Health inspection·June 3, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was of a female resident with a blue gown on making a statement with a smiley face halfway covering the face. NA Employee E1 pointed to the name in the left corner of the video and indicated that was NA Employee E2. When asked how NA Employee E1 knew this, NA Employee E1 indicated because it's a Tic/Toc on Instagram friend group. Review of NA Employee E1's witness statement signed and dated 5/5/25, indicated On May 4, 2025, I got a video sent to my phone of Resident R1. NA Employee E2 recorded Resident R1 on Instagram in close friends. Resident R1 was in bed and talking nasty and NA Employee E2 was laughing at her. I showed it the nurse and we reported it to the supervisor. Review of RN Employee E5's witness statement signed and dated 5/4/25, indicated at approximately 10:00 p.m. RN Employee E3 and NA Employee E1 approached me to report something that disturbed them that they had seen on a social media site. The video was a person in what appeared to be a hospital gown with an enlarged laughing emoji superimposed over the face in an attempt to obstruct the person's face, at a point the emoji moved and the face of Resident R1 could be recognized who is a resident of the facility. The person recording the video could be heard to speak to Resident R1. The voice sounded like NA Employee E2. NA Employee E1 was asked if it was posted by NA Employee E2, and NA Employee E1 confirmed it was posted by NA Employee E2. Review of Human Resource Director Employee E15's witness statement signed and dated 5/5/25, indicated Management was made aware of a video on social media that one of the staff made showing a resident of the facility. Upon interviewing NA Employee E1, who still had the video and showed it to Management. NA Employee E1 explained what Resident R1 said in the video and confirmed Resident R1 does make sexual comments frequently. Interview on 6/3/25, at 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to make certain residents were free from mental abuse, including abuse facilitated or enabled through the use of technology for one of five residents reviewed (Residents R1). 28 Pa. Code 201.18(b)(1)(2)(3) Management. 28 Pa. Code 201.29 Responsibility of licensee. 28 Pa. Code 211.10(a)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - 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 follow a physician order for a Bipap device (a positive airway pressure machine when breathing in and breathing out) and failed to act on a malfunctioning Bipap in a timely manner for one of three residents (Resident R2) which resulted in actual harm of dyspnea (difficulty breathing), hypoxemia (a low level of oxygen in the blood), hypercapnia (too much carbon dioxide in the blood stream), requiring an intensive care unit (ICU specialized hospital department where critically ill patients receive intensive, round-the-clock care) admission for Bipap. Residents Affected - Few Findings include: Review of the facility policy CPAP/Bipap Support dated 1/2/25, indicated Bipap delivers continuous positive airway pressure, but allows separate pressure settings for expiration (EPAP -breathing out) and inspiration (IPAP- breathing in). Document in the resident's medical record how the resident tolerated the procedure. Review of facility provided education from April 2025, indicated Cpap vs Bipap which defined each term and compared differences in the equipment. Section titled What are the potential problems? indicated if the machine malfunctions, seek professional assistance. Review of the admission record indicated Resident R2 was admitted on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/4/25, indicated the diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), acute and chronic respiratory failure (when the lungs can't properly exchanges gases causing abnormal levels of carbon dioxide and/or oxygen in the arteries), and heart failure (heart doesn't pump blood as well as it should). Section C0500 indicated a Brief Interview for Mental Status (BIMS - is a screening test that aides in detecting cognitive impairment) as 15 - cognitively intact. Review of Resident R2's physician order dated 4/28/25, indicated Bipap settings (IPAP/EPAP) 18/5 with oxygen bleed at 2 liters/minute. Please fill the reservoir with sterile water. Apply Bipap at 9:00 p.m. Remove Bipap at 6:00 a.m. Review of Resident R2's care plan dated 1/7/25, indicated problem - resident is having difficulty adjusting to nursing home and is experiencing loneliness as evidenced by refusing Bipap and demanding family come in. Goal - resident will have increased compliance with