Health inspection·July 7, 2025

F 0600 Review of Resident R2's MDS Section GG- Functional Abilities were as follows: Level of Harm - Actual harm - Toileting was coded a 1- dependent, helper does all the effort Residents Affected - Few - Shower/Bathe Self was coded a 2- Substantial Maximum Assistance, helper does more than half the effort - Roll left and right was coded a 1- dependent, helper does all the effort Review of Resident R2's care plan dated 5/22/25, indicated Activity of Daily Living Functional Bed Mobility Assistance. Long term goal indicated resident will accept assistance of two for bed mobility, and tasks while on air mattress. Approach indicated is to provide assist of two at all times for bed mobility related tasks. Air mattress will increase and decrease pressure with rolling, and movement and may increase risk for injury. Review of a written witness statement dated 6/14/25, from NA Employee E1 stated, Resident rolled out of bed. When asked, Did you know or were you aware that Resident R2 was a two assist for bed mobility? NA Employee E1 stated, No. When asked, Did you have the assignment sheet? NA Employee E1 stated, Yes, but I do not know if that was on there. I saw a metal box and I asked the resident to lean towards me, more on your back and I stood in the doorway to talk to the nurse to ask what it was and to get a new patch on the wire. At that time, I heard a loud bang and then my worst fear came true, my resident fell out of bed. Review of documentation provided by the facility dated 6/14/25, stated the following: Factual Description. On 6/14/25, at approximately 1:00 p.m. NA Employee E1 was providing care to Resident R2. During care, the NA placed the resident in a lateral position (side lying) near the edge of the bed. While the resident remained in this position NA Employee E1 noted a spinal cord stimulator (an implanted device in the body that had wires exposed within a wound) and stepped out of the room to consult with the nurse regarding whether a new patch was required. While unattended, the resident rolled out of bed. Description of follow-up action: Immediate assistance was provided, physical assessment performed, bleeding from above the left eyebrow was noted, both knees presented with bruising. Supervisor determined Resident R2 was able to be moved, was transferred back to bed via a Hoyer lift (a mechanical lift) with three caregivers present. A full post fall evaluation was conducted. At the time of the incident, the resident had a care plan and assignment sheet indicating that two caregivers were required for bed mobility and personal care, but the NA stated that she was unaware that a second caregiver was required, although the assignment sheet clearly reflects this instruction. MD, family, and Adult Protective Serviced notified. The NA was removed from the schedule. Education will be provided to all aides regarding the requirement for two-person assistance with bed mobility. In addition, staff will be instructed to review their assignments thoroughly prior to the start of each shift to ensure awareness of residents' specific care needs and safety precautions. During an interview on 7/7/25, at 2:44 p.m. the facility was unable to provide the education provided to all aides regarding two-person assistance with bed mobility and to review their assignment every shift per facilities plans of correction as described in their follow up action to incident. During a review of Resident R2's physician orders dated 8/14/24, indicated resident's Bed Mobility: Assist of two due to air mattress. Review of documentation provided by the facility labeled Event Report dated 6/14/25, indicated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395606 If continuation sheet Page 2 of 9 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 395606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-Ro 110 McIntyre Road Pittsburgh, PA 15237 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 - Actual harm Resident R2's fall that occurred on 6/14/25, in her room. Fall was unwitnessed as NA Employee E1 went to the door to ask the nurse a question and heard resident yell for help. Resident R2 reported pain to her right knee. Resident was observed on the floor next to her bed and stated, I was too close to the edge of the bed and rolled off. Resident was bleeding from around her left eye, forehead and bilateral knees. Residents Affected - Few During a review of Resident R2 progress note dated 6/14/25, indicated that resident has a hematoma to left side of forehead measuring approximately 5.0 cm by 4.5 cm, resident has a small laceration above left eye, 1.0 cm long with moderate bleeding that has stopped. Steri-strips (a thin adhesive strip used to close small wounds, lacerations, and surgical incisions). Resident sustained hematoma