Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Rehab & Nursing Ctr Greater Pittsburgh during CMS and state inspections, most recent first.
A resident with muscle weakness, spinal stenosis, depression, high fall risk, and an order for 2-person assist for transfers and bed mobility was injured when an aide changed her brief and linens without using the required assistance. The aide rolled the resident away from himself during care, and she fell out of bed, causing a forehead laceration, hematoma, and an acute subarachnoid bleed that required hospital transfer and anticoagulation reversal while she was on Eliquis.
A resident with a high fall risk, confusion, weakness, and orders for 2-person assistance for transfers and bed mobility fell out of bed while an NA was changing her brief and linens. The NA rolled her away from himself instead of maintaining safe support, and the resident fell to the floor with a forehead laceration and hematoma, then was sent to the hospital with a subarachnoid bleed while on Eliquis.
A resident with dementia, psychotic disorder with delusions, and a known history of wandering and wanting to leave, had been identified as an elopement risk and was documented as testing door handles and keypads and running toward open lobby doors. One evening, the resident was last observed in a wheelchair at the nurse’s station before EMS arrived and was granted entry through a remotely opened coded mag lock door. The resident, positioned close enough to the door, prevented it from closing, then moved through the corridor to an unalarmed exterior door, exited undetected, and was later found outside in a wheelchair by EMS attempting to approach the ambulance. Facility leadership acknowledged that adequate supervision to prevent elopement was not provided.
Surveyors observed that food products in the main kitchen's walk-in cooler and freezer were not stored according to facility policy, including an undated opened jar of grape jelly and boxes of food stacked to the ceiling and under fans. The Dietary Manager confirmed these improper storage practices and the failure to maintain sanitary conditions.
Three residents with diabetes experienced low blood glucose levels, but staff did not assess for hypoglycemia, monitor the effectiveness of treatment, or notify the physician as required by facility policy and physician orders. Care plans lacked appropriate interventions, and the DON confirmed these failures in documentation and protocol adherence.
Four residents with various medical conditions requiring oxygen therapy were found using oxygen equipment that was not labeled with the required date, contrary to facility policy and physician orders. Observations and staff interviews confirmed that proper labeling and maintenance procedures for oxygen tubing were not followed.
Grievance boxes in three facility locations were mounted above ADA-recommended heights and were sometimes blocked by furniture, making them inaccessible to residents, especially those using wheelchairs. Residents reported being unable to file grievances anonymously and often had to ask staff for assistance, which compromised their privacy. The NHA confirmed the lack of accessibility for these grievance boxes.
A resident who was cognitively intact and required moderate assistance for mobility was subjected to neglect and verbal abuse when a nurse aide failed to respond promptly to a call bell, made dismissive remarks, and exhibited a pattern of negative behavior including swearing and refusing assistance. The DON did not recognize these incidents as potential neglect or abuse and did not investigate further.
A resident with multiple medical conditions reported delayed response to a call bell and dismissive behavior from a nurse aide. Staff statements described the aide as having a negative attitude, swearing, and being unhelpful to residents. The DON did not recognize these incidents as potential abuse or neglect, failed to conduct a thorough investigation, and did not report findings to the State Survey Agency as required.
The facility did not post up-to-date nurse staffing information, as required, with the displayed information being outdated and not reflecting the current census or staffing hours. Both the receptionist and the NHA confirmed the posting was not current.
Surveyors found that the facility did not post required contact information for APS, the Medicaid Fraud Control Unit, or a statement about filing complaints with the State Survey Agency. The Nursing Home Administrator confirmed the absence of this information during an interview.
A resident with multiple medical conditions and a high risk for falls was not provided with adequate assistance or bedrails during incontinence care. A nurse aide turned the resident away and left her unsupervised while retrieving supplies, resulting in the resident falling from bed and sustaining a head injury and cervical fracture. Staff and leadership confirmed that proper supervision and interventions were not provided, constituting neglect.
A resident with multiple medical conditions and a high risk for falls was left unattended during incontinence care when a nurse aide turned away to retrieve supplies, resulting in the resident rolling out of bed. Bedrails, which were part of the care plan, were not in place at the time, leading to the resident sustaining a subarachnoid hemorrhage, scalp laceration, and C4 fracture. Staff and leadership confirmed that proper supervision and interventions were not provided.
