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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BRIDGEVILLE REHABILITATION & CARE CENTER
Inspection Results For:

There are 147 surveys for this facility. Please select a date to view the survey results.

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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 two complaints, and an incident completed on October 8, 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:

483.25(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 review of facility policy and staff interviews, it was determined that the facility failed to provide adequate supervision to ensure a safe environment with unrestricted access to the outdoor courtyard area for thirteen of one 168 residents.

Findings include:

Review of the facility policy "Resident Rights" dated 7/7/25, indicated "this includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. "

During an observation with the Director of Nursing (DON) on 10/7/25 at approximately 9:20 a.m. the facility Rose Garden exit door was propped open. This door is located down a corridor next to the family room, out of the view of the nursing units. A resident was observed in the courtyard unattended, an additional resident was attempting to egress out to the courtyard, and visitors processed out the during this observation period. The door has two signs one reads " Keep Door Closed " the second reads " Not an Exit " . The DON confirmed the door should not be propped open at the time of the observation.

During an interview on 10/7/25, at approximately 2:30 p.m., the Nursing Home Administrator (NHA), DON, and Assistant Director of Nursing (ADON) they confirmed the courtyard is the new smoking location as of 10/6/25, the door is not part of the wander guard or alarm system, any mobile resident could egress through this location with the door propped open as the door locks when properly closed.

During an observation on 10/8/25, at approximately 9:30 a.m. The exit door to the courtyard was observed as closed.

During an interview on 10/8/25, at approximately 10:00 a.m. the NHA and the DON confirmed that the facility failed to provide adequate supervision to ensure a safe environment with unrestricted access to the outdoor courtyard area for mobile residents, by propping open a secure door.

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

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

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

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

Plan of Correction - To be completed: 11/04/2025

1.The Facility immediately ensured that the Rose Garden exit door was closed and implemented a plan to remain
compliant.
2.An initial audit of all external facility doors and courtyard doors has been conducted to ensure doors are closed and
unrestricted access to the outdoors was not present.
3. The Maintenance Director re-educated Staff on keeping the courtyard doors closed and a sign was posted on the door to remind staff and visitors to make sure the door is closed, in order to
ensure a safe resident environment.
4. The Maintenance Director or designee will conduct Weekly audits x4, then monthly x 2 of the courtyard doors to
ensure they are closed and do not provide unrestricted access to the outdoors
5.The Maintenance Director or designee will report finding QAPI.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations:
Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of eighteen residents (Resident R1).

Findings include:

Review of facility policy "Medication Errors" dated 7/7/25, indicated " Significant Medication Error means one which causes the patient discomfort or jeopardizes their health and safety. " To prevent medication errors and ensure safe medication administration, nurses should very the following information: Right medication, dose, route, and time of administration; Right patient and right documentation.

Review of the clinical record indicated Resident R1 was admitted to the facility on 3/4/25.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/2/25, included diagnoses of diabetes mellitus (high blood sugar), end stage renal disease (kidney failure requiring dialysis), and high blood pressure.

Review of the physician orders September 2025, indicated to give Resident R1 insulin Lantus (glargine - long-acting insulin) 4 units inject subcutaneously two times a day, timed at 9:00 a.m. and 9:00 p.m...

Review of the Medication Administration Record (MAR) for September 2025 indicated Resident R1 was given Lantus insulin as per provider order.

Review of the physician orders September 2025, indicated to give Resident R1 insulin Lispro (fast-acting insulin) 4 units inject subcutaneously every four hours daily, timed at 7:30 a.m., 11:30 a.m., 4:30 p.m. and 9:30 p.m. and additional units, according to a blood glucose reading following the sliding scale:

200-299 =1 unit
300-399 =2 units
400-499 =3 units
400-499 = 4 units
500-599 = 5 units

Call provider if blood sugar is greater than 500.

Review of the Medication Administration Record (MAR) for September 2025 indicated Resident R1 was given Lispro insulin as per provider order.

During a phone interview with LPN Employee E1 on 10/7/25 at approximately 2:20 p.m., Employee E1 stated on she was preparing insulin for the insulin for Resident R2, 30 units of NovoLog and prior to administration was interrupted by a resident. Employee E1 returned to the room and confirmed that she inadvertently administered Resident R2 insulin to Resident R1.

