F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**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 notify
physicians of increased and decreased capillary blood glucose (CBG) levels for two of five residents
(Resident R11 and R52).Findings: Review of the facility policy, Nursing Care of the Older Adult with
Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of
time) dated 8/27/25, indicated, The provider will order the frequency of glucose monitoring and establish
appropriate glycemic targets for individual residents. The policy indicated for the facility to establish provider
notification guidelines, and provided examples of possible guidelines. Further review failed to reveal a
specific facility protocol. Review of the clinical record indicated Resident R11 admitted to the facility on
[DATE]. Review of Resident R11's Minimum Data Set (MDS - periodic assessment of resident care needs)
dated 11/9/25, included diagnoses of dementia (a group of symptoms that affects memory, thinking and
interferes with daily life) and diabetes. Review of Resident R11's care plan revised on 9/26/24, for Potential
for hypo/hyperglycemia (low blood sugar/high blood sugar levels in the blood) failed to include interventions
related to physician notification for elevated blood sugar levels. Review of a physician order dated 12/30/25,
indicated to inject Basaglar insulin (an injectable medication to treat diabetes) 20 units one time daily.
Further review of Resident R11's physician orders failed to reveal an order for blood sugar checks or
specific parameters for physician notification. Review of Resident R11's blood sugar record revealed the
following elevated blood sugar levels without documentation that the provider was notified:12/31/25, at 7:08
p.m. - 524.0 mg/dL (milligrams per deciliter)01/01/26, at 2:49 a.m. - 499.0 mg/dL01/03/26, at 7:10 p.m. 434.0 mg/dL01/04/26, at 7:01 p.m. - 402.0 mg/dL01/07/26, at 7:36 p.m. - 498.0 mg/dL01/08/26, at 7:23 p.m.
- 430.0 mg/dL01/14/26, at 7:05 p.m. - 453.0 mg/dL01/18/26, at 7:07 p.m. - 486.0 mg/dL01/19/26, at 7:04
p.m. - 463.0 mg/dL01/20/26, at 7:20 p.m. - 482.0 mg/dL01/22/26, at 9:43 p.m. - 494.0 mg/dL Review of the
clinical record indicated Resident R52 originally admitted to the facility on [DATE] and readmitted on
[DATE]. Review of Resident R52's MDS dated [DATE], included diagnoses of epilepsy (disorder of the brain
characterized by repeated seizures) and diabetes. Review of Resident R52's care plan initiated 10/19/23,
for Potential for hypo/hyperglycemia (low blood sugar / high blood sugar levels in the blood) indicated
Accuchecks (blood sugar checks) as ordered, call MD (doctor of medicine) per order/facility protocol.
Review of a physician order dated 12/30/25, indicated to inject Lantus insulin (an injectable medication to
treat diabetes) 20 units at bedtime. Further review of Resident R52's physician orders failed to reveal an
order for blood sugar checks or specific parameters for physician notification. Review of Resident R52's
blood sugar record revealed the following elevated blood sugar levels without documentation that the
provider was notified:11/15/25, at 9:07 p.m. - 419.0 mg/dL (milligrams per deciliter)12/23/25, at 9:48 p.m. 404.0 mg/dL01/04/26, at 9:43 p.m. - 482.0 mg/dL During an interview on 1/23/26,
(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 28
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
01/23/2026
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 0580
Level of Harm - Minimal harm
or potential for actual harm
at approximately 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the
facility failed to notify physicians of increased and decreased capillary blood glucose levels for two of five
residents. 28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 211.10 (c)(d) Resident care policies28 Pa.
Code 211.12 (d)(1)(2)(3)(5) Nursing services
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 2 of 28
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
01/23/2026
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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
review of facility policy, resident council group interview, observations and staff interviews it was determined
that the failed to provide a clean, safe, comfortable, and homelike environment for clean public shower
areas and equipment for two of two resident shower rooms (B/C and A/E shower rooms), failed to provide a
clean, safe, comfortable, and homelike environment for two of four resident hallways (B/C Hallways), and
two of two resident lounges B/C and A/E resident lounges).Findings include:Review of the facility policy
Homelike environment dated 8/27/25, indicated to provide a safe, clean and comfortable environment.
Provide a clean, sanitary, and orderly environment and provide comfortable and safe temperatures between
71 and 81.During a tour on 1/21/26, at 2:20 p.m. with the Nursing Home Administrator the following
observations were noted:-B/C shower room had a dark brown/black substance in the grout of the shower's
floor, cracked tiles at base of the shower and the wall. Thes shower chairs were soiled with brown
residue.-A/E shower room had a metal pin sticking out of stall one's rear wall, had discolored shower grout,
the third stall's shower head handle with brown substance. Shower chair with brown residue and rust
apparent on all four wheels.During an interview on 1/21/26, at 2:21 p.m. the Nursing Home Administrator
confirmed the observations of the B/C and A/E shower rooms and equipment.During a Resident council
group interview on 1/21/26, at 1:00 p.m. five out of five residents indicated the resident lounges on each
side (B/C and A/E) are too cold in the winter months.During an interview and tour on 1/21/26, at 2:50 p.m.
with the Nursing Home Administrator and Maintenance Director Employee the following areas indicated
inadequate temperatures:-B/C lounge noted to be blowing cold air. Temperature 58.1 F (Fahrenheit).-room
[ROOM NUMBER], the temperature was 68 F.-room [ROOM NUMBER], the temperature was 68.9 F.-room
[ROOM NUMBER], the temperature was 65.6 F.-room [ROOM NUMBER], the temperature was 64.7
F.-room [ROOM NUMBER], the temperature was 68.3 F.During an interview on 1/21/26, at 4:00 p.m. the
Nursing Home Administrator confirmed the facility failed to provide a clean, safe, comfortable, and homelike
environment for two of four resident hallways (B/C Hallways), and two of two resident lounges B/C and A/E
resident lounges), and failed to provide clean public shower areas and equipment for two of two resident
shower rooms (B/C and A/E shower rooms).28 Pa. code: 201.14 (b) Responsibility of licensee.28 Pa Code:
201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c) Resident Rights.
Event ID:
Facility ID:
395289
If continuation sheet
Page 3 of 28
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
01/23/2026
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, facility documentation and staff interview, it was determined that the facility failed to
protect a resident from neglect for one of three residents resulting in pain and the need for Xray's to rule out
possible injuries/ fractures for one of three residents (Resident R11).Findings include:Review of the facility
policy Abuse and Neglect dated 8/27/25, indicated that neglect is the failure of the facility to provide
services to a resident that are necessary to avoid physical harm, pain or mental anguish. Review of the
clinical record indicated that Resident R11 was admitted to the facility on [DATE] with diagnoses which
included Alzheimer's dementia, obstructive uropathy, glaucoma, obesity, lack of coordination, and history of
right open repair internal fixation of right hip (ORIF). An MDS (Minimum Data Set- a periodic review of a
resident care needs) dated 10/24/25, indicated the diagnoses remained current. An MDS dated [DATE],
Section G0110 (bed mobility) indicated bed mobility as total assistance of two staff. Section GG0170
(amount of assistance required to perform task) indicated substantial/maximum assistance for turning left
and right in bed. During an interview on 1/21/26, at 10:00 a.m., Nurse Aide (NA) Employee E6 stated that
substantial maximum assistance indicated the use of two staff to perform task. During an Interview on
1/21/26, at 10:03 a.m., NA Employee E7 and Licensed Practical Nurse (LPN) Employee E3 stated that
substantial maximum assistance indicated the use of two staff to perform task.During an interview on
1/21/26, at 10:10 LPN Employee E5 stated that substantial maximum assistance indicated the use of two
staff to perform task.Review of Resident R11's orders identified an order dated 1/16/19, which indicated the
use of bilateral enabler bars for positioning for Resident R11.During a clinical record review, a progress
note dated 8/22/25, at 8:19 a.m., indicated the nurse had been called into Resident R11's room at 5:10
a.m., to find the resident on the floor on her left side. Review of the facility provided document indicated that
Nurse Aide Employee E9 had gone into Resident R11's room to provide incontinence care by herself,
turned Resident R11 onto her side. The NA then identified that Resident R11 had had a bowel movement.
