Health inspection·February 27, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on review of facility policy, facility documentation, clinical record review, and staff interview it was determined that the facility failed to protect residents from neglect for one of three residents reviewed (Resident R1). Findings include: Review of facility policy Prevention of Abuse and Response dated 7/30/24, indicated Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs on an individual basis when a resident does not receive care in one or more areas. Review of the clinical record revealed Resident R1 was admitted to the facility 8/14/24. Review of the clinical record MDS (minimum data set - a periodic assessment of resident needs) indicated diagnosis of dementia with other behavioral disturbances and cerebral infraction. Review of facility submitted documentation dated 2/9/25, indicated Resident R1 was observed by staff outside of the facility (unattended without staff) by an employee entrance. Review of facility documentation indicated the following: 12:55 p.m. - alarm bracelet on ankle checked on Resident R1 and in working order 4:05 p.m. - alarm bracelet on ankle checked on Resident R1 and in working order. 5:05 p.m. - Employee E1 maintenance fixing door for employee entrance - door not latching. 5:12 p.m. - Employee E1 maintenance leaves the door not fixed - not latching 7:00 p.m. - Resident R1 sitting in common area /tv lounge, calm no unusual behaviors 8:00 p.m. Employee E2 NA (Nurse Aide) reports seeing resident R1 sitting in common area. 8:00 p.m. Employee E3 NA reports seeing Resident R1 walking down hallway. 8:30 p.m. Resident R1 received medication from Employee E4 RN (registered nurse) (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 2 Event ID: 395561 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 02/27/2025 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)