Health inspection·June 26, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to report an allegation of neglect to the State Agency for one of four residents (Resident R325). Finding include: Review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 3/26/25, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated 3/26/25, indicated if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: state licensing/certification agency responsible for surveying/licensing the facility; local/state ombudsman, resident's representative, adult protective services, law enforcement officials, resident's attending physician and the facility medical director. Review of Resident R325's admission record indicated the resident was admitted on [DATE] , with diagnoses that included high blood pressure, diabetes (blood sugar too high or too low), muscle weakness and cognitive communication deficit (difficulties in communication due to impairments in cognitive processes like attention, memory, and problem-solving, rather than primary speech or language disorders). Review of Resident R325's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/13/25, indicated the diagnoses remained current. Review of Resident R325's progress note dated 6/15/25. indicated that Registered Nurse (RN) Employee E8 came to RN Employee E9 stating that the resident wanted to speak with the supervisor on duty. Upon entering the resident's room, resident was sitting in the wheelchair watching TV. When asked, how may I help you, resident stated that the certified nursing aide (CNA) Employee E10 was abusing an old lady. This Page 1 of 18 395391 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few RN Employee E8 asked resident to explain what had happened, the resident explained that the CNA Employee E10 told her to use the wheelchair to go to the bathroom instead of walking, which the resident didn't want to do, then the CNA Employee E10 pushed my chair hard and on purpose. Resident stated she wanted something done about this immediately and in writing. Resident R325 requested for this CNA Employee E10 not to be assigned to her or come in her room again. Director of Nursing (DON) and Nursing Home Administrator (NHA) were made aware of situation. RN Employee E8 was made aware that going forward there will have to be two aides going into her room to provide care. Review of documentation provided to the State Agency from 6/1/25, to 6/22/25, did not include Resident R325's incident of abuse. During an interview on 6/24/25, at 2:50 p.m. the Director of Nursing confirmed the facility failed to report an allegation of abuse to the State Agency for one of four residents (Resident R325). 28 Pa. Code:201.14(a) Responsibility of licensee. 28 Pa. Code:201.18(e)(1) Management. 28 Pa. Code:207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(d) Resident care policies. 395391 Page 2 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0641 Ensure each resident receives an accurate assessment. 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 clinical records, observations and staff interview, it was determined that the facility failed to make certain that resident assessments were accurate for one of five residents (Resident R71). Residents Affected - Few Findings include: Review of facility policy Resident Assessments reviewed 4/1/24 and 3/26/25, indicated a comprehensive assessment of every resident ' s needs is made at intervals designated by OBRA and PPS requirements. A comprehensive assessment includes completion of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs), completion of the care area assessment (CAA) process, and development of the comprehensive care plan. Review of the clinical record indicated that Resident R71 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, dementia (group of symptoms affecting memory, thinking and social abilities), and repeated falls. Review of a physician order dated 7/12/24, indicated Resident R71 was admitted to hospice services. Review of the MDS dated [DATE], indicated the diagnoses remain current. Further review of the MDS dated [DATE], Section O: Special Treatments, Procedures, and Programs, O0110 K1 Hospice Care failed to indicate Resident R71 was receiving hospice care at the facility. Review of the MDS dated [DATE], Section O: Special Treatments, Procedures, and Programs, O0110 K1 Hospice Care indicated Resident R71 was not receiving hospice care at the facility. During an interview on 2/14/25, at 12:05 p.m. the Registered Nurse Assessment Coordinator (RNAC) Employee E7 confirmed the facility failed to complete an accurate assessment for Resident R58. 395391 Page 3 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for one of three residents (Resident R57). Findings include: Review of facility's policy Care Plans, Comprehensive Person-Centered dated 3/26/25, indicated the facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Review of the clinical record face sheet revealed that Resident R57 was admitted to the facility on [DATE], with a diagnosis of dementia. Review of the comprehensive Minimum Data Set (MDS - periodic assessment of resident care needs) dated 11/14/24, indicated Resident R57 had a diagnosis of dementia. Review of Resident R57's care plan dated 5/22/25, failed to reveal a care plan with goals and interventions for dementia. During an interview on 6/26/25, at 12:30 p.m. the Director of Nursing confirmed that the facility failed to ensure that a comprehensive resident care plan was complete for resident care needs for Resident R57. 28 Pa. Code 211.12(d)(5) Nursing Services. 395391 Page 4 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