Bipap use. Support calls with family as needed and assist with putting Bipap on. Monitor and document changes in orientation, increased restlessness, anxiety, and air hunger. Notify physician of signs of respiratory distress. Interventions dated 9/3/24, indicated BiPap settings as ordered, and failed to identify the specific settings required. The plan of care failed to identify steps to follow in the event the machine malfunctioned or required service. Review of Resident R2's progress notes indicated the following: -Licensed Practical Nurse (LPN) Employee E6's note on 5/9/25, at 9:15 p.m. - no significant changes at this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2025 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 0695 Level of Harm - Actual harm Residents Affected - Few -Registered Nurse (RN) Employee E7's note on 5/10/25, at 3:48 p.m. - issues with the Bipap throughout the night. Evening shift nurse left note that it was not working when was placed on resident. Resident placed on 2liters of oxygen via nasal cannula (two thin prongs that sit below the nose to administer oxygen) oxygen saturation at 96 percent. Respirations at 16 breaths a minute and resident denies shortness of breath or discomfort at this time. -LPN Employee E8's note on 5/11/25, at 12:56 a.m. - no significant changes at this time. -LPN Employee E9's note on 5/13/25, at 7:04 p.m. - resident complained of shortness of breath. Oxygen water changed, inhaler given, repositioned in bed, other nurse has been in her room to fix the phone, will continue to monitor. -LPN Employee E10's note on 5/13/25, at 10:00 p.m. - at the beginning of this shift resident was complaining of shortness of breath while on the phone with the son. This nurse checked the oxygen saturation, and it was 93 percent on 2 liters of oxygen. Resident indicated their bottom hurt and legs from sitting up in the chair yesterday. This nurse offered to reposition resident, and resident said it was okay then changed their mind. Tylenol given with evening medication. Resident was changed, Bipap placed. No issues noted at this time. -LPN Employee E11's note on 5/15/25, at 2:00 a.m. from the start of shift resident constantly complaining of everything possible. Staff constantly in and out the room. Pulled up in bed numerous times vital signs taken. Oxygen saturation 99 percent on 2 liters of oxygen. Resident is calling staff saying I'm awake now and currently is screaming help calling the desk phone. When staff go in the room resident is quiet saying I'm awake, what do I do now. Resident complained of shortness of breath oxygen saturation was 99 percent, but her Bipap has not been working. Has a history where carbon dioxide rises but resident is full alert and saturations are fine at the moment. -LPN Employee E11's note on 5/15/25, at 2:14 a.m. resident ringing now, wanting to know if it's time to get out of bed. It's 2:15 a.m., redirected resident who didn't have complaints of shortness of breath at all. Saturation 99 percent. -LPN Employee E11's note on 5/15/25, at 2:57 a.m. called the On-Call doctor regarding complaints and the son. Nurse aide that is working currently said Bipap wasn't put on in the evening. The nurse stated it would just cut off. This nurse put Bipap on and water in and oxygen bleed into Bipap so far working fine. Physician stated if Bipap stops or malfunctions it's ok to send to resident to the emergency room. Resident was yelling at top of the lungs help me. Earlier in the night and became slightly sweaty. Heart rate maintained in the 80's 90's and saturation was 99 percent. Physician also made aware of that. Son called back for update. Son is mad and on the way to the facility. -LPN Employee E11's note on 5/15/2025, at 3:08 a.m. resident's sons are here and upset about Bipap not working. They had a backup Bipap and are hooking it up right now. -LPN Employee E11's note on 5/15/25, at 3:23 a.m. the sons left secondary Bipap on and working. They apologized to this nurse and was appreciative of letting them know about resident's condition and the Bipap issues. -LPN Employee E11's note on 5/15/25, 6:01 a.m. resident responds to name answers questions still (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2025 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 0695 Level of Harm - Actual harm Residents Affected - Few seems slightly off, such as hypercapnic like symptoms. Mentioned this to the sons when they were here about going to the hospital now. They declined and wanted to try to wear the secondary Bipap first for an extended period of time. RN Supervisor aware and physician. -RN Employee E12's note on 5/15/25, at 9:52 