Health inspection·August 30, 2023

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility's admission packet, as well as observations and staff interviews, it was determined that the facility failed to ensure that the results of all recent surveys conducted by state surveyors (Department of Health) were made accessible for residents to review without asking for staff assistance. Residents Affected - Few Findings Include: A facility policy regarding examination of survey results, dated December 21, 2022, revealed that a copy of the most recent survey, including any subsequent extended surveys, follow-up revisits reports, along with state approved plans of correction of noted deficiencies, would be maintained in a three-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room. An interview with a group of residents on August 28, 2023, at 3:00 p.m. indicated that the results of the state inspection surveys were available in the lobby. However the lobby door was locked, and the results were not accessible to residents to read without asking for facility staff assistance to open the door. Observations during the survey on August 28 through 29, 2023, revealed that the three-ring binder was on the bottom shelf at the visitor sign in table. The lobby door was locked at all times and only accessible by an access code. Interview with the Nursing Home Administrator on August 29, 2023 at 12:07 and 12:19 p.m. confirmed that the survey results were located only in the lobby area. She indicated that the survey results were available to to public, and residents would have to ask facility staff to open the door to have access to the lobby area. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. Page 1 of 12 395646 395646 08/30/2023 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a nurse aide registry verification upon hire for one of two nurse aides reviewed (Nurse Aide 1) and failed to complete a licensed practical nurse (LPN) license check prior to hire for one of one licensed practical nurses reviewed (LPN 2). Residents Affected - Few Findings include: The facility's policy regarding background screening investigations, dated December 21, 2022, revealed that the purpose of the policy was to ensure the Director of Personnel, or designee, would conduct background checks, reference checks, and criminal conviction checks on all potential direct access employees and contractors. Background and criminal checks were to be initiated within two days of an offer of employment or contract agreement and completed prior to employment. Applicants for a position of nurse assistant would have the state nurse aide registry contacted to determine any findings of abuse, neglect, mistreatment of individuals, and/or theft of property, and the check would be entered into the applicant's file. For any licensed professional applicants that may be involved in direct contact with residents, his/her respective licensing board would be contacted to determine if any sanctions have been assessed against the applicant's license. The personnel file for Nurse Aide 1 revealed that she was hired as a nurse aide on July 6, 2023, and the Pennsylvania Nurse Aide Registry check was verified on August 28, 2023, over one month after she was hired. The personnel file for LPN 2 revealed that she was hired as a licensed practical nurse on July 18, 2023, and the Pennsylvania Professional Licensure check was not verified until August 29, 2023, over one month after she was hired. Interview with the Nursing Home Administrator on August 29, 2023, at 4:10 p.m. confirmed that there was no documented evidence of a nurse aide registry check being completed as required upon hire for Nurse Aide 1 or a professional licensure check being completed as required upon hire for LPN 2. Interview with the Human Resources/Scheduler on August 30, 2023, at 11:55 a.m. confirmed that there was no documented evidence of a nurse aide registry check being completed as required upon hire for Nurse Aide 1 or a professional licensure check being completed as required upon hire for LPN 2. She added that she completed the required checks, but either forgot to print the documents for the personnel file or was pulled away to complete other tasks before printing the documents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 395646 Page 2 of 12 395646 08/30/2023 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for two of 25 residents reviewed (Residents 8, 27). Findings include: The facility's policy regarding care plans, dated December 21, 2022, indicated that the facility was responsible for the development of an individualized comprehensive care plan for each resident. A significant change comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated August 6, 2023, revealed that the resident was understood and could understand, was cognitively intact, required extensive assistance from staff for her daily care tasks, and had a diagnoses that included respiratory failure, chronic obstructive pulmonary disease (COPD - impaired air flow in lungs), and used oxygen therapy. A care plan for Resident 8, dated April 30, 2021, revealed that the resident had respiratory impairment and staff was to provide oxygen at two liters per minute as needed. Physician's orders for Resident 8, dated July 31, 2023, included an order for staff to administer six liters per minute via nasal cannula (a tube in the nose to administer oxygen). As of August 30, 2023, there was no documented evidence that Resident 8's care plan was revised/updated to include her current oxygen needs. Interview with the Director of Nursing on August 30, 2023, at 9:25 a.m. confirmed that Resident 8's care plan was not revised/updated to reflect current physican's orders. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated June 5, 2023, revealed that the resident usually understood, usually understands, required extensive assistance from staff for his daily care tasks, and had a diagnosis of Clostridioides difficile (C-Diff - a germ that causes diarrhea and colitis (an inflammation of the colon). A care plan for Resident 27, dated June 12, 2023, revealed that the resident had an infection of C-Diff and staff was to maintain isolation precautions (used to reduce transmission of microorganisms in healthcare) as indicated. Physician's orders for Resident 27, dated July 29, 2023, included an order for staff to discontinue contact precautions (used for infections, diseases, or germs that are spread by touching the patient or items in the room) for C-Diff. As of August 30, 2023, there was no documented evidence that Resident 27's care plan was revised/updated to include the discontinuation of contact precautions for C-Diff. Interview with the Director of Nursing on August 30, 2023, at 2:25 p.m. confirmed that Resident 27's care plan was not revised/updated to include the discontinuation of contact precautions for 395646 Page 3 of 12 395646 08/30/2023 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601

F 0657 C-Diff. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. Residents Affected - Few 395646 Page 4 of 12 395646 08/30/2023 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on the review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician order for daily weights was followed for one of the 25 residents reviewed (Resident 8) and failed to ensure medications were provided as ordered for one of the 25 residents reviewed (Resident 24). Residents Affected - Few Findings include: The facility policy for documentation of medication orders, dated December 21, 2022, indicated that when recording treatment orders, specify the treatment, frequency, and duration of the treatment. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated August 6, 2023, revealed that the resident was understood and understands, was cognitively intact, required extensive assistance from staff for her daily care tasks, and had a diagnosis which included respiratory failure, chronic obstructive pulmonary disease (COPD impaired air flow in lungs), and congestive heart failure. Physician's orders for Resident 8, dated August 18, 2023, included an order for the resident to be weighed daily. A cardiac consult for Resident 8, dated August 17, 2023, revealed that it was recommended that she have a daily weight. A nursing note for Resident 8, dated August 17, 2023, revealed that the resident went to a cardiac clinic appointment for a follow up regarding her congestive heart failure and all recommendations were reviewed and accepted. A review of the weights obtained by facility date, revealed there was no documented evidence that Resident 8 was weighed on August 23, 26, and 27, 2023. Interview with the Director of Nursing on August 29, 2023, at 3:25 p.m. confirmed that there was no evidence that Resident 8 was weighed on the dates listed above per physician's orders. The facility policy for documentation of medication administration, dated December 21, 2022, indicated that documentation of the medication administration record (MAR) should include the resident name, name and strength of the drug, dosage, route of administration, date and time of the administration, signature and title of the person administering the medication, and the resident response to the medication (for example as needed pain medication). The facility policy for controlled medications, dated December 21, 2022, indicated that when a controlled medication is administered, the licensed nurse administering the medication immediately enters the date and time of administration, amount administered, and the signature of the nurse administering the dose, completed after the medication is actually administered. The significant change minimum data set (MDS) assessment (mandated to assess the resident's abilities and care needs) for Resident 24, dated July 5, 2023, indicated that she was alert and oriented, required extensive assistance of two for bed mobility and transfers, and she had occasional pain at the level of 4 (pain scale of 1-10 with 10 the most severe). 395646 Page 5 of 12 395646 08/30/2023 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601

