Inspection Report
Census: 66
Capacity: 112
Deficiencies: 0
May 9, 2025
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, with the reason noted as 'Incident'.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 112
Residents Served: 66
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 10
Residents Age 60 or Older: 66
Residents with Mental Illness: 1
Residents with Mobility Need: 30
Inspection Report
Complaint Investigation
Census: 66
Capacity: 112
Deficiencies: 0
Apr 16, 2025
Visit Reason
The inspection was conducted as a complaint investigation at THE PINES OF MT. LEBANON facility on 04/16/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this complaint investigation inspection.
Complaint Details
The inspection was triggered by a complaint, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 66
License Capacity: 112
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 13
Residents Age 60 or Older: 66
Residents with Mobility Need: 33
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 51
Capacity: 112
Deficiencies: 0
Sep 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Report Facts
License Capacity: 112
Residents Served: 51
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 9
Hospice Current Residents: 6
Resident Age 60 or Older: 51
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Total Daily Staff: 67
Waking Staff: 50
Inspection Report
Renewal
Census: 54
Capacity: 112
Deficiencies: 25
Mar 18, 2024
Visit Reason
The inspection was conducted as part of a renewal and provisional exit conference to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall but had multiple deficiencies including failure to post current license inspection summaries, confidentiality breaches of resident records, lack of influenza posters, inadequate first aid/CPR trained staff, insufficient annual training for direct care staff, heat source safety issues, ventilation problems in bathrooms, improper food storage, missing emergency procedures postings, inadequate fire alarm signaling for hearing impaired residents, medication packaging violations, outdated service descriptions, incomplete preadmission screenings, unsigned support plans, delayed medical evaluations, missing directions for key-locking devices, incomplete resident records logs, and abuse incidents.
Complaint Details
The April 2024 and July 2024 inspections were complaint-related, investigating incidents including abuse of resident #2 by staff, failure to assist resident #1 with transfers, and other regulatory violations. The abuse allegation was substantiated by APS following investigation.
Deficiencies (25)
| Description |
|---|
| Failure to post current license inspection summaries in a public and conspicuous place. |
| Resident records were unlocked, unattended and accessible, violating confidentiality requirements. |
| No influenza poster posted in a public place as required by the Influenza Awareness Act. |
| Insufficient number of staff trained in first aid and certified in obstructed airway techniques and CPR present during shifts. |
| Direct care staff did not receive required annual training hours related to job duties. |
| Direct care staff did not receive required training on specified topics including medication self-administration, dementia care, infection control, and others. |
| Direct care staff did not receive required annual training on fire safety by a fire safety expert. |
| Heat sources exceeding 120°F accessible to residents were not equipped with protective guards or insulation. |
| Bathrooms without operable outside windows lacked exhaust fans for ventilation. |
| Food and emergency water stored on the floor in kitchen storage room. |
| No thermometer present in special needs kitchen drink refrigerator. |
| Food stored in open and unsealed containers in walk-in freezer and cooler. |
| Emergency preparedness plans not posted in a conspicuous and public place. |
| Residents with hearing impairment lacked approved signaling devices in common areas to alert fire alarms. |
| Medications repackaged into small bags not in original labeled containers. |
| Written description of services inaccurately indicated transportation was provided when it was not. |
| Preadmission screening forms incomplete, unsigned, or missing for several residents. |
| Resident support plan not signed by resident and lacked documentation of refusal or inability to sign. |
| Medical evaluation for secured dementia care unit resident completed after admission date. |
| No directions posted for operating key-locking devices at secured dementia care unit exit door. |
| Resident records destruction log missing birthdates and admission dates. |
| Resident #1 not assisted with transfers due to inoperable Hoyer lift. |
| Resident #2 subjected to inappropriate and non-consensual kissing by staff, causing fear and distress. |
| Poisonous materials left unlocked and accessible in secured dementia care unit storage room. |
| Sanitary conditions not maintained; red sticky substance found on freezer drawer bottom. |
Report Facts
License Capacity: 112
Residents Served: 54
Residents Served: 51
Residents Served: 50
Capacity of Secure Dementia Care Unit: 18
Residents Served in Secure Dementia Care Unit: 8
Residents Served in Secure Dementia Care Unit: 5
Residents Served in Secure Dementia Care Unit: 7
Total Daily Staff: 70
Waking Staff: 53
Total Daily Staff: 67
Waking Staff: 50
Total Daily Staff: 66
Waking Staff: 50
Gallons of Emergency Water Stored on Floor: 137
Open Hot Dogs: 7
Open Box of Corn Kernels: 30
Open Bag of Cookie Pieces: 0.5
Open Bag of Sugar: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Roser | Lead Inspector | Lead inspector for multiple inspections including March 18, 2024 and April 18, 2024. |
| Eric Ambrose | SMD | Responsible for conducting fire safety training and monitoring compliance. |
| Staff person A | Involved in abuse incident with resident #2; suspended and terminated. |
Inspection Report
Renewal
Census: 54
Capacity: 112
Deficiencies: 18
Mar 18, 2024
Visit Reason
The inspection was conducted as a renewal, provisional exit conference on March 19, 2024, to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall, but several deficiencies were cited including failure to post current license inspection summaries, resident record confidentiality breaches, lack of influenza poster, incomplete quality management plan content, insufficient first aid/CPR trained staff, inadequate annual training for direct care staff, heat source safety issues, bathroom ventilation problems, improper food storage, missing emergency procedures posting, hearing impairment fire alarm signaling deficiencies, medication packaging violations, inaccurate description of services, incomplete preadmission screening, unsigned support plans, late medical evaluations, missing directions for key-locking devices, and incomplete resident records destruction logs.
