Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wecare At Mt Lebanon Rehabilitation And Nrsg Ctr during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and physical debility, requiring assistance of two staff for transfers, was transferred by a single nurse aide who relied on incorrect information from a census sheet rather than the care plan. This failure to follow the resident's plan of care resulted in an ankle fracture, with the incident substantiated as neglect after facility investigation.
A review of staffing records and staff interviews revealed that the facility did not provide the minimum required number of nurse aides on several day, evening, and night shifts, resulting in staffing levels below regulatory requirements for the census on those days. The Nursing Home Administrator confirmed the deficiency.
A resident with diabetes, obesity, and hypertension reported that an LPN performed a blood glucose finger stick while she was sleeping on two occasions. The DON and administrator confirmed that the facility did not conduct a full investigation into the alleged abuse, failing to interview the accused employee, witnesses, or other staff, as required by policy.
A medication cart on the first floor was observed left unlocked and unattended in the hallway near the nurse's station, contrary to facility policy requiring all medications and biologicals to be securely stored. Both a nurse and the DON confirmed the cart should have been secured when not in use.
Multiple residents did not receive their selected menu items, including desserts, beverages, supplements, and preferred salad dressings, as documented on their meal tickets. Additionally, artificial sweetener was unavailable for residents with diabetes or those preferring non-sugar options, and staff confirmed the facility could not meet these dietary needs due to supply shortages.
The facility did not consistently offer evening snacks to residents as required by its policy, with several residents reporting that snacks were rarely or never provided and sometimes consumed by staff instead. This failure was confirmed by the administrator and affected the majority of residents interviewed.
Multiple residents reported seeing ants and spiders in their rooms, and observations confirmed the presence of ants in several rooms and common areas. During PTAC unit replacement, no measures were taken to prevent insect entry, and the facility's pest control program was not effectively implemented, as confirmed by the administrator.
The facility failed to provide the required number of nurse aides (NAs) per resident on several shifts. Specifically, the facility did not meet the mandated staffing levels for NAs during the daylight, evening, and night shifts on multiple days. This deficiency was confirmed through staffing documents and an interview with the Nursing Home Administrator.
The facility did not meet the required minimum of 3.20 PPD hours of direct resident care on four days, with PPD hours recorded as 2.73, 2.78, 3.01, and 3.00. This was confirmed by the Nursing Home Administrator after reviewing staffing documents and schedules.
The facility did not meet the required staffing levels for nurse aides on multiple occasions. Specifically, the facility failed to provide the mandated number of NAs during the daylight, evening, and night shifts on various days, as confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.2 PPD hours of direct care on two days, providing only 3.16 and 2.94 PPD hours. This was confirmed by the Nursing Home Administrator.
A resident with severe cognitive impairment eloped from the facility due to inadequate supervision and outdated care plans. The resident was found on a highway by a CNA and returned to the facility. The incident highlighted lapses in updating elopement risk assessments and care plans.
A facility failed to reassess a resident with cognitive decline for elopement risk, despite a significant drop in BIMS scores and incidents of confusion and anxiety. The resident, diagnosed with dementia, was found outside the facility on a highway, indicating a risk of elopement. The facility did not update the resident's care plan or complete a new elopement risk assessment, as confirmed by interviews with the DON and Regional DON.
The facility failed to maintain a homelike environment due to lukewarm water issues and structural problems on two floors. Residents and staff reported that water needed to run for extended periods to become warm, and there were holes in walls and unfinished plaster. A black substance with a musty odor was found on a shower room ceiling. The Maintenance Director confirmed the water system's limitations, affecting the entire building.
A facility failed to maintain infection control practices during a dressing change, as observed by surveyors. The RN did not wash or sanitize hands before donning clean gloves multiple times, did not use a clean barrier for items on the bedside table, and failed to label the dressing with date, time, and initials. Despite a bathroom being available, the RN claimed there was nowhere to wash hands. The Director of Nursing confirmed the failure to prevent cross-contamination.
