Health inspection·January 13, 2025

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for six of 24 residents (Resident R67, R147, R148, R153, R248, and R249). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that an admission MDS assessment was to be completed no later than 14 days following admission. Resident R148 had an admission date of 12/20/24, with an MDS not completed as of 1/13/25. Resident R249 had an admission date of 12/21/24, with an MDS not completed as of 1/13/25. During an interview on 1/8/24, at 1:35 p.m. the Registered Nurse Assessment Coordinator (RNAC) Employee E9 confirmed that the facility failed to make certain that MDS assessments were completed in the required time frame for six of 24 residents. 28 Pa. Code: 211.5(f) Clinical records. Page 1 of 24 395719 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that that quarterly Minimum Data Set (MDS- periodic review of resident care needs) assessments were completed within the required time frame for three of eight residents reviewed (Resident R44, R52, and R76). Residents Affected - Some Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required MDS assessments, dated October 2023, indicated that quarterly MDS assessments were to be completed no later than 14 days after the Assessment Reference Date (ARD). Resident R52 had an ARD of 12/18/24, with the MDS not completed as of 1/13/25. During an interview on 1/8/24, at 1:35 p.m. the Registered Nurse Assessment Coordinator (RNAC) Employee E9 confirmed that the facility failed to make certain that MDS assessments were completed in the required time frame for three of eight residents residents. 28 Pa. Code: 211.5(f) Clinical records. 395719 Page 2 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan that included diabetes care and interventions needed to provide effective and person-centered care for four of fourteen residents (Resident R22, R32, R44, R150, and R195) . Finding include: The facility policy Baseline-Care Plans reviewed 1/2/24, indicated a baseline care plan to meet the resident's immediate needs shall be developed within forty-eight hours of the resident's admission. Review of the admission record indicated Resident R22 was admitted to the facility on [DATE], with the diagnosis of diabetes mellitus (too much sugar in the blood). Review of Resident R22's baseline care plan completed on 1/11/25, indicated the resident has not been care planned for diabetes. Review of the admission record indicated Resident R32 was admitted to the facility on [DATE], with the diagnosis of diabetes mellitus. Review of Resident R32's baseline care plan completed on 11/9/24, indicated the resident has not been care planned for diabetes. Review of the admission record indicated Resident 150 was admitted to the facility on [DATE], and readmitted on [DATE], with the diagnosis of diabetes mellitus. Review of Resident R150's baseline care plan completed 11/30/24, indicated the resident has not been care planned for diabetes. Review of the admission record indicated Resident R195 was admitted to the facility on [DATE], and readmitted [DATE], with the diagnosis of diabetes mellitus. Review of Resident R195's baseline care plan completed 9/2/24, indicated the resident was not care planned within 48 hours and has not been care planned for diabetes. During an interview on 1/8/25, at approximately 11:30 a.m. the Director of Nursing and Assistant Director of Nursing confirmed that the baseline care plan for Residents R22, R32, R44, R150, and R195 did not accurately include their immediate care needs. 28 Pa. Code: 211.11 (a)(c)(d) Resident care plan. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. 395719 Page 3 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Resident Assessment Instrument (RAI) User's Manual, facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for five of fourteen residents (R22, R32, R44, R150, R195). Finding include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions or completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated the following instructions for Section V Care Area Assessment (CAA) Summary, Questions V0200: For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The Care Planning Decision column must be completed within 7 days of completing the RAI (MDS and CAA(s)). Check column B if the triggered care area is addressed in the care plan. Review of the facility Comprehensive Care Planning Policy dated 1/13/25, previously reviewed 1/2/24, indicated the facility must develop a comprehensive, person-centered care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessments. Review of Resident R22's admission record indicated she was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes mellitus (too much sugar in the blood)and chronic kidney disease (kidneys have trouble filtering waste out of the blood). Review of the MDS dated [DATE], Section V Care Area Assessment (CAA) Summary, Question V0200 was not completed. Review of Resident R22's care plan dated 1/9/25, failed to include goals and interventions related to diabetes mellitus. Review of Resident R32's admission record indicated he was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes mellitus (too much sugar in the blood)and end-stage renal disease (severe loss of kidney function). Review of the MDS dated [DATE], Section V Care Area Assessment (CAA) Summary, Question V0200 was not completed. Review of Resident R32's care plan dated 1/9/25, failed to include goals and interventions related to diabetes mellitus. Review of Resident R44's admission record indicated he