Health inspection·April 4, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, facility documents, clinical records, and staff interview, it was determined that the facility failed to identify and investigate incidents of possible neglect and abuse for two of three residents (Residents R1 and R2). Residents Affected - Some Findings include: Review of the facility policy Abuse/ Neglect, last reviewed on 1/2/24, with a previous review date of 4/21/23, indicated that it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, exploitation, etc. Facility staff must immediately report all such allegations to the Administrator. The Administrator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy. Review of the facility Event Summary Report, dated from 1/1/24 through 3/31/24, indicated Resident R1 had a fall while receiving care when Resident R1 rolled out of bed with no injuries identified on 2/21/24. Review of the incident report dated 2/21/24, indicated Resident R1 kept rolling during incontinence care and slid onto the fall mat. Review of the Minimum Data Set (MDS- periodic assessment of care needs) dated 2/13/24 indicated Resident R1 , indicated that Resident R1 had diagnoses that included a bacterial intestinal infection, arthritis, anxiety disorder, post traumatic stress disorder, muscle wasting. Section G0110 indicated Resident R1 required assistance of two for bed mobility and transfers. Section GG 0170 indicated dependent for rolling left and right while in bed. During an interview on 4/4/24, at 1:15 p.m., the Director of Nursing (DON) stated that she was notified of the allegations made by Resident R1 but did not complete an investigation and/or report the incident as neglect as required. Review of a facility Concern Form dated 1/19/24, indicated Resident R2 had alleged neglect when he stated he had sat in his own urine for four hours on 1/18/24. Resident R2 stated he yelled out for staff and had the call bell on for two and a half hours. The form had been filled out by the Social Worker and the DON had documented that she had spoken to Resident R2. During an interview on 4/4/24, at 1:15 p.m., the DON stated that she had spoken to Resident R2 and did not identify the incident as neglect and did not complete an investigation and /or report the incident as required. Page 1 of 3 395719 395719 04/04/2024 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0610 28 Pa.Code: 201.14 (a) (c) (e) Responsibility of licensee. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.18 (e) (1) Management. Residents Affected - Some 395719 Page 2 of 3 395719 04/04/2024 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to make certain significant medications are administered as ordered by the physician for one of four residents (Resident R3). Residents Affected - Some Findings include: A review of the facility policy Medication Administration last reviewed on 1/2/24, with a previous review date of 4/21/23, indicated to administer medications as prescribed by the provider. A review of the clinical record indicated that Resident R3 was admitted to the facility on [DATE], with diagnoses that included syncope, muscle weakness and rheumatoid arthritis (the body's immune system attacks its own tissue, mainly in the hands and feet). A review of the MDS(Minimum Data Set - periodic assessment of resident care needs) dated 2/15/2024, indicated the diagnoses remain current. A review of a physician order dated 2/14/2024, indicated to give Hydroxychloroquine (immunosuppressive) oral tablet 200 mg (milligrams) one tablet by mouth every twelve hours at 07:00 (7:00 a.m.) and 21:00 (9:00 p.m.). A review of the Medication Administration Record (MAR) log dated 2/8/2024, through 2/19/2024, indicated the Hydroxychloroquine was not given to resident R3 for the dates 2/14/2024, through 2/19/2024. Review of a progress note dated 2/14/2024, indicated that the order had been sent to the pharmacy via fax after the order was obtained. Review of a progress note dated 2/17/2024 indicated that the medication continued to not be available and that the Nursing Supervisor had been made aware. During an interview on 4/4/2024, at 1:40 p.m., the Assistant Director of Nursing (ADON) Employee E1 confirmed that the facility failed to make certain Resident R3 was provided medications per a physician order which caused a significant medication error as the medication was for Resident R3's immunosuppressive disorder. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code:211.9(e)(f)(g)(h) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies. 395719 Page 3 of 3