Complaint Details
Complaint investigation conducted on April 18 and 25, 2024, revealed an incident of verbal and physical abuse by staff person A toward resident #2, which was substantiated by Adult Protective Services. Staff person A was terminated. Additional deficiencies related to activities of daily living assistance were also cited, including failure to provide required assistance due to inoperable Hoyer lift. Follow-up and corrective actions were directed.
Deficiencies (18)
| Description |
|---|
| Failure to post current license inspection summaries in a public and conspicuous place. |
| Resident records were unlocked, unattended, and accessible, violating confidentiality requirements. |
| No influenza poster posted in a public place as required by the Influenza Awareness Act. |
| Quality management plan did not include review of staff training or licensing violations and plans of correction. |
| Insufficient number of staff trained in first aid and certified in obstructed airway techniques and CPR present during shifts. |
| Direct care staff person did not receive required 12 hours of annual training related to job duties. |
| Direct care staff person did not receive required annual training on specified topics including medication, dementia care, infection control, and resident rights. |
| Direct care staff person did not receive required annual training on fire safety, emergency preparedness, and resident rights. |
| Fireplace in special needs kitchen was on and measured 152°F on glass protective guard without proper safety guards. |
| Bathrooms in bedrooms #154 and #229 lacked operable outside windows or exhaust fans for ventilation. |
| Emergency water stored on kitchen storage room floor. |
| No thermometer present in special needs kitchen drink refrigerator. |
| Open and unsealed food items found in walk-in freezer including frozen carrots and muffins. |
| Emergency preparedness plans not posted in a conspicuous and public place in the home. |
| Resident #7's support plan not signed by resident and did not indicate reason for absence of signature. |
| Resident #6's medical evaluation was completed after admission to secured dementia care unit. |
| No directions posted for operating locking mechanism near secured dementia care unit exit door. |
| Resident records destruction log did not include birthdates and admission dates of destroyed records. |
Report Facts
License Capacity: 112
Residents Served: 54
Residents Served in Secured Dementia Care Unit: 8
Staffing Hours: 70
Waking Staff: 53
Deficiency Counts: 18
Residents Served: 51
Residents Served in Secured Dementia Care Unit: 5
Staffing Hours: 67
Waking Staff: 50
Residents Served: 50
Residents Served in Secured Dementia Care Unit: 7
Staffing Hours: 66
Waking Staff: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and certificate of compliance. |
| Staff person A | Named in abuse finding involving resident #2; suspended and terminated following investigation. | |
| Eric Ambrose | SMD | Responsible for conducting annual fire safety training and ensuring staff training compliance. |
Inspection Report
Renewal
Census: 54
Capacity: 112
Deficiencies: 24
Mar 18, 2024
Visit Reason
The inspection was conducted as a renewal and provisional exit conference 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 several deficiencies were cited including failure to post current license inspection summaries, resident record confidentiality breaches, lack of influenza poster, incomplete quality management plan content, insufficient first aid/CPR trained staff, incomplete annual staff training, heat source safety issues, bathroom ventilation problems, improper food storage, missing emergency procedures posting, inadequate fire alarm signaling for hearing impaired residents, medication packaging violations, outdated description of services, incomplete preadmission screening, unsigned support plans, delayed medical evaluations, missing directions for key-locking devices, incomplete resident records log, and abuse incident involving a staff member.
Complaint Details
The complaint investigation included incidents of abuse involving staff person A and resident #2, which was substantiated by Adult Protective Services. The investigation also addressed multiple regulatory violations related to resident care, safety, and facility operations.
