Wecare At South Hills Rehabilitation And Nrsg Ctr

F 0575 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Based on observation and staff interview, it was determined that the facility failed to post complete and current contact information for the Grievance Officer in the facility on three of three nursing units (Bird Room (Main area near dining room), Solarium C and Solarium E).Findings include:During an observation completed 8/21/25, through 8/22/25, of the Bird Room (common area), the facility failed to reveal the address and email contact information for Adult Protective Services and the Office of the State Long-Term Care Ombudsman program along with the Grievance Officer for the facility, observations revealed in Solarium C and Solarium E common areas, the facility failed to reveal the correct contact information for the Grievance Officer.During an interview on 8/22/25, at approximately 2:50 p.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to post complete contact information for Adult Protective Services, State Long-Term Care Ombudsman, and the Grievance Officer as required in one resident common area and failure to list an updated contact for Grievance Officer in two of two common areas.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(e) Management.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wecare at South Hills Rehabilitation and Nrsg Ctr

201 Village Drive Canonsburg, PA 15317

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 documentation, clinical records, staff interviews and resident interviews it was determined the facility failed to submit, document and/or follow-up on concerns/grievances presented by staff and residents (staff and residents wished to remain anonymous).Finding include:Review of Federal Regulation 483.10(i)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatments which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.Review of facility policy, Skilled Nursing Facility Grievance Policy dated 1/27/25, revealed the facility is committed to maintaining transparent, fair, and accessible grievance process. Every grievance will be addressed promptly and appropriately, in accordance with federal and state regulations.

Residents and their representative must be assured that: They can submit grievances orally or in writing; Their concerns will be investigated and responded to promptly; They will not face discrimination, reprisal, or retaliation; They will receive written notice of grievance outcomes within required timeframes.Review of the last six months of grievances revealed only three grievances filed. One grievance from March was from a visitor that sent negative feedback for a smell and T.V. and controller not working. In April a Grievance form was completed that should have been an incident report with an investigation done due to resident not receiving medication or vitals as ordered. The last Grievances were from July regarding a resident accusing another resident of physical harm (running over toes and ankle with wheelchair) which led to an investigation. The second grievance was a son that called in asking for records to be sent to an attorney,

the attorney had not sent in a request and would need to do so. These grievances were resolved.Interview

on 8/21/25, at 10:30 a.m. with Resident Resident R8 and Resident R9 revealed that they had filed both verbal and written grievances about another resident (male) being aggressive towards female residents and no actions were taken, did not receive a written confirmation that anything was being done and were threatened by staff to stop filing grievances and to quit complaining. Resident Resident R8 and Resident R9 revealed that at one point there were no forms at the grievance boxes to fill out, thus the grievances could not remain anonymous because they had to be submitted verbally.Interview on 8/21/25, at 10:43 a.m. with Employee E4 and E5 revealed that they had attempted to file grievances about a resident and were told that if they continued there would be consequences to them, that they would lose their jobs. Employee E4 and E5 stated that they started to refuse to file grievances for residents because they were afraid, they would be accused of complaining too much.During an interview on 8/22/25, at 2:50 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to address concerns from staff and residents.28 Pa. Code 201.29(a) Resident Rights.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wecare at South Hills Rehabilitation and Nrsg Ctr

201 Village Drive Canonsburg, PA 15317

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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

2/4/2025.On 8/22/25, at 2:38 p.m. an acceptable Corrective Action Plan was received which included the following interventions:Immediate action(s) taken for the resident(s) found to have been affected include: Resident Resident R1 was placed on 1:1 8/22/25 and will remain on 1:1. Facility will ensure 1:1 is in place at all times by scheduling specific staff to perform this 1:1 duty each day on all three shifts.Residents Resident R3, Resident R4, Resident R5, and Resident R6 will remain safe from resident initiated sexual abuse through the facility providing 1:1 to Resident Resident R1.Resident Resident R1 and Resident R2 were immediately separated on 8/21/25.Resident Resident R2 was assessed for injuries and no injuries noted on 8/21/25. Resident Resident R2 was sent to the hospital for further evaluation on 8/21/25 and remains at hospital.Identification of other residents having the potential to be affected was accomplished by:Current female residents who were cognitively intact were interviewed on 8/21/25. Current female residents who were cognitively impaired had a skin assessment completed on 8/21/25.No issues identified from interviews or skin assessments.Actions taken/systems put into place to reduce the risk of future occurrence include:Education will be completed by all staff on Abuse/Neglect and Reporting of Incident and Accidents by the Director of Nursing or designee by 8/22/25.How the corrective action(s) will be monitored to ensure the practice will not recur: Resident Resident R1 will remain on 1:1. Resident Resident R1 will be evaluated by psychiatry services on 8/22/25 in conjunction with the facility medical director.While Resident Resident R1 remains in

