Health inspection·August 1, 2024

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 provided documents, resident, and staff interviews, it was determined that the facility failed to report an alleged allegation of abuse for one of two residents (Resident R31). Findings include: Review of the policy Abuse Prevention dated 8/21/23, indicated it is the facility's policy to assure residents the right to 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. Review of admission record indicated that Resident R31 was admitted to the facility on [DATE]. Review of R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/11/24, indicated the diagnoses of renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), high blood pressure, and heart failure (the heart doesn't pump blood as well as it should). On 7/29/24, at 9:30 a.m. a review of Resident R31's care plan dated 5/7/24, indicated to monitor, document, and report adverse reactions of anticoagulant (medication reduces the coagulation of blood blood thinner) therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Revision added on 7/29/24, to monitor for increased senile purpura (dark purple bruises or blotches on the skin). Review of facility provided report dated 7/26/24, indicated during morning care an unnamed nurse aide noted a large bruise on Resident R31's left leg (measurement of 10 x 5 centimeters {cm} and 2 x 2cm). The assessment found two bruises on right leg as well (measurement of 4 x 1cm and 2 x 1 cm). Further review of the facility documentation provided and dated 7/26/24, indicated Resident Description Resident R31 stated A Nurse Aide (NA) pressed my leg tightly during care. Review of reports submitted and provided by the facility dated July 2024 did not include a report for the allegation of abuse. Page 1 of 10 395638 395638 08/01/2024 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 Interview on 7/29/24, at 9:15 a.m. Resident R31 indicated The only problems I've had here is that aide who pushed on my legs real hard and left me this big bruise as she pulled her sheets back to show her leg and injury. Observation on 7/29/24, at 9:15 a.m. Survey Agency (SA) visualized a large area to the left leg with bruising and areas of purpura. Interview on 7/30/24, at 10:24 a.m. Registered Nurse (RN) Supervisor Employee E1 indicated Resident R31 stated An aide pressed my leg tightly during care. It resulted in 10 x 5cm bruise. She mentioned the name NA Employee E12 who is a NA here, but she is confused. I let the Assistant Director of Nursing (ADON) Employee E2 know and put out the investigation forms. Interview on 7/31/24, at 10:11 a.m. the Director of Nursing confirmed it was an allegation of abuse that should have been reported and was not due to the fact it was unknown to management that a perpetrator (NA Employee E12), was identified during the initial report and confirmed the facility failed to report an alleged allegation of abuse for one of two residents (Resident R31). 28 Pa. Code 201.14(a)(c.)(e.) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(b) Staff development. 28 Pa. Code 211.10(c.)(d) Resident care policies. 395638 Page 2 of 10 395638 08/01/2024 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 for one of two residents (Resident R31). Residents Affected - Few Findings include: Review of the policy Abuse Prevention dated 8/21/23, indicated it is the facility's policy to assure residents the right to 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. Review of admission record indicated that Resident R31 was admitted to the facility on [DATE]. Review of R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/11/24, indicated the diagnoses of renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), high blood pressure, and heart failure (the heart doesn't pump blood as well as it should). Review of Resident R31's care plan on 7/29/24, at 9:30 a.m. dated 5/7/24, indicated to monitor, document, and report adverse reactions of anticoagulant (medication reduces the coagulation of blood - blood thinner) therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Revision added on 7/29/24, to monitor for increased senile purpura (dark purple bruises or blotches on the skin). Review of facility provided report dated 7/26/24, indicated during morning care an unnamed nurse aide noted a large bruise on Resident R31's left leg (measurement of 10 x 5 centimeters {cm} and 2 x 2cm). The assessment found two bruises on right leg as well (measurement of 4 x 1cm and 2 x 1 cm). Further review of the facility provided report dated 7/26/24, indicated Resident Description Resident R31 stated A Nurse Aide (NA) pressed my leg tightly during care. Interview on 7/29/24, at 9:15 a.m. Resident R31 indicated The only problems I've had here is that aide who pushed on my legs real hard and left me this big bruise as she pulled her sheets back to show her leg and injury. Observation on 7/29/24, at 9:15 a.m. Survey Agency (SA) visualized a large area to the left leg with bruising and areas of purpura. Interview on 7/29/24, at 2:28 p.m. Licensed Practical Nurse (LPN) Employee E8 indicated Resident R31 makes up stories about the NA Employee E12 who works as needed here and she (Resident R31), always picks on her (NA Employee E12). Resident gets purpura because she's on blood thinners and steroids. NA Employee E12 would never hurt her. Interview on 7/30/24, at 10:24 a.m. Registered Nurse (RN) Supervisor Employee E1 indicated Resident R31 stated An aide pressed my leg tightly during care. It resulted in 10 x 5cm bruise. She 395638 Page 3 of 10 395638 08/01/2024 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 mentioned the name NA Employee E12 who is a NA here, but she is confused. I let the Assistant Director of Nursing (ADON) know and put out the investigation forms. On 7/30/24, at 10:24 a.m. SA requested to see the investigation regarding the allegation of neglect. RN Supervisor Employee E1 indicated I sent the investigation forms out (questionnaire of who was giving care that asks them questions about what they perceived to have happened). They are supposed to give them back to me or put them in the Director of Nursing's (DON) box. The ones I get, I give to the DON. The staff from the night before wouldn't have signed them yet. I don't know where the forms are at this moment, I do not have them. Interview on 7/30/24, atm 1:11 p.m. the Director of Nursing provided three witness statements dated 7/26/24. A witness statement from the alleged perpetrator NA Employee E12 was taken today on 7/30/24, four days after the allegation was known. Interview on 7/31/24, at 10:11 a.m. the Director of Nursing confirmed the facility failed to complete a comprehensive investigation for an allegation of abuse to include identifying all the persons involved, interviewing all potential witnesses and interviewing the alleged perpetrator timely. 28 Pa. Code 201.14(a)(c.)(e.) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(b) Staff development. 28 Pa. Code 211.10(c.)(d) Resident care policies. 395638 Page 4 of 10 395638 08/01/2024 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

