Rehab & Nursing Ctr Greater Pittsburgh

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of nine residents (Resident R1). This was identified as past non-compliance.Findings include:Review of the facility policy Safety and Supervision of Residents dated 1/15/26, indicated the facility will provide a safe environment for all residents.Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/3/26, included diagnoses of dementia (a decline in mental ability severe enough to interfere with daily life, cause by physical changes in the brain) and a psychotic disorder with delusions. Review of an Elopement Risk Evaluation completed on 5/25/24, indicated Resident R1 was at risk for elopement.Review of Resident R1's plan of care for Risk for Elopement initiated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for four of five sampled residents (Residents R1, R2, R53, and R98).Findings include: Review of the facility policy Departmental (Respiratory Therapy) - Prevention of Infection last reviewed on 1/16/25, indicated that considerations related to oxygen administration include change the oxygen cannula and tubing every seven days or as needed. Keep the oxygen and tubing used as needed in a plastic bag when not in use. Considerations related to medication nebulizers/continuous aerosol include store the circuit in a plastic bag, marked with date and resident's name, between uses. Discard the administration set up every seven days. Review of Resident R1's admission record indicated she was originally admitted on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/1/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 [DATE]. 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,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for four of the nine residents reviewed (Resident R24, R29, R57, R71). Findings Include: A review of the facility policy Advanced Directives last reviewed 1/18/24, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the medical record indicated Resident R24 was admitted to the facility on [DATE], with diagnoses that included type II diabetes (long-term condition in which the body has trouble controlling blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to properly secure medication in one of two medication carts on the 300 hall nursing unit (B cart). Findings include: Review of the facility policy Medication Labeling and Storage last reviewed on 1/18/24, indicated the facility stores medications in locked compartments and only authorized have access to the keys. During an observation on 12/8/24, at 12:10 p.m., the 300 hall B medication cart was left unsecured and unattended and accessible to any passerby. During an interview on 12/8/24, at 12:15 p.m., the Director of Nursing confirmed the facility failed to properly secure medications on one of two medication carts on the 300 hall nursing unit accessible to any passerby. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of manufacturer guidelines, observation, and staff interview, it was determined that the facility failed to make certain that medications were properly stored in two of two medication carts (200 B and 200 A). Findings include: Review of the Humalog lispro insulin (injectable medication used to treat high blood sugar) prescribing information revised 02/2020, indicated that for Humalog injection pens Do not use your pen past the expiration date printed on the label or for more than 28 days after you first start using the pen. For Humalog vials of insulin Do not use Insulin Lispro Injection past the expiration date printed on the label or 28 days after you first use it. During an observation of the 200 B medication cart on 11/17/23, at 11:17 a.m. a partially used flex-pen of Humalog was observed, without an open date. During an interview on 11/17/23, at 11:18 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the above observation. During an observation of the 200 A medication cart on 11/17/23, at 11:21 a.m. two partially used vials of Humalog were observed,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.