Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Masonic Village At Sewickley during CMS and state inspections, most recent first.
Failure to implement water management controls for the cooling tower and closed loop systems led to a Legionella deficiency. The facility did not document required monitoring or servicing for some months, had low or minimum CHEMWAY 918 levels in the closed loop systems, and could not show the required disinfection or decontamination steps after a positive Legionella result in the cooling tower. The facility also retested before the plan’s 30-day interval.
Failure to Explain NOMNC and SNF-ABN to Resident with Cognitive Impairment: A resident with hypokalemia, rhabdomyolysis, and mild cognitive impairment had a BIMS score indicating moderate cognitive impairment, yet signed both the NOMNC and SNF-ABN forms. The facility’s NHA stated the resident should not have been signing their own paperwork due to the lower BIMS score, and the forms were not shown to have been explained in a manner the resident or POA could understand.
A resident with a BIMS of 15 reported that a male RN gave her cough syrup without an order after she had a cough. Facility records showed no active or discontinued order for the medication, and the incident was later identified as possible medication misappropriation or medical neglect. The DON did not begin investigating immediately, the nurse continued working for several shifts after the allegation was reported, and the investigation was not completed until days later.
Failure to Timely Report Alleged Medication Misappropriation and Abuse: A cognitively intact resident reported receiving cough medication from an RN without an active MD order, and staff found no cough syrup order in the chart. The facility became aware of the allegation but did not report it to the State field office within 24 hours, did not notify APS, and did not submit the investigation results within the required timeframe.
Incomplete Investigation of Alleged Medication Abuse: A cognitively intact resident with muscle weakness, HTN, and a thyroid disorder reported that an RN gave her cough syrup without an order. The facility did not obtain timely written statements from the alleged perpetrator, the resident, or the assigned nurse aides, and did not interview other residents to determine whether similar events occurred. Leadership later confirmed the investigation was not thorough.
The facility failed to develop complete, individualized care plans for two residents. One resident with dementia, MDD, agitation, hallucinations, and inappropriate sexual behaviors did not have a care plan addressing those behaviors, and another resident with a pacemaker did not have care plan interventions for the pacemaker transmitter or cardiologist contact information. Staff confirmed the omissions during interview.
Failure to Follow Ordered Bowel Protocol: The facility failed to follow physician-ordered bowel protocols for two residents. One resident with CKD, anemia, and DM had no BM for nine shifts, yet ordered prune/apricot juice and Dulcolax were not given. Another resident with dementia and constipation reported ongoing constipation and no BM for nine shifts; staff confirmed the ordered prune/apricot juice and Dulcolax were not administered, and the MAR showed no evidence of either treatment being provided.
Failure to Manage Resident Pain: A resident admitted with multiple rib fractures, pneumonia, and pain continued to report severe rib, back, and right-sided pain despite scheduled and PRN analgesics. Documentation showed the meds were ineffective, the resident barely slept and said pain was hindering appetite, and the MD was not notified until several days later that the pain regimen needed evaluation.
A resident with Parkinson’s disease, dementia, and major depressive disorder did not have an individualized, person-centered dementia care plan included in the comprehensive care plan. The RNAC confirmed the dementia diagnosis and that the facility failed to develop and implement a dementia care plan for the resident.
Expired medical supplies were found in the Redwood Medication Room during a storage review, including a Universal Catheter Tray and an IV Start Kit. The facility's policy stated that medications and biologicals are to be stored safely, securely, and properly, and an LPN confirmed the expired supplies and the improper storage of medical supplies in the room.
Failure to Coordinate Hospice Services for a Resident: The facility failed to coordinate hospice services with facility services for a resident admitted under hospice care. The resident had CAD, Alzheimer's disease, and arthritis, but the physician order did not include a hospice diagnosis, and the care plan lacked hospice agency contact information, access to the hospice 24-hour on-call system, and a hospice diagnosis. The RNAC confirmed these omissions during interview.
Missing Infection Control Training for a Nurse Aide. Facility education records for the year reviewed did not include Infection Control training for one of five direct care staff, a Nurse Aide. The NHA stated education is distributed electronically during the calendar year and confirmed the training was not provided.
The facility failed to ensure that one of two nurse aides received the required 12 hours of annual in-service education. The NHA stated that education is distributed electronically for completion during the calendar year, but the employee file for one nurse aide did not show the required yearly training for the prior year, and the NHA confirmed the lapse.
A resident with osteoporosis and cognitive impairment, care-planned for two-person assist with a mechanical lift, was transferred from wheelchair to bed by a single NA using a sit-to-stand lift. Policy and the care plan required two staff for all mechanical lift transfers. The resident had been using the right arm normally earlier in the evening, but after the transfer was found in bed, crying and in pain, with a swollen, hard right arm. An LPN and RN assessed the resident, and imaging later confirmed an acute displaced mid-shaft humerus fracture with soft tissue swelling. Facility investigation, including staff statements, established that no second staff member assisted with the lift, and leadership acknowledged that the NA did not follow the care plan requirement for two-person assistance.
