Rehab & Nursing Ctr Greater Pittsburgh: Fall Causes Brain Bleed - PA
The resident, identified in inspection records as Resident R1, was found on the floor next to her bed on May 2, 2026, at approximately 3:30 p.m. A laceration had opened on the left side of her forehead. A hematoma had formed at the center. She was on blood thinners. The LPN on duty described "a good bit of blood."
She was transferred to the hospital and admitted with a subarachnoid hemorrhage, a bleed around the brain, and a facial laceration.
Her care plan, recorded in her Kardex dated May 3, required a two-person assist for bed mobility. The aide was alone.
During a phone interview with inspectors on May 28, the nurse aide, identified as Employee E1, described what happened. He had entered the room to conduct rounds and raised the bed to waist height. As he went to roll the resident, he said he didn't realize how far she was toward the side of the bed. He had his hand on her, but as he moved toward the corner of the bed, she rolled the opposite direction and started falling head first. Her head struck the foot of the bed. Once she came off the bed frame, he saw blood coming from her head.
He confirmed to inspectors that he had failed to use the correct level of assistance for her bed mobility, and that he had rolled her away from himself rather than toward him.
The LPN confirmed both things: that staff are trained to always roll residents toward themselves to prevent falls, and that the resident was on blood thinners at the time.
The resident's most recent MDS assessment, completed April 15, had documented her as a partial to moderate assist for rolling left to right. She weighed 143 pounds. She was noted to have baseline confusion.
An interdisciplinary team meeting held May 4, two days after the fall, reviewed the incident, updated her interventions, and revised her care plan. The nursing progress note documenting that meeting was dated May 5.
The hospital's after-visit summary, dated May 8, confirmed the subarachnoid hemorrhage and facial laceration. Physicians instructed that her Eliquis, a blood thinner she had been taking at 2.5 milligrams, be paused until a doctor cleared her to restart it.
When inspectors visited on May 28, they observed the resident lying in bed with a scabbed area on the left side of her head.
The facility's response to the fall was narrow. Only Employee E1 received re-education on proper bed mobility technique. The Director of Therapy, interviewed at 10:34 a.m. on May 28, confirmed that the resident had required a moderate assist of two persons at the time of the fall, and that therapy staff are considered direct care staff. She also confirmed that no one in the therapy department had received any education since the incident. Other nursing staff told inspectors they knew the rule — always roll toward yourself — but the retraining stopped at the one aide who had been present.
The Nursing Home Administrator, interviewed at 12:03 p.m. on May 28, confirmed the finding: the facility had failed to ensure the resident received adequate supervision and assistance for bed mobility, and the result was an actual brain bleed.
The inspection was conducted as a complaint investigation. The violation was cited at the level of actual harm affecting a small number of residents.
On May 28, twenty-six days after she fell, Resident R1 was still in her bed at the facility, the scab on the side of her head visible to inspectors who came to ask what had gone wrong.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rehab & Nursing Ctr Greater Pittsburgh from 2026-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 11, 2026 · Our methodology
REHAB & NURSING CTR GREATER PITTSBURGH in GREENSBURG, PA was cited for violations during a health inspection on May 28, 2026.
The resident, identified in inspection records as Resident R1, was found on the floor next to her bed on May 2, 2026, at approximately 3:30 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.