Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at John J Kane Regional Center-gl during CMS and state inspections, most recent first.
Failure to Prevent and Treat Pressure Ulcers: Two residents with significant mobility dependence developed facility-acquired pressure injuries after inconsistent skin monitoring, limited repositioning documentation, and delayed wound assessment. One resident with Parkinson's disease and DM developed sacral and heel pressure injuries and was hospitalized with septic shock and soft tissue infection; another resident with Alzheimer's disease and HTN developed worsening bilateral hip wounds with odor, drainage, and undermining, later requiring hospitalization for sepsis and suspected wound-related infection.
Ineffective Bathroom Call System: Surveyors observed that call light cords in multiple shared resident restrooms were wrapped so tightly around handrails that they could not be alarmed. The issue affected residents in several shared bathrooms, and the NHA confirmed the facility failed to maintain an effective call system for 14 of 17 residents.
A resident with multiple chronic conditions who required staff assistance for meal set-up sustained a burn to the chest after hot coffee obtained from the employee café by a staff member was left on a desk for the resident to pick up independently. The coffee temperature was not monitored, there was no policy governing staff obtaining resident beverages from the employee café, and standard practice among nursing staff was to provide hot beverages only from meal carts. The resident reported the incident the following day, at which time a significant burn was observed, and the DON acknowledged that inadequate supervision and lack of controls over beverage provision led to actual harm.
A resident with severe cognitive impairment and multiple diagnoses was found physically restrained in bed using furniture and equipment, without a physician's order. Staff reported the restraint was used to prevent the resident from self-harm due to repeated attempts to get out of bed and combative behavior. Facility leadership confirmed that the restraint was applied without proper authorization, contrary to policy and regulatory requirements.
A resident with severe cognitive impairment and multiple comorbidities was not adequately supervised during bed mobility care, resulting in a fall from bed and a deep leg laceration that required hospital treatment. The resident was being assisted by a CNA and was care planned for one-person assist at the time, but the supervision and assistance provided were insufficient to prevent the accident.
Kitchen staff, including supervisors and the dietary manager, were observed not wearing required beard restraints and improperly wearing hair nets that did not fully cover their hair, in violation of facility policy and professional standards.
The facility did not maintain an ongoing activities program to meet the interests and support the well-being of residents with dementia on one unit. Most weekends had only one scheduled activity, and observations showed residents were often left with only television for engagement, with staff present but not interacting. Staff interviews confirmed minimal activity programming, especially during staff absences, and that residents from this unit did not participate in activities on other units.
The facility did not implement or maintain an effective training program for contracted nursing staff, as required by its own policies and facility assessment. When requested, the administrator could not provide training records for these staff, confirming the deficiency in staff development.
Two residents who required assistance with personal hygiene did not receive necessary care, resulting in one having long, unkempt fingernails and another with noticeable facial hair growth. Both residents' care needs were confirmed by staff and documented in their assessments.
Staff failed to assess, document, and notify physicians of abnormal blood glucose levels for three residents with diabetes, and did not appropriately respond to a change in condition for a resident with Alzheimer's and pulmonary hypertension who later required hospitalization. Nursing staff and the DON confirmed that required protocols for assessment and physician notification were not followed, and the facility lacked a specific diabetic care policy.
A resident with dementia, blindness, and mobility deficits, who required partial to moderate assistance with a manual wheelchair, fell forward from the wheelchair while being pushed by a nurse aide. The resident did not have leg rests, as therapy determined they were not needed for residents who could self-propel, though staff confirmed the resident could not propel herself. The facility lacked a specific policy for wheelchair transport, and the aide continued to push the wheelchair after the resident's feet were down, resulting in the fall.
The facility failed to provide eleven residents the opportunity to formulate an advance directive, as required by policy. A review of clinical records showed no documentation of advance directive discussions for residents with conditions like diabetes, high blood pressure, and congestive heart failure. The DON confirmed this deficiency.
