Health inspection·November 9, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility provided policies and documentation, clinical records, and resident and staff interviews, it was determined that the facility failed to protect residents from staff-initiated abuse and/or neglect. This failure resulted in a staff member physically abusing a resident and multiple staff neglecting care of 18 of 184 residents reviewed. This failure created an Immediate Jeopardy situation for 18 of 184 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18). Findings include: Review of facility policy Abuse, Neglect, & Misappropriation, reviewed 6/6/23, revealed that it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. It is the intent of the facility to prevent abuse, mistreatment, or neglect of residents and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect, or misappropriation of their property. The policy further defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect was defined as the failure of the facility, its employees or services providers to roved goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated 8/3/23, included diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) and osteoporosis (condition when the bones become brittle and fragile). Review of Section C: Cognitive Patterns revealed Resident R1 to be severely cognitively impaired. Review of Section D: Behavior indicated that Resident R1 is known to have behavioral symptoms. Review of Resident R1 ' s care plan for behavior problems initiated 10/21/22, included the intervention for staff to approach and speak in a calm manner. Review of a progress note written by Registered Nurse (RN) Employee E12 dated 9/13/23, at 6:56 p.m. indicated Was informed of an incident at 5:30 of an incident by the Unit Manager (Employee E22), that there was an incident involving RN Employee E1 and Resident R1. RN Employee E1 was sent home, 911 was called at 5:50 p.m. Review of facility submitted information dated 9/14/23, indicated that on 9/13/23, Nurse Aide (NA) Employee E2 reported that RN Employee E1 had called Resident R1 a bitch and moved around the desk towards the resident. NA Employee E2 stepped between the resident and the nurse. No physical contact occurred between the nurse and the resident. Page 1 of 28 395745 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of an employee statement written by RN Employee E1 dated 9/13/23, indicated This RN was at nurse's station trying to get the two residents apart from one another. We (staff) had been trying this for a length of time and the two were not moving/separating. I was telling them to go to their rooms or the dining room and Resident R1 grabbed the pen from my hand and threw it at me. I then went from behind the desk to get them to move. The NA thought I was going to harm the resident, but I was attempting to get her to move from the nurse's station. I did mumble under my breath and called her a bitch. Resident was never touched or harmed. Staff continued to work to get them apart. They then moved to the dining room. NA Employee E2 went downstairs to find supervisor. I did tell NA Employee E2 my supervisor was (the Director of Nursing). NA Employee E2 did not contact (the DON), however she did tell Licensed Practical Nurse Employee E15 that she recorded the abuse stated on her phone. She was also recording other staff while in the dining rooom that were addressing the two residents. Review of an undated employee statement written by NA Employee E2 indicated While sitting at the nurse's station I began to hear Resident R1 become upset about being alone with Resident R54. The Unit Manager (UM - RN Employee E1) began to explain why she couldn't and Resident R1 started getting more frustrated, the UM became angry and started to yell back in a mean tense. At this moment I became concerned, and recorded for my resident's safety as well as myself. The UM called the resident a little bitch and charged towards (Resident R1) as if she wanted to hit her. At this moment I stepped in between and let the UM know she was out of line and to remember she was on a dementia unit. I also stated that she needed to apologize to the resident. I asked her if she had another supervisor present, and I went to speak with him. I felt unsafe for my resident, the UM apologized but that shouldn't have occurred. I understand recording is not permitted, but needed to be able to support my statement. Review of an employee statement written by NA Employee E3 dated 9/13/23, indicated I was the one-on-one with Resident R54 when issue happened. I was standing between Resident R1 and Resident R54. Resident R1 was not listening (to) me and (NA Employee E4) both kept redirecting Resident R1 to go back to dining room and sit down she was not easily redirected at all. RN Employee E1(UM) heard us having a hard time came out her office to redirect Resident R1. Resident R1 then grabbed her pen out of her and hit RN Employee E1(UM) in the face with it. Yes, RN Employee E1(UM) did call her a little bitch but it wasn't loud she kinda muttered it. She was a little angry at the situation but we know she would never put her hand on any resident. RN Employee E1 (UM) also wanted NA Employee E2 to come talk in her office and she wouldn't go. NA Employee E2 started scolding RN Employee E1(UM) like she was a child. Review of an employee statement written by NA Employee E4 dated 9/13/23, indicated NA Employee E3 was standing in between Resident R54 and Resident R1 trying to get her to go into the dining room. Resident R1 kept getting angrier and we kept trying to redirect her. RN Employee E1 (UM) came over and told her to go to her room or go sit in the dining room. Resident R1 grabbed the pen out of RN Employee E1's (UM) hand and threw it at her and hit her in the face. RN Employee E1(UM) came from behind the desk. NA Employee E2 stared scolding RN Employee E1(UM) like she was a little child. RN Employee E1 (UM) asked her to go into her office and talk but she wouldn't go. NA Employee E2 was being very unprofessional. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cirrhosis (chronic damage leading to scarring and failure) of the liver and a seizure disorder. Review of Section C revealed Resident R2 to be cognitively intact. Review of Section H - Bladder and Bowel revealed that Resident R2 is occasionally incontinent. 395745 Page 2 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of Section C revealed Resident R3 to be cognitively intact. Review of Section G: Activities of Daily Living (ADL) Assistance indicated Resident R3 required staff assistance for bed mobility, toilet use, and personal hygiene. Resident R3 ' s care plan for ADL assistance initiated 5/17/23, indicated Resident R3 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and an anoxic brain injury (injury to the brain caused by a complete lack of oxygen). The facility diagnosis list included Review of Section C revealed Resident R4 to be moderately cognitively impaired. Review of Section G: indicated Resident R4 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R4 is always incontinent of bladder and bowel. Review of Resident R4 ' s care plan initiated 12/21/21, and revised on 9/21/23, revealed that he has impaired cognitive function, and the care plan for incontinence revised on 11/15/22, revealed that Resident R4 should be checked for incontinence and for his brief to be changed as needed. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Review of Section C revealed Resident R5's BIMS score to be 12, moderately cognitively impaired. Review of Section G: indicated Resident R5 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R5 is frequently incontinent of bladder and bowel. Review of Resident R5 ' s care plan initiated 7/26/23, revealed that she has impaired cognitive function, and the assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of bipolar disorder (a mental condition marked by alternating periods of elation and depression) and a seizure disorder. Review of Section C revealed Resident R6 to be moderately cognitively impaired. Review of Section G indicated Resident R6 required staff assistance for bed mobility, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R6 is always incontinent of bladder and bowel. Resident R6 ' s care plan for ADL assistance initiated 5/17/23, indicated Resident R6 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Review of Resident R6 ' s care plan for incontinence initiated 7/19/21, revealed that Resident R6 should be checked for incontinence and that briefs should be changed as needed. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of metabolic encephalopathy (alteration in consciousness caused by a chemical imbalance affecting the brain) and diabetes. Review of Section C revealed Resident R7 to be moderately cognitively impaired. Review of Section G indicated Resident R7 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R7 has a urinary catheter and is always incontinent of bowel. Resident R7 ' s care plan for bowel incontinence initiated 7/13/23, indicated for staff to provide assistance as needed, and to provide peri-care (cleaning the genitalia and surrounding area) after each incontinent episode. 395745 Page 3 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the clinical record indicated Resident R8 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of a seizure disorder and history of a stroke. Review of Section C revealed Resident R8 to be moderately cognitively impaired. Review of Section G indicated Resident R8 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R8 is always incontinent of bladder and bowel. Resident R8 ' s care plan for ADL assistance initiated 2/21/23, revealed Resident R8 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R8 ' s care plan for bowel incontinence initiated 2/28/23, indicated for staff to provide assistance as needed, and to provide peri-care (cleaning the genitalia and surrounding area) after each incontinent episode. Review of the clinical record indicated Resident R9 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and osteoporosis (condition when the bones become brittle and fragile). Review of Section C revealed Resident R9 to be severely cognitively impaired. Review of Section G indicated Resident R9 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R9 was frequently incontinent of bladder and bowel. Resident R9 ' s care plan for ADL assistance initiated 5/12/23, revealed Resident R9 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R9 ' s care plan for bladder incontinence initiated 5/22/23, revealed staff should check resident for incontinence. Wash, rinse, and dry perineum. Change clothes as needed after incontinent episodes. Change briefs as needed. Review of the clinical record indicated Resident R10 was admitted to the facility 10/10/19. Review of the MDS dated [DATE], included diagnoses of atrial fibrillation and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Section C revealed Resident R10 to be severely cognitively impaired. Review of Section G indicated Resident R10 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R10 is frequently incontinent of bladder and bowel. Resident R ' s care plan for ADL assistance initiated 7/1/21, revised 1/30/23, revealed that staff should observe and anticipate Resident R10 ' s needs: food, thirst, body positioning, pain, and toileting needs. Resident R10 ' s care plan for bowel incontinence initiated 8/5/22, revealed that staff should provide peri-care after each incontinence episode. Resident R10 ' s care plan for bladder incontinence initiated 8/5/22, staff should check Resident R10 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of the clinical record indicated Resident R11 was admitted to the facility 3/10/23. Review of the MDS dated [DATE], included diagnoses of COPD and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior). Review of Section C revealed Resident R11 to be moderately cognitively impaired. Review of Section G indicated Resident R11 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R11 is always incontinent of bladder and bowel. Resident R11 ' s care plan for ADL assistance initiated 6/15/23, revealed Resident R11 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R11 ' s care plan for bowel incontinence initiated 3/21/23, revealed that staff should provide peri-care after each incontinence episode. Resident R11 ' s care plan for bladder incontinence initiated 3/21/23, staff should check Resident R11 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. 395745 Page 4 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the clinical record indicated Resident R12 was admitted to the facility 5/31/23. Review of the MDS dated [DATE], included diagnoses of heart failure and muscle weakness. Review of Section C revealed Resident R12 to be cognitively intact. Review of Section G indicated Resident R12 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R12 is frequently incontinent of bladder and bowel. Resident R12 ' s care plan for ADL assistance initiated 6/1/23, revealed Resident R12 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R12 ' s care plan for bowel incontinence initiated 6/5/23, revealed that staff should provide peri-care after each incontinence episode. Resident R12 ' s care plan for bladder incontinence initiated 3/21/23, staff should check Resident R12 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of the clinical record indicated Resident R13 was admitted to the facility 1/14/23. Review of the MDS dated [DATE], included diagnoses of chronic kidney disease (gradual loss of kidney function) and dementia. Review of Section C revealed Resident R13 to be severely cognitively impaired. Review of Section G indicated Resident R13 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R13 is frequently incontinent of bladder and bowel. Resident R12 ' s care plan for ADL assistance initiated 1/16/23, revealed Resident R13 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R13 ' s care plan for frequent bowel incontinence initiated 1/23/23, revealed that staff should provide peri-care after each incontinence episode. Resident R11 ' s care plan for bladder incontinence initiated 3/21/23, staff should check Resident R11 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode Review of the clinical record indicated Resident R14 was admitted to the facility 11/22/22. Review of the MDS dated [DATE], included diagnoses of heart failure and muscle weakness. Review of Section C revealed Resident R14 to be moderately cognitively impaired. Review of Section G indicated Resident R14 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R14 is always incontinent of bladder and bowel. Resident R14 ' s care plan for history of a cerebral vascular accident (CVA, stroke) initiated 12/5/22, revealed staff should assist with ADL and provide passive range of motion with care. Resident R14 ' s care plan for bowel incontinence initiated 12/5/22, revealed that staff should provide peri-care after each incontinence episode. Resident R14 ' s care plan for bladder incontinence initiated 8/5/22, staff should check Resident R14 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of facility staffing information indicated that NA Employee E5 was responsible for ADL care for Residents R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14. Review of a report dated 10/2/23, indicated the local police were dispatched to the facility and they had been called by the facility to report neglect. The Director of Nursing (DON) provided the officer with four sworn statements dated 10/1/23. The DON also provided a list of highlighted patients (Residents R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14) that were named in the allegation. Review of an employee statement written by Licensed Practical Nurse (LPN) Employee E6, this nurse expressed concerns with the nursing supervisor throughout the shift. This NA (NA Employee E5) was missing for over 30 minutes. The call lights were going off. The nursing supervisor made an announcement. The NA sat at the nursing station. This nurse encouraged this NA to change the resident. The NA 395745 Page 5 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some kept disappearing. The NA was asked to do walking rounds. The NA was late. The residents were complete [sic]. NA Employee E5 told this nurse she could not get residents up because of it by six hoyers. Review of an employee statement written by RN Employee E7 indicated that the B-1 unit 3:00 pm to 11:00 p.m. aide and the assigned nurse for 7:00 a.m. to 7:00 p.m. reported NA Employee E5 who worked that none of the residents were changed and all the residents were soaked, and their briefs were torn due to excess voiding. 3:00 pm to 11:00 p.m. aide had to change every bed also. Review of an employee statement written by LPN Employee E8 indicated .had (list of room numbers) on the 3:00 p.m. to 11:00 p.m. shift .whoever was the 7:00 a.m. to 3:00 p.m. daylight aid did not do no last rounds at all. Resident R4 was laying in his own BM (bowel movement) it was everywhere from his head to feet covered in his own BM. Resident R5 was wet with old urine ring stains in the sheets. Resident R6 was soaking wet in urine. Resident R7 was sitting wet in urine. Resident R9 was soaking wet in urine. Resident R11 was soaking wet, also Resident R12. Everyone total bed changes with old urine rings on the sheet. Review of an employee statement written by NA Employee E5: I didn't get some up because one of them refused. It was only three people and a busy day so I couldn't get help with Hoyer for all six people. For the people I didn't change in the afternoon I got a really bad pain in my knee from slipping in the shower room the previous day. It got so bad to the point I couldn't move but I tried my best to finish up it just got unbearable, and I didn't want to go home and leave only two aides on the floor. During an interview on 11/8/23, at 11:12 a.m. NA Employee E5 confirmed she did not provide care to her unit (Resident R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14). NA Employee E5 confirmed she did not previously inform facility staff of her injury on 10/1/23, that she stated prevented her from providing care. NA Employee E5 confirmed she did not inform facility management or a charge nurse on 10/2/23, that she was unable to provide care, and that multiple of her residents were left in soiled briefs, clothing, and linen. The facility failed to remove this aide from the schedule until further investigations were completed putting these residents at risk for continued neglect. Review of the clinical record indicated Resident R15 was admitted to the facility 7/3/23. Review of the MDS dated [DATE], included diagnoses of obstructive uropathy (condition where the flow of urine is blocked), reduced mobility, and the need for assistance with personal care Review of Section C revealed Resident R15 to be cognitively intact. Review of Section G indicated Resident R15 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R15 has a urinary catheter and is always frequently of bowel. Resident R15 ' s care plan for ADL assistance initiated 7/5/23, revealed that Resident R15 is extensive to total assistance with toileting and that Resident R15 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R15 ' s care plan for bowel incontinence initiated 7/5/23, revealed that staff should provide peri-care after each incontinence episode. Review of facility submitted information dated 10/3/23, indicated that on 10/3/23, Resident R15 stated that the NA on the 3:00 p.m. - 11:00 p.m. shift had yelled at her because she had to call her back into the room after an incontinent episode. Resident R15 stated that the NA was very rough with her. Resident stated that her vagina was still burning and sore hours after the incident. 