Inspection visit
Health inspection
28 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 28 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, review of facility policies and documentation, clinical record review and interviews with
residents and staff, it was determined that the facility failed to honor a resident's right to smoke, for 4 of 10
residents reviewed (Residents R11, R19, R28, and R53).
Findings include:
A review of the facility Smoking Policy dated 10/20/24, indicated the facility follows a supervised smoking
policy and smoking is permitted in designated areas.
A review of the facility policy Smoke Free Facility dated 2/5/25, indicated that smoking is prohibited in all
areas of the facility and facility grounds.
A review of Resident R11's clinical record indicated the resident was admitted to the facility on [DATE] with
diagnoses that included anxiety, depression, and hypertension (high blood pressure). The resident is alert
and able to make needs known.
A review of Resident R11's care plan dated 1/15/25, indicated the resident has history of smoking in the
community and wishes to continue smoking.
A review of a social service progress note dated 2/4/25, indicated Resident R11 was informed that smoking
is no longer permitted on the premises. The resident declined to have a smoking patch and wants to
transfer to a smoking facility.
During an interview on 2/12/25, at 10:30 a.m. Resident R11 stated I want to smoke, and I don't want the
patch, if I can't smoke here, I want transferred to a place I can smoke. I am an addict who quit drugs, I
shouldn't have to give up my cigarettes.
A review of Resident R19's clinical record indicated the resident was admitted to the facility on [DATE] with
diagnoses that included paranoid schizophrenia (a type of psychosis where the mind does not agree with
reality), diabetes, and tobacco use. The resident is alert and able to make needs known.
A review of Resident R19's care plan dated 6/24/24, indicated the resident has history of smoking in the
community and wishes to continue smoking.
A review of a social service progress note dated 2/3/25, indicated Resident R19 was informed that
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 46
Event ID:
395028
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
smoking is no longer permitted on the premises. The resident declined to have a smoking patch or be
referred to another smoking facility.
During an interview on 2/14/25, at 9:35 a.m. Resident R19 stated I want to smoke, and I don't want the
patch or to go anywhere else.
Residents Affected - Few
A review of Resident R28's clinical record indicated the resident was admitted to the facility on [DATE] with
diagnoses that included heart failure, and nicotine dependence. The resident is alert and able to make
needs known.
A review of Resident R28's care plan dated 11/1/24, indicated the resident has history of smoking in the
community and wishes to continue smoking.
A review of a social service progress note dated 2/4/25, indicated Resident R28 was informed that smoking
is no longer permitted on the premises. The resident declined to have a smoking patch and wanted referred
to another smoking facility.
During an interview on 2/11/24, at 10:30 a.m. (resident still not transferred to another smoking facility)
Resident R28 stated I don't want the patch, I told them if I can't smoke here, I want transferred to a place I
can smoke. They said someone would come in and get me moved, no one has come in. Resident 28
repeatedly stated she does not want the patch and wants to go anywhere she can smoke right now.
A review of Resident R53's clinical record indicated the resident was admitted to the facility on [DATE] with
diagnoses that included heart failure, diabetes, and high blood pressure. The resident is alert and able to
make needs known.
A review of Resident R53's admission Agreement signed 6/12/23, indicated the facility is a smoking facility.
A review of Resident R53's care plan dated 12/8/24, indicated the resident has history of smoking in the
community and wishes to continue smoking.
A review of a social service progress note dated 2/3/25, indicated Resident R53 was informed that smoking
is no longer permitted on the premises. The resident declined to have a smoking patch and wanted referred
to another smoking facility.
During an interview on 2/14/25, at 9:45 a.m. Resident R53 stated I want to smoke, and I don't want the
patch, and I really do not want to go anywhere else.
During an interview on 2/14/25 at 1:00 p.m. the Director of Nursing confirmed the above findings and that
the facility changed their smoking policy on 2/5/25, and Resident's R11, R19, R28, and R53's right to
smoke was no longer honored at the facility.
28 Pa. Code 201.29(a)(j) Resident rights.
28 Pa. Code 209.3(a) Smoking.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 2 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0565
Honor the resident's right to organize and participate in resident/family groups in the facility.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of facility policy, facility documentation, resident group and staff interviews, it was
determined the facility failed to provide Resident Council the opportunity for meetings for three of twelve
months (September 2024, October 2024, and November 2024).
Residents Affected - Few
Findings include:
Review of the facility policy titled, Resident Council Meetings reviewed 10/20/24, states the council meets
at least quarterly but no less than as determined by the group. The Activity Director/designee shall be
designated to serve as the group liaison. The designated liaison shall be responsible for providing
assistance with facilitating successful group meetings and responding to written requests from the group
meetings.
During Resident Group, with four alert and oriented residents and the Ombudsman on 2/11/25, at 10:30
a.m., Residents R5, R26 R28 and R52 indicated some months no meetings were arranged. The attendees
reported that the activities department had organized the meetings until the activity director and one other
activity staff member resigned. Council members reported, now there is only one part time activity aide in
the facility.
During an interview on 2/12/25, at 12:00 p.m. the Nursing Home Administrator (NHA) confirmed the facility
failed to provide Resident Group the opportunity for meetings for three of twelve months (September 2024,
October 2024, and November 2024).
28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.18 (e)(1)(4) Management.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 3 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0577
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation and staff interview, it was determined the facility failed to ensure the Department of
Health most recent survey results were readily accessible to residents and visitors, for three of three
locations (first floor lobby, nursing units fourth, and six floors).
Residents Affected - Many
Findings Include:
During an interview on 2/11/25, at 10:30 a.m., the Resident Group, four of four residents agreed that they
were unaware of the location of the Department of Health survey results (Residents R5, R26 R28 and
R52).
During an observation on 2/12/25, at 9:20 a.m., signage in the lobby, fourth floor and sixth floor read survey
results can be found on the 1st, 4th, and 6th floors (the public entry and resident care areas).
During an observation on 2/12/25, at 9:20 a.m. in the lobby, no survey result book could be located.
During an observation on 2/12/25, at 9:22 a.m. on the fourth floor, the survey result book was located
behind empty folders and contained survey results from 2023. The prior survey date for this facility was on
2/12/24.
During an observation on 2/12/25, at 9:24 a.m. on the sixth floor, no survey result book could be located.
During an interview on 2/12/25, at 9:25 a.m. the Director of Nursing (DON) confirmed the facility failed to
ensure the Department of Health most recent survey results were readily accessible to residents and
visitors for three of three locations, (first floor lobby, nursing units fourth, and six floors).
28 Pa. Code 201.14(a) Responsibility of licensee.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 4 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the facility policy and clinical records and staff interview, it was determined that the facility failed to
provide the opportunity to formulate an advance directive (written instructions for when the individual is
incapacitated) or conduct periodic review of instructions, for seven of the twenty-two residents reviewed
(Resident R5, R11, R35, R41 R45, R52, and R55).
Findings Include:
A review of the facility policy Resident Rights Regarding Treatment and Advanced Directives last reviewed
10/20/24, indicated it's the policy of this facility to support and facilitate a resident's right to request, refuse
and/or discontinue medical or surgical treatment and to formulate and advance directive. Decisions
regarding advanced directives and treatment will be periodically reviewed as part of the comprehensive
care planning process, the existing care instructions and whether the resident wishes to change or continue
these instructions.
Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2023, indicated that a
Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment.
The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment
Review of the clinical record indicated Resident R5 was originally admitted to the facility on [DATE].
Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/17/24,
indicated diagnoses of Anxiety, depression, and dementia, a BIMS of 15.
A review of the clinical record failed to reveal an advance directive, evidence that a periodic advanced
directive review occurred or documentation that Resident R5 was given the opportunity to formulate an
Advanced Directive.
Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE].
Review of Resident R11's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/16/24,
indicated diagnoses of Anxiety, depression, and hypertension (high blood pressure), a BIMS of 15.