The facility did not provide behavioral health training for ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, an RN, and an occupational therapy employee. This deficiency was confirmed by the Nursing Home Administrator and violates Pennsylvania Code regulations on licensee responsibility, management, and staff development.
The facility failed to provide several residents with the opportunity to formulate an advance directive, as required by policy. Clinical records for residents with various medical conditions lacked documentation of advance directives or evidence that residents were given the chance to create one. This was confirmed by a social worker during an interview.
The facility failed to provide the required 12 hours of annual in-service education for five nurse aides, who each received only 4 hours of training within the specified timeframe. This deficiency was confirmed by the Nursing Home Administrator, acknowledging the shortfall in meeting the mandated training requirements.
A facility failed to conduct a required Level II PASARR evaluation for a resident diagnosed with Schizophrenia and bipolar disorder. Despite the facility's policy requiring a Level I screening and referral for Level II evaluation, the necessary referral and evaluation were not completed, as confirmed by a review of clinical records and an interview with a social services employee.
The facility failed to notify physicians and assess two residents for abnormal blood glucose levels. One resident had CBG levels of 53 and 477, while another had levels of 62 and 416, without proper notification or assessment. Care plan interventions were not followed, and interviews with LPNs revealed inconsistencies in handling abnormal CBG levels.
A resident with multiple health conditions required extensive assistance for bed mobility, but the facility failed to document this need adequately. The resident rolled out of bed during care, resulting in a head injury. The incident was witnessed, and the resident was taken to the hospital for evaluation. The Director of Nursing confirmed the lack of proper documentation contributed to the fall.
The facility failed to dispose of expired medical supplies in a medication room on the first floor. Observations revealed expired povidone iodine swabsticks, oil emulsion dressings, super absorbent dressings, strip paste coloplasts, and a small bore extension set. The Nursing Home Administrator confirmed the oversight, violating resident care policies and nursing services regulations.
The facility did not complete annual performance evaluations for five nurse aides, violating personnel policies. Employees hired between 1993 and 2020 lacked documented evaluations, confirmed by the Nursing Home Administrator. This deficiency breaches staff development regulations.
The facility failed to implement and maintain an effective training program for staff under contractual agreements, as required by their policy. The Director of Nursing and the Nursing Home Administrator confirmed that the previous HR Director did not maintain accurate and complete training files, leading to a deficiency in the facility's adherence to its training policy.
The facility failed to provide communication training to ten direct care staff members, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. This deficiency was confirmed by the Nursing Home Administrator and violates the facility's responsibility under relevant state codes.
The facility did not provide training on resident rights to ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeper, a registered nurse, and an occupational therapy employee. This deficiency was confirmed by the Nursing Home Administrator and violates Pennsylvania Code sections on licensee responsibility and staff development.
The facility did not provide mandatory QAPI training to ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. This was confirmed by the Nursing Home Administrator and constitutes a violation of state regulations regarding staff development and licensee responsibility.
The facility did not provide compliance and ethics training for ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. This was confirmed by the Nursing Home Administrator.
A resident with anxiety and depression, who used jewelry making as a therapeutic activity, did not have her personal belongings returned for four weeks after returning from a psychiatric commitment. The facility delayed the return of her possessions to ensure she would remain in her new room, which was confirmed by the Social Worker and acknowledged by the Nursing Home Administrator.
