Inspection Reports for Sycamore Estate Personal Care Residence
717 DUQUESNE BLVD,, DUQUESNE, PA, 15110
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
27.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
481% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
59% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 29
Capacity: 49
Deficiencies: 0
Date: Jul 3, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at Sycamore Estate Personal Care Residence on 07/03/2025.
Complaint Details
The inspection was triggered by a complaint and incident. No deficiencies or citations were found, indicating no substantiated violations.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 49
Residents Served: 29
Current Hospice Residents: 7
Residents Receiving Supplemental Security Income: 5
Residents Aged 60 or Older: 29
Residents Diagnosed with Mental Illness: 8
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 4
Residents with Physical Disability: 1
Total Daily Staff: 33
Waking Staff: 25
Inspection Report
Complaint Investigation
Census: 28
Capacity: 49
Deficiencies: 9
Date: Mar 10, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations at Sycamore Estate Personal Care Residence.
Complaint Details
The inspection was conducted due to a complaint. The report indicates substantiation of multiple deficiencies related to staffing, medication management, and resident care documentation.
Findings
The inspection found multiple deficiencies including lack of direct care staff presence during certain hours, insufficient personal care service hours during waking hours, inadequate staffing to meet resident needs, medication storage and administration issues, and incomplete resident assessments and support plans.
Deficiencies (9)
No direct care staff person present in the home from 7:34 a.m. until approximately 9:08 a.m. with 28 residents present.
Only 18 hours of personal care services were provided during waking hours when 24 hours were required for 28 residents including 4 with mobility needs.
Only one direct care staff present from 9:00 a.m. until approximately 6:00 p.m. despite residents requiring assistance of 2 staff persons to transfer.
No staff person trained to administer medications present on the overnight shift from 11:00 p.m. until 7:00 a.m.
Discontinued medication found stored in the medication cart.
Staff person administered medications but did not initial the medication administration record (MAR).
Medication prescribed to resident was not administered because it was not available in the home.
Resident assessment did not include hospice admission and did not document recent falls despite unsteady gait.
Resident support plan did not include hospice admission or address numerous falls.
Report Facts
Residents present during inspection: 28
Licensed capacity: 49
Personal care service hours required during waking hours: 24
Personal care service hours provided during waking hours: 18
Residents requiring assistance of 2 staff persons to transfer: 2
Medication cart audit frequency: 3
Medication cart audit frequency: 2
MAR audit frequency: 3
MAR audit frequency: 2
Inspection Report
Complaint Investigation
Census: 29
Capacity: 49
Deficiencies: 1
Date: Dec 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 12/18/2024.
Complaint Details
The visit was complaint-related. The deficiency involved failure to report a resident's death incident to the Department as required. The plan of correction was accepted and implemented.
Findings
The facility was found to have failed to submit a required incident report to the Department after a resident ceased to breathe. The submitted plan of correction was accepted and fully implemented by 01/27/2025.
Deficiencies (1)
The home did not submit an incident report to the Department after a resident ceased to breathe.
Report Facts
License Capacity: 49
Residents Served: 29
Current Hospice Residents: 4
Residents Diagnosed with Mental Illness: 6
Residents with Mobility Need: 7
Residents Age 60 or Older: 29
Inspection Report
Renewal
Census: 49
Capacity: 49
Deficiencies: 6
Date: Aug 27, 2024
Visit Reason
The inspection was conducted as part of a renewal, complaint, and provisional licensing process with multiple inspection dates in August and September 2024.
Complaint Details
The inspection included complaint-related components. One complaint involved failure to refund charges after a resident's death, which was addressed with a plan of correction and documentation provided to the complainant.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 after corrections were made. Several deficiencies were cited related to resident refunds after death, staff CPR/First Aid training, and medication management including storage, administration, and following prescriber's orders. Plans of correction were accepted and implemented by November 25, 2024.
Deficiencies (6)
Failure to provide refund in accordance with the Elder Care Payment Restitution Act after death of a resident over 60 years old.
