JEFFERSON HILLS, PA - Federal inspectors identified multiple care deficiencies at Jefferson Hills Rehabilitation and Wellness Center during a March 2025 inspection, including inadequate bathing practices, improper diabetes management, and inaccurate medical documentation that could compromise resident safety and health outcomes.
Chronic Bathing Deficiencies Leave Resident Without Preferred Hygiene Care
The most significant violation involved a systematic failure to provide adequate bathing services to residents who preferred and required shower assistance. Resident R37, who required partial assistance with bathing and expressed that choosing between different bathing options was "somewhat important," received only sporadic shower access over an eight-month period.
According to inspection records, this resident received showers on only 18 occasions between August 2024 and March 2025, while receiving bed baths 261 times during the same period. The bathing schedule showed concerning gaps, including the entire month of August 2024 and January 2025 when no showers were documented at all.
When interviewed by inspectors, the resident stated he preferred showers but "was unable to recall when he last had one." This preference had been documented in facility assessments since August 2024, yet the care team failed to honor this choice consistently.
The facility's own care plan emphasized keeping the resident's skin clean and dry while monitoring for skin breakdown - goals that are more effectively achieved through regular bathing and shower access. The Director of Nursing acknowledged during the inspection that the facility "failed to consistently provide showers and/or baths for Resident R37."
Medical Significance of Proper Hygiene Care
Regular bathing serves multiple critical health functions beyond basic cleanliness. For elderly residents with mobility limitations, proper hygiene prevents bacterial and fungal infections, reduces the risk of pressure sores, and maintains skin integrity. When residents require assistance with bathing, consistent access becomes even more important as they cannot independently maintain adequate hygiene.
Shower access specifically provides therapeutic benefits that bed baths cannot replicate. The warm water and gentle pressure can improve circulation, provide pain relief for arthritis and joint conditions, and offer psychological benefits through increased dignity and normalcy. For residents in long-term care, maintaining autonomy in personal care choices like bathing preferences directly impacts quality of life and emotional well-being.
Critical Diabetes Management Failures Endanger Residents
Inspectors identified serious deficiencies in diabetes care that left two residents vulnerable to life-threatening complications. The facility failed to properly monitor, assess, and respond to dangerous blood glucose levels that could result in diabetic emergencies.
Resident R20 experienced a severe hypoglycemic episode on October 2, 2024, requiring emergency glucagon administration at 6:05 a.m. When blood glucose was checked 29 minutes later, it measured only 50 mg/dL - a dangerously low level. Additionally, another critically low reading of 52 mg/dL occurred on December 7, 2024. In both instances, nursing staff failed to conduct proper hypoglycemia assessments, monitor treatment effectiveness, or notify the attending physician as required.
Resident R24 faced the opposite extreme when blood glucose spiked to 438 mg/dL on August 6, 2024 - a level that poses immediate health risks. Despite facility protocols requiring physician notification for readings above 400 mg/dL, staff failed to contact the doctor or implement appropriate interventions.
The facility's own diabetes care protocols clearly outlined required responses: for blood glucose below 70 mg/dL, staff should administer rapid-acting carbohydrates, recheck levels within 15 minutes, and notify physicians if residents show symptoms. For elevated readings above 400 mg/dL, protocols required immediate physician notification and careful monitoring.
Understanding Diabetes Emergency Risks
Blood glucose levels outside normal ranges create immediate and long-term health threats. Hypoglycemia below 70 mg/dL can rapidly progress to confusion, loss of consciousness, heart rhythm abnormalities, and death if untreated. The levels documented for Resident R20 - 50 and 52 mg/dL - represent severe hypoglycemia requiring immediate intervention and close monitoring.
Conversely, hyperglycemia above 400 mg/dL signals a potential diabetic crisis. These elevated levels can lead to diabetic ketoacidosis, severe dehydration, and coma. Both conditions require prompt medical intervention and careful monitoring to prevent life-threatening complications.
The facility's care plans specifically identified monitoring and physician notification as essential interventions, yet staff failed to implement these basic safety measures. Licensed nurses interviewed during the inspection demonstrated knowledge of proper protocols but acknowledged these procedures weren't consistently followed.
Inaccurate Cognitive Assessment Documentation Compromises Care Planning
A third major violation involved systematic documentation errors that misrepresented a resident's cognitive abilities. Resident R37's official medical assessments showed declining cognitive function over time, with Brief Interview for Mental Status (BIMS) scores dropping from 15 to 10 between different assessment periods. However, palliative care notes consistently recorded the same resident's BIMS score as 15 across five months of documentation.
These scoring discrepancies represent more than clerical errors. BIMS scores directly influence care planning, medication management, and safety protocols. A score of 15 indicates intact cognition, while scores of 10-12 suggest moderate cognitive impairment requiring different care approaches and safety measures.
The facility's Director of Nursing confirmed the documentation was neither accurate nor complete and acknowledged the facility lacked specific policies for ensuring clinical record accuracy.
Impact of Inaccurate Cognitive Assessments
Cognitive assessment scores guide critical care decisions including medication dosages, fall risk protocols, and the level of supervision required for daily activities. When documentation doesn't accurately reflect a resident's true cognitive status, care teams may implement inappropriate interventions or fail to provide necessary safeguards.
Federal regulations require nursing homes to conduct comprehensive assessments and maintain accurate medical records to ensure appropriate care. These assessments form the foundation for care planning and are used to determine staffing levels and specialized services. Inaccurate documentation can result in residents receiving either excessive or insufficient care based on incorrect cognitive evaluations.
Additional Issues Identified
The inspection also documented several other concerning practices that warrant attention:
Care Plan Implementation: The facility failed to consistently follow established care plan interventions for diabetes management, despite having appropriate protocols in place.
Staff Training Gaps: While nursing staff demonstrated knowledge of proper diabetes protocols during interviews, their actual implementation fell short of facility standards and regulatory requirements.
Communication Failures: The facility's physician notification system broke down during critical situations, leaving medical providers unaware of significant changes in residents' conditions.
Policy Deficiencies: The facility acknowledged lacking specific policies for ensuring clinical documentation accuracy, representing a systemic gap in quality assurance procedures.
These violations highlight systemic issues that extend beyond individual incidents to suggest broader problems with care delivery, staff oversight, and quality assurance systems at Jefferson Hills Rehabilitation and Wellness Center.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Jefferson Hills Rehabilitation and Wellness Center from 2025-03-13 including all violations, facility responses, and corrective action plans.
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