Health inspection·November 9, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, facility documentation and staff interview, it was determined the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice form (SNF ABN CMS-10055)published by the Centers for Medicare and Medicaid Services which provides information to residents/resident representatives so they can decide if they wish to continue skilled nursing services that may not be paid for by Medicare and assume financial responsibility for one of three residents (Resident R182). Residents Affected - Few Findings include: Review of facility policy titled Advance Beneficiary Notices last reviewed 1/30/23, informed it is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. The facility shall inform Medicare beneficiaries of his or her potential liability for payment. The current CMS approved version of forms shall be used at the time of issuance to the beneficiary (resident or resident representative). For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), form CMS-1005. A review of Resident R182's clinical record documented the resident was admitted to the facility on [DATE], and discharged [DATE]. A review of the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form CMS-20052 (published by the Centers for Medicare and Medicaid Services and used to determine if nursing care facilities are in compliance with notifying residents/resident representatives of a termination/denial/resident discharge from Medicare Part A services) documented Resident R182 had a Medicare Part A termination date of 7/6/23. The facility failed to provide Resident R182 with a Skilled Nursing Facility Advanced Beneficiary Notice form (SNF ABN CMS-10055) which provides information to residents/resident representatives so that they can decide if they wish to continue receiving skilled nursing services that may not be paid for by Medicare and assume financial responsibility. During an interview on 11/8/23, at 12:45 p.m. Social Worker Employee E1 confirmed the facility failed to issue Skilled Nursing Facility Advanced Beneficiary Notice form (SNF ABN CMS-10055) to decide if residents/resident representatives wish to continue skilled nursing services that may not be paid for by Medicare and assume financial responsibility. 28 Pa. Code 201.18(e)(1) Management. Page 1 of 11 395032 395032 11/09/2023 McMurray Hills Rehabilitation and Healthcare Cente 249 West McMurray Road McMurray, PA 15317

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical record, investigation documentations and staff interview, it was determined that the facility failed to report an injuries of unknown sources which caused severe bruising requiring xrays for two of four residents (R15 and R20), failed to report neglect when staff failed to making certain alert equipment was properly functioning to prevent a potential injury for one of four residents (Resident R24) and failed to protect a resident from further potential neglect and retaliation for one of four residents (Resident R131). Findings include: Review f the facility policy Abuse Policy and Procedure last reviewed on 1/30/23, indicated that the facility staff are trained to identify abuse, neglect, etc. and understanding that an injury that is unusual can also indication of alleged violations, protecting the victim during the investigation, and reporting allegations to the appropriate agencies. Review of the clinical record indicated that Resident R15 was admitted to the facility on [DATE], with diagnoses which included Dementia with psychotic episodes, history of falls, anxiety and vascular disease. A Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 9/25/23, indicated the diagnoses remained current. Review of Resident R15's plan of care included staff encourage Resident R15 the wear non skid socks and/or shoes prior to attempting to ambulate and to ensure equipment is readily available for Resident R15 and Resident R15 is a transfer with assistance of two staff and a Hoyer lift (total lift). Review of a progress note dated 9/30/23, indicated that Resident R15 had developed a bruise on the top and bottom of her right great toe extending down the foot including other toes. Review of the incident report dated 9/30/23, did not include a full investigation to determine the root cause and also indicated xrays had been ordered, which were indicated as negative for fracture. The document did not include that the State agency or other agencies had been notified of the injury of unknown origin. Review of the clinical record indicated that Resident R20 was admitted to the facility on [DATE], with diagnoses which included history of falls, with a fracture of her right arm, macular degeneration (poor vision), dementia, difficulty with ambulation and refusal of care. A MDS dated [DATE], indicated that diagnoses remained current with the healing of the right arm fracture. Review of Resident R20's plan of care indicated the placement of upper siderails to Resident R20's bed for mobility and weakness. Resident R20 was a transfer with assistance of one staff. Review of a progress note dated 9/17/23, indicated that Resident R20 developed a bruise to her right forearm from the top of the right arm extending to the elbow. Review of an incident report dated 9/17/23, indicated xrays had been ordered and were identified as no fractures. The document did not include that the State office and other agencies had been notified of the injury of unknown origin. 395032 Page 2 of 11 395032 11/09/2023 McMurray Hills Rehabilitation and Healthcare Cente 249 West McMurray Road McMurray, PA 15317

