Wecare at Murrysville Rehab and Nursing Center

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to conduct care plan conferences and failed to ensure a resident or resident representative was notified in advance of care conference meetings for one of two residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain a resident had an updated, person-centered care plan individualized to each specific resident's needs for one of two residents (Resident R1).

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by not maintaining a clean environment for three of three resident rooms (Residents R22, R50, and R65), and one of three resident wheelchairs (Resident R61). Findings Include: Review of the facility policy Homelike Environment dated 6/11/25, indicates the facility will provide an environment that is safe, clean, comfortable, and homelike. Review of the admission record indicated Resident R22 admitted to the facility on [DATE]. Observation on 3/16/26, at 9:19 a.m. Resident R22 was lying in bed. The resident's floor was sticky, stained with darkened areas, and covered in grime. Interview on 3/16/26, at 9:20 a.m. [...]

Inspectors wroteBased on review of the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for five of eight residents (Residents R4, R11, R33, R80, and R85).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for three of eight residents (Resident R4, R29, and R33).

Inspectors wroteBased on review of personnel files and staff interview it was determined that the facility failed to complete annual nurse aid employee evaluations for four of five sampled records (Nurse aide (NA) Employees E1, E2, E3 and E4).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to discard expired medical supplies and ensure all drugs and biologicals were stored under proper temperature controls for one of three of three medication carts (115 Hall Medication Cart, 136 Hall Medication Cart, and East Zone Two Medication Cart), and one of two Medication Rooms (West Side Medication Room).

Inspectors wroteBased on review of facility policy and documentation, resident and staff interview it was determined that the facility failed to address residents' council ongoing concerns for three of three months (March, February and January of 2026).

Inspectors wroteBased on facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide a Skilled Nursing Advanced Beneficiary Notice of Non-coverage (SNF-ABN) with the estimated amount of nursing services that will be charged for two of three residents (Residents R8, and R31).

Inspectors wroteBased on review of facility policy, clinical records and staff interview it was determined that the facility failed to make certain resident medication regimes were free from potentially unnecessary psychotropic medications for one of three residents (Resident R1 ).

Inspectors wroteBased on a review of the facility policy, clinical record review and staff interview, it was determined that the facility failed to accurately assess the nutritional status, and failed to update an individualized care plan to address the resident's specific nutritional concerns for two of five residents (Resident R4 and R49) records reviewed.

Inspectors wroteBased on review of facility policy, clinical records, and staff and resident interview, it was determined that the facility failed to ensure Total Parenteral Nutrition (TPN) was administered consistent with professional standards of practice and in accordance with physician orders for one of three residents (R96).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R9).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to use proper hand washing to prevent cross contamination during a dressing change for one of three residents (Resident R11).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of three shower chairs (Resident R82).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to conduct a thorough investigation of an allegation of abuse for one of two residents (Resident R1).

Inspectors wroteBased on review of facility policy, observations and staff interview it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for eight of 15 resident rooms (Rooms 114, 116, 119, 122, 139, 140, 143, and 144).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS- assessments completed indicating a change in condition of a resident requiring change in care) assessment for one of two residents (Residents R1).

Inspectors wroteBased on a review of resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for one of two residents (Resident R1).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of six residents (Resident R1) reviewed, relating to wandering/elopement.

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of six residents (Resident R1).

Inspectors wroteBased on review of facility policy, resident and staff interviews, and group interviews, 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 ten out of ten residents during group. Findings Include: Review of the facility policy Resident Rights dated 2/12/25, indicated all residents will be treated with kindness, respect, and dignity. Residents have the right to a dignified existence, Review of the facility Facility Assessment Tool dated 1/1/25, indicated the nursing facility will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents. [...]

