Health inspection·July 21, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for two of five residents (Residents R123 and R129). Residents Affected - Few Findings include: Review of the facility's policy Self-Administration of Medication dated 4/26/23, indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Review of the admission record indicated Resident R123 was admitted to the facility on [DATE]. Review of Resident R123's Minimum Data Set assessment (MDS- a periodic assessment of care needs) dated 5/13/23, indicated a Brief Interview for Mental Status (BIMS- a screening test that aides in detecting cognitive impairment) of 11 indicating moderate impairment, and the diagnoses of high blood pressure, anemia (the blood doesn't have enough healthy red blood cells), and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids). Review of Resident R123's physician orders failed to include an order for self-administration of medications. Review of Resident R123's care plan on 7/19/23, failed to include self-administration of medication management. Review of Resident R123's clinical record indicated the absence of a Self-Administration of Medication assessment. Observation of Resident R123's overbed table on 7/17/23, at 10:56 a.m. revealed a medication cup with one white circular pill. Interview with Registered Nurse (RN) Employee E13 on 7/17/23, at 10:58 a.m. confirmed the pill was at bedside and resident was not assessed for self-administration. Review of the admission record indicated Resident R129 admitted to the facility on [DATE]. Review of Resident R129's MDS dated [DATE], indicated the diagnoses of high blood pressure, heart failure (heart doesn't pump blood as well as it should), and coronary artery disease (narrow arteries Page 1 of 14 395034 395034 07/21/2023 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0554 decreasing blood flow to heart). Level of Harm - Minimal harm or potential for actual harm Review of Resident R129's physician orders failed to include an order for self-administration of medications. Residents Affected - Few Review of Resident R129's care plan on 7/20/23, failed to include self-administration of medications management. Review of Resident R129's clinical record indicated the absence of a Self-Administration of Medication assessment. Observation of Resident R129's overbed table on 7/20/23, at 2:46 p.m. revealed three medication cups, two with a variety of pills inside each, and one with a clear gel substance. Interview with RN Employee E3 on 7/20/23, at 2:48 p.m. confirmed the medications were at bedside and resident was not assessed for self-administration. Interview on 7/21/23, at 10:16 a.m. the Director of Nursing confirmed the above medications at bedside and that the facility failed to determine the ability to self-administer medications for two of five residents reviewed (Residents R123 and R129). 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 28 Pa. Code: 211.9(a)(1) Pharmacy services. 395034 Page 2 of 14 395034 07/21/2023 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from neglect for two of five residents (Resident R45 and R98), that resulted in falls during care and the facility failed to protect residents from physical abuse for one of five residents (Resident R20). Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR §483.12. Freedom from Abuse, Neglect, and Exploitation defines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of facility policy Freedom From Abuse, Neglect, and Exploitation dated 4/26/23, indicated that each resident has the right to be free from neglect. Review of facility policy Activities of Daily Living dated 4/26/23, indicated the facility will conduct ADL's (Activities of Daily Living) in a safe, timely and effective manner, that best helps the resident thrive. Review of the clinical record indicated that Resident R45 was admitted to the facility on [DATE], with diagnoses which included heart failure, anemia and type 2 diabetes (chronic disease. It is characterized by high levels of sugar in the blood). A review of Resident R45's Minimum Data Set (MDS- a periodic assessment of resident care needs), dated 12/12/22, indicated the diagnoses remained current. Review of Section G: Functional Status indicated the resident required a physical assist of two or more. Review of Resident R45's progress notes dated 1/24/23, at 1:17 p.m. indicated resident had an unwitnessed fall and was complaining of of pain in left shoulder. Review of facility documentation dated 1/24/23 that Resident was identified as a falls risk because of history of falls. Assist of two for transfers and toileting. Staff was educated to stay with the resident while on the bedside commode. Interview on 7/20/23, 2:00 p.m. Employee E18 confirmed that the Resident R45 was left unattended and sustained a fall. Interview on 7/20/23, 9:15 a.m. RN Employee E16 indicated the NA have a assignment sheet on the resident assistant needs. Interview on 7/20/23, 9:25 a.m. NA Employee E17 indicates she looks on her assignment sheet, if there is something new, the nurse on the floor let them know. Review of Resident R98's admission record indicated he was admitted to the facility on [DATE]. 