The facility failed to notify physicians of abnormal blood glucose levels and did not assess residents for hyperglycemia and hypoglycemia, affecting four residents. Despite facility policies requiring staff to monitor conditions and notify physicians, these protocols were not followed. Interviews with nursing staff revealed inconsistencies in handling abnormal glucose levels, and the Director of Nursing confirmed the failure to notify physicians, highlighting a significant deficiency in diabetes care management.
The facility failed to provide mandatory QAPI training to four staff members, including a nurse aide, an environmental services employee, an administrative employee, and a unit clerk. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the lack of documented training within the required time frames.
Failure to Prevent and Manage Facility-Acquired Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement care and services consistent with professional standards of practice to prevent the new development of pressure ulcers, and two residents developed facility-acquired pressure ulcers that resulted in hospitalization for wound treatment. The report cites professional guidance requiring comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address risk factors, along with treatment measures such as support surfaces, repositioning, nutritional support, wound cleansing, debridement, and other therapies. The facility policy stated residents should receive care to prevent pressure ulcers, should not develop pressure ulcers unless unavoidable, and residents with pressure ulcers should receive necessary treatment and services to promote healing and prevent infection and new ulcers. One resident was admitted with diagnoses including Parkinson's disease and diabetes and required substantial to dependent assistance for mobility and transfers. Admission documentation indicated no skin alterations, but the record showed inconsistent mobility documentation, no documented Braden observations on two required weekly dates, and limited evidence that repositioning was provided by staff other than one nurse aide. A weekly skin assessment was documented by an LPN who was not present at the bathing times recorded that day, and no skin alteration was documented at that time. Shortly afterward, a coccyx area breakdown was noted, followed by wound nurse practitioner findings of a new sacral unstageable pressure injury and a left heel deep tissue pressure injury. The resident was later sent to the emergency room, and hospital records described progressive altered mental status over several days, hypotension, concern for malnutrition and dehydration, possible inadequate care at the SNF, bedside debridement of the sacral wound, and treatment for multiorgan dysfunction, septic shock, and soft tissue infection. The second resident was admitted with Alzheimer's disease and hypertension and was dependent on staff for bed mobility and transfers. Admission records indicated no pressure injuries and no skin alterations, but later progress notes documented a reopened hematoma on the right hip and an unstageable wound on the left hip. Wound rounds and wound nurse practitioner notes showed ongoing bilateral hip wounds with repeated measurements over several weeks, with deterioration noted, increasing depth, undermining, odor, and drainage. The record showed a delay between discovery of the wounds and assessment by a medical doctor or nurse practitioner, and later notes documented purulent drainage, wound cultures with three bacteria, and antibiotics started after the wounds worsened. The resident was ultimately sent to the hospital for worsening wounds, where emergency room and consultation notes described dehydration in the setting of sepsis, likely infection from the chronic bilateral hip wounds, concern for soft tissue infection or osteomyelitis, pain with palpation of the hips, and necrotic tissue with purulent drainage and deep tracking in the left hip wound.
Ineffective Bathroom Call System
Penalty
Summary
The facility failed to maintain an effective call system in resident bathrooms and bathing areas for 14 of 17 residents, including residents R1 through R14. The Facility Assessment, last reviewed on 2/9/26, indicated the facility was equipped with a nurse call system. However, during observations on 5/16/26, surveyors found that in the shared restroom for residents R1, R2, R3, and R4, the call light cord was wrapped so tightly around the handrail that it could not be alarmed. Similar observations were made in the shared restroom for residents R5, R6, and R7, for residents R8, R9, R10, and R11, and for residents R12, R13, and R14, where the call light cords were also wrapped so tightly around the handrail that they could not be alarmed. During an interview on 5/26/26, the Nursing Home Administrator confirmed that the facility failed to maintain an effective call system for 14 of 17 residents.
