Health inspection·January 17, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, newly hired personnel records and staff interviews it was determined that the facility failed to properly screen an employment by completing a state background check prior to hire for two out of five personnel records (Licensed Practical Nurse Employee E1, and Registered Nurse Employee E4). Residents Affected - Few Findings include: The facility Abuse, Neglect, Exploitation, and Misappropriation policy dated 1/11/24, indicated the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Conduct employee background checks. The facility Background Checks for Nursing Home Employees policy dated 1/11/24, indicated that the purpose of the background check is to ensure the safety and well-being of all residents and staff by conducting background checks on all potential and current employees. Background checks requirements, Pre-Employment Screening include: - Criminal history check, including national and state records. - Verification of identity through government-issued identification. - Verification of professional licenses, certifications, and qualifications as required for the position. - Monitoring for changes in professional licensure status. Review of Licensed Practical Nurse (LPN) Employee E1's personnel record indicated she was hired on 11/14/24. Review of LPN Employee E1's personnel record did not include a completed state criminal background check prior to her date of hire. Review of Registered Nurse (RN) Employee E4's personnel record indicated he was hired on 11/4/24. Review of RN Employee E4's personnel record did not include a completed state criminal background check prior to his date of hire. During an interview on 1/16/25, at 10:05 a.m. the Regional Human Resource Employee E2 stated, The background checks should have been completed prior to their start date. Page 1 of 9 395295 395295 01/17/2025 Wecare at Murrysville Rehab and Nursing Center 3300 Logan Ferry Road Murrysville, PA 15668

F 0607 Level of Harm - Minimal harm or potential for actual harm During an interview on 1/17/25, at 3:30 p.m. the Nursing Home Administrator confirmed that the facility failed to properly screen LPN Employee E1, and RN Employee E4 by completing a state criminal background check prior to hire, as required. 28 Pa Code: 201.14(a) (c)(d)(e) Responsibility of licensee Residents Affected - Few 28 Pa Code: 201.19 Personnel policies and procedures 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development 395295 Page 2 of 9 395295 01/17/2025 Wecare at Murrysville Rehab and Nursing Center 3300 Logan Ferry Road Murrysville, PA 15668

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, job descriptions, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of five employees reviewed (Registered Nurse (RN) Employee E4). Residents Affected - Few Findings include: The facility RN job description indicated that licensed personnel have graduated from a State Accredited Educational Institution/Program registered by the State education department. Nursing license is valid for life, unless it is surrendered or revoked, annulled or suspended by the State Board. Registration certificate will authorize licensed personnel to practice nursing and renewed as per state mandate to continue practicing in nursing. Licensed personnel are not legally allowed to practice nursing while registration is expired. Legal/ Ethical- RNS is required to understand legal/ethical professional standards of practice including but not limited to: -Practicing in accordance with legislation affecting nursing practice -Fulfilling duty of care including recognizing standards of care, clarifying responsibilities for aspects of care with other members of the interdisciplinary team, and recognizing responsibility to prevent harm. -Recognizing and responding appropriately to unsafe or unprofessional practice -Practicing within the professional and ethical nursing framework, practicing in accordance with nursing profession code of ethics -Understanding and practicing within own scope of practice Review of personnel record on [DATE], at 9:45 a.m. revealed that RN Employee E4 was hired on [DATE]. Review of Employee E4's license verification that was completed on [DATE], revealed that the expiration date was [DATE], and the status of his license was expired - on probation. Review of facility provided documentation on [DATE], at 2:30 p.m. indicated that RN Employee E4 worked as med cart nurse (provides medications prescribed by a physician to the residents), and worked as a RN supervisor while having an expired RN license throughout his employment. Review of RN Employee E4's job task revealed that he was performing duties, providing care, completing documentation in residents medical record failed to be with in his scope of practice with an expired RN license. During an interview on [DATE], at 12:17 p.m. the DON confirmed that the facility failed to provide care and services to meet the accepted standards of practice as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 395295 Page 3 of 9 395295 01/17/2025 Wecare at Murrysville Rehab and Nursing Center 3300 Logan Ferry Road Murrysville, PA 15668

