrepancies were found in blood sugar readings documentation.
2600.187a Medication records did not include dose and special precautions for residents.
2600.187d The home did not follow prescriber's orders for multiple residents, including missed medications.
2600.224a No preadmission screening was completed for several residents prior to admission.
2600.225a Initial resident assessments were incomplete and lacked documentation of diagnoses and medical conditions.
2600.231b Medical evaluations by a physician or nurse were not completed within 60 days prior to admission for residents in the secured dementia care unit.
2600.231c Cognitive preadmission screenings were not completed within 72 hours prior to admission for residents in the secured dementia care unit.
2600.233c Key-locking devices and electronic systems preventing immediate egress were not posted near the device in the secured dementia care unit.
2600.253c Resident records were destroyed without including required identifying information such as birth date and admission date.
Report Facts
Residents served: 62
Residents served in secured dementia care unit: 8
Fine amount per day: 285
Total daily staff: 72
Waking staff: 54
Residents served: 57
Total daily staff: 80
Waking staff: 60
Inspection Report — Oct 17, 2022
Complaint Investigation
Date: Oct 17, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on October 13, 14, and 17, 2022, to review compliance and the submitted plan of correction.
Complaint Details
The inspection was complaint-driven, with a review of submitted plans of correction which were found not implemented as of June 14, 2023.
Findings
Multiple deficiencies were found including unsanitary conditions with feces smeared in resident bathrooms, multiple stains on bedroom carpets, incomplete annual medical evaluations, missing posted menus for the week, and incomplete medication administration records for a resident.
Citations (5)
Sanitary conditions not maintained; feces smeared on toilet seats and floors in multiple resident bathrooms.
Multiple stains on carpeting in bedrooms 127 and 201.
Annual medical evaluation for resident #1 was incomplete and missing medication list.
Menus were not posted for the week of 10/16/22 – 10/22/22.
Medication administration records for resident #2 were not initialed at required times for multiple medications.
Report Facts
Residents Served: 52
Secured Dementia Care Unit Residents Served: 7
Hospice Current Residents: 9
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 10
Residents 60 Years or Older: 52
Residents with Physical Disability: 3
Inspection Report — May 19, 2022
Complaint Investigation
Date: May 19, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 05/19/2022 and 05/31/2022, followed by a plan of correction submission and review.
Complaint Details
The inspection was complaint-driven, with a follow-up plan of correction submission and review. The complaint involved medication administration and adherence to prescriber's orders.
Findings
The facility was found to have deficiencies related to medication administration documentation and failure to follow prescriber's orders for blood glucose monitoring and insulin administration. A plan of correction was submitted and determined to be fully implemented.
Citations (3)
Medication administration record did not include initials of staff who administered medication to resident #1 at specified times.
Resident #2's blood glucose checks were not performed as prescribed, and insulin doses were inconsistently administered or documented.
Resident #3's blood glucose was not checked as prescribed.
Report Facts
Residents Served: 34
Staffing Hours: 51
Waking Staff: 38
Residents Served in SDCU: 6
Hospice Residents: 7
Residents 60 Years or Older: 334
Residents with Mobility Need: 17
Residents with Physical Disability: 1
Inspection Report — Feb 23, 2022
Renewal
Date: Feb 23, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection of THE PINES OF MT. LEBANON facility on 02/23/2022 through 02/25/2022.
Findings
The inspection identified multiple deficiencies including missing influenza awareness posters, entrapment hazards due to uncovered bedrails, unsecured poisonous materials accessible to residents, incomplete medical evaluations, medication record errors, unsigned resident contracts, and failure to follow prescriber's medication orders. Plans of correction were accepted and documented as implemented.
Citations (7)
Influenza awareness poster was not posted in a public and conspicuous place as required by the Influenza Awareness Act.
Bedrails on both sides of resident #2's bed were uncovered, posing an entrapment hazard.
An 8 ounce tube of Colgate toothpaste with poison control warning was unlocked and accessible in a secured dementia unit bathroom, posing a risk to residents not assessed as capable of safely using poisons.
Medical evaluation for resident #1 did not include cognitive function or health status.
Medication prescribed to resident #1 was not indicated on the medication administration record.
Resident-home contract for resident #1 was not signed by the resident.
