Health inspection·September 22, 2023

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. Based on review of facility documentation, resident family and staff interview it was determined that the facility failed to provide a resident's representative with right to participate in the care planning process for one of eight residents reviewed (Resident Family RF1). Findings include: Federal Regulation §483.10(c)(3) states: The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must(i) Facilitate the inclusion of the resident and/or resident representative. During an interview on 9/21/23, at 5:30 p.m. Resident Family RF1 asked about care planning meetings, and if the facility has them? Resident RF1 stated that they have attended them with other family members in long term care settings and has not had one recently for Resident R1. Review of the clinical documentation (progress notes) for Resident R1 failed to show an invitation for Resident Family R1. During an interview on 9/22/23, at 10:38 a.m. Social Services Employee E7 indicated: the facility is doing Grand Rounds a new program quarterly care conferences meeting interdisciplinary team review over the quarter any declines significant changes, review the resident therapy needs, after we have interdisciplinary team meeting then we interview resident assess the room, after the meeting we give them a call to the family to see if they have any concerns. During an interview on 9/22/23, at 11:13 a.m. RNAC (Registered Nurse Assessment Coordinator) Employee E6 was asked for documentation showing that Residents and Resident families are invited to care conference/Grand Round meetings. During an interview on 9/22/23, at 11:32 a.m. RNAC Employee E6 confirmed that the facility could not provide documentation showing that Residents and Resident families are invited to care conference /Grand Round meetings and the facility failed to provide a resident's representative with right to participate in the care planning process. 28 Pa. Code 201.29(a) Resident rights. Page 1 of 12 395638 395638 09/22/2023 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

F 0553 28 Pa. Code 211.11e Resident Care Plan. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395638 Page 2 of 12 395638 09/22/2023 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

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 facility policy and clinical record review, and staff interview, it was determined the facility failed to notify the physician of a change in condition for two of five residents. (Resident R35 and R34) Findings include: Review of the facility policy Provider and Resident/Resident Representative Notification last reviewed 8/21/23, indicated the facility will keep residents' primary care providers informed of change in resident status as it occurs. Review of the American Heart Association indicated a normal heart rate is 60 to 100 beats per minute and bradycardia (a heart rate that ' s too slow) can cause fainting and fatigue. Review of the face sheet indicated Resident R35 was admitted to the facility on [DATE]. Review of Resident R35's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/1/23, indicated the diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn ' t pump blood as well as it should), high blood pressure, hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone). Review of Resident R35's physician orders dated 9/13/23, indicated to obtain and record weekly pulse and blood pressure. Review of Resident R35's care plan dated 8/23/23, indicated an alteration in cardiac status and to check and record blood pressure and pulse as ordered and report variances to provider per policy, and assess for signs and symptoms of cardiac distress: change in vital signs, complaints of chest pain, dizziness, pallor, or anxiety. Review of Resident R35's care plan dated 8/23/23, indicated an alteration in metabolic/thyroid function due to hypothyroidism. Observe for symptoms of hypothyroidism: slow heart rate. Review of Resident R35's vital signs record, and progress notes indicated on 5/2/23, at 1:22 p.m. a heart rate of only 51, and on 7/14/23, a heart rate of only 56 with complaints of substernal chest pain. Resident stated she had heavy pressure that went up into her throat that scared her and took her breath away. Review of Resident R35's progress notes on 5/2/23, and 7/14/23, failed to include documentation of notifying the physician of change in status. Review of the face sheet indicated Resident R34 was admitted to the facility on [DATE]. Review of Resident R34's MDS dated [DATE], indicated the diagnoses of anemia (the blood doesn ' t have enough healthy red blood cells), high blood pressure, and anxiety. Review of Resident R34's physician progress notes on 9/14/23, indicated follow up with holistic medicine service regarding thyroid replacement dosing with hyperthyroid indices. 395638 Page 3 of 12 395638 09/22/2023 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

