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:

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

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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 a Medicare/Medicaid, Civil Rights Compliance, State Licensure, and an Abbreviated survey in response to two complaints completed on November 26, 2025, it was determined that Rehab and 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 and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations: Based 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). Findings include: Review of facility policy "Food Receiving and Storage" dated 1/16/25, indicated foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer are covered, labeled and dated. Refrigerated foods are stored in a way which allows for adequate air circulation around food containers. During an observation of the main kitchen on 11/24/25, at 9:50 a.m., the following was observed: Walk in cooler: -one jar of grape jelly was opened undated. Freezer - boxes of multiple types of food items stored to ceiling on top shelves of whole freezer and under fans. During an interview on 11/24/25, at 10:00 a.m., Dietary Manager Employee E1 confirmed that the facility failed to properly store food products and maintain sanitary conditions which created the potential for food borne illness and cross contamination in the Main Kitchen. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(3) Management.

Plan of Correction - To be completed: 01/12/2026

The unopened/undated jar of grape jelly has been discarded. The boxes of multiple types of food items stored to the ceiling on top shelves of whole freezer and under fans were prompted moved to comply with safe food handling practices.

All other food stored in the kitchen was audited; no other improper storage was noted.

Culinary staff were educated re: facility policy of Food Receiving and Storage.

Food storage areas in the kitchen will be audited weekly for two months to ensure proper food storage is being maintained.

Results of these audits will be reviewed in the monthly Quality Assurance Quality Improvement meeting.

483.25 REQUIREMENT Quality of Care:

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.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations: Based 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). Findings include: The Centers for Disease Control define diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy "Management of Hypoglycemia" reviewed 1/16/25, indicated the facility provided guidelines for managing hypoglycemia secondary to insulin therapy, or oral hypoglycemic agents. The facility classification/implement protocol of hypoglycemia is as follows: - Level 1: Blood glucose is less than 70mg/dl but greater than 54 mg/dl. Protocol: give oral form of glucose, notify provider immediately, remain with resident, recheck blood glucose in 15 minutes, provide resident meal or snack. - Level 2: Blood glucose is less than 54 mg/dl. Protocol: administer glucagon (rapid form of glucose), notify provider immediately, remain with the resident, place resident in a comfortable and safe place, monitor vital signs, and recheck blood glucose in 15 minutes. - Level 3: Altered mental and/or physical status requiring assistance for treatment of hypoglycemia. Protocol: call 911, administer glucagon or intravenous (IV) 50% glucose, if IV access. Review of the facility policy "Change in Resident's Condition or Status" reviewed 1/16/25, indicated the nurse will notify the resident's attending physician or physician on call when there has been a need to alter the resident's medical treatment significantly. A "significant change" of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the clinical record revealed Resident R6 was admitted to the facility on 10/3/25, with diagnoses that included congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), diabetes, and high blood pressure. Review of Resident R6 physician's order revealed the following orders: - On 10/3/25, Hypoglycemic protocol for blood sugar less than 80 if symptomatic or blood sugar less than 70 with or without symptoms present (1) Administer approximately 15 grams of glucose by mouth or carbohydrates found in any of the following: 1/2 cup juice, 1/2 cup applesauce, one cup milk, one tube glucose gel, three glucose tablets AND (2) Wait 15 minutes AND (3) Recheck blood sugar levels, if level still below target give another 15 grams of glucose or meal/snack within one hour. Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed the CBG's were as follows: - On 10/4/25, at 7:01 p.m. CBG was noted to be 49. - On 10/17/25, at 8:04 a.m. CBG was noted to be 65. - On 11/22/25, at 4:21 p.m. CBG was noted to be 61. Review of Resident R6 eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician order was not followed for hypoglycemic protocol. Review of Resident R6 care plan revised on 11/18/25, failed to reveal interventions for diabetes management, including hypo-/hyperglycemia. Review of a clinical record indicated Resident R86 was admitted to the facility on 10/2/25, with diagnoses that included diabetes, anxiety, and generalized muscle weakness. Review of Resident R86 physician's orders on 11/24/25, failed to reveal orders for hypoglycemic protocol. Review of the clinical record and eMAR revealed the CBG's were as follows: - On 10/24/25, at 12:07 p.m. CBG was noted to be 58. Review of the care plan dated 10/2/25 and 10/13/25, indicated the following interventions: - Administer medications per physician order. - Obtain glucometer readings and report abnormalities as ordered. - Report symptoms of hyperglycemia. - Report symptoms of hypoglycemia. Review of Resident R86's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Review of the clinical record indicated Resident R100 was re-admitted to the facility on 7/1/25, with diagnoses that included diabetes, generalized muscle weakness, and high blood pressure. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 10/1/25, indicated the diagnoses remain current. Review of Resident R100 physician's order revealed the following orders: - On 7/1/25, Hypoglycemic protocol for blood sugar less than 80 if symptomatic or blood sugar less than 70 with or without symptoms present (1) Administer approximately 15 grams of glucose by mouth or carbohydrates found in any of the following: 1/2 cup juice, 1/2 cup applesauce, one cup milk, one tube glucose gel, three glucose tablets. - On 8/30/25, Check blood sugar at bedtime, notify MD (doctor) if blood sugar is less than 70 or greater than 400. Document in progress notes MD notification. Review of the clinical record and eMAR revealed the CBG's were as follows: - On 10/19/25, at 8:20 a.m. CBG was noted to be 63. - On 11/8/25, at 7:45 a.m. CBG was noted to be 61. - On 11/8/25, at 4:31 p.m. CBG was noted to be 69. - On 11/9/25, at 8:02 a.m. CBG was noted to be 65. - On 11/13/25, at 7:41 a.m. CBG was noted to be 63. Review of the care plan dated 5/14/25 and 5/15/25, indicated the following interventions: - Administer medications per physician order. - Obtain glucometer readings and report abnormalities as ordered. - Report symptoms of hyperglycemia. - Report symptoms of hypoglycemia. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed date. During an interview on 11/25/25, at 11:50 a.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition, failed to document an assessment or interventions used related to blood glucose, and failed to follow physicians orders for Residents R6, R86, and R100.