The facility failed to offer four residents the opportunity to formulate advance directives, as required by policy. Despite having significant medical conditions, their records lacked documentation of being informed about their rights to accept or refuse treatment and to create an advance directive. This was confirmed by the Social Worker and DON.
The facility failed to secure medications in the B cart on the 300 hall, leaving it unattended and accessible to passersby. This was against the facility's policy, which requires medications to be stored in locked compartments with access limited to authorized personnel. The issue was confirmed by the DON.
A resident suffered a superficial frostbite burn due to improper supervision of cold pack use. The resident, with a history of sciatica and other conditions, reported that the ice pack was left on direct skin for too long, causing redness and blistering. The facility's policy required toweling and regular checks, but these were not effectively implemented, leading to harm.
Failure to Provide Required Assistance During Bed Mobility Resulted in Head Injury
Penalty
Summary
The facility failed to ensure that a resident was free from neglect when staff did not provide the required level of assistance and safe handling during bed mobility. The resident had diagnoses including muscle weakness, spinal stenosis, and depression, was receiving Eliquis 2.5 mg twice daily, had a high fall risk score, and had a care plan and physician order indicating a minimum assist of two persons for transfers and bed mobility. The resident’s MDS also showed partial/moderate assistance was needed for rolling and returning to lying. On the day of the incident, a nurse aide was changing the resident’s brief and bed linens when the resident was rolled onto her right side away from the caregiver. The aide then attempted to tuck the sheets under the resident while she remained on her side. As the aide moved to the other side of the bed, the resident started to fall out of bed and the aide could not prevent the fall. Staff later found the resident on the floor next to the bed with a laceration to the left forehead and a hematoma to the center forehead, and bleeding from the head wound. The resident was transported to the hospital and was admitted with an acute subarachnoid bleed and facial laceration. The hospital record indicated the resident received anticoagulation reversal and was instructed to pause Eliquis until directed otherwise. Staff interviews confirmed the aide failed to use the correct level of assistance for the resident’s bed mobility and rolled the resident away from himself. The LPN stated staff should check the Kardex for transfer and bed mobility status and should always roll residents toward themselves to prevent falls from the bed.
Failure to Provide Adequate Bed Mobility Assistance
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for bed mobility for a resident who had multiple fall risk factors, including muscle weakness, spinal stenosis, depression, baseline confusion, and a high fall risk score. The resident’s record showed she required a minimum of two-person assistance for transfers and bed mobility, and her care plan noted staff assistance had been increased to two persons because therapy reported she tended to make quick movements that increased her fall risk. She was also receiving Eliquis, a blood thinner, at the time of the incident. On the day of the event, a nurse aide was changing the resident’s brief and bed linens when he rolled her onto her right side away from himself. According to the aide’s statement, while he was tucking the sheets under her and moving to the other side of the bed, the resident began to fall out of bed and he could not prevent the fall. Other staff statements and the facility’s report described the resident as falling to the floor beside the bed with a laceration to the left forehead and a hematoma to the center of the forehead, with bleeding that required pressure to be applied. The resident was transported to the hospital for further evaluation and treatment. The resident was admitted to the ICU with an acute subarachnoid bleed and her head laceration was sutured. The hospital discharge summary noted anticoagulation reversal and instructed that Eliquis be paused until a provider directed otherwise. Interviews with staff confirmed that residents should be rolled toward the caregiver during bed mobility and that the aide failed to use the correct level of assistance for the resident’s bed mobility. The Director of Therapy confirmed the resident was a moderate assist of two persons for mobility at the time of the fall, and the Nursing Home Administrator confirmed the facility failed to ensure adequate supervision and assistance for bed mobility, resulting in actual harm.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident who had documented dementia, a psychotic disorder with delusions, and a known history of wandering and expressing a desire to leave the facility. An Elopement Risk Evaluation completed months earlier identified the resident as being at risk for elopement, and the care plan reflected this risk due to wandering and verbalizations about wanting to leave. A progress note documented that the resident had been testing door handles and keypads and would run toward the lobby door when it was open, indicating ongoing elopement-seeking behavior. On the night of the elopement event, the resident was last seen by an LPN sitting in a wheelchair at the nurse’s station. When EMS arrived and rang the buzzer for entry, staff remotely opened the coded mag lock door after visually confirming who was entering. Based on the facility’s reenactment, the resident was close enough to the door to keep it from closing and then propelled through the door and down a 25-foot corridor to an outside door that was not alarmed. The resident pushed this outside door open and went outside undetected by staff. EMS later found the resident outside in a wheelchair attempting to go toward the ambulance, and nursing staff then brought the resident back inside. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent this elopement.