under her left eye approximately 3.0 cm by 2.0 cm. Right knee hematoma that measures approximately 4.0 cm by 3.0 cm. Spoke to physician who ordered hold Xarelto (blood thinner) for two days, monitor neurological status, Xray ordered to bilateral knees due to pain. Daughter was notified. Review of a written witness statement dated 6/14/25, from Registered Nurse (RN) Employee E3 stated: I was standing in the hallway at the medicine cart when NA Employee E1 came out of the room to ask a question. Resident R2 yelled from the room. Employee E1 and I entered room to find resident on the floor. Resident R2 stated she was too close to the edge of her bed, and she rolled off to the floor. Resident was bleeding from her left eye area, forehead and bilateral knees with hematomas. Resident placed back into bed. Physician was notified. During an interview on 7/7/25, at 1:00 p.m. NA Employee E4 indicated that Resident R2 required assist of two. The amount of assistance a resident needs is on our assignment sheets. I would not leave anyone unattended during care. During an interview on 7/7/25, at 1:13 p.m. NA Employee E5 stated that if a resident is on an air mattress, it takes two people, or if I check assistance level in the computer or assignment sheets and it says two, I get someone to help me. I wouldn ' t ever leave someone unattended if I was giving care. During an observation on 7/7/25, at 1:30 p.m. Resident R2 had light bruising noted to her left side of her face that included forehead, around left eye, and left cheek. During an interview on 7/7/25, at 1:33 p.m. Resident R2 was lying in bed with the television on. Resident stated, An aide left me at the edge of the bed, and I fell out of bed. Two NA's help me now since my fall. During an interview on 7/7/25, at 3:15 p.m. Director of Nursing (DON) stated that Resident R2 did fall out of bed on 6/14/25, was left unattended and received injuries. DON stated that NA Employee E1 was an agency aide and was put on a Do Not Return list related to the incident findings. During an interview on 7/7/25, at 3:45 p.m. the DON confirmed that the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect for one of two residents (Resident R2), which resulted in actual harm of a hematoma on residents left side of forehead, a laceration above the left eye, and a hematoma to right knee with pain for Resident R2. 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e)(1) Management. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395606 If continuation sheet Page 3 of 9 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 395606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-Ro 110 McIntyre Road Pittsburgh, PA 15237 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 28 Pa Code 201.29(a) Resident rights. Level of Harm - Actual harm 28 Pa Code 211.12(d)(1)(3)(5) Nursing services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395606 If continuation sheet Page 4 of 9 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 395606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-Ro 110 McIntyre Road Pittsburgh, PA 15237 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, facility policy, clinical records, resident interviews, and staff interviews, it was determined that the facility failed to provide appropriate equipment to prevent an accident for one of two residents (Resident R1), which resulted in actual harm of bruising and a fracture of residents right foot for Resident R1, and failed to provide adequate supervision and assistance for one of two residents (Resident R2), which resulted in actual harm of a hematoma (localized collection of blood outside the blood vessels, typically caused by blood vessel damage from trauma or injury) on residents left side of forehead, a laceration (cut) above the left eye, and a hematoma to right knee with pain for Resident R2. Findings include: Review of facility policy Accident Prevention dated 1/2/25, indicated it is the policy of the facility to prevent resident accidents and injuries to the extent possible by maintaining an environment free from accident hazards and by assuring residents receive adequate supervision and assistive devices to prevent accidents. Review of facility policy Abuse, Resident and Reasonable Suspicion of a Crime dated 1/2/25, indicated that facility will treat every resident with consideration, respect, and full recognition of his/her dignity and individuality. This policy is part of the centers overall prevention of abuse, neglect, exploitation of residents, and misappropriation of resident property program. Definition of neglect is defined by the failure of the facility, the staff, or service providers to provide goods and services to a resident that are necessary to avoid or may result in physical harm, pain, mental anguish, or