Resident #4 was not administered prescribed medications on multiple occasions due to medication unavailability in the home.
Report Facts
Residents Served: 33
Secured Dementia Care Unit Residents Served: 9
Hospice Current Residents: 8
Resident Support Staff Hours: 33
Total Daily Staff: 84
Waking Staff: 63
Inspection Report — Dec 13, 2021
Complaint Investigation
Date: Dec 13, 2021
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 12/13/2021 and 12/14/2021.
Complaint Details
The inspection was complaint-driven, investigating incidents reported during the week of 12/6/21 involving staff person A's failure to assist residents as required. The complaint was substantiated with repeat violations noted.
Findings
The facility was found to have deficiencies related to incomplete training records, unsigned support plans for residents, and failure to provide assistance with activities of daily living as indicated in residents' support plans. Plans of correction were submitted and some were accepted and implemented.
Citations (3)
Lack of documentation for required training for staff person A.
Support plans for residents #2 and #3 were not signed by the assessor or the resident.
Staff person A failed to assist residents #1 and #2 with activities of daily living as indicated in their support plans, including refusal to assist resident #1 with bedpan use.
Report Facts
Residents Served: 36
Residents Served in Dementia Unit: 9
Current Hospice Residents: 7
Resident Age 60 or Older: 35
Residents with Mental Illness: 2
Residents with Mobility Need: 18
Residents with Physical Disability: 1
Total Daily Staff: 54
Waking Staff: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to lack of training documentation and failure to assist residents with activities of daily living. | |
| RWD | Responsible for conducting audits and education related to support plan compliance. |
Inspection Report — Sep 27, 2021
Renewal
Date: Sep 27, 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 — Sep 8, 2021
Renewal
Date: Sep 8, 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 — Aug 27, 2021
Complaint Investigation
Date: Aug 27, 2021
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Complaint Details
The visit was complaint-related, triggered by concerns about resident safety and support plan adequacy. The plan of correction was accepted and fully implemented.
Findings
The facility was found to have deficiencies related to support plan revisions for residents, specifically failure to update support plans to reflect residents' safety risks and care needs. The submitted plan of correction was determined to be fully implemented.
Citations (2)
Resident #1’s support plan was not updated to indicate the resident’s lack of regard for safety while self-propelling a wheelchair or the care and services needed to prevent injuries.
Resident #2’s support plan did not indicate the high fall risk including the home’s care and services to protect the resident despite multiple unwitnessed falls.
Report Facts
Residents Served: 39
Secured Dementia Care Unit Residents Served: 7
Hospice Residents: 5
Resident #2 Falls: 5
Inspection Report — May 21, 2021
Renewal
Date: May 21, 2021
Visit Reason
The document is a renewal license issued in response to the facility's April 6, 2021 renewal application to operate the Personal Care Home. The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
The Department has issued a regular license for The Pines of Mt. Lebanon following the renewal application. No findings of noncompliance are stated in this document, but the Department notes that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal license letter |
Inspection Report — May 18, 2021
Complaint Investigation
Date: May 18, 2021
Visit Reason
The inspection was a partial, unannounced complaint investigation conducted on 05/18/2021 and 05/20/2021 at The Pines of Mt. Lebanon.
Complaint Details
The inspection was triggered by a complaint, as indicated by the inspection reason 'Complaint' and the partial, unannounced nature of the visit.
Findings
The inspection found multiple deficiencies related to expired administrator license, medication storage and administration errors, inaccurate glucometer calibration and blood glucose recording, and failure to follow prescriber's orders for resident #1. Plans of correction were accepted and implemented with specified completion dates.
Citations (5)
The nursing home administrator license for Staff person A expired on 6/30/2020.
The glucometer belonging to resident #1 was not calibrated to the current date, and blood glucose readings were inaccurately recorded on the Medication Administration Record.
Resident #1's MAR was not initialed by staff who administered Lantus insulin on 5/7/2021 at 8:00 p.m.
Resident #1's insulin and other medications were administered late or withheld without proper documentation on multiple occasions.
The home failed to develop and implement procedures for safe storage, access, security, distribution and use of medications and medical equipment by trained staff.
