Above 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 Providence Point Healthcare Residence during CMS and state inspections, most recent first.
The facility did not provide the opportunity to formulate or periodically review advance directives for several residents with varying medical and cognitive conditions. Clinical records lacked documentation of these required actions, and the NHA confirmed the deficiency during an interview.
The facility did not ensure that comprehensive MDS assessments were accurate and fully completed for several residents. In multiple cases, a resident's ability to be understood was inconsistently documented across different MDS sections, resulting in required cognitive and mood interviews not being conducted. The DON confirmed these assessment inaccuracies and omissions.
A resident admitted for post-surgical care with a cold therapy device did not have all assigned staff adequately trained on its use. Only a portion of the staff received education on the device, and posted instructions in the resident's room did not address its operation or care. The facility confirmed that an effective training program for non-common procedures, such as the use of cold therapy machines, was not developed or maintained.
A resident with severe upper and lower extremity contractures and total care needs was unable to reach the call light or hand bell due to physical limitations. Despite policy and care plan instructions to keep the call light in reach, observations and interviews confirmed the devices were inaccessible, and the care plan did not address the resident's decreased range of motion or need for alternative alert systems.
A resident with a history of high blood pressure, osteoporosis, and post-joint replacement aftercare had her hospital discharge information, including personal and medical details, posted on her wall without her knowledge or consent. This information included her name, medical record number, medications, and follow-up appointments. The facility administrator confirmed that confidentiality requirements were not met.
A resident with dementia, COPD, and diabetes was administered quetiapine, an antipsychotic, without a documented indication or evidence of behavioral symptoms. Physician orders lacked an associated diagnosis, and behavior monitoring showed no behaviors to justify the medication. The facility's failure to ensure drug regimens were free from unnecessary psychotropic drugs was confirmed by the administrator.
A resident admitted for aftercare following joint replacement surgery, with intact cognition and multiple diagnoses, was using a cold therapy device that was not addressed in the comprehensive care plan developed at admission. The omission was confirmed by the Nursing Home Administrator after the resident reported issues with the device and uncertainty about staff knowledge regarding its use.
Two residents did not have care plans that reflected their current needs and provider orders. One resident with hand contractures and limited mobility was unable to use the call light or hand bell, yet the care plan only stated to keep the call light in reach. Another resident with Alzheimer's and dysphagia had a provider order to be out of bed for all meals, but this was not included in the care plan. The DON confirmed the care plans were not updated to provide person-centered care.
A resident admitted for post-operative care following joint replacement did not receive appropriate treatment and services due to the facility's failure to provide timely physician orders, develop a care plan, educate all staff on the use of a cold therapy device, and monitor the resident's skin condition. The resident reported concerns about staff knowledge and device operation, and observations confirmed a lack of clear instructions and staff competency.
The facility did not consistently obtain or document weights for two residents with complex medical conditions, nor did staff act upon significant weight changes as required by care plans and physician orders. Missed weight recordings were attributed to staff being too busy, equipment issues, and lack of follow-through on orders, resulting in inadequate monitoring of nutrition status.
Surveyors identified multiple expired and improperly stored medical supplies, including IV sets, catheters, and dressing change kits, in a medication room. Some supplies were found outside of their packaging, and non-sterile gloves were opened where sterile gloves were required. These issues were confirmed by nursing staff and facility administration, indicating a failure to follow proper storage and disposal protocols.
The facility failed to meet the required staffing levels for nurse aides during the night shift on multiple occasions, with staffing shortages noted on 9 out of 21 days. Despite the regulation requiring one nurse aide per 15 residents overnight, the facility consistently provided fewer aides than needed, as confirmed by the Nursing Home Administrator.
The facility failed to meet the required LPN staffing levels, with shortages during both day and night shifts over a 21-day period. On specific days, the facility did not provide the minimum LPNs needed per resident census, as confirmed by the Nursing Home Administrator.
