Inspection Reports for Overlook Green Senior Living
5250 Meadowgreen Dr, Pittsburgh, PA 15236, United States, PA, 15236
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Inspection Report
Follow-Up
Census: 68
Capacity: 128
Deficiencies: 2
Aug 12, 2025
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. Deficiencies involved failure to report an allegation of neglect within 24 hours and failure to provide timely assistance with activities of daily living (ADLs). Staff member A was suspended and terminated, and staff education and monitoring measures were implemented.
Deficiencies (2)
| Description |
|---|
| Failure to report an allegation of neglect to the Department within 24 hours as required by regulation 2600.16c. |
| Failure to provide timely assistance with changing a resident's brief despite multiple call bell requests, violating regulation 2600.23a. |
Report Facts
License Capacity: 128
Residents Served: 68
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 8
Current Hospice Residents: 8
Residents Diagnosed with Mental Illness: 16
Residents with Mobility Need: 11
Residents Age 60 or Older: 67
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in findings related to neglect and failure to assist resident with ADLs; suspended and terminated. |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 128
Deficiencies: 1
May 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements at the facility.
Findings
The submitted plan of correction was found to be fully implemented. A deficiency was noted regarding a resident being undressed and covered only with a sheet while being transported through common areas to the shower room, which did not respect the resident's dignity.
Complaint Details
The visit was complaint-related. The plan of correction was accepted on 07/02/2024 and implemented on 07/03/2024.
Deficiencies (1)
| Description |
|---|
| Resident was undressed in bedroom and covered with only a sheet while being propelled in a wheelchair through common areas to access the shower room, violating dignity and respect requirements. |
Report Facts
License Capacity: 128
Residents Served: 55
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Care Unit: 10
Hospice Residents: 3
Resident Mobility Need: 26
Residents Age 60 or Older: 55
Inspection Report
Follow-Up
Census: 53
Capacity: 128
Deficiencies: 2
Feb 1, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted on 02/01/2024 for complaint and monitoring purposes, including a follow-up on a previously submitted plan of correction.
Findings
The facility was found to have implemented the submitted plan of correction fully. Deficiencies related to medication administration documentation were identified, including missing entries on medication administration records (MAR) and improper documentation of blood glucose monitoring, but no resident suffered ill effects.
Complaint Details
The visit was complaint-related and monitoring in nature. The submitted plan of correction was reviewed and found fully implemented. No substantiation status explicitly stated.
Deficiencies (2)
| Description |
|---|
| Failure to enter blood glucose readings on the resident’s January medication administration record (MAR) as ordered. |
| The January 2024 MAR for multiple residents was not initialed by staff for numerous medications on multiple dates and times. |
Report Facts
License Capacity: 128
Residents Served: 53
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 9
Resident Support Staff: 0
Total Daily Staff: 74
Waking Staff: 56
Residents with Mobility Need: 21
Residents with Physical Disability: 1
Residents Diagnosed with Mental Illness: 1
Residents 60 Years or Older: 53
Inspection Report
Renewal
Census: 53
Capacity: 128
Deficiencies: 12
Nov 30, 2023
Visit Reason
The inspection was conducted for renewal, complaint, and incident reasons as part of a full, unannounced licensing inspection.
Findings
Multiple deficiencies were identified including inadequate first aid/CPR trained staff coverage, incomplete direct care staff training, sanitary condition violations, hot water temperature exceeding limits, fire drill record issues, incomplete medical evaluations, and improper storage procedures for medical equipment. Plans of correction were accepted with specified completion dates.
