Inspection·July 25, 2024

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation for two of seven residents (Resident R1, R7). Findings include: Review of Resident R1 was admitted [DATE] with diagnoses that include dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anemia and COPD (COPD, or chronic obstructive pulmonary disease, is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R1 admission MDS assessment ( Minimum Data Set assessment MDS- a periodic assessment of resident care needs) dated 6/25/24 indicated the resident was assessed as having a BIMS score of 10, which indicates moderately impaired. Review of Resident R1's admission packet dated 6/20/24 indicated a signature from R1. Review of Resident R6 was admitted [DATE] with diagnoses that include catatonic disorder (group of symptoms that usually involve a lack of movement and communication, and also can include agitation, confusion) and schizophrenia. Review of Resident R6's admission packet dated 3/12/24 indicated a no signature from resident or POA (power of Attorney). During an interview with Nursing Home Administrator on 7/26/24 at 11:30 a.m. confirmed Resident R1 was cognitivly impaired and should not have signed facility paperwork and R6 never had his admission paper work completed as required. (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 4 Event ID: 395423 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 395423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Champion City Nursing and Rehabilitation Center 6655 Frankstown Avenue Pittsburgh, PA 15206 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)