Health inspection·January 10, 2025

F 0607 Review of NA Employee E19 was hired to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of NA Employee E19 personnel record did not include a copy of the employee's State background check. Residents Affected - Some Review of nurse deployment documents, indicated that NA Employee E19 worked on 11/04/24, and was no longer on orientation. NA continued to work for the facility. Review of RN Employee E20 was hired to the facility on [DATE]. Review of RN Employee E20 personnel record did not include a copy for the employee's State background check. Review of nurse deployment documents, indicated that RN Employee E20 worked on 11/19/24, and was no longer on orientation. RN continued to work for the facility. During an interview on 1/10/25, at 1:12 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to implement their written procedures to prohibit and prevent abuse, neglect, and exploitation of residents by failing to perform criminal history background checks prior to the date of hire for Registered Nurse (RN) Employee E2 as required, Nurse Aide (NA) Employee E17, Licensed Practical Nurse (LPN) Employee E18, NA Employee E19, and RN Employee E20). 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.19(3) Personnel policies and procedures FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 2 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record, and staff interview it was determined that the facility failed to conduct a thorough investigation for one of three residents (Resident R77). Residents Affected - Few Findings include: Review of facility policy Abuse Neglect Exploitation General Policy dated 1/3/25, indicated Investigation The facility is responsible for investigating and reporting cases of possible abuse, neglect including involuntary seclusion, exploitation, and misappropriation of property to external agencies in accordance with laws and regulations. Review of facility policy Abuse Investigation and Reporting, Protection and Response dated 1/??/25, indicated skilled nursing facilities are responsible for the investigation and reporting of allegation of abuse, neglect, or misappropriation of a resident's property. Review of Resident R77 clinical record was admitted on [DATE]. Review of Resident R77 MDS (minimum data set - a periodic assessment of resident needs) dated 11/26/24, indicated diagnosis of renal insufficiency (kidneys functioning poorly) and diabetes mellitus (when your blood sugar is to high). During a review of Resident R77 clinical record progress note dated 12/21/24, indicated 2 cups of meds from different times unknown days found at bedside hidden. During a review of facility documentation a concern form about the incident was noted, but failed to include documentation of the investigation to include - what the pills were, if the pills were the facilities or brought in from outside the facility, if medication that was documented as being taken by resident was noted in the medication found by the bedside, , interviews with staff , etc. During an interview on 1/3/25, at 2:25 p.m. Director of Nursing confirmed that the investigation was incomplete and that the facility did not document nor investigate what the medication was, where it came from, complete interviews with staff from various recent shifts and that the facility failed to complete a thorough investigation for Resident R77 medication found by bedside. 28 Pa. Code 201.14(a) (c) (e) Responsibility of licensee. 28 Pa. Code 201.18 (e) (1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 3 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for two of seven residents (Residents R8 and R316) to accurately reflect the current status of the resident and care needs. Findings include: Review of the facility policy Care Plans, Comprehensive Person-Centered dated 1/2/25, indicated the facility must develop a comprehensive Person-Centered Care Plan for each resident that includes measurable objectives and timeframes and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the admission record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/23/24, indicated the diagnoses of heart failure, mild cognitive impairment, and anxiety disorder. Review of Resident R8's physician order dated 11/19/24, indicated FreeStyle Libre 3 Reader Device (Continuous Glucose System Receiver) Apply 1 unit transdermally one time a day every 14 days. Review of Resident R8's current care plan on 1/8/25, at 11:55 a.m., failed to include the use, as well as the care and services interventions related to the FreeStyle Libre 3 Continuous Glucose monitoring system. During an interview on 1/8/25, at 2:37 p.m., the Director of Nursing (DON) confirmed that Resident R8's current care plan failed to include the use, and care and service interventions for her FreeStyle Libre 3 Continuous Glucose Monitoring system. Review of