F 0658 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395295 Page 4 of 9 395295 01/17/2025 Wecare at Murrysville Rehab and Nursing Center 3300 Logan Ferry Road Murrysville, PA 15668

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of personnel files, facility documentation, policy review and interviews with staff, it was determined that the facility failed to ensure that nursing staff possessed the required skills to properly care for residents' needs for one out of five personnel files reviewed (Registered Nurse Employees E4). Findings include: The facility RN job description indicated that licensed personnel have graduated from a State Accredited Educational Institution/Program registered by the State education department. Nursing license is valid for life, unless it is surrendered or revoked, annulled or suspended by the State Board. Registration certificate will authorize licensed personnel to practice nursing and renewed as per state mandate to continue practicing in nursing. Licensed personnel are not legally allowed to practice nursing while registration is expired. Legal/ Ethical- RNS is required to understand legal/ethical professional standards of practice including but not limited to: -Practicing in accordance with legislation affecting nursing practice -Fulfilling duty of care including recognizing standards of care, clarifying responsibilities for aspects of care with other members of the interdisciplinary team, and recognizing responsibility to prevent harm. -Recognizing and responding appropriately to unsafe or unprofessional practice -Practicing within the professional and ethical nursing framework, practicing in accordance with nursing profession code of ethics -Understanding and practicing within own scope of practice Review of personnel record on [DATE], at 9:45 a.m. revealed that RN Employee E4 was hired on [DATE]. Review of employee personnel records on [DATE], at 10:05 a.m. revealed that RN Employee E4's RN license expired on [DATE], and was working with an expired RN license. During an interview on [DATE], at 11:30 a.m. Director of Nursing stated that RN Employee E4 works the night shift full time. He works as a cart nurse (passing medications), documents in medical records, and sometimes works as an RN supervisor overseeing the function of the building, and the care of the residents. Review of personnel record indicated that Employee E4 was working as a license professional RN performing duties that can only be done with a current and active license in the state of PA while possessing an expired RN license. During an interview on [DATE], at 3:30 p.m. Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure that nursing staff possessed the required skills to properly care for residents' needs for one out of five personnel files reviewed (Registered Nurse Employees 395295 Page 5 of 9 395295 01/17/2025 Wecare at Murrysville Rehab and Nursing Center 3300 Logan Ferry Road Murrysville, PA 15668

F 0726 E4). Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.19(7) Personnel records 28 Pa. Code 201.20(b) Staff development Residents Affected - Few 395295 Page 6 of 9 395295 01/17/2025 Wecare at Murrysville Rehab and Nursing Center 3300 Logan Ferry Road Murrysville, PA 15668

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure licensed professional staff held an active license in accordance with state laws for one of five staff members reviewed (Registered Nurse (RN) Employee E4). Findings include: Review of facility policy Background Checks for Nursing Home Employees policy dated [DATE], indicated that the purpose of the background check is to ensure the safety and well-being of all residents and staff by conducting background checks on all potential and current employees. Background checks requirements, Pre-Employment Screening include: - Criminal history check, including national and state records. - Verification of identity through government-issued identification. - Verification of professional licenses, certifications, and qualifications as required for the position. - Monitoring for changes in professional licensure status. The facility Abuse, Neglect, Exploitation, and Misappropriation policy dated [DATE], indicated the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Conduct employee background checks. The facility RN job description indicated that licensed personnel have graduated from a State Accredited Educational Institution/Program registered by the State education department. Nursing license is valid for life, unless it is surrendered or revoked, annulled or suspended by the State Board. Registration certificate will authorize licensed personnel to practice nursing and renewed as per state mandate to continue practicing in nursing. Licensed personnel are not legally allowed to practice nursing while registration is expired. Review of personnel record on [DATE], at 9:45 a.m. revealed that RN Employee E4 was hired on [DATE]. Review of facility provided documents indicated that the Human Resource Employee (terminated on [DATE]) commented on his application that He sent up for his RN renewal license, but failed to ensure his license was updated and in an active status prior to his start date. Review of RN Employee E4 personnel record indicated that the facility failed to verify his RN license until [DATE], in which it showed that his RN license expired [DATE], and that he was on probation. During an interview on [DATE], at 10:15 a.m. Regional Human Resource Employee E2 stated that Human Resource employee at the time has been terminated, and that she should have made management aware of the expired license and criminal background check but failed to do so. Regional Human Resource 395295 Page 7 of 9 395295 01/17/2025 Wecare at Murrysville Rehab and Nursing Center 3300 Logan Ferry Road Murrysville, PA 15668