emotional distress. Review of the facility job description for Nursing Assistant (NA), indicated that staff will provide each of his or her assigned residents with routine daily individualized nursing care and services in a safe and effective manner using therapeutic interactions in accordance with the resident ' s assessment and care plan to assure that the highest degree of quality resident care is maintained at all times. Duties and responsibilities include delivers care in accordance with the daily review of the resident ' s care plan, provides personal hygiene to residents such as bathing, toileting incontinent residents, and grooming. NA will utilize safe techniques in care of residents. Review of Resident R1's admission record indicated resident was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 4/7/25, indicated diagnoses of high blood pressure, arthritis, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Resident R1's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R1's BIMS score was a 1 indicating Resident R1 was severe impairment. Review of Section GG Functional Abilities GG0120 was coded wheelchair for device. During a review of Resident R1's physician orders dated 6/12/25, at 11:04 a.m. indicated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395606 If continuation sheet Page 5 of 9 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 395606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-Ro 110 McIntyre Road Pittsburgh, PA 15237 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 0689 resident to wear post op shoe to right foot when out of bed daily for eight weeks for right 5th toe fracture. Level of Harm - Actual harm Review of a written witness statement dated 6/11/25, from NA Employee E6 stated: While taking Resident R1 down the hall for her shower, she put both of her feet down and I think that's where the open wound came from on her foot. During her shower saw right lateral (side) foot with open area. Residents Affected - Few During an interview conducted by Assistant Director of Nursing Employee E7 on 6/12/25, with NA Employee E6, NA stated I wheeled resident to shower room. I wasn ' t paying attention to her feet, but at some point Resident R1 lowered her foot all the way down to the floor and her shoe came off. I took her to the shower and afterwards we took the resident back to her room. During an interview conducted by Assistant Director of Nursing Employee E7 on 6/12/25, with NA Employee E9, NA stated I was helping NA Employee E6 with a shower. Halfway down the hallway she dropped her feet and then turned her around in the wheelchair and then pulled her backwards because it was safer pushing her backwards. She seemed out of it all day. Review of documentation provided by the facility dated 6/12/25, stated the following: On 6/11/25, at 8:00 a.m. Resident R1 was taken to the shower room by two NA's. As per NA Employee E6, resident was wearing a gown and her black shoes, was in wheelchair that had no footrests. While wheeling the resident to the shower room, resident dropped her foot all the way down, her shoe came off. NA could not remember if she put shoe back on. NA continued to wheel resident with her foot all the way down. Once in the shower room, resident placed in shower chair and the Registered Nurse (RN) came in to do shower skin assessment. The nurse noticed a bruise on the right dorsal (refers to the back of foot). Description of follow-up action: Investigation was initiated immediately. NA's removed from the assignment. Resident was assessed, a bruise observed on the right foot which presented with scattered petechiae (tiny, flat, reddish or purple spots on the skin caused by minor bleeding from capillaries (small blood vessels). Physician was notified and ordered a X-ray of the foot. During a review of Resident R1's clinical record on 7/7/25, at 12:04 p.m. indicated results of X-ray to right foot were an acute fracture of the 5th proximal phalanx neck (left side of little toe). During a review of facility provided documentation labeled Resident Incident/Event Investigation Form dated 6/11/25, at 10:00 a.m. indicated Registered Nurse Employee E8 completed the form. Describe Injury: Right foot reddened/open areas 1.0 cm by 4.0 cm by 0.1 c.m. Resident dropped foot down when being taken to shower room. During an observation on 7/7/25, at 1:02 p.m. Resident R3 was observed being pushed in her wheelchair without leg rests by Beautician Employee E2. During an observation on 7/7/25, at 1:03 p.m. R5 was observed being pushed in her wheelchair without leg rests by an unidentified employee. During an observation on 7/7/25, at 1:05 p.m. Resident R4 was observed being pushed in her wheelchair without leg rests by NA Employee E4. During an interview on 7/7/25, at 1:15 p.m. Director of Nursing stated