Inspection Reports for The Residence at Arrowood
512 N Lewis Run Rd, West Mifflin, PA 15122, USA, PA, 15122
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
15.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
223% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
56% occupied
Based on a January 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Census: 47
Capacity: 84
Deficiencies: 0
Jan 29, 2025
Visit Reason
The inspection was conducted as a result of complaint, monitoring, and settlement reasons during an unannounced partial inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 84
Residents Served: 47
Current Hospice Residents: 15
Residents Age 60 or Older: 47
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 10
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 46
Capacity: 84
Deficiencies: 3
Oct 1, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation, unannounced, to review compliance and address reported issues at the facility.
Findings
The inspection found multiple medication administration violations, including failure to administer prescribed medications due to lack of qualified staff and improper documentation on medication administration records (MARs). The facility submitted a plan of correction which was accepted and implemented.
Complaint Details
The visit was complaint-related and incident-based, investigating medication administration errors and staffing issues. The submitted plan of correction was determined to be fully implemented.
Deficiencies (3)
| Description |
|---|
| Numerous residents did not receive their prescribed morning medications due to no qualified staff present to administer medications. |
| Medication administration records (MARs) lacked proper staff initials for administered medications on multiple dates. |
| Failure to report medication errors to the Department as required. |
Report Facts
License Capacity: 84
Residents Served: 46
Hospice Current Residents: 10
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 7
Residents 60 Years or Older: 46
Total Daily Staff: 53
Waking Staff: 40
Inspection Report
Census: 43
Capacity: 84
Deficiencies: 0
May 23, 2024
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 84
Residents Served: 43
Current Hospice Residents: 11
Resident Support Staff: 0
Total Daily Staff: 51
Waking Staff: 38
Residents Age 60 or Older: 43
Residents with Mobility Need: 8
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 43
Capacity: 84
Deficiencies: 1
Mar 22, 2024
Visit Reason
The inspection visit on 03/22/2024 was conducted as a complaint investigation, unannounced and partial in nature.
Findings
The inspection found multiple pieces of trash outside the personal care home near the kitchen delivery area and main entrance, including cigarette butts, plastic silverware, napkins, and a torn plastic bag. The facility submitted a plan of correction which was determined to be fully implemented by 04/18/2024.
Complaint Details
The visit was complaint-related and the plan of correction was accepted and fully implemented. No substantiation status explicitly stated.
Deficiencies (1)
| Description |
|---|
| Multiple pieces of trash found outside the home including cigarette butts, plastic silverware, napkins, and a torn plastic bag, violating regulation 85e requiring trash to be kept in covered receptacles. |
Report Facts
License Capacity: 84
Residents Served: 43
Current Hospice Residents: 11
Waking Staff: 39
Total Daily Staff: 52
Mobility Need: 9
Trash Items: 11
Inspection Report
Follow-Up
Census: 24
Capacity: 84
Deficiencies: 17
Mar 15, 2023
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction for the facility.
Findings
The inspection found multiple deficiencies including breaches in record confidentiality, expired carbon monoxide detector batteries, improper storage of poisonous materials, unsanitary conditions, evidence of insect infestation, damaged window screens, broken furniture, unsafe ice and snow removal, inadequate lighting in resident rooms, improper food storage, lint accumulation in dryers, overdue fire extinguisher inspection, and unsecured medications. All deficiencies had plans of correction accepted and were reported as implemented by June 8, 2023.