395034 Page 3 of 14 395034 07/21/2023 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R98's Minimum Data Set (MDS -a periodic assessment of care needs) dated 6/6/23, indicated diagnoses of stroke with left sided weakness, high blood pressure, and muscle wasting. Section G Functional Status indicated resident required extensive assistance of two staff for bed mobility, toilet use and hygiene. Review of Resident R98's plan of care for ADL and functional mobility deficit related to stroke dated 7/4/23, indicated Resident R98 required extensive assist of two staff for both bed mobility and transfer. Review of Resident R98's Cheat sheet (paper document that outlines the patients' ADLs, and assistance required) utilized by nurse aide staff undated, indicated that Resident R98 as extensive assist of two for care. Review of Resident R98's progress note dated 7/11/23, at 12:42 p.m. indicated during morning care resident rolled out of bed onto the floor. Review of facility documentation Join conversation electronic message page, undated indicated Resident rolled out of bed during morning care. He appears to have no injuries but I am sure that he may have hit his head on the floor. Review of Employee Statement Form dated 7/11/23, indicated Nursing Assistant (NA) Employee E5 went into Resident R98's room to get him cleaned and dressed. Upon rolling him to his right side he fell off the other side of the bed. Telephone interview with Employee E5 on 7/20/23, at 11:49 a.m. indicated That morning I got him up out of bed I went in to get him up, I pulled him to me and then rolled him towards the window, I was on the right and pushed him to the left the side and the bed collapsed and he fell off the bed. I remember he was an assist of two in the past. Usually we don't have enough hands to grab someone for help. We have a booklet for how he's supposed to be a Hoyer but I wasn't getting him up. I didn't check to see if he needed two assist in bed. Review of facility investigation dated 7/13/23, the Director of Nursing confirmed NA Employee E5 provided care alone and did not have two assist as required. Interview on 7/20/23, at 8:29 a.m. NA Employee E6 indicated The [NAME] shows us where to look for how many people to give care, bed mobility, toileting, transfers and they have a cheat sheet. Interview on 7/20/23, at 8:34 a.m. NA Employee E7 indicated They give us an assignment sheet with the people and what their transfer status is, if their thickened liquids, all that good stuff we need. It's a run-down of your assignment. Interview on 7/20/23, at 9:00 a.m. NA Employee E2 indicated I have it written down, got report from previous shift, nurse is helping when asked where to look for ADL assistance for resident care. Interview on 7/20/23, at 9:10a.m. Registered Nurse (RN) Employee E1 indicated Once therapy evaluates the resident, they put an order in that states their mobility level, so I would look in the orders section when asked where to look for ADL assistance for resident care. 395034 Page 4 of 14 395034 07/21/2023 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 7/20/23, 9:06 a.m. NA Employee E8 indicated the [NAME] is where to find information on resident assistance needs. Review of admission record indicated Resident R20 was admitted to the facility on [DATE]. Review of Resident R20's MDS dated [DATE], indicated the diagnoses of high blood pressure, arthritis, and osteoporosis (bones become weak and brittle). Section C indicated Resident R20's cognition was intact. Section G Functional Status indicated resident required extensive assistance of two staff for bed mobility, toilet use and hygiene. Review of Resident R20's plan of care for ADL and functional mobility deficit dated 4/11/23, indicated Resident R20 had decreased independence for bed mobility, transfer, and lower body self-care. Review of facility provided documentation dated 4/7/23, indicated that Resident R20 had a bruise on her right forearm and indicated that it may have occurred during care with a Nursing Assistant. Review of an interview with the Director of Nursing, Resident R20 reluctantly disclosed NA's name (NA Employee E9) and stated She is often rough during care. A few days ago, she grabbed my arm and rolled me, which at that time it hurt my arm, then I had this bruise. She often causes me pain especially with the rough care and when she pulls on my arms. Review of Employee Statement Form dated 4/12/23, NA Employee E10 indicated I was washing Resident R20 and she mentioned to me that her usual aide (NA Employee E9) was pretty rough with turning and grabs her by her sides and arms and aggressively turns her side to side. She said the bruise to her right arm was from her grabbing her and that NA Employee E9 said it wasn't when she mentioned it to her. Resident stated NA Employee E9 doesn't allow her to hold on to anything when she's turning and she feels unsafe turning that way. Interview on 7/19/23, at 9:26 a.m. Resident R20 indicated Everything is fine now, they got rid of the girl who pulled on my arms and hurt me. I had a bad bruise here on my right arm from her being so rough with me. Review of Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of property dated 4/19/23, indicated the facility's investigation substantiated physical abuse. Interview on 7/21/23, at 10:16 a.m. the Director of Nursing confirmed the facility failed to protect residents from neglect (Resident R45 and R98), that resulted in falls during resident care and failed to protect a resident from physical abuse (Resident R20). 