Report Facts
Residents Served: 40
Staffing Hours - Total Daily Staff: 62
Staffing Hours - Waking Staff: 47
Residents with Mobility Need: 22
Residents Age 60 or Older: 39
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Physical Disability: 1
Residents Diagnosed with Intellectual Disability: 0
Inspection Report — Apr 8, 2021
Renewal
Date: Apr 8, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of THE PINES OF MT. LEBANON facility by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 04/08/2021 through 04/13/2021.
Findings
The inspection identified multiple deficiencies including failure to post required documents, unsecured resident records, lack of carbon monoxide detectors near hot water tanks, improper resident transfer assistance, unsigned resident contracts, failure to educate a resident on rights, unsanitary conditions, incomplete menu postings, unlocked medications, discontinued medications present, and inaccurate medication records. Plans of correction were accepted for all deficiencies with specified completion dates.
Citations (11)
Failure to post a copy of 55 Pa. Code Chapter 2600 in a conspicuous and public place in the home.
Resident records, including personal identifiable information, were unlocked, unattended, and accessible in unsecured areas.
No carbon monoxide detector installed in close proximity to the home's 3 hot water tanks as required by law.
Residents requiring two-person transfer assistance were transferred with only one staff member, contrary to their assessments and support plans.
Resident #7's contract was not signed by the resident.
Resident #7 was not educated on resident rights or the right to lodge complaints without retaliation.
Walls of the microwave in the secured dementia care unit were covered in dried food.
Menu for the upcoming week was not posted in a conspicuous and public place as required.
A box of over-the-counter medication was unlocked, unattended, and accessible in the Wellness room.
Discontinued medication (Montelukast Sod 10mg) was found in the medication cart.
Blood glucose readings for resident #9 were not accurately recorded on the medication administration record.
Report Facts
Residents Served: 37
Secured Dementia Care Unit Residents Served: 9
Hospice Current Residents: 6
Staffing Hours - Total Daily Staff: 58
Staffing Hours - Waking Staff: 44
Inspection Report — Mar 25, 2021
Follow-Up
Date: Mar 25, 2021
Visit Reason
The inspection was conducted as a follow-up to review the submitted plan of correction related to a resident abuse incident that occurred on 03/16/2021.
Complaint Details
The visit was complaint-related due to an incident on 03/16/2021 where direct care staff person D mocked resident #1 by making noises and using inappropriate language during incontinence care. The home delayed reporting the incident until 03/19/2021. The staff member was not immediately suspended and continued to work until later that evening and the following day. The staff member resigned during the investigation.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing the failure to immediately report suspected resident abuse and failure to properly supervise the involved staff. The incident involved direct care staff mocking a resident and inappropriate language during care. The staff member involved resigned during the investigation.
Citations (4)
Failure to immediately report suspected abuse of a resident in accordance with regulations.
Failure to immediately develop and implement a plan of supervision or suspend the staff person involved in the alleged abuse incident.
Failure to report the incident or condition to the Department within 24 hours as required.
Failure to treat a resident with dignity and respect; direct care staff mocked the resident and used inappropriate language during care.
Report Facts
Residents Served: 37
Secured Dementia Care Unit Residents Served: 10
Current Residents Receiving Hospice: 7
Residents Age 60 or Older: 40
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 22
Residents with Physical Disability: 1
Inspection Report — Nov 18, 2020
Follow-Up
Date: Nov 18, 2020
Visit Reason
The inspection was a partial unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to delayed reporting of suspected resident abuse and incomplete staff training on infection control and hygiene. Continued compliance and ongoing monitoring were emphasized.
Citations (2)
15a - Resident Abuse Report: The home failed to immediately report a resident's allegation of sexual abuse to the Area Agency on Aging, delaying the report from 11/14/20 to 11/15/20.
65f - Training Topics: A direct care staff person did not complete required annual training on infection control and hygiene related to immobility during the 2019 training year.
Report Facts
Residents Served: 35
Secured Dementia Care Unit Residents Served: 8
Hospice Current Residents: 5
Inspection Report — Apr 22, 2020
Routine
Date: Apr 22, 2020
Visit Reason
The Department's Bureau of Human Services Licensing Representatives conducted an inspection of The Pines of Mt. Lebanon facility on April 22, 2020.
