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) Page 1 of 2 395561 395561 02/27/2025 Reformed Presbyterian Home 2344 Perrysville Avenue Pittsburgh, PA 15214

F 0600 9:00 p.m.- Employee E4 saw Resident R1 walking in hallway Level of Harm - Minimal harm or potential for actual harm 9:15 p.m. - Employee E5 NA saw Resident R1 in the community. 9:30 p.m. Employee E6 NA saw Resident R1 in the hallway. Residents Affected - Few 9:50 p.m. - Employee E7 LPN found Resident R1 outside by employee entrance in upper parking lot. 9:55 p.m. Employee E4 completes last rounds - does not see Resident R1 goes to find Employee E4 RN to report Resident R1 is missing - Employee E4 RN I s outside assessing Resident R1 for injury. Resident R1 brought back into facility and new alarm bracelet is placed on ankle. Review of Employee E1 maintenance indicated: On Thursday evening (2/6/25), I was approached by a member of nursing staff about the rear door not closing all the way, as I looked at it, I noticed it wasn't closing all the way due to the magnet not being attached to the door making it stay open. One of the nursing staff and I were trying to put it back in place and we noticed that some of the screws were missing as well. The nurse returned to his patients as I said I'll take care of it. I was asked by my supervisor if the door was secured so that he could inform staff , I told him it was, but was unable to repair the door at that time and I placed the parts in a box and I placed it outside my supervisor door. During an interview on 2/25/25, at 4:15 p.m. Nursing Home Administrator confirmed that Employee E1 maintenance did work on the door, but failed to inform anyone that evening that the door was not secure and locking properly, Employee E1 was written up over the indicate and the facility failed to prevent Resident R1 from neglect with allowing access to an outside door. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1)( e) (1)Management. 395561 Page 2 of 2