Health inspection·October 25, 2024

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 facility policy, review of clinical documentation, staff interviews and review of facility reported events, it was determined the facility failed to ensure that physician orders were properly obtained, failed to identify pain or spasms to warrant medication, and failed to notify family for one of five residents (Resident R1). Residents Affected - Few Findings: Review of facility policy Transcription of Orders dated 9/30/24, indicated orders from an authorized licensed independent practitioner are accepted by a Registered Nurse (RN) or Licensed Practical Nurse (LPN). A RN or LPN must review and verify accuracy and sign off orders. Review of facility policy Resident Rights under Federal Law dated 9/30/24, indicated that residents have the fundamental right to considerate care that safeguards their personal dignity along with respecting cultural, social, and spiritual values. Centers do not discriminate on the basis of race, color, religion, national origin, gender, disability or veteran status. The purpose is to treat each resident with respect and dignity and care for each resident in a manner an in an environment that promotes maintenance or enhancement of his or her self-esteem and self-worth. Review of facility policy Licensure and Certification of Personnel dated 9/30/24, indicated those employees whose jobs require specific licenses or certifications to maintain their credentials in compliance with state and federal laws at all times. Review of facility LPN Job Description indicated that nursing personnel to deliver nursing care and within scope of practice (a range of activities that a licensed health professional is permitted to perform within their profession) coordinates care delivery, which will ensure that patients needs are met in accordance with professional standards of practice through physician orders, center policy and procedures, and federal, state, and local guidelines. (LPN's cannot order medications under their scope of practice). Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/2/24, indicated diagnoses of aphasia (a language disorder that affects a person ' s ability to speak), depression, and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). Review of employee file on 10/23/24, at 9:30 a.m. indicated that LPN Employee E5 was hired on (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 6 Event ID: 395251 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 395251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Park Post Acute 5609 Fifth Avenue Pittsburgh, PA 15232 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)