the admission record indicated Resident R316 admitted to the facility on [DATE]. Review of Resident R316's MDS dated [DATE], indicated the diagnoses of high blood pressure, Multiple Sclerosis (immune system eats away at protective covering of nerve cells), and diabetes(a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R316's physician order dated 12/5/24, indicated Wound Vac (a negative pressure wound therapy device) to sacral (above the tail bone) wound. Wound vac to function at 125mm/hg (millimeters of mercury) continuously. Change on Monday, Wednesday, Friday, and as needed for displacement. Review of Resident R316's current plan of care on 1/10/25, at 9:24 a.m. failed to include the wound vac to the sacral wound. Interview on 1/10/25, at 10:00 a.m. the Director of Nursing (DON) confirmed Resident R316's care plan failed to include the wound vac to the sacral wound as required. Interview on 1/10/25, at 3:00 p.m. the DON confirmed the facility failed to update a care plan for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 4 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0657 two of seven residents (Residents R8 and R316) to accurately reflect the current status of the resident and care needs. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 211.11 (a).(c)(d) Resident care plan. Residents Affected - Few 28 Pa. Code: 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 5 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of abnormal glucose readings as per order for one out of three residents (Resident R108). Residents Affected - Few Findings include: Review of the facility policy Diabetes - Clinical Protocol dated 1/2/25, indicated the physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters into the Medication Administration Record (MAR). Review of the admission record indicated Resident R108 was admitted on [DATE]. Review of Resident R108's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/16/24, indicated the diagnoses of benign prostatic hyperplasia (BPH- age related prostate gland enlargement that can cause urination difficulties), obstructive uropathy (a structural or functional hindrance of normal urine flow), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R108's physician orders dated 12/26/24, indicated Insulin Lispro (a short acting, manmade version of human insulin) inject subcutaneously as per sliding scale: if 0 - 140 = 0; 141 - 180 = 1; 181 - 220 = 2; 221 - 260 = 3; 261 - 300 = 4; 301 - 340 = 5; 341+ = 6 >340 administer 6 units and notify the physician. Review of Resident R108's care plan dated 12/30/24, indicated the resident will be free from signs and symptoms of hyperglycemia (elevated glucose levels). Monitor, document, and report as needed, any symptoms of hyperglycemia. Review of Resident R108's glucose log indicated the following: 12/30/24, at 5:19 p.m. glucose result was 398. 12/25/24, at 12:02 p.m. glucose result was 415. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 6 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0684 12/24/24, at 10:41 a.m. glucose result was 431. Level of Harm - Minimal harm or potential for actual harm 12/17/24, at 8:10 p.m. glucose result was 446. 12/17/24, at 5:13 p.m. glucose result was 374. Residents Affected - Few 12/13/24, at 12:52 p.m. glucose result was 354. Review of Resident R108's progress notes did not include notification to the physician for the glucose levels above 340 as per physician's order. Interview on 1/9/25, at 10:03 a.m. the Director of Nursing confirmed that the facility failed to notify a physician of abnormal glucose readings as per order for Resident R108 as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 7 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain that residents received the necessary services to prevent/treat pressure ulcers/wounds for two of six residents (Residents R317 and Resident R51). Residents Affected - Few Findings include: Review of the facility policy Prevention of Pressure Injuries dated 1/3/24, indicated review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Use a standardized pressure injury screening tool to determine and document risk factors. Conduct a comprehensive skin assessment. Implement preventative skin care interventions. Select appropriate support surfaces based on the resident's risk factors. Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility policy Care Plans, Comprehensive Person-Centered dated 1/3/24, indicates the facility must develop a comprehensive Person-Centered Care Plan for each resident that includes measurable objectives and timeframes, and describes the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. Review of the admission record indicated Resident R317 was admitted to the facility on [DATE]. Review of Resident R317's Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/24/24, indicated the diagnoses of atrial fibrillation (irregular heart rhythm), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and Section M indicated Stage 3 pressure injury (full thickness tissue loss). Section GG indicated resident requires substantial/maximal assistance to roll left and right in the bed and required full dependence for sitting to lying flat on the bed and lying to sitting on the side of the bed with no back support. Review of Resident R317's Braden Scale for Predicting Pressure Sore Risk dated 1/8/25, indicated a score of 16 - mild risk of developing pressure ulcers. Review of Resident R317's Wound Consult Note dated 12/30/24, indicated right gluteal fold (the horizontal crease of skin at the inferior border of the buttocks) is an acute Stage 3 pressure injury. Pressure ulcer/injury has received a status of not healed. Review of Resident R317's physician orders on 1/9/25, at 9:00 a.m. failed to include preventative measures of a low air loss mattress (prevent pressure ulcers) and to assist resident with turning and repositioning on a routine schedule. Review of Resident R317's care plan dated 12/27/24, indicated bed mobility: the resident is totally dependent on staff for repositioning and turning in bed and as necessary. The care plan failed to include care and management of the Stage 3 pressure injury to the right gluteal fold and failed to include use of the low air loss mattress. Review of the admission record indicated Resident R51 was admitted on [DATE]. Review of Resident R51 MDS, dated [DATE] indicated diagnosis of dementia ( loss of memory, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 8 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few language, problem-solving and other thinking abilities that are severe enough to interfere in daily life) and depression (mood disorder that causes serious persistent feeling of sadness and loss of interest and can interfere with daily life). Review of Resident R51 clinical record progress notes dated 10/15/24, indicated: Right big toe noted to have increased redness to the tip, potentially as a result of the boot having been too tight. Nursing staff to continue to monitor and call the MD if it does not resolve. Additional progress notes indicated: 10/15/2024, Note Text: 2.5cm round red/ purple area to R Great toe- no drainage, no edema, no open area noted, no s/s of pain with light palpation to area, and res denies discomfort. 10/15/2024,Purple area of discoloration about 2.5cm on medial aspect of R great toe. NA noticed this She wears soft bunny boots. Unsure if this area was bumped. Will observe for now and observe Will have my CRNP see her tomorrow Additional review of Resident R51 clinical record failed to include follow up information of area on right great toe. During an interview on 1/8/25, at 10:23 a.m. Registered Nurse RN Employee E21 confirmed that the facility failed to include progression of the injury, how the injury occurred, when it healed or any follow up information and the facility failed to prevent/treat a wound. During an interview on 1/9/25, at 9:21 a.m. the Director of Nursing confirmed the facility failed to develop a pressure ulcer care plan, implement preventative measures, and failed to make certain that residents received the necessary services to prevent/treat pressure ulcers/wounds for two of six residents (Residents R317). During an interview on 1/8/25, at 10:23 a.m. Registered Nurse (RN) Employee E21 confirmed that the facility failed to include progression of the injury, how the injury occurred, when it healed or any follow up information. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.11 (a).(c)(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 9 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to ensure that the physician order for a urinary catheter (insertion of a tube into the bladder to remove urine) included the size of the suprapubic catheter, balloon sizing, and the amount of fluid needed to insert for balloon inflation/securement (the balloon keeps catheter in the bladder) for three out of seven sampled residents (Residents R53, R58, and R316 ) and failed to ensure catheter bags were covered as required for two of seven sampled residents (Residents R58, and R316). Findings include: Review of the facility policy Suprapubic Catheter Replacement dated 1/3/24, indicated verify that there is a physician's order. Review the resident's care plan to assess for any special needs of the resident. Supplies needed indicated catheter of proper size and composition (ordered by the physician). Review of the facility policy Dignity dated 1/3/24, indicated staff are expected to promote dignity and assist residents; for example: helping the resident to keep urinary catheter bags covered. Review of Resident R53's admission record indicated he was originally admitted [DATE]. Review of Resident R53's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/28/24, indicated