Waynesburg Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Waynesburg, Pennsylvania.
- Location
- 300 Center Avenue, Waynesburg, Pennsylvania 15370
- CMS Provider Number
- 395675
- Inspections on file
- 28
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Waynesburg Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to provide accessible grievance boxes for residents in wheelchairs, with boxes mounted at 57 inches above the floor in three locations, contrary to ADA guidelines. This was confirmed by the Nursing Home Administrator and a surveyor.
The facility failed to ensure a safe environment in the Beauty Shop, Lift Room, Shower Room, and Boiler Room. Observations revealed unlocked doors and access to hazardous items, such as scissors, needles, and chemicals. Staff interviews confirmed these findings, acknowledging the facility's failure to maintain safety standards.
Two residents experienced neglect and inappropriate interactions in the facility. A resident was neglected by a Nurse Aide who refused to assist despite the call light being on, while another resident was made anxious by an LPN questioning their actions and contacting them on Facebook. Both incidents were confirmed by facility management.
A facility failed to maintain a mechanical lift in safe operating condition, leading to its malfunction. Despite routine checks and inspections by a contracted vendor, the lift was deemed safe for use before the incident. Staff confirmed visual checks and education on lift usage, but the malfunction was confirmed by the DON and Interim Nursing Home Administrator, resulting in the lift's removal from service.
The facility failed to provide the opportunity to formulate an advance directive for nine residents, despite their significant health conditions. A review of clinical records showed no documentation that these residents were informed about their rights regarding advance directives. Staff confusion between POLST and advance directives contributed to this oversight.
Inaccessible Grievance Boxes for Wheelchair Users
Penalty
Summary
The facility failed to ensure that grievance boxes were accessible to residents, particularly those using wheelchairs, in three key locations: nursing units A and C Wings, and across from the social service department. The grievance boxes were mounted at approximately 57 inches above the floor, which is beyond the reach of residents in wheelchairs. This oversight was identified during an observation conducted on March 19, 2025, at 11:25 a.m., and was later confirmed by the Nursing Home Administrator and a surveyor during rounds at 12:40 p.m. on the same day. The facility's policy on Resident and Family Grievances, reviewed on January 31, 2025, supports the right of residents and family members to voice grievances without fear of discrimination or reprisal. However, the placement of the grievance boxes did not comply with the ADA Standards for Accessible Design, which recommend that operable parts be mounted between 15 and 48 inches above the floor. This deficiency was acknowledged by the Nursing Home Administrator during an interview at 1:00 p.m. on March 19, 2025, confirming the facility's failure to provide accessible grievance boxes in the specified locations.
Facility Fails to Maintain Safe Environment in Multiple Areas
Penalty
Summary
The facility failed to provide a safe environment for residents in four specific areas: the Beauty Shop, Lift Room, Shower Room, and Boiler Room. During observations, it was noted that the Beauty Shop was unlocked, despite having a locking mechanism, and contained potentially hazardous items such as scissors, hair dryers, curling irons, and disinfecting solution. The Lift Room, which had a sign instructing that the door be kept closed, was found open and contained exhaust fan panels, circuit breaker boards, charging stations for lift batteries, and needles used for drawing blood. Additionally, the Shower Room had a cabinet with a disengaged padlock, containing a spray bottle without a front label, but with instructions for use as a virucide on the back label. Further observations revealed that the Boiler Room door was unlocked, with signage indicating access for authorized personnel only. Inside, various tools, degreasers, and personal drinks were found, and the rear door was open, providing access to the grassy area behind the building. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed these observations and acknowledged the facility's failure to maintain a safe environment. The Nursing Home Administrator also confirmed the deficiency, which is in violation of several Pennsylvania Code regulations related to management, staff development, and resident rights.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to ensure that two residents were free from abuse and neglect. Resident R1, who was cognitively intact with a BIMS score of 15, was neglected by a Nurse Aide (NA) who refused to assist the resident after the call light was activated. The NA, identified as Employee E1, was scheduled to work on the wing where Resident R1 resided but did not respond to the resident's request for assistance to use the bathroom, leaving the call light on for an extended period. This neglect was corroborated by a housekeeper who witnessed the NA ignoring the call light and refusing to provide care, stating it was not her job. Resident R2, also cognitively intact, experienced a situation where an LPN, identified as Employee E3, questioned the resident about contacting the Department of Health (DOH) and later confronted the resident after the Nursing Home Administrator (NHA) intervened. This interaction made Resident R2 anxious, and it was reported that the LPN contacted the resident on Facebook, causing discomfort. The facility's management, including the NHA and Director of Nursing (DON), confirmed the failure to protect these residents from abuse and neglect.
Failure to Maintain Safe Operating Condition of Mechanical Lift
Penalty
Summary
The facility failed to maintain patient care equipment in a safe operating condition, specifically concerning one of four mechanical lifts reviewed. The facility's policy on Safe Lifting and Movement of Residents requires routine checks and maintenance of lifting equipment to ensure it remains in good working order. However, during an observation, it was noted that one of the lifts malfunctioned, leading to its removal from service. The facility's preventive maintenance documents indicated that internal checks were completed, and the contracted vendor, ISS Solutions, had inspected the lift equipment, with the most recent inspection deeming the lift in question as safe for use. Interviews with staff members confirmed that visual checks of the lifts were conducted prior to use, and education on lift usage was provided upon hire and after a fall incident involving a resident. Despite these measures, the malfunction of the lift was confirmed by the Director of Nursing and the Interim Nursing Home Administrator, indicating a lapse in ensuring the equipment's safe operation. The malfunctioning lift and its pad were sequestered and removed from service following the incident.
Failure to Provide Opportunity to Formulate Advance Directives
Penalty
Summary
The facility failed to provide the opportunity to formulate an advance directive for nine of the sixteen residents reviewed. The facility policy on advance directives, which was reviewed on 3/1/2023 and 1/31/2024, mandates that the facility must inform and provide written information to all adult residents about their right to accept or refuse medical or surgical treatment and to formulate an advance directive. However, a review of the clinical records for residents R14, R18, R43, R84, R87, R96, R98, R99, and R108 revealed no documentation that these residents were given the opportunity to formulate an advance directive upon admission or periodically during their stay in the facility. These residents had various diagnoses, including Parkinson's disease, diabetes, high blood pressure, paraplegia, GERD, morbid obesity, chronic pain, cancer, COPD, stroke, and dysphagia, among others. Despite these significant health conditions, there was no evidence that the facility complied with its policy to ensure these residents were informed about their rights regarding advance directives. During an interview on 3/13/2024, the Social Worker (Employee E1) and Medical Records Employee (Employee E2) admitted to confusing the POLST (Physician Orders for Life-Sustaining Treatment) with advance directives. This confusion led to the failure to provide the necessary information and opportunity for the residents to formulate advance directives. This oversight indicates a systemic issue within the facility's process for handling advance directives, affecting the residents' rights to make informed decisions about their medical care and end-of-life preferences.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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