Three residents with indwelling urinary catheters, each with complex medical conditions, were observed with uncovered catheter drainage bags, in violation of facility policy requiring drainage bags to be covered for dignity. Staff, including RNs and an LPN, confirmed the deficiency during interviews, and the DON acknowledged the failure to provide appropriate catheter care.
Surveyors found that medications and biologicals, including insulin pens and tuberculin vials, were not properly labeled, stored, or secured in two medication rooms and on two medication carts. Expired medications and unlabeled opened vials were observed, and an LPN left an insulin pen unattended on a medication cart while administering other medications to a resident with diabetes, hypertension, and COPD. These deficiencies were confirmed by staff interviews.
A resident with hypertension, diabetes, and COPD was found with nasal spray at bedside without a physician's order or interdisciplinary assessment for self-administration, as required by facility policy. An LPN and the DON confirmed that the necessary evaluation and authorization for self-administration had not been completed.
The facility did not provide timely Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms to two residents with complex medical conditions, either issuing the notice on the same day services ended or failing to provide it at all, as confirmed by staff and record review.
The facility did not document or communicate essential resident information, such as care plan goals, advanced directives, and contact details, to the receiving health care provider during hospital transfers for two residents with complex medical needs. This failure was confirmed by the DON and was not in accordance with facility policy.
The facility did not obtain physician orders for two residents who went on therapeutic leave and failed to follow the bowel protocol in a timely manner for a resident with Alzheimer's disease and other conditions, resulting in delayed interventions for constipation and lack of required documentation.
Two residents with limited mobility did not receive appropriate services, equipment, or assistance to maintain or improve mobility. One resident experienced skin injury due to an improperly sized hand brace without proper assessment or documentation, while another had a TLSO brace ordered without directions or interventions for monitoring skin integrity. The facility lacked policies and care plan interventions for assistive devices and skin monitoring, as confirmed by staff and the DON.
A resident with a PICC line for IV antibiotics did not have physician orders specifying the substance or amount for required line flushes before and after medication administration. Facility policy required flushing with 10 ml normal saline, but the omission in the orders was confirmed by an LPN, resulting in inadequate care in line with professional standards.
Two residents receiving oxygen therapy did not have their humidification bottles changed weekly as required by facility policy. Observations showed that the bottles were either empty or had not been changed for extended periods, and this was confirmed by nursing staff and the DON.
A resident with severe cognitive impairment, as indicated by a low BIMS score and a diagnosis of dementia, was required to sign a binding arbitration agreement at admission without an option to decline. The agreement was presented as mandatory, and the facility's process did not ensure the resident's capacity to understand or provide a choice to refuse.
The facility did not conduct a required quarterly QAA meeting with all mandated committee members, as the DON was absent for one of the meetings. This was confirmed through policy review, attendance records, and staff interview.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility failed to maintain an effective annual in-service training program for several nurse aides, as their records lacked required trainings in infection control, dementia, communication, and abuse for 2024. Despite policies mandating compliance education, the facility did not ensure completion of these trainings, as confirmed by the NHA.
A facility failed to report an alleged abuse incident involving a resident with renal insufficiency, high blood pressure, and heart failure. The resident reported bruising caused by a nurse aide pressing their leg tightly during care. Despite the resident's account and visible bruising, the facility did not report the incident, as management was unaware of the identified perpetrator. This resulted in a deficiency for not adhering to reporting policies.
A resident reported that a nurse aide pressed their leg tightly during care, resulting in bruising. Despite the resident's medical history and visible bruising, the facility failed to conduct a timely and comprehensive investigation. The alleged perpetrator was interviewed four days after the incident, and the facility did not promptly collect or review investigation forms, violating their abuse prevention policy.
A resident with severe cognitive impairment and a high elopement risk score managed to leave an unsupervised area without staff knowledge. The resident was found at a different location after taking a staff elevator. The incident was confirmed by the DON, who also noted that staff were not reeducated following the event.
A facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy. The resident's care plan lacked necessary interventions, and there was no facility policy for oxygen therapy. Observations showed the resident's oxygen equipment improperly placed, and staff interviews revealed discrepancies in oxygen use documentation. The DON confirmed the absence of a policy, leading to the deficiency.
Failure to Implement Water Management Controls for Cooling Tower and Closed Loop Systems
Penalty
Summary
The facility failed to implement the infection prevention and control measures in its water management plan for the cooling tower and closed loop systems. The plan identified the cooling tower as a significant risk and control location for Legionella growth and required remedial or emergency disinfection when indicated by test results or other conditions, along with ongoing monitoring of disinfectant levels, pH, temperature, conductivity, biocidal indicators, and weekly HPC testing. The plan also required communication and documentation of corrective actions by the designated verification person, but the report noted that a verification person was not listed in a further review. Facility documentation showed gaps in monitoring and servicing of the cooling tower and closed loop systems for November 2025 and January 2026. Technical service reports dated 10/22/25, 12/5/25, and 2/16/26 documented low or minimum CHEMWAY 918 corrosion inhibitor levels in the closed loop systems, with instructions to add 5 gallons of CHEMWAY 918 and change the filter bag. The facility was unable to provide evidence that the cooling tower and closed loop systems were serviced during the missing months, and staff confirmed there was no evidence the cooling tower was monitored for November 2025 and January 2026. A lab report collected on 2/18/26 and completed on 3/2/26 showed the cooling tower was positive for Legionella pneumophila at 35.0 CFU/ml. A later lab report collected on 3/10/26 and completed on 3/17/26 showed Legionella was not detected, but the facility retested 20 days after the positive result instead of waiting 30 days as the water management plan indicated. During interviews, staff stated the cooling tower was maintained by an outside contractor, but the facility could not provide evidence that the required disinfection, biocide adjustment, or full system decontamination was completed within the timeframes specified in the water management plan after the positive Legionella result.
