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 and documentation, resident and staff interviews, it was determined that
the facility failed to demonstrate response to grievances from resident council for six of six months (
January 2024, February 2024, March 2024, April 2024, May 2024, June 2024).
Residents Affected - Some
Findings include:
Review of the facility policy Grievance/Concern Resolution dated 1/18/24, indicated to resolve resident
concerns in a timely manner, facility utilizes a grievance form to identify concerns and track via a monthly
log.
Unable to review resident council meeting minutes for indication of any concerns.
During an interview on 7/18/2024, at 10:30 a.m. and 1:38 p m. Residents indicated that residents' concerns
are not being addressed and are on-going.
During an interview on 7/18/24 at 1:34 p.m., with the previous Resident Council president it was discussed
that the resident was relieved of their duties while unavailable and a new president was named in their
place with no vote occurring.
During an interview on 7/18/2024, at 2:48 p.m. Nursing Home Administrator and Regional Nursing Home
Coordinator confirmed that residents have on-going concerns and the facility is not using concern forms or
providing a resident council meeting and could not produce documentation showing they addressed the
residents' concerns from previous meetings.
28 Pa. Code 201.18 e(1)Management.
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 3
Event ID:
395289
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
395289
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at South Hills Rehabilitation and Nrsg Ctr
201 Village Drive
Canonsburg, PA 15317
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
Based on a resident group interview and staff interview, it was determined that the facility failed to provide
an ongoing program of activities based on the identified preferences/interests for seven of seven residents
to enhance the resident's quality of life (Residents R100, R101, R102, R103, R104, R105 and R106).
Residents Affected - Some
Findings include:
During an attempted review of facility activity calendars, there were no Activities Calendars for the dates
May 2024- June 2024. There is a calendar in all residents rooms listing one activity each day with no time
associated for these activities.
During an interview on 7/18/24 at 9: 23 a.m., the Ombudsman indicated that they had been contacted by
residents that were complaining that there were no activities occurring. The Ombudsman had contacted the
previous Nursing Home Administrator that stated they would take care of the situation.
During an interview on 7/18/24, at 1:30 p.m.,Resident Council president indicated that activities were
occurring until the Activities Director was terminated April 3, 2024.
During an interview on 7/18/24, at 2:30 p.m. the Nursing Home Administrator (NHA) indicated the facility
was unable to locate Resident Council Group meeting minutes from January 2024- June 2024, but was
able to locate Food Committee meeting minutes from January 2024- June 2024. The NHA also inidcated
that Physical Therapy was covering the activities for July and will only cover during their normal work hours,
leaving no activites for evenings.
28 Pa. Code: 201. 18(b)(3) Management
28 Pa. Code: 207.2(a) Administrators Responsibility
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 2 of 3
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
395289
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at South Hills Rehabilitation and Nrsg Ctr
201 Village Drive
Canonsburg, PA 15317
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 review of the facility policy, Resident Council Meeting minutes, facility documentation and staff
interview, it was determined that the facility failed to ensure that the Activities Department had a qualified
director to oversee the activities program for three out of six months (April, May, June).
Residents Affected - Some
The findings include:
Review of Activities Director job description/competency/evaluation last reviewed on 1/18/24, indicated the
education and qualifications for the job of Activities Director included post-secondary education in a related
field is desired, and two years experience as a supervisor or long-term care Activity Director or previous
work experience under a Certified Activity Consultant.
Review of the previous Activity Director Employee personnel file indicated they became the activities
director on 6/23/23 and then was terminated 4/3/24. Further review did not include information regarding a
replacement being
hired.
During interviews and observations on 7/18/24 at 11:30 a.m., residents that stated there have been no
activites since the previous Activities Director left and the calendar for July did not come out until the very
end of June. During the interviews some of the residents have stated they missed the activity of the day.
During an interview on 7/18/24, 12:00 p.m., the Nursing Home Administrator confirmed there currently was
not an Activities Director qualified to oversee the Activity Program.
28 Pa. Code: 201.18(b)(3) Management.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 3 of 3
