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

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

There are  129 surveys for this facility. Please select a date to view the survey results.

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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 an Abbreviated survey in response to a complaint completed on March 27, 2025, it was determined that WeCare at Rolling Meadows Rehab and Nursing was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.
Observations:
Based on staff interviews and observations, it was determined that the facility failed to employ staff with the appropriate competencies and skills to carry out the daily functions of the food and nutrition services department.

Finding include:

During an interview on 3/27/25, at 8:33 a.m., the Nursing Home Administrator (NHA) confirmed that the facility currently did not have a Dietary Manager and a Dietary Manager from South Hills facility has been ordering the facility food. The NHA stated that the remote Dietician who covers the facility is there a weekly. The Regional Dietician will be coming in the facility but this will be her second visit since the last Dietary Manager quit. The NHA stated that he has cooked evening meals and the Maintenance Director has been helping when able. The NHA stated that if an immediate food item is needed he goes to Walmart. The previous Dietary Manager was terminated on 2/18/25, per facility staffing records.

During an observation on 3/27/25, at 8:43 a.m., staff in the kitchen indicated they did not have a Dietary Manager and that a Dietary Manager from another facility was ordering food and came in "occasionally". A list of needed food items is on a "whiteboard" for her to order foods needed.

During a phone interview on 3/27/25, the South Hills Dietary Manager stated that she orders the facility food every two weeks and asks staff to keep a list of needed items.

During an interview on 3/27/25, at 8:33 a.m., the Nursing Home Administrator confirmed that the facility did not possess the qualifications of a Certified Dietary Manager as required.

28 Pa. Code: 211.6(c)(d) Dietary services.




 Plan of Correction - To be completed: 05/14/2025

A qualified Dietary Manager has been hired and has accepted the full-time position effective 5/5/25. The facility continues to employ a qualified dietitian to oversee the nutritional needs of residents, ensuring that dietary requirements are consistently met. The Regional Director of Food Services has been assigned to manage the Dietary Department on an interim basis, maintaining seamless dietary services during the recruitment process for a permanent director. An assessment of current dietary staffing qualifications has been conducted to ensure compliance with regulatory standards and to address any gaps affecting resident meal services. Feedback from residents and families has been requested to address any meal service concerns promptly. The facility will maintain a proactive recruitment strategy to identify and attract qualified candidates to ensure that any future vacancies in the Dietary Manager position are promptly addressed to prevent lapses in compliance. The interim director, in collaboration with the Quality Assurance Performance Improvement (QAPI) committee, will conduct weekly audits of meal service quality for the next 4 weeks. Audit findings will be presented to the QAPI committee monthly to assess the effectiveness of corrective actions and implement further adjustments as necessary.
483.70(o)(1)(2) REQUIREMENT Qualifications of Social Worker >120 Beds:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.70(o) Social worker.
Any facility with more than 120 beds must employ a qualified social worker on a full-time basis. A qualified social worker is:

§483.70(o)(1) An individual with a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and psychology; and

§483.70(o)(2) One year of supervised social work experience in a health care setting working directly with individuals.
Observations:
Based on review of facility files and an interview with the Nursing Home Administator, it was determined that the facility failed to employ a qualified social worker.

Findings include:

Review of the staffing records indicated that the previous Social Worker was terminated on 2/24/25, and the facility has been without a qualified Social Worker in the position since.

During interview with the Nursing Home Administrator on 3/27/25, at 8:45 a.m., the Nursing Home Administrator confirmed that the facility failed to employ a qualified social worker.

Pa Code 211.16. Social Services.

Pa Code 201.14 (a)Responsibility of licensee.


 Plan of Correction - To be completed: 05/14/2025

A qualified social worker has been hired and has accepted the full-time position effective 4/21/25. The individual possesses the requisite educational background and supervised experience as specified in the regulations. The new social worker will begin employment upon completion of the pre-employment process. A review was conducted to determine if any residents experienced inadequate social work services due to the previous vacancy. No adverse effects were identified. The facility will maintain a proactive recruitment strategy to identify and attract qualified candidates to ensure that any future vacancies in the social worker position are promptly addressed to prevent lapses in compliance. The Administrator, along with assistance from the Regional Social Worker, will oversee the integration of the new social worker and ensure that all social services are delivered in accordance with regulatory standards. The Quality Assurance Performance Improvement (QAPI) committee will monitor the effectiveness of social services on a quarterly basis and address any concerns promptly.
§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(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 review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one nurse aide per 10 residents during the day shifts on five of 21 days ( 2/3/25, 2/7/25, 2/8/25, 2/9/25 and 2/22/25), one nurse aide per 11 residents on evening shift on two of 21 days ( 2/10/25 and 2/22/25), and one nurse aide per 15 residents on night shift on seven of 21 days ( 2/2/25, 2/6/25, 2/8/25. 2/9/25, 2/12/25, 2/14/25 and 2/22/25).

