Wecare at Mt Lebanon Rehabilitation and Nrsg Ctr

Inspectors wroteBased on review of select facility documents, clinical record review as well as resident and staff interviews, it was determined that the facility failed to ensure sufficient staffing to meet resident need for ten of 21 residents (Resident R4, R6, R7, R8, R13, R15, R18, R19, R30, R31).

Inspectors wroteBased on a review of facility policies, documents, observations and resident and staff interviews it was determined that the facility failed to serve hot food products at acceptable palatable temperatures for two of two meals (lunch and dinner meal) and to ten of sixteen residents. (Residents R3, R8, R9, R10, R14, R16, R17, R21, R22, and R32).

Inspectors wroteBased on a review of resident choice menu selections, and Resident Group and staff interviews, it was determined that the facility failed to provide resident selected menu items for eight of 21 residents (R1, R2, R3, R5, R10, R11, R12, and R15).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement an effective system of surveillance designed to identify possible tuberculosis ( TB a contagious bacterial infection that typically attacks the lungs) exposures for seven of twenty residents (R23, R24, R25, R26, R27, R28, and R29).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to store medications properly, for one of two medication rooms (First-floor medication room).

Inspectors wroteBased on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision during transfers for one of three residents (Resident R1). This was identified as past-noncompliance.

Inspectors wroteBased on facility document review and staff interviews it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department.

Inspectors wroteBased on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label and date food, clean and sanitize food service items/dishes, and maintain cleanliness in the Main Kitchen and one of two nursing unit nutrition rooms (Ground floor nursing units).

Inspectors wroteBased on policy review, documentation and review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for eleven of twelve months (October 2024 through August 2025).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to make certain that equipment was maintained in operating condition in the Main Kitchen.

Inspectors wroteBased on review of the facility policy, clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions for when the individual is incapacitated) or conduct periodic review of advance directive instructions, for two of eight residents reviewed (Resident R13, and R85). Findings Include: A review of the facility policy Advance Directives last reviewed 1/22/25, indicated it's the policy of this facility that each resident has the right to formulate an Advance Directive. The interdisciplinary team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded in the medical record. [...]

Inspectors wroteBased on review of facility policy, observation, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for thirteen of twenty residents (R2, R10, R13, R77, R500, R501, R502, R503, R504, R505, R506, R507, R508, and 509) on two of two nursing units (ground floor G wing and first floor 1 wing).

Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make certain, residents who voice grievances can do so without fear of discrimination or reprisal for ten of seventeen residents (R86, R500, R501, R502, R503, R504, R505, R506, R507, and R508) and failed to display written information on the grievance procedure and grievance official contact information in the building (main lobby, ground floor G wing and first floor 1 wing).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for two of four residents reviewed for hospitalization (Resident R5 and R12). Findings Include: Review of the facility policy Bed-Holds and Returns dated 1/22/25, indicated, All residents/ representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalizations or therapeutic leave). Residents are provided written information about these policies at least twice: Well in advance of any transfer (e.g. in the admission packet); and At the time of transfer (or, if the transfer was an emergency, within 24 hours). [...]

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for five of twelve residents (Resident R2, R5, R53, R66, and R82).

Inspectors wroteBased on review of facility policy and documents, clinical record review, resident, and staff interviews, it was determined that the facility failed to make certain that necessary care and services were provided for four of sixteen residents (Resident R5, R13, R71, and R97).

Inspectors wroteBased on a review of observations and resident and staff interviews, it was determined that the facility failed to follow physician's orders for five of eight residents (Resident R4, R5, R10, R37, and R77).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide a safe environment for residents on two of two nursing units (Ground Floor and First Floor).

Inspectors wroteBased on review of resident and staff interviews, 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 for nineteen of twenty-four residents (Residents R5, R11, R13, R48, R62, R64, R71, R77, R79, R81, R500, R501, R502, R503, R504, R505, R506, R507, R508, and R509).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medical supplies were properly stored and/or disposed of in two of two nursing units (Ground Floor and First Floor) and one of four medication carts (First Floor, high hall).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify physicians of increased capillary blood glucose (CBG) levels for one of three residents (Resident R42).

Inspectors wroteBased on a review of facility policy, clinical record review, observations, and staff interview it was determined that the facility failed to develop person-centered care plans for three of eight residents (Resident R14, R62, and R77).

Inspectors wroteBased on review of observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents are free of significant medication errors for two of five residents reviewed (Resident R94 and R85).