28 Pa Code: 201.29 (i) Resident rights. 28 Pa Code: 211.12(d)(1)(2) Nursing Services 395034 Page 5 of 14 395034 07/21/2023 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation that included statements from the witnesses and/or statements from the residents for accident investigation for one of five residents (Resident R45). Residents Affected - Few Findings include: The facility Incidents and Accidents policy dated 4/26/23, indicated anyone who witnesses, discovers or is involved in a an incident is responsible for reporting it to an Licensed Nurse on the unit it as soon as possible , on the day of discovery. The incident report should include factual information concerning only the details of what happened, clinically relevant facts and statements made by the residents. Review of the clinical record indicated that Resident R45 was admitted to the facility on [DATE], with diagnoses which included heart failure, anemia and type 2 diabetes (chronic disease. It is characterized by high levels of sugar in the blood). A review of Resident R45's Minimum Data Set (MDS- a periodic assessment of resident care needs), dated 12/12/22, indicated the diagnoses remained current. Review of Section G: Functional Status indicated the resident required a physical assist of two or more. Review of Resident R45's investigation report dated 1/24/23 stated Resident sitting on floor in front of BSC, slid off seat, denies hitting head. The investigation report failed to include statements from staff who provided care for the resident. During an interview on 7/20/23, at 9:56 a.m. the Nursing Home Administrator confirmed that the facility failed to complete a thorough investigation that included statements from the witnesses for one of five residents (Resident R45). 28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c)(d) Resident Rights. 28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services. 395034 Page 6 of 14 395034 07/21/2023 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, job description review, observation, and staff interview, it was determined the facility failed to provide care and services to meet the accepted standards of practice for one of four residents (Resident R59). Residents Affected - Few Review of facility policy Skin Assessment - Clean/Dry Dressing change procedure dated 4/26/23, indicated to verify that there is a physician's order for this procedure. Review of the facility Registered Nurse (RN) job description indicated that an RN will perform and/or supervise individualized personal care for residents in accordance with the established nursing care plan a within scope of licensure. Review of the clinical record indicated Resident R59 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/10/23, indicated diagnoses of hypertension (high blood pressure in the arteries), adult failure to thrive (seen in older adults with multiple medical conditions resulting in a downward spiral of poor nutrition, wight loss, inactivity, depression, and decrease in functional abilities), and hip fracture. Review of a physician's order dated 7/9/23, indicated to cleanse buttock wound with mild soap and water, pat dry, crush Flagyl (a medication used to treat various infections) 500mg (milligrams) and apply to wound bed for odor control, then apply silver collagen (a type of dressing that is used to reduce and prevent bacterial formation within the wound dressing), and cover with a border dressing (a self-adhering, multilayer foam dressing) daily and as needed. During an observation of Resident R59's buttocks dressing change on 7/19/23, at 10:28 a.m. RN Employee E3 was asked if she would verify the physician's order for the dressing requirements prior to performing the dressing change. RN Employee E3 stated, I don't need to look at it, I know it. RN Employee E3 was asked again if she would verify the physician's order prior to the dressing change and RN Employee E3 again stated, I don't need to look at it because I know it. RN Employee E3 then stated, the hospice nurse was in yesterday and recommended we start using AG Ribbon (a high absorbent silver alginate dressing for moderately to heavily draining infected wounds), I don't think the order is in yet, but I am going to do it that way regardless. RN Employee E3 also stated, the hospice nurse recommended to add water to the crushed Flagyl to make it a paste so it doesn't go everywhere. During an interview on 7/19/23, at 10:55 a.m. RN Employee E3 confirmed she failed to meet accepted standards of clinical practice by not verifying and following a physician's order prior to performing a dressing change for one of four residents (R59). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services 28 Pa. Code: 211.12(d)(3) Nursing services. 