Inspection·November 21, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision during transfers for one of three residents (Resident R1). This was identified as past-noncompliance.Findings include:Review of facility Safety and Supervision of Residents dated 1/22/25, indicated that the facility takes an initialized resident centered approach to resident safety including implementing interventions with adequate supervision.Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairmentReview of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 9/12/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), arthritis (inflammation of one or more joints, causing pain and stiffness), and physical debility. Review of Section G: indicated that Resident R1 required substantial/maximal assistance to transfer to and from a chair or bed.Review of Resident R1's plan of care for Functional Decline in ADLs (activities of daily living) initiated 8/29/22, revised on 8/13/25, indicated, Transfer resident with Ax2 (assist of two people).Review of Resident R1's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated 10/8/25, indicated that Resident R1 as Transfer resident with Ax2.Review of a progress note dated 10/8/25, at 12:15 p.m. indicated, [Provider] notified of residents left foot and ankle is swollen, warm to touch and tender. Orders received for 2 view xray.Review of a progress note dated 10/9/25, at 9:06 a.m. indicated, X-ray positive for left ankle fracture. [Provider] in facility and aware. Investigation into fracture in process. Could be related to disease process. Family notified by MD (doctor of medicine).Review of facility submitted information dated 10/9/25, indicated, [Resident R1] had an X-Ray of the left ankle due to swelling. Results positive for left ankle fracture. Resident has a BIMS of 0 and unable to state what occurred. Investigation started. Upon conclusion of investigation it was determined that the residents plan of care was not followed on 10/6/2025 with [Nurse Aide Employee E1] as resident was transferred with an assist x1 and her plan of care is assist x2. This happened due to census sheets at nurses' station having the incorrect transfer status.Review of an employee statement written by NA Employee E1 dated 10/9/25, indicated, I got [Resident R1] up on Monday and she stayed up all day until I put her back at 2 pm. This is my usual routine with her. When I put her back or got her up, there was nothing that I observed about her injury. She did not moan or scream. I had her in bed at 2 pm and that was the last time I saw her until this morning. I have always transferred her by myself because that is what is on the census sheet. I never looked at PCC (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 2 Event ID: 395434 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 395434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wecare at MT Lebanon Rehabilitation and Nrsg Ctr 350 Old Gilkeson Road Pittsburgh, PA 15228 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)