395745 Page 6 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of a progress note dated 10/4/23, at 12:34 p.m. indicated Resident assessed with LPN Employee E23, resident was incontinent of BM, cleaned, new brief applied. Resident's peri/ buttocks are excoriated, bright red, multiple wounds present. No new wounds were noted. Review of a transcribed employee statement to the DON from NA Employee E9 on 10/4/23, indicated, Took care of Resident R15 last night every time you clean her up, she is in pain. I was not being rough with her on the way out she offered me candy. Am I being rough with her, no I am not. Review of an employee statement written by NA Employee E10 dated 10/4/23, indicated Resident R15 called me into the room at 11:30 p.m. and asked to be changed because the aide before (NA Employee E9) didn't clean her well enough. While I was helping her, Resident R15 began to tell me what NA Employee E9 did to her. Resident R15 called NA Employee E9 into the room the first time because Resident R15 needed a blanket and Employee E9 obliged her. About five minutes later Resident R5 put her call light on again because she moved her bowels and asked to be changed and Resident R15 stated that NA Employee E9 screamed at her and while she (NA Employee E9) was attempting to clean her up, scrubbed Resident R15's vagina so roughly that she hurt hours after the fact. Resident R15 waited until 11:30 p.m. to put on the call bell again because she wanted to make sure that NA Employee E9 wasn't in the facility. Review of an employee statement written by LPN Employee E24 dated 10/4/23, indicated NA Employee E10 made this nurse aware at 11:30 p.m. that resident wanted to speak to me. Resident told this nurse that NA Employee E9 on 3:00 p.m. - 11:00 p.m. had yelled at her because she had to call her back into the room after an incontinent episode. She stated that NA Employee E9 was very rough with doing her incontinence care. She stated her vagina was still burning and sore hours after incident. Resident had waited to report this incident until after 11:00 p.m. when she knew NA had left. She staed that she had never been treated so roughly. She said that she had called the main number of the facility but was not able to get anyone to give me the message that she needed me to help. NA Employee E10 provided incontinence care at this time. Resident positioned for comfort. RN Supervisor made aware of incident. During an interview on 11/9/23, at 11:00 a.m. Resident R15 described the incident. It was about nine (9:00 p.m.) I asked NA Employee E9 to cover me with a blanket. Right after, I needed to be changed. She yelled and screamed at me, she hurt me when she was changing me. After that the man aide (NA Employee E10) took good care of me and cleaned me up. When asked if she felt scared, Resident R15 responded, Oh, yeah. It was an assault. Definitely was. When she stuck her hand in between my legs so hard, I was hurting for a couple days. It was painful what she did to me. Seemed like she was ready to kill me. It was really nasty. Review of the clinical record indicated Resident R16 was admitted to the facility 12/14/21. Review of the MDS dated [DATE], included dementia and high blood pressure. Review of Section C revealed Resident R16 to be severely cognitively impaired. Review of Section G indicated Resident R16 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R16 is always incontinent of bladder and bowel. Resident R16 ' s care plan for bowel incontinence initiated 12/27/21, revealed that staff should provide peri-care after each incontinence episode. Resident R16 ' s care plan for bladder incontinence initiated 12/27/21, staff should check Resident R16 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of facility submitted information dated 10/5/23, indicated that on 10/5/23, at 2:00 p.m. 395745 Page 7 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Resident R16 was moved from one wing of the facility to a different wing. He was noted with a ring of wet urine on the fitted sheet with a dry brief. Review of a progress note written by RN Employee E12 dated 10/5/23, at 5:55 p.m. indicated Resident had urine-soaked bed, resident sound asleep, no injuries noted. Resident and resident's bed changed. Review of an employee statement written by LPN Employee E25 on 10/5/23, indicated Nurse aides reported that when patient (Resident R16) one wing to the other, he was noted with a round ring, wet fitted sheet with dry brief. Review of an employee statement written by NA Employee E26 on 10/5/23, indicated Resident R16 came downstairs after being upstairs for a few days and his bed was dirty with a big dirty ring around the butt area and the brief was dry. Review of an employee statement written by NA Employee E11 on 10/5/23, indicated I never got the chance to wash and change Resident R16 yet because I had showers to do this morning. I'm always on the back of (unit) everyday and it's heavy and don't nobody want to work back so I'm stuck working back there every day. I was going to change and wash him after lunch before he went downstairs. Review of the clinical record indicated Resident R17 was admitted to the facility 6/3/22. Review of the MDS dated [DATE], included psychotic disorder (mental disorder characterized by a disconnection from reality) and intellectual disabilities. Review of Section C revealed Resident R17 to be severely cognitively impaired. Review of Section G indicated Resident R17 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R17 is always incontinent of bladder and bowel. Resident R17 ' s care plan for bladder incontinence initiated 6/15/22, revealed staff should check Resident R11 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of facility submitted information dated 10/11/23, indicated that on 10/10/23, at 11:30 p.m. NA Employee E14 stated that on 10/10/23, at 6:30 a.m. he had written the date, time, and his initials on Resident R17's brief. When NA Employee E14 came on duty on 10/10/23, at 11:30 p.m. he went to change Resident R17's brief which still had on the date, time, and his initials. Review of facility staffing information indicated that NA Employee E5 was responsible for Resident R17's care on 10/10/23, day shift; NA Employee E14 was responsible for Resident R17's care on 10/10/23, evening shift, Review of an employee statement written by NA Employee E14 on 10/10/23, at 11:30 p.m. indicated Resident is consistently overly saturated. Date, timed, and initial briefs for 10/10/23, at 6:30 a.m. when resident was changed on last rounds. Came in tonight to resident stating My pee-pee hurts and asked to change him he complied. Pulled the same brief off that I put on. Let the nurse know, went and got supervisor, advised her of it. Supervisor did ask me why I was dating briefs, to cause problems. I stated no, it's because residents are being abused and neglected. Supervisor escalated to DON. Review of an employee statement written by NA Employee E5 on 10/11/23, indicated Resident R17 did not get changed because he was already irritated and screaming and yelling when I asked him, he started to scream and yell more and left unit. 395745 Page 8 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Review of an employee statement written by LPN Employee E27 on 10/11/23, indicated Around 8:30 p.m. NA Employee E28 approached this nurse and said that resident was refusing to be changed and put in bed and was barricading himself inside the dining room. Resident was in the dining room at the end of shift. Review of behavior charting completed by NA Employees E5 and E13 both documented that Resident R17 had not displayed behaviors on 10/10/23. Residents Affected - Some Review of a progress note written by RN Employee E12 dated 10/11/23, at 6:01 p.m. indicated Resident assessed post complaint from previous shift. Peri area is reddened with two open areas, right groin and left lower groin area. Resident also has reddened areas under breast folds, red and yeast like. Resident's thighs and lower legs are also reddened. During an interview on 11/8/23, at 11:12 a.m. NA Employee E5 confirmed she did not provide incontinence care to Resident R17 on 10/10/23. When asked the reason why, she stated that Resident R17 had been displaying behaviors that day. NA Employee E5 confirmed that she had documented Resident R17 as having no behaviors, as this level of behavior