Health inspection·August 22, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to notify the family of a change in condition in a timely manner for one of four residents (Resident R1). Findings include: Review of the facility policy Notification of Change Condition: Responsible Party/Guardian dated 5/1/24, indicated the responsible party or guardian is to be notified when there has been any break in the resident's skin integrity. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia and a fractured left leg. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/4/24, indicated the diagnoses remain current. Review of Resident R1's admission assessment dated [DATE], indicated the resident had a skin alteration to the coccyx (lower back) 0-0.3 cm (centimeters) with light exudate (abrasion) and granulated (healing) tissue. Review of Resident R1's nurse progress note dated 7/8/24, indicated possible Kennedy Wound (pressure ulcer that has a sudden onset and rapid progression) to coccyx 6.5 cm X 7 cm, dressing applied and wound care CRNP (certified registered nurse practitioner) sent to assist in treatment plan. There was no evidence in the clinical record that the resident's family was notified of this change in condition. During an interview on 8/22/24, at 3:0 p.m. the Director of Nursing confirmed that the facility failed to notify the family of a change in condition in a timely manner for one of four residents (Resident R1). 28 Pa. Code: 201.29(a)(b)(c)(d)(j)(m) Resident rights. 28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. Page 1 of 3 395948 395948 08/22/2024 Rehabilitation Center at Jefferson Hills, The 540 Coal Valley Road Jefferson Hills, PA 15025

F 0580 28. Pa. Code: 211.10(a)(c)(d) Resident care policies. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395948 Page 2 of 3 395948 08/22/2024 Rehabilitation Center at Jefferson Hills, The 540 Coal Valley Road Jefferson Hills, PA 15025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of four residents (Resident R1) Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia, and a left leg fracture. Review of the Minimum Data Set (MDS-periodic assessment of care needs) dated 7/4/24, indicated the diagnoses remain current. Review of a physician order dated 7/15/24, indicated to cleanse the top of both feet with NSS (normal saline solution), apply Xeroform (a moisture dressing) to open areas, apply 4X4 gauze, and wrap with gauze daily for wound care. Review of Resident R1's Treatment Administration Record (TAR), dated July 2024, indicated the treatment was applied on 7/16, and 7/17/2024. Resident R1 was discharged to home on 7/17/24. Review of weekly skin check documentation dated, 06/28/24, 7/3/24, and 7/10/24, indicated that Resident R1 did not have open areas to the top of both feet. During an interview on 8/22/24 at 1:30 p.m., Licensed Practical Nurse (LPN) Employee E1 revealed Resident R1 did not have wounds to the feet while a resident at the facility. During a telephone interview on 8/22/24 at 2:25 p.m., LPN Employee E2 revealed the documentation on Resident R1's TAR was incorrect. During an interview on 8/22/24 at 2:15 p.m., The Director of Nursing (DON) confirmed the above findings and revealed the physician order and TAR documentation for wound care to both feet was entered on the wrong resident's chart, and the facility failed to make certain that medical records were complete and accurately documented for Resident R1. 28 Pa. Code: 211.5(f) Clinical records. 28 Pa. Code: 211.5(g)(h) Clinical records. 395948 Page 3 of 3