was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes mellitus,and heart failure (heart 395719 Page 4 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0656 doesn't pump blood as well as it should). Level of Harm - Minimal harm or potential for actual harm Review of the MDS dated [DATE], Section V Care Area Assessment (CAA) Summary, Question V0200 was not completed. Residents Affected - Few Review of Resident R44's care plan dated 1/9/25, failed to include goals and interventions related to diabetes mellitus. Review of Resident R150's admission record indicated she was admitted to the facility on [DATE] and readmitted [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes mellitus and dementia (thinking and social symptoms that interferes with daily functioning). Review of the MDS dated [DATE], Section V Care Area Assessment (CAA) Summary, Question V0200 was not completed. Review of Resident R150's care plan dated 1/9/25, failed to include goals and interventions related to diabetes mellitus. Review of Resident R195's admission record indicated he was admitted to the facility on [DATE] and readmitted [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes mellitus and lung cancer. Review of the MDS dated [DATE], Section V Care Area Assessment (CAA) Summary, Question V0200 was not completed. Review of Resident R195's care plan dated 1/9/25, failed to include goals and interventions related to diabetes mellitus. During an interview on 1/8/25, at approximately 11:30 a.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to develop and implement comprehensive care plans to meet residents care needs for five of fourteen residents. 28 Pa. Code 211.11(d) Resident care plan. 395719 Page 5 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **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 revise/update care plans for two of eight residents to accurately reflect the current status of the resident (Residents R5 and R195). Findings include: Review of facility Comprehensive Care Planning Policy dated 1/13/25, previously reviewed 1/2/24, indicated that in cases of significant changes in the resident's condition, the care plan must be updated within seven days of the new MDS. Review of the admission record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/4/24, indicated the diagnoses of Alzheimer ' s disease (a type of brain disorder that causes problems with memory, thinking and behavior), anemia (too little iron in the body causing fatigue), and chronic kidney disease (gradual loss of kidney function). Review of Resident R5's physician order dated 6/11/24, indicated to that Resident R5 began receiving hospice services. Review of Resident R5 ' s Significant Change MDS dated [DATE], indicated Resident R5 began receiving hospice care while a resident. Review of Resident R5's current care plan on 1/9/25, failed to include goals and interventions related to Resident R5 receiving hospice services. Review of the admission record indicated Resident R195 was admitted to the facility on [DATE]. Review of Resident R195's MDS dated [DATE], indicated the diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), respiratory failure with hypoxia (condition where the body doesn't have enough oxygen in the tissues), and lung cancer. Review of Resident R195's physician order dated 12/22/24, indicated to that Resident R195 was to receive continuous oxygen therapy. During an observation on 1/8/25, at approximately 1:30 p.m. Resident R195 was noted to be wearing a nasal canula (flexible tube that gives additional oxygen through the nose). Review of Resident R195's current care plan on 1/8/25, failed to include goals and interventions related to Resident R195 receiving oxygen therapy. During an interview on 1/13/25, at approximately 3:00 p.m. the Director of Nursing confirmed the facility failed to revise/update care plans for two of eight residents to accurately reflect the current status of the resident. 395719 Page 6 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0657 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.11(e) Resident care plan. Residents Affected - Some 395719 Page 7 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility review of policy, manufacturer's instructions, clinical records and staff interviews, the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for 14 of 22 residents (R6, R8, R22, R32, R38, R39, R44, R56, R57, R59, R65, R79, R150, R195). Residents Affected - Some Findings Include: Review of facility policy Diabetic Protocol dated 1/2/24, indicated provider and staff will work together to give appropriate treatment to manage diabetes. The provider will follow up on any acute episodes associated with significant blood glucose level changes and deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. The staff will identify and report complications such as hypoglycemia. Review of the facility Hypoglycemia Policy dated 1/2/24, indicated nursing personnel are responsible for recognizing signs and symptoms of hypoglycemia and responding accordingly. When acute hypoglycemia is suspected, assess mental status (alert, drowsy, uncooperative, or unconscious) and use glucometer to determine the resident's blood sugar level. A blood glucose of 70 mg/dL or less may indicate the need for intervention. If there are no provider orders for specific treatment do the following: -If the resident is conscious and treatment is indicated, give 1 tube of dextrose gel (15 grams). -After 15 minutes, repeat blood sugar and if still under 70 mg/dL, repeat glucose gel. -After 15 minutes repeat blood sugar. If above 70 mg/dL, give a snack