Health inspection·June 18, 2025

F 0583 28 Pa. Code: 201.18(e)(1) Management 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 2 of 17 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 06/18/2025 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)

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, facility documents, resident clinical records, resident and staff interviews it was determined that the facility failed to maintain an environment free of neglect and provide necessary goods and services for one of four sampled residents (Resident R26). Findings include: The facility Prevention of abuse and response policy dated 2/28/25, indicated that abuse is the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Neglect is the failure of the faciltiy, its employees or service providers to provide goods and services. Neglect occurs on an individual basis when a resident does not receive care. The Facility safety data sheet (a document indicating manufacturer guidelines to use for cleaners in addition to potential dangers involved chemicals) for germicidal bleach wipes (no date) indicated that first-aide measure are not necessary if direct contact with skin. If irritation occurs, remove clothing and wash all exposed skin with soap and water. Review of Resident R26's admission record indicated she was admitted on [DATE], and re-admitted on [DATE]. Review of Resident R26's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 3/25/25, indicated she had diagnoses that included hyperlipidemia (elevated lipid levels within the blood), neuropathy (condition impacting peripheral nerves), and depression (a state of consistent sadness and loss of interest interfering in daily life activities). Review of Resident R26's care plan dated 3/25/25, indicated to monitor adverse effects of pain with participation in ADL care. During a resident council group interview on 6/17/25, at 11:43 a.m. Resident R26 stated that during care on the overnight shift her back was wiped off with a bleach wipe. During an interview on 6/17/25, at 11:54 a.m. Resident R26 was interviewed in private and stated: I told someone after the council meeting. She will come in and examine me. My back and butt are itchy and uncomfortable. I remember what the aide looked like; I cannot recall her name. She used a Clorox wipe. I told her to stop and she kept going. During an interview on 6/17/25, at 11:59 a.m. Resident R26's allegation was relayed to Nursing Home Administrator (NHA). During an interview on 6/17/25, at 1:10 p.m. Resident R26 was asked for appearance of wipes used: the top of the container of wipes was blue. It says do not use on skin. She did not wipe the bed first. She wiped my back. During observations on 6/17/25, at 1:15 p.m. Registered Nurse (RN) Employee E2 provided bleach wipes with blue lid. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 3 of 17 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 06/18/2025 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/17/25, at 1:18 p.m. Resident R26 was asked to identify the wipes and she confirmed the wipes with the blue lid with written description of bleach wipes was used on her by a nurse aide. During an interview on 6/17/25, at 2:46 p.m. Registered Nurse (RN) Employee E2 stated: Resident R26 peri area was showing mild redness. I checked her buttocks area as well. Review of Nurse aide Employee E4's personnel record involved in incident indicated she was hired on 11/25/29. Nurse aide Employee E4 was trained on abuse and neglect on 11/25/19 and 12/30/24. Facility investigation documents dated 6/17/25, indicated that [NAME] Hunt received allegation from Resident R26. Nurse Aide Employee E3 provided statement: I went into Resident R26's room to giver her care and she said there was burning. Resident R26 stated that the aide on 11-7 shift used bleach wipes on her to clean her bottom. Nurse aide Employee E4 electronic statement dated 6/17/25, indicated the following: I changed Resident R26 bed. She was a complete bed change. As I did a complete bed change I wiped the mattress with bleach wipes and dried the mattress before finishing task. Review of Resident R26's skin evaluation dated 6/17/25, indicated she was assessed after the allegation and the assessment showed mild redness to the peri-area and complaint of burning sensation. During an exit interview on 6/18/25, at 2:50 p.m. information was disseminated to the Nursing Home Administrator (NHA) and the Director of Nursing (DON) that the facility failed to maintain an environment free of neglect and provide necessary goods and services for Resident R26 as required. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights 28 Pa. Code 211.12(d)(1)(3) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 4 of 17 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 06/18/2025 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)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, resident records and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one out of two residents sampled with facility-initiated transfers (Resident R34). Finding include: Review of the facility policy Transfer or Discharge Documentation dated 8/1/24, indicated when a resident is transferred or discharged , the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving facility. A facility will provide and document preparation and orientation to each resident to ensure safe and orderly transfer or discharge from the facility. Information will be provided to the receiving provider regardless if the facility or resident initiated discharge. -Contact information of the