Health inspection·May 9, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm 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 policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to protect residents from staff initiated verbal abuse for two of nine residents (Resident R74 and R156). Findings include: A review of facility policy Abuse Prohibition, dated 1/30/24, indicated the facility prohibits abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all patients. This includes, but is not limited to, freedom from corporeal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the patient's medical condition. The policy further defined Verbal Abuse as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are limited to threats of harm, saying things to frighten a patient, such as telling a patient they will never see their family again. A review of the clinical record indicated that Resident R74 was readmitted to the facility on [DATE], with diagnoses that include Acute Kidney Injury (AKI-kidneys can no longer filter waste from blood), gastroesophageal reflux disease (GERD-stomach acid irritates the food pipe lining), small b-cell lymphoma (a type of slow growing cancer that attacks the blood), and high blood pressure. A review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 3/8/24, indicated the diagnoses remained current. A review of the care plan dated 11/4/23, 11/6/23, and 12/20/23 indicated that the facility is to honor food preferences, provide diet as ordered: NAS (low salt)/regular texture, encourage to avoid eating late in the evening, and to consult dietary to modify meals and snack plan as needed. During a group interview on 5/7/24, at approximately 11:00 a.m. Resident R74 stated that she asked for a second sandwich with a meal and Registered Nurse (RN) Employee E12 stated, Do you really think you need that, it will just be more difficult for you to get out of bed. The resident stated she did not tell anyone because she was afraid of retribution or that she wouldn't get extra food if she asked again. A review of the clinical record indicated that Resident R156 was admitted on [DATE], with diagnoses that include embolism (blood clot) of left lower leg, muscle weakness, and depression. Page 1 of 17 396066 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0600 A review of the MDS dated [DATE], indicated the diagnoses remained current. Level of Harm - Minimal harm or potential for actual harm A review of the care plan dated 4/19/24, and 5/7/24, indicated that the facility is to honor food preferences within the meal plan and resident does not eat pork with no pork to be placed on meal tray. Resident stated that she received her breakfast tray and there was pork on her plate. The resident notified NA Employee E11 about the pork and that she needs food so that she could take her medications. The NA Employee E11 said back, What the f*** do you want me to do about it? NA Employee E11 did get her another tray ordered for breakfast and the patient was able to eat. Residents Affected - Some During an interview on 5/7/24, at approximately 12:50 p.m., the Nursing Home Administrator and Director of Nursing were notified about the incidents that were made known during the resident group interview and confirmed that the facility failed to make certain that residents were free from neglect that resulted in verbal abuse for two of nine residents. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services. 396066 Page 2 of 17 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set (MDS- periodic assessment of care needs) assessments were completed in the required time frame for 12 of 16 residents (Resident R104, R120, R262, R263, R264, R265, R320, R321, R322, R362, R363, and R364). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required MDS, dated [DATE], indicated that an admission MDS assessment was to be completed no later than 14 days following admission, and annual MDS assessment was to be completed no later than Assessment Reference Date (ARD). Resident R263 had an admission date of 4/19/24, with an MDS completion due date of 5/2/24, this was not completed as of the end of the survey on 5/9/24. Resident R321 had an admission date of 4/19/24, with an MDS completion due date of 5/2/24, this was not completed as of the end of the survey on 5/9/24. Resident R264 had an admission date of 4/20/24, with an MDS completion due date of 5/7/24, this was not completed as of the end of the survey on 5/9/24. Resident R320 had an admission date of 4/20/24, with an MDS completion due date of 5/3/24, with a Resident R364 had an admission date of 4/23/24, with an MDS completion due date of 5/6/24, this was not completed as of the end of the survey on 5/9/24. Resident R262 had an admission date of 4/24/24, with an MDS completion due date of 5/7/24, this was not completed as of the end of the survey on 5/9/24. Resident R362 had an admission date of 4/24/24, with an MDS completion due date of 5/7/24, this was not completed as of the end of the survey on 5/9/24. Resident R120 had an admission date of 4/25/24, with an MDS completion due date of 5/8/24, this was not completed as of the end of the survey on 5/9/24. Resident R363 had an admission date of 4/25/24, with an MDS completion due date of 5/8/24, this was not completed as of the end of the survey on 5/9/24. Resident R104 had an admission date of 4/26/24, with an MDS completion due date of 5/9/24, this was not completed as of the end of the survey on 5/9/24. Resident R265 had an admission date of 4/26/24, with an MDS completion due date of 5/9/24, this was not completed as of the end of the survey on 5/9/24. 