A review of the clinical record failed to reveal an advance directive, evidence that a periodic advanced
directive review occurred or documentation that Resident R11 was given the opportunity to formulate an
Advanced Directive.
Review of the clinical record indicated Resident R35 was admitted to the facility on [DATE].
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 5 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of Resident R35's MDS dated [DATE], indicated diagnoses of Anxiety, depression, and coronary
artery disease (heart disease), a BIMS of 15.
A review of the clinical record failed to reveal an advance directive, evidence that a periodic advanced
directive review occurred or documentation that Resident R35 was given the opportunity to formulate an
Advanced Directive.
Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE].
Review of Resident R41's MDS dated [DATE], indicated diagnoses of stroke, depression, and dementia, a
BIMS of 7.
A review of the clinical record failed to reveal an advance directive, evidence that a periodic advanced
directive review occurred or documentation that Resident R41 was given the opportunity to formulate an
Advanced Directive.
Review of the clinical record indicated Resident R45 was admitted to the facility on [DATE].
Review of Resident R45's MDS dated [DATE], indicated diagnoses of left shoulder fracture, depression,
and dementia, a BIMS of 8.
A review of the clinical record failed to reveal an advance directive, evidence that a periodic advanced
directive review occurred or documentation that Resident R45 was given the opportunity to formulate an
Advanced Directive.
Review of the clinical record indicated Resident R52 was originally admitted to the facility on [DATE].
Review of Resident R52's MDS dated [DATE], indicated diagnoses of coronary artery disease (heart
disease), dementia, depression, a BIMS of 15.
A review of the clinical record failed to reveal an advance directive, evidence that a periodic advanced
directive review occurred or documentation that Resident R52 was given the opportunity to formulate an
Advanced Directive.
Review of the clinical record indicated Resident R55 was admitted to the facility on [DATE].
Review of Resident R55's MDS dated [DATE], indicated diagnoses of schizoaffective disorder (mental
illness affects thoughts, mood and behavior), diverticulitis of large intestine with perforation and abscess
(inflammation of the colon), and hypertension (high blood pressure), a BIMS of 15.
A review of the clinical record failed to reveal an advance directive, evidence that a periodic advanced
directive review occurred or documentation that Resident R55 was given the opportunity to formulate an
Advanced Directive.
During an interview on 2/11/25 at 8:00 a.m. the Nursing Home Administrator (NHA) confirmed that the
facility failed to provide the opportunity to formulate an advance directive or conduct periodic review of
instructions, for seven of the twenty-two residents reviewed (Resident R5, R11, R35, R41 R45, R52, and
R55).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 6 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578
28 Pa. Code: 201.29(b)(d)(j) Resident rights.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 7 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of facility policy, facility documents, and staff interviews, it was determined that the facility
failed to provide in a timely manner, notice of Medicare non coverage (payment) for two of two residents
(Resident R217 and R218).
Residents Affected - Some
Findings include:
Review of CMS guidelines, Medicare provider or health plan must deliver a completed copy of the Notice of
Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home
health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice
services. The NOMNC must be delivered at least two calendar days before Medicare covered services end
or the second to last day of service if care is not being provided daily. The Skilled Nursing Facility Advanced
Beneficiary Notice of Non-Coverage, (SNF ABN) must be issued to Medicare Fee -for-Service (original
Medicare) beneficiaries who are receiving care in a Skilled Nursing Facility (SNF) when: Medicare is
expected to deny coverage and when the SNF wants to charge the beneficiary for the non-covered
services.
A review of the facility policy Advance Beneficiary Notices, last reviewed 10/20/24, indicated the facility
assures appropriate Advance Beneficiary Notices are issued in accordance with CMS guidelines.
A review of the list of Medicare residents who were discharged from a Medicare Part A stay with benefit
days remaining, provided by the facility on 2/11/25, included Residents R217 and R218.
A review of the SNF ABN form for Residents R218 indicated payment for skilled nursing services would end
on 8/2/24. The facility failed to provide the document for Resident R218 and failed to provide the resident
time to appeal.
A review of the SNF ABN form for Residents R217 indicated payment for skilled nursing services would end
on 10/21/24. The facility failed to provide the document for Resident R 217 and failed to provide the resident
time to appeal.
A review of the facility NOMNC form indicated that the resident has a right to appeal non-payment of
services, your request must be made no later than noon of the day before the effective date of
non-coverage.
A review of the NOMNC form for Resident R217 indicated payment for skilled nursing services will end
10/21/24. The facility failed to provide the document for Resident R 217 and failed to provide the resident
time to appeal.
During an interview on 2/11/25, at 10:20 a.m. the NHA confirmed that the facility was unable to provide the
NOMNC form for Resident R217 and the SNF ABN for Residents R217 and R218.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(2) Management.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 8 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0582
28 Pa. Code 201.29(a): Resident rights.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 9 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
policy review and observations and staff interviews it was determined that the facility failed to maintain a
homelike environment throughout the facility (resident rooms, dining rooms and hallways) for three of three
nursing units. (4th, 5th, and 6th floor nursing units)
Findings include:
A review of the facility policy Safe and Homelike Environment dated 10/20/24, indicated the facility will
provide a safe, clean, comfortable, and homelike environment.
During an observation of the facility on 2/14/25, at 9:30 a.m., the following was revealed:
* Resident room [ROOM NUMBER] W (window) air condition/heating unit had broken vents and dusty
debris and trash particles inside the unit. The wall next to the bathroom entrance had missing molding and
holes around the night light.
* Resident room [ROOM NUMBER] W air condition/heating unit had broken vents and dusty debris and
trash particles inside the unit.
* Resident room [ROOM NUMBER] W air condition/heating unit had broken vents and dusty debris and
trash particles inside the unit.
* Resident room [ROOM NUMBER] W air condition/heating unit had broken vents and dusty debris and
trash particles inside the unit.
* Resident room [ROOM NUMBER] W air condition/heating unit had broken vents and dusty white debris
and trash particles inside the unit.
* Resident rooms [ROOM NUMBERS] had molding around the perimeter of the rooms with exposed tubing
and black cables that lead into the bathroom sink drainage connection and not in use.
* Dining rooms on the 4th, 5th, and 6th floors had brown vinyl flooring that was lifting up and had worn
black holes throughout.
* Fifth Floor nursing units rooms 511, 512, and multiple rooms with no room numbers had walls with holes
and scratches behind the beds.
*Sixth Floor nursing unit room [ROOM NUMBER] had holes in the wall and scratches behind the bed.
During an interview on 2/14/25, at 10:30 a.m., the Director of Nursing confirmed that the facility failed to
maintain the facility in a homelike environment.
Pa Code: 207.2 (a) Administrator's responsibility
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 10 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0585
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must
establish a grievance policy and make prompt efforts to resolve grievances.
Based on review of facility policy, observations, and resident and staff interviews, it was determined that the
facility failed to provide and make accessible grievance forms to residents and visitors on one of two
nursing units (fourth floor) and failed to make the grievance box accessible on one of two nursing units
(fourth floor).
Findings include:
A review of the facility policy Resident and Family Grievance reviewed 10/20/24, indicated the facility
utilizes a grievance form to identify concerns and for tracking.
During an observation on 2/12/25, at 9:25 a.m. revealed the grievance box and forms were not accessible
due to a trash bin placed in front of the grievance box on the fourth-floor nursing unit.
During an observation on 2/12/25, at 9:25 a.m. revealed the grievance forms were not present on the
fourth-floor nursing unit.
During an interview on 2/12/25, at 9:25 a.m. The Director of Nursing confirmed the facility failed to provide
and make accessible grievance forms to residents and visitors on one of two nursing units (fourth floor) and
failed to make the grievance box accessible on one of two nursing units (fourth floor).
28 PA Code: 201.18(e)(4) Management.
28 PA Code: 201.29(a)(b)(c) Resident rights.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 11 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make
certain allegations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated for one of
two residents reviewed. (Resident R46).
