Highland Hills Post Acute

9/24/25, at 1:00 p.m. the Director of Nursing confirmed the facility failed to implement written

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

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

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Highland Hills Post Acute 1105 Perry Highway Pittsburgh, PA 15237

the elopement on 8/16/25, involving Resident R1, and that it was not reported as required; and

(e)(1) Management.

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Highland Hills Post Acute 1105 Perry Highway Pittsburgh, PA 15237

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.

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Highland Hills Post Acute 1105 Perry Highway Pittsburgh, PA 15237

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.

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Highland Hills Post Acute 1105 Perry Highway Pittsburgh, PA 15237

the rear parking lot.

Resident returned to the unit on 8/16/25. No signs or symptoms of any adverse

jeopardy to resident health or Nursing staff will be re-educated on updating the elopement care plan form immediate interventions safety and elopement assessment.

All residents will be reassessed by the unit manager/designee by 9/24/25, for an elopement risk.

All staff will be educated on elopement risk and assessments, care

measurable goals and interventions for residents will be implemented to identify residents at risk for eloping by the unit manager/designee by 9/24/25.

Review and revise policies if needed to identify residents who are at risk for eloping.

Door will be monitored by staff stationed at the door, until door vendor arrives by 9/24/25, to verify functioning of the door and residents are unable to exit.

Facility will review the incidents at an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting on 9/24/25.

Monitoring:New admissions, change in condition or any new behavior will be monitored by the DON/designee weekly for four weeks, monthly for two months to ensure elopement assessments are completed and care plans updated as required.

Maintenance/designee will audit the doors are secure seven days a week for four weeks.

Findings of audits will be submitted through facility QAPI program.

Verification of the facility's Corrective Action Plan revealed all elements of plan were met as follows:-Vendor into facility and checked that everything was functioning on the door, the magnetic lock and the keypad to the door itself.

The door alarm was not alarming. It's going to alarm instantly instead of 25 second delay.

Changing deliveries to the front door.

Code is changed to an eight-digit number instead of four digits.-97% of all staff educated on risk, assessments, care plan, and supervision - 201 of 206 total employees verified with signatures.- 51-in-person interviews conducted of all staff confirmed education and understanding.-32 of 32 residents identified as elopement risks were identified.

Twenty new residents were identified as at risk for elopement within the dementia secured unit.-Policy reviewed and revised by the Director of Nursing to identify residents who are at risk for eloping.-Door monitor by staff was in place on 9/24/25. - Ad Hoc QAPI held 9/24/25.-Audit tool for new admissions, change in condition or any new behavior will be monitored moving forward will be conducted weekly for four weeks, monthly four two months to ensure elopement 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.

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Highland Hills Post Acute 1105 Perry Highway Pittsburgh, PA 15237

Summary resident was in a different lock down unit previously.

Resident has been having increasing aggressive behaviors since moving to this unit.

Resident hit another resident.-7/9/25, at 11:07 a.m. another nurse reported to this nurse resident was aggressive with her.

Reported to supervisor. DON and social worker in with resident to talk with resident.7/9/25, at 12:01 p.m. resident was verbally abusive and threatening physical violence by swinging punches at staff. At the nursing cart when resident walked up and quickly grabbed the scissors and attempted to harm me with them.

Staff grabbed the end of the scissors to take them away from resident and yelled for help.

Staff came and helped prevent the resident from physically attacking and assaulting staff with a deadly weapon.

Floor nurse, DON, and Administrator were notified of the incident.

Resident eligible for 302. 911 was called and picked up patient to take him to a city hospital for psychiatric evaluation and treatment.-7/9/25, at 1:01 p.m.

Resolve in and warranted for 302 committal.

Family notified via voice message to return the call.-7/9/25, at 2:03 p.m.

Provider note the resident was seen and examined this morning at the request of staff after the patient was reported to have grabbed a pair of scissors and attempted to stab a nurse.

Reportedly, the patient had increasing agitation throughout the morning and was difficult to redirect.

Discussed with DON as well as unit director.

Resolve Crisis has been called with a probable petition to 302.-7/9/25, at 9:34 p.m.

Resident returned from hospital with diagnosis of urinary tract infection with antibiotics ordered.-7/17/25, at 7:59 p.m. resident swinging fist at another resident on unit. No contact made.

Residents were separated.-9/23/25, at 9:02 a.m. SW Employee E11 called the VA center to obtain information about a transfer for resident and was unable to reach them.

Left message and will follow up if SW doesn't receive a call back.

Interview on 9/22/25, at 2:00 p.m. the Director of Nursing indicated SW Employee E10 was working on getting Resident R1 transferred to the VA, but SW Employee E10 no 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.

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Highland Hills Post Acute 1105 Perry Highway Pittsburgh, PA 15237

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.

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Highland Hills Post Acute 1105 Perry Highway Pittsburgh, PA 15237

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.

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Highland Hills Post Acute 1105 Perry Highway Pittsburgh, PA 15237

through 9/2/25.Findings include: Review of facility provided payroll documentation on 9/25/25, at

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.

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Highland Hills Post Acute 1105 Perry Highway Pittsburgh, PA 15237

communications for direct care staff members.

facility failed to provide training on effective communication for two of five staff members (Nurse

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.

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Highland Hills Post Acute 1105 Perry Highway Pittsburgh, PA 15237

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.