Rehab & Nursing Ctr Greater Pittsburgh

Inspectors wroteBased on review of facility policy, clinical records, documentation provided by the facility, facility investigation, resident interview, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by failing to provide adequate assistance and interventions to prevent fall with injury, which resulted in actual harm of a scalp laceration, brain bleed and hospital admission to reverse anticoagulation for one of three residents (Resident R1). Findings Include: Review of the facility policy Abuse, Neglect, Misappropriation Prevention Program last reviewed on 1/16/26, indicated that the residents of the facility have a right to be free from abuse, neglect, exploitation and misappropriation of property. The facility will develop and implement policies to prevent and identify such concerns. [...]

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance for bed mobility to prevent accidents which resulted in actual harm of a head bleed for one of three residents (Resident R1). Findings Include: Review of facility Falls and Fall Risk, Managing policy dated 1/15/26, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of the admission record indicated that Resident R1 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of muscle weakness, spinal stenosis, and depression. [...]

Inspectors wroteBased on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of nine residents (Resident R1). This was identified as past non-compliance.

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to properly store food products in the walk-in cooler and freezer which created the potential for cross contamination (Main Kitchen).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of decreased Capillary Blood Glucose (CBG) levels for three of seven residents reviewed (Residents R6, R86, and R100).

Inspectors wroteBased on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for four of five sampled residents (Residents R1, R2, R53, and R98).

Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents in three of three locations, 300-lounge, main dining room, and front lobby.

Inspectors wroteBased on review of facility policy, facility documentation and staff interview, it was determined that the facility failed to protect a resident from neglect and verbal abuse for one of three residents (Resident R114).

Inspectors wroteBased on a review of facility policy, information provided by the facility, clinical records and staff interview, it was determined the facility failed to promptly conduct a thorough investigation to rule out abuse and implement corrective action and submit the results of the completed investigation to the State Survey Agency within five working days of the incident as evidenced by one of three residents reviewed (Resident R114).

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility at the beginning of each shift.

Inspectors wroteBased on observations and a staff interview, it was determined the facility failed to post contact information, Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the resident may file a complaint with the State Agency as required, in the building.

Inspectors wroteBased on review of facility policy, clinical records, documentation provided by the facility, facility investigation, resident interview, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by failing to provide adequate assistance and interventions to prevent fall with injury, which resulted in actual harm as evidenced by a subarachnoid hemorrhage, six staples to the left side of the scalp, and a C4 (fourth cervical vertebra) fracture which required use of a cervical collar to be worn at all times for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, facility documentation, and staff interviews, it was determined that the facility failed to provide adequate assistance and interventions to prevent fall with injury, that resulted in actual harm causing a subarachnoid hemorrhage, six sutures to the scalp, and a C4 (fourth cervical vertebrae) fracture for one of three residents (Resident R1)

Inspectors wroteBased on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for four of the nine residents reviewed (Resident R24, R29, R57, R71). Findings Include: A review of the facility policy Advanced Directives last reviewed 1/18/24, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. [...]

Inspectors wroteBased on review of facility policy, observation and staff interview, it was determined that the facility failed to properly secure medication in one of two medication carts on the 300 hall nursing unit (B cart).

Inspectors wroteBased on reviews of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to implement effective safety measures by not supervising use of a cold pack in a manner that promotes safety for one of three residents reviewed (Resident R1), which resulted in actual harm of a superficial frostbite burn (involving the epidermis and dermis layers of the skin that is red blistered swollen and painful). This was identified as harm for one resident (Resident R1).

Inspectors wroteBased on review of manufacturer guidelines, observation, and staff interview, it was determined that the facility failed to make certain that medications were properly stored in two of two medication carts (200 B and 200 A).