practitioner responsible for the care of the resident. -Resident representative information including contact information -Advance Directive information -Instructions for ongoing care -Comprehensive care plan goals; -All other necessary information, including a copy of the resident's discharge summary, to ensure effective transitional care Review of Resident R34's admission record indicated she was admitted [DATE], with diagnosis that included anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), adult failure to thrive, and malnutrition. Review of Resident R34's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/27/25, indicated the diagnoses were current. Review of Resident R34's progress note dated 6/1/25, indicated the resident complaining of chest pain and right sided weakness. Resident was transferred to the hospital for further evaluation. Review of Resident R34's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 6/18/25, at 8:45 a.m. the Nursing Home Administrator confirmed that there was no evidence that the necessary information was communicated to the receiving health care institution or provider upon transfer for one out of two residents sampled with facility-initiated transfers (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 5 of 17 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 06/18/2025 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)

F 0628 (Residents R34). Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.29 (a)(c.3)(2) Resident rights. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 6 of 17 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 06/18/2025 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for one of six residents (Resident R197). Findings include: Review of facility policy Care Management dated 9/4/18, last reviewed 1/7/25, stated management of resident care is conducted systematically and comprehensively by a facility-wide (interdisciplinary) team. Resident care management sha;; be consistent with the medical plan of care. The physician orders shall be considered the part of the plan of care in addition to the formal care plan that is developed from the MDS process. Review of the clinical record indicated Resident R197 was admitted to the facility on [DATE]. Review of Resident R197's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/23/25, indicated diagnoses of anemia (too little iron in the blood), muscle weakness, and Parkinson's disease (a progressive movement disorder of the nervous system). Review of a physician order dated 3/13/25, revealed the resident was ordered assist of one person with transfers. Review of Resident R197's care plan on 6/16/25, at 12:22 p.m. revealed the resident required assistance of two persons with transfers. During an interview on 6/16/25, at 1:08 p.m. Registered Nurses Assessment Coordinator (RNAC), Employee E5 confirmed Resident R197 was ordered a transfer of one person assist, however the resident's care plan indicated the resident required an assist of two persons. RNAC, Employee E5 stated When things like that happen, I am not made aware, nursing does not let me know it changed. It's not just my responsibility, they can do it. During an interview on 6/16/25, at 2:29 p.m. the Director of Nursing confirmed that the facility failed to revise Resident R197's care plan to reflect the resident's specific care needs as required. 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 7 of 17 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 06/18/2025 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, staff, and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one out of two residents (Resident R34). Residents Affected - Few Findings include: Review of Resident R34's admission record indicated she was admitted [DATE], with diagnosis that included anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), adult failure to thrive, and malnutrition. Review of Residents R34's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/27/25, indicated the diagnoses were current. Section GG- Functional Abilities revealed the resident needed partial/moderate assistance with showering and bathing. Review of Resident R34's care plan dated 2/24/24, last revised 3/26/25, revealed the resident had a decline in the ability to perform dressing and hygiene tasks and is at risk for further decline. Interventions indicated to monitor ability to participate in ADL's and document self-care ability and assistance provided each shift. Provide assistance as needed. During an on 6/17/25, at 1:37 p.m. Resident R34 hair was disheveled and appeared sweaty and greasy. Resident R34 indicated a preference of having showers instead of bed baths. Resident R34 stated it's been weeks since I had a shower. Review of Resident R34's clinical record on 6/17/25, at 1:45 p.m. revealed the resident was scheduled showers on Tuesdays and Fridays on the day shift. During an interview on 6/17/25, at 1:51 p.m. Registered Nurse, Employee E2 stated nurse aides are required to document when showers are completed. RN, Employee E2 conifrmed Resident R34's last documented shower was on 5/13/25. During an interview completed on 6/17/25, at 1:56 p.m. the Nursing Home Administrator was notified of the facility failed to provide Activity of Daily Living (ADL) assistance for one out of two residents (Resident R34). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(2.1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 8 of 17 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 06/18/2025 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)

