Inspection·December 19, 2024

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation three two of seven residents (Resident R1, R2, R3). Findings include: Review of Resident R96 was admitted [DATE] with diagnoses that include cytomegaloviral disease (common virus that infects people of all ages and can cause a range of symptoms), diabetes mellitus and protein calorie malnutrition. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R1 admission MDS assessment (Minimum Data Set assessment MDS- a periodic assessment of resident care needs) dated 12/3/24 indicated the resident was assessed as having a BIMS score of 11, which indicates moderately impaired. Review of Resident R1's admission packet indicated a signature by the resident. Review of Resident R2 was admitted [DATE] with diagnoses that include encephalopathy (brain disorder that affects the brain's structure or function), chronic kidney disease and anemia. Review of Resident R2's medical record revealed no signed admission packet. Review of Resident R3 was admitted [DATE] with diagnoses that include multiple fracture of the ribs, urinary tract infection and lack of coordination. Review of Resident R3's medical record revealed no signed admission packet. During an interview with Nursing Home Administrator on 12/19/24 at 2:00 p.m. confirmed Resident R1 (continued on next page) 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 Page 1 of 3 Event ID: 395011 Printed: 05/15/2026 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 395011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Platinum Ridge Ctr for Rehab & Healing 1050 Broadview Boulevard Brackenridge, PA 15014 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)