F 0684 Level of Harm - Minimal harm or potential for actual harm Physician order for Resident 24, dated June 22, 2023, included an order for Oxycodone 5 milligrams (mg) by mouth every six hours as needed for pain for five days. The medication administration record for Resident 24 for June 2023 indicated that the resident was provided Oxycodone on June 23 at 11:56 a.m. Residents Affected - Few There was no documented evidence where the staff would have obtained the medication for administration. The physician order, dated June 3, 2023 for Resident 24 included an order for Tramadol 50 mg every eight hours as needed for pain. The medication administration record for Resident 24 for July and August 2023 indicated that the resident was provided Tramadol on July 9 at 2:11 p.m. and August 15 at 10:00 a.m. There was no documented evidence where the staff would have obtained the medication for administration. Interview with the Director of Nursing on August 30, 2023, at 8:52 a.m. confirmed that there was no documented evidence that the medications were removed from the controlled medications to be provided to the resident at those times; therefore, it could not have been provided. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 395646 Page 6 of 12 395646 08/30/2023 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for an indwelling urinary catheter for one of 25 residents reviewed (Resident 25) who had a indwelling urinary catheter. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated June 5, 2023, revealed that the resident usually understood, usually understands, required extensive assistance from staff for his daily care tasks, and had an indwelling urinary catheter. Physician's orders for Resident 27, dated June 12, 2023, included an order for staff to check the patency and output from the resident's left nephroureteral catheter (a tube inserted directly into the kidney. The tube then drains urine from the kidney into a collection bag outside of the body) every shift. Resident 27's Treatment Administration Record, dated June, July, and August 2023, revealed that there was no documented evidence that the resident's nephroureteral tube's patency and output was completed as ordered during the 6:00 a.m. to 2:00 p.m. shift on June 18, 2023, and July 13, 2023; on the 2:00 p.m. to 10:00 p.m. shift on June 17, 2023; and on the 10:00 p.m. to 6:00 a.m. shift on July 8 and 21, 2023, and August 11 and 15, 2023. Interview with the Director of Nursing on August 30, 2023, at 1:00 p.m. confirmed that there was no documented evidence that Resident 27's nephroureteral tube's patency and output was completed as ordered by the physician on the above dates. 28 Pa. Code 211.12(d)(5) Nursing services. 395646 Page 7 of 12 395646 08/30/2023 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an intravenous line was flushed in accordance with professional standards for three of 25 residents reviewed (Residents 24, 27, 39) and failed to ensure that physician's orders were followed for intravenous line care for one of 25 residents reviewed (Resident 39). Residents Affected - Some Findings include: The facility's policy regarding flushing of central venous (a thin, flexible tube (catheter) that is placed into the large vein above the heart for the administration of fluids and/or medications) and midline (catheter inserted in the upper arm for the administration of fluids and/or medications) catheters, dated December 21, 2022, revealed that staff were to flush catheters at regular intervals to maintain patency and before and after the following: administration of intermittent solutions, administration of medications, administration of blood or blood products, obtaining blood samples, and/or converting from continuous to intermittent therapies. The diagnosis record for Resident 24, last updated June 30, 2023, included the diagnosis of pneumonia. A nursing note for Resident 24, dated June 25, 2023, indicated that the IV team inserted a midline (catheter inserted directly into a vein for provision of medications). Physician's orders for Resident 24, dated June 25, 2023, included an order for Ceftriaxone Sodium (antibiotic)intravenous (IV-directly into the vein) 2 gram (gm) at bedtime for respiratory infection. Physician's orders for Resident 24, dated June 26, 2023, included an order for a 10 cubic centimeters (cc) normal saline flush (sterile salt and water solution to help prevent IV catheters from becoming blocked and to help remove any medication that may be left in the catheter after medication administration) IV every shift for maintenance, and a 10 cc normal saline flush IV before and after each medication administration as needed. The medication administration record for Resident 24 for June and July 2023 revealed that she was administered the IV ceftriaxone sodium at 8:00 p.m. daily as ordered from June 25 through July 3, 2023 (9 doses); however, there was no documented evidence that the midline was flushed before and after each medication administration as per the facility's policy and physician's order. Physician's orders for Resident 27, dated June 28, 2023, included an order for the resident to