Health inspection·January 22, 2026

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 three residents (CRR2).Findings include: Review of facility policy Wound Management Program, last reviewed 7/15/25, indicated the 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 individuals' 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 of 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. A visual skin assessment is completed by the nurse upon admission, re-admission and as needed by the nurse aide / therapy report or nurse identification. Results are documented in the Nursing admission Screening and/or Skin Observation Tool in Point Click Care. Review of the clinical record revealed that Resident CRR2 was admitted to the facility on [DATE]. Review of Resident CRR2's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 11/30/25, indicated diagnoses of anxiety, depression, and adult failure to thrive (a state of decline that may be caused by chronic disease and functional impairment). Review of Resident CRR2's physician order dated 8/23/24, indicated Skin assessment weekly (from head to toe) at bedtime every Thursday. Review of Resident CRR2's clinical record on 1/22/26, failed to indicate documentation that the skin observation tool was completed between 9/15/25, through 12/20/25. Review of Resident CRR2's physician orders dated 12/20/25, at 8:26 a.m. indicated sacrum wound: Clean with normal saline, apply Medi honey, calcium alginate and boarder gauze one time a day. Further review of Resident CRR2's December treatment administration record indicated that the dressing was not documented completed until 12/22/25. Review of Resident CRR2's physician orders dated 12/22/25, at 3:14 p.m. indicated treatment to sacrum: Cleanse wound with soap & water and cover with dry dressing daily and as needed every night shift for wound care. Further review of Resident CRR2's December treatment administration record indicated that the dressing was not documented as completed on 12/30/25. During an interview completed on 1/22/26, at 2:25 p.m. the Director of Nursing (DON) confirmed that Resident CRR2's skin observation tool was not completed between 9/15/25, through 12/20/25, and that a treatment ordered on 12/20/25, was not documented as completed until 12/22/25. The DON also confirmed that the treatment orders dated 12/22/25, for Resident CRR2 were also not documented as completed on 12/30/25, and that the facility failed to ensure residents were assessed, Residents Affected - Few (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 3 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 01/22/2026 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)