he had diagnoses that included chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning), and benign prostatitis hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty). The diagnoses were the most recent upon review. Section H (Bladder and Bowel) H0100A indicated an X for the use of an indwelling catheter. Review of Resident R53's care plans dated 11/11/24, indicated he had suprapubic catheter and to monitor for pain and discomfort. Review of Resident R53's physician orders dated 11/16/24, indicated to provide catheter bag to gravity drainage below level of bladder, irrigate suprapubic catheter, and maintain suprapubic catheter in place. Resident R53's suprapubic catheter order did not indicate sizing of the catheter. Review of Resident R53's physician progress notes, other physician orders, nurse clinical notes, and certified nurse practitioner notes did not include the size of catheter in use. During observations on 1/8/25, at 10:04 a.m. Resident R53 observed being assisted to common area on Renaissance Hall (dementia unit). Resident R53 observed with catheter bag and catheter line in use. During an interview completed on 1/8/25, at 2:07 p.m. Registered Nurse (RN) Employee E4 confirmed that the facility failed to indicate the size of the suprapubic catheter in the physician order for Resident R53 as required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 10 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0690 Review of the admission record indicated Resident R58 admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident R58's MDS dated [DATE], indicated the diagnoses of End Stage Renal Disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), obstructive uropathy (a structural or functional hindrance of normal urine flow), and gastric reflux (stomach acid). Section H (Bladder and Bowel) H0100A indicated an X for the use of an indwelling catheter. Residents Affected - Some Review of Resident R58's care plan dated 11/4/24, indicated resident is dependent for suprapubic catheter care. Catheter: last changed (specify date). Change catheter (Frequency specify size and type). Catheter: The resident has (SPECIFY Size) (SPECIFY Type of Catheter). Position catheter bag and tubing below the level of the bladder and away from entrance room door. Review of Resident R58's physician order dated 11/13/24, indicated apply dignity bag and check placement each shift. Exchange suprapubic catheter monthly for chronic urinary retention. The physician order failed to include the size and type of catheter to be utilized for the exchange. Observation on 1/7/25, at 10:03 a.m. Resident R58 observed in bed with catheter drainage bag facing the door entrance and not covered with a dignity bag as required. Interview on 1/7/25, at 10:05 a.m. Registered Nurse (RN) Employee E8 confirmed Resident R58 was in bed with catheter drainage bag facing the door entrance and not covered with a dignity bag as required. Review of the admission record indicated Resident R316 admitted to the facility on [DATE]. Review of Resident R316's MDS dated [DATE], indicated the diagnoses of high blood pressure, Multiple Sclerosis (immune system eats away at protective covering of nerve cells), and Diabetes(a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R316's care plan dated 12/5/24, indicated the resident has suprapubic catheter. Position catheter bag and tubing below the level of the bladder and away from entrance door. The plan of care failed to include the type and size of catheter being utilized. Review of Resident R316's physician orders on 1/9/25, at 9:00 a.m. failed to indicate the size and type of catheter to be utilized. Observation on 1/7/25, at 12:05 p.m. Resident R316 observed in bed with catheter drainage bag facing the door entrance and not covered with a dignity bag as required. Interview on 1/7/25, at 12:05 p.m. Registered Nurse (RN) Employee E8 confirmed Resident R316 was in bed with catheter drainage bag facing the door entrance and not covered with a dignity bag as required. Observation on 1/9/25, at 9:30 a.m. Resident R316 observed in bed with catheter drainage bag facing the door entrance and not covered with a dignity bag as required. Interview on 1/10/25, at 3:00 p.m. the Director of Nursing confirmed the facility failed to ensure that the physician order for a urinary catheter included the size of the suprapubic catheter, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 11 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0690 Level of Harm - Minimal harm or potential for actual harm balloon sizing, and the amount of fluid needed to insert for balloon inflation/securement for four out of seven sampled residents (Residents R53, R58, R316) and failed to ensure catheter bags were covered as required for two of seven sampled residents (Residents R58, and R316). 