Highland Hills Post Acute

Review of Nurse Aide (NA) Employee E13's witness statement dated 5/15/25, indicated when entering dining room, observed Resident R1 holding Resident R3 by the arm and hitting her in the back.

Attempting to separate them Resident R1 hit Resident R3 again in the back.

Resident R3 was seated into the chair and Resident R1 walked away like nothing had happened.

Interview on 9/24/25, at 1:00 p.m. the Director of Nursing confirmed the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of two allegations of abuse for two of three residents (Resident R1 and R3). 28. Pa Code 201.14(a) Responsibility of licensee.28. Pa Code 201.18(b)(1)(e)(1) Management.28. Pa.

Code 211.12(d)(1)(5) Nursing services.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Hills Post Acute

1105 Perry Highway Pittsburgh, PA 15237

SUMMARY STATEMENT OF DEFICIENCIES

dated 5/15/25, indicated when entering dining room, observed Resident R1 holding Resident R3 by the arm and hitting her in the back.

Attempting to separate them Resident R1 hit Resident R3 again in the back.

Resident R3 was seated into the chair and Resident R1 walked away like nothing had happened.

Interview on 9/24/25, at 2:00 p.m. the Director of Nursing indicated the Administrator was aware of the elopement on 8/16/25, involving Resident R1, and that it was not reported as required; and indicated the resident-to-resident abuse was not reported as required involving Resident R1 and Resident R3. 28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management 28 Pa Code: 201.18 (b)(1) (e)(1) Management.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Hills Post Acute

1105 Perry Highway Pittsburgh, PA 15237

SUMMARY STATEMENT OF DEFICIENCIES

Review of the admission record indicated Resident R1 was admitted to the facility on [DATE].

Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/18/25, indicated the diagnoses of high blood pressure, dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), and insomnia (persistent problems falling and staying asleep) Section C0500 the Brief Interview for Mental Status (BIMS is a screening test that aids in detecting cognitive impairment) indicated a score of eight - moderately impaired cognition.

Review of the clinical record and staff interviews indicated on 8/16/25, Resident R1 was found in the parking lot outside by the fire hydrant and was discovered by Resident R2 who alerted staff resident eloped.

Review of the clinical record failed to include documentation of the event, notification to family, or physician was not completed as required.

The facility failed to investigate the elopement and possibility of neglect, failed to report it as required.

Interview on 9/22/25, at 11:25 a.m.

Nurse Aide (NA) Employee E4 indicated Resident R1 went out the door down the hall by room [ROOM NUMBER]. It's an emergency door.

Staff is not to use that door, only central supply and maintenance get deliveries through there.

They were bringing supplies in through that door for the carnival. NA Employee E5 had to go out and get resident in the parking lot.

Interview on 9/22/24, at 11:35 a.m.

Resident R2 indicated I'm the one that saw Resident R1 go out.

Resident R1 was always trying to get out that door. A lot of the residents do, that are, you know confused. I try to explain to them the best I can that they can't go out the door. I heard the door open just outside my room, looked out the window and saw Resident R1 in the parking lot walking towards the street by the fire hydrant.

When I went in the hallway the door was still partially open but I was afraid to go out to get Resident R1 because resident can have a temper, so I went to the nurses station, nobody was there, until finally a NA came into the hall and I screamed help, Resident R1 is outside in the parking lot.

Per Resident R2, Resident R1 leaned on the door and it just opened, it wasn't locked.

Interview on 9/24/25, at 2:00 p.m. the Director of Nursing indicated the Administrator was aware of the elopement on 8/16/25, involving Resident R1, and could not provide an investigation on the event, confirming that the facility failed to conduct a thorough investigation of an elopement and possibility of neglect for one of three residents (Resident R1). 28 Pa Code: 201.18 (e)(1)(2) Management.28 Pa Code: 201.29 (a)(c) Resident Rights.28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Hills Post Acute

1105 Perry Highway Pittsburgh, PA 15237

SUMMARY STATEMENT OF DEFICIENCIES

Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE].

Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/1/25, indicated diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and aphasia (difficulty with either language or speech).

Observation on 9/24/25, at 9:05 a.m.

Resident R4 was observed in bed. A hand splint was noted in the bedside stand.

Resident R4 had no splints on either hand.

Interview on 9/24/25, at 2:00 p.m.

Director of Rehabilitation Employee E12 indicated Resident R4 was discharged from therapy last on 9/4/25, to the Rehab Restorative transition program and a right resting hand splint (device to hold the hand in a functional resting position) on in the evening and off in the morning.

Review of Rehab Restorative Transition Program document for Resident R4, provided by Director of Rehabilitation Employee E12, indicated right resting hand splint on in the evening and off in the morning.

Review of Resident R4's current physician orders on 9/23/25, failed to indicate an order for use of a right resting hand splint.

Review of Resident R4's current care plan on 9/24/25, failed to indicate a plan of care for use of a right resting hand splint.

Interview on 9/24/25, at 2:16 p.m. the Director of Nursing confirmed the failure to process the Rehab Restorative Transition Program recommendations and indicated the facility is working on the processes for when a resident transfers from rehab to a long term care unit, and that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of four residents (Resident R4). 28 Pa.

Code: 201.14(a) Responsibility of licensee.28 Pa.

Code: 201.18 (b)(1) Management.28 Pa.

Code: 211.10(a)(c)(d) Resident care policies.28 Pa.

Code: 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Hills Post Acute

1105 Perry Highway Pittsburgh, PA 15237

SUMMARY STATEMENT OF DEFICIENCIES

jeopardy to resident health or safety

assessments are completed and care plans updated as required and reviewed at the QAPI meeting.-Audit by maintenance will be completed on the doors being secure seven days a week for four weeks and reviewed at the QAPI meetings.

Next QAPI meeting is at the end of September 2025.

The Director of Nursing was made aware that the Immediate Jeopardy was lifted on 9/24/25, at 1:31 p.m.

Interview on 9/24/25/25, at 2:35 p.m. the Director of Nursing confirmed the facility failed to provide adequate supervision for one resident resulting in elopement.

This failure created an immediate jeopardy situation for one of twelve residents (Resident R1) identified as having a high risk for wandering. 28 Pa.

Code 201.18(b)(1)(3) Management.28 Pa.

Code 201.29(a) Responsibility of Licensee.28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services.28 Pa.

Code 211.10(d) Resident care policies.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Hills Post Acute

1105 Perry Highway Pittsburgh, PA 15237

SUMMARY STATEMENT OF DEFICIENCIES

longer works here.

Interview on 9/24/25, at 3:30 p.m. the Director of Nursing confirmed that documentation indicated active transfer efforts on 6/24/25, and 6/27/25, under the previous SW Employee E10 and that SW Employee E11 did not have active transfer efforts until 9/23/25, almost a three month delay, confirming the facility failed to provide sufficient and timely social services related to assistance in transferring to the Veterans Affairs (VA) for a behavioral bed for one of twelve residents (Resident R1). 28 Pa.

Code 201.14(b) Responsibility of licensee.28 Pa.

Code 201.18 (b)(1)(3) Management.28 Pa.

Code 201.29 (a) Resident rights.28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services.Pa Code 211.16.

Social Services.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Hills Post Acute

1105 Perry Highway Pittsburgh, PA 15237

SUMMARY STATEMENT OF DEFICIENCIES

Based on a review of a job description, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) did not effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required, resulting in a resident elopement creating an immediate jeopardy situation.Findings include: The job description for the NHA specified the primary purpose of the job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times.

Based on the findings in this report that identified that the facility failed to effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required, resulting in a resident elopement creating an immediate jeopardy situation.

The facility failed to provide fundamental principal that apply to treatment and care provided to facility residents.

