Pennsylvania Department of Health
WECARE AT ROLLING MEADOWS REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WECARE AT ROLLING MEADOWS REHABILITATION AND NURSING CENTER
Inspection Results For:

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WECARE AT ROLLING MEADOWS REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit survey completed on May 21, 2025, it was determined that Wecare at Rolling Meadows Rehab and Nursing Center failed to correct the deficiencies cited during the survey of March 27, 2025, under the requirements of the 28 Pa, Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of staffing documents provided by the facility and staff interview it was determined that the facility failed to provide one nurse assistant (NA) per 10 residents on the day shift for three of six days (5/15/25, 5/17/25 and 5/18/25), one NA per 11 residents on the second shift for one of six days (5/18/25) and one NA per 15 residents on the night shift on two of six days (5/16/25 and 5/17/25) as required.

Findings include:

A review of facility staffing documents provided by the facility from 5/14/25 through 5/19/25, revealed the facility failed to provide NA on the following shifts as required:

Day shift:CensusActual hours Hours required

5/15/2511080.2682.50
5/17/2510777.8080.25
5/18/2510748.3180.25

Evening shift:CensusActual hoursHours required

5/18/2510769.9672.95

Night shift:CensusActual hoursHours required

5/16/2510845.5154.00
5/17/2510732.8053.50

During an interview on 5/21/25 at 3:32 p.m., the Director of Nursing confirmed that the facility failed to provide NA's in the facility on the above shifts as required.

Plan of Correction - To be completed: 06/24/2025

Facility cannot retroactively correct. The facility shall make reasonable attempts to acquire new staff, including offering competitive pay rates, shift differentials, partnering with local community schools, and offering employee benefits. Facility is currently offering bonuses. The facility previously submitted a nurse aide training program application to the department of education to hold classes in house and is awaiting final approval. More variations of shifts have been posted to recruit/retain employees. The staffing team projects PPD and ratios for 2 weeks which is discussed in a staffing meeting daily. The NHA/DON/Human Resources Director will review the previous day, actual PPD and ratio and address projected 2-week schedule on an ongoing basis. Audit is completed during meeting of projected staffing, actual staffing PPD/Ratio for previous day. A review of PA Code 211.12 will be completed with NHA and DON. Additional education will be provided to the staff scheduler. Results of audit to be reported to QAPI committee.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents on the day shift on two of six days (5/18/25 and 5/19/25) and one LPN per 40 residents on the night shift on one of six days (5/14/25)..

Findings include:

Review of facility census data and nursing time schedules from 5/14/25 through 5/19/25, revealed the following LPN staffing shortage:

Day shift:CensusActual hoursHours required

5/18/2510729.6532.10
5/19/2510724.9332.10

Night shift:CensusActual hoursHours required

5/14/2511019.5520.63

During an interview on 5/21/25, at 3:32 p.m. the Director of Nursing confirmed the facility failed to provide the minimum of LPN's on the above days as required.

Plan of Correction - To be completed: 06/24/2025

Facility cannot retroactively correct. The facility shall make reasonable attempts to acquire new staff, including offering competitive pay rates, shift differentials, partnering with local community schools, and offering employee benefits. Facility is currently offering bonuses. More variations of shifts have been posted to recruit/retain employees. The staffing team projects PPD and ratios for 2 weeks which is discussed in a staffing meeting daily. The NHA/DON/Human Resources Director will review the previous day, actual PPD and ratio and address projected 2-week schedule on an ongoing basis. Audit is completed during meeting of projected staffing, actual staffing PPD/Ratio for previous day. A review of PA Code 211.12 will be completed with NHA and DON. Additional education will be provided to the staff scheduler. Results of audit to be reported to QAPI committee.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on four of six days (5/15/25 through 5/18/25).

Findings include:

Nursing time schedules for the time period of 5/14/25 through 5/19/25, revealed that the facility failed to maintain 3.2 hours of general nursing care to each resident in a 24 hour period on the following dates:

5/15/25= 2.94 PPD.
5/16/25= 3.08 PPD.
5/17/25= 2.84 PPD.
5/18/25= 2.99 PPD.

During an interview on 5/21/25 at 3:32 p.m. the Director of Nursing confirmed the the facility failed to provide the minimum number of general nursing hours to each resident in a 24 hour period as required.

Plan of Correction - To be completed: 06/24/2025

Facility cannot retroactively correct. The facility shall make reasonable attempts to acquire new staff, including offering competitive pay rates, shift differentials, partnering with local community schools, and offering employee benefits. Facility is currently offering bonuses. More variations of shifts have been posted to recruit/retain employees. The staffing team projects PPD and ratios for 2 weeks which is discussed in a staffing meeting daily. The NHA/DON/Human Resources Director will review the previous day, actual PPD and ratio and address projected 2-week schedule on an ongoing basis. Audit is completed during meeting of projected staffing, actual staffing PPD/Ratio for previous day. A review of PA Code 211.12 will be completed with NHA and DON. Additional education will be provided to the staff scheduler. Results of audit to be reported to QAPI committee.

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