Health inspection·May 21, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated diagnoses of high blood pressure, depression (a constant feeling of sadness and loss of interest), and age-related physical debility. Review of a physician order dated 1/17/24, indicated to transfer Resident R1 with a Sara lift, 2 assist - 2nd person hands on resident Pivot transfers only with lift from bed to wheelchair, wheelchair to recliner. For toileting: bring lift into bathroom, then bring wheelchair into bathroom. Pivot transfer with Sara lift, 2 assist, on/off of toilet. Review of Resident R1's Kardex indicated Resident R1 required transfer assistance x 2 Sara lift. Review of Resident R1's care plan indicated Resident R1 will transfer with the Sara lift at least once in the morning and once in the evening with two assist. Review of a nursing progress note dated 4/27/24, completed by Registered Nurse (RN) Employee E11 stated, Called to room by NA due to resident being lowered to the floor out of the Sara lift on the window side of the room. NA reports that she was providing incontinence care to the resident and she became weak and had to be lowered to the floor out of the lift. Staff assessed resident and no visible injury noted. Resident has no new pain. She was assisted off of the floor with the hoyer lift and 3 assist and into bed. Review of a witness statement dated 4/28/24, completed by RN Employee E11 stated, I worked on Saturday 4/27/24 and I was in the team room doing some documentation and I heard a loud noise on the household. The NA was also in the team room and she went to see where the noise came from. The NA called for me and when I entered Resident R1's room, I observed resident laying on the floor of her room. Resident R1's legs were still strapped into the Sara lift and her upper body was unstrapped from the lift and her head was resting against the mattress. Assessed the resident for injury then this writer, two NAs, and the Clinical Coordinator used the hoyer lift to get Resident R1 off of the floor and into bed safely. Review of a witness statement dated 4/28/24, completed by NA Employee E8 stated, Yesterday afternoon myself, RN Employee E11 and another NA were in the team room when we heard a loud noise. I went to see what it was and the other aide was coming out of room [ROOM NUMBER] (Resident R1's room). I walked into her room and witnessed Resident R1 laying in between the recliner and bed, her head resting on the mattress and her legs still strapped into Sara lift. None of us were asked to help aide with transfer. In the morning I did give her (NA Employee E10) a detailed report on resident's routine and transfers and RN Employee E11 also told her that rooms [ROOM NUMBER] were assist of two with the lift. Review of a telephonic interview conducted by the Director of Nursing 2 (DON) dated 4/29/24, indicated NA Employee E10 stated, I came on the unit that day. I got a verbal report from the floor nurse and nurse aide staff on floor for each resident I had for the day. They did go over each resident I had, they told me Resident R1 was a Sara lift. Never said a two person Sara lift. After lunch I went to go lay resident down for a nap. I had her in the lift and was going to change her brief, and then put her in bed and take her pants off. That's when I noticed diarrhea coming from under her brief. So I stopped, tried to put another brief on, she started to slide down, so I tried to hold her up and yelled for help. I used my body to lower her to floor. Then staff came in room to help me. During an interview on 5/21/24, at 9:29 a.m. the Nursing Home Administrator (NHA) stated that the facility was providing whole-house re-education regarding proper transfer assistance and lift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395001 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Passavant Retirement and Healt 105 Burgess Drive Zelienople, PA 16063 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 operation. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/21/24, at 9:43 a.m. DON 1 stated, It is facility policy that all nurse aides must review a resident's Kardex on the touchscreen (kiosk) prior to providing care to a resident. Residents Affected - Few During an interview on 5/21/24, at 11:23 a.m. NA Employee E1 stated, I look in the computer to verify a resident's transfer assistance. I haven't gotten the new training yet, I'm going on Thursday, they are holding classes. During an interview on 5/21/24, at 11:27 a.m. NA Employee E2 stated, I look on the computer at the start of my shift to verify a resident's transfer status. I have not gone down to do the re-education yet. During an interview on 5/21/24, at 12:47 p.m. NA Employee E3 stated, I look in the aide care plan for transfer statuses. There is an education I think at the end of this week, I haven't gone yet. During an interview on 5/21/24, at Licensed Practical Nurse (LPN) Employee E4 stated, Nurses are able to look in the resident's profile and look in the treatment orders to see what their transfer status is. The aides know they can always ask us if they are unsure. I haven't done the training yet, I will probably go down some time today or tomorrow. During an interview on 5/21/24, at 12:58 p.m. NA Employee E5 stated, I look in the kiosk charting to verify how many people are needed for lift assistance. There is a training coming up so I will be going to that, I haven't gone yet. During an interview on 5/21/24, at 1:02 p.m. RN Employee E6 stated, The aides can look up transfer assistance requirements in the kiosk and we also have paper profiles printed out for them to review. I have not yet attended the training. I know there are a couple sessions coming up, I will be attending one of those. During an interview on 5/21/24, at 1:06 p.m. NA Employee E7 stated, I look in the chart to verify how many people are needed for transfer assistance. I have not yet attended the re-training on the lifts. During an interview on 5/21/24, at 1:11 p.m. NA Employee E8 stated, I look on the kiosk to verify transfer assistance. I have not gotten education yet, I think I saw a sign about it on the scheduler's desk. During an interview on 5/21/24, at 1:35 p.m. the RN Clinical Nurse Educator confirmed that 5/21/24 was the first day that she was offering training sessions addressing how to verify a resident's transfer status and how to properly operate the mechanical lifts. RN Clinical Education Employee E9 stated, I have two sessions today, two or three tomorrow and Thursday and then I will have make-up days next week for staff who are unable to attend this week. During an interview on 5/21/24, at 1:56 p.m. the NHA confirmed that the facility failed to ensure that a resident was free from neglect by not providing a two-person transfer per physician's order for one of four residents (Resident R1) resulting in a fall. 28. Pa Code 201.14(a) Responsibility of licensee. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395001 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Passavant Retirement and Healt 105 Burgess Drive Zelienople, PA 16063 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 28. Pa Code 201.18(b)(1)(e )(1) Management. Level of Harm - Minimal harm or potential for actual harm 28. Pa. Code 211.12(d)(1)(5) Nursing services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395001 If continuation sheet Page 4 of 4