Findings
No regulatory citations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Notice — Mar 4, 2020
Date: Mar 4, 2020
Visit Reason
This document serves as a renewal approval for the license to operate The Pines of Mt. Lebanon Personal Care Home 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 4, 2020
Renewal
Date: Mar 4, 2020
Visit Reason
The inspection was a full, unannounced renewal inspection of The Pines of Mt. Lebanon facility conducted by the Pennsylvania Department of Human Services on March 4, 2020.
Findings
The inspection found multiple violations related to resident privacy, emergency preparedness, medication administration, safety, and documentation. Plans of correction were submitted and fully implemented by April 24, 2020.
Citations (11)
A black plastic wall bin in the main lobby contained unlocked binders with confidential resident information accessible to the public.
The influenza awareness poster was not posted in a public and conspicuous place as required by the Influenza Awareness Act.
Resident #9's contract addendum was not signed by the resident, nor did it indicate refusal or inability to sign.
A square trash receptacle at the main entrance was uncovered and approximately one quarter full, posing a risk of insect and rodent infestation.
Resident #1's room lacked telephone numbers for emergency services and the personal care complaint hotline posted on or by the telephone.
Resident #10's medication administration record did not list the ordered Arthritis Pain 650mg medication.
Resident #10's medication administration of Menthol-Zinc Oxide 0.45% - 20% was not documented on specified dates and times.
Resident #1's administration of Inzo Barrier Cream was not documented on several dates as ordered.
The fire drill record did not indicate whether the drill was conducted at 5:00 a.m. or 5:00 p.m. on 2/28/2020.
Resident #11's annual support plan did not include a plan to meet service needs or frequency for multiple areas of the support plan.
Resident #10 admitted to secured dementia care unit did not have a support plan developed, implemented, and documented until 8/27/19.
Report Facts
Residents Served: 37
Secured Dementia Care Unit Residents Served: 4
Hospice Current Residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Belinda McQuaide | Executive Operations Officer | Signed multiple plans of correction and was named responsible for ongoing monitoring and corrective actions |
| Jon Kimberland | Human Services Licensing Supervisor | Signed the cover letter confirming plan of correction implementation |
Inspection Report — Feb 10, 2020
Follow-Up
Date: Feb 10, 2020
Visit Reason
The visit was a follow-up review conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing, to verify that the submitted plan of correction was fully implemented following a prior incident-related inspection.
Findings
The submitted plan of correction was determined to be fully implemented. The facility demonstrated compliance with the requirement that individuals who participate in the development of the support plan sign and date the plan.
Citations (1)
2600.227.g requires individuals who participate in the development of the support plan to sign and date it. Resident #1's support plan dated 12/29/2019 was not signed by the staff person completing it.
Report Facts
Residents Served: 39
Memory Support Unit Residents Served: 5
Hospice Current Residents: 3
Residents with Mobility Need: 18
Residents 60 Years or Older: 39
Residents Diagnosed with Mental Illness: 3
Residents with Physical Disability: 3
Inspection Report — Jan 23, 2020
Routine
Date: Jan 23, 2020
Visit Reason
The Department’s Bureau of Human Services Licensing Representatives conducted an inspection of The Pines of Mt. Lebanon facility on January 23, 2020.
Findings
No regulatory citations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Notice — Mar 29, 2019
Date: Mar 29, 2019
Visit Reason
The document is a letter responding to a waiver request related to qualifications for direct care staff persons at The Pines of Mt. Lebanon.
Findings
The Department reviewed the submitted documentation and determined that the individual meets the educational requirement to serve as a direct care staff person. The Department recommends keeping a copy of the educational documentation in the personnel file.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the letter regarding the waiver request |
Inspection Report — Mar 26, 2019
Annual Inspection
Date: Mar 26, 2019
Visit Reason
The annual inspection was conducted to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes, including renewal and provisional licensing.
Findings
Multiple violations of state regulations were found related to food safety certification, medication management, documentation, and resident care procedures. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (12)
REGULATION 2600.18: The facility lacked a certified food protection safety manager on site during all hours of food preparation and handling.
REGULATION 2600.183(d): Two of four residents had medication in the medication cart without a current order for the medication.
REGULATION 2600.184(a): Resident #3's prescription medication label lacked complete information, only indicating sliding scale directions and dosages.