Burn Injury from Unsupervised Hot Coffee Obtained from Employee Café
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and a safe environment, resulting in a coffee burn injury to one resident. Facility policies on Abuse-Resident and Reasonable Suspicion of a Crime and on Accident Prevention require that residents be protected from abuse and neglect and that the environment be kept as free from accident hazards as possible, with adequate supervision and assistive devices to prevent accidents. Despite these policies, there was no policy governing staff obtaining food or beverages for residents from the employee café, which is intended for staff and has self-service beverages. The resident involved had diagnoses including hypertension, seizure disorder, diabetes, and bipolar disorder, and required staff assistance for meal set-up and clean-up, though she could eat independently after set-up. On one day, a staff member (the Director of Rehab) obtained hot coffee for the resident from the employee café, placed ice in it, double-cupped it, and left it on her desk for the resident to pick up. The coffee temperature was not monitored, and the facility did not know the temperature of the beverage, as kitchen temperature logs only covered foods and beverages served from the main kitchen at mealtimes. The resident later reported that she was drinking coffee from a disposable cup with a lid when it spilled, causing a burn to her chest. The next morning, the resident informed a nurse aide and nurse that she had accidentally burned herself with the coffee the previous day. Assessment revealed a burn above the left breast measuring approximately 5 cm by 10 cm, irregularly shaped and red, with a 1 cm by 1 cm superficial open area. Staff interviews confirmed that nurses and nurse aides were expected to provide hot beverages only from the meal carts, and there was no existing policy for staff to obtain resident beverages from the employee café. The DON acknowledged that the facility failed to provide adequate supervision to ensure a safe environment for this resident, resulting in actual harm in the form of a burn.
Resident Restrained Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, as indicated by a BIMS score of 0 and diagnoses including vascular dementia, peripheral vascular disease, and anxiety disorder, was found physically restrained in bed without a physician's order. The resident was discovered by therapy staff with the bed pushed against the wall, an over-bed table placed over them, and multiple pieces of furniture, including two chairs, a wheelchair, and a nightstand, barricading them in the bed. Review of facility policies confirmed that residents are to be free from physical restraints unless required to treat a medical symptom and ordered by a physician, with ongoing evaluation of need. Staff interviews revealed that the restraint was implemented in an attempt to keep the resident safe after multiple incidents of the resident placing themselves on the floor and exhibiting combative and verbally aggressive behavior. There was no evidence of harm or distress to the resident at the time, and no restraint order was found in the clinical record. The facility's Director of Nursing and Nursing Home Administrator confirmed that the use of physical restraints occurred without a physician's order, in violation of facility policy and state regulations.
Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including diabetes, cardiomyopathy, congestive heart failure, and morbid obesity, was not provided adequate supervision during care. The resident, who required partial to moderate assistance with bed mobility and was care planned for one-person assist, rolled out of bed while being changed by a CNA after starting to cough. This resulted in a significant laceration to the right lower leg, exposing the tendon and requiring hospital treatment and sutures. The incident took place while the resident was on a bariatric air mattress, and the care plan at the time specified monitoring the resident's position in bed every two hours. The facility's policies require staff to provide necessary goods and services to prevent physical harm and to treat residents with dignity and respect. However, the review of clinical records and staff interviews confirmed that the supervision provided was not adequate to prevent the fall and subsequent injury. The resident's care plan and assistance level were only updated after the incident, indicating that the supervision and assistance provided at the time of the event did not meet the resident's needs, resulting in a preventable accident and injury.
Failure to Ensure Proper Use of Hair and Beard Restraints in Kitchen
Penalty
Summary
The facility failed to ensure that kitchen staff properly restrained their hair and facial hair in accordance with facility policy and professional standards. Multiple food service workers, including a food service supervisor and the dietary manager, were observed in the kitchen without required beard restraints. Additionally, a staff member was seen wearing a hair net that did not cover the front portion of her hair, and this issue was observed on more than one occasion with the same employee and another dietary aide. The dietary manager confirmed that all kitchen staff should wear hair nets to cover all hair and use mustache/beard restraints if facial hair is present. These observations were made during routine kitchen operations and were in direct violation of the facility's policy on hair restraints.
