Health inspection·August 14, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of five resident rooms (Resident R55). Findings include: Review of the facility policy Resident Rights, last reviewed 7/22/24, indicated a resident has the right to a safe, clean comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. During an observation on 8/12/24 at 10:00 a.m. The wall area behind residents R55's headboard was noted to have pieces of drywall missing, large gouges, and denting. During an interview on 8/12/24, at 10:03 a.m. Licensed Practical Nurse Employee E3 confirmed the observation and stated that the facility has started to put protective sheets behind the headboards. 28 Pa Code: 201.18 (e)(1)(2) Management 28 Pa Code: 201.29 (a)(c)(d) Resident Rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 2 of 16 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 08/14/2024 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 facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans to meet care needs for two of four residents (Resident R9 and R15). Findings include: A review of facility policy Care Management reviewed 7/22/24, indicated the care plan will be developed consistent with each resident's rights and to meet the residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. Review of Resident R9's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 7/25/24, indicates reentry to facility on 7/12/24, with the diagnosis of diagnoses of anemia (low iron in the blood) hypertension (high blood pressure) and Diabetes (high sugar in the blood) Review of physician orders 7/23/24, Indicates FreeStyle Libre 3 reader device (continuous glucose system receiver) check residents blood sugar before meals and at bedtime. Review of Resident R9's July 2024, medication administration record (MAR) indicates in use. Review of Resident R9's care plan did not include interventions for the FreeStyle Libre 3 reader device. During an interview on 8/14/24, Registered Nurse Employee (RN) Employee E5 confirmed the facility failed to develop a care plan to meet the resident R9's medical, nursing, and psychosocial needs. Review of Resident R15's MDS dated [DATE], indicated reentry date of 4/9/24, with the diagnosis of hypertension (high blood pressure) end stage renal disease (last stage of kidney failure) and diabetes (high sugar in the blood) Review of physician orders dated 6/5/24, indicate FreeStyle Libre 3 reader device before meals and at bedtime. Review of Resident R15's June MAR indicates in use. Review of Resident R15's care plan did not include interventions for the FreeStyle Libre 3 reader device. During an interview on 8/14/24, at 1:15 pm RN Employee E5 confirmed the facility failed to develop a care plan to meet the resident R15's medical, nursing, mental and psychosocial needs. 28 Pa. Code 211.10(c)(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services 28 Pa. Code: 201.29(i) Resident Rights (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 3 of 16 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 08/14/2024 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 28 Pa. Code: 211.11 (a,c)(d) Resident care plan. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 4 of 16 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 08/14/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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, resident clinical records, and staff interviews, it was determined that the facility failed to accurately monitor and provide comprehensive assessments of a pressure area for one of three resident (Resident R17). Residents Affected - Few Findings include: The facility Wound management program dated 3/25/24, indicated that the facility is committed to providing a comprehensive wound management program to minimize the development of pressure injuries. A visual skin assessment is completed by the nurse. Results are documented in the skin observation tool. When the nurse observes a wound, he or she will assess the wound and document the findings. The following may be documented such as skin issues, type, length, width, depth, and wound stage. Review of Resident R17's admission record indicated she was admitted on [DATE], and readmitted on [DATE]. Review of Resident R17's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/26/24, indicated that she had diagnoses that included vascular dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning), hyperlipidemia (elevated lipid levels within the blood), obesity, compression fracture of the lumbar vertebrae, cellulitis (bacterial infection of the skin causing redness, aches, and swelling), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). The record indicated the diagnoses were still current upon review. Review of Resident R17's physician ordered dated 1/17/22, indicated to complete skin assessments weekly every Monday. Write a note or complete a skin sheet. Review of Resident R17's care plan dated 5/2/24, indicated Resident R17 is at risk for signs of skin integrity impairment/pressure injury due to incontinence. Notify doctor as