NA Employee E9 then left Resident R11 on her side to go into the bathroom to wet a towel and Resident
R11 rolled out of bed.Review of the facility provided documentation did not include documentation of
making certain Resident R11 was protected from neglect as the facility called the physician who ordered
Xray's be completed to rule out possible injury/ fracture when Resident R11 complained of pain. The
documentation did not include whether or not the enabler bars were being utilized.During an interview of
1/20/26, at 1:58 p.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility
failed to protect a resident from neglect for one of three residents resulting in pain and the need for Xray's
to rule out possible injuries including fractures for one of three residents (Resident R11).28 Pa. Code
201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.29(a)
Resident rights.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing
services.
Event ID:
Facility ID:
395289
If continuation sheet
Page 4 of 28
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
01/23/2026
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 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 a
review of facility policy, information provided by the facility, clinical records and staff interview, it was
determined the facility failed to promptly conduct a thorough investigation to rule out neglect and implement
corrective action and submit the results of the completed investigation to the State Survey Agency within
five working days of the incident as evidenced by one of three residents reviewed (Resident R11).Findings
include:Review of the facility policy Abuse and Neglect dated 8/27/25, indicated that neglect is the failure of
the facility to provide services to a resident that are necessary to avoid physical harm, pain or mental
anguish. Staff and management will help to identify situations that might constitute neglect. The facility will
investigate alleged abuse and neglect to clarify what happened and identify possible causes. Review of the
facility policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated 8/27/25,
indicated that all reports of resident abuse including injuries of unknown origin, neglect, etc., are reported to
local, state and federal agencies as required and thoroughly investigated by the facility. Findings of the
investigation are documented and reported. Review of the clinical record indicated that Resident R11 was
admitted to the facility on [DATE], with diagnoses which included Alzheimer's dementia, obstructive
uropathy, glaucoma, obesity, lack of coordination, and history of right open repair internal fixation of right
hip (ORIF). A Minimum Data Set (MDS- a periodic review of a resident care needs) dated 07/30/25,
indicated the diagnoses remained current. Section G0110 (bed mobility) indicated bed mobility as total
assistance of two staff. Section GG0170 (indicating the assistance required to perform task) indicated
substantial/maximum assistance for turning left and right in bed. During an interview on 1/21/26, at 10:00
a.m., Nurse Aide (NA) Employee E6 stated that substantial maximum assistance indicated the use of two
staff to perform task. During an Interview on 1/21/26, at 10:03 a.m., NA Employee E7and Licensed
Practical Nurse (LPN) Employee E3 stated that substantial maximum assistance indicated the use of two
staff to perform task.During an interview on 1/21/26, at 10:10 LPN Employee E5 stated that substantial
maximum assistance indicated the use of two staff to perform task.Review of Resident R11's orders
identified an order dated 1/16/19, which indicated the use of bilateral enabler bars for positioning for
Resident R11.During a clinical record review, a progress note dated 8/22/25, at 8:19 a.m., indicated the
nurse had been called into Resident R11's room at 5:10 a.m., to find the resident on the floor on her left
side. Review of the facility provided document indicated that Nurse Aide Employee E9 had gone into
Resident R11's room to provide incontinence care by herself, turned Resident R11 onto her side. The NA
then identified that Resident R11 had had a bowel movement. NA Employee E9 then left Resident R11 on
her side to go into the bathroom to wet a towel and Resident R11 rolled out of bed. The documentation did
not include whether or not the enabler bar was in use.Review of the facility provided documentation did not
include documentation of making certain Resident R11 was protected from neglect as the facility called the
physician who ordered Xray's be completed to rule out possible injury/ fracture when Resident R11
complained of pain.During an interview of 1/20/26, at 1:58 p.m., the Nursing Home Administrator and
Director of Nursing confirmed that the facility failed to to promptly conduct a thorough investigation to rule
out neglect and implement corrective action and submit the results of the completed investigation to the
State Survey Agency within five working days of the incident as evidenced by one of three residents
reviewed (Resident R11). 28 Pa. Code 201.14 (c) Responsibility of licensee.28 Pa. Code 201.18 (b)(1)
Management.28 Pa. Code 201.29 (a) Resident rights.28 Pa. Code 211.10(d) Resident care policies.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 5 of 28
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
01/23/2026
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 0628
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide the required documentation or notification related to the resident's needs, appeal rights, or
bed-hold policies.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
facility policy review, clinical record review, and staff interview, it was determined that the facility failed to
ensure that the resident and/or their representative received written notice of the facility bed-hold policy at
the time of transfer for five of six residents reviewed for hospitalization (Resident R8, R9, R23, R57, and
R79). Findings Include: Review of federal regulation S483.15(d) Notice of Bed-Hold Policy, indicated,
facilities must provide written information about these policies to residents prior to and upon transfer for
such absences. This information must be provided to all facility residents, regardless of their payment
source. These provisions require facilities to issue two notices related to bed-hold policies. The first notice
could be given well in advance of any transfer, i.e., information provided in the admission packet.
Reissuance of the first notice would be required if the bed-hold policy under the State plan or the facility's
policy were to change. The second notice must be provided to the resident, and if applicable the resident's
representative, at the time of transfer, or in cases of emergency transfer, within 24 hours. It is expected that
facilities will document multiple attempts to reach the resident's representative in cases where the facility
was unable to notify the representative. The notice must provide information to the resident that explains
the duration of bed-hold, if any, and the reserve bed payment policy. It should also address permitting the
return of residents to the next available bed. Review of facility Bed Hold Policy dated 8/27/25, indicated,
Prior to transfers and therapeutic leaves, residents or resident representatives will be informed of the
bed-hold and return policy by staff. Review of the clinical record indicated Resident R8 was readmitted to
the facility on [DATE]. Review of Resident R6's minimum data set (MDS - periodic assessment of resident
care needs) dated 10/24/25, included diagnoses of coronary artery disease (damage or disease in the
heart's major blood vessels), diabetes, and hemiplegia. Review of a progress note dated 9/4/25, at 1:17
p.m. indicated, Resident sent to [hospital] per MD (doctor of medicine) order. [Spouse] made aware. Further
review of Resident R8's clinical record failed to reveal notation that the written notice of bed hold notification
was provided to the resident or resident representative upon transfer. Review of the Forms section of the
electronic medical record failed to include a Transfer/Discharge/Bed Hold Form completed for this hospital
discharge. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE].
Review of Resident R9'sMDS dated [DATE], included diagnoses of CAD, diabetes, and a seizure disorder.
Review of a progress note dated 5/4/25, at 8:51 p.m. indicated, Resident was admitted to [hospital] with
pneumonia. Family called and updated. RN (registered nurse) made aware. Review of a progress note
dated 6/19/25, at 10:46 a.m. indicated, Family notified of the transfer from dialysis to [hospital]. Review of a
progress note dated 8/31/25, at 12:30 p.m. indicated, Resident lethargic, noticeable change in mental
status. Unable to eat or take p.o. (oral) meds. POA (power of attorney) aware and wants resident in the ER
(emergency room) due to holiday weekend. MD notified. Will send to [hospital] at family request. Review of
a progress note dated 1/16/26, at 11:33 p.m. indicated, Condition is worsening transferred to the
emergency room for further evaluation and treatment. Further review of Resident R9's clinical record failed
to reveal notation that the written notice of bed hold notification was provided to the resident or resident
representative upon transfer for 5/4/25, 6/19/25, 8/31/25, and 1/16/26). Review of the Forms section of the
electronic medical record failed to include a Transfer/Discharge/Bed Hold Form completed for these hospital
discharges.Review of the clinical record indicated Resident R23 was readmitted to the facility on [DATE].