Failure to Explain Medicare Non-Coverage Notices to Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident’s rights to make informed decisions and choices about important aspects of health, safety, and welfare were protected when the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) forms were not explained in a form and manner the resident or representative could understand. Facility policy stated that the resident’s capacity status would be determined and that the appropriate notice would be presented to the resident or authorized representative, with the resident’s representative signing if the resident was not capable of understanding the form contents. Resident R67 was admitted to the facility and, on the MDS dated 6/2/26, was documented with hypokalemia, rhabdomyolysis, and mild cognitive impairment. The BIMS score was 9, indicating moderate cognitive impairment. The resident’s demographic information identified a friend as power of attorney. Despite this, the NOMNC and SNF-ABN forms dated 6/12/26 were signed by Resident R67. During interview, the NHA stated that Resident R67 should not have been signing their own paperwork due to the lower BIMS score and confirmed the facility failed to ensure the resident understood the forms and that the agreement was explained to the resident and/or representative in a manner understood by the resident.
Failure to Immediately Investigate Allegation of Unordered Medication Administration
Penalty
Summary
The facility failed to implement abuse prevention and investigation procedures after an allegation that a nurse provided Resident R79 with cough syrup without an order and may have misappropriated medication. Resident R79 was admitted with diagnoses including muscle weakness, high blood pressure, and thyroid disorder, and her MDS dated 5/24/26 showed a BIMS score of 15, indicating she was cognitively intact. The facility policy stated that allegations of abuse require immediate investigation, reporting, and response, and defined medical neglect and misappropriation of resident property. On 3/22/26, Resident R79 told staff that a male nurse had given her a red liquid in a small cup the night before for her cough, but staff found no active or discontinued order for cough syrup. Facility documentation stated the resident reported the medication helped her sleep and reduce coughing, and that the male nurse told her it could be obtained over the counter. The HR Director’s investigation summary identified RN Employee E16 as the nurse who provided the cough medication without an active MD order, and the DON later stated the incident could be viewed as a medication error or possibly misappropriation of another resident’s medication and that outside entities might need to contact the nurse. The facility did not begin the investigation immediately after being made aware of the allegation and did not suspend RN Employee E16 timely pending investigation. The DON stated she began investigating when she returned to work on 3/23/26, and the facility’s records showed the nurse continued to work on multiple shifts after the allegation was reported. Additional statements from staff and the resident were not obtained until several days later, and the facility completed its investigation 10 days after being made aware of the incident. Interviews with the NHA, DON, and RN Supervisor confirmed the facility expected immediate investigation when an incident was reported, including on weekend shifts, but that did not occur in this case.
Failure to Timely Report Alleged Medication Misappropriation and Abuse
Penalty
Summary
The facility failed to report allegations of possible misappropriation of medication and medical abuse involving a cognitively intact resident. Resident R79, who had diagnoses including muscle weakness, high blood pressure, and a thyroid disorder, was assessed as cognitively intact with a BIMS score of 15. On 3/22/26, the resident told the unit nurse that she wanted the cough syrup medication she had received the prior night from a male nurse. Staff reviewed the resident’s active and discontinued orders and found no order for cough syrup. The incident report documented that the resident stated a male nurse had left her room and returned with a red liquid in a small cup, telling her it was cough medication and that it would help her cough. The resident reported that the medication made her sleepy and reduced her coughing. The report also identified RN Employee E16 as the employee who provided medication to the resident without an active MD order. Facility documentation submitted for review did not include the incident on 3/22/26 or 3/23/26, and the facility did not report the incident within 24 hours. Information submitted to the State Agency on 3/31/26 showed the facility became aware of the allegation on 3/22/26, but the incident was not reported to the State field office until 9 days later. During interviews, the DON and NHA confirmed the facility was aware of the allegation on 3/22/26, that the DON began investigating when she returned to work on 3/23/26, and that APS was not notified. The facility also failed to report the results of the investigation to the State field office within five working days of the incident.