Residents Affected - Few
Findings include:
A review of the facility Abuse, Neglect, and Exploitation policy dated 10/20/24, indicated that the facility will
provide complete and through documentation of the investigation. Identify and interviewing all involved
persons, including the alleged victim, alleged perpetrator, witness and others who might have knowledge of
the allegations.
A review of Resident R46's admission record indicated the resident was admitted on [DATE]. Resident R46
was transferred to the hospital 2/3/25 for evaluation of a Deep Vein Thrombosis (blood clot).
Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a
Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment.
The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment
A review of Resident R46 Minimum Data Set assessment (MDS-a periodic assessment of resident care
needs) dated 1/23/25, included diagnoses of Cerebrovascular Accident (stroke), anxiety disorder,
depression, and chronic osteomyelitis of the left ankle and foot (bone infection). Review of Section C:
Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R46's score to be 14, intact
cognition.
A review of facility submitted documents, indicated Resident R46 and nursing staff, RN Employee E14 and
LPN Employee R15 were giving Resident R46 a hard time when the resident asked why his pain
medication was late, an escalation between resident and staff occurred. Reportedly LPN Employee E15
stated in fact now I am going to make sure you're the last one who gets medication and Employee E14 was
heard saying let him shit and piss on himself and sit in it. The investigation report indicates the resident
(victim) was interviewed, (no resident interview was attached) and the report indicates Resident R46 is not
a credible source, referencing residence past behaviors and medical history.
A review of the personnel files indicates that both RN Employee E14 and LPN Employee E15 were
terminated from the facility after this event.
There was no documented evidence the facility interviewed Resident R46 for the alleged incident of abuse.
During an interview on 2/12/25, at 11:15 a.m. the Nursing Home Administrator (NHA) and Director of
Nursing (DON) confirmed that the facility failed to thoroughly investigate an alleged incident of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 12 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
neglect for one of two residents (Resident R46).
Level of Harm - Minimal harm
or potential for actual harm
28 Pa Code: 201.14(a)(c)(e) Responsibility of licensee
28 Pa Code: 201.18 (b)(1)(e)(1) Management
Residents Affected - Few
28 Pa. Code: 201.20 (b) Staff development.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 13 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0636
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every
12 months.
Based 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
(MDS- periodic assessment of resident care needs) assessments were completed in the required time
frame for seven of 25 residents (Resident R1, R23, R45, R49, R52, R57, and R58).
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides
instructions and guidelines for completing required MDS assessments, dated October 2024, indicated that
an admission MDS assessment was to be completed no later than 14 days following admission (admission
date plus 13 calendar days), and annual MDS assessment was to be completed no later than Assessment
Reference Date (ARD).
Resident R1 had an ARD of 11/13/24, with an MDS completion date of 11/28/24.
Resident R23 had an ARD of 1/16/25, with an MDS completion due date of 1/31/25.
Resident R45 had an admission date of 1/13/25, with an MDS completion due date of 1/27/25.
Resident R49 had an ARD of 12/15/24, with an MDS completion date of 1/3/25.
Resident R52 had an ARD of 11/13/24, with an MDS completion date of 11/29/24.
Resident R57 had an admission date of 1/15/25, with an MDS completion due date of 1/30/25.
Resident R58 had an admission date of 1/11/25, with an MDS completion due date of 1/30/25.
During an interview on 2/14/25, at approximately 2:00 p.m. the Nursing Home Administrator and the
Director of Nursing were made aware that the facility failed to make certain that MDS assessments were
completed in the required time frame for seven of 25 residents.
28 Pa. Code: 211.5(f) Clinical records.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 14 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0638
Assure that each resident’s assessment is updated at least once every 3 months.
Level of Harm - Minimal harm
or potential for actual harm
Based 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 ten of 51 residents (Resident R12, R14,
R20, R30, R34, R35, R41, R43, R44, and R55).
Residents Affected - Some
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides
instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated
assessments of a resident's abilities and care needs), dated October 2024, indicated that quarterly MDS
assessments were to be completed no later than 14 days after the Assessment Reference Date (ARD).
Resident R12 had an ARD of 12/12/24, with an MDS completion date of 1/3/25.
Resident R14 had an ARD of 12/20/24, with an MDS completion date of 1/7/25.
Resident R20 had an ARD of 11/14/24, with an MDS completion date of 11/30/24.
Resident R30 had an ARD of 12/4/24, with an MDS completion date of 1/3/25.
Resident R34 had an ARD of 11/28/24, with an MDS completion date of 1/3/25.
Resident R35 had an ARD of 12/5/24, with an MDS completion date of 1/3/25.
Resident R41 had an ARD of 12/19/24, with an MDS completion date of 1/3/25.
Resident R43 had an ARD of 1/15/25, with an MDS completion date of 1/31/25.
Resident R44 had an ARD of 11/14/24, with an MDS completion date of 11/28/24.
Resident R55 had an ARD of 12/4/24, with an MDS completion date of 1/3/25.
During an interview on 2/14/25, at approximately 2:00 p.m. the Nursing Home Administrator and the
Director of Nursing were made aware that the facility failed to make certain that quarterly MDS
assessments were completed in the required time frame for six of 25 residents.
28 Pa. Code: 211.5(f) Clinical records.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 15 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff
interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set
assessments were accurate and fully completed for seven of ten residents (Resident R8, R10, R13, R29,
R36, R40, and R54).
Residents Affected - Some
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives
instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs)
dated October 2024, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview
for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or
it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes
understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be
coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and the assessment
should be completed if the resident is at least sometimes understood.
-Resident R8 had an MDS completed on 1/9/25. Review of Section B: Hearing, Speech, and Vision,
Question B0700 indicated that Resident R8 is sometimes understood. Review of Section C: Cognitive
Patterns, Question C0100 indicated that Resident R8 is rarely understood, and the BIMS assessment was
not completed. Review of Section D: Mood, Question C0100 indicated that Resident R8 is rarely
understood, and the Resident Mood Interview assessment was not completed.
-Resident R10 had an MDS completed on 11/13/24. Review of Section B: Hearing, Speech, and Vision
indicated Resident R10 was not in a persistent vegetative state/no discernible consciousness. The
remainder of the questions in this section were documented as Not Assessed. Review of Sections C:
Cognitive Patterns and Section D: Mood, BIMS and Resident Mood Interview indicated all questions were
documented as Not Assessed.
-Resident R13 had an MDS completed on 11/19/24. Review of Section B: Hearing, Speech, and Vision,
Question B0700 indicated that Resident R13 is understood. Review of Sections C: Cognitive Patterns,
Question C0100 indicated the BIMS assessment should be completed. All further questions were
documented as Not Assessed.
-Resident R29 had an MDS completed on 2/4/25. Review of Section B: Hearing, Speech, and Vision,
Question B0700 indicated that Resident R29 is sometimes understood. Review of Sections C: Cognitive
Patterns and Section D: Mood, BIMS and Resident Mood Interview indicated all questions were
documented as Not Assessed.
-Resident R36 had an MDS completed on 11/16/24. Review of Section B: Hearing, Speech, and Vision
indicated Resident R10 was not in a persistent vegetative state/no discernible consciousness. Question
B0700: Makes Self Understood was documented as Not Assessed. Review of Sections C: Cognitive
Patterns and Section D: Mood, BIMS and Resident Mood Interview indicated all questions were
documented as Not Assessed.
-Resident R40 had an MDS completed on 1/9/25. Review of Section B: Hearing, Speech, and Vision,
Question B0700 indicated that Resident R40 is understood. Review of Sections C: Cognitive Patterns and
Section D: Mood, BIMS and Resident Mood Interview indicated all questions were documented as Not
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 16 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Assessed.