Review of Resident R23's MDS dated [DATE], included diagnoses of chronic obstructive pulmonary
disease CKD, high blood pressure, and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 6 of 28
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
01/23/2026
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 0628
Level of Harm - Potential for
minimal harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
history of a stroke. Review of a progress note dated 8/7/25, at 8:04 a.m. indicated, During video assess
slurred speech and tremors observed. Pt remains A/O (alert and oriented), VSS (vital signs stable). Transfer
to ED is warranted D/T (due to) possible neurological event). Further review of Resident R23's clinical
record failed to reveal notation that the written notice of bed hold notification was provided to the resident or
resident representative upon transfer. Review of the Forms section of the electronic medical record failed to
include a Transfer/Discharge/Bed Hold Form completed for this hospital discharge. Review of the clinical
record indicated Resident R57 was admitted to the facility on [DATE]. Review of Resident R57's MDS dated
[DATE], included diagnoses of COPD, heart failure, and arthritis. Review of a progress note dated 9/14/25,
at 6:21 p.m. indicated, Resident stating he wanted to go to the hospital due to increased swelling in his
lower leg r/t (related to) cellulitis. MD made aware and order received to send him out. 911 called,
ambulance personnel arrived, and resident left the facility via stretcher. Further review of Resident R57's
clinical record failed to reveal notation that the written notice of bed hold notification was provided to the
resident or resident representative upon transfer. Review of the Forms section of the electronic medical
record failed to include a Transfer/Discharge/Bed Hold Form completed for this hospital discharge. Review
of the clinical record indicated Resident R79 was admitted to the facility on [DATE]. Review of Resident
R79's MDS dated [DATE], included diagnoses of ALS, high blood pressure, and a seizure disorder. Review
of a progress note dated 10/22/25, at 12:37 p.m. indicated, Hospice RN came in to assess at this time the
resident's respirations were approximately 8 per minute with 10 second periods of apnea. She contacted
teh resident's husband who did want her sent out the othe [hospital] for evaluation. Further review of
Resident R79's clinical record failed to reveal notation that the written notice of bed hold notification was
provided to the resident or resident representative upon transfer. Review of the Forms section of the
electronic medical record revealed the Transfer/Discharge/Bed Hold Form completed on 10/22/25, was
incomplete with the section that indicated the method of resident or resident representative notification was
blank. During an interview on 1/23/24, at approximately 1:30 p.m. the Nursing Home Administrator and the
Director of Nursing confirmed the facility failed to ensure that the resident and/or their representative
received written notice of the facility bed-hold policy at the time of transfer for five of six residents reviewed
for hospitalization. 28 Pa. Code 201.14(a) Responsibility of licensee
Event ID:
Facility ID:
395289
If continuation sheet
Page 7 of 28
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
01/23/2026
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Potential for
minimal harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it
was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care
needs) accurately reflected the resident's status for two of six residents (Resident R50, and R65).Findings
include:The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing
Minimum Data Set (MDS) assessments (periodic assessments of care needs), dated October 2025,
indicated the following instructions:Intent: The intent of the items in this section (Section O) is to identify any
special treatments, procedures, and programs that the resident received or performed during the specified
time periods.O0110: Special Treatments, Procedures, and Programs. Facilities may code treatments,
programs and procedures that the resident performed themselves independently or after set-up by facility
staff. Do not code services that were provided solely in conjunction with a surgical procedure or diagnostic
procedure, such as IV medications or ventilators. Surgical procedures include routine pre- and
post-operative procedures.Review of the clinical record indicated Resident R50 was admitted to the facility
on [DATE].Review of Resident R50's MDS dated [DATE], indicated diagnoses of diabetes (a long-term
condition in which the body has trouble controlling blood sugar and using it for energy), and obstructive
sleep apnea (a chronic condition in which the throat muscles relax during sleep and the airway may
become partially or fully blocked), and renal insufficiency (a condition in which the kidneys lose the ability to
remove waste and balance fluids). Section O0110 G1, Use of a non-invasive mechanical ventilator was
documented as not indicated as in use.Review of Resident R50's physician order dated 12/26/25, indicated
CPAP with oxygen four liter bleed every evening and night for obstructive sleep apnea.Review of Resident
R50's current care plan indicated oxygen at four liters/minute to the CPAP device.Review of Resident R50's
treatment administration record dated December 2025 indicated a Bipap was administered from 12/5/25,
through 12/25/25.During an interview on 1/20/26, at 1:42 p.m. Resident R50 indicated using the CPAP
machine every night.Interview completed on 1/20/26, at 1:42 p.m. The Director of Nursing confirmed
Resident R50's MDS did not indicate use of CPAP or Bipap as required and documented as administered
on the treatment administration record.Review of the clinical record indicated Resident R65 was admitted to
the facility on [DATE].Review of Resident R65's MDS dated [DATE], indicated diagnoses of diabetes,
obstructive sleep apnea, and chronic obstructive pulmonary disease (COPD, a group of progressive lung
disorders characterized by increasing breathlessness). Section O0110 G1, Use of a non-invasive
mechanical ventilator was documented as not indicated as in use.Review of Resident R65's physician order
dated 3/27/25, indicated BiPAP use at bedtime for obstructive sleep apnea.Review of Resident R65's
current care plan indicated BiPAP sat 91%, exp (expiration)-6, insp (inspiration) - 12 O2 2L bleed, assist
with BiPAP as ordered.Review of Resident R65's treatment administration record dated January 2025,
indicated a BiPAP was administered from 12/5/25, through 12/25/25.During an interview on 1/21/26, at
approximately 11:30 a.m. Resident R65's BiPAP mask was on the floor next to her bed. When asked,
Resident R65 stated she tries to use her BiPAP but is unable to put the mask on herself, and the nursing
staff, doesn't get in here much to assist in applying the mask.Interview on 1/23/26, at 12:00 p.m. the
Director of Nursing confirmed the facility failed to ensure MDS assessments accurately reflected the
resident's status for two of six residents.28 Pa. Code 211.12(c)(d)(5) Nursing services.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 8 of 28
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
01/23/2026
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, clinical records, and staff interview, it was determined that the facility failed to
update a care plan for two of six residents (Residents R50 and R58) to accurately reflect the current status
of the resident. Findings include: Review of the facility policy Care Plans, Comprehensive Person-Centered
dated 8/27/25, indicated the person-centered care plan describes services that are to be furnished to attain
or maintain the resident's highest practicable physical, mental, and psychosocial well-being including
services for each element of care. Review of the clinical record indicated Resident R50 was admitted to the
facility on [DATE]. Review of Resident R50's Minimum Data Set (MDS- a periodic assessment of care
needs) dated 12/9/25, indicated diagnoses of diabetes (a long-term condition in which the body has trouble
controlling blood sugar and using it for energy), obstructive sleep apnea (a chronic condition in which the
throat muscles relax during sleep and the airway may become partially or fully blocked), and renal
insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids). Section
O0110 G3 CPAP (non-invasive treatment for sleep apnea that uses a machine to deliver pressurized air
through a mask, keeping the airway open during sleep to prevent breathing pauses) was not indicated as in
use. Review of Resident R50's current physician orders included the following medications:-Glargine insulin
28 units subcutaneously (fatty tissue layer between the skin and muscle) for diabetes.-Jardiance 12.5 mg
(milligrams) for diabetes.-Eliquis 5mg for anticoagulant (blood thinner).-Bumex 2mg for fluid
management.-Flomax 0.4 mg for Benign prostatic hyperplasia (BPH - a common enlargement of the
prostate gland in aging men that squeezes the urethra).-Finasteride 5mg for BPH.-Lyrica 50mg for
neuropathy (nerve damage causing pain and numbness).-Oxycodone 5-325 mg for pain.-Metoprolol 100mg
for high blood pressure. Review of Resident R50's current care plan failed to include goals and
interventions for management and monitoring of diabetes, anticoagulants, fluid management, BPH,
neuropathy, pain, high blood pressure, and potential for constipation related to oxycodone use. Interview on
1/23/26, at 11:55 a.m. the Director of Nursing confirmed Resident R50's care plan was lacking identified
medications and disease processes as required. Review of the clinical record indicated Resident R58 was
admitted to the facility on [DATE]. Review of Resident R58's MDS dated [DATE], indicated diagnoses of
traumatic brain dysfunction (a disruption in the normal function of the brain), anxiety, depression, and
post-traumatic stress disorder (PTSD, mental health condition triggered by experiencing or witnessing a
terrifying event). Review of Resident R58's facility diagnosis listing included PTSD, dated 4/28/25. Review of
a psychiatry note dated 3/6/25, indicated, [Resident R58] detailed a past event that lead to her TBI
(traumatic brain injury) and long hospital stay. She reported severe trauma from the experience, and said
she had been diagnosed with PTSD after the event. Often experiences mood swings and depression, as
well as hypervigilance and increased anxiety and I feel nervous around other people.Review of further
psychiatry notes refer to Resident R58's PTSD diagnosis on 7/14/25, 8/26/25 Review of Resident R58's
current care plan failed to include goals and interventions 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. Interview on 1/23/26, at 12:00 p.m. the Director of Nursing confirmed the facility failed to update a
care plan for two of six residents (Residents R50 and R58) to accurately reflect the current status of the
resident. 28 Pa. Code 211.12(d)(5) Nursing services.
