Inspection·September 9, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few get ready to transfer her into bed. As the resident was going up into the air, she started to lean to the right and fell forward hitting her face on the floor. We both hooked the resident up to the Hoyer lift. I didn't notice if any of the loops had unhooked and I am not certain what happened because it happened so suddenly. Review of NA Employee E3's employee education indicated that LPN Employee E3 received education on Mechanical Lift on 12/5/24. Review of documentation provided by the facility dated 8/7/25, stated the following: Factual Description. On 8/7/2025, at 6:30 pm Resident R1 was being transferred from her wheelchair to her bed via Hoyer lift with assist x2 staff members. Resident is ordered to be transferred via Hoyer lift with assist x2. During the transfer, the resident was being lifted from her wheelchair when the resident began to lean towards the Right and the front right Hoyer pad loop popped off causing resident to fall forward, her knees hit her wheelchair's leg rests and the resident then hit her head on the floor. The remaining 3 Hoyer pad loops remained intact. The resident was immediately assessed and was noted to have an abrasion to her forehead, upon any movement resident grimaced with pain to her Right leg. Resident is alert and oriented to self only. VSS, neuro within normal limits. Resident has no loss of consciousness. MD notified. A new order received to send the resident to ED for further evaluation. POA/daughter updated. Description of Follow-up Action: Resident was admitted to hospital with diagnosis Fall. Upon residents return, residents care plan will be updated. Residents Pain will be managed per MD order. Hoyer lift and Hoyer pad were evaluated by maintenance and both deemed safe to use, neither have mechanical defects. Upon further investigation it was determined that the two staff members transferring the resident had not ensured that the Right front Hoyer lift pad loop was properly attached to the Hoyer lift. Both staff members have been suspended at this time. Education provided to all staff members to ensure the Hoyer lift loops area is secured prior to resident transfers. All falls reviewed weekly with RN, PT and Administrator. Monthly falls reviewed with RN PT and Medical Director. Monthly falls reported at QAPI. Resubmission 8/13/2025- The resident was diagnosed with Right nondisplaced tibial plateau fracture. Resubmission 8/14/2025: PB 22 submitted for each perpetrator. Staff education attached under PB 22 # 2under section VIII Titled All required witness information. This also includes Hoyer and Sara lift safety re-education initiated after incident. Annual education on mechanical lift safety is provided to nursing staff annually. Review of documentation provided by the facility labeled Incident Report Investigation dated 8/7/25, at 9:39 p.m. completed by DON Employee E2 indicated that LPN Employee E3 and NA Employee E4 were transferring resident from wheelchair to bed via Hoyer lift, resident leaned to the right side of lift pad, the right front lift pad loop popped off and resident fell to bottom of wheelchair pedals and hit face on floor with the three other loops still attached. Abrasion noted to the right side of forehead, right leg internally rotated. Grimaces in pain with movement of right leg. Physician and family notified. Additional comments: After investigation, the right Hoyer pad loop was not secured prior to resident being transferred. During a review of Resident R1 progress note dated 8/7/25, indicated resident was sent to the hospital for evaluation and treatment. During a review of Resident R1 progress note dated 8/8/25, indicated resident was admitted to the hospital. During a review of Resident R1 progress note dated 8/10/25, indicated resident arrived back at the facility from acute care hospital. A small bruise on the right side of forehead noted and her right foot is rotated internally. During an observation on 9/9/25, at 1:11 p.m. DON Employee E1 and E2 used a Hoyer lift and Hoyer pad and demonstrated the proper way to ensure the Hoyer pad is secured onto the Hoyer lift. DON Employee E1 stated that they have reenacted the incident multiple times, and the root cause of the incident is that staff did not ensure the Hoyer pad loop was in a secure position on the Hoyer lift. During an interview on 9/9/25, at 2:02 p.m. Registered Nurse (RN) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395001 If continuation sheet Page 2 of 6 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 09/09/2025 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 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Employee E5 stated that after you put the loop in the hook, make sure it's snug and appropriate. Ensure that it can't come off. The spring button gets pushed down to get the loop in and then it comes back up to make sure the strap can't come out. I would not use it if the black button was not working right. During an interview on 9/9/25, at 2:06 p.m. NA Employee E6 stated it takes two people to use. I hook the straps on and then I pull them to make sure they are secure. I make sure the spring button is up so the straps can't come off. The button is to make sure it is secure. If the button isn't up, the strap can slip off the hook. I'd never lift a resident without double checking.During an interview