Pennsylvania Department of Health
REHABILITATION & NURSING CENTER AT GREATER PITTSBURGH, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

REHABILITATION & NURSING CENTER AT GREATER PITTSBURGH, THE
Inspection Results For:

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REHABILITATION & NURSING CENTER AT GREATER PITTSBURGH, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to an incident, completed on March 2, 2026, it was determined that Rehab &; Nursing Center of Greater Pittsburgh was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based 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.

Findings include:

Review of the facility policy "Safety and Supervision of Residents" dated 1/15/26, indicated the facility will provide a safe environment for all residents.

Review of the clinical record revealed Resident R1 was admitted to the facility on 11/14/20.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/3/26, included diagnoses of dementia (a decline in mental ability severe enough to interfere with daily life, cause by physical changes in the brain) and a psychotic disorder with delusions.

Review of an "Elopement Risk Evaluation" completed on 5/25/24, indicated Resident R1 was at risk for elopement.

Review of Resident R1's plan of care for "Risk for Elopement" initiated 6/5/25, indicated Resident R1 is at risk for elopement due to a history of wandering and verbalized wanting to leave the facility.

Review of a progress note dated 7/7/25, at 8:43 a.m. indicated Resident R1 was testing door handles and keypads. When lobby door is open, she will start to run for the door.

Review of facility incident report dated 2/5/26 at 10:25 pm, indicated "Nurse was assisting other resident with a fall and EMS (emergency medical services). EMS reported resident was outside in wheelchair attempting to go into ambulance. LPN (licensed practical nurse) and RN (registered nurse) brought resident back in wheelchair".

Review of a progress note dated 2/5/26, at 11:10 p.m. indicated "Resident was reported outside by EMS ambulance when they were attempting to load other resident. LPN and RN saw resident in wheelchair outside and immediately brought indoors and wrapped in blankets. RN and LPN were with another resident on 100 [unit] who fell. LPN on floor said the last time she saw resident was [on] 400".

Review of facility submitted information dated 2/6/26, indicated that on 2/5/26, At 10:25pm, "LPN had visualized resident at 2200 sitting in wheelchair on his unit at the nurse's station. EMS crew arrived at facility at 2208. EMS rings buzzer to gain access to the facility. Staff remotely opens the coded mag lock door once they see who is trying to enter. Per reenactment, resident had to have been close enough to the door to prop it open with his foot or his arm when EMS entered. Door closes in less than 4 seconds. Per investigation findings, resident propelled through the door [and] through the 25' corridor to the outside door. This door is not alarmed, and resident pushed it open to the outside [and] propelled outside undetected by staff. EMS crew found resident at 2225- 17 minutes after they entered the building."

On 1/6/26, the facility initiated a plan of correction that included:

-Immediate count of all facility residents.

-Elopement assessment completed.

-Update to Resident R1's baseline care plan.

-Audit of all facility residents for elopement risk.

-Update of elopement binders located at the front desk and the first and second floor nurses' stations.

-Education for all staff on the facility elopement policy and elopement prevention.

-Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting, with resolutions to purchase/install concave mirrors and complete audits.

-Audits of admissions to be completed by Director of Nursing or designee five times per week for four weeks, to be reviewed at next QAPI meeting.

The facility was incompliance as of that date.

Review of Resident R1's clinical record completed on 3/2/26, revealed the elopement assessment and care plan had been updated to include information on his elopement, risk for further elopement, and interventions.

During interviews on 3/2/26, staff confirmed they received education on elopement prevention and procedures if an elopement occurs.

During an interview on 3/2/26, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent elopement for one of nine residents.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(e)(1) Management.

28 Pa. Code 201.20(b)(1) Staff Development.

28 Pa. Code 201.29(a) Resident rights.

28 Pa. Code 211.10(c)(d) Resident care policies.

28 Pa. Code 211.11(d) Resident care plan.

28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Plan of Correction - To be completed: 03/12/2026

Past noncompliance: no plan of correction required.

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