Health inspection·April 19, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to document notification of changes in conditions for three of six residents (Resident R1, R2, and R3). Findings include: Review of the facility, Resident Change of Condition Policy last reviewed 1/1/24, indicated the family/responsible party will be notified when there has been a accident or incident involving the resident, a discovery of an injury, a reaction to medication or treatment, a significant change in the resident's physical/emotional/mental condition, a need to alter the resident's medical treatment including a change in provider orders, when there is a consistent refusal of treatment or medications, and a need to transfer the resident to the emergency room and/or admission to the hospital. Review of the clinical record revealed that Resident R1 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 4/3/24, included diagnoses chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and chronic kidney disease (gradual loss of kidney function). Review of Section C: Cognitive Patterns indicated that Resident R1 is cognitively intact. Review of Resident R1's demographic information indicated her daughter to be her emergency contact, responsible party, and healthcare power of attorney. Review of a facility provided incident report dated 1/27/24, stated, CNA (nurse aide) went to answer call light as resident stated she lost her balance and put herself on the floor. RN (registered nurse) supervisor assessed resident. Right elbow with scrapes, right shoulder has pink area. Review of the portion of the report entitled Notifications revealed the question of Resident Representative Notified as No. Review of Resident R1's progress notes revealed a note dated 1/24/24, and no new notes until 1/29/24. No progress notes were present providing information on Resident R1 placing herself on the floor, the injuries sustained then, or notification to her daughter. Review of family submitted information dated 4/5/24, indicated the daughter of Resident R1 stated she was not informed of her mother's changes in condition. Page 1 of 5 395653 395653 04/19/2024 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/19/24, at 11:55 a.m. Resident R1 stated that she has had emergencies that her daughter had not been notified of. Review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses psuedobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder) and coronary artery disease (damage or disease in the heart's major blood vessels). Review of Section C: Cognitive Patterns indicated that Resident R2 had cognitive impairment. Review of Resident R2's demographic information indicated his son to be his emergency contact and responsible party. Review of a progress note dated 2/16/24, at 6:00 p.m. indicated Resident R1 had an unwitnessed fall at 5:10 p.m. Nurse was called to residents room by (nurse aides). Resident was on the floor on the right side of bed. RNS (Registered Nurse Supervisor) called and assessed resident. He said he was dancing in bed when he fell out of bed. Resident stated his right arm was in pain, no bruising or laceration noted at this time on right arm. Both knees have abrasions from the fall. Bed bolsters on bed, fall mats in place, and bed was in lowest position during fall with call light within reach. Resident placed back into bed, bed bolsters replaced, bed in lowest position, fall mats in place, and call bell left within reach. Non skid footwear placed on resident. VS WNL (Vital signs within normal limits). Neuro checks initiated. RNS notified MD and family. Review of a second progress note dated 2/16/24, at 6:37 p.m. indicated Call to MD and notified of fall, he has no family to notify. Review of a facility provided incident report dated 2/16/24, stated, Unwitnessed fall. Review of the portion of the report entitled Notifications revealed the question of Resident Representative Notified as No. Review of the clinical record revealed that Resident R3 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses diffuse traumatic brain injury (a widespread disruption in the normal function of the brain) and coronary artery disease. Review of Section C: Cognitive Patterns indicated that Resident R3 had severe cognitive impairment. Review of Resident R3's demographic information indicated his daughter to be his emergency contact and responsible party. Review of a grievance report submitted on 2/12/24, from Resident R3's daughter indicated that she was not notified that Resident R3 tested positive for Covid-19 on 2/5/24. Further review of the grievance form confirmed that the nurse failed to notify Resident R3's daughter. During an interview on 4/19/24, at approximately 1:15 p.m. the Nursing Home Administrator confirmed that the facility failed to document notification of changes in conditions for three of six residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 395653 Page 2 of 5 395653 04/19/2024 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0580 28 Pa. Code 201.18(b)(1)(3) Management. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.29(a)(c)(d)(j) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. Residents Affected - Some 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395653 Page 3 of 5 395653 04/19/2024 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility policy, resident record, observation, resident interview and staff interview, it was determined the facility failed to provide necessary services to maintain adequate grooming and personal hygiene for ten of 18 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10). Residents Affected - Some Findings include: Based on review of facility policy titled Resident Bath/Showering/Scheduling Policy dated 1/1/24, indicated residents will be bathed or showered according to their preferences in order to maintain health hygiene and skin condition. During in observation on 4/19/24, at 11:40 a.m. Resident R4 was noted to be seated in a wheelchair in the hallway, with unkempt hair and long facial hair. During an interview and observation on 4/19/24, at 11:43 a.m. Resident R5 confirmed that she had filed a grievance on 3/28/24, related to not receiving showers. Resident R5 stated she has missed multiple showers, and would like at least one per week adding, I don't want to look like a hag, just because I'm in a place like this. During an observation on 4/19/24, at 11:48 a.m. Resident R8 was observed with greasy appearing, unbrushed hair. During an interview and observation on 4/19/24, at 11:55 a.m. Resident R1 requested assistance from the surveyor to put her socks on, stating she had been waiting two hours for help. Review of a grievance report filed on 4/2/24, by Resident R2's son revealed a request for Resident R2 to have twice weekly showers, a haircut, and to be shaved. The resolution of the grievance indicated that Resident R2 received a shower on 4/2/24, and a haircut on 4/8/24, and that Resident R2's showers will be monitored for two weeks to ensure compliance from staff. Review of Resident R2's electronic shower record from 3/1/24, through 4/19/24, revealed only bed baths, no showers. During an observation on 4/19/24, at 12:05 p.m. Resident R2 was noted to be unshaven, with what appeared to be multiple days growth of facial hair. During an observation on 4/19/24, at 12:10 p.m. Resident R6 was sleeping in a wheelchair in the hallway, wearing only a gown. Resident R6 was noted to have long fingernails and toenails. Review of Resident R6's plan of care initiated 4/12/24, failed to include information related to a possible desire to remain in a gown. During an interview and observation on 4/19/24, at 12:15 p.m. Resident R7 was observed with long, matted hair and a full beard. When asked, Resident R7 stated that he desired to keep the long hair and beard, but would like to have it brushed. Resident R7 was noted to have long fingernails on his left hand. Resident R7 stated that he is able to pull at the other ones and displayed using his left hand to tear off pieces of nail on his right hand, and stated that he is not able to use his right 395653 Page 4 of 5 395653 04/19/2024 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0677 hand to pull at the nails on his left (due to injury to right arm), I keep asking them to cut them. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/19/24, at 12:21 p.m. Resident R9 stated she had been waiting two hours to have her leaking colostomy bag changed. At this time, Resident R9 pulled her blanket to the side to display the leaking colostomy bag. Residents Affected - Some During an observation on 4/19/24, at 12:27 p.m. Resident R10 was observed to be wearing pants and a shirt with food spillage on both. During an interview on 4/19/24, 12:31 p.m. Resident R3 was observed with long nails on his left hand, which appeared contracted. During an interview on 4/19/24, at approximately 1:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide necessary services to maintain good grooming and personal hygiene for ten of 18 residents. 28 Pa. Code: 211.10(a)(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 28 Pa. Code: 201.29(j) Resident rights 395653 Page 5 of 5