Health inspection·September 29, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation and staff interview it was determined that the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Form (SNF ABN CMS 10055) for one of three residents reviewed (Resident CR203) 48 hours before services ended. Residents Affected - Some Findings include: Review of facility documentation showed Resident CR203 was admitted to the facility on [DATE], and remained in the facility as of 4/27/23. Review of the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN CMS-10055) form which provides information to residents/resident representatives that skilled nursing services may not be paid by Medicare and so that the resident/resident representatives can decide if they wish to continue receiving skilled nursing services and assume financial responsibility indicated Resident CR203 last day of Medicare Part A coverage was 4/26/23. Review of the Resident CR203's Notice of Medicare Non-Coverage dated 4/25/23, indicated the facility failed to issue the NOMNC within 48 hours. During an interview on 9/28/23, at 10:56 a.m. Social Services, Employee E3 confirmed that the facility failed to provide Resident CR203 with SNF ABN CMS-10055 form within 48 hours. 28 Pa. Code 201.18 e (1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 2 of 8 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 09/29/2023 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 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 review of clinical records and staff interview it was determined that the facility failed to develop comprehensive care plans for one of twelve residents reviewed (Resident R33). Findings include: Review of Resident R33 clinical record was re-admitted on [DATE]. Review of Resident R33 MDS (minimum data set - a brief periodic assessment of resident needs) dated 7/24/23, indicated that Resident R33 had diagnosis of congestive heart failure ( when your heart can't pump blood well enough to your body), and arthritis ( swelling and tenderness of one or more joints). Review of Resident R33 clinical record, listed care plans as cancelled, with no active care plans in place. Review of the MDS Section B0200. Hearing indicates Resident R33 has minimal difficulty hearing difficulty in certain environments. Review of Resident R33 hospital record dated 4/13/23, indicated that resident has an impacted cerumen, right ear (causes symptoms such as hearing loss). During an interview on 9/27/23, at 10:17 a.m. Resident R33 indicated that they could not hear the surveyor during the interview. Review of the clinical record care plans showed care plans were listed as cancelled with no active care plans in place. During an interview on 9/29/23, at 2:17 p.m. Nursing Home Administrator confirmed that the facility failed to have any active care plans in place for Resident R33. 28 Pa. Code211.11(a)c Resident care policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 3 of 8 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 09/29/2023 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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, job description review, observation, and staff interview, it was determined the facility failed to provide care and services to meet the accepted standards of practice for one of four residents (Resident R100). Residents Affected - Few Review of the facility Licensed Practical Nurse (LPN) job description indicated that it is the responsibility of the LPN to provide care, based on physical, psycho/social, safety, and related criteria, appropriate to the residents served in his/her assigned area. It was indicated the LPN must maintain a current knowledge of federal, state, and other regulations applicable to job. Review of Resident R100's Minimum Data Set (MDS-periodic review of care needs) dated 9/20/23, indicated the resident was admitted on [DATE]. Review of Resident R100's diagnoses dated 9/20/23, indicated a diagnosis of low blood pressure, depression, and hypothyroidism (occurs when the thyroid gland can't make enough thyroid hormone to keep the body running normally). Review of Resident R100's physician order dated 9/25/23, instructed the nurse to give 600mg of gabapentin (medication for nerve pain) by mouth, three times a day, for neuropathy (a form of nerve damage). During an observation of Resident R100's medication administration on 9/27/23, at 9:43 a.m. LPN, Employee E7 administered 600 mg of gabapentin from another resident's card. LPN, Employee E7 stated she used an extra card from someone else because Resident 100's gabapentin was not available. During an interview on 7/19/23, at 10:55 a.m. LPN Employee E7 confirmed she failed to meet accepted standards of clinical practice by administering another resident's medication for one of four residents (R100). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services 28 Pa. Code: 211.12(d)(3) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 4 of 8 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 09/29/2023 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 0685 Assist a resident in gaining access to vision and hearing services. 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 documents, clinical record review and staff interview it was determined that the facility failed to provide hearing assistive devices, treatment and services to one of two residents reviewed (Resident R33). Residents Affected - Few Findings include: Federal regulations states: §483.25(a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the residentReview of clinical record indicated Resident R33 was admitted to the facility on [DATE]. Review of Resident R33 MDS (minimum data set - a brief periodic assessment of resident needs) dated 7/24/23, indicated that Resident R33 had diagnosis of congestive heart failure (when your heart can't pump blood well enough to your body), and arthritis (swelling and tenderness of one or more joints). Review of the MDS Section B0200. Hearing indicates Resident R33 has minimal difficulty hearing difficulty in certain environments. Review of Resident R33 hospital record dated 4/13/23, indicated that resident has an impacted cerumen, right ear (causes symptoms such as hearing loss). During an interview on 9/27/23, at 10:17 a.m. Resident R33 indicated that they could not hear the surveyor during the interview. During a review of the clinical record Resident R33 family member requested assistance with Resident R33 for hearing. Review of the clinical record for Resident R33 failed to include assistance for assistive hearing and treatment. During a phone interview with Resident R33 family member indicated that the family member and the resident wanted assistance with hearing services. During an interview on 9/29/23, at 2:07 p.m. the Nursing Home Administrator confirmed that the facility failed to provide hearing assistive devices, treatment and services for Resident R33. 