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the clinical record indicated that Resident R24 had been admitted to the facility on [DATE], with diagnoses which included heart failure, bladder cancer, heart block, dementia and repeated falls. A MDS dated [DATE], indicated the diagnoses remained current. Review of Resident R24's plan of care indicated siderails placed on Resident R24's bed for mobility and weakness. Resident R24 is a transfer of two staff. Resident R24 on a fall protocol which included determination of root causes and try to remove the potential for falls and placement of bed and chair alarms to alert staff of Resident R24's rising. Review of a progress note dated 5/27/23, indicated that the nurse heard Resident R24's alarm sounding and found Resident R24 on the floor when he attempted to place himself in bed. This occurred at 9:45 p.m. Review of a progress note dated 6/20/23, indicated that a Hospice aide had taken Resident R24 to the bathroom and had Resident hold grab bar for her to remove wheelcahir. Resident R24 became dizzy and had to be lowered to the floor. Resident R24 required assistance of three staff to transfer back into wheelchair. Review of an incident report dated 6/20/23, indicated that the resident was educated to use the shower chair instead of standing in the shower. The incident was not fully investigated to include whether one staff had transferred the resident, was he in the bathroom or shower, etc. The incident was not reported to the State agency or other agencies as required. Review of progress note dated 7/4/23, at 3:15 a.m., indicated that Resident R24 had fallen from his wheelchair. The staff identified that Resident R24 bed alarm was not plugged in. Review of an incident report dated 7/4/23, indicated that two nurse aides came down hall and found Resident on floor beside wheelchair with bed alarm not sounding as it was not plugged in. Resident R24 had self transferred. The incident report indicated that Resident R24 stated he had to poop and was trying to get to his wheelchair and he slid . The bed was in high position and he did not have non skid socks on. The report indicated that the bed pad plug would not stay in unless the alarm box was kept upright, the bed alarm was broken. The report did not indicate the State agency and other agencies being notified. Review of the clinical record indicated that Resident R131 had been admitted to the facility on [DATE], with diagnoses which included enlarged prostate with lower urinary tract symptoms, heart flutter, blood cancer, blindness, pressure ulcer of his sacrum and buttocks and clostridium difficile( C-Diff-causing frequent liquid stools related to a intestinal infection). A MDS dated [DATE], indicated the diagnoses remained current. Resident R131 had been admitted with a urinary catheter. Review of the Facility Grievance logs dated from 12/30/22, through October 2023, indicated that Resident R131's daughter had submitted a grievance on 3/15/23, related to Resident R131 being in therapy for 15 minutes and needing to get changed as he had soiled his brief with stool. The grievance indicated that once upstairs, he waited for a total of an hour and a half for someone to change him and then he was not returned to therapy to finish his session. Review of the grievance log indicated that on 5/31/2, Resident R131's daughter submitted a grievance realte to Resident R131 having issues with two Nurse Aides, because he had been incontinent of bowel due to his C-Diff and his being embarrassed about not being able to control it. The one 395032 Page 3 of 11 395032 11/09/2023 McMurray Hills Rehabilitation and Healthcare Cente 249 West McMurray Road McMurray, PA 15317

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some specifically named Nurse Aide had made comments of I don't get paid enough, Why can't you take yourself to the bathroom. Resident R131's daughter stated that the named Nurse Aide gets angry. The daughter went on to state that she was afraid to say anything as she did not her dad to be retaliated against. Review of the staffing sheets on dates of June 2nd, 3rd, 4th etc. revealed the facility schedule did not protect Resident R131 from potential retaliation; employees named in the greivance were not removed from the schedule pending an investigation. During an interview on 11/8/23, at 12: 48 p.m., the Director of Nursing confirmed that the facility failed to report potential abuse/neglect for four of four residents. Failed to protect one of four residents from potential for continued neglect (Resident R131). 28 Pa. Code: 201.4(c)(d)(e) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(2) Management. 28 Pa. Code: 201.29(a)(c)(d)(j)(m) Resident rights. 395032 Page 4 of 11 395032 11/09/2023 McMurray Hills Rehabilitation and Healthcare Cente 249 West McMurray Road McMurray, PA 15317

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy and clinical record reviews and interview with staff, it was determined that the facility failed to review and revise the comprehensive care plan after a fall for two of six residents. (Resident R12 and R62) Findings include: A review of the facility policy Care Plan Revisions upon Status Change reviewed 12/23/22 and 1/30/23, indicated the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment A review of the clinical record indicated Resident R12 was admitted to the facility on [DATE], with diagnoses that included dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), major depressive disorder, an artificial hip joint, history of falling, and ataxic gait (poor muscle control and clumsy voluntary movements). A review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 9/2/23, indicated the diagnoses remained current. Further review of the MDS dated [DATE], Section C: Cognitive Patterns indicated the resident had a Brief Inventory for Mental Status (BIMS) score of 03. A review of a physician orders dated 11/9/2023, indicated Resident R12 was ordered a Wander Guard bracelet on 7/6/22, and it was discontinued on 1/5/23. A review of Resident R12's progress notes revealed on 9/21/23, the resident self propelling self in w/c [wheelchair] out front door. He was redirected by CNA [certified nursing assistant]. Wanderguard was applied. A review of the care plan dated 9/7/23, failed to include Resident R12's elopement on 9/21/23. A review of the comprehensive care plan did not include interventions for Resident R35 ' s fall. A review of the clinical record indicated Resident R62 was admitted to the facility on [DATE], with 395032 Page 5 of 11 395032 11/09/2023 McMurray Hills Rehabilitation and Healthcare Cente 249 West McMurray Road McMurray, PA 15317

