Health 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 Page 1 of 2 395034 395034 04/11/2023 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0656 Level of Harm - Minimal harm or potential for actual harm comprehensive assessment for all residents of long-term care facilities) dated 3/14/23, 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 R2 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Question G0120 Bathing indicated Resident R2 required physical help in part of bathing activity. Residents Affected - Few A review of the clinical record's physicians order dated 3/8/23, indicated that Resident R2 Transfers 2 assist. A review of Resident R2'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. During an interview on 4/10/23, at 3:15 p.m. the Director of Nursing and the Director of Quality and Risk Management confirmed the facility failed to develop a comprehensive care plan for two of two residents (Resident R1 and R2). 28 Pa. Code 211.11(d) Resident care plan. 395034 Page 2 of 2