Inspection visit

Health inspectionOctober 25, 2024

CARING HEIGHTS COMMUNITY CARE & REHAB CTRCMS #39560325 citations on this visit

25 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 25 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, and interviews with staff, it was determined that the facility failed to promote and protect a resident's dignity for one out of three residents reviewed (Resident R38). Findings include: Review of Resident R38's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses of transient cerebral ischemic attack (a temporary blockage of blood flow to the brain, usually caused by a blood clot.), muscle weakness, and cerebrovascular disease (condition that affect blood flow to your brain). Review of Resident R38's physician order dated 11/11/23, indicated a regular puree diet order with nectar thick liquid. Review of Resident R38's Minimum Data Set (MDS - periodic assessment of care needs) dated 9/7/24, indicated the diagnoses were current. During an observation on 10/21/24, at 10:01 a.m. a sign was observed posted on Resident R38's head board that stated Nectar Thick. During an observation and interview on 10/22/24, at 11:57 a.m. Registered Nurse, Employee E7 confirmed the facility failed to promote and protect a residents' dignity for one out of three residents (Residents R38). 28 Pa Code:201.29(j) Resident rights. 28 Pa Code: 211.11(d)(1)(5) Nursing services. Page 1 of 42 395603 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Based on review of resident personal fund accounting, clinical record review and resident and staff interview, it was determined that the facility failed to provide a resident funds quarterly statement for five of eight residents reviewed for personal funds concerns (Resident R2, R30, R67, R99 and R94). Findings include: During resident group indicated they did not know how much money they had and do not receive financial statements. Interview with Resident R2 on 10/22/24, at 11:30 a.m., revealed that she did not receive any financial statements pertaining to her personal fund account. Resident R2 denied that she had any family or individuals who assisted her to manage her finances. Interview with Business Office Manager E11 on 10/23/24 at 1:00 p.m. revealed that she knows those statements are an issue. Interview with the Nursing Home Administrator (NHA) on 10/24/24 at 11:30 a.m. revealed that the statements come from their corporate office in Ohio and she could not provide proof of who received them and what time frame. NHA confirmed there is no evidence that the resident's received statements of their personal fund account at least quarterly. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(3) Nursing services 395603 Page 2 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify a physician for a change in condition for one of five residents (Resident R14). Findings include: Review of the clinical record indicated that Resident R14 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnosis that included Friedreich ataxia (a rare genetic condition that causes progressive nervous system damage and movement issues), heart failure (condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), and atrial fibrillation (irregular and often faster heartbeat). An MDS (Minimum Data Set- periodic assessment of care needs) dated 7/12/24, indicated the diagnoses remain current. Review of Resident R14's care plan dated 4/16/24, indicated to observe resident for non-verbal signs of distress. Review of Resident R14's care plan dated 7/9/24, indicated the resident is at risk for pain related to the diagnosis of Friedreich ataxia and to notify the physician as needed with any changes. Review of Resident R1 progress note dated 9/14/24, at 11:23 p.m. entered by Registered Nurse (RN), Employee E20, stated checked resident's vitals because he was having pain and stating that he was not feeling well at 6:00 p.m. The resident's heart rate was 130. At 11:15 p.m. he was complaining of having trouble breathing. He did not want to sit up even though I told him that would help his breathing. I checked his vitals and his heart rate was 116. I asked him if he was anxious about anything and he said no. He asked for Tylenol to help his back and that was given. There was no documentation that the physician was notified. Review of Resident R1 progress note dated 9/15/24, at 3:00 a.m. entered by RN, Employee E21, stated the report given from the last shift nurse is that the resident is not feeling well, he was short of breath and restless. The resident was complaining the same and vital signs were obtained. The resident's heart rate was 139. The RN was notified, assessed the resident and the resident's heart beat was 135. The RN told the nurse to keep monitoring the resident. At 3:00 a.m. the resident asked for Tylenol and two, 325 mg of Tylenol was administered. There was no documentation that the physician was notified. Review of Resident R14's progress note dated 9/15/24, at 10:17 a.m. Licensed Practical Nurse, Employee E22, stated the resident was yelling out for help, stated he was in pain and felt like his heart rate was high. Repositioned resident in bed helped a little with pain, checked his vitals around 8:00 a.m. and his blood pressure was 62/42, heart rate was 87. Gave the resident his morning medications and checked back in 30 minutes and his blood pressure was 112/82, heart rate 142. It was indicated supervisor is sending resident out to hospital. Review of Resident R14's hospital discharge summary it was indicated the resident was admitted to the hospital from [DATE], through 9/19/24, with discharge diagnoses of atrial fibrillation, atrial flutter, high blood pressure, and non-ST elevation myocardial infarction (NSTEMI- a type of heart attack that usually happens when your heart ' s need for oxygen can't be met.) 395603 Page 3 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/22/24, at 9:15 a.m. RN, Employee E3 indicated if a resident has a change in condition, the RN supervisor must be made aware and then a call is placed to the physician. It was indicated it is documented in the resident's clinical record when a physician is notified. During an interview on 10/23/23 at 12:53 p.m., the Director of Nursing and Nursing Home Administrator confirmed the facility failed to timely notify a physician for a change in condition for one of five residents (Resident R14). 28 Pa. Code: 201.29(a)(b)(c)(d)(j)(m) Resident rights. 28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 28. Pa. Code: 211.10(a)(c)(d) Resident care policies. 395603 Page 4 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the Notice of Medicare Non-Coverage (NOMNC) form for one of three residents (Resident R105) and failed to ensure NOMNC notices were provided timely for one of three residents (Resident R321). Residents Affected - Few Findings include: 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 R105's admission record indicated the resident was admitted to the facility 9/28/24. Review of Resident R105's demographic information available in the electronic medical record indicated that Resident R105's spouse was the emergency and primary financial contact. Review of Resident R105's Minimum Data Set (MDS - periodic assessment of care needs) dated 10/2/24, included diagnoses of cancer, anxiety, and encephalopathy (a disease that affects brain structure or function). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R105's score to be 3, severe impairment. Review of the NOMNC form dated 10/10/24, revealed that it was signed by Resident R105. Review of Resident R321's admission record indicated the resident was admitted to the facility 9/28/24. Review of Resident R321's Minimum Data Set (MDS - periodic assessment of care needs) dated 6/18/24, included diagnoses of high blood pressure, alcohol abuse, and sciatica (a pain that travels along the sciatic nerve from the buttock to the leg). Review of the NOMNC form indicated services will end 6/20/24. Resident R321 signed the NOMNC on 6/21/24, the facility failed to issue the NOMNC timely. During an interview on 10/25/24, at 9:34 a.m., the Director of Nursing confirmed the facility failed to ensure the NOMNC is explained to the resident and his or her representative in a form and manner that he or she understands for one of three residents (Resident R105), and failed to ensure NOMNC notices were provided timely for one of three residents (Resident R321). 395603 Page 5 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0582 28 Pa. Code 201.24 (b) admission Policy. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(2) Management. Residents Affected - Few 28 Pa. Code 201.29(a) Resident Rights. 