Pennsylvania Department of Health
 BRIDGEVILLE REHABILITATION & CARE CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BRIDGEVILLE REHABILITATION & CARE CENTER
Inspection Results For:

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BRIDGEVILLE REHABILITATION & CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on an Abbreviated Survey in response to a complaint completed on December 26, 2025, it was determined that Bridgeville Rehabilitation and Care Center 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:


483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations: Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly secure stored medications and/or biologicals in two of three medication rooms (TCU and Harmony Unit Medication Rooms). Findings include: Review of facility policy " Medication Storage" dated 10/27/25, indicated that medications and biologicals that the medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. During rounds on 12/22/25, at 10:45 a.m. the Director of Nursing (DON) and surveyor checked the Harmony Unit Medication Room and the TCU Medication Room. The doors were unlocked with medications that were designated to be returned, sitting on the counter. These doors require a key to be locked. Education was completed in November by the facility in response to this event, policy for controlled substances administration, ordering, storage, handling and disposal, confirmed with staff interviews. During an interview on 12/22/25, at approximately 9:50 a.m. Licensed Practical Nurse Employee E1 confirmed he had a key to the Harmony Unit Medication Room and that the door should be locked. During an interview on 12/22/25, at approximately 9:55 a.m. Licensed Practical Nurse Employee E2 confirmed she had a key to the Harmony Unit Medication Room and that the door should be locked and proceeded to lock the unlocked door. During an interview on 12/22/25, at approximately 10:00 a.m. Licensed Practical Nurse Employee E3 confirmed she had a key to the TCU Unit Medication Room and that the door should be locked and proceeded to lock the unlocked door. During an interview on 12/22/25, at approximately 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to properly secure medications and/or biologicals in one of two medication rooms. 28 Pa. Code: 211.9(a)(1)(j.1)(k) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
 Plan of Correction - To be completed: 01/28/2026

1. How the corrective action will be accomplished

Immediately upon identification, all medication room doors on the TCU and Harmony Units were secured and locked. Medications awaiting return are now properly stored.

2. How other areas were identified and corrected

A facility-wide audit of all medication rooms, carts, and storage areas was completed to ensure compliance with locking and storage requirements. No additional unsecured areas were identified.

3. Measures to prevent recurrence
Don or designee will re-educate licensed staff on Medication storage with emphasis for medication doors being closed and locked.


4. Monitoring system

The DON or designee will conduct random weekly audits x 8, then monthly x 2 of medication rooms to ensure doors are closed and locked. Results will be reported through QAPI.All corrective actions will be reviewed through the facility's Quality Assurance and Performance Improvement (QAPI) program to ensure sustained compliance.