a.m. - resident was sent to the hospital at 9:45 a.m. Vital signs were taken. Resident was in respiratory distress. Skin diaphoretic (sweaty). Loose black stools. This writer requested to have resident go to local hospital. The paramedics took resident to a different local hospital instead, due to the resident having loose black stools. -RN Employee E4's note on 5/15/25, at 3:39 p.m. resident at hospital, the carbon dioxide is ranging from 56, 51, 44 (normal range is 35 -45). Resident will be admitted to hospital. -RN Employee E4's note on 5/15/25, at 4:51 p.m. call placed to son for update on resident. Son responded her carbon dioxide was elevated, and resident kept twitching and falling asleep intermittently. The son was also asked when here this morning at 3:00 a.m. to swap out the Bipap machine the resident uses, if the Bipap by the bedside was working upon arrival to resident's bedside. Son responded at this point I don't even know. Review of the hospital record dated 5/15/25, indicated Resident R2 with history of chronic hypercapnia (on nighttime Bipap) COPD, obstructive sleep apnea, obesity hypoventilation syndrome, who presented on 5/15/25 from skilled nursing facility due to dyspnea, hypoxemia, hypercapnia, requiring ICU admission for Bipap. Interview on 6/3/25, at 9:42 a.m. LPN Employee E11 indicated remembering a note that said the Bipap wasn't working right for Resident R2, recalled resident not being their normal self on 5/14/25, I called the resident's son to update them and asked if they knew the Bipap was broken. The son indicated not being aware. The other nurses were saying when putting the Bipap on Resident R1 in about 30 minutes it would shut off. One day the sons pulled another Bipap out and hooked that one up instead. The sons are familiar with the resident's carbon dioxide levels being elevated and didn't want Resident R2 to go to the hospital until wearing the second Bipap for a while to see if it would blow off the carbon dioxide. Later that day she had bloody stools and went to the hospital. Further indicated they've had training on the Bipap recently. Interview on 6/3/25, at 1:08 p.m. Infection Preventionist Employee E13 and Materials Manager Employee E14 indicated they checked the Bipap machine on 5/15/25, as Resident was in the hospital at this time, and it worked fine. The respiratory company checked the Bipap and indicated nothing was wrong with it. When asked how they knew which Bipap machine the vendor checked the original or secondary machine brought from family, they could not answer or provide documentation that the vendor checked the machine. Telephonic interview on 6/3/25, at 1:24 p.m. LPN Employee E8 indicated if they found the Bipap to be malfunctioning or questionable a call to the doctor and family would be made, and the respiratory company to come look at the machine. Telephonic interview on 6/3/25, at 1:47 p.m. RN Employee E7 indicated being familiar with Resident R2 and that the Bipap was not liked by Resident R2. Indicated upon arrival to Resident R2's room the tube that connects to the mask and to the machine itself whenever in the room the tube would be off, and they would reconnect it. The only issue with the Bipap for RN Employee E7 was with the tubing. Further indicated they've had training on the Bipap recently. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 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 395146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2025 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 0695 Level of Harm - Actual harm Residents Affected - Few Interview on 6/3/25, at 1:52 p.m. LPN Employee E6 indicated Everyone says it's not broke, but sometimes you'll turn it on, and it turns itself back off. You try to put it back on and it stops blowing and turns off again. This happens once in a while not all the time. The day I left the note I turned the Bipap on, and I stood there to make sure the numbers were right, and the air was blowing, it didn't blow, and it shut itself off, and kept shutting off after I turned it back on. I told the next shift to keep a good eye on it. When asked if the physician or family was notified, LPN Employee E6 indicated No, I'm sorry, I did not. Interview on 6/3/25, at 2:45 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to make certain the facility failed to follow a physician order for a Bipap device, failed to act on a malfunctioning Bipap in a timely manner which resulted in actual harm of dyspnea, hypoxemia, hypercapnia, and requiring intensive care unit admission for Bipap. 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395146 If continuation sheet Page 6 of 6