Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Townview Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with MS, chronic pain, depression, and anxiety, who was alert, oriented, and fully dependent on staff for ADLs including eating, experienced choking and subsequent aspiration pneumonia while being assisted with a meal. Facility policies and the resident’s care plan required upright positioning, small bites and sips, and monitoring for aspiration during feeding. During the meal, the resident began coughing, felt food was stuck, and had difficulty breathing, later requiring diagnostic testing and treatment for pneumonia and then aspiration pneumonia. The resident reported being fed with the head of the bed too flat, while the CNA who provided the feeding stated the resident was nearly upright and attributed the event to talking while eating, and also admitted not knowing where to find the resident’s specific feeding care needs, unlike other CNAs who could locate this information in the ECS.
A resident with MS, chronic pain, depression, and anxiety, who was alert and oriented, experienced choking and vomiting, after which a physician was notified and a chest X-ray was ordered. Nursing notes later documented minimal right base atelectasis and an order for Augmentin PO BID for 7 days for pneumonia. Facility policy required that changes in condition be charted and that family communication be documented, but the clinical record contained no documentation that the resident’s family was notified of this change in condition. The resident reported that their son was not informed, and the Nursing Home Administrator confirmed that the family was not notified, resulting in a violation of state regulations regarding management, resident rights, resident care policies, and nursing services.
The facility failed to follow its abuse/neglect reporting policy after a dependent, cognitively intact resident with MS and other chronic conditions experienced a choking episode during a meal while being fed by a CNA. Nursing notes documented coughing, difficulty breathing, choking, and vomiting food, followed by diagnostic testing and treatment for pneumonia, and the resident later reported that her head was too flat during feeding and that she informed staff she could not continue. Although the resident stated Administration interviewed her about the event, the DON confirmed no investigation documentation was completed, the incident did not appear on the incident/accident log, and no report of possible neglect was submitted to the State Survey Agency, despite the Medical Director’s statement that the incident should have been reported per facility policy.
A resident with MS, chronic pain, depression, and anxiety, who was alert, oriented, and dependent on staff for all ADLs including eating, experienced a choking episode during a meal while being fed by a CNA, with documented coughing, difficulty breathing, vomiting food, and subsequent pneumonia treated with Augmentin. The resident reported their head was too flat during feeding and that they told staff they could not do it. Although administration was reportedly aware and interviewed the resident, the DON acknowledged that no incident report or investigation documentation was completed, the choking event was not entered on the Incident and Accident Log, and the Medical Director and NHA confirmed the incident should have been investigated as possible neglect per facility policy.
The facility failed to provide thirteen residents the opportunity to formulate an advance directive, as required by their policy. This deficiency was identified through a review of clinical records and confirmed by staff interviews, revealing a lack of documentation for residents with various medical conditions, including diabetes, dementia, and heart disease.
The facility failed to notify physicians and assess two residents for abnormal blood glucose levels. One resident with Parkinson's disease had a low CBG of 43, and another with diabetes had multiple high CBG readings over 400. Staff did not follow care plan interventions or notify physicians, as confirmed by the DON.
A resident with significant mobility impairments fell from bed due to inadequate supervision, as a CNA failed to follow physician orders requiring two-person assistance for bed mobility. The resident was left unattended during care, leading to a fall and subsequent hospital evaluation.
The facility failed to notify the State Ombudsman Office of resident transfers and discharges for a year, as required by regulations. This deficiency was identified through a review of facility documents and information from the State Ombudsman Office, which indicated non-compliance since October 2021. The Nursing Home Administrator confirmed the failure to report these events.
Failure to Follow Assisted-Feeding Care Needs Resulting in Aspiration Pneumonia
Penalty
Summary
The facility failed to prevent an accident and ensure safe supervision during feeding for a resident who was dependent on staff for all ADLs, including eating. Facility policies on Fall and Accident Prevention and Restorative Nursing-Eating/Swallowing required a safe environment free from hazards and specified that residents needing assistance with eating should be kept upright, observed for aspiration, and given small bites and sips. The resident’s MDS documented multiple sclerosis, chronic pain, depression, and anxiety, with the resident being alert, oriented, and fully dependent on staff for ADLs. The resident’s care plan and ECS documentation specified dependence on staff for eating and the need for upright positioning and monitoring for aspiration. On the identified dinner meal, the resident began coughing, felt food was stuck, and had difficulty breathing while being fed by a CNA. Nursing notes documented choking and vomiting of food, followed by physician notification and diagnostic testing that led to treatment for pneumonia and then aspiration pneumonia, including antibiotics, respiratory treatments, and oxygen as needed. During an interview, the resident reported that at the time of the choking event the head of the bed was too flat compared to the current 45-degree elevation, and expressed distress about the incident. In a separate interview, the CNA who fed the resident stated the resident had been positioned “damn near 90 degrees,” attributed the coughing to talking while eating, and admitted not knowing where to find the resident’s specific care needs for eating, only knowing the resident as a “feed.” Other CNAs interviewed were able to locate and describe the resident’s eating-related care needs in the ECS. The Nursing Home Administrator confirmed the facility failed to prevent an accident that resulted in actual harm of aspiration pneumonia for this resident.