Deficiencies (17)
| Description |
|---|
| Resident medication administration record and confidential information were left unsecured in the unlocked, unattended Director of Nursing's office. |
| Carbon monoxide detector batteries were outdated in multiple laundry room locations. |
| Poisonous materials were stored with food items in a kitchenette cabinet. |
| Sanitary conditions were poor including water and dead bugs in ice cream freezer, cigarette butts outside kitchen exit, dirty wash rag in shower, and uncleaned areas in kitchenette. |
| Infestation of over 30 dead stink bugs in window track of second-floor laundry room. |
| Trash outside the home was kept in an uncovered container overflowing with trash. |
| Tears and missing screens on windows in laundry rooms and hallways. |
| Broken inside shelf in lower cabinet under coffee maker in kitchenette. |
| Thin layer of ice and snow partially covering sidewalk cement pads near exit door. |
| Bedside lamp in resident room did not stay on when switched. |
| Refrigerator and freezer temperatures above required limits (5°F and 8°F respectively). |
| Food items stored in opened and unsealed containers in pantry, walk-in freezer, cooler, and baker's rack. |
| Lint accumulation covering most of lint filter in laundry room dryer. |
| Fire extinguisher system last inspected in 2022, overdue for annual inspection. |
| Unlocked medications and syringes found in unlocked filing cabinet and office closet in Director of Nursing's office. |
| Unlocked medications found in unlocked refrigerator in Director of Nursing's office. |
| Medications for residents no longer residing in the home were found unsecured in the office. |
Report Facts
Residents Served: 24
License Capacity: 84
Cigarette Butts: 15
Dead Stink Bugs: 30
Lint Coverage: 7
Temperature: 5
Temperature: 8
Sidewalk Cement Pads: 6
Inspection Report
Monitoring
Census: 24
Capacity: 84
Deficiencies: 1
Feb 21, 2023
Visit Reason
The inspection was conducted as a monitoring visit to assess compliance with licensing regulations for The Residence At Arrowood.
Findings
The inspection found a violation related to evacuation procedures during a fire drill where only 26 of 27 residents present were evacuated. A plan of correction was directed to educate staff and residents and to audit fire drill records.
Deficiencies (1)
| Description |
|---|
| During a fire drill on 10/19/22, only 26 of 27 residents present were evacuated. |
Report Facts
Residents present during fire drill: 27
Residents evacuated during fire drill: 26
Residents served: 24
License capacity: 84
Inspection Report
Monitoring
Census: 27
Capacity: 84
Deficiencies: 4
Nov 7, 2022
Visit Reason
The inspection was a monitoring visit conducted on November 7, 2022, as part of the Pennsylvania Department of Human Services licensing oversight of The Residence At Arrowood.
Findings
The inspection identified multiple violations related to medication storage, labeling, administration errors, and support plan revisions. Several repeat violations were noted, and plans of correction were directed to address these issues.
Deficiencies (4)
| Description |
|---|
| Medication (Ozempic) was not dated when opened. |
| Medication label did not have a 'directions changed' sticker despite dosage change. |
| Incorrect insulin doses administered to Resident #1 on multiple occasions. |
| Resident #2's support plan did not specify hospice care and services despite hospice status. |
Report Facts
License Capacity: 84
Residents Served: 27
Current Hospice Residents: 7
Staffing Hours: 37
Waking Staff: 28
Medication Errors: 3
Inspection Report
Renewal
Census: 28
Capacity: 84
Deficiencies: 8
Aug 16, 2022
Visit Reason
The inspection was conducted as a renewal, incident, and monitoring visit to assess compliance with licensing regulations at The Residence at Arrowood.
Findings
Multiple violations were found including failure to post current license inspection summaries, lack of no smoking signage, unsanitary conditions in resident rooms, damaged furniture, lack of operable bedside lighting, inadequate emergency water supply, missing fire drills, and issues with fire drill evacuation procedures. Plans of correction were accepted for all violations with specified completion dates.
Deficiencies (8)
| Description |
|---|
| Failure to post current license inspection summaries on the bulletin board. |
| No smoking signs were not posted at the main entrance as required by the Clean Indoor Air Act. |
| Accumulation of dead bugs and dirt in the window track of Room #146 and unsanitary toilet conditions in resident room #339. |
| Brown faux leather recliner in resident room #339 was severely worn and damaged. |
| No operable lamp or other source of lighting at bedside in room #356. |
| Emergency water supply was insufficient with only 12.67 gallons on site instead of the required 84 gallons for 28 residents. |
| No fire drill was conducted in December 2021; only a notation stating 'COVID' was present. |
| Residents were reportedly not routinely evacuated to a designated fire safe area during fire drills, though documentation supported compliance and violation was later withdrawn. |
Report Facts
License Capacity: 84
Residents Served: 28
Emergency Water Supply Required: 84
Emergency Water Supply On Site: 12.67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary | Signed the cover letter regarding licensing inspection results. |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 84
Deficiencies: 2
Jul 7, 2022
Visit Reason
The inspection was conducted as a complaint and monitoring visit to assess compliance with licensing regulations at The Residence at Arrowood.
Findings
The inspection found violations related to medication management, including failure to have prescribed medications available for administration and failure to follow prescriber's orders.