of protein and a carbohydrate (ex. ½ sandwich with bread and a protein or crackers and a protein.) Monitor until stable. -If the resident is drowsy or unconscious or is unable or unwilling to consume anything orally, administer glucagon 1 mg subcutaneously. Monitor the resident for 15 minutes after treatment. -If, after 15 minutes, the resident is conscious and able to consume orally, give a snack of a protein and a carbohydrate (ex. ½ a sandwich with bread and a protein or crackers and a protein). Monitor until stable; -If, after 15 minutes the resident still cannot consume anything orally, repeat glucagon 1 mg subcutaneously and call 911. Further review of the policy failed to reveal procedures in the event of a resident experiencing hyperglycemia. Review of the Facility assessment dated [DATE], indicated the facility will provide care for residents diagnosed with diabetes. Review of the glucometer manufacturer's instructions indicated Low refers to less than 20 mg/dl, and High refers to greater than 600 mg/dl. 395719 Page 8 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0684 Review of the clinical record indicated that Resident R150 was admitted to the facility on [DATE]. Level of Harm - Immediate jeopardy to resident health or safety Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 12/4/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) with hyperglycemia and severe chronic kidney disease (gradual loss of kidney function). Residents Affected - Some Review of physician orders dated 11/30/24, 12/5/24, and 1/6/25, indicated to check blood sugar before meals, and call MD (Doctor of Medicine) for BS (blood sugar) <70 and >340. Review of Resident R150's plan of care failed to reveal goals and interventions related to diabetes and blood sugar level maintenance. Review of Resident R150's blood sugar record indicated that on 1/8/24, at 12:25 p.m. Resident R150's blood sugar was 509, documented by Licensed Practical Nurse (LPN) Employee E1. During an interview on 1/8/25, at approximately 2:30 p.m. LPN Employee E1 stated she had advised the Registered Nurse Supervisor (RNS) Employee E2 but had not had a response from her or the provider, and that no additional interventions or blood sugar rechecks had been completed on Resident R150. LPN Employee E1 further confirmed that the facility process is to notify the RNS, who then notifies the provider. During an interview on 1/8/25, at approximately 2:40 p.m. RNS Employee E2 stated she was not informed until 1:21 p.m. but she had not notified the provider stating, It is on my list. RNS Employee E2 confirmed no additional interventions or blood sugar rechecks had been completed on Resident R150. During an interview on 1/8/25, at approximately 2:45 p.m. the Director of Nursing (DON) confirmed that out of range blood sugar levels need to be addressed at the time of occurrence, and that a delay of greater than two hours was not appropriate. Further review of Resident R150's blood sugar record failed to reveal documentation of notification or follow-up for the following: 12/6: Result high 12/4: 448 Review of the clinical record indicated that Resident R195 was admitted to the facility on [DATE] and then readmitted [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes with hyperosmolarity (life threatening metabolic complication with severe high blood sugar) and lung cancer. Review of physician orders dated 12/21/24, indicated to check blood sugar twice a day (before breakfast and dinner), and call MD for BS <60 and >350. Review of Resident R195's plan of care failed to reveal goals and interventions related to diabetes and blood sugar level maintenance. 395719 Page 9 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0684 Level of Harm - Immediate jeopardy to resident health or safety During an interview on 1/8/25, at approximately 2:48 p.m. the Director of Nursing (DON) confirmed that out of range blood sugar levels need to be addressed at the time of occurrence, and that a delay of greater than two hours was not appropriate or documenting 24-48 hours later is not acceptable. Further review of Resident R195's blood sugar record failed to reveal documentation of notification or follow-up for the following: Residents Affected - Some 12/1: Went out to the hospital for change in condition and no BS done per protocol 11/9: Result 59-Note placed 48 hrs later 11/7: Result High-No note showing notification or follow-up 9/25: Result 473-No note documented until 24 hrs later Review of the clinical record indicated that Resident R32 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and end stage renal disease (ESRD - an inability of the kidneys to filter the blood). Review of a physician order dated 11/9/24, indicated for Resident 32 to receive Glipizide extended release (oral medication to treat diabetes) once daily. Review of physician's orders for November 2024, failed to reveal an order to check Resident R32's blood sugar level. Review of Resident R32's plan of care failed to reveal goals and interventions related to diabetes. Review of a progress note dated, at 11/17/24, at 9:00 a.m. indicated, Notified by RN assigned to resident that resident was observed on floor. Resident assessed no injuries at time of incident. Resident states he hit head neuro-checks initiated at time of incident and noted with some confusion but resident baseline. Resident able to state place and time and current needs at time of incident. Review of a progress note written by RNS Employee E8 dated 11/17/24, at 6:47 p.m. indicated, Notified by nurse assigned to resident that resident has become