Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Rose Meadows Health & Rehab Center during CMS and state inspections, most recent first.
A resident with cellulitis, muscle weakness, and an MDS indicating a need for dependent, two-person assistance with transfers was injured during a wheelchair-to-bed transfer performed by a single CNA. During the transfer, the resident’s leg struck or was dragged along the bed frame, causing a significant laceration to the lower leg that required sutures. At the time of the incident, the resident’s care plan did not yet reflect the two-person transfer requirement, and facility leadership later acknowledged that adequate supervision to prevent the injury had not been provided.
Multiple live and dead cockroaches, as well as pest debris and waste, were observed in various areas of the main kitchen, including under equipment and behind counters. Staff confirmed ongoing pest control issues and acknowledged the facility's failure to maintain an effective pest control program.
Failure to ensure availability of prescribed medications for three residents. One resident with diabetes and atrial fibrillation had multiple ordered meds documented as pending delivery or awaiting RX delivery, another resident with diabetes and HTN had an insulin aspart dose documented as unavailable, and a third resident with atrial fibrillation and anxiety had buspirone and apixaban doses documented as awaiting medications. The NHA and DON confirmed the issue.
A resident with diabetes, ASHD, and hyperlipidemia had multiple CBG readings above the ordered notification threshold while receiving Apidra before meals. The record showed no rechecks, no documented assessment for hypoglycemia, no monitoring for treatment effectiveness, and no physician notification of the abnormal results, which the DON confirmed during interview.
A resident with PTSD, anxiety, and diabetes did not receive trauma-informed care as required by facility policy. The resident’s PTSD was added to the diagnosis list, but the care plan was not initiated until later and included only one intervention: slow/deep breathing exercises and reassuring conversation with pleasant topics. The NHA and DON confirmed the failure to ensure trauma-informed care to identify and mitigate triggers.
A resident with type 2 DM and encephalopathy had a provider order for insulin aspart only when blood sugars were below a set threshold, but the MAR audit showed multiple doses were given outside the ordered parameters. Facility policy required meds to be administered as prescribed, and the DON and NHA confirmed the insulin was administered outside the physician order.
Failure to Provide Written Bed-Hold Notice at Transfer: The facility failed to ensure that written bed-hold policy notice was provided to the resident and/or representative when two residents were transferred to the hospital. One resident had dementia, metabolic encephalopathy, and severe cognitive impairment, with multiple hospital sends documented; the other had diabetes, HTN, and severe cognitive impairment. The NHA and DON confirmed the missing documentation.
A resident dependent on staff for transfers, with hemiplegia and a history of falls, was injured when a CNA attempted a transfer alone, contrary to the care plan requiring two staff and a mechanical lift. The resident slid from the bed and sustained a left humerus fracture, with documentation and staff interviews confirming the care plan was not followed.
A resident with hemiplegia and a history of falls, who required two-person assistance for transfers, was injured when a CNA attempted a transfer alone, resulting in a fall and a left humerus fracture. Despite staff training and clear care plan instructions, the required supervision was not provided, leading to actual harm.
The facility failed to protect two residents from abuse and neglect. One resident did not receive care during a shift, and another experienced discomfort from an LPN during medication administration. The facility's investigation was inconclusive, and there was a lack of documentation on staff re-education.
The facility failed to identify, investigate, and report potential abuse and neglect for four residents. Incidents included a resident being sent to an appointment improperly dressed, another not receiving care due to staff attending to other residents, a resident unable to get out of bed due to perceived lack of lift pads, and a resident not being assisted into bed as requested. The facility's policies on timely identification and reporting of such incidents were not followed.
The facility failed to notify physicians of abnormal blood glucose levels and did not assess residents for hyperglycemia and hypoglycemia, affecting multiple residents. Residents with diabetes were not monitored for treatment effectiveness, and abnormal results were not communicated to physicians. Facility policies on glucose monitoring and condition change notifications were not followed, leading to deficiencies in care and documentation.
The facility failed to administer medications as ordered, resulting in significant errors for residents with diabetes. Insulin was given contrary to physician orders, and insulin pens were not primed before administration. The DON confirmed these deficiencies.
An LPN failed to maintain infection control practices during a dressing change by not cleansing scissors between handling soiled and clean items, leading to potential cross-contamination. Despite following some aseptic practices, the oversight was confirmed by the LPN and the Director of Nursing, violating facility policies and Pennsylvania Code regulations.