A resident with multiple health conditions did not receive scheduled medications, including those for blood pressure and heart rate regulation, as documented by an RN. The medications were found in the cart later, and neither the physician nor the resident's representative was notified. The facility failed to document vital signs or assess for ill-effects.
A resident with dementia and multiple medical conditions sustained a skin tear during care due to neglect. The incident occurred when a nurse aide turned the resident, causing pressure and shearing on the resident's folded arms. The facility's Director of Nursing later acknowledged the failure to protect the resident from neglect.
The facility failed to investigate possible neglect and abuse for two residents. One resident with dementia suffered a skin tear during care, which was not classified as neglect by the DON. Another resident with Alzheimer's was transferred without the required assistance, as reported by the family. The facility did not investigate these incidents as potential neglect.
A resident with heart failure and dementia, requiring substantial assistance for daily activities, sustained a leg fracture after sliding off the bed during incontinence care. The CNA providing care was alone and rolled the resident away from herself, contrary to usual practice, leading to the fall. The facility failed to provide appropriate assistance, resulting in actual harm.
Failure to Provide and Review Advance Directives for Multiple Residents
Penalty
Summary
The facility failed to provide residents with the opportunity to formulate an advance directive or to conduct periodic reviews of existing advance directives as part of the comprehensive care planning process. This deficiency was identified for four out of eight residents reviewed. For each of these residents, a review of their clinical records did not show evidence that the facility had offered the chance to create an advance directive or had periodically reviewed the residents' care instructions and whether the residents or their designated surrogates wished to change or continue these instructions. The affected residents had various medical conditions, including heart failure, depression, anxiety, cerebrovascular disease, hypothyroidism, aphasia, skin cancer, osteoarthritis, and Alzheimer's disease. Cognitive assessments such as the Brief Interview for Mental Status (BIMS) indicated varying levels of cognitive impairment among these residents, with some being moderately to severely impaired. Despite these conditions, there was no documentation in the clinical records to show that the facility had addressed advance directives in accordance with its policy and regulatory requirements. The Nursing Home Administrator confirmed this failure during an interview.
Inaccurate and Incomplete MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for six out of fifteen residents. According to the Resident Assessment Instrument (RAI) User's Manual, specific sections of the MDS, such as Section C (Cognitive Patterns) and Section D (Mood), require completion of the Brief Interview for Mental Status (BIMS) and Resident Mood Interview if the resident is at least sometimes understood. However, for the identified residents, there were inconsistencies between their ability to be understood as documented in Section B (Hearing, Speech, and Vision) and the coding in Sections C and D, resulting in the required assessments not being completed. For example, several residents were documented as being 'usually' or 'sometimes' understood in Section B, but were coded as 'rarely understood' in Sections C and D, leading to the omission of the BIMS and Mood Interview assessments. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged that the facility did not ensure the accuracy and completeness of the MDS assessments for these residents.
Failure to Provide Comprehensive Staff Training on Cold Therapy Device
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for staff regarding the use of a cold therapy device, specifically the Breg Polar Care Cube, for a resident who was admitted after a right shoulder replacement. The manufacturer's instructions for the device require specific procedures for safe use, including regular skin inspections and ensuring the device is not run without water. However, the only information posted in the resident's room pertained to general post-operative care and did not include instructions on the use or care of the cold therapy machine. Interviews and documentation revealed that the use of cold therapy machines was not common in the facility, and education on the device was inconsistently provided. While some nurse aides and therapy staff received instruction on the device, this education was not extended to all staff assigned to the resident's care, particularly those on afternoon and evening shifts. Staff members confirmed that not all personnel were trained, and some had never previously cared for a patient using such a device. The deficiency was further substantiated by the resident's own report that staff seemed unaware of how to use the cold therapy machine, and by the facility's own admission that an effective training program, including additional topics based on the resident population and non-common procedures, was not in place. Facility records showed that only a subset of staff received education on the device, despite multiple staff being assigned to the resident's unit during the relevant period.