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 clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exited to an unsupervised and unauthorized location without staff's knowledge) for one of two resident (Residents R17). Findings include: Review of the admission Record indicated Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/6/24, indicated the diagnoses of Dementia (a group of symptoms that affects memory, thinking and interferes with daily life), chronic kidney disease and venous insufficiency (leg veins don't allow blood to flow back up to your heart). Section C: Cognitive Patterns, Question C0100 indicated a BIMS score of 1- severe cognitive impairment. 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 Elopement/Exit Seeking Evaluation Form dated 12/7/23, indicated that Resident R17 had a score of 21 indicating elopement risk. Per facility provided documents on 11/5/23 6:50 a.m. alerted by 2nd floor NA that Resident R17 was on Magnolia neighborhood nurses' station. Per NA Resident R17 had wandered off and took the back staff elevator. He was reported missing 6:45 a.m. and was last seen approximately 15 minutes prior, returned from the 2nd floor 6:55 a.m. Interview with Director of Nursing (DON) on 7/31/24 at 10 a.m. indicated staff were not reeducated after incident. During an interview on 7/31/24 at 10:30 a.m. the DON confirmed the facility failed to provide adequate supervision for one resident resulting in elopement (Resident R17). 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies. 395638 Page 5 of 10 395638 08/01/2024 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

F 0689 28 Pa. Code: 201.29(a)(b)(c)(I)(n) Resident rights. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(1) Management. Residents Affected - Few 395638 Page 6 of 10 395638 08/01/2024 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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, observations, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Resident R25). Residents Affected - Few Findings include: Review of federal guidance §483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. Review of facility policies failed to reveal a policy for oxygen therapy. Review of the clinical record indicated that Resident R25 was admitted to the facility on [DATE]. Review of Resident R25's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/17/24, indicated diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking, and behavior. This is a gradual progressive condition), dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Section O - Special Treatments, Procedures, and Programs, Sub-section O0110C, Oxygen Therapy indicated the use of oxygen therapy. During an observation on 7/29/24, at 10:45 a.m., Resident R25 was observed sitting at her bedside; on the other side of her bed was an oxygen concentrator (medical device that removes nitrogen from room air and provides oxygen-enriched gas for people who need more oxygen in their blood) which was attached to a nasal cannula (light weight tube placed in the nose to provide oxygen) that was lying directly on the floor. Resident R25 stated that she only uses oxygen via nasal cannula at night from the concentrator. During an observation and interview at 10:53 a.m., Licensed Practical Nurse (LPN) Employee E9 confirmed that the nasal cannula tubing was lying on Resident R25's floor in her room next to the concentrator. LPN Employee E9 stated that tubing is changed weekly, and that the nasal cannula should not be lying directly on the floor. Review of Resident R25's physician orders on 7/29/24, indicated an order initiated on 5/1/24, for Oxygen at 2 L (liters) per nasal cannula every shift. Review of Resident R25's Treatment Administration Record (TAR) on 7/29/24, for the month of July 2024, indicated documentation every shift that oxygen per physician orders was being administered. During an interview on 7/31/24, at 9:56 a.m., Nurse Aide (NA) Employee E10 stated that Resident R25 only uses her oxygen at night. During an interview on 7/31/24, at 10:30 a.m., Licensed Practical Nurse (LPN) Employee E9 stated in 395638 Page 7 of 10 395638 08/01/2024 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reference to R25's oxygen use, that her (R25's) doctor gave her (LPN E9) verbal orders to allow oxygen use at night, and acknowledged that the current physician order does not reflect oxygen use at night for Resident R25, and that the doctor was in the building and would clarify Resident R25's oxygen order for use. Review of Resident R25's clinical record on 7/31/24, at 10:40 a.m., indicated that on 7/31/24, at 10:25 a.m., physician orders for Resident R25's oxygen administration were changed to Oxygen at 2 L (liters) per minute via NC (nasal cannula) for nocturnal use at bedtime; Oxygen at 2 L per minute via NC for nocturnal use every night shift; and Oxygen at 2 L per minute via NC as needed for shortness of breath or O2 (oxygen) sats (saturation) <90% on room air. Review of Resident R25's Treatment Administration Record (TAR) on 8/1/24, for the month of July 2024, indicated changes to physician orders for oxygen use per above were initiated 7/31/24, and prior oxygen use order for every shift initiated 5/1/24, were discontinued 7/31/24. Review of Resident R25's current plan of care updated 5/14/24, indicated that a plan of care was developed for respiratory diagnoses, which included interventions for monitor for respiratory distress, however current care plan failed to indicate that a plan of care was developed for the use of oxygen therapy, maintenance of humidification cannisters, changing of tubing, possible skin breakdown from tubing use, and signs and symptoms related to oxygen therapy to be reported to the provider. During an interview on 7/31/24, at 12:28 p.m., Registered Nurse Assessment Coordinator (RNAC) Employee E11 confirmed that the facility to develop a plan of care for Resident R25's care and use of oxygen. During an interview on 8/1/24, at 9:45 a.m., the Director of Nursing (DON) confirmed that the facility does not have a policy for oxygen administration, and that the facility failed to appropriate respiratory care for one of three residents (Resident R25). 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 395638 Page 8 of 10 395638 08/01/2024 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