Failure to Provide Adequate Supervision During Resident Transfer Resulting in Injury
Penalty
Summary
The facility failed to provide adequate supervision during transfers for one resident, resulting in an ankle fracture. The resident in question had a history of diabetes, arthritis, and physical debility, and was assessed as severely cognitively impaired with a BIMS score of 0. According to the resident's care plan and Kardex, the resident required assistance from two staff members for transfers. However, on the day of the incident, the resident was transferred by a single nurse aide, contrary to the documented care plan. The nurse aide relied on an outdated census sheet that incorrectly listed the transfer status and did not consult the electronic charting system for the most current information. Following the transfer, the resident was found to have swelling, warmth, and tenderness in the left foot and ankle, which was later confirmed by x-ray to be a fracture. The resident was unable to communicate what had occurred due to cognitive impairment. The facility's investigation substantiated neglect, as the nurse aide did not follow the resident's plan of care, leading to actual harm. Staff interviews and documentation confirmed that the plan of care was not followed during the transfer, resulting in the injury.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet required nurse aide (NA) staffing ratios on multiple shifts over a six-day period, as evidenced by a review of staffing documents and staff interviews. Specifically, the facility did not provide at least one NA per 10 residents during the day shift on two days, one NA per 11 residents during the evening shift on three days, and one NA per 15 residents during the night shift on two days. Staffing records showed that the actual NA hours provided were below the required hours for the census on these dates. The Nursing Home Administrator confirmed during an interview that the facility did not meet the required NA staffing levels on the identified shifts.
Plan Of Correction
The Facility submits this Plan of Correction under the procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the department alleges is deficient under state and/or Federal Long Term Care regulations. This Plan of Correction should not be construed as either a waiver or the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. The CNA schedule is created to ensure staffing ratios reflect the current census per shift. Each shift's staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff. The facility is utilizing agency to assist with open shifts. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately. We have a dedicated recruiter to assisting us with recruiting and hiring new nursing staff. The Administrator or designee will educate the Nursing Admin, the scheduler, and RN Supervisors on the staffing ratio grid and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, and scheduler. Daily recruiting calls occur to update the status of new applicants and interviews. The 3-week DOH Staffing Calculator Tool will be updated daily to monitor hours. The audits will be taken to QAPI for review.
Failure to Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to investigate incidents of possible abuse and neglect involving one resident. According to facility policy, staff are required to assess, document, and investigate all alleged abuse and neglect, including interviewing witnesses and other relevant individuals. In this case, a resident reported that a nurse entered her room and performed a blood glucose finger stick while she was sleeping on two occasions. The Director of Nursing confirmed that the incident occurred, but the facility did not conduct a full investigation as required by policy. Specifically, the facility did not interview the accused employee, any possible witnesses, other staff members present, or other residents who may have received care from the same employee. The resident involved had diagnoses including diabetes, obesity, and high blood pressure, and was re-admitted to the facility prior to the incident. The failure to follow investigative procedures was confirmed by both the Director of Nursing and the Nursing Home Administrator.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to properly secure a medication cart, as observed during a survey. On the first floor, Team #1's medication cart was found unlocked and unattended in the hallway near the nurse's station. Facility policy requires that medications and biologicals be stored safely and securely in locked compartments, with access limited to authorized personnel. During interviews, both a registered nurse and the Director of Nursing confirmed that the cart was left unattended and unlocked, which was not in accordance with facility policy.
Failure to Provide Resident-Selected Menu Items and Dietary Preferences
Penalty
Summary
The facility failed to provide resident-selected menu items for 14 out of 20 residents, as evidenced by meal observations and review of meal tickets. Specific deficiencies included residents not receiving requested items such as ginger ale, puddings, cookies, ice cream, house supplements, cranberry juice, nutritional supplements, and preferred salad dressings. In one instance, a resident received Italian dressing instead of the requested ranch, which the resident stated caused heartburn. Additionally, several residents consistently received fewer cookies than requested on their meal tickets. During staff interviews and cart inspections, it was revealed that the facility did not have any artificial sweetener available for residents with diabetes or those who preferred non-sugar sweeteners. The Dietary Manager confirmed the absence of artificial sweetener and indicated that the next food delivery was not expected for several days. The Nursing Home Administrator also confirmed the failure to provide selected food items to the affected residents. These findings are in violation of the facility's policy and state dietary service regulations.