Failure to Ensure Call Light Accessibility for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident with significant upper and lower extremity range of motion impairment and contractures had access to a call light or alert device within reach, as required by facility policy. The resident, who had diagnoses including stroke, diabetes, and heart disease, was documented as needing total care and assistance with activities of daily living and feeding, and was non-ambulatory. Despite care plan instructions to keep the call light in reach at all times, observations and interviews revealed that the resident was unable to reach the call light tube placed on their lap or a hand bell located on a table, due to their physical limitations. Review of the resident's clinical record and therapy notes indicated ongoing issues with contractures and the use of bilateral palm guards, but the care plan did not address the progression of the resident's hand contractures or decreased range of motion that affected their ability to access the call light system or other alert devices. Staff interviews and direct observation confirmed that the resident could not activate the call light or reach the hand bell, and the care plan lacked specific interventions to accommodate these needs.
Failure to Maintain Resident Medical Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information, as required by both facility policy and state regulations. During an interview, a resident indicated that information about her cold therapy device was posted on her wall. Upon review, it was found that a copy of her hospital discharge information was taped to the wall, which included her name, gender, medical record number, birth date, hospital name, medications with dosages and reasons for use, diet order, and follow-up appointment information. The resident confirmed she was unaware of all the information posted and had not given permission for it to be displayed. The resident involved had a history of high blood pressure, osteoporosis, and was receiving aftercare following joint replacement surgery. A recent BIMS assessment indicated she was cognitively intact. The Nursing Home Administrator acknowledged that the facility did not maintain the confidentiality of the resident's medical information, as required by facility policy and state regulations.
Unnecessary Use of Psychotropic Medication Without Adequate Indication
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary psychotropic medications, as required by policy and regulation. Specifically, a resident with diagnoses of COPD, diabetes, and dementia (without behavioral, psychotic, or mood disturbances) was administered quetiapine, an antipsychotic medication, without an adequate indication for use. The physician orders for quetiapine did not list an associated diagnosis, and the resident's care plan for the medication lacked specific goals or evidence of behavioral symptoms that would justify its use. Behavior monitoring documentation over a two-and-a-half-month period showed no documented behaviors that would warrant antipsychotic therapy. Further review of psychiatric progress notes indicated the resident was diagnosed with major depressive disorder, generalized anxiety disorder, dementia, and primary insomnia, but there was no documentation of psychotic symptoms. Additionally, a psychiatric assessment was unable to be completed due to the resident's excessive sleepiness. During an interview, the Nursing Home Administrator confirmed the failure to ensure that residents' drug regimens were free from unnecessary medications used without adequate indications.
Failure to Include Cold Therapy Device in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan that included all required elements for a newly admitted resident when using a comprehensive care plan in place of a baseline care plan. Specifically, the care plan did not address the resident's use of a cold therapy device, which was brought with the resident upon admission following a right shoulder replacement. The resident, who had diagnoses including high blood pressure, osteoporosis, and was receiving aftercare for joint replacement surgery, was assessed to have intact cognition. Documentation showed that the cold therapy device was in use, but the comprehensive care plan initiated at admission did not include information or instructions regarding its use. During interviews, the resident reported that the ice in the cold therapy device had been running out and expressed uncertainty about staff understanding of the device's operation, referencing a paper with information taped to her wall. The Nursing Home Administrator confirmed that the facility did not develop a comprehensive, person-centered care plan with all requirements for this resident, as required when a comprehensive care plan is used in place of a baseline care plan.
Failure to Develop and Update Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and update comprehensive, person-centered care plans for two residents, as required by policy and regulation. For one resident with a history of cerebrovascular disease, hypothyroidism, and aphasia, clinical records and therapy notes indicated the presence of hand contractures and the need for bilateral palm guards with specific instructions. Despite these documented needs and the resident's inability to reach the call light or hand bell due to contractures, the care plan only included a generic instruction to keep the call light in reach, without addressing the resident's physical limitations or providing alternative alert methods. For another resident diagnosed with Alzheimer's disease, cerebrovascular disease, and dysphagia, a provider's order required the resident to be out of bed for all meals. This instruction was posted on the nursing unit communication board, but the resident's care plan did not include this requirement. The Director of Nursing confirmed that care plans for both residents lacked necessary instructions to provide individualized, person-centered care as indicated by their current conditions and provider orders.
