Inspection·February 3, 2024

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 job description, resident record review, and staff interview, it was determined that the facility failed to follow professional standards of practice for to three of four residents reviewed (Resident R1, R2, and R3). Residents Affected - Some Review of the facility Licensed Practical Nurse job description, effective 9/1/23, indicated the Licensed Practice Nurse (LPN) is responsible for rendering nursing care in terms of individualized resident needs based on the scope of practical nursing. The job description further stated the LPN performs delegated nursing functions using established procedures, policies, guidelines and standards. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 1/15/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and hypertension (high blood pressure in the arteries). Review of Resident R1's January 2024 vital sign record revealed LPN Employee E1 documented blood pressures (BP) and heart rates (HR) on Resident R1 on nine separate shifts, which revealed the following: -1/12/24, at 12:00 a.m.: LPN Employee E1 documented BP 152/88 and HR 80, a duplicate of the previous BP/HR completed on 1/11/24, at 9:07 p.m., approximately three hours prior. -1/16/24, at 12:31 a.m.: LPN Employee E1 documented BP 133/72 and HR 77, a duplicate of the previous BP completed on 1/15/24, at 10:56 p.m., approximately one and a half hours prior. -1/16/24, at 11:33 p.m.: LPN Employee E1 documented BP 137/85 and HR 71, a duplicate of the previous BP/HR completed on 1/16/24, at 10:36 p.m., approximately one hour prior. -1/18/24, at 12:15 a.m.: LPN Employee E1 documented BP 126/75 and HR 72, a duplicate of the previous BP/HR completed on 1/17/24, at 6:57 p.m., approximately five hours prior. -1/20/24, at 12:57 a.m.: LPN Employee E1 documented BP 163/78 and HR 70, a duplicate of the previous BP/HR completed on 1/19/24, at 6:22 p.m., approximately six hours prior. -1/21/24, at 11:55 p.m.: LPN Employee E1 documented BP 168/88 and HR 80, a duplicate of the previous BP/HR completed on 1/21/24, at 6:30 p.m., approximately five and a half hours prior. (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 4 Event ID: 395675 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 395675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waynesburg Nursing and Rehab 300 Center Avenue Waynesburg, PA 15370 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)