Bridgeville Rehabilitation & Care Center
BRIDGEVILLE REHABILITATION & CARE CENTER in BRIDGEVILLE, PA — inspection on December 26, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of a statement written by RN Employee E4
cart with RN Employee E5. 27 of 27 narcotic cards.
Approximately 4:45 a.m.
Resident R1 requested a pain pill oxycodone, and none were signed out on the computer. I looked for the controlled substance tracking sheet and card, there were none. I flipped to the shift change inventory count signoff sheet from the prior day and it was missing.
Review of a statement written by Licensed Practical Nurse (LPN) Employee E6 dated 11/9/25. RN Employee E4 asked her opinion with Resident R1 wanting a pain pill however she doesn't have a medication card or paper for the requested narcotic.
The resident states she has been getting pain medication, but it hadn't been documented in the computer as given.
LPN Employee E6 and RN Employee E4 reviewed the controlled substance tracking book and RN Employee E4 stated the original tracking sheet had been removed and a new one placed (as the new document didn't have RN Employee E4's documentation of 11/8/25 acknowledgement of the Oxycodone card (receipt), the card identification number, and a count of 29/29 narcotic cards documented. LPN Employee E6 found the missing narcotic count signoff sheet that contained the acknowledgement of the Oxycodone card (receipt) and the card identification number documented by RN Employee E4 folded in half, in the recycle bin, it was unsigned by RN Employee E5 during that shift change (shift change count sheets note nurse coming on shift must verify count of all controlled substances with nurse going off shift and anytime the medication cart keys are exchanged.). LPN Employee E6 stated they did not find the missing Oxycodone or the corresponding drug count record paper that should have been in the binder.
During review of facility documents, dated 11/9/25 at approximately 4:45 a.m. the resident requested Oxycodone pain medication and did not receive the medication until 6:00 a.m. on 11/9/25 due to the missing medication and associated medication documents. RN Employee E4 discussed with LPN Employee E6 resident states she has been getting pain medication, but it hadn't been documented in the computer as given.
There is no evidence that RN Employee E5 was asked for or provided any statement regarding not signing the shift change count sheet of 11/8/25 at 7:00 a.m. that contained the 29/29 narcotic cards and or how the count changed to 27/27 narcotic cards at 11/8/25 p.m.
There is no evidence of an interview being conducted with the resident.
Education was completed in November by the facility in response to this event, policy for abuse, neglect and exploitation was conducted and confirmed with staff interviews.
During an interview on 12/22/25 at approximately 12:00 p.m. the Director of Nursing confirmed only RN's Employee ?s E4 and E5 had the keys that access to the medication cart from 11/7/25 at 11:00 p.m. through 11/9/25 at approximately 10:15 a.m. employee RN Employee E5 (left her shift due to a family emergency).
The facility determined, they are unable to identify a perpetrator in this event, and the facility did file a report with the local police department.
During an interview on 12/22/25, at approximately 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to ensure that residents are free from misappropriation of property for one of four residents (Resident R1). 28 Pa.
Code: 211.12 (d)(1)(5) Nursing services. 28 Pa.
Code: 201.29(j) Resident rights.
395596 12/26/2025
Bridgeville Rehabilitation & Care Center 3590 Washington Pike Bridgeville, PA 15017
During review of facility documents, dated 11/9/25 at approximately 4:45 a.m. the resident requested Oxycodone pain medication and did not receive the medication until 6:00 a.m. on 11/9/25 due to the missing medication and associated medication documents. RN Employee E4 discussed with LPN Employee E6 resident states she has been getting pain medication, but it hadn't been documented in the computer as given.
There is no evidence that RN Employee E5 was asked for or provided any statement regarding not signing the shift change count sheet of 11/8/25 at 7:00 a.m. that contained the 29/29 narcotic cards and or how the count changed to 27/27 narcotic cards at 11/8/25 p.m.
There is no evidence of an interview being conducted with the resident.
During rounds on 12/22/25, at 10:45 a.m. the Director of Nursing (DON) and surveyor checked the Harmony Unit Medication Room and the TCU Medication Room.
The doors were unlocked with medications that were designated to be returned, sitting on the counter.
These doors require a key to be locked.
Education was completed in November by the facility in response to this event, policy for controlled substances administration, ordering , storage, handling and disposal, confirmed with staff interviews.
During an interview on 12/22/25 at approximately 11:00 a.m. with the Director of Nursing (DON), the surveyor requested to see the original shift change counts sheets and was informed they are missing (copies were available and reviewed). RN's Employee's E4 and E5 were placed on a ten day leave during the investigation.
The facility did not place the employees on leave until 11/9/25 at 10:15 a.m. after RN Employee E5 left work due to a family emergency.
The facility did not require, request, or offer any staff drug screening to be completed. RN Employee E4 independently had a hair drug screening that was reportedly negative. RN's Employees E4 and E5 did return to work after 10 days' leave. On or around 12/20/25, RN Employee E5 requested and was granted permission to leave work early (due to illness) and has been a no call no show since.
Only RN's Employee ?s E4 and E5 had the keys that access to the medication cart from 11/7/25 at 11:00 p.m. through 11/9/25 at approximately 10:15 a.m. employee RN Employee E5 (left her shift due to a family emergency).
The facility determined, they are unable to identify a perpetrator in this event, and the facility did file a report with the local police department.
The facility investigation confirmed the Oxycodone is missing.
During an interview on 12/22/25, at approximately 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to implement policies and procedures to investigate misappropriation of resident property for one of four residents (Resident R1). 28 Pa.
Code: 201.18(e)(1)(2) Management. 28 Pa.
Code: 201.29(a)(c)(d) Resident rights. 28 PA.
Code: 211.12(a)(c)(d)(1)(3)(5) Nursing services.
395596 12/26/2025
Bridgeville Rehabilitation & Care Center 3590 Washington Pike Bridgeville, PA 15017
Based on review of facility policies, observations, and staff interviews, it was determined that the
rooms (TCU and Harmony Unit Medication Rooms).Findings include: Review of facility policy Medication Storage dated 10/27/25, indicated that medications and biologicals that the medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.
Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access.
During rounds on 12/22/25, at 10:45 a.m. the Director of Nursing (DON) and surveyor checked the Harmony Unit Medication Room and the TCU Medication Room.
The doors were unlocked with medications that were designated to be returned, sitting on the counter.
These doors require a key to be locked.
Education was completed in November by the facility in response to this event, policy for controlled substances administration, ordering, storage, handling and disposal, confirmed with staff interviews.
During an interview on 12/22/25, at approximately 9:50 a.m.
Licensed Practical Nurse Employee E1 confirmed he had a key to the Harmony Unit Medication Room and that the door should be locked.
During an interview on 12/22/25, at approximately 9:55 a.m.
Licensed Practical Nurse Employee E2 confirmed she had a key to the Harmony Unit Medication Room and that the door should be locked and proceeded to lock the unlocked door.
During an interview on 12/22/25, at approximately 10:00 a.m.
Licensed Practical Nurse Employee E3 confirmed she had a key to the TCU Unit Medication Room and that the door should be locked and proceeded to lock the unlocked door.
During an interview on 12/22/25, at approximately 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to properly secure medications and/or biologicals in one of two medication rooms. 28 Pa.
Code: 211.9(a)(1)(j.1)(k) Pharmacy services. 28 Pa.
Code: 211.12(d)(1)(2)(3)(5) Nursing services.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.