Failure to Provide Appropriate Post-Operative Care and Staff Education for Cold Therapy Device
Penalty
Summary
The facility failed to provide appropriate treatment and services related to post-operative care for a resident who was admitted after a right shoulder joint replacement. The resident was prescribed the use of a cold therapy device (Breg Polar Care Cube) with specific instructions for application duration and the use of a barrier, but the physician's order did not include detailed directions on device operation or necessary safety precautions to prevent skin injury. The resident's comprehensive care plan did not address the use of the cold therapy device or the need for skin monitoring, and there was no timely development of a care plan or orders for monitoring skin health following admission. Staff interviews and documentation revealed that education on the use and care of the cold therapy device was inconsistent and incomplete. While some nurse aides received education from therapy staff, this training was not provided to all shifts, and there was no evidence that all relevant staff were competent in operating the device or monitoring for potential complications. The resident reported that the device frequently ran out of ice and expressed concerns that staff were not knowledgeable about its use. Observations confirmed that instructions posted in the resident's room did not include information on the cold therapy device. The facility's policy required staff to have appropriate competencies to ensure resident safety, but this was not met in the case of the cold therapy device. The Nursing Home Administrator confirmed that there was a delay in obtaining a physician's order for the device, a delay in care planning, a lack of staff education, and no established plan for monitoring the resident's skin condition. These failures resulted in the facility not providing appropriate treatment and services for the resident's post-operative care as required.
Failure to Monitor and Document Resident Weights and Nutrition Status
Penalty
Summary
The facility failed to properly monitor the weight and nutritional status of two residents by not obtaining weights as ordered and not acting upon significant weight changes. For one resident with diagnoses including COPD, diabetes, and dementia, the care plan did not include goals or interventions related to nutrition. Despite physician orders to obtain monthly weights, there were missed weight recordings on multiple occasions, with nursing notes indicating the task was not done or staff were too busy. Additionally, a dietitian's order for special weight monitoring was not carried out, and a subsequent physician order to obtain and document weight was also not completed. For another resident with lymphedema, morbid obesity, and hypertension, the care plan required weight monitoring and notification of the physician for significant weight changes. However, weight documentation was inconsistent, with several missed entries due to resident refusal, equipment issues, or lack of documentation. The facility's failure to consistently obtain and document weights, as well as to act upon notable weight changes, was confirmed by the Nursing Home Administrator during an interview.
Expired and Improperly Stored Medical Supplies Found in Medication Room
Penalty
Summary
The facility failed to ensure that medical supplies and medications were properly stored and disposed of on one of its nursing units. During an observation of the Second-Floor Nursing Unit medication room, multiple expired medical supplies were found, including IV administration sets, central line dressing change kits, Sterilux AMD gauze, winged IV catheters, IV catheters, Luer Lok access devices, and syringe tip caps. Additionally, some Sterilux AMD gauze was found outside of its packaging, and a package of non-sterile gloves was opened when sterile gloves were required. These findings were confirmed by a registered nurse during the observation. The facility's policy requires that medications and biologicals be stored safely, securely, and according to manufacturer or supplier recommendations. However, the presence of expired and improperly stored supplies in the medication room indicated non-compliance with this policy. The Nursing Home Administrator confirmed that the facility did not ensure proper storage and disposal of medical supplies on the affected nursing unit.
