Inspection Reports for AHAVA Memory Care
200 JHF Dr, Pittsburgh, PA 15217, United States, PA, 15217
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Inspection Report
Complaint Investigation
Census: 28
Capacity: 30
Deficiencies: 0
May 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 05/04/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and the follow-up was not required.
Report Facts
License Capacity: 30
Residents Served: 28
Current Hospice Residents: 4
Residents Diagnosed with Mental Illness: 5
Residents Aged 60 or Older: 28
Residents with Mobility Need: 28
Total Daily Staff: 56
Waking Staff: 42
Inspection Report
Complaint Investigation
Census: 27
Capacity: 30
Deficiencies: 0
Feb 1, 2023
Visit Reason
The inspection was conducted as a complaint investigation at the AHAVA Memory Care Residence.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-driven and the findings indicate no deficiencies or citations.
Report Facts
License Capacity: 30
Residents Served: 27
Current Residents in Hospice: 4
Residents Age 60 or Older: 27
Residents with Mental Illness: 2
Residents with Mobility Need: 27
Inspection Report
Renewal
Census: 26
Capacity: 30
Deficiencies: 7
Jun 29, 2022
Visit Reason
The inspection was a renewal, provisional licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing, to evaluate compliance with 55 Pa. Code Ch. 2800 relating to Assisted Living Residence.
Findings
The facility was found to be in compliance after the inspection and corrections were made. Several deficiencies were identified related to resident contracts, locked poisons, window screens, bedside tables, unobstructed egress, preadmission screening, and key-locking devices, all of which had plans of correction implemented and accepted.
Deficiencies (7)
| Description |
|---|
| Resident #1 does not have a resident-home contract in place. |
| An unlocked, accessible, and unattended 4oz. tube of WeCare CalaSoothe Cream was found in the common bathroom next to the sunroom. |
| Right window screen in bedroom #M02 is in disrepair with frayed and pulled corner; right window screen in bedroom #M09 has two small holes approximately 1 inch in diameter. |
| Resident #2's bedside table measures approximately 56 inches from the resident's bedside with a chair between the bed and table. |
| Emergency exit door from activity room into secured courtyard was unable to be opened due to a yellow hose obstructing the door. |
| Resident #1 was admitted without a written cognitive preadmission screening completed within 72 hours prior to admission. |
| No codes were posted at the locking mechanisms keypads at the gates on the left and right side of the secured courtyard. |
Report Facts
Residents Served: 26
License Capacity: 30
Staffing Hours: 52
Staffing Hours: 39
Current Residents: 6
Residents Age 60 or Older: 26
Residents with Mobility Need: 26
Inspection Report
Monitoring
Census: 29
Capacity: 30
Deficiencies: 6
Oct 20, 2021
Visit Reason
The inspection was a monitoring visit conducted on 10/20/2021 to assess compliance with licensing requirements at AHAVA Memory Care Residence.
Findings
The inspection identified multiple medication-related deficiencies including incorrect labeling of insulin pens, discrepancies in blood glucose documentation versus glucometer readings, and failure to follow prescriber orders for insulin administration. Plans of correction were accepted or directed to address these issues with staff education, audits, and updated medication orders.
Deficiencies (6)
| Description |
|---|
| Insulin pens were not labeled correctly according to pharmacy labels, causing potential medication errors. |
| Blood glucose readings documented on medication administration records (MAR) did not match glucometer readings for residents, including failure to document 'HI' readings properly. |
| Resident #1's medication administration record did not include additional insulin doses required when blood glucose was less than 100 mg/dl at meals. |
| Resident #1 was administered incorrect amounts of insulin on multiple occasions, not consistent with prescribed orders. |
| Resident #2's blood glucose checks and insulin administration were inconsistently documented and did not always follow prescribed sliding scale orders. |
| Resident #3's blood glucose monitoring was incomplete with missing glucometer readings despite prescribed twice daily checks. |
Report Facts
License Capacity: 30
Residents Served: 29
Total Daily Staff: 58
Waking Staff: 44
Hospice Residents: 6
Blood Glucose Readings Discrepant: 8
Inspection Report
Renewal
Census: 27
Capacity: 30
Deficiencies: 5
Jul 7, 2021
Visit Reason
The inspection was conducted as a full, unannounced renewal inspection of the AHAVA Memory Care Residence on 07/07/2021 and 07/08/2021.
Findings
The inspection identified multiple deficiencies related to medication administration and equipment use, including sharing of glucometers between residents, unlabeled medication pens, glucometers not set to the correct time, and discrepancies in medication administration records. The facility submitted an acceptable plan of correction addressing these issues.
Deficiencies (5)
| Description |
|---|
| Resident #1’s glucometer was used to test resident #2’s blood glucose. |
| Resident #2’s Humalog Kwik pen does not have a pharmacy label. |
| Resident #1 and resident #3's glucometers are not set to the current time. |
| Resident #1's medication administration record (MAR) indicates incorrect sliding scale blood glucose range. |
| Resident #2 is prescribed insulin but no glucometer was present in the residence for this resident. |
Report Facts
License Capacity: 30
Residents Served: 27
Current Hospice Residents: 6
Total Daily Staff: 54
Waking Staff: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN, Infection Control | Conducted glucometer audits from July 12 through July 26, 2021 | |
| RN, Director of Resident Care | Conducted audits of glucometers and medication carts; responsible for ongoing monitoring and training |
Inspection Report
Follow-Up
Census: 22
Capacity: 30
Deficiencies: 5
Jan 7, 2021
Visit Reason
The visit was a follow-up review to verify the implementation of a previously submitted plan of correction related to an incident of resident abuse and failure to report.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing the abuse incident involving resident #1. Staff were reeducated on abuse reporting, and the staff member involved was terminated and prohibited from returning to the facility.
Complaint Details
The visit was triggered by an incident reported involving resident #1, diagnosed with Alzheimer's dementia, who was abused by staff on 12/21/2021. The complaint was substantiated as the facility failed to report the abuse timely and did not immediately suspend the staff involved.
Deficiencies (5)
| Description |
|---|
| Failure to immediately report suspected abuse of resident #1 in accordance with the Older Adult Protective Services Act. |
| Failure to immediately develop and implement a plan of supervision or suspend the staff person involved in the alleged abuse incident. |
| Failure to immediately notify the resident and the resident’s designated person of a report of suspected abuse. |
| Resident #1 was subjected to abuse including being forcibly restrained in a reclined chair, dragged down the hall, and left alone in a room with the door closed. |
| Prohibited procedure of seclusion by involuntary confinement of resident #1 in a room from which the resident was physically prevented from leaving. |
Report Facts
License Capacity: 30
Residents Served: 22
Current Residents in Hospice: 3
Residents Age 60 or Older: 22
Residents with Mobility Need: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Involved in abuse incident; terminated and prohibited from returning to the facility | |
| Jason Williams | Signed the letter confirming plan of correction implementation |
Document
Capacity: 30
Deficiencies: 0
Oct 14, 2021
Visit Reason
The document includes a certificate of compliance granting operation of the Ahava Memory Care Residence and a letter acknowledging receipt of a renewal application for the assisted living home license.
Findings
No inspection findings or deficiencies are reported; the letter states that an annual inspection will be conducted within the next twelve months and enforcement action will be taken if noncompliance is found.
Report Facts
Maximum capacity: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal application acknowledgment letter |
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