483.12 REQUIREMENT Free from Misappropriation/Exploitation: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.
§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
Observations: Based on a review of facility policy, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to ensure that residents are free from misappropriation of property for one of four residents (Resident R1). Findings include: Review of the facility policy "Abuse Prohibition" dated 10/27/25, defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the patient's consent. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed that Resident R1 was admitted to the facility on 11/6/25. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 11/13/25, included diagnoses of left knee replacement, obstructive sleep apnea (repeated interruptions in breathing during sleep, and morbid obesity (overweight with a body mass index (BMI) of 40 or higher (normal BMI for a female is 18.5 to 24.9) Review of Section C revealed Resident R1's BIMS score to be "13." Review of a physician's order dated 11/6/25, indicated Resident R1 is to receive Oxycodone HCL 5 mg (milligrams) tablet (a narcotic pain medication), to give 5 mg by mouth every 6 hours as needed for pain mild to moderate AND give 10 mg by mouth every 6 hours as needed for severe pain. Review of a physician's order dated 11/6/25, indicated Resident R1 is to receive Tylenol Extra Strength Oral Tablet 500 mg (milligrams) tablet (a pain medication), to give 1,000 mg by mouth every 8 hours as needed for mild pain. Review of Resident R1's Medication Administration Record (MAR) for November 2025, indicated sixteen administrations of oxycodone: 11/09/25: 5 mg at 6:03 a.m. 11/10/25: 5 mg at 1:30 a.m.; 5 mg at 11:15 a.m.; 5 mg at 4:00 p.m. 11/11/25: 10 mg at 5:57 a.m. 11/12/25: 5 mg at 3:24 p.m. 11/13/25: 10 mg at 8:00 p.m. 11/14/25: 10 mg at 6:28 p.m. 11/15/25: 10 mg at 3:02 a.m. 11/16/25: 10 mg at 4:13 a.m.; 10 mg at 8:35 p.m. 11/17/25: 10 mg at 8:00 p.m. 11/18/25: 10 mg at 3:32 p.m.; 10 mg at 9:30 p.m. 11/20/25: 5 mg at 3:21 a.m.; 10 mg at 4:00 p.m. Review of Resident R1's Medication Administration Record (MAR) for November 2025, indicated sixteen administrations of Tylenol Extra Strength: 11/10/25: 1000 mg at 12:18 a.m. 11/11/25: 1000 mg at 2:00 a.m. 11/13/25: 1000 mg at 2:00 a.m. The MAR indicated RN Employee E4 administered oxycodone once and never administered Tylenol Extra Strength between 11/6/25, through 11/21/25. The MAR indicated RN Employee E5 never administer oxycodone or Tylenol Extra Strength between 11/6/25, through 11/21/25. Review of facility submitted documentation on 11/10/25, indicated that on 11/7/25, Employee E4 Registered Nurse (RN) worked the 11:00 p.m. to 7:00 a.m. shift and signed in a narcotic card containing 26 Oxycodone HCL 5 mg for Resident R1, from the facilities pharmacy provider, at approximately 0130 (1:30 a.m.). At 7:00 a.m. on 11/8/25 Employees RN E4 and RN E5 counted and the count was accurate. 11/8/25 RN Employee E5 worked from 7:00 a.m. to 11:00 p.m., at 11:00 p.m. on 11/8/25 Employees RN E5 and RN E4 counted 27 of 27 cards in the narcotic drawer and signed the count was correct. On 11/9/25 at approximately 4:45 a.m. Resident R1 requested the Oxycodone HCL 5 mg. Employee RN E4 was unable to locate the Oxycodone in the narcotic drawer, both the narcotic card and narcotic sheet was unaccounted for. Review of a statement written by RN Employee E5 dated 11/9/25, indicated "I counted with RN Employee E4 at 11:00 p.m. count correct." " I never gave Resident R1 a pain pill other than Tylenol as she did not request for anything stronger." RN Employee E5 at approximately 1:00 p.m. on 11/8/25 noted the binder fell off the med cart and RN Employee E5 had to put all the papers back in the narcotic book. Review of a statement written by RN Employee E4 dated 11/9/25, indicated, on 11/9/25 approximately 2306 (11:06 p.m.) Counted narcs (narcotics), TCU cart with RN Employee E5. 