F 0576
Ensure residents have reasonable access to and privacy in their use of communication methods.
Level of Harm - Minimal harm
or potential for actual harm
Based on resident and staff interviews, it was determined that the facility failed to provide reasonable
access to mail services as available in the community to all residents of the facility.Findings include: A
review of the facility policy Mail last reviewed 12/5/25, indicated Delivery of mail or other materials to the
resident within 24 hours of delivery by the postal service (or facility post office box ) and delivery of
outgoing mail to the postal service within 24 hours, when there is no regularly scheduled postal delivery
and pick-up service. During a group interview on 2/11/26, at approximately 11:30 a.m., consensus from the
group revealed that residents reported the facility did not deliver mail or provide mail services on Saturdays.
Review of the facility documents (activity calendars) for the past six months from 9/25 through 2/26 reveal a
statement of Mail Delivery is Monday - Friday During an interview on 2/12/26, at 1:15 p.m. Activities
Director Employee E1 confirmed that she does not deliver mail on Saturday as she is not in the building on
weekends and she is the only employee of the activity department. During an interview on 2/13/26, at 9:22
a.m. Business Office Manager Employee E4 stated the facility does not get mail delivered on Saturday from
the postal service. During an interview on 2/13/26, at 9:45 a.m. the Nursing Home Administrator and
Director of Nursing confirmed that the facility failed to ensure mail was delivered to the residents on
Saturdays. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management 28 Pa.
Code 201.29(j) Resident rights
Residents Affected - Few
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 12
Event ID:
395948
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
395948
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center at Jefferson Hills, The
540 Coal Valley Road
Jefferson Hills, PA 15025
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)
F 0579
Provide information about how to apply for and use Medicare and Medicaid benefits.
Level of Harm - Potential for
minimal harm
Based on observations and a staff interview, it was determined that the facility failed to display (for
residents and/or their responsible person) written information on how to apply for Medicare and Medicaid
benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the
building, where postings are available (first floor lobby). Findings include: The facility must display in the
facility, written information, and provide to residents and applicants for admission, oral and written
information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for
previous payments covered by such benefits. During observations completed on 2/11/26, at approximately
11:30 a.m., in the lobby, hallways in and around the nursing units, revealed the facility failed to include
information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous
payments covered by Medicare and Medicaid. During rounds and an interview with the Nursing Home
Administrator (NHA) on 2/12/26, at 9:00 a.m., the NHA confirmed the facility failed to display (for residents
and/or their responsible person) written information on applying for Medicare and Medicaid benefits and
receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building. 28
Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395948
If continuation sheet
Page 2 of 12
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
395948
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center at Jefferson Hills, The
540 Coal Valley Road
Jefferson Hills, PA 15025
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)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean,
comfortable, and homelike environment on one of two nursing units (North Nursing Unit).Findings include:
Review of the facility policy Resident Environment dated 12/5/25, indicated in part The facility will provide
an environment that is safe, clean comfortable and homelike, allowing the resident to use his or her
personal belongings to the extent possible. During an observation on 02/12/2026, at 8:30 a.m., the
following was identified: Residents R19 and R30 had tape surrounding the ceiling air vent. The air vent and
tape had dust collected on both. Residents R4 and R41 had the rubber baseboard molding pulled away
from the wall, for the entire length of the wall. Residents R26 and R40 had the rubber baseboard molding
pulled away from the wall, for the entire length of the wall. Resident R26 had approximately a
30.61-millimeter hole in the wall at the outlet junction box that was in use. This was located near the floor
between the head of Resident 26 bed and the outside wall. Hallway outside (room [ROOM NUMBER]) the
ceiling has a cracked and partially patched and unpainted area. North Hallway handrails appear to have
unpainted patched spots on both sides of the hall. Physical Therapy Department has a large vent in the
middle of the room that has dust weaved throughout the vent. During an interview with Resident R26 and
his parents, they confirmed that the room condition have been in existence since admission. During rounds
and an interview on 2/12/26, at 9:00 a.m., the Nursing Home Administrator confirmed the above findings
and that the facility failed to provide a safe, clean, comfortable, and homelike environment. 28 Pa. Code:
207.2(a) Administrator's responsibility.28 Pa. Code: 201.29(k) Resident rights.
