Pennsylvania Department of Health
 WECARE AT MT LEBANON REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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WECARE AT MT LEBANON REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  232 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
WECARE AT MT LEBANON 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 August 1, 2024, it was determined that Mt. Lebanon Rehabilitation and Wellness Center 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:


483.10(e)(2) REQUIREMENT Respect, Dignity/Right to have Prsnl Property:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.
Observations:
Based 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).

Findings include:

A review of the facility policy "Personal Property" dated 4/9/24, stated the resident has the right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.

Review of the clinical record indicated that Resident R1 was originally admitted to the facility on 6/16/23, with a readmission date of 2/6/24.

Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/5/24, included diagnoses of anxiety and depression.

Review of Resident R1's care plan, most recently updated on , included goals and interventions for a psychosocial wellbeing problem.

Review of a psychotherapy progress note dated 10/4/23, indicated that Resident R1 "tries to keep busy with arts and crafts projects."

Review of a psychology progress note dated 10/25/23, indicated that Resident R1 "prefers to stay in room and work on her jewelry (has an impressive array of jewelry making supplies and finished pieces)."

Review of monthly psychiatry progress notes dated from August 2023, through July 2024, all indicated that Resident R1 used making jewelry as an alleviating factor for her depression and anxiety.

Review of a progress note dated 6/25/24, at 3:59 p.m. indicated Resident R1 had verbalized suicidal plans, had a significant increase in behaviors, and was transported to the hospital for an involuntary psychiatric commitment.

Review of a progress note dated 6/26/24, at 10:23 p.m. indicated Resident R1 returned to the facility.

Review of information submitted to the Department of Health on 7/1/24, stated that she had not had her property returned.

Review of a progress note written by Social Worker (SW) Employee E1 dated 7/24/24, at 8:36 a.m. indicated, "Resident had all of her belongings given back to her with the exception of anything sharp due to her history of harming herself in the facility."

During an interview on 8/1/24, at 12:42 p.m. the SW Employee confirmed that the above referenced return of property was the property removed from Resident R1's room on 6/25/24. When asked why the return of the property safe for Resident R1 to have took four weeks, SW Employee E1 stated Resident R1 "had a lot of stuff" and the facility want to "make sure she would be staying in that room."

Review of facility census information confirmed that Resident R1 was moved to a different room upon return from the hospital on 6/26/24, and had remained in that room through her property return date of 7/24/24, and remained in that same room through the survey date.

During an interview on 8/1/24, at approximately 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to ensure the right to retain personal possessions for one of three residents.

28 Pa. Code 201.18(b)(2)Management.


 Plan of Correction - To be completed: 08/22/2024

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."

F557
1. Resident R1's belongings were returned to her on 7/24/24.
2. The facility will ensure residents have the right to retain personal possessions. Social
Service Director/designee will interview current residents to ensure they have all personal
possessions in their room.
3. The facility staff will be re-educated by the Nursing Home Administrator/designee on the facility policy for personal property.
4. The Social Service Director/designee will interview 5 residents weekly for four weeks and monthly for three months to ensure personal property is in the resident's possession. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

§ 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 15 residents on night shift, on 13 of 21 days (7/7/24, 7/10/24, 7/11/24, 7/12/24, 7/13/24, 7/14/24, 7/15/24, 7/16/24, 7/17/24, 7/18/24, 7/20/24, 7/21/27, and 7/27/24).

Findings include:

Review of the facility policy, "Nursing Department Staffing" dated 4/9/24, indicated the facility will provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
-Licensed Nurses
-Other nursing personnel

Review of the nursing schedules and census information for 7/7/24, through 7/27/24, revealed that the facility failed to meet the following:

7/07/24: Night shift required 42.00 hours of nurse aide care, facility provided 31.25.
7/10/24: Night shift required 42.50 hours of nurse aide care, facility provided 36.00.
7/11/24: Night shift required 43.00 hours of nurse aide care, facility provided 38.50.
7/12/24: Night shift required 43.50 hours of nurse aide care, facility provided 39.25.
7/13/24: Night shift required 43.00 hours of nurse aide care, facility provided 39.75.
7/14/24: Night shift required 43.50 hours of nurse aide care, facility provided 31.50.
7/15/24: Night shift required 43.50 hours of nurse aide care, facility provided 40.50.
7/16/24: Night shift required 43.50 hours of nurse aide care, facility provided 39.50.
7/17/24: Night shift required 43.50 hours of nurse aide care, facility provided 39.75.
7/18/24: Night shift required 42.50 hours of nurse aide care, facility provided 38.25.
7/20/24: Night shift required 42.50 hours of nurse aide care, facility provided 32.75.
7/21/24: Night shift required 43.00 hours of nurse aide care, facility provided 38.25.
7/27/24: Night shift required 43.50 hours of nurse aide care, facility provided 34.75.

During an interview on 8/1/24, at approximately 3:00 p.m. the Nursing Home Administrator and confirmed that the facility administrative staff failed to provide a minimum of one nurse aide per 15 residents on night shift, on 13 of 21 days.


 Plan of Correction - To be completed: 08/22/2024

1. The facility cannot correct that the nurse aide staffing ratio was not meet on 7/7/24,7/10/24,7/11/24,7/12/24,7/13/24,7/14/24,7/15/24,7/16/24,7/17/24,7/18/24,7/20/24,7/21/24,7/27/24. There were no adverse effects to residents on the identified dates.
2. The facility will ensure that staffing ratios are met every shift.
3. Nursing administration and the nursing scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring staffing ratios are meet each shift. A Daily staffing meeting will be held by administration to monitor staffing ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios the scheduler/or designee will call off duty facility staff, and will utilize external staffing support resources.
4. The Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.


§ 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 interviews, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift and one LPN per 40 residents during the night shift on four of 21 days (7/11/24, 7/12/24, 7/13/24, and 7/14/24).

Findings include:

Review of the facility policy, "Nursing Department Staffing" dated 4/9/24, indicated the facility will provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
-Licensed Nurses
-Other nursing personnel

Review of the nursing schedules and census information for 7/7/24, through 7/27/24, revealed that the facility failed to meet the following:

7/11/24: Night shift required 17.20 hours of LPN care, facility provided 15.00.
7/12/24: Night shift required 17.40 hours of LPN care, facility provided 15.50.
7/13/24: Day shift required 27.52 hours of LPN care, facility provided 25.25.
7/14/24: Day shift required 27.84 hours of LPN care, facility provided 24.50.

During an interview on 8/1/24, at approximately 3:00 p.m. the Nursing Home Administrator and confirmed that the facility administrative staff failed to ensure a minimum of one LPN per 25 residents during the day shift and one LPN per 40 residents during the night shift on four of 21 days.


 Plan of Correction - To be completed: 08/22/2024

P5530
1. The facility cannot correct that the Licensed Practical Nursing staffing ratio was not meet on 7/11/24, 7/12/24, 7/13/24 and 7/14/24. There were no adverse effects to residents on the identified dates.
2. The facility will ensure that staffing ratios are met every shift.
3. Nursing administration and the nursing scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring staffing ratios are meet each shift. A Daily staffing meeting will be held by administration to monitor staffing ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios the scheduler/or designee will call off duty facility staff, and will utilize external staffing support resources.
4. The Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.



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