Health inspection·April 18, 2024

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 review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess residents for hypoglycemia (low blood glucose), failed to document and/or institute interventions for hypoglycemia, and failed to document notification to physicians of decreased capillary blood glucose (CBG) levels for one of three residents (Residents R154). Residents Affected - Few Findings include: Review of the facility Hypoglycemia Protocol dated 8/3/23, indicated for conscious persons with a CBG level: - less than 45 mg/dl (milligrams per deciliter), to give 30 g (grams) of carbohydrates (8 ounces of juice or soda or 2 tablespoons jelly or sugar). Repeat CBG level in 15 minutes. - between 45-59 mg/dl, to give 20 g of carbohydrates (6 ounces of juice or soda or 1.5 tablespoons jelly or sugar). Repeat CBG level in 15 minutes. - between 60-100 mg/dl, to give 15 g of carbohydrates (4 ounces of juice or soda or 1 tablespoon jelly or sugar). Repeat CBG level in 15 minutes. Review of the facility policy Notification of Changes dated 8/3/23, indicated the facility will promptly consult with the resident's physician when there is a change requiring notification. Circumstances requiring notification include significant changes in the resident's physical, mental, or psychosocial conditions. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R154's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 4/11/24, included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of a physician's order dated 4/5/24, indicated to inject Humalog insulin (fast-acting medication to lower blood sugar levels) per sliding scale; if blood glucose is less than 70 initiate hypoglycemic protocol. Review of the Resident R154's blood sugar record revealed: Page 1 of 6 396089 396089 04/18/2024 Concordia of the South Hills 1300 Bower Hill Road Pittsburgh, PA 15243

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -4/11/24, at 6:28 a.m. the CBG was 44 mg/dl. The clinical record failed to reveal documentation in a progress note addressing the low CBG level, failed to reveal the initiation of the hypoglycemic protocol, failed to reveal a recheck of the CBG level, and failed to reveal documentation of physician notification. -4/14/24, at 5:49 a.m. the CBG was 48 mg/dl. The clinical record failed to reveal a recheck of the CBG level and failed to reveal documentation of physician notification. -4/16/24, at 5:50 a.m. the CBG was 62 mg/dl. The clinical record failed to reveal documentation in a progress note addressing the low CBG level, failed to reveal the initiation of the hypoglycemic protocol, failed to reveal a recheck of the CBG level, and failed to reveal documentation of physician notification. During an interview on 4/18/24, at approximately 11:05 a.m. the Corporate Director of Nursing confirmed the facility failed to assess residents for hypoglycemia (low blood glucose), failed to document and/or institute interventions for hypoglycemia, and failed to document notification to physicians of decreased capillary blood glucose (CBG) levels for one of three residents. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services. 396089 Page 2 of 6 396089 04/18/2024 Concordia of the South Hills 1300 Bower Hill Road Pittsburgh, PA 15243

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 three residents (Resident R7). Residents Affected - Few Findings include: Review of the facility policy Pressure Ulcer Protocol dated 8/3/23, indicated the facility will provide a program of prevention, care, and treatment of pressure ulcers to all residents to prevent skin breakdown and to promote healing. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 2/14/24, included the diagnoses of anemia (too little iron in the body causing fatigue) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section GG - Functional Abilities and Goals indicated that Resident R1 required partial/ moderate assistance to roll left and right. Review of the list of residents with pressure ulcers provided by the facility on 4/16/24, indicated Resident R1 had an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) on her left buttock, present upon her admission on [DATE]. Review of Resident R7's clinical admission evaluation dated 2/7/24, indicated Resident R7 had skin warm & dry, skin color WNL (within normal limits), mucous membranes moist, turgor (ability of skin to change shape and return to normal) normal. This document further indicated Detailed documentation of skin issues can be completed within the COMS Skin Only Evaluation. Further review of Resident R1's clinical record revealed the skin only evaluation was not completed. Review of the section Body System Notes revealed Skin as unchecked. Review of the Braden Scale Assessment (a tool utilized to assess a patient's risk of developing a pressure ulcer) dated 2/7/24, revealed Resident R7 was at risk for the development of pressure ulcers. Review of Resident R7's baseline care plan dated 2/7/24, revealed the entry for pressure ulcer to be unchecked, and the need for wound care to be unchecked. Review of MDS dated [DATE], Section M - Skin Conditions indicated that Resident R7 had no current pressure ulcers. Review of Resident R7's physicians orders failed to reveal an order for treatment of pressure ulcers until 3/9/24, when an order was placed for care of a left buttock wound. Review Resident R7's care plan dated 2/7/24, for skin impairment, risk of impaired skin integrity, indicated Resident R1 will remain free of any new skin breakdown through next review date. Resident R7's care plan was updated on 3/12/24, to include an actual unstageable pressure ulcer of the left 396089 Page 3 of 6 396089 04/18/2024 Concordia of the South Hills 1300 Bower Hill Road Pittsburgh, PA 15243