Deficiencies (12)
| Description |
|---|
| At least one staff person for every 50 residents trained in first aid and certified in CPR was not present at all times. |
| Direct care staff provided unsupervised ADL services without completing required training and competency tests. |
| Direct care staff did not receive required annual training topics including care for dementia, infection control, safe management, emergency preparedness, resident rights, and falls prevention. |
| Enabler bar on resident's bed was not well-secured, posing entrapment and fall hazard. |
| Resident's glucometer was used improperly and insulin was administered without cleaning site with alcohol wipe. |
| Hot water temperature in resident-accessible bathrooms exceeded 120°F. |
| Fire drill records lacked indication of AM or PM for drill times. |
| Alternate exit routes were not consistently used during fire drills. |
| Fire drills were routinely held at the end of the month, not varying days and times as required. |
| Medical evaluation for resident did not include ability to self-administer medications. |
| Annual medical evaluations for residents in secured dementia care unit were incomplete or missing attachments. |
| Resident's glucometer was not calibrated to the correct date and time. |
Report Facts
Residents served: 53
License capacity: 128
Staff daily total: 75
Waking staff: 56
Residents with mobility need: 22
Residents age 60 or older: 53
Residents with mental illness: 1
Residents with physical disability: 1
Residents in hospice: 6
Hot water temperature: 132.1
Hot water temperature: 131.9
Inspection Report
Census: 63
Capacity: 128
Deficiencies: 0
Apr 21, 2023
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, on 04/21/2023.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Report Facts
License Capacity: 128
Residents Served: 63
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 12
Residents Age 60 or Older: 63
Residents with Mobility Need: 33
Inspection Report
Follow-Up
Census: 64
Capacity: 128
Deficiencies: 1
Apr 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation and a follow-up to verify the implementation of a previously submitted plan of correction.
Findings
The report found a medication safety violation involving an unlocked pill accessible in a resident's room. The facility implemented corrective actions including removal of the medication, notification of involved parties, staff training, and auditing procedures to ensure compliance.
Complaint Details
The visit was complaint-related as indicated by the inspection information. The plan of correction was fully implemented as of the follow-up review on 04/04/2023.
Deficiencies (1)
| Description |
|---|
| Unlocked, unattended, and accessible medication found in resident #1's bedroom, violating medication security requirements. |
Report Facts
License Capacity: 128
Residents Served: 64
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 11
Residents Age 60 or Older: 64
Residents with Mobility Need: 39
Total Daily Staff: 103
Waking Staff: 77
Inspection Report
Complaint Investigation
Census: 59
Capacity: 128
Deficiencies: 3
Mar 2, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with multiple on-site visits between 03/02/2023 and 03/09/2023 to review compliance and the submitted plan of correction.
Findings
The facility was found to have deficiencies including failure to report incidents to the Department, incomplete annual medical evaluations for residents, and improper narcotic storage and documentation procedures. The submitted plan of correction was determined to be fully implemented by April 10, 2023.
Complaint Details
The visit was complaint-related, triggered by allegations of abuse/neglect and an incident involving suspected theft of an Amazon Alexa device. The plan of correction was fully implemented and compliance maintained.
Deficiencies (3)
| Description |
|---|
| Failure to report incidents of alleged abuse and theft to the Department within 24 hours as required. |
| Residents did not have annual medical evaluations completed timely as required. |
| Failure to properly document and report discrepancies in narcotic inventory counts according to facility policy. |
Report Facts
License Capacity: 128
Residents Served: 59
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 8
Number of Residents Age 60 or Older: 59
Residents with Mobility Need: 36
Inspection Report
Routine
Deficiencies: 0
Jun 6, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 06/06/2022, 06/08/2022, and 06/10/2022.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report
Renewal
Census: 48
Capacity: 128
Deficiencies: 10
Apr 19, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility Overlook Green on 04/19/2022 through 04/21/2022.
Findings
The inspection identified multiple deficiencies including failure to post the current license inspection summary, lack of privacy locks on bedroom and bathroom doors, sanitary condition issues such as lack of hand-drying methods in bathrooms, lack of operable ventilation fans in bathrooms, inadequate lighting at bedside for a resident, obstructed emergency egress, missing exit signage, incomplete support plan signatures, unsecured confidential resident records, and unsigned resident contracts. Plans of correction were accepted and implemented with specified completion dates.
