Health inspection·June 26, 2024

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for two of ten residents (Residents R1 and R2). Residents Affected - Few Findings include: Review of the CFR §483.10(c)(7) indicated the resident has the right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate. Interview with the Nursing Home Administrator on 6/26/24, at 1:00 p.m. indicated the facility did not have a policy for self-administration of medications. Review of the admission 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 5/2/24, indicated the diagnoses of high blood pressure, anxiety (intense, excessive, and persistent worry and fear about everyday situations), and depression. Review of Resident R1's current physician orders on 6/26/24, at 9:04 a.m. failed to include an order for resident to self-administer medications. Review of Resident assessments on 6/26/24, at 9:04 a.m. failed to include that an interdisciplinary team had determined that the practice was clinically appropriate. Review of Resident R1' current care plan on 6/26/24, at 9:04 a.m. failed to include a problem, goal, or intervention for resident to self-administer medication. Observation on 6/26/24, at 9:10 a.m. Resident R1 was sitting up in bed finishing the breakfast meal with a medication cup full of 14 different pills on the bedside stand. Interview with Resident R1, on 6/26/24, at 9:10 a.m. indicated she doesn't take them until after she finishes her breakfast to prevent her stomach from becoming upset. Interview with Licensed Practical Nurse (LPN) Employee E1 on 6/26/24, at 9:12 a.m. confirmed the medications were left at bedside and resident was not assessed for self-administration. Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Page 1 of 7 395603 395603 06/26/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R2's MDS dated [DATE], indicated the diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), and coronary artery disease (narrow arteries decreasing blood flow to heart). Review of Resident R2's current physician orders on 6/26/24, at 9:20 a.m. failed to include an order for resident to self-administer medications. Review of Resident R2's current physician orders on 6/26/24, at 9:20 a.m. failed to include an order for resident to self-administer medications. Review of Resident assessments on 6/26/24, at 9:20 a.m. failed to include that an interdisciplinary team had determined that the practice was clinically appropriate. Review of Resident R2' current care plan on 6/26/24, at 9:20 a.m. failed to include a problem, goal, or intervention for resident to self-administer medication. Observation on 6/26/24, at 9:22 a.m. Resident R2 was sitting in the wheelchair with a medication cup full of three different pills on the bedside stand. Interview with Resident R2, on 6/26/24, at 9:22 a.m. indicated she was getting ready to take them. Interview on 6/26/24, at 9:24 a.m. Registered Nurse (RN) Employee E2 confirmed the medications were left at bedside and resident was not assessed for self-administration. Interview on 6/26/24, at 9:30 a.m. RN Supervisor Employee E3 confirmed the above medications at bedside and that the facility failed to determine the ability to self-administer medications for two of five residents reviewed (Residents R1 and R2). 28.Pa.Code: 211.10 (c) Resident care policies. 28.Pa.Code: 211.12 (d)(1)(2)(5) Nursing services. 395603 Page 2 of 7 395603 06/26/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to update a care plan for one of 10 residents (Resident R3) to accurately reflect the current status of the resident. Findings include: Review of the facility policy Comprehensive Care Planning Policy dated 7/1/23, indicated an interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on as needed basis. Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 4/9/24, indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), weakness, and dermatitis (skin inflammation). Section J1300 indicated tobacco use - Yes. Review of facility provided list of Smoking Residents updated 6/26/24, indicated Resident R3 was an active smoking resident. Review of Resident R3's Smoking Risk evaluation dated 6/4/24, indicated the resident currently smokes and his intentions related to smoking indicated the resident intends to smoke. Review of the current care plan for Resident R3 on 6/26/24, at 8:35 a.m. failed to include a problem, goal, or interventions for smoking and current use of tobacco. Interview on 6/26/24, at 2:51 p.m. the Nursing Home Administrator confirmed the facility failed to update a care plan for one of 10 residents (Resident R3) to accurately reflect the current status of the resident. 28 Pa. Code 211.12 (d)(1)(2)(3) Nursing services 28 Pa. Code: 201.14(a) Responsibility of licensee. 395603 Page 3 of 7 395603 06/26/2024 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 record, observation, and staff interview it was determined that the facility failed to have timely smoking assessments for two of ten residents (Residents R4, and R5). Residents Affected - Few Findings include: Review of the facility policy Resident Smoking Policy dated 7/1/23, indicated residents are asked if they have a desire/intent to smoke while in the facility. Anyone answering yes is further assessed for smoking safety awareness and the need for reasonable physical or safety accommodations. The assessment is completed thereafter on readmission, quarterly and with any significant change in the resident's condition. Review of the admission record indicated Resident R4 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 4/4/24, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), heart failure (heart doesn't pump blood as well as it should), and asthma (airways become inflamed, narrow, and swell, producing extra mucous making it hard to breathe). Section J1300 indicated resident currently uses tobacco. Review of Resident R4's Smoking Risk Assessment on 6/26/24, at 10:00 a.m. indicated the last assessment completed was on 3/1/24. Review of the admission record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's MDS dated [DATE], indicated the diagnoses of coronary artery disease (narrow arteries decreasing blood flow to heart), high blood pressure, and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs). Review of Resident R4's Smoking Risk Assessment on 6/26/24, at 10:05 a.m. indicated the last assessment completed was on 2/1/24. Interview on 6/26/24, at 10:49 a.m. the Nursing Home Administrator confirmed the facility failed to have timely smoking assessments for two of ten residents as required (Residents R4, and R5). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28.Pa.Code: 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3) Nursing services 395603 Page 4 of 7 395603 06/26/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, observations and staff interviews it was determined that the facility failed to ensure that residents received complete neurological assessments after a fall and a complete set of vital signs every shift for 72 hours for one of three residents (Closed Record Resident CR1) and failed to make certain each resident received adequate supervision that resulted in two elopements (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of three residents (CR1). Findings include: Review of the facility's Incident and accident policy dated 7/1/23, indicated that an accident is any occurrence which is not consistent with routine care. The incident/accident will be recorded in the health record. Documentation regarding post-incident response and symptoms, and a complete set of vital signs will be completed every shift for 72 hours post-occurrence. Review of the facility's Neurological Checks dated 7/1/23, indicated upon initiation of the schedule neurological checks will be completed, every 15 minutes x four; every 30 minutes x four, every one-hour x four, every four hours x four, and every eight hours x seven. Review of the facility's Elopement/Unauthorized Absence policy dated 7/1/23, indicated the facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. Review of the admission record indicated Resident CR1 was admitted to the facility on [DATE], with the following diagnoses of stroke (damage to the brain from an interruption of blood supply), altered mental status (a change in mental function), and adult failure to thrive (a syndrome of global decline in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment). Review of Resident CR1's admission Observation dated 6/7/24, indicated the resident has a diagnosis of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). Review of Resident CR1's Brief Interview for Mental Status (BIMS- is a screening test that aides in detecting cognitive impairment) dated 6/10/24, indicated a result of seven - severe impairment. Review of baseline care plan dated 6/7/24, at 5:00 p.m. indicated safety - resident will be monitored to minimize risk of wandering and/or elopement: - YES. Falls - minimize potential risk factors related to falls/injury - YES. Review of CR1's progress notes indicated on 6/7/24, at 7:17 p.m. resident was standing in the middle of the room naked and had a BM (bowel movement) in the middle of the room on the floor. Resident was very confused. Easy to redirect. Review of CR1's progress notes indicated on 6/8/24, at 12:45 p.m. Resident observed sitting on the floor in the bathroom, covered in feces. Resident had ambulated to the bathroom without calling for 395603 Page 5 of 7 395603 06/26/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assistance. Call light was not on. Resident last seen when lunch tray was collected around 1230. Neuros, vitals, and ROM WNL. Resident did not have footwear on at the time of the fall. Resident assisted to wheelchair and given a shower. Educated resident to call for assistance when needing to use the restroom and encouraged to wear non-skid socks/footwear when ambulating. Review of CR1's Neurological Checks dated 6/8/24, at 1:39 p.m. indicated four of the seven required every eight-hour checks were not completed. (Checks #3, #4, #5, and #6). Further review of CR1's Neurological Checks dated 6/8/24, Vital signs section dated 6/8/24, through 6/10/24, failed to include a complete set of vital signs on four of nine required shifts post occurrence. (6/9/24, on daylight, 6/10/24 on daylight and evenings, and 6/11/24, on nights). Review of Resident CR1's Elopement evaluation on 6/7/24, indicated: -No- clinically not at risk for elopement. -Does the resident have any of the following risk factors? Resident is cognitively impaired, has poor decision-making skills, and pertinent diagnoses of Dementia was not checked off. -Does the resident exhibit any additional elopement risk criteria? Current acute exacerbation of medical conditions such as sudden changes in cognition/confusion was not checked off. -Elopement care plan not initiated - Resident not elopement risk. Review of Resident CR1's progress note dated 6/12/24, at 11:45 p.m. indicated the physical therapy door alarm sounded. Nurse found resident in the parking lot trying to open car doors. Resident stated he was going to the store. Review of Resident CR1's care plan dated 6/13/24, indicated divert resident's exit seeking behavior by offering an activity. Increased purposeful rounding. Resident is an active participant in the happy feet initiative (a binder with photos of exit seeking residents). Review of Resident CR1's progress note dated at 6/17/24, at 6:46 a.m. one on one maintained. Resident very restless up and down all night long urinating on floor. Review of Resident CR1's progress note dated 6/20/24, at 3:39 p.m. indicated Resident exited the front doors by following a family when exiting on Saturday afternoon. Interview on 6/26/24, at 2:51 p.m. the Nursing Home Administrator confirmed the facility failed to ensure that residents received complete neurological assessments after a fall and a complete set of vital signs every shift for 72 hours for one of three residents (Resident CR1) and failed to make certain each resident received adequate supervision that resulted in two elopements (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of three residents (CR1). 28.Pa.Code: 211.10 (c) Resident care policies. 28 Pa. Code: 201.14(a) Responsibility of licensee. 395603 Page 6 of 7 395603 06/26/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0689 28 Pa. Code 211.12 (d)(1)(2)(3) Nursing services Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. Residents Affected - Few 395603 Page 7 of 7