Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 50
Capacity: 80
Deficiencies: 1
Oct 9, 2025
Visit Reason
The inspection visit occurred as a follow-up to review the submitted plan of correction related to an incident at the facility.
Findings
The plan of correction was determined to be fully implemented, with retraining and education conducted for staff regarding securing medical care for residents. Continued compliance must be maintained.
Deficiencies (1)
| Description |
|---|
| Failure to secure medical care promptly after a resident experienced an unwitnessed fall and called for help, resulting in delayed emergency medical services response. |
Report Facts
License Capacity: 80
Residents Served: 50
Current Hospice Residents: 4
Residents Age 60 or Older: 50
Residents with Mobility Need: 20
Total Daily Staff: 70
Waking Staff: 53
Inspection Report
Renewal
Census: 49
Capacity: 80
Deficiencies: 7
Sep 16, 2025
Visit Reason
The inspection was conducted as a renewal review of the facility's license to ensure compliance with applicable regulations and to verify that the submitted plan of correction was fully implemented.
Findings
The inspection identified multiple deficiencies including unsecured resident records, improper placement and labeling of carbon monoxide detectors, incomplete training records, inadequate fire drill documentation, medication labeling and administration errors, and incomplete resident assessments. Plans of correction were accepted and implemented with retraining and audits scheduled.
Deficiencies (7)
| Description |
|---|
| Resident records were found unlocked, unattended, and accessible on the medication cart. |
| Carbon monoxide detectors lacked battery installation dates and were improperly placed too close to fossil fuel burning devices; no detector on the 2nd floor. |
| Orientation training records for direct care staff did not include source of training or specific training topics. |
| Fire drill records lacked year, exit routes, and accurate resident evacuation numbers. |
| Medication cards contained discontinued medications and incorrect labeling of prescribed dosages. |
| Medication administration records did not include initials of staff administering medications. |
| Resident assessment did not reflect diagnosis of unspecified atrial fibrillation and ability to safely use or avoid poisonous materials. |
Report Facts
Residents Served: 49
License Capacity: 80
Total Daily Staff: 73
Waking Staff: 55
Current Hospice Residents: 7
Residents Age 60 or Older: 49
Residents with Mobility Need: 24
Inspection Report
Complaint Investigation
Census: 50
Capacity: 80
Deficiencies: 0
Mar 17, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 03/17/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 80
Residents Served: 50
Resident Diagnosed with Mental Illness: 1
Residents with Mobility Need: 21
Residents Age 60 or Older: 50
Resident Receiving Supplemental Security Income: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Inspection Report
Follow-Up
Census: 45
Capacity: 80
Deficiencies: 2
Feb 9, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction related to abuse allegations.
Findings
The submitted plan of correction was determined to be fully implemented. The report details a repeated abuse violation involving a staff person verbally abusing a resident and attempting to take the resident's cell phone, with subsequent staff retraining and suspension of the involved staff member.
Complaint Details
The visit was complaint-related due to an incident involving abuse allegations against staff person A. The plan of correction was submitted and fully implemented, including suspension of the staff person and staff retraining. The violation was a repeat from 07/05/2023.
Deficiencies (2)
| Description |
|---|
| Staff person A entered resident bedroom and began yelling and swearing at resident, attempted to grab resident's cell phone, and knocked personal items off resident's side table, causing distress to the resident. |
| Staff person A continued to work unsupervised after the incident until the end of the shift. |
Report Facts
License Capacity: 80
Residents Served: 45
Current Hospice Residents: 6
Residents 60 Years or Older: 45
Residents with Mobility Need: 19
Residents with Physical Disability: 1
Total Daily Staff: 64
Waking Staff: 48
Inspection Report
Census: 56
Capacity: 80
Deficiencies: 0
Mar 1, 2023
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 83
Waking Staff: 62
Resident Support Staff: 0
Current Residents in Hospice: 3
Residents Served: 56
License Capacity: 80
Residents Age 60 or Older: 56
Residents with Mobility Need: 27
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Inspection Report
Renewal
Census: 46
Capacity: 80
Deficiencies: 5
Jun 13, 2022
Visit Reason
The inspection was a renewal licensing inspection conducted on 06/13/2022 through 06/15/2022 to assess compliance with Department statutes and regulations.