F 0657 diagnoses that included diabetes, high blood pressure, and anxiety. Level of Harm - Minimal harm or potential for actual harm A review of the MDS dated [DATE], indicated the diagnoses remain current. Further review of the MDS dated [DATE], Section O: Special Treatments, Procedures, and Programs Question O0100; K: Hospice Care, indicated Resident R62 receives hospice care. Residents Affected - Few A review of a physician order dated 9/30/2022, indicated Resident R62 was admitted to hospice services as of 9/7/2022. A review of the care plan failed to include hospice services. During an interview on 11/8/23, at 1:05 p.m. Registered Nurse admission Coordinator (RNAC) Employee E4 confirmed that Resident R12 and R62's comprehensive care plan was not revised to reflect the resident's current status. 28 Pa. Code 211.11(d) Resident Care Plans. 395032 Page 6 of 11 395032 11/09/2023 McMurray Hills Rehabilitation and Healthcare Cente 249 West McMurray Road McMurray, PA 15317

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, personnel records, and staff interview, it was determine that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program. Residents Affected - Some Findings include: Review of the Activity Supervisor job description indicated the qualifications were as required by State and Federal Regulations. Review of Activities Director Employee E3's personnel record indicated she was hired on 8/9/23. Review of Activities Director Employee E3's personnel record did not include evidence that Activities Director Employee E3 had proper qualifications as an Activities Director. The personnel record did not include previous history as an Activity Director within the last five years, education in therapeutic services, education as a social worker or occupational therapist, or a background in recreational services. During a interview on 11/8/23, at 12:05 p.m. Activities Director Employee E3 confirmed that she did not have education in therapeutic services, education as a social worker or occupational therapist, or a background in recreational services. During an interview on 11/8/23, at 12:30 p.m. the Nursing Home Administrator confirmed Activities Director Employee E3 was hired on 8/9/23, and the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program. 28 Pa. Code: 201.18(b)(3) Management. 395032 Page 7 of 11 395032 11/09/2023 McMurray Hills Rehabilitation and Healthcare Cente 249 West McMurray Road McMurray, PA 15317

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical and facility record review, facility policy review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for two of six residents (Resident R35 and R12). Findings include: Review of the facility policy Accidents and Supervision reviewed 1/30/23, indicated the resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. All staff are to be involved observing and identifying potential hazards while taking into consideration the unique characteristics and abilities of each resident. Implementation of interventions includes development of interim safety measures may be necessary if interventions cannot immediately be implemented fully. Review of the facility policy Use of Assistive Devices reviewed 1/30/23, includes wheelchairs and indicated the nurse with responsibility for the resident will monitor for the consistent use of the device and safety in the use of the device. Refusals of use will be documented in the medical record. Modifications to the care plan will be made as needed. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment A review of the clinical record revealed that Resident R35 was admitted to the facility on [DATE], with diagnoses that included dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), high blood pressure, and muscle weakness. Review of Resident R35's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 8/15/23, indicated the diagnoses remain current. Further review of the MDS dated [DATE], indicated Resident R35's BIM score was 11. Review of a nurse progress note dated 10/6/23, indicated that Resident R35 was self-propelling her wheelchair in the hallway on her way back to her bedroom. Staff asked Resident R35 if she needed assistance as she had two cups of ice in one hand and one of juice in her other hand. Resident R35 stated she did need assistance, but refused to allow the nurse to attach the leg rests. When the nurse reached the resident's room, she placed her feet on the floor and fell face forward onto the floor. 395032 Page 8 of 11 395032 11/09/2023 McMurray Hills Rehabilitation and Healthcare Cente 249 West McMurray Road McMurray, PA 15317