Failure to Provide Ongoing Activities Program for Dementia Unit
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of residents on Nursing Unit 3B, a secure unit for residents with dementia. Review of the activities calendars from January through June 2025 showed that weekends typically had only one scheduled activity, with most Sundays limited to social visits. Observations over several days revealed that residents were often left in the dining room/lounge with only a television program or movie playing, and staff were present but not interacting with residents. On multiple occasions, no structured activities were occurring, and staff were either engaged in personal conversations or using electronic devices rather than engaging with residents. Interviews with staff confirmed that activity programming was minimal, especially during staff vacations, and that there was no additional staff coverage to maintain activity levels during these times. It was also confirmed that residents from Nursing Unit 3B did not participate in activities held on other units. On one occasion, only two out of 37 residents were provided an activity, while the rest had no engagement. The Nursing Home Administrator acknowledged that the facility failed to provide an ongoing program of activities to meet the needs of residents on this unit.
Failure to Provide Required Training for Contracted Staff
Penalty
Summary
The facility failed to implement and maintain an effective training program for individuals providing services under contractual arrangements, as required by their roles. The facility assessment indicated that all personnel, including contracted staff, should receive education and training in areas such as resident rights, abuse prevention, compliance, infection control, psychosocial needs, dementia care, emergency preparedness, accident prevention, communication, QAPI, person-centered care, trauma-informed care, behavioral health, and HR policy. The facility's own policy stated that in-service training applies to all employees, contractual staff, and volunteers. During the survey, the Nursing Home Administrator was unable to provide required training records for the contracted nursing staff when requested. The administrator confirmed that the facility had not implemented or maintained an effective training program for these contracted individuals, consistent with their expected roles. This deficiency was cited under 28 Pa. Code 201.20(a)(b)(c)(d) regarding staff development.
Failure to Provide Necessary Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary care and services to two residents who required assistance with activities of daily living. One resident, with a history of cerebral infarct, aphasia, and hemiparesis, was assessed as severely cognitively impaired and fully dependent on caregivers for personal hygiene. This resident was observed to have long, unkempt fingernails, indicating a lack of appropriate hygiene care. The clinical record confirmed the resident's dependency and need for full assistance. Another resident, diagnosed with cerebral infarct, dysarthria, and heart failure, was assessed as cognitively intact but required substantial to maximal assistance with personal hygiene. This resident was observed to have noticeable facial hair growth and expressed a desire for assistance in its removal. Staff interviews confirmed that both residents did not receive the necessary care and services as outlined in their care plans and facility policy.
Failure to Assess, Document, and Notify Physicians of Abnormal Blood Glucose and Resident Condition Changes
Penalty
Summary
The facility failed to assess, document, and notify physicians of abnormal capillary blood glucose (CBG) levels for three residents with diabetes. For these residents, there were multiple instances where CBG readings were either extremely high (noted as 'HI' on the glucometer) or low, but staff did not follow physician orders or care plan interventions that required assessment, documentation, and physician notification for such results. Specifically, the clinical records and electronic medication administration records (eMAR) showed that staff did not assess for signs and symptoms of hyperglycemia or hypoglycemia, did not monitor the effectiveness of any interventions, and did not notify the physician as required by the residents' individualized orders and care plans. Additionally, the facility failed to appropriately respond to a change in condition for a resident with Alzheimer's disease and pulmonary hypertension. This resident exhibited a significant and sustained increase in heart rate, behavioral changes, and signs of possible infection, including blood in the brief and increased aggression. Despite these changes, there was a delay in assessment, documentation, and physician notification. The resident was eventually hospitalized for urinary tract infection, dehydration, hypernatremia, and atrial fibrillation with rapid ventricular response, but the initial signs and symptoms were not promptly addressed by the facility staff. Interviews with nursing staff and the Director of Nursing confirmed that the facility did not follow required protocols for assessment, documentation, and physician notification regarding abnormal blood glucose levels and changes in resident condition. The facility also lacked a specific policy for the care of diabetic residents, further contributing to the deficiencies identified during the survey.