Complaint Details
The inspection was complaint-related and monitoring in nature. No substantiation status is explicitly stated.
Deficiencies (2)
| Description |
|---|
| Resident #1 was prescribed benzonatate 100 mg capsule three times a day as needed for cough, but the medication was not available in the home at 3:45 p.m. |
| Resident #1 was prescribed donepezil 5 mg tablet nightly, but the medication was not available on certain dates and was not administered accordingly. |
Report Facts
License Capacity: 84
Residents Served: 29
Total Daily Staff: 40
Waking Staff: 30
Residents Diagnosed with Mental Illness: 16
Residents with Mobility Need: 11
Residents 60 Years or Older: 29
Hospice Residents: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the cover letter regarding the inspection results |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 84
Deficiencies: 4
Feb 2, 2022
Visit Reason
The inspection was conducted as a complaint and monitoring visit, unannounced, to investigate alleged violations at The Residence at Arrowood.
Findings
The inspection found violations related to safety issues including lack of handrails on steps, locked emergency exit doors obstructing egress, and admission of residents despite a ban on new admissions. Plans of correction were directed to address these issues.
Complaint Details
The visit was complaint-related and monitoring in nature. The complaint involved safety violations and admission of residents despite a ban. The report does not explicitly state substantiation status.
Deficiencies (4)
| Description |
|---|
| The first-floor short hall emergency exit door near room #117 had a step-down of approximately eight inches with no handrail or grab bar. |
| The first floor short-hall emergency exit door near room #117 was locked with a computer software application and could not be opened from the interior. |
| The first-floor dining room emergency exit, double door number 3, was manually locked with a key not available to staff. |
| Residents were admitted to the home on 01/21/22 and 01/30/22 despite a Department ban on new admissions issued on 12/20/21. |
Report Facts
License Capacity: 84
Residents Served: 40
Staffing Hours: 55
Waking Staff: 41
Hospice Residents: 5
Residents Diagnosed with Mental Illness: 15
Residents with Mobility Need: 15
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the cover letter regarding the inspection results. |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 84
Deficiencies: 2
Nov 1, 2021
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Findings
The inspection found deficiencies related to medication administration, including failure to document medication refusal and failure to follow prescriber's orders for multiple medications for Resident #1. Plans of correction were submitted and accepted with education and monitoring measures.
Complaint Details
The visit was complaint-related. The complaint involved medication administration errors for Resident #1, including refusal documentation and missed doses. The deficiencies were substantiated with repeat violations noted.
Deficiencies (2)
| Description |
|---|
| Failure to document refusal of prescribed medication and notify prescriber within 24 hours. |
| Failure to follow prescriber's orders with multiple medications not administered as prescribed. |
Report Facts
License Capacity: 84
Residents Served: 44
Current Hospice Residents: 9
Residents Diagnosed with Mental Illness: 14
Residents with Mobility Need: 19
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon Kimberland | Signed the letter regarding plan of correction implementation. |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 84
Deficiencies: 7
Aug 4, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to an incident involving a resident who was injured and subsequently passed away after a fall inside the facility's transport van.
Findings
The investigation found multiple violations including failure to report the incident timely, improper securing of a resident's wheelchair in the transport van, inadequate staff orientation and training on fire safety, abuse reporting, and transportation safety. The resident sustained fatal injuries due to blunt force trauma from falling inside the van. Plans of correction were accepted and directed for staff education and procedural improvements.
Complaint Details
The complaint investigation was substantiated based on findings that a resident was injured and died due to improper securing in the transport van by staff person A, who failed to follow safety protocols. The incident was not reported timely to the appropriate Department office.
Deficiencies (7)
| Description |
|---|
| Failure to report the incident to the Department within 24 hours as required. |
| Resident was neglected and improperly secured in the transport van, leading to injury and death. |
| Staff person A did not receive orientation in general fire safety and emergency preparedness prior to or during first day of work. |
| Staff person A did not receive orientation on resident rights, emergency medical plan, abuse reporting, and reporting of incidents within 40 working hours. |
| Staff person A did not receive training on how to properly secure a wheelchair in the facility's van prior to working in that capacity. |
| Staff person A's training record lacked required details such as source, date, content, and length of training courses. |
| Occupants of the vehicle were not properly restrained at all times during transport. |
Report Facts
Residents Served: 46
License Capacity: 84
Staff Total Daily: 61
Waking Staff: 46
Current Residents in Hospice: 4
Residents Diagnosed with Mental Illness: 12
Residents with Mobility Need: 15
Residents Age 60 or Older: 46
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to improper securing of wheelchair in transport van, lack of proper orientation and training, and involvement in resident injury and death. | |
| Larry Mazza | Signed the cover letter regarding the inspection report and plan of correction acceptance. |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 84
Deficiencies: 1
Jul 15, 2021
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 07/15/2021.