395034 Page 7 of 14 395034 07/21/2023 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to provide specialty briefs (used for sensitive skin) for a resident in a timely manner (Resident R104), resulting in a delay of treatment. Residents Affected - Few Findings include: Review of admission record indicated that Resident R104 was admitted to the facility on [DATE]. Review of Resident R104's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/6/23, indicated the diagnoses of high blood pressure, pruritis (uncomfortable, irritating sensation that creates the urge to scratch), and bullous pemphigoid (a rare skin condition causing large, fluid-filled blisters). Review of physician progress note dated 7/18/23, indicated Still unable to get specialty Tena briefs #613. Review of nursing progress note dated 7/8/23, at 2:30 p.m. indicated Resident R104 has a red, itchy rash on her lower back buttocks and under both breasts. Review of physician progress note date 6/12/23, at 11:50 a.m. indicated Resident R104 is requesting specialty briefs used previously, as with history of eczema (condition that causes dry, itchy and inflamed skin), and pemphigus current brand is causing issues. Interview on 7/17/23, at 10:48 a.m. Resident R104 indicated It's been over a month since the doctor authorized the staff to get the correct briefs for me, I'm totally broken out again because they aren't using the Tena ProSkin #613. Observation on 7/17/23, at 10:48 a.m. indicated a box of briefs in Resident R104's room that were not specialty brief Tena ProSkin #613. Interview on 7/20/23, at 9:13 a.m. Central Supply Employee E14 indicated she orders two cases ahead and keeps two down and one up. They are in the storage room and the aides might not have known where to find them. Interview with the Assistant Director of Nursing (ADON) on 7/19/23, at 10:00 a.m. confirmed the facility failed to provide specialty briefs in a timely manner for Resident R104, resulting in a delay of treatment. 28 Pa Code: 201.29 (i) Resident rights. 28 Pa Code: 201.18 (b)(1)(3) Management. 28 Pa Code: 211.10 (c ) Resident care policies. 28 Pa Code: 211.12 (a )(d)(1)(2)(3)(5) Nursing services. 395034 Page 8 of 14 395034 07/21/2023 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to properly assess pressure ulcers for one of five residents (Residents R59). Residents Affected - Few Findings include: Review of the facility policy Pressure Injury Prevention Program dated 4/26/23, indicated the program shall have a system in place that ensures assessments are timely and appropriate, interventions are implemented, monitored, and revised as appropriate and changes in condition are recognized, evaluated and reported to the resident's practitioner. Review of admission record indicated Resident R59 was admitted to the facility on [DATE]. Review of Resident R59's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/10/23, indicated the diagnoses of Non-Alzheimer's Dementia (loss of memory and function), high blood pressure and anemia (the blood doesn't have enough healthy red blood cells). Section M indicated no areas of pressure injury. Review of Resident R59's care plan dated 4/11/23, indicated resident is at risk for skin breakdown (pressure ulcer development) related to immobility and incontinence. Goal dated 4/24/23, indicated resident will be free of pressure ulcer development throughout the length of stay. Intervention dated 4/24/23, indicated preventative skin protocol- Cavilon (protective barrier) cream to high risk areas (heels, coccyx, buttocks, and sacrum) three times a week on Monday, Wednesday, and Friday. Braden scale dated 4/11/23 indicated a score of 16 at risk for pressure ulcer development. Review of skilled clinical admission dated 3/30/23, indicated skin is intact. Review of skilled evaluation notes dated 4/19/23, and 4/26/23, indicated no skin issues noted. Review of Hospice Registered Nurse (RN) Skilled Nursing Visit Note dated 5/1/23, indicated a coccyx wound stage II (a shallow wound with a pink or red base or blister) 3 cm (centimeters) long and 2.5 cm wide and 0.1 cm deep. Wound bed red edges attached, drainage bloody, small amount, no odor. Review of skin notes indicated the following: 4/1/23 - no issues 4/8/23 - no issues 4/11/23 - right hip surgical incision 5/3/23 - no issues 5/10/23 - new issue, coccyx pressure Consultant's wound documentation dated 7/18/23, indicated the coccyx wound was acquired on 3/30/23. 395034 Page 9 of 14 395034 07/21/2023 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0686 Interview on 7/20/23, at 11:55 a.m. the Director of Nursing confirmed the facility failed to properly assess pressure ulcers for Residents R59 and that he could not answer when the coccyx ulcer was acquired. Level of Harm - Minimal harm or potential for actual harm 28 Pa Code: 201.29 (i) Resident rights. Residents Affected - Few 28 Pa Code: 211.10 (c ) Resident care policies. 28 Pa Code: 211.12 (a )(d)(1)(2)(3)(5) Nursing services. 