Health inspection·February 21, 2024

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 record review, investigation documentation, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect and/or abuse for one of three sampled residents (Resident R1). Residents Affected - Few Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 8/3/23, indicated it is the facility policy to investigate all suspicions and incidents of neglect and injuries of unknown source. It was indicated written statements must be obtained from the resident, if possible, the accused, and each witness. It was indicated if there are no direct witnesses, then the interviews may be expanded. The facility policy Fall Prevention and Management Policy last reviewed 7/1/23, indicated all falls will be reviewed and investigated. Review of the clinical record indicated that Resident R1's was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/26/23, indicated diagnoses fall, dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), generalized weakness. Review of Resident R1's care plan dated 1/29/24, indicated the resident was at risk of falling. Review of Resident R1's Event Report dated 2/5/24, entered by Registered Nurse, Employee E2 indicated Resident R1 had a fall with minor injury. It was indicated the resident had a bump on her head. Review of the facility's Post Fall Huddle (PFH) Form that was not dated or signed, indicated Resident R1 had a fall on 2/5/24, at 12:45 a.m. It was indicated Registered Nurse (RN), Employee E1, RN, Employee E2, and Nurse Aide (NA), Employee E3 assisted the resident after the fall. Review of Resident R1's investigation report failed to include NA, Employee E3's witness statement and a statement from the resident. During an interview on 2/21/24, at 12:59 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the facility failed to conduct a thorough investigation to rule out neglect and/or abuse as required for one of three residents (Resident R1). Page 1 of 6 395603 395603 02/21/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0610 28 Pa. Code: 201.14 (a)(c)(e) Responsibility of licensee. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.18 (e)(1) Management. Residents Affected - Few 395603 Page 2 of 6 395603 02/21/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan that included interventions needed to provide effective and person-centered care for one of three residents (Resident R1). Findings include: The facility policy Interim/Baseline Care Planning Policy last reviewed 7/1/23, indicated a baseline care plan to meet the resident's immediate needs shall be developed within forty-eight hours of the resident's admission. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE], with the diagnoses of diagnoses fall, dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), and COVID (a contagious respiratory virus). Review of Resident R1's John Hopkins Fall Risk dated 12/19/23, indicated the resident was a high fall risk. Review of Resident R1's clinical record from 12/19/23, through 12/21/23, failed to include a baseline care plan that was implemented. The to provide effective and person-centered care. During an interview on 2/21/24, at 12:50 p.m. the Director of Nursing confirmed that the facility failed to implement a baseline care plan for one of three residents (Resident R1). 28 Pa. Code: 211.11 (a)(c)(d) Resident care plan. 28 Pa. Code: 211.12(d)(1)(5) Nursing services 395603 Page 3 of 6 395603 02/21/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

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, clinical records, and staff interviews it was determined that the facility failed to provide needed care and services to prevent falls, provide an ongoing assessment post fall, and follow physician orders for one of three residents (Resident R1). Residents Affected - Few Findings include: The facility policy Fall Prevention and Management Policy last reviewed 7/1/23, indicated residents will be assessed for fall risks on admission, quarterly, after any fall, and as needed. It was indicated if risks are identified, preventive measures will be put in place and care planned. All falls will be reviewed and investigated. The facility policy Interim/Baseline Care Planning Policy last reviewed 7/1/23, indicated a baseline care plan to meet the resident's immediate needs shall be developed within forty-eight hours of the resident's admission. Review of the clinical record indicated that Resident R1's was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/26/23, indicated diagnoses of history of falling, dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), and generalized weakness. Review of Resident R1's physician order dated 12/19/23, indicated administer 2.5 mg Eliquis (blood thinner) twice a day. Review of Resident R1's John Hopkins Fall Risk assessment dated [DATE], indicated the resident was a high fall risk. Review of Resident R1's clinical record from 12/19/23, through 1/28/24, failed to include a focus and interventions to prevent falls from occurring. Review of Resident R1's care plan dated 1/25/24, indicated the resident is prescribed anticoagulant therapy (medications that prevent the blood from clotting as quickly which increases the risk of