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 products in one of two nursing unit pantries (Rose Dining Room) which created the potential for food borne illness. Findings Include: During an observation in the [NAME] Dining Room, resident refrigerator, on 3/28/25, at 10:25 a.m. the following items were found with no label, name, or date; a glass bowl containing cucumber salad, a plastic container of Chinese food, a plastic container with pumpkin pie, a plastic container of spaghetti and meatballs that had a fuzzy, green substance on top, and a cardboard container of rice. During an interview on 3/28/25, at 10:34 a.m. [...]

Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to follow established procedures of water storage to ensure that water is available to essential areas when there is a loss of normal water supply for two of two nursing wings (East Wing, and [NAME] Wing)

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure complete and thorough investigations of allegations of abuse and neglect for four of five residents (Resident R14, R44, R46, and R286).

Inspectors wroteBased on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report allegations of abuse and neglect in the required time frame for four of five residents (Resident R14, R44, R46, and R286).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct thorough investigations of allegations of abuse neglect for four of five residents (Resident R14, R44, R46, and R286).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of three residents sampled with facility-initiated transfers (Residents R22, R45, and R58).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, 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 three of three residents reviewed (Residents R45, R48, and R54).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that quarterly Minimum Data Set assessments were completed within the required time frame for four of four residents (Residents R2, R8, R23, and R41).

Inspectors wroteBased on observation, and staff interviews, it was determined that the facility failed to provide a resident environment free of potential accidental hazards in four out of six resident care areas (Zone 1, Zone 2, Zone 4, and Zone 5).

Inspectors wroteBased on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed for four of six residents (Residents R6, R22, R45, and R76).

Inspectors wroteBased on a review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to provide therapeutic meal selections for residents with diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and resident preferences for eight of twelve months.

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to prevent the potential spread of infection for two of two residents in isolation precautions (Resident R25, and R66), and failed to maintain proper infection control practices related to care of indwelling urinary catheters (tube inserted in the bladder to drain urine) for one of three residents (Resident R187).

Inspectors wroteBased on observations and staff interview it was determined that the facility failed to maintain essential PTAC (a ductless self-contained air conditioning and heating unit that plugs directly into an electrical outlet, providing climate control for individual rooms) units for seven rooms on the east and west wings (room [ROOM NUMBER], 123, 127, 146, 147, 148, and 156).

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain an effective call system for four rooms on East and [NAME] wing (room [ROOM NUMBER], 147, 148, and 158)

Inspectors wroteBased on review of facility policy, facility documents and staff interviews, it was determined that the facility failed to provide Communication training to five of five direct care facility staff reviewed (Employees E3, E4, E5, E6, and E7).

Inspectors wroteBased on review of facility policy, facility documents, and staff interview, it was determined that the facility failed to provide training on Resident Rights for five of five staff members (Employee E3, E4, E5, E6, and E7).

Inspectors wroteBased on review of facility policy, facility documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for five of five staff members (Employee E3, E4, E5, E6, and E7).

Inspectors wroteBased on review of facility policy, facility documents and staff interviews, it was determined that the facility failed to provide Behavioral Health training to five of five direct care facility staff reviewed (Employees E3, E4, E5, E6, and E7).

Inspectors wroteBased on review of facility policy, resident records, observation, and staff interview it was determined that the facility failed to uphold the privacy and dignity of two of four residents reviewed utilizing an indwelling urinary catheter (foley - a thin rubber tube inserted either through the urethra or suprapubic [abdomen] to allow for bladder drainage) for two of four residents (Residents R12 and R187).

Inspectors wroteBased on observations, and staff interview it was determined that the facility failed to have complete contact information for State Long-Term Care Ombudsman program posted at the facility.

Inspectors wroteBased on review of facility policy, resident grievances for 90 days, clinical records, and resident and staff interviews, it was determined that the facility failed to effectively resolve, in a timely manner, a grievance in relation to concerns documented via Grievance procedure and complete the reports in their entirety for one of five grievances reviewed (R58), failed to provide grievance forms, and failed to post an updated policy and procedure that included the current grievance officer name in an accessible location (Front lobby area).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of three residents reviewed (Resident R46).

