Health inspection·November 3, 2023

F 0585 Level of Harm - Potential for minimal harm Residents Affected - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, observations, resident and staff interviews, it was determined the facility failed to provide grievance forms for filing anonymous grievances on three of three units (second floor unit, third floor unit and fourth floor unit). Findings include: Review of facility policy titled Concerns-Complaints-Grievances last reviewed on 1/9/23, informed it is the policy of the [NAME] Community Living Centers to assist residents and/or Resident Representatives in resolving issues of concerns in a prompt and timely fashion. The social service department reviews with the resident and/or resident representative how to file a grievance or complaint, including anonymously. During an observation on 10/31/23, at 10:10 a.m. the fourth floor unit did not have grievance forms available for residents/resident representatives to file anonymous grievances. During an interview on 10/31/23, at 10:15 a.m. the Social Service Director and Grievance Official Employee E1 informed grievance forms are placed in resident bedside tables and/or dressers. Families and visitors can request grievance forms from the administrative staff. The Social Service Director and Grievance Offical Employee E1 also informed this practice is in use on all three units. During a Resident Group meeting held on 11-1-23, at 10:30 a.m. 16 of the 16 attendees reported not receiving grievance forms in their bedside tables and/or dressers and did not know how to file an anonymous grievance. During an observation on 11/3/23, at 1:15 p.m. the second floor unit did not have grievance forms available to file anonymous grievances. During an observation on 11/3/23, at 1:20 p.m. the third floor unit did not have grievance forms available to file anonymous grievances. During an interview on 10/31/23, at 10:15 a.m. the Social Service Director and Grievance Official Employee E1 confirmed the facility failed to provide grievance forms for filing anonymous grievances. 28 Pa. Code: 201.18(e)(4) Management. Page 1 of 5 395640 395640 11/03/2023 John J Kane Regional Center-MC 100 Ninth Street McKeesport, PA 15132

F 0585 28 Pa. Code: 201.29(i) Resident Rights. Level of Harm - Potential for minimal harm Residents Affected - Many 395640 Page 2 of 5 395640 11/03/2023 John J Kane Regional Center-MC 100 Ninth Street McKeesport, PA 15132

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, resident clinical record, investigation documentations and staff interview, it was determined that the facility failed to report an injury of unknown source which caused severe bruising and required xrays for one of three residents (Resident R148). Findings include: Review of the facility policy Abuse, last reviewed on 1/9/23, indicated that every complaint or allegation of resident abuse shall be promptly reported and an investigation initiated. The resident will be protected and definition of abuse can include injuries of unknown source and can be suspicious due to the extent of the injury. Failure to report abuse, cooperate with the investigation can result in disciplinary action. During an interview on 11/1/23, at 2:08 p.m., the Director of Nursing(DON) stated that the facility does not have a resident transfer policy. Review of the clinical record indicated that Resident R148 was admitted to the facility on [DATE], with diagnoses which included Myopathy(a disease that affects the muscles that control voluntary movement in the body), malnutrition, contracture of both knees(inability to straighten legs completely), difficulty walking, dementia, and anxiety during transfers. A Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 9/13/23, indicated the diagnoses remained current with additional diagnoses of right shoulder pain added on 9/1/23. Review of an Annual Assessment progress note dated 8/3/23, indicated Resident R148 screams when touched and is fearful, Resident R148 has a right leg contracture requiring a pillow between the knees and a six inch foam mattress and express comfort cushion while in the wheelchair. The documentation indicated that Resident R148 is an assistance of one for transfers with pivoting. Review of a progress note dated 8/3/23, indicated that Resident R148 developed a bruise under her right upper arm 8 centimeters (cm) x 7 cm. The documentation indicated the Nurse Aide believed it was the result of lifting Resident R148 under the arms. An incident report dated 8/3/23, indicated bruising from unknown etiology requiring xrays of right forearm , right humerus(upper arm) and right hand being completed; the xray of her right humerus indicated a possible fracture. A MRI and/or CT scan was recommended, however, the facility Medical Director stated Resident R148 would not be able to tolerate a MRI and she was to be evaluated by Ortho specialist. Review of a progress note dated 8/11/23, indicated the bruising worsened and now had covered the whole right side of Resident R148's body including the right arm and shoulder right side and torso, and Resident R148 grimaced in pain when touched. Xrays of the right humerus, right forearm, right hand, and thoracic spine were completed on 8/12/23, indicating no fractures. Hoyer lift transfers were now ordered. An Orthopedic specialist saw Resident R148 and declined to perform MRI or CT scan and reordered xray of Resident R148 shoulder and stated no fracture and put Resident R148 in a sling. During an interview on 11/1/23, at 2:08 p.m., the Director of Nursing confirmed that the facility 395640 Page 3 of 5 395640 11/03/2023 John J Kane Regional Center-MC 100 Ninth Street McKeesport, PA 15132

F 0609 failed to report the injury of unknown source causing severe bruising to Resident R148 had not been identified as potential abuse/neglect and and reported to the State agency as required. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.14(a)(b)(c)(d) Responsibility of licensee. Residents Affected - Few 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 201.20(b) Staff Development. 395640 Page 4 of 5 395640 11/03/2023 John J Kane Regional Center-MC 100 Ninth Street McKeesport, PA 15132

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 review of facility policies, water testing logs and staff interview, it was determined that the facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia). Residents Affected - Few Findings include: The facility Water Management Program last reviewed on 1/9/23, indicated that the plan is to minimize risk for Legionella associated with the building water systems at [NAME] McKeesport. Based on framework outlined in ASHRAE Standards. During a review of the annual testing dated 7/31/23, of the facility water systems indicated that Resident room [ROOM NUMBER] sink had a positive result for Legionella requiring treatment and re-testing which occurred on 9/2/23,. This result indicated Resident room [ROOM NUMBER] sink had no detection of Legionella. During review of Resident room [ROOM NUMBER] did not indicate the facility protected residents as the residents were not removed from the room once positive until a negative result was obtained. During an interview on 11/2/23, at 11:17 a.m., Maintenance Director Employee E4 and the Nursing Home Administrator confirmed that the facility did not remove residents from the positive room [ROOM NUMBER] and did not report the positive result to the appropriate agencies as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code:201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.20(c) Staff development. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 395640 Page 5 of 5