396066 Page 3 of 17 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident R322 had an admission date of 4/26/24, with an MDS completion due date of 5/7/24, this was not completed as of the end of the survey on 5/9/24. During an interview on 5/9/24, at approximately 11:00 a.m. the RNAC (Registered Nurse Assessment Coordinator) Employee E1 confirmed the above assessments were not completed, due to a lack of sufficient staff. During an interview on 5/9/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that MDS assessments were completed in the required time frame for 12 for 16 residents. 28 Pa. Code: 211.5(f) Medical records. 396066 Page 4 of 17 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of the Long-Term Care Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to transmit Minimum Data Set's (MDS -periodic assessment of care needs) to the required electronic system within the mandated time frame for one of 16 residents reviewed (Resident R20). Residents Affected - Few Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required MDS assessments, dated October 2023, indicated that Entry, Death and Facility and Discharge tracking MDS assessments must be completed and transmitted within 14 days of the event date. Resident R20 had a discharge date of 4/17/24, with a Discharge/Return Anticipated MDS completion due date of 5/1/24, this was not completed until 5/7/24, six days later. During an interview on 5/9/24, at approximately 11:00 a.m. the RNAC (Registered Nurse Assessment Coordinator) Employee E1 confirmed the above assessment was not completed, due to a lack of sufficient staff. During an interview on 5/9/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to transmit MDS's to the required electronic system within the mandated time frame for one of 16 residents reviewed. 28 Pa. Code 211.5(d) Medical records. 396066 Page 5 of 17 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record reviews and interviews with staff, it was determined that the facility failed to establish a baseline care plan within 48 hours of admission/readmission for three of twelve residents (Resident R61, R72 and R324). Findings include: A review of facility policy Person Centered Care Plan reviewed 1/30/24, indicated it is the policy of this facility to develop and implement a baseline person-centered care plan for each resident within 48 hours of admission/readmission that will include the instructions needed to provide effective and person-centered care that meet professional standards of quality care. Review of the clinical record indicated Resident R61 was admitted to the facility on [DATE], with diagnoses that included fracture of left femur (a break in the long bone in the thigh), high blood pressure, repeated falls, and dementia (group of thinking and social symptoms that interferes with daily functioning), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). Review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 4/11/24, indicated the diagnoses remained current. Review of Resident R61's nurse progress notes dated 4/30/24, indicated that toileting frequency was being attempted every two hours without success. In tasks-toileting section, question three-urinary continence, it was documented that from 4/30/24, to 5/9/24, the resident was incontinent for seventeen out of eighteen documented actions. Review of Resident R61's care plan failed to provide a baseline plan of care for incontinence (lack of voluntary control over urination) within the forty-eight-hour timeframe. Review of the clinical record indicated Resident R72 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, fracture of right humerus (break of long bone in upper arm), and constipation. Review of the MDS dated [DATE], indicated the diagnoses remained current. Review of Resident R72's progress notes on 4/26/24, and 5/6/24, indicated bowel and bladder management will continue to monitor in conjunction with nursing team; will discuss any issues identified with internal medicine. Resident takes lubiprostone 24 mcg (micrograms) twice a day for chronic constipation. Resident also ordered milk of magnesia (MOM), fleet enema, dulcolax suppository as well as miralax powder all as necessary for chronic constipation. Review of Resident R72's care plan failed to provide a baseline care plan for constipation care within the forty-eight-hour timeframe. Review of the clinical record indicated Resident R324 was admitted to the facility 5/1/24, with diagnoses that included high blood pressure, fracture of left tibia (break in one of the bones in the 396066 Page 6 of 17 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some lower leg), and seizures (uncontrolled activity in the brain that can cause temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, or state of awareness). Review of the MDS dated [DATE], indicated the diagnoses remained current. Review of Resident R324's nurse progress notes indicated the resident was assessed for all medical diagnoses (pain, movement, dysphagia (difficulty swallowing), anticoagulants (blood thinners), constipation, seizures, and falls)daily but did not have an adequate baseline care plan for all diagnoses. Review of Resident R324's care plan failed to provide an adequate baseline care plan for all medical issues within the forty-eight-hour timeframe. During an interview on 5/7/24, at 11:28 a.m. the Director of Nursing confirmed Residents R61, R72 and R324 a baseline care plan was not initiated to reflect the resident's current status within forty-eight hours of admission. 