Inspectors wroteBased on review of facility policies and clinical records, observations and staff interviews it was determined that the facility failed to identify a bolster (a long, thick cushion) as a possible restraint, failed to assess the functional status of the individual resident to determine if the use of a bolster is a restraint, and failed to obtain physician's order for the use of a bolster for one of two residents (Resident R70.)

Inspectors wroteBased on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDs - a periodic assessment of care needs) assessments accurately reflected the resident's status for two of two residents (Residents R39 and R45).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for one of four residents (Resident R12).

Inspectors wroteBased a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to address the resident's specific nutritional interventions for two of two residents (Residents R39 and R45), failed to complete a comprehensive nutritional assessment for two of two residents (Resident R39 and R45), and failed to make certain that significant weight loss was addressed in a timely manner for two of two residents (Resident R39 and R45).

Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R70).

Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for one of two residents (Resident R40).

Inspectors wroteBased on facility policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary medications for two of six residents (Residents R6 and R45).

Inspectors wroteBased on facility policy, observation, and staff interviews, it was determined that the facility failed to provide food in a form to meet individuals' needs in one of six residents (Resident R44).

Inspectors wroteBased on review of facility policy, newly hired personnel records and staff interviews it was determined that the facility failed to properly screen an employment by completing a state background check prior to hire for two out of five personnel records (Licensed Practical Nurse Employee E1, and Registered Nurse Employee E4).

Inspectors wroteBased on review of facility policy, job descriptions, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of five employees reviewed (Registered Nurse (RN) Employee E4).

Inspectors wroteBased on review of personnel files, facility documentation, policy review and interviews with staff, it was determined that the facility failed to ensure that nursing staff possessed the required skills to properly care for residents' needs for one out of five personnel files reviewed (Registered Nurse Employees E4).

Inspectors wroteBased on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure licensed professional staff held an active license in accordance with state laws for one of five staff members reviewed (Registered Nurse (RN) Employee E4).

Inspectors wroteBased on review of facility documentation and interviews with staff it was determined that the facility failed to maintain and implement an effective, quality assurance and performance improvement program that focuses on outcome as required by failing to follow a performance improvement project (PIP) for new hire employee files.

Inspectors wroteBased on review of facility document, clinical records, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of two resident hospital transfers (Resident R1). Findings Include: Review of the facility document admission Agreement indicated that before a resident may be transferred to a hospital or for therapeutic leave, the facility is required to provide the facility's Bed Hold Policy to the resident and a family member or Resident Representative. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for incident or accidents for one of three residents (Residents R1).

Inspectors wroteBased on facility policy review, clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in a burn for one of four resident's (Residents R1).

Inspectors wroteBased on review of facility documentation and interviews with staff it was determined that the facility failed to maintain and implement an effective, quality assurance and performance improvement program that focuses on outcome as required by failing to implement a QAPI for overall PPD calculation for four days.

Inspectors wroteBased on a review of facility documents, an audit conducted by the State Ombudsman Office and staff interviews, it was determined that the facility failed to notify the State Ombudsman Office of resident transfers and discharges for 28 of 28 months (5/22, 6/22, 7/22, 8/22, 9/22, 10/22, 11/22, 12/22, 1/23, 2/23, 3/23, 4/23, 5/23, 6/23, 7/23, 8/23, 9/23, 10/23, 11/23, 12/23, 1/24, 2/24, 3/24, 4/24, 5/24, 6/24, 7/24, and 8/24) as required.

Inspectors wroteBased on a review of facility policies, resident medical records, facility submitted documents, and staff interviews it was determined that the facility failed to provide adequate supervision to be aware of a resident's departure from the facility for one of six residents (Resident R1).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the Main Kitchen and the facility failed to properly label and date food products in East nursing unit failed to maintain sanitary conditions which created the potential for cross contamination (1 of 2 units).