Event ID:
Facility ID:
395948
If continuation sheet
Page 3 of 12
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
395948
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center at Jefferson Hills, The
540 Coal Valley Road
Jefferson Hills, PA 15025
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)
F 0585
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must
establish a grievance policy and make prompt efforts to resolve grievances.
Based on review of facility policy, observations, and resident and staff interviews, it was determined that the
facility failed to make accessible grievance boxes to residents in three of three locations where grievances
boxes are located (main lobby, north and south nursing units). Findings include: A review of the facility
policy Grievances/Complaints, Filing reviewed 1/16/25, grievances and/or complaints may be submitted
orally or in writing and may be filed anonymously. The Centers for Medicare & Medicaid Services (CMS)
does not specify exact height requirements for grievance boxes in skilled nursing facilities. However, CMS
mandates that grievance procedures be accessible to all residents, including those with disabilities, in
compliance with the Americans with Disabilities Act (ADA). In Pennsylvania, the Department of Health
incorporates by reference the federal requirements outlined in 42 CFR Part 483, Subpart B, which pertains
to long-term care facilities. These regulations emphasize the importance of accessibility but do not provide
additional specifications regarding grievance box placement. To ensure accessibility, the ADA Standards for
Accessible Design recommend that operable parts, such as slots on grievance boxes, be mounted between
15 and 48 inches above the floor. This range accommodates individuals using wheelchairs and ensures
usability for a broad range of residents. During a resident group interview, on 2/11/26 at approximately
11:30 a.m., when asked if they felt they could anonymously file a grievance in the grievance boxes,
consensus from the group was no. Residents stated, there a couple of boxes they are too high to reach,
they are not made for people in wheelchairs, the boxes are in view of the staff, and you have to ask
someone to help you, so we just ask the staff to do it for us. During an observation and interview on
2/12/26, at 9:00 a.m. the Nursing Home Administrator and surveyor measured the height of the grievance
boxes; the lobby height was 54 inches, north nursing unit box height was 53 inches, and south nursing unit
box, height was 57 inches. The box in the lobby was in view of the reception desk and blocked by a chair,
the north nursing unit box was in view of the nursing station, and the south nursing unit box was blocked by
a cart with a cooler in front of it and the box is in view of the nursing station. During an interview on 2/12/26,
at 9:00 a.m. the Nursing Home Administrator confirmed the facility failed to make accessible grievance
boxes to residents. 28 PA Code: 201.18(e)(4) Management.28 PA Code: 201.29(a)(b)(c) Resident rights.
Event ID:
Facility ID:
395948
If continuation sheet
Page 4 of 12
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
395948
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center at Jefferson Hills, The
540 Coal Valley Road
Jefferson Hills, PA 15025
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)
F 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
Based on a review of scheduled activities, observations, and staff interviews, it was determined that the
facility failed to provide an ongoing program of activities to meet the interests of and support the physical,
mental, and psychosocial well-being of residents. Findings include: Review of the activity's calendars for the
facility, from September through February 2026 revealed there are no group activities on Sunday's. There
are three activities a day listed on the calendar with the last activity at 1 pm following lunch in the dining
room. Review of the Activities calendar from September 2025 through February 2026 revealed the
following: Daily9:30 a.m. 1 on 1 visits by distributing the facility Daily Chronicle (document for residents to
read).11:30 a.m. Lunch Monday through Friday1:00 p.m. group activity Saturday1:00 p.m. rotating cycle one
Saturday puzzles, one Saturday coloring, and one Saturday games. Sunday1:00 p.m. residents' choice a
cart with books, magazines and items is taken around the facility if residents want to select something to do
independently. During a group interview on 2/11/26, at approximately 11:30 a.m., consensus from the group
revealed that residents would like additional activities. Residents stated there is only one activity during the
week, it's at 1 pm. Residents stated they want to do something, not just have a cart that they can pick up
something to do in their room on their own. The residents verbalized that they like the socialization of the
group activity. The residents stated there isn't much to do on the weekend. During an interview on 2/11/26,
at 1:15 p.m. Activities Director Employee E1 stated there is no activity coverage on the weekend from the
activity department at this time. The activity assistant left the department approximately six months ago.
