Waynesburg Nursing and Rehab

Inspectors wroteBased on review of job descriptions, and staff interviews, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian for 12 of 12 months. (February 2025 - February 2026)

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse or neglect for one of two residents reviewed (Resident R89).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews it was determined that the facility failed to make certain comprehensive Minimum Data Set (MDS- periodic assessment of care needs) assessments were accurate and fully completed for one of eight residents (Resident R21).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of post-traumatic stress disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of three residents reviewed (Resident R7).

Inspectors wroteBased on review of facility documents, clinical record review, and resident and staff interview, it was determined that the facility failed to complete a significant change on the Minimum Data Set (MDS - core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid) for one of three residents (Resident R9).

Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents on three of three locations, nursing units (A and C Wings) and across from the social service department.

Inspectors wroteBased on a review of facility policy, federal regulation and staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for 10 of 11 months from April 2024 through February 2025. (April, May, June, July, August, September, October, November, December 2024 and January 2025).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to provide a safe environment for residents in four areas of the facility (Beauty Shop, Lift Rom, Shower Room, and Boiler Rom).

Inspectors wroteBased on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that each resident's drug regimen was free from unnecessary drugs used without adequate indications for use for two of three residents. (Resident R11 and R38).

Inspectors wroteBased on review of facility policies, facility provided documentation, clinical records and staff interview, it was determined that the facility failed to make certain a resident was free from abuse/neglect for two of five residents(Residents R1 and R2).

Inspectors wroteBased on review of facility policy, observation of life equipment, and staff interviews, it was determined that the facility failed to maintain patient care equipment in a safe operating condition to keep mechanical lift in safe operating condition for one of four mechanical lifts reviewed ).

Inspectors wroteBased on review of the facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for nine of the sixteen residents reviewed (Resident R14, R18, R48, R84, R86, R96, R98, R99, R108). Findings Include: A review of the facility policy Advanced Directives reviewed 3/1/2023 and 1/31/2024, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. [...]

Inspectors wroteBased on review of facility job description, resident record review, and staff interview, it was determined that the facility failed to follow professional standards of practice for to three of four residents reviewed (Resident R1, R2, and R3). Review of the facility Licensed Practical Nurse job description, effective 9/1/23, indicated the Licensed Practice Nurse (LPN) is responsible for rendering nursing care in terms of individualized resident needs based on the scope of practical nursing. The job description further stated the LPN performs delegated nursing functions using established procedures, policies, guidelines and standards. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on a review of the Activity Calendars for two months (December 2023 and January 2024), and resident and staff interview, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for five of eleven residents.

Inspectors wroteBased on a review of clinical records, facility documents, and resident and staff interviews, it was determined that the facility failed to provide appropriate assistance to prevent falls, resulting in actual harm of a leg fracture for one of four residents reviewed (Resident R8).

Inspectors wroteBased on a review of clinical records, facility documents, and resident and staff interviews, it was determined that the facility failed to make certain residents were free from emotional trauma for two of six residents (Residents R2 and R5) and neglect to provide goods and services of changing a brief to one of three residents (Resident R7).

Inspectors wroteBased on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of staff to resident abuse or neglect for two of four residents reviewed (Resident R4 and R7).