Health inspection·October 22, 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/complaint logs, as well as staff interviews, it was determined that the facility failed to ensure that a written copy of the grievance/complaint decision was provided to the resident and/or resident representative for one of four residents reviewed (Resident 1). Findings include: The facility's policy regarding grievances/complaints, dated June 7, 2024, revealed that the resident, or the person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. The administrator or designee will make such reports orally within five working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office. The facility's grievance/complaint logs, dated July through October 22, 2024, revealed that Resident 1 filed a verbal grievance/complaint with the facility on September 9, 2024. The concern/grievance report stated that a nurse aide rushes her out of the dining room, and that the nurse aide has an attitude, making it hard for her and the other table members to approach the nurse aide. The nurse aide also makes the dining room uncomfortable when she is there, and that the nurse aide also slammed a cup down. A summary of the investigation revealed that the nurse aide stated there may be a delay on requested items at times. They educated the nurse aide and will evaluate the need for extra assistance in the dining room at meal times. The facility indicated that the grievance/complaint investigation was completed on September 13, 2024. However, as of October 22, 2024, there was no documented evidence that Resident 1 received a written grievance/complaint report. Interview with the Nursing Home Administrator on October 22, 2024, at 4:00 p.m. confirmed that there was no documented evidence until October 22, 2024, that Resident 1 was informed of the findings of the investigation. 28 Pa. Code 201.29(i) Resident Rights. Page 1 of 3 395646 395646 10/22/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on review of Pennsylvania's Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a questionable physician's order for one of four residents reviewed (Resident 1). Residents Affected - Few Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. Physician's orders for Resident 1, dated August 25, 2024, included an order for the resident to receive the Restorative Nursing (a person-centered program that helps residents in long-term care facilities improve or maintain their ability to live independently and safely) Range of Motion (ROM - the distance and direction a joint can move between its fully extended and flexed positions) program to maintain her current upper extremity strength through use of a weighted dowel rod. There was no documented evidence that Resident 1's physician was contacted to clarify how much weight was to be on the dowel rod, how often and/or how many repetitions the resident was to complete. Interview with the Nursing Home Administrator on October 22, 2024, at 4:10 p.m. confirmed that Resident 1's Restorative Nursing ROM program should have been clarified with the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395646 Page 2 of 3 395646 10/22/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of four residents reviewed (Resident 1). Findings include: Physician's orders for Resident 1, dated August 25, 2024, included an order for the resident to receive the Restorative Nursing (a person-centered program that helps residents in long-term care facilities improve or maintain their ability to live independently and safely) Range of Motion (ROM - the distance and direction a joint can move between its fully extended and flexed positions) program to maintain her current upper extremity strength through use of a weighted dowel rod. Restorative Nursing documentation for Resident 1, dated August, September, and October 2024, revealed that staff documented N/A during the 2:00 p.m. to 10:00 p.m. shift on August 27, 2024; documented as N/A during the 6:00 a.m. to 2:00 p.m. shift on September 1, 3, 5, 6, 22, and 29, 2024, and during the 2:00 p.m. to 10:00 p.m. shift on September 2, 3, 6, 9, 14, 16-19, 26-28, and 30, 2024; and documented as N/A during the 6:00 a.m. to 2:00 p.m. shift on October 6, 13, 18-21, 2024, and during the 2:00 p.m. to 10:00 p.m. shift on October 1, 9, 10, 12, and 20, 2024. Review of Resident 1's clinical record revealed no documented evidence that staff completed and/or that the resident refused the Restorative Nursing ROM program on the above dates. Interview with the Nursing Home Administrator on October 22, 2024, at 4:10 p.m. confirmed that Resident 1's Restorative Nursing ROM program was not accurately documented to reflect if staff completed and/or if the resident refused on the above dates. 28 Pa. Code 211.5(f) Clinical Records. 395646 Page 3 of 3