28 Pa. Code 211.11(d) Resident care plans. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 396066 Page 7 of 17 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical record review and resident and staff interviews, it was determined that the facility failed to make certain that showers were consistently provided for three of six residents (Resident R74, R85, and R124, R328). Residents Affected - Some Findings include: Review of the facility policy Activity of Daily Living (ADLs) dated 1/30/24, indicated the center must provide the necessary care and services to ensure that a resident's activities of daily living (ADL) abilities are maintained. Activities of daily living include hygiene care and will be recorded in the medical record. Review of Resident R74's admission record indicated that Resident R74 was admitted to the facility on [DATE], with diagnoses that included kidney failure, neurocognitive disorder (decreased mental function and loss of ability to do daily tasks), diabetes, and obesity. Review of Resident R74's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 3/8/24, indicated that diagnoses remain current. Resident R74 is alert and oriented and able to make needs known. Resident R74 requires assistance of 2 staff members for hygiene care. During an interview on 5/9/24 at 9:00 a.m., Resident R74 stated I only get one shower a week and sometimes none at all. I want to get two every week. A review of the facility Shower Schedule updated 1/22/24, indicated Resident R74's shower is to be given every Wednesday and Saturday. Review of Resident R74's Point of Care-Bathing documentation, dated April and May 2024, indicated that Resident R74 did not receive a shower on three out of four opportunities in April. The May record indicated Resident R74 did not receive a shower on two of three opportunities. The clinical record did not indicate a reason for the missed opportunities. Review of Resident R85's admission record indicated that Resident R85 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease. Review of Resident R85's MDS dated [DATE], indicated the diagnosis remains current. Resident R85 has impaired cognition and is totally dependent on two staff for bathing and showering. A review of the facility Shower Schedule updated 1/22/24, indicated Resident R85's shower is to be given every Wednesday and Saturday. During an interview with Resident R85's family member on 5/8/24, at 1:00 p.m. revealed Resident R85 does not get showers as scheduled. There is not enough staff to get the showers done. Review of Resident R85's Point of Care-Bathing documentation, dated April 2024, indicated that Resident R85 did not receive a shower on four out of four opportunities in April. The clinical record did not indicate a reason for the missed opportunities. 396066 Page 8 of 17 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident R124's admission record indicated that Resident R124 was admitted to the facility on [DATE], with diagnoses that included left lower leg fracture and diabetes. Review of Resident R124's MDS dated [DATE], indicated the diagnosis remains current. Resident R124 is alert and oriented and able to make needs known. Resident R124 requires limited assistance of two staff for bathing and showering. A review of the facility Shower Schedule updated 1/22/24, indicated Resident R124's shower is to be given every Monday and Thursday. During an interview on 5/9/24 at 9:30 a.m. Resident R124 revealed showers are not done as scheduled. They do not have enough staff. Review of Resident R124's Point of Care-Bathing documentation, dated April and May 2024, indicated that Resident R124 did not receive a shower on four out of five opportunities in April and two of three opportunities in May. The clinical record did not indicate a reason for the missed opportunities. Review of Resident R328 admission record indicated that Resident R328 was admitted to the facility on [DATE] with diagnoses that included multiple rib fractures (broken bone) on right side, muscle weakness, and high blood pressure. Review of Resident R328's MDS dated [DATE] indicated the diagnoses remains current. Resident R328 is alert and oriented and able to make needs known. Resident R328 requires limited assistance of two staff for bathing and showering. A review of the facility Shower Schedule updated 4/19/24, indicated Resident R328's shower is to be given every Monday and Thursday During an interview on 5/6/24 at 8:30 a.m., with Resident R328 and a family member it was revealed that Resident R328 was only receiving bed baths and would have liked to receive a shower. Family member stated that they come every day to ensure that Resident R328 is receiving some kind of bathing. They understand that the facility is short-staffed but would appreciate a shower at least once a week. Resident R328 did not receive a shower on three out of three opportunities in April and two out of two in May. The clinical record did not indicate a reason for the missed opportunities. During an interview on 5/9/24 at 9:50 a.m., Nursing Assistant (NA) Employee E7 revealed We can not get showers done because we do not have enough people. During an interview on 5/9/24, at 10:00 a.m., NA Employee E8 revealed I can't get my showers done because we are short staffed. During an interview on 5/9/24, at 10:15 a.m., NA Employee E9 revealed It is not manageable, we don't have enough people to do the hygiene care. During an interview on 5/9/24, at 11:00 a.m., NA Employee E10 revealed, Every day, I can not get my showers done. We are always understaffed. 396066 Page 9 of 17 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0677 During an interview on 5/9/24 at 1:00 p.m., the Director of Nursing (DON) confirmed the facility failed to consistently provide showers for Residents R74, R85, R124, and R328. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 211.11(d) Resident care plan. Residents Affected - Some 28 Pa. Code: 211.12(d)(1) Nursing services. 28 Pa. Code: 211.12(d)(3) Nursing services. 28 Pa. Code: 211.12(d)(5) Nursing services. 396066 Page 10 of 17 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for one of four residents (Resident R128). Residents Affected - Few Findings include: Review of the facility policy Skin Integrity and Wound Management dated 1/8/24, previously dated 3/28/23, indicated the facility will provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing within the context of what matters most to all patients. Review of the clinical record indicated Resident R128 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 3/6/24, included the diagnoses of history of a stroke, hemiplegia (paralysis on one side of the body), and the need for assistance with personal care. Review of Section C - Cognitive Patterns indicated that Resident R128 was cognitively intact. Review of Section GG - Functional Abilities and Goals indicated that Resident R128 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) to roll left and right. Review of Section M - Skin Conditions indicated that Resident R128 was at risk for pressure ulcer development and that Resident R128 had one unhealed, Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure ulcer. Review of the Braden Scale Assessment (a tool utilized to assess a patient's risk of developing a pressure ulcer) dated 10/23/23, revealed Resident R128 was at high risk for the development of pressure ulcers. Review Resident R128's care plan dated 2/7/24, for risk for alteration in skin integrity, indicated Resident R128 revealed the following interventions: -Administer treatment per physician orders. -Elevate heels as able. -Encourage to reposition as needed. -Use positioning devices as needed. Review of a wound nurse practitioner's report dated 5/1/24, indicated: -Wedge for offloading. 396066 Page 11 of 17 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0686 -Offload heels per facility protocol. Level of Harm - Minimal harm or potential for actual harm -Avoid direct pressure to wound site. Residents Affected - Few Review of Resident R128's physician orders failed to include an order for the use of a positioning wedge or an order for staff to offload Resident R128's heels. Review of Resident R128's [NAME] (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff as of 5/5/24, failed to include direction to nurse aide staff to assist to turn and reposition, to utilize a positioning wedge, or to offload Resident R128's heels. During an interview on 5/6/24, at approximately 12:30 p.m., when asked if she is assisted to reposition every two hours stated, that doesn't happen. While conducting the interview, a nursing staff member entered the room. Resident R128 requested for the staff member to remove the blanket from her feet, due to her toes becoming sore. Resident R128 was not noted to have her heels offloaded at this time. The surveyor asked Resident R128 if her heels were sore, and she confirmed that the were. Observation and palpation at this time revealed Resident R128's heels to be reddened and overly soft. During observations completed on: -5/6/24, at approximately 12:30 p.m. -5/7/24, at approximately 11:30 a.m. 2:30 p.m., and 4:40 p.m. -5/8/24, at approximately 9:50 a.m., and 11:10 a.m. all revealed that Resident R128 to be lying flat on her back, with her head slightly elevated, positioning wedge not in place, heels not elevated. During the above observations, the bed wedge was noted to be on a chair in the room, not utilized. During an interview and observation of wound care on 5/8/24, at 11:12 a.m. Resident R128 stated that she did not get out of bed yesterday (5/7/24) because was not enough people to get me up. CRNP Employee E6 asked Resident R128 if she was wearing her heel protector boots. The surveyor confirmed with CRNP Employee E6 that Resident R128 does not have an order for heel protector boots or a positioning wedge. When the survey communicated the above observations showing a lack of repositioning to CRNP Employee E6, she stated That is a problem, I will be speaking to the DON (Director of Nursing) about it. When the surveyor advised of Resident R128 stating on 5/6/24, that here heels and toes hurt, CRNP Employee E6 confirmed that she had not been advised by nursing staff about these concerns, and observed Resident R128's feet, which showed bruising on the right heel. During an interview on 5/9/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for one of four residents. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 396066 Page 12 of 17 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