Failure to Consistently Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to consistently provide evening snacks to residents as required by its own policy and in accordance with residents' needs and preferences. The facility's policy, dated 9/9/24, states that evening snacks will be routinely offered to all residents. However, interviews with six out of eight residents revealed that snacks were either not provided, only occasionally provided, or not available when requested. Several residents reported that they rarely or never received evening snacks, with some stating that staff consumed the snacks instead of offering them to residents. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged that the facility did not consistently provide snacks as desired by the majority of residents interviewed. The findings indicate a failure to adhere to established policy and to meet the nutritional and personal preferences of residents regarding snack availability outside of scheduled meal times.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program on the Ground Floor nursing unit, as required by its own pest control policy. Multiple residents reported seeing ants and spiders in their rooms, with one resident specifically noting that her room was not treated during a recent exterminator visit. Observations confirmed the presence of ants in several resident rooms, including under and inside PTAC units, as well as in the lounge area where both live ants and dead bugs were found. An empty room with a removed PTAC unit had visible ants in the remaining metal case, which had grates allowing air flow and potential pest entry. Interviews with the Maintenance Director revealed that no measures had been taken to prevent insects from entering the building during PTAC unit replacement. The Nursing Home Administrator confirmed the failure to maintain an effective pest control program for the affected nursing unit. These findings were based on direct observations and resident and staff interviews, and were cited under 28 Pa. Code: 207.2 (a) regarding the administrator's responsibility.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple occasions. Specifically, the facility did not provide the mandated one NA per 10 residents during the daylight shift on five out of eight days, one NA per 11 residents during the evening shift on four out of eight days, and one NA per 15 residents during the night shift on one out of eight days. This deficiency was confirmed through a review of staffing documents and an interview with the Nursing Home Administrator, who acknowledged the failure to meet the staffing requirements on the specified shifts.
Plan Of Correction
The Facility submits this Plan of Correction under the procedures established by the Department of Health in order to comply with the Departments directive to change conditions which the department alleges is deficient under state and/or Federal Long Term Care regulations. This Plan of Correction should not be construed as either a waiver or the facility right to appeal or challenge the accuracy of severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. The CNA schedule is created to ensure staffing ratios reflect the current census per shift. Each shifts staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, text messages are sent to staff. The Administrator or designee will educate the Nursing Admin, the scheduler and RN Supervisors on the staffing ratio grid and how to adjust. A staffing meeting will occur daily to review ratios and audited for 3 weeks. The Audits will be taken to QAPI for review.
Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-required minimum of 3.20 hours of direct resident care per patient daily (PPD) on four specific days. A review of staffing documents and nursing staff schedules from January 21, 2025, through January 28, 2025, revealed that the facility did not provide the required PPD on January 24, 26, 27, and 28, 2025. Specifically, the PPD hours were 2.73, 2.78, 3.01, and 3.00, respectively, on these dates. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 29, 2025, who acknowledged the failure to meet the required staffing levels on the specified days.
Plan Of Correction
The Nursing schedule is created to ensure staffing ratios reflect the current census per shift to meet PPD. When additional staff is needed to meet PPD, shifts are posted on our staffing portal, bonuses are offered, and text messages are sent to staff. The Administrator or designee will educate Nursing Admin, the Scheduler, and RN Supervisors on the staffing ratio grid and how to adjust. A staffing meeting will occur daily to review PPD and audited for 3 weeks. The Audits will be taken to QAPI for review.
Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on several occasions between December 10, 2024, and December 15, 2024. Specifically, on December 13, 2024, the facility did not provide the mandated one NA per 10 residents during the daylight shift. Additionally, on December 12 and December 15, 2024, the evening shift was understaffed, with the facility failing to provide one NA per 11 residents. Furthermore, on the night shift of December 15, 2024, the facility did not meet the requirement of one NA per 15 residents. These deficiencies were confirmed by the Nursing Home Administrator during an interview on December 16, 2024.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. P5520 1. The facility cannot correct that the nurse aide staffing ratio was not met on 12/12/24, 12/13/24, and 12/15/24. There were no adverse effects to residents on the identified dates. 2. The scheduler will be re-educated regarding the state ratios by the Nursing Home Administrator/designee. 3. Nursing Administration will be re-educated on staffing ratios by the Nursing Home Administrator/designee. Twice a day staffing meetings will be held to review the schedule with ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios, the scheduler/or designee will call off duty facility staff and will utilize external staffing support resources. The facility has started regular job fairs to increase staffing. 4. Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-mandated requirement of providing a minimum of 3.2 hours of direct resident care per patient daily (PPD) on two specific days. A review of staffing documents and nursing schedules from December 10, 2024, through December 15, 2024, revealed that the facility did not meet the required PPD hours on December 12, 2024, and December 15, 2024. On December 12, 2024, the facility provided 3.16 PPD hours, and on December 15, 2024, it provided only 2.94 PPD hours. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 16, 2024, who acknowledged the failure to meet the required direct care hours on the specified dates.
Plan Of Correction
1. The facility cannot correct that the state required PPD (per patient daily) minimum hours of 3.20 was not met on 12/12/24 and 12/15/24. 2. The facility scheduler will continue to be educated regarding the state ratios and daily PPD by the NHA/designee. 3. The NHA, DON and scheduler will meet twice a day to review PPD and projected PPD. Nursing supervisors will monitor it on weekends. If the facility is projected to not meet daily PPD, the scheduler or designee will call off duty facility staff and utilize external staffing support resources. 4. NHA/designee will audit staffing daily for three weeks and monthly for three months to ensure daily PPD is being met. Outcomes will be reported to the QA&A committee for review and recommendations.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of Resident R1, who was identified as having a severe cognitive impairment with a BIMS score of 5. Despite having a care plan initiated for the risk of wandering and elopement, the plan was not updated until after the incident occurred. The facility's elopement evaluations previously documented Resident R1 as not being at risk for elopement, and a significant change assessment that included an elopement risk evaluation was not completed. This lack of updated assessments and care plan adjustments contributed to the resident's ability to leave the facility unsupervised. On the day of the incident, Resident R1 was found outside the facility on a highway by a CNA, who brought the resident back. The resident was reportedly attempting to get a cigarette. The incident was confirmed by the Director of Nursing and the Regional Director of Nursing, who acknowledged the failure in supervision. The facility's policies and procedures, as well as the resident's rights, were not adhered to, resulting in the resident's unsupervised exit from the facility.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. F689 1. Resident R1 was safely returned to the facility by nurse aide. Resident R1 was assessed for injuries upon return and no injuries noted. Resident R1 was dressed appropriately for the weather. A new elopement assessment was completed 11/15/24 and wander guard placed on Resident R1. 2. The facility will provide adequate supervision to prevent elopements. Residents are evaluated for elopement risk on admission, readmission and as needed. 3. Facility staff will be re-educated on the wandering and elopement policy by the Director of Nursing/designee. 4. The Interdisciplinary Team (IDT) will meet weekly for four weeks and then monthly for three months to discuss any potential elopement risks with each department including status changes of current residents and new admissions. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Reassess Elopement Risk for Resident with Cognitive Decline
Penalty
Summary
The facility failed to reassess a resident with cognitive decline for elopement risk, leading to a deficiency. Resident R1, who was diagnosed with dementia and mood disturbance, exhibited a significant decline in cognitive function over several months, as evidenced by a decrease in BIMS scores from 14 and 15 to 5. Despite this decline, the resident's care plan did not include goals or interventions for dementia or cognitive decline, and the facility did not complete a new elopement risk assessment after the resident's cognitive status changed. The resident's clinical records and staff notes indicated ongoing memory problems, confusion, and episodes of anxiety, such as worrying about his truck and attempting to leave the facility to check on it. On one occasion, the resident was found outside the facility on the highway, indicating a clear risk of elopement. Despite these incidents, the facility's elopement evaluations had previously documented the resident as not being at risk for elopement, and a significant change assessment initiated in September was not completed. Interviews with the Director of Nursing and the Regional Director of Nursing confirmed that the facility did not reassess residents with cognitive decline for elopement risk as required. The facility's failure to complete the necessary assessments and update the resident's care plan contributed to the resident's ability to leave the facility unsupervised, posing a potential risk to the resident's safety.