Employee E1 confirmed that there is only one group activity during the week at 1:00 p.m. and she is not in
the building to confirm the weekend activities. During an interview on 2/13/26, at approximately 9:30 a.m.
the Nursing Home Administrator confirmed the facility failed to provide an ongoing program of activities to
meet the interests of and support the physical, mental, and psychosocial well-being of residents on one of
five nursing units. 28 Pa. Code: 201. 18(b)(3) Management.28 Pa. Code: 207.2(a) Administrators
Responsibility.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395948
If continuation sheet
Page 5 of 12
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
395948
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center at Jefferson Hills, The
540 Coal Valley Road
Jefferson Hills, PA 15025
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)
F 0680
Ensure the activities program is directed by a qualified professional.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of facility policy, personnel records, and staff interview, it was determined that the facility
failed to ensure that the Activities Department had a qualified director to oversee the activities
program.Findings include: The facility Activities Director employee job description indicated; The primary
purpose of the job position is to plan, organize, implement, evaluate and direct the Activity Programs in
accordance with the current federal, state, and local standards governing the facility and as directed by
administrator, to ensure that the emotional, recreational, and social needs of the residents are met and
maintained on an individual basis. Review of Activities Director Employee E1's personnel record indicated
she was hired on 1/9/25. Review of Activities Director Employee E1's personnel record did not include
evidence that Activities Director Employee E1 had proper qualifications as an Activities Director. The
personnel record did not include previous history as an Activity Director, education in therapeutic services,
education as a social worker or occupational therapist, or a background in recreational services. During an
interview on 2/12/26, at 1:15 p.m. Activities Director Employee E1 confirmed that she did not have
education in therapeutic services, education as a social worker or occupational therapist, or a background
in recreational services. During an interview on 2/12/26, at 1:25 p.m. Occupational Therapist Employee E3
confirmed that she did not have any oversite or involvement with the activity program at the facility.
Employee E3 confirmed that she was the only regularly scheduled Occupational Therapist for the facility.
During an interview on 2/12/26, at 1:35 p.m. Certified Occupational Therapy (COTA) Rehabilitation Services
Director, Employee E2 confirmed that she only completes the mobility portion of the activities assessment
in the clinical record and did not have any other involvement or oversite with the facility activity department
programing or employee. During an interview on 2/13/26, at 9:45 a.m. the Nursing Home Administrator
confirmed that the facility failed to ensure that the Activities Department had a qualified director to oversee
the activities program.28 Pa Code 201.18(b)(3) Management28 Pa Code 201.189(e)(6) Management
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395948
If continuation sheet
Page 6 of 12
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
395948
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center at Jefferson Hills, The
540 Coal Valley Road
Jefferson Hills, PA 15025
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)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of clinical records, observations, and staff interviews, it was determined that the facility failed to
provide prescribed treatments and services related to the care of pressure ulcers and/or pressure ulcer
prevention for three of six residents (Resident R6, R7, and R23).Findings Include: Review of the United
States Department of Health and Human Services, Agency for Healthcare Research & Quality's, Safety
Program for Nursing Home: On-Time Pressure Ulcer Prevention dated May 2016, indicated that Pressure
ulcers cause pain, disfigurement, and increased infection risk and are associated with longer hospital stays
and increased morbidity and mortality. Three critical components in preventing pressure ulcers were listed:
