Inspection Reports for Personal Care at Evergreen
25 GLADE AVENUE,, WAYNESBURG, PA, 15370
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
66% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
61% occupied
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 27
Capacity: 44
Deficiencies: 0
Date: Feb 20, 2025
Visit Reason
The inspection was conducted as a complaint investigation at the facility.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 27
License Capacity: 44
Current Residents in Hospice: 6
Total Daily Staff: 42
Waking Staff: 32
Resident Support Staff: 0
Inspection Report
Renewal
Census: 32
Capacity: 44
Deficiencies: 11
Date: Apr 3, 2024
Visit Reason
The inspection visit on 04/03/2024 was conducted for renewal and complaint reasons, including a full unannounced inspection and review of submitted plan of correction.
Complaint Details
The inspection included complaint investigation as part of the renewal process. The submitted plan of correction was determined to be fully implemented as of 05/02/2024.
Findings
The inspection identified multiple deficiencies including record confidentiality breaches, incomplete staff training, insufficient emergency water supply, missing fire extinguisher, missed fire drills, medication storage issues, glucometer calibration problems, failure to follow prescriber's orders, and incomplete description of services regarding financial management.
Deficiencies (11)
Privacy coding for the licensing inspection conducted on 11/1/22 included resident #1's name and a white binder containing resident information was left unlocked and accessible.
Staff person B did not receive required training in care for residents with dementia and medication self-administration for 2023.
Staff persons A and B did not receive training in emergency preparedness during 2023.
Staff person B's training record lacked date, trainer, and duration of training.
The home had only 55 gallons of emergency drinking water for 32 residents requiring 96 gallons and lacked a contract with a bottled water supplier.
No fire extinguisher was present in the home's attic.
Unannounced fire drills were not conducted during July and August 2023.
Medication carts contained 7 pills in an unlabeled pill cup and 2 loose pills in a drawer.
Resident #3's glucometer was not calibrated to the current date and time; staff unaware of calibration procedures.
Resident #2's ordered twice daily blood glucose checks were not completed on a specified date.
The home's written description of services did not include financial management, although such services were provided.
Report Facts
License Capacity: 44
Residents Served: 32
Current Residents in Hospice: 6
Residents with Mobility Need: 14
Gallons of Emergency Drinking Water Required: 96
Gallons of Emergency Drinking Water Available: 55
Total Daily Staff: 46
Waking Staff: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Did not receive emergency preparedness training in 2023. | |
| Staff person B | Did not receive training in dementia care, medication self-administration, emergency preparedness in 2023; training record incomplete. | |
| Executive Director | Conducted audits, educated staff, developed training plans, and implemented corrective actions. | |
| Director of Resident Care | Responsible for auditing medication carts and monitoring compliance with medication storage and glucometer calibration. |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 44
Deficiencies: 0
Date: Jan 4, 2024
Visit Reason
The inspection was conducted as a complaint investigation at the facility.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 32
License Capacity: 44
Current Hospice Residents: 8
Total Daily Staff: 45
Waking Staff: 34
Inspection Report
Complaint Investigation
Census: 26
Capacity: 44
Deficiencies: 0
Date: Jun 28, 2023
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit on 06/28/2023 and a follow-up off-site on 07/28/2023.
Complaint Details
The inspection was complaint-driven, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of the inspection.
Report Facts
License Capacity: 44
Residents Served: 26
Current Residents in Hospice: 6
Total Daily Staff: 34
Waking Staff: 26
Residents with Mobility Need: 8
Residents 60 Years or Older: 26
Inspection Report
Follow-Up
Census: 35
Capacity: 44
Deficiencies: 3
Date: Nov 1, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident at the facility to review the submitted plan of correction.
Complaint Details
The visit was complaint-related due to an incident involving alleged resident abuse. The allegation was not reported to the Area Agency on Aging until after the incident. The plan of correction included staff education on abuse reporting and supervision.
Findings
The submitted plan of correction was determined to be fully implemented, with education and supervision measures put in place regarding suspected resident abuse and treatment of residents with dignity and respect.
Deficiencies (3)
Failure to immediately report suspected abuse of a resident and failure to submit a written incident report within required timeframes.
Failure to immediately develop and implement a plan of supervision or suspend the staff person involved in the alleged abuse incident.
Failure to treat a resident with dignity and respect, including staff loudly scolding a resident and not assisting appropriately.
Report Facts
License Capacity: 44
Residents Served: 35
Current Residents in Hospice: 13
Total Daily Staff: 46
Waking Staff: 35
Inspection Report
Renewal
Census: 33
Capacity: 44
Deficiencies: 8
Date: Jun 15, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Personal Care at Evergreen facility on 06/15/2022 and 06/16/2022.