Inspectors wroteBased on observations and a staff interview, it was determined the facility failed to post information for the State Agency, Adult Protective Services (APS), and a statement that residents may file a complaint with the State Agency as required in the building (main lobby, ground floor G wing and first floor 1 wing).

Inspectors wroteBased on observations and a staff interview, it was determined that the facility failed to display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building (main lobby, ground floor G wing and first floor 1 wing).

Inspectors wroteBased on a review of facility documents, observations, and staff interviews, it was determined that the governing body failed to implement policies regarding the management of the operation of the facility by failing to respond to facility requests for equipment repairs.

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to investigate incidents of possible abuse and neglect for one of two residents (Residents R1). Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to investigate incidents of possible abuse and neglect for one of two residents (Residents R1). Review of facility policy Abuse and Neglect - Clinical Protocol reviewed 1/22/25, indicated the nurse will assess the individual and document related findings. The facility defines abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. [...]

Inspectors wroteBased on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly secure the treatment cart for one of four carts observed (First floor Team #1 medication cart). Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly secure the treatment cart for one of four carts (First Floor Team #1 Medication Cart). Review of the facility policy Storage of Medications reviewed 1/22/25, indicated medications and biologicals are stored safely, securely, and properly. Drugs and biologicals used in the facility are stored in locked compartments. Only persons authorized to prepare and administer medications have access to locked medications. During an observation on 7/15/25, at 9:40 a.m. [...]

Inspectors wroteBased on a review of facility policy, resident choice menu selections, resident interviews, it was determined that the facility failed to provide resident selected menu items for 14 of 20 residents (Resident R2, R5, R6, R7, R8, R9, R10, R12, R13, R14, R15, R16, R17, R19, and R20).

Inspectors wroteBased on review of facility policy and resident staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents for of residents six of eight residents (Resident R2, R9, R11, R17, R19, and R20).

Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to maintain an effective pest control program for one of two nursing units (Ground Floor nursing unit).

Inspectors wroteBased on facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent elopement one of four residents (Resident R1).

Inspectors wroteBased on facility documents, clinical record review, and staff interview, it was determined that the facility failed to make certain residents with cognitive decline were reassessed for elopement, for one of four residents (Resident R1).

Inspectors wroteBased on observations, resident and staff interviews, it was determined that the facility failed to maintain a clean homelike environment for two of two nursing floors observed. (Ground and First Floor). Findings Include: During an observation on 10/31/24, from 8:06 a.m., through 10:00 a.m., the following was identified: Resident room [ROOM NUMBER] G- empty bathroom faucet was turned on to hot, from 8:06 a.m., though 8:26 a.m, the water ran continuously producing luke warm water to touch. There were holes in the wall in the bathroom. Resident R1 bathroom water was started at 8:12 a.m., and ran til 8:28 a.m., and was lukewarm to touch. Resident R1 stated that the water has to run and run for it to get hot. Holes were identified in the bathroom wall. room [ROOM NUMBER]G- empty bathroom faucet ran from 8:17 a.m., through 8:32 a.m, producing lukewarm water to touch. [...]

Inspectors wroteBased on review of facility policy, observations and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the potential for cross contamination during a dressing change.

Inspectors wroteBased on review of facility documents and staff interview, it was determined that he facility failed to provide training on behavioral health for ten of ten staff members (Employees E1, E2, E3, E4, E5, E7, E8, E9, E10, E11).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for six of nine residents reviewed (Resident R27, R39, R42, R50, R55, and R67).

Inspectors wroteBased on review of facility policy and documentation, and staff interview, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for five of five nurse aides (Employee E1, E2, E3, E4 and E5).

Inspectors wroteBased on review of facility policy, clinical records, and interviews with staff, it was determined that the facility failed to complete a Level II evaluation by a state Preadmission Screening and Resident Review (PASARR) representative to determine if the resident has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate for one of three residents (Resident R15).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for two of seven residents reviewed (Residents R39, and R78).

Inspectors wroteBased on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision due to documentation for the bed mobility needs for one of five residents (Resident R8), which resulted in a roll out of bed.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to properly dispose of expired and/or opened medical supplies in one of two medication rooms (First floor).

Inspectors wroteBased on employee personnel review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for five of five nurse aides reviewed (Employees E1, E2, E3, E4, and E5).

Inspectors wroteBased on the review of the facility policy and staff interviews, it was determined that the facility failed to implement and maintain an effective training program for individuals providing services under contractual agreement, consistent with their expected roles.