Incomplete Investigation of Alleged Medication Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation involving Resident R79, a cognitively intact resident with diagnoses including muscle weakness, high blood pressure, and a thyroid disorder. Resident R79 reported that a male nurse gave her a red liquid in a small cup for her cough the prior night, even though no cough syrup order was found in her active or discontinued medication orders. The resident stated the medication helped her sleep and reduced her coughing, and she said the male nurse told her she could get the medication over the counter. The facility’s incident and investigation records showed that the allegation was first documented on 3/22/26, but the investigation was incomplete. The DON did not obtain a written statement from the alleged perpetrator, RN Employee E16, on the day the allegation was reported. Instead, RN Employee E16 was later asked questions by email and responded that he did not recall. The facility also did not obtain a signed witness statement from Resident R79, and no written statements were collected from the nurse aides assigned to the unit during the shift when the medication was allegedly given. The investigation further showed that the facility did not interview other residents to determine whether they had received medication they were not ordered from the alleged perpetrator. Social work staff met with Resident R79 several days after the allegation to ask what occurred and to identify the nurse who provided the cough medication. During interviews, facility leadership acknowledged that investigations were expected to begin immediately and that witness statements should be obtained the same shift an incident occurs, but the facility confirmed it failed to conduct a thorough investigation and failed to obtain all witness statements for Resident R79.
Incomplete Care Plans for Mental Health Needs and Pacemaker Transmitter
Penalty
Summary
The facility failed to develop a comprehensive care plan with specific, individualized interventions for a resident with mental health needs and for a resident with a pacemaker transmitter. Facility policy stated that comprehensive care plans must include measurable objectives, time frames, and interventions tailored to the resident’s assessed needs, and that the interdisciplinary team must develop the plan within 21 days of admission. Review of the clinical record showed that Resident R20 was admitted with diagnoses including Parkinson’s disease, dementia, and major depressive disorder, and the PASSAR identified moderate MDD, insomnia, depression with agitation, agitation, amnesia, hallucinations, and inappropriate sexual behaviors. However, the comprehensive care plan reviewed on 6/17/26 did not include a care plan for inappropriate sexual behaviors, and the Social Worker confirmed this omission during interview. Resident R23 was admitted with diagnoses including heart failure, hypertension, and presence of a cardiac pacemaker. Her care plan noted that she had a pacemaker, but it did not include interventions for the pacemaker transmitter or contact information for the cardiologist. During interview, the resident stated the transmitter was kept next to her bed and needed to remain plugged in with the green light on to work properly. The RN Supervisor and RNAC both confirmed that the care plan lacked interventions related to the transmitter and did not include the cardiologist’s contact information, and the NHA confirmed the facility failed to develop a comprehensive care plan with specific and individualized interventions for the resident’s pacemaker transmitter.
Failure to Follow Ordered Bowel Protocol
Penalty
Summary
The facility failed to follow physician-ordered bowel protocols for two residents. Resident R39 had diagnoses including chronic kidney disease, anemia, and diabetes mellitus, and the record showed no bowel movement for nine shifts from 5/30/26 through 6/1/26. Although the physician ordered Dulcolax 5 mg by mouth as needed after nine shifts with no bowel movement and a normal abdominal exam, and prune or apricot juice as needed after six shifts with no bowel movement, the May and June MAR showed that neither treatment was given during that time. Resident R75 had diagnoses including dementia, polyneuropathy, and constipation, and the care plan directed staff to monitor and observe for constipation. The physician ordered eight ounces of prune or apricot juice after six shifts with no bowel movement and Dulcolax 5 mg after nine shifts with no bowel movement and a normal abdominal exam, with instructions to hold and call the provider if the abdominal exam was abnormal. The resident stated she had not had a bowel movement for more than three days and remained constipated, and the record showed no bowel movement over nine shifts on 6/13/26, 6/14/26, and 6/15/26. Interviews with the RN supervisor, nurse aide, resident, DON, and NHA confirmed that prune/apricot juice and Dulcolax were not administered as ordered, and the MAR showed no prune/apricot juice and no Dulcolax given.
Failure to Manage Resident Pain
Penalty
Summary
The facility failed to provide safe, appropriate pain management for one resident who required pain services. The resident was admitted with multiple rib fractures, pneumonia, and pain. The care plan identified the resident as experiencing pain or being at risk for pain and discomfort, with interventions to administer pain medications as ordered, observe for side effects and effectiveness, complete pain assessments, and observe for pain each shift. Physician orders included Tramadol 50 mg, 0.5 tablet by mouth every 6 hours as needed for moderate pain related to multiple fractures, and Acetaminophen 325 mg, 2 tablets by mouth every 6 hours for rib pain. Clinical documentation showed the resident barely slept, complained of rib, back, and right-sided pain, and received scheduled and PRN pain medication that was documented as ineffective. The resident continued to report severe pain and discomfort, and a dietary note stated the pain was hindering appetite. The physician was not notified until several days later that the resident’s pain had increased and the pain medication needed to be evaluated. During interview, the Nursing Home Administrator confirmed the facility failed to meet the resident’s pain needs.