Level of Harm - Minimal harm
or potential for actual harm
-Resident R54 had an MDS completed on 2/4/25. Review of Section B: Hearing, Speech, and Vision,
Question B0700 indicated that Resident R54 is understood. Review of Sections C: Cognitive Patterns,
Question C0100 indicated the BIMS assessment should be completed. All further questions were
documented as Not Assessed.
Residents Affected - Some
During an interview on 2/14/25, at approximately 12:00 p.m. the Resident Nurse Assessment Coordinator
confirmed that the facility failed to make certain that comprehensive Minimum Data Set assessments were
accurate and fully completed for seven of ten residents.
28 Pa. Code: 211.5(f) Clinical records.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 17 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of the facility policy, clinical record and staff interviews, it was determined that the facility failed to
provide an ongoing program of activities to meet the interests of and support the physical, mental, and
psychosocial well-being of each resident for eight of ten residents (Residents R5, R11, R26, R35, R41,
R45, R52, and R55).
Residents Affected - Some
Findings included:
Review of the facility policy Resident Rights reviewed 10/20/24, indicated the resident has the right to a
dignified existence, self-determination, and communication with and access to persons and services inside
and outside the facility. Self-Determination - The resident has the right to, and the facility must promote and
facilitate self-determination through support of resident choice, including but not limited to: The resident has
a right to choose activities, schedules, health care and providers of health care services consistent with his
or her interests, assessments and plan of care and other applicable provisions of this part.
Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2023, indicated that a
Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment.
The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment
During Resident Group on 2/12/25, at 10:30 a.m. the attendees Resident R5, R26, and R52 reported there
are fewer activities since activity director and one other activity staff member resigned. Resident Group
members reported, now there is only one part time activity aide in the facility, and she is doing the best she
can.
Review of the clinical record indicated Resident R5 was originally admitted to the facility on [DATE].
Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/17/24,
indicated diagnoses of anxiety, depression, and dementia, a BIMS of 15. Activity preferences are reading,
music, animals, news, group activities, going outside, and participation in religious services.
Review of Resident R5's plan of care for leisure lifestyle choices and group activities initiated 11/28/17, and
most recently revised 5/18/21, indicated the resident can make leisure lifestyle choices and attends daily
group activities as an active participant daily. Resident does enjoy coloring, socializing, bingo, Resident
Council President, arts/crafts, joking with staff and other residents she to receive a monthly activities
calendar.
Review of Resident R5's clinical record for 1/25, revealed the facility failed to provide an ongoing program of
activities to meet the resident's interests. Review of Resident R5's Documentation
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 18 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Level of Harm - Minimal harm
or potential for actual harm
Survey Report indicated Resident R5 participated in group programs on four of thirty-one days, three on
the evening shift (3 p.m. to 11 p.m.) and one on the night shift (11 p.m. 7 a.m.).
During resident group interview on 2/11/25, at 10:30 a.m. Resident R5 stated, the facility had a lot of group
activities, not as many over the past months, we don't get the activities calendars anymore.
Residents Affected - Some
Review of the clinical record indicated Resident R26 was originally admitted to the facility on [DATE].
Review of Resident R26's MDS dated [DATE], indicated diagnoses of End Stage Renal Disease (kidney
failure), COPD (lung disease), systemic lupus erythematosus (body's immune system attacks its own
tissues), a BIMS of 15. Activity preferences are reading, music, animals, news, group activities, going
outside, and participation in religious services.
Review of Resident R26's plan of care for activities intervention for acknowledge and strive to maintain
positive compliance with treatment and care initiated 6/28/23.
Review of Resident R26's clinical record for 1/25, revealed the facility failed to provide an ongoing program
of activities to meet the resident's interests. Review of Resident R26's Documentation Survey Report
indicated Resident R26 had not participated in any group activity.
During resident group interview on 2/11/25, at 10:30 a.m. Resident R26 stated, I agree with the group
comments of there being few activities now.
Review of the clinical record indicated Resident R52 was originally admitted to the facility on [DATE].
Review of Resident R52's MDS dated [DATE], indicated diagnoses of coronary artery disease (heart
disease), dementia, depression, a BIMS of 15. Activity preferences are reading, music, news, going
outside, and participation in religious services.
Review of Resident R52's plan of care for leisure lifestyle choices and group activities initiated 11/25/24,
indicated the resident engages in daily activities of choice including reading his bible and sightseeing on
the administrative floor with supervision/assistance.
Review of Resident R52's clinical record for 1/25, revealed the facility failed to provide an ongoing program
of activities to meet the resident's interests. Review of Resident R52's Documentation Survey Report
indicated Resident R52 had not participated in any group activity.
During resident council group interview on 2/11/25, at 10:30 a.m. Resident R52 stated, since two of the
three activity staff left, the one girl does the best she can when she is here.
Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE].
Review of Resident R11's MDS dated [DATE], indicated diagnoses of Anxiety, depression, and
hypertension (high blood pressure), a BIMS of 15. Activity preferences are reading, music, animals, news,
group activities, and going outside.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 19 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of Resident R11's plan of care for activities intervention for encourage participation in enjoyable
activities initiated 5/24/24.
Review of Resident R11's clinical record for 1/25, revealed the facility failed to provide an ongoing program
of activities to meet the resident's interests. Review of Resident R11's Documentation Survey Report
indicated Resident R11 participated in group programs on three of thirty-one days, on the evening shift (3
p.m. to 11 p.m.).
During an interview on 2/12/25, at 10:30 a.m. Resident R11 stated, I like group activities and the games like
cornhole they played here and crafts, they don't do many activities, crafts, or games now.
Review of the clinical record indicated Resident R35 was admitted to the facility on [DATE].
Review of Resident R35's MDS dated [DATE], indicated diagnoses of Anxiety, depression, and coronary
artery disease (heart disease), a BIMS of 15. Activity preferences are reading, music, animals, news, and
going outside.
Review of Resident R35's plan of care for activities intervention do not leave unattended while smoking
initiated 12/19/23.
Review of Resident R35's clinical record for 1/25, revealed the facility failed to provide an ongoing program
of activities to meet the resident's interests. Review of Resident R35's Documentation Survey Report
indicated Resident R35 participated in group programs on three of thirty-one days, three on the evening
shift (3 p.m. to 11 p.m.).
During an interview on 2/12/25, at 10:45 a.m. Resident R35 stated, I like going on the outings, they don't do
that anymore, there's not much to do now.
Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE].
Review of Resident R41's MDS dated [DATE], indicated diagnoses of stroke, depression, and dementia, a
BIMS of 7. Activity preferences had not been prioritized.
Review of Resident R41's plan of care for leisure lifestyle choices and group activities initiated 4/21/21, and
most recently revised 5/18/21, indicated the resident engages in daily independent activities of choice
watching television, rosary, socializing with staff, wanting to sit outside when the weather is good and to
receive a monthly activities calendar.
Review of Resident R41's clinical record for 1/25, revealed the facility failed to provide an ongoing program
of activities to meet the resident's interests. Review of Resident R41's Documentation Survey Report
indicated Resident R41 had not participated in any group activity.
During an interview on 2/12/25, at 10:55 a.m. Resident R41 stated, I don't get to do much with activities.
Review of the clinical record indicated Resident R45 was admitted to the facility on [DATE].
Review of Resident R45's MDS dated [DATE], indicated diagnoses of left shoulder fracture,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 20 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
depression, and dementia, a BIMS of 8. Activity preferences are reading, music, news, and going outside.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident R45's plan of care does not address recreational activities.
Residents Affected - Some
Review of Resident R45's clinical record for 1/25, revealed the facility failed to provide an ongoing program
of activities to meet the resident's interests. Review of Resident R41's Documentation Survey Report
indicated Resident R45 had not participated in any group activity.
During an interview on 2/12/25, at 11:05 a.m. Resident R45 stated, I haven't been here long and don't know
many people.
Review of the clinical record indicated Resident R55 was admitted to the facility on [DATE].