more confused throughout the day. Assessed resident and resident noted with increased confusion and speaking in incoherent sentences. Resident speech noted slurred, noted unable to hold self-up in wheelchair. Resident skin noted pale in color, pupils unequal but reactive to light. Resident able to state name but unable to state where he was. Obtained order from doctor and resident sent out to [hospital] via ambulance. Review of Resident R32's dietary intake indicated he did not eat breakfast or lunch, and there was no documentation of dinner. Review of Resident R32's blood sugar record failed to reveal that his blood glucose level was checked at the time of the fall as a possible reason for the fall, and failed to reveal that his blood sugar was checked at his change in mental status as a possible reason. Review of a progress note dated 11/18/24, at 3:02 a.m. indicated Resident R32 was admitted to the hospital with a diagnosis of hypoglycemia. 395719 Page 10 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of a hospital note dated 11/18/24, at 3:31 p.m. indicated, Blood glucose monitoring found severe hypoglycemia and further stated, EMS (emergency medical services) checked BG (blood glucose) at nursing home and was noted to be 27. During an interview on 1/11/25, at 3:21 p.m. RNS Employee E8 confirmed she wrote the above note about Resident R32's change in condition, and stated the LPN who was assigned to Resident R32 stated she had checked Resident R32's blood sugar. Review of the clinical record indicated that Resident R44 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes with hyperglycemia, right leg-below knee amputation, high blood pressure and heart failure (heart doesn ' t pump blood as well as it should). Review of a physician orders dated 8/3/24, and remained current, indicated to check blood sugar before meals and to call MD for BS <70 and >340. Review of Resident R44's plan of care for diabetes diagnosis; Interventions do not include instructions for staff on actions to take for hyper/hypoglycemia. Further review of Resident R44's blood sugar record failed to reveal documentation of notification or follow-up for the following: 9/2: Result High-No note showing notification, Result 4:46 p.m. 368-no documentation of notification. 9/1: Result 445-No note showing notification or follow-up. 8/31: Results 5:39 a.m.: 405, 11:23 a.m.: 415 (insulin given, recheck-470 with no further notes for further instruction), 4:29 p.m.: 404-No documentation of notification or follow-up. 8/29: Result 4:59 p.m.: 526, 6:00 p.m.:557-instructed to give insulin but no order to repeat or if more insulin should be given after repeated. Result 8:27 p.m.: 478-no documentation. Review of the clinical record indicated that Resident R65 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes with hyperglycemia and dementia (group of thinking and social symptoms that interferes with daily functioning). Review of a physician orders dated 11/9/23, and remained current, indicated to check blood sugar before meals and at bedtime, to call MD for BS >420. Review of Resident R65's plan of care included a diabetes diagnosis. No further documentation or interventions regarding this was noted. Further review of Resident R65's blood sugar record failed to reveal documentation of notification or follow-up for the following: 12/22: Result 487-Note documented 12/23 (the next day) 395719 Page 11 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0684 12/5: Result 422-Note documented 12/6 (the next day) Level of Harm - Immediate jeopardy to resident health or safety 7/13: Result High-Note documented 7/15 (Notes from 7/13 discuss resident receiving long-acting insulin at 7:29 p.m. and then the nurse attempting to give 6 Units of coverage but resident was screaming and punching people, so insulin not administered). Residents Affected - Some 7/7: Result High-Note documented 7/8 (the next day) During an interview on 1/11/25, at 3:02 p.m. LPN Employee E3 reviewed with the surveyor the blood sugar level of 487 for Resident R65 on 12/22/24. LPN Employee E3 stated she usually puts in a note and is unsure why she did not that day. Review of the clinical record indicated that Resident R22 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and dementia. Review of a physician orders dated 5/29/24, and remained current, indicated to check blood sugar twice daily at breakfast and dinner and to call MD for BS <70 and >400. Review of Resident R22's plan of care failed to reveal goals and interventions related to diabetes. Review of Resident R22's blood sugar record failed to reveal documentation of notification or follow-up for the following: 1/3: 412 12/11: 478 12/5: 411 11/14: 443 11/08: 400 10/27: 439 During an interview on 1/11/25, at 3:32 p.m. RN Employee E7 reviewed with the surveyor the blood sugar level of 478 on 12/11/24. RN Employee E3 stated she would have informed the RNS but was not able to provide a reason why it was not documented. Review of the clinical record indicated that Resident R38 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes with hyperglycemia and chronic kidney disease. Review of a physician orders dated 11/9/23, and remained current, indicated to check blood twice a day and to call MD for BS <70 and >420. Resident R38 is care planned for diabetes diagnosis. 395719 Page 12 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Further review of Resident R38's blood sugar record failed to reveal documentation of notification or follow-up for the following: 12/31: Result 441-No note showing notification or follow-up. 12/29: Result 401-No note showing notification or follow-up. Residents Affected - Some 12/28: Result 470-No note showing notification or follow-up. 12/25: Result 415-No note showing notification or follow-up. 12/21: Result 499-No note showing notification or follow-up. 12/20: Result 470-No note showing notification or follow-up. 12/19: Result 484-No note showing notification or follow-up. 12/17: Result 524-No note showing notification or follow- up Review of the clinical record indicated that Resident R39 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes with hyperglycemia. Review of a physician orders dated 8/14/24, and remained current, indicated to check blood sugar before meals and at bedtime and to call MD for BS <70 and >450. Resident R39 is care planned for diabetes diagnosis. Further review of Resident R39's blood sugar record failed to reveal documentation of notification or follow-up for the following: 11/14: Result 574-Note documented 11/15 (the next day). 10/2: Result HIGH-No note showing notification or follow-up. Review of the clinical record indicated that Resident R8 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes. Review of a physician orders dated 12/28/23, and remained current, indicated to check blood sugar twice a day and to call MD for BS <60 and >500. Resident R8 is care planned for diabetes diagnosis. Further review of Resident R8's blood sugar record failed to reveal documentation of notification or follow-up for the following: 12/27: Result HIGH-No note showing notification or follow-up. 395719 Page 13 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0684 12/13: Result HIGH-No note showing notification or follow-up. Level of Harm - Immediate jeopardy to resident health or safety 12/1: Result HIGH-No note showing notification or follow-up. Residents Affected - Some During an interview on 1/11/25, at 3:11 p.m. LPN Employee E5 reviewed with the surveyor the blood sugar levels of HIGH on 12/13/24, and 12/27/24. LPN Employee E5 stated always does a recheck but is unsure why it is not showing up in the electronic charting system. 11/19: Result HIGH-Note documented 11/20 (the next day). Review of the clinical record indicated that Resident R6 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes. Review of a physician orders dated 12/28/23, and remained current, indicated to check blood sugar before meals and bedtime and to call MD for BS <60 and >500. Resident R6 is care planned for diabetes diagnosis. Further review of Resident R6's blood sugar record failed to reveal documentation of notification or follow-up for the following: 12/13: Result HIGH-No note showing notification or follow-up. 8/14: Result HIGH-No note showing notification or follow-up. During an interview on 1/11/25, at 3:11 p.m. LPN Employee E5 reviewed with the surveyor the blood sugar levels of HIGH on 12/13/24. LPN Employee E5 stated always does a recheck but is unsure why it is not showing up in the electronic charting system. Review of the clinical record indicated that Resident R57 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and chronic kidney disease. Review of a physician orders dated 6/12/24, and remained current, indicated to check blood sugar twice a day and to call MD for BS <70 and >340. Resident R57 is care planned for diabetes diagnosis. Further review of Resident R57's blood sugar record failed to reveal documentation of notification or follow-up for the following: 11/28: Result 390-No note showing notification or follow-up. 11/14: Result 407-Note documented 11/15 (the next day). 9/6: Result 529-No note showing notification or follow-up. Review of the clinical record indicated that Resident R56 was admitted to the facility on [DATE]. 395719 Page 14 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0684 Review of the MDS dated [DATE], included diagnoses of diabetes. Level of Harm - Immediate jeopardy to resident health or safety Review of a physician orders dated 10/24/24, and remained current, indicated to check blood sugar before meals and at bedtime and to call MD for BS <70 and >400. Resident R56 is care planned for diabetes diagnosis. Residents Affected - Some Further review of Resident R56's blood sugar record failed to reveal documentation of notification or follow-up for the following: 11/8: Result HIGH-No note showing notification or follow-up. Review of the clinical record indicated that Resident R79 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes mellitus and dementia. Review of a physician order dated 3/8/24,and remained current, indicated to check blood sugar twice a day on Sunday, Monday, Wednesday, and Friday before breakfast and before dinner, check blood sugar twice a day on Tuesday, Thursday and Saturday between 11:00 a.m. and 2:00 p.m., 8:00 p.m. and 11:00 p.m., all without a sliding scale. Resident R79 is care planned for diabetes diagnosis only related to skin integrity. No information provided on hyper/hypoglycemia. Further review of Resident R79's blood sugar record failed to reveal documentation of notification or follow-up for the following: 11/18: Result Low-No documentation of notification or follow-up. Review of the clinical record indicated that Resident R59 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes mellitus and ESRD. Review of Resident R59's plan of care on 1/8/24, revealed that the care plan for diabetes did not include instructions for staff on actions to take for hyper/hypoglycemia. Review of a physician order dated 7/25/24, and remained current, indicated to check blood sugar before meals and to call MD for BS <70 and >340. Review of Resident