Missing Dementia Care Plan
Penalty
Summary
Facility staff failed to develop and implement an individualized, person-centered care plan to address dementia for Resident R20. The facility policy on comprehensive care plans stated that each care plan should include measurable objectives and time frames to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment, and should describe the services and care to be furnished to attain the resident’s highest practicable physical, mental, and psychosocial well-being. Resident R20 was admitted to the facility and the MDS indicated diagnoses of Parkinson’s disease, dementia, and major depressive disorder. Review of the clinical record showed that the resident’s care plans did not include a care plan for dementia. During interviews, the RNAC confirmed that Resident R20 had a diagnosis of dementia and that a dementia care plan was not included in the comprehensive care plans, and also confirmed that the facility failed to develop and implement an individualized person-centered care plan to address dementia for this resident.
Expired Medical Supplies Found in Medication Storage Room
Penalty
Summary
The facility failed to properly store medical supplies in one of two medication storage rooms, the Redwood Medication Room. During a medication storage room review, surveyors observed expired supplies in the room, including a Universal Catheter Tray that had expired and an IV Start Kit that had expired. A review of the facility's Storage of Medications policy indicated that medications and biologicals are to be stored safely, securely, and properly. During an interview, an LPN confirmed the expired supplies and acknowledged that the facility failed to properly store medical supplies in the Redwood Medication Room.
Failure to Coordinate Hospice Services for a Resident
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the needs of Resident R44 for end-of-life care. Resident R44 was admitted to the facility on [DATE] and, according to the quarterly MDS, had diagnoses of coronary artery disease, Alzheimer's disease, and arthritis. A physician order dated 3/13/26 indicated that Resident R44 was admitted under hospice services, but the order failed to include a diagnosis for hospice care. Review of Resident R44's current comprehensive care plan showed that it did not include a plan of care by the facility that coordinated hospice services. The care plan also failed to include contact information for the hospice agency, how to access the hospice's 24-hour on-call system, and a diagnosis for hospice care. During an interview on 6/16/26 at 2:29 p.m., the RNAC, Employee E3, confirmed that the facility failed to include the hospice agency contact information, failed to include how to access the hospice 24-hour on-call system, failed to include a diagnosis for hospice care, and failed to ensure coordination of hospice services with facility services for Resident R44.
Missing Infection Control Training for Nurse Aide
Penalty
Summary
The facility failed to provide Infection Control training to one of five direct care staff reviewed, Nurse Aide Employee E19. Review of the Nursing Assistant - HC position description showed that staff in this role are expected to maintain compliance with yearly education requirements according to facility policies and DOH regulations and to maintain competencies through continued education, including in-service education, programs, floor conferences, and nursing staff meetings. Facility education records for 2025 did not include Infection Control training for Employee E19. During interviews, the Nursing Home Administrator stated that education is distributed electronically for completion during the calendar year and later confirmed that the facility failed to provide Infection Control training to Employee E19.
Nurse aide annual in-service training not completed
Penalty
Summary
The facility failed to ensure that all nurse aide staff received a minimum of 12 hours of in-service education training each year for one of two Nurse Aide employees, Employee E19. Review of the Nursing Assistant - HC Position Description showed that nurse aides are expected to maintain compliance with yearly education requirements according to facility policies and DOH regulations and to maintain competencies and skills through continued education, including in-service education, programs, floor conferences, and nursing staff meetings. During an interview, the Nursing Home Administrator stated that education is distributed electronically to be completed within the calendar year from January through December. Review of Employee E19's current employee file did not show that the employee had received the required minimum of 12 hours of yearly in-service training for calendar year 2025, and the Nursing Home Administrator later confirmed that the facility failed to ensure that all nurse aide staff received the required annual in-service education for Employee E19.
Failure to Use Two-Person Assist With Mechanical Lift Resulting in Humerus Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from accident hazards and received adequate supervision during a mechanical lift transfer. Facility policy on "Resident Transfers To/From and Within Equipment" required staff to use appropriate safety techniques and to follow the resident’s individualized transfer status as documented in the care plan and nursing assistant documentation. For this resident, the Resident Care Guide directed that transfers be completed using a Sara (sit-to-stand) lift with two-person assist, and the care plan specified use of a Maxi lift with assistance from two staff. The resident’s MDS assessments documented the need for maximal assistance and two-person support for transfers, and the facility’s NHA confirmed that the facility requires two-person assist with all mechanical lifts. The resident had diagnoses including osteoporosis and a displaced fracture of the surgical neck of the right humerus, and later a significant change MDS reflected severely impaired cognition and a change in functional ability requiring a Maxi lift for transfers. On the evening of the incident, the resident was observed at dinner and afterward in her wheelchair using her right arm normally and coloring, with no complaints of pain. Around the time of the event, an LPN was in another resident’s room with a nursing assistant (Employee 3) setting up a shower, and later returned to the office when another nursing assistant (Employee 1) requested that she assess the resident’s arm. When the LPN entered the room, the resident was already in bed, changed into a gown, visibly upset, crying, and in pain, with a hard, swollen right arm that was painful with movement. The resident was unable to explain what had happened but repeatedly referred to "he" and asked the LPN not to leave her. Employee 1 initially told facility administration that a second staff member (Employee 3) had assisted with the stand-up lift transfer, but subsequent investigation and a written statement from Employee 3 confirmed that Employee 3 did not assist with putting the resident to bed. In a written statement, Employee 1 reported transferring the resident into bed with the sit-to-stand lift and then noticing the right arm swelling while the resident was still in a sitting position in bed, at which point the nurse was alerted. An incident report documented that the resident’s right arm appeared swollen, she was crying and expressing pain, and she was unable to explain what may have happened. An x-ray obtained that evening showed an acute mid-shaft fracture of the right humerus with moderate angulation and displacement and mild soft tissue swelling, without dislocation. Subsequent observation showed the resident’s right hand to be non-functional, with curled fingers and wrist and inability to move the right hand, while the left arm and hand remained functional. The DON and NHA confirmed that Employee 1 was the only person who provided evening care and transferred the resident from wheelchair to bed during the shift in question, and agreed that Employee 1 should have followed the care plan and had a second person present for the lift transfer.