Review of Resident R55's MDS dated [DATE], indicated diagnoses of schizoaffective disorder (mental
illness affects thoughts, mood and behavior), diverticulitis of large intestine with perforation and abscess
(inflammation of the colon), and hypertension (high blood pressure), a BIMS of 15. Activity preferences are
reading, music, news, going outside, and participation in religious services.
Review of Resident R55's plan of care intervention for activities, offer activities for resident such as listening
to music, watching sports etc . initiated 7/26/24.
Review of Resident R55's clinical record for 1/25, revealed the facility failed to provide an ongoing program
of activities to meet the resident's interests. Review of Resident R55's Documentation Survey Report
indicated Resident R55 had not participated in any group activity.
During an interview on 2/12/25, at 11:15 a.m. Resident R55 stated, I want to be able to go somewhere
outside, you can't go anywhere or do anything outside of here.
During observation on the sixth floor on 2/12/25, at 5:00 p.m. it was observed fifteen of twenty resident
rooms had activity calendars posted the heading is January 2025 this was confirmed with the Director of
Nursing (DON) on 2/12/25 at 5:00 p.m.
During an interview on 2/12/25, at 5:00 p.m. with the Nursing Home Administrator (NHA) and DON a
request for the activity staff persons schedule, personnel file, interview and the activity calendar for the
months of 10/24, 11/24,12/24 and 2/25 was made.
During an interview on 2/13/25 at 1:30 p.m. the NHA confirmed the facility could not locate the personnel
file of the employee, the requested activities calendars for 10/24, 11/24 and 12/24, or the activity employee
schedule.
During an interview on 2/14/25 at 10:30 a.m. the DON confirmed the facility was unable schedule the
activity employee interview.
During an interview on 2/13/25, at 12:00 p.m. the Nursing Home Administrator (NHA) confirmed the facility
failed to provide an ongoing program of activities to meet the interests of and support the physical, mental,
and psychosocial well-being of each resident for eight of ten residents (Residents R5, R11, R26, R35, R41,
R45, R52, and R55).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 21 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
28 Pa. Code: 201. 18(b)(3) Management.
Level of Harm - Minimal harm
or potential for actual harm
28 Pa. Code: 207.2(a) Administrators responsibility.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 22 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0680
Ensure the activities program is directed by a qualified professional.
Level of Harm - Minimal harm
or potential for actual harm
Based on staff interviews and review of facility provided documentation, it was determined the facility failed
to provide a qualified professional to direct the activities program as required for two of 12 months (12/6/24
through 2/14/25).
Residents Affected - Some
Findings include:
Review of the Activities Director job description required Qualifications The activities program must be
directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities
professional.
During an interview on 2/13/25, at 1:30 p.m. the Nursing Home Administrator (NHA) and Director of Nursing
(DON) confirmed the facility failed to provide a qualified professional to direct the activities program for two
of 12 months (12/6/24 through 2/14/25).
28 Pa Code 201.18(b)(3) Management.
28 Pa Code 201.18(e)(6) Management
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 23 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, manufacturer's information, clinical record review, observations, and staff interview,
it was determined the facility failed to provide to provide appropriate care and services to residents
receiving tube feedings for one of two residents reviewed (Residents R20).
Findings include:
The facility policy entitled Care and Treatment of Feeding Tubes (delivery of food or medication via tube
surgically inserted into stomach) dated 10/20/24, indicated the facility must utilize feeding tubes in
accordance with current clinical standards of practice, with interventions to prevent complications to the
extent possible.
Review of the manufacturer's information, Glucerna 1.5 Cal dated 9/7/24, indicated, All medical foods,
regardless of type of administration system, require careful handling because they can support microbial
growth.
NOTE: Failure to follow the increases the potential for microbial contamination and may reduce
Hang product for up to 48 hours after initial connection when clean technique and only one new set are
used. Otherwise hang for no more than 24 hours
Review of the clinical record revealed that Resident R20 was originally admitted to the facility on [DATE],
and readmitted on [DATE].
Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 2/2/25,
included diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of
time), dysphagia (difficulty swallowing), and hemiplegia (paralysis on one side of the body) following a
stroke. Section K- Swallowing/Nutritional Status indicated the resident had a feeding tube while a resident.
Review of Resident R20's plan of care developed initiated 7/7/22, and updated 11/1/24, indicated Resident
R20 required tube feedings related to dysphagia.
Review of a physician order dated 2/7/25, indicated that Resident R20 was to receive Glucerna 1.5 via
peg-tube (a tube inserted through the abdominal wall that brings nutrition directly to the stomach) at a rate
of 80 ml (milliliters) per hour, from 8:00 p.m. to 8:00 a.m.
During an observation on 2/13/25, at 11:38 a.m. Resident R20 was observed with his tube feeding
attached. Observation of the tube feeding formula container did not show that it was dated when opened.
During an observation on 2/14/25, at 11:00 a.m. Resident R20's tube feeding formula container did not
show that it was dated when opened.
During an interview on 2/14/25, at 11:02 a.m. Registered Nurse Employee E10 confirmed that the tube
feeding container was still hanging, and that it was not possible to know what date it was opened.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 24 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 2/14/25, at 11:09 a.m. the Director of Nursing (DON) confirmed that when the tube
feeding is stopped at 8:00 a.m. in the morning, the container should be removed as the formula should not
be used after opened for 24 hours. The DON further confirmed that leaving the tube feeding container
hanging after the stop time, without a date and time, provided the potential for the use of the tube feeding
formula beyond the 24 hour limitation.
Residents Affected - Few
During an interview on 2/14/25, at approximately 2:00 p.m. the Nursing Home Administrator and the the
Director of Nursing confirmed the facility failed to provide to provide appropriate care and services to
residents receiving tube feedings for one of two residents reviewed.
28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 211.12(d)(1) Nursing services.
28 Pa. Code: 211.10(c) Resident care policies.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 25 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy and clinical records, and staff interview, it was determined that facility staff failed to
maintain ongoing communication with the hemodialysis (a machine filters wastes, salts and fluid from your
blood when your kidneys are no longer healthy enough to do this work adequately) center for one of two
residents reviewed (Resident R18).
Residents Affected - Few
Findings include:
A review of the facility policy Hemodialysis reviewed 10/20/24, indicated residents ordered dialysis will have
ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The
licensed nurse will communicate via written format with a dialysis communication form.
A review of the clinical record indicated Resident R18 was re-admitted to the facility on [DATE], with
diagnoses that included end-stage renal disease (ESRD - the kidneys permanently fail to work) and low
blood pressure.
A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 2/2/25, indicated the
diagnoses remain current.
A review of a physician's order summary dated 1/1/25 through 2/28/25, indicated Resident R18 was to
receive dialysis three days a week on Tuesday, Thursday, and Saturday. A review of the nurse progress
notes indicated Resident R18 receives dialysis three times a week.
A review of Resident R18's Dialysis Hand Off Communication Report forms from 1/14/25 through 2/13/25,
revealed 9 communication forms out of 9 scheduled treatments were observed. The section to be
completed by dialysis and returned with the resident were left blank on 1/14, 1/16, 1/21, 1/25, 1/28, 1/30,
2/6, 2/8, and 2/13/25.
During an interview on 2/14/25, at 1:00 p.m. the Director of Nursing confirmed the above findings and the
facility failed to ensure the dialysis communication form was completed between the facility and dialysis
center for Resident R18.
28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 26 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0699
Provide care or services that was trauma informed and/or culturally competent.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to
provide culturally competent, trauma care in accordance with professional standards of practice, accounting
for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may
cause re-traumatization of the resident for three of eight residents (Resident R58, R20, and R30).
Residents Affected - Few
Findings include:
Review of the facility policy, Trauma Informed Care dated 10/20/24, indicated the facility will provide care
and services which are delivered using approaches which are culturally-competent, account for
experienced and preferences, ad address the needs of trauma survivors by minimizing triggers and/or
retraumatization. The policy indicated trauma results from an event, series of events, or set of
circumstances that is experienced by an individual ' s physically or emotionally harmful or life threatening
and that has lasting adverse effects on the individual. Included in the list of common sources was violent
crime.
