Inspection Report
Renewal
Census: 42
Capacity: 47
Deficiencies: 15
May 21, 2025
Visit Reason
The inspection was conducted on 05/21/2025 as a renewal inspection combined with a complaint investigation at Allegheny Place.
Findings
The inspection identified multiple deficiencies including issues with resident contracts, staff training and orientation, medication storage and administration, fire safety drills and documentation, resident assessments, support plans, and record content. Plans of correction were submitted and accepted with completion dates mostly by 06/30/2025 and implemented by 07/09/2025.
Complaint Details
The inspection included a complaint investigation component, but the substantiation status is not explicitly stated in the report.
Deficiencies (15)
| Description |
|---|
| Resident-home contracts did not include the correct resident names. |
| No staff person trained in first aid and CPR was present during night shifts from 5/4/25 to 5/17/25. |
| Ancillary and direct care staff did not receive required orientation and training within specified timeframes. |
| Direct care staff did not receive required annual training hours or training on specified topics during 2024. |
| Uncovered trash can found in staff bathroom; dumpster door left open during inspection. |
| Egress routes were obstructed by objects outside emergency exit door. |
| No unannounced fire drill conducted since 1/30/25; fire drill records incomplete. |
| No medical evaluation completed for resident #2 at admission; annual medical evaluations for residents #1 and #3 were not current. |
| Medications were opened and undated beyond manufacturer guidelines; missing pharmacy labels on medications. |
| Medication administration records lacked staff initials for administered medications on 5/4/25. |
| Resident #2 did not receive prescribed monthly Cyanocobalamin injection on 5/1/25. |
| No preadmission screening completed for residents #2 and #4. |
| Resident assessments and support plans were not completed timely; some assessments and support plans lacked signatures. |
| Resident support plans were not accessible to direct care staff. |
| Resident photographs were missing or undated, making it unclear if they were current. |
Report Facts
License Capacity: 47
Residents Served: 42
Total Daily Staff: 52
Waking Staff: 39
Deficiency Counts: 15
Inspection Report
Complaint Investigation
Census: 39
Capacity: 47
Deficiencies: 2
Oct 1, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial review of the facility on 10/01/2024.
Findings
Two deficiencies were identified: one related to evacuation procedures during a fire drill where a resident did not evacuate as required, and another related to incomplete annual medical evaluations for a resident. Both deficiencies had plans of correction accepted and implemented by 10/22/2024.
Complaint Details
The inspection was complaint-driven as indicated by the inspection information section stating 'Reason: Complaint'.
Deficiencies (2)
| Description |
|---|
| During a fire drill with 38 residents present, one resident did not evacuate and was advised to remain in their room, contrary to fire safety requirements. |
| A resident's current medical evaluation was incomplete, missing dates, height, weight, and pulse rate; previous evaluation was undated though signed. |
Report Facts
Residents present during fire drill: 38
Residents served: 39
License capacity: 47
Staff total daily hours: 44
Waking staff hours: 33
Hospice current residents: 4
Residents age 60 or older: 39
Residents with mobility need: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in plan of correction for fire drill participation and medical evaluation audits | |
| Director of Facility Operations | Named in plan of correction for fire drill participation | |
| Director of Health & Wellness (DHW) | Performed audit of medical evaluations and responsible for ensuring compliance |
Inspection Report
Renewal
Census: 24
Capacity: 47
Deficiencies: 5
Nov 2, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's license by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
The inspection identified several deficiencies including lack of soap in the dining area, improper storage and labeling of medications, incomplete medication administration records, and restricted accessibility of resident support plans. Plans of correction were submitted and determined to be fully implemented.
Deficiencies (5)
| Description |
|---|
| No soap present in the soap dispenser at the sink in the common dining area. |
| Insulin pen was open and undated; insulin pens must be discarded within 28 days of opening. |
| Medication administration record (MAR) for resident #2 did not include frequency or amount of cream to be used per administration. |
| Medication administration record (MAR) for resident #2 did not include initials of staff person who administered ointment. |
| Resident support plans were stored in a locked office and not accessible to all direct care staff at all times. |
Report Facts
License Capacity: 47
Residents Served: 24
Current Residents in Hospice: 4
Residents Age 60 or Older: 24
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S. Harris | Director of Health & Wellness | Took order and transcribed it on the medication administration record (MAR) for resident #2. |
Inspection Report
Follow-Up
Census: 19
Capacity: 47
Deficiencies: 2
Jun 13, 2023
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. The report details repeated violations related to treatment of residents with dignity and respect and fire safety orientation deficiencies, with corrective actions completed and ongoing monitoring planned.