Deficiencies (24)
| Description |
|---|
| Failure to post current license inspection summaries in a public and conspicuous place. |
| Resident records were unlocked, unattended and accessible, violating confidentiality requirements. |
| No influenza poster posted in a public place as required by the Influenza Awareness Act. |
| Quality management plan did not include review of staff training or licensing violations and plans of correction. |
| Insufficient number of staff trained in first aid and certified in obstructed airway techniques and CPR present during shifts. |
| Direct care staff person did not receive required 12 hours of annual training related to job duties during 2023. |
| Direct care staff person did not receive required annual training on specified topics including medication self-administration, dementia care, infection control, and others during 2023. |
| Direct care staff person did not receive required annual training on fire safety, emergency preparedness, resident rights, and other topics during 2023. |
| Fireplace glass protective guard measured 152°F, exceeding safe temperature without protective guards. |
| Bathrooms in bedrooms #154 and #229 lacked operable outside windows or exhaust fans for ventilation. |
| Emergency water stored on kitchen storage room floor, violating food storage requirements. |
| No thermometer present in special needs kitchen refrigerator. |
| Open and unsealed food items found in walk-in freezer and dry storage pantry. |
| Emergency preparedness plans not posted in a conspicuous and public place in the home. |
| Residents #7 and #9 unable to hear fire alarm system in common areas; no approved signaling devices present. |
| Resident #6's Alprazolam tablets were cut in half and repackaged into small bags, not kept in original labeled containers. |
| Home's written description of services incorrectly indicated transportation was provided when it was not. |
| Preadmission screenings were incomplete, unsigned, or missing for several residents. |
| Resident #7's support plan was not signed by the resident and lacked indication of refusal or inability to sign. |
| Resident #6 admitted to secured dementia care unit without medical evaluation completed within 60 days prior to admission. |
| No directions posted near key-locking device at secured dementia care unit exit door. |
| Resident records destruction log did not include birthdates and admission dates of destroyed records. |
| Resident #1 was not assisted with transfers as required due to inoperable Hoyer lift. |
| Resident #2 was verbally and physically abused by staff person A, causing fear and distress. |
Report Facts
License Capacity: 112
Residents Served: 54
Residents Served in Secured Dementia Care Unit: 8
Staffing Hours: 70
Waking Staff: 53
Residents Served: 51
Residents Served in Secured Dementia Care Unit: 5
Staffing Hours: 67
Waking Staff: 50
Residents Served: 50
Residents Served in Secured Dementia Care Unit: 7
Staffing Hours: 66
Waking Staff: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in abuse incident involving resident #2 and subsequent investigation and termination. | |
| Resident #6 | Named in medication packaging and medical evaluation deficiencies. | |
| Resident #7 | Named in support plan signature and fire alarm signaling deficiencies. | |
| Resident #9 | Named in fire alarm signaling deficiency. | |
| Resident #1 | Named in ADL assistance deficiency due to inoperable Hoyer lift. | |
| Resident #2 | Named in abuse incident. |
Inspection Report
Follow-Up
Census: 49
Capacity: 112
Deficiencies: 4
Jan 18, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit to verify the implementation of a previously submitted plan of correction related to medication storage, labeling, changes, and administration documentation.
Findings
The facility was found to have repeat violations regarding medication storage, labeling, changes in medication orders, and documentation of medication administration. The submitted plan of correction was determined to be fully implemented as of the follow-up inspection.
Deficiencies (4)
| Description |
|---|
| Medication eye drops were opened, undated, and filled beyond the manufacturer's 28-day discard requirement. |
| Several residents' prescription medications lacked pharmacy labels on the original containers. |
| Medication changes were not properly documented in writing; a medication was omitted without a discontinuation order. |
| Medications were administered by staff but not documented in the medication administration record (MAR) with no exceptions noted. |
Report Facts
License Capacity: 112
Residents Served: 49
Memory Care Capacity: 18
Memory Care Residents Served: 8
Hospice Residents: 12
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Total Daily Staff: 65
Waking Staff: 49
Inspection Report
Complaint Investigation
Census: 66
Capacity: 112
Deficiencies: 23
Aug 14, 2023
Visit Reason
The inspection was conducted due to complaints, provisional license issues, and incidents at The Pines of Mt. Lebanon facility.
Findings
Multiple violations were found including confidentiality breaches, resident elopement, medication errors, incomplete assessments, abuse allegations, and deficiencies in resident care and documentation. The facility was issued a second provisional license with required corrective actions and monitoring.
Complaint Details
The visit was complaint-related involving allegations of abuse, neglect, medication errors, and failure to comply with regulatory requirements. Some abuse allegations were substantiated leading to staff suspension and termination. The facility failed to report abuse and incidents timely to authorities and failed to notify residents and designated persons.
