Health inspection·June 10, 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 clinical record review, and staff interviews, it was determined that the facility failed to implement a physician ordered follow-up MRI Scan for one of three residents reviewed with brain cancer (Resident R1). Residents Affected - Few Findings include: Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included a Glioblastoma removal with a craniotomy from a traumatic brain injury. Resident R1 had developed behaviors s/p the craniotomy and required constant monitoring, he was placed on the MIU(Memory care unit) of the facility as the resident also been exit seeking. Review of the clinical record indicated that on 4/30/25, Resident R1 had been sent to the hospital due to increased unsteadiness on his feet and a change in condition. Review of the clinical record indicated that on 5/7/25, Resident R1 returned to the facility with and order for a MRI on May 9, 2025. Resident R1's wife gave the paperwork and information to Licensed Practical Nurse (LPN) Employee E1. Review of a progress note dated 5/7/25, at 1:54 p.m., by LPN Employee E1 indicating the appointment being placed in the appointment book, the notification of the Staff Scheduler Employee E2 and the notification of the physician for the Ativan medication necessary for Resident R1 to tolerate the MRI scan. Review of the physician orders dated 4/4/25, through current indicated the Ativan order to be given on 5/9/25, prior to the MRI scan. Review of the Appointment Book provided by the facility identified Resident R1 being scheduled on 5/9/25, for pick up at 5:30 p.m., for the MRI scan and a note identifying his need for an escort. The appointment had been crossed out without explanation. During an interview on 6/10/25, at 10:39 a.m., Staff Scheduler Employee E2 stated that she writes escort under the area where the resident is to notify staff of the need for their resident to be escorted for an appointment. This was identified on the deployment sheet provided for 5/9/25. During an interview on 6/10/25, at 11:36 a.m., the Interim Director of Nursing(DON) stated that she was on duty that evening and remembered the previous DON having cancelled the appointment with no explanation. Page 1 of 2 395719 395719 06/10/2025 Riverside Health & Rehab Center 100 8th Street McKeesport, PA 15132

F 0684 Level of Harm - Minimal harm or potential for actual harm During an interview on 6/10/25, at 11:56 a.m., the Nursing Home Administrator confirmed that the facility failed to implement a physician ordered follow up MRI Scan for one of three residents reviewed with brain cancer (Resident R1). 28 Pa. Code 211.12(d)(1)(5) Nursing services Residents Affected - Few 395719 Page 2 of 2