Inspection Reports for Heritage Grove at Penn Hills LLC
7151 SALTSBURG ROAD,, PENN HILLS, PA, 15235
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
7.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
100% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 24
Capacity: 24
Deficiencies: 9
Jul 30, 2025
Visit Reason
The inspection was conducted as a partial, announced review due to a change in legal entity for the facility.
Findings
The inspection identified multiple deficiencies including sanitary conditions, hot water temperature exceeding limits, missing emergency telephone numbers, window screens in disrepair, improper food storage, insufficient emergency water supply, incomplete fire drill records, evacuation issues, and failure to activate fire alarms during drills. Plans of correction were directed and implemented for all deficiencies.
Deficiencies (9)
| Description |
|---|
| Ceiling fan vents in multiple locations had a layer of dust/lint approximately one-eighth of an inch thick. |
| Hot water temperature at sinks in resident rooms and staff bathroom exceeded 120°F, measuring up to 122.5°F. |
| Emergency telephone numbers were not posted near the telephone in the activities room. |
| No screen was present in the right-side window of two windows in a resident room. |
| Opened and unsealed bags of dried pasta were stored in an unlidded plastic container in the kitchen dry storage area. |
| Emergency water supply was insufficient with only 50 gallons available for 24 residents requiring 72 gallons, and no contract with a bottled water supplier for emergencies. |
| Fire drill records did not indicate problems encountered during evacuation, and some drills did not fully evacuate residents due to refusal or other issues. |
| The home did not have fire safe areas designated in writing by a fire safety expert, and multiple fire drills had incomplete evacuations. |
| Fire alarm or smoke detector was not set off during a fire drill conducted at 5:20 a.m. |
Report Facts
Residents served: 24
License capacity: 24
Water temperature: 122.5
Water temperature: 121.4
Emergency water supply: 50
Emergency water required: 72
Fire drill residents: 18
Fire drill residents evacuated: 17
Fire drill residents: 17
Fire drill residents: 21
Fire drill residents evacuated: 20
Fire drill residents: 23
Fire drill residents evacuated: 22
Inspection Report
Complaint Investigation
Census: 17
Capacity: 26
Deficiencies: 0
Mar 26, 2025
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 03/26/2025, 03/28/2025, and 04/04/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and the report indicates no deficiencies or citations were found, implying the complaint was not substantiated.
Report Facts
License Capacity: 26
Residents Served: 17
Current Residents in Hospice: 3
Total Daily Staff: 21
Waking Staff: 16
Resident Mobility Need: 4
Inspection Report
Complaint Investigation
Census: 17
Capacity: 26
Deficiencies: 0
Jan 14, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 26
Residents Served: 17
Current Hospice Residents: 3
Residents Age 60 or Older: 26
Residents with Mobility Need: 5
Total Daily Staff: 22
Waking Staff: 17
Inspection Report
Renewal
Census: 22
Capacity: 26
Deficiencies: 10
Oct 1, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection identified multiple deficiencies including issues with record confidentiality, quality management, resident personal equipment safety, food labeling and storage, combustible storage, evacuation procedures, and medication administration and labeling. All deficiencies had plans of correction accepted and were implemented by December 23, 2024.
Deficiencies (10)
| Description |
|---|
| Privacy coding document listing names of residents was attached to the Licensing Inspection Summary posted in the front lobby. |
| The home had not conducted a quality management review since a prior date. |
| Resident had an uncovered enabler bar at the top right side of bed which was not secured and could be pulled out from under the mattress. |
| Unlabeled and undated 24-ounce bag of Swiss cheese slices and 2-pound bag of chopped spinach found in kitchen refrigerator. |
| Unlabeled and undated bag of breadsticks and 2-pound bag of chicken cubes found in kitchen freezer. |
| Combustible and flammable materials stored near heat sources in mechanical room. |
| Evacuation drills exceeded the safe evacuation time of 3 minutes and 45 seconds; residents did not evacuate to outside of building during one drill. |
| Prescription medication administered by staff not certified to administer the medication. |
| Two discontinued boxes of medication found in medication room refrigerator, one opened and one with unopened pens of different dosages. |
| Pharmacy labels for residents' medications did not accurately reflect prescribed dosage and instructions for administration. |
Report Facts
License Capacity: 26
Residents Served: 22
Current Hospice Residents: 5
Residents with Mobility Need: 9
Residents Age 60 or Older: 22
Staffing Hours - Total Daily Staff: 31
Staffing Hours - Waking Staff: 23
Inspection Report
Complaint Investigation
Census: 19
Capacity: 26
Deficiencies: 4
Jun 22, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements at Brookdale Penn Hills.