F 0580 Level of Harm - Minimal harm or potential for actual harm Review of progress note dated 9/15/23, indicated a Registered Nurse from a Holistic Physician service arrived to provide Resident R34 Testosterone injections (hormone treatment) as she has in the past. It explained to the RN that The Facility would need her Credentials and other items required. I asked her to withhold from seeing Resident and took her information to provide to the Director of Nursing. Residents Affected - Few Review of Resident R34's additional clinical record indicated no follow up on testosterone injections. Interview with Director of Nursing on 9/22/23 at 9:00 a.m. indicated the Holistic RN did come into building and was not permitted as per the above progress note and that the physician was not notified that the resident was on the prior injections and if he wanted resident to continue with the medication. Interview on 9/21/23, at 1:32 p.m. the Director of Nursing confirmed that the physician was not notified of Resident R35's change in status and that the facility failed to notify the physician of a change in condition for two of five residents. (Resident R35 and R34). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.14(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.20(b) Staff development. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. 395638 Page 4 of 12 395638 09/22/2023 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation and staff interview it was determined that the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Form (SNF ABN CMS 10055) for two of three residents reviewed (Resident R28 and R37). Residents Affected - Some Findings include: Review of facility documentation showed Resident R28 was admitted to the facility on [DATE], and remained in the facility as of 8/31/22. Review of facility documentation showed Resident R37 was admitted to the facility on [DATE], and remained in the facility as of 8/3/23. Review of the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN CMS-10055) form which provides information to residents/resident representatives that skilled nursing services may not be paid by Medicare and so that the resident/resident representatives can decide if they wish to continue receiving skilled nursing services and assume financial responsibility indicated Resident R28 last day of Medicare Part A coverage was to end 8/31/23, and Resident R37 last day of Medicare Part A coverage was to end 8/3/23. Review of the facility documentation for Resident R28 and R37 failed to include SNF ABN CMS-10055 form. During an interview on 9/21/23, at 12:05 p.m. Nursing Home Administrator confirmed that the facility failed to provide Resident R28 and Resident R37 with SNF ABN CMS-10055 forms. 28 Pa. Code 201.18 e(1) Management. 395638 Page 5 of 12 395638 09/22/2023 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on review of facility policy, resident documents, resident and family and staff interviews, it was determined that the facility failed to document, resolve and provide a response to a grievance for the responsible party of three of four residents (Resident R20, R62 and R1). Findings include: Review of facility policy Grievance Procedure last updated 8/21/23, indicated resident and/or representative shall be informed of his right to file a complaint and procedure. Complaints should be handled by the employee hearing the complaint. The appropriate person needs to make contact with the resident or representative within 5 days and return completed form to the Facility Grievance Official with outcome. During a file review, Resident R62 revealed family concern of wheelchair being dirty and needing cleaned on 8/23/23. Review of concern log revealed no form with the above family concern. During a file review, Resident R20 revealed family concern of resident phone being set up on 9/7/23. Review of concern low revealed no form with the above family concern. During an interview on 9/22/23, at 12:45 p.m. the Nursing Home Administrator confirmed the facility failed to document, resolve, and provide a response to grievances of to the responsible party of Resident R20, R62. Review of Resident R1 clinical record progress notes dated 8/3/23, indicated that the Resident R1 family member had concerns with Resident R1 being moved to the secured dementia nursing unit. Review of the concern log for August failed to include Resident R1 family member concern. During an interview on 9/22/23, at 12:28 p.m. Nursing Home Administrator confirmed that the Resident R1 family member concern was not included in the August concern log and that the facility failed to document grievances for Resident R1 family member. 28 PA. Code: 201.18(b)(2) Management. 28 PA. Code: 201.29(a) Resident's Rights. 395638 Page 6 of 12 395638 09/22/2023 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

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 five residents (Resident R54). Findings include: Review of the facility policy Abuse Prevention reviewed 8/21/23, indicated the facility is to assure residents to the right of freedom from abuse. This is assured by implementing a system of prevention, screening, identification, and training. When an allegation is made the facility will investigate, report, and respond appropriately to the allegation. Identification - procedures are in place to assure adequate review of all incidents and accidents, including suspicious bruising or injuries of unknown origin. Review of the face sheet indicated that Resident R54 was admitted to the facility on [DATE]. Review of Resident R54's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/14/23, indicated the diagnoses of Dementia, hyperlipidemia (high levels of fat in the blood), and depression. Review of Resident R54's incident report dated 8/16/23, indicated therapy was starting to work with resident on feeding in the dining room and had asked if this bruise was new or not. Upon evaluation the anterior (top) aspect of the left hand extending toward the thumb was bruised and had purpura throughout the green and yellow bruising present. Resident does not remember how skin discoloration may have happened. Review of Resident R54's physician order dated 8/9/23, indicated out of bed to hemi wheelchair (a wheelchair for residents with partial weakness or paralysis on one side) with left padded lateral support, provide repositioning as needed to maintain upright posture. Interview with the Director of Nursing on 9/22/23 at 9:49 a.m. indicated the there was no report to the local State field office. During an interview on 9/22/23, at 3:00 p.m. the Director of Nursing confirmed the facility failed to report an allegation of neglect for one of five residents (Resident R54). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.14(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.20(b) Staff development. 395638 Page 7 of 12 395638 09/22/2023 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