REGULATION 2600.185(a): Medication team failed to maintain accurate narcotic counts and blood glucose testing documentation for residents #3 and #4.
REGULATION 2600.187(a)(13): Medication trained team members failed to initial medications when administered for four residents at varying times during March.
REGULATION 2600.187(c): No notifications of medication refusals were made to physicians for four residents during the review period.
REGULATION 2600.187(d): Resident #3's insulin was administered incorrectly on two occasions during the survey.
REGULATION 2600.224(a): Resident #4 and #5's preadmission screening was completed after admission.
REGULATION 2600.227(g): Resident #2's support plan did not have any signatures.
REGULATION 2600.227(h): Resident #1's support plan was not signed by the resident and refusal was not documented.
REGULATION 2600.16.c: The facility failed to report a medication incident to the Department's personal care home complaint hotline within 24 hours.
REGULATION 2600.185a: Medication Assistant was terminated for violating policies regarding handling and storage of medications after a medication delivery incident.
Report Facts
Residents Served in Secured Dementia Care Unit: 5
Number of Current Hospice Residents: 3
Residents Served: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jackie Hauner | Executive Director | Signed multiple plans of correction and was named as responsible party for corrective actions. |
| Josh Hoover | Department Representative | On-site inspector on March 26, 27, and May 3, 2019. |
| Patricia Bartlett | Department Representative | On-site inspector on March 26, 27, and May 3, 2019. |
| Staff Person B | Named in medication administration documentation deficiencies and education. | |
| Staff Person A | Involved in medication delivery incident resulting in termination. |
Notice — Mar 4, 2019
Date: Mar 4, 2019
Visit Reason
The document serves as a notification that a waiver request related to qualifications for direct care staff persons was reviewed and determined not to be needed.
Findings
The Department of Human Services reviewed the submitted documentation and determined the waiver was unnecessary. It recommends maintaining a copy of the educational documentation in personnel files.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the waiver approval letter. |
Inspection Report — Feb 22, 2019
Complaint Investigation
Date: Feb 22, 2019
Visit Reason
The inspection was conducted as a complaint investigation and fine related to regulatory compliance at The Pines of Mt. Lebanon.
Complaint Details
The inspection was complaint-driven and included a fine. Specific complaints involved safety issues with handrails, lack of activity programming, and improper discharge notification procedures.
Findings
The inspection identified violations related to unsecured handrails, lack of planned activities due to separation of the Activity Director, and failure to provide a 30-day advance written discharge notice to a resident or their designated person.
Citations (3)
REGULATION 2600.93(a): Each ramp, interior stairway and outside steps must have a well-secured handrail. The handrail was found loose and taken out of use pending repair.
REGULATION 2600.221(b): The program must provide social, physical, intellectual and recreational activities in a planned, coordinated and structured manner. The activity calendar was not followed and activities were often canceled due to the Activity Director's separation.
REGULATION 2600.228(b): The home must provide a 30-day advance written discharge notice to the resident or their designated person. The home failed to provide this notice for a resident discharged on 1/17/19.
Report Facts
Number of Residents Served: 44
Number of Residents Served in Secured Dementia Care Unit: 9
Number of Current Hospice Residents: 6
Number of Hospice Residents in Past Year: 14
Residents Age 60 or Older: 44
Residents with Mental Illness: 1
Residents with Intellectual Disability: 0
Residents with Mobility Need: 23
Residents with Physical Disability: 2
Notice — Feb 4, 2019
Date: Feb 4, 2019
Visit Reason
The document communicates the Department's determination that a waiver for qualifications of direct care staff persons is not needed based on submitted documentation.
Findings
The Department reviewed the submitted documentation and determined that the educational requirement to serve as a direct care staff person is met, so no waiver is required.
Report Facts
Pa.Code section: 2600.54
License number: 433611
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the waiver determination letter |
Inspection Report — Dec 27, 2018
Routine
Date: Dec 27, 2018
Visit Reason
The Department’s Bureau of Human Services conducted an inspection of The Pines of Mt. Lebanon facility to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
No regulatory violations were identified as a result of this inspection.
Inspection Report — Dec 10, 2018
Enforcement
Date: Dec 10, 2018
Visit Reason
The Department of Human Services issued a notice of intent to assess a fine for regulatory violations related to personal care homes at The Pines of Mt. Lebanon.
