Inspection·March 14, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for nine of the sixteen residents reviewed (Resident R14, R18, R48, R84, R86, R96, R98, R99, R108). Findings Include: A review of the facility policy Advanced Directives reviewed 3/1/2023 and 1/31/2024, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the medical record indicated Resident R14 was admitted to the facility on [DATE], with diagnoses that included Parkinson ' s disease (affects movement of muscles often seen with tremors, shaking), diabetes, and depression. A review of the clinical record failed to reveal an advance directive or documentation that Resident R14 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R18 was re-admitted to the facility on [DATE], with diagnoses that include diabetes, high blood pressure, and paraplegia (no movement of lower body or legs). A review of the clinical record failed to reveal an advance directive or documentation that Resident R18 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R43 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, gastro-esophageal reflux disease (GERD-severe indigestion), gastro-intestinal bleed (bleeding from either the stomach or the intestines). A review of the clinical record failed to reveal an advance directive or documentation that Resident R43 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R84 was admitted to the facility on [DATE], with diagnoses that include diabetes, morbid obesity (severely overweight) and foot drop of both feet (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: 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 03/14/2024 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)