Deficiencies (23)
| Description |
|---|
| Resident records were left unlocked and accessible, breaching confidentiality. |
| Resident #5 left the home unattended without staff hearing the wander guard alarm. |
| Exit doors were missing required exit signs. |
| Resident #5's annual medical evaluation was outdated. |
| Discontinued medication was still present in the home. |
| Medication administration times were not properly documented. |
| Resident #6's assessment did not reflect exit-seeking behavior and resident #7 had no assessment completed. |
| Resident #5 left the home unattended and unsupervised, causing safety concerns. |
| Resident #7 had no support plan completed within 30 days of admission. |
| Resident #6's medical evaluation did not indicate need for secured dementia care unit. |
| Multiple medications were not current or properly labeled. |
| Medications were not stored with proper labeling or security. |
| Medications were administered late or not available as prescribed. |
| Allegations of abuse were not reported timely to the appropriate authorities. |
| Staff person involved in abuse allegations was not immediately suspended. |
| Residents and designated persons were not notified of abuse allegations. |
| Incidents were not reported to the Department within required timeframes. |
| Resident #7 waited excessive time for assistance, resulting in falls and soiling. |
| Resident #2 was transferred without required assistance, causing pain. |
| Resident #3's insulin administration was not properly documented. |
| Resident assessments and support plans were incomplete or unsigned. |
| Medication carts were left unlocked and unattended. |
| Glucometers were not set to correct date and time. |
Report Facts
License Capacity: 112
Residents Served: 66
Secured Dementia Care Unit Capacity: 18
Residents Served in Secured Dementia Care Unit: 14
Current Residents on Hospice: 7
Staffing Hours - Resident Support Staff: 4
Staffing Hours - Total Daily Staff: 86
Staffing Hours - Waking Staff: 65
Number of Residents Aged 60 or Older: 66
Number of Residents Diagnosed with Mental Illness: 2
Number of Residents with Mobility Need: 16
Number of Residents with Physical Disability: 3
Fine Amount Per Violation: 310
Number of Violations with Fine: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in multiple abuse and neglect findings including rough handling of residents and failure to suspend immediately. | |
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters. |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 112
Deficiencies: 19
Aug 14, 2023
Visit Reason
The inspection was conducted due to complaints, provisional license issues, and incidents at The Pines of Mt. Lebanon facility. Multiple visits occurred between August and October 2023 to investigate violations and compliance.
Findings
The facility was found to have multiple violations including confidentiality breaches, resident elopement, medication administration errors, incomplete medical evaluations and assessments, improper medication storage and labeling, failure to report and investigate abuse allegations properly, and deficiencies in resident support plans and signatures. Several repeat violations were noted. Plans of correction were directed with deadlines, but many were not implemented by the time of the last report.
Complaint Details
The complaint investigation involved allegations of abuse, neglect, medication errors, and failure to comply with regulatory requirements. Some allegations were substantiated, including rough handling of residents by staff and failure to report abuse to authorities. The facility was required to implement corrective actions including staff training, improved documentation, and enhanced supervision.
Deficiencies (19)
| Description |
|---|
| Resident records were left unsecured and accessible, violating confidentiality requirements. |
| Resident #5 left the home unattended without staff hearing the wander guard alarm. |
| Exit doors were not properly labeled with exit signs. |
| Resident #5's annual medical evaluation was outdated. |
| Discontinued medications were still present in the home. |
| Medication administration times and documentation were inaccurate or incomplete. |
| Resident #6's initial assessment was incomplete and did not reflect exit-seeking behavior. |
| Resident #7 had no initial assessment or support plan completed. |
| Resident #5 left the home unattended and unsupervised, causing safety concerns. |
| Resident #6's medical evaluation did not indicate need for secured dementia care unit. |
| Medications were not current or properly labeled; some lacked pharmacy labels or had incorrect instructions. |
| Medications and syringes were left unlocked and accessible in medication carts. |
| Resident abuse allegations were not reported timely to appropriate authorities and designated persons. |
| Staff person involved in abuse allegations was not immediately suspended. |
| Incident reports were not submitted to the Department within required timeframes. |
| Residents were left waiting excessive times for toileting assistance, resulting in neglect. |
| Residents were subjected to verbal and physical abuse by staff. |
| Medication administration records lacked required details including insulin units administered. |
| Resident assessments and support plans were incomplete, unsigned, or missing required documentation. |
Report Facts
License Capacity: 112
Residents Served: 66
Secured Dementia Care Unit Capacity: 18
Residents Served in Secured Dementia Care Unit: 14
Fine Amount Per Violation: 310
Number of Violations Listed for Fine: 11
Staffing Hours: 86
Waking Staff: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Direct Care Staff | Named in multiple abuse and neglect allegations involving rough handling of residents and failure to follow proper procedures. |
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters. |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 112
Deficiencies: 27
Aug 14, 2023
Visit Reason
The inspection was conducted due to complaints, provisional license issues, and incidents at The Pines of Mt. Lebanon facility.
Findings
Multiple violations were found including confidentiality breaches, resident elopement, medication administration errors, incomplete medical evaluations and assessments, failure to report and investigate abuse allegations properly, and deficiencies in resident support plans and signatures.
Complaint Details
The visit was complaint-related involving allegations of abuse, neglect, medication errors, and failure to comply with regulations. Some abuse allegations were substantiated, and investigations were conducted. The facility failed to report abuse and incidents timely to the Department and Area Office of Aging.