Review of the clinical record revealed that Resident R58 was admitted to the facility on [DATE].
Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 1/23/25,
included diagnoses of unspecified multiple injuries, fractures of both femurs (upper leg bones), insomnia,
and depression.
Review of a progress note dated 1/14/25, indicated Resident R58 has a history of GSW (gunshot wound) to
legs and left hand and was admitted to [hospital] as level 1 trauma and had emergency surgery for BL
(bilateral, both sides of the body) femur fractures and had IM nail (a metal rod forced into the cavity of a
bone). Has significant pain legs and difficulty ambulating.
Review of Resident R58's evaluations failed to reveal an assessment for trauma-informed care or possible
post-traumatic stress disorder. (PTSD, mental health condition triggered by experiencing or witnessing a
terrifying event).
Review of a progress note dated 1/16/25, indicated Resident R58 has moderate depression.
Review of Resident R58's Social History Assessment completed on 1/16/25, at 1:28 p.m. indicated
Resident R58 experienced anxiety, agitation, and depression.
Review of a progress note dated 2/12/25, at 10:53 a.m. Resident R58 reported increased anxiety.
Review of Resident R58's plan of care developed 1/14/25, failed to include goals and interventions related
to trauma-informed care.
During an interview on 2/12/25, at 1:25 p.m. Resident R58 stated she had five gunshot wounds, and the
perpetrator has not been apprehended. Resident R58 stated she had set up a code word on admission, but
she is worried that the facility does not stop visitors when they enter the building before being allowed on
the elevator. Additionally, Resident R58 requested that her name not be placed outside of her door,
identifying her room. Observation at this time revealed Resident R58's name placed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 27 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0699
outside of her door.
Level of Harm - Minimal harm
or potential for actual harm
Review of the clinical record revealed that Resident R20 was originally admitted to the facility on [DATE],
and readmitted on [DATE].
Residents Affected - Few
Review of the MDS dated [DATE], included diagnoses of anxiety, depression, and PTSD.
Review of Resident R20's plan of care developed initiated 7/7/22, and updated 11/1/24, failed to include
goals and interventions related to PTSD.
Review of Resident R20's evaluations failed to reveal an assessment for trauma-informed care or PTSD.
Review of the clinical record revealed that Resident R30 was admitted to the facility on [DATE].
Review of the MDS dated [DATE], included diagnoses of anxiety, depression, and PTSD.
Review of Resident R30's plan of care developed initiated 12/3/23, and updated 8/261/24, failed to include
goals and interventions related to PTSD.
Review of Resident R30's evaluations failed to reveal an assessment for trauma-informed care or PTSD.
During an interview on 2/14/25, at approximately 11:00 a.m. the Director of Nursing that the facility failed to
provide culturally competent, trauma care in accordance with professional standards of practice, accounting
for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may
cause re-traumatization of the resident for three of eight residents.
28 Pa. Code 211.10 (a) Resident care policies.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 28 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0730
Observe each nurse aide's job performance and give regular training.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of facility policy, personnel records, and staff interview it was determined that the facility
failed to complete annual performance evaluations for one out of four nurse aides (NA Employee E3).
Residents Affected - Few
Findings include:
Review of nurse aide performance evaluations completed by the facility failed to include a performance
evaluation for Nurse Aide Employee E3, with a hire date of 10/11/04.
During an interview on 2/14/25, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that
the facility failed to complete annual performance evaluations for one of four nurse aides as required.
28 Pa Code: 201.20 (a)(b)(c)(d) Staff development.
28 Pa Code: 201.14 (a) Responsibility of licensee.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 29 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure the
pharmacy completed a Medication Regime Review (MRR) at least monthly for two of five residents
(Resident R5 and R56).
Findings:
Review of facility policy Medication Regimen Review reviewed 10/20/24, indicated the drug regimen of each
resident is reviewed at least once a month by a licensed pharmacist. The Medication Regimen Review
(MRR) is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive
outcomes and minimizing adverse consequences and potential risks associated with medications.
Review of the clinical record revealed Resident R5 was admitted to the facility on [DATE], with diagnoses
that included dementia (group of symptoms affecting memory, thinking and social abilities), depression, and
diabetes.
Review of Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs)
dated 11/6/24, indicated the diagnoses remain current.
Review of the care plan dated 2/9/20, indicated to consult with pharmacy, and MD to gradually reduce
dosages if clinically appropriate to do so.
Review of Resident R5 clinical record failed to indicate a MRR was completed for February 2024, April
2024, May 2024, June 2024, July 2024, September 2024, October 2024, and November 2024.
Review of the clinical record indicated Resident R56 was admitted to the facility on [DATE], with diagnoses
that included high blood pressure, diabetes, and dementia.
Review of MDS dated [DATE], indicated the diagnoses remain current.
Review of the care plan dated 5/31/24, indicated to consult with pharmacy, and MD to gradually reduce
dosages if clinically appropriate to do so.
Review of Resident R56 clinical record failed to indicate a MRR was completed for September 2024,
October 2024, November 2024, and December 2024.
During an interview on 2/14/25, at 2:00 p.m. the Director of Nursing confirmed the facility failed to complete
monthly pharmacy MRR's.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 30 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 two of
four residents (Residents R59 and R61)
A review of the facility policy Documentation in the Clinical Record dated 10/20/24, indicated the resident's
medical record shall be complete, accurate, and timely.
During an interview on 2/13/25, at 1:00 p.m. the Director of Nursing revealed that clinical records shall be
completed within 30 days of a resident discharge from the facility.
A review of the clinical record on 2/13/25, indicated that Resident R59 was admitted to the facility on
[DATE] and ceased to breathe on 12/2/24.
A review of the Interdisciplinary Discharge Summary and Disposition of Medications forms dated 12/2/24,
were not completed.
A review of the clinical record on 2/13/25, indicated that Resident R61 was admitted to the facility 10/14/24,
and discharged on 11/19/24.
A review of the Interdisciplinary Discharge Summary and Disposition of Medications forms dated 11/19/24,
were not completed.
During an interview on 2/13/25 at 1:00 p.m., The Director of Nursing (DON) confirmed the above findings,
and the facility failed to make certain that medical records on each resident are complete and accurately
documented for Residents R59 and R61.
28 Pa. Code: 211.5(f)(g)(h) Clinical records.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 31 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm
or potential for actual harm
Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was
determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least
quarterly with all the required committee members for three of four quarterly meetings (January 2024
through December 2024).
Residents Affected - Some
Findings Include:
The facility Quality Assurance and Performance Improvement (QAPI) Program policy dated 10/20/24,
indicated that the facility shall develop, implement, and maintain an effective, comprehensive, data-driven
QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the
care and unique services the facility provides. The QAA committee shall meet at least quarterly and as
needed to coordinate and evaluate activities under the QAPI program.
A review of the Quality assurance and performance improvement sign in sheets and attendance records
indicated the facility had a first quarter meeting on 2/22/24. The facility failed to failed to provide evidence
that the facility conducted a second third and fourth quarter meeting for 2024.
During an interview on 2/14/25, at 10:20 a.m. the Director of Nursing (DON) confirmed that the facility failed
to conduct QAA meetings at least quarterly with all the required committee members for three of four
quarterly meetings (January 2024 through December 2024), as required.
28 Pa Code: 201.18(e)(1)(2)(3)(4) Management.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 32 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0940
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of facility policy, personnel in-service training records, and staff interview, it was
determined that the facility failed to implement and maintain an effective training program for four of four
nurse aides (Employee E1, E3, E4, and E5).
Residents Affected - Some
Findings include:
Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility
will develop, implement, and maintain an effective training program for all new and existing staff.