Deficiencies (10)
| Description |
|---|
| Current licensing inspection summary, dated 4/22/21, was not posted in a conspicuous and public place. |
| Shared resident bedroom door and bathroom door not equipped with locks, preventing resident privacy. |
| Shared resident bathrooms in rooms 220 and 224b lacked paper towels, mechanical air dryers, or other sanitary hand-drying methods. |
| Bathrooms in rooms 220, 223, and 239 did not have operable ventilation fans or windows. |
| Resident #2 did not have a source of light that can be turned on/off at bedside. |
| Emergency exit door in lower level laundry room was blocked by garbage and a gas can, obstructing egress. |
| No exit sign posted above the exit door in the staff break room. |
| Residents #1 and #4 participated in support plan development but did not sign the support plan. |
| Several boxes of confidential files of former residents were unlocked, accessible, and unattended in an unlocked storage room. |
| Resident #1's home contract was not signed by the resident; repeat violation from 4/22/2021. |
Report Facts
License Capacity: 128
Residents Served: 48
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 15
Hospice Residents: 5
Staffing Hours - Total Daily Staff: 80
Staffing Hours - Waking Staff: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to corrective actions for privacy locks, sanitary conditions, ventilation, lighting, exit signage, and audits. | |
| Executive Director | Named in multiple findings related to corrective actions, retraining staff, and ensuring compliance. | |
| DRC | Named in findings related to support plan signatures and corrective actions. | |
| Business Office Manager | Named in findings related to securing confidential records and key control. | |
| Marketing Director | Named in corrective action related to contract signature audits. |
Inspection Report
Routine
Deficiencies: 0
Oct 6, 2021
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
Routine
Deficiencies: 0
Oct 6, 2021
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
Renewal
Deficiencies: 0
Jun 25, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Renewal
Deficiencies: 0
Jun 11, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Renewal
Deficiencies: 0
May 26, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Renewal
Census: 45
Capacity: 128
Deficiencies: 9
Apr 22, 2021
Visit Reason
The inspection was conducted as a renewal inspection along with complaint and provisional reasons, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall but had several deficiencies including unsigned resident contracts, wheelchair repair needs, sanitary condition issues with urine odor, hot water temperature exceeding limits, furniture and equipment hazards, emergency procedures not posted, medication administration errors, and incomplete resident assessments. Plans of correction were accepted and implemented for all deficiencies.
Complaint Details
The inspection included complaint-related reasons; however, substantiation status is not explicitly stated.
Deficiencies (9)
| Description |
|---|
| Resident #1's resident-home contract was not signed by the resident. |
| Resident #1's resident-home contract statement acknowledging receipt of information was not signed by the resident. |
| Vinyl on the arm rests of resident #3’s wheelchair was cracked and missing, posing a laceration hazard. |
| Strong, pungent odor of urine in resident rooms #173 and #174, with wet bedsheet and urine puddle observed. |
| Hot water temperature in the secure dementia care unit kitchen sink measured 125.2°F, exceeding the 120°F limit. |
| Metal edging on PTAC unit in resident bedroom #431 was separated and sharp, posing a hazard; exhaust fan knob in shared bathroom was missing. |
| Emergency preparedness plans were not posted in a public and conspicuous place. |
| Medication error: Resident #6 received incorrect dose of Olanzapine from 4/16/21 to 4/23/21. |
| Resident #1’s initial assessment was not updated to include diagnoses of diabetes mellitus, glaucoma, and muscle spasms. |
Report Facts
License Capacity: 128
Residents Served: 45
Secured Dementia Care Unit Capacity: 23
Residents Served in Secure Dementia Care Unit: 14
Current Hospice Residents: 8
Waking Staff: 56
Total Daily Staff: 75
Hot Water Temperature: 125.2
Urine puddle size: 18
Urine puddle width: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary | Signed licensing letter and certificate of compliance. |
| Executive Director | Named in plan of correction audits and contract signing compliance. | |
| Maintenance Director | Repaired wheelchair, PTAC unit, exhaust fan knob, and coordinated hot water temperature correction. | |
| Director of Maintenance | Responsible for ongoing inspections of wheelchairs, PTAC units, exhaust fans, and water temperature. | |
| Director of Resident Care | Responsible for grievance reviews, medication audits, resident care plan meetings, and assessment audits. | |
| Business Office Manager / Designee | Ensures contracts are signed and emergency plans are posted. | |
| Maintenance Assistant | Completed audit of PTAC units and exhaust fan knobs. | |
| Staff person A | Provided information about medication administration process. |
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