was his normal. NA Employee E5 was unable to explain why, if this level of behavior is normal, he is able to be provided incontinence care[TRUNCATED] 395745 Page 9 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility provided policies and documentation, provided reports, clinical records, and resident and staff interviews, it was determined that the facility failed to ensure abuse and neglect prevention training was completed for all facility staff after substantiated abuse incidents, resulting in an Immediate Jeopardy for 18 of 184 residents. (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18). Residents Affected - Some Findings include: Review of facility policy Abuse, Neglect, & Misappropriation, reviewed 6/6/23, revealed that it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. It is the intent of the facility to prevent abuse, mistreatment, or neglect of residents and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect, or misappropriation of their property. The policy further stated the facility will provide education and training upon hire, annually, and as needed for retraining. Education and training in-services documentation of attendance will be maintained. Review of a facility submitted report dated 9/14/23, indicated that on 9/13/23, Nurse Aide (NA) Employee E2 reported that RN Employee E1 had called Resident R1 a bitch and moved around the desk towards the resident. NA Employee E2 stepped between the resident and the nurse. No physical contact occurred between the nurse and the resident. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property completed 9/19/23, indicated verbal abuse was substantiated. Review of facility provided education sign-in sheets dated 9/21/23, 63 staff members of the 200 staff current at the time of the education, who remained employed at the facility at the time of the survey, were documented as having received education. Review of a provided report dated 10/2/23, indicated the local police were dispatched to the facility, after the facility had called to report an allegation of abuse/neglect. The Director of Nursing (DON) was noted to have provided provided the officer with four sworn statements dated 10/1/23. The DON also provided a list of highlighted patients. These statements alleged neglect of Residents R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14 by Nurse Aide (NA) Employee E5. A facility submitted report and a Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property were not completed. Review of a facility submitted report dated 10/4/23, indicated that on 10/3/23, Resident R15 stated that the NA (NA Employee E9) on the 3:00 p.m. - 11:00 p.m. shift had yelled at her because she had to call her back into the room after an incontinent episode. Resident R15 stated that the NA was very rough with her. Resident stated that her vagina was still burning and sore hours after the incident. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property for NA Employee E9 completed 10/4/23, indicated the investigation was ongoing. Review of NA Employee E9's personnel file on 11/4/23, indicated that NA Employee E9 was terminated 395745 Page 10 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0607 from employment at the facility, related to substantiated abuse. Level of Harm - Immediate jeopardy to resident health or safety Review of a facility submitted incident dated 10/5/23, indicated that on 10/5/23, at 2:00 p.m. Resident R16 was moved from one wing of the facility to a different wing. He was noted with a ring of wet urine on the fitted sheet with a dry brief. NA Employee E11 was immediately suspended. A Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property was not completed. Residents Affected - Some Review of the education provided for the above-mentioned incident on 9/13/23, failed to include reeducation for the alleged perpetrators NA Employee E5 (10/2/23), NA Employee E9 (10/3/23), and NA Employee E11 (10/5/23). Review of facility provided education sign-in sheets dated 10/2/23, through 10/6/23, 64 staff members of the 214 staff current at the time of the education, who remained employed at the facility at the time of the survey, were documented as having received education. Review of a facility submitted incident dated 10/11/23, indicated that on 10/10/23, at 11:30 p.m. NA Employee E14 stated that on 10/10/23, at 6:30 a.m. he had written the date, time, and his initials on Resident 17's brief. When NA Employee E14 came on duty on 10/10/23, at 11:30 p.m. he went to change Resident R17's brief which still had on the date, time, and his initials. Review of facility staffing information indicated that NA Employee E5 was responsible for Resident R17's care on 10/10/23, day shift; NA Employee E13 was responsible for Resident R17's care on 10/10/23, evening shift. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property for NA Employee E5 completed 10/11/23, indicated the investigation was ongoing. A Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property for NA Employee E13 was not completed. Review of NA Employee E5's personnel record included a corrective action. Employee had a report of neglect (this is the 2nd report of this since the start of employment). The investigation was unsubstantiated but this employee will be brought back to work and will need to complete her Relias (electronic educational program) to 100% and will be retrained by a senior aide. Suspended 10/12/23, and 10/13/23, back to work on 10/16/23. Review of the facility reeducation provided to NA Employee E5 after this second incident (10/2/23, 10/11/23) included: Bathing, urinary drainage bag maintenance, care of indwelling urinary catheter care, skin check, and shaving - electric razor. During an interview with NA Employee E34, responsible retraining NA Employee E5, on 11/5/23, at 5:13 p.m. NA Employee E34 confirmed that she provided hands-on reeducation on how to change a brief, hand-washing, and other hands-on care issues. When asked if she felt NA Employee E5 needed retraining, NA Employee E34 responded, Absolutely needed retraining. Even when I retrained her, she was having a rough time to be involved in the care. Maybe she didn't want to do it, maybe she was uncomfortable. It didn't seem like she cared or was getting it. Further review of facility provided investigation documentation failed to include reeducation on abuse or neglect for NA Employee E5 related to the incident on 10/11/23. 395745 Page 11 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on 11/8/23, at 11:12 a.m. NA Employee E5 confirmed she did not received in-person abuse and neglect retraining based on the 10/2/23, and 10/11/23, incidents. Review of a facility submitted report dated 11/5/23, indicated that on 11/5/23, at 6:00 a.m. Resident R18 was found to have a bedpan underneath her for an unknown amount of time. Evening shift staff stated that a bedpan had been placed under Resident R18 at approximately 7:00 p.m. on 11/4/23. The assigned nurse aide stated that she checked when Resident R18 wasn't sure if there was a bedpan underneath her or that she might be dreaming. The nurse aide put her hand underneath Resident R18's left buttock and between her legs and did not feel a bedpan. The nurse aide didn't completely roll the resident to check. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property for LPN Employee E29 initiated 11/5/23, indicated the investigation was ongoing. During an interview on 11/7/23, at 11:00 a.m. the Nursing Home Administrator stated that for the above incidents, facility staff education was completed at 100% due to a text blast that included all facility staff members. The Nursing Home Administrator confirmed that while it could be verified that the education was sent out via text message to all employees, there was no capability or process in place to ensure that the receiving staff member opened, read, or understood the education. On 11/7/23, at 11:04 a.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed and the Immediate Jeopardy template was provided to facility administration. On 11/7/23, at 5:24 p.m. an acceptable Corrective Action Plan was received which included the following interventions: -Ad hoc QAPI (Quality Assurance and Performance Improvement) will be conducted by facility QAPI committee to report allegations of noncompliance during the survey on 11/7/23. -RDO will provide abuse education to facility leadership, including a posttest. Facility leadership will administer same education and posttest to employees and contracted employees of the facility. This will be completed by 11/7/23. -Any employee that is not available to come into the facility will be educated regarding abuse over the phone and will not be permitted to return to the active work schedule until they come into the facility and satisfactorily complete the posttest. -The front desk of the facility will be staffed by facility, leadership around the clock to ensure compliance with education for all employees unable to come to the facility on [DATE]. -Random skin sweeps and abuse questionnaires on five residents five times a week for the next two weeks and weekly for eight weeks of the residents of the facility by the DON/designee. -Random education audits will be conducted by the employees utilizing the same abuse posttest to ensure retention of knowledge. This will be contacted with 10 staff members five times a week for the next two