Event ID:
Facility ID:
395289
If continuation sheet
Page 9 of 28
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
01/23/2026
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 0685
Assist a resident in gaining access to vision and hearing services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
facility policies, clinical record reviews, and staff interview, it was determined the facility failed to ensure
each resident receives proper treatment and services to maintain hearing abilities for five of eight residents
reviewed for hearing (Residents R3, R26, R36, R48 and R23). Findings include:Review of the facility policy
Consults Policy and Procedures, dated 8/27/25, indicated to ensure all in-facility consults are timely,
clinically indicated and in compliance, the facility nursing staff shall notify the attending provider of the
consulting provider's recommendations, review the attending physician's acceptance of the
recommendation and monitor the compliance with the recommended treatment.Review of the clinical
record indicated Resident R3 had been admitted to the facility on [DATE], with diagnoses which included
traumatic brain injury, obesity, stroke and heart fibrillation. An MDS (Minimum Data Set- a periodic review of
resident needs) dated 11/4/25, indicated the diagnoses remained current.Review of Resident R3's
physician orders dated 4/1/15, through current identified an order dated 12/20/16, indicating that Resident
R3 may receive audiology services.Review of Resident R3's clinical record did not include an audiologist
assessment being completed in the duration of Resident R3's admission from 4/1/15, through
current.Review of the clinical record indicated Resident R26 had been admitted to the facility on [DATE],
with diagnoses which included autism, intellectual disabilities, obesity and visual disabilities. An MDS dated
[DATE] indicated the diagnoses remained current.Review of Resident R26's physician orders dated
3/20/24, through current identified an order for Resident R26 to receive audiology services.Review of
Resident R26's clinical record did not include an audiologist assessment being completed in the duration of
Resident R26's admission from 3/20/24, through current.Review of the clinical record indicated that
Resident R36 was admitted to the facility on [DATE], with diagnoses which included quadriplegia, seizures,
dementia, glaucoma and kidney disease. An MDS dated [DATE], indicated the diagnoses remained
current.Review of Resident R36's physician orders dated 5/24/22 through current identified an order dated
5/24/22, indicating that Resident R36 may receive audiology services.Review of Resident R36's clinical
record identified audiologist assessment on 9/17/25, identifying impacted cerumen of his left ear and
Debrox ear drops to be instilled into left ear to remove cerumen.Review of Resident R36's Medication
Administration Record (MAR) dated September 2025, did not include an order for Debrox ear drops as per
recommendation.Review of Resident R36's clinical record identified an audiologist assessment again on
10/22/25, which again identified impacted cerumen of his left ear and Debrox drops again for left
ear.Review of Resident R36's MAR dated October 2025, did not include an order for Debrox ear drops had
been obtained as per recommendation.Review of the clinical record indicated Resident R48 was admitted
to the facility on [DATE], with diagnoses which included anoxic brain damage and dementia. An MDS dated
[DATE], indicated the diagnoses remained current.Review of Resident R48's physician orders dated
7/21/25, through current identified an order for Resident R48 to receive audiology services.Review of
Resident R48's clinical record identified an audiologist assessment on 1/5/26, which identified impacted
cerumen of left ear and recommendation of Debrox drops.Review of Resident R48'd MAR dated January
2026, did not include and order for Debrox drops to left ear being obtained as per recommendation. Review
of the clinical record indicated Resident R23 had been admitted to the facility on [DATE], with diagnoses
which included stage IV kidney disease, schizophrenia and unspecified psychosis. An MDS dated [DATE]
indicated the diagnoses remained current.Review of Resident R23's physician orders dated 5/10/24,
through current identified an order for Resident R23 to receive audiology services.Review of Resident
R23's clinical record identified an audiologist assessment on 9/17/25, which identified impacted cerumen of
both ears and
Residents Affected - Some
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 10 of 28
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
01/23/2026
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 0685
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
recommendation of Debrox drops.Review of Resident R23's MAR dated September 2025, did not include
an order for Debrox drops as per recommendation.Review of Resident R23's clinical record identified and
audiologist assessment on 10/22/25, which identified impacted cerumen of both ears and recommendation
of Debrox drops.Review of Resident R23's MAR dated October 2025, did not include and order for Debrox
drops as per recommendation.During an interview on 1/22/26, at 10:04 a.m., the Director of Nursing on
1/22/26, at 10:04 a.m., confirmed that facility failed to ensure each resident receives proper treatment and
services to maintain hearing abilities for five of eight residents reviewed for hearing (Residents R3, R26,
R36, R48 and R23). 28 Pa. Code 211.12 (d) (5) Nursing services
Event ID:
Facility ID:
395289
If continuation sheet
Page 11 of 28
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
01/23/2026
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of clinical records, facility provided documentation and staff interviews, it was determined that the
facility failed to make certain each resident received adequate supervision and assistance to prevent
accidents for one of three residents (Resident R11).Findings include:Review of the clinical record indicated
that Resident R11 was admitted to the facility on [DATE]m with diagnoses which included Alzheimer's
dementia, obstructive uropathy, glaucoma, obesity, lack of coordination, and history of right open repair
internal fixation of right hip (ORIF). An MDS (Minimum Data Set- a periodic review of a resident care
needs) dated 10/24/25, indicated the diagnoses remained current. An MDS dated [DATE], Section G0110
(bed mobility) indicated bed mobility as total assistance of two staff. Section GG0170 How much assistance
required to perform task) indicated substantial/maximum assistance for turning left and right in bed. During
an interview on 1/21/26, at 10:00 a.m., Nurse Aide (NA) Employee E6 stated that substantial maximum
assistance indicated the use of two staff to perform task. During an Interview on 1/21/26, at 10:03 a.m., NA
Employee E and Licensed Practical Nurse (LPN) Employee E3 stated that substantial maximum assistance
indicated the use of two staff to perform task. During an interview on 1/21/26, at 10:10 LPN Employee E5
stated that substantial maximum assistance indicated the use of two staff to perform task. Review of
Resident R11's orders identified an order dated 1/16/19, which indicated the use of bilateral enabler bars
for positioning for Resident R11. During a clinical record review, a progress note dated 8/22/25, at 8:19
a.m., indicated the nurse had been called into Resident R11's room at 5:10 a.m., to find the resident on the
floor on her left side. Review of the facility provided document indicated that Nurse Aide Employee E9 had
gone into Resident R11's room to provide incontinence care by herself, turned Resident R11 onto her side.
The NA then identified that Resident R11 had had a bowel movement. NA Employee E9 then left Resident
R11 on her side to go into the bathroom to wet a towel and Resident R11 rolled out of bed. The
documentation did not include whether or not the enabler bar was in use. Review of the facility provided
documentation did not include an investigation to identify why NA Employee E9 attempted to provide care
alone when Resident R11 was identified to require assistance of two staff. During an interview of 1/20/26,
at 1:58 p.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to
make certain Resident R11 received proper assistance and supervision to prevent an accident which
resulted in pain and the need for Xray's to rule out injury /fractures for Resident R11. 28 Pa. Code
211.10(c)(d) Resident Care Policies28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services28 Pa. Code:
201.18(b)(1) Management.
