Inspection·April 11, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on review of facility policies, clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for two of two residents (Resident R1 and R2). Residents Affected - Few Findings include: A review of facility policy Comprehensive Care Plan Policy dated 4/27/22, indicated that a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial (referring to the mind's ability to, consciously or unconsciously, adjust and relate the body to its social environment) and functional needs is developed and implemented on each resident. A review of the clinical record indicated that Resident R1 was admitted to facility 3/9/23, with diagnoses that included respiratory failure, urinary tract infections, and dysphagia (a condition with difficulty in swallowing food or liquid). A review of admission Minimum Data Set (MDS - assessment tool which forms the foundation of the comprehensive assessment for all residents of long-term care facilities) dated 3/16/23, indicated diagnosis to remain current upon review. Further review indicated that Section G: Functional Status, Question G0110 Activities of Daily Living (ADL) Assistance, indicated Resident R1 required extensive assistance with bed mobility, and toilet use, and required limited assistance for transfers, dressing, and personal hygiene. Question G0120 Bathing indicated Resident R1 required total dependence in bathing. A review of the clinical record's physicians order dated 3/24/23, indicated that Resident R1 Transfers: Full body lift with A(ssist) of 2. A review of Resident R1's clinical record failed to reveal a person-centered care plan was developed to address interventions for Resident R1's ADL status and assistance needed for bed mobility, transfers, dressing, personal hygiene, and toilet use, or physician ordered transfer status. A review of the clinical record indicated that Resident R2 was admitted to facility 3/7/23, with diagnoses that included muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), respiratory failure, and diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). A review of admission Minimum Data Set (MDS - assessment tool which forms the foundation of the (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 2 Event ID: 395034 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 395034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237 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)