Health inspection·April 29, 2024

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 policies, clinical records, and facility grievance forms, as well as staff interviews, it was determined that the facility had no documented evidence of the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the resident's concerns, or any corrective action taken or to be taken by the facility as a result of the grievance for one of five residents reviewed (Resident 1). Findings include: The facility's grievance policy, dated December 18, 2023, indicated that all grievances and complaints filed with the facility would be investigated and corrective actions would be taken to resolve the grievance(s). The investigation and report would include, as applicable: the date and time of the alleged incident; the circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their accounts of the alleged incident; the resident's account of the alleged incident; the employee's account of the alleged incident; accounts of any other individuals involved; and recommendations for corrective actions. The Grievance Officer would record and maintain all grievances and complaints on the Resident Grievance Complaint Log. The following information would be recorded and maintained in the log: the date the grievance was received; the name and room number of the resident filing the grievance/complaint; the name and relationship of the person filing the grievance/complaint on behalf of the resident; the date the alleged incident took place; the name of the person investigating the incident; the date the resident or interested party was informed of the findings; and the disposition of the grievance. The Resident Grievance/Complaint Investigation Report Form would be filed with the Nursing Home Administrator within five working days of the incident. A copy of the Resident Grievance/Complaint Investigation Report Form must be attached to the Resident Grievance/Complaint Form and filed in the business office. Copies of all reports must be signed and would be made available to the resident or person acting on behalf of the resident. The resident, or person acting on behalf of the resident, would be informed of the findings of the investigation, as well as any corrective actions recommended. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 27, 2024, revealed that the resident's cognition was moderately impaired and she was able to make her needs known. Information reported by the facility, dated February 6, 2024, revealed that Resident 1 submitted a concern that her i-Pad (electronic tablet) was missing again. The resident and staff were interviewed as to the last time that the i-Pad was seen and an exact date and time was not able to be obtained. However, it was last seen approximately the first week of January. The resident then asked that Page 1 of 2 395646 395646 04/29/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the i-Pad be replaced by the facility and after being told on February 5, 2024, that it was not the responsibility of the facility to replace the i-Pad, the resident stated that some one must have stolen it. She then requested to speak with a corporate representative who could get her a new i-Pad, and a corporate representative was scheduled to meet with the resident. There was no documented evidence that the resident's complaint/grievance was thoroughly investigated, including interviews and/or written statements from the staff who worked during the shift in question or whether the corporate representative met with the resident. There was also no documented evidence of a summary of the findings or conclusion regarding the resident's concerns or corrective actions taken or to be taken by the facility as a result of the grievance. Interview with the Regional Director of Clinical Operations on April 29, 2024, at 1:27 p.m. confirmed that there was no documented evidence that Resident 1's grievance was thoroughly investigated, including interviews with staff regarding the mentioned concerns, and no summary of the findings or corrective actions taken or to be taken by the facility. He confirmed that they were unable to find a grievance regarding her concern. 28 Pa. Code 201.29(i) Resident Rights. 395646 Page 2 of 2