Inspection Reports for
Serenity at Lgar
800 ELSIE STREET,, TURTLE CREEK, PA, 15145
Back to Facility Profile5 Reports
Inspection Report — Jun 4, 2026
Complaint Investigation
Date: Jun 4, 2026
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 06/04/2026.
Complaint Details
The inspection was complaint-related as indicated by the reason 'Complaint'. No deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 12
Current Residents Hospice: 3
Residents Age 60 or Older: 12
Residents Diagnosed with Mental Illness: 12
Residents with Mobility Need: 12
Inspection Report — Apr 7, 2026
Complaint Investigation
Date: Apr 7, 2026
Visit Reason
The inspection was a partial, unannounced visit triggered by a complaint and incident reported at the facility.
Complaint Details
The visit was complaint-related and incident-driven, focusing on allegations of abuse and unsafe conditions. The submitted plan of correction was fully implemented as of the inspection date.
Findings
The inspection identified violations related to resident abuse and neglect, specifically inadequate incontinence care, and failure to keep poisonous materials locked and inaccessible to residents. Plans of correction were submitted and implemented to address these issues.
Citations (2)
42b Abuse: A resident was found in wet pull-ups saturated in urine, and incontinent care checks were not provided every 2 hours as required. Staff education and shift walking rounds were directed to prevent abuse and neglect.
82c Locking Poisonous Materials: Poisonous cleaning materials were found unlocked and accessible to residents in the activity room despite the facility being a secured dementia care unit. Materials were removed and staff educated on poisonous substances.
Report Facts
Residents served: 9
Current Hospice Residents: 1
Staffing Hours - Total Daily Staff: 18
Staffing Hours - Waking Staff: 14
Inspection Report — Feb 5, 2026
Follow-Up
Date: Feb 5, 2026
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and incident review purposes.
Findings
The facility was found to have deficiencies in emergency procedures, fire drill records, evacuation times, use of alternate exit routes during fire drills, and documentation of medical evaluations. The submitted plan of correction was determined to be fully implemented as of the inspection date.
Citations (5)
107b Emergency Procedures: The home lacked written emergency procedures including resident contact information, emergency medical information confidentiality, emergency agency contacts, transportation means, staff duties during emergencies, and alternate means for resident needs during utility outages.
132c Fire Drill Records: Fire drill records did not include number of staff participating or whether the fire alarm was operative, and evacuation times were recorded only in minutes without seconds.
132d Evacuation: The home did not have a written maximum safe evacuation time by a fire safety expert at the time of the 9/8/2025 drill, and evacuation times exceeded the expert's specified maximum time in subsequent drills.
132f Alternate Exit Routes: Only the main exit was used during fire drills from 9/8/2025 to 1/8/2026, failing to utilize alternate exit routes.
141a Medical Evaluation: Medical evaluations for Residents #1 and #2 were not documented on forms specified by the Department.
Report Facts
Residents served: 12
Current residents in Hospice: 1
Residents aged 60 or older: 12
Residents with mobility need: 12
Residents diagnosed with mental illness: 1
Residents served in secured dementia care unit: 12
Notice — Nov 18, 2025
Date: Nov 18, 2025
Visit Reason
The document serves as a waiver approval for Serenity at LGAR to use preadmission screening and medical evaluation forms from Point, Click, Care instead of the Department's forms, with conditions for compliance and review during the annual inspection.
Findings
The waiver is granted under the authority of 55 Pa. Code § 2600.19 with the condition that Serenity at LGAR uses the specified alternative forms. The Department will review compliance with this waiver during its annual inspection, and failure to comply may result in termination of the waiver or other licensing actions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter and stated conditions for compliance. |
Inspection Report — Aug 20, 2025
Original Licensing
Date: Aug 20, 2025
Visit Reason
The inspection was conducted as a licensing inspection for a newly licensed personal care home facility that is not yet serving four or more residents.
Findings
The facility was found to be in substantial compliance with applicable regulations, but several deficiencies were identified including issues with carbon monoxide detector batteries, missing influenza posters, uncovered trash receptacles, improper emergency preparedness documentation, obstructed egress routes, lack of electronic/magnetic locking systems on exit doors, and lint accumulation in dryers. Plans of correction were accepted and implemented with follow-up inspections scheduled.
Citations (7)
Carbon monoxide detector batteries were not dated or missing in multiple locations; influenza poster was not posted in the home.
Trash cans in common resident bathroom and staff bathroom lacked lids.
A red stop sign was posted on the emergency exit leading to the courtyard, posing a hazard.
Lint accumulation was found on half of the lint trap in the dryer on the unit.
The home did not have a copy of the emergency preparedness plan for the local municipality.
Three exit gates had 'pool gate latches' that required reaching through the gate to unlatch, blocking egress.
No electronic/magnetic locking system on three exit doors leading to parking lot and courtyard.
Report Facts
Residents Served: 0
Inspection Date: Aug 20, 2025
Plan of Correction Completion Date: Sep 2, 2025
Plan of Correction Implementation Date: Sep 17, 2025
Directed Completion Date: Sep 12, 2025
Directed Completion Date: Sep 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Courtney Hamilton | Assistant Nursing Home Administrator | Named in relation to trash receptacle lids deficiency and lint removal. |
Viewing
Loading inspection reports...
