Inspection Report
Census: 80
Capacity: 102
Deficiencies: 0
Aug 1, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 102
Residents Served: 80
Memory Care Capacity: 32
Memory Care Residents Served: 30
Current Hospice Residents: 4
Residents Age 60 or Older: 80
Residents Diagnosed with Mental Illness: 5
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 30
Residents with Physical Disability: 30
Inspection Report
Complaint Investigation
Census: 76
Capacity: 102
Deficiencies: 5
Mar 3, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at Friendship Village of South Hills on 03/03/2025 and 03/04/2025.
Findings
The facility was found to have multiple violations related to failure to report suspected resident abuse to the local Area Agency on Aging and the Department, failure to notify residents and their designated persons of suspected abuse, and incidents of resident abuse/neglect involving sexual behaviors between residents in the special care unit. Additionally, deficiencies were found in annual resident assessments not reflecting current diagnoses.
Complaint Details
The visit was complaint-related due to allegations of resident abuse involving sexual behaviors between residents and failure to report these incidents appropriately. The complaint was substantiated with multiple violations found.
Deficiencies (5)
| Description |
|---|
| Failure to immediately report suspected abuse of residents to the local Area Agency on Aging as required. |
| Failure to immediately notify residents and their designated persons of reports of suspected abuse or neglect. |
| Failure to report incidents or conditions to the Department’s assisted living residence office or complaint hotline within 24 hours. |
| Resident abuse/neglect involving inappropriate sexual contact and relationships between residents in the special care unit, with multiple witnessed incidents and inadequate supervision. |
| Annual resident assessments did not include all current diagnoses as required. |
Report Facts
License Capacity: 102
Residents Served: 76
Special Care Unit Capacity: 32
Special Care Unit Residents Served: 30
Staff Interviews: 5
Resident Interviews: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Care Coordinator | Named in multiple findings related to abuse reporting and notification. | |
| Memory Care Coordinator | Involved in abuse reporting, notification, and ongoing compliance monitoring. | |
| Administrator | Responsible for reviewing internal incidents daily and involved in compliance monitoring. | |
| Staff person A | LPN/charge nurse | Reported multiple incidents of resident abuse. |
| Staff person B | Observed and reported incidents of inappropriate resident contact. | |
| Staff person C | Observed and reported incidents of inappropriate resident contact. | |
| Staff person D | Observed and reported incidents of inappropriate resident contact. |
Inspection Report
Follow-Up
Census: 78
Capacity: 102
Deficiencies: 9
Dec 10, 2024
Visit Reason
The inspection was a full, unannounced review conducted on 12/10/2024 and 12/11/2024 for renewal, complaint, and incident reasons, including a follow-up on plan of correction submissions.
Findings
The facility was found to have multiple deficiencies including failure to post licensing inspection summaries, direct care staff not completing required competency tests before providing care, equipment not in good repair, missing smoke detectors, missing fire extinguisher in a kitchen, improper evacuation procedures, inaccurate resident dietary assessments, and incomplete cognitive preadmission screenings. All deficiencies had plans of correction accepted and were reported as implemented by the end of January 2025.
Deficiencies (9)
| Description |
|---|
| Licensing Inspection Summaries from earlier in 2024 were not posted in a conspicuous and public place in the residence. |
| Direct care staff persons B and C did not successfully complete and pass the Department-approved direct care competency test before providing direct care to residents. |
| Bed enabler in resident room #205 was not securely attached to the bed frame, posing an entanglement risk. |
| No smoke detectors were present in several resident living units (#128, #205, #218, #306, #310). |
| No 2A-10BC fire extinguisher was present in the kitchen area of the home’s second floor multipurpose room; only a 2A-Kitchen rating extinguisher was present. |
| Evacuation procedures did not follow the fire safety expert's written designation of fire-safe areas; residents outside the simulated affected area were not evacuated. |
| Resident #1's initial assessment incorrectly documented dietary need as 'General diet, Regular Texture, Thin Liquids' instead of 'mechanical soft' as per medical evaluation. |
| Resident #2's initial assessment incorrectly documented dietary need as 'Regular diet' instead of 'consistent carb, pureed texture, thin liquids' as per medical evaluation. |
| Resident #2's written cognitive preadmission screening for admission to the special care unit was not dated within 72 hours prior to admission as required. |
Report Facts
License Capacity: 102
Residents Served: 78
Memory Care Capacity: 32
Memory Care Residents Served: 31
Hospice Residents: 10
Total Daily Staff: 109
Waking Staff: 82
Residents with Mobility Need: 31
Residents 60 Years or Older: 78
Inspection Report
Complaint Investigation
Census: 76
Capacity: 102
Deficiencies: 4
Oct 31, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial review on 10/31/2024 and 11/01/2024.