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 policies, clinical records, facility documents and staff interviews, it was determined that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of five residents (Resident R147). Residents Affected - Few Findings include: Review of facility policy Wound Management Program, dated 6/30/24, indicated facility is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure injuries, unless the individual's clinical condition demonstrates they are unavoidable. Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically, the goal is one of promoting healing and prevention infection unless a resident's preferences and medical condition necessitates palliative care as the primary focus. A commitment to the Wound Management Program is demonstrated by implementation of the processes founded on accepted standards of practice, research-driven clinical guidelines, and interdisciplinary involvement. Review of the clinical record revealed that Resident R147 was admitted to the facility 3/21/25, and readmitted on [DATE]. Review of Resident R147's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 3/25/25, included diagnoses hypotension (low blood pressure), protein-calorie malnutrition, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R147's Braden Scale for Predicting Pressure Sore Risk dated 15/2/25, indicated a score of 16 - moderate risk of developing pressure ulcers. Review of Resident R147's Clinical admission assessment, dated 5/2/25, indicated that a new skin issue on coccyx was identified and described as other skin issue open area. Review of Resident R147's physician order dated 5/2/25, indicated Skin assessment weekly (from head to toe) at bedtime every Tuesday. Review of Resident R147's Medication Administration Record (MAR) for May 2025, failed to indicate documentation that weekly skin assessments were completed on 5/6/25, 5/13/25, and 5/20/25 as ordered. Review of Resident R147's clinical nurse progress notes N Adv Skilled Evaluation dated 5/3/25 through 5/8/25, and 5/10/25 through 5/19/25, revealed Skin Issue #001: Skin issue has not been evaluated. Location: coccyx. Other skin issue description: open area Wound was present on admission. Review of Resident R147's Skin Observation Tool - (Licensed Nurse), dated 5/19/25, revealed a right gluteal fold area of MASD (Moisture associated skin damage) measuring 1.0 cm (centimeters) length x 1.5 cm width x 0.1 cm depth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 9 of 17 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 06/18/2025 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R147's physician order dated 5/20/25, discontinued 5/22/25, indicated Desitin External Paste 40% (zinc oxide topical) apply to right butt open area topically every morning and at bedtime for wound care per wound care consultant recommendation cover with border gauze. Review of Resident R147's Skin Observation Tool - (Licensed Nurse), dated 5/22/25, revealed a coccyx, stage II (partial thickness loss of dermis presenting as a shallow open ulcer with res pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister) pressure injury, measuring 1.5 cm length x 1.5 cm width x 0.1 cm depth. Review of Resident R147's physician order dated 5/22/25, discontinued 5/27/25, indicated Desitin External Paste 40% (Zinc oxide topical) apply to right butt open area topically every morning and at bedtime for wound care per wound care consultant recommendations cover with calcium alginate (topical dressing for wounds) and secure with border gauze. Review of Resident R147's physician orders, clinical assessments, nurse and physician progress notes did not include any wound treatment orders or comprehensive wound assessment from 5/2/25, until 5/19/25. During an interview on 6/18/25, at 11:45 a.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to ensure Resident R147 was assessed, and provided necessary treatment and services for a pressure ulcer as reviewed. 28 Pa. Code 201.18 (b)(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 10 of 17 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 06/18/2025 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review facility polices, observations, clinical records, and staff and resident interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a colostomy as required for one of three residents (Resident R20). Findings include: Review of the clinical record indicated Resident R20 was admitted to the facility on [DATE]. Review of Resident R20's Minimum Data Set (MDS - a period assessment of care needs) dated 5/16/25, indicated diagnoses of intellectual disabilities, urinary incontinence, and colostomy status. Review of the clinical record revealed Resident R20 had a physician's order dated 9/12/18, for colostomy care every shift. No directions specified for order. A further review failed to reveal an order to change the colostomy bag and wafer, including size. Review of Resident R20's care plan dated 9/14/18, last reviewed 4/10/25, indicated to assess stoma and surrounding tissue every shift for signs and symptoms of skin impairment including redness, irritation, drainage, and bleeding. During an interview on 6/16/25, at 11:39 a.m. Resident R20 was observed with a colostomy. Resident R20 stated staff help me, nursing empties and cleans it. It was indicated the facility staff puts a new bag on each week. A review of Resident R20's clinical record on 6/17/25, at 10:00 a.m. failed to include evidence the resident's stomas and surrounding skin was assessed every shift as the care plan indicated. During an interview on 6/17/25, at 10:58 a.m. the Director of Nursing stated the resident just does it as needed, if it's leaking, he puts a new one on. The DON confirmed the facility failed to make certain that appropriate treatments and services were provided for the use of a colostomy as required for one of three residents (Resident R20). 28 Pa. Code: 201.14(a) Responsibility of licensee. 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 11 of 17 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 06/18/2025 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)