Failure to Provide Required Two-Person Assistance During Transfer Resulting in Laceration
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance during a transfer, resulting in a laceration that required sutures for one resident. The resident had diagnoses including cellulitis and muscle weakness, and the MDS dated 1/11/26 documented that the resident required dependent assistance from two or more helpers for chair/bed-to-chair transfers. On 2/5/26, while being transferred from a wheelchair to bed, the resident’s left leg struck or was dragged along the edge of the bed, causing a laceration to the left lateral lower leg. An on-call physician note documented a 6 cm by 0.5 cm by 0.25 cm laceration with some earlier bleeding, and a nursing progress note later that day described a 6 cm by 0.5 cm by 0.0 cm laceration, with the resident stating that their leg was dragged on the side of the bed during the transfer. Staff documentation and interviews showed that the transfer was performed by a single CNA without another employee assisting, despite the resident’s documented need for two-person assistance for transfers. The CNA confirmed via phone statement that they transferred the resident from the wheelchair to the bed without another employee. At the time of the incident, the resident’s care plan did not yet include the requirement for two-person assistance with all transfers; this intervention was not initiated in the care plan until the day after the incident. During an interview, the Nursing Home Administrator and the DON confirmed that the facility failed to provide adequate supervision to prevent the injury that resulted in the laceration requiring sutures.
Failure to Maintain Effective Pest Control in Main Kitchen
Penalty
Summary
Surveyors observed multiple instances of cockroach activity and pest evidence in the Main Kitchen, including one live cockroach on the wall of the food service hallway, two dead cockroaches in the food service staff restroom, four live cockroaches under the range in the food service preparation area, and food waste debris and dead cockroaches behind food service counters. Additionally, cockroach waste was noted on the wall in the food cart storage area. During staff interviews, the Food Service Director confirmed an ongoing pest control issue in the main kitchen, and the DON acknowledged the facility's failure to maintain an effective pest control program in this area.
Failure to Ensure Availability of Prescribed Medications
Penalty
Summary
The facility failed to implement procedures to ensure availability of prescribed medications for three residents. Resident R5 was admitted with diagnoses including diabetes and atrial fibrillation, and had physician orders for gabapentin, omeprazole, lisinopril/hydrochlorothiazide, duloxetine, apixaban, and carvedilol. The MAR showed multiple doses documented with code 9, and the associated notes stated the medications were pending delivery, pending pharmacy delivery, or that the CRNP was aware and awaiting delivery from RX for the new admission. The facility’s automated medication dispensing machine inventory included those medications. Resident R66 was admitted with diagnoses of high blood pressure and diabetes and had an order for insulin aspart 12 units four times daily. The MAR documented the 9:00 p.m. dose as code 9, and the progress note stated the medication was pending delivery. Resident R102 was admitted with diagnoses of atrial fibrillation and anxiety disorder and had orders for buspirone twice daily and apixaban twice daily. The MAR documented the hour of sleep doses with codes 5 and 5, and the progress notes stated the medications were awaiting delivery, with the CRNP aware. The facility’s automated medication dispensing machine inventory included insulin aspart, apixaban, and buspirone. During interview, the NHA and DON confirmed the facility failed to implement procedures to ensure availability of prescribed medications for these three residents.
Failure to Notify Physician of Abnormal Blood Glucose Results
Penalty
Summary
The facility failed to assess, document, and notify the physician of abnormal capillary blood glucose (CBG) results for one resident with diabetes, atherosclerotic heart disease, and hyperlipidemia. The resident had a physician order for Apidra SoloStar before meals, with instructions to notify the physician if the CBG was greater than 340. Review of the clinical record showed CBG readings of 342, 353, 384, and 406 on separate dates, and no recheck was documented for any of those readings. Review of the eMAR and clinical progress notes showed the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of the abnormal results on the listed dates. During interview, the DON confirmed the facility failed to notify the doctor of a change in condition and failed to document an assessment or interventions related to the abnormal blood glucose levels for the resident.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that trauma-informed care was provided to eliminate or mitigate triggers for a resident with PTSD. Review of the facility policy indicated that each resident should be screened for a history of trauma upon admission and, if trauma was identified, triggers should be discussed and identified during the assessment process. Resident R37 was admitted to the facility and had diagnoses including diabetes, anxiety, and PTSD; the facility diagnosis list showed PTSD was added on 7/25/25. The resident’s care plan for PTSD was not initiated until 11/25/25 and included only one intervention: encourage slow/deep breathing exercises and reassuring conversation with pleasant topics. During interview, the NHA and DON confirmed that the facility failed to ensure trauma-informed care was provided to eliminate or mitigate triggers for the resident with PTSD.
Significant Medication Errors With Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Resident R66 was admitted to the facility with diagnoses of type 2 diabetes and encephalopathy. A physician order dated 10/31/25 directed that the resident receive 12 units of insulin aspart subcutaneously four times a day for blood sugars less than 140. The facility’s medication audit report for 11/1/25 through 11/30/25 showed multiple administrations of insulin aspart when the resident’s blood sugar was below the ordered parameter, including readings of 110, 70, 125, 139, 110, 138, 138, 127, and 90 at the times the doses were given. Facility policy stated that medications are administered only as prescribed by the provider. During interviews on 12/3/25, the DON confirmed that the insulin aspart orders were administered outside the parameters set in the physician order, and the NHA confirmed that the facility failed to ensure that residents were free from significant medication errors for one of five residents.