Event ID:
Facility ID:
395289
If continuation sheet
Page 12 of 28
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
01/23/2026
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 0694
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
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 policies, clinical records, and staff interviews, it was determined that the facility failed to
provide prescribed treatment and services related to an implanted venous port (a small implantable device
placed under the skin usually in the chest to provide reliable long term venous access) for one of three
residents (Resident R73), and failed to properly care for total parenteral nutrition (TPN - a method of
delivering essential nutrients - fats, proteins, carbohydrates, electrolytes, and vitamins directly into the
bloodstream via an intravenous (IV) catheter, bypassing the digestive system)for one of three residents
(Resident R74).Findings include:Review of the facility policy Implanted Venous Port - Accessing dated
8/27/25, indicated to cover needle and access site with transparent sterile dressing when the port is
accessed. Label dressing with date, time, and initials of the person who is performing the procedure.Review
of the facility policy Total Parenteral Nutrition dated 8/27/25, indicated nursing checks the TPN label with the
physician order, checks the pump delivery settings in accordance with the order and documents all.Review
of the clinical record indicated Resident R73 was admitted to the facility on [DATE], with the diagnoses of
chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to
breathe), heart failure (heart doesn't pump blood as well as it should), and high blood pressure.Review of
Resident R73's physician order dated 1/18/26, indicated to change venous port dressing weekly.Review of
Resident R73's baseline care plan failed to include instructions for the care and management of the venous
port.Observation on 1/20/26, at 10:15 a.m. Resident R73 was sitting up in bed with a venous port noted to
the left upper chest. The dressing covering the venous port was not labeled or dated as
required.Observation and interview on 1/20/26, at 10:30 a.m. Registered Nurse (RN) Employee E2
confirmed the dressing to the venous port was not labeled or dated as required.Review of the clinical
record indicated Resident R74 was admitted to the facility on [DATE], with the diagnoses of atrial fibrillation
(irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), and high blood
pressure.Review Resident R74's physician order dated 1/16/26, indicated the following:-TPN up at 10:00
p.m. start at 81ml (milliliters) for one hour (until 11:00 p.m.).-TPN at 163 ml for ten hours from 11:00 p.m.
until 9:00 a.m.-TPN at 81ml for one hour from 9:00 a.m. to 10:00 a.m.Review of Resident R74's care plan
dated 1/19/26, indicated the resident has potential for fluid volumechanges related to TPN as primary
hydration source.Observation on 1/20/26, at 9:30 a.m. Resident R74 was lying in bed attached to an IV
pump that had a bag of TPN actively infusing. The bag did not have verification checks of the TPN content,
a date it was hung, or the initials of the person who administered it as required. Observation and interview
on 1/20/26, at 9:35 a.m. Registered Nurse (RN) Employee E2 confirmed the bag did not have verification
checks of the TPN content, a date it was hung, or the initials of the person who administered it as required.
During an interview on 1/20/26, at 3:00 p.m. the Director of Nursing confirmed the facility failed to provide
prescribed treatment and services related to an implanted venous port for one of three residents (Resident
R73) and failed to properly care for total parenteral nutrition for one of three residents (Resident R74).28
Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code
211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3) Nursing services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 13 of 28
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
01/23/2026
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, review of clinical record, review of facility policy, interview with staff and residents, it was
determined the facility failed to provide tracheostomy care consistent with professional standards of
practice for one resident with a tracheostomy (Resident R25), and failed to provide appropriate respiratory
care and maintain respiratory equipment for five of five residents (Resident R25, R41, R50, R65, and R74).
Findings include: Review of the facility policy Tracheostomy Care dated 8/27/25, indicated a replacement
tracheostomy tube (a hollow tube inserted into a surgical opening in the neck (stoma) directly into the
windpipe to provide long-term ventilation) must be available at the bedside at all times. A suction machine
must be available at the bedside at all times. Review of the facility policy Departmental (Respiratory
Therapy) - Prevention of Infection last reviewed on 8/27/25, indicated that considerations related to oxygen
administration include change the oxygen cannula and tubing every seven days or as needed. Keep the
oxygen and tubing used as needed in a plastic bag when not in use. Considerations related to medication
nebulizers/continuous aerosol include store the circuit in a plastic bag, marked with date and resident's
name, between uses. Discard the administration set up every seven days. Review of the facility policy
CPAP/BiPap Support dated 8/27/25, indicated Continuous Positive Airway Pressure (CPAP-keeps airways
open when you sleep) or Bilevel Positive Airway Pressure (BIPAP-normalizes breathing by delivering
pressurized air)are to be labeled with room number/bed and to be stored in a plastic bag when not in use.
Review of the admission record indicated R25 was admitted to the facility on [DATE]. Review of Resident
R25's Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/28/25, indicated the
diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and
make it hard to breathe), anxiety, and hip fracture. Section O - E1 indicated that resident received
tracheostomy care. Review of Resident R25's current physician orders failed to include the type and size of
tracheostomy tube. Review of Resident R25's care plan dated 11/21/25, indicated resident will be free from
infection related to tracheostomy and failed to include the type and size of tracheostomy tube. Observation
on 1/20/26, at 9:30 a.m. Resident R25 was resting in bed with a tracheostomy tube visible and connected
to oxygen. A suction cannister was at the bedside with a date that read 12/10/25. The cannister was half full
of white/light yellow substance. Observation and interview on 1/20/26, at 9:35 a.m. Registered Nurse (RN)
Employee E2 confirmed there was not an order or care plan for the type and size of tracheostomy tube and
that the suction cannister had not been changed since 10/10/25. Review of the admission record indicated
R41 was admitted to the facility on [DATE]. Review of Resident R41's MDS dated [DATE], indicated the
diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and
depression. Review of Resident R41's physician orders dated 11/9/25, indicated to change oxygen tubing
weekly and label with date. Also apply water bottle and change it weekly to humidify oxygen. Write date on
bottle. Review of Resident R41's current care plan indicated to change respiratory equipment as ordered.
Observation on 1/20/26, at 9:20 a.m. Resident R41 was observed with eyes closed sleeping in bed. The
oxygen bottle or tubing was dated as required. Interview on 1/20/26, at 9:25 a.m. RN Employee E2 verified
the oxygen bottle and tubing were not dated as required. Review of the clinical record indicated Resident
R50 was admitted to the facility on [DATE]. Review of Resident R50's MDS dated [DATE], indicated
diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and
using it for energy), and obstructive sleep apnea (a chronic condition in which the throat muscles relax
during sleep and the airway may become partially or fully blocked), and renal insufficiency (a condition in
which the kidneys lose the ability to remove waste and balance
Residents Affected - Some
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 14 of 28
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
01/23/2026
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 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
fluids). Section O0110 G3 CPAP (non-invasive treatment for sleep apnea that uses a machine to deliver
pressurized air through a mask, keeping the airway open during sleep to prevent breathing pauses) was not
indicated as in use. Review of Resident R50's physician order dated 12/26/25, indicated CPAP with oxygen
four liter bleed every evening and night for obstructive sleep apnea. Review of Resident R50's current care
plan indicated oxygen at four liters/minute to the CPAP device. Observation on 1/20/26, at 9:30 a.m.
Resident R50's CPAP mask was hanging off the bedside stand not contained in a bag as required.