Plan Of Correction
F744 1. The facility cannot correct that Resident R1 was not reassessed for elopement with a cognitive decline until 11/15/24. 2. The Social Service Director/designee will review current residents BIMS to ensure if there was a cognitive decline they were reassessed for elopement. 3. The nursing staff and social service will be re-educated on the policy dementia -clinical protocol by the Director of Nursing/designee. Social Service will notify the interdisciplinary team when there is a change in resident BIMS to ensure resident is reassessed for elopement risk. 4. The Social Service will audit 5 residents BIMS weekly for four weeks and then monthly for three months to ensure if there was cognitive decline the resident was reassessed for elopement. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Facility Fails to Maintain Homelike Environment Due to Water and Structural Issues
Penalty
Summary
The facility failed to maintain a clean and homelike environment on both the ground and first floors, as observed during a survey. Several issues were identified, including lukewarm water in resident bathrooms that required running for extended periods to reach a warmer temperature. This was confirmed by residents and staff, who noted that the water system's inefficiency affected the entire building. Additionally, there were structural issues such as holes in the walls, unfinished plaster, and an HVAC unit improperly installed, which compromised the homelike environment. Further observations revealed a black substance with a musty odor on the ceiling of a shower room, indicating potential mold presence. The Maintenance Director acknowledged the water system's limitations, citing a single water holding tank for the entire building, which led to inconsistent water temperatures. These deficiencies were noted under the Pennsylvania Code sections related to the responsibility of the licensee, management, and resident rights.
Infection Control Deficiency During Dressing Change
Penalty
Summary
The facility failed to maintain proper infection control practices during a dressing change, as observed during a survey. The facility's policy on Dry/Clean Dressings required cleaning the bedside stand before and after the dressing change, placing clean equipment on a clean field, and washing and drying hands thoroughly. However, during an observation, several lapses were noted. A red biohazard bag was improperly placed in the resident's regular garbage can, and the registered nurse (RN) did not wash or sanitize hands before donning clean gloves multiple times throughout the procedure. The bedside table was wiped but not cleared of resident belongings, and a clean barrier was not used for the items placed on it. Personal scissors were cleansed, but the same scissors were used to cut a dirty dressing without being cleansed afterward. The RN also failed to label the dressing with the date, time, and initials as required by the facility policy. Despite the presence of a bathroom with running water and soap in the resident's room, the RN claimed there was nowhere to wash hands. The Director of Nursing confirmed the facility's failure to prevent cross-contamination during the dressing change. These actions and inactions led to a deficiency in infection control practices, as outlined by the relevant Pennsylvania Code sections.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide behavioral health training for ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. The deficiency was identified through a review of facility documents and staff interviews, which revealed that none of the ten employees had received the required training on behavioral health. This lack of training was confirmed by the Nursing Home Administrator during an interview. The deficiency is in violation of several Pennsylvania Code regulations related to the responsibility of the licensee, management, and staff development.
Failure to Provide Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide six out of nine residents reviewed with the opportunity to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy on advance directives, dated 12/29/23 and 4/9/24, states that residents have the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The clinical records of residents with various diagnoses, including diabetes, depression, anxiety, high blood pressure, Huntington's Disease, cancer, congestive heart failure, obesity, and chronic pain, were reviewed. For each of these residents, the records did not contain an advance directive or documentation indicating that they were given the opportunity to formulate one. This was confirmed during an interview with Social Worker Employee E6, who acknowledged the absence of such documentation for the residents in question.