Deficiencies (27)
| Description |
|---|
| Resident records were left unlocked and accessible, breaching confidentiality. |
| Resident #5 left the home unattended without staff hearing the wander guard alarm. |
| Exit doors were not labeled with exit signs. |
| Resident #5's annual medical evaluation was outdated. |
| Discontinued medications were still present in the home. |
| Medication administration times were not properly documented. |
| Resident #6's initial assessment was incomplete and no assessment was completed for resident #7. |
| Resident #5 left the home unattended and unsupervised, causing safety concerns. |
| Resident #7's support plan was not completed within 30 days of admission. |
| Resident #6's medical evaluation did not indicate need for secured dementia care unit. |
| Medications were not current or properly labeled, including insulin and other prescriptions. |
| Medications were not administered at prescribed times. |
| Allegations of abuse were not reported to the Area Office of Aging or Department as required. |
| Staff person involved in abuse allegations was not immediately suspended. |
| Residents and designated persons were not notified of abuse allegations. |
| Incidents of abuse were not reported to the Department timely. |
| Resident #7 waited excessive time for toileting assistance and fell without timely help. |
| Residents were neglected and verbally abused by staff. |
| Medication carts were left unlocked and accessible. |
| Discontinued medications were not removed timely from medication carts. |
| Resident support plans were not signed by required individuals. |
| Medical evaluations were incomplete or missing required information. |
| Glucometers were not set to correct date and time. |
| Medication administration records did not document insulin units administered. |
| Resident assessments were incomplete or missing diagnoses. |
| Resident support plans were incomplete or missing required signatures. |
| Resident #2 was transferred without required assistance causing pain. |
Report Facts
License Capacity: 112
Residents Served: 66
Secured Dementia Care Unit Capacity: 18
Residents Served in Secured Dementia Care Unit: 14
Staffing Hours: 86
Waking Staff: 65
Fine Amount Per Violation: 310
Number of Violations Listed for Fine: 11
Resident Wait Time for Toileting Assistance: 72
Resident Wait Time for Toileting Assistance: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in multiple abuse and medication administration findings. | |
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters. |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 112
Deficiencies: 17
Aug 14, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by multiple complaints and incidents, including allegations of mistreatment, abuse, failure to submit and comply with plans of correction, and other regulatory concerns at The Pines of Mt. Lebanon.
Findings
The inspection identified multiple deficiencies including breaches in resident record confidentiality, failure to prevent resident elopement, medication administration errors, incomplete or untimely resident assessments and support plans, inadequate staff training, and failure to report and respond appropriately to allegations of abuse. Several repeat violations were noted. Plans of correction were directed but many were not implemented as of the last follow-up.
Complaint Details
The complaint investigation involved multiple allegations including resident abuse, neglect, medication errors, failure to report abuse, and inadequate care. The investigation found substantiated violations and repeat deficiencies. The facility was issued a second provisional license and directed to correct all deficiencies.
Deficiencies (17)
| Description | Severity |
|---|---|
| Resident records were left unsecured and accessible without proper authorization. | — |
| Resident #5 left the home unattended and unsupervised, triggering safety concerns. | — |
| Medications were not current; discontinued medications were found in the home. | Class II |
| Exit doors were not properly labeled with exit signs. | — |
| Resident medical evaluations and assessments were incomplete, untimely, or missing required information. | — |
| Medication administration records lacked documentation of administration times and doses. | — |
| Medications were administered late or not available when scheduled. | — |
| Allegations of resident abuse were not reported timely to appropriate authorities. | — |
| Staff failed to immediately suspend or supervise staff involved in abuse allegations. | — |
| Residents and their designated persons were not notified of abuse allegations. | — |
| Incident reports were not submitted timely to the Department. | — |
| Residents did not consistently receive assistance with activities of daily living as indicated in their plans. | — |
| Residents were subjected to neglect and verbal/physical abuse by staff. | — |
| Medications and syringes were left unlocked and accessible. | — |
| Medication carts contained discontinued medications that were not removed timely. | — |
| Resident support plans and assessments were incomplete, unsigned, or missing required documentation. | — |
| Glucometers were not set to the correct date and time. | — |
Report Facts
License Capacity: 112
Residents Served: 66
Secured Dementia Care Unit Capacity: 18
Residents Served in Secured Dementia Care Unit: 14
Staffing Hours: 86
Waking Staff: 65
Fine Amount Per Violation: 310
Number of Violations with Fines: 10
Resident Wait Time for Assistance: 72
Resident Wait Time for Assistance: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in multiple abuse and neglect findings involving rough handling of residents and failure to follow care plans. | |
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters. |
Inspection Report
Renewal
Census: 57
Capacity: 112
Deficiencies: 32
Mar 27, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of The Pines of Mt. Lebanon facility to assess compliance with Pennsylvania Department of Human Services regulations.
Findings
Multiple violations were found related to resident confidentiality, contract completion, staff training, sanitary conditions, emergency preparedness, medication management, fire safety, and record keeping. Many corrective actions were directed with specified completion dates, but several were noted as not implemented as of July 24, 2023.