28 Pa. Code 211.10(a)(d)Resident care policies. 28 Pa. Code 211.11(d)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 5 of 8 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 09/29/2023 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 0759 Ensure medication error rates are not 5 percent or greater. 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 and clinical record, observation and staff interviews it was determined that the facility failed to administer medications with a medication error rate that was less than five percent for two of four residents (Resident R20). Residents Affected - Few Findings include: Two medication errors occurred during 26 observed opportunities, which resulted in a 7.69% medication error rate. Review of Resident R20's Minimum Data Set (MDS-periodic review of care needs) dated 7/15/23, indicated the resident was admitted on [DATE], and diagnosis included depression, chronic pain, and schizophrenia (combination of mood disorder, depression and delusions). Review of Resident R20's physician order dated 7/11/23, instructed the nurse to give one tablet of Senna (stool softener to prevent constipation) one time a day for bowel regularity. During an observation of Resident R20's medication administration on 9/27/23, at 9:26 a.m. Licensed Practical Nurse (LPN), Employee E7 had Resident R20's morning medications signed off for completion prior to administration. During the observation, Resident R20's Senna was unavailable and needed to be refilled. LPN, Employee E7 failed to administer the Senna and struck it out. LPN, Employee E7 failed to use the Omnicell to administer Resident R20's Senna. Review of Resident R100's Minimum Data Set (MDS-periodic review of care needs) dated 9/20/23, indicated the resident was admitted on [DATE]. Review of Resident R100's diagnoses dated 9/20/23, indicated a diagnosis of low blood pressure, depression, and hypothyroidism (occurs when the thyroid gland can ' t make enough thyroid hormone to keep the body running normally). Review of Resident R100's physician order dated 9/25/23, instructed the nurse to give 600mg of gabapentin by mouth, three times a day, for neuropathy (a form of nerve damage). During an observation of Resident R100's medication administration on 9/27/23, at 9:43 a.m. LPN, Employee E7 administered 600 mg of gabapentin from another resident's card. LPN, Employee E7 stated she used an extra card from someone else because Resident 100's gabapentin was unavailable. During an interview on 9/29/23, at 3:22 p.m. the Nursing Home Administrator confirmed that the facility failed to administer medications with less than a 5% error rate. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 6 of 8 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 09/29/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain and implement updated COVID-19 polices based on national standards and perform hand hygiene for one of four residents (Resident R49). Residents Affected - Few Findings include: Review of the facility Hand Hygiene policy dated 6/9/20, last reviewed 6/23, indicated hand hygiene must be performed before and after resident contact and before and after performing any procedure. Review of the facility COVID-19, Coronavirus Prevention and Response dated 6/6/23, indicated residents are tested on admission Day 1, then if negative, test again 3 Day, then again on Day 5. It was indicated resident who become symptomatic will be tested. Review of the facility COVID-19 Contingency Staffing policy dated 6/6/23, indicated If staffing were to fall below the state required 2.7 hours of staffing per resident per day, the community would notify the Pennsylvania Department of Health, document the reason for inability to maintain 2.7 requirement. The facility policy failed to reflect the updated required 2.87 hours of staffing per resident per day. During an interview on 9/27/23, at 8:57 a.m., the Director of Nursing (DON) stated the facility is in an outbreak for COVID-19 and residents who were exposed are tested every three days. Review of Resident R49's clinical record revealed an admission date of 6/1/23. Review of R49's Minimum Data Set (MDS-periodic assessment of resident care needs) dated 8/15/23, included diagnoses of diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high) and Human Herpes Virus 6 (a viral infection). Review of Resident R49's physician order dated 9/11/23, indicated to inject Insulin Lispro per sliding scale, subcutaneously every six hours, for diabetes and tube feeds. During an observation of Resident R49's insulin administration on 9/28/23, at 11:52 a.m. Licensed Practical Nurse (LPN), Employee E6 failed to perform hand hygiene prior to preparing the insulin, as well as before and after he administered the insulin. LPN, Employee E6 failed to wear gloves during the administration of insulin. During an interview on 9/28/23, at 11:59 p.m. LPN, Employee E6 confirmed that he failed to perform hand hygiene and apply gloves during insulin administration. During an interview on 9/28/23, at 1:47 p.m. the Nursing Home Administrator (NHA) confirmed the facility failed to have updated COVID-19 policies to reflect current national standards. During an interview on 9/29/23, at 3:22 p.m. the NHA and DON confirmed the facility failed to maintain updated COVID-19 policies to reflect national standards, and the facility staff failed to implement appropriate standards and transmission-based precautions for hand hygiene for one of four residents (Resident R49). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 7 of 8 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 09/29/2023 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 0880 28 Pa. Code 211.10(c)(d) Resident Care Policies Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12 (d)(2) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 8 of 8