Health inspection·April 13, 2023

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 facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident for five of eight residents (Resident R1, R2, R3, R4, and R5). Residents Affected - Some Findings include: Review of the facility policy Abuse Prohibition reviewed on 4/26/22, indicated the facility will implement an abuse prohibition program including investigation of possible incidents and allegations to ensure facility staff are doing all that is within their control to prevent abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown origin, and misappropriation of property. Injuries of unknown origin are defined as a source of injury that was not observed by any person or cannot be explained by the patient, and is suspicious due to the location, number of injuries, extent of the injuries. A review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression and high blood pressure. A review of the Minimum Data Set (MDS- periodic assessment of care needs) dated 2/24/23, indicated the diagnoses remain current. A review of the Brief Interview for Mental Status (BIMS- evaluation aimed at assessing aspects of cognition in elderly patients) score was 99, indicating severe cognitive impairment. A review of facility records indicated Resident R1 sustained an injury on 4/10/23, to his elbow. It was not known how the injury occurred. A review of the clinical record indicated Resident R2 was admitted to the facility on [DATE], with diagnoses that included stroke, slurred speech, seizures, and difficulty swallowing. A review of facility records indicated Resident R2 had an incident of unknown cause occur on 3/22/23, she was sent to the hospital. An investigation was not completed. A review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], with diagnoses that included Alzheimer ' s Disease (brain disorder that causes problems with memory, thinking and behavior), difficulty swallowing, and high blood pressure. A review of the MDS dated [DATE], indicated the diagnoses remain current. A review of the BIMS score was 99, indicating severe impairment. Page 1 of 4 395243 395243 04/13/2023 Laurel Ridge Center 75 Hickle Street Uniontown, PA 15401

F 0610 Level of Harm - Minimal harm or potential for actual harm A review of facility documents indicated Resident R3 had a choking incident on 3/10/23, and the Heimlich maneuver was performed. A review of the clinical record indicated Resident R4 was admitted to the facility on [DATE], with diagnoses that included depression, diabetes, and anxiety. Residents Affected - Some A review of the MDS dated [DATE], indicated the diagnoses remain current. A review of the BIMS score was 13, indicated no impairment. A review of the facility records indicated Resident R4 sustained a skin tear under her right breast skin fold on 2/12/23. Resident R4 stated she did not know how it happened. A review of the clinical record indicated Resident R5 was admitted to the facility on [DATE], with diagnoses that included Cerebral Palsy (group of disorders that affect movement, muscle tone, balance, and posture), seizures, and depression. A review of the MDS dated [DATE], indicated the diagnoses remain current. A review of the BIMS score was 99, indicating severe impairment. A review of the facility records indicated Resident R5 sustained an unwitnessed bruise to the right side of his face. During an interview on 4/13/23, at 3:24 p.m. the Director of Nursing confirmed that the incident's were not fully investigated, no cause, or conclusion were considered or eliminated for the incidents for Residents R1, R2, R3, R4, and R5. 28 Pa. Code: 201.149(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 395243 Page 2 of 4 395243 04/13/2023 Laurel Ridge Center 75 Hickle Street Uniontown, PA 15401

F 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on staff interviews it was determined that the facility failed to employ a full-time director of food service for one of one month (March 2023). Residents Affected - Many Findings include: During a kitchen tour on 4/14/23, at 11:15 a.m., Dietary [NAME] Employee E1 stated the kitchen has not had a manager for about three weeks. During an interview on 4/14/23, at 4:20 p.m. the Nursing Home Administrator confirmed that the facility has not had a Dietary Manager since 3/13/23, as required, the Registered Dietitian is here one day per week and the District Manager one day per week. 28 Pa. Code 201. 18(e)(1)(6)Management. 28 Pa. Code 211. 6(c) Dietary services. 395243 Page 3 of 4 395243 04/13/2023 Laurel Ridge Center 75 Hickle Street Uniontown, PA 15401

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on review of facility menu, observations, and staff interviews, it was determined that the facility failed to follow the menu for one of one lunch meal (lunch meal Thursday 4/13/23). Residents Affected - Some Findings include: A review of the menu indicated that the menu for lunch was as follows: Cream of Potato Soup Italian Sub Sandwich Snickerdoodle Cookie Creamy Coleslaw During an observation of lunch meal service in the main dining room on 4/13/23, at 12:20 p.m., it was revealed that all of the residents(18) had the following instead: Ham Sandwich (on Bread) French Fries Snickerdoodle Cookie Coleslaw Mixed Vegetables During an interview on 4/14/23, at 12:15 p.m. Dietary [NAME] Employee E1 confirmed that was a different menu. She stated The truck hasn't come in yet, I know what the resident's like. During an interview on 4/14/23, at 4:45 p.m. the Nursing Home Administrator confirmed that the facility failed to serve what was on the menu and failed to reflect menu changes. 28 Pa. Code: 211.6(a)(b) Dietary services. 395243 Page 4 of 4