Findings
The inspection found several deficiencies including uncovered trash receptacles, improper signage on emergency exit doors, lack of thermometers in refrigerators, missing emergency preparedness plan posting, lack of annual fire safety inspection, medication labeling issues, failure to follow prescriber's orders, and use of correction fluid in resident records. All deficiencies had acceptable plans of correction which were implemented or scheduled for completion.
Deficiencies (8)
Trash can in the kitchen was uncovered and 3/4 full of paper and food waste.
Orange signs posted on each of the 4 emergency exit doors indicating 'STOP DO NOT OPEN STAFF ONLY.'
No thermometer in the small refrigerator in the dining room and broken thermometer in the third upright refrigerator in the kitchen.
The home’s emergency preparedness plan for the municipality was not posted in a conspicuous and public place.
The home did not have a fire safety inspection conducted by a fire safety expert in the past year.
Pharmacy label for Resident #1's prescription medication was incomplete or incorrect.
Resident #2 was prescribed medication that was not available and not administered on multiple dates and times.
Correction fluid was used to cover the day of the month on Resident #1's contract.
Report Facts
License Capacity: 44
Residents Served: 33
Total Daily Staff: 42
Waking Staff: 32
Hospice Residents: 11
Residents 60 Years or Older: 33
Residents with Mental Illness: 1
Residents with Mobility Need: 9
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 20, 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.
Notice
Capacity: 44
Deficiencies: 0
Date: Jul 21, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Personal Care at Evergreen following receipt of the renewal application dated April 29, 2021. It also advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and the requirement for a future annual inspection.
Report Facts
Maximum capacity: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 32
Capacity: 44
Deficiencies: 15
Date: May 4, 2021
Visit Reason
The inspection was conducted as a full, unannounced review for renewal and complaint reasons from 05/04/2021 to 05/07/2021.
Findings
The facility was found to have multiple deficiencies including failure to submit incident reports timely, unsigned resident contracts, improper rent rebate collection, incomplete staff training, indoor temperature below required levels, incomplete first aid kits, inoperable bedside lamps, dietary noncompliance, medication labeling errors, improper medication storage and documentation, expired staff medication training, lack of resident education on medication refusal rights, incomplete resident assessments, and outdated resident photographs. Plans of correction were accepted and implemented with completion dates mostly in July 2021.
Deficiencies (15)
Failure to submit incident reports to the Department’s personal care home regional office when state police were on site responding to allegations of indecent assault.
Resident contracts were not signed by residents.
Contracts indicated residents would retain only 10% of rent rebate monies, exceeding allowed collection limits.
Direct care staff person did not receive initial training regarding emergency medical plan and abuse reporting within 40 scheduled working hours.
Indoor temperature in resident bedroom measured 68°F, below the required minimum of 70°F.
First aid kit lacked non-porous disposable gloves, thermometer, and tweezers.
Bedside lamp in resident room was inoperable due to missing knob.
Resident #4 was served food inconsistent with prescribed mechanical soft diet.
Medication containers had labeling inconsistent with prescribed dosage and instructions.
Blood glucose readings were incorrectly documented and glucometers were not labeled.
Staff person B administered medication without current Department-approved medication administration course completion within past 2 years.
No documentation that resident #1 was educated on the right to refuse or question medication.
Resident initial assessments were incomplete, missing hospice service details and supervision/medication self-administration information.
Annual assessment for resident #5 was not updated to include repeated incidents of sexually inappropriate behavior.
Resident photographs were outdated beyond 2 years.
Report Facts
Inspection Dates: 4
Licensed Capacity: 44
Resident Census: 32
Current Hospice Residents: 6
Staffing Hours: 38
Waking Staff: 29
Deficiency Completion Dates: 15
Inspection Report
Follow-Up
Census: 28
Capacity: 44
Deficiencies: 2
Date: Feb 12, 2021
Visit Reason
The inspection visit on 02/12/2021 was an unannounced partial inspection triggered by an incident.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies included a violation related to staff treating residents with dignity and respect, and failure to use standardized forms for resident preadmission screening. Corrective actions and trainings were completed.
Deficiencies (2)
Staff person was rude and inappropriate verbally to resident #1, leading to termination of employment.
Resident #1’s preadmission screening was not completed on the Department’s current standardized form.
Report Facts
License Capacity: 44
Residents Served: 28
Current Hospice Residents: 8
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 7
Residents Age 60 or Older: 28
Residents with Physical Disability: 1
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 6, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 01/06/2021 and 01/07/2021 for the facility Personal Care at Evergreen.
Findings
No regulatory citations were identified as a result of this inspection.
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