on 9/9/25, at 2:15 p.m. NA Employee E7 stated I put residents in the sling. I make sure the black button is down and then I put the straps over the hook. I tug to make sure that it is secure and not going to slide off. The black button pops up to make sure it's secure. I would not put someone in a lift and not check to see if it is secure. During an interview on 9/9/25, at 2:47 p.m. DON Employee E1 stated that Resident R1 did fall out of a Hoyer lift on 8/7/25, went to the hospital, and it was determined that staff failed to ensure that the Hoyer pad was securely latched on the Hoyer lift prior to using to ensure the safety of the resident. During an interview on 9/9/25, at 2:50 p.m. Nursing Home Administrator stated that LPN Employee E3 was terminated and NA Employee E4 was put on the facilities Do Not Return list. During an interview on 9/9/25, at 3:45 p.m. DON Employee E1 confirmed that the facility failed to ensure that a resident was free from neglect by not ensuring a safe transfer, which resulted in actual harm (abrasion to right forehead and a right nondisplaced tibial (leg) plateau fracture with pain) for one of two residents (Resident R1). 28 Pa Code 201.14(a) Responsibility of licensee.28 Pa Code 201.18(b)(1)(e)(1) Management.28 Pa Code 201.29(a) Resident rights.28 Pa Code 211.12(d)(3)(5) Nursing services. Event ID: Facility ID: 395001 If continuation sheet Page 3 of 6 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 09/09/2025 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, incident reports, facility documents, employee education, and staff interviews, it was determined that the facility failed to ensure that a resident was free from a preventable accident during a transfer, which resulted in actual physical harm (an abrasion to right forehead and a right nondisplaced tibial (leg) plateau fracture with pain) for one of two residents (Resident R1). Findings include:Review of the facility Accidents and Incidents policy dated 1/2025, indicated that the facility will provide a safe and secure environment in order to prevent incidents and accidents from occurring.Review of Resident R1's admission record indicated resident was admitted to the facility on [DATE].Review of Resident R1's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 8/2/25, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking), and depression.Review of Resident R1's physician orders dated 5/9/24, indicated that Resident R1 was to be transferred with a Hoyer lift, Assist of two.Review of Resident R1s care plan dated 8/8/25, indicated a Problem- I have problems that limit my ability to perform mobility tasks such as bed mobility, transfers, ambulating and wheelchair mobility. Goal I will not experience a decline in my mobility tasks. Interventions- Hoyer Lift, assist of two.Review of documentation provided by the facility labeled Resident Profile/Resident Preferences on 9/9/25, indicated that transfer/positioning need was total dependence, Assist times two with Hoyer lift/Full Lift.Review of a written witness statement dated 8/7/25, from NA Employee E4 stated, Nurse and I were transferring Resident R1 at 6:30 p.m. As we lifted her about half a foot in the air off of her chair the front loop of the Hoyer pad popped off the back of the Hoyer. The resident fell face forward to the right side of her wheelchair. We log rolled her and noticed her right leg looked misshaped. Supervisor and nurse notified.Review of an interview conducted by Director of Nursing (DON) Employee E1 dated 8/8/25, at 10:00 a.m. with Nurse Aide (NA) Employee E4 stated I dont remember who hooked what Hoyer pad straps.Review of NA Employee E4's employee education indicated that NA Employee E4 received education on Mechanical Lift on 7/18/24.Review of an interview conducted by DON Employee E1 dated 8/8/25, at 9:30 a.m. with Licensed Practical Nurse (LPN) Employee E3 stated NA Employee E4 and I went in and got resident hooked up to the Hoyer lift to get ready to transfer her into bed. As the resident was going up into the air, she started to lean to the right and fell forward hitting her face on the floor. We both hooked the resident up to the Hoyer lift. I didnt notice if any of the loops had unhooked and I am not certain what happened because it happened so suddenly.Review of NA Employee E3's employee education indicated that LPN Employee E3 received education on Mechanical Lift on 12/5/24.Review of documentation provided by the facility dated 8/7/25, stated the following: Factual Description. On 8/7/2025, at 6:30 pm Resident R1 was being transferred from her wheelchair to her bed via Hoyer lift with assist x2 staff members. Resident is ordered to be transferred via Hoyer lift with assist x2. During the transfer, the resident was being lifted from her wheelchair when the resident began to lean towards the Right and the front right Hoyer pad loop popped off causing resident to fall forward, her knees hit her wheelchairs leg rests and the resident then hit her head on the floor. The remaining 3 Hoyer pad loops remained intact. The resident was immediately assessed and was noted to have an abrasion to her forehead, upon any movement resident grimaced with pain to her Right leg. Resident is alert and oriented to self only. VSS, neuro within normal limits. Resident has no loss of consciousness. MD notified. A new order received to send the resident to ED for further evaluation. POA/daughter