F 0686 buttock. Level of Harm - Minimal harm or potential for actual harm Review of a progress note dated 3/9/24, at 6:55 a.m. indicated an open area was noted on left medial buttocks. Residents Affected - Few Review of a wound nurse practitioner's progress note dated 3/11/24, at 8:06 a.m. indicated Resident R7 is being seen for a new left buttock wound noted by the facility staff on 3/9/24. Review of Resident R7's clinical record revealed no Skin & Wound Evaluation assessments completed for the left buttock wound until 3/11/24. Review of Resident R7's Treatment Administration Record for April 2024, revealed no documentation for completion of Resident R7's left buttock wound treatment on 4/11/24 and 4/15/24. Review of progress notes for those dates failed to reveal information on the wound treatment's completion. Review of a physician's orders dated 2/7/24, indicated to Encourage to turn & reposition and Bed Wedge. Review of Resident R7'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 4/16/24, indicated for staff to turn and reposition. During observations completed on: -4/16/24, at approximately 10:45 a.m., and 1:30 p.m. -4/17/24, at approximately 9:00 a.m., 11:30 a.m., 1:30 p.m., and 3:00 p.m. -4/17/24, at approximately 9:00 a.m., and 11:00 a.m. all revealed Resident R7 to be lying flat on her back, with her head slightly elevated. During the above observations, the bed wedge was noted to be on a chair in the room, not utilized. During an interview on 4/18/24, at approximately 11:05 a.m. the Corporate Director of Nursing confirmed the inaccuracy of the facility provided pressure ulcer list, confirmed the development of a new pressure ulcer for Resident R7, and was made aware of the lack of assistance from staff for Resident R7 to turn and reposition. During an interview on 4/18/24, at approximately 12:15 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 three residents. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 396089 Page 4 of 6 396089 04/18/2024 Concordia of the South Hills 1300 Bower Hill Road Pittsburgh, PA 15243

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of manufacturer ' s guidelines, observations, and staff interview, it was determined that the facility failed to make certain that medications and medication supplies were properly stored and/or disposed of in one of two medication rooms (First-floor medication room) and one of one medication carts (First-floor medication cart). The facility failed to make certain medication rooms were secured for one of two medication rooms (Second Floor Medication room). Findings include: Review of the facility policy Medication Storage dated [DATE], indicated the facility will ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations. The policy further stated all medication rooms are routinely inspected for discontinued and outdated medications, which would be destroyed. Review of the facility policy Medication Storage dated [DATE]. indicated the facility will ensure all medications will be stored in med rooms according to manufacturers recommendations sufficient to ensure proper sanitation, light and security. Review of the facility provided document Medication Storage in the facility - expiration dates other than the manufacturer's, updated [DATE], indicated that ophthalmic medications have an expiration date 28 days from the date opened. During an observation of the First-floor medication room on [DATE], at 10:50 a.m. revealed the following: -(11) bottles of glucometer testing control solution with an expiration date of [DATE]. -(3) bottles of glucometer testing control solution with an expiration date of [DATE]. -(11) bottles of glucometer testing control solution with an expiration date of [DATE]. -(9) colostomy barriers with an expiration date [DATE]. -(9) colostomy pouches with an expiration date [DATE]. -(2) colostomy pouches with an expiration date [DATE]. -(5) urinary pouches with an expiration date 12/2022. -(28) ostomy pouches with an expiration date 12/2022. -(8) ostomy pouches with an expiration date [DATE]. During an interview on [DATE], at 11:20 a.m. Licensed Practical Nurse Employee E1 confirmed the above expired items. 396089 Page 5 of 6 396089 04/18/2024 Concordia of the South Hills 1300 Bower Hill Road Pittsburgh, PA 15243

F 0761 During an observation of the First-floor medication cart on [DATE], at 2:30 p.m. revealed the following: Level of Harm - Minimal harm or potential for actual harm -(1) bottle of atropine ophthalmic solution, with an open date of [DATE], and no use-by date noted. -(1) bottle of prednisolone ophthalmic solution, with an open date of [DATE], with a use-by date of [DATE]. Residents Affected - Some -(1) bottle of brimonidine ophthalmic solution, with an open date of [DATE]/24, with a use-by date of [DATE]. -(1) bottle of tobramycin ophthalmic solution, with an open date of [DATE], and no use-by date noted. During an interview on [DATE], at 2:35 p.m. Licensed Practical Nurse Employee E1 confirmed the above expired items. During an interview on [DATE], at approximately 12:15 p.m. the Nursing Home Administrator(NHA) confirmed that the facility failed to make certain that medications and medication supplies were properly stored and/or disposed of in one of two medication rooms (First-floor medication room) and one of one medication carts (First-floor medication cart). During an observation on [DATE], at 11:00 a.m., Housekeeping Employee E2 was exiting the second floor medication room after mopping. During an interview on [DATE], at 11:12 a.m., Licensed Practical Nurse Employee E3 stated that she had opened the door of the medication room for Housekeeping Employee E2 and did not know that he was not authorized to be in the room without authorized staff. During an interview on [DATE], at 11:48 a.m., the NHA and Corporate Director of Nursing confirmed that the facility failed to make certain medication rooms are secured. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services. 396089 Page 6 of 6