Failure to Notify Family of Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family of a significant change in condition as required by facility policy and state regulations. Facility policy and nursing documentation dated 3/26/25 state that changes in a resident’s condition must be charted and that communication with family should be documented. The clinical record shows that a resident with multiple sclerosis, chronic pain, depression, and anxiety, who was alert, oriented, and able to understand and be understood, was admitted on an unspecified date and had an MDS dated 5/2/25. A nurse progress note dated 1/11/26 documented that the resident experienced choking and vomiting of food, was assessed, the physician was notified, and a chest X-ray was ordered. A subsequent nurse progress note dated 1/12/26 documented that the X-ray showed minimal right base atelectasis and that Augmentin 875/125 mg PO BID for 7 days was ordered for pneumonia. During an interview on 1/18/26, the resident stated that their son was not notified and that they had pneumonia for a week. Review of the progress notes did not show any documentation that the resident’s family was notified of this change in condition. In a later interview on 2/18/26, the Nursing Home Administrator confirmed that the facility failed to notify the family of the resident’s change in condition, resulting in noncompliance with 28 Pa. Code 201.18(b)(1), 201.29(d), 211.10(c)(d), and 211.12(d)(1)(2)(3)(5).
Failure to Report and Investigate Possible Neglect After Choking Incident
Penalty
Summary
The facility failed to implement its abuse/neglect reporting policies by not reporting and investigating a possible neglect incident involving one resident. Facility policy dated 3/26/25 required that alleged violations involving abuse/neglect be reported immediately to the Administrator and that results of all investigations be reported to the Administrator and the PA Department of Health within five working days. The resident involved had multiple diagnoses including MS, chronic pain, depression, and anxiety, was alert and oriented, able to understand and be understood, and was dependent on staff for all ADLs, including eating. On the date of the incident, nursing progress notes documented that during dinner the resident began coughing, felt like food was stuck, had difficulty breathing, and was choking and vomiting food. The resident was assessed, the physician was notified, a chest X-ray was ordered, and the following day the X-ray showed minimal right base atelectasis, with Augmentin ordered for pneumonia. During a later interview, the resident reported that a CNA had been feeding her, that her head was too flat while eating, that she said she could not do it, and that she subsequently developed pneumonia. The resident stated that Administration was aware of the incident and had interviewed her the following day. However, the DON acknowledged that no investigation documentation was completed, and the January incident and accident log did not include the choking incident. Documentation submitted by the facility to the State Survey Agency did not include any report of possible neglect related to this event. The Medical Director stated that the choking incident should have been reported per facility policy, and the Nursing Home Administrator confirmed that the facility failed to implement its policies and procedures to report possible neglect for this resident.
Failure to Investigate Choking Incident as Possible Neglect
Penalty
Summary
The facility failed to follow its Abuse Prevention Policy requiring prompt and thorough investigation of all alleged violations involving abuse or neglect after a resident experienced a choking incident. The resident, who had multiple sclerosis, chronic pain, depression, and anxiety, was alert, oriented, able to understand and be understood, and was dependent on staff for all ADLs, including eating. The facility’s electronic charting system identified the resident as dependent on staff for meals. Nurse progress notes documented that during a dinner meal the resident began coughing, felt like food was stuck, had difficulty breathing, and was choking and vomiting food. The resident was assessed, the physician was notified, a chest X-ray was ordered, and the subsequent nurse note documented minimal right base atelectasis and an order for Augmentin for pneumonia. During a later interview, the resident reported that a CNA had been feeding the meal, that their head was too flat while being fed, that they said they could not do it, and that they subsequently developed pneumonia. The resident stated administration was aware of the incident and interviewed them the following day and was tearful about the event. When surveyors requested investigation documents and an incident report for the choking event, the DON stated no documentation had been completed. The facility’s Incident and Accident Log for the relevant month did not list the choking incident. The Medical Director stated the choking incident should have been investigated per facility policy, and the Nursing Home Administrator confirmed the facility failed to implement its policies and procedures to investigate this incident of possible neglect.