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 review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for one of three sampled residents (Resident R17). Residents Affected - Few Findings include: The facility Oxygen administration policy last reviewed on 6/30/24, indicated that each resident ordered oxygen will follow current best practices including maintenance of best practices for infection control. Review of Resident R17's admission record indicated she was admitted on [DATE]. Review of Resident R17's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 4/9/25, indicated that she had diagnoses that included hypertension (a condition impacting blood circulation through the heart related to poor pressure), unspecified chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and depression. Review of Resident R17's care plans dated 4/9/25, indicated to administer oxygen as ordered and to change oxygen tubing and humidifier bottle as per facility policy. Review of Resident R17's physician orders dated 4/5/25, indicated to change tubing and water for concentrator weekly. During observations on 6/16/25, at 9:33 a.m. Resident R17 was observed in bed and using oxygen. Observations of the oxygen line found it dated 6/1/25. During observations of Resident R17 room on 6/16/25, at 11:10 AM observations with Agency Registered Nurse (RN) Employee E1 found that the oxygen line being used by Resident R17 was dated 6/1/25. During an interview on 6/16/25, at 11:11 a.m. Agency Registered Nurse (RN) Employee E1 was asked if the oxygen Resident R17 was dated 6/1/25? Yes, That is dated 6/1/25. We will change the oxygen line today. During an interview on 6/17/25, at 10:55 a.m. information disseminated to the Nursing Home Administrator (NHA) and Director of Nursing (DON) that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for 28 Pa. Code: 201.29(i) Resident Rights. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 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 12 of 17 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 06/18/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident records, medication incident reports, and staff interview, it was determined that the facility failed to implement pharmaceutical services to ensure availability and administration of prescribed medications for one of three sampled resident records (Closed Resident Record CR145). Findings include: The facility Resident medication regimen review policy last reviewed 6/30/24, indicated that the pharmacist will perform a prospective review of medications ordered at the time of dispensing. Any problems that are identified are addressed immediately before the medication is dispensed. Medication and pharmacy support includes providing the facility an available supply of contingency and emergency medications for immediate resident needs. Review of Closed Resident Record CR145's admission record indicated she was admitted [DATE]. Review of Closed Resident Record CR145's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 5/4/25, indicated she had diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and hyperlipidemia (elevated lipid levels within the blood). These were the most recent diagnoses upon review. Review of Closed Resident Record CR145's care plans initiated on 4/30/25, indicated to administer medications as ordered. Review of Closed Resident Record CR145's physician orders dated 4/30/25, indicated she was ordered Pregablim 150mg (medication for nerve pain) to be given by mouth once daily. Review of Closed Resident Record CR145's Medication Administration Record (MAR) for April and May of 2025, indicated Pregablim was coded a 9- not available for administration on 4/30/25, 5/1/25, 5/3/25, and 5/4/25. Review of Closed Resident Record CR145's medication incident report dated 5/9/25, indicated her dosage of the Pregablim was missed on 4/30/25, 5/1/25, 5/2/25, 5/3/25, and 5/4/25. During an interview on 6/17/25, at 12:03 p.m. Director of Nursing (DON) confirmed that the facility failed to implement pharmaceutical services to ensure availability and administration of prescribed medications for Closed Resident Record CR145 as required. 28 Pa. Code 211.9(a)(1)(k)(l)(1)(4) 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 13 of 17 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 06/18/2025 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to provide documentation of medication regimen reviews (MRR) were completed at least monthly for two of three sampled resident records (Resident R4 and R20). Finding include: The facility Medication regimen review policy last reviewed 1/7/25, indicated that the drug regimen review of each resident is completed at least monthly by the consultant pharmacist and any irregularities are reported. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident R4's Minimum Data Set (MDS - a period assessment of care needs) dated 5/25/25, indicated diagnoses of depression, chronic pain due to trauma, and dementia (a loss of thinking, remembering, and reasoning skills.) Review of Resident R4's care plan indicated that the resident requires use of psychotropic medication and is at risk for adverse side effects. Review of Resident R4's clinical progress notes did not include a pharmacy notation or review by a licensed pharmacist for November 2024, December 2024, January 2025, February 2025, March 2025, and May 2025. During an interview on 6/17/25, at 12:01 p.m. Registered Nurse, Employee E2 confirmed facility failed to provide documentation of Resident R4's medication regimen reviews (MRR) completed for November 2024, December 2024, January 2025, February 2025, March 2025, and May 2025. Review of the clinical record indicated Resident R20 was admitted to the facility on [DATE]. Review of Resident R20's MDS dated [DATE], indicated diagnoses of intellectual disabilities, urinary incontinence, and colostomy status. Review of Resident R20's care plan last reviewed 4/10/25, indicated that the resident requires use of psychotropic medication and is at risk for adverse side effects. Review of Resident R20's clinical progress notes did not include a pharmacy notation or review by a licensed pharmacist for October 2024, November 2024, January 2025, February 2025, March 2025, and May 2025. Review of Resident R20's medication regimen reviews did not indicate a review for October 2024, November 2024, January 2025, February 2025, March 2025, and May 2025. During an interview on 6/17/25, at 12:12 p.m. Registered Nurse, Employee E2 confirmed facility failed to provide documentation of Resident R20's medication regimen reviews (MRR) completed for October (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 14 of 17 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 06/18/2025 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)

F 0756 2024, November 2024, January 2025, February 2025, March 2025, and May 2025. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/17/25, at 2:09 p.m. the Nursing Home Administrator confirmed that the facility failed to provide documentation of medication regimen reviews (MRR) completed at least monthly for Residents R4 and R20 as required. Residents Affected - Few 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.5(f) Medical records. 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 15 of 17 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 06/18/2025 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)

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 medications for one of four residents (Resident R34). Findings include: Review of Resident R34's admission record indicated she was admitted [DATE], with diagnosis that included anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), adult failure to thrive, and malnutrition. Review of Resident R34's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/27/25, indicated the diagnoses were current. Review of Resident R34's physician order dated 1/8/25, instructed to apply two grams of 1% Voltaren Gel to back and bilateral arms topically every shift for pain. During an observation on 6/16/25, at 11:23 a.m., a cup of gel substance was located on Resident R34's bedside dresser. Resident R34 indicated the gel substance in the medicine cup was Voltaren gel (topical pain reliever for arthritis joint pain). Resident R34 stated the nurse left the Voltaren gel at the bedside around 2 a.m. During an interview on 6/16/25, at 11:32 a.m. Registered Nurse, Employee E1 confirmed the above observations and that the facility failed to properly store medications. 28 Pa. Code: 201(a) Responsibility of licensee. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 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 16 of 17 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 06/18/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly monitor food temperatures and failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility. Findings include: A review of facility policy Food Safety and Sanitation, dated 6/30/24, indicated that all local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. A review of facility policy Food Temperatures, dated 6/30/24, indicated the temperatures of all food items will be taken and properly recorded prior to service of each meal. During an observation on 6/16/25, at 10:00 a.m., of the walk-in cooler in the main kitchen, conducted with the Director of Food Service (DFS) Employee E6, revealed that the shelving unit immediate left of cooler entrance and a sheet tray pan rack adjacent had a build-up of fuzzy grime and dark colored debris on their surfaces. DFS Employee E6 confirmed observation by surveyor when viewed. During an interview on 6/16/25, at 10:05 a.m., DFS Employee E6 confirmed that the facility failed to properly maintain kitchen equipment in the walk-in cooler, in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility. During an observation in the main kitchen on 6/17/25, at 11:45 a.m., Trayline Temperature Log for June 2025, was noted to have missing data. 50 meals had been served during the month, and 41 meals had no recorded food temperatures. The missing data was as follows: 13 breakfast meals with no recorded food temperatures 14 lunch meals with no recorded food temperatures 14 dinner meals with no recorded food temperatures During an interview on 6/17/25, at 12:02 p.m., DFS Employee E6 confirmed that the facility failed to monitor temperatures of foods to prevent food born illness. During an interview on 6/18/25, at 3:00 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to properly monitor food temperatures and failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395561 If continuation sheet Page 17 of 17