bleeding), and interventions indicated to protect the resident from injury and trauma. No further interventions to protect the resident from injuries or trauma was documented. Review of the facility's fall report dated 11/21/23, through 2/21/23, indicated Resident R1 had a fall on 1/27/24, 2/2/24, and 2/5/24. Review of Resident R1's progress note dated 1/27/24, entered at 4:15 p.m. by Licensed Practical Nurse (LPN), Employee E4 indicated the resident was found sitting on the floor next to her bed, LPN called the RN to assess, no injuries noted. The family and physician were notified. Review of Resident R1's John Hopkins Fall Risk assessment dated [DATE], indicated the resident was a high fall risk. 395603 Page 4 of 6 395603 02/21/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R1's care plan dated 1/29/24, indicated the resident was at risk of falling. Interventions included to wear non-skid footwear, give resident verbal reminders not to ambulate or transfer without assistance, and keep call light and personal items frequently used in reach at all times. No further interventions were implemented to prevent the resident from falling. Review of Resident R1's progress note dated 2/2/24, entered at 5:24 p.m. by RN, Employee E5 indicated upon being notified by a visitor, staff found resident sitting on the floor in front of a chair in the day lounge. She was facing her wheelchair that was unlocked. Resident was unaware of what she was attempting to do. No injuries were observed. The resident's daughter and physician were notified. It was indicated a physical assessment was completed and neurological checks were initiated. Review of Resident R1's Neurological Checks form dated 2/2/24, indicated a set of vital signs must be obtained with each neurological check (assess an individual ' s neurological functions, motor and sensory response, and level of consciousness) until the observation is completed. It was indicated to complete neurological checks every 15 minutes for one hour, then every 30 minutes for two hours, then hourly for four hours, then every four hours for 16 hours, then every eight hours for 56 hours. The facility staff failed to obtain vital signs and complete a neurological check after the first assessment. During an interview on 2/21/24, at 9:42 a.m. LPN, Employee E6 indicated if a resident has an unwitnessed fall, neurological checks must be completed every 15 minutes, then half hour, then hourly, then every eight hours for 72 hours. During an interview on 2/21/24, at 11:25 a.m. LPN, Employee E6 confirmed the facility failed to obtain Resident R1's vital signs and complete a neurological check after the first assessment on 2/2/24. Review of Resident R1's John Hopkins Fall Risk assessment dated [DATE], indicated the resident was a moderate fall risk. The assessment indicated the resident did not have a fall within the previous six months and was on zero high risks medications. The facility failed to accurately complete Resident R1's fall risk assessment. Review of Resident R1's Event Report dated 2/5/24, entered by Registered Nurse, Employee E2 indicated Resident R1 had a fall with minor injury. It was indicated the resident had a bump on her head. Review of the facility's Post Fall Huddle (PFH) Form undated and unsigned, indicated Resident R1 had a fall on 2/5/24, at 12:45 a.m. Review of the facility's Focused Head to Toe Observation dated 2/5/24, entered at 1:38 a.m. indicated the assessment was completed after the resident fell. It was indicated the resident did not have any alteration in skin such as bruises. Review of Resident R1's progress notes on 2/5/24, failed to include documentation regarding the resident's fall. Review of Resident R1's physician order dated 2/5/24, indicated to apply ice to the affected area of injury post fall for 20 minutes, four times a day, for three days. It indicated to monitor for significant injury, and notify the physician if severe swelling, bruising, or pain is present. 395603 Page 5 of 6 395603 02/21/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R1's weekly skin note dated 2/6/24, indicated the resident had an existing skin issue. It was documented the resident had left side head and face contusion. No further description was documented. Review of Resident R1's clinical record failed to indicate a physician was notified of the resident's bruising to her left side head and face as ordered. Review of Resident R1's late entry progress note entered by Nurse Practitioner, Employee E7 on 2/12/24, dated 2/9/24, indicated the resident was seen for a fall review and follow up. It stated the resident had a large hematoma (a solid swelling of clotted blood within the tissues) on the left side of her forehead that was tender to touch, and left periorbital (around the eye) ecchymosis (occurs when blood leaks from a broken capillary into surrounding tissue under the skin) and bruising. During an interview on 2/21/24, at 12:59 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the facility provide needed care and services to prevent falls, provide an ongoing assessment post fall, and follow physician orders for one of three residents (Resident R1). 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 395603 Page 6 of 6