F 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employee E2 stated that she was completing audits of employee files on [DATE], and indicated that she let the Nursing Home Administrator know at that time of RN Employee E4's expired license and criminal background check status. During a review of the facility provided document titled, Daily Time Card, for RN Employee E4 revealed that the staff member had worked 48 shifts from [DATE] through [DATE] while his RN license was expired: [DATE] on 11/4, 11/5, 11/6, 11/7, 11/8, 11/9, 11/11, 11/12, 11/13, 11/14, 11/15, 11/19, 11/20, 11/21, 11/22, 11/23, 11/24, 11/26, 11/27, 11/28, and 11/29. [DATE] on 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, 12/10, 12/11, 12/12, 12/13, 12/17, 12/18, 12/19, 12/20, 12/21, 12/22, 12/24, 12/25, 12/26, 12/27, 12,29, and 12/31. [DATE] on 1/1, 1/2, 1/3,1/4, and 1/5. During an interview on [DATE], at 1:33 p.m. Director of Nursing stated that RN Employee E4 worked as a medication passing nurse and as a RN supervisor during his employment. During an interview on [DATE], at 3:30 p.m. Nursing Home Administrator confirmed that the facility failed to ensure licensed professional staff held an active license in accordance with state laws for one of five staff members reviewed (Registered Nurse (RN) Employee E4). 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 395295 Page 8 of 9 395295 01/17/2025 Wecare at Murrysville Rehab and Nursing Center 3300 Logan Ferry Road Murrysville, PA 15668

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. 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 documentation and interviews with staff it was determined that the facility failed to maintain and implement an effective, quality assurance and performance improvement program that focuses on outcome as required by failing to follow a performance improvement project (PIP) for new hire employee files. Residents Affected - Few Finding include: Review of facility Quality Assurance Assurance policy dated [DATE], indicated that facility is to establish a framework for continuous improvement in the quality of care and services provided. Quality assurance ensures that the facility meets or exceeds regulatory standards, promotes resident satisfaction, and fosters a culture of accountability and excellence. Review of facility provided documentation on [DATE], at 10:02 a.m. indicated a new process for new hire employees were initiated at facility on [DATE]. During an interview on [DATE], at 10:15 a.m. Regional Human Resource (HR) Employee E2 stated I put this initiative together after one of my other buildings that I oversee got a Federal citation for employee files so I started it across all of my buildings. During five employee record reviews completed on [DATE], at 9:30 a.m. revealed the following: - Four out of Five professional license were not verified to ensure accuracy of license prior to employment. - Five out of Five physicals were not completed prior to employment. - Five out of Five Tuberculin tests (a test to detect respiratory disease) was not completed. - Four out of Five employee job descriptions were missing. - Two out of Five background checks were not completed prior to employment. During a personnel record review on [DATE], at 10:20 a.m. revealed that the facility performed a Registered Nurse (RN) license verification for RN Employee E4 on [DATE], in which it came back as expired-on probation and continued to allow RN Employee to work. During an interview on [DATE] at 2:15 pm Director of Nursing stated the past HR director did not tell anyone about the expired license and confirmed that the facility failed to maintain and implement an effective, quality assurance and performance improvement program by failing to implement an effective QAPI plan for new employees hired. 28 Pa. Code 201.14(a)Responsibility of licensee. 28 Pa. Code 201.18(a)(b)(3)e(1)(3)(4)Management. 395295 Page 9 of 9