Health inspection·June 17, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. 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, review of resident council meeting minutes, review of grievance logs, observations, staff and resident interviews it was determined that the facility failed to accommodate the call bell needs for four of nine residents (Resident R2, R3, R4 and R7) Residents Affected - Few Findings include: Review of facility policy Call Lights last reviewed 4/2/25, indicated a call light system is used by this facility to respond to the resident request and needs. Answer the resident's call as soon as possible. Review of the facility policy Call Light Response last reviewed 4/2/25, indicated staff will respond to the call light and the residents request and needs in a timely manner. Review of the facility policy Flow of Care last reviewed 4/2/25, indicated care will be provided to residents, as needed 24 hours a day to attain and maintain the highest level of functioning. The flow of care is to be implemented on a continuous basis to promote quality of life with the resident. Call light within reach for all residents and answered timely. Review of Resident council meeting minutes dated 4/14/25, indicated a concern about call bells being answered timely. Review of Resident council meeting minutes dated 5/19/25, indicated a concern about call bells being answered timely. Review of Resident council meeting minutes dated 6/9/25, indicated a concern about call lights being answered timely. Review of grievance log for 4/9/25, indicated a concern completed by family member for call bell times. Review of the admission record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's MDS (minimum data set a periodic assessment of needs) dated 5/15/25, indicated the diagnosis of deep vein thrombosis (DVT-blood clot) multiple sclerosis (MS- autoimmune disease that affects the brain and spinal cord) and reduced mobility. Section C -Cognitive Patterns Brief Interview for Mental Status (BIMS- tool used to screen and identify the cognition condition of a resident) indicated a score of 15 intact cognition. Page 1 of 3 395620 395620 06/17/2025 Cedar Hill Healthcare and Rehabilitation Center 951 Brodhead Road Coraopolis, PA 15108

F 0558 0-7 Severely impaired cognition Level of Harm - Minimal harm or potential for actual harm 8-12 moderately impaired cognition 13-15 intact cognition Residents Affected - Few Review of Resident R4's care plan date initiated 9/27/23, indicated Focus: Resident R4 has bowel incontinence. Interventions that include but not inclusive to check resident every two hours and assist with toileting as needed During an interview completed on 6/17/24 at 10:38 a.m. upon asking Resident R4 concerning call bell response times replied, I have waited in the evening for over a hour, it happens often, a couple of times a week. Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], indicated the diagnosis of anemia (low iron in the blood), heart failure (heart doesn't pump the way it should) and high blood pressure. Section C Cognitive Patterns BIMS score indicated a score of 15 (intact cognition). Review of Resident R3's care plan date initiated 11/29/22, indicated at risk for bladder incontinence related to impaired mobility. Interventions include but not inclusive to Check every 2-3 hours and as required for incontinence. During an interview completed on 6/17/24, at 10:49 a.m. upon asking Resident R3 concerning call bell response times replied, I use the urinal at night, about a month ago I put my light on for someone to empty it, no one came in so I used a cup to urinate in, I have two urinals now. Review of the admission record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's MDS) dated [DATE], indicated the diagnosis of cancer, high blood pressure and diabetes (high sugar in the blood) Section C Cognitive Patterns BIMS score indicated a score of 15 (intact cognition). Review of Resident R7's care plan date initiated 10/11/22 indicated Resident R7 has an ADL Self Care Performance Deficit related to decreased mobility, osteoarthritis, chronic Pain, morbid obesity. Interventions that included but not inclusive to requires setup and clean-up assist with urinal usage and requires extensive assist of one staff after episodes of bowel incontinence. During an interview completed on 6/17/25, at 11:05 a.m. upon asking Resident R7 concerning call bell response time replied, it varies, the problem is when they use the agency staff, I have waited as long as two hours. Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS (minimum data set a periodic assessment of needs) dated 5/10/25, indicated a diagnosis of cancer, hypertension (high blood pressure) and diabetes (high sugar in the blood). Section C Cognitive Pattern- BIMS indicated a score of 11 (moderately impaired cognition). 395620 Page 2 of 3 395620 06/17/2025 Cedar Hill Healthcare and Rehabilitation Center 951 Brodhead Road Coraopolis, PA 15108

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R2's care plan date initiated 5/16/24, indicated ADL function deficit as evidenced by resident needing supervision/touch assist to needing substantial/total dependence with ADLS. Interventions include but not inclusive to Check for incontinence and change brief every 2 hours and as needed. Encourage resident to ask for assistance. Keep call light within reach During an interview completed on 6/17/25, at 11:20 a.m. upon asking Resident R2 concerning call bell response time replied, Sunday during midnight shift I had an accident, I waited well over an hour, it was too long I had diarrhea, a man finally came in and helped me he gave me a complete bed bath. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS dated [DATE] indicated the diagnosis anemia, high blood pressure and diabetes. Section C Cognitive Patterns BIMS score indicated a score of 15 (intact cognition). During an interview completed on 6/17/25, at 11:22 a.m. Resident R1 (Resident R2's roommate) stated I went out to the nursing station that night, they told me to put the call light on and they would get someone, we waited over an hour. During an observation completed on 6/17/25, at 11:22 a.m. the call light was activated in room [ROOM NUMBER] at 11:22 a.m. and was answered at 11:39 a.m. During an interview completed on 6/17/25, at 11:39 a.m. Nurse Aide Employee E6 confirmed the call light was answered at 11:39 a.m. with a wait time of 17 minutes. During an interview completed on 6/17/25, at 12:56 a.m. the Director of Nursing confirmed that the facility had received some complaints concerning the weekend call bell timeliness and indicated she had emailed the staff to remind that they need to be rounding and answering the call lights timely. During an interview completed on 6/17/25, at 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to accommodate the call bell needs for four of nine residents (Resident R2, R3, R4 and R7) 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 395620 Page 3 of 3