R59's blood sugar record failed to reveal documentation of notification or follow-up for the following: 11/5/24: 49 During an interview on 1/8/25, at approximately 2:50 p.m. LPN Employee E3 was able to describe where to find parameters for notification on physician's order. Stated that she would notify RNS if blood sugar was out of range and document a nursing note in the medical record. During an interview on 1/8/25, at approximately 2:55 p.m. LPN Employee E4 stated low is below 70, 395719 Page 15 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0684 Level of Harm - Immediate jeopardy to resident health or safety and the high can be dependent on parameters in the physician's orders. Stated that if blood sugar was out of range she would notify the RNS, and if no response from RNS, she would text the provider directly. During an interview on 1/8/25, at approximately 3:00 p.m. LPN Employee E5 stated parameters are on the MD order, and she stated she would call the MD if outside the parameters. After prompting from the surveyor, stated she would document symptoms and follow-up in the medical record. Residents Affected - Some During an interview on 1/8/25, at approximately 3:00 p.m. RN Employee E6 stated the parameters for blood sugar are on the sliding scale order. Stated for out of range blood sugars, she would recheck the blood sugar. Stated for high, she would call the doctor, and for low she would initially provide a snack and recheck. Stated she is often RNS, and staff report high and low blood sugars to her, and she notifies the provider. The Nursing Home Administrator (NHA) and the DON were made aware that an Immediate Jeopardy situation existed for residents on 1/9/24, at 1:34 p.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time. On 1/9/24, at 6:29 p.m. an acceptable Corrective Action Plan was received which included the following interventions: After record review, it was determined that [the facility] failed to notify the physician of blood sugars out of range timely for 14 residents and care plans were absent or did not include approaches for diabetic emergency management. Immediate Actions: -Resident R150 was assessed by the Assistant Director of Nursing on 1/8/25 at 3:30 p.m. Resident had no s/s (signs or symptoms) of hyperglycemia at that time. -RNS Employee E2 spoke with the physician at 3:46 p.m. and reported the blood sugar of 509. The physician did not give any further orders. -Education was initiated on 1/8/25, with facility RNs and LPNs on the Diabetic Protocol, the Hypoglycemia policy, and the Resident Change in Condition policy to include hyperglycemia is a change in condition, and notifications to the physician of blood sugars out of range. -On 1/9/25, Residents R150, R195, R8, R6, R57, R56, R79, R32, R44, R65, R22, R38, R39, and R59's blood sugars were reviewed from the past 24 hours to ensure none were out of range without physician notification. -On 1/9/25, an ad hoc QAPI (Quality Assurance and Performance Improvement) committee meeting was held, and the medical director was made aware of the findings. -On 1/9/25, the RN assessment coordinator is reviewing the care plans for residents R150, R195, R8, R6, R57, R56, R79, R32, R44, R65, R22, R38, R39, and R59 to ensure the care plan reflects diabetes and there are approaches for diabetic emergency management. This will be completed by 1/9/25, at 10:00 p.m. 395719 Page 16 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0684 Like Residents: Level of Harm - Immediate jeopardy to resident health or safety -Current residents with diabetes have the potential to be affected. Current residents with diabetes were reviewed on 1/8/25 by the ADON (Assistant Director of Nursing) to determine if blood sugars were out of range and none were noted out of range. Residents Affected - Some -Current residents with diabetes are being reviewed by the RN assessment coordinator on 1/9/25, to ensure the care plan reflects diabetes and there are approaches for diabetic emergency management and will be completed by 1/9/25 at 10:00 p.m. Correction of System: -Root cause analysis completed by the center QAPI committee on 1/9/25, and determined failure to follow the Resident Change in Condition policy led to the allegation. -To prevent recurrence, the Director of Nursing initiated education with facility RNs and LPNs including agency staff on 1/8/25, on the Diabetic Protocol, the Hypoglycemia policy, and the Resident Change in Condition policy to include hyperglycemia is a change in condition and notification of the physician of blood sugars out of range. RNs and LPNs that were not on duty received education via phone and will receive in person education on their next scheduled shift. -Newly hired RNs and LPNs will be educated on the Resident Change of Condition policy, the Diabetic Protocol, and the Hypoglycemia policy in orientation by the Director of Nursing/ designee. Monitoring: -To monitor and maintain compliance, the Director of Nursing/ designee will review blood sugars daily x 2 weeks, 3x a week x 2 week and then weekly x 2 weeks to determine if any blood sugars were out of range and notifications made. If notification not documented, the physician will be contacted at the time of discovery and notified, and new orders implemented as needed. -To monitor and maintain compliance, new admissions/ readmissions with diabetes will be reviewed by the DON/ designee to ensure a care plan is implemented for diabetes including approaches for diabetic emergency management 5 x a week for 2 weeks, then weekly x 3 weeks. -Results of the audits will be forwarded to