27 of 27 narcotic cards. Approximately 4:45 a.m. Resident R1 requested a pain pill oxycodone, and none were signed out on the computer. I looked for the controlled substance tracking sheet and card, there were none. I flipped to the shift change inventory count signoff sheet from the prior day and it was missing. Review of a statement written by Licensed Practical Nurse (LPN) Employee E6 dated 11/9/25. RN Employee E4 asked her opinion with Resident R1 wanting a pain pill however she doesn't have a medication card or paper for the requested narcotic. The resident states she has been getting pain medication, but it hadn't been documented in the computer as given. LPN Employee E6 and RN Employee E4 reviewed the controlled substance tracking book and RN Employee E4 stated the original tracking sheet had been removed and a new one placed (as the new document didn't have RN Employee E4's documentation of 11/8/25 acknowledgement of the Oxycodone card (receipt), the card identification number, and a count of 29/29 narcotic cards documented. LPN Employee E6 found the missing narcotic count signoff sheet that contained the acknowledgement of the Oxycodone card (receipt) and the card identification number documented by RN Employee E4 folded in half, in the recycle bin, it was unsigned by RN Employee E5 during that shift change (shift change count sheets note "nurse coming on shift must verify count of all controlled substances with nurse going off shift and anytime the medication cart keys are exchanged."). LPN Employee E6 stated they did not find the missing Oxycodone or the corresponding drug count record paper that should have been in the binder. During review of facility documents, dated 11/9/25 at approximately 4:45 a.m. the resident requested Oxycodone pain medication and did not receive the medication until 6:00 a.m. on 11/9/25 due to the missing medication and associated medication documents. RN Employee E4 discussed with LPN Employee E6 resident states she has been getting pain medication, but it hadn't been documented in the computer as given. There is no evidence that RN Employee E5 was asked for or provided any statement regarding not signing the shift change count sheet of 11/8/25 at 7:00 a.m. that contained the 29/29 narcotic cards and or how the count changed to 27/27 narcotic cards at 11/8/25 p.m. There is no evidence of an interview being conducted with the resident. Education was completed in November by the facility in response to this event, policy for abuse, neglect and exploitation was conducted and confirmed with staff interviews. During an interview on 12/22/25 at approximately 12:00 p.m. the Director of Nursing confirmed only RN's Employee 's E4 and E5 had the keys that access to the medication cart from 11/7/25 at 11:00 p.m. through 11/9/25 at approximately 10:15 a.m. employee RN Employee E5 (left her shift due to a family emergency). The facility determined, they are unable to identify a perpetrator in this event, and the facility did file a report with the local police department. During an interview on 12/22/25, at approximately 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to ensure that residents are free from misappropriation of property for one of four residents (Resident R1). 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. 28 Pa. Code: 201.29(j) Resident rights.
 Plan of Correction - To be completed: 01/28/2026