Deficiencies (2)
| Description |
|---|
| Resident #1 was treated disrespectfully by staff person A, who reacted angrily and stormed out of the resident's bedroom. |
| Direct care staff person A did not receive required orientation on fire safety and emergency preparedness on their first day of work. |
Report Facts
License Capacity: 47
Residents Served: 19
Current Residents in Hospice: 2
Residents Age 60 or Older: 19
Residents with Mobility Need: 9
Total Daily Staff: 28
Waking Staff: 21
Inspection Report
Follow-Up
Census: 19
Capacity: 47
Deficiencies: 2
Jun 8, 2023
Visit Reason
The inspection was conducted as a follow-up to review the submitted plan of correction related to an incident involving verbal abuse of a resident by a staff person.
Findings
The plan of correction was determined to be fully implemented with continued compliance required. The report details the investigation of verbal abuse allegations against a staff person and the corrective actions taken, including staff re-education and auditing procedures.
Complaint Details
The visit was complaint-related due to an allegation of verbal abuse against staff person A involving resident #1. The allegation was substantiated with findings that the staff person was not immediately suspended or placed on supervision and the incident was not reported timely to the Department.
Deficiencies (2)
| Description |
|---|
| Failure to immediately place staff person A on a plan of supervision or suspend pending investigation after an allegation of verbal abuse involving resident #1. |
| Failure to report the incident of verbal abuse to the Department within 24 hours as required. |
Report Facts
License Capacity: 47
Residents Served: 19
Current Hospice Residents: 3
Staffing Hours: 30
Waking Staff: 23
Inspection Report
Follow-Up
Census: 20
Capacity: 47
Deficiencies: 3
May 18, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 05/18/2023 due to an incident, to review the submitted plan of correction and verify its implementation.
Findings
The facility was found to have fully implemented the submitted plan of correction related to deficiencies in assistance with activities of daily living, treatment of residents with dignity and respect, and residents' rights to personal clothing and possessions. No new violations were identified during resident interviews and record reviews.
Deficiencies (3)
| Description |
|---|
| Resident #1's care needs were not met for approximately 6 weeks, including ignored call bells and inadequate assistance with transfers requiring two staff persons. |
| Resident #1 was treated dismissively and condescendingly by direct care staff person A over approximately 6 weeks. |
| Direct care staff person A took resident #1's personal wipes without permission and ignored residents' rights to personal belongings. |
Report Facts
License Capacity: 47
Residents Served: 20
Current Residents in Hospice: 3
Residents Age 60 or Older: 20
Residents with Mobility Need: 12
Total Daily Staff: 32
Waking Staff: 24
Inspection Report
Complaint Investigation
Census: 22
Capacity: 47
Deficiencies: 1
May 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation and incident review related to allegations of abuse and misappropriation of resident property.
Findings
The investigation found that a former staff member committed access device fraud using a resident's credit card for approximately $25,000. The facility implemented a plan of correction including termination of the staff member, notification of authorities, resident interviews, staff re-education, and ongoing audits to ensure no further abuse or neglect.
Complaint Details
The complaint involved an active criminal investigation into access device fraud by a former staff person who used a resident's credit card for cash advances and personal debts. The complaint was substantiated with corrective actions implemented.
Deficiencies (1)
| Description |
|---|
| A resident was subjected to misappropriation of property and abuse involving access device fraud by a former staff member. |
Report Facts
Residents Served: 22
License Capacity: 47
Amount of Fraud: 25000
Inspection Report
Follow-Up
Census: 25
Capacity: 47
Deficiencies: 2
Mar 31, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident, with a follow-up on a submitted plan of correction to verify full implementation.
Findings
The facility was found to have fully implemented the submitted plan of correction related to a resident abuse incident involving delayed reporting. Continued compliance and ongoing auditing were required to ensure proper abuse reporting.