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 interviews, it was determined that the facility failed to assess, document, and notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels for three of nine residents reviewed (Residents R58, R64, and R111). Residents Affected - Few Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy Obtaining a Fingerstick Glucose Level reviewed 4/1/24 and 3/26/25, indicated the documentation after the procedure should contain all assessment data obtained during the procedure. Document the blood sugar results. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages), etc. Review of the facility policy Change in Resident ' s Condition or Status reviewed 4/1/24 and 3/26/25, indicated the nurse will notify the resident ' s attending physician or physician on call when there has been a need to alter the resident ' s medical treatment significantly. A significant change of condition is a major decline or improvement in the resident ' s status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. Review of the care plan Charting and Documentation reviewed 4/1/24 and 3/26/25, indicated the following information is to be documented in the resident medical record: (a) Objective observations; and (d) Change ' s in resident ' s condition. Documentation of procedures and treatments will include care-specific details, including the assessment data and/or unusual findings obtained by the procedure and notification of family, physician, or other staff, if indicated. Review of the facility policy Care Plans, Comprehensive Person-Centered reviewed 4/1/24 and 395391 Page 5 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3/26/25, states a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. When possible, interventions address underlying source(s) of the problem area(s), not just symptoms or triggers. The facility was unable to provide a policy regarding care of the diabetic resident. Review of the clinical record revealed Resident R58 was admitted to the facility on [DATE], with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities), diabetes, and aphasia (an impairment in a person's ability to comprehend or formulate language because of dysfunction in specific brain regions). Review of Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 5/28/25, indicated the diagnoses remain current. Review of Resident R58 physician ' s order revealed the following orders: On 12/31/24, Humalog (a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) insulin per sliding scale with meals; For blood sugar 331 and greater, give six units then call MD (doctor). Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 5/6/25, at 5:58 p.m. the CBG was noted to be 413. Recheck CBG at 5:59 p.m. was noted to be 413. On 5/9/25, at 5:50 p.m. the CBG was noted to be 393. Recheck CBG at 6:28 p.m. was noted to be 393. On 5/12/25, at 7:58 p.m. the CBG was noted to be 397. Recheck CBC at 7:59 p.m. was noted to be 397. On 5/18/25, at 6:08 p.m. the CBG was noted to be 359. Recheck CBG at 6:14 p.m. was noted to be 359. On 5/26/25, at 5:52 p.m. the CBG was noted to be 354. Recheck CBG at 5:52 p.m. was noted to be 354. 395391 Page 6 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0684 On 5/27/25, at 8:47 a.m. the CBG was noted to be 350. Level of Harm - Minimal harm or potential for actual harm On 6/1/25, at 6:52 p.m. the CBG was noted to be 438. Recheck CBG at 6:54 p.m. was noted to be 438. Residents Affected - Few On 6/6/25, at 5:37 p.m. the CBG was noted to be 438. Recheck CBG at 6:54 p.m. was noted to be 438. On 6/17/25, at 7:36 a.m. the CBG was noted to be 368. On 6/23/25, at 6:28 p.m. the CBG was noted to be 349. Recheck CBG at 6:31 p.m. was noted to be 349 Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed date. Review of a clinical record indicated Resident R64 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and lymphedema (accumulation of protein-rich fluid that's usually drained through the body's lymphatic system, most commonly affects the arms and legs). Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R64 physician ' s orders revealed the following orders: On 7/16/24, Humalog insulin per sliding scale. For blood sugar 331 and greater, cover with 7 units and call MD for further orders. Review of Resident 64's eMAR revealed that the resident's CBG's were as follows: On 3/26/25, at 11:43 a.m. the CBG was noted to be 334. On 4/16/25, at 12:41 p.m. the CBG was noted to be 350. On 5/28/25, at 7:57 a.m. the CBG was noted to be 374. 