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of a physician order dated 10/7/23, indicated neuro checks every four hours for 48 hours, post-fall 10/6/23, every shift until 10/9/23, at 7:00 p.m., Further review of the physician orders dated 10/7/23, indicated to apply ice pack to head injury for 10-15 minutes every two hours every shift for head injury, and Tylenol Extra Strength 500 milligrams (mg) one 500 mg tablet as needed for head injury. Review of the care plan dated 4/17/23, indicated Resident R35 had Activities of Daily Living (ADL) self-care deficit and wheels herself in wheelchair. Further review of the care plan dated 4/17/23, revealed the resident was at risk for falls and instructed staff to encourage resident to have staff carry her items to her desired location. Monitor/anticipate/intervene for causative factors, and follow facility fall protocol. Care plan dated 4/21/23, indicated resident had impaired cognition related to dementia and to cue, reorient, and supervise as needed. During an interview on 11/7/23, at 1:05 p.m. Rehab Director Employee E7 stated therapy assesses each resident on admission and quarterly for walkers, wheelchairs, and other assistive devices. If residents self-propel in their wheelchairs, leg rests are provided for emergency use, and stored in the resident's room. If a self-propelling resident is alert and oriented and able to hold their legs up, they are sometimes pushed without leg rests. He was unsure how the nurses or nurse aides assist the residents on the units. During a telephone interview on 11/8/23, at 3:00 p.m. Licensed Practical Nurse (LPN) Employee E6 stated Resident R35 was carrying two 8 ounce (oz) cups of ice in one hand and another 8 oz cup of juice in the other. She asked Resident R35 if she would like help and was told yes. LPN Employee E6 stated she offered leg rests, that are stored in the resident's room, and the resident refused. LPN Employee E6 stated she told Resident R35 that she would help and to keep her legs up, Resident R35 put her feet down a few times on the way to her room. When they reached Resident R35's room, she was asked if she needed a break from holding her legs up, she stated she did not. Resident R35 then placed her feet on the floor and fell face forward onto the floor. There was a little bit of blood noted from Resident R35's mouth where a tooth might have hit her lip. LPN Employee E6 noted bruising from a previous fall, and a goose egg above her left eyebrow. When asked how well Resident R35 responds to being educated on leg rests, LPN Employee E6 replied that it depended on the topic of education and Resident R35 had short term memory loss. When asked how LPN Employee E6 evaluated Resident R35 for the ability to hold her legs up, she answered Resident R35 was sore from her previous fall so she couldn't hold them up that long. LPN employee E6 stated that the residents are still pushed in their wheelchairs even if they refuse leg rests. During an interview on 11/8/23, at 10:30 a.m. the Director of Nursing stated if a resident asked for assistance, and they are alert and oriented they can be pushed without leg rests. If the resident had dementia and self-propelled their wheelchair, they should not be pushed without leg rests as they are at a higher risk of putting their feet down. The Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent a fall for Resident R35. A review of the clinical record indicated Resident R12 was admitted to the facility on [DATE], with diagnoses that included dementia, major depressive disorder, an artificial hip joint, history of falling, and ataxic gait (poor muscle control and clumsy voluntary movements). A review of the MDS dated [DATE], indicated the diagnoses remained current. Further review of the MDS dated [DATE], Section C: Cognitive Patterns indicated the resident had a Brief Inventory for Mental Status (BIMS) score of 03. 395032 Page 9 of 11 395032 11/09/2023 McMurray Hills Rehabilitation and Healthcare Cente 249 West McMurray Road McMurray, PA 15317

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of a physician orders dated 11/9/2023, indicated Resident R12 was ordered a Wander Guard bracelet on 7/6/22, and it was discontinued on 1/5/23. A review of Resident R12's progress notes revealed on 9/21/23, the resident self propelling self in w/c [wheelchair] out front door. He was redirected by CNA [certified nursing assistant]. Wanderguard was applied. During an interview on 11/8/23, at 12: 48 p.m., the Director of Nursing confirmed that the facility failed to provide proper supervision to prevent an elopement for Resident R12. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395032 Page 10 of 11 395032 11/09/2023 McMurray Hills Rehabilitation and Healthcare Cente 249 West McMurray Road McMurray, PA 15317

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of facility policies, observations and staff interviews it was determined that the facility failed to maintain food equipment in a clean, sanitary condition, to prevent the potential for cross-contamination. (Main Kitchen) Findings include: A review of the facility Handling Clean Equipment and Utensils reviewed 1/30/23, indicated clean equipment and utensils will be stored in a clean, dry location in a way that protects them from contamination by splashes and dust During an observation of the Main Kitchen on 11/7/23, at 9:40 a.m. pots and pans were observed being stored hanging over the two-compartment sink where soiled pots and pans are washed. During an interview on 11/7/23, at 9:42 a.m. the Dietary Manager Employee E5 confirmed the hanging pots and pans should not be stored over the dirty sink. 28 Pa. Code 211.6(c)(f) Dietary services. 395032 Page 11 of 11