395603 Page 6 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for five of twelve residents (Residents R21, R59, R68, R84, R97). Findings include: Review of Title 42 Code of Federal Regulations §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. A facility tour with Maintenance Director Employee E9 on 10/25/24, at 10:00 a.m. revealed five resident rooms had deep gouges behind the head of the bed. Resident R21, R59, R68, R84 and R97. Two resident rooms had sticky, debris, and grime on the floor under the bedside table, and between the door and window beds. The base of Resident R68's tube feeding pole was corroded with dried tube feed formula. An interview on 10/25/24, at 10:00 a.m. the Maintenance Director Employee E9 confirmed the facility failed to provide a clean, safe, comfortable, and homelike environment for five of twelve residents (Residents R21, R59, R68, R84, R97 ). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code 201.29(d) Resident Rights 395603 Page 7 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, facility documents, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain residents were free from abuse and neglect for two of three residents (Resident R57 and R84). Findings include: Review of facility policy Abuse, Neglect and Exploitation dated 7/1/24, indicated neglect as the failure of the facility, its employees or service providers to provide goods and services to resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the admission record indicated Resident R57 admitted to the facility on [DATE]. Review of Resident R57's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/2/24, indicated the diagnoses of multiple sclerosis (immune system eats away at protective covering of nerve cells), peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), and coronary artery disease (narrow arteries decreasing blood flow to heart). Section GG0170 indicated dependent for transfers to and from the bed. Review of Resident R57's current physician orders on 10/21/24, indicated transfers with assist of two staff with Hoyer lift (a machine that safely lifts residents with limited mobility from point A to point B). Resident R57's care plan dated 9/24/24, indicated provide assistance of two for transferring and use Hoyer lift for transferring. Interview on 10/21/24, at 9:51 a.m. Resident R57 indicated the only trouble he has had at the facility was with an agency Nurse Aide (NA) Employee E10 who transferred him without a second person. He indicated NA Employee E10 proceeded with transferring him alone despite him telling her two people were required. NA Employee E10 had him twisted in the bed at the time of transfer and hurt his left lower leg. Review of Nurse Practitioner progress note dated 10/9/24, at 12:26 p.m. indicated Resident R57 reports having increased pain in his left lower extremity due to issues during transferring the other day. Interview with the Director of Nursing on 10/22/24, at 11:00 a.m. indicated a witness statement from NA Employee E10 could not be produced. Review of the admission record indicated Resident R84 admitted to the facility on [DATE], with diagnosis that include cirrhosis of the liver, chronic kidney disease and autoimmune hepatitis. Review of Resident R84's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/13/24, indicated diagnosis remained current. Review of facility provided documents revealed that on 9/26/24, 9:00 p.m., Resident R84 resident 395603 Page 8 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few informed her NA that the NA that worked the morning shift took pictures of her with diarrhea on her without her consent and violated her rights. Facility statement for NA Employee E13 taken on 9/26/24, indicated the Employee E13 went in to change Resident R84 and she was full of BM (bowel movement), R84 stated she was not changed from night shift. NA E13 stated she took a picture of R84 and sent it to the NA that had her on the previous shift. Facility substantiated investigation and terminated NA Employee E13 for violating resident rights. Interview with the Director of Nursing on 10/22/24, at 11:00 a.m. confirmed the facility failed to make certain residents were free from abuse and neglect for two of three residents (Resident R57 and R84 ). 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 9 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility incident documents, resident, and staff interviews, it was determined that the facility failed to report an alleged allegation of neglect for one of three residents (Resident R57). Findings include: Review of facility policy Abuse, Neglect and Exploitation dated 7/1/24, indicated facility staff must immediately report all abuse allegations to the Administrator. The Administrator will notify the applicable local and state agencies. Review of the admission record indicated Resident R57 admitted to the facility on [DATE]. Review of Resident R57's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/2/24, indicated the diagnoses of multiple sclerosis (immune system eats away at protective covering of nerve cells), peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), and coronary artery disease (narrow arteries decreasing blood flow to heart). Section GG0170 indicated dependent for transfers to and from the bed. Review of Resident R57's current physician orders on 10/21/24, indicated transfers with assist of two staff with Hoyer lift (a machine that safely lifts residents with limited mobility from point A to point B). Resident R57's care plan dated 9/24/24, indicated provide assistance of two for transferring and use Hoyer lift for transferring. Interview on 10/21/24, at 9:51 a.m. Resident R57 indicated the only trouble he has had at the facility was with an agency Nurse Aide (NA) Employee E10 who transferred him without a second person. He indicated NA Employee E10 proceeded with transferring him alone despite him telling her two people were required. NA Employee E10 had him twisted in the bed at the time of transfer and hurt his left lower leg. Interview on 10/21/24, at 9:51 a.m. further indicated that Resident R57 informed the Director of Nursing the following morning of the event. Interview with the Director of Nursing on 10/22/24, at 11:00 a.m. confirmed Resident R57 had informed her of the event and confirmed that the facility failed to report an allegation of neglect for one of three residents (Resident R57) as required. 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. 395603 Page 10 of 42 395603 10/25/2024 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 investigate an allegation of abuse/neglect for one of three residents (Resident R57). Residents Affected - Few Findings include: Review of facility policy Abuse, Neglect and Exploitation dated 7/1/24, indicated once the Administrator and Department of Health are notified, an investigation of the allegation will be conducted and completed within five days of the alleged occurrence. Review of the admission record indicated Resident R57 admitted to the facility on [DATE]. Review of Resident R57's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/2/24, indicated the diagnoses of multiple sclerosis (immune system eats away at protective covering of nerve cells), peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), and coronary artery disease (narrow arteries decreasing blood flow to heart). Section GG0170 indicated dependent for transfers to and from the bed. Review of Resident R57's current physician orders on 10/21/24, indicated transfers with assist of two staff with Hoyer lift (a machine that safely lifts residents with limited mobility from point A to point B). Resident R57's care plan dated 9/24/24, indicated provide assistance of two for transferring and use Hoyer lift for transferring. Interview on 10/21/24, at 9:51 a.m. Resident R57 indicated the only trouble he has had at the facility was with an agency Nurse Aide (NA) Employee E10 who transferred him without a second person. He indicated NA Employee E10 proceeded with transferring him alone despite him telling her two people were required. NA Employee E10 had him twisted in the bed at the time of transfer and hurt his left lower leg. Interview on 10/21/24, at 9:51 a.m. further indicated that Resident R57 informed the Director of Nursing the following morning of the event. Review of Nurse Practitioner progress note dated 10/9/24, at 12:26 p.m. indicated Resident R57 reports having increased pain in his left lower extremity due to issues during transferring the other day. Interview with the Director of Nursing on 10/22/24, at 11:00 a.m. indicated a witness statement from NA Employee E10 could not be produced and that the facility failed to investigate the allegation of neglect for one of three residents (Resident R57). 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. 