Health inspection·June 13, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of five residents reviewed (Resident R38,R57). Findings Include: A review of the facility policy Advanced Directives on 1/1/2024, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the medical record indicated Resident R38 was admitted to the facility on [DATE], with diagnoses that included diabetes(high blood sugar), high blood pressure, congestive heart failure(chronic condition in which the heart doesn't pump blood as well as it should), and morbid (severe) obesity. A review of the clinical record failed to reveal an advance directive or documentation that Resident R38 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R57 was admitted to the facility on [DATE], with diagnoses that included morbid (severe) obesity, hypertensive heart disease with heart failure (uncontrolled high blood pressure that lead to the heart not being able to pump correctly), chronic obstructive pulmonary disease (COPD-a combination of lung diseases that block airflow and make it difficult to breathe), and wound to right lower leg. A review of the clinical record failed to reveal an advance directive or documentation that Resident R21 was given the opportunity to formulate an Advanced Directive. During an interview on 6/13/2024, at 10:32 p.m. the DON and Social Worker Employee E17 confirmed that the clinical record did not include documentation that Resident R38 and R57 were afforded the opportunity to formulate Advance Directives. 28 PA. Code 201.29(b)(d)(j) Resident rights. Page 1 of 2 395653 395653 06/13/2024 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, personnel records, clinical records and activity calendars, and staff interview, it was determined that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program. Residents Affected - Many Findings include: Review of the Life Enrichment Director job description indicated the qualifications were as required by State and Federal Regulations. Review of Life Enrichment Director Employee E2's personnel record indicated she was hired on 12/27/23. Review of Life Enrichment Director Employee E2's personnel record did not include evidence that Life Enrichment Director Employee E2 had proper qualifications as a Life Enrichment Director. The personnel record did not include education in therapeutic services, education as a social worker or occupational therapist, or a background in recreational services. Further review of resident records and facility activity calendars since Life Enrichment Director Employee E2 hire date, indicated she has been performing this job without any required oversight from an employee qualified to hold this position. During an interview on 6/13/24, at 10:42 a.m. the Director of Nursing (DON) confirmed Life Enrichment Director Employee E2 was hired on 12/27/23, and the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program. DON also confirmed that Life Enrichment Director Employee E2 was completing quarterly and annual assessments unsupervised by qualified staff. During an interview on 6/13/24, at 10:50 a.m. Life Enrichment Director Employee E2 confirmed that she did not have education in therapeutic services, education as a social worker or occupational therapist, or a background in recreational services. 28 Pa. Code: 201.18(b)(3) Management. 395653 Page 2 of 2