weeks and weekly, eight for eight weeks of the employees of the facility by the DON/designee. -Additional abuse education will be completed monthly for three months to be completed by the 395745 Page 12 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0607 Level of Harm - Immediate jeopardy to resident health or safety DON/designee. Compliance will be monitoring and ensuring completion of this education will be done by the HR manager/designee. -Facility will reach out to (directed in-service provider) regarding the scheduling of a directed in-service for all employees and contracted employees of the facility. This will be scheduled with (directed in-service provider) within the next 30 days. Residents Affected - Some -All abuse training will be certified complete by the HR manager/designee against an active employee/ contracted employee roster, starting at 11/7/233 and ongoing. -All findings regarding the IJ citation reported monthly in the facility's QAPI meeting for the next three months. During observations completed on 11/8/23, between 9:30 a.m. and 4:00 p.m. the Director of Nursing was observed providing confirmatory education to staff who had received education via telephone, and education to agency staff prior to the start of the shift. During staff interviews conducted on 11/8/23, between 9:30 a.m. and 4:00 p.m. 25 staff members confirmed they received education on abuse prevention. During staff interviews conducted on 11/9/23, between 9:30 a.m. and 11:30 a.m. 16 staff members confirmed they received education on abuse prevention. The Immediate Jeopardy was lifted on 11/9/23, at 11:55 a.m. when the action plan implementation was verified. During an interview on 11/9/23, at approximately 12:15 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure abuse and neglect prevention training was completed for all facility staff after substantiated abuse incidents, resulting in an Immediate Jeopardy for 18 of 184 residents. (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18). 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. 395745 Page 13 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of state laws, facility policies, police reports, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures for covered individuals to report the suspicion, observation, or knowledge of staff to resident neglect for thirteen of eighteen residents (Resident R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14). Findings include: Review of facility policy Abuse, Neglect, & Misappropriation, reviewed 6/6/23, indicated a covered individual is obligated to report any reasonable suspicion of a crime against a resident, or one who is receiving care from a long-term care facility. A covered individual is defined as anyone who is an owner, operator, employee, manager, agent or contractor of the facility. The report further stated that a report will be sent to the Pennsylvania Department of Health for alleged violations concerning neglect no later than 24 hours. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, 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 intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cirrhosis (chronic damage leading to scarring and failure) of the liver and a seizure disorder. Review of Section C revealed Resident R2's BIMS score to be 14. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of Section C revealed Resident R3's BIMS score to be 13. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE]/23, included diagnoses of diabetes and an anoxic brain injury (injury to the brain caused by a complete lack of oxygen). Review of Section C revealed Resident R4's BIMS score to be 10. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Review of Section C revealed Resident R5's BIMS score to be 12. 395745 Page 14 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of bipolar disorder (a mental condition marked by alternating periods of elation and depression) and a seizure disorder. Review of Section C revealed Resident R6's BIMS score to be 11. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of metabolic encephalopathy (alteration in consciousness caused by a chemical imbalance affecting the brain) and diabetes. Review of Section C revealed Resident R7's BIMS score to be 8. Review of the clinical record indicated Resident R8 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of a seizure disorder and history of a stroke. Review of Section C revealed Resident R8's BIMS score to be 12. Review of the clinical record indicated Resident R9 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and osteoporosis (condition when the bones become brittle and fragile). Review of Section C revealed Resident R9's BIMS score to be 5. Review of the clinical record indicated Resident R10 was admitted to the facility 10/10/19. Review of the MDS dated [DATE], included diagnoses of atrial fibrillation and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Section C revealed Resident R10's BIMS score to be 6. Review of the clinical record indicated Resident R11 was admitted to the facility 3/10/23. Review of the MDS dated [DATE], included diagnoses of COPD and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior). Review of Section C revealed Resident R11's BIMS score to be 8. Review of the clinical record indicated Resident R12 was admitted to the facility 5/31/23. Review of the MDS dated [DATE], included diagnoses of heart failure and muscle weakness. Review of Section C revealed Resident R12's BIMS score to be 13. Review of the clinical record indicated Resident R13 was admitted to the facility 1/14/23. Review of the MDS dated [DATE], included diagnoses of chronic kidney disease (gradual loss of kidney function) and dementia. Review of Section C revealed Resident R13's BIMS score to be 7. Review of the clinical record indicated Resident R14 was admitted to the facility 11/22/22. Review of the MDS dated [DATE], included diagnoses of heart failure and muscle weakness. Review of Section C revealed Resident R14's BIMS score to be 12. Review of a police report dated 10/2/23, the local police were dispatched to the facility. The Director of Nursing (DON) provided the officer with four sworn statements dated 10/1/23. The DON also provided a list of highlighted patients. Sworn statement/written statement from Licensed Practical Nurse (LPN) Employee E6, this nurse expressed concerns with the nursing supervisor throughout the shift. This NA (NA Employee E5) was missing for over 30 minutes. The call lights were going off. The nursing supervisor made an announcement. 395745 Page 15 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The NA sat at the nursing station. This nurse encouraged this NA to change the resident. The NA kept disappearing. The NA was asked to do walking rounds. The NA was late. The residents were complete [sic]. NA Employee E5 told this nurse she could not get residents up because of it by six hoyers. Sworn statement from RN Employee E7. B-1 unit 3:00 pm to 11:00 p.m. aide and the assigned nuse for 7:00 a.m. to 7:00 p.m. reported NA Employee E5who worked. None of the residents were changed and all the residents were soaked and their briefs were torn due to excess voiding. 3:00 pm to 11:00 p.m. aide had to change every bed also. Sworn statement from LPN Employee E8. I had (list of room numbers) on the 3:00 pm to 11:00 p.m. shift. Whoever was the 7:00 a.m. to 3:00 p.m. daylight aid did not do no last rounds at all. Resident R4 was laying in his own BM (bowel movement) it was everywhere from his head to feet covered in his own BM. Resident R5 was wet with old urine ring stains in the sheets. Resident R6 was soaking we in urine. Resident R7 was sitting wet in urine. Resident R9 was soaking we in urine. Resident R11 was soaking wet, also Resident R12. Everyone total bed changes with old urine rings on the sheet. Sworn statement from NA Employee E5 I didn't get some up because one of them refused. It was only three people and a busy day so I couldn't get help with hoyer for all six people. For the people I didn't change in the afternoon I got a really bad pain in my knee from slipping in the shower room the previous day. It got so bad to the point I couldn't move but I tried my best to finish up it just got unbearable and I didn't want to go home and leave only two aides on the floor. Review of facility submitted information to the Pennsylvania Department of Health failed to include a report for an allegation of neglect. During an interview on 11/9/23/23, at approximately 12:15 p.m. the Nursing Home Administrator confirmed that facility failed to implement policies and procedures for covered individuals to report the suspicion, observation, or knowledge of staff to resident neglect for thirteen of eighteen residents. 28 Pa Code: 201.14 (a)(c)(e) Responsibility of management 28 Pa Code: 201.18 (b)(1)(e)(1) Management. 395745 Page 16 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