Plan of Correction - To be completed: 01/12/2026

Blood glucose levels from the past month for residents R6, R86, and R100 have been reviewed by the physician/physician assistant to determine if any new orders/recommendations are necessary in relation to Capillary Blood Glucose (CBG) levels. All three residents remain at the facility and are medically stable.

Capillary Blood Glucose levels of all other residents who are being monitored per physician's orders have been reviewed by the Director of Nursing/designee to determine if changes in condition are present that need to be further addressed by a physician.

Licensed staff have been educated re: facility policy "Management of Hypoglycemia" and facility policy "Change in Resident's Condition or Status." Moving forward with an understanding of these policies will ensure physicians are notified of a change in resident condition, assessment/intervention will occur as related to blood glucose levels, and physician orders will be followed.

Random Capillary Blood Glucose levels of five residents per week for two months will be reviewed by Director of Nursing/designee for compliance with changes in condition, assessment/intervention related to blood glucose levels, and the following of physician orders.

Results of these audits will be reviewed in the monthly Quality Assurance Quality Improvement meeting.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Plan of Correction - To be completed: 01/12/2026

The respiratory equipment for Residents R1, R2, R53, and R98 has been changed, washed and labeled per physician orders and is being properly maintained.

The respiratory equipment of all other residents in-house has been audited for compliance with washing/labeling.

Licensed staff will be educated on the facility policy of the Prevention of Infection in the Respiratory Department.

Ten residents per week who utilize respiratory equipment will be audited for two months to make sure equipment is being properly maintained.

Results of these audits will be reviewed in the monthly Quality Assurance Quality Improvement meeting.

483.10(j)(1)-(4) REQUIREMENT Grievances:

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.

§483.10(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Observations: Based 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. Findings include: A review of the facility policy "Grievances/Complaints, Filing" reviewed 1/16/25, grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. The Centers for Medicare &; Medicaid Services (CMS) does not specify exact height requirements for grievance boxes in skilled nursing facilities. However, CMS mandates that grievance procedures be accessible to all residents, including those with disabilities, in compliance with the Americans with Disabilities Act (ADA). In Pennsylvania, the Department of Health incorporates by reference the federal requirements outlined in 42 CFR Part 483, Subpart B, which pertains to long-term care facilities. These regulations emphasize the importance of accessibility but do not provide additional specifications regarding grievance box placement. To ensure accessibility, the ADA Standards for Accessible Design recommend that operable parts, such as slots on grievance boxes, be mounted between 15 and 48 inches above the floor. This range accommodates individuals using wheelchairs and ensures usability for a broad range of residents. During a resident group interview, on 11/24/25 at approximately 1:30 p.m., when asked if they felt they could anonymously file a grievance in the grievance boxes, consensus from the group was "no". Residents stated, "they are too high to reach", "they are not made for people in wheelchairs", and "you have to ask someone to help you, so we just ask the staff to do it for us". During rounds on 11/26/25, at 8:15 a.m. the Nursing Home Administrator and surveyor measured the height of the grievance boxes in the 300-lounge, height was 53 inches, main dining room, height was 52 inches, and front lobby, height was 51 inches. Access to the boxes in both the 300 lounge and front lobby were blocked by a table. During an interview on 11/26/25, at 8:30 a.m. the Nursing Home Administrator confirmed the facility failed to make accessible grievance boxes to residents in three of three locations, 300-lounge, main dining room, and front lobby. 28 PA Code: 201.18(e)(4) Management. 28 PA Code: 201.29(a)(b)(c) Resident rights.