395034 Page 10 of 14 395034 07/21/2023 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, resident observations and interviews, clinical record review, and staff interview, it was determined that the facility failed to prove appropriate respiratory care for five of eight residents (Residents R348, R349, R359, R370, and R372). Residents Affected - Some Findings include: Review of the facility's policy Oxygen Therapy dated 4/26/23, indicated the oxygen tubing and humidifier must be change every 7 days and that the oxygen tubing and humidifier must be labeled with date and initials. Review of the clinical record indicated that Resident R348 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 7/9/23, indicated diagnoses of pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest), muscle weakness, and shortness of breath. Review of physician's orders dated 7/3/23, indicated to administer supplemental oxygen to maintain comfortable respirations as needed. Observation and interview of Resident R348 on 7/17/23, at 12:27 p.m. revealed an oxygen concentrator in Resident R348's room with no date written on the oxygen tubing or the humidification bottle. Resident R348 stated that he was short of breath yesterday and required supplemental oxygen. Review of the clinical record indicated that Resident R349 was admitted to the facility on [DATE]. Review of the clinical record indicated Resident R349 had diagnoses of hypertension (high blood pressure in the arteries), muscle weakness, and hip fracture. Review of physician's orders dated 7/11/23, indicated to administer oxygen at 2 liters continuously every shift for oxygen supplementation. Observation of Resident R349 on 7/17/23, at 12:00 p.m. revealed the resident was receiving oxygen at 4 liters per minute via a nasal cannula (a lightweight tube placed in the nostrils to deliver oxygen). The nasal cannula tubing and the humidification bottle had no dates on them. Interview on 7/17/23, at 2:20 p.m. with Registered Nurse (RN) Employee E1 confirmed the oxygen tubing and humidifier were not labeled with a date and initials for Residents R348 and R349. Review of the clinical record indicated that Resident R359 was admitted to the facility on [DATE]. Review of the clinical record indicated Resident R359 had diagnoses of obstructive sleep apnea (intermittent airflow blockage during sleep), hypertension, and muscle weakness. Review of physician's orders dated 7/7/23, indicated to administer supplemental oxygen to maintain comfortable respirations as needed. 395034 Page 11 of 14 395034 07/21/2023 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation and interview of Resident R359 on 7/17/23, at 11:38 a.m. revealed an oxygen concentrator in Resident R359's room with the nasal cannula on the floor, and no date on the oxygen tubing or the humidification bottle. Resident R359 stated that she sometimes needs to wear the oxygen at night as she uses a continuous positive airway pressure (CPAP - a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathed, used in the treatment of sleep apnea) machine at home. Review of the clinical record indicated that Resident R370 was admitted to the facility on [DATE]. Review of the clinical record indicated Resident R370 had diagnoses of pneumonia (lung inflammation caused by bacteria or viral infection), obstructive sleep apnea, and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Review of physician's orders dated 7/10/23, indicated to administer supplemental oxygen to maintain comfortable respirations as needed. Observation of Resident R370 on 7/17/23, at 11:31 a.m. revealed the resident was receiving oxygen at 2 liters per minute via a nasal cannula. The nasal cannula tubing and humidification bottle had no dates on them. Review of the clinical record indicated that Resident R372 was admitted to the facility on [DATE]. Review of the clinical record indicated Resident R372 had diagnoses of COPD, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and hypertension. Review of physician's orders dated 7/10/23, indicated to administer supplemental oxygen to maintain comfortable respirations as needed. Observation and interview of Resident R372 on 7/17/23, at 2:08 p.m. revealed and oxygen concentrator in Resident R372's room with no date on the nasal cannula tubing or the humidification bottle. Resident R372 stated that he wears oxygen at night. Interview on 7/17/23, at 2:10 p.m. with Agency RN Employee E4 confirmed the oxygen tubing and humidification bottles were not labeled with a date and initials for Residents R359, R370, and R372. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services 28 Pa. Code: 211.12(d)(3) Nursing services 395034 Page 12 of 14 395034 07/21/2023 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, observation, and staff interview, it was determined the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R59). Residents Affected - Few Findings include: Review of facility policy Skin Assessment - Clean/Dry Dressing change procedure dated 4/26/23, indicated wash and dry hands thoroughly, put on clean gloves, and clean bedside stand to establish a clean field. Place clean equipment on the barrier and arrange supplies so they can be easily reached. Use a waste basket away from clean field. Position resident and adjust clothing to provide access to affected area. Place a clean barrier on bed. Wash and dry hands thoroughly and put on clean gloves. Loosen tape and remove soiled dressing. Pull glove over dressing and discard into waste basket. Wash and dry hands thoroughly. Open dry, clean dressings by pulling corners of the exterior wrapping outward, touching only the exterior