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 policies and documents, resident observations, resident and staff interviews, and resident care records, 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 of nine of 32 residents (Resident R74, R85, R124, R128, and R328) and four of nine group residents (R401, R402, R403, and R404). Findings Include: Review of the facility policy Activity of Daily Living (ADLs) dated 1/30/24, indicated the center must provide the necessary care and services to ensure that a resident ' s activities of daily living (ADL) abilities are maintained. Activities of daily living include hygiene care and will be recorded in the medical record. During an interview on 5/6/24, at 1:10 p.m. Registered Nurse (RN) Employee E12 stated that the staffing is not adequate. When asked what care was not being provided consistently to the residents, RN Employee E12 stated that there is not time to get showers completed on the weekends, pass water timely, answer call lights timely, and not enough time to complete resident rounds. During an interview on 5/9/24 at 9:00 a.m., Resident R74 stated I only get one shower a week and sometimes none at all. I want to get two every week. Review of the facility Shower Schedule updated 1/22/24, indicated Resident R74's shower is to be given every Wednesday and Saturday. Review of Resident R74's Point of Care-Bathing documentation, dated April and May 2024, indicated that Resident R74 did not receive a shower on three out of four opportunities in April. The May record indicated Resident R74 did not receive a shower on two of three opportunities. The clinical record did not indicate a reason for the missed opportunities. During an interview with Resident R85's family member on 5/8/24, at 1:00 p.m. revealed Resident R85 does not get showers as scheduled. There is not enough staff to get the showers done. Review of the facility Shower Schedule updated 1/22/24, indicated Resident R85's shower is to be given every Wednesday and Saturday. Review of Resident R85's Point of Care-Bathing documentation, dated April 2024, indicated that Resident R85 did not receive a shower on four out of four opportunities in April. The clinical record did not indicate a reason for the missed opportunities. During an interview on 5/9/24 at 9:30 a.m. Resident R124 revealed showers are not done as scheduled. They do not have enough staff. Review of the facility Shower Schedule updated 1/22/24, indicated Resident R124's shower is to be given every Monday and Thursday. Review of Resident R124's Point of Care-Bathing documentation, dated April and May 2024, indicated 396066 Page 13 of 17 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that Resident R124 did not receive a shower on four out of five opportunities in April and two of three opportunities in May. The clinical record did not indicate a reason for the missed opportunities. During an interview on 5/6/24 at 8:30 a.m., with Resident R328 and a family member it was revealed that Resident R328 was only receiving bed baths and would have liked to receive a shower. Family member stated that they come every day to ensure that Resident R328 is receiving some kind of bathing. They stated they understand that the facility is short-staffed but would appreciate a shower at least once a week. Review of the facility Shower Schedule updated 4/19/24, indicated Resident R328's shower is to be given every Monday and Thursday Review of Resident R328's Point of Care-Bathing documentation, dated April and May 2024 indicated that Resident R328 did not receive a shower on three out of three opportunities in April and two out of two in May. The clinical record did not indicate a reason for the missed opportunities. During an interview on 5/6/24, at approximately 12:30 p.m. Resident R128 confirmed that from her stroke, she has almost no use of her right side. Resident R128 stated that she is not assisted by staff to reposition and has been left in a soiled brief the entire day. During an interview and observation of wound care on 5/8/24, at 11:12 a.m. when CRNP (Certified Registered Nurse Practitioner) Employee E6 asked Resident R128 is she was getting out of bed to relieve pressure on her wound, Resident R128 stated that she did not get out of bed yesterday (5/7/24) because there was not enough people to get me up. During a resident group interview conducted on 5/7/24, at 11:00 a.m. the following concerns were discussed: Staffing - Multiple residents