Health inspection·September 3, 2025

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to provide treatment and services related to heart failure (a progressive heart disease that affects pumping action of the heart muscles) for one of three residents (Resident R1).Findings Include:Review of the Unites States National Library of Medicine information Heart Failure dated 3/11/25, indicated symptoms of heart failure can include: Shortness of breath. Fatigue or weakness. Coughing. Swelling and weight gain from fluid in the ankles, lower legs, or abdomen. Difficulty sleeping when lying flat. Nausea and loss of appetite. Swelling in the veins of your neck. Needing to urinate often. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/18/25, included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R1's plan of care initiated 6/12/25, did not include documentation of goals and interventions related to heart failure upon its facility diagnosis on 7/21/25. Review of Resident R1's facility diagnosis list failed to include heart failure. Review of a provider order dated 6/13/25, indicated Weights: Obtain weight upon admission, then weekly x 4. Review of a provider order dated 7/22/25, indicated Please obtain weight on 7/25/25. Review of a provider order dated 7/23/25, indicated Resident R1 was to receive daily weights related to edema. Review of a provider's order dated 6/12/25, indicated Resident R1 was to be given furosemide (Lasix) 20 mg (milligrams) once daily as needed. Review of a provider's order dated 7/22/25, through 7/25/25, indicated Resident R1 was to be given Lasix 40 mg once daily. Review of a provider's order dated 7/26/25, indicated Resident R1 was to be given Lasix 20 mg once daily. Review of Resident R1's weight record revealed the following: 6/12/25: 220.7 lbs. (pounds)6/17/25: 218.0 lbs. 7/01/25: 217.0 lbs.7/04/25: 234.2 lbs. (Gain of 14 pounds in three days)7/15/25: 235.0 lbs. 7/22/25: 240.0 lbs. (Gain of five pounds in seven days) 7/23/25: 241.4 lbs. 7/25/25: 242.6 lbs. 7/26/25: 246.8 lbs. (Gain of four pounds in one day)8/01/25: 241.8 lbs.8/03/25: 238.2 lbs.8/04/25: 234.6 lbs.8/05/25: 232.5 lbs.8/07/25: 235.2 lbs.8/09/25: 213.0 lbs. Review of Resident R1's progress notes (6/12/25-8/9/25) failed to reveal documentation referencing the 17-pound weight gain that occurred between 7/1/25, and 7/4/25. Review of a nurse practitioner note dated 7/8/25, at 12:08 a.m. does not include documentation that the weight gain was reviewed or addressed. Review of a physician note dated 7/10/25, at 11:27 a.m. does not include documentation that the weight gain was reviewed or addressed. Review of a physician note dated 7/15/25, at 9:46 a.m. does not include documentation that the weight gain was reviewed or addressed. Review of a progress note dated 7/19/25, at 11:07 p.m. indicated, [Resident R1] has a PRN order for (Lasix, a medication to remove excess fluid in the tissue). I advised she would need to ask for it when Residents Affected - Few Page 1 of 6 395653 395653 09/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she needs it and her legs are swollen. Otherwise, suggest switching to daily dose. Review of a progress note dated 7/21/25, at 9:04 a.m. indicated, Resident has increase resp (respirations) with use of accessory muscles. Lungs have wheezes bil (bilaterally, both sides) with scattered crackles bil. Pulse ox is 90% with oxygen at 3 liters via nasal cannula. Resident has increased confusion during verbal interaction. Resident is easy to arouse with verbal stimuli. Heart rate strong and strong and reg. Cap refill (capillary refill) is less than 3 sec. VSS (vital signs stable) resident is afebrile. RNS (Registered Nurse Supervisor) aware and will make MD (Doctor of Medicine) aware during AM (morning) rounds. Review of a physician's note dated 7/21/25, at 11:03 a.m. indicated, Patient seen for increased LE (lower extremity) edema. Daughter had called in expressing concern in swelling in her legs. Patient is seen in her room this morning. The note further stated suspect CHF congestive heart failure. Review of a progress note dated 7/22/25, at 1:02 p.m. indicated that the physician was advised of a 13-pound weight gain. Review of the weight records indicated that Resident R1 had a 23-pound weight gain, not 13-pound. Review of a physician's note dated 7/23/25, at 9:46 a.m. indicated, Patient seen for follow-up of recent visits for leg swelling and weight gain. This morning, nursing noted her HR (heart rate) to be elevated to 120s. Patient was started on increased dose of Lasix yesterday for finding of LLL (left lower lobe of the lung) fluid on CXR (chest x-ray). During an interview on 8/27/25, at approximately 12:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide treatment and services related to heart failure for one of three residents. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. 395653 Page 2 of 6 395653 09/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, physician documents, and staff interviews, it was determined that the facility failed to make certain residents with intellectual disabilities receive appropriate services for one of three residents (Resident R2).Based on review of clinical records, and staff interview it was determined that the facility failed to make certain residents receive appropriate treatment and services for highest practicable mental and psychosocial services for one of three residents (Resident R28). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record indicated Resident R2 was initially admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) for Resident R2 dated 3/30/24, included diagnoses of end stage renal disease (ESRD, an inability of the kidneys to filter the blood), cancer of the breast and lung, and intellectual disabilities. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R2's score to be 03. Review of a provider note dated 3/14/24, indicated, Left voicemail for Director of Nursing at [facility]. Advised patient was dropped off at the front door again without any caregiver/attendant. Patient needs to have a caregiver with her when she comes for her appointments. Review of a provider note dated 4/1/24, indicated, Spoke with nursing supervisor at [facility], advised patient needs to arrive with caregiver as she has been dropped off at front door of the cancer center in the past and this is inappropriate for this patient and her needs. Nursing supervisor stated they would send a caregiver with patient to her upcoming appointment. Review of a provider note dated 4/9/24, indicated, Called and spoke with nursing supervisor, reviewed appointment on 4/11 for Faslodex and to ensure someone would be coming with the patient. Nursing supervisor stated they were told patient did not need an attendant with her because it was an injection. Advised at patient's last visit, the patient was very fearful coming to the infusion area alone and it created a negative experience for her. Nursing supervisor stated they would ensure that someone came with her. Review of a provider note dated 11/15/24, indicated, Pt with Faslodex appt on 11/12: Unable to receive treatment as a member from the patient's facility was unable to stay with her. AVS (After Visit Summary) with next appts printed and mailed to patient's facility. A note stating that a member from her facility must accompany her and stay for the duration of her treatment, as this has been previously discussed and agreed upon. Review of a provider note dated 1/7/25, indicated, Called [facility] to discuss the need to send a caregiver to [Resident R2's] appts. Spoke to Nursing Supervisor, and let her know that moving forward we will need to have a caregiver with [NAME] during her visits. We reviewed [Resident R2's] appts. Nursing Supervisor apologized and said she will communicate this with the administrator and this will be the case moving forward. Review of a provider note dated 6/5/25, indicated, Pt did not show for her Faslodex injection today. She resides at [facility] and requires a caregiver to accompany her. This is an ongoing issue. Pt did receive her last injection in May. Review of a provider note dated 6/5/25, indicated, Received call from Director of Nursing (DON) at [facility]. Reviewed ongoing issue of patient coming for Faslodex injections without an escort as well as during her office visits with [Doctor]. Reviewed patient has missed multiple appointments. DON stated he would help facilitate these appointments. Able to reschedule patients' Faslodex to 6/1/25, at 3:30 p.m. Advised subsequent 395653 Page 3 of 6 395653 09/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few appointments in July would be changed. Review of provider office visit notes dated 8/19/25, indicated, [Urology provider] stated there have been 4 appointments scheduled for this patient and [facility] had cancelled 3 of these appointments and had reported to [Urology provider] the did not have a escort for the appointment. The last appointment (4th appointment) was a no show. During an interview on 9/3/25, at approximately 12:00 p.m. the Nursing Home Administrator confirmed the facility failed to schedule ordered appointments and failed to make certain residents with intellectual disabilities receive appropriate services for one of three residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29 (a)(j) Resident rights. 