F 0609 28 Pa. Code 211.10(c) Resident care policies. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.10(d) Resident care policies. Residents Affected - Few 395638 Page 8 of 12 395638 09/22/2023 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate alleged allegation of abuse/neglect for one of five residents (Resident R54). Residents Affected - Few Findings include: Review of the facility policy Abuse Prevention reviewed 8/21/23, indicated the facility is to assure residents to the right of freedom from abuse. This is assured by implementing a system of prevention, screening, identification, and training. When an allegation is made the facility will investigate, report, and respond appropriately to the allegation. Identification - procedures are in place to assure adequate review of all incidents and accidents, including suspicious bruising or injuries of unknown origin. Review of the face sheet indicated that Resident R54 was admitted to the facility on [DATE]. Review of Resident R54's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/14/23, indicated the diagnoses of Dementia, hyperlipidemia (high levels of fat in the blood), and depression. Review of Resident R54's incident report dated 8/16/23, indicated therapy was starting to work with resident on feeding in the dining room and had asked if this bruise was new or not. Upon evaluation the anterior (top) aspect of the left hand extending toward the thumb was bruised and had purpura throughout the green and yellow bruising present. Resident does not remember how skin discoloration may have happened. Review of Resident R54's Notes portion of the incident report dated 8/16/23, indicated resident with severe dementia. Resident does not remember how skin discoloration may have happened but is able to state that no one caused her harm. Review of Resident R54's physician order dated 8/9/23, indicated out of bed to hemi wheelchair (a wheelchair for residents with partial weakness or paralysis on one side) with left padded lateral support, provide repositioning as needed to maintain upright posture. Review of Resident R54's physician order dated 8/9/23, indicated out of bed to hemi wheelchair (a wheelchair for residents with partial weakness or paralysis on one side) with left padded lateral support, provide repositioning as needed to maintain upright posture. Interview on 9/19/22, at 12:10 p.m. Resident R54's husband indicated I think they bumped her hand pushing her into the table for meals. She's had two x-rays now because of the bruising, swelling, and warmth to that area. Interview on 9/22/23, at 8:54 a.m. Registered Nurse Employee E2 indicated there's a progress note from 9/2/23, that indicated the bruise was still present and that on 8/16/23, it was discovered in the dining room. Interview on 9/22/23, at 8:58 a.m. Nursing Assistant Employee E1 indicated I worked a few days 395638 Page 9 of 12 395638 09/22/2023 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few after the bruise was discovered. It's possible her left hand was bumped into the table at mealtimes because she has that bolster on her chair. She's a two assist for transfers. Interview with the Director of Nursing on 9/22/23, at 9:49 a.m. indicated there was not a thorough investigation completed and the only witness statements obtained were from Resident R54 who has severe dementia and that the facility failed to fully investigate (interviewing the persons involved, interviewing all potential witnesses and to interview other staff members who had contact with Resident R54) alleged allegation of abuse/neglect for one of five residents (Resident R54). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.14(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.20(b) Staff development. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. 395638 Page 10 of 12 395638 09/22/2023 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and staff interviews it was determined that the facility failed to maintain sanitary conditions in the Main Kitchen which created the potential for cross contamination. (Main Kitchen) Residents Affected - Many Findings include: During an observation on 9/19/23, at 10:00 a.m. it was revealed one ice machine in the main kitchen contained a brown substance inside the machine. Review of Masonic Village work orders dated May-July 2023, revealed the ice machine was last serviced 7/17/23. During an interview on 9/19/23, at 9:50 a.m. the Food Service Director Employee E5 confirmed the brown substance in ice machine and it has not been cleaned since 7/17/23, creating the potential for cross contamination. 28 Pa Code: 201.14(a) Responsibility of licensee. 395638 Page 11 of 12 395638 09/22/2023 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

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 the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R36). Residents Affected - Few Findings include: Review of the facility Competency and Procedure: Wound Dressing Change last reviewed 8/21/23, indicated prepare a clean, dry work area at bedside and place linen saver or towel under resident if needed. Review of face sheet indicated Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/4/23, indicated the diagnoses of anemia (the blood doesn ' t have enough healthy red blood cells), coronary artery disease (narrow arteries decreasing blood flow to heart), and high blood pressure. Review of Resident R36's physician's order dated 8/29/23, indicated to cleanse open area to coccyx (tail bone area) with wound cleanser, pat dry after two minutes. Apply Medi honey (a gel used for its anti-inflammatory effects) to wound base, cover with mepilex foam (a self-adhering, multilayer foam dressing) daily. During an observation of Resident R36's dressing change on 9/20/23, at 11:00 a.m. Registered Nurse (RN) Employee E3 was being assisted by Licensed Practical Nurse (LPN) Employee E4. RN Employee E3 opened the resident's brief on one side to expose the coccyx area. Removed the old dressing with gloves on and proceeded to the bathroom to wash her hands. During this time LPN Employee E4 was holding Resident R36 on her side, she rolled resident back down flat onto the dirty brief to allow her to rest while waiting for RN to return. A clean field was not placed in between the exposed wound and the inside of the dirty brief. Interview on 9/20/23, at 1:00 p.m. the Director of Nursing was informed of the above observations during the dressing change for Resident R36 and that the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R36). 28 Pa. Code: 201.20(c) Staff Development. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. 395638 Page 12 of 12