395391 Page 7 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0684 - Level of Harm - Minimal harm or potential for actual harm On 5/29/25, at 8:33 a.m. the CBG was noted to be 375. - Residents Affected - Few On 6/1/25, at 6:58 p.m. the CBG was noted to be 367. Review of the care plan dated 6/17/24, indicated the following interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Monitor/document/report PRN (as needed) any psychosocial problem areas Monitor/document/report PRN compliance with diet and document any problems. Monitor/document/report PRN any sign/symptoms of infection to any open area. Review of the care plan revised on 6/5/25, failed to reveal a person-centered care plan with interventions specific to Resident R64. Review of Resident R64's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Review of the clinical record indicated Resident R111 was admitted to the facility on [DATE], with diagnoses that included diabetes, aphasia (an impairment in a person's ability to comprehend or formulate language because of dysfunction in specific brain regions), and dysphagia (difficulty swallowing). Review of Resident R111 physician ' s order revealed the following orders: On 4/3/25 through 5/8/25, Humalog insulin per sliding scale. If blood sugar is 341 and greater, give six units and call MD. Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: 395391 Page 8 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0684 On 4/4/25, at 12:37 p.m. the CBG was noted to be 408. Recheck CBG at 12:49 p.m. was noted to be 408. Level of Harm - Minimal harm or potential for actual harm On 5/3/25, at 5:43 p.m. the CBG was noted to be 434. Recheck CBG at 5:43 p.m. was noted to be 434. Residents Affected - Few Review of the care plan dated 1/30/24, indicated the following interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Monitor/document/report PRN (as needed) any psychosocial problem areas Monitor/document/report PRN compliance with diet and document any problems. Monitor/document/report PRN any sign/symptoms of infection to any open area. Review of the care plan revised on 4/4/25, failed to reveal a person-centered care plan with interventions specific to Resident R111. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed date. During an interview on 6/25/25, at 10:15 a.m. Licensed Practical Nurse (LPN) Employee E1 stated it depends on the resident ' s order for when to notify the doctor. If the blood sugar was below 70, they would provide juice or snack depending on their signs and symptoms. If the blood sugar was greater that 300, they would give the resident water, the ordered insulin, and assess the resident to see if signs and symptoms were present, they would notify the doctor. They stated they would document in the eMAR and progress notes. During an interview on 6/25/25, at 10:05 a.m. Registered Nurse (RN) Employee E2 stated for blood sugar less than 70, they would call the doctor and give a snack or juice. If the blood sugar was over 330, they would give the ordered insulin, call the doctor, check the resident ' s vital signs. They would document in the eMAR and a progress note. During an interview on 6/25/25, at 10:08 a.m. RN Employee E3 stated if the blood sugar was less that 70 or over 400, they would notify the doctor. If the blood sugar was less than 70, they would provide a snack or juice and recheck the blood sugar in 15 minutes. If the blood sugar was over 400, they would check the resident ' s vital signs, assess the resident for any signs and/or symptoms, and call the doctor. They would document in the eMAR and progress notes. 395391 Page 9 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/25/25, at 10:10 a.m. LPN Employee E4 stated if the resident ' s blood sugar was less than 60, they would provide a snack or juice and call the doctor if the blood sugar did not During an interview on 6/25/25, at 10:15 a.m. RN Employee E5 stated they would check the doctor ' s orders to check when to notify the doctor. If the blood sugar was less than 70, they would assess the resident for signs and symptoms and provide a snack or juice. For blood sugar over 140, they would monitor the resident. They would document in the eMAR and progress notes. During an interview on 6/26/25, at 10:00 a.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition, failed to document an assessment or interventions used related to blood glucose, and failed to follow physicians orders for Residents R58, R64, and R111. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident rights 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services 395391 Page 10 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observations, clinical record review, review of facility document and staff interviews, it was determined that the facility failed to provide an environment free from potential accident hazards due to uncovered electrical plugs, accessible potential hazardous materials, foods and sharps that had potential to cause injury and actual removal of a elopement bracelet for one resident (Resident R225) on one of four nursing units( Memory Care Unit). Findings include: Review of the facility policy Accidents and Incidents-Investigating and Reporting dated 3/26/25, with a previous review date of 3/1/24, indicated that all accidents or incidents involving residents occuring on the premises shall be investigated and reported. the investigation shall be initiated promptly and documented on the Report of Incident/Accident Form. During an observation of the Secured Memory Care Nursing Unit on 6/23/25, from 11:26 a.m., through 11:48 a.m., the following was identified: Three plug outlets in the right wing hallway had no covers with exposed wiring. An unsecured room identified as the Activity Room had shelving/drawer units with five unsecured drawers four of which had packages of wipes, two pretzels, clips, hand sanitizer packs and sugar packs, paper files which the sharp file holder metal bar fell off, within the drawer also was a roll of tape, paperclips and binding clips and other unidentifiable items. The cabinet contained two electrical extension cords and a coiled wire for an unidentified item. During the observation, Resident R97 was in the hall attempting to wheel his wheelchair throughout the hallway. During an interview on 6/23/25, at 11:33 a.m., Registered Nurse Employee E11 confirmed that the facility failed to provide an environment free from potential accident hazards. During a clinical record review Resident R225 was admitted to the facility on [DATE], with diagnoses which included dementia, anxiety, insomnia and kidney disease. Resident R225 was identified as requiring placement on the memory care secured unit. Review of a physician order dated 6/14/25, indicated placement of a wanderguard bracelet and placement checked each shift for security. Review of a progress noted dated 6/18/25, at 1:34 p.m., indicated Resident R225 had cut off the wanderguard bracelet with nail clippers and the nurse had taken the clippers and replaced the bracelet. During an interview on 6/24/25, at 2:50 p.m., the Nursing Home Administrator(NHA) and Director of Nursing stated that the incident was put the information on a Incident Statement Form by the nurse however, the incident investigation did not take place. The NHA confirmed that the facility failed to provide an environment free from potential accidents hazards. 395391 Page 11 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0689 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies Residents Affected - Some 395391 Page 12 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 policies, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of an indwelling urinary catheter as required for two of four residents (Resident R51 and R331). Findings include: Review of the facility policy Indwelling (Foley) Catheter Removal dated 3/26/25, indicated documentation in the medical record should consist of the following: date and time the procedure was performed, name and title of the individual who performed the procedure, all assessment data (urine amount, color, clarity, etc.) obtained during procedure, time and amount of first void after catheter removal, how the resident tolerated the procedure, if resident refused the procedure, reason and interventions taken, signature and title of person recording data. Review of the facility policy Output, Measuring and Recording dated 3/26/25, indicated this procedure is to accurately determine the amount of urine that a resident excretes in a 24 hour period. Review of the facility policy Urinary Continence and Incontinence-Assessment and Management dated 3/26/25, indicated the staff and practitioner will appropriately screen for, and manage individuals with urinary incontinence. Management of incontinence will follow relevant clinical guidelines. The physician and staff will provide appropriate services and treatments to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. Indwelling urinary catheters will be used sparingly, for appropriate indications only. Identification and management of urinary tract infections will follow relevant clinical guidelines. Antibiotics will be used appropriately. Review of Resident R51's medical record indicated admission to the facility on 6/2/25, with diagnoses that include history of falling, chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), urinary tract infection, and obstructive and reflux uropathy (two distinct conditions of the urinary tract where one causes a blockage allowing for normal flow and the other causing urine in the bladder to the back up into the kidneys). Review of Resident R51's Minimum Data Set (MDS-a periodic assessment of care needs) dated 6/9/25, indicates the diagnoses are current. Review of Resident R331's medical record indicated admission to the facility on 6/9/25, with diagnoses that include history of falling, obstructive and reflux uropathy, urinary tract infection, and cognitive communication deficit (difficulties in communication due to impairments in cognitive processes like attention, memory, and problem-solving, rather than primary speech or language disorders). Review of Resident R331's MDS dated [DATE], indicates the diagnoses are current. Review of Resident R331's clinical record indicated the foley catheter was to be discontinued on 6/23/25, review of the record revealed that bladder scans were ordered every shift for 72 hours with resident to receive a straight catheter (temporary catheter used once to empty the bladder and then removed immediately) for residual of greater than 450 milliliters. 