F 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies, in-service documentation, personnel records, and staff interviews it was determined that the facility failed to implement and maintain an effective annual in-service training program for four of of eight personnel records (Nurse Aide Employee E3, Nurse Aide Employee E4, Nurse Aide Employee E5, and Nurse Aide Employee E6). Residents Affected - Some Findings include: The facility Employee Compliance Education procedure policy dated 8/21/23, indicated that it is the policy of the facility to provide employees with compliance education and training. Education and issues on specific issues will be provided to staff members. The facility Employee policy handbook dated 12/2023, indicated in order to remain at the highest level of skill and training, employees are requested and may be required to attend or complete the periodic in-service training programs. Review of the facility Annual In-Service course listing dated 2024, included the following courses: Abuse Prevention, Reporting, and Resident Rights Active Shooter: Emergency Preparedness Communicating with Older Adults Cultural Competence Culture, Quality Assurance Performance Improvement, and Regulatory Compliance De-Escalation General De-Escalation Dementia Basics Elder Abuse Emergency Preparedness Fire Safety and Life Safety Codes Hand Hygiene Hand Hygiene Competency HIPAA (Health Information Portability Accountability Act) and Data Protection Infection Prevention 395638 Page 9 of 10 395638 08/01/2024 Masonic Village at Sewickley 1000 Masonic Drive Sewickley, PA 15143

F 0940 Internal Compliance Documents Level of Harm - Minimal harm or potential for actual harm Resident Emergencies Workplace Communication Residents Affected - Some Workplace Safety Review of Nurse Aide (NA) Employee E3's personnel record indicated she was hired on 7/17/19. Nurse Aide (NA) Employee E3's in-service education records did not include annual in-service trainings for infection control, dementia training, communication, and abuse training for 2024. Review of Nurse Aide (NA) Employee E4's personnel record indicated she was hired on 6/8/11. Nurse Aide (NA) Employee E4's in-service education records did not include annual in-service trainings for infection control, dementia training, communication, and cultural competence for 2024. Review of Nurse Aide (NA) Employee E5's personnel record indicated she was hired on 3/17/17. Nurse Aide (NA) Employee E5's in-service education records did not include annual in-service trainings for infection control, dementia training, and communication for 2024. Review of Nurse Aide (NA) Employee E6's personnel record indicated she was hired on 7/26/13. Nurse Aide (NA) Employee E6's in-service education records did not include annual in-service trainings for infection control, dementia training, communication, and abuse training for 2024. During an interview on 7/31/24, at 10:12 a.m. Nurse Aide (NA) Employee E7 stated the following: I have been here for ten years. There are a lot of trainings online. We (staff) have to do so many trainings and for so many hours per year. During an interview on 7/31/24, at 12:11 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to implement and maintain an effective annual in-service training program for Nurse Aide Employee E3, Nurse Aide Employee E4, Nurse Aide Employee E5, and Nurse Aide Employee E6 as required. 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(a)(d) Staff development 395638 Page 10 of 10