Health inspection·June 6, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to provide adequate bed mobility supervision for one of three residents (Resident R6). Findings include: Review of American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2018, indicated that Section G: Functional Status, Question G0110 A indicates Bed Mobility is how the resident moves to and from lying position, turns side to side, and positions body while in bed. The RAI User's Manual further defines bathing as solely how the resident takes a full body bath, shower or sponge bath, including transfers in and out of the tub or shower. Review of the facility policy Falls - Clinical Protocol dated 10/31/22, indicated The staff and practitioner will review each resident's risk factors for falling and document in the medical record. Review of Resident R6's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS) assessments (mandated assessment of a resident's abilities and care needs) dated 3/6/23, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), abnormalities of gait and mobility, and muscle weakness. Review of Resident R6's admission MDS assessments dated 1/2/23, and 3/6/23, Section G - Functional Status, indicated that Resident R6 required extensive physical assistance of two or more persons for bed mobility. Review of Resident R6's current plan of care for ADL self-care performance initiated 12/9/22, failed to reveal any goals or interventions related to bed mobility, or the staff assistance level required. Page 1 of 4 395742 395742 06/06/2023 Southwestern Nursing and Rehabilitation Center 500 North Lewis Run Road Pittsburgh, PA 15122

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R6's [NAME] (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated 4/30/23, failed to include the staff assistance level required for bed mobility. Review of the physical therapy Discharge summary dated [DATE], indicated that Resident R6 required assistance during bed mobility. Review of a progress note written dated 5/1/23, at 2:03 p.m. indicated that a nurse aide informed her that Resident R6 had fallen out of bed during a brief change and hygiene care. No injuries were noted at that time. The note further indicated that Resident R6 was sent to the hospital. Review of a progress note dated 5/1/23, at 6:18 p.m. indicated Resident R6 returned to the facility with no fractures and no new orders. During an interview on 6/4/23, at 3:40 p.m. the Nursing Home Administrator confirmed that the facility failed to provide adequate bed mobility supervision for one of three residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services. 395742 Page 2 of 4 395742 06/06/2023 Southwestern Nursing and Rehabilitation Center 500 North Lewis Run Road Pittsburgh, PA 15122

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, observations, and staff interviews it was determined that the facility failed to provide adaptive feeding devices for five of seven residents (Resident R1, R2, R3, R4, and R5). Residents Affected - Some Findings include: Review of the facility policy Food and Nutrition Services dated 10/31/22, indicated that nursing staff will ensure that assistive devices are available to residents as needed. 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 4/27/23, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and dysphagia (difficulty swallowing). During an observation of Resident R1 on 6/5/23, at 12:50 p.m. Resident R1's meal ticket indicated that she was to be provided a two-handled cup with a lid. Observation indicated that a lid was not provided on the cup, containing coffee. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia and osteoarthritis (degeneration of the joint causing pain and stiffness). During an observation of Resident R2 on 6/5/23, at 12:54 p.m. Resident R2's meal ticket indicated that she was to be provided built-up utensils. Observation indicated that built up utensils were not provided for the noon meal. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of malnutrition (lack of sufficient nutrients in the body) and muscle weakness. During an observation of Resident R3 on 6/5/23, at 12:59 p.m. Resident R3's meal ticket indicated that she was to be a two-handled cup with a lid. Observation revealed that a two-handled cup was not provided. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of malnutrition and dementia. During an observation of Resident R4 on 6/5/23, at 1:03 p.m. Resident R4's meal ticket indicated that she was to be a two-handled cup with a straw. Observation revealed that a two-handled cup was not provided. Review of the clinical record indicated Resident R5 was readmitted to the facility on [DATE]. 395742 Page 3 of 4 395742 06/06/2023 Southwestern Nursing and Rehabilitation Center 500 North Lewis Run Road Pittsburgh, PA 15122

F 0810 Level of Harm - Minimal harm or potential for actual harm Review of the MDS dated [DATE], included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and muscle weakness. During an observation of Resident R5 on 6/5/23, at 1:10 p.m. Resident R5's meal ticket indicated that she was to be a two-handled cup with a lid. Observation revealed that a two-handled cup was not provided. Residents Affected - Some During an interview on 6/5/23, at 3:40 p.m. Nursing Home Administrator confirmed that the facility failed to provide the correct adaptive equipment to five residents. 28 Pa Code: 211.6(a) Dietary service. 395742 Page 4 of 4