Deficiencies (32)
| Description |
|---|
| Resident privacy coding document containing names of multiple residents was posted in a public area. |
| Resident-home contracts were not completed timely for certain residents. |
| Telephone number of the Department’s personal care home regional office was not posted in a conspicuous and public place. |
| Staff trained in first aid and CPR were not present at all times as required. |
| Direct care staff did not receive required annual training hours. |
| Direct care staff did not receive required training in infection control, personal care needs, and safe management techniques. |
| Sanitary conditions were not maintained; freezer in secure dementia care unit kitchen had large splatters of sherbet and vanilla ice cream. |
| Emergency telephone numbers for nearest hospital, police, fire department, etc. were not posted in the secure dementia care unit kitchen. |
| No operable lamp or other source of lighting that can be turned on/off at bedside for residents #1 and #2. |
| No grab bar, hand rail or assist bar in unlocked employee bathroom in main hallway. |
| Food was stored uncovered in the freezer in the secure dementia care unit kitchen. |
| Outdated or unlabeled food was found in the freezer in the secure dementia care unit kitchen. |
| Residents #5 and #6 unable to hear fire alarm system; no approved signaling device installed. |
| Unannounced fire drills were not held monthly as required. |
| Fire drill records did not indicate time or exact evacuation times for multiple drills. |
| Fire drill during sleeping hours was not conducted as required. |
| Fire drills were not held on different days and times as required. |
| Residents #2 and #7 medical evaluations lacked required clinical details and documentation. |
| Discontinued medications were found in medication carts for resident #4 and #8. |
| Medication labels did not match prescribed dosages for residents #2 and #4. |
| Blood sugar readings did not match documented medication administration records for resident #2. |
| Certain prescribed medications for resident #4 were not available in the home. |
| Resident #4's medication administration record indicated incorrect dosing for acetaminophen and oxycodone. |
| Resident #4's medication administration record was not updated with correct prescriptions. |
| Resident #2 was prescribed multiple medications that were not administered on 3/11/23. |
| Resident #8's prescribed medications were not available in the home on 3/27/23. |
| No preadmission screening was completed for residents #4 and #8. |
| Resident #4 and #5 initial assessments were incomplete or missing required diagnoses and medical information. |
| Resident #8's medical evaluation was not completed within 60 days prior to admission as required. |
| Resident #8 did not have a completed cognitive preadmission screening within 72 hours prior to admission. |
| Key-locking devices and directions for operating the home's locking mechanism were not posted near the door leading from the secure dementia care unit courtyard. |
| Multiple resident records were destroyed in 2023 without including required resident identifying information. |
Report Facts
Residents served: 57
License capacity: 112
Staff total daily: 80
Waking staff: 60
Census at inspection: 57
Fine per day: 285
Fine per resident per day: 5
Inspection Report
Complaint Investigation
Census: 62
Capacity: 112
Deficiencies: 3
Jan 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on January 4, 5, and 19, 2023, to assess compliance with regulations related to Personal Care Homes.
Findings
Multiple violations were found including failure to report incidents and medication errors, incomplete medication administration records, and failure to follow prescriber's orders. A provisional license was issued due to failure to submit or comply with an acceptable plan of correction. Several deficiencies remained not implemented as of July 24, 2023.
Complaint Details
The inspection was complaint-driven, focusing on incidents involving smoke alarms, sprinkler leaks, and multiple medication errors involving residents #1, #2, #4, and #5. The complaint was substantiated with findings of unreported incidents and medication administration issues.
Deficiencies (3)
| Description |
|---|
| Failure to report incidents such as smoke detection and sprinkler leaks to the Department within 24 hours. |
| Medication administration records did not include initials of staff administering medications for multiple residents. |
| Failure to follow prescriber's orders with numerous medications not administered to residents on multiple dates. |
Report Facts
License Capacity: 112
Residents Served: 62
Fine per day: 285
Staffing: 72
Waking Staff: 54
Inspection Report
Complaint Investigation
Census: 52
Capacity: 112
Deficiencies: 5
Oct 17, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on October 13, 14, and 17, 2022, to review compliance and the submitted plan of correction.
Findings
Multiple deficiencies were found including unsanitary conditions with feces smeared in resident bathrooms, multiple stains on bedroom carpets, incomplete annual medical evaluations, missing posted menus for the week, and incomplete medication administration records for a resident.
Complaint Details
The inspection was complaint-driven, with a review of submitted plans of correction which were found not implemented as of June 14, 2023.
Deficiencies (5)
| Description |
|---|
| Sanitary conditions not maintained; feces smeared on toilet seats and floors in multiple resident bathrooms. |
| Multiple stains on carpeting in bedrooms 127 and 201. |
| Annual medical evaluation for resident #1 was incomplete and missing medication list. |
| Menus were not posted for the week of 10/16/22 – 10/22/22. |
| Medication administration records for resident #2 were not initialed at required times for multiple medications. |
Report Facts
License Capacity: 112
Residents Served: 52
Secured Dementia Care Unit Capacity: 17
Secured Dementia Care Unit Residents Served: 7
Hospice Current Residents: 9
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 10
Residents 60 Years or Older: 52
Residents with Physical Disability: 3
Inspection Report
Complaint Investigation
Census: 34
Capacity: 112
Deficiencies: 3
May 19, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 05/19/2022 and 05/31/2022, followed by a plan of correction submission and review.