Findings
The facility was assessed a fine of $3,264 for uncorrected violations under 55 Pa.Code Chapter 2600 Section 65f, Class III violation, based on a census of 64 residents during the inspection period.
Report Facts
Fine amount: 3264
Fine per resident per day: 3
Calculated fine per day: 192
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shivani Patel | Enforcement Manager | Named as contact for appeal and invoice questions |
| Jacqueline L. Rowe | Director | Signed the enforcement letter |
Notice — Oct 16, 2018
Date: Oct 16, 2018
Visit Reason
The document serves as a renewal approval for the Personal Care Home license for The Pines of Mt. Lebanon and notifies that an 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 the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Sep 19, 2018
Complaint Investigation
Date: Sep 19, 2018
Visit Reason
Complaint investigation triggered by allegations related to regulatory compliance at The Pines of Mt. Lebanon.
Complaint Details
Complaint investigation with substantiated violations related to resident care, medication management, staff training, and facility safety.
Findings
Multiple violations were found including failure to post licensing inspection summary, unsecured resident records, missing resident signatures on contracts, incomplete staff training records, improper medication storage and administration, and failure to conduct monthly fire drills.
Citations (14)
55 Pa.Code §2600.3(c) The personal care home did not post the current licensing inspection summary in a public and conspicuous place.
55 Pa.Code §2600.17 Resident records were unsecured and accessible to unauthorized persons.
55 Pa.Code §2600.25(b) Resident home contracts were not signed by the residents.
55 Pa.Code §2600.65(e) Staff training records did not include length of each training course.
55 Pa.Code §2600.65(f) Staff did not receive required annual training on medication administration, infection control, safe management, and care for residents with mental illness.
55 Pa.Code §2600.65(g) The home failed to conduct an unannounced fire drill in August 2017.
55 Pa.Code §2600.85(a) Medication storage was unsanitary; resident glucometers were shared and not properly sanitized.
55 Pa.Code §2600.92 Windows in the laundry room lacked proper screening.
55 Pa.Code §2600.141(b)(1) Resident medical evaluation was not completed annually as required.
55 Pa.Code §2600.162(c) Weekly menus were not posted one week in advance as required.
55 Pa.Code §2600.183(e) Prescription medications were not stored with proper pharmacy labels.
55 Pa.Code §2600.184(a) Medication records did not include length of training courses for staff.
55 Pa.Code §2600.185(a) The home failed to implement procedures for safe medication storage and use; resident glucometers were not calibrated to current date and time.
55 Pa.Code §2600.231(b) Resident medical evaluation did not indicate need for secured dementia care unit placement.
Report Facts
Number of Current Hospice Residents: 8
Number of Residents Served: 60
Number of Residents with Mental Illness: 2
Number of Residents with Mobility Needs: 30
Number of Residents with Physical Disability: 3
Number of Residents with Intellectual Disability: 0
Number of Residents Served in Secured Dementia Unit: 14
Number of Residents Served in Memory Care: 60
Number of Residents Served in Secured Dementia Care Unit: 14
Number of Residents Served in Hospice: 7
Number of Residents Served in Past Year Hospice: 14
Fine Amount Per Day: 192
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa D'Avico | Administrator | Named in plan of correction for posting licensing inspection summary. |
| Michael Marini | Surveyor | Conducted on-site inspections May 24-25, 2018. |
| Barbara Barona | Surveyor | Conducted on-site inspection May 19, 2018. |
| Shivani Patel | Enforcement Manager | Named in enforcement appeal instructions. |
Notice — Jul 24, 2018
Date: Jul 24, 2018
Visit Reason
The document is a response to a waiver request related to qualifications for direct care staff persons under Pennsylvania Code Chapter 2600 for a personal care home.
Findings
The Department determined that a waiver is not needed because the staff person meets the educational qualifications with a diploma from Notre Dame-Siena School of Marbel, Philippines. The facility is advised to keep documentation of the staff's qualifications in personnel files.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the waiver determination letter. |
Inspection Report — Apr 16, 2018
Routine
Date: Apr 16, 2018
Visit Reason
The Department's Bureau of Human Services representatives conducted an inspection of The Pines of Mt. Lebanon facility on April 16, 2018.