Findings
The inspection identified deficiencies related to the residence's provision of assisted living services, discharge or transfer procedures, and medical evaluations for special care unit residents. The facility submitted plans of correction which were accepted and later determined to be fully implemented.
Complaint Details
The visit was complaint-related and included an incident investigation. The submitted plan of correction was accepted and fully implemented as of the follow-up dates.
Deficiencies (4)
| Description |
|---|
| The residence did not provide assistance with performing ADLs and IADLs to residents who require total assistance with two or more activities of daily living. |
| The residence did not provide basic cognitive support services to residents who are not able to communicate needs and whose Resident Representative does not live with them in the Assisted Living Community. |
| No 30-day advance written notice was provided to a resident, their family, or designated person prior to discharge from the residence. |
| A resident transferred to the special care unit did not have a medical evaluation indicating the need for SCU placement. |
Report Facts
License Capacity: 102
Residents Served: 76
Special Care Unit Capacity: 32
Special Care Unit Residents Served: 29
Current Hospice Residents: 12
Residents Age 60 or Older: 76
Residents with Mobility Need: 29
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Complaint Investigation
Census: 53
Capacity: 102
Deficiencies: 1
Aug 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation and incident review, including partial and unannounced visits on 08/12/2024, 08/13/2024, and 09/10/2024, to assess compliance and follow up on a plan of correction.
Findings
The report found a violation of abuse/neglect where a staff member verbally abused a resident and inappropriately moved the resident's hand. The staff member was removed, suspended, and later resigned. The facility submitted a plan of correction which was fully implemented by 10/31/2024.
Complaint Details
The visit was complaint-related and involved substantiation of verbal abuse and neglect by a staff member. The staff member was removed immediately, suspended pending investigation, and later resigned. The facility implemented corrective training and monitoring.
Deficiencies (1)
| Description |
|---|
| A resident was verbally abused and intimidated by a staff member who chastised the resident and moved the resident's hand away from their face. |
Report Facts
License Capacity: 102
Residents Served: 53
Special Care Unit Capacity: 32
Special Care Unit Residents Served: 31
Current Hospice Residents: 6
Residents Age 60 or Older: 53
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 31
Inspection Report
Complaint Investigation
Census: 82
Capacity: 102
Deficiencies: 0
Apr 22, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 04/22/2024.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Complaint Details
The inspection was complaint-related; however, no deficiencies were found and no follow-up was required.
Report Facts
License Capacity: 102
Residents Served: 82
Special Care Unit Capacity: 32
Special Care Unit Residents Served: 32
Hospice Current Residents: 10
Resident Support Staff: 0
Total Daily Staff: 114
Waking Staff: 86
Residents Age 60 or Older: 82
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 32
Inspection Report
Follow-Up
Census: 83
Capacity: 102
Deficiencies: 2
Jan 11, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident at the facility to verify the implementation of the submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to incident reporting and resident assessment deficiencies. The report highlights prior violations involving failure to timely report incidents and update resident assessments after significant changes.
Complaint Details
The visit was related to an incident complaint involving allegations of abuse and failure to report incidents timely. The plan of correction was accepted and implemented, indicating the complaint was addressed.
Deficiencies (2)
| Description |
|---|
| Failure to report incidents of abuse and altercations to the Department’s assisted living residence office or complaint hotline within 24 hours. |
| Failure to update resident assessments to reflect significant changes in supervision needs in a timely manner. |
Report Facts
License Capacity: 102
Residents Served: 83
Special Care Unit Capacity: 32
Special Care Unit Residents Served: 29
Hospice Residents: 9
Residents with Mobility Need: 29
Residents 60 Years or Older: 83
Total Daily Staff: 112
Waking Staff: 84
Inspection Report
Complaint Investigation
Census: 81
Capacity: 102
Deficiencies: 0
Dec 11, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection on 12/11/2023.