surface. Label tape or dressing with date, time, and initials. Place on clean field. Using clean technique, open other products. Wash and dry hands thoroughly. Put on clean gloves. Cleanse the wound with ordered cleanser. In using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated are. Use dry gauze to pat the wound dry. Wash and dry hands thoroughly and put on clean gloves. Apply the ordered dressing and secure with dated tape or bordered dressing per order. Discard disposable items including the barrier from the bed into the waste basket. Remove disposable gloves and discard into waste basket. Wash and dry hands thoroughly. Clean the bedside stand. Remove garbage from the waste basket. Wash and dry hands thoroughly. Review of the clinical recorded indicated Resident R59 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/10/23, indicated diagnoses of hypertension (high blood pressure in the arteries), adult failure to thrive (seen in older adults with multiple medical conditions resulting in a downward spiral of poor nutrition, wight loss, inactivity, depression, and decrease in functional abilities), and hip fracture. Review of a physician's order dated 7/9/23, indicated to cleanse buttock wound with mild soap and water, pat dry, crush Flagyl (a medication used to treat various infections) 500mg (milligrams) and apply to wound bed for odor control, then apply silver collagen (a type of dressing that is used to reduce and prevent bacterial formation within the wound dressing), and cover with a border dressing (a self-adhering, multilayer foam dressing) daily and as needed. During an observation of a dressing change on 7/19/23, at 10:28 a.m. Registered Nurse (RN) Employee E3 had already prepared the dressing field on Resident R59's bedside table prior to surveyor arrival on the right side of the bed. Observation of the bedside table included a Chux (an absorbent pad intended to catch fluids and allow for easy cleanup) open on the table surface with dressing supplies and a medicine cup containing a white paste. RN Employee E3 stated, I took a sanitary wipe and cleaned the top and edges of the table, then I let it dry and sat the Chux down on it and then I put the gauze and dressings on top. I mixed the Flagyl as a paste because it's easier to get it on the wound bed. RN Employee E3 preformed hand hygiene in Resident R59's bathroom. RN Employee E3 placed a red 395034 Page 13 of 14 395034 07/21/2023 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0880 biohazard bag on the foot of Resident R59's bed. Level of Harm - Minimal harm or potential for actual harm RN Employee E3 donned clean gloves and opened a package of Aquacel AG Ribbon (a high absorbent silver alginate dressing for moderately to heavily draining infected wounds) and placed it on the bedside table. RN Employee E3 stated, the hospice nurse recommended yesterday to start using this, I don't think it's ordered yet but I'm going to use it. Residents Affected - Few Observation of Resident R59's buttocks revealed no dressing present covering the wound. RN Employee E3 stated that the previous nurse did not indicate in their report that the dressing was missing and NA Employee E15 stated that she had not removed Resident R59's brief during the shift. RN Employee E3 sprayed wound cleanser on Resident R59's buttock wound and stated, I like this better than soap and water and then patted the wound dry with gauze and discarded the gauze in the biohazard bag. RN Employee E3 removed her gloves and opened a single-use hand sanitizer wipe packet and performed hand hygiene while stating, so I don't have to walk back into the bathroom. The sanitizer wipe was disposed of in the biohazard bag and RN Employee E3 donned new gloves and ripped the palm of the right glove during the donning process. RN Employee E3 opened a pack of cotton tip applicators and proceeded to mix the white paste in the medicine cup with the wooden end of the applicator. RN Employee E3 stated, the hospice nurse recommended to add water to the crushed Flagyl to make it a paste so it doesn't go everywhere and proceeded to apply the paste to Resident R59's buttock wound with gloved fingers. RN Employee E3 used scissors to cut a piece of the Aquacel AG Ribbon dressing and packed it into Resident R59's buttock wound with her gloved fingers. RN Employee E3 then placed a layer of silver collagen over the wound bed. RN Employee E3 applied skin prep (a liquid that forms a protective film or barrier when applied to skin) to the skin around the wound. RN Employee E3 then placed a border dressing over the buttocks wound. RN Employee E3 removed the Chux from under Resident R59 and removed her gloves and placed them in the biohazard bag. RN Employee E3 then rolled all of the supplies on the bedside table in the Chux and placed it in the biohazard bag. During an interview on 7/19/23, at 10:55 a.m. RN Employee E3 confirmed the above observations during the dressing change for Resident R59 and that the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R59). 28 Pa. code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code: 211.10 (d) Resident care policies. 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services. 395034 Page 14 of 14