Health inspection·November 13, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on review of facility policy, resident grievances for prior 60 days and resident and staff interviews, it was determined that the facility failed to effectively resolve and provide responses to residents and/or their responsible parties in a timely manner in relation to concerns documented via Grievance procedure and complete the reports in their entirety for four of nine grievances. Findings include: The facility policy entitled Grievance Policy dated 3/15/23, indicated that the facility grievance process will address resident concerns and seek to resolve them in a prompt and fair manner. The facility will complete written grievance resolutions/decisions to the resident involved. The Grievance Officer will complete a written response to the resident or resident representative which includes date of grievance, summary of grievance, investigation steps, findings, and resolution outcome and actions taken and date decision was issued. Review of the facility's Grievance/Complaint Logs for October and November 2023 indicated there were a total of nine grievances as of 11/13/23. Further review of the grievance logs indicated the following grievances that had not been responded to in a timely manner. Date Parties Informed of Findings Response Letter column of the log was blank for the following responses: -10/2/23 Resident R1's daughter filed a Grievance via email in relation to chronically experiencing a lack of care regarding Resident R1's toileting. This was requested in May 2023 but we have received little to no response or cooperation and requested a meeting with the Director of Nursing and Social Services Director. -10/23/23 Resident R2's daughter reported resident has requested to get up between 5:00-6:00 a.m. every morning. Resident will ask to go to the bathroom but waits a few hours until she is assisted out of bed and bed is saturated at that point. -10/23/23 Resident R3's daughter reported resident is not being toileted, restorative programs are not consistently being completed, resident moved from one unit to another due to Covid symptoms causing increased confusion, and feels that there needs to be more staff for the Dementia (memory impaired) Residents. (The Date Parties Informed of Findings Response Letter column indicated it was completed on 10/12/23. The grievance wasn't created until 10/23/23). -10/24/23 Resident R4's family reported concern with lack of staff. Feels more staff is needed for Page 1 of 2 395391 395391 11/13/2023 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0585 Level of Harm - Minimal harm or potential for actual harm the Dementia population. Feel positioning devices would not be needed if staff would recline the resident when he falls asleep in the chair. They've witnessed altercations between residents in the dining area between residents and residents standing from wheelchairs and walking about, and when they visit, nobody checks on the resident. Resident R4 has called family and indicated there is no staff around in the evening at 8:00 p.m. Residents Affected - Few Interview with the Nursing Home Administrator on 11/13/23, at 2:45 p.m. indicated what the facility provided the Survey Agency (SA) was not the entire four page grievance. A second review of the four page grievances provided by the Nursing Home Administrator indicated the following: Resident R1, Resident R2, Resident R3, and Resident R4 all had incomplete reports. Investigation completed by and the Grievance officer signatures failed to be present for Resident R1, R2, R3, and R4). Nursing Home Administrator signature failed to be present for Resident R3's report. Interview with the Nursing Home Administrator on 11/13/23, at 3:00 p.m. confirmed the facility failed to effectively resolve and provide responses to residents and/or their responsible parties in a timely manner in relation to concerns documented via Grievance procedure and complete the reports in their entirety for four of nine grievances. 28 Pa. Code 201.29(a) Resident rights. 395391 Page 2 of 2