Findings
The inspection found that resident #1's dentures were misplaced in May 2021 and no assistance was provided to obtain new dentures. As of the inspection date, the resident still did not have dentures despite requiring total physical assistance with healthcare management. A plan of correction was accepted, including scheduling a dental appointment and staff education.
Complaint Details
The inspection was complaint-driven and partial, unannounced. The complaint investigation found the denture assistance deficiency for resident #1.
Deficiencies (1)
| Description |
|---|
| Resident #1's dentures were misplaced and no assistance was provided to obtain new dentures, despite the resident requiring total physical assistance with healthcare management. |
Report Facts
Residents served: 47
License capacity: 84
Current hospice residents: 4
Residents diagnosed with mental illness: 12
Residents with mobility need: 16
Residents age 60 or older: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Larry Mazza | Signed the letter regarding the inspection results and plan of correction acceptance |
Inspection Report
Renewal
Census: 47
Capacity: 84
Deficiencies: 24
Jun 22, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation of THE RESIDENCE AT ARROWOOD.
Findings
The inspection identified multiple deficiencies including delayed incident reporting, confidentiality breaches, inadequate assistance with activities of daily living, incomplete criminal background checks, staff qualification and training deficiencies, sanitary and safety issues, medication administration errors, incomplete resident assessments, and incomplete support plans.
Complaint Details
The inspection included a complaint investigation related to allegations of neglect and other concerns at the facility.
Deficiencies (24)
| Description |
|---|
| Delayed reporting of an allegation of neglect to the Department beyond the required 24 hours. |
| Unlocked medication room with resident records and controlled substance logs left unattended. |
| Residents experienced excessive delays in call bell response and inadequate assistance with activities of daily living. |
| Failure to complete Pennsylvania criminal background checks for certain direct care staff. |
| Administrator's nursing license expired and direct care staff lacked required qualifications. |
| Direct care staff lacked required first aid, CPR, fire safety, and abuse reporting training and orientation. |
| Resident #7 unable to access tub/shower in room; sanitary conditions not maintained in resident rooms. |
| Furniture and equipment not in good repair; lighting not operable at bedside for some residents. |
| Unlabeled and undated leftover food in kitchen refrigerators. |
| Pets present in the home despite rules prohibiting pets; missing or expired rabies vaccinations. |
| Emergency exit door blocked by a cart. |
| Incomplete or missing medical evaluations and medication addendums for residents. |
| Medications administered without proper observation; medications and syringes not always locked. |
| Discontinued medications and medications for deceased residents not removed from storage. |
| Pharmacy labels on medications inaccurate or missing required information. |
| Resident OTC medications not labeled with resident's name. |
| Inaccurate blood sugar documentation and missing glucometer readings. |
| Medication administration records missing staff initials and documentation of administration times. |
| Prescriber's orders not consistently followed; medications not administered as ordered due to unavailability. |
| Staff person administered medications without completing required Department-approved medication administration course and diabetes education. |
| Incomplete training records for diabetic administration training. |
| Incomplete or missing preadmission screening forms for residents. |
| Resident assessments incomplete or missing required information. |
| Resident support plans incomplete, missing hospice service documentation, or unsigned by participants. |
Report Facts
Inspection dates: 4
Residents served: 47
Licensed capacity: 84
Staffing hours: 63
Waking staff hours: 47
Hospice residents: 7
Residents with mental illness: 6
Residents with mobility needs: 16
Deficiency completion dates: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to delayed incident reporting and expired nursing license | |
| Staff person B | Named in findings related to incomplete criminal background check, lack of qualifications, incomplete training, and medication administration | |
| Staff person C | Named in findings related to incomplete criminal background check and incomplete training records | |
| Staff person D | Named in findings related to lack of qualifications and incomplete training |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 84
Deficiencies: 10
Jun 3, 2021
Visit Reason
The inspection was a complaint investigation conducted on 06/03/2021 and 06/04/2021 at The Residence at Arrowood to address specific citations found during the licensing inspection.