Plan of Correction - To be completed: 01/12/2026

Grievance boxes in the 300 Unit lounge, main dining room, and front lobby have been made accessible to all residents.

Residents will be reminded upon admission, quarterly, and in monthly Resident Council meetings that grievance boxes are available and accessible for grievances and/or complaints to be submitted in writing and may be filed anonymously.

Department Heads have been educated re: how the grievance procedure must be accessible to all residents, including those with disabilities, in compliance with the Americans with Disabilities Act (ADA).

Grievance boxes will be audited monthly for three months to ensure accessibility of the boxes.

Results of these audits will be reviewed in the monthly Quality Assurance Quality Improvement meeting.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

§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 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). Findings include: Review of facility policy "Abuse, Neglect, Exploitation and Misappropriation Prevention Program" dated 1/16/25, indicated residents have a right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy indicated that the facility will identify and investigate all possible incidents of abuse, neglect, mistreatment or misappropriation of resident property within times frames required by federal requirements. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a Brief Interview for Mental Status ("BIMS") is a screening test that aides in detecting cognitive impairment. Review of the clinical record indicated Resident R114 was admitted to the facility on 9/17/25. Review of Resident R114's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 9/24/25, indicated diagnoses of kidney disease, Chron's disease and diabetes. Question C0500 BIMS Summary Score indicated the resident scored a "15", cognitively intact. Question GG0170 Mobility indicated the resident was coded moderate assist (requiring assist of one staff). Review of a facility grievance document dated 9/24/25, indicated the following: "Resident R114 reported that she had not been given an "attitude" by the nurse aide(NA) (identified as NA Employee E3) when she asked for help to go to the bathroom, but the call bell was not responded to until after she had to take herself to the bathroom as she could not wait any longer and NA Employee E3 responded, "it looks like you're already doing it" and walked out huffing and puffing. Review of a statement obtained on 9/23/25, from NA Employee E4 indicated that NA Employee E3 had gone in to check on Resident R114 and was told that Employee E3 had slammed Resident R114's door and had been "bullying" residents all day and swearing and stating that she does not "have time for the resident's crap". NA Employee E4 stated that NA Employee E3 is thrown out of resident rooms, and they don't want her in their rooms. Review of a statement obtained on 9/23/25, from NA Employee E5 indicated that when the nurse aides were coming into work, NA Employee E3 was swearing and upset due to staffing being changed. Later when she and NA Employee E3 entered a resident's room, NA Employee E3 stated "can you shut the f*** up so he (the resident) can finish talking so he can shut the f*** up" and NA Employee E5 stated NA Employee E3 had an attitude and leaving her call bells ringing and did not help pass or pick up trays. During an interview on 11/24/25, at 11:19 a.m., the Director of Nursing confirmed that she did not identify the grievance and statements as potential neglect/ abuse and felt the information was enough of an investigation and took it no further. Confirmed the facility failed to identify, thoroughly investigate 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). 28 Pa. Code 201.14 (c) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10(d) Resident care policies.

Plan of Correction - To be completed: 01/12/2026

Resident R114 has been discharged from the facility, however, the grievance has been thoroughly investigated and reported to the Department of Health.

The staff member involved in this situation was terminated. The staff member who was aware of the situation but did not immediately report it was counseled.

Random resident interviews were conducted to ensure staff treatment/conduct is appropriate and professional.

All other grievances have been reviewed, and no other situations were identified as potential neglect/abuse situations that needed to be investigated with results submitted to the State Survey Agency within five working days of the incident.

Facility staff will be educated re: the requirement 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.

Grievances will be discussed/reviewed with the Interdisciplinary Team for the next three months to ensure concerns of potential neglect/abuse have been promptly and thoroughly investigated and reported to the State Survey Agency within five working days of the incident.

All grievances/reportable events will be discussed in the monthly Quality Assurance Quality Improvement meeting.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