Night Shift Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during the night shift on 9 out of 21 days between November 22, 2024, and December 12, 2024. The regulation mandates a minimum of one nurse aide per 15 residents overnight, but the facility did not comply with this requirement on several occasions. For instance, on November 23, 2024, with a census of 42 residents, the facility required 2.80 nurse aides but only provided 2.28. Similarly, on November 24, 2024, with a census of 41, the facility required 2.73 nurse aides but only provided 2.16. These staffing shortages were consistent across multiple dates, with no additional higher-level staff available to compensate for the deficiencies. The Nursing Home Administrator confirmed the staffing shortfalls during an interview on December 12, 2024. The facility's failure to provide the mandated number of nurse aides was evident in the review of nursing time schedules and deployment sheets. The report highlights specific dates and census numbers, illustrating the consistent inability to meet the required staffing levels, which directly led to the deficiency noted by the surveyors.
Plan Of Correction
The facility will correct the deficiency: the administrator educated the director of Nursing and the Staffing Coordinator on PA Code 211.12 as it relates to Staff to resident Ratios and Direct Nursing Care Hours for certified nurse aides for the following dates: 11/23, 11/24, 11/26, 11/27, 11/28, 11/29, 12/03, 12/08, and 12/12/2024. To prevent reoccurrence, the staffing coordinator will ensure that the correct number of NA's are scheduled for each shift (day, evening and night) utilizing the staffing ratio/PPD worksheet and review with the DON daily. The facility will utilize the on-call nursing staff to maintain nursing hours should the facility fall below nursing rations on the overnight shift with an RN within a 30-minute drive from the facility. The facility will continue weekly recruitment and retention meetings to review open positions, post open positions weekly for internal and external candidates, and offer referral bonuses to attract and retain staff. The facility will conduct audits by the DON/Designee/Scheduling Coordinator, who will review the worksheet daily for compliance for two weeks, then weekly for two weeks, and continue with weekly review and report quarterly thru QAPI.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) as per the regulation effective July 1, 2023. Specifically, the facility did not provide the minimum of one LPN per 25 residents during the day shift on two occasions and one LPN per 40 residents during the night shift on three occasions within a 21-day period. On November 30, 2024, with a census of 32 residents, the facility required 1.28 LPNs during the day shift but only provided 1.00 LPN. Similarly, on December 1, 2024, with a census of 33 residents, 1.32 LPNs were needed, but only 1.03 LPNs were available. No additional higher-level staff were available to compensate for these deficiencies. During the night shifts on November 22, 23, and 24, 2024, the facility also failed to meet the required LPN staffing levels. With a census of 42 residents on November 22 and 23, 1.05 LPNs were needed, but only 1.00 LPN was provided. On November 24, with a census of 41 residents, 1.03 LPNs were required, yet only 1.00 LPN was available. The Nursing Home Administrator confirmed these staffing shortages during an interview on December 12, 2024, acknowledging the facility's failure to meet the minimum LPN staffing requirements on these specific days.
Plan Of Correction
The facility will correct the deficiency. The administrator educated the Director of Nursing and the Staffing Coordinator on PA Code 211.12 as it relates to Staff to Resident Ratios and Direct Nursing Care Hours for LPN's for the following dates: 11/22, 11/23, 11/24, 11/30, and 12/01/2024. To prevent reoccurrence, the Staffing Coordinator will ensure that the correct number of LPN's are scheduled for each shift (day, evening, and night) utilizing the staffing ratio/PPD worksheet and review with the DON daily. The facility will utilize the on-call nursing staff to maintain nursing hours should the facility fall below nursing ratios on the overnight shift with an RN within a 30-minute drive from the facility. The facility will continue with weekly recruitment and retention meetings to review open positions, post open positions weekly for internal and external candidates, and offer referral bonuses to attract and retain staff. The facility will conduct audits by the DON/Designee/Scheduling Coordinator, who will review the worksheet daily for compliance for two weeks, then weekly for two weeks, and continue with weekly review and report quarterly through QAPI.