Failure to Cover Catheter Drainage Bags as Required by Policy
Penalty
Summary
The facility failed to provide appropriate treatments and services for residents with indwelling urinary catheters, as required by facility policy and state regulations. Specifically, observations revealed that three residents with physician orders for indwelling urinary catheters were found in bed with their catheter drainage bags uncovered, contrary to the facility's Continence Care Program and Indwelling Catheter Management policy, which requires drainage bags to be covered for dignity. These findings were confirmed through staff interviews, including with registered nurses and a licensed practical nurse, who acknowledged that the drainage bags were not covered as required. The residents involved had significant medical histories, including diagnoses such as hypertension, obstructive uropathy, Parkinson's disease, hyperlipidemia, Alzheimer's disease, atrial fibrillation, and heart failure. Despite these conditions and the presence of indwelling urinary catheters per physician orders, the facility did not ensure that the drainage bags were covered during the survey observations. The Director of Nursing confirmed the failure to provide appropriate treatments and services for the use of indwelling urinary catheters for these residents.
Failure to Properly Store, Label, and Secure Medications and Biologicals
Penalty
Summary
The facility failed to properly store and label medications and biologicals in accordance with professional standards and facility policy. During reviews of two out of three medication rooms and two out of three medication carts, surveyors observed expired medications, including a vial of tuberculin and insulin pens, as well as insulin pens that were not labeled with expiration dates as required. Additionally, a tuberculin vial in one medication room was found to be opened without being labeled with the date it was opened. These findings were confirmed by LPNs and the Director of Nursing during interviews. In one instance, a resident with diagnoses of hypertension, diabetes, and COPD was prescribed Basaglar insulin. During a medication pass, an LPN prepared the resident's insulin pen and left it unattended on top of the medication cart while administering oral medications in the resident's room, making the insulin pen accessible to anyone passing by. This was acknowledged by the LPN during an interview. The facility's failure to ensure proper storage, labeling, and security of medications and biologicals was observed and confirmed by staff.
Failure to Evaluate and Authorize Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly evaluated and authorized to self-administer medication, as required by facility policy. According to the policy, residents may self-administer medications only after an interdisciplinary team evaluation and approval from their medical provider, followed by a physician's order. During a medication pass observation, a can of nasal spray was found on a resident's over-bed table, and the LPN confirmed there was no physician order for self-administration of this medication. Review of the resident's records showed no current order or interdisciplinary assessment for self-administration. The Director of Nursing confirmed that the necessary evaluation and authorization had not been completed for this resident, who had diagnoses of hypertension, diabetes, and COPD.
Failure to Provide Timely SNF ABN Forms to Residents
Penalty
Summary
The facility failed to provide timely Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms to two of three reviewed residents. According to facility policy, residents must be given advance notice when Medicare Part A or Managed Skilled Care benefits will no longer cover their care and services. For one resident, the SNF ABN form was signed on the same day that services were set to end, rather than in advance as required. For another resident, there was no completed SNF ABN form found in the records, and staff confirmed that the notice had not been provided. Both residents had significant medical conditions, including coronary artery disease, high blood pressure, arthritis, heart failure, diabetes, and depression. The deficiency was identified through a review of facility documents, clinical records, and staff interviews, which confirmed that the facility did not adhere to its own policy or regulatory requirements regarding timely notification of non-coverage. This failure was cited under multiple state codes related to admission policy, licensee responsibility, management, and resident rights.
Failure to Communicate Required Resident Information During Hospital Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during hospital transfers for two residents. According to the facility's own policy, information such as the provider's contact details, resident representative or POA contact, advanced directives, special care instructions, care plan goals, and other relevant information must be provided to ensure a safe and effective transition. However, clinical record reviews for two residents who were transferred to the hospital and later returned showed no documented evidence that this required information was communicated to the receiving provider. One resident had diagnoses including lung cancer, stroke, and anemia, while another had a left femur fracture, dysphagia, and muscle weakness. In both cases, the clinical records did not contain documentation of communicated care plan goals, advanced directive information, specific instructions for ongoing care, or resident representative information at the time of transfer. The DON confirmed during interviews that the necessary information was not communicated for these residents, as required by facility policy and regulatory standards.