Failure to Provide Adequate Supervision During Wheelchair Transport
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall from a wheelchair for one resident. The resident in question had multiple diagnoses, including dementia, anxiety, blindness, difficulty walking, cognitive and communication deficits, and agitation, and was also on blood thinners. The resident required a manual wheelchair and needed partial to moderate assistance to move it. Occupational therapy notes indicated the resident needed frequent adjustments for lateral supports due to leaning and falling asleep in the wheelchair. On the day of the incident, a nurse aide attempted to redirect the resident's wheelchair from behind, during which the resident put her feet down and subsequently fell forward out of the wheelchair. Staff statements and documentation confirmed that the resident could not propel herself and that leg rests were not provided, as therapy determined they would interfere with independence for residents who could self-propel. The facility did not have a specific policy for transporting residents in wheelchairs, and staff relied on the electronic kardex for resident-specific care needs. The nurse aide involved reported that she was pushing the resident, who then put her feet down and fell forward. Other staff confirmed the resident was unable to propel herself and did not have leg rests. The facility's administration acknowledged, after reviewing CCTV footage, that the aide continued to push the wheelchair after the resident's feet were down, resulting in the fall. The facility was unable to produce the resident's plan of care prior to the incident, but the current plan of care identified the use of leg rests.
Failure to Provide Advance Directive Opportunities
Penalty
Summary
The facility failed to provide the opportunity for eleven out of nineteen residents to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, dated January 2, 2024, mandates compliance with maintaining written policies and procedures regarding advance directives, including informing and providing written information to all adult residents about their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. The clinical records of residents with various medical conditions, including diabetes, high blood pressure, congestive heart failure, dysphagia, and obesity, were reviewed. For each of these residents, there was no documentation indicating that they were given the opportunity to formulate an advance directive. During an interview, the Director of Nursing confirmed the absence of such documentation for the residents in question, which is a violation of the residents' rights as per 28 PA. Code 201.29(b)(d)(j).
Failure to Notify Physicians of Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, affecting four residents. The facility's policies required staff to monitor residents' conditions and notify physicians of significant changes, but these protocols were not followed. For instance, Resident R13 had a CBG of 52 and a 'HI' reading on separate occasions, yet there was no documentation of physician notification or assessment for hyper-/hypoglycemia. Resident R89 experienced multiple instances of low CBG readings, with values as low as 41, but the facility did not notify the physician or reassess the resident's condition. Similarly, Resident R147 had several high CBG readings, exceeding 340, without any physician notification or documented assessment for hyperglycemia. The care plans for these residents included instructions to notify physicians of abnormal glucose levels, which were not adhered to. Interviews with nursing staff revealed inconsistencies in following the facility's protocols for managing abnormal blood glucose levels. Staff members provided varying responses on how they would handle such situations, indicating a lack of standardized practice. The Director of Nursing confirmed the failure to notify physicians of changes in residents' conditions related to blood glucose levels, highlighting a significant deficiency in the facility's management of diabetes care.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program for four out of ten staff members, as required by their own facility assessment. The assessment, which was reviewed on multiple occasions, included QAPI as a necessary educational topic. However, upon reviewing the facility's documents and training records, it was found that Nurse Aide Employee E2, Environmental Services Employee E3, Administrative Employee E4, and Unit Clerk Employee E5 did not receive documented QAPI training within the specified time frames corresponding to their hire dates. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of training for these employees.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pittsburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Care Center | 1.7 mi | ★★★★★ | 43 | 0 |
| Eldercrest Rehabilitation & Healthcare Center | 1.7 mi | ★★★★★ | 10 | 0 |
| Squirrel Hill Wellness And Rehabilitation Center | 1.8 mi | ★★★★★ | 15 | 0 |
| Upmc Magee-womens Hospital Tcu | 2.6 mi | ★★★★★ | 5 | 0 |
| Ivy Park Post Acute | 2.9 mi | ★★★★★ | 10 | 1 |
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