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 type was noted as not required.
Report Facts
Residents Served: 81
License Capacity: 102
Special Care Unit Capacity: 32
Special Care Unit Residents Served: 30
Hospice Current Residents: 10
Resident Support Staff: 0
Total Daily Staff: 110
Waking Staff: 83
Residents Age 60 or Older: 81
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 29
Residents with Physical Disability: 0
Inspection Report
Complaint Investigation
Census: 80
Capacity: 102
Deficiencies: 0
Oct 4, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Complaint Details
The inspection was complaint and incident related; no deficiencies were found and no follow-up was required.
Report Facts
License Capacity: 102
Residents Served: 80
Special Care Unit Capacity: 32
Special Care Unit Residents Served: 32
Hospice Residents: 9
Total Daily Staff: 112
Waking Staff: 84
Residents 60 Years or Older: 80
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 32
Inspection Report
Complaint Investigation
Census: 80
Capacity: 102
Deficiencies: 0
May 31, 2023
Visit Reason
The inspection was conducted as a complaint investigation at Friendship Village of South Hills on 05/31/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 102
Residents Served: 80
Special Care Unit Capacity: 32
Special Care Unit Residents Served: 32
Hospice Current Residents: 6
Residents Age 60 or Older: 80
Residents with Intellectual Disability: 1
Residents with Mobility Need: 32
Inspection Report
Census: 84
Capacity: 102
Deficiencies: 0
Mar 2, 2022
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 03/02/2022, triggered by an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 102
Residents Served: 84
Special Care Unit Capacity: 32
Special Care Unit Residents Served: 32
Hospice Current Residents: 7
Total Daily Staff: 116
Waking Staff: 87
Inspection Report
Renewal
Census: 79
Capacity: 102
Deficiencies: 5
Dec 8, 2021
Visit Reason
The inspection was conducted as a renewal inspection combined with a complaint investigation, including a full unannounced review of the facility from 12/08/2021 to 12/10/2021.
Findings
The inspection identified several deficiencies including missing emergency telephone numbers, medical evaluations not completed within required timeframes, discrepancies in medication administration records, incomplete support plans, and undated cognitive preadmission screenings. Plans of correction were submitted and fully implemented by the facility.
Complaint Details
The inspection included a complaint investigation as part of the renewal process. Specific complaint substantiation status is not stated.
Deficiencies (5)
| Description |
|---|
| No emergency telephone numbers posted on or by telephones in the 1st floor family meeting room, 2nd floor fitness room, and 2nd floor multipurpose room. |
| Resident #1's medical evaluation was completed more than 60 days prior to admission, exceeding regulatory requirements. |
| Discrepancies between glucometer blood glucose readings and medication administration record (MAR) for Resident #2. |
| Resident #3's use of a bed enabler for positioning was not indicated on the most recent support plan. |
| Resident #4 and Resident #5 had undated cognitive preadmission screenings, making it impossible to verify completion within 72 hours prior to admission to the special care unit. |
Report Facts
License Capacity: 102
Residents Served: 79
Special Care Unit Capacity: 32
Special Care Unit Residents Served: 32
Hospice Residents: 5
Staffing Hours: 111
Waking Staff: 83
Residents with Mobility Need: 32
Inspection Report
Plan of Correction
Census: 79
Capacity: 102
Deficiencies: 1
Oct 21, 2021
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a submitted plan of correction related to an incident.
Findings
The plan of correction was found to be fully implemented, with ongoing compliance to be maintained. The deficiency involved a resident being treated without dignity and respect, which was addressed through staff re-training and education.
Deficiencies (1)
| Description |
|---|
| A resident was not treated with dignity and respect; staff failed to assist appropriately and agitated the resident by yelling. |
Report Facts
License Capacity: 102
Residents Served: 79
Special Care Unit Capacity: 32
Special Care Unit Residents Served: 31
Current Hospice Residents: 8
Residents with Mobility Need: 31
Residents Age 60 or Older: 79
Resident Support Staff: 0
Total Daily Staff: 110
Waking Staff: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon Kimberland | Signed the letter confirming plan of correction implementation |
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