Inspection·February 11, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, facility provided documentation, clinical records and staff interview, it was determined that the facility failed to make certain a resident was free from abuse/neglect for two of five residents(Residents R1 and R2). Findings include: Review of the facility policy Abuse, Neglect and Exploitation last reviewed on 1/31/25, with a previous review date of 1/31/24, indicated that the facility will provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Potential employees will be screened for a history of abuse, etc. New employees will be educated on abuse, neglect, etc. The facility will have ongoing training for facility personnel as to he requirements of the facility's policies and procedures for assuring resident safety. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included dementia, difficulty walking, cognitive communication disorder and heart failure. A Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 1/14/25, indicated the diagnoses remained current. Section C0500 (Brief Interview for Mental Status - BIMS) indicated a score of 15; which indicated the resident was cognitively intact. Review of the facility provided information dated 1/15/25, indicated that Resident R1 had been identified as being neglected by Nurse Aide Employee E1 when she put on her call light for assistance. The Housekeeper who submitted the allegation indicated that NA Employee E1 stated It was not her job to care for Resident R1 that the floater would do it. The information submitted indicated that NA Employee E1 confirmed that she refused to provide Resident R1 assistance. Review of the Alleged Neglect report dated 1/15/25, indicated that Resident R1 was interviewed by the Director of Nursing and Resident R1 stated she put on her call bell to use the bathroom, and she waited more than usual time to be provided assistance (30- 40 minutes). Review of a phone interview with NA Employee E1 dated 1/15/25, indicated that she was scheduled to be the NA on the wing where Resident R1 resides and that she refused to respond to Resident R1's request for assistance. Review of the statement submitted by the Housekeeper Employee E2 indicated that at approximately 3:30 a.m., Resident R1's call light was illuminated and NA Employee E1 walked past the room. At (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 02/11/2025 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)