Review of facility provided documents and training records revealed the following:
Nurse Aide (NA) Employee E1 had a hire date of 10/9/22. The facility provided education filed failed to have
any dates or times provided on any documents within the file.
NA Employee E3 had a hire date of 10/11/04. The facility was unable to provide an education file or any
other documentation that NA Employee E3 had completed any education from 10/11/23, through 10/11/24.
NA Employee E4 had a hire date of 10/11/05. The facility provided education filed revealed a 12-hour
in-service packet, but no dates were present confirmed that the education occurred between 10/11/23,
through 10/11/24.
NA Employee E5 had a hire date of 11/12/13. The facility provided education filed revealed a 12-hour
in-service packet, but no dates were present confirmed that the education occurred between 11/12/23,
through 11/12/24.
During an interview on 2/14/25, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that
the facility failed to provide training on infection prevention and control program for six of nine staff
members.
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(c) Staff development.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 33 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0941
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop, implement, and/or maintain an effective training program that includes effective communications
for direct care staff members.
Based on review of facility policy, personnel in-service training records, and staff interview, it was
determined that the facility failed to provide training on Effective Communication for five of nine staff
members (Employee E1, E3, E4, E7, and E8).
Findings include:
Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility
will develop, implement, and maintain an effective training program for all new and existing staff. Training
content includes, at a minimum:
a. Effective communication for direct care staff.
b. Resident rights and facility responsibility for caring of residents.
c. Elements and goals of the facility's Quality Assurance and Performance Improvement program.
d. Written standards, policies, and procedures for the facility's infection prevention and control program.
e. Written standards, policies, and procedures for the facility's compliance and ethics program.
f. Behavioral health.
g. Dementia management and care of the cognitively impaired.
h. Abuse, neglect, and exploitation prevention.
i. Safety and emergency procedures.
Review of facility provided documents and training records revealed the following staff members did not
have documented training on the effective communication.
Nurse Aide (NA) Employee E1 had a hire date of 10/9/22, failed to have effective communication in-service
education between 10/9/23, and 10/9/24.
NA Employee E3 had a hire date of 10/11/04, failed to have effective communication in-service education
between 10/11/23, and 10/11/24.
NA Employee E4 had a hire date of 10/11/05, failed to have effective communication in-service education
between 10/11/23, and 10/11/24.
Dietary Employee E7 had a hire date of 12/27/15, failed to have effective communication in-service
education between 12/27/23, and 12/27/24.
Licensed Practical Nurse Employee E8 had a hire date of 12/27/15, failed to have effective communication
in-service education between 12/27/23, and 12/27/24.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 34 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0941
During an interview on 2/14/25, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that
the facility failed to provide training on effective communication for five of nine staff members.
Level of Harm - Minimal harm
or potential for actual harm
28 Pa Code: 201.14 (a) Responsibility of licensee.
Residents Affected - Some
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(c) Staff development.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 35 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0942
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for
its residents.
Based on review of facility policy, personnel in-service training records, and staff interview, it was
determined that the facility failed to provide training on Resident Rights for six of nine staff members
(Employee E1, E3, E4, E7, E8, and E9).
Findings include:
Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility
will develop, implement, and maintain an effective training program for all new and existing staff. Training
content includes, at a minimum:
a. Effective communication for direct care staff.
b. Resident rights and facility responsibility for caring of residents.
c. Elements and goals of the facility's Quality Assurance and Performance Improvement program.
d. Written standards, policies, and procedures for the facility's infection prevention and control program.
e. Written standards, policies, and procedures for the facility's compliance and ethics program.
f. Behavioral health.
g. Dementia management and care of the cognitively impaired.
h. Abuse, neglect, and exploitation prevention.
i. Safety and emergency procedures.
Review of facility provided documents and training records revealed the following staff members did not
have documented training on the resident rights.
Nurse Aide (NA) Employee E1 had a hire date of 10/9/22, failed to have resident rights in-service education
between 10/9/23, and 10/9/24.
NA Employee E3 had a hire date of 10/11/04, failed to have resident rights in-service education between
10/11/23, and 10/11/24.
NA Employee E4 had a hire date of 10/11/05, failed to have resident rights in-service education between
10/11/23, and 10/11/24.
Dietary Employee E7 had a hire date of 12/27/15, failed to have resident rights in-service education
between 12/27/23, and 12/27/24.
Licensed Practical Nurse Employee E8 had a hire date of 12/27/15, failed to have resident rights in-service
education between 12/27/23, and 12/27/24.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 36 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0942
Level of Harm - Minimal harm
or potential for actual harm
Maintenance Director Employee E9 had a hire date of 8/21/18, failed to have resident rights in-service
education between 8/21/23, and 8/21/24.
During an interview on 2/14/25, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that
the facility failed to provide training on resident rights for six of nine staff members.
Residents Affected - Some
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(c) Staff development.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 37 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0943
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to
report abuse, neglect, and exploitation.
Based on review of facility policy, personnel in-service training records, and staff interview, it was
determined that the facility failed to provide training on Abuse and Neglect Prevention for six of nine staff
members (Employee E1, E3, E4, E7, E8, and E9).
Findings include:
Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility
will develop, implement, and maintain an effective training program for all new and existing staff. Training
content includes, at a minimum:
a. Effective communication for direct care staff.
b. Resident rights and facility responsibility for caring of residents.
c. Elements and goals of the facility's Quality Assurance and Performance Improvement program.
d. Written standards, policies, and procedures for the facility's infection prevention and control program.
e. Written standards, policies, and procedures for the facility's compliance and ethics program.
f. Behavioral health.
g. Dementia management and care of the cognitively impaired.
h. Abuse, neglect, and exploitation prevention.
i. Safety and emergency procedures.
Review of facility provided documents and training records revealed the following staff members did not
have documented training on the abuse and neglect prevention.
Nurse Aide (NA) Employee E1 had a hire date of 10/9/22, failed to have abuse and neglect prevention
in-service education between 10/9/23, and 10/9/24.
NA Employee E3 had a hire date of 10/11/04, failed to have abuse and neglect prevention in-service
education between 10/11/23, and 10/11/24.
NA Employee E4 had a hire date of 10/11/05, failed to have abuse and neglect prevention in-service
education between 10/11/23, and 10/11/24.
Dietary Employee E7 had a hire date of 12/27/15, failed to have abuse and neglect prevention in-service
education between 12/27/23, and 12/27/24.
Licensed Practical Nurse Employee E8 had a hire date of 12/27/15, failed to have abuse and neglect
prevention in-service education between 12/27/23, and 12/27/24.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 38 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0943
Level of Harm - Minimal harm
or potential for actual harm
Maintenance Director Employee E9 had a hire date of 8/21/18, failed to have abuse and neglect prevention
in-service education between 8/21/23, and 8/21/24.
During an interview on 2/14/25, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that
the facility failed to provide training on abuse and neglect prevention for six of nine staff members.
Residents Affected - Some
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(c) Staff development.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 39 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0944
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement
Program.
Based on review of facility policy, personnel in-service training records, and staff interview, it was
determined that the facility failed to provide training on the Quality Assurance and Performance
Improvement (QAPI) program for six of nine staff members (Employee E1, E3, E4, E7, E8, and E9).
Findings include:
Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility
will develop, implement, and maintain an effective training program for all new and existing staff. Training
content includes, at a minimum:
a. Effective communication for direct care staff.
b. Resident rights and facility responsibility for caring of residents.
c. Elements and goals of the facility's Quality Assurance and Performance Improvement program.
d. Written standards, policies, and procedures for the facility's infection prevention and control program.
e. Written standards, policies, and procedures for the facility's compliance and ethics program.
f. Behavioral health.
g. Dementia management and care of the cognitively impaired.
h. Abuse, neglect, and exploitation prevention.
i. Safety and emergency procedures.
Review of facility provided documents and training records revealed the following staff members did not
have documented training on the QAPI program.