395603 Page 11 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0610 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395603 Page 12 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two out of four residents sampled with facility-initiated transfer (Residents R49 and R59). Findings include: Review of Resident R59's admission record indicated he was originally admitted on [DATE], with diagnoses that included heart failure, obesity and dysphagia (difficulty swallowing). Review of Resident R59's clinical record revealed that the resident was transferred to the hospital on 4/15/24, and returned to the facility on 4/17/24. Review of Resident R59's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents specific needs at the receiving facility. Review of the clinical record indicated Resident R49 was admitted to the facility on [DATE]. Review of Resident R49's MDS (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 10/6/24, indicated diagnoses of chronic obstructive pulmonary disease (progressive airflow limitation and tissue destruction), obstructive sleep apnea and hypertension. Review of the clinical record indicated Resident R49 was transferred to hospital on 5/24/24 and returned to the facility on 6/3/24. Review of Resident R49's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents specific needs at the receiving facility. During an interview on 10/23/24 at 11:30 a.m. the Director of Nursing (DON) confirmed that the facility failed to provide the necessary information for Resident R49 and R59. 28 Pa. Code 201.29(a)(c.3)(2) Resident rights. 395603 Page 13 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for four of four residents (Residents R14, R49, R59, R120). Findings include: Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R14's MDS (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 7/19/24, indicated diagnoses of adult failure to thrive, high blood pressure, and atrial fibrillation (irregular heart beat). Review of the clinical record indicated Resident R14 was transferred to hospital on 9/15/24, and returned to the facility on 9/19/24. Review of Resident R14's clinical record and facility documents indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for the transfer to the hospital on 9/15/24. Review of Resident R59's admission record indicated he was originally admitted on [DATE], with diagnoses that included heart failure, obesity and dysphagia (difficulty swallowing). Review of Resident R59's clinical record revealed that the resident was transferred to the hospital on 4/15/24, and returned to the facility on 4/17/24. Review of Resident R59's clinical record and facility documents indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for the hospitalization on 4/15/24. Review of the clinical record indicated Resident R49 was admitted to the facility on [DATE]. Review of Resident R49's MDS (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 10/6/24, indicated diagnoses of chronic obstructive pulmonary disease (progressive airflow limitation and tissue destruction), obstructive sleep apnea and hypertension. Review of the clinical record indicated Resident R49 was transferred to hospital on 5/24/24 and returned to the facility on 6/3/24. Review of Resident R49's clinical record and facility documents indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for the hospitalization on 5/24/24. Review of the clinical record indicated Resident R120 was admitted to the facility on [DATE], and readmitted on [DATE]. 395603 Page 14 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0623 Level of Harm - Minimal harm or potential for actual harm Review of Resident R120's MDS dated [DATE], indicated diagnoses of adult failure to thrive, high blood pressure, and atrial fibrillation (irregular heart beat). Review of the clinical record indicated Resident R120 was transferred to hospital on 8/30/24, and ceased to breathe at the hospital. Residents Affected - Some Review of Resident R120's clinical record and facility documents indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for the transfer to the hospital on 8/30/24. Review of the documents provided by the facility, from January 2024, through September 2024, indicated the facility last notified the Office of the Long-Term Care Ombudsman Division of discharges on 3/4/24. During an interview on 10/22/24 at 10:30 a.m. the Director of Nursing (DON) confirmed the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for four out of four residents (Residents R14, R49, R59, R120). 28 Pa. Code 201.29(a)(c.3)(2) Resident rights. 395603 Page 15 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for four of four resident hospital transfers (Resident R14, R49, R59, and R120). Findings Include: Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R14's MDS (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 7/19/24, indicated diagnoses of adult failure to thrive, high blood pressure, and atrial fibrillation (irregular heart beat). Review of the clinical record indicated Resident R14 was transferred to hospital on 9/15/24, and returned to the facility on 9/19/24. Review of Resident R14's clinical record and facility documents failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 9/15/24. Review of Resident R59's admission record indicated he was originally admitted on [DATE], with diagnoses that included heart failure, obesity and dysphagia (difficulty swallowing). Review of Resident R59's clinical record revealed that the resident was transferred to the hospital on 4/15/24, and returned to the facility on 4/17/24. Review of Resident R59's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 4/15/24. Review of the clinical record indicated Resident R49 was admitted to the facility on [DATE]. Review of Resident R49's dated 10/6/24, indicated diagnoses of chronic obstructive pulmonary disease (progressive airflow limitation and tissue destruction), obstructive sleep apnea and hypertension. Review of the clinical record indicated Resident R49 was transferred to hospital on 5/24/24 and returned to the facility on 6/3/24. Review of Resident R49's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 5/24/24. Review of the clinical record indicated Resident R120 was admitted to the facility on [DATE], and 395603 Page 16 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0625 readmitted on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident R120's MDS dated [DATE], indicated diagnoses of adult failure to thrive, high blood pressure, and atrial fibrillation (irregular heart beat). Residents Affected - Some Review of the clinical record indicated Resident R120 was transferred to hospital on 8/30/24, and ceased to breathe at the hospital. Review of Resident R120's clinical record and facility documents indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for the transfer to the hospital on 8/30/24. During an interview on 10/22/24, at 11:30 a.m. Director of Nursing Employee confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for four of four resident hospital transfers as required. 28 Pa. Code 201.29 (a)(c.3)(2) Resident rights 395603 Page 17 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for two of eight residents (Residents R68, and R114). Residents Affected - Some Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated October 2024, indicated the following: -Section O 1. Code 0, no: if the resident ' s pneumococcal vaccination status is not up to date or cannot be determined. Proceed to item O0300B, If Pneumococcal vaccine not received, state reason. 2. Code 1, yes: if the resident ' s pneumococcal vaccination status is up to date. Skip to O0350. Review of the admission record indicated Resident R68 admitted to the facility on [DATE]. Review of Resident R68's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/1/24, indicated the diagnoses of anemia (the blood doesn ' t have enough healthy red blood cells), high blood pressure, and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids). Review of Resident R68's Vaccine Consent form dated 11/27/23, indicated To my knowledge, Resident has had the Pneumococcal Vaccine: Yes, Date or No. Consent indicated yes in the year 2020. Further review of Section O of Resident 68's MDS dated [DATE], indicated Section O300 A and B both to be answered with a dash. Review of the admission record indicated Resident R114 admitted to the facility on [DATE]. Review of Resident R114's MDS dated [DATE], indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), atrial fibrillation (irregular heart rhythm), and high blood pressure. Review of Resident R114's Vaccine Consent form dated 9/19/24, indicated To my knowledge, Resident has had the Pneumococcal Vaccine: Yes, Date or No. Consent indicated No and that they give permission for Resident to receive the vaccination if ordered by the physician. Further review of Section O of Resident 114's MDS dated [DATE], indicated Section O300 A and B both to be answered with a dash. Interview on 10/25/24 Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed the Section O300 A and B were both incorrectly dashed out for Residents R68 and R114 and the facility failed to make certain that resident assessments were accurate for two of twelve residents (Residents R68, 395603 Page 18 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0641 and R111). Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.10(c)(d) Resident care policies. Residents Affected - Some 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 395603 Page 19 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 make certain that residents received the necessary services, consistent with professional standards of practice to promote healing and prevent infection for one of four residents (Residents R26). Residents Affected - Few Findings include: Review of the facility Pressure Injury Prevention and Treatment Policy dated 9/18/23, last reviewed 7/1/24, indicated residents admitted with existing pressure injuries will receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. Pressure injuries identified will be assessed initially and at least weekly thereafter. Pressure injuries will be documented and orders obtained from providers for treatment. Review of the facility Comprehensive Care Planning Policy dated 7/1/24, last indicated a baseline care plan must be developed within 48 hours of admission to insure that the resident's needs are met appropriately until the comprehensive care plan is completed. It was indicated there must always be back up documentation to show that approaches in care plan are being followed. Review of the facility policy Physician/Provider Order dated 12/14/21, last reviewed 7/1/24, indicated the nurse shall transcribe and review all physician/provider orders The attending physician shall review and confirm the orders. The order must be transcribed to all appropriate areas. Review of the admission record indicated Resident R26 was admitted to the facility on [DATE], with diagnoses of cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced) and hemiplegia (paralysis that affects only one side of the body) and hemiparesis (one-sided muscle weakness caused by brain, spinal cord, or nerve problems) following cerebral infarction affecting the left non-dominate side. Review of Resident R26's progress note dated 6/26/24, indicated the resident has two areas to left hip noted. Review of Resident R26's skin observation dated 6/26/24, indicated the resident had a 12 centimeters (cm) x 7 cm left hip unstageable pressure ulcer (wounds that are filled with slough (soft, yellowish, or white type of necrotic tissue that accumulates on the surface of a wound) or eschar (typically tan, brown, or black dead tissue that falls of the skin) and depth cannot be measured.) with heavy seropurulent drainage (thin, watery, cloudy yellow to tan in color that is an indicator of infection), and a 7 cm x 3 cm left hip unstageable pressure ulcer with heavy seropurulent drainage and slough. Review of Resident R26's baseline care plan dated 6/26/24, failed to include a pressure ulcer care plan. Review of Resident R26's Minimum Data Set (MDS - periodic assessment of care needs) dated 6/29/24, indicated the diagnoses were current. Section M-Skin Conditions indicated the resident had two unstageable pressure ulcers. Review of Resident R26's physician orders from 6/26/24, through 7/11/24, failed to include an order 395603 Page 20 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0686 to cleanse the resident wounds or apply a wound dressing. Level of Harm - Minimal harm or potential for actual harm Review of Resident R26's Braden Scale assessment dated [DATE], indicated Resident R26 was at mild risk (score of 16) for pressure ulcer development (a standardized, evidence-based assessment tool commonly used in health care to assess and document a client ' s risk for developing pressure injuries). The interventions for skin and pressure ulcer treatments was left blank and not completed. The facility failed to indicate if the plan of care was continued, initiated, or updated. Residents Affected - Few Review of Resident R26's physician order dated 7/12/24, indicated to clean left hip with normal saline solution and apply honey and cover with dry dressing every day. Review of Resident R26's Skin and Wound Note dated 7/15/24, entered by Nurse Practitioner, Employee E23 indicated the resident's left superior unstageable hip pressure ulcer measured 8 cm x 4 cm x 0 cm with scant amount of serous, green tinged drainage. The resident's left inferior unstageable hip pressure ulcer measured 5 cm x 2 cm x 0 cm and had a scant amount of serous green tinged drainage. A surgical wound debridement was completed at the bedside to remove necrotic (dead) tissue. It was recommended to obtain a wound culture of the left hip wounds. Review of Resident R26's physician orders dated 7/16/24, indicated to obtain wound culture to left hip wounds. Review of Resident R26's Skin and Wound Note dated 7/22/24, entered by Nurse Practitioner, Employee E23 indicated the resident was unable to be evaluated because she was out of the facility for an appointment. The resident's wound culture results were reviewed and treatment was changed to apply Gentamicin (topical medication used to prevent or treat a wide variety of bacterial infections) then acetic acid (wound cleansing solution) moistened gauze twice a day. It was indicated the resident also needed antibiotics for pseudomonas (a type of bacteria) and MRSA (Methicillin-resistant Staphylococcus aureus-a type of infection caused by specific bacteria that are resistant to commonly used antibiotics) coverage. Review of Resident R26's clinical record from 6/26/24, through 7/22/24, failed to include a pressure ulcer care plan. Review of Resident R26's care plan dated 7/23/24, indicated the resident has impaired skin integrity and had a stage 4 left superior hip pressure ulcer. Interventions were not added to the care plan by Wound Care Licensed Practical Nurse, Employee E2, until 7/30/24. It was indicated to assess the pressure ulcer for stage, size, presence/absence of granulation tissue (type of connectiv etiisue that forms during wound healing) and epithelization (the formation of a new layer of skin over the wound), and condition of surrounding skin. The frequency was left blank. The care plan failed to indicate how often to complete wound assessments. Review of the clinical record indicated the resident was out to the hospital from [DATE], through 7/26/24. Review of Resident R26's physician order dated 7/26/24, indicated to administer 800-160 mg sulfamethoxazole-trimethoprim (antibiotic used to treat bacterial infections), two times a day, for unstageable left hip pressure ulcer. During an interview on 10/23/24, at 10:56 a.m. Wound Care Licensed Practical Nurse, Employee E2 395603 Page 21 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated Resident R26 was admitted to the facility with pressure ulcers on 6/26/24. It was indicated Wound Care Nurse, Employee E2 was on vacation at that time and she didn't see her until 7/8/24. Wound Care LPN, Employee E2 confirmed the facility failed to enter a physician order to cleanse and cover the wound from 6/26/24, through 7/12/24. During an interview on 10/25/24, at 9:50 a.m. Registered Nurse Assessment Coordinator, Employee E1 confirmed the facility failed to timely implement a pressure ulcer care plan. During an interview on 10/25/24, at 1:07 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to make certain that residents were received the necessary services, consistent with professional standards of practice, to promote healing and prevent infection for one of four residents (Residents R26). 28 Pa. Code: 201.29(i) Resident Rights. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395603 Page 22 of 42 395603 10/25/2024 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, and staff interviews, it was determined that the facility failed to provide adequate assistance during a transfer for one of six residents (Resident R102), which resulted in a laceration of right lower extremity that required 15 sutures for Resident R102. Findings include: Review of the facility Incident/ Accident Policy dated 7/1/24, indicated an incident/accident is any occurrence which is not consistent with the routine care of a particular resident An incident/ accident can occur anywhere and be discovered by anyone. All incident/accidents involving residents will be analyzed and reported. Review of Resident R102's admission record indicated he was admitted to the facility on [DATE]. Review of Resident R102's physician order dated 9/5/24, indicated to transfer the resident with an assist of two persons. Review of Resident R102's Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 9/11/24, indicated diagnoses of dementia (disorder that affect the brain and impair a person's memory, thinking, behavior, or emotions enough to interfere with daily life and independence), depression, and displaced ankle fracture of the lower left leg. Review of Resident R102's care plan dated 9/8/24, indicated the resident is at risk for falling due to weakness, pain, and left ankle fracture. It was indicated to transfer the resident with an assist of two as ordered. The resident's goal was to remain free from injury. Review of Resident R102's progress note dated 10/4/24, at 9:20 p.m. entered by Registered Nurse, Employee E14 indicated staff assisted resident from her wheelchair to her bed. Upon lying in bed resident stated that she thought that she bumped her right leg. Staff assessed her right lower extremity and found a laceration then altered the charge nurse. Charge nurses assessed the laceration. Small amount of blood noted. The doctor was notified, and determined that the laceration will need possible sutures and the resident was sent to the hospital for further evaluation. Review of RN, Employee E3 witness statement dated 10/4/24, indicated the incident was unwitnessed. RN, Employee E3 stated he was called to the room by the nurse aide who stated she got a skin tear on her leg. The resident was lying in bed on left side with a towel over her right calf. Nurse aide stated she caught her left on side rail getting into bed. Blood was noted on the floor and bottom on exposed metal side rail and in the bed. A 17 centimeter skin tear was observed on the resident's right lateral calf. The supervisor was notified and arranged transport to the hospital for further evaluation. Review of Nurse Aide, Employee E4 witness statement dated 10/4/24, indicated as the resident was transferred from the chair to the bed the resident obtained an open tear on the bed rail. Review of Resident R102's physician orders from 9/5/24, through 10/4/24, failed to include an order for bed rails. 