Improper Food Storage in Main Kitchen
Penalty
Summary
The facility failed to properly store food products in the main kitchen's walk-in cooler and freezer, as observed during a survey. Specifically, an opened jar of grape jelly was found undated in the walk-in cooler, and multiple boxes of food items were stored up to the ceiling on top shelves and under fans in the freezer. These practices did not comply with the facility's policy, which requires all refrigerated and frozen foods to be covered, labeled, dated, and stored to allow adequate air circulation. The Dietary Manager confirmed these storage issues and acknowledged that the facility did not maintain sanitary conditions in the main kitchen.
Failure to Assess, Document, and Notify Physician of Hypoglycemia
Penalty
Summary
The facility failed to assess, document, and notify physicians of decreased capillary blood glucose (CBG) levels for three residents with diabetes. Facility policy required specific actions for hypoglycemia, including immediate notification of the provider, administration of glucose, monitoring, and documentation. However, clinical records and electronic medication administration records (eMAR) showed that when residents experienced low blood glucose readings, these protocols were not followed. For one resident with diagnoses including congestive heart failure and diabetes, multiple CBG readings below 70 mg/dL were recorded, but there was no evidence of assessment for hypoglycemia, monitoring for effectiveness of treatment, or physician notification as required by both physician orders and facility policy. The resident's care plan also lacked interventions for diabetes management, including hypo- or hyperglycemia. Another resident with diabetes had a CBG reading of 58 mg/dL, but again, there was no assessment, monitoring, or physician notification documented, despite care plan interventions instructing staff to report symptoms of hypo- and hyperglycemia. A third resident with diabetes had several CBG readings below 70 mg/dL, but the clinical record and eMAR did not show that the resident was assessed for hypoglycemia, that blood glucose was monitored for effectiveness of treatment, or that the physician was notified of abnormal results. The Director of Nursing confirmed that the facility failed to notify the doctor of a change in condition, failed to document assessments or interventions related to blood glucose, and failed to follow physician orders for these residents.
Failure to Maintain and Label Oxygen Equipment for Residents Receiving Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and maintain oxygen equipment for four out of five sampled residents. According to facility policy, oxygen cannulas and tubing should be changed every seven days or as needed, and both oxygen and nebulizer equipment should be labeled with the date and stored properly between uses. During observations and interviews, it was found that residents with diagnoses such as pneumonia, coronary artery disease, heart failure, anemia, hypertension, respiratory failure, chronic obstructive pulmonary disease, bipolar disorder, and diabetes mellitus were receiving oxygen therapy, but the tubing in use was not labeled with an identifiable date as required by policy and physician orders. Specifically, residents were observed either in bed or sitting in a chair while using oxygen, and in each case, the oxygen tubing lacked proper labeling. Staff interviews confirmed that the required labeling and maintenance procedures were not followed for these residents. The Nursing Home Administrator acknowledged that the facility did not meet the standards for respiratory care and equipment maintenance for these residents, as outlined in both facility policy and physician orders.
Inaccessible Grievance Boxes Limit Resident Access
Penalty
Summary
The facility failed to provide accessible grievance boxes to residents in three locations: the 300-lounge, main dining room, and front lobby. According to the facility's own grievance policy, grievances may be submitted orally or in writing and may be filed anonymously. However, observations and interviews revealed that the grievance boxes were mounted at heights of 53, 52, and 51 inches, respectively, which exceeds the ADA-recommended maximum height of 48 inches for operable parts to ensure accessibility for individuals using wheelchairs. Additionally, access to the boxes in the 300-lounge and front lobby was obstructed by tables. During a resident group interview, residents reported that they could not anonymously file grievances because the boxes were too high to reach, not designed for people in wheelchairs, and required assistance from staff, which compromised anonymity. The Nursing Home Administrator confirmed these findings during an interview, acknowledging that the facility did not make the grievance boxes accessible in the identified locations.
