Inspection·April 9, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on review of facility policy, observations and staff interviews it was determined the facility failed to ensure comfortable air temperature levels were provided for 22 of 25 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22). Findings include: Review of the facility policy Homelike Environment dated 2/3/25, indicated the facility will provide residents with a safe, clean, comfortable, and homelike environment. The policy further stated the facility staff and management maximizes, to the extent possible comfortable and safe temperatures (71°F 81°Fahrenheit). Review of Title 42 Code of Federal Regulations §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. During an interview on 4/8/25, at approximately 3:15 p.m. Maintenance Employee E1 stated the boiler (a closed tank where water is heated under pressure, and then used for hot water or heating a building) stopped functioning on 4/5/25. At this time, temperature logs since the boiler malfunction were requested. During an interview on 4/8/25, at 3:40 p.m. Maintenance Employee E1 confirmed the boiler went down Saturday (4/5/25), and was repaired late this morning (4/8/25). During observations of resident area temperatures on 4/8/25, Maintenance Employee E1 received a phone call from Maintenance Employee E2, which he answered on Speakerphone in the presence of the surveyor and the Nursing Home Administrator (NHA). During this phone call, Maintenance Employee E2 stated the temperatures on the log were really low, and that's why they are here. Maintenance Employee E2 asked if he should make new temperature records. During an interview of 4/8/25, at 3:56 p.m. Maintenance Employee E2 was asked when the boiler stopped functioning, and he stated, I believe it was Sunday afternoon (4/6/25). When asked when he started monitoring facility temperatures, Maintenance Employee E2 stated, 6 am Monday morning. During this interview, Maintenance Employee E2 stated that he felt the low temperatures were inaccurate. When asked why if he felt they were inaccurate, he did not act upon them, he was unable to provide an answer. During a confidential interview on 4/8/25, at 4:10 p.m. the resident stated, The boiler is broken. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 395423 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 395423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Champion City Nursing and Rehabilitation Center 6655 Frankstown Avenue Pittsburgh, PA 15206 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)