1. How the corrective action will be accomplished

Resident R1 narcotics were replaced. Resident offered no complaints of pain with no ill effects noted..


2. How other residents were identified and protected-

An initial audit of controlled substance documentation, narcotic counts, and MARs was completed for all current facility residents receiving controlled medications to ensure no additional discrepancies existed. No further concerns were identified. Facility residents continue to be monitored to ensure medications are administered safely and appropriately.

3. Measures to prevent recurrence
DON or designee re-education was completed with licensed nursing staff regarding abuse prohibition, misappropriation of resident property, and proper controlled substance handling and documentation.

4. Monitoring system
The DON or designee will conduct random weekly narcotic audits for 10 residents for 8 weeks, then 10 residents monthly for 1 month, including review MARs, and controlled substance records. The DON or designee will conduct 5 random weekly Shift count audits for 8 weeks, then 10 residents monthly for 1 month. Findings will be reviewed during QAPI meetings and corrective action taken as indicated.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations: Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures to investigate misappropriation of resident property for one of four residents (Resident R1). Findings include: Review of the facility policy "Abuse Prohibition" dated 10/27/25, defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the patient's consent. Review of the facility policy "Controlled Substances" dated 10/27/25, indicated "controlled medications" are substances that have and accepted medical use (medications which fall under U.S. Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse. These medications are subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal and state laws and regulations. Controlled medications are obtained from the locked cabinet, or safe, or medication cart. At each shift change, a physical inventory of controlled medications, as defined by state regulation, is conducted by two licensed clinicians and is documented on an audit record. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of a physician's order dated 11/6/25, indicated Resident R1 is to receive Oxycodone HCL 5 mg (milligrams) tablet (a narcotic pain medication), to give 5 mg by mouth every 6 hours as needed for pain mild to moderate AND give 10 mg by mouth every 6 hours as needed for severe pain. Review of a physician's order dated 11/6/25, indicated Resident R1 is to receive Tylenol Extra Strength Oral Tablet 500 mg (milligrams) tablet (a pain medication), to give 1,000 mg by mouth every 8 hours as needed for mild pain. Review of Resident R1's Medication Administration Record (MAR) for November 2025, indicated sixteen administrations of oxycodone: 11/09/25: 5 mg at 6:03 a.m. 11/10/25: 5 mg at 1:30 a.m.; 5 mg at 11:15 a.m.; 5 mg at 4:00 p.m. 11/11/25: 10 mg at 5:57 a.m. 11/12/25: 5 mg at 3:24 p.m. 11/13/25: 10 mg at 8:00 p.m. 11/14/25: 10 mg at 6:28 p.m. 11/15/25: 10 mg at 3:02 a.m. 11/16/25: 10 mg at 4:13 a.m.; 10 mg at 8:35 p.m. 11/17/25: 10 mg at 8:00 p.m. 11/18/25: 10 mg at 3:32 p.m.; 10 mg at 9:30 p.m. 11/20/25: 5 mg at 3:21 a.m.; 10 mg at 4:00 p.m. Review of Resident R1's Medication Administration Record (MAR) for November 2025, indicated sixteen administrations of Tylenol Extra Strength: 11/10/25: 1000 mg at 12:18 a.m. 11/11/25: 1000 mg at 2:00 a.m. 11/13/25: 1000 mg at 2:00 a.m. The MAR indicated RN Employee E4 administered oxycodone once and never administered Tylenol Extra Strength between 11/6/25, through 11/21/25. The MAR indicated RN Employee E5 never administer oxycodone or Tylenol Extra Strength between 11/6/25, through 11/21/25. Review of facility submitted documentation on 11/10/25, indicated that on 11/7/25, Employee E4 Registered Nurse (RN) worked the 11:00 p.m. to 7:00 a.m. shift and signed in a narcotic card containing Oxycodone HCL 5 mg for Resident R1, from the facilities pharmacy provider, at approximately 0130 (1:30 a.m.). At 7:00 a.m. on 11/8/25 Employees RN E4 and RN E5 counted and the count was accurate. 11/8/25 RN Employee E5 worked from 7:00 a.m. to 11:00 p.m., at 11:00 p.m. on 11/8/25 Employees RN E5 and RN E4 counted 27 of 27 cards in the narcotic drawer and signed the count was correct. On 11/9/25 at approximately 4:45 a.m. Resident R1 requested the Oxycodone HCL 5 mg. Employee RN E4 was unable to locate the Oxycodone in the narcotic drawer, both the narcotic card and narcotic sheet was unaccounted for. Review of a statement written by RN Employee E5 dated 11/9/25, indicated "I counted with RN Employee E4 at 11:00 p.m. count correct." " I never gave Resident R1 a pain pill other than Tylenol as she did not request for anything stronger." RN Employee E5 at approximately 1:00 p.m. on 11/8/25 noted the binder fell off the med cart and RN Employee E5 had to put all the papers back in the narcotic book. Review of a statement written by RN Employee E4 dated 11/9/25, indicated, on 11/9/25 approximately 2306 (11:06 p.m.) Counted narcs (narcotics), TCU cart with RN Employee E5. 