Findings
Several deficiencies were identified including issues with resident personal equipment (wheelchair armrest damage), missing supplies in first aid kits, lack of current rabies vaccination documentation for a resident cat, and incomplete annual medical evaluations for a resident. Plans of correction were accepted and implemented with follow-up audits and staff retraining scheduled.
Deficiencies (5)
| Description |
|---|
| The right armrest on the wheelchair of resident #1 was missing padding and the vinyl was only attached approximately 2 ½ inches, exposing the underlying hard plastic and hardware, also the outer edge of the left armrest was cracked, posing a skin tear hazard. |
| The first aid kit in the wellness center did not include gauze. |
| A cat named Penelope was in the home without a current certificate of rabies vaccination. |
| The medical evaluation for resident #2 was blank in the area of body positioning/movement. |
| The first aid kit in the van used for transporting residents did not contain eye coverings. |
Report Facts
License Capacity: 80
Residents Served: 46
Current Residents in Hospice: 3
Residents with Mobility Need: 20
Waking Staff: 50
Total Daily Staff: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Named in multiple findings related to wheelchair replacement, staff retraining, and audit oversight | |
| Health and Wellness Coordinator | Named in findings related to auditing wheelchairs, restocking first aid kits, and coordinating medical evaluation updates | |
| Executive Director | Named in findings related to notifying family for cat rabies vaccination and staff retraining | |
| Resident Program Manager | Responsible for auditing pet vaccination records and ongoing compliance | |
| Activities Director | Responsible for auditing van first aid kit and reviewing audit results |
Inspection Report
Follow-Up
Census: 44
Capacity: 80
Deficiencies: 1
Jan 26, 2022
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 submitted plan of correction related to a deficiency in the initial resident assessment was found to be fully implemented. The deficiency involved the lack of documentation for 'Supervision need' in the assessment tool, which has since been addressed through staff retraining and audits.
Deficiencies (1)
| Description |
|---|
| Resident #1's initial assessment did not include an assessment for 'Supervision need' as it was not part of the home's assessment tool. |
Report Facts
License Capacity: 80
Residents Served: 44
Current Hospice Residents: 1
Residents with Mobility Need: 19
Total Daily Staff: 63
Waking Staff: 47
Notice
Capacity: 80
Deficiencies: 0
Aug 25, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for the Personal Care Home, Brookdale Mt. Lebanon, following receipt of the renewal application. It also advises that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and outlines the requirement for an annual inspection to ensure compliance with applicable regulations.
Report Facts
Total licensed capacity: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Follow-Up
Census: 36
Capacity: 80
Deficiencies: 6
Apr 1, 2021
Visit Reason
The inspection was a full, unannounced licensing inspection conducted on 04/01/2021 and 04/02/2021 to review compliance and verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including undated carbon monoxide alarm batteries, missing bedside table and operable lamp for a resident, and food safety violations such as uncovered and unsealed food items stored improperly. All deficiencies had plans of correction accepted and were documented as implemented.
Deficiencies (6)
| Description |
|---|
| Undated batteries in the battery-operated carbon monoxide detector in the boiler room attic. |
| No bedside table or shelf beside resident #1's bed. |
| Resident #1 did not have access to a source of light that can be turned on/off at bedside. |
| Uncovered tray of cooked rice stored in the walk-in cooler. |
| Ten 5-gallon bottles of water stored on the floor in the basement. |
| Unsealed bag of french fries stored in the kitchen freezer. |
Report Facts
Residents Served: 36
License Capacity: 80
Total Daily Staff: 51
Waking Staff: 38
Number of Deficiencies: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzy Quinn | Signed letter confirming plan of correction implementation | |
| Barbara Barone | On-site Department Representative for inspection dates 04/01/2021 and 04/02/2021 | |
| Maintenance Manager | Responsible for replacing carbon monoxide detector batteries and conducting audits | |
| Health & Wellness Director | Retrained staff and monitored compliance related to bedside table and lighting deficiencies | |
| Dining Director | Removed contaminated food items and retrained dining staff on food safety policies | |
| Maintenance Director | Relocated water bottles off the floor and retrained staff on storage policies | |
| Executive Director | Oversaw retraining and compliance monitoring related to food storage and carbon monoxide detector policies |
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