395391 Page 13 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R331's clinical record indicated the resident was not offered attempts to toilet more frequently per policy for post removal of catheter, incontinent without measurement (resident also had order to push fluid of 250 milliliters every 2 hours while awake), and no documentation of staff's assistance in resident's continence/incontinence per policy. Review of Resident R331's clinical record indicated resident had to have foley replaced on 6/24/25, due to inability to empty bladder completely. Observation on 6/23/25 at approximately 1:30 p.m. Resident R51 was noted up in wheelchair with foley bag hanging on side of wheelchair with no dignity bag for privacy. Resident R331 was noted to be in bed with foley bag hanging on side of bed with no dignity bag for privacy. Observation on 6/25/25 at 12:40 p.m., noted Resident R51 sitting in wheelchair with foley hanging on walker with dignity bag next to it. Resident R331 was noted in bed with foley hanging on side of bed with no dignity bag in place. Interview with Nurse Aide (NA) Employee E12 on 6/25/25 at 12:40 p.m. confirmed the catheter drainage bag facing entrance door on the walker and bed frame were not covered with a dignity bag for privacy as required. Interview with Director of Nursing (DON) on 6/26/25, at 10:15 a.m. confirmed the facility failed to ensure that appropriate treatment and services were provided for two of four residents (Resident R51 and R331) with an indwelling urinary catheter. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(a)(c)(d)(1)(2)(5) Nursing services. 395391 Page 14 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure the pharmacy completed a Medication Regime Review (MRR) at least monthly for one of five residents (Resident R58). Findings: Review of facility policy Medication Regimen Review reviewed 4/1/24 and 3/26/25, indicated the consultant pharmacist performs a MRR for every resident in the facility receiving medications. Medication regimen reviews are done upon admission and at least monthly thereafter, or more frequently if indicated. Copies of MRR reports, including physician responses, are maintained as part of the permanent medical record. Review of the clinical record revealed Resident R58 was admitted to the facility on [DATE], with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities), diabetes, and aphasia (an impairment in a person's ability to comprehend or formulate language because of dysfunction in specific brain regions). Review of Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 5/28/25, indicated the diagnoses remain current. Review of Resident R58 clinical record failed to indicate a MRR was completed for February 2025, March 2025, and May 2025. During an interview on 6/26/25, at 10:15 a.m. the Nursing Home Administrator (NHA) confirmed the facility failed to complete monthly pharmacy MRR's for Resident R58. 395391 Page 15 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of facility policies, observations and staff interview, it determined the facility failed to maintain sanitary conditions to prevent the potential for cross contamination during lunch time tray line. Residents Affected - Many Findings include: Review of a facility policy Food Preparation and Service dated 3/26/25, indicated that food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness. Bare hand contact with food is prohibited. Gloves are to be worn when handling food directly and changed between tasks. During an observation on 6/23/25, from 10:48 a.m., through 11:28 a.m., the following was identified: Dietary Aide Employee E13 had three racks/trays of bowls leaning over food items on the steam table while food was being plated. Dietary Aide Employee E14 had gloves on touching the outer surfaces of bags of buns, removing a bun, plating it then with same gloved hands picking up lettuce and tomatoes and placing it on the burger, was also turning around opening packages of buns and cheese then returning and placing them on burgers with no glove change and/or hand washing between tasks. During an interview on 6/23/25, at 11:28 a.m., Interim Dietary Manager Employee E15 confirmed that the facility failed to maintain sanitary conditions to prevent the potential for cross contamination during lunch time tray line. 28 Pa. Code: 211.6 (c)(f) Dietary services. 