comprehensive skin assessments, standardized pressure ulcer risk assessments, and care planning and
implementation to address areas of risk. Review of the National Library of Medicine, The Braden Scale for
Predicting Pressure Sore Risk indicated the scale was developed to foster early identification of patients at
risk for forming pressure ulcers. Review of the facility policy, Pressure Ulcers dated 12/5/25, indicated,
Pressure ulcers are usually formed when a resident remains in the same position for an extended period of
time. Residents will receive skin care, repositioning, and nutritional support to assist in preventing the
development of avoidable pressure ulcers. The scale consists of six subscales and the total range from
6-23, with the following distributions:-Severe Risk: Less than or equal to 9.-High Risk: 10-12.-Moderate
Risk: 13-14.-Mild Risk: 15-18. Review of the clinical record indicated that Resident R6 was admitted to the
facility on [DATE]. Review of the Minimum Data Sent (MDS - periodic assessment of resident care needs)
dated 2/2/26, included hemiplegia (paralysis on one side of the body), diabetes (a metabolic disorder in
which the body has high sugar levels for prolonged periods of time), and high blood pressure. Section M:
Skin Conditions indicated Resident R6 has a Stage III pressure ulcer. Review of the most recent Braden
Scale for Predicting Pressure Sore Risk (tool help health professionals assess a patient's risk of developing
a pressure ulcer) completed on 9/9/21, indicated Resident R6 was at risk for pressure ulcer development.
Review of R6's plan of care for risk of skin integrity impairment revised on 2/11/26, indicated to offload both
heels while in bed every shift, turn and reposition Q2 (every two) hours, and wear palm guard on left hand
at all times except during hygiene tasks. Review of a physician order dated 9/14/22, indicated a turn and
position q2 (every two) hours while in bed. Review of a physician's order 8/21/23, indicated, Please use
off-loading cushion under left calf to keep pressure off of left heal. Review of a physician's order 8/23/24,
indicated, off load both heels while in bed. Review of Resident R6's treatment administration record (TAR)
for February 2026, revealed Resident R6's palm guard was applied on 2/11/26, and 2/12/26. During an
observation on 2/11/26, at 11:30 a.m. and Resident R6 was observed lying on his back, heels not
offloaded, without the palm guard in place. During observations on 2/12/26, at 9:15 a.m., 11:00 a.m., 12:52
p.m., and 2:45 p.m. Resident R6 was observed lying on his back, heels not offloaded, without the palm
guard in place. During observations on 2/13/26, at 8:45 a.m. and 10:45 a.m. Resident R6 was observed
lying on his back, heels not offloaded, without the palm guard in place. During an interview on 2/13/26, at
approximately 10:45 a.m. when asked if staff assisted him to elevate his heels or apply his palm guard,
Resident R6 stated, Sometimes. During an interview on 2/13/26, at approximately 11:00 a.m. Licensed
Practical Nurse (LPN) Employee E17 confirmed that Resident R6's heels were not offloaded, and he did
not have a palm guard in place. Review of the clinical record indicated that Resident R7 was admitted to the
facility on [DATE]. Review of the MDS dated [DATE], included Parkinson's disease (neuromuscular disorder
causing tremors and difficulty walking), diabetes, and muscle weakness. Section M: Skin Conditions
indicated Resident R7 has a
Residents Affected - Some
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395948
If continuation sheet
Page 7 of 12
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
395948
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center at Jefferson Hills, The
540 Coal Valley Road
Jefferson Hills, PA 15025
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)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Stage IV pressure ulcer. Section GG: Functional Ability indicated that Resident R7 required assistance to
roll left and right in bed. Review of the most recent Braden Scale for Predicting Pressure Sore Risk
completed on 3/14/23, indicated Resident R7 was at high risk for pressure ulcer development. Review of
R7's plan of care for risk of skin integrity impairment revised on 2/11/26, indicated heel pillow boots to be
on when in bed, turn and reposition Q2 hours, and to use wedge cushion to offload buttocks off sides.