Failure to Obtain Physician Orders and Timely Follow Bowel Protocol
Penalty
Summary
The facility failed to obtain required physician orders for two residents who went on therapeutic leave and did not follow the established bowel protocol in a timely manner for another resident. Specifically, two residents with diagnoses including vascular dementia, kidney disease, congestive heart failure, Alzheimer's disease, hypothyroidism, and a history of repeated falls were documented in nurse progress notes as being on leave with family, but there were no corresponding physician orders authorizing these therapeutic leaves. The Director of Nursing confirmed that the required orders were not present in the clinical records for these residents. Additionally, a resident with high blood pressure, hyperlipidemia, and Alzheimer's disease experienced significant lapses between documented bowel movements, with intervals ranging from five to seven days. During these periods, there was no evidence in the clinical record of abdominal assessments or timely interventions as outlined in the facility's bowel protocol. The first intervention, administration of bisacodyl, was not provided until after a prolonged lapse, and the Director of Nursing confirmed the protocol was not followed in a timely fashion.
Failure to Provide Appropriate Mobility and Skin Integrity Interventions for Residents with Limited Mobility
Penalty
Summary
The facility failed to ensure that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. For one resident with diagnoses including high blood pressure, hyperlipidemia, and Alzheimer's Disease, there was no documented assessment of a right hand brace provided after an orthopedic appointment, nor was the appearance of the hand upon return recorded. The resident subsequently experienced skin irritation and a skin tear below the thumb, with the brace found to be too small and causing damage. The facility did not have a policy for assistive devices or splints, and staff confirmed the lack of documentation and assessment regarding the brace. Another resident with osteomyelitis of the vertebra, depression, and atrial fibrillation had a physician order for a thoraco-lumbar sacral orthosis (TLSO) brace, but the order did not specify directions for use or interventions for monitoring skin integrity under the brace. The resident's care plan also failed to include interventions for monitoring skin integrity. Staff interviews confirmed these omissions, and the Director of Nursing acknowledged the failure to provide appropriate services and documentation for both residents.
Failure to Specify PICC Flush Protocol in IV Medication Orders
Penalty
Summary
The facility failed to provide adequate treatment and care for a resident with a peripherally inserted central catheter (PICC) in accordance with professional standards of practice. Facility policy required that intermittent infusions, such as antibiotics, be flushed with 10 ml normal saline solution (NSS) before and after medication administration. For a resident admitted with osteomyelitis of the thoracic vertebra, depression, and atrial fibrillation, physician orders directed the use of Cefepime HCl Solution intravenously every 12 hours and specified that the right upper arm PICC be flushed prior to and after infusion. However, the orders did not specify the substance or the amount to be used for the flush. This omission was confirmed by an LPN during an interview, indicating that the facility did not ensure the PICC was managed according to professional standards for this resident.
Failure to Provide Timely Respiratory Equipment Changes
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required oxygen therapy. According to facility policy, humidification bottles and tubing for oxygen concentrators are to be changed weekly. For one resident with diagnoses including high blood pressure, hyperlipidemia, and Alzheimer's Disease, a physician's order required oxygen via nasal cannula at 2 liters per minute to maintain oxygen saturation above 90%. Observation revealed that the humidification bottle in use was empty and had not been changed for over a week, as indicated by the date on the bottle. A registered nurse confirmed that the bottle was not changed as required. Similarly, another resident with diagnoses of high blood pressure, heart failure, and diabetes had a physician's order for oxygen via nasal cannula at 2 liters per minute. Observation showed that the humidification bottle in use for this resident had not been changed for two weeks, contrary to facility policy. This was also confirmed by a registered nurse. The Director of Nursing acknowledged that the facility did not provide appropriate respiratory care for these two residents.
Failure to Ensure Resident Capacity and Choice in Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident had the capacity to understand the terms of a binding arbitration agreement prior to signing. Review of clinical records showed that the resident had a diagnosis of dementia and a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. Despite this, the resident personally signed the binding arbitration agreement at admission. The agreement was labeled as 'Mandatory Arbitration Agreement' and did not provide an option for the resident or their representative to decline or refuse to sign. Interviews with the Nursing Home Administrator (NHA) confirmed that all new admissions were required to sign the arbitration agreement as part of the admission packet, and the NHA was unable to explain what would happen if a resident chose not to sign. The NHA acknowledged that the process did not allow for resident choice and confirmed the failure to ensure the resident's capacity to understand the agreement. The deficiency was cited under 28 Pa. Code: 201.14(a)(c) and 28 Pa. Code: 201.18(e)(1).