395603 Page 23 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0689 Level of Harm - Minimal harm or potential for actual harm Review of Resident R102's witness statement dated 10/5/24, at 10:00 a.m. indicated the DON obtained a verbal statement from Resident R102 that stated They were putting me into bed from by wheelchair and when I got in the bed they noticed blood on the sheet. I did not have any pain or notice that I had an opening on my leg. It was just an accident and this happened in the hospital. The witness statement was not signed by Resident R102. Residents Affected - Few Review of Resident R102's progress note dated 10/5/24, at 11:18 a.m. indicated the resident returned to the facility and had 15 sutures to her right calf laceration. Review of the facility report submitted to the Department of Health on 10/5/24, at 1:42 p.m. by the Director of Nursing (DON) indicated on 10/4/24, Resident R102 was being transferred by nurse aides from wheelchair to bed and her calf got scraped by the mobility bar on her bed causing a laceration (17 centimeters (cm) x 1 cm x 0. 1cm) to her right outer calf area. It was indicated the resident is an assist of two persons with transfers and was being transferred appropriately. During an interview on 10/23/24, at 11:50 a.m. RN, Employee E3 indicated NA, Employee E4 was transferring Resident R102 from her wheelchair to bed and her leg got caught on the bottom of the side rail. RN, Employee E3 stated NA, Employee E4 was the only aide in the room at the time of the incident. NA, Employee E4 did not answer the phone or return the message left by the State Agency on 10/24/24. Review of the facility's Incidents/Accident Report Q & A Log: for the month of October 2024, failed to include Resident R102's incident that occurred on 10/4/24. During an interview on 10/24/24, at 10:02 a.m. the Director of Therapy, Employee E16 confirmed on 10/4/24, Resident R102 required two people for transfers. Director of Therapy, Employee E16 stated Resident R102 was evaluated by occupational therapy on 10/4/24, and was dependent with care, required a maximum assist for upper body, and was dependent for lower body. The Director of Therapy indicated nurses are responsible for entering an order in the clinical record for bed rails, and nurse aides must refer to the clinical record for a resident's transfer status. During an interview 10/24/24, at 10:22 a.m. NA, Employee E17 was asked how she knows where to find the transfer status of a resident. NA, Employee E17 stated from her assignment sheet or in the clinical record. NA, Employee E17 indicated she documents how a resident transfers in the clinical record using the tablet on the wall. During an interview on 10/24/24, at 10:23 a.m. RN, Supervisor, Employee E14 indicated aides have assignment sheets that have the transfer status of residents, and nurse aides are given resident's transfer status during report. During an interview 10/24/24, at 10:27 a.m. NA, Employee E18 was asked how she knows where to find the transfer status of a resident. NA Employee E18 stated the resident's transfer status should be listed on the assignment sheet, if not on their, then the nurse will let you know. During an interview on 10/24/24, at 1:38 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to provide adequate assistance during a transfer for one of six residents (Resident R102), which resulted in a laceration of Resident R1 of right lower extremity. 395603 Page 24 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0689 28 Pa. Code 201.14(a) Responsibility of licensee. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. Residents Affected - Few 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 395603 Page 25 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0692 Provide enough food/fluids to maintain a resident's health. 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to update an individualized care plan to address the resident's specific nutritional concerns and preferences for one of four (Resident R82) records reviewed. Residents Affected - Few Findings include: Review of facility policy Comprehensive Care Planning dated 7/1/24, indicated an interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis. Review of the admission record indicated that Resident R82 was admitted to the facility on [DATE]. Review of Resident R82's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/5/24, indicated the diagnoses cerebral palsy (a group of conditions that affect movement and posture caused by brain damage before birth), aspiration pneumonia (a lung infection caused by inhaling foreign substances like food, liquid or vomit), and gall bladder stones. Review of current physician orders indicated Resident R82's current diet order was Regular, Nectar thick (liquids), Mech Soft (texture), initiated 9/10/24. Review of Resident R82's care plan initiated 9/2/24, indicated an approach/intervention to nutritional status problem to provide diet per order: Puree (texture)/Nectar thick (liquids). During an interview on 10/23/24, at 9:54 a.m., Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that the facility failed to update an individualized care plan to address the resident's specific nutritional concerns and preferences for one of four (Resident R82) records reviewed. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.12(d)(3)(5)Nursing services. 395603 Page 26 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 and clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained and failed to maintain an accurate care plan for dialysis access site for one of one dialysis resident (Resident R39). Residents Affected - Few Findings include: Review of the facility policy Hemodialysis Care Policy dated 7/1/24, indicated communication between the dialysis provider and facility staff will occur before and after each hemodialysis (a treatment for advanced kidney failure that filters wastes, salts, and fluid from your blood) treatment and as needed. Review of the facility policy Comprehensive Care Planning Policy, dated 7/1/24, indicated an interdisciplinary plan of care will be established for every resident and updated on an as needed basis. Review of the admission record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/29/24, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), renal failure (condition where the kidneys lose the ability to remove waste and balance fluids) with dialysis, and high blood pressure. Review of current physician orders on 10/21/24, indicated Resident R39 attends dialysis on Monday, Wednesday, and Friday each week. Check bruit and thrill to access site every eight hours. Review of Resident R39's care plan failed to include management or monitoring of the access site, an AV fistula (a connection that is made between an artery and vein for dialysis access). It incorrectly indicated Resident R39 will not exhibit signs or symptoms of infection at peritoneal access site. Resident R39 does not have a peritoneal access site. Interview on 10/21/24, at 1:00 p.m. with Registered Nurse (RN) Employee E8 confirmed Resident R39 has never had a peritoneal access site and has an AV fistula in the right upper arm, and that the care plan did not reflect Resident R39's current needs. A review of the clinical record did not include complete communication forms since admission on [DATE]. There were only four incomplete communication sheets (dialysis portion, and facility medications missing) for the following dates: 10/16/24, 10/18/24, 10/21/24, and one without a date. Interview on 10/21/24, at 1:30 p.m. the Director of Nursing confirmed the above dates did not include complete communication forms as required for Resident R39. Interview on 10/21/24, at 2:00 p.m. the Director of Nursing confirmed the facility failed to make certain consistent dialysis communication was maintained and failed to maintain an accurate care plan for dialysis access site for one of one dialysis resident (Resident R39). 28 Pa. Code: 201.14(a) Responsibility of licensee. 