Failure to Protect Resident from Neglect and Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from neglect and verbal abuse. The resident, who was cognitively intact and required moderate assistance for mobility, reported that her call bell was not answered in a timely manner when she requested help to use the bathroom. As a result, she had to take herself to the bathroom, and when the nurse aide eventually responded, the aide made a dismissive comment and left the room in a huff. Facility grievance documentation and staff statements indicated that the nurse aide in question had a pattern of negative behavior, including slamming doors, bullying residents, swearing, and refusing to assist with resident needs such as answering call bells and helping with meal trays. Despite these reports and statements from multiple staff members, the Director of Nursing did not identify the incidents as potential neglect or abuse and did not conduct a further investigation. The facility's failure to recognize and address these behaviors resulted in a lack of protection for the resident from neglect and verbal abuse, in violation of facility policy and state regulations.
Failure to Investigate and Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to promptly conduct a thorough investigation into allegations of potential abuse and neglect involving a resident. According to the report, a resident with diagnoses including kidney disease, Crohn's disease, and diabetes, who was cognitively intact and required moderate assistance with mobility, reported that her call bell was not answered in a timely manner when she needed help to go to the bathroom. The nurse aide responded dismissively, and additional staff statements described the same aide as having a negative attitude, swearing, and being unhelpful to residents, including leaving call bells unanswered and making inappropriate comments to residents. Despite these grievances and staff statements indicating possible abuse and neglect, the Director of Nursing confirmed that she did not identify these as potential abuse or neglect incidents and did not conduct a thorough investigation or implement corrective actions. Furthermore, the facility did not submit the results of a completed investigation to the State Survey Agency within the required five working days, as mandated by facility policy and federal requirements.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that current and accurate nurse staffing information was posted at the beginning of each shift. During an observation, it was found that the nurse staffing information displayed in the main lobby was outdated, showing a date from over two weeks prior and not reflecting the current resident census or the actual staffing hours for licensed and unlicensed nursing staff responsible for resident care. Interviews with the receptionist and the Nursing Home Administrator confirmed that the posted staffing information was not up to date and did not meet the required standards for accuracy and timeliness.
Failure to Post Required State Agency and Advocacy Contact Information
Penalty
Summary
Surveyors observed that the facility failed to post the required contact information for Adult Protective Services (APS), the Medicaid Fraud Control Unit, and a statement informing residents that they may file a complaint with the State Survey Agency. During observations on the nursing units, it was noted that the necessary elements, including agency names, addresses (mailing and email), and telephone numbers, were not accessible or visible to residents or their representatives. In an interview, the Nursing Home Administrator confirmed that this information was not posted as required by regulations. The deficiency was identified based on these observations and staff confirmation.
Failure to Prevent Resident Fall Due to Inadequate Supervision and Assistance
Penalty
Summary
The facility failed to protect a resident from neglect by not providing adequate assistance and interventions to prevent a fall with injury. The resident, who had multiple diagnoses including anemia, gastrointestinal bleed, diabetes, stroke, sacroilitis, anxiety, difficulty walking, abnormal posture, and Stage 5 kidney disease, was assessed as having intact cognition and required moderate assistance for bed mobility. The resident's care plan identified her as being at risk for falls due to impaired balance and poor coordination, and specified that staff should provide necessary assistance during transfers and ambulation, as well as use bedrails as needed. On the day of the incident, the resident had recently returned from the hospital after a blood transfusion and required incontinence care. During care, a nurse aide turned the resident away from herself and then turned away to retrieve supplies, leaving the resident unsupervised. At this time, the resident rolled out of bed, resulting in a head laceration, subarachnoid hemorrhage, and a C4 cervical fracture. Bedrails were not present on the bed at the time, despite the resident's care plan indicating their use. Staff interviews confirmed that proper technique would have involved either using bedrails or turning the resident toward the caregiver, or obtaining a second staff member for assistance. The Director of Nursing and the Nursing Home Administrator confirmed that the nurse aide's actions constituted neglect, as the resident was not adequately supervised or assisted during care, directly leading to the fall and resulting injuries. Facility policies reviewed emphasized the importance of safe resident handling, use of bedrails when indicated, and the need to prevent neglect by providing necessary goods and services to avoid physical harm.