Findings
No regulatory violations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Inspection Report — Nov 29, 2017
Routine
Date: Nov 29, 2017
Visit Reason
The Department's Bureau of Human Services Licensing representatives conducted an inspection of The Pines of Mt. Lebanon facility.
Findings
No regulatory violations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Williams | Human Services Licensing Supervisor | Signed the inspection report letter. |
Notice — Oct 16, 2017
Date: Oct 16, 2017
Visit Reason
This document serves as a renewal notification and license issuance for The Pines of Mt. Lebanon Personal Care Home, confirming the facility's compliance and renewal application under PA Code Chapter 2600.
Findings
No inspection findings are reported in this document. It confirms that a regular license is being issued following the renewal application and advises that an onsite inspection will be conducted within the next twelve months.
Report Facts
Inspection Report — Jun 7, 2017
Annual Inspection
Date: Jun 7, 2017
Visit Reason
The inspection was an annual licensing inspection conducted on June 7 and June 8, 2017, including a renewal and complaint investigation.
Complaint Details
The inspection included a complaint investigation related to privacy breaches, contract signing delays, and staff training deficiencies. The complaint was substantiated with findings documented.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to resident confidentiality, contract signing, resident rights, staff training, medication administration, sanitary conditions, and preadmission screening. Plans of correction were submitted and partially implemented with adequate progress.
Citations (14)
2600.17 - Resident records containing confidential medical information were left unlocked and unattended on a table in the activity room.
2600.25(a)(1) - A resident's written home contract was not signed by the resident within 24 hours of admission.
2600.42(s) - Two individuals from a hospice agency were observed asking a resident health-related questions in the lobby, violating privacy rights.
2600.65(d) - Staff persons hired after April 24, 2006, provided unsupervised ADL services without completing required direct care training or competency testing.
2600.65(g) - Direct care staff and volunteers did not receive required fire safety and emergency preparedness training during 2016.
2600.85(a) - The toilet on the second floor spa room was clogged with paper towels and feces at time of inspection.
2600.107(c) - The home did not maintain a sufficient emergency supply of drinking water; only 78 gallons were available for a 3-day supply for 60 residents.
2600.141(a)(1) - A resident's medical evaluation did not include the resident's weight as required within 60 days prior to admission or within 30 days after admission.
2600.183(f) - Prescription medications, including eye drops, were not properly disposed of after expiration; medication errors and expired medications were found during audit.
2600.184(a) - Prescription medication containers were not labeled with all required information including resident name, medication name, dosage, and prescriber.
2600.187(a) - Medication records lacked required details such as dosage form, administration times, and staff initials for administered medications.
2600.226(b) - Resident assessments did not document required care and safety needs, including repositioning and evacuation assistance.
2600.225(c) - Resident preadmission screening forms were incomplete and did not document primary medical, psychological, or behavioral diagnoses.
2600.231(c) - Cognitive preadmission screening forms were incomplete and did not indicate resident ability to safely use or avoid poisonous materials.
Report Facts
Staffing Hours: 151
Walking Staff: 113
Number of Residents Served in Secured Dementia Care Unit: 14
Number of Current Hospice Residents: 13
Number of Hospice Residents in Past Year: 8
Residents Age 60 or Older: 60
Residents with Mobility Need: 31
Residents with Physical Disability: 1
Emergency Drinking Water Supply: 78
Required Emergency Drinking Water Supply: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa D'Avico | Administrator | Named as legal entity representative and signer of plans of correction. |
| Staff person C | Hired 4/3/2017, provided unsupervised ADL services without completing training. | |
| Staff person D | Hired 2/5/2013, provided unsupervised ADL services without completing training. | |
| Staff person E | Hired 5/15/2012, did not receive required training on medication self-administration and infection control. | |
| Staff person F | Hired 6/9/2015, did not receive required training on fire safety and emergency preparedness. | |
| Staff person A | Administrator involved in medication error related to morphine dosing. | |
| Staff person B | Involved in medication error related to morphine dosing. |
Inspection Report — Nov 1, 2016
Complaint Investigation
Date: Nov 1, 2016
Visit Reason
The inspection was conducted as a complaint investigation at The Pines of Mt Lebanon personal care home on November 1, 2016.
Complaint Details
The inspection was triggered by a complaint. Specific substantiation status is not stated in the report.