§483.12 Freedom from Abuse, Neglect, and Exploitation
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.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations: Based 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). Findings include: Review of facility policy "Abuse, Neglect, Exploitation and Misappropriation Prevention Program" dated 1/16/25, indicated residents have a right to be free from abuse, neglect, misappropriation of resident property and exploitation. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a Brief Interview for Mental Status ("BIMS") is a screening test that aides in detecting cognitive impairment. Review of the clinical record indicated Resident R114 was admitted to the facility on 9/17/25. Review of Resident R114's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 9/24/25, indicated diagnoses of kidney disease, Chron's disease and diabetes. Question C0500 BIMS Summary Score indicated the resident scored a "15", cognitively intact. Question GG0170 Mobility indicated the resident was coded moderate assist (requiring assist of one staff). Review of a facility grievance document dated 9/24/25, indicated the following: "Resident R114 reported that she had not been given an "attitude" by the nurse aide(NA) (identified as NA Employee E3) when she asked for help to go to the bathroom, but the call bell was not responded to until after she had to take herself to the bathroom as she could not wait any longer and NA Employee E3 responded, "it looks like you're already doing it" and walked out huffing and puffing. Review of a statement obtained on 9/23/25, from NA Employee E4 indicated that NA Employee E3 had gone in to check on Resident R114 and was told that Employee E3 had slammed Resident R114's door and had been "bullying" residents all day and swearing and stating that she does not "have time for the resident's crap". NA Employee E4 stated that NA Employee E3 is thrown out of resident rooms, and they don't want her in their rooms. Review of a statement obtained on 9/23/25, from NA Employee E5 indicated that when the nurse aides were coming into work, NA Employee E3 was swearing and upset due to staffing being changed. Later when she and NA Employee E3 entered a resident's room, NA Employee E3 stated "can you shut the fuck up so he (the resident) can finish talking so he can shut the fuck up" and NA Employee E5 stated NA Employee E3 had an attitude and leaving her call bells ringing and did not help pass or pick up trays. During an interview on 11/24/25, at 11:19 a.m., the Director of Nursing confirmed that she did not identify the grievance and statements as potential neglect/ abuse and felt the information was enough of an investigation and took it no further. Confirmed the facility failed to protect one of three residents (Resident R114) from neglect and abuse. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 01/12/2026

Resident R114 has been discharged from the facility.

All other grievances have been reviewed, and no other situations were identified as potential neglect/abuse.

Facility staff will be educated re: the resident right to be free from abuse, neglect, misappropriation of resident property, and exploitation.

Grievances will be discussed/reviewed with the Interdisciplinary Team for the next three months to ensure concerns of potential neglect/abuse have been identified.

All grievances will again be discussed in the monthly Quality Assurance Quality Improvement meeting.

483.35(i)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.35(i) Nurse Staffing Information.
§483.35(i)(1) Data requirements. The facility must post the following information on a daily basis:

(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

§483.35(i)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (i)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents, staff, and visitors.

§483.35(i)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

§483.35(i)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Observations: Based 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. Findings include: Observation conducted on 11/24/25, at approximately 9:00 a.m., revealed that nurse staffing information was posted in the main lobby on the reception desk. At that time, the nurse staffing information had the date of (11/7/25), resident census, and the staffing hours did not accurately reflect the current total number of hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift for the current date. During an interview on 11/24/25, at 9:05 a.m., Employee E2 receptionist stated that the posting for staffingisn't up to date. During an interview with the Nursing Home Administrator (NHA) on 11/24/25, at approximately 9:50 a.m., the NHA confirmed the facility failed to post the required current facility information for staffing hours and the census for 11/24/25. 201.18(b)(3) Management.

Plan of Correction - To be completed: 01/12/2026

The nurse staffing information is posted at the reception desk with the required current facility information for staffing hours and the census.

No residents have been adversely affected due to a lack of this required posting.

Staffing coordinator and licensed nursing staff have been educated re: the requirements of posted nurse staffing information; i.e. data requirements, posting requirements, public access to posted nurse staffing data, and facility data retention requirements.

Director of Nursing/designee will audit the posted nurse staffing information twice weekly for two months.

Results of these audits will be reviewed in the monthly Quality Assurance Quality Improvement meeting.

483.10(g)(5)(i)(ii) REQUIREMENT Required Postings:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.10(g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives:
(i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and
(ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community.

Observations: Based 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. Findings include: The facility must post, in a form and manner accessible and understandable to residents, resident representatives; a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. Observations conducted on 11/25/25, at approximately 11:30 a.m., on the nursing units, revealed the facility did not have the required elements (agency name, address, email address, and phone number) of Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the residents may file a complaint with the State Agency posted or accessible to residents or resident representatives. During rounds and an interview with the Nursing Home Administrator (NHA) on 11/26/25, at 8:15 a.m., the NHA confirmed the facility failed to post required information for Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the residents may file a complaint with the State Agency as required, in the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management

Plan of Correction - To be completed: 01/12/2026

The required elements (agency name, address, email address, and phone number) of Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the residents may file a complaint with the State Agency posted have been publicized on two bulletin boards that are accessible to residents and/or resident representatives.

Residents will be reminded upon admission, quarterly, and in monthly Resident Council meetings that important information is posted for their reference on the 100 and 400 Units.

Department Heads have been educated re: the requirement to post required elements of all pertinent State agencies and advocacy groups, plus a statement that the resident may file a complaint with the State Survey Agency re: any suspected violation of state or federal nursing home regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements and requests for information re: returning to the community.

Bulletin boards will be audited monthly for three months to ensure all required elements are posted and accessible to residents and/or resident representatives.

Results of these audits will be reviewed in the monthly Quality Assurance Quality Improvement meeting.

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