needed if wound worsened or does not respond to current treatment. Review of Resident R17's physician ordered dated 8/13/24, indicated to cleanse Stage two wound. Hospice nurse to complete on Tuesdays and Thursdays. Facility nurse to complete on Saturdays and as needed. Review of Resident R17's wound assessment, skin observation documents, and nurse progress notes did not include a wound assessment with measurements for the week of 7/4/24. Review of Resident R17's wound assessment dated [DATE], indicated that Resident R17's pressure area was a Stage three wound measuring 4.00cm x 3.00 cm x 0.30cm. The assessment indicated the area to the coccyx began on 5/26/24. Review of Resident R17's skin observation tool dated 7/17/24, indicated that Resident R17 had a Stage two wound to the coccyx area. The assessment tool did not include measurements of the area. During an interview on 8/14/24, at 8:44 a.m. Registered Nurse (RN) Employee E2 stated: Resident R17 still has a wound. All information and assessments should be in the miscellaneous section on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 5 of 16 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 08/14/2024 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 0686 computer. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/14/24, at 8:55 a.m. the Registered Nurse Assessment Coordinator (RNAC)/Infection Control Preventionist Employee E5 stated: the wound team comes once a week. A wound nurse saw Resident R17 upon admission. Residents Affected - Few During an interview on 8/14/24, at 9:51 a.m. the Registered Nurse Assessment Coordinator (RNAC)/Infection Control Preventionist Employee E5 confirmed that the facility failed to accurately monitor and provide comprehensive assessments of a pressure area for Resident R17 as required. 28. Pa Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 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 16 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 08/14/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for one of three residents(Resident R49). Residents Affected - Few Findings include: A review of the facility policy Respiratory Equipment last reviewed on 7/22/24, indicates to prevent the administration of oxygen or medication through contaminated equipment. Nebulizer sets will be changed weekly or as needed. After treatments units will be rinsed with hot tap water and allowed to dry. Set will be stored in clean plastic bags between treatments. Nebulizer sets will be marked with Resident's name, the date and initials when changed. A review of the admission record indicated Resident R49 was admitted to the facility on [DATE]. A review of R49's Minimum Data Set (MDS-periodic assessment of care needs) dated 7/6/24, included diagnoses of anemia (low iron in the blood), chronic obstructive pulmonary disease (COPD-makes it hard to breathe), and chronic kidney disease (gradual loss of kidney function). A review of Resident R49's physician orders dated 7/19/23, indicate DuoNeb Solution 0.5-2.5 MG/3ML (Ipratropium-Albuterol) 1 dose inhale orally every 6 hours as needed for wheezing. During an observation on 8/12/24 at 9:42 a.m. resident R49 was in her bed, a nebulizer was noted to be sitting on top of dresser not bagged and failed to be labeled with resident ' s name and date. During an interview 8/12/24 at 10:21 a.m. Registered Nurse (RN) Employee E2 E confirmed that Resident R49's nebulizer was not bagged and failed to be labeled with resident ' s name and date. 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 7 of 16 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 08/14/2024 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident clinical records, facility policy and staff interview, it was determined the facility failed to provide consistent and complete communication with the dialysis (treatment that helps body remove extra fluid and waste products) center for one of one resident receiving hemodialysis (Resident R15). Residents Affected - Few Findings include: A review of the facility policy Dialysis Services dated 7/22/24, indicated to ensure that residents who require dialysis receives such service, consist with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. Communication between the dialysis staff and nursing staff provide continuity of care will be ongoing via dialysis assessment binder. A review of Resident R15's MDS dated [DATE], indicated reentry date of 4/9/24, with the diagnosis of hypertension (high blood pressure) end stage renal disease (last stage of kidney failure) and diabetes (high sugar in the blood) A review of Resident R15's physician orders last revised on 8/3/24, indicate dialysis Tuesdays, Thursdays, and Saturdays. A review of Resident R15's nursing progress notes indicated attendance to dialysis sessions. A review of Resident R15's dialysis communication binder indicated dialysis sheets completed on 7/20/24, 7/25/24, 7/30/24, 8/8/24, and 8/10/24 were incomplete, the section for the dialysis unit is blank. No dialysis sheets were found for the following days 7/23/24, 7/27/24, and 8/6/24. During an interview on 8/12/24, at 10:29 a.m. Licensed Practical Nurse (LPN) Employee E3 indicated a dialysis assessment binder is a binder that holds a dialysis communication form. The form is to be completed by facility and sent with the resident to the dialysis center, the dialysis center is to complete their portion of the form and return in binder to facility. LPN Employee E3 confirmed the dialysis communication forms were incomplete as the dialysis center had not completed their portion and some days were missing. 28 Pa. Code: §211.5(g)(h) Clinical records. 28 Pa. Code: §201.14(a)(b)(e)(1)(3) Management. 28 Pa. Code: §211.10(c) Resident care policies. 28 Pa. Code: §211.12(c)(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 8 of 16 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 08/14/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on manufacturer's instructions, clinical record review, and staff interview it was determined that the facility failed to ensure that nursing staff have the specific competencies and skill sets necessary to provide care for a resident with a Free Style Libre 3 system (a new way for people with diabetes to check their sugar levels, without a finger stick test, using a sensor that can read changes in the liquid just underneath the skin) for two of two residents (Resident R9 and R15) Findings include: Review of the FreeStyle Libre 3 continuous glucose monitoring system updated 5/2023, indicated the following: . What to know before using the system. . Who should not use the system. . What you should know about wearing a sensor. . How to store the sensor kit. . How to store the unit. . When not to use the system. . What to know about the system. . What to know before applying the sensor. . When is sensor glucose different from blood glucose. . What to know about x rays. . When to remove the sensor. . What to know about the reader. . What to know about charging your reader. . Interfering substances. Review of Resident R9's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 7/25/24, indicates reentry to facility on 7/12/24, with the diagnosis of diagnoses of anemia (low iron in the blood) hypertension (high blood pressure) and Diabetes (high sugar in the blood) Review of Resident R9's physician orders dated 7/23/24, Indicates FreeStyle Libre 3 reader device (continuous glucose system receiver) check residents blood sugar before meals and at bedtime. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 9 of 16 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 08/14/2024 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 0726 Review of Resident R9's July 2024, medication administration record (MAR) indicates in use. Level of Harm - Minimal harm or potential for actual harm Review of Resident R15's MDS dated [DATE], indicated reentry date of 4/9/24, with the diagnosis of hypertension (high blood pressure) end stage renal disease (last stage of kidney failure) and diabetes (high sugar in the blood) Residents Affected - Few Review of Resident R15's physician orders dated 6/5/24, indicate FreeStyle Libre 3 reader device before meals and at bedtime. Review of Resident R15's June MAR indicates in use. During an interview on 8/14/24, at 11:05 a.m. Registered Nurse (RN) Employee E E2 stated I know absolutely nothing about the system, a packet comes with the machine, I did educate myself, I have read the instructions, I received no facility in-servicing concerning the system. During an interview on 8/14/24, at 11:33 a.m. Licensed Practical Nurse LPN E3 stated I received no in-service here, I am familiar with the system as I have used them before in different facilities. During an interview 8/14/24, at 11:53 a.m. RN Unit Manager Employee E6 stated no staff in -servicing has been completed concerning the use of the FreeStyle Libre system, we missed the in-service piece, and confirmed the facility failed to ensure that nursing staff have the specific competencies and skill sets necessary to provide care for a resident with a Free Style Libre 3 system. 28 Pa. Code 201.14(a) Responsibility of licensee 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 10 of 16 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 08/14/2024 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for two of five nurse aide personnel records (Nurse aide Employee E8 and Nurse aide Employee E9). Residents Affected - Few Findings include: The facility Certified nursing assistant position description last reviewed 7/22/24, indicated that the performance expectations are that the incumbent must be able to demonstrate the knowledge and skills necessary to provide care. Each employee is to be evaluated based on the standards set forth in the position description. Review of Nurse aide (NA) Employee E8's personnel record indicated she was hired to the facility on 2/4/19. The record indicated that the position description and the employee handbook were both signed on 2/4/19. Review of Nurse aide (NA) Employee E8's performance evaluation for the evaluation period of 3/14/23 to 1/26/24, did not indicate a review with the employee and was observed without a review date. Review of Nurse aide (NA) Employee E9's personnel record indicated she was hired to the facility on 1/13/20. The record indicated that the position description and the employee handbook were both signed on 1/13/20. Review of Nurse aide (NA) Employee E9's performance evaluation for the evaluation period of 7/12/23 to 7/24/24 did not indicate a review with the employee and was observed without a review date. During an interview on 8/13/24, at 12:48 p.m. the Director of human resources Employee E10 confirmed that the facility failed to complete annual performance evaluations for Nurse aide (NA) Employee E8 and Nurse aide (NA) Employee E9 as required. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 11 of 16 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 08/14/2024 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **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 make certain residents receive appropriate treatment and services for highest practicable mental and psychosocial services for one of three residents (Resident R28). Findings include: Review of facility policy dated 7/11/24, Behavioral Health Services, Trauma Informed Care indicated: It is the goal of the facility to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Review of Resident R28's indicated was originally admitted on [DATE], and readmitted on [DATE]. Review of the MDS (minimum data set - a periodic assessment of resident needs) dated 4/30/24, with the following diagnosis adjustment disorder with depression (mental condition triggered by a serious event). Review of Resident R28's clinical record indicated the following: 7/4/24: nurses notes : alerted by Resident R28's roommate that resident demonstrating behaviors such as coming into roommates space being exposed. 7/14/24: nurses note: Resident R37 Reported to nurse that Resident R28 exposed himself. Review of the clinical record for Resident R28 failed to include documentation/referral for psych services between 7/4/24 and 7/14/24. During an interview on 8/14/24, at 10:38 a.m. Social service Employee E11 confirmed that the facility had an allegation of Resident R28 acting out sexually on 7/4/24 and again on 7/14/24. Social Service Employee 11 confirmed that psych services were not provided between the first incident on 7/4/24 and 7/14/24, and the facility failed to help Resident R28 receive appropriate treatment and services for highest practicable mental and psychosocial services. 28 Pa. Code 201.18(b)(1)Management. 28 Pa. Code 211.12(d)(3)(5)Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 12 of 16 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 08/14/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and staff interviews it was determined that the facility failed to properly store medical supplies and biologicals in one of one medication rooms (third floor medication room) and one of three medication carts (yellow medication cart), properly secure medications in one of three medication carts (green hall medication cart) and failed to date open medications. Findings include: Review of the facility policy Medication Distribution System dated 7/22/24, indicate medications and biologicals are stored safely, securely, and properly. Orally administered medications are kept separate from medication administered by other routes. The facility's medication room is used to ensure an effective medication distribution by availability of a medication only refrigerator limiting access to only authorized personnel, kept clean, well-lit, and free of clutter. During an observation on 8/12/24, at 12:25 p.m. Licensed Practical Nurse (LPN) Employee E3 was completing a medication pass for Resident R261. LPN Employee E3 administered medications for Resident R261, after using the artificial tears eye drops, LPN Employee E3 placed the eye drops back in box and placed on top of the medication cart and returned to the room to inquire about medication and any further needs. The medication cart was placed across the hall from Resident R261 's room and the medication was left unattended. During an interview on 8/12/24, at 12:40 p.m. LPN Employee E3 confirmed the medication for Resident R261 (Artificial Tears eye drops) was left unattended and not properly secured on top of the medication cart accessible to anyone passing by in the hallway. During a review of Resident R15's MDS dated [DATE], indicated reentry date of 4/9/24, with the diagnosis of hypertension (high blood pressure) end stage renal disease (last stage of kidney failure) and diabetes (high sugar in the blood) During a review of physician orders dated 8/5/24, indicate Stiolto Respimat inhalation aerosol 2.5-2.5 mcg/act two puffs inhaled on time a day. During an observation on 8/12/24, 10:00 a.m. a Stiolto inhaler was placed on Resident R15's bedside table. Resident R15 stated they left it here. During an interview 08/12/24, 10:03 a.m. with LPN Employee E3 confirmed Resident R15's Stiolto inhaler was in the room, should not have been left, removed it and stated, I was