Interview on 1/20/26, at 9:30 a.m. RN Employee E2 verified the CPAP mask was not stored in a bag as
required when not in use. Review of the clinical record indicated Resident R74 was admitted to the facility
on [DATE], with the diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump
blood as well as it should), and high blood pressure. Review Resident R74's physician order dated 1/16/26,
indicated CPAP unit with 2-liter bleed in of oxygen at night every evening shift. Review of Resident R74's
current care plan indicated resident will be compliant with use of CPAP. Observation on 1/20/26, at 9:35
a.m. Resident R74 was out of bed. On the bedside stand was the CPAP mask, not stored in a bag as
required. Interview on 1/20/26, at 9:35 a.m. RN Employee E2 verified the CPAP mask was not stored in a
bag as required when not in use.Review of the clinical record indicated Resident R65 was admitted to the
facility on [DATE].Review of Resident R65's MDS dated [DATE], indicated diagnoses of diabetes,
obstructive sleep apnea, and chronic obstructive pulmonary disease (COPD, a group of progressive lung
disorders characterized by increasing breathlessness). Section O0110 G1, Use of a non-invasive
mechanical ventilator was documented as not indicated as in use.Review of Resident R65's physician order
dated 3/27/25, indicated BiPAP use at bedtime for obstructive sleep apnea.Review of Resident R65's
current care plan indicated BiPAP sat 91%, exp (expiration)-6, insp (inspiration) - 12 O2 2L bleed, assist
with BiPAP as ordered.Review of Resident R65's treatment administration record dated January 2025,
indicated a BiPAP was administered from 12/5/25, through 12/25/25.During an interview on 1/21/26, at
approximately 11:30 a.m. Resident R65's BiPAP mask was on the floor next to her bed. When asked,
Resident R65 stated she tries to use her BiPAP but is unable to put the mask on herself, and the nursing
staff, doesn't get in here much to assist in applying the mask.Further discussion revealed that the current
mask used is uncomfortable for Resident R65. Resident R65 stated that she has not been provided with
options for other types of masks to increase comfort and compliance. Interview on 1/20/26, at 3:00 p.m. the
Director of Nursing confirmed the facility failed to provide tracheostomy care consistent with professional
standards of practice for one resident with a tracheostomy (Resident R25) and failed to provide appropriate
respiratory care and maintain respiratory equipment for five of five residents (Resident R25, R41, R50,
R65, and R74). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care
policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
Event ID:
Facility ID:
395289
If continuation sheet
Page 15 of 28
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
01/23/2026
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 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
resident record review and staff interviews, it was determined that the facility failed to provide a trauma
survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the
resident for two of four residents (Resident R7 and R33). Findings include: Review of the facility policy
Trauma Informed Care and Culturally Competent Care dated 8/27/25, indicated the purpose is to address
the needs of trauma survivors by minimizing triggers and/or re-traumatization. Review of the admission
record indicated Resident R7 admitted to the facility on [DATE]. Review of Resident R7's Minimum Data Set
(MDS - a periodic assessment of care needs) dated 11/10/25, indicated the diagnoses of post-traumatic
stress disorder (PTSD - a psychiatric disorder that may occur in persons that have witnessed a traumatic
event causing intense, disturbing thoughts and feelings related to the experience), dementia (a general
term for loss of memory, language, problem solving and other thinking abilities that are severe enough to
interfere with daily life), and high blood pressure. Section I6100 indicated PTSD is present. Review of
Resident R7's current care plan indicated the resident uses psychotropic medications related to vascular
dementia and PTSD. The care plan failed to have a traumatic informed care plan addressing the PTSD or
identifying potential triggers and prevention for re-traumatization. During an interview on 1/21/26, at 2:30
p.m. the Director of Nursing confirmed the care plan failed to have a traumatic informed care plan
addressing the PTSD or identifying potential triggers and prevention for re-traumatization. Review of the
admission record indicated Resident R33 admitted to the facility on [DATE]. Review of Resident R33's MDS
dated [DATE], indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells),
heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Interview on 1/22/26,
at 11:30 a.m. Resident R33's Legal Guardian indicated that Resident R33 has a history of being victimized
by predators involving cellular phone usage. Review of the resident's care plan and clinical record failed to
identify this past trauma. Interview with the Director of Nursing on 1/22/26, at 1:00 p.m. indicated that the
facility was unaware of Resident R33's traumatic history of being victimized by predators and did not have a
plan in place to have a traumatic informed care plan addressing the PTSD or identifying potential triggers
and prevention for re-traumatization. Interview on 1/22/26, at 3:00 p.m. the Nursing Home Administrator
confirmed that the facility failed to provide a trauma survivor with trauma informed care to eliminate or
mitigate triggers that may cause re-traumatization of the resident for two of four residents (Resident R7 and
R33). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 16 of 28
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
01/23/2026
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 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a
resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed
consent; and (4) Correctly install and maintain the bed rail.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, review of facility policy, clinical record review, and staff interview, it was determined that the
facility failed to conduct accurate assessments to ensure that bedrails were used to meet residents' needs
and the risks associated with bedrail usage for one of two residents (Residents R78).Findings
include:Review of facility policy Bed Safety and Bed Rails dated 8/27/25, indicated the use of bed rails or
side rails is prohibited unless the criteria for use of bed rails have been met, including attempts to use
alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Review of the clinical
record indicated Resident R78 was admitted to the facility on [DATE], with diagnoses that include
Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), bipolar (a
disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and
paralytic syndrome (rapid onset of paralysis).Review of Resident R78's physician order dated 1/19/26,
indicated bilateral grab bars to bed (used to assist residents to position self in the bed).During an
observation on 1/20/26, at 9:15 a.m. Resident R78's bed did not have bilateral grab bars as ordered.Review
of Resident R78's care plan dated 1/19/26, indicated bilateral grab bars to bed.Review of Resident R78's
Enabler Bar assessment dated [DATE], indicated bilateral grab bars recommended for use by therapy
department. The Nursing portion of the assessment was blank.Interview on 1/20/26, at 9:20 a.m. Resident
R78 indicated the facility promised to provide side rails to assist self-positioning in bed and resident still did
not have them.Interview on 1/20/26, at 9:25 a.m. Registered Nurse (RN) Employee E2 confirmed Resident
R78's bed failed to have grab bars bilaterally as ordered and that the facility failed to conduct accurate
assessments to ensure that bedrails were used to meet residents' needs and the risks associated with
bedrail usage for one of two residents (Residents R78).28 Pa. Code: 201.14 (a) Responsibility of
licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code 211.10 (c)(d) Resident care policies.28
Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.
Event ID:
Facility ID:
395289
If continuation sheet
Page 17 of 28
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
01/23/2026
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 0740
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure each resident must receive and the facility must provide necessary behavioral health care and
services.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, resident clinical records, and staff interviews, it was determined that the facility
failed to ensure a resident received appropriate behavioral health services to maintain the highest
practicable well-being for one of two sampled residents (Resident R33).Findings include:Review of the
facility policy Behavioral health Services dated 8/27/25, indicated behavioral health services are provided to
residents as needed as part of the interdisciplinary, person-centered approach to care.Review of the
admission record indicated Resident R33 admitted to the facility on [DATE].Review of Resident R33's
Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/14/26, indicated the diagnoses of
heart failure (heart doesn't pump blood as well as it should), anxiety, and depression.Review of Resident
R33's current care plan indicated resident has a behavior problem of requesting staff to purchase gift cards
for an online friend and requesting staff take her to the store to purchase gift cards related to intellectual
disability and poor safety awareness.Interview with Resident R33 on 1/22/26, at 10:00 a.m. indicated the
Legal Guardian took the resident's personal cell phone a few weeks ago and resident hasn't had their
private therapy call for two weeks now.Interview with Director of Nursing (D0N) 1/22/26, at 11:20 a.m.
indicated Resident R33 has a private therapy call every Monday at 1:00 p.m. for as long as the DON has
worked at the facility. Resident R33 has missed two therapy appointments because the facility did not have
the private therapist's name or number because the Legal Guardian took the phone for repairs and has not
returned it.Further interview with the DON on 1/22/26, at 11:50 a.m. revealed the facility did not have the
contact name and number of the resident's therapist and indicated the facility has not reached out to the
Legal Guardian in attempt to retrieve the therapist's name and number to continue Resident R33's weekly
calls from a facility phone for their therapy. During an interview on 1/22/26, at 3:00 p.m. the Director of
Nursing confirmed that Resident R33 missed two therapy treatment calls and that the facility failed to
ensure a resident received appropriate behavioral health services to maintain the highest practicable
well-being for one of two sampled residents (Resident R33).28 Pa. Code 201.14(a) Responsibility of
licensee28 Pa. Code 201.18(b)(1)(3)(e)(1) Management28 Pa. Code 211.12(c)(d)(3) Nursing services28
Pa. Code 211.16(a) Social services
Event ID:
Facility ID:
395289
If continuation sheet
Page 18 of 28
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
01/23/2026
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 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, review of facility policy, resident interviews, clinical records, and staff interview, it was
determined that the facility failed to make certain that residents are free of significant medication errors for
one of five residents observed (Resident R73).Findings include:Review of the facility policy Adverse
Consequences and Medication Errors dated 8/27/25, indicated a medication error is defined as the
preparation or administration of drugs or biological which is not in accordance with physician's orders,
manufacturer's specifications, or accepted professional standards and principles of the professional
providing services. Examples include omission - a drug is ordered but not administered.Review of the
clinical record indicated Resident R73 was admitted to the facility on [DATE], with the diagnoses of chronic
obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe),
heart failure (heart doesn't pump blood as well as it should), and high blood pressure.Review of Resident
R73's physician order dated 1/17/26, indicated Xanax 0.5 mg (an anti-anxiety medication -milligrams) three
times a day for anxiety.Review of Resident R73's Medication Administration Record (MAR) indicated the
Xanax was not administered as ordered.Provider note dated 1/18/26, indicated resident was admitted to
facility on 1/18/26, was sent back to the hospital that evening due to crushing chest pain and tachycardia
(heart rate greater than 100 beats/minute). Resident was treated with one dose of IV lasix (intravenous
diuretic) to help with breathing. CTA (computed tomographic angiography) negative for acute pulmonary
emboli (blood clot in the lung). Lab work was within normal limits. Of note, due to awaiting pharmacy patient
did not have their medications at the facility. He was transferred back to the facility later that
night.Observation of Resident R73 on 1/20/26, at 9:15 a.m. indicated resident complaining of nausea and
feeling shaky.Interview on 1/20/26, at 9:15 a.m. Registered Nurse (RN) Employee E2 indicated Resident
R73 did not receive the physician ordered Xanax as prescribed and that RN felt Resident R73 was
experiencing symptoms of withdrawal after long history of receiving the Xanax three times a day.Interview
on 1/20/26, at 9:15 a.m. Resident R73 indicated they only received the Xanax twice since being at the
facility.Interview on 1/23/25, at 12:00 p.m. the Director of Nursing confirmed that facility failed to make
certain that residents are free of significant medication errors for one of five residents observed (Resident
R73).28 Pa Code: 211.10 (d) Resident care policies.28 Pa. Code 211.12 (c)(1)(3) Nursing Services.28 Pa
Code: 201.18 (b)(1)(3) Management.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 19 of 28
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
01/23/2026
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on review of facility policies, observations, and staff interviews, it was determined that the facility
failed to store medications properly, for one of two medication carts (A side medication cart).Findings
include:Review of the facility policy Storage of Medications dated 8/27/25, indicated the facility stores all
drugs and biologicals in a safe, secure, and orderly manner.During an observation on 1/20/26, at 2:58 p.m.
