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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 43 surveys for this facility. Please select a date to view the survey results.

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

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on September 15, 2025, at Wecare at Mt. Lebanon Rehabilitation and Nursing Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 137202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 15, 2025, it was determined that WeCare at Mt. Lebanon Rehabilitation and Nursing Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type II (000), unprotected noncombustible building, without a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting two of ten smoke compartments.

Findings include:

1. Observation on September 15, 2025, revealed the following deficiencies which may affect the operation of the automatic sprinkler system:

a) 10:25 a.m., there were multiple dirty/dusty sprinkler heads in the Laundry room;
b) 10:50 a.m., there were multiple gaps, greater than 1/8 inch, in the ceiling tiles above the kitchen doors.

Interview with the Facility Administrator and Maintenance Director on September 15, 2025 at 1:00 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 10/29/2025

The Facility submits this plan of correction under the procedures established by the Department of Health in order to comply with the department's directive to change conditions which the department alleges are deficient under date and/or federal long term care regulations. This plan of correction should not be construed as either a waiver or the facility right to appeal or challenge the accuracy of severity of the alleged deficiencies or an admission of past or ongoing violation of state or federal regulatory requirements.

The dirty/dusty sprinkler heads in the laundry room were cleaned and the gaps greater than 1/8 inch in the ceiling tiles above the kitchen doors were repaired.
Sprinkler heads were evaluated for dirt/dust and cleaned. Ceiling tiles were evaluated for gaps greater than 1/8 inch and repaired.
The NHA educated the Maintenance Director and Housekeeping Director on dirty/dusty sprinkler heads and how there should not be any gaps in the ceiling tiles.
The Maintenance Director will complete random audits 5 sprinkler heads for dirt/dust weekly for 2 weeks. The Maintenance Director will complete random audits of ceiling tiles weekly for 2 weeks to ensure that there are not any gaps.
The audits will be taken to QAPI for review.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in three instances, affecting three of ten smoke compartments.

Findings include:

1. Observation on September 15, 2025, revealed the following corridor door deficiencies:

a) 9:20 a.m., the door to housekeeping storage failed to latch when tested;
b) 9:45 a.m., the door to central supply had a gap around the new locking mechanism;
c) 10:43 a.m., the door to the soiled linen closet on the low side had a gap around the new locking mechanism.

Interview with the Facility Administrator and Maintenance Director on September 15, 2025, at 1:00 p.m., confirmed the corridor door deficiencies.

Plan of Correction - To be completed: 10/29/2025

The door to the housekeeping storage was repaired to latch. The gap around the new locking mechanism was repaired for the central supply door and the soiled linen closet on the low side.
An audit was completed to ensure doors have positive latching and no gaps are found around locking mechanisms.
The NHA educated the Maintenance Director on positive latching of doors and gaps around locking mechanisms.
The Maintenance Director will complete random audits of 5 doors weekly for 2 weeks to ensure that there is positive latching and no gaps are found around the locking mechanism.
The audits will be taken to QAPI for review.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in two instances, affecting three of ten smoke compartments.

Findings include:

1. Observation on September 15, 2025, revealed the following smoke barrier door deficiencies;

a) 9:35 a.m., the doors to the kitchen failed to latch when tested;
b) 10:30 a.m., there was a gap greater than 1/8" between the smoke doors near the lounge when they were closed.

Interview with the Facility Administrator and the Maintenance Director on September 15, 2025, at 1:00 p.m., confirmed the listed smoke barrier door deficiencies.

Plan of Correction - To be completed: 10/29/2025

The smoke doors to the kitchen were repaired to latch. The gap greater than 1/8 inch between the smoke doors near the lounge were repaired.
Whole house audit of smoke doors was completed to ensure that they latch and there are no gaps between the doors greater than 1/8 inch.
The NHA educated the Maintenance Director on smoke doors to have positive latching and no gaps when closed greater than 1/8 inch.
The Maintenance Director will complete random audits of 2 smoke doors weekly for 2 weeks to ensure that there is positive latching and no gaps greater than 1/8 inch when closed.
The audits will be taken to QAPI for review.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator in one instance, affecting the entire facility.

Findings include:

1. Document review on September 15, 2025, at 8:30 a.m., revealed the facility failed to provide documentation for the required weekly battery voltage check.

Interview with the Facility Administrator and Maintenance Director on September 15, 2025, at 1:00 p.m., confirmed the lack of emergency generator documentation at the time of the survey.

Plan of Correction - To be completed: 10/29/2025

TELS was updated to reflect battery voltage check documentation to be completed weekly.
The NHA will educate the Maintenance Director on required documentation needed for the weekly generator test to include battery voltage check.
The NHA will audit the weekly generator test to ensure that the battery voltage check was recorded weekly for 2 weeks.
The audits will be taken to QAPI for review.

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