receive one gram (gm) of Cefepime (an antibiotic) IV every 12 hours for 10 days and an order for the resident to receive a 10 cc normal saline flush before and after each medication administration as needed. Review of Resident 27's MAR for July 2023 revealed that Cefepime was administered as ordered from June 27, 2023, through July 8, 2023. There was no documented evidence that the resident's IV catheter was flushed before or after medication administration on those dates. Physician's orders for Resident 27, dated July 31, 2023, included an order for the resident to receive 3.375 gm of Zosyn (an antibiotic) IV every six hours for 10 days and to receive 10 cc of normal 395646 Page 8 of 12 395646 08/30/2023 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601

F 0694 saline IV before and after each medication administration as needed. Level of Harm - Minimal harm or potential for actual harm A review of Resident 27's MAR's for June and August 2023 revealed that Zosyn was administered as ordered from July 31, 2023, through August 10, 2023; however, there was no documented evidence that the resident's IV catheter was flushed before or after medication administration on August 1 through 5, 2023. Residents Affected - Some Physician's orders for Resident 39, dated June 19, 2023, included an order for the resident to receive one gm of ceftriaxone (an antibiotic) IV one time a day for seven days and to receive 10 cc of normal saline IV before and after each medication administration as needed. A review of Resident 39's MAR for June 2023 revealed that ceftriaxone was administered one time a day on June 19 through 25, 2023; however, there was no documented evidence that the resident's IV catheter was flushed with 10 cc of normal saline before or after medication administrations on June 20 through 25, 2023. Physician's orders for Resident 39, dated July 17, 2023, included an order for the resident to receive two gm of ceftriaxone IV one time a day for seven days and for the resident to receive 10 cc of normal saline before and after each medication administration as needed. Physician's orders for Resident 39, dated July 22, 2023, included an order for the resident to receive two gm of ceftriaxone IV one time a day until July 26, 2023. A review of Resident 39's MAR for July 2023 revealed that ceftriaxone was administered one time a day on July 17 through 26, 2023. However, there was no documented evidence that the resident's IV catheter was flushed with 10 cc of normal saline before or after medication administrations on July 17 through 25, 2023. Interview with the Assistant Director of Nursing on August 29, 2023, at 1:31 p.m. indicated that the physician's orders should have been placed as a routine flush before and after medication administration as per the facility policy and that it was incorrect in the electronic system. Physician's orders for Resident 39, dated July 17, 2023, included an order for staff to measure the circumference of the resident's upper arm at the IV insertion site in centimeters (cm) every shift and as needed. Resident 39's MAR's for July 2023 revealed that staff were documenting the circumference of the resident's upper arm at the IV insertion site each shift. However, there was no documented evidence that the measurement was in cm each shift on July 17 through 30, 2023. Interview with the Director of Nursing on August 30, 2023, at 8:50 a.m. confirmed that there was no documented evidence that the circumference of Resident 39's upper arm was measured in cm on the above dates. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395646 Page 9 of 12 395646 08/30/2023 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on clinical record reviews and staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for two of 25 residents reviewed (Residents 24, 35). Findings include: The facility's policy for controlled medications, dated December 21, 2023, indicated that when a controlled medication is administered, the licensed nurse administering the medication immediately enters the date and time of administration, amount administered, and the signature of the nurse administering the dose after the medication is actually administered. A diagnosis record for Resident 24, dated June 22, 2023, had diagnoses that included neuropathy (weakness numbness and pain from nerve damage), pneumonia, fracture of the upper left arm, pain disorder with psychological factors, depression and anxiety. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated July 5, 2023, revealed that she was alert and oriented, required extensive assistance of two for bed mobility and transfers, and she had occasional pain. Physician's orders for Resident 24, dated June 22, 2023, included an order for 5 milligrams (mg) of Oxycodone (opioid pain medication) every six hours as needed for pain for five days. The controlled drug log for Resident 24 for June 2023 indicated that 5 mg of Oxycodone was removed on June 24, 2023, at 4:00 a.m. and June 25, 2023, at 3:40 p.m. However, the resident's clinical record, including the medication administration record (MAR) and nursing notes, contained no documented evidence that the signed-out doses of Oxycodone were administered to the resident on these dates and times. Physician's orders for Resident 24, dated June 3, 2023, included an order for 50 mg of Tramadol (opioid pain medication) every eight hours as needed for pain rated 7-10 on a scale (scale of 1-10, with 10 being the worst pain imaginable). The controlled medication log for Resident 24 for Tramadol, from June through August 2023, indicated that the medication was removed on June 6 at 4:00 a.m.; June 8 at 8:45 a.m.; June 11 at 5:45 a.m.; June 17 at 7:00 p.m.; June 18 at 5:30 a.m.; June 21 at 8:00 p.m.; June 22 at 4:48 a.m., 1:00 p.m. and 10:00 p.m.; June 23 at 4:30 a.m.; June 24 at 12:00 a.m.; June 27 at 12:00 a.m.; June 30 at 9:10 p.m.; July 1 at 10:00 p.m.; July 2 at 8:00 p.m.; July 4 at 7:00 p.m.; July 15 at 8:00 p.m.; July 20 at 12:00 a.m.; July 29 at 4:00 a.m.; August 4 at 3:30 a.m.; August 7 at 9:00 p.m.; August 15 at 8:00 p.m.; August 16 at 8:00 p.m.; August 17 at 9:00 p.m.; and August 25 at 5:30 a.m. (25 times). However, the resident's clinical record, including the medication administration record (MAR) and nursing notes, contained no documented evidence that the signed-out doses of Tramadol were administered to the resident on these dates and times. Interview with the Director of Nursing on August 30, 2023, at 8:52 a.m. confirmed that there was no documented evidence that the medications were provided to the resident at these times. 395646 Page 10 of 12 395646 08/30/2023 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601

F 0755 Level of Harm - Minimal harm or potential for actual harm An admission MDS assessment for Resident 35, dated July 11, 2023, revealed that the resident was cognitively intact, required extensive assist from staff for daily care needs, and had diagnoses that included fibromyalgia (causes pain and tenderness throughout the body) and Parkinson's disease (causes stiffness and uncontrollable movements). A care plan, dated July 5, 2023, indicated that Resident 35 had pain with an intervention for staff to administer pain medication per physician's orders. Residents Affected - Some Interview with Resident 35 on August 28, 2023, at 10:54 a.m. revealed that she had pain in her left leg and back. Current physician's orders for Resident 35 included an order for the resident to receive 5-325 mg of Oxycodone/acetaminophen every 12 hours as needed for pain. A review of the controlled drug record for Resident 35 for July and August 2023 indicated that 5-325 mg of Oxycodone/acetaminophen was removed from the controlled drugs on July 20, 2023, at 8:00 p.m.; on July 21, 2023, at 8:00 p.m.; on July 27, 2023, at 10:00 a.m.; on July 29, 2023, at 8:00 p.m.; on August 3, 2023, at 11:15 a.m.; on August 9, 2023, at 10:00 a.m.; on August 18, 2023, at 1:30 a.m.; on August 24, 2023, at 6:30 p.m.; and on August 27, 2023, at 12:00 a.m. However, the resident's clinical record, including the medication administration record (MAR) and nursing notes, contained no documented evidence that the signed-out tablets of Oxycodone/acetaminophen were administered to the resident on these dates and times. Interview with the Director of Nursing on August 30, 2023, at 9:26 a.m. confirmed that there was no documented evidence that the narcotic pain medication was provided to Resident 35 at the dates and times listed above. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.9(a)(1)(h) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395646 Page 11 of 12 395646 08/30/2023 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility policies, as well as interviews with residents and a meal test tray, it was determined that the facility failed to serve food items that were palatable and at proper temperatures. Residents Affected - Some Findings include: The facility's policy for food preparation and service, dated December 21, 2022, indicated that fresh, frozen or canned foods are cooked to a holding temperature of 135 degrees Fahrenheit and the proper hot and cold temperatures are to maintained during food distribution. An interview with a group of residents on August 28, 2023 at 3:00 p.m. revealed a concern about food being cold when served in the dining room and that it is not always good. Observations on August 30, 2023, at 11:57 a.m. in the dietary department revealed that the broccoli was in a vented steam table pan with another pan underneath it that had water in it and the container was sitting on the stove griddle area. The stove temperature controls were noted to be in the off position. The last resident was served their lunch meal at 12:09 p.m. in the dining room. Temperatures of the test tray on August 29, 2023, at 12:11 p.m. revealed that the broccoli was 111 degrees Fahrenheit, cold, and not palatable to taste. Interview with the Dietary Manager on August 29, 2023, at 12:17 p.m. confirmed that the stove top was not on, or even warm, and that the broccoli was not hot. 28 Pa. Code 201.18(b)(1)(2)(e) Management. 28 Pa. Code 211.6(c) Dietary services. 395646 Page 12 of 12