Findings include:

Review of the nursing schedules and census information for 2/2/25, through 2/22/25, revealed that the facility failed to meet the following:

2/2/25: Night shift required 53 hours of nurse aide care, facility provided 40.92, the census was 106.
2/3/25: Day shift required 78 hours of nurse aide care, facility provided 76.90, the census was 104.
2/6/25: Night shift required 51.50 hours of nurse aide care, facility provided 51.41, the census was 103.
2/7/25: Day shift required 78 hours of nurse aide care, facility provided 73.60, census was 104.
2/8/25: Day shift required 78 hours of nurse aide care, facility provided 74.70, census was 104.
2/8/25: Night shift required 52 hours of nurse aide care, facility provided 40.80, census was 104.
2/9/25: Day shift required 78.75 hours of nurse aide care, facility provided 59.23, census was 105.
2/9/25: Night shift required 52.50 hours f nurse aide care, facility provided 36.56, census was 105.
2/10/25: Evening shift required 72.27 hours of nurse aide care, facility provided 54.0, census was 106.
2/12/25: Night shift required 52 hours of nurse aide care, facility provided 49.36, census was 104.
2/14/25: Night shift required 52.0 hours of nurse aide care, facility provided 40.80, census was 104.
2/22/25: Day shift required 77.25 hours of nurse aide care, facility provided 69.06, census was 103.
2/22/25: Evening shift required 70.23 hours of nurse aide care, facility provided 65.62, census was 103.
2/22/25: Night shift required 51.50 hours of nurse aide care, facility provided 49.60, census was 103.

During an interview on 3/27/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility administrative staff failed to provide a minimum of one nurse aide per 10 residents during the day shifts on five of 21 days ( 2/3/25, 2/7/25, 2/8/25, 2/9/25 and 2/22/25), one nurse aide per 11 residents on evening shift on two of 21 days ( 2/10/25 and 2/22/25), and one nurse aide per 15 residents on night shift on seven of 21 days ( 2/2/25, 2/6/25, 2/8/25. 2/9/25, 2/12/25, 2/14/25 and 2/22/25).


 Plan of Correction - To be completed: 05/14/2025

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. Facility held an open interview hiring event on 3/27/25. The facility has submitted a nurse aide training program application to the department of education to hold classes in house. 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 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. :State only Deficiency.
(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 one of 21 days ( 2/9/25) and one LPN per 40 residents on Night shift on one of 21 days ( 2/22/25).

Findings include:

Review of facility census data and nursing time schedules from 2/2/25, through 2/22/25, revealed the following LPN staffing shortage:

Day shift:

2/9/25census 10530.73 actual hours31.50 hours required.

Night shift

2/22/25 census 103 16.60 actual hours 19.31 hours required

During an interview on 3/27/25, at approximately 1:00 p.m., the Nursing Home Administrator confirmed the facility failed to provide the minimum of LPN's on the above day as required.


 Plan of Correction - To be completed: 05/14/2025

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. Facility held an open interview hiring event on 3/27/25. 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 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.:State only Deficiency.
(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 a review of nursing time schedules and staff interview, it was determined that the facility failed to provide a minimum of 3.20 PPD (per patient daily) hours of direct care for each resident on six of 21 days ( 2/2/25, 2/7/25, 2/8/25, 2/9/25, 2/14/25 and 2/22/25).

Findings include:

Review of staffing documents and nursing staff schedules from 2/2/25 through 2/22/25, indicated that the State required PPD minimum hours of 3.20 was not met on the following days:

2/2/25= 3.08 PPD.
2/7/25= 3.17 PPD.
2/8/25= 3.06 PPD.
2/9/25= 2.76 PPD.
2/14/25= 3.07 PPD.
2/22/25= 2.95 PPD.

During an interview on 3/27/25, at 1:00 p.m., the Nursing Home Administrator confirmed that the facility failed to provide a minimum of 3.20 PPD hours of direct care on the above dates as required.


 Plan of Correction - To be completed: 05/14/2025

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. Facility held an open interview hiring event on 3/27/25. 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 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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