Failure to Hold Required QAA Meeting with All Committee Members
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for one of four quarterly meetings in Quarter One of 2025. Review of the facility's QAPI policy and attendance records revealed that the Director of Nursing (DON) was not present at the QAA meeting for that quarter. This was confirmed during an interview with the DON, who acknowledged the absence and the failure to meet the federal requirement for QAA committee composition and meeting frequency as outlined in facility policy and state code. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Deficiency in Annual In-Service Training Program
Penalty
Summary
The facility failed to implement and maintain an effective annual in-service training program for several nurse aides, as evidenced by a review of personnel records and staff interviews. Specifically, the records for Nurse Aide Employees E3, E4, E5, and E6 did not include required annual in-service trainings for infection control, dementia training, communication, and abuse training for the year 2024. The facility's policy mandates compliance education and training for employees, yet these nurse aides' records were incomplete in these critical areas. Interviews with staff, including a ten-year employee, indicated that while there are numerous online trainings required annually, the facility did not ensure completion of these essential trainings for the mentioned nurse aides. The Nursing Home Administrator confirmed the deficiency, acknowledging the failure to uphold the facility's training requirements as per their policies and procedures, which are designed to maintain high levels of skill and training among staff.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident, identified as Resident R31, who was admitted with diagnoses including renal insufficiency, high blood pressure, and heart failure. The resident's care plan included monitoring for adverse reactions to anticoagulant therapy, which was revised to include monitoring for increased senile purpura. On a specific date, a nurse aide observed large bruises on the resident's legs, and the resident reported that a nurse aide had pressed their leg tightly during care, resulting in the bruising. Despite this allegation, the facility did not include a report of the abuse allegation in their submitted reports for the month. Interviews with the resident and staff confirmed the resident's account of the incident, and the bruising was observed by the survey agency. The RN Supervisor acknowledged the resident's statement and mentioned that the Assistant Director of Nursing was informed, and investigation forms were prepared. However, the Director of Nursing confirmed that the allegation of abuse was not reported to management because it was not known that a specific perpetrator was identified during the initial report. This oversight led to the facility's failure to report the alleged abuse incident as required by their policy and state regulations.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to fully investigate an alleged abuse incident involving a resident, identified as Resident R31, who reported that a nurse aide pressed their leg tightly during care, resulting in bruising. The resident, who has a medical history of renal insufficiency, high blood pressure, and heart failure, was on anticoagulant therapy, which can increase the risk of bruising. Despite the resident's report and visible bruising, the facility did not conduct a timely and comprehensive investigation. The initial report of the incident was made on 7/26/24, but the alleged perpetrator was not interviewed until four days later, on 7/30/24. Interviews with staff revealed a lack of urgency and thoroughness in addressing the allegation. The RN Supervisor indicated that investigation forms were distributed but not promptly collected or reviewed. The Director of Nursing confirmed that the facility did not complete a comprehensive investigation, failing to identify all involved parties and interview potential witnesses in a timely manner. This lack of prompt and thorough investigation is a violation of the facility's policy on abuse prevention and the residents' right to freedom from abuse.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident, resulting in an elopement incident. Resident R17, who was admitted to the facility with diagnoses of dementia, chronic kidney disease, and venous insufficiency, was identified as having severe cognitive impairment with a BIMS score of 1. An Elopement/Exit Seeking Evaluation Form dated December 7, 2023, indicated that the resident was at risk for elopement with a score of 21. Despite this known risk, the resident managed to leave an unsupervised and unauthorized location without staff knowledge. On November 5, 2023, at 6:50 a.m., a nursing assistant on the second floor alerted staff that Resident R17 was found at the Magnolia neighborhood nurses' station after having wandered off and taken the back staff elevator. The resident was reported missing at 6:45 a.m. and was last seen approximately 15 minutes prior, returning from the second floor at 6:55 a.m. An interview with the Director of Nursing on July 31, 2024, confirmed that staff were not reeducated following the incident, indicating a lapse in the facility's response to the elopement event.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident R25, who required oxygen therapy. The clinical record review and observations revealed that the facility did not have a policy for oxygen therapy, and the resident's care plan did not include necessary interventions related to oxygen therapy. Resident R25, diagnosed with Alzheimer's disease, dementia, and chronic obstructive pulmonary disease, was observed with an oxygen concentrator and nasal cannula tubing lying on the floor, which was confirmed by an LPN. The resident stated that she only used oxygen at night, contrary to the physician's order for oxygen administration every shift. Further investigation showed discrepancies in the documentation and administration of oxygen therapy. The Treatment Administration Record indicated compliance with the physician's orders, but interviews with staff revealed that the resident only used oxygen at night. The LPN acknowledged that the physician's order did not reflect the actual use and intended to clarify it. The resident's care plan lacked specific details for oxygen therapy, such as maintenance of equipment and monitoring for potential complications. The Director of Nursing confirmed the absence of a policy for oxygen administration, contributing to the deficiency in providing appropriate respiratory care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,387 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sewickley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Caring Heights Community Care & Rehab Ctr | 2.5 mi | ★★★★★ | 4 | 0 |
| Cedar Hill Healthcare And Rehabilitation Center | 4.7 mi | ★★★★★ | 2 | 0 |
| Highland Hills Post Acute | 5.6 mi | ★★★★★ | 37 | 1 |
| Vincentian Home | 5.6 mi | ★★★★★ | 13 | 0 |
| Little Sisters Of The Poor | 6.3 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Masonic Village At Sewickley.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.