Findings
The facility was found to have deficiencies related to medication administration documentation and failure to follow prescriber's orders for blood glucose monitoring and insulin administration. A plan of correction was submitted and determined to be fully implemented.
Complaint Details
The inspection was complaint-driven, with a follow-up plan of correction submission and review. The complaint involved medication administration and adherence to prescriber's orders.
Deficiencies (3)
| Description |
|---|
| Medication administration record did not include initials of staff who administered medication to resident #1 at specified times. |
| Resident #2's blood glucose checks were not performed as prescribed, and insulin doses were inconsistently administered or documented. |
| Resident #3's blood glucose was not checked as prescribed. |
Report Facts
License Capacity: 112
Residents Served: 34
Staffing Hours: 51
Waking Staff: 38
Secured Dementia Care Unit Capacity: 18
Residents Served in SDCU: 6
Hospice Residents: 7
Residents 60 Years or Older: 334
Residents with Mobility Need: 17
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 33
Capacity: 112
Deficiencies: 7
Feb 23, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection of THE PINES OF MT. LEBANON facility on 02/23/2022 through 02/25/2022.
Findings
The inspection identified multiple deficiencies including missing influenza awareness posters, entrapment hazards due to uncovered bedrails, unsecured poisonous materials accessible to residents, incomplete medical evaluations, medication record errors, unsigned resident contracts, and failure to follow prescriber's medication orders. Plans of correction were accepted and documented as implemented.
Deficiencies (7)
| Description |
|---|
| Influenza awareness poster was not posted in a public and conspicuous place as required by the Influenza Awareness Act. |
| Bedrails on both sides of resident #2's bed were uncovered, posing an entrapment hazard. |
| An 8 ounce tube of Colgate toothpaste with poison control warning was unlocked and accessible in a secured dementia unit bathroom, posing a risk to residents not assessed as capable of safely using poisons. |
| Medical evaluation for resident #1 did not include cognitive function or health status. |
| Medication prescribed to resident #1 was not indicated on the medication administration record. |
| Resident-home contract for resident #1 was not signed by the resident. |
| Resident #4 was not administered prescribed medications on multiple occasions due to medication unavailability in the home. |
Report Facts
License Capacity: 112
Residents Served: 33
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 9
Hospice Current Residents: 8
Resident Support Staff Hours: 33
Total Daily Staff: 84
Waking Staff: 63
Inspection Report
Complaint Investigation
Census: 36
Capacity: 112
Deficiencies: 3
Dec 13, 2021
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 12/13/2021 and 12/14/2021.
Findings
The facility was found to have deficiencies related to incomplete training records, unsigned support plans for residents, and failure to provide assistance with activities of daily living as indicated in residents' support plans. Plans of correction were submitted and some were accepted and implemented.
Complaint Details
The inspection was complaint-driven, investigating incidents reported during the week of 12/6/21 involving staff person A's failure to assist residents as required. The complaint was substantiated with repeat violations noted.
Deficiencies (3)
| Description |
|---|
| Lack of documentation for required training for staff person A. |
| Support plans for residents #2 and #3 were not signed by the assessor or the resident. |
| Staff person A failed to assist residents #1 and #2 with activities of daily living as indicated in their support plans, including refusal to assist resident #1 with bedpan use. |
Report Facts
License Capacity: 112
Residents Served: 36
Secured Dementia Care Unit Capacity: 16
Residents Served in Dementia Unit: 9
Current Hospice Residents: 7
Resident Age 60 or Older: 35
Residents with Mental Illness: 2
Residents with Mobility Need: 18
Residents with Physical Disability: 1
Total Daily Staff: 54
Waking Staff: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to lack of training documentation and failure to assist residents with activities of daily living. | |
| RWD | Responsible for conducting audits and education related to support plan compliance. |
Inspection Report
Renewal
Deficiencies: 0
Sep 27, 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
Sep 8, 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
Complaint Investigation
Census: 39
Capacity: 112
Deficiencies: 2
Aug 27, 2021
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Findings
The facility was found to have deficiencies related to support plan revisions for residents, specifically failure to update support plans to reflect residents' safety risks and care needs. The submitted plan of correction was determined to be fully implemented.
Complaint Details
The visit was complaint-related, triggered by concerns about resident safety and support plan adequacy. The plan of correction was accepted and fully implemented.
Deficiencies (2)
| Description |
|---|
| Resident #1’s support plan was not updated to indicate the resident’s lack of regard for safety while self-propelling a wheelchair or the care and services needed to prevent injuries. |
| Resident #2’s support plan did not indicate the high fall risk including the home’s care and services to protect the resident despite multiple unwitnessed falls. |
Report Facts
License Capacity: 112
Residents Served: 39
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 7
Hospice Residents: 5
Resident #2 Falls: 5
Inspection Report
Renewal
Capacity: 112
Deficiencies: 0
May 21, 2021
Visit Reason
The document is a renewal license issued in response to the facility's April 6, 2021 renewal application to operate the Personal Care Home. The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
The Department has issued a regular license for The Pines of Mt. Lebanon following the renewal application. No findings of noncompliance are stated in this document, but the Department notes that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Maximum capacity: 112
Secure Dementia Care Unit capacity: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal license letter |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 112
Deficiencies: 5
May 18, 2021
Visit Reason
The inspection was a partial, unannounced complaint investigation conducted on 05/18/2021 and 05/20/2021 at The Pines of Mt. Lebanon.