Review of a physician order dated 3/28/23, indicated, Use wedge cushion to offload buttocks off sides Q4
(every four) hours. Review of a physician order dated 5/25/23, indicated a turn and position q2 hours while
in bed. During observations on 2/12/26, at 9:15 a.m., 11:00 a.m., 12:52 p.m., and 2:45 p.m. Resident R7
was observed lying on her back, without a wedge in place. The wedge was observed in the chair next to the
bed. During observations on 2/13/26, at 8:45 a.m. and 10:45 a.m. Resident was observed lying on her
back, without a wedge in place. The wedge was observed in the chair next to the bed. During an interview
on 2/13/26, at approximately 8:45 a.m. when asked if staff assist in positioning her wedge, Resident R7
shook her head negatively. Review of the clinical record indicated that Resident R23 was admitted to the
facility on [DATE]. Review of the MDS dated [DATE], included hemiplegia, aphasia (language disorder that
affects communication and difficulty speaking), and history of a stroke. Section M: Skin Conditions indicated
Resident R23 was at risk for pressure ulcer development. Section GG: Functional Ability indicated that
Resident R23 required assistance to roll left and right in bed. Review of the most recent Braden Scale for
Predicting Pressure Sore Risk completed on 7/30/21, indicated Resident R23 was at moderate risk for
pressure ulcer development. Review of R23's plan of care for risk of skin integrity impairment revised on
4/21/25, indicated to obtain wedge for offloading in bed and to turn and reposition Q2 hours. Review of a
physician order dated 4/27/22, indicated, Turn and position q2 hours. Review of a physician order dated
1/17/25, indicated, Obtain wedge for offloading while in bed. During an observation on 2/11/26, at 11:30
a.m. and Resident R6 was observed without a wedge in place. During observations on 2/12/26, at 9:15
a.m., 11:00 a.m., 12:52 p.m., and 2:45 p.m. Resident R6 was observed without a wedge in place. During
observations on 2/13/26, at 8:45 a.m. and 10:45 a.m. Resident R6 was observed without a wedge in place.
During an interview on 2/13/26, at approximately 11:00 a.m. LPN Employee E17 confirmed that Resident
R23 did not have a positioning wedge. During an interview on 2/13/26, at approximately 12:00 p.m. the
Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide
prescribed treatments and services related to the care of pressure ulcers and/or pressure ulcer prevention
for three of six residents. 28 Pa. Code: 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care
policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Event ID:
Facility ID:
395948
If continuation sheet
Page 8 of 12
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
395948
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center at Jefferson Hills, The
540 Coal Valley Road
Jefferson Hills, PA 15025
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observations and staff interview it was determined that the facility failed to provide a safe
environment for residents in one of two nursing units (waste room and staff restroom). Findings
include:During an observation on 2/11/26, at approximately 11:45 a.m. the biohazardous waste room was
noted to be unlocked. Within the room were 13 sharps containers on a shelf and two large biohazardous
waste bag with multiple sharps containers in them on the floor. During an observation on 2/11/26, at
approximately 11:50 a.m. the beauty shop was noted to be unlocked. Within the room was an
environmental services cart with cleaning supplies and a large putty knife on top. During an observation on
2/11/26, at approximately 11:53 a.m. the staff restroom was noted to be not fully closed. Observation of the
restroom revealed no emergency call light or call cord attached for emergency use. During an observation
on 2/12/26, at approximately 11:00 a.m. the biohazardous waste room and the staff restroom were noted to
be unlocked and accessible to residents. During an observation on 2/13/26, at approximately 10:45 a.m. the
biohazardous waste room and the staff restroom were noted to be unlocked and accessible to residents.
