Pennwood Nursing COVID Protocol Failures Pittsburgh PA
PITTSBURGH, PA - State health inspectors documented serious infection control failures at Burgh Care Center on West Street, including inadequate COVID-19 outbreak management, improper wound care procedures that risked cross-contamination, and the absence of a qualified infection prevention specialist for nearly three months.
Infection Control Failures During Active COVID-19 Outbreak
During the April 2025 inspection, surveyors discovered that Burgh Care Center failed to implement proper COVID-19 monitoring and testing protocols despite having an active outbreak that began in January 2025. The facility's infection preventionist admitted to inspectors, "I am still just learning what to do," having started the role in January 2025 without certification until March 27, 2025.
The facility demonstrated multiple failures in outbreak management. When asked about testing protocols during a COVID outbreak, the infection preventionist could not provide specific testing schedules and incorrectly stated the outbreak period lasted 21 days, when CDC guidelines specify 14 days from the last positive case. The facility failed to maintain required line listings tracking ill residents and staff, a fundamental tool for outbreak management that helps identify transmission patterns and monitor recovery.
Most concerning was the observation of a symptomatic staff member who continued working while ill. A licensed practical nurse was observed coughing during the inspection and stated, "I was up all night coughing, all my joints are aching." The nurse reported informing both human resources and the Director of Nursing about the symptoms but was not instructed to test for COVID-19. This represents a critical breakdown in infection control protocols during an active outbreak.
The facility's COVID-19 testing approach lacked consistency and adherence to national standards. The Director of Nursing could not specify testing days, stating only that testing occurred "twice a week" without a structured schedule. Federal guidelines require systematic testing of all residents and staff during outbreaks, typically every 3-7 days, to quickly identify and isolate new cases.
Cross-Contamination Risks During Wound Care
Inspectors observed alarming infection control breaches during routine wound care that created multiple opportunities for spreading infections between residents. During a dressing change for one resident, a licensed practical nurse placed a garbage bag directly on the resident's bedside table and used a yellow disposable gown as a makeshift clean field by laying it on the dresser.
The nurse removed the soiled wound dressing, disposed of it along with her protective equipment, then washed her hands and put on new gloves but failed to wear any other protective equipment while cleaning the wound. This practice violates fundamental wound care protocols that require maintaining full barrier protection throughout the entire procedure to prevent contamination of the wound site and surrounding environment.
After completing the dressing change, the nurse left the room without cleaning either the bedside table or dresser that had been contaminated during the procedure. These surfaces could harbor infectious organisms that might be transmitted to the resident or others who contact these surfaces. Proper protocol requires thorough disinfection of all surfaces used during wound care procedures.
Medication Administration Contamination Incidents
The inspection revealed concerning practices during medication administration that could facilitate disease transmission between residents. One nurse was observed using a washcloth soaked in hand sanitizer for hand hygiene between residents, keeping the contaminated cloth in the medication cart's side compartment. After handling medications with bare hands and administering eye drops, the nurse reused the same washcloth and returned it to the cart, potentially spreading pathogens to subsequent residents.
Another nurse was observed dropping a medication bottle cap on the floor, picking it up, and placing it back on the bottle without performing hand hygiene before continuing the medication pass. The floor in healthcare facilities harbors numerous pathogens including antibiotic-resistant bacteria. Returning a contaminated cap to a medication bottle creates risk for all residents who receive that medication.
These practices violate CDC guidelines requiring hand hygiene with soap and water or alcohol-based sanitizer between each resident contact. Reusable cloths for hand hygiene and contaminated medication supplies create vectors for transmitting infections throughout the facility.
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: September 22, 2026 · Our methodology
BURGH CARE CENTER in PITTSBURGH, PA was cited for violations during a health inspection on April 5, 2025.
The facility demonstrated multiple failures in outbreak management.
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.