28 Pa. Code 211.16 (a) Social services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395653 Page 4 of 6 395653 09/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, physician records, documents, and staff interviews, it was determined that the facility failed to schedule ordered appointments and failed to provide transportation for one of three residents (Resident R2). Findings include: Review of the United States Food and Drug Administration product information dated January 2021, indicated that Faslodex (fulvestrant) is an injectable medication for the treatment of advanced breast cancer. Not taking Faslodex for hormone receptor-positive (HR+), HER2-negative advanced or metastatic breast cancer can lead to the cancer progressing more quickly or returning sooner, potentially lowering the chances of extending life and improving symptoms. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record indicated Resident R2 was initially admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) for Resident R2 dated 3/30/24, included diagnoses of end stage renal disease (ESRD, an inability of the kidneys to filter the blood), cancer of the breast and lung, and intellectual disabilities. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R2's score to be 03. Review of a provider note dated 3/7/24, indicated, Called [facility] and spoke to supervisor. Advised supervisor last dose of Faslodex here at the cancer center given in November 2023. Patient has not showed to appointment for follow up visit in January or CT scan. Advised that patient is to have monthly Faslodex injections to treat breast cancer. Supervisor confirmed patient is not receiving Faslodex at [facility]. Review of a provider note dated 10/31/24, indicated, [Facility] called about missed Faslodex appointment today. Rescheduled to next available opening on November 12th at 3:30 p.m. Adjusted future appointments to reflect every 28-day schedule. Review of a provider note dated 4/1/25, indicated, Spoke with staff at [facility] to alert them that [Resident R2] missed her 11:30 a.m. appt today for Faslodex. They will call back to reschedule. Review of a provider note dated 5/8/25, indicated, This writer called and spoke with nursing supervisor at [facility] where patient resides. Nursing supervisor aware patient needs to follow up/make appt with urology related to patient c/o (complaints of) right flank pain and hematuria. Review of a provider note dated 6/5/25, indicated, Pt did not show for her Faslodex injection today. She resides at [facility] and requires a caregiver to accompany her. This is an ongoing issue. Pt did receive her last injection in May. Review of a provider note dated 6/5/25, indicated, Received call from Director of Nursing (DON) at [facility]. Reviewed ongoing issue of patient coming for Faslodex injections without an escort as well as during her office visits with [Doctor]. Reviewed patient has missed multiple appointments. DON stated he would help facilitate these appointments. Able to reschedule patients' Faslodex to 6/1/25, at 3:30 p.m. Advised subsequent appointments in July would be changed. Review of a provider note dated 8/7/25, stated, Placed on hold by [facility], unable to leave message. Call was made to let caretakers know that [Resident R2] missed her appointment today. Waited on hold for 8 minutes but had to hang up. Review of office visit notes dated 8/19/25, indicated, [Urology provider] stated there have been 4 appointments scheduled for this patient and [facility] had cancelled 3 of these appointments and had reported to [Urology provider] they did not have an escort for the appointment. The last appointment (4th appointment) was a no show. Review of an appointment history from 4/1/25, through 8/27/25, provided by outside medical provider indicated the following cancelled or missed appointments: 4/01/25, Faslodex/labs: Cancelled.4/22/25, Residents Affected - Few 395653 Page 5 of 6 395653 09/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Faslodex injection: Cancelled.4/29/25, Faslodex injection: Cancelled.4/30/25, Abdominal CT: Cancelled.5/01/25, Faslodex/labs: Cancelled.5/13/25, Three-month follow-up: Cancelled.5/21/25, Abdominal CT: Cancelled.5/27/25, Faslodex injection: Cancelled.5/29/25, Faslodex injection: Cancelled.6/02/25, DXA (type of bone density x-ray): Cancelled.6/05/25, Faslodex/labs: No show.6/26/25, Faslodex injection: Cancelled.7/03/25, Faslodex injection: Cancelled.7/10/25, Faslodex injection: No show.7/31/25, Faslodex injection: Cancelled.8/07/25, Faslodex injection: No show. During an interview on 9/3/25, at approximately 12:00 p.m. the Nursing Home Administrator confirmed the facility failed to schedule ordered appointments and failed to provide transportation for one of three residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1))(3)(e)(1) Management. 28 Pa. Code 201.29 (a)(j) Resident rights. 28 Pa. Code 211.2 (a) Physician services. 28 Pa. Code 211.16 (a) Social services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395653 Page 6 of 6