During an interview on 2/13/26, at approximately 10:50 a.m. Licensed Practical Nurse Employee E17
confirmed the biohazardous waste room was unlocked, and at that time she engaged the locking
mechanism on the interior side of the door. At approximately 10:52 a.m. LPN Employee E17 confirmed that
the staff restroom was unlocked and accessible to residents and that a call light was not available for use.
During an interview on 2/13/26, at approximately 12:00 p.m. the Nursing Home Administrator confirmed
that the facility failed to provide a safe environment for residents in one of two nursing units. 28 Pa. Code
201.18(e)(1) Management.28 Pa. Code 201.20(a)(b) Staff development.28 Pa. Code 201.29(a)(c)(d)
Resident rights.
Event ID:
Facility ID:
395948
If continuation sheet
Page 9 of 12
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
395948
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center at Jefferson Hills, The
540 Coal Valley Road
Jefferson Hills, PA 15025
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on review of facility policy, observations, and staff interview, it was determined that the facility failed
to make certain that medications were properly stored and/or disposed of in one of two medication carts
and one of two medication storage rooms (North Hall storage room and South Hall medication
cart).Findings include:Review of facility policy Storage of Medications dated 12/5/25, stated that
medications are stored in a safe, secure, and orderly manner in accordance with federal and state
regulations and facility policies. During an observation of the North Unit medication room on 2/11/26, at
approximately 12:00 p.m. the following was observed:59 blood collection tubes with an expiration date of
10/31/25.7 blood collection tubes with an expiration date of 1/31/25.2 vacutainers with an expiration date of
11/30/25.3 vacutainers with an expiration date of 10/31/25.8 IV start kits with an expiration date of
11/30/23.4 IV extension sets with an expiration date of 5/31/25.1 syringe with an expiration date of
9/30/24.3 syringes with an expiration date of 6/1/25.4 package antibiotic ointment with an expiration date of
05/2025.1 box of (100) cleansing towelettes with an expiration date of 6/28/25.27 oral fluid collection
devices with an expiration date of 03/2025.1 vial of tuberculin solution in the medication room refrigerator,
partially used and undated. During an interview on 2/11/26, at 12:15 p.m. Licensed Practical Nurse
Employee E10 confirmed the above observations. During an observation of the South Unit medication cart
on 2/12/26, at approximately 8:35 a.m. the following was observed:-(1) bottle of Timolol eye drops, open
and undated on bottle and storage container.-(1) bottle of Dorzolamide/Timolol open and undated on bottle
and storage container.-(1) bottle of Latanoprost open and undated on bottle and storage
container.Employee E16 confirmed that the above observation of medications not being labeled with dates
on bottles or storage containers were noted on the multi-dose bottles that were in her cart when she started
medication administration.During an interview on 2/12/26, at approximately 9:15 a.m. the Director of
Nursing confirmed that the facility failed to make certain that unlabeled medications were in one of two
medication carts and out of date supplies were properly stored and/or disposed of in one of two medication
storage rooms. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1)(e)(1)
Management.28 Pa Code: 211.9 (a)(1) Pharmacy services.28 Pa Code: 211.12 (d)(1)(3)(5) Nursing
services.
Event ID:
Facility ID:
395948
If continuation sheet
Page 10 of 12
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
395948
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center at Jefferson Hills, The
540 Coal Valley Road
Jefferson Hills, PA 15025
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)
F 0941
Level of Harm - Potential for
minimal harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Develop, implement, and/or maintain an effective training program that includes effective communications
for direct care staff members.