the facility audits will be completed on female residents who are cognitively intact daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety. These audits will be completed by Social Services or designee. While Resident Resident R1 remains in the facility audits will be completed on female residents who are cognitively impaired daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.An Ad Hoc Quality Assurance and Process Improvement Meeting was held by the Administrator on 8/21/25.Affected residents will be seen by facility contracted psychiatry/psychology provided if they request to do so to address their emotional trauma.This plan of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met. During staff interviews conducted on 8/22/25, between 12:00 p.m. and 3:30 p.m. 12 staff members confirmed they received education on abuse prevention.The Immediate Jeopardy was lifted on 8/22/25, at 3:52 p.m., when

the action plan implementation was verified.During an interview on 8/22/25, at approximately 4:00 p.m. the Nursing Home Administrator confirmed that the facility failed, to protect residents from resident-to-resident sexual abuse for five of 67 residents. This failure resulted in a resident with a known history of sexually inappropriate behavior touching a non-consenting resident, which created an Immediate Jeopardy situation for five of 67 residents. 28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.20(a)(b) Staff development28 Pa. Code 201.29(a)(c)(d) Resident rights

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wecare at South Hills Rehabilitation and Nrsg Ctr

201 Village Drive Canonsburg, PA 15317

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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

facility failed to protect female residents from the male resident wandering into their rooms with no grievances or investigations available to confirm that the facility was aware of the situation or that they were doing anything regarding his behavior. The NHA and DON also stated they failed to make the staff feel safe from retaliation of being threatened with termination if they spoke with family, filing a grievance or talking amongst themselves regarding the male resident.28 Pa. Code 201.14(a): Responsibility of licensee.28 Pa.

Code 201.18(b)(1)(e)(1): Management.28 Pa Code: 201.20 (b): Staff development.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wecare at South Hills Rehabilitation and Nrsg Ctr

201 Village Drive Canonsburg, PA 15317

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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

the Director of Nursing, and was told not to worry about it. I don't want to get anyone in trouble, but it (referring to the incident involving Resident Resident R2 on 8/22/25) never should have happened. I still picture her.

It's awful.On 8/22/25, at 11:56 a.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for four of 67 residents, and the Immediate Jeopardy template was provided to facility administration.This Immediate Jeopardy situation began 2/4/25.On 8/22/25, at 2:38 p.m. an acceptable Corrective Action Plan was received which included the following interventions:Immediate action(s) taken for the resident(s) found to have been affected include: Resident Resident R1 was placed on 1:1 8/22/25 and will remain on 1:1. Facility will ensure 1:1 is in place at all times by scheduling specific staff to perform this 1:1 duty each day on all three shifts.Residents Resident R3, Resident R5, and Resident R6 will remain safe from resident initiated sexual abuse through the facility providing 1:1 to Resident Resident R1. Resident Resident R1 and Resident R2 were immediately separated on 8/21/25.Resident Resident R2 was assessed for injuries and no injuries noted on 8/21/25.

Resident Resident R2 was sent to the hospital for further evaluation on 8/21/25 and remains at hospital.Identification of other residents having the potential to be affected was accomplished by:Current female residents who were cognitively intact were interviewed on 8/21/25. Current female residents who were cognitively impaired had a skin assessment completed on 8/21/25.No issues identified from interviews or skin assessments.Actions taken/systems put into place to reduce the risk of future occurrence include:Education will be completed by all staff on Abuse/Neglect and Reporting of Incident and Accidents by the Director of Nursing or designee by 8/22/25.How the corrective action(s) will be monitored to ensure

the practice will not recur: Resident Resident R1 will remain on 1:1. Resident Resident R1 will be evaluated by psychiatry services on 8/22/25 in conjunction with the facility medical director.While Resident Resident R1 remains in the facility audits will be completed on female residents who are cognitively intact daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety. These audits will be completed by Social Services or designee. While Resident Resident R1 remains in the facility adults will be completed on female residents who are cognitively impaired daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.An Ad Hoc Quality Assurance and Process Improvement Meeting was held by the Administrator on 8/21/25.Affected residents will be seen by facility contracted psychiatry/psychology provided if they request to do so to address their emotional trauma.This plan of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met. During staff interviews conducted on 8/22/25, between 12:00 p.m. and 3:30 p.m. 12 staff members confirmed they received education on abuse prevention.The Immediate Jeopardy was lifted on 8/22/25, at 3:52 p.m., when

the action plan implementation was verified.During an interview on 8/22/25, at approximately 4:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to implement policies and procedures to report allegations of abuse. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wecare at South Hills Rehabilitation and Nrsg Ctr