Failure to Provide Written Bed-Hold Notice at Transfer
Penalty
Summary
The facility failed to ensure that the resident and/or the resident representative received written notice of the facility bed-hold policy at the time of transfer for hospitalization for two of four residents reviewed. Federal regulation S483.15(d) requires written information about bed-hold policies to be provided prior to and upon transfer, including the duration of any bed-hold and reserve bed payment policy, and the facility’s policy dated 4/17/25 stated that written notice would be provided before transfer and at the time of transfer for hospitalization or therapeutic leave. For Resident R1, the clinical record showed multiple hospital transfers after progress notes dated 7/18/25, 8/21/25, and 9/23/25 ordered the resident to be sent to the hospital. R1’s MDS dated 11/29/25 listed dementia and metabolic encephalopathy, and Section C indicated severe cognitive impairment. The record did not show documentation that written bed-hold notice was provided to the resident or representative for these transfers. For Resident R4, the clinical record showed a hospital transfer after a progress note dated 10/6/25 ordered the resident to be sent to the hospital. R4’s MDS listed diabetes and high blood pressure, and Section C indicated severe cognitive impairment. The record also did not show documentation that written bed-hold notice was provided to the resident or representative upon transfer. During interview, the NHA and DON confirmed the facility failed to ensure the written bed-hold notice was provided for these residents.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
A resident with a history of hemiplegia, diabetes, and previous falls was admitted and readmitted to the facility, requiring total assistance from two staff members and a mechanical lift for transfers and for moving from lying to sitting. The resident's care plan and Kardex both specified the need for two or more helpers for all transfers. Despite these documented requirements, a CNA attempted to transfer the resident alone by sitting her at the edge of the bed while waiting for help. The force of this action caused the resident to slide forward, resulting in her falling to the floor and sustaining a left humerus fracture. The CNA involved had recently been hired and had completed competencies related to safe transfers and following care plans. However, the CNA did not adhere to the resident's care plan or the facility's documented transfer protocols, which directly led to the resident's fall and subsequent injury. The incident was documented in the facility's progress notes, incident report, and an x-ray confirmed the fracture. Interviews with staff and review of records confirmed that the resident's care plan and transfer requirements were clearly documented and accessible to staff through the Kardex. The failure to follow these established protocols resulted in actual harm to the resident, as evidenced by the fracture. The deficiency was identified as neglect, defined by the facility as the failure to provide necessary goods and services to avoid physical harm, pain, or emotional distress.
Failure to Provide Adequate Supervision During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with hemiplegia, diabetes, and a history of falls, who was dependent on staff for bed-to-chair transfers and required the assistance of two staff members for transfers, was not provided adequate supervision during a transfer. The resident's care plan and facility policy specified that two staff members were required for all transfers and for moving the resident from lying to sitting on the side of the bed. Despite this, a CNA attempted to transfer the resident alone, resulting in the resident sliding out of bed and sustaining a left humerus fracture. The CNA involved had received training and demonstrated competencies in safe transfer methods and was aware of the resident's care requirements. The incident report and the CNA's written statement confirmed that the CNA sat the resident at the edge of the bed while waiting for help, but the resident slid forward and fell, injuring her shoulder. The facility's policies emphasized minimizing safety hazards and ensuring safe handling and transfers, but these were not followed in this instance. Interviews with multiple CNAs, LPNs, and RNs confirmed that staff were trained to use the Kardex and care plans to guide safe care and that education on safe transfers was provided. However, the failure to follow the resident's care plan and facility policy directly led to the resident's fall and injury. The deficiency was identified as past noncompliance, and facility leadership acknowledged the failure to provide adequate supervision to prevent the accident.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to ensure that residents were free from abuse, neglect, or misappropriation of property, as evidenced by incidents involving two residents. One resident, identified as R190, was reportedly not provided care by a nurse aide during a specific shift, as stated by the resident's roommate. The facility's documentation did not show any care provided to this resident until late in the evening, despite the resident being in isolation due to a positive COVID-19 diagnosis and having multiple medical conditions, including encephalopathy and dementia. The facility's investigation could not confirm whether neglect occurred, and there was a lack of documentation indicating that the involved staff member received re-education on abuse prevention. Another incident involved a resident, identified as R400, who reported discomfort caused by an LPN while administering medication. The resident stated that the LPN stretched her hand painfully while checking for a pill. The LPN's account differed, indicating that she found a pill in the resident's hand and placed it in the resident's mouth. The resident had a history of serious medical conditions, including diabetes and kidney failure, and was found unresponsive in her apartment prior to admission. The Director of Nursing confirmed the facility's failure to protect these residents from abuse and neglect.