395391 Page 16 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility documents and interviews with staff it was determined that the facility failed to provide the State Agency with access to facility information, causing a delay in the survey process. Findings include: During the entrance conference on [DATE], the Nursing Home Administrator(NHA) and Director of Nursing(DON) were provided information requesting a list of new hires in the last four months as identified on the state entrance conference form including any contracted employees and also an all house employee list and their date of hire for annual education purposes. Review of the five new hire personnel files requested on [DATE], at 10:40 a.m., were not received until 1:30 p.m. a second request for Human Resources(HR) Employee E16 at 2:15 p.m., due to information related to expired licenses on file, documentation of employee physicals, employees reference checks and documention of employees receiving facility orientation was made. On [DATE], at 8:20 a.m., the New Employee Files were not provided until 9:20 a.m. New Employee file review again still incomplete with new hire orientation documentation still not identified. The State Agency (SA) had to find the information with another new employee file review as HR Employee E16 did not provide the information., adding another hour to the review. Review of 10 employees annual educational records requested on [DATE], at 10:40 a.m., were received at 1:30 p.m., and did not include 12 hours of annual trainings for the five Nurse Aides and for all 10 employees did not include all required trainings. The NHA was asked again for complete documentation of their education's and any additional information to assist in producing the trainings and the 12 hour need for Nurse Aides as required. on [DATE], at 2:15 p.m., the second request for the information was placed. On [DATE], at 9:20 a.m., the information was reviewed and documentation for four employees including two Nurse Aides(NA), a Therapy staff person and a Registered Nurse(RN) was not included. Additional information was not provided until 1:43 p.m. At this time the facility Executive Director stated We are at 100 percent compliance, we have emails from two staff (one NA and the RN)stating they completed the trainings, they were here at the time of trainings onsite but did not complete them and did them at home, why are you picking this apart?. Additional information was not provided. During an interview on 6/26, at 9:16 a.m., the NHA was asked to provide an investigation for Resident R39 and a staffing deployment sheet for [DATE], the documentation for Resident R39 was not provided until 10:16 a.m., an hour later. During the exit conference, the facility was made aware that the surveyor completing the tasks for new employee files and employee education had stated the multiple requests for information that should readily be available due to the annual process being unchanged was delaying the survey process. 28 Pa.Code 201.14(a) Responsibility for licensee. 28 Pa.Code 201.18(d)(e)(1) Management. 395391 Page 17 of 18 395391 06/26/2025 Asbury Health Center 700 Bower Hill Road Pittsburgh, PA 15243

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policies and procedures, current Centers for Disease Control (CDC) guidelines, clinical record review, and staff interview, it was determined that the facility failed to document each resident was offered an influenza and/or pneumococcal immunization and the resident or resident's representative was provided education regarding the benefits and potential side effects of immunizations, for one of five residents reviewed for influenza and pneumococcal immunizations (Resident R53). Residents Affected - Few Findings include: A review of facility policies, Pneumococcal Vaccine and Influenza Vaccine, dated 4/1/24, indicated vaccines are administered in accordance with Centers for Disease Control and Prevention (CDC) recommendations. All residents are offered pneumococcal and influenza vaccines to aid in preventing infections. The resident or resident's legal representative will be provided information and education regarding the benefits and potential side effects of the vaccines and will be documented in the medical record. A review of the clinical record indicated Resident R53 was admitted to the facility on [DATE], with diagnoses that included dementia and high blood pressure. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 4/15/24, indicated the resident had severely impaired cognition, did not receive the influenza vaccine, and was not offered the pneumococcal vaccine. A review of the electronic clinical record Immunizations documentation on 6/25/25 at 11:00 a.m., did not include information that the influenza or pneumococcal vaccines were offered or declined. A review of a nurse progress note dated 10/18/24, indicated the resident refused the flu vaccine. There was no documentation in the clinical record that the resident's legal representative was provided information and education regarding the benefits and potential side effects of the vaccines or notification that the vaccines were offered or declined. During an interview on 6/25/25 at 11:45 a.m., the Director of Nursing confirmed the above findings, and that the facility failed to document each resident was offered an influenza and/or pneumococcal immunization and the resident or resident's representative was provided education regarding the benefits and potential side effects of immunizations, for Resident R53. 28 Pa. Code 211.5(f)(i)-(xi) Medical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395391 Page 18 of 18