28 Pa. Code: 201.29(j) Resident rights. Residents Affected - Some 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 12 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of three residents (Residents R14). Findings include: Review of facility policy Enteral Nutrition dated 1/2/25, indicated adequate nutritional support through enteral nutrition is provided to residents as ordered. The use of enteral nutrition is based on the results of the comprehensive nutritional assessment, and is consistent with current standards of practice, the resident's advance directives, treatment goals and facility policy. Review of Resident R14's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/11/24, indicated diagnoses of cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain), dependance on renal dialysis (a blood purifying treatment given when kidney function is not optimum), and aphasia (an acquired communication disorder that impairs a person's ability to process language). MDS Section K0520 indicated a feeding tube present. Review of current physician orders indicated an enteral feed order continuous for feeding is to be down at 1330 (1:30 p.m.) up at 1830 (6:30 p.m.) Nepro @85 ml (milliliters)/hr (per hour) * 19 hours (1615 ml) with 60 ml water flush every 4 hours. During an observation on 1/7/25, at 10:45 a.m., Resident R14's enteral feeding and water flush bag were hanging on a pole at bedside, both undated. During a follow-up observation, and interview on 1/7/25, at 10:55 a.m., Registered Nurse (RN) Employee E6 confirmed that Resident R14's enteral feeding and water flush bag were undated as observed, and confirmed that the facility failed to ensure that residents with an enteral feeding tube received appropriate treatment and services to prevent potential complications for one of three residents (Residents R14). 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(1) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 13 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for four of five residents (Residents R14, R22, R58, and R314) and failed to maintain an accurate care plan for dialysis access site for two of five (Resident R22, and R314). Residents Affected - Some Findings include: Review of the facility policy End-Stage Renal Disease, Care of a Resident with dated 1/3/24, indicated communication between the dialysis provider and facility staff will occur, and staff will be knowledgeable of the care of grafts and fistulas. The resident's comprehensive care plan will reflect the resident's needs related to End Stage Renal Disease and dialysis care. Review of Resident R14's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/11/24, indicated diagnoses of cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain), dependance on renal dialysis (a blood purifying treatment given when kidney function is not optimum), and aphasia (an acquired communication disorder that impairs a person's ability to process language). Review of current physician orders on 1/9/25, indicated Resident R14 attends dialysis on Monday, Wednesday, and Friday each week. A review of the clinical record did not include complete communication forms for the month of December 2024. There were nine incomplete communication sheets (Portion Completed by Nursing Home was incomplete) for the following dates: 12/2/24, 12/4/24, 12/6/24, 12/9/24, 12/13/24, 12/18/24, 12/26/24, 12/28/24, and 12/30/24; and there were 4 communication sheets that were unable to be found for 12/11/24, 12/16/24, 12/20/24, and 12/23/24. During an interview on 1/9/25, at 10:38 a.m., Registered Nurse (RN) Employee E6 confirmed that the above dates did not include completed communication forms as required. Review of the admission record indicated Resident R22 was admitted to the facility on [DATE]. Review of Resident R22's MDS dated [DATE], indicated the diagnoses of renal failure (condition where the kidneys lose the ability to remove waste and balance fluids) with dialysis, stroke (damage to the brain from an interruption of blood supply), and hemiplegia (paralysis of one side of the body). Review of physician order dated 12/22/24, indicated Resident R22 attends dialysis on Monday and Sunday. Review of physician order dated 10/2/24, indicated check AV Fistula (arteriovenous a surgical connection between an artery and a vein creating a natural pathway for blood flow) every shift for bruit (heard with a stethoscope) and thrill (a palpated vibration caused by flood flowing through fistula). Notify physician if either is absent. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 14 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0698 Review of Resident R22's care plan failed to include monitoring of the AV fistula for bruit and thrill. Level of Harm - Minimal harm or potential for actual harm A review of Resident R22's clinical record did not include complete dialysis communication forms. Communications in the book were incomplete dated: Residents Affected - Some 12/30/24 before dialysis blank no date form before dialysis blank 12/23/24 before and after dialysis incomplete 12/26/24 before dialysis incomplete 12/9/24 before and after dialysis incomplete 10/25/24 before dialysis incomplete 10/21/24 before dialysis incomplete 10/18/24 before dialysis incomplete 10/14/24 before dialysis incomplete 10/11/24 before dialysis incomplete 10/7/24 before dialysis incomplete Interview on 1/7/25, at 2:43 p.m. Registered Nurse (RN) Employee E6 confirmed the dialysis communication forms were incomplete on the 11 forms reviewed. Review of the admission record indicated Resident R58 was admitted to the facility on [DATE]. Review of Resident R58's MDS dated [DATE], indicated the diagnoses of renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), obstructive uropathy (a structural or functional hindrance of normal urine flow), and dependence on dialysis. Review of Resident R58's current physician orders indicated Dialysis Monday, Wednesday, Friday at 5:00 a.m. Check hemodialysis catheter dressing every shift. Review of Resident R58's care plan dated 10/24/14 indicated do not take blood pressure in arm with graft. Monitor access site for redness. Review of Resident R58's clinical record did not include complete dialysis communication forms. Communications in the book were incomplete dated: 1/6/25, 1/2/25, 12/30/24, 12/28/24, and 12/23/24. Interview on 1/7/24, at 1:10 p.m. Registered Nurse (RN) Employee E8 confirmed the dialysis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 15 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0698 communication forms were incomplete on the five forms reviewed. Level of Harm - Minimal harm or potential for actual harm Review of the admission record indicated Resident R314 was admitted to the facility on [DATE], with the diagnoses of anemia (the blood doesn ' t have enough healthy red blood cells), heart failure (heart doesn ' t pump blood as well as it should), and end stage renal disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) Residents Affected - Some Review of physician order dated 1/6/25, indicated renal dialysis on Monday, Wednesday, and Friday. Right tunneled dialysis catheter for dialysis. Review of Resident R314's care plan did not include a nursing plan of care for dialysis monitoring of access device or communication with the dialysis center. Simply stated he goes Monday, Wednesday, and Friday to dialysis. Review of Resident R314's clinical record did not include complete dialysis communication forms for 1/6/25. Interview on 1/7/25, at 1:10 p.m. Health Unit Coordinator (HUC) Employee E9 confirmed there was not a sheet from 1/6/25, as he just made the dialysis book today, 1/7/25. Interview on 1/10/25, at 3:00 p.m. the Director of Nursing confirmed the facility failed to make certain consistent dialysis communication was maintained for four of five residents (Residents R14, R22, R58, and R314) and failed to maintain an accurate care plan for dialysis access site for two of five (Resident R22, and R314). 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 16 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for three out of four nurse aide personnel records (Nurse Aide (NA) Employee E10, NA Employee E11, and NA Employee E12). Residents Affected - Some Findings include: Review of CFR (Code of Federal Regulations) §483.35(d)(7) Regular in-service education. The facility must complete a performance review of every nurse aide at least once every 12 months and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g). Review of NA Employee E10's personnel record indicated she was hired to the facility on 8/25/14. Review of NA Employee E11's personnel record indicated she was hired to the facility on 3/2/09. Review of NA Employee E12's personnel record indicated he was hired to the facility on [DATE]. Review of personnel records did not include an annual performance evaluations based on the date of hire for NA Employee E10, NA Employee E11, and NA Employee E12. Interview on 1/10/25, at 2:21 p.m. the Nursing Home Administrator confirmed that the facility failed to complete annual performance evaluations based on date of hire for NA Employee E10, NA Employee E11, and NA Employee E12. 