The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and facility policies. 28 Pa Code 201.14(a) Responsibility of licensee.28 Pa Code 201.18(b)(1)(e)(1) Management.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Hills Post Acute

1105 Perry Highway Pittsburgh, PA 15237

SUMMARY STATEMENT OF DEFICIENCIES

Based on a review of regulations, documents submitted to the State agency and staff interviews it was determined that the facility failed to notify the State agency of a change in the facility's Nursing Home Administrator (NHA) at the time of the change.

Findings include:

Review of the facility's password agreement document dated 9/16/25, indicated NHA became the Interim Administrator effective 9/5/25, and that they are responsible for submitting a Plan of Correction in response to deficiencies cited by the Pennsylvania Department of Health on CMS Form 2567.

During an interview on 9/22/25, at 9:00 am the Director of Nursing confirmed that NHA Employee E14 was on leave and that the administrator for the facility was the Interim NHA.

During an interview on 9/22/25, at 9:00 a.m. the Director of Nursing confirmed that on 9/5/25, the facility failed to notify by written letter the State Agency of the change of administrators which failed to meet the requirement of notification at the time of the change. PA Code: 201.14(a) Responsibility of licensee.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Hills Post Acute

1105 Perry Highway Pittsburgh, PA 15237

SUMMARY STATEMENT OF DEFICIENCIES

Based on review of facility files and an interview with the Human Resources Director Employee E9, it was determined that the facility failed to employ a full-time qualified social worker from 7/27/25, through 9/2/25.Findings include: Review of facility provided payroll documentation on 9/25/25, at 10:00 a.m.

Social Worker Employee E10's last day worked was 7/27/25.

Review of facility provided payroll documentation on 9/25/25, at 10:00 a.m.

Social Worker Employee E11's first day worked was 9/2/2/25.

Interview with the Human Resources Director Employee E9 on 9/24/25, at 10:05 a.m. confirmed that the facility failed to employ a full time qualified social worker from 7/27/25, through 9/2/25. Pa Code 211.16.

Social Services. Pa Code 201.14 (a)Responsibility of licensee.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Hills Post Acute

1105 Perry Highway Pittsburgh, PA 15237

SUMMARY STATEMENT OF DEFICIENCIES

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide training on effective communication for two of five staff members (Nurse Aide (NA) Employee E15, and NA Employee E5).

Findings include: Review of facility provided documents and training records for NA Employees E15 and NA Employee E5, failed to include education on effective communication as required.

Telephonic interview on 9/25/25, at 9:52 a.m.

Human Resource Employee E9 confirmed that the facility failed to provide training on effective communication for two of five staff members (NA Employee E15, and NA Employee E5). 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(6)(d) Staff development.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Hills Post Acute

1105 Perry Highway Pittsburgh, PA 15237

SUMMARY STATEMENT OF DEFICIENCIES

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on QAPI (Quality Assurance and Performance Improvement) for three of five employees (Nurse Aide (NA) Employee E15, and NA Employee E5, and Licensed Practical Nurse (LPN) Employee E16).

Findings include:

Review of the Facility assessment dated Quarter one 2025, indicated staff training/education and competencies will be completed during general orientation upon hire, annually, and as needed.

Educations listed included:-Communication, resident rights and facility responsibilities, abuse, neglect and exploitation of residents, quality assurance and performance improvement (QAPI), infection control, compliance and ethics, and behavioral health.

Findings include: Review of facility provided documents and training records for NA Employees E15 and NA Employee E5 and LPN Employee E16, failed to include education on QAPI as required.

Telephonic interview on 9/25/25, at 9:52 a.m.

Human Resource Employee E9 confirmed that the facility failed to provide training on QAPI for three of five staff members (Nurse Aide (NA) Employee E15, and NA Employee E5, and Licensed Practical Nurse (LPN) Employee E16). 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(6)(d) Staff development.

Facility ID: