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F0677
D

Failure to Provide Timely ADL Assistance and Meal Setup

Pittsburgh, Pennsylvania Survey Completed on 09-12-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with diagnoses of depression, macular degeneration, and muscle wasting, who required substantial to maximal assistance with toileting and personal hygiene, did not receive timely Activity of Daily Living (ADL) assistance. The resident, who is legally blind and has limited ability to dress or undress due to weakness, reported that after activating the call light at 11 a.m. for toileting assistance, a nurse aide responded at 11:20 a.m. and stated they would return, but did not come back until approximately four hours later. During this period, the resident remained without the needed assistance, and the nurse aide admitted to being aware of the request but was delayed due to being on break. The interaction between the resident and the nurse aide was described as argumentative, and the resident expressed concerns about staff professionalism and facility understaffing. Additionally, the resident was observed sitting in front of a lunch tray without knowledge of its contents and confirmed that no one had assisted with meal setup, as required by their care plan. A registered nurse acknowledged the failure to provide necessary meal setup assistance. These findings were corroborated by clinical record reviews, staff and resident interviews, and direct observations, demonstrating a failure to provide required ADL support as outlined in the resident's care plan and facility policy.

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