28 Pa Code: 201.14 (a ) Responsibility of licensee 28 Pa Code: 201.18 (b)(1)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 17 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for one of three residents (Resident R59). Findings include: Review of the facility policy Hospice Services dated 1/2/25, indicated that hospice services are available to residents at the end of life. The facility is responsible for collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services; obtaining the following information from the hospice: - the most recent hospice plan of care - hospice election form - physician certification and recertification of the terminal illness - names and contact information for hospice personnel involved in hospice care - instruction on how to access the hospice's 24-hour on-call system Coordinated care plan for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by the facility. The coordinated care plan will be revised and updated as necessary. Review of Resident R59's clinical admission record indicated that she was admitted to the facility 3/11/22, with diagnoses of heart failure, dysphagia (a condition with difficulty swallowing food or liquid), and high blood pressure. Review of Resident R59's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 11/2/24, indicated diagnoses remain current upon review. Section O-0110 Special treatments indicated an x for hospice services. Review of Resident R59's physician order dated 10/7/24, indicated hospice services were to be provided as of this date. Further review of Resident R59's current physician orders failed to indicate a diagnosis for hospice care, which hospice provider was providing this service, and this hospice providers contact information. Review of Resident R59's current care plan on 1/10/25, failed to indicate a plan of care for hospice care and services by facility. During an interview on 1/10/25, at 9:00 a.m., Registered Nurse Assessment Coordinator (RNAC) Employee E7 confirmed that the facility failed to provide appropriate physician orders for hospice to contain hospice diagnosis, hospice provider, and contact information, and at 9:05 a.m., RNAC Employee E7 confirmed that the facility failed to provide a comprehensive care plan to address facility care and services for hospice for Resident R59. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 18 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0849 Level of Harm - Minimal harm or potential for actual harm During an interview on 1/10/25, at 3:10 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for one of three residents (Resident R59). 28 Pa Code: 211.12 (d)(3)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 19 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for two of seven residents (Residents R22, and R315), failed to have proper interventions carried out by staff for one of two positive Covid residents (Resident R34). Residents Affected - Few Findings include: Review of the facility policy Transmission Based Precautions dated 1/3/24, indicated enhanced barrier precautions (EBP) are in place for residents with an infection or colonization of a multi-drug resistant organism (MDRO), wounds and/or indwelling medical devices, such as an indwelling catheter, trach/vent, central line, and feeding tube. Gowns and gloves are to be on and used when providing high contact care with a resident who is in EBP. Review of the facility policy Covid -19 Identification and Management of Ill Residents dated 1/3/24, indicated newly identified Covid-19 infection in a resident is evaluated as a potential outbreak. Symptomatic residents are restricted to their rooms and cared for by staff with N95 or higher-level respirator, eye protection, gloves, and a gown. They are placed in Transmission-based precautions with contact isolation for 10 days. Review of the admission record indicated Resident R22 was admitted to the facility on [DATE]. Review of Resident R22's MDS dated [DATE], indicated the diagnoses of renal failure (condition where the kidneys lose the ability to remove waste and balance fluids) with dialysis, stroke (damage to the brain from an interruption of blood supply), and hemiplegia (paralysis of one side of the body). Review of physician order dated 12/22/24, indicated Resident R22 attends dialysis on Monday and Sunday. Review of physician order dated 10/2/24, indicated check AV Fistula (arteriovenous a surgical connection between an artery and a vein creating a natural pathway for blood flow) every shift for bruit (heard with a stethoscope) and thrill (a palpated vibration caused by flood flowing through fistula). Notify physician if either is absent. The orders failed to include an order for enhanced barrier precautions (EBP) for indwelling medical devices as required. Review of Resident R22's care plan failed to include interventions and management of EBP relating to dialysis access devices as required. Observation on 1/8/25, at 10:09 a.m. Resident R22's door was adorned with EBP signage. Interview on 1/8/25, at 10:09 a.m. Registered Nurse (RN) Employee E14 was asked to show Survey Agency (SA) Resident R33's tunneled catheter and AV fistula site. SA had to stop and instruct RN Employee E14 that a gown and gloves were required for the EBP. Observation on 1/8/25, at 10:10 a.m. RN Employee E14 proceeded to don gown. He tied the arms of the gown around his neck leaving his arms and upper body exposed. The built in hole for the head to go through was not utilized. Both arms were not inside the sleeves of the gown. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 20 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 1/8/25, at 10:11 a.m. RN Employee E14 indicated he thought these gowns were the apron type and admitted he was not familiar with donning these gowns. Review of the admission record indicated Resident R315 was admitted to the facility 12/25/24. Review of Resident R315's MDS dated [DATE] indicated the diagnoses of breast cancer with secondary bone cancer, pain, and anxiety. Review of Resident R315's physician orders 1/4/25, indicated Isolation-Contact and Droplet Precautions. In private room due to respiratory symptoms on 1/3/25. Care and services to be provided in the resident's room. Review of Resident R315's care plan failed to include interventions and management of isolation- contact and droplet precautions. Observation on 1/8/25, at 9:22 a.m. the sign on Resident R315's door indicated EBP. Nurse Aide (NA) Employee E15 was observed assisting resident out of the bed and transferring her into the bathroom. NA Employee E15 did not have a gown on as required for EBP and did not have a N95 respirator on for Droplet precautions as required by physician orders. Interview on 1/8/25, at 9:30 a.m. RN Employee E8 confirmed the signage was not appropriate for Resident R315 and that the NA Employee was not wearing the appropriate PPE as required. Review of the admission record indicated Resident R34 admitted to the facility on [DATE]. Review of Resident R34's MDS dated [DATE], indicated diagnoses of Down's Syndrome (a genetic chromosome 21 disorder causing developmental and intellectual delays), heart failure (heart doesn ' t pump blood as well as it should), and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids). Review of Resident R34's physician orders dated 1/7/24, indicated vital signs every shift for ten days due to covid positive testing. Covid isolation-contact and airborne precautions in private room due to positive for covid on 1/7/25. Care and services to be provided in the residents room until 1/16/25. Review of Resident R34's care plan dated 1/8/25, indicated the resident has covid, airborne contact isolation initiated on 1/7/25. Observation on 1/8/25, at 9:20 a.m. Resident R34's door was wide open, NA Employee E15 was inside the room with a regular surgical mask in place, no gloves, no eye protection, no N95, and no gown. Signage on door indicated airborne precautions. Interview on 1/8/25, at 9:30 a.m. RN Employee E8 confirmed the signage on the door only listed airborne, and that NA Employee E15 was not wearing the appropriate PPE as required. Interview on 1/8/25, at 2:00 p.m. the Infection Preventionist Employee E16 confirmed the facility failed to follow enhanced barrier precautions for two of seven residents (Residents R22, and R315), failed to have proper interventions carried out by staff for one of two positive Covid residents (Resident R34). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 21 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0880 28 Pa. Code: 211.5(f) Clinical records Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 22 of 23 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Place 310 Fisk Street Pittsburgh, PA 15201 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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on review of facility policy, employee personnel records, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation on the date of orientation for one out of five sampled records (Nurse aide Employee E3). Findings include: The Safety-01 Abuse, Neglect, Exploitation general policy dated 5/1/22, last reviewed 1/3/24, indicated that all employees and contracted staff will be educated upon orientation, annually, and as indicated on topics to include resident rights,privacy and confidentiality , and abuse prevention. Staff will be educated on recognizing the signs of abuse, neglect and exploitation. Review of Nurse aide (NA) Employee E3's personnel record indicated she was hired 10/2/24. Review of nurse deployment documents (form indicating the name and number of nursing staff working a specific date), indicated that Nurse aide (NA) Employee E3 first worked on the floor starting 10/7/24. After her orientation was completed, Nurse aide (NA) Employee E3 worked on 10/13/24 and continued to work at the facility. Review of Nurse aide (NA) Employee E3's personnel record did not indicate that she was trained on Abuse, Neglect, and Exploitation policies and procedures until 12/6/24, two months after her date of hire. During an interview on 1/10/25, at 1:12 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide training on Abuse, Neglect, and Exploitation to Nurse aide (NA) Employee E3 on the date of orientation as required. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 23 of 23