Pennsylvania Department of Health
MASONIC VILLAGE AT SEWICKLEY
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MASONIC VILLAGE AT SEWICKLEY
Inspection Results For:

There are 78 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


MASONIC VILLAGE AT SEWICKLEY - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated survey completed on March 13, 2026, it was determined that Masonic Village at Sewickley was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care 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 more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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, clinical records, investigation documents, and other resources, as well as staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that a resident was free from accident/hazards by failing to provide a second person to assist with a stand-up lift transfer, which resulted in harm as evidenced by a displaced fractured humerus (upper arm bone), hospitalization, and functional loss of right hand for one of three residents reviewed (Resident 1).

Findings include:

A review of the facility policy, titled "Resident Transfers To/From and Within Equipment," last reviewed August 28, 2025, indicated employees will utilize appropriate body mechanics and safety techniques to prevent injury to the residents and themselves while transferring a resident to/from and with resident care equipment. The resident's current transfer status will be included in the individualized plan of care and noted within the nursing assistant documentation area of the resident's electronic health record.

Review of Resident 1's admission record indicated she was admitted to the facility on August 22, 2025.

A review of Resident 1's clinical record revealed diagnoses that included osteoporosis (decreased bone density and softening of the bone) and displaced fracture surgical neck of right humerus (a serious, often high-energy injury where the upper arm bone breaks just below the ball-and-socket joint, separating and shifting the bone fragments).

Review of the Resident Care Guide (followed by Nursing Assistants), revealed Resident 1 transfers using a Sara lift (a standing aid used for transfers) with two person assist.Date Initiated: 08/23/2025 Revision on: 02/03/2026

Review of Resident 1's current care plan for transfers revealed:
Transfers: Maxi lift Assist x 2 persons. Revised 2/19/2026

Review of Resident 1's Significant Change MDS (Minimum Data Set - an assessment triggered by a major, non-self-limiting decline of physical or mental health) dated December 19, 2025, indicated a BIMS (brief interview of mental status) score of 9, indicating moderately impaired cognitive status.

Section G0110-B (functional mobility describing how a resident move between surfaces including to or from a bed, chair, or wheelchair) of the MDS assessment indicated a performance level of "2-Maximal assistance" and a support level of "2-two-person assistance", meaning that Resident 1 received two-person assistance when transferring between surfaces. The current Significant change MDS dated February 27, 2026, revealed a BIMS score of 6, indicating severely impaired cognitive status and change in functional ability (use of Maxi lift for transfers).

A written statement dated February 17, 2026, at 10:16 PM, by Employee 2 (Licensed Practical Nurse [LPN]) on February 17, 2026, at 8:00 PM, stated, "I was passing meds around 8 PM and helping a resident, doing his pills, drops, and answering a question he had about his med list. Employee 3 (Nursing Assistant) was in the room with me setting up a shower per resident request since he is going out tomorrow. I came back to the office and Employee 1 came in and asked me to look at Resident 1's arm because it looked swollen. I entered the room and Resident 1 was visibly upset and in pain. The arm and it was hard and swollen, caused pain with movement. I immediately called the Registered Nurse to come and assess as well. Resident 1 was unable to tell us what happened, however would very distraughtly say 'he' and asked me not to leave her. The Registered Nurse and I sat with Resident 1 until calm however still in visible pain. Resident 1 was not complaining at dinner and was using her arm normally, and was okay when I took her to her room after dinner and sat up her tray table for her to color. Resident 1 was content and okay up until Employee 1 asked me into her room. Resident 1 was already changed into a gown and in bed when Employee 1 called me in."

Review of facility incident report dated February 17, 2026, at 8:00 PM, reports the following:
Employee 2 was called to Resident 1's room due to right arm appearing swollen. Resident was crying, expressing pain. Employee 1 (Nursing Assistant [NA]) provided evening care to Resident. Resident observed with both arms normal at dinner. Last seen by medication nurse around 7:15 PM, seated content in her wheelchair, coloring. Registered Nurse called to assess, right arm swollen, Resident unable to explain what may have happened. Physician called, order to obtain complete x-ray of shoulder/humerus in house. POA (Power of Attorney) updated. X-ray results sent to MD, order received to send Resident to hospital for suspected fracture of humerus. POA called and updated and agreed to have Resident sent to ER. Left facility with chart information with medics via ambulance.

The initial facility interview with Employee 1 on February 17, 2026, stated that he had a second staff person (Employee 3) to transfer Resident 1 with the stand-up lift but later admitted to the Administration that he did not have a second person assist with the transfer. The facility confirmed with Employee 3 that he did not care for or assist with the transfer of Resident 1.