Findings
Multiple deficiencies were found including failure to complete new resident-home contracts within 24 hours of admission, incomplete contract signatures, insufficient direct care staffing hours especially for residents with mobility needs, inadequate staffing for safe evacuation during night hours, unsanitary conditions with dried blood on carpeting, missing bedroom furnishings for resident #2, failure to administer prescribed medications to resident #3, and lack of required preadmission screening and initial assessments for transferred residents.
Complaint Details
The inspection was conducted as a complaint investigation with unannounced notice, triggered by concerns regarding compliance with licensing regulations.
Deficiencies (10)
| Description |
|---|
| New resident-home contracts were not completed within 24 hours of admission for numerous residents transferred on 5/20/21. |
| Resident-home contracts for residents #4, #5, and #6 were not properly signed by required parties. |
| Insufficient direct care staffing hours provided on 5/23/21; only 59.5 hours provided versus 66 hours required for residents with mobility needs. |
| Insufficient direct care staffing during waking hours on 5/23/21; only 48.5 hours provided versus 49.5 hours required. |
| Only 2 staff present from 10:00pm-7:00am on 5/22/21 and 5/23/21, inadequate for safe evacuation of all residents. |
| Approximately 15 spots of dried blood found on carpeting near resident #7's bed. |
| Resident #2 lacked a chest of drawers, bedside table/shelf, and operable lamp at bedside. |
| Resident #3 was not administered numerous prescribed medications on the afternoon and evening of 5/24/21. |
| Preadmission screening was not completed within 30 days prior to admission for any of the 13 residents transferred on 5/20/21. |
| Initial assessments were not completed within 15 days of admission for any of the 13 residents transferred on 5/20/21. |
Report Facts
Residents served: 49
License capacity: 84
Direct care hours required: 66
Direct care hours provided: 59.5
Direct care waking hours required: 49.5
Direct care waking hours provided: 48.5
Residents with mobility needs: 17
Staff present overnight: 2
Residents transferred: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Larry Mazza | Signed the letter regarding plan of correction acceptance | |
| Director of Nursing | Named in medication administration deficiency and responsible for staff education and medication review |
Inspection Report
Re-Inspection
Census: 45
Capacity: 70
Deficiencies: 7
Oct 1, 2020
Visit Reason
The inspection was conducted due to a change in legal entity operating the home and was a full announced inspection.
Findings
The facility was found to be in substantial compliance with regulations, but several deficiencies were identified including improper storage of poisonous materials, unsanitary conditions in a refrigerator, uncovered trash receptacles, non-functional ventilation, incomplete first aid kit supplies, improper refrigerator/freezer temperatures, and presence of outdated food.
Deficiencies (7)
| Description |
|---|
| Poisonous materials were not stored in their original, labeled containers; two spray bottles with yellow liquid were found in the hallway. |
| An orange sticky substance with food particles was found on the bottom shelf of the refrigerator in the activity room. |
| Full uncovered garbage cans were found in the kitchenette area of the dining room on the third floor and in the shared bathroom of bedroom 328. |
| The ventilation fan in the ground floor ladies restroom was not functional, vent uncovered, fan dusty, and no window present. |
| The first aid kit at the front desk lacked goggles and a thermometer. |
| The walk-in refrigerator in the kitchen was at 42°F and the freezer in the activity room was above 0°F, exceeding required temperatures. |
| A half-full package of Philadelphia Cream Cheese with an expiration date of 3/13/20 was found in the activity room refrigerator. |
Report Facts
License Capacity: 70
Residents Served: 45
Staffing Hours: 4
Total Daily Staff: 67
Waking Staff: 50
Current Residents in Hospice: 7
Residents 60 Years or Older: 45
Residents Diagnosed with Mental Illness: 8
Residents with Mobility Need: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyffini Balog | Administrator | Named as facility administrator. |
| Debbie Johnson | Legal Entity Contact | Named as legal entity contact. |
| Thomas Smith | Lead Inspector | Lead inspector for the 10/01/2020 inspection. |
| Amy Duncan | Department Representative | Department representative present during inspection. |
| Jody Garvey | Lead Reviewer | Lead reviewer for follow-up submissions and document reviews. |
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