Bridgeville Rehabilitation & Care Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

cover up with and she throw it at me and was still cussing. I left out the room and went and let the nurse know what was going on.Review of a facility submitted Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated [DATE REDACTED], indicated that the facility investigation substantiated

the abuse investigation.During an interview on [DATE REDACTED], at 6:53 p.m. Resident Resident R9 stated that NA Employee E1 left her unclothed after Resident Resident R9 had asked her for a cover. Resident Resident R9 stated that she did not lay naked, and NA Employee E1 told her she had to wait. She kept yelling at me, telling me, you are the one with the attitude. You are the one being a bitch because you are mad the nurse wasn't here yet. You are the one that's miserable. You can't tell me what, I'll tell you what to do. Resident Resident R9 stated she responded by saying, Maybe we will just not talk, to which Resident Resident R0 stated NA Employee E1 responded, No, I'll talk and you listen. Resident Resident R9 stated she has never been treated like that before while residing at the facility.

Resident Resident R9 stated, I was so upset, I have not cried that hard since my husband died.During an interview

on [DATE REDACTED], at approximately 7:15 p.m. the Nursing Home Administrator confirmed that the facility failed to protect residents from staff-initiated abuse. This failure resulted in a staff member physically abusing a resident and multiple staff neglecting care of one of four residents.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 201.20(a)(b) Staff development.28 Pa. Code 201.29(a)(c)(d) Resident rights.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bridgeville Rehabilitation & Care Center

3590 Washington Pike Bridgeville, PA 15017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Based on review of resident and staff interviews, Resident Council minutes review, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of eight of eleven residents (Residents Resident R1, Resident R2, Resident R3, Resident R4, Resident R5, Resident R6, Resident R7, and Resident R8).Findings include:During an interview on 11/5/25, at 5:00 p.m. when asked if he felt the facility maintained enough staff to care for resident needs, Resident Resident R1 stated, No. Resident Resident R1 stated that call light response usually takes a long time. Resident Resident R1 further stated that he receives late medications and is not assisted in and out of bed timely.During an interview on 11/5/25, at 5:03 p.m. when asked if she felt the facility maintained enough staff to care for resident needs, Resident Resident R2 stated, There could be more. During an interview on 11/5/25, at 5:09 p.m. when asked if he felt

the facility maintained enough staff to care for resident needs, Resident Resident R3 stated, At times not. During an

observation on 11/5/25, at 6:18 p.m., Resident Resident R4 and Resident Resident R5's room smelled overpoweringly of urine.Review of Resident Resident R4's toileting record indicated Resident Resident R4 was incontinent of urine, and incontinence care was documented on 11/5/25, at 2:25 p.m. and not documented as completed again until 11/6/25, at 12:32 a.m. During an interview on 11/5/25, at 2:56 p.m., Resident Resident R6, when asked if she felt the facility maintained sufficient staff to care for resident needs, stated, At times I be sitting in piss for two to three hours. People don't want to help. I had to call my family at 2:00 a.m. to have them call (the nurses).

When I call the nurse's station, they hang up on me. Resident Resident R6 stated that he waited from 3:00 a.m. until 11:00 a.m. before receiving assistance. Resident Resident R6 stated he has been told, You aren't the only one here and stated, You are lucky to see them one time a shift. Observation at this time revealed large amounts of a brown substance under Resident Resident R6's fingernails and for Resident Resident R6 to be malodorous. During an

interview on 11/5/25, at 6:35 p.m., Resident Resident R7, when asked if she felt the facility maintained sufficient staff to care for resident needs, stated, No, all I hear is complaints that they only have three aides, and I have to wait. One time the night shift aide found out she had the whole floor and told me I will have to wait. Resident Resident R7 stated she has waited up to three hours for assistance after activating her call light. Resident Resident R7 stated that she was told on Monday (11/3/25) that she could not have a shower due to insufficient staffing, and that she would get it on Tuesday, But I didn't end up getting a shower at all. I'm completely dependent on aides. I've laid as much as 12 hours in my own body fluids. Sunday is the worst.Review of Resident Resident R7's shower record revealed that on her scheduled shower day of Monday, 11/3/25, or Tuesday 11/4/25, she did not receive a shower. No shower refusals were documented. Review of Resident Council meeting minutes for 8/22/25, included concerns about staff not assisting to change soiled sheets. Review of Resident Council meeting minutes for 9/24/25, included concerns about from two residents about not getting showers when scheduled. Review of a grievance filed on behalf of Resident Resident R8, dated 8/20/25, revealed concerns that Resident Resident R8 was still in bed at 11:30 a.m. and had not been provided bathing assistance.

During an interview on 11/5/25, at approximately 7:15 p.m. the Nursing Home Administrator and confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of eight of eleven residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(6) Management.28 Pa. Code: 201.20(a) Staff development.28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

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