201 Village Drive Canonsburg, PA 15317

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident R1 is sexually inappropriate. I feel like if this had been handled when this started, today (referring to incident with Resident Resident R2) would never have happened. When asked about reporting, Employee E12 stated, The entire building knew. There was a lady who cannot communicate who he was touching inappropriately, [Resident Resident R6] was her name.Review of the facility-provided incident from March 2025, through August 2025, list failed to include documentation of an incident or investigation related to possible abuse of Resident Resident R6.During an interview completed during the survey, Employee E20 stated that Resident Resident R1's behaviors have been going on for over a month, that he goes around touching women, up their pants, fingers in their mouth, and grabbing their breasts. Employee E20 stated that the incidents were reported verbally. Through other staff members, was told that, They are older people and allowed to touch. Review of

the facility-provided incident list from March 2025, through August 2025, failed to include documentation of

an incident or investigation related to Employee E20's report of Resident Resident R1's inappropriate sexual behavior. During an interview completed during the survey, Employee E32 stated they told the Director of Nursing that Resident Resident R1's behaviors were increasing, that he seems to target women that cannot defend themselves, and that other residents are attempting to stop Resident Resident R1's behaviors. Employee E32 stated

the Director of Nursing said, Some of these ladies enjoy it, should we be stopping their pleasure? Employee E32 stated, I was so angry, was told we should not be taking his past and applying it to now. I redirected him and the ladies thanked me. Told my colleagues to keep an eye on him. Review of the facility-provided incident list from March 2025, through August 2025, failed to include documentation of an incident or investigation related to Employee E32's report of Resident Resident R1's inappropriate sexual behavior.During an

interview completed during the survey, Employee E33 stated, Yeah, touchy-feely. Employee E33 stated Resident Resident R1's behaviors have not been addressed. Employee E33 stated Employee E17 had reported Resident Resident R1's behaviors to administration, with the response that the Director of Nursing told her it was wrong and get rid of it. Employee E33 stated that facility management has been aware of Resident Resident R1's behavior since February (2025).Review of the facility-provided incident list from March 2025, through August 2025, failed to include documentation of an incident or investigation related to Employee E17's report of Resident Resident R1's inappropriate sexual behavior. During an interview completed on 9/9/25, Employee E34 stated, Yesterday (9/8/25) he was holding a resident's hand and they (staff) felt it could lead to other things, tried to move him and he grabbed the chair and them became aggressive. Employee E34 stated that Resident Resident R1's behavior has been reported to both the current Director of Nursing and the previous Director of Nursing. Review of the facility-provided incident list from March 2025, through August 2025, failed to include documentation of an incident or investigation related to Employee E34's confirmation of previous report of Resident Resident R1's inappropriate sexual behavior. During an interview on 08/22/25, at approximately 4:00 p. m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to implement policies and procedures to report allegations of abuse for four of 61 residents. This failure resulted in a resident with a known history of sexually inappropriate behavior touching non-consenting residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wecare at South Hills Rehabilitation and Nrsg Ctr

201 Village Drive Canonsburg, PA 15317

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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

lung cancer. Question C0500 BIMS Summary Score revealed Resident Resident R35's score to be 14, cognitively intact.Review of Resident Resident R35's care plan initiated 7/2/25, does not reveal that he was care planned to be

in a consensual romantic relationship with Resident Resident R21.During an interview on 8/29/25, Resident Resident R21 referred to Resident Resident R35 as my man. Resident Resident R35 stated that Resident Resident R21 is going to be my wife.During

an interview on 8/29/25, at approximately 4:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to develop and implement comprehensive care plans to meet resident care needs for four of 67 residents.28 Pa. Code 211.11(d) Resident Care Plan

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wecare at South Hills Rehabilitation and Nrsg Ctr

201 Village Drive Canonsburg, PA 15317

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 - Immediate jeopardy to resident health or safety

8/29/25, confirmed either interviews or audits were completed on all female residents.The Immediate Jeopardy was lifted on 8/29/25, at 3:50 p.m., when the action plan implementation was verified. During an

interview on 8/29/25, at approximately 4:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide necessary supervision of a resident with known sexually inappropriate behaviors. This failure resulted in an immediate jeopardy situation for five of 67 residents. 28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wecare at South Hills Rehabilitation and Nrsg Ctr

201 Village Drive Canonsburg, PA 15317

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 0744 Level of Harm - Minimal harm or potential for actual harm

Administrator confirmed that the facility failed to provide the necessary services to meet the psychosocial needs resulting in the commitment of resident-to-resident sexual abuse for one of two residents with unmonitored hypersexual behaviors.28 Pa. Code 211.11(d) Resident care plan28 Pa. Code 211.12(d)(3)(5) Nursing services28 Pa. Code 211.16(a)Social services

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wecare at South Hills Rehabilitation and Nrsg Ctr

201 Village Drive Canonsburg, PA 15317

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 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to protect residents from resident-to-resident sexual abuse. This failure resulted in a resident with a known history of sexually inappropriate behavior touching a non-consenting resident, which created an Immediate Jeopardy for five of 67 residents (Resident Resident R2, Resident R3, Resident R4, Resident R5, Resident R6).Findings include:Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, The primary purpose of the job position is to manage

the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times.Review of

the facility-provided Director of Nursing (DON) job description indicated, To plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times.Based on findings identified in this report, the facility failed to prevent the failed protect residents from resident-to-resident sexual abuse. The NHA and the DON failed to fulfill their essential job duties to ensure

the federal and state guidelines and regulations were followed.During an interview on 8/21/25, at approximately 3:45 p.m. the NHA and DON confirmed that they failed to effectively manage the facility to protect residents from resident-to-resident sexual abuse, which created an Immediate Jeopardy for five of 67 residents.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wecare at South Hills Rehabilitation and Nrsg Ctr

201 Village Drive Canonsburg, PA 15317

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 0865

Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or potential for actual harm

Based on review of facility documentation, cited deficiencies from previous surveys, review of plan of correction documentation, and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has the potential to affect 5 of 67 residents.Finding include:Review of the facility policy Quality Assurance and Performance Improvement (QAPI) Program dated 1/27/25, indicated objectives of the QAPI program include providing a means to measure current and potential indicators for outcomes of care and quality of life; establish and implement performance improvement projects to correct identified negative or problematic indicators; reinforce and build upon effective systems and processes related to the delivery of quality care and services; and establish systems through which to monitor and evaluate corrective actions.Review of the facility's deficiencies and plan of corrections for the State Survey and Certification (Department of Health) survey ending 2/3/25, revealed the facility developed a plan of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations.Review of the plan of correction for survey ending 2/3/25, revealed the following:-Charts will be updated to reflect current status, guardians will be updated regarded any suspected abuse.-House

review has been completed to ensure no other residents have been identified as abused, neglected or exploited.-All staff will be in-serviced via [outside consulting company] for freedom from abuse/neglect with focus on sexual abuse.-24-hour report, progress notes, grievance reports will be reviewed at morning clinical meeting to ensure investigation is completed for any incidents, accidents or grievances if warranted.-Director of Nursing/designee will educate all staff on facilities policy and procedure of abuse/neglect.-Director of Nursing/designee will monitor 24-hour report, progress notes for any instances that fall into this category at clinical meeting.-Director of Nursing/designee will audit weekly x2, monthly x2 progress notes and 24-hour report.-Results of in-service, monitoring and audits will be submitted to the Quality Assurance Improvement Committee.The results of the current survey, ending 9/12/25, identified a repeated deficiency related to sexual abuse for five of five residents.During the survey process the following was revealed:-Resident Resident R2 was found in a bed with her pants around her ankles, brief off and perpetrator standing over her, had been observed with his hand on her hip.-Resident Resident R3's guardian filing a complaint with CMS regarding the perpetrator coming into her room, touching her and knocking things off her wall and table. Guardian was interviewed in the evening during the survey process.-Resident Resident R4's guardian was interviewed and stated that the resident had told him that the perpetrator comes into the resident's room and has touched her.-Resident Resident R5 was observed by other residents in the hallway and dining room with perpetrator sticking his fingers in her mouth, grabbing her breasts and touching her groin.-Staff stated Resident Resident R1 had attempted to get to Resident Resident R5 and Resident R6.During an interview on 8/21/25 at approximately 3:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to maintain

an effective Quality Assurance Committee to ensure that the concerns related to sexual abuse were identified, with potential to affect 5 of 67 residents.42 CFR 483.75 (a)(2)(h)(i) QAPI Program/Plan, Disclosure/Good Faith Attempt.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 201.18(e)(2)(3)(4) Management.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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If continuation sheet