A written statement was obtained by Employee 3 stating, "On February 17, 2026, during the 3-11 shift, I, Employee 3, did not assist with putting Resident 1 to bed."

A written statement by Employee 1 on the evening of February 17, 2026, not timed, stated the following:
"At 8 PM I transferred Resident 1 into her bed with the sit to stand once placed into bed still in sitting position I began to take off her clothes and noticed that her right arm was swollen and I alerted the nurse."

Resident 1's final x-ray report on February 17, 2026, at 11:56 AM, revealed an acute fracture involving the mid shaft of the right humerus, with moderate angulation and displacement. There was mild soft tissue swelling. There was no dislocation. Resident 1 was being treated with a non-operative approach (immobilization) using a splinted cast and sling at that time. Resident will continue to follow-up with orthopedics for further evaluations.

Based on the American Academy of Orthopedic Surgeons, Humerus fractures are primarily caused by high energy trauma like falls from heights, motor vehicle accidents, direct blows to the arm, or sports injuries. In older adults with osteoporosis, these fractures often result from minor falls or low energy impacts. Humerus fractures are frequently treated without surgery (immobilization). Loss of hand function can occur with radial nerve damage (wrist drop).

On March 11, 2026, at 10:30 AM, Resident 1 was observed in her room in bed. Resident 1's right hand was non-functional, fingers and wrist were curled under, and Resident was unable to move any of her right hand when asked but was able to hold her left arm up and extend her wrist, hand, and fingers. Resident was right-handed prior to fractured humerus.

The Director of Nursing (DON) stated that therapy was trying to teach the Resident how to feed herself with her left hand.

During an interview with the DON and Nursing Home Administrator (NHA) on March 11, 2026, at approximately 11:15 AM, both confirmed the only person who provided PM care and transferred Resident 1 from her wheelchair to the bed on the evening shift of February 17, 2026, was Employee 1.

On February 17, 2026, Employee 1 was removed from staffing pending the outcome of the investigation. All appropriate agencies were notified.

The facility initiated a plan of correction on February 17, 2026, that included:

2/17/2026- A full in house review of residents that utilize lifts for transfers and require 2-person assistance for transfer was reviewed.

2/17/2026- Audits were initiated on February 17, 2026, for compliance of type of lift and 2-person assist compliance. Additional audits were performed on March 5 and 11, 2026, and will continue weekly.

2/18/2026- QAPI (Quality Assessment Performance Review) Ad Hoc meeting was held 2/18/2026 regarding the incident and the plan of correction, that included full house review of residents with lifts, education, and audits. Audits will be reviewed at the next scheduled QAPI meeting.

2/19/2026- Education for all staff was initiated 2/19/2026, with a review of the policy "Residents Transferred to/from and Within Equipment" and education was completed on February 26, 2026.

March 5, 2026- Date of Compliance

During a telephone interview March 13, 2026, at 10:30 AM, with Employee 4 (Registered Nurse), the Employee said that education was received on lifts, two-person transfer, and abuse related to the event that occurred with Resident 1 on February 17, 2026. Employee stated that she has assisted and educated Employee 1 in the past on lifts and was surprised that he did not have a second person to assist.

During a telephone interview March 13, 2026, at 10:38 AM, with Employee 5 (NA) the employee said that education was received on lifts, two-person transfer, and abuse related to the event that occurred with Resident 1 on February 17, 2026. Employee stated that she feels competent in caring for residents that require a lift and is aware that two-persons are required. Employee said she knows where to find the care plan for residents. She added that she feels sorry that this happened to Resident 1, and added that staff have to be present when Resident 1 is attempting to feed herself and that she is improving with use of her left hand.

During a telephone interview March 13, 2026, at 10:42 AM, with Employee 6 (NA) the employee said that education was received on lifts, two-person transfer, and abuse related to the event that occurred with Resident 1 on February 17, 2026. Employee stated that she feels competent caring for her assigned residents.

During an interview with the NHA and DON on March 13, 2026, at 10:50 AM, both agreed that Employee 1 should have followed the care plan and had a second person present. The NHA added that the facility requires 2-person assist with all mechanical lifts.

The facility displayed past non-compliance in its failure to ensure that a resident was free from accident/hazards by failing to provide a second person to assist with a stand-up lift transfer, per care plan, resulting in harm immediately after transfer as evidenced by a displaced fractured right humerus, hospitalization, splint casting, and functional loss of right hand for Resident 1.

28. Pa Code 201.14(a) Responsibility of licensee.
28. Pa Code 201.18(b)(1)(3) Management.
28. Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 03/16/2026

Past noncompliance: no plan of correction required.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement