Health inspection·April 28, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Wanderguard got on elevator and went out front door. [Resident] made onto driveway but did not make it to sidewalk. Review of a facility provided document dated 4/14/23, indicated bystanders saw [resident] in w/c (wheelchair) at entry of facility called facility to report resident was outside. Resident removed Wanderguard which was found in the trash. Resident exited the the third floor onto the elevator at 20:03 (8:03 p.m.) then got off at reception area (closed for the night thus [NAME] [sic] at the desk) and sat at the door inside reception until 20:08 (8:08 p.m.) when resident opened the door to the vestibule where [resident] sat until 20:11 (8:11 p.m.) when [resident] opened the door to the outside and sat on the sit [sic] walk in w/c. Visitor approached resident at 20:29 (8:29) when then visitor called facility and notified the nursing facility that resident was outside. Review of Resident R1's care plan initiated 2/23/23, included the focus of impaired memory and intellectual disability with interventions of anticipate needs, provide appropriate activities and provide re-orientation aides. The care plan included the focus that the resident is at risk for elopement and related injury, with interventions to assess for elopement risk, redirect resident, encourage activities, ensure safety needs are net, functioning Wanderguard and door alarms, and to notify MD (physician) for attempts to elope and/or if current interventions are ineffective. The care plan was not reviewed and revised to reflect the actual elopement that occurred on 4/13/23, and resident specific interventions were not revised. During an interview on 4/28/23, at 11:05 a.m. the Director of Nursing confirmed the care plan and resident specific interventions for Resident R1 were not revised to reflect the actual elopement that occurred on 4/13/23. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.11(a) Resident care plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 2 of 9 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 395561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Reformed Presbyterian Home 2344 Perrysville Avenue Pittsburgh, PA 15214 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 a review of facility policy, resident clinical record review, resident interview, observation, and staff interview it was determined the facility failed to follow physician orders as required to ensure a Wanderguard device was in place for one of six elopment risk residents (Resident R2) Residents Affected - Few Findings include: Review of facility policy title Physician Orders last reviewed on 9/9/22, informed The physician order sheet shall be utilized to ensure proper communication of care desired by the attending physician for the resident for whom he/she is responsible. The physician's initial orders shall stand as part of the baseline care plan. Review of Resident R2's clinical record indicated the resident was admitted to the facility on [DATE]. Diagnoses included traumatic brain injury (sudden trauma to the brain), delusional disorders, paranoid personality disorder, protein calorie malnutrition an imbalance of nutrients from food and drinks needed to keep the body healthy and functioning), schizoaffective disorder ( a mental health condition where a person experiences both psychosis and a mood disorder), depression, and anxiety. Review of the facility's Wandering Risk Assessment scoring indicated the following: 0-8 Low risk 9-10 At risk to wander 11-above High risk to wander Review of Resident R2's admission Wander Risk assessment dated [DATE], score was 9, indicating the resident was at risk to wander. Review of Resident R2's Wander Risk assessment dated [DATE], changed to a score was 11, indicating the resident was a high risk to wander. Review of Resident R2's current physician orders dated 4/27/23, included Wanderguard placement effective 3/3/22, Clonazepam for anxiety, Abilify for schizophrenia, and Zoloft for depression. The orders remained current. Review of Resident R2's Minimum Data Set (a periodic federally mandatory assessment that guides a resident's care) dated 2/21/23, indicated the diagnoses remained current. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 3 of 9 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 395561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Reformed Presbyterian Home 2344 Perrysville Avenue Pittsburgh, PA 15214 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 0-7: severe impairment Level of Harm - Minimal harm or potential for actual harm Review of Resident R2's BIMS score dated 2/21/23, was 15, indicating the resident is cognitively intact. Residents Affected - Few Review of Resident R2's care plan dated 2/20/23, addressed the resident is at risk for elopement and a history of elopement attempt, is unable to independently choose activities and is at risk for social isolation due to confusion/cognitive loss, is dependent on staff for meeting emotional, intellectual, physical and social needs, and suicide attempt. Review of Resident R2's progress note dated 3/2/22, documented the resident called to the police, the [resident] wanted them to take her out of here as staff took the resident's Power of Attorney number so the resident could not call. Resident R2 stated [resident] hates this place. Review of Resident R2's provider note dated 3/2/22, documented staff reported the resident tried to leave the building. Review of Resident R2's progress note dated 3/2/22, documented at approximately 7:30 p.m. the resident called 911 and the paramedics arrived. The resident was crying that she wanted to be anywhere but here. During an observation on 4/26/23, at 12:55 p.m. Resident R2 did not have the Wanderguard on their person or wheelchair. Registered Nurse Supervisor Employee E5 observed the resident, and thoroughly checked the resident's wheelchair, including lifting the wheelchair cushion and looking at the underside of the wheelchair, and was unable to find the Wanderguard. The Registered Nurse Supervisor also received permission from Resident R2 to look in dresser drawers, nightstand drawer and resident's bag, and was unable to find the Wanderguard. During an interview on 4/26/23, at 1:00 p.m. Resident R2 reported not knowing where the Wanderguard was or when it was last seen. During an interview on 4/26/23 at 1:07 p.m. Registered Nurse Supervisor Employee E5 confirmed Resident R2 was without their Wanderguard and the facility failed to follow physician orders for the placement of a Wanderguard on an elopement risk resident. 28 Pa. Code: 201.14(a) 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)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 4 of 9 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 395561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Reformed Presbyterian Home 2344 Perrysville Avenue Pittsburgh, PA 15214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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 facility policy, facility provided documents, resident clinical record, observation, and staff interviews, it was determined the facility failed to ensure resident safety and to prevent the elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge) of a resident which resulted in an Immediate Jeopardy situation for one of 55 residents (Resident R1). Findings include: Based on a review of facility policy titled Elopement Prevention and Response last reviewed 9/9/22, informed the [facility] strives to promote resident safety and protect the rights and dignity of residents. The facility maintains a process to assess all residents for risk for elopement; implement prevention strategies for those identified as elopement risk, and follow a missing resident procedure. A facility approved risk assessment form will be used to evaluate the resident's physical, behavioral, psychological, and cognitive functions. If the assessment determines the resident scores a high risk of elopement, a physician's order will be secured for an ankle wander bracelet and the care plan updated accordingly. Staff will observe the resident and facility environment and report when a resident is at risk for elopement or has eloped. Review of Resident R1's clinical record indicated the resident was admitted to the facility on [DATE]. Diagnoses included neoplasm of the brain (brain cancer), diabetes, alcohol abuse, moderate intellectual disabilities (diminished abilities in intellectual and adaptive functioning), anxiety, autistic disorder (challenges with social skills, repetitive behaviors, speech and non-verbal communication), and chronic kidney disease (the kidneys inability to filter waste and excess fluid from the blood). Review of Resident R1's Minimum Data Set (MDS - a periodic federally mandated assessment that guides a resident's care) dated 2/26/23, indicated the diagnoses remained current. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R1's BIMS score dated 2/26/23, recorded a score of 10, indicating moderate impairment. Review of Resident R1's Nursing admission Screening dated 2/22/23, indicated resident was confused and had a flat affect (low, or lack of emotional expression when the situation may merit a more evident reaction). Review of the facility's Wandering Risk Assessment scoring indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 5 of 9 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 395561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Reformed Presbyterian Home 2344 Perrysville Avenue Pittsburgh, PA 15214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 0-8 Low risk Level of Harm - Immediate jeopardy to resident health or safety 9-10 At risk to wander Residents Affected - Few Review of Resident R1's Wandering Risk Assessment at admission, dated 2/22/23, recorded a score of 9, indicating the resident was at risk to wander. 