Review of the approximate event timeline of 9/22/25 reveals:
5:50 p.m., the incorrect resident was administered insulin.
5:52 p.m., the supervisor was notified.
6:00 p.m., the resident notified her family.
6:15 p.m., the provider notified, and orders received to monitor blood sugars. Blood sugar was 354.
6:30 p.m., the supervisor notified residents family.
7:45 p.m., the family requested resident be sent to the emergency department.
8:10 p.m., the resident was transported to the emergency department where she received D10w (an intravenous solution) at 250cc/hr.
Resident R1 returned from the emergency department 9/23/25 approximately 10:00 a.m.

During an interview on 10/8/25, at approximately 10:30 a.m., the Director of Nursing confirmed the facility failed to make certain that residents are free of significant medication errors for one of eighteen residents.

28 Pa. Code 207.2(a) Administrator's responsibility.

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

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

Plan of Correction - To be completed: 11/04/2025

The facility will ensure physician's orders are followed to prevent significant
Medication error and Nurses will Verify right medication, dose,route, time of
administration, right Resident and right documentation.

1.The insulin Lispro order for Resident #1 is being administered as per the physician order.
2. DON/Designee completed an initial audit of residents who are ordered insulin in the last seven days to ensure insulin is given as per physician orders.
3.NPE / DON / Designee to educate licensed nurses regarding following physician
orders as written including any insulin parameters
.
4.NPE/DON/Designee to complete weekly observation audits of 10 residents receiving insulin weekly X 4 then monthly X 2 to ensure physician orders are followed.
5.DON/designee will report the findings of the audits at QAPI.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 11/04/2025

residents received care in accordance with their plan of care and attending physician orders.
2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs the facility follows staffing policies
including exhausting all possible replacements from internal staffing pool and contracted agency staff. Facility continues to offer
incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and
additional pool staff.
3. Facility nursing staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of
maintaining the schedule as posted.
4. To monitor and maintain ongoing compliance the DON or designee will audit staffing weekly x4 weeks then monthly for two
months.
Results will be taken to the QAPI for review and revision as needed.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 40 residents during the day shift on one of twenty-one days.

Findings include:

Review of the nursing schedules and census information for the weeks of 9/14/25 through 9/20/25, 9/21/25 through 9/27/25 and 9/28/2025 through 10/4/25, revealed the following LPN staffing shortages:

Day shift:

10/4/25 census 167 49.20 actual hours 53.44 hours required.

During electronic communication on 10/8/25, at 4:37 p.m. the Director of Nursing confirmed the above findings, and that the facility failed to provide the minimum of LPN's on the above days and shift as required.

Plan of Correction - To be completed: 11/04/2025

All residents received care in accordance with their plan of care and attending physician orders.
2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs the facility follows staffing policies
including exhausting all possible replacements from internal staffing pool and contracted agency staff. Facility continues to offer
incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and
additional pool staff.
3. Facility nursing staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of
maintaining the schedule as posted.
4. To monitor and maintain ongoing compliance the DON or designee will audit staffing weekly x4 weeks then monthly for two
months.
Results will be taken to the QAPI for review and revision as needed.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on fourteen of twenty-one days.

Findings include:

Review of the nursing schedules and census information for the weeks of 9/14/25 through 9/20/25, 9/21/25 through 9/27/25 and 9/28/2025 through 10/4/25, revealed that the facility failed to maintain 3.20 hours of general nursing care to each resident in a 24-hour period on the following dates:

-9/14/25 census 171. PPD 2.91
-9/16/25 census 176. PPD 2.99
-9/20/25 census 169. PPD 3.00
-9/21/25 census 168. PPD 3.18
-9/22/25 census 170. PPD 2.97
-9/23/25 census 173. PPD 2.85
-9/27/25 census 171. PPD 3.06
-9/28/25 census 173. PPD 2.72
-9/29/25 census 172. PPD 2.90
-9/30/25 census 175. PPD 2.86
-10/1/25 census 171. PPD 3.18
-10/2/25 census 172. PPD 2.90
-10/3/25 census 167. PPD 2.90
-10/4/25 census 167. PPD 2.78

During electronic communication on 10/8/25, at 4:37 p.m. the Director of Nursing confirmed the above findings, and that the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on fourteen of twenty-one days.

Plan of Correction - To be completed: 11/04/2025

1. All residents received care in accordance with their plan of care and attending physician orders.
2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs the facility follows staffing policies
including exhausting all possible replacements from internal staffing pool and contracted agency staff. Facility continues to offer
incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and
additional pool staff.
3. Facility nursing staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of
maintaining the schedule as posted.
4. To monitor and maintain ongoing compliance the DON or designee will audit staffing weekly x4 weeks then monthly for two
months.
Results will be taken to the QAPI for review and revision as needed.

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