395603 Page 27 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0698 28 Pa. Code: 211.10(d) Resident care policies. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services. Residents Affected - Few 395603 Page 28 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of five residents (Resident R2). Findings include: Interview with the facility's Administrator on 10/25/24, at 11:30 a.m. indicated they did not have a policy relating to treatment and services for mental and or psychosocial concerns. Review of the facility policy Managing Use of Unauthorized/Illegal Substances Policy dated 7/1/24, indicated this community does not permit the use of unprescribed medications, drugs, alcohol, or substances and/or those that are illegal by state or federal law. Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/15/24, indicated diagnoses of wound infection, depression, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and below the knee amputation of right leg (R BKA). Review of Resident R2's current physician orders on 10/25/24, indicated: -Medication monitoring - antianxiety special instructions Xanax (an antianxiety medication) monitor for side effects. Possible side effects of drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behaviors every shift. -Xanax 0.5mg (milligrams) oral tablet once a day as needed for anxiety. -10/7/24, oxycodone solution give 5ml (milliliters) oral for break thru pain every eight hours as needed. -10/21/24, OxyContin oral extend release, over 12 hours, 10mg tablet every 12 hours every day. Review of Resident R2's care plan dated: -10/22/24, indicated Resident in long term placement at the facility related to Right BKA. -9/13/24, indicated Resident displays behavioral symptoms of attention seeking and manipulative behaviors. Intervention to set limits, if possible, for behaviors related to attention seeking. -9/13/24, indicated Resident is non-compliant with care at times. Review of Resident R2's progress notes on 10/25/24, at 11:30 a.m. indicated the following: 395603 Page 29 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0742 -5/18/24, at 10:01 p.m. Resident requesting oxycodone 2 tabs. twice this shift. C/O's R hip and Level of Harm - Minimal harm or potential for actual harm sciatica discomfort. Residents Affected - Few -8/14/24, Psychology note indicated today, Resident presented with perseverative thoughts about medication, stating I can't function without my pills, they should know that. -9/13/24, Psychology note indicated Resident was guarded throughout the session. How do you think I'm feeling? Everything is going wrong! in reference to recent increased care needed for amputation stump and wounds. -9/27/24, Psychology note indicated Resident presented with perseverative (repeatedly dwell) thoughts about medication, stating I need to see the psychiatry person soon, I just want this anxiety to get under control. -10/14/24, Psychiatric note indicated Resident appears anxious and tearful I am not doing well with this anxiety I am so worried about my nephew who is not in a good living situation Dr cut my anxiety med down and my pain (PCP) med and I feel terrible, Pain, anxious and can't sleep. Also witnessed by two nursing staff to be snoring her oxycodone after crushing it. Primary Care Physician aware and started taper of her narcotic which she is obviously very upset about. Requesting from this Nurse Practitioner (NP) to increase Xanax and help with mood and anxiety. Decision was made to increase her bipolar disorder medication and not the Xanax. Plan: PCP initiated a narcotic weaning schedule due to witnessed snorting of her narcotic pain med. -10/20/24, at 12:55 p.m. Nurse Aide (NA) came and asked Licensed Practical Nurse (LPN) Employee E14 to look in on Resident. When entered the room the resident had her back to me hunched over the desk crushing her Xanax between a 20-dollar bill. She was using her vape to crush the Xanax. When confronted she said she was going to eat the pill. -10/23/24, Psychology note indicated recent pause in treatment was prompted by Resident declining to meet over the past few weeks. Currently, Resident presents as tearful, stating Nothing is going right, I'm so worried about my family. She described increased anxiety and depression. Interview on 10/25/24, at 11:00 a.m. LPN Employee E14 indicated I saw her do it. I was coming down the hallway and NA Employee E15 told me she's crushing her pills. I entered her room, and she was hunched over her table with her back to me, ironing a 20-dollar bill with her vape back and forth. She opened the 20-dollar bill, and the pink Xanax pill was totally crushed into powder. She turned and saw me; I asked her what she was doing. I know they have caught her in the past with a straw. She opened the bill and ate the powder into her mouth. Interview on 10/25/24, at 11:01 a.m. NA Employee E15 indicated on Saturday, she heard a banging noise from Resident R2's room, so she peaked her head in and saw Resident with a folded bill, like she was going to snort it up her nose. NA Employee E15 reported it to the nurse. The interview further indicated Resident R2 acts highed up. She's real groggy and hard to arise. I work evening shift sometimes. She was very angry when they changed her meds to a liquid form. She would pull her hair out. 395603 Page 30 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0742 She likes to manipulate people. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on 10/25/24, at 12:00 p.m indicated Resident R2's PCP changed her oxycodone to a liquid form because she was caught crushing her medications. The nurses are supposed to make sure she takes it with water, and she still pockets it (Xanax). Residents Affected - Few Review of the clinical record on 10/25/24, at 12:00 p.m., provided no evidence of addressing the potential drug addiction, drug manipulation problem for ongoing solutions. Plan of care did not reflect this behavior or interventions to prevent future snorting episodes. Interview on 10/25/24, at 1:00 p.m. the Director of Nursing was informed that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of five residents (Resident R2). 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 31 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review, and staff interview, it was determined that the facility failed to ensure that any irregularities submitted in the medication regiment reviews (MRR) by pharmacy were acted upon for one out of five residents (Resident R12). Findings include: Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/7/24, indicated diagnoses heart failure condition in which the heart muscle is unable to pump enough blood to meet the body ' s needs for blood and oxygen), respiratory failure (results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels), and rhabdomyolysis (A breakdown of skeletal muscle due to direct or indirect muscle injury). Review of Resident R12's active physician order dated 2/28/24, indicated to administer 0.5ml of 2mg/ml lorazepam as needed for anxiety, every four hours. Review of Resident R12's pharmacy regimen review dated 3/25/24, indicated Resident R12 had an order for an anxiolytic, which has been in place for greater than 14 days without a stop date: Lorazepam concentrate 0.5 ml (1mg) by mouth every four hours, as needed, for anxiety. The recommendation indicated to please review and add a potential stop-date to this prn anxiolytic (drug used to treat anxiety) order. If the Lorazepam needs to continue, please document the intended duration of therapy and the rationale for the extended time period. The pharmacy review was not signed by the physician. Review of Resident R12's pharmacy regimen review dated 5/22/24, indicated Resident R12 prn order for Lorazepam concentrate 0.5 ml (1mg) by mouth every four hours, as needed, for anxiety, has not been given since 2/28/24. The recommendation was to please consider discontinuing due to lack of use. The pharmacy review was not signed by the physician. Review of Resident R12's clinical record from 2/28/24, through 10/23/24, failed to indicate a rationale why the 0.5ml of 2mg/ml lorazepam by mouth, as needed for anxiety, was ordered for more than 14 days without a stop date. During an interview on 10/23/24, at 12:27 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to ensure that any recommendations and orders that were submitted in the medication regimen reviews by pharmacy and the physician were acted upon for Resident R12 as required. 28 Pa Code: 201.14 (a ) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 395603 Page 32 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0756 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395603 Page 33 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, and staff interview it was determined the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days for one of five residents (Resident R12), failed to identify a diagnosed specific condition for treatment, and failed to monitor the effectiveness or adverse consequences of psychotropic medication use for one of five residents (Resident R82) reviewed. Findings Include: Review of facility policy Psychoactive Medication Policy dated 7/1/24, indicated all residents receiving psychoactive medication[s] will have their behaviors, effectiveness of interventions (pharmacological and non-pharmacological) and potential for a gradual dose reduction of psychoactive medication monitored and documented. Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/7/24, indicated diagnoses heart failure condition in which the heart muscle is unable to pump enough blood to meet the body ' s needs for blood and oxygen), respiratory failure (results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels), and rhabdomyolysis (A breakdown of skeletal muscle due to direct or indirect muscle injury). Review of Resident R12's active physician order dated 2/28/24, indicated to administer 0.5ml of 2mg/ml lorazepam as needed every four hours. Review of Resident R12's clinical record from 2/28/24, through 10/23/24, failed to indicate a rationale why the 0. 5ml of 2mg/ml lorazepam by mouth, as needed for anxiety, was ordered for more than 14 days without a stop date. During an interview on 10/23/24, at 12:27 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days for one of five residents (Resident R12) Review of the admission record indicated that Resident R82 was admitted to the facility on [DATE]. Review of Resident R82's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/5/24, indicated the diagnoses cerebral palsy (a group of conditions that affect movement and posture caused by brain damage before birth), aspiration pneumonia (a lung infection caused by inhaling foreign substances like food, liquid or vomit), and gall bladder stones. Section N - Medications, N0415A indicated that Resident R82 was taking, and indication noted for use of Antipsychotic medication. Review of Resident R82's physician orders indicated an order for Quetiapine (Seroquel) tablet; 300 mg (milligram); amount: 2 tabs; oral. Special Instructions: Give 2 tabs for total of 600 mg; at bedtime; 21:00 (9:00 p.m.), initiated 9/16/24. This physician order for antipsychotic medication failed to identify a diagnosed specific condition for treatment. 395603 Page 34 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R82's care plan initiated on 9/1/24, identified problem that resident is at risk for adverse consequence R/T (regards to) receiving antipsychotic medication; goal - resident will not exhibit signs of drug related side effects or adverse drug reaction; and approach - Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms. Monitor resident's behavior and response to medication. Quantitatively and objectively document the resident's behavior. Review of Resident R82's clinical record failed to reveal any documented evidence that the facility was monitoring the effectiveness or adverse consequences of antipsychotic medication use. During an interview on 10/23/24, at 9:56 a.m., Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that the facility failed to identify a diagnosed specific condition for treatment for a physician ordered antipsychotic medication and failed to monitor the effectiveness or adverse consequences of psychotropic medication use for one of five residents (Resident R82) reviewed. 28 Pa Code 211.5(f) Medical records 28 Pa code 211.10(c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services 395603 Page 35 of 42 395603 10/25/2024 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 - Few 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, observations and staff interview it was determined that the facility failed to date opened medications and properly store medications in one of three medication carts observed Findings include: Review of facility policy Storage and Expiration Dating of Medications and Biologicals dated 7/1/24, indicated once any medication or biological package is opened, the facility staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened. Observation on 10/22/24, at 10:02 a.m. of the East Wing Front Hall medication cart indicated the following medications stored in the drawer without a date and time opened as required: -Symbicort (an inhaler used for easier breathing). -Albuterol (an inhaler used for easier breathing). -Fluticasone Propionate (steroid inhaler used for easier breathing) three separate inhalers not dated. Interview on 10/22/24, 10:05 a.m. Registered Nurse (RN) Employee E8 verified the multiple inhalant medications above were not dated when opened as required. Interview on 10/22/24, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to date opened medications and properly store medications in one of three medication carts observed (East Wing Front Hall medication cart). 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 395603 Page 36 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure timely dental services for one of six residents reviewed for dental concerns (Resident 11). Residents Affected - Few Findings include: Review of the facility Dental Services Policy dated 7/1/24, indicated the facility will assist residents in obtaining routine and 24-hour emergency dental care services to meet the needs of each resident. The Social Service personnel or designees will, if necessary or requested, assist the resident/ resident representative in making dental appointments and transportation arrangements to and from the dental services locations. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R11's MDS (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/18/24, indicated diagnoses depression and orthostatic hypotension (a form of low blood pressure that occurs when standing after sitting or lying down). Review of Resident R11's clinical record indicated he was evaluated by the dentist on 8/6/24. It was indicated the resident was seen for upper complete dentures. Review of Resident R11's progress note dated 8/6/24, entered by Activities Director, Employee E6 indicated the resident was seen by the dentist on this date to begin process and evaluation for new upper dentures. Resident has two roots that need extracted. It was stated this director will contact resident's daughter regarding consent for the extraction. During an interview on 10/21/24, at 12:34 p.m. Resident R11 indicated he had a concern for his dentures. Resident R11 stated he has been waiting over a month to get his dentures. During an interview on 10/22/24, at 1:30 p.m. Activities Director, Employee E6 stated she still needs to contact Resident R11's daughter for consent and confirmed the facility failed to ensure timely dental services for one of six residents reviewed for dental concerns (Resident 11). 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.15. Dental services 395603 Page 37 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. 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 documents, resident clinical records and staff interviews it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not.) for one of three residents (Resident R61). Residents Affected - Few Findings include: Review of the admission record indicated Resident R61 was admitted to the facility on [DATE]. Review of Resident R61's Binding Arbitration Agreement indicated that the resident signed the document on 6/20/24. Review of Resident R61's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/26/24, indicated the diagnoses of cancer, Bipolar disorder (a serious mental illness characterized by extreme mood swings), and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Resident R61's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, 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. Resident R61's BIMS score was a six, indicating severe impairment. During an interview on 10/22/24, at 9:58 a.m. admission Director, Employee E12 confirmed the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement) for one of three residents (Resident R61). 28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management 395603 Page 38 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of Resident Assessment Instrument (RAI) User's Manual, facility policy, resident clinical records, and staff interviews, it was determined the facility failed to obtain a diagnosis for hospice service, to ensure an accurate MDS assessment, and failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for two of four residents (Resident R12 and R41). Findings include: Review of facility policy Hospice Care Policy dated 7/1/24, indicated that this community provides hospice services through collaboration with a Medicare certified hospice agency when ordered by a resident's physician. Such services will be provided following these requirements: - The hospice services and those providing them will meet professional standards and be provided timely. - The facility will ensure that the resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS - mandated assessments of a resident's abilities and care needs), dated October 2023, indicated the following instructions: -Section O: Special Treatments, Procedures, and Programs: Check all of the following treatments, procedures, and programs that were performed during the last 14 days. Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/7/24, indicated diagnoses heart failure condition in which the heart muscle is unable to pump enough blood to meet the body ' s needs for blood and oxygen), respiratory failure (results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels), and rhabdomyolysis (A breakdown of skeletal muscle due to direct or indirect muscle injury). Section O: Special Treatments, Procedures, and Programs: Section O0100 question K1 indicated that Resident R41 has received hospice care while a resident. Review of Resident R12's physician order dated 3/30/24, indicated to admit to hospice for COPD (a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough.) Review of Resident R12's care plan last revised 9/16/24, failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to included contact information for the hospice agency and how to access the hospice's 24 hour on-call system. During an interview on 10/22/24 11:49 a.m., Social Worker, Employee E5 confirmed the facility 395603 Page 39 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for Resident R12. Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE]. Review of Resident R41's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/27/24, indicated diagnoses of cerebral infarction (also known as an ischemic stroke which results from disrupted blood flow to the brain due to problems with the blood vessels that supply it), anemia (deficiency of healthy red blood cells in the blood), and high blood pressure. Section O: Special Treatments, Procedures, and Programs: Section O0100 question K1 indicated that Resident R41 has received hospice care while a resident. Review of Resident R41's clinical record indicated an original hospice election date of 8/21/23. Review of a physician order dated 6/11/14, indicated Resident R41 was admitted to hospice, but did not include a diagnosis related to the need of hospice service. Review of Resident R41's MDS dated [DATE], Section O0100 question K1 failed to indicate that Hospice programs were performed during the last 14 days. During an interview on 10/23/24, at 11:32 a.m., Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that Resident R41 has never been off hospice coverage since original election date 8/3/23. RNAC Employee E1 further confirmed that the facility failed to identify hospice diagnosis with the physician order and failed to ensure that MDS assessments accurately reflected the status of Resident R41's hospice services. 28 Pa. Code 211.2(d)(3) Physician services. 28 Pa Code: 211.12 (d)(3)(5) Nursing services 395603 Page 40 of 42 395603 10/25/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for one of two residents with an enteral feeding tube. (Resident R68) Residents Affected - Few Findings include: Review of the Centers for Disease Control (CDC) signage for Enhanced Barrier Precautions (EBP) indicated wear gloves and a gown for the following high contact resident care activities: Device care or use: central line, urinary catheter, feeding tube, and tracheostomy. Review of the facility policy Transmission-Based Precautions and Isolation Policy dated 7/1/24, indicated Enhanced Barrier Precautions (EBP) are indicated for high contact care activities for residents with chronic wounds and indwelling devices. Review of the clinical record indicated Resident R68 was admitted to the facility on [DATE]. Review of Resident R68's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/1/24, indicated the diagnoses of anemia (the blood doesn ' t have enough healthy red blood cells), high blood pressure, and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), and gastrostomy (the creation of an artificial external opening into the stomach for nutritional support). Review of Resident R68's current physician orders on 10/21/24, failed to include an order for EBP. Review of Resident R68's care plan on 10/21/24, failed to include EBP for care and management of the enteral feeding tube as required. Observation on 10/21/24, at 10:30 a.m. Resident R68 was in bed. He lifted his shirt and revealed an enteral feeding tube in his abdomen. The doorway failed to have signage indicating EBP was required. Interview on 10/24/24, at 2:04 p.m. Infection Preventionist Employee E19 confirmed that Resident R68 should have had an order for EBP for care and management of his enteral feeding tube. Interview on 10/25/24, at 12:30 p.m. the Director of Nursing confirmed the facility failed to follow enhanced barrier precautions for one of two residents with an enteral feeding tube. (Resident R68) 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(3) Nursing services. 395603 Page 41 of 42 395603 10/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that pneumococcal vaccinations were addressed in a timely fashion for two of five residents (Residents R68, and R114). Residents Affected - Few Findings include: Review of the facility policy Resident Vaccination Policy dated 7/1/24, indicated residents and/or their responsible party will be asked about prior vaccinations at admission. Prior doses of influenza, pneumococcal, COVID-19, and other vaccines will be documented in the immunization portal in the electronic health record. Review of the admission record indicated Resident R68 admitted to the facility on [DATE]. Review of Resident R68's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/1/24, indicated the diagnoses of anemia (the blood doesn ' t have enough healthy red blood cells), high blood pressure, and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids). Review of Resident R68's Immunizations on 10/21/24, at 11:00 a.m. in the electronic health record, failed to include documentation of pneumococcal status. Review of the admission record indicated Resident R114 admitted to the facility on [DATE]. Review of Resident R114's MDS dated [DATE], indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), atrial fibrillation (irregular heart rhythm), and high blood pressure. Review of Resident R114's Immunization tab 0n 10/21/24, at 11:00 a.m. in the electronic health record, failed to include documentation of pneumococcal status. Interview on 10/24/24, at 11:00 a.m. Infection Preventionist Employee E19 confirmed the pneumococcal immunization information was not present in the Electronic Health Record as required, and that the facility failed to make certain that pneumococcal vaccinations were addressed in a timely fashion for two of five residents (Residents R68, and R114). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(3) Nursing services. 395603 Page 42 of 42

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Citations

25 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0625GeneralS&S Epotential for harm
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
0641GeneralS&S Epotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0568GeneralS&S Dpotential for harm
F568 - Accounting and Records
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
0580GeneralS&S Dpotential for harm
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
0582GeneralS&S Dpotential for harm
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
0584GeneralS&S Dpotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0600GeneralS&S Dpotential for harm
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
0609GeneralS&S Dpotential for harm
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
0610GeneralS&S Dpotential for harm
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
0622GeneralS&S Dpotential for harm
F622 - Transfer and discharge-
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
0623GeneralS&S Epotential for harm
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0698GeneralS&S Dpotential for harm
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
0742GeneralS&S Dpotential for harm
F742 - Based on the comprehensive assessment of a resident, the facility must
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
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.
0791GeneralS&S Dpotential for harm
F791 - Dental Services
Provide or obtain dental services for each resident.
0847GeneralS&S Dpotential for harm
F847 - Entering Into Binding Arbitration Agreements
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
0849GeneralS&S Dpotential for harm
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0883GeneralS&S Dpotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.

FAQ · About this visit

Common questions about this visit

What happened during the October 25, 2024 survey of CARING HEIGHTS COMMUNITY CARE & REHAB CTR?

This was a inspection survey of CARING HEIGHTS COMMUNITY CARE & REHAB CTR on October 25, 2024. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at CARING HEIGHTS COMMUNITY CARE & REHAB CTR on October 25, 2024?

Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed i..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 29, 2026. If you believe any information is inaccurate, report it here.

Health inspection·October 25, 2024