the center QAPI committee for review and recommendations. On 1/10/24, care plans for affected residents were reviewed, and confirmed they were corrected to show goals and interventions related to diabetes and blood glucose monitoring. On 1/10/24, the whole house audit was reviewed by surveyors, revealing its completion and accuracy. During interviews beginning at approximately 9:00 a.m. on 1/10/24, five LPNs and RNs were able to describe the correct procedure for documenting, monitoring, and needs of notification for blood sugars outside of the ordered parameters. During interviews beginning at approximately 1:30 p.m. on 1/10/24, three additional LPNs and RNs 395719 Page 17 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some were able to describe the correct procedure for documenting, monitoring, and needs of notification for blood sugars outside of the ordered parameters. The Immediate Jeopardy was removed on 1/10/24, at 2:13 p.m. when the action plan implementation was verified. During an interview on 1/13/24, at approximately 3:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for 14 of 22 residents. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. 395719 Page 18 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility documentation, cited deficiencies from previous surveys, review of plan of correction documentation, and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has the potential to affect 26 of 84 residents. Residents Affected - Some Finding include: Review of the facility policy Quality Assurance and Performance Improvement (QAPI) Program Policy dated 1/13/2025, indicated objectives of the QAPI program include providing a means to establish and implement performance improvement projects to correct identified negative or problematic indicators and to establish systems through which to monitor and evaluate corrective actions involving all levels of the organization. Health) survey ending 1/5/24, revealed the facility developed a plan of correction that included quality assurance systems to ensure the facility maintained compliance with cited nursing home regulations. Review of the plan of correction for the survey ending 1/5/24, revealed the following: - To identify other residents that have the potential to be affected, the Director of Nursing/designee will conduct a 14 day look back by 1/29/24, of current residents who receive glucometers to ensure blood glucose results outside of ordered parameters have been called to the physician. -To prevent recurrence, licensed nursing staff will be reeducated by the Director of Nursing/designee by 1/26/24 on calling the physician for blood glucose results outside of ordered parameters. -To monitor and maintain ongoing compliance, the Director of Nursing/designee will conduct audits weekly x 4 and monthly x2 of 7 residents who receive glucometers to ensure blood glucose results outside of ordered parameters have been called to the physician. -Results of the audits will be forwarded to the center QAPI committee for review and recommendations. The results of the current survey, ending 1/13/24, identified a repeated deficiency related to documentation of hypo/hyperglycemia, plan of care, and notification to the medical director in a timely manner. During the survey process the following was revealed: Resident R195- Order: if blood sugar (BS) <60 or >350 notify Medical Director (MD) -12/1: went out to the hospital for a change in condition and no blood sugar obtained as per protocol -11/9: Result 59 -note placed 48 hrs later 395719 Page 19 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0865 -9/25: Result 473-note documented 24 hrs later Level of Harm - Minimal harm or potential for actual harm Resident R150- Order: if BS <70 or >340 notify MD -12/6: Result High- No documentation or notification Residents Affected - Some -12/4: Result 448- No documentation or notification Resident R32-Order: if BS <70 or >350 notify MD -11/18: admitted to the hospital with severe hypoglycemia, result obtained by EMS was 27, staff did not follow the protocol for change in condition. Resident R44: Order-If BS <70 or >340 notify MD -9/2: Result High-No documentation -9/2: Result 368-No documentation of notification -9/1: Result 445-No documentation of notification -8/31: Results- 539 am-405 (no documentation), 1123 am-415 (insulin given recheck 470 with no documentation of what to do next), 429 pm-404 (no documentation or follow-up) -8/29: Results- 459 pm-526 (no documentation), 600 pm-557 (instructed to give insulin but no order to repeat or if more insulin should be given after repeated), 827 pm-478 (no documentation) Resident R65: Order-If BS >420 notify MD -12/5: Result 422-Note placed on 12/6 -7/13: Result High-Note documented 7/15 (Note on 7/13 received long acting insulin at 729 pm and nurse attempting to give 6 Units of coverage but resident screaming and punching people, so no insulin administered). -7/7: Result High- documented on 7/8 Resident R22: Order-If BS <70 or >400 notify MD -1/3: Result 412-No documentation or notification -12/11: Result 478-No documentation or notification -12/5: Result 411- No documentation or notification -11/14: Result 443-No documentation or notification -11/8: Result 400- No documentation or notification 395719 Page 20 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0865 -10/27: Result 439-No documentation or notification Level of Harm - Minimal harm or potential for actual harm Resident R38: Order-If BS <70 or >400 notify MD -12/31: Result 441- Note does not match BS result Residents Affected - Some -12/29: Result 401-No documentation or notification -12/28: Result 470-No documentation or notification -12/25: Result 415-No documentation or notification -12/21: Result 499-No documentation or notification -12/20: Result 470-No documentation or notification -12/19: Result 484-No documentation or notification -12/17: Result 524-No documentation or notification Resident R39: Order- If BS <70 or >340 notify MD -12/14: Result 445-No documentation or notification -12/13: Result 357-No documentation or notification -11/14: Result 574-Documentation 24 hrs later by ADON -11/3: Result 441-No documentation or notification -10/17: Result 371-No documentation or notification -10/2: Result High-No documentation or notification -8/4: Result 375-No documentation or notification -8/3: Result 560- Note placed 48 hrs later by ADON Resident R8: Order- If BS <60 or >500 notify MD -12/27: Result High- No documentation or notification -12/13: Result High- No documentation or notification -12/1: Result High- No documentation or notification -11/19: Result High-No documentation or notification Resident R6: Order- If BS <60 or >500 notify MD 395719 Page 21 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0865 -12/13: Result High-No documentation or notification Level of Harm - Minimal harm or potential for actual harm -8/14: Result High-No documentation or notification Resident R57: Order-If BS <70 or >340 notify MD Residents Affected - Some -11/28: Result 390-No documentation or notification -11/14: Result 407- Note placed 24 hrs later by ADON -9/6: Result 529-No documentation or notification Resident R56: Order-If BS <70 or >400 notify MD -11/8: Result High-No documentation or notification Resident R79: Order-No order for low or high levels, policy states if <70 notify MD -11/18: Result Low-No documentation or notification Resident R59: Order- If BS < 70 or >340 notify MD -11/5: Result 49- No documentation or notification During an interview on 1/8/25, at approximately 2:38 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to maintain an effective Quality Assurance Committee to ensure that the concerns related to documentation and notification of hypo/hyperglycemic events, with the potential to affect 26 of 84 residents. 42CFR 483.75(a)(2)(h)(i) QAPI Program/Plan, Disclosure/Good Faith Attempt. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.18 (e)(2)(3)(4) Management. 395719 Page 22 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on policy review, documentation and review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for ten of twelve months (April 2024 through January 2025). Residents Affected - Few Finding include: Review of the facility policy Legionella Assessment and Prevention Program dated 1/13/25, previously dated 1/2/24, indicated the facility will utilize water management practices to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Core Elements of the Water Management Plan are: 1. Establish Water Management Plan team. 2. Describe Center's water system using text and flow diagram. 3. Risk assessment with control methods and corrective actions. 4. Monitoring control measures. 5. Corrective actions. 6. Verification and validation. 7. Documentation and communication. memo, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated 7/6/18, revealed, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread Legionella and other opportunistic pathogens in water. This policy memorandum applies to Hospitals, Critical Access Hospitals (CAHs) and Long-Term Care (LTC). However, this policy memorandum is also intended to provide general awareness for all healthcare organizations. Facilities must have water management plans and documentation that, at minimum, ensure each facility: -Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Nontuberculous Mycobacteria, Burkholderia, Stenotrophomonas, and fungi) could grow and spread in the facility water system. -Develops and implements a water management program that considers the ASHRAE (American Society of Heating, Refrigerating, and Air Conditioning Engineers) industry standard and the CDC toolkit. -Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. 395719 Page 23 of 24 395719 01/13/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0880 -Maintains compliance with other applicable Federal, State and local requirements. Level of Harm - Minimal harm or potential for actual harm Review of the ASHRAE guidance Managing the Risk of Legionellosis Associated with Building Water Systems dated December 2020, indicated the most commonly used supplemental disinfection methods are treatment with chlorine, chlorine-dioxide, copper-silver ions, and monochloramine. The guidance further indicated the recommended levels of residual chlorine are 0.50-3.00 ppm (part per million). Residents Affected - Few Review of the facility provided water management information failed to include specific testing protocols and acceptable ranges for control measures along with a description of the facility's water system using a flow diagram. Review of the Water Management Program Control Measures did not contain a log for Point of Use Disinfectant (the level of chlorine concentration in the water) indicated to measure and record hot water and cold water chlorine concentration as point of use, and to note that chlorine concentration below 0.5 ppm and above 4.0 ppm as outside the control limits. During an interview on 1/8/25, at approximately 11:30 a.m. the Nursing Home Administrator confirmed that they do not have a Maintenance Director and that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 395719 Page 24 of 24