Findings
The inspection identified deficiencies related to staff training in first aid and CPR, direct care staff providing unsupervised services without completing required training, and issues with discharge or transfer procedures including failure to provide required 30-day notice and lack of consultation with appropriate agencies when a resident's functional level declined.
Complaint Details
The inspection was complaint-driven as indicated by the reason for inspection and the unannounced partial inspection on 06/22/2023.
Deficiencies (4)
| Description |
|---|
| Direct care staff persons were not trained in first aid and certified in obstructed airway techniques and CPR during certain shifts despite having 22 residents present. |
| Direct care staff person B provided unsupervised direct care services without successfully completing and passing the Department-approved direct care training course and competency test. |
| The home discharged a resident without issuing a 30-day advance written notice and without certification that delay in discharge would jeopardize health or safety. |
| The home discharged a resident due to functional decline without consultation with an appropriate assessment agency or the resident’s physician to determine need for a higher level of care. |
Report Facts
Residents present: 22
Residents served: 19
License capacity: 26
Total daily staff: 27
Waking staff: 20
Current hospice residents: 3
Residents with mobility need: 8
Residents aged 60 or older: 19
Inspection Report
Renewal
Census: 24
Capacity: 26
Deficiencies: 4
Dec 20, 2022
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal and complaint reasons on 12/20/2022 and 12/21/2022.
Findings
The facility was found to have multiple deficiencies including a direct care staff member lacking required qualifications at hire, incomplete annual furnace inspections, incomplete and inaccurate fire drill records, and fire drill evacuation times exceeding the maximum allowed. The submitted plan of correction was determined to be fully implemented as of the follow-up date.
Deficiencies (4)
| Description |
|---|
| Direct care staff person hired without a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Six of seven gas furnaces had not been inspected by a professional furnace cleaning company or trained maintenance staff since 12/10/2019. |
| Fire safety inspection and fire drill documentation were incomplete or missing for multiple dates, including missing details such as evacuation times, exit routes, number of residents and staff participating, and operability of alarms. |
| Fire drill evacuation times exceeded the maximum evacuation time of 6 minutes, with one drill taking 8 minutes and 56 seconds. |
Report Facts
License Capacity: 26
Residents Served: 24
Number of Furnaces: 7
Furnaces Not Inspected: 6
Fire Drill Evacuation Time: 536
Residents Present at Fire Drill: 26
Residents Evacuated at Fire Drill: 23
Inspection Report
Renewal
Census: 19
Capacity: 26
Deficiencies: 11
Aug 30, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility Brookdale Penn Hills on 08/30/2021 through 09/02/2021.
Findings
The inspection identified multiple deficiencies including breaches in record confidentiality, improper storage of poisonous materials, trash management issues, furniture repair needs, food contamination and outdated food, obstructed egress due to locked doors, emergency procedure posting issues, menu change notification failures, expired medications, and inoperable bedside lamps. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (11)
| Description |
|---|
| Resident privacy coding document and resident rosters containing confidential information were accessible in public areas. |
| Clear liquid in an unlabeled 32-ounce spray bottle used for cleaning was found. |
| Uncovered dumpster with trash and a mattress sticking out, with trash scattered around. |
| Broken and detached bottom hinge on a kitchen cabinet door. |
| Dirty rims and handles on plastic powder sugar and cinnamon shakers in kitchen cabinet. |
| Multiple undated foods stored in the freezer including raw chicken, jumbo pasta shells, and hot sausage links. |
| Front and rear doors were locked with keypad access not posted and not all residents could independently open them. |
| Municipality’s emergency procedures were kept in administrator’s office, not a conspicuous and public place. |
| Menu changes were not posted in a conspicuous and accessible place prior to meals. |
| Multiple expired medications found in the home’s van first aid kit. |
| Bedside lamp not within reach and tap light on bed’s headboard not working in bedroom 5. |
Report Facts
Inspection Dates: 4
Total Daily Staff: 24
Waking Staff: 18
License Capacity: 26
Residents Served: 19
Hospice Residents: 2
Residents 60 Years or Older: 19
Residents with Mobility Need: 5
Expired Medications: 3
Expired Medications: 10
Expired Medications: 10
Notice
Capacity: 26
Deficiencies: 0
Mar 19, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home, Brookdale Penn Hills, following receipt of the renewal application dated December 30, 2020. 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 issuance of a regular license and states that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Maximum capacity: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
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