CHESWICK REHABILITATION AND WELLNESS CENTER, LLC

Nursing Home Inspector

3876 SAXONBURG BOULEVARD
CHESWICK, PA 15024
Allegheny County
Phone: 412-767-4998
Provider Number: 395538
Last Inspection: 11/14/2016

About the Nursing Home

Number of Beds: 121
Number of Residents: 92
Beds Available: 29
Percent Occupancy: 76%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

66

Facility
19

County
23

PA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

66

2016
25

2016
31

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

11/14/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 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. Isolated : Minimal 3 12/29/2016
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 12/29/2016
 
Failed To: Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. Isolated : Minimal 3 12/29/2016
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 12/29/2016
 
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 12/29/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 12/29/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 12/29/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 12/29/2016
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Pattern : Minimal 4 12/29/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 12/29/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 12/29/2016
 
Failed To: Make sure that paid feeding assistants 1) completed training; 2) work under the supervision of a RN or LPN; and 3) feed only residents who have no complicated feeding problems. Isolated : Minimal 3 12/29/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 12/29/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 12/29/2016
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Pattern : Minimal 4 12/29/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 12/29/2016
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 12/29/2016
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Pattern : Minimal 4 12/29/2016
 

2/19/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Potential 3 4/11/2016
 
Failed To: 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. Pattern : Minimal 4 4/11/2016
 
Failed To: Provide activities to meet the interests and needs of each resident. Pattern : Minimal 4 4/11/2016
 
Failed To: Develop policies and procedures for influenza and pneumococcal immunizations. Isolated : Minimal 3 4/11/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 4/11/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 4/11/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 4/11/2016
 

4/17/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 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. Isolated : Minimal 3 6/30/2015
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 5/15/2015
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 5/15/2015
 
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 6/30/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 6/30/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 5/15/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 5/15/2015
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Pattern : Minimal 4 6/30/2015
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Isolated : Minimal 3 5/15/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

6/19/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 7/12/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 7/12/2017
 

10/4/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 10/21/2016
 

8/23/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Use a registered nurse at least 8 hours a day, 7 days a week. Pattern : Minimal 4 10/14/2016
 

11/5/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 12/5/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 12/5/2015
 

9/25/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 unknown
 

9/3/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 9/9/2015
 

6/26/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 unknown
 

3/19/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 unknown
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 unknown
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 unknown
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 unknown
 

1/22/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 3/5/2015
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Isolated : Minimal 3 3/5/2015
 
Failed To: Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. Widespread : Minimal 5 3/5/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg PA State Avg
Number of Residents 92 110.11 110.03
Registered Nurses 0.65 1.05 0.94
Licensed Practical / Vocational Nurses 1.09 0.74 0.85
Certified Nursing Assistants 2.05 2.12 2.26
Total Staff Hours 3.80 3.91 4.05

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% PA State Avg%
of high risk long-stay residents with pressure ulcers 16 6 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 73 93 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 60 95 95
of long-stay residents experiencing one or more falls with major injury 3 3 3
of long-stay residents who have depressive symptoms 3 2 2
of long-stay residents who lose too much weight 4 7 7
of long-stay residents who received an antianxiety or hypnotic medication 35 19 22
of long-stay residents who received an antipsychotic medication 22 14 15
of long-stay residents who self-report moderate to severe pain 17 7 6
of long-stay residents who were physically restrained 2 0 0
of long-stay residents whose ability to move independently worsened 19 21 20
of long-stay residents whose need for help with daily activities has increased 18 17 15
of long-stay residents with a catheter inserted and left in their bladder 2 2 1
of long-stay residents with a urinary tract infection 2 3 3
of low risk long-stay residents who lose control of their bowels or bladder 33 58 56
of short-stay residents assessed and appropriately given the pneumococcal vaccine 80 87 83
of short-stay residents who had an outpatient emergency department visit 18 10 10
of short-stay residents who made improvements in function 61 59 64
of short-stay residents who newly received an antipsychotic medication 2 2 1
of short-stay residents who self-report moderate to severe pain 24 16 15
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 76 84 82
of short-stay residents who were rehospitalized after a nursing home admission 21 22 20
of short-stay residents with pressure ulcers that are new or worsened 1 54 52