Nurse Aide (NA) Employee E1 had a hire date of 10/9/22, failed to have the QAPI program in-service
education between 10/9/23, and 10/9/24.
NA Employee E3 had a hire date of 10/11/04, failed to have the QAPI program in-service education
between 10/11/23, and 10/11/24.
NA Employee E4 had a hire date of 10/11/05, failed to have the QAPI program in-service education
between 10/11/23, and 10/11/24.
Dietary Employee E7 had a hire date of 12/27/15, failed to have the QAPI program in-service education
between 12/27/23, and 12/27/24.
Licensed Practical Nurse Employee E8 had a hire date of 12/27/15, failed to have the QAPI program
in-service education between 12/27/23, and 12/27/24.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 40 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0944
Level of Harm - Minimal harm
or potential for actual harm
Maintenance Director Employee E9 had a hire date of 8/21/18, failed to have the QAPI program in-service
education between 8/21/23, and 8/21/24.
During an interview on 2/14/25, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that
the facility failed to provide training on the QAPI program for six of nine staff members.
Residents Affected - Some
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(c) Staff development.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 41 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0945
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Include as part of its infection prevention and control program, mandatory training that includes written
standards, policies, and procedures for the program.
Based on review of facility policy, personnel in-service training records, and staff interview, it was
determined that the facility failed to provide training on the Infection Prevention and Control program for six
of nine staff members (Employee E1, E3, E4, E7, E8, and E9).
Findings include:
Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility
will develop, implement, and maintain an effective training program for all new and existing staff. Training
content includes, at a minimum:
a. Effective communication for direct care staff.
b. Resident rights and facility responsibility for caring of residents.
c. Elements and goals of the facility's Quality Assurance and Performance Improvement program.
d. Written standards, policies, and procedures for the facility's infection prevention and control program.
e. Written standards, policies, and procedures for the facility's compliance and ethics program.
f. Behavioral health.
g. Dementia management and care of the cognitively impaired.
h. Abuse, neglect, and exploitation prevention.
i. Safety and emergency procedures.
Review of facility provided documents and training records revealed the following staff members did not
have documented training on the infection prevention and control program.
Nurse Aide (NA) Employee E1 had a hire date of 10/9/22, failed to have infection prevention and control
program in-service education between 10/9/23, and 10/9/24.
NA Employee E3 had a hire date of 10/11/04, failed to have infection prevention and control program
in-service education between 10/11/23, and 10/11/24.
NA Employee E4 had a hire date of 10/11/05, failed to have infection prevention and control program
in-service education between 10/11/23, and 10/11/24.
Dietary Employee E7 had a hire date of 12/27/15, failed to have infection prevention and control program
in-service education between 12/27/23, and 12/27/24.
Licensed Practical Nurse Employee E8 had a hire date of 12/27/15, failed to have infection prevention and
control program in-service education between 12/27/23, and 12/27/24.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 42 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0945
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Maintenance Director Employee E9 had a hire date of 8/21/18, failed to have infection prevention and
control program in-service education between 8/21/23, and 8/21/24.
During an interview on 2/14/25, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that
the facility failed to provide training on infection prevention and control program for six of nine staff
members.
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(c) Staff development.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 43 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0947
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in
dementia care and abuse prevention.
Based on review of facility policy, personnel in-service training records, and staff interview, it was
determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of
their hire date anniversary, for nurse aides as required for four of four nurse aides (Employee E1, E3, E4,
and E5).
Findings include:
Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility
will develop, implement, and maintain an effective training program for all new and existing staff.
Review of facility provided documents and training records revealed the following:
Nurse Aide (NA) Employee E1 had a hire date of 10/9/22. The facility provided education filed failed to have
any dates or times provided on any documents within the file to confirm education occurred between
10/9/23, through 10/9/24.
NA Employee E3 had a hire date of 10/11/04. The facility was unable to provide an education file or any
other documentation that NA Employee E3 had completed any education from 10/11/23, through 10/11/24.
NA Employee E4 had a hire date of 10/11/05. The facility provided education filed revealed a 12-hour
in-service packet, but no dates were present confirmed that the education occurred between 10/11/23,
through 10/11/24.
NA Employee E5 had a hire date of 11/12/13. The facility provided education filed revealed a 12-hour
in-service packet, but no dates were present confirmed that the education occurred between 11/12/23,
through 11/12/24.
During an interview on 2/14/25, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that
the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date
anniversary, for nurse aides as required for four of four nurse aides.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 44 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0949
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide behavior health training consistent with the requirements and as determined by a facility
assessment.
Based on review of facility policy, personnel in-service training records, and staff interview, it was
determined that the facility failed to provide training on behavioral health for seven of nine staff members
(Employee E1, E3, E4, E6, E7, E8, and E9).
Findings include:
Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility
will develop, implement, and maintain an effective training program for all new and existing staff. Training
content includes, at a minimum:
a. Effective communication for direct care staff.
b. Resident rights and facility responsibility for caring of residents.
c. Elements and goals of the facility's Quality Assurance and Performance Improvement program.
d. Written standards, policies, and procedures for the facility's infection prevention and control program.
e. Written standards, policies, and procedures for the facility's compliance and ethics program.
f. Behavioral health.
g. Dementia management and care of the cognitively impaired.
h. Abuse, neglect, and exploitation prevention.
i. Safety and emergency procedures.
Review of facility provided documents and training records revealed the following staff members did not
have documented training on behavioral health.
Nurse Aide (NA) Employee E1 had a hire date of 10/9/22, failed to have behavioral health in-service
education between 10/9/23, and 10/9/24.
NA Employee E3 had a hire date of 10/11/04, failed to have behavioral health in-service education between
10/11/23, and 10/11/24.
NA Employee E4 had a hire date of 10/11/05, failed to have behavioral health in-service education between
10/11/23, and 10/11/24.
Environmental Services Employee E6 had a hire date of 9/18/20, failed to have behavioral health in-service
education between 9/18/23, and 9/18/24.
Dietary Employee E7 had a hire date of 12/27/15, failed to have behavioral health in-service education
between 12/27/23, and 12/27/24.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 45 of 46
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395028
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Squirrel Hill Wellness and Rehabilitation Center
2025 Wightman Street
Pittsburgh, PA 15217
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0949
Level of Harm - Minimal harm
or potential for actual harm
Licensed Practical Nurse Employee E8 had a hire date of 12/27/15, failed to have behavioral health
in-service education between 12/27/23, and 12/27/24.
Maintenance Director Employee E9 had a hire date of 8/21/18, failed to have behavioral health in-service
education between 8/21/23, and 8/21/24.
Residents Affected - Some
During an interview on 2/14/25, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that
the facility failed to provide training on infection prevention and control program for six of nine staff
members.
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(c) Staff development.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395028
If continuation sheet
Page 46 of 46
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
28 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
F577 - The resident has the right to-
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
F638 - Quarterly Review Assessment
Assure that each resident’s assessment is updated at least once every 3 months.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F679 - Activities
Provide activities to meet all resident's needs.
F680 - The activities program must be directed by a qualified professional
Ensure the activities program is directed by a qualified professional.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F699 - Trauma-informed care
Provide care or services that was trauma informed and/or culturally competent.
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F940 - Training Requirements
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
F941 - Training Requirements
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
F942 - Training Requirements
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
F943 - Abuse, neglect, and exploitation
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
F944 - Quality assurance and performance improvement
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
F945 - Infection control
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
F949 - Training Requirements
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
FAQ · About this visit
Common questions about this visit
What happened during the February 14, 2025 survey of SQUIRREL HILL WELLNESS AND REHABILITATION CENTER?
This was a inspection survey of SQUIRREL HILL WELLNESS AND REHABILITATION CENTER on February 14, 2025. The surveyor cited 28 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SQUIRREL HILL WELLNESS AND REHABILITATION CENTER on February 14, 2025?
Yes, 28 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.