Inspectors wroteBased on staff interviews it was determined that the facility failed to employ a full-time director of food service for the past six out of 31 days (August 2024).

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 products, and to properly segregate damage food in the Main Kitchen, creating the potential for food-borne illness.

Inspectors wroteBased on review of facility policy, resident council minutes, group interview, resident interviews, and staff interviews it was determined that the facility failed to respond to resident concerns and grievances identified during resident council minutes for three of three months (January 2024 through March 2024).

Inspectors wroteBased on review of facility policy, observations, resident council group interview, and staff interviews, it was determined that the facility failed to maintain a clean, safe, homelike environment for five out of 12 residents (Resident R33, R25, R70, R80, and Resident R81).

Inspectors wroteBased on review of facility policies, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for accidents or incidents included statements for three of five residents (Residents R11, R45, and R76).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to implement a bowel protocol as ordered (Resident R11), notify a physician of abnormal glucose readings (Resident R14), provide necessary care and treatment for Resident R60' s pacemaker, and ensure timely follow-up for a resident's appointment as ordered (Resident R62) for 4 out of 29 residents. (Residents R11, R14, R60, R62) Review of facility's policy, Transfer to Appointment Outside the Facility, policy interpretation dated 1/1/24, indicated the facility will verify that a physician order for an appointment/consult is present. Notify the appropriate office of the appointment by the next business day. Arrange for transportation as appropriate. Enter the appointment on the consultation/appointment log. [...]

Inspectors wroteBased on clinical record review, staff interview and a review of the facility's assessment it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for a resident using a LifeVest for eight out of eight months (September 2023 through April 2024 )

Inspectors wroteBased on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify the physician of a change in condition for one of three residents. (Resident R56)

Inspectors wroteBased on review of facility policy, resident record, investigation documents, resident interveiw, and staff interview, it was determined that the facility failed to report allegation of neglect and report an allegation of verbal abuse for two out of four sampled residents (Resident R40 and Resident R69).

Inspectors wroteBased on review of facility policy, resident records, admissions documentation and staff interview it was determined that the facility failed to provide a comprehensive review of resident admission rights and maintain admission documentation for one out of out three sampled records (Resident R4).

Inspectors wroteBased on a review of clinical records, and staff interview, it was determined that the facility failed to ensure that a comprehensive resident care plan was complete for resident care needs related to a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death) for one of five residents (Resident R56).

Inspectors wroteBased on the review of facility job descriptions, clinical records, and staff interviews, it was determined that the facility failed to follow standards of professional practice for one of six residents (Resident R25).

Inspectors wroteBased on facility policy clinical record review and staff interviews, it was determined that the facility failed to make certain that residents receive assistance with nail care for one of two residents (Resident R53).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to provide services and treatment to prevent further limitations in range of motion for one of two residents who had limitations in range of motion (Resident R81).

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents for one of five residents (Resident R11).

Inspectors wroteBased on a review of clinical record, and staff interview, it was determined that the facility failed to ensure a resident was offered sufficient fluid intake to maintain proper hydration and health for one of seven residents (Resident R55).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide oxygen as ordered for one of four residents (Resident R55).

Inspectors wroteBased on review of facility policy, clinical record review, resident interview, and staff interviews it was determined that the facility failed to develop and implement a person-centered care plan that supports the behavioral health care needs for one of three residents (Resident R11), and that the facility failed to provide on-going, necessary behavioral healthcare services to a resident to maintain the highest practicable mental and psychosocial well-being for one of three residents (Resident R33), the discontinuation of behavioral healthcare services preceded an attempt of suicide for one resident (Resident R33), and also failed to offer psychiatric services for one resident (Resident R33) after an attempt of suicide.

Inspectors wroteBased on a review of facility policy, clinical records and staff interviews, it was determined that the facility failed to limit as needed antipsychotic drugs to 14 days for one of five residents (Resident R11).