Failure to Administer Scheduled Medications and Notify Physician
Penalty
Summary
The facility failed to provide scheduled medication to a resident, identified as Resident R1, who was readmitted with diagnoses including malnutrition, orthostatic hypotension, high blood pressure, and paroxysmal atrial fibrillation. On a specific date, the Medication Administration Record (MAR) indicated that several medications were documented as administered by RN Employee E1, but a subsequent check revealed that the medications were still in the medication cart and had not been given. The medications included Eliquis, Immodium, Klor-Con, Midodrine, and Sotalol, which are critical for managing the resident's conditions. The facility's Medication Error Report and Safety Events documentation showed that the physician and the resident's representative were not notified of the medication omission. Additionally, there was no documentation of vital signs being assessed for potential ill-effects after the missed medications. The Nursing Home Administrator confirmed the lack of documentation and notification, acknowledging the failure to provide care as per the resident's needs and the facility's policies.
Neglect Resulting in Resident Skin Tear
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, resulting in a skin tear that required treatment. The incident involved a resident with a medical history of dementia with behavioral disturbances, atrial fibrillation, a pacemaker, difficulty walking, artificial heart valve, artificial knees, left hip, and malnutrition. The resident required assistance from two staff members for care while in bed. During a routine round, a nurse aide turned the resident, causing a skin tear on the left forearm due to the resident's arms being folded, which likely led to pressure and shearing. The incident was reported by the nurse aide to a licensed practical nurse, who observed the skin tear and notified the physician for treatment. The Director of Nursing initially did not identify the incident as neglect but later acknowledged the failure to protect the resident from neglect. The facility's policies on preventing resident abuse and incident reporting were reviewed, indicating that the facility did not adequately protect the resident from neglect, as required by federal regulations.
Failure to Investigate Possible Neglect and Abuse
Penalty
Summary
The facility failed to identify and investigate incidents of possible neglect and abuse for two residents. Resident R7, who has a history of dementia, atrial fibrillation, and other conditions, experienced a skin tear on her left forearm. This occurred when a nurse aide turned her during rounds, and it was reported to an LPN. The Director of Nursing (DON) acknowledged looking into the incident but did not classify it as neglect, despite the skin tear requiring treatment. Resident R28, diagnosed with Alzheimer's disease, dementia, and other conditions, was to be transferred with the assistance of two staff members for safety. However, a grievance was filed by the resident's family, indicating that staff transferred him without a second person, contrary to the physician's order. The Nursing Home Administrator and DON confirmed that the facility did not identify and investigate the potential neglect in this case.
Failure to Provide Appropriate Assistance Resulting in Resident Injury
Penalty
Summary
The facility failed to provide appropriate assistance to prevent falls, resulting in actual harm to a resident who sustained a leg fracture. The resident, who had diagnoses of heart failure and dementia, required substantial to maximal assistance for activities of daily living, including rolling in bed. Despite this, the resident's care documentation showed inconsistencies in the level of assistance provided, with the resident being documented as totally dependent 66% of the time, requiring extensive assistance 28% of the time, and limited assistance 6% of the time over a one-month period. On the night of the incident, two CNAs transferred the resident to bed using a Hoyer lift. One CNA left to attend to other residents, leaving the remaining CNA to provide incontinence care alone. The CNA rolled the resident to her left side, away from herself, which is not the usual practice. The resident began to slide off the bed, and the CNA was unable to prevent the fall due to the resident's size and lymphedema. The resident landed on her knee and buttocks, resulting in a fracture of the distal femoral diaphysis. Interviews with the involved CNA and another staff member confirmed that residents should be rolled towards the person providing care to prevent such incidents. The Nursing Home Administrator in training acknowledged that the facility failed to provide appropriate assistance, leading to the resident's fall and subsequent injury.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| John J Kane Regional Center-sc | 0.3 mi | ★★★★★ | 4 | 0 |
| Concordia Of The South Hills | 0.8 mi | ★★★★★ | 0 | 0 |
| Asbury Health Center | 1.7 mi | ★★★★★ | 1 | 0 |
| Carnegie Park Post Acute | 1.7 mi | ★★★★★ | 21 | 0 |
| Wecare At Mt Lebanon Rehabilitation And Nrsg Ctr | 1.8 mi | ★★★★★ | 21 | 0 |
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