updated. Description of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395001 If continuation sheet Page 4 of 6 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 09/09/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few Follow-up Action: Resident was admitted to hospital with diagnosis Fall. Upon residents return, residents care plan will be updated. Residents Pain will be managed by MD order. Hoyer lift and Hoyer pad were evaluated by maintenance and both deemed safe to use, neither have mechanical defects. Upon further investigation it was determined that the two staff members transferring the resident had not ensured that the Right front Hoyer lift pad loop was properly attached to the Hoyer lift. Both staff members have been suspended at this time. Education provided to all staff members to ensure the Hoyer lift loops area is secured prior to resident transfers. All falls reviewed weekly with RN, PT and Administrator. Monthly falls reviewed with RN PT and Medical Director. Monthly falls reported at QAPI. Resubmission 8/13/2025- The resident was diagnosed with Right nondisplaced tibial plateau fracture. Resubmission 8/14/2025: PB 22 submitted for each perpetrator. Staff education attached under PB 22 # 2under section VIII Titled All required witness information. This also includes Hoyer and Sara lift safety re-education initiated after incident. Annual education on mechanical lift safety is provided to nursing staff annually.Review of documentation provided by the facility labeled Incident Report Investigation dated 8/7/25, at 9:39 p.m. completed by DON Employee E2 indicated that LPN Employee E3 and NA Employee E4 were transferring resident from wheelchair to bed via Hoyer lift, resident leaned to the right side of lift pad, the right front lift pad loop popped off and resident fell to bottom of wheelchair pedals and hit face on floor with the three other loops still attached. Abrasion noted to the right side of forehead, right leg internally rotated. Grimaces in pain with movement of right leg. Physician and family notified. Additional comments: After investigation, the right Hoyer pad loop was not secured prior to resident being transferred.During a review of Resident R1 progress note dated 8/7/25, indicated resident was sent to the hospital for evaluation and treatment.During a review of Resident R1 progress note dated 8/8/25, indicated resident was admitted to the hospital.During a review of Resident R1 progress note dated 8/10/25, indicated resident arrived back at the facility from acute care hospital. A small bruise on the right side of forehead noted and her right foot is rotated internally.During an observation on 9/9/25, at 1:11 p.m. DON Employee E1 and E2 used a Hoyer lift and Hoyer pad and demonstrated the proper way to ensure the Hoyer pad is secured onto the Hoyer lift. DON Employee E1 stated that they have reenacted the incident multiple times, and the root cause of the incident is that staff did not ensure the Hoyer pad loop was in a secure position on the Hoyer lift.During an interview on 9/9/25, at 2:02 p.m. Registered Nurse (RN) Employee E5 stated that after you put the loop in the hook, make sure its snug and appropriate. Ensure that it cant come off. The spring button gets pushed down to get the loop in and then it comes back up to make sure the strap cant come out. I would not use it if the black button was not working right.During an interview on 9/9/25, at 2:06 p.m. NA Employee E6 stated it takes two people to use. I hook the straps on and then I pull them to make sure they are secure. I make sure the spring button is up so the straps cant come off. The button is to make sure it is secure. If the button isnt up, the strap can slip off the hook. Id never lift a resident without double checking.During an interview on 9/9/25, at 2:15 p.m. NA Employee E7 stated I put residents in the sling. I make sure the black button is down and then I put the straps over the hook. I tug to make sure that it is secure and not going to slide off. The black button pops up to make sure its secure. I would not put someone in a lift and not check to see if it is secure.During an interview on 9/9/25, at 2:47 p.m. DON Employee E1 stated that Resident R1 did fall out of a Hoyer lift on 8/7/25, went to the hospital, and it was determined that staff failed to ensure that the Hoyer pad was securely latched on the Hoyer lift prior to using to ensure the safety of the resident.During an interview on 9/9/25, at 2:50 p.m. Nursing Home Administrator stated that LPN Employee E3 was terminated and NA Employee E4 was put on the facilities (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395001 If continuation sheet Page 5 of 6 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 09/09/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Do Not Return list.During an interview on 9/9/25, at 3:45 p.m. DON Employee E1 confirmed that the facility failed to ensure that a resident was free from a preventable accident during a transfer, which resulted in actual physical harm (an abrasion to right forehead and a right nondisplaced tibial plateau fracture with pain) for one of two residents (Resident R1).28 Pa Code 201.14(a) Responsibility of licensee.28 Pa Code 201.18(b)(1)(e)(1) Management.28 Pa Code 201.29(a) Resident rights.28 Pa Code 211.12(d)(1)(3)(5) Nursing services. Event ID: Facility ID: 395001 If continuation sheet Page 6 of 6