Failure to Provide Advance Directive Opportunities
Penalty
Summary
The facility failed to provide the opportunity for residents to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care, for thirteen out of eighteen residents reviewed. This deficiency was identified through a review of the facility's policy on advance directives, clinical records, and staff interviews. The facility's policy, last reviewed on March 27, 2024, mandates compliance with maintaining written policies and procedures regarding advance directives, including informing and providing written information to all adult residents about their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. The clinical records of several residents, including those with serious medical conditions such as diabetes, dementia, chronic obstructive pulmonary disease, and Alzheimer's, were reviewed. These records failed to show any documentation that the residents were given the opportunity to formulate an advance directive upon admission or readmission to the facility. The absence of such documentation was confirmed during an interview with the Social Worker and the Assistant Director of Nursing (ADON), who acknowledged that the clinical records did not include evidence that the residents were afforded this opportunity. The deficiency was noted for residents with a range of medical diagnoses, including diabetes, dementia, chronic kidney disease, and heart conditions, among others. The lack of documentation and opportunity for these residents to formulate advance directives indicates a failure to adhere to the facility's policy and regulatory requirements. This oversight was identified as a violation of specific Pennsylvania Code regulations related to clinical records and nursing services.
Failure to Notify Physicians and Assess 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 two residents. Resident R27, who was readmitted with diagnoses including Parkinson's disease, depression, and high blood pressure, had a CBG level of 43 on a specific date. Despite having a care plan that included observing for hypo/hyperglycemia and notifying the physician if symptoms occurred, the staff did not assess the resident for hypoglycemia, monitor the effectiveness of treatment, or notify the physician of the abnormal result. Resident R46, admitted with diagnoses including diabetes, depression, and anxiety, had multiple instances of CBG levels exceeding 400, with one instance as high as 524. The care plan for this resident included performing Accuchecks as ordered and observing for signs of hypo/hyperglycemia. However, the staff failed to assess the resident for hyper-/hypoglycemia, did not follow the care plan interventions, did not recheck blood sugar levels, and did not notify the physician of the abnormal results. Interviews with various nursing staff, including RNs and LPNs, revealed inconsistencies in following the facility's protocols for managing abnormal blood glucose levels. Staff members described different actions they would take in response to low or high blood glucose readings, but the documentation and actions taken did not align with these descriptions. The Director of Nursing confirmed the facility's failure to notify the doctor of changes in condition and to document assessments or interventions related to blood glucose for the affected residents.
Failure to Provide Adequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for Resident R51, who required extensive assistance for bed mobility due to conditions such as morbid obesity, neuromyelitis optica, and paraplegia. The resident's care plan and physician orders specified the need for assistance from two staff members for mobility tasks. However, on the day of the incident, CNA Employee E9 attempted to provide care alone, contrary to the established care plan and physician orders. During the incident, CNA Employee E9 positioned Resident R51 on her side and left the bedside to retrieve additional supplies, leaving the resident unattended. While unattended, Resident R51 attempted to stabilize herself by holding onto the bed's siderail, which resulted in her legs sliding off the bed and her falling to the floor. The fall led to complaints of pain in the resident's head and left shoulder, and she was subsequently sent to the hospital for evaluation. The facility's investigation revealed that CNA Employee E9 did not adhere to the physician's orders requiring two-person assistance for bed mobility. This breach of protocol was acknowledged by the facility, and the CNA received a written warning for not following professional standards. Interviews with other staff members confirmed that the facility's policy for ADL care and resident mobility was communicated at the start of each shift, indicating a failure in individual compliance rather than a systemic issue.
Failure to Notify State Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Ombudsman Office of resident transfers and discharges for the period from October 2023 through October 2024, as required by regulations. This deficiency was identified through a review of facility documents, information from the State Ombudsman Office, and staff interviews. The facility was unable to provide documented evidence of compliance with the notification requirement during this time frame. Additionally, information from the State Ombudsman Office indicated that the facility had not been notifying them of transfers and discharges since October 2021. The Nursing Home Administrator confirmed the failure to report these events for the specified year.
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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 Canonsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenery Center For Rehab And Nursing | 0.8 mi | ★★★★★ | 45 | 1 |
| Wecare At South Hills Rehabilitation And Nrsg Ctr | 2 mi | — | 42 | 3 |
| Kadima Rehabilitation & Nursing At North Strabane | 2.5 mi | ★★★★★ | 3 | 0 |
| Mcmurray Hills Rehabilitation And Healthcare Cente | 3.3 mi | ★★★★★ | 3 | 0 |
| Peters Township Post Acute | 3.5 mi | ★★★★★ | 11 | 0 |
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