Deficiency in Nurse Aide In-Service Training
Penalty
Summary
The facility failed to provide the required 12 hours of annual in-service education for nurse aides within 12 months of their hire date anniversary, as mandated by regulations. This deficiency was identified for five nurse aides, Employees E1, E2, E3, E4, and E5, who each received only 4 hours of in-service training within the specified timeframe. The facility's policy on in-service training, dated 4/9/24 and 12/29/23, requires all staff to demonstrate competency in training topics to enhance residents' quality of life and care. A review of the facility's assessment indicated that staff training should align with their roles and include updates to policies and procedures as needed. However, the education records for the nurse aides showed a shortfall in the required training hours. During an interview, the Nursing Home Administrator confirmed the deficiency, acknowledging that the facility did not meet the 12-hour annual in-service education requirement for the five nurse aides.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to complete a Level II evaluation for a resident, as required by the Preadmission Screening and Resident Review (PASARR) process. The facility's policy mandates that all residents undergo a Level I screening and, if necessary, a referral for a Level II evaluation in compliance with state and federal regulations. Resident R15, who has been diagnosed with Schizophrenia and bipolar disorder, was identified as needing a Level II evaluation. However, a review of the clinical records and an interview with Social Services Employee E6 confirmed that the referral and completion of the Level II evaluation by a state PASARR representative were not conducted for this resident.
Failure to Notify Physicians and Assess Residents for Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, affecting two residents. Resident R39, who was readmitted with diagnoses including diabetes, had a CBG of 53 and 477 on separate occasions, but the physician was not notified, and the resident was not assessed for hyper-/hypoglycemia. The care plan interventions, such as monitoring for signs and symptoms of hypoglycemia and providing insulin coverage, were not followed. Similarly, Resident R78, admitted with diagnoses including diabetes, had a CBG of 62 and 416 on different dates. The facility failed to assess the resident for hyper-/hypoglycemia, did not recheck blood sugar levels, and did not notify the physician of these abnormal results. The care plan interventions, which included monitoring for signs and symptoms of hypo and hyperglycemia, were not adhered to. Interviews with LPNs revealed inconsistencies in the actions taken when abnormal CBG levels were detected, such as notifying the doctor and documenting in the medical records. The Director of Nursing confirmed the facility's failure to notify the doctor of changes in condition related to blood glucose for the affected residents.
Inadequate Supervision and Documentation Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and documentation for the bed mobility needs of a resident, resulting in the resident rolling out of bed. The resident, who had diagnoses of diabetes, end-stage renal failure, and intellectual disabilities, required extensive assistance from two or more staff members for bed mobility. However, there was no documented assistance level for bed mobility in the resident's care plan until several months after admission. A progress note indicated that the resident was found lying on the floor with a hematoma on the right side of the head after a CNA attempted to turn the resident for care. The CNA reported that the resident became stiff and rolled out of bed, hitting the head on the nightstand. The incident was witnessed, and the resident was subsequently taken to the hospital for evaluation. A CT scan showed no acute central nervous system findings or fractures, but a small right frontal hematoma was noted. The Director of Nursing confirmed the lack of adequate documentation for the resident's bed mobility needs, which contributed to the incident.
Expired Medical Supplies Not Disposed Properly
Penalty
Summary
The facility failed to properly dispose of expired and/or opened medical supplies in one of the two medication rooms located on the first floor. During an observation, it was noted that the medication room contained 19 Medline triple pack povidone iodine swabsticks, 16 Curad oil emulsion dressings, 16 Dynarex DynaSorb super absorbent dressings, 25 Brava strip paste coloplasts, and one I Medical Devices IM41000 small bore extension set, all of which were past their expiration dates. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to dispose of these expired supplies appropriately. The deficiency was identified as a violation of 28 Pa. Code: 211.10(c) regarding resident care policies and 28 Pa. Code: 211.12(d)(1)(2)(5) concerning nursing services. The presence of expired medical supplies in the medication room indicates a lapse in the facility's adherence to proper storage and disposal protocols, as required by the regulations.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for five nurse aides. The employees involved were hired on various dates ranging from 1993 to 2020. Upon review, there was no documented evidence that the facility conducted these evaluations annually as required. An interview with the Nursing Home Administrator confirmed that the performance evaluations were not completed for the five employees in question. This deficiency is a violation of the facility's personnel policies and procedures as outlined in 28 Pa. Code 201.19 (2) and 28 Pa Code: 201.20 (a)(b)(c)(d) regarding staff development.