Based on review of facility policy, personnel in-service training records, and staff interview, it was
determined that the facility failed to provide training on resident rights for nine of thirteen staff members
(Employee E5, E6, E7, E8, E9, E10, E11, E12, E13, E14, and E15).Findings include: Review of the facility
policy, Staff Development Program most recently reviewed 12/5/25, indicated, There shall be an ongoing
coordinated education program which is planned and conducted for the development and improvement of
skills of the facility personnel, including training related to technology, problems, needs and rights of
residents Review of facility provided documents and training records revealed the following staff members
did not have documented training on the resident rights Program. Nurse Aide Employee E5 had a hire date
of 10/24/25, and failed to have resident rights education upon hire or thereafter.Nurse Aide Employee E6
had a hire date of 11/23/25, and failed to have resident rights education upon hire or thereafter.Nurse Aide
Employee E7 had a hire date of 2/5/24, failed to have resident rights in-service education between 2/5/25,
and 2/5/26.Nurse Aide Employee E8Licensed Practical Nurse Employee E9 had a hire date of 11/24/25,
and failed to have resident rights education upon hire or thereafter.Licensed Practical Nurse Employee E10
had a hire date of 1/29/24, failed to have resident rights in-service education between 1/29/25, and
1/29/26.Registered Nurse Employee E11 had a hire date of 1/14/16, failed to have resident rights in-service
education between 1/14/25, and 1/14/26.Therapy Employee Employee E12 had a hire date of 12/12/22,
failed to have resident rights in-service education between 12/12/25, and 12/12/26.Therapy Employee
Employee E13 had a hire date of 12/18/23, failed to have resident rights in-service education between
12/18/25, and 12/18/26. During an interview on 2/13/26, at approximately 1:00 p.m. the Nursing Home
Administrator confirmed that the facility failed to provide training on resident rights for nine of thirteen staff
members 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa
Code: 201.20 (a)(c) Staff development.
Event ID:
Facility ID:
395948
If continuation sheet
Page 11 of 12
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
395948
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center at Jefferson Hills, The
540 Coal Valley Road
Jefferson Hills, PA 15025
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)
F 0944
Level of Harm - Potential for
minimal harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement
Program.
Based on review of facility policy, personnel in-service training records, and staff interview, it was
determined that the facility failed to provide training on Quality Assurance and Performance Improvement
(QAPI) for eleven of fifteen staff members (Employee E5, E6, E7, E8, E9, E10, E11, E12, E13, E14, and
E15).Findings include: Review of the facility policy, Staff Development Program most recently reviewed
12/5/25, indicated, There shall be an ongoing coordinated education program which is planned and
conducted for the development and improvement of skills of the facility personnel, including training related
to technology, problems, needs and rights of residents Review of facility provided documents and training
records revealed the following staff members did not have documented training on the QAPI Program.
Nurse Aide Employee E5 had a hire date of 10/24/25, and failed to have QAPI education upon hire or
thereafter.Nurse Aide Employee E6 had a hire date of 11/23/25, and failed to have QAPI education upon
hire or thereafter.Nurse Aide Employee E7 had a hire date of 2/5/24, failed to have QAPI in-service
education between 2/5/25, and 2/5/26.Nurse Aide Employee E8Licensed Practical Nurse Employee E9 had
a hire date of 11/24/25, and failed to have QAPI education upon hire or thereafter.Licensed Practical Nurse
Employee E10 had a hire date of 1/29/24, failed to have QAPI in-service education between 1/29/25, and
1/29/26.Registered Nurse Employee E11 had a hire date of 1/14/16, failed to have QAPI in-service
education between 1/14/25, and 1/14/26.Therapy Employee Employee E12 had a hire date of 12/12/22,
failed to have QAPI in-service education between 12/12/25, and 12/12/26.Therapy Employee Employee
E13 had a hire date of 12/18/23, failed to have QAPI in-service education between 12/18/25, and
12/18/26.Dietary Employee E14 had a hire date of 12/6/25, and failed to have QAPI education upon hire or
thereafter.Environmental Services Employee E15 had a hire date of 12/26/23, failed to have QAPI
in-service education between 12/26/25, and 12/26/26. During an interview on 2/13/26, at approximately
1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on QAPI for
eleven of fifteen staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18
(b)(1) Management.28 Pa Code: 201.20 (a)(c) Staff development.
Event ID:
Facility ID:
395948
If continuation sheet
Page 12 of 12