the A side medication cart indicated the following medications opened and not dated as
required:-Budesonide inhalation suspension (medication that reduces airway inflammation)-Ipratropium
bromide (medication that acts as a bronchodilator) - two boxes-Trelegy Ellipta (medication that's inhaled to
treat chronic respiratory illness)-Lantus insulin pen (long-acting insulin used to regulate blood
sugar)Interview on 1/20/26, at 2:58 p.m. Registered Nurse (RN) Employee E2 confirmed the medications
listed were opened and not dated as required.Interview on 1/20/26, at 3:00 p.m. the Director of Nursing
confirmed that the facility failed to store medications properly, for one of two medication carts (A side
medication cart).28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care
policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
Event ID:
Facility ID:
395289
If continuation sheet
Page 20 of 28
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
01/23/2026
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 0801
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the
food and nutrition service, including a qualified dietician.
Based on staff interview it was determined that the facility failed to employ a qualified Food Service Director
to manage the daily operations of the Dietary Department for 12 out of 12 months (February 2025 through
January 2026).Findings include:During an interview on 1/20/26, at approximately 9:00 a.m., the Dietary
Supervisor Employee E8 stated she was not certified and that the Dietician only works two days a week in
the facility and another two days in another facility.During an interview on 1/20/26, at 11:20 a.m., the
Nursing Home Administrator stated that the Registered Dietitian (RD) was not employed full time she
comes two times a week.During an interview on 1/20/26, 11:20 a.m., the Nursing Home Administrator
(NHA) confirmed that the facility failed to provide documented evidence that Dietary Supervisor Employee
E8 met the qualifications for the position of Food Service Director. Pa Code: 201.18(e)(6) Management.
Event ID:
Facility ID:
395289
If continuation sheet
Page 21 of 28
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
01/23/2026
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on a review of facility policy, observations and staff interview it was determined that the facility failed
to properly store food products in the Main Kitchen, which created the potential for foodborne
illness.Findings include:Review of the facility policy Food Storage, dated 8/27/25, indicated that food shall
be stored to facilitate thorough cleaning, and areas will be maintained in a clean, safe sanitary manner. A
thermometer is available in a storeroom, freezer and refrigerator units. During an observation on 1/20/26,
from 8:50 a.m., through 9:15 a.m., the following was observed:The drink/food line cooler did not have an
internal thermometer. The refrigerator and deep freezer had food stored approximately 3 inches from the
ceilings During an interview on 1/20/26, at 9:15 a.m., the Dietary Supervisor Employee E8 confirmed that
the facility failed to properly store food products in the Main Kitchen, which created the potential for
foodborne illness. Pa. 28 Code: 211.6(c)(d)(f) Dietary services.
Event ID:
Facility ID:
395289
If continuation sheet
Page 22 of 28
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
01/23/2026
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 0842
Level of Harm - Potential for
minimal harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on review of facility documents, 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
of four of nine residents (R8, R18, R46, and R57).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 2025, 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. The BIMS total score suggests the
following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of
Resident R8's previous BIMS assessments revealed the following:02/05/25: 1403/31/25: 1405/06/25:
1407/28/25: 1410/23/25: 15 Review of Resident R8's BIMS assessment completed on 1/19/26, by Licensed
Practical Nurse (LPN) Employee E6, documented that Resident R8 was rarely/never understood, and
coded Resident R8 as 0.0 severe impairment. Review of Resident R18's previous BIMS assessments
revealed the following:01/21/25: 1504/14/25: 1505/05/25: 1506/09/25: 1510/20/25: 15 Review of Resident
R18's BIMS assessment completed on 1/19/26, by LPN Employee E6, documented that Resident R18 was
rarely/never understood, and coded Resident R18 as 0.0 severe impairment. Review of Resident R46's
previous BIMS assessments revealed the following:02/05/25: 1105/05/25: 1207/28/25: 1510/20/25: 15
Review of Resident R46's BIMS assessment completed on 1/19/26, by LPN Employee E6, documented
that Resident R46 was rarely/never understood, and coded Resident R46 as 0.0 severe impairment.
Review of Resident R57's previous BIMS assessments revealed the following:02/02/25: 1505/02/25:
1507/28/25: 1510/20/25: 15 Review of Resident R57's BIMS assessment completed on 1/19/26, by LPN
Employee E6, documented that Resident R57 was rarely/never understood, and coded Resident R57 as
0.0 severe impairment. During an interview on 1/21/26, at 12:50 p.m. LPN Employee E6 confirmed that
Residents R8, R18, R46, and R57 are alert and oriented. LPN Employee E6 confirmed that she incorrectly
completed the BIMS assessments completed on 1/19/26. During an interview on 01/23/26, at
approximately 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed failed to
make certain that medical records on each resident are complete and accurately documented for of four of
nine residents. 28 Pa. Code: 211.5(f)(g)(h) Clinical records.
Event ID:
Facility ID:
395289
If continuation sheet
Page 23 of 28
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
01/23/2026
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 0847
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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 facility admission documents and staff interview, it was determined that the facility failed to ensure
resident rights to make informed decisions and choices in the residents' welfare by making certain
residents understand the conditions of a binding arbitration agreement and failed to ensure the agreement
is explained to the resident and his or her representative in a form and manner that he or she understands,
including in a language the resident and his or her representative understands for two of five residents
(Resident R27 and R48).Findings include: Review of the Resident Assessment Instrument 3.0 User ' s
Manual effective October 2025 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 intact8-12: moderately impaired0-7: severe impairment Review of the
facility's admission packet contained the document Alternative Dispute Resolution Agreement Between
Resident and Facility, indicated With the exception of payment disputes, all other disputes are governed by
this agreement, and each of the parties is giving up his/her/its right to resort to the courts and further
indicated Binding arbitration means that the parties are waiving their right to a trial, including their right to a
jury trial, their right to trial by judge and their right to appeal the decision of the arbitrator(s) except as
provided for under applicable state and/or federal laws governing arbitration. Review of Resident R27's
admission record indicated the resident was admitted to the facility on [DATE]. Review of Resident R27's
admission assessment dated [DATE], indicated that Resident R27 was alert and oriented to person only.