No staff present trained in First Aid and certified in obstructed airway techniques (CPR) during multiple shifts in August 2024.
Unopened insulin pen with resident's name present but discontinued and not disposed of.
Medication administration record missing initials of staff who administered medication on 8/27/24 at 9:00 p.m.
Failure to follow prescriber's orders including incorrect insulin dosage, missed blood glucose check, and missed medication doses for residents.
Prescription medication not stored properly; insulin pen did not indicate date opened as required.
Report Facts
Inspection dates: 4
Staffing hours: 56
Waking staff hours: 42
Residents served: 49
License capacity: 49
Deficiency dates: 8
Inspection Report
Complaint Investigation
Census: 28
Capacity: 49
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
The inspection was conducted as a complaint investigation with a fine, as indicated by the reason 'Complaint, Fine' and the unannounced partial inspection on 07/01/2024.
Complaint Details
The inspection was complaint-related with a fine, but no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified during this inspection of Sycamore Estate Personal Care Residence.
Report Facts
License Capacity: 49
Residents Served: 28
Total Daily Staff: 32
Waking Staff: 24
Residents Receiving Supplemental Security Income: 2
Residents 60 Years or Older: 28
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 4
Residents with Physical Disability: 0
Inspection Report
Complaint Investigation
Census: 33
Capacity: 49
Deficiencies: 14
Date: Mar 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation and provisional license review for Sycamore Estate Personal Care Residence.
Complaint Details
The inspection was complaint-driven and provisional license related. Specific substantiation status is not stated.
Findings
Multiple violations were found including record confidentiality breaches, sanitary condition issues, medication administration errors, and safety concerns. A second provisional license was issued with required plans of correction and fines pending if violations are not corrected.
Deficiencies (14)
Resident records were left unlocked and accessible, including medication bottles and prescription orders.
Trash outside the home was found with dumpster lid open and trash bags loose.
A bathroom fan was inoperable and there was no window for ventilation.
Medication administration records were incomplete or missing documentation.
Medication storage included expired medications and improper labeling.
Sanitary conditions were poor with cigarette butts scattered and paper towel dispensers empty.
Lighting in resident rooms was inoperable or unplugged.
Grab bars were missing in resident bathrooms.
Combustible materials were stored near heat sources.
Fire drill records did not indicate exit routes used during drills.
Medical evaluations were incomplete, missing vital signs and weights.
Prescription medications were not stored or administered according to regulations.
Medication administration times and documentation were incomplete or inaccurate.
Follow prescriber's orders were not consistently followed or documented.
Report Facts
License Capacity: 49
Residents Served: 33
Staffing Hours: 37
Waking Staff: 28
Fine Amount: 150
Fine Duration: 5
Inspection Report
Complaint Investigation
Census: 30
Capacity: 49
Deficiencies: 14
Date: Mar 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation and monitoring visit to assess compliance with Personal Care Homes regulations and to address violations found during prior inspections.
Complaint Details
The visit was complaint-related and included monitoring. The complaint was found to be substantiated with multiple violations noted. The facility was issued a second provisional license due to failure to submit and comply with acceptable plans of correction.
Findings
Multiple violations were found including issues with record confidentiality, trash outside the home, sanitary conditions, medication storage and administration, fire safety, and staff training. Several violations were repeat citations. Plans of correction were submitted with varying degrees of implementation.
Deficiencies (14)
Resident records were left unlocked and accessible, including medication bottles and physician orders.
Trash dumpster lid was open with trash bags and loose garbage outside.
Sanitary conditions not maintained; cigarette butts scattered and lack of paper towels in bathrooms.
Direct care staff completed only 12 hours of required annual training instead of 24 hours.
Bathroom ventilation fan was inoperable and there was no window.
Lighting in resident bedroom was inoperable and unplugged.
Grab bars missing in shared resident bathroom.
Combustible materials stored near heat sources and furnaces.
First aid kit missing adhesive tape and bandages.
Resident medical evaluations missing vital signs and weight documentation.
Prescription medications and OTC medications not stored properly or labeled correctly.