27 of 27 narcotic cards. Approximately 4:45 a.m. Resident R1 requested a pain pill oxycodone, and none were signed out on the computer. I looked for the controlled substance tracking sheet and card, there were none. I flipped to the shift change inventory count signoff sheet from the prior day and it was missing. Review of a statement written by Licensed Practical Nurse (LPN) Employee E6 dated 11/9/25. RN Employee E4 asked her opinion with Resident R1 wanting a pain pill however she doesn't have a medication card or paper for the requested narcotic. The resident states she has been getting pain medication, but it hadn't been documented in the computer as given. LPN Employee E6 and RN Employee E4 reviewed the controlled substance tracking book and RN Employee E4 stated the original tracking sheet had been removed and a new one placed (as the new document didn't have RN Employee E4's documentation of 11/8/25 acknowledgement of the Oxycodone card (receipt), the card identification number, and a count of 29/29 narcotic cards documented. LPN Employee E6 found the missing narcotic count signoff sheet that contained the acknowledgement of the Oxycodone card (receipt) and the card identification number documented by RN Employee E4 folded in half, in the recycle bin, it was unsigned by RN Employee E5 during that shift change (shift change count sheets note "nurse coming on shift must verify count of all controlled substances with nurse going off shift and anytime the medication cart keys are exchanged."). LPN Employee E6 stated they did not find the missing Oxycodone or the corresponding drug count record paper that should have been in the binder. During review of facility documents, dated 11/9/25 at approximately 4:45 a.m. the resident requested Oxycodone pain medication and did not receive the medication until 6:00 a.m. on 11/9/25 due to the missing medication and associated medication documents. RN Employee E4 discussed with LPN Employee E6 resident states she has been getting pain medication, but it hadn't been documented in the computer as given. There is no evidence that RN Employee E5 was asked for or provided any statement regarding not signing the shift change count sheet of 11/8/25 at 7:00 a.m. that contained the 29/29 narcotic cards and or how the count changed to 27/27 narcotic cards at 11/8/25 p.m. There is no evidence of an interview being conducted with the resident. During rounds on 12/22/25, at 10:45 a.m. the Director of Nursing (DON) and surveyor checked the Harmony Unit Medication Room and the TCU Medication Room. The doors were unlocked with medications that were designated to be returned, sitting on the counter. These doors require a key to be locked. Education was completed in November by the facility in response to this event, policy for controlled substances administration, ordering , storage, handling and disposal, confirmed with staff interviews. During an interview on 12/22/25 at approximately 11:00 a.m. with the Director of Nursing (DON), the surveyor requested to see the original shift change counts sheets and was informed they are missing (copies were available and reviewed). RN's Employee's E4 and E5 were placed on a ten day leave during the investigation. The facility did not place the employees on leave until 11/9/25 at 10:15 a.m. after RN Employee E5 left work due to a family emergency. The facility did not require, request, or offer any staff drug screening to be completed. RN Employee E4 independently had a hair drug screening that was reportedly negative. RN's Employees E4 and E5 did return to work after 10 days' leave. On or around 12/20/25, RN Employee E5 requested and was granted permission to leave work early (due to illness) and has been a no call no show since. Only RN's Employee 's E4 and E5 had the keys that access to the medication cart from 11/7/25 at 11:00 p.m. through 11/9/25 at approximately 10:15 a.m. employee RN Employee E5 (left her shift due to a family emergency). The facility determined, they are unable to identify a perpetrator in this event, and the facility did file a report with the local police department. The facility investigation confirmed the Oxycodone is missing. During an interview on 12/22/25, at approximately 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to implement policies and procedures to investigate misappropriation of resident property for one of four residents (Resident R1). 28 Pa. Code: 201.18(e)(1)(2) Management. 28 Pa. Code: 201.29(a)(c)(d) Resident rights. 28 PA. Code: 211.12(a)(c)(d)(1)(3)(5) Nursing services.
 Plan of Correction - To be completed: 01/28/2026

1. How the corrective action will be accomplished
Education was provided to administrative and nursing leadership by the NHA/designee on timely, complete investigations and reporting requirements. A complete and thorough investigation was completed for R1.

2. How other residents were identified and protected
An initial audit will be completed on current facility residents receiving controlled medications to review the medical record for the last 7 days to ensure accurate documentation and appropriate medication was accessible. Any discrepancies identified will be investigated with applicable reporting as warranted.

3. Measures to prevent recurrence
NHA or designee will re-educate Facility IDT facility policy accidents and incidents OPS100 with emphasis on facility investigation protocol.

4. Monitoring system
The Administrator or DON will review facility abuse and misappropriation investigations for completeness and timeliness weekly for 90 days. Results will be reported through QAPI.All corrective actions will be reviewed through the facility's Quality Assurance and Performance
Improvement (QAPI) program to ensure sustained compliance.

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