Inspectors wroteBased on review of facility policy and clinical record, observation and staff interviews it was determined that the facility failed to make certain that residents are free from significant medication errors for one of three residents (Resident R45).

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to obtain laboratory services as ordered for one of two residents reviewed (Resident R55). Findings Include: Review of the facility Transcribing Physician Orders policy dated 1/1/24, indicated physician orders will be transcribed when they are received. It was indicated ordered lab work will be documented in the facility's lab tracking tool, a lab form will be completed listing the ordered test, and diagnostic studies will be called to the appropriate diagnostic service for scheduling and noted in the nursing progress notes. Review of Resident R55's Follow-Up summary dated 3/25/23, completed by Nurse Practitioner (NP) Employee E23 indicated the resident was seen for follow up for pneumonia. [...]

Inspectors wroteBased on review of clinical records, and staff interview it was determined that the facility failed to ensure that a resident's physician was notified about abnormal laboratory test results for one of two residents (Resident R60).

Inspectors wroteBased on facility policy, observations, and staff interviews it was determined that the facility failed to provide adaptive feeding devices for one of three residents (Resident R55).

Inspectors wroteBased on the review of facility job descriptions, clinical records, and staff interviews, it was determined that the facility failed to maintain and complete accurate documentation for one of six residents (Resident R25).

Inspectors wroteBased on review of facility policy, resident record and staff interview it was determined that the facility failed to establish a written agreement with a Medicare-certified hospice provider prior to the start of hospice services for one of two sampled resident records (Resident R59).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to implement procedures to prevent the development and transmission of communicable diseases and infections for three of 11 residents. (Resident R55, R60, and R63)

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance for bed mobility to prevent accidents which resulted in actual harm of a head injury for one of four residents (Resident CR1).

Inspectors wroteBased on review of facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for three of six residents (Resident R2, R3, and CR1). Review of facility policy Flow of Care dated 7/24/23, indicated the provision of targeted care needs shall be documented on Care Tracker/Point of Care/ADL Flow Records (clinical documents). Review of the admission record indicated Resident R2 admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/6/23, indicated the diagnoses of high blood pressure, diabetes (too much sugar), and muscle weakness. Review of Resident R2's Documentation Survey Report v2 dated December 2023 indicated the following: [...]

Inspectors wroteBased on a review of the minutes from Resident Council meetings and grievances filed with the facility, resident interviews and staff interviews, it was determined that the facility failed to put forth efforts to sustain resolution and prevent continued resident complaints expressed during Resident Council meetings for three of three months. (November 2023, December 2023, and January 2024). Findings Include: Review of resident council meeting minutes from 11/2/23, indicated that the residents in attendance voiced complaints regarding the following: [...]

Inspectors wroteBased on facility policy, observations and staff interviews, it was determined that the facility failed to provide personal privacy during showers for one of three residents (Resident R1).

Inspectors wroteBased on a review of the grievance policy and clinical records, staff and resident interviews, it was determined that the facility failed to resolve a grievance related no privacy during showers for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain call bells were in reach for four of eight residents (R4, R5, R6, and R7) as required. Based on policy review, staff and resident interview, observations, and staff interview, it was determined that the facility failed to make certain call bells were in reach for four of eight residents observed (Resident R4, R5, R6, and R7).

Inspectors wroteBased on staff interview it was determined that the facility failed to employ a full-time qualified dietary services supervisor in the absence of a full-time qualified dietitian.

Inspectors wroteBased on review of facility policy, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide care and services to maintain personal hygiene by failing to provide scheduled showers for four of eight residents (Residents R1, R2, R3, and R4).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to notify the family or responsible party for a change in room assignment for three of six residents (Resident R1, R2, and R3).

Inspectors wroteBased on a review of employee personnel files and staff interviews, it was determined that the facility failed to complete State criminal background check prior to the date of hire for one out of three reviewed personnel records (Activities Assistant Employee E2).