11-above High risk to wander Review of Resident R1's care plan initiated 2/23/23, included the focus of impaired memory and intellectual disability with interventions of: anticipate needs, provide appropriate activities and provide re-orientation aides. The care plan did not address the resident was at risk for wandering. Review of Resident R1's progress note dated 3/9/23, at 18:00 (6:00 p.m.), documented the resident wandered off, wheeled self to the elevator and went to the first floor where [resident] ask receptionist to call an Uber so they can go to Blawnox (a [NAME] in the Greater Pittsburgh area). The resident was redirected back to the third floor (skilled nursing unit in the building). Review of Resident R1's progress note dated 3/9/23, at 19:07 (7:07 p.m.), documented the resident continues to exit seek and cry throughout the unit. Wanderguard (electronic monitoring device placed on/with the resident for residents at risk for wandering/elopement) functioning properly when close or attempting to go through the doors off unit. Resident R1 continues to ask multiple staff, residents and family members to help get out of here. Very difficult to redirect. Review of Resident R1's current physician orders dated revealed an order on 3/10/23, for a Wanderguard for resident safety related to wandering and/or exit seeking behaviors. The April 2023 recapitulation reveled that order has remained unchanged since onset. Review of Resident R1's progress note dated 4/13/23, at 9:00 p.m, documented the resident took off Wanderguard got on elevator and went out front door. Resident R1 made onto driveway but did not make it to sidewalk. Review of a facility provided document dated 4/14/23, indicated bystanders saw Resident R1 in w/c (wheelchair) at entry of facility called facility to report resident was outside. Resident removed Wanderguard which was found in the trash. Resident exited the third floor onto the elevator at 20:03 (8:03 p.m.) then got off at reception area (closed for the night thus [NAME] [sic] at the desk) and sat at the door inside reception until 20:08 (8:08 p.m.) when resident opened the door to the vestibule where [resident] sat until 20:11 (8:11 p.m.) when Resident R1 opened the door to the outside and sat on the sit [sic] walk in w/c. Visitor approached resident at 20:29 (8:29 p.m.) and the visitor called facility and notified the nursing facility that resident was outside. This area includes a small sidewalk with some parking spaces and a circular driveway to the public sidewalk, the entrance and exit to the driveway both have an incline leading down to the sidewalk with a curb to the main road running in front of the facility. Review of The Weather Channel's forecast for Pittsburgh, PA. on 4/13/23, revealed the high was 84 degrees and the low was 51 degrees. Review of the Nursing Home Administrator's (NHA) witness statement dated 4/19/23, documented staff returned the resident to the building at 20:31 (8:31 p.m.). The witness statement did not include a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 6 of 9 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 395561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Reformed Presbyterian Home 2344 Perrysville Avenue Pittsburgh, PA 15214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 description of Resident R1's clothing at the time of the elopement. Level of Harm - Immediate jeopardy to resident health or safety Review of Registered Nurse Employee E1's witness statement, not dated, documented the resident was seen after dinner in the hallway roaming by the common area near the nurse's station. Resident R1's alarm was going off near door earlier in the shift. Residents Affected - Few During an interview on 4/26/23, at 11:40 a.m., Nursing Assistant (NA) Employee E2 reported Resident R1 was very smart and knew how to take off the Wanderguard bracelet. The employee also reported it is difficult to watch residents when evening care is being provided and there is not enough staff to provide evening care. The employee presented a paper of seven resident photographs with names that were the residents with Wanderguard bracelets. During an observation on 4/26/23, at 11:50 a.m., Resident R1's room was located on the section of the hall furthest from the common area/nurse's station area, opposite two closed double doors, and closest to the elevator that lead to the reception area and main entrance on the first floor. The main entrance led out to a sidewalk, parallel to the front of the building. In front of the sidewalk was a small parking area for picking up or returning residents. Parallel to the small parking lot and sidewalk was the facility driveway. At the corner of the facility driveway and side street was a public transportation stop. During an interview on 4/26/23, at 2:00 p.m., Registered Nurse (RN) Employee E4 reported Resident R1 kept removing the Wanderguard bracelet and that the band could