looking for that. During an observation on 8/12/24 at 9:25 a.m. a opened bottle of saline solution was noted on Resident R52's night stand. During an interview on 8/12/24 at 10:19 a.m. Registered Nurse Employee E2 confirmed the saline solution should not have been on resident R52's night stand and removed it. During an observation 8/13/24, 8:52 a.m. the yellow hall medication cart top drawer contained an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 13 of 16 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 08/14/2024 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 0761 unlabeled open tube of diclofenac sodium (topical medication for joint pain). Level of Harm - Minimal harm or potential for actual harm During an interview 8/13/24, at 8:52 a.m. LPN Employee E4 confirmed the unlabeled open tube of diclofenac sodium in the top drawer of the medication cart did not belong in the medication cart and removed it. Residents Affected - Few Observation on 8/13/24, at 8:53 a.m. the third-floor medication room refrigerator contained one vial of tuberculin solution noted to be opened and without a date. The freezer contained a container of chocolate ice cream. The chair in the medication room had a large leopard print tote bag on it. The medication room shelf contained: . One black thermos . One grey travel cup . One green travel cup . One opened can of Celsius sparkling drink, with a cup on top of it. During an interview on 8/13/24, at 8:55 a.m. LPN Employee E4 confirmed the tuberculin solution did not have a date opened, ice cream was in the freezer, and employee personal items were stored in the medication room. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies. 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 14 of 16 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 08/14/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R17) and failed to implement infection control practices during administration of eye drops on one of three residents. (Resident R261) Residents Affected - Few Findings include: A review of the facility policy Dressing Change, Clean Technique, last reviewed 7/22/24 indicates to prevent contamination of wounds such as pressure ulcers procedure includes but not limit to: . Remove the soiled dressing, place in trash bags. . Remove your gloves, wash your hands, and apply new gloves. . Clean the wound with normal saline solution or prescribed cleanser. . Use a dry 4x4 to pat the tissue surrounding the wound dry. . Remove your gloves, wash your hands, and apply new gloves. Review of the facility policy Medication Administration and Charting Guidelines, last reviewed 7/22/24, indicate ophthalmic (eye) drops administration procedure: . Wash hands, apply clean gloves. A review of the facility procedure Hand Hygiene last reviewed 7/22/24 indicates to prevent the transmission of infectious disease, therefore, all personnel working in the facility are required to wash their hands before and after resident contact, before and after performing any procedure, after sneezing or blowing their nose, after using the bathroom, before handling food, and when hands become visibly soiled. Review of the admission record indicated Resident R17 was admitted to the facility on [DATE]. Review of R17's Minimum Data Set (MDS-periodic assessment of care needs) dated 4/26/24, included diagnoses of anemia (the blood doesn't have enough healthy red blood cells), hypertension (high blood pressure), and hyperlipidemia (high fats in the blood) Review of Resident 17's physician order dated 7/13/24 indicates cleanse coccyx with wound cleanser, blot dry, cover with Opti-foam dressing daily. Observation of Resident R17's dressing change on 8/13/24 at 12:56 p.m. Registered Nurse (RN) Employee E7 failed to complete hand hygiene. After cleansing wound, RN Employee E7 continued the pat the wound dry and apply the opti-foam dressing. During an interview on 8/13/24, at 1:37 p.m. RN Employee E7 confirmed she failed to implement infection control practices to prevent cross contamination during a dressing change for Resident R17 by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 15 of 16 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 08/14/2024 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 not completing hand hygiene after cleansing and patting the wound dry. Level of Harm - Minimal harm or potential for actual harm During an observation on 8/12/24, at 12:25 p.m. Licensed Practical Nurse (LPN) Employee E3 was completing a medication pass. LPN Employee E3 took Resident R261's Artificial tears (for dry eyes) into room with oral medications, after administering oral medications LPN Employee E3 proceeded to instill the eye drops without utilizing gloves. Residents Affected - Few During an interview on 8/12/24, at 12:40 p.m. LPN Employee E3 confirmed the failure to implement infection control practices during administration of eye drops. 28 Pa. code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code: 211.10 (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: 395561 If continuation sheet Page 16 of 16