that leg rest orders are not ordered by the physician for anyone typically and staff know if residents do have leg rests because they are sitting on the wheelchair. DON stated the facility failed to inform nursing staff of who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395606 If continuation sheet Page 6 of 9 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 395606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-Ro 110 McIntyre Road Pittsburgh, PA 15237 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 0689 needs leg rests, and they would know only if leg rests were on the chair. Level of Harm - Actual harm During an interview on 7/7/25, at 1:00 p.m. NA Employee E4 stated that leg rests are in their room or on their chair. If they don ' t have any, I will ask them to hold their legs up. Residents Affected - Few During an interview on 7/7/25, at 1:48 p.m. NA Employee E10 was asked, How do you know if someone needs leg rests? NA Employee E10 stated I ' m not gonna lie, I can't give you an answer. If I was to push someone, I would look for leg rests. During an interview on 7/7/25, at 2:58 p.m DON stated that Resident R1 was being pushed to the shower room without leg rests, resident dropped her feet to the floor and sustained a fractured toe on 6/11/25. During an interview on 7/7/25, at 3:04 p.m DON stated that NA Employee E6 was an agency employee and was put on the facilities Do Not Return list. Review of Resident R2's admission record indicated resident was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 5/21/25, indicated diagnoses of depression, high blood pressure, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Resident R2's MDS assessment section C0200 BIMS score was a 15 indicating Resident R2 was cognitively intact. Review of Resident R2's MDS Section GG- Functional Abilities were as follows: - Toileting was coded a 1- dependent, helper does all the effort - Shower/Bathe Self was coded a 2- Substantial Maximum Assistance, helper does more than half the effort - Roll left and right was coded a 1- dependent, helper does all the effort Review of Resident R2's care plan dated 5/22/25, indicated Activity of Daily Living Functional Bed Mobility Assistance. Long term goal indicated resident will accept assistance of two for bed mobility, and tasks while on air mattress. Approach indicated is to provide assist of two at all times for bed mobility related tasks. Air mattress will increase and decrease pressure with rolling, and movement and may increase risk for injury. Review of a written witness statement dated 6/14/25, from NA Employee E1 stated, Resident rolled out of bed. When asked, Did you know or were you aware that Resident R2 was a two assist for bed mobility? NA Employee E1stated, No. When asked, Did you have the assignment sheet? NA Employee E1 stated, Yes, but I do not know if that was on there. I saw a metal box and I asked the resident to lean towards me, more on your back and I stood in the doorway to talk to the nurse to ask what it was and to get a new patch on the wire. At that time, I heard a loud bang and then my worst fear came true, my resident fell out of bed. Review of documentation provided by the facility dated 6/14/25, stated the following: Factual (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395606 If continuation sheet Page 7 of 9 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 395606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-Ro 110 McIntyre Road Pittsburgh, PA 15237 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 0689 Level of Harm - Actual harm Residents Affected - Few Description. On 6/14/25, at approximately 1:00 p.m. NA Employee E1 was providing care to Resident R2. During care, the NA placed the resident in a lateral position (side lying) near the edge of the bed. While the resident remained in this position NA Employee E1 noted a spinal cord stimulator (an implanted device in the body that had wires exposed within a wound) and stepped out of the room to consult with the nurse regarding whether a new patch was required. While unattended, the resident rolled out of bed. Description of follow-up action: Immediate assistance was provided, physical assessment performed, bleeding from above the left eyebrow was noted, both knees presented with bruising. Supervisor determined Resident R2 was able to be moved, was transferred back to bed via a Hoyer lift (a mechanical lift) with three caregivers present. A full post fall evaluation was conducted. At the time of the incident, the resident had a care plan and assignment sheet indicating that two caregivers were required for bed mobility and personal care, but the NA stated that she was unaware that a second caregiver was required, although the assignment sheet clearly reflects this instruction. MD, family, and