Medication administration records missing documentation of administration times and areas.
Medication errors including expired medications and incorrect documentation.
Failure to follow prescriber's orders for medication administration.
Report Facts
License Capacity: 49
Residents Served: 30
Residents Served: 33
Current Residents: 7
Current Residents: 8
Staffing Hours: 37
Staffing Hours: 33
Fine Amount: 150
Fine Per Resident Per Day: 5
Fine Mandated Correction Date: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in relation to record confidentiality violation and medication administration training. | |
| Staff Person B | Named in relation to record confidentiality violation, bathroom ventilation fan repair, grab bar installation, and medication administration training. | |
| Administrator | Responsible for overseeing plans of correction, staff training, medication audits, and monitoring compliance. | |
| Staff Person F | Direct care staff who administered medications without completing required training. | |
| Staff Person D | Staff member registered for medication administration course. |
Inspection Report
Follow-Up
Census: 33
Capacity: 49
Deficiencies: 2
Date: Feb 1, 2024
Visit Reason
The inspection was a follow-up review conducted on 02/01/2024 to verify the implementation of a previously submitted plan of correction related to a complaint and incident.
Complaint Details
The inspection was complaint-related, triggered by a complaint and incident. Substantiation status is not explicitly stated.
Findings
The facility was found to have fully implemented the submitted plan of correction. Deficiencies related to medication administration and program activities were addressed with updated procedures, staff training, and monitoring.
Deficiencies (2)
Failure to follow prescriber's orders resulting in multiple instances where residents did not receive prescribed medications as ordered.
Lack of a program of activities designed to promote each resident's active involvement with other residents, family, and the community; activity schedules were not posted in advance.
Report Facts
License Capacity: 49
Residents Served: 33
Current Hospice Residents: 6
Residents 60 Years or Older: 31
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 3
Residents with Physical Disability: 0
Total Daily Staff: 36
Waking Staff: 27
Inspection Report
Census: 28
Capacity: 49
Deficiencies: 0
Date: Nov 29, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Resident Support Staff: 30
Waking Staff: 23
Residents Served: 28
License Capacity: 49
Current Hospice Residents: 4
Residents Diagnosed with Mental Illness: 6
Residents Diagnosed with Intellectual Disability: 1
Residents Receiving Supplemental Security Income: 2
Residents Aged 60 or Older: 2
Residents with Mobility Need: 2
Residents with Physical Disability: 0
Inspection Report
Complaint Investigation
Census: 29
Capacity: 49
Deficiencies: 17
Date: Jun 22, 2023
Visit Reason
The inspection was conducted as a complaint investigation following licensing inspections on June 22, 2023, June 23, 2023, and September 19, 2023, due to violations found related to Personal Care Homes regulations.
Complaint Details
The inspection was complaint-driven due to allegations of noncompliance with Personal Care Homes regulations, including medication errors, improper storage, and staffing issues. The complaint was substantiated with multiple deficiencies found during the inspection.
Findings
Multiple deficiencies were found including breaches in resident record confidentiality, failure to obtain written receipts for cash disbursements, improper storage of poisonous materials and food, hot water temperatures exceeding limits, inadequate lighting, missing handrails, medication storage and administration errors, and failure to conduct unannounced fire drills.
Deficiencies (17)
Emergency medical plan binder was unlocked and accessible containing confidential resident information.
No written receipts obtained for numerous cash disbursements for residents #4, #6, and #7.
Unlabeled bottle of Lysol Multi-Surface Cleaner stored improperly near food items.
Unlabeled, used towels and washcloths found in shared bathroom.
Hot water temperature exceeded 120°F at multiple sinks accessible to residents.
No handrail present at step leading to porch from 1st floor North emergency exit.
Resident bedside lamps missing or not operable for residents #4, #5, and #2.
No grab bar at toilet in East Wing employee bathroom.
Food stored on floor and in unsealed containers.
Undated leftover food found in refrigerator.
Fire drills were announced in advance and not conducted monthly as required.
Residents evacuated through the same exit during fire drills instead of alternating exits.