Failure to Provide Adequate Supervision and Assistance During Incontinence Care Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate assistance and interventions to prevent a fall with injury for a resident who had multiple medical conditions, including anemia, diabetes, stroke, sacroiliitis, difficulty walking, abnormal posture, and advanced kidney disease. The resident was identified as being at risk for falls and required partial to moderate assistance for bed mobility, with care plans specifying the use of bedrails and staff assistance during transfers and ambulation. Despite these documented needs, during incontinence care, a nurse aide turned the resident away from her and left the resident unattended on the bed while reaching for supplies, resulting in the resident rolling out of bed. At the time of the incident, bedrails were not in place, contrary to the resident's care plan and facility policy. As a result of this lapse in supervision and failure to follow established protocols, the resident sustained significant injuries, including a subarachnoid hemorrhage, a scalp laceration requiring six sutures, and a C4 vertebrae fracture. Staff interviews confirmed that proper procedures, such as using bedrails or turning the resident toward the caregiver, were not followed. Facility leadership acknowledged that adequate assistance and interventions were not provided to prevent the fall and resulting harm.
Failure to Provide Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide the opportunity for four residents to formulate an advance directive, as required by their policy and regulatory standards. The facility's policy on Advance Directives, last reviewed on January 18, 2024, mandates that all adult residents be informed and provided with written information regarding their right to accept or refuse medical or surgical treatment and to formulate an advance directive. However, upon review of the clinical records for Residents R24, R29, R57, and R71, there was no documentation indicating that these residents were given the opportunity to formulate an advance directive. Resident R24 was admitted with diagnoses including type II diabetes, dysphagia, muscle weakness, and a left below-knee amputation. Resident R29 had type II diabetes, dysphagia, high blood pressure, and difficulty walking. Resident R57 was diagnosed with high blood pressure, a history of falling, and stage III chronic kidney disease. Resident R71 had multiple sclerosis, dysphagia, and stage III chronic kidney disease. Despite these significant medical conditions, the clinical records for these residents did not contain any advance directives or documentation of being offered the opportunity to create one. This deficiency was confirmed during an interview with the Social Worker and the Director of Nursing.
Medication Cart Left Unsecured on 300 Hall
Penalty
Summary
The facility failed to properly secure medications in one of the two medication carts on the 300 hall nursing unit, specifically the B cart. According to the facility's policy on Medication Labeling and Storage, medications should be stored in locked compartments with access restricted to authorized personnel. However, during an observation, the B medication cart was found unsecured and unattended, making it accessible to any passerby. This was confirmed by the Director of Nursing during an interview, indicating a breach in the facility's protocol for securing medications.
Failure to Supervise Cold Pack Use Results in Resident Harm
Penalty
Summary
The facility failed to implement effective safety measures by not supervising the use of a cold pack, resulting in actual harm to a resident. The resident, who was cognitively intact and had a history of sciatica, hyperlipidemia, polyneuropathy, and hypertension, suffered a superficial frostbite burn on the right knee. The facility's policy required appropriate toweling between the ice pack and the skin, with treatment times of 10-20 minutes and checks every 10 minutes. However, the resident reported that the ice pack was left on direct skin for too long, leading to redness and blistering. The incident occurred after the resident refused physical therapy due to pain and requested pain medication and an ice pack. A PT employee provided the ice pack, allegedly with proper toweling, but the resident later admitted to removing the cloth and placing the ice pack directly on the skin. The care plan did not include the use of cold packs as an intervention, and there was a lack of clear communication and supervision between the PT employee and the nursing staff. Interviews with staff revealed inconsistencies in the handling of the ice pack, and the facility acknowledged the failure to provide adequate education and supervision, resulting in harm to the resident.
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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 Greensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saint Anne Home | 1.2 mi | ★★★★★ | 2 | 0 |
| Westmoreland Manor | 1.3 mi | ★★★★★ | 9 | 0 |
| Hempfield Manor | 2.2 mi | ★★★★★ | 20 | 0 |
| Oak Hill Rehabilitation & Healthcare Center | 2.4 mi | ★★★★★ | 1 | 0 |
| Greene Health & Rehab Center | 2.7 mi | ★★★★★ | 44 | 0 |
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