Review of Resident R27's baseline care plan dated 1/2/26, indicated that Resident R27 cannot
communicate easily with staff and has cognitive needs. Review of a BIMS assessment completed on
1/2/26, revealed Resident R27's score to be 3. Review of Resident R27's admission paperwork indicated all
sections, including the Alternative Dispute Resolution Agreement Between Resident and Facility, were
signed by Resident R27. Review of Resident R48's admission record indicated the resident was admitted to
the facility on [DATE]. Review of Resident R48's admission assessment dated [DATE], indicated that
Resident R48 was alert and oriented to person only. Review of Resident R48's baseline care plan dated
7/21/25, indicated that Resident R48 was, very confused, agitated and yelling out. Review of a BIMS
assessment completed on 7/22/25, revealed Resident R48's score to be 2. Review of Resident R48's
admission paperwork indicated all sections, including the Alternative Dispute Resolution Agreement
Between Resident and Facility, were signed by Resident R48. During an interview on 1/23/36, at
approximately 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility
failed to ensure resident rights to make informed decisions and choices in the residents' welfare by making
certain residents understand the conditions of a binding arbitration agreement and failed to ensure the
agreement is explained to the resident and his or her representative in a form and manner that he or she
understands, including in a language the resident and his or her representative understands for two of five
residents. 28 Pa. Code 201.24 (b) admission Policy 28 Pa. Code 201.14(a) Responsibility of Licensee 28
Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(a)(j) Resident Rights
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 24 of 28
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
01/23/2026
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain
infection control practices to prevent the potential for cross contamination while during wound care for one
of six residents (Resident R8), failed to maintain two ice machines in a sanitary manner ( A/E wing and B/C
wing ice machines), failed to properly monitor residents in room personal refrigerator temperatures for two
of two residents (Residents R33 and R64) which created the potential for food borne illness and failed to
follow Enhanced Barrier Precautions (EBP) for one of eight residents (Resident R6).Findings include:
Residents Affected - Some
Review of the facility policy, Dressings, Dry/Clean dated 8/27/25, indicated in the Steps in the Procedure to
cleanse hands between glove changes.
Review of facility policy Enhanced Barrier Precautions dated 8/27/25, indicated the facility will implement
enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO).
Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include
wound care (any surgical wound requiring a dressing, any pressure injury that is a Stage 2, 3, 4,
unstageable or deep tissue injury requiring a dressing, and lacerations that require a dressing).
Review of the clinical record revealed Resident R8 was readmitted to the facility on [DATE].
Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 10/24/25,
included diagnoses of peripheral vascular disease (PVD, circulatory condition in which narrowed blood
vessels reduce blood flow to the limbs), heart failure (a progressive heart disease that affects pumping
action of the heart muscles), and diabetes (a metabolic disorder in which the body has high sugar levels for
prolonged periods of time). Review of Section M: Skin Conditions indicated Resident R8 a stage four
pressure ulcer (injury to the skin and underlying tissue, primarily caused by prolonged pressure on the skin,
with full-thickness skin and tissue loss).
Review of the plan of care for stage four pressure ulcer dated 10/23/25, indicated for staff to administer
treatments as ordered and monitor for effectiveness.
Review of the plan of care for enhanced barrier precautions dated 12/11/24, indicated gloves and gowns
are worn for high contact care activity. Included in the list of high contact care was wound care.
Review of a physician's order dated 7/6/25, indicated Resident R8 was ordered Enhanced Barrier
Precautions related to the presence of a wound and a catheter.
During an observation of a wound dressing change on 1/22/26, at approximately 11:00 a.m. the following
was observed:
-Licensed Practical Nurses (LPN) Employees E3 and E4 provided wound care without wearing gowns.
-Resident R8 was noted to have a cloth underpad on his bed that was soiled with wound drainage. Per
resident request, the ABD Pad (highly absorbent dressing that provides padding and protection for large
wounds) covering the wound is left without a covering dressing. When the dressing change was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 25 of 28
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
01/23/2026
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 0880
completed, Resident R8 was rolled onto his back, onto the soiled underpad.
Level of Harm - Minimal harm
or potential for actual harm
-LPN Employee E4 did not clean her hands after removing the soiled gloves and putting on clean gloves.
Residents Affected - Some
During an interview on 1/23/26, at approximately 1:30 p.m. the Nursing Home Administrator and the
Director of Nursing confirmed the failed to maintain infection control practices to prevent the potential for
cross contamination while during wound care for one of six residents.
Review of the facility policy Ice Machines and Ice Chests Maintenance dated 8/27/25, indicated that ice
machines and ice storage/distribution containers will be used and maintained to assure a safe sanitary
supply of ice.
During an observation on 1/20/26, at 10:00 a.m., of the A/E and B/C pantries, each ice machine drainpipe
was coiled into the drain with no space for an air gap, allowing for the potential for contamination of the ice
in the ice machine. Used small heaters, paper towels gloves and wash basins were underneath the ice
machines and debris such as gloves paper towels and dust were within and around the drain and ice
machine drainpipe.
During an interview on 1/20/26, at 10:15 a.m., Maintenance Director Employee E1 confirmed that the
facility failed to maintain two of two ice machines in a sanitary manner.
Review of the admission record indicated Resident R33 admitted to the facility on [DATE].
Review of Resident R33's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/14/26,
indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), anxiety, and
depression.
Observation on 1/21/26, at 2:00 p.m. Resident R33 had a personal refrigerator in the room. The
temperature log was dated October 2025.
Review of the admission record indicated Resident R64 admitted to the facility on [DATE].
Review of Resident R64's MDS dated [DATE] indicated the diagnoses of atrial fibrillation (irregular heart
rhythm), heart failure (heart doesn't pump blood as well as it should), and high blood pressure.
Observation on 1/21/26, at 2:05 p.m. Resident R65 had a personal refrigerator in the room. The
temperature log was dated October 2025.
Interview on 1/21/26, at 2:10 p.m. the Nursing Home Administrator confirmed the facility failed to properly
monitor residents in room personal refrigerator temperatures for two of two residents (Residents R33 and
R64) which created the potential for food borne illness.
Review of the facility policy Enhanced Barrier Precautions dated 8/27/25, indicated EBP employ targeted
gown and glove use during high contact resident care activities. EBP are initiated for residents with wounds
and MDRO (multiple drug-resistant organism).
Review of the admission record indicated Resident R6 admitted to the facility on [DATE].
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 26 of 28
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
01/23/2026
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of Resident R6's MDS dated [DATE] indicated the diagnoses of anemia (the blood doesn't have
enough healthy red blood cells), heart failure (heart doesn't pump blood as well as it should), and high
blood pressure.
Review of Resident R6's physician order dated 12/7/25, indicated Enhanced Barrier Precautions related to
history of MDRO/wound every shift.
Observation on 1/21/26, at 10:00 a.m. Nurse Aide (NA) Employee E10 was providing morning care
(personal hygiene, brief change, and dressing) to Resident R6. NA Employee E10 failed to have a gown
during high contact resident care activities.
Interview on 1/21/26, at 10:01 a.m. NA Employee E10 indicated the sign for EBP has been on Resident
R6's door forever and staff did not have to wear a gown for resident's care.
Interview on 1/21/26, at 1:00 p.m. the Infection Preventionist (IP) Employee E11 indicated Resident R6 was
in EBP currently and did require a gown during high contact resident care activities.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 201.20(c) Staff development.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 27 of 28
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
01/23/2026
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 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm
or potential for actual harm
Based on a review of facility policy, observations, and staff interviews, it was determined the facility failed to
maintain a fully functioning resident call bell system that allows residents to call for staff assistance through
a communication system which relays the call directly to a staff member or to a centralized staff work area
in two of five rooms (Resident R10 and R46).Findings include: To ensure accessibility, the ADA (Americans
with Disabilities Act) Standards for Accessible Design dated 9/15/10, indicated that emergency call system
pull cords must be accessible to individuals with disabilities, ensuring they can reach the activation point
from a seated or fallen position. While specific string length is not explicitly defined in inches by the ADA,
the cord must be reachable, the operating mechanism must be within the ADA reach range of 15 to 48
inches from the floor Review of the facility policy Call System, Residents dated 8/27/25, indicated, Each
resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing
facilities and from the floor. During an observation on 1/20/26, at 10:32 a.m. the call light in Resident R10's
restroom was noted to be approximately three inches long, only the short portion of the chain extending
from the wall, without a string or call pendant at the end of the string. During an observation on 1/20/26, at
10:35 a.m. the call light in Resident R46's restroom was noted to be approximately three inches long, only
the short portion of the chain extending from the wall, without a string or call pendant at the end of the
string. During an interview on 1/23/26, at 1:30 p.m. the Nursing Home Administrator and the Director of
Nursing confirmed that the facility failed to maintain a fully functioning resident call bell system that allows
residents to call for staff assistance through a communication system which relays the call directly to a staff
member or to a centralized staff work area in two of five rooms. 28 Pa Code 207.2(a) Administrators
responsibility 28 Pa Code 205.28 (c)(1)(4) Nurses station
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395289
If continuation sheet
Page 28 of 28