Adult Protective Serviced notified. The NA was removed from the schedule. Education will be provided to all aides regarding the requirement for two-person assistance with bed mobility. In addition, staff will be instructed to review their assignments thoroughly prior to the start of each shift to ensure awareness of residents' specific care needs and safety precautions. During an interview on 7/7/25, at 2:44 p.m. the facility was unable to provide the education provided to all aides regarding two-person assistance with bed mobility and to review their assignment every shift per facilities plans of correction as described in their follow up action to incident. During a review of Resident R2's physician orders dated 8/14/24, indicated resident's Bed Mobility: Assist of two due to air mattress. Review of documentation provided by the facility labeled Event Report dated 6/14/25, indicated that Resident R2's fall that occurred on 6/14/25, in her room. Fall was unwitnessed as NA Employee E1 went to the door to ask the nurse a question and heard resident yell for help. Resident R2 reported pain to her right knee. Resident was observed on the floor next to her bed and stated, I was too close to the edge of the bed and rolled off. Resident was bleeding from around her left eye, forehead and bilateral knees. During a review of Resident R2 progress note dated 6/14/25, indicated that resident has a hematoma to left side of forehead measuring approximately 5.0 cm by 4.5 cm, resident has a small laceration above left eye, 1.0 cm long with moderate bleeding that has stopped. Steri-strips (a thin adhesive strip used to close small wounds, lacerations, and surgical incisions). Resident sustained hematoma under her left eye approximately 3.0 cm by 2.0 cm. Right knee hematoma that measures approximately 4.0 cm by 3.0 cm. Spoke to physician who ordered hold Xarelto (blood thinner) for two days, monitor neurological status, Xray ordered to bilateral knees due to pain. Daughter was notified. Review of a written witness statement dated 6/14/25, from Registered Nurse (RN) Employee E3 stated: I was standing in the hallway at the medicine cart when NA Employee E1 came out of the room to as a question. Resident R2 yelled from the room. Employee E1 and I entered room to find resident on the floor. Resident R2 stated she was too close to the edge of her bed, and she rolled off to the floor. Resident was bleeding form her left eye area, forehead and bilateral knees with hematomas. Resident placed back into bed. Physician was notified. During an interview on 7/7/25, at 1:00 p.m. NA Employee E4 indicated that Resident R2 required assist of two. The amount of assistance a resident needs is on our assignment sheets. I would not leave anyone unattended during care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395606 If continuation sheet Page 8 of 9 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 395606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-Ro 110 McIntyre Road Pittsburgh, PA 15237 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 0689 Level of Harm - Actual harm Residents Affected - Few During an interview on 7/7/25, at 1:13 p.m. NA Employee E5 stated that if a resident is on an air mattress, it takes two people, or if I check assistance level in the computer or assignment sheets and it says two, I get someone to help me. I wouldn't ever leave someone unattended if I was giving care. During an observation on 7/7/25, at 1:30 p.m. Resident R2 had light bruising noted to her left side of her face that included forehead, around left eye, and left cheek. During an interview on 7/7/25, at 1:33 p.m. Resident R2 was lying in bed with the television on. Resident stated, An aide left me at the edge of the bed, and I fell out of bed. Two NA's help me now since my fall. During an interview on 7/7/25, at 3:15 p.m. Director of Nursing (DON) stated that Resident R2 did fall out of bed on 6/14/25, was left unattended and received injuries. DON stated that NA Employee E1 was an agency aide and was put on a Do Not Return list related to the incident findings. During an interview on 7/7/25, at 3:45 p.m. the DON confirmed that the facility failed to provide appropriate equipment to prevent an accident for one of two residents (Resident R1), which resulted in actual harm of bruising and a fracture of residents right foot for Resident R1, and failed to provide appropriate goods and services to prevent falls for one of two residents (Resident R2), which resulted in actual harm of a hematoma on residents left side of forehead, a laceration above the left eye, and a hematoma to right knee with pain for Resident R2. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.20(b) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395606 If continuation sheet Page 9 of 9