Health 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 Page 1 of 2 395434 395434 11/21/2025 Wecare at MT Lebanon Rehabilitation and Nrsg Ctr 350 Old Gilkeson Road Pittsburgh, PA 15228

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [electronic charting system].Review of a facility submitted Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 10/9/25, included the information, Neglect substantiated due to CNA (nurse aide) not following the plan of care. CNA immediately educated to find all transfer statuses in PCC under the Kardex and to follow the plan of care.On 10/9/25, the facility initiated a plan of correction that included:-Residents' representative aware. -Census sheets on the units updated to remove transfer statuses.-Therapy evaluated resident and noted that Broda chair has a metal bar footrest and padding was applied. -Physician notified and POLST (Physician Orders for Life-Sustaining Treatment, set of medical orders signed by both the patient and their healthcare provider, which allows emergency medical personnel to follow the patient's specific preferences) will continue comfort measures only in house and MD to conduct a medication review for pain meds/comfort. -Whole house audit of residents to ensure accuracy of transfer status. -Whole house education to obtain transfer status in PCC by reviewing the Kardex and following each resident's plan of care.-All incidents are reviewed by the IDCP team and QAPI committee.During observations of the census sheets for use by staff confirmed that the transfer status was not included. During interviews completed on 11/6/25, six staff interviewed confirmed they had received education on the appropriate way checking a resident ' s transfer status and demonstrated how to navigate to the appropriate area in the electronic medical record system. Facility in compliance as of 11/6/25.During an interview on 11/6/25, at approximately 5:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision during transfers that resulted in the actual harm of an ankle fracture one of three residents. This was identified as past-noncompliance. 395434 Page 2 of 2