Inspectors wroteBased on review of facility documents and staff interviews, it was determined that the facility failed to provide Communication training to ten of ten direct care facility staff reviewed (Employees E1, E2, E3, E4, E5, E7, E8, E9, E10, and E11).

Inspectors wroteBased on review of facility documents and staff interview it was determined that the facility failed to provide training on residents rights for ten of ten staff members (E1, E2, E3, E4, E5, E7, E8, E9, E10, E11).

Inspectors wroteBased on the review of facility documents and staff interview, it was determined that he facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to ten of ten facility staff reviewed (E1, E2, E3, E4, E5, E7, E8, E9, E10, E11\).

Inspectors wroteBased on review of facility policy and documents and staff interview, it was determined that the facility failed to provide training on compliance and ethics for ten of ten staff members (E1, E2, E3, E4, E5, E7, E8, E9, E10, E11).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interview, it was determined the facility failed to ensure the right to retain personal possessions for one of three residents (Resident R1).

Inspectors wroteBased on review of facility financial documents, interviews with vendors and staff, it was determined that the facility failed to pay bills in a timely manner for services without which the residents' health and safety are potentially impacted.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure that residents were provided a written notice of his or her rights and services provided, as well as all rules and regulations governing resident conduct and responsibilities during their stay in the facility prior to or upon admission for 13 of 13 residents (R4, R5, R6, R2, R7, R8, R9, R3, R10, R11, R12, and R13).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to document notification of emergency contacts of emergent hospital transports for two of five residents (Resident R1 and R2).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for 14 of 20 newly admitted residents.

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed accurately for eleven of 20 newly admitted residents (R14, R16, R18, R20, R21, R22, R23, R25, R26, R28, and R29).

Inspectors wroteBased on a review of facility admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the conditions of a binding arbitration agreement and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands, three of seven residents (Resident R14, R30, and R31).

Inspectors wroteBased on review of the facility's admission agreement and staff interviews, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator.

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to provide nutritional services by enteral feeding as ordered by the physician for one of two residents reviewed (Residents R3).

Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for seven of seven residents reviewed (Resident R9, R15, R48, R52, R68, R76, and R90).

Inspectors wroteBased on observation, review of Centers for Disease Control(CDC) guidelines for Legionella Control, the facility's infection control tracking log for water management and staff interviews it was determined that the facility failed to ensure the consistent implementation of infection control procedures designed to prevent the spread of infection or cross-contamination during medication administration by using handwashing, alcohol-based hand sanitizer, or wearing gloves while preparing resident medications. The facility failed to maintain a comprehensive program for water management to monitor the the potential development and spread of Legionella within the facility.

Inspectors wroteBased on observations, and resident and staff interviews, it was determined that the facility failed to maintain a clean, homelike environment on one of two nursing units ( First Floor nursing unit) and for six of 30 residents of the ground floor nursing units (Residents R13, R65, R60, R87, R33 and R32). The facility failed to provide residents with a personal laundry.

Inspectors wroteBased on review of facility policy, clinical records, facility incident reports, facility submitted documentation, and staff interviews it was determined that the facility failed to report elopements for two of three residents (Resident R23 and R67) and failed to investigate and report an incident when a resident swallowed a potentially poisoned substance (Resident R67).

Inspectors wroteBased on resident interviews, review of clinical records and staff interview, it was determined that the facility failed to obtain physician orders for outside dental/oral services for two of three residents (Resident R1 and R33) and failed to provide foot care according to professional standards of practice for one of two residents (Resident R62).

Inspectors wroteBased on review of facility policy, observations, clinical records, facility incident reports, facility submitted documentation, and staff interviews it was determined that the facility failed to provide necessary supervision and maintain an environment free from potential accident hazards on one of two nursing units (Ground Floor) with unlocked accessible personal laundry area and unlocked unattended therapy rooms, failed to prevent actual elopements for two of three residents (Residents R23 and R67) and failed to make certain potentially poisonous substances were not accessible to confused residents for one of three residents (Resident R67).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly and securely store medications in two of four medication carts ( Front hall and Back Hall first floor medication carts), failed to secure narcotics on one of two medication carts (Front Hall medication cart, first floor).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to update a care plan for two of seven residents (Resident R68, and R90) to accurately reflect the current status of the resident.

Inspectors wroteBased on facility policy observation, clinical record review and staff interview, it was determined that the facility failed to provide treatment and services to prevent further decrease in range of motion for one of three residents (Resident R62).

Inspectors wroteBased on review of facility records and staff interview, it was determined that the facility failed to ensure the designated Infection Preventionist was qualified with specialized training in infection prevention and control.