Deficiencies (2)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident as required by the Older Adult Protective Services Act. |
| Failure to report the incident or condition to the Department’s personal care home regional office within 24 hours as required. |
Report Facts
Residents Served: 25
License Capacity: 47
Total Daily Staff: 38
Waking Staff: 29
Current Residents in Hospice: 4
Residents Age 60 or Older: 25
Residents with Mental Illness: 1
Residents with Mobility Need: 13
Inspection Report
Follow-Up
Census: 26
Capacity: 47
Deficiencies: 6
Jan 19, 2023
Visit Reason
The inspection was conducted as a follow-up review to verify that the facility's submitted plan of correction was fully implemented following prior complaint and incident investigations.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple deficiencies related to activities of daily living assistance, treatment of residents, direct care staff training, menu changes, medication records, medication administration timing, prescriber order compliance, and activity programming. Continued compliance and ongoing auditing were planned.
Complaint Details
The inspection was complaint-related, triggered by concerns about incidents and care deficiencies; the plan of correction was reviewed and accepted as fully implemented.
Deficiencies (6)
| Description |
|---|
| Resident #1 did not receive timely assistance with personal hygiene and toileting as required by their assessment and support plan, including being found soaked in urine and not receiving regular denture and hearing aid care. |
| Staff person A spoke to residents in a rude and condescending manner on multiple occasions, including intimidating and yelling at residents. |
| Direct care staff person C provided unsupervised ADL services without completing required training and competency testing. |
| Menus posted did not accurately reflect the food served, and residents were not given advance notice of menu changes on multiple dates. |
| Resident #3's medication administration records did not accurately reflect administration times, and medications were sometimes not administered as prescribed. |
| Activities calendar was not followed, and activities were infrequently and inconsistently offered to residents. |
Report Facts
License Capacity: 47
Residents Served: 26
Current Residents in Hospice: 5
Staffing Hours - Total Daily Staff: 40
Staffing Hours - Waking Staff: 30
Inspection Report
Routine
Deficiencies: 0
Aug 24, 2022
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
Complaint Investigation
Census: 23
Capacity: 47
Deficiencies: 1
Jul 19, 2022
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 07/19/2022.
Findings
The submitted plan of correction related to the posting of weekly menus was found to be fully implemented. The facility corrected the menu posting violation during the inspection and re-educated staff to maintain compliance.
Complaint Details
The inspection was complaint-driven and the plan of correction was submitted and fully implemented as verified on 07/19/2022 with follow-up submissions on 08/01/2022 and 08/05/2022.
Deficiencies (1)
| Description |
|---|
| Menus posted in the home’s dining room were only for dates 7/18/22 through 7/24/22, and the following week was not posted in a conspicuous and public place. |
Report Facts
License Capacity: 47
Residents Served: 23
Staffing Hours: 32
Waking Staff: 24
Current Residents in Hospice: 2
Residents with Mental Illness: 1
Residents with Mobility Need: 9
Residents 60 Years or Older: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director (ED) | Re-educated cooks on menu posting regulation and ensured compliance |
Inspection Report
Renewal
Census: 25
Capacity: 47
Deficiencies: 6
May 10, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the facility Allegheny Place on 05/10/2022 through 05/12/2022.
Findings
The inspection found multiple deficiencies including breaches in record confidentiality, inadequate staffing during certain shifts, missing window screens, outdated food items, medication storage and administration discrepancies, and support plans not being accessible to direct care staff. All deficiencies had plans of correction implemented and were found to be in compliance by the end of the inspection period.
Complaint Details
The inspection included a complaint investigation component, but the report does not explicitly state the substantiation status.