stated that this is always an issue and know that it needs resolved. Residents stated they feel that because the aides are short (staffed), they don't get the care they need. Call Lights - Multiple residents stated it feels like it takes forever for them to be answered, stated up to three hours. -Resident R401 stated her husband timed a call bell and it took three hours for it to be answered. -Resident R404 stated she needed to use the bathroom (not allowed to on her own, needs assistance), used her call bell and saw someone walk past her room multiple times, she waited two hours before someone came in. Personal Care - Residents stated that they were told that the new rule was that they had to wait every two hours if they are incontinent, not additionally if needed. Showers - Residents stated they are not getting them due to not enough help. -Resident R402 stated she doesn't get them because she goes to dialysis on her scheduled shower day, and they won't change her day. 396066 Page 14 of 17 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0725 Level of Harm - Minimal harm or potential for actual harm -Resident R403 stated she doesn't get showers twice a week and she is independent; she just needs someone to assist in turning water on. During an interview on 5/9/24, at 9:29 a.m. the facility Medical Director confirmed that there have been issues with staffing. The Medical Director stated that call light response has been a concern. Residents Affected - Some During an interview on 5/9/24 at 9:50 a.m., Nursing Assistant (NA) Employee E7 revealed We cannot get showers done because we do not have enough people. During an interview on 5/9/24, at 10:00 a.m., NA Employee E8 revealed I can't get my showers done because we are short staffed. During an interview on 5/9/24, at 10:15 a.m., NA Employee E9 revealed It is not manageable, we don't have enough people to do the hygiene care. During an interview on 5/9/24, at 11:00 a.m., NA Employee E10 revealed, Every day, I cannot get my showers done. We are always understaffed. During an interview on 5/9/24, at approximately 10:09 a.m. the RNAC (Registered Nurse Assessment Coordinator) Employee E1 confirmed that the facility had approximately 20 overdue Minimum Data Set assessments not completed on time, due to a lack of sufficient staff. During an interview on 5/9/24 at 1:00 p.m., the Director of Nursing (DON) confirmed the facility failed to consistently provide showers for Residents R74, R85, and R124. During an interview on 5/9/24, at 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to have sufficient nursing staff to provide nursing and related services nine of 32 residents and four of nine group 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)(5) Nursing services. 396066 Page 15 of 17 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0944 Level of Harm - Potential for minimal harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on review of facility policy, training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for four of ten staff members (Employees E2, E3, E4, and E5). Findings include: Review of the facility policy In-service Training dated 1/8/24, previously dated 3/28/23, indicated all mandatory in-service requirements must be completed annually as a condition of continued employment. Listed in the training topics to include: Quality assurance and performance improvement (QAPI) training on the elements and goals of the QAPI program. Review of facility provided documents and training record for Employees E2, E3, E4, and E5 revealed the following staff members did not have documented training on QAPI. Nurse Aide (NA) Employee E2 had a hire date of 2/26/07, failed to have QAPI in-service education between 2/26/23, and 2/26/24. NA Employee E3 had a hire date of 3/23/09, failed to have QAPI in-service education between 3/23/23, and 3/23/24. NA Employee E4 had a hire date of 1/3/18, failed to have QAPI in-service education between 1/3/23, and 1/3/24. Licensed Practical Nurse Employee E5 had a hire date of 2/24/19, failed to have QAPI in-service education between 2/24/23, and 2/24/24. During an interview on 5/9/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on QAPI for four of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 396066 Page 16 of 17 396066 05/09/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0947 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Nurse Aide (NA)Employees E2 and E3). Finding include: Review of the facility policy In-service Training dated 1/8/24, previously dated 3/28/23, indicated all mandatory in-service requirements must be completed annually as a condition of continued employment and further stated the facility will ensure continuing competence for no less than 12 hours per year for nurse aides. Review of NA Employees Employees E2 and E3 education records with hire date greater than 12 months revealed the following: NA Employee E2 had a hire date of 2/26/07, with 9:05 hours in-service education between 2/26/23, and 2/26/24. NA Employee E3 had a hire date of 3/23/09, with 9:05 hours in-service education between 3/23/23, and 3/23/24. During an interview on 5/9/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 201.20(c) Staff Development. 396066 Page 17 of 17