Deficiency Records for Mt Lebanon Rehabilitation and Wellness Center
Updated as of February 01, 2021
This is not the most recent data for Mt Lebanon Rehabilitation and Wellness Center. For the most recent information, click here.
A list of the most recent deficiencies for Mt Lebanon Rehabilitation and Wellness Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2020-08-20 | 2020-09-29 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2020-09-01 | 2020-09-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-09-01 | 2020-09-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-07-17 | 2020-08-02 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-10-04 | 2019-10-24 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-05-23 | 2019-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-23 | 2019-06-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-23 | 2019-06-20 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-05-23 | 2019-06-20 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-05-23 | 2019-06-20 | N |
| Provide or obtain dental services for each resident. | Health | 2019-05-23 | 2019-06-20 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-05-23 | 2019-06-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-23 | 2019-06-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-23 | 2019-06-20 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-05-23 | 2019-06-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-23 | 2019-06-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Be properly staffed | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-05 | 2019-02-26 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2018-11-20 | 2018-12-17 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-20 | 2018-12-17 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-05-01 | 2018-06-02 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-05-01 | 2018-06-02 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-05-01 | 2018-06-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-05-01 | 2018-06-02 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-05-01 | 2018-06-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-04-20 | 2018-05-15 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-04-27 | 2018-04-27 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-04-27 | 2018-04-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-27 | 2018-04-27 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-04-27 | 2018-04-27 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2018-04-27 | 2018-04-27 | N |
| 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. | Health | 2018-04-27 | 2018-04-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-27 | 2018-04-27 | N |
| Meet other general requirements. | Fire Safety | 2017-03-06 | 2017-04-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-03-06 | 2017-04-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-03-06 | 2017-04-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-03-06 | 2017-04-13 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-03-03 | 2017-04-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-03-03 | 2017-04-13 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-03-03 | 2017-04-13 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-03-03 | 2017-04-13 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-03-03 | 2017-04-13 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-03 | 2017-04-13 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-03 | 2017-04-13 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-03-03 | 2017-04-13 | N |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | Health | 2017-03-03 | 2017-04-13 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-03 | 2017-04-13 | N |