be stretched or torn. The employee reported Resident R1 knew the Wanderguard set off the alarm. The resident verbalized wanting to go to Blawnox for beer and vodka. During an interview on 4/26/23, at 2:18 p.m., the NHA reported the facility had five residents that were elopement risks. During an interview on 4/27/23, at 12:15 p.m., NA Employee E2 reported Resident R1 would comment about wanting to go to a hockey game, have a beer and a shot of vodka, and would cry if unable to go out. The elopement happened when staff were doing rounds, and Resident R1 was savvy enough to leave during rounds. During an interview on 4/27/23, at 11:20 a.m., RN Employee E3 reported Resident R1 was smart, always wanted to go somewhere, knew the band triggered the alarm. Friends took Resident R1 out of the building, [resident] knew the path to the front door. Resident R1 left at prime time during P.M. care. On 4/26/23, at 3:03 p.m., the NHA was made aware Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called as the facility failed to ensure resident safety for one of 55 residents and failed to prevent the elopement of Resident R1. The Immediate Jeopardy template was provided at that time and a corrective action plan was requested. On 4/26/23, at 9:02 p.m. an Immediate Action Plan was accepted with the following actions: - All residents will have Elopement Assessments Screenings completed. Elopement Risk residents will have updated physician orders, care plans, and any other necessary medical record documents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 7 of 9 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 395561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Reformed Presbyterian Home 2344 Perrysville Avenue Pittsburgh, PA 15214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 - Care plans will be updated for elopement risk residents to include interventions specific to the resident. Level of Harm - Immediate jeopardy to resident health or safety - Policies will be updated: Elopement Risk Guidelines - to include assessment frequency, environmental intervention Residents Affected - Few (door alarms, wanderguards), and resident interventions and redirection strategies; and Elopement and Missing Persons. - Staff education to include elopement prevention guidelines, recognizing signs and symptoms of wandering for at risk residents, elopement and missing residents response protocol, and rounding techniques to include frequency, observation of resident and behaviors, and interventions to meet resident needs before unsafe behaviors occur. - Front desk notification to include updated photograph list with names of at risk residents. Also applicable to nursing staff and facility managers. - New admission elopement risk screenings conducted and audited weekly. - Quality Assurance and Performance Improvement (QAPI) notification and reviews. - Daily documentation for signs and symptoms of elopement risk residents for 3 months, then quarterly thereafter. During observations and interviews on 4/28/23, at 1:30 p.m., fifty-five residents had elopement screening and assessments completed, resident records were updated physician orders, care plans, and other necessary medical records documentations as appropriate, the facility had trained 93% of it's staff on the Elopement Policies, prevention guidelines, recognizing signs and symptoms of at risk residents, elopement and missing resident protocol, and rounding techniques, 14 staff interviews were conducted and confirmed receiving training on the content of the trainings, updated policies were reviewed for content, front desk notification of at risk wander residents, as well as the nursing office and staff kitchenette room was completed, two new admission elopement risk screenings were conducted, QAPI was notified on 4/26/23, at 6:45 p.m., and daily documentation for signs and symptoms of elopement risk behaviors were documented for 4/27/23, and 4/28/23. On 4/28/23, at 1:43 p.m. the Nursing Home Administrator was made aware the Immediate Jeopardy was lifted. During an interview on 4/26/23, at 12:35 p.m. the Nursing Home Administrator confirmed the facility failed to ensure resident safety and to prevent the elopement of a resident which resulted in an Immediate Jeopardy situation for one of 55 residents (Resident R1). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 8 of 9 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 395561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Reformed Presbyterian Home 2344 Perrysville Avenue Pittsburgh, PA 15214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 28 Pa. Code 201.14(a) Responsibility of licensee. Level of Harm - Immediate jeopardy to resident health or safety 28 Pa. Code 201.18(b)(e)(1) Management. Residents Affected - Few 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete 28 Pa. Code 211.10(c)(d) Resident care policies. Event ID: Facility ID: 395561 If continuation sheet Page 9 of 9