Findings
The inspection found multiple deficiencies related to expired administrator license, medication storage and administration errors, inaccurate glucometer calibration and blood glucose recording, and failure to follow prescriber's orders for resident #1. Plans of correction were accepted and implemented with specified completion dates.
Complaint Details
The inspection was triggered by a complaint, as indicated by the inspection reason 'Complaint' and the partial, unannounced nature of the visit.
Deficiencies (5)
| Description |
|---|
| The nursing home administrator license for Staff person A expired on 6/30/2020. |
| The glucometer belonging to resident #1 was not calibrated to the current date, and blood glucose readings were inaccurately recorded on the Medication Administration Record. |
| Resident #1's MAR was not initialed by staff who administered Lantus insulin on 5/7/2021 at 8:00 p.m. |
| Resident #1's insulin and other medications were administered late or withheld without proper documentation on multiple occasions. |
| The home failed to develop and implement procedures for safe storage, access, security, distribution and use of medications and medical equipment by trained staff. |
Report Facts
License Capacity: 112
Residents Served: 40
Staffing Hours - Total Daily Staff: 62
Staffing Hours - Waking Staff: 47
Residents with Mobility Need: 22
Residents Age 60 or Older: 39
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Physical Disability: 1
Residents Diagnosed with Intellectual Disability: 0
Inspection Report
Renewal
Census: 37
Capacity: 112
Deficiencies: 11
Apr 8, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of THE PINES OF MT. LEBANON facility by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 04/08/2021 through 04/13/2021.
Findings
The inspection identified multiple deficiencies including failure to post required documents, unsecured resident records, lack of carbon monoxide detectors near hot water tanks, improper resident transfer assistance, unsigned resident contracts, failure to educate a resident on rights, unsanitary conditions, incomplete menu postings, unlocked medications, discontinued medications present, and inaccurate medication records. Plans of correction were accepted for all deficiencies with specified completion dates.
Deficiencies (11)
| Description |
|---|
| Failure to post a copy of 55 Pa. Code Chapter 2600 in a conspicuous and public place in the home. |
| Resident records, including personal identifiable information, were unlocked, unattended, and accessible in unsecured areas. |
| No carbon monoxide detector installed in close proximity to the home's 3 hot water tanks as required by law. |
| Residents requiring two-person transfer assistance were transferred with only one staff member, contrary to their assessments and support plans. |
| Resident #7's contract was not signed by the resident. |
| Resident #7 was not educated on resident rights or the right to lodge complaints without retaliation. |
| Walls of the microwave in the secured dementia care unit were covered in dried food. |
| Menu for the upcoming week was not posted in a conspicuous and public place as required. |
| A box of over-the-counter medication was unlocked, unattended, and accessible in the Wellness room. |
| Discontinued medication (Montelukast Sod 10mg) was found in the medication cart. |
| Blood glucose readings for resident #9 were not accurately recorded on the medication administration record. |
Report Facts
License Capacity: 112
Residents Served: 37
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 9
Hospice Current Residents: 6
Staffing Hours - Total Daily Staff: 58
Staffing Hours - Waking Staff: 44
Inspection Report
Follow-Up
Census: 37
Capacity: 112
Deficiencies: 4
Mar 25, 2021
Visit Reason
The inspection was conducted as a follow-up to review the submitted plan of correction related to a resident abuse incident that occurred on 03/16/2021.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing the failure to immediately report suspected resident abuse and failure to properly supervise the involved staff. The incident involved direct care staff mocking a resident and inappropriate language during care. The staff member involved resigned during the investigation.
Complaint Details
The visit was complaint-related due to an incident on 03/16/2021 where direct care staff person D mocked resident #1 by making noises and using inappropriate language during incontinence care. The home delayed reporting the incident until 03/19/2021. The staff member was not immediately suspended and continued to work until later that evening and the following day. The staff member resigned during the investigation.
Deficiencies (4)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident in accordance with regulations. |
| Failure to immediately develop and implement a plan of supervision or suspend the staff person involved in the alleged abuse incident. |
| Failure to report the incident or condition to the Department within 24 hours as required. |
| Failure to treat a resident with dignity and respect; direct care staff mocked the resident and used inappropriate language during care. |
Report Facts
License Capacity: 112
Residents Served: 37
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 10
Current Residents Receiving Hospice: 7
Residents Age 60 or Older: 40
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 22
Residents with Physical Disability: 1
Loading inspection reports...