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 a review of nursing job description, facility policy, clinical record, and staff interview, it was determined that the facility staff failed to provide treatments as ordered by the physician for seven of twelve residents (R23, R36, R47, R13, R48, R42, and R10). Residents Affected - Some Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS)assessment is a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the facility policy Wound Care dated 6/26/23, indicated Residents admitted with or develop skin integrity issues will receive treatment as indicated. Review of the clinical record indicated Resident R23 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident's care needs) dated 10/4/23, revealed diagnoses of chronic respiratory failure with hypercapnia (inadequate respiration resulting in high levels of carbon dioxide in the blood) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Section C: Cognitive Patterns indicated that a BIMS score of 15. Review of a physician's order dated 1/7/23, indicated for staff to clean Resident R23's left abdomen with NSS (normal saline solution) and cover with border gauze every 48 hours. During an interview and observation on 11/4/23, at 10:16 a.m. Resident R23's left abdomen dressing was noted to have a date of 10/28/23. Review on 11/7/23, of Resident R23's Treatment Administration Record (TARs) for October and November 2023 indicated the dressing change was completed on 10/28/23. The scheduled dressing change for 10/30/23, was not documented on, either as provided or refused. The scheduled dressing changes for 11/1/23, 11/3/23, and 11/5/23 were not documented on, either as provided or refused. During an interview and observation on 11/7/23, at 1:57 p.m. Resident R23's left abdomen dressing was dated 11/5/23. Resident R23 confirmed that the dressing was not changed from 10/28/23, until 11/5/23. Review of the clinical record indicated Resident R36 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) and a seizure disorder. Section C: 395745 Page 17 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0684 Cognitive Patterns indicated that a BIMS score of 11. Level of Harm - Minimal harm or potential for actual harm Review of a physician's order dated 11/2/23, indicated for staff to clean Resident R36's right foot great toe with normal saline solution, dry, apply Iodosorb (antibacterial gel medication) to site. Cover with 4x4 border gauze (a gauze of approximately 2 to 2.5 inches square, surrounded by an adhesive border measuring 4 x 4 inches square). To be changed daily. Residents Affected - Some During an observation on 11/5/23, at 9:56 a.m. Resident R36's right great toe had a 2 x 2 inch square of non-adherent gauze, with adhesive tape wrapped around the toe. This dressing was not dated. Review on 11/5/23, of Resident R36's TAR for November 2023 indicated the dressing change was completed on 11/2/23, and not again until 11/6/23. The scheduled dressing changes for 11/3/23, 11/4/23, and 11/5/23 were not documented on, either as provided or refused. Review of a nurse practitioner skin and wound note dated 11/6/23, at 5:44 p.m. indicated that resident R36 was seen on weekly wound rounds. At this time, Resident R36's wound care order was changed to: cleanse with normal saline, apply Betadine (an antiseptic solution) to base of the wound, leave open to air, change twice daily. Review of the clinical record indicated Resident R47 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and dementia. Section C: Cognitive Patterns indicated that a BIMS score of 08. Review of a physician's order dated 9/7/23, indicated for staff apply ACE wraps to bilateral lower extremities, from toes to knees in the morning for edema, DVT (deep vein thrombosis, blood clot in a deep vein). Remove at HS (hour of sleep). During an observation on 11/5/23, at 10:18 a.m. Resident R47's legs did not have ACE wraps applied. Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of dementia and high blood pressure. Section C: Cognitive Patterns indicated that a BIMS score of 07. Review of a physician's order dated 5/1/23, indicated for staff to apply ace wraps to be applied in the AM and off at bedtime; every morning and at bedtime for reduce swelling. During an observation on 11/5/23, at 12:52 p.m. Resident R13's legs were noted to be wrapped with ACE wraps, starting at the knees, and progressing downward. During an observation on 11/9/23, at 10:48 a.m. Resident R13's legs did not have ace wraps applied. Review of the clinical record indicated Resident R48 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of hemiplegia (paralysis on one side of the body) and high blood pressure. Section C: Cognitive Patterns indicated that a BIMS score of 05. 395745 Page 18 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of a physician's order dated 6/20/23, indicated for staff to apply ace wraps for every hour OOB (out of bed). Remove for QHS (hour of sleep). During an observation on 11/5/23, at 1:13 p.m. Resident 48's legs were noted to be wrapped with ACE wraps, starting at the knees, and progressing downward. Residents Affected - Some Review of the clinical record indicated Resident R42 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and heart failure. Section C: Cognitive Patterns indicated that a BIMS score of 14. Review of a physician's order dated 10/13/23, indicated for staff to apply ace wraps to be applied in the AM and off at night; every shift for edema. During an interview and observation on 11/7/23, at 2:06 p.m. Resident R42's legs did not have ace wraps applied. When asked if staff normally applied the ace wrap, Resident R42 stated, Not as a rule. I have to ask for it. I'd like to get it. During an observation on 11/9/23, at 10:45 a.m. Resident R42's legs did not have ace wraps applied. Review of the Medication Administration Record (MAR) revealed documentation that the ace wraps were applied. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and high blood pressure. Section C: Cognitive Patterns indicated that a BIMS score of 06. Review of a physician's order dated 19/23, indicated for staff to apply ace wraps to be applied in the AM and removed at bedtime; in the morning for edema ([NAME] caused by too much fluid trapped in the body's tissues). During an observation on 11/7/23, at 2:13 p.m. Resident 10's legs did not have ace wraps applied. Review of the Medication Administration Record (MAR) revealed documentation that the ace wraps were applied. During an interview on 11/7/23, at 2:16 p.m. LPN Employee E21 confirmed that she had been told in nurse to nurse report that they had been applied, and further confirmed that they were not applied. During an interview on 11/7/23, at approximately 4:30 p.m. the Director of Nursing (DON) confirmed that ACE wraps are to be applied beginning at the lower end of the leg, then progressing upward. During an interview on 11/7/23, at 2:16 p.m. LPN Employee E21 confirmed that she had been told in nurse to nurse report that they had been applied, and further confirmed that they were not applied. 395745 Page 19 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0684 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/9/23, at approximately 12:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility staff failed to provide treatments as ordered by the physician for seven of twelve residents. Residents Affected - Some 395745 Page 20 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on review of facility policy, resident observations, resident interviews and confidential staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 31 of 63 residents (R2, R11, R12, R21, R22, R23, R24, R25, R26, R27, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43, R44, R45, R50, R51, and R52). Findings Include: Review of the Facility Assessment Tool dated 10/1/23, indicated the facility will have the overall number of facility staff needed to ensure enough qualified staff are available to meet each resident's needs. During an interview on 11/4/23, at 9:57 a.m. Resident R21, when asked if he felt the facility maintained sufficient staff stated, There could be more. During an interview on 11/4/23, at 9:59 a.m. Resident R22, when asked if she felt the facility maintained sufficient staff, she stated loudly, Hell no. Sometimes you wait for a couple hours. Definitely need more aides. I've been left wet a couple times. A girl will come in, say they will be right back, and you never see them again. On 11/5/22, at 12:18 p.m. Resident R22 stated that night shift is especially bad for call light response, and that she tries to use the bed pan as much as possible, but they take a while and sometimes she soils the bed. During an interview on 11/4/23, at 10:03 a.m. Resident R43, when asked if she felt the facility maintained sufficient staff stated, No, I do not. During an interview on 11/4/23, at 10:07 a.m. Resident R50, when asked if she felt the facility maintained sufficient staff stated, No way in the world. Resident R50 stated that she has timed call lights lasting up to 40 minutes. When asked if she is ever left in a wet brief or bed, Resident R50 stated, Oh yes, I'm on a water pill. Get told to just go. Resident R50 stated she has missed a lot of showers. During an interview and observation on 11/4/23, at 10:16 a.m. Resident R23 when asked if he felt the facility maintained sufficient staff stated, No, they have too much agency and what not. When asked about call light response, Resident R23 stated A couple weeks ago I had to wait 3-4 hours. Resident R23 confirmed that he has been left in bowel movement. When asked about bathing, Resident R23 stated, When I can get someone to do it. Staff pretend they don't know how. Resident R23 was observed with greasy appearing hair and unclean fingernails. During an interview on 11/4/23, at 10:25 a.m. Resident R24, when asked if he felt the facility maintained sufficient staff stated, No. Resident R24 confirmed he has waited up to an hour for call light response. During a second interview and observation on 11/9/23, at 10:10 a.m. Resident R24, stated, No, they are very short. I've asked for pain medication in the morning, and don't get it until 2:00 p.m. Resident R24 was observed to have long fingernails and an unkempt beard. When asked if he preferred the long nails, Resident R24 stated, I hate them. I've been trying to get them cut. When asked about the beard, Resident R24 stated, I would like a mustache, but I would like the rest trimmed 395745 Page 21 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0725 down to the skin. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/4/23, at 10:26 a.m. Resident R25, when asked if he felt the facility maintained sufficient staff stated, No, it's terrible care. Resident R25 confirmed he has waited up to an hour for call light response, and further stated, They only change me once every eight hours. I sit in the chair from noon until 8:00 p.m. When asked if he wanted to stay in the chair that long, Resident R25 stated that he didn't, but if they put me back in bed earlier than that, they won't get me back up. Resident R25 confirmed that facility staff do not assist him in brushing his teeth. During a second interview on 11/9/23, at 10:12 a.m. Resident R25, stated, They take a long time. And to be ignorant, they say I'll be back, and don't plan on coming back. Residents Affected - Some During an observation on 11/4/23, at 11:28 a.m. Resident R26 was noted to be unshaven, with bushy hair growing from his ears. During an observation on 11/4/23, at 11:29 a.m. Resident R27 was noted to be not dressed for the day and unshaven. During an observation on 11/4/23, at 11:31 a.m. Resident R29 was noted to have greasy appearing hair. During a second observation on 11/5/23, at 12:49 p.m. Resident R29 was again noted to have unbrushed hair. During an interview and observation on 11/4/23, at 11:34 a.m. Resident R11, when asked if she felt the facility maintained sufficient staff stated, No, we need more nurses. When asked about call light response, Resident R11 stated Sometimes very long. Resident R11 confirmed that she has been in a soiled brief/clothing when they are busy. Resident R11 was observed with unbrushed hair. During a second observation on 11/5/23, at 12:50 p.m. Resident R11 was observed with unbrushed hair. During an interview and observation on 11/4/23, at 11:35 a.m. Resident R12, when asked if she felt the facility maintained sufficient staff stated, Oh, they definitely need more people. Resident R12 was observed wearing a shirt and brief, with no pants. During an interview an observation on 11/4/23, at 11:40 a.m. Resident R31 was noted to have facial hair. When asked if he prefers a beard, Resident R31 stated he prefers to be clean shaven. During an observation on 11/4/23, at 1:35 p.m. Resident R28 was noted to have unbrushed, greasy-appearing hair and was unshaven. During an observation on 11/4/23, at 1:37 p.m. Resident R32 was noted long, dirty fingernails. During an observation on 11/5/23, at 1:02 p.m. Resident R32 was noted to be dressed in a gown, with messy hair. During an observation on 11/4/23, at 1:40 p.m. Resident R33 was noted to have greasy-appearing hair. During an interview and observation on 11/4/23, at 4:57 p.m. Resident R34, when asked if he felt the facility maintained sufficient staff stated, No. When asked about call light response, Resident R34 stated, About a half an hour. Resident R34 confirmed that he has been in a soiled brief/clothing stating, I get stuck in it. When asked about showers, Resident R34 stated he cannot shower. When asked if staff assisted in washing him up, Resident R34 stated, No, I wish they did, but they don't. 395745 Page 22 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0725 Level of Harm - Minimal harm or potential for actual harm Resident R34 was noted to have facial hair extending down his neck. When asked if he prefers a beard, Resident R34 stated, I want shaved. Resident R34 was observed wearing an unclean gown, with unbrushed hair, and fingernails with a brownish-red substance underneath them. During an observation on 11/4/23, at 5:01 p.m. Resident R35 was noted to have extremely messy hair. Residents Affected - Some During an interview and observation on 11/4/23, at 5:03 p.m. Resident R51, when asked if she felt the facility maintained sufficient staff stated, They don't have enough staff here, I don't give a poop what they say. When asked about call light response, Resident R51 confirmed that they were long. When asked about showers, Resident R51 stated, Yes, I chase them down. Resident R51 stated she has been told by a nurse aide, I'm the only one here, I don't know if you are getting up today. During an interview and observation on 11/4/23, at 5:07 p.m. Resident R2, when asked if she felt the facility maintained sufficient staff stated, No, not on this hallway. This unit doesn't have help The other day, there was no nurse from 7-11 (7:00 p.m. - 11:00 p.m.). The aides didn't get to us until really late. During an interview on 11/5/23, at 9:56 a.m. Resident R36, when asked about call light response times stated, Sometimes long. During an interview on 11/5/23, at 10:02 a.m. Resident R37, when asked if she felt the facility maintained sufficient staff stated, No. I feel bad because the staff are under stress. When asked about call light response, Resident R37 confirmed that they were long during the night shift. It varies. I've had 20 minutes, I've had two hours. Resident R37 stated she only receives one shower per week. During an interview on 11/5/23, at 10:05 a.m. Resident R44, when asked if she felt the facility maintained sufficient staff stated, Sometimes yes, sometimes no. When asked about call light response, Resident R37 confirmed that they were worse during the night shift. During an interview and observation on 11/5/23, at 10:11 a.m. Resident R38, when asked if she felt the facility maintained sufficient staff stated, Nope. When asked about call light response, Resident R37 stated, Too long sometimes. During an observation on 11/5/23, at 11:22 a.m. Resident R52 was noted to have greasy appearing hair and food-soiled bed linen. During an interview and observation on 11/5/23, at 12:21 p.m. Resident R39, when asked about call light response, Resident R39 stated, About an hour. During an interview and observation on 11/5/23, at 12:25 p.m. Resident R45, when asked if she felt the facility maintained sufficient staff stated, Depends on the day. Weekends, ehh. When asked about call light response, Resident R37 confirmed she has experienced long wait times. During an interview and observation on 11/5/23, at 12:59 p.m. Resident R40, when asked if he felt the facility maintained sufficient staff stated, No. When asked about call light response, Resident R40 stated, Sometimes a little while, sometimes a lot. The longest was an hour and a half, to two hours. Resident R40 was noted to have long fingernails and facial hair. Resident R40 confirmed he prefers to be clean shaven. 395745 Page 23 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0725 Level of Harm - Minimal harm or potential for actual harm During an interview and observation on 11/5/23, at 1:16 p.m. Resident R41, when asked if she felt the facility maintained sufficient staff stated, They never have enough staff. Resident R41 was noted to have messy hair. 0 Residents Affected - Some During an interview and observation on 11/7/23, at 2:06 p.m. Resident R42, when asked if she felt the facility maintained sufficient staff stated, There are times when they are really short from call-offs. When asked about call light response, Resident R37 stated, Depends on who is working, sometimes an hour. During an interview on 11/7/23, at 2:13 p.m. Resident R30 stated, The night nurse doesn't do anything. Confidential staff interviews conducted during the survey about sufficient facility staffing indicated the following: -It's good as long as there aren't a bunch of call offs. -There's supposed to be five (aides), but usually there is only four. There are a lot of feeds (residents needing fed by staff) and no one to answer call lights. -There always has to be an aide in the dining room, and that leaves us short too. -There have been a time or two when I've come in and the beds are all wet. -There are more problems on 3-11 shift (3:00 p.m. - 11:00 p.m.). -There is not enough staff. We don't have time to do charting, give showers, take breaks. -There's not enough for the demand. During an interview on 11/9/23, at approximately 12:15 p.m. the Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 31 of 63 residents. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code: 201.20(a) Staff development. 28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services. 395745 Page 24 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of nursing job description, facility policy, clinical record, and staff interview, it was determined that the facility failed to assure that licensed nurses displayed the appropriate competencies and skills sets to provide nursing services to maintain safety for two of thirteen residents (Resident R19 and R20), and actual harm resulting increased pain during the provision of nursing care for one of thirteen residents. (Resident R20). Findings include: Review of the facility provided Licensed Practical Nurse (LPN) job description titled, Charge Nurse dated 6/6/23, indicated the LPN/charge nurse must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guideline that pertain to long-term care. Review of the facility policy Colostomy Appliance Bag Change dated 6/26/23, indicated that staff will cleanse surrounding skin area and stoma with mild soap and water - rinse. Review of the facility policy Medication Administration dated 6/26/23, indicated for transdermal patches, Remove old patch and dispose of properly. Review of the clinical record indicated Resident R20 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident's care needs) dated 8/21/23, revealed diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior). Section H - Bladder and Bowel indicated the presence of an ostomy (an artificial opening in an organ of the body, created during an operation). Review of a physician's order dated 8/14/23, indicated for staff to clean Resident R20's ostomy site with soap and water. Review of Resident R20's care plan for alteration in bowel elimination initiated 4/5/23, indicated for staff to cleanse area around stoma/colostomy site with soap and water. pat dry. Apply skin prep non sting. During an interview and observation on 11/4/23, at 1:35 p.m. Resident R20 stated to the surveyor that the nurse was coming to provide colostomy care to him. Surveyor exited the room at 1:36 p.m. when Licensed Practical Nurse (LPN) Employee E20 entered the room. Resident R20 could be heard to be screaming loudly It burns, it burns for the next few minutes. On 11/4/23, at 1:41 p.m. the surveyor reentered the room to observe the care that was causing Resident R20 to scream loudly. Resident R20 was observed to be holding a towel over his stoma site. After about a minute he removed the towel, and LPN Employee E20 said she needed to finish cleaning the stoma. With a spray bottle in her hand, she began to spray directly onto the stoma and the surrounding area. Resident R20 immediately began screaming that it was burning him again. The surveyor asked LPN Employee E20 what she was using to clean the stoma and surrounding area. LPN Employee E20 stated that it was peri-cleaner (perineal cleanser that gently cleans urine, emesis and fecal matter) and 395745 Page 25 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0726 Level of Harm - Actual harm displayed the bottle to the surveyor. The surveyor took the bottle from LPN Employee E20's hand. The bottle was labeled Bye-Bye Odor and stated on the front of the bottle ODOR ELIMINATOR, neutralizes odors and freshens the air. The surveyor informed LPN Employee E20 that she had been using air freshener to clean Resident R20's stoma and surrounding skin. Residents Affected - Few During an interview on 11/4/23, at 1:43 p.m. LPN Employee E20 confirmed that she was unaware she was using air freshener rather than peri-cleaner. During an interview on 11/4/23, at 1:49 p.m. the Director of Nursing (DON) confirmed that the facility failed to assure nursing competency in relation to stoma care. Review of the clinical record indicated Resident R19 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and quadriplegia (paralysis of all four limbs). Review of a physician's order dated 3/24/22, indicated for staff to apply one Nitroglycerin Patch 24 Hour 0.1 MG/HR (medication used to prevent episodes of chest pain in people who have coronary artery disease) transdermally (providing a medication in a form for absorption through the skin) one time a day, and remove per schedule. Review of Resident R19's Medication Administration Record (MAR) for November 2023 indicated the nitroglycerin patch is ordered to be removed at 8:59 a.m. and the new patch applied at 9:00 a.m. Review of a facility reported incident indicated When the medication nurse (LPN Employee E17) was administering (Resident R19's) nitroglycerin patch she noted 1 patch on the right chest wall, and three on the left chest wall. Review of Resident R19's MAR for 11/1/23, through 11/6/23. indicated the nitroglycerin patch was documented as removed prior to administration by LPN Employees E18, E19, and E20. During an interview on 11/9/23, at approximately 12:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to assure that licensed nurses displayed the appropriate competencies and skills sets to provide nursing services to maintain safety for two of thirteen residents, resulting in actual harm of increased pain during the provision of nursing care for one of thirteen residents (Resident R20). 28 Pa. Code: 201.14(1) Responsibility of licensee. 28 Pa. Code: 201.18(a)(3) Management. 395745 Page 26 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on review of Federal regulation, facility documents, and staff interviews, it was determined that the facility failed to develop, implement, and permanently maintain a training program for all staff which included training on abuse and neglect, as determined by staff need for 121 of 204 employees (Employees E4, E5, E8, E12, E13, E16, E20, E21, E27, E33, E35, E36, E37, E38, E39, E40, E41, E42, E43, E44, E45, E46, E47, E48, E49, E50, E51, E52, E53, E54, E55, E56, E57, E58, E59, E60, E61, E62, E63, E64, E65, E66, E67, E68, E69, E70, E71, E72, E73, E74, E75, E76, E77, E78, E79, E80, E81, E82, E83, E84, E85, E86, E87, E88, E89, E90, E91, E92, E93, E94, E95, E96, E97, E98, E99, E100, E101, E102, E103, E104,

E105, E106, E107, E108, E109, E110, E111, E112, E113, E114, E115, E116, E117, E118, E119, E120,

E121, E122, E123, E124, E125, E126, E127, E128, E129, E130, E131, E132, E133, E134, E135, E136,

E137, E138, E139, E140, E141, E142, E143, E144, and E145). Findings include: Review of the United States Code of Federal Regulations, §483.95 Training requirements, the guidance indicated facilities must develop, implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, that is appropriate and effective, as determined by staff need. The guidance further stated there should be a process in place to track staff participation in the required trainings. Review of facility policy Abuse, Neglect, & Misappropriation, reviewed 6/6/23, revealed that it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. It is the intent of the facility to prevent abuse, mistreatment, or neglect of residents and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect, or misappropriation of their property. The policy further stated the facility will provide education and training upon hire, annually, and as needed for retraining. Education and training in-services documentation of attendance will be maintained. Review of a facility submitted report dated 9/14/23, indicated that on 9/13/23, Nurse Aide (NA) Employee E2 reported that RN Employee E1 had called Resident R1 a bitch and moved around the desk towards the resident. NA Employee E2 stepped between the resident and the nurse. No physical contact occurred between the nurse and the resident. Review of a provided report dated 10/2/23, indicated the local police were dispatched to the facility, after the facility had called to report an allegation of abuse/neglect. The Director of Nursing (DON) was noted to have provided the officer with four sworn statements dated 10/1/23. Review of a facility submitted report dated 10/4/23, indicated that on 10/3/23, Resident R15 stated that the NA (NA Employee E9) on the 3:00 p.m. - 11:00 p.m. shift had yelled at her because she had to call her back into the room after an incontinent episode. Resident R15 stated that the NA was very rough with her. Resident stated that her vagina was still burning and sore hours after the incident. Review of a facility submitted incident dated 10/5/23, indicated that on 10/5/23, at 2:00 p.m. Resident R16 was moved from one wing of the facility to a different wing. He was noted with a ring of wet urine on the fitted sheet with a dry brief. 395745 Page 27 of 28 395745 11/09/2023 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the educational records for staff members currently employed at the time of the survey, with hire dates previous to 9/13/23, failed to reveal at least one documented Abuse and Neglect reeducation training that was provided by the facility on the following dates: 9/13/23 – 9/17/23, 10/2/23, or 10/5/23, for the following employees: Employees E4, E5, E8, E12, E13, E16, E20, E21, E27, E33, E35, E36, E37, E38, E39, E40, E41, E42, E43, E44, E45, E46, E47, E48, E49, E50, E51, E52, E53, E54, E55, E56, E57, E58, E59, E60, E61, E62, E63, E64, E65, E66, E67, E68, E69, E70, E71, E72, E73, E74, E75, E76, E77, E78, E79, E80, E81, E82, E83, E84, E85, E86, E87, E88, E89, E90, E91, E92, E93, E94, E95, E96, E97, E98, E99, E100, E101,

E102, E103, E104, E105, E106, E107, E108, E109, E110, E111, E112, E113, E114, E115, E116, E117,

E118, E119, E120, E121, E122, E123, E124, E125, E126, E127, E128, E129, E130, E131, E132, E133,

E134, E135, E136, E137, E138, E139, E140, E141, E142, E143, E144, and E145) During an interview on 11/9/23, at approximately 12:15 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure abuse and neglect prevention training was completed for all facility staff after substantiated abuse incidents for 121 of 204 staff members. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 201.19 Personnel Policies and Procedures 28 Pa. Code: 201.20(a)(c) Staff Development 28 Pa. Code: 201.29 (d) Resident Rights 395745 Page 28 of 28