Findings
Multiple violations were found related to resident assessments, assistance with activities of daily living, and documentation of hospice services. Plans of correction were submitted addressing staff training, assessment accuracy, and updating resident support plans.
Citations (4)
55 Pa.Code §2600.23(a): Staff failed to provide timely assistance to Resident #1, leaving them unattended for approximately 40 minutes despite the care plan requiring 1-2 staff assistance for transfers.
55 Pa.Code §2600.225(a): Resident #1's initial assessment did not accurately reflect mobility needs requiring 1-2 staff for transfers; Resident #2's assessment omitted diagnosis of senile degeneration and dietary needs.
55 Pa.Code §2600.225(c): Resident #3's assessment lacked diagnosis of congestive heart failure as indicated in medical evaluation.
55 Pa.Code §2600.227(d): Resident #2 and #3's support plans did not include specific hospice services or frequency of those services.
Report Facts
Number of Residents Served: 56
Number of Current Hospice Residents: 6
Number of Residents Served in Secured Dementia Care Unit: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa D'Auilo | Administrator | Named in relation to multiple findings and plans of correction. |
Inspection Report — Oct 26, 2016
Complaint Investigation
Date: Oct 26, 2016
Visit Reason
The inspection was conducted due to a complaint and incident involving failure to report a resident's death to the Department as required by 55 Pa.Code Chapter 2600.
Complaint Details
The visit was complaint-related and substantiated. The complaint involved failure to report a resident's death to the Department within the required timeframe.
Findings
The facility failed to report the death of Resident #1 to the Department within 24 hours as required. The home staff misunderstood the reporting requirement, thinking it applied only if the resident expired in the home.
Citations (1)
2600.16(c) The home failed to report the incident of Resident #1's death to the Department within 24 hours as required by regulation. Resident #1 died in the hospital, but the home did not notify the Department until after the fact.
Report Facts
Number of Residents Served: 55
Number of Residents Served in Secured Dementia Care Unit: 12
Number of Current Hospice Residents: 5
Number of Hospice Residents in Past Year: 18
Number of Residents Age 60 or Older: 55
Number of Residents with Mobility Need: 30
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa D'Avico | Administrator | Signed plan of correction and responsible for corrective actions |
Inspection Report — Jan 29, 2016
Complaint Investigation
Date: Jan 29, 2016
Visit Reason
The inspection was conducted as a licensing inspection triggered by complaint and incident reports at The Pines of Mt Lebanon personal care home.
Complaint Details
The inspection was complaint-related with substantiated findings of neglect and abuse involving residents #1, #2, and #3. The home failed to timely report an incident of neglect and had multiple staff-witnessed incidents of resident-to-resident abuse.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including failure to report incidents timely, resident abuse and neglect, incomplete fire drill records, and incomplete medical evaluations. Plans of correction were submitted addressing these issues.
Citations (7)
2600.16(c) - The home failed to report a caregiver neglect incident involving resident #3 unattended from 6:00 a.m. to 2:00 p.m. on 7/9/15 until 9/17/15.
2600.42(b) - Resident #2 physically abused resident #1 multiple times, including slapping and rough handling, witnessed by staff on several occasions.
2600.132(c) - The home's fire drill record did not include the AM/PM time for drills on 5/29/15 and 12/17/15 and lacked the date for a November 2015 drill.
2600.141(a)(2) - Medical evaluations for residents #1 and #4 were incomplete or missing required information such as weight, temperature, or medication self-administration ability.
2600.141(b)(1) - Resident #5 had a medical evaluation completed on 10/03/13 and not again until 2/26/15, failing the annual evaluation requirement.
2600.225(a) - Resident #6 did not have a written initial assessment completed within 15 days of admission as required.
2600.225(c) - Resident #2's assessment dated 7/14/15 indicated no problems, but resident #2 was receiving psychological treatment and had documented incidents of aggression and abuse.
Report Facts
Number of Residents Served: 70
Number of Current Hospice Residents: 8
Number of Hospice Residents in past year: 15
Number of Residents Served in Secured Dementia Care Unit: 18
Total Daily Staff: 106
Waking Staff: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Delio | Executive Director | Named in multiple findings and plans of correction related to violations and corrective actions |
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