Deficiencies (6)
| Description |
|---|
| Confidential resident information was found unsecured in an accessible activity room. |
| Inadequate staffing during early morning shifts to meet residents' needs in emergencies. |
| Windows in bedroom #107 lacked screens. |
| Open, unsealed, and undated food items found in freezers. |
| Discrepancy between blood glucose levels documented on MAR and glucometer readings for resident #5. |
| Resident support plans were not accessible to direct care staff at all times. |
Report Facts
License Capacity: 47
Residents Served: 25
Staffing Hours: 38
Waking Staff: 29
Residents with Mobility Needs: 13
Residents with Mental Illness: 1
Residents in Hospice: 3
Direct Care Staff on 4/25/22 Morning Shift: 2
Direct Care Staff on 4/28/22 Morning Shift: 1
Remaining Eggo Waffles: 4
Box Weight: 15
Blood Glucose Level: 141
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director (ED) | Removed unsecured confidential records, reviewed staffing schedules, re-educated staff, and implemented corrective actions. | |
| Regional Director of Care Services (RDCS) | Provided re-education to ED on regulatory requirements. | |
| Maintenance Tech (MT) | Re-inserted window screen and checked all windows for compliance. | |
| Chef | Discarded outdated food items and conducted kitchen audits. | |
| Care Services Manager (CSM) | Conducted audits on medication administration, educated staff, moved support plan binder, and ensured accessibility of support plans. | |
| Staff person A | Indicated support plans were not accessible to all staff. |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 47
Deficiencies: 3
Aug 16, 2021
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Findings
The inspection found deficiencies related to housekeeping services not being provided after the housekeeper quit, a broken wheelchair used by a resident, and unsanitary conditions in a resident's bathroom. Corrective actions were implemented including additional staffing, equipment replacement, re-education of staff, and ongoing audits to ensure compliance.
Complaint Details
The visit was complaint-related as indicated by the inspection reason and was a partial unannounced inspection triggered by a complaint.
Deficiencies (3)
| Description |
|---|
| Housekeeping services were not provided including cleaning of resident #1's restroom and toilet after the housekeeper quit. |
| Resident #2 utilized a broken wheelchair with a tipped seat pan and broken seatbelt, posing a risk of falling. |
| Accumulation of dried feces on the toilet bowl, raised toilet seat, toilet safety frame, and restroom floor in resident #1's bathroom. |
Report Facts
License Capacity: 47
Residents Served: 32
Total Daily Staff: 50
Waking Staff: 38
Current Residents on Hospice: 3
Residents with Mobility Need: 18
Residents 60 Years or Older: 32
Residents Diagnosed with Mental Illness: 2
Inspection Report
Renewal
Census: 28
Capacity: 47
Deficiencies: 10
Jan 12, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation to assess compliance with applicable regulations and licensing requirements.
Findings
The inspection identified multiple deficiencies including outdated carbon monoxide detector batteries, unsigned resident contracts and support plans, improper bedside lamp placement, incomplete medical evaluations, presence of non-fire-resistant materials in the smoking area, outdated menus, medication storage and administration issues, and failure to follow prescriber's orders. Plans of correction were accepted and implemented with ongoing monitoring.
Deficiencies (10)
| Description |
|---|
| Carbon monoxide detector batteries were last changed on 4/5/19 and detectors outside bedrooms lacked installation dates. |
| Resident #1 and Resident #3's resident contracts were not signed by the resident. |
| Resident #4's bedside lamp was approximately 3 feet from the bed and could not be turned on/off from bedside. |
| Resident #2's most recent medical evaluation did not include the resident's temperature. |
| A blue cushion not made of fire-resistant material was present in the designated smoking area. |
| Menus posted were outdated, dated from 11/30/20-12/6/20 and 12/28/20-1/3/21. |
| Resident #4's prescribed medication Bisacodyl was not available in the home. |
| Medication administration records for Residents #1, #3, and #4 lacked staff initials for several medication administrations. |
| Resident #1's sliding scale insulin was not administered according to prescribed blood glucose levels on multiple occasions. |
| Resident #1 and Resident #3's most recent support plans were not signed by the resident and did not indicate inability or refusal to sign. |
Report Facts
License Capacity: 47
Residents Served: 28
Staff Total Daily: 44
Waking Staff: 33
Deficiency Completion Date: Apr 19, 2021
Inspection Report
Renewal
Capacity: 47
Deficiencies: 0
Apr 16, 2021
Visit Reason
The document is a renewal license issued in response to the January 26, 2021 renewal application to operate the Personal Care Home Allegheny Place. The Department advises that an onsite annual inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It is a license renewal notice confirming the issuance of a regular license and advising of future inspection requirements.
Report Facts
Maximum licensed capacity: 47
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