Failure to Identify and Report Potential Abuse and Neglect
Penalty
Summary
The facility failed to identify, investigate, and report potential abuse and neglect for four residents. One resident was sent to an appointment not appropriately dressed, which was identified as a failure to freshen up the resident before leaving. Another resident's daughter reported that her parent was not provided care on a specific date, and it was found that the assigned nurse aide was attending to another resident, with care being provided by a different aide. A third resident reported that staff would not assist him out of bed due to a lack of lift pads, although the facility had sufficient supplies. This resident also reported poor customer service, but the facility did not specify the nature of the service issues. The fourth resident requested assistance to be put into bed, but the assigned nurse aide went on break, and another nurse eventually assisted the resident. This resident required a two-person transfer with a hoyer lift, as indicated in his care plan. The Director of Nursing confirmed the facility's failure to properly address these incidents, which were not adequately identified, investigated, or reported as potential abuse or neglect. The facility's policies on abuse, neglect, and misappropriation emphasize the importance of timely identification and reporting of incidents that could place residents at risk, which was not adhered to in these cases.
Failure to Monitor and Report Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, affecting three of six residents reviewed. Specifically, residents with diabetes were not monitored for the effectiveness of their treatment, and abnormal CBG results were not communicated to their physicians. This lack of communication and assessment was evident in the cases of residents who had documented low blood glucose levels, yet no follow-up actions were taken as per the care plan or physician's orders. The facility's policies on blood glucose monitoring and notification of changes in condition were not adhered to, as evidenced by the failure to document and report significant changes in residents' conditions. For instance, residents with CBG levels below 70 mg/dL were not assessed for hypoglycemia, and their physicians were not notified of these critical results. Additionally, the facility did not document the interventions taken to address these abnormal findings, which is a requirement under their clinical documentation standards. Interviews with nursing staff revealed inconsistencies in the handling of abnormal blood glucose levels, with some staff indicating they would notify a physician for levels below 70 mg/dL, while others did not follow through with this protocol. The Director of Nursing confirmed these deficiencies, acknowledging the facility's failure to document hypo-/hyperglycemic episodes, follow physician orders, and notify medical providers of changes in residents' conditions. This lack of adherence to established protocols and documentation standards contributed to the deficiencies identified in the report.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for several residents, leading to significant medication errors. Resident R52, who has diabetes and chronic kidney disease, received insulin on multiple occasions despite physician orders to hold the medication if blood sugar levels were below 120. Similarly, Resident R69, diagnosed with diabetes and dementia, did not have a documented blood sugar result on a specific date, and insulin was not administered as ordered. The Director of Nursing confirmed these findings, indicating a failure in adhering to physician orders for these residents. Additionally, the facility did not ensure that insulin pens were primed before administration, as observed in the cases of Residents R301 and R24. Resident R301, with a history of diabetes and muscle weakness, received insulin without the pen being primed, as did Resident R24, who has diabetes and high blood pressure. Both LPNs involved in these incidents confirmed the failure to prime the insulin pens before administration. The Director of Nursing acknowledged that the facility did not administer the correct dose of insulin due to this oversight.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to maintain proper infection control practices during a dressing change, as observed during a survey. The Licensed Practical Nurse (LPN) involved did not cleanse the scissors used between handling soiled and clean items, which could lead to cross-contamination. The dressing change procedure involved multiple steps where the same uncleaned scissors were used to cut tape, dressings, and gauze for wounds on both legs and the sacral area of a resident. Despite using alcohol-based hand sanitizer and changing gloves between tasks, the failure to clean the scissors was a significant oversight. The facility's policies on skin care, wound management, and infection control were reviewed, indicating that residents should reside in a safe environment with reduced infection risks. However, during the dressing change, the LPN did not adhere to these policies, as confirmed in interviews with the LPN and the Director of Nursing. The Director of Nursing acknowledged the failure to prevent cross-contamination, which is a violation of several Pennsylvania Code regulations related to staff development, licensee responsibility, management, and resident care policies.
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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) |
|---|---|---|---|---|
| Whitehall Borough Post Acute | 2 mi | ★★★★★ | 8 | 1 |
| Southwestern Nursing And Rehabilitation Center | 2.9 mi | ★★★★★ | 0 | 0 |
| John J Kane Regional Center-gl | 3.4 mi | ★★★★★ | 5 | 0 |
| Rehabilitation Center At Jefferson Hills, The | 3.5 mi | ★★★★★ | 11 | 0 |
| Eldercrest Rehabilitation & Healthcare Center | 3.5 mi | ★★★★★ | 10 | 0 |
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