Menus not posted in a conspicuous and public place in the home.
Resident #4's Novolog insulin pen was opened and undated, violating medication storage requirements.
Resident #4's blood glucose documentation was inaccurate or incomplete; medications not available for resident #6.
Resident #6 prescribed Hydrocortisone suppository still present on June 2023 MAR despite discontinuation.
Resident #4 administered Novolog insulin instead of prescribed Admelog Solostar insulin.
Report Facts
License Capacity: 49
Residents Served: 29
Staffing Hours: 30
Waking Staff: 23
Hot Water Temperature: 146.4
Hot Water Temperature: 136.1
Cash Disbursement: 368
Deficiency Count: 17
Residents Served: 31
Total Daily Staff: 33
Waking Staff: 25
Inspection Report
Complaint Investigation
Census: 29
Capacity: 49
Deficiencies: 17
Date: Jun 22, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on allegations received, with follow-up and monitoring activities to verify correction of previous deficiencies.
Complaint Details
The inspection was complaint-driven with monitoring and follow-up to verify correction of cited deficiencies. The complaint involved issues such as medication errors, staffing inadequacies, and safety concerns.
Findings
Multiple deficiencies were found including breaches in resident record confidentiality, failure to obtain written receipts for cash disbursements, improper storage of poisonous materials and food, hot water temperatures exceeding limits, inadequate lighting, missing handrails, medication administration and documentation errors, and insufficient staffing during overnight hours.
Deficiencies (17)
Emergency medical plan binder was unlocked and accessible containing confidential resident information.
No written receipts obtained for numerous cash disbursements for residents #4, #6, and #7.
Unlabeled bottle of Lysol Multi-Surface Cleaner stored on serving cart near food items.
Unlabeled, used towels and washcloths found in shared bathroom.
Hot water temperatures exceeded 120°F at multiple sinks accessible to residents.
No handrail present at step leading to porch from 1st floor North emergency exit.
Resident #4's bedside lamp was not within reach; resident #5 had no operable lamp at bedside.
No grab bar at toilet in East Wing employee bathroom.
Food stored on floor in temporary serving area.
Undated leftover food container found in refrigerator.
Opened, unsealed bags of snacks stored on serving cart.
Staff notified in advance of scheduled fire drills, violating unannounced drill requirement.
Resident #4's Novolog insulin pen was opened and undated, exceeding manufacturer's discard timeframe.
Resident #4's blood glucose documentation was inaccurate or incomplete on multiple dates.
Medications prescribed to resident #6 were not available for administration on inspection date.
Resident #6's Hydrocortisone suppository was still present on MAR after prescribed course ended.
Resident #4 was administered Novolog insulin instead of prescribed Admelog Solostar insulin.
Report Facts
License Capacity: 49
Residents Served: 29
Current Residents: 3
Total Daily Staff: 30
Waking Staff: 23
Residents Served: 31
Total Daily Staff: 33
Waking Staff: 25
Inspection Report
Complaint Investigation
Census: 30
Capacity: 30
Deficiencies: 2
Date: May 4, 2023
Visit Reason
The inspection was conducted due to a complaint and a change in legal entity for the newly licensed personal care home.
Complaint Details
The inspection was complaint-related and also due to a change in legal entity. Substantiation status is not explicitly stated.
Findings
The facility was found to be in substantial compliance with applicable regulations, though the licensing inspector was unable to complete a full inspection due to the new legal entity. Citations were found related to trash receptacles and ventilation issues, which required correction.
Deficiencies (2)
A 3/4 full, uncovered, unattended trash can in the kitchen.
Bathrooms in multiple areas of the home lacked operable windows, fans, air conditioners, or other mechanical ventilation to ensure airflow.
Report Facts
Residents Served: 30
Current Residents in Hospice: 3
Residents Receiving Supplemental Security Income: 7
Residents 60 Years or Older: 27
Residents Diagnosed with Mental Illness: 6
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 1
Residents with Physical Disability: 0
Total Daily Staff: 31
Waking Staff: 23
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