Health inspection·September 8, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to report injuries of unknown source as possible abuse and/or neglect for one of two residents (Resident R108). Findings include: Review of the facility's Abuse - Resident and Reasonable Suspicion of a crime revision dated 2/7/23, stated, Any injury should be classified as an injury of unknown source, when all of the following criteria are met. The source of the injury was not observed by any person, and the source of the injury cannot be explained by the resident, and the injury is suspicious, because of the extent of the injury or the location of the injury. It further stated Alleged violations, whether or not confirmed, must be reported to the administrator, Pennsylvania Department of Health, the Area Agency on Aging, compliance officer, and to the Executive Director, and a full investigation conducted. Review of the clinical record revealed that Resident R108 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- periodic assessment of care needs), indicated diagnoses of dementia (a group of symptoms affecting memory, thinking and social abilities), muscle wasting, and atrophy (loss of muscle leading to its shrinking, weakening, and/or stiffness). Review of progress note dated 9/2/23, at 10:00 a.m. stated that the Resident R108 was found naked in the hallway with the right hand being edematous (abnormally swollen with fluid). Review of a progress noted dated 9/2/23, at 7:40 p.m. stated that the right hand was swollen with +3 edema (when the swollen area pressed with a finger tip, it takes up to 30 seconds for the depression to go away) and bruising from the right thumb down to wrist. The MD (medical doctor) was notified, and an X-ray ordered. Review of a progress note dated 9/2/23, at 10:14 p.m. stated the results showed a fracture to right thumb and resident was sent to the hospital. The physician progress noted dated 9/6/23, stated, The cause of the injury is not known, though R108 does have times where she climbs out of bed and crawls on the floor. During an interview with the Assistant Director of Nursing on 9/7/23, at 11:58 a.m. stated these are behaviors where she throws herself on the floor and were really supposed to ignore it since it's attention seeking behaviors. During an interview with the Director of Nursing (DON) on 9/7/23, at 12:35 p.m. stated that these are behaviors for this resident. After being asked how the facility was able to determine that this was a behavior if the documentation states the cause is unