Health inspection·November 9, 2023

F 0575 Level of Harm - Minimal harm or potential for actual harm Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observations and staff interviews it was determined that the facility failed to have required postings for the Medicaid fraud control unit for the facility. Residents Affected - Few Findings include: Observations on the nursing care unit bulletin board failed to include information for the Medicaid fraud control unit throughout the survey from 11/6/23 through 11/9/23. During observations on 11/9/23, at 12:29 p.m. with Nursing Home Administrator confirmed that the facility failed to post information about the Medicaid fraud control unit. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18e Management. Page 1 of 5 395603 395603 11/09/2023 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

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 records, facility documents, and staff interview, it was determined that the facility failed to fully investigate an incident for one of three residents reviewed (Resident R157). Residents Affected - Few Findings include: A review of the facility's Abuse, Neglect, and Exploitation dated 7/1/23, indicated It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility staff must immediately report all such allegations to the Administrator/abuse Coordinator. Review of the clinical record indicated Resident R157 was admitted to the facility on [DATE]. Resident R157 admit sheet indicated they were admitted , with diagnosis of Fibromyalgia (chronic disorder characterized by widespread pain and other symptoms such as fatigue and muscle stiffness), Type 2 Diabetes (problem in the way the body regulates and uses sugar as fuel), and muscle weakness (lack of muscle strength) . Review of the MDS (minimum data set a periodic assessment of periodic needs) dated 10/18/23, indicated the diagnosis remained the same. Review of facility submitted report indicated: on 11/6/23, Resident R157, asked Employee E2 LPN (Licensed Practical Nurse) to push him/her to the vending machines because they were tired of propelling their chair. Resident R157 put their feet down onto the floor while being pushed and stopped the wheelchair. Later that evening Resident R157 complained of pain in the right leg with swelling noted. Review of the incident report (completed by Employee E2 LPN) #1519 - Other dated 11/6/23, resident requested to be pushed to the vending machine in wheel chair. Resident stated she got tired and need to put her legs down. Further review of the investigation had a witness statement by Employee E2 LPN, and a statement from Resident R157 documented by the DON (Director of Nursing). No other witness statements were completed in the investigation. During an interview on 11/8/23, with the NHA (Nursing Home Administrator) and the DON, they confirmed that other witness statements were not completed. Review of the investigation indicated that only Employee E2 LPN saw Resident R157 after the incident, and an assessment was not completed by a RN (Registered Nurse) until the morning. During interviews with two of the RN supervisors who worked on 11/6/23, per the deployment sheets both indicated that they did not assess Resident R157 the day of the incident. Review of the investigation failed to identify that Resident R157 was not assessed by an RN or other staff then Employee E2 LPN. No information was included if other staff had any information on the incident or the follow up care for Resident R157. 395603 Page 2 of 5 395603 11/09/2023 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0610 During an interview on 11/8/23, at 3:50 p.m. with NHA and DON confirmed that the facility failed to fully investigate an incident for Resident R157. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.14 (a) Responsibility of licensee. Residents Affected - Few 28 Pa. Code: 201.14 (c)(e) Responsibility of licensee. 28 Pa. Code: 201.18 (e)(1) Management. 395603 Page 3 of 5 395603 11/09/2023 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to properly store medical supplies and biologicals in one of two medication rooms (East Medication Room). Review of the facility policy Storage and Expiration of Medications, Biologicals, Syringes, and Needles dated 7/1/23, indicated the facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. The facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medications are biologicals are stored. Findings include: During an observation of the East Medication Room on 11/7/23, at 10:01 a.m. the following was observed in the medication refrigerator: - Three single serve packages of butter, stored in a Tylenol box. During an observation of the East Medication Room on 11/7/23, at 10:04 a.m. the following was observed under the sink: - A silver tray - A can of soup - A sharps storage container During an interview on 11/7/23, at 10:10 a.m. Registered Nurse Employee E3 and Registered Nurse Employee E1 confirmed the above observations. During an interview on 11/7/23, at 10:10 a.m. the Director of Nursing confirmed the facility failed to properly store medical supplies and biologicals in one of two medication rooms. 28.Pa.Code: 211.10 (c) Resident care policies. 28.Pa.Code: 211.12 (d)(1)(2)(5) Nursing services. 395603 Page 4 of 5 395603 11/09/2023 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for one of two medication rooms (East Medication Room). Residents Affected - Some Findings include: Review of the facility policy Storage and Expiration of Medications, Biologicals, Syringes, and Needles dated 7/1/23, indicated the facility should ensure that resident medication and biological storage areas are locked and do not contain non-medical biological items. Review of the facility policy Infection Prevention and Control Program Policy dated 7/1/23, indicated the facility is to maintain a facility-wide program designed to prevent, identify, control and reduce the risk of acquiring and transmitting infection among employees, volunteers, and contracted health care workers. During an observation of the East Medication Room on 11/7/23, at 10:06 a.m. personal staff jackets were hanging on a coat rack that had been adhered to the wall on the right side of wall immediately upon entrance of medication room. During an observation of the East Medication Room on 11/7/23, at 10:06 a.m. one reusable fabric lunch box was present on the sink counter of the medication room. During an interview on 11/7/23, at 10:10 a.m. Registered Nurse Employee E3 and Registered Nurse Employee E1 confirmed the above observations and that the jackets and fabric lunch box belonged to staff members working on the unit. During an interview on 11/7/23, at 10:10 a.m. the Director of Nursing confirmed the facility failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for one of two medication rooms. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services. 395603 Page 5 of 5