Deficiency in Staff Training Program Implementation
Penalty
Summary
The facility failed to implement and maintain an effective training program for individuals providing services under contractual agreements, as required by their policy. The policy, dated April 9, 2024, mandates the development, implementation, and maintenance of a training program for all new and existing staff, including those under contractual arrangements, consistent with their expected roles. However, during interviews, both the Director of Nursing and the Nursing Home Administrator confirmed that the previous Human Resource Director did not maintain accurate and complete training files. This deficiency was identified during a review of the facility's policy and staff interviews, indicating a lapse in the facility's adherence to its own training policy.
Failure to Provide Communication Training to Direct Care Staff
Penalty
Summary
The facility was found to have failed in providing necessary communication training to all ten direct care staff members reviewed. This deficiency was identified through a review of facility education documents and staff interviews, which revealed that the facility did not offer communication education to its direct care staff. The staff members affected included nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. Each of these employees' records lacked documentation of training on effective communication. During an interview, the Nursing Home Administrator confirmed the absence of communication training for the direct care staff. This lack of training is a violation of the facility's responsibility under the 28 Pa. Code: 201.14(a) and 201.20(c), which pertain to the responsibility of the licensee and staff development, respectively. The failure to provide this essential training could potentially impact the quality of care and communication within the facility.
Failure to Provide Resident Rights Training
Penalty
Summary
The facility failed to provide training on resident rights to its staff members, as revealed by a review of facility documents and staff interviews. This deficiency affected ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeper, a registered nurse, and an occupational therapy employee. The facility's education documents did not include any training on resident rights for these employees. During an interview, the Nursing Home Administrator confirmed the lack of Resident Rights training for direct care staff. This failure is a violation of the Pennsylvania Code, specifically sections 201.14(a) and 201.20(c), which pertain to the responsibility of the licensee and staff development, respectively.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to all staff members reviewed. This deficiency was identified through a review of facility documents and staff interviews, which revealed that ten employees, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee, did not receive QAPI training. The Nursing Home Administrator confirmed the lack of training for these employees during an interview. This failure is a violation of the 28 Pa. Code: 201.20(a) Responsibility of Licensee and 28 PA. Code: 201.20(c) Staff Development.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide training on compliance and ethics for all ten staff members reviewed, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. The review of facility-provided information for each of these employees revealed the absence of training on compliance and ethics. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of such training for the staff members in question.
Failure to Return Personal Possessions in a Timely Manner
Penalty
Summary
The facility failed to ensure the right of a resident to retain personal possessions, as required by their policy. The resident, who had been diagnosed with anxiety and depression, used jewelry making as a therapeutic activity. After being transported to the hospital for an involuntary psychiatric commitment due to suicidal plans and increased behaviors, the resident returned to the facility. However, her personal belongings, which included jewelry making supplies, were not returned to her for four weeks. The delay in returning the resident's belongings was confirmed by the Social Worker, who stated that the facility wanted to ensure the resident would remain in her new room before returning her possessions. The Nursing Home Administrator acknowledged the failure to uphold the resident's rights. The facility's policy allows residents to retain personal possessions unless it infringes on the rights or safety of others, but the delay in returning the resident's belongings was not justified by these criteria.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 985 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pittsburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Hills Post Acute | 1.1 mi | — | 0 | 0 |
| Concordia Of The South Hills | 1.1 mi | — | 0 | 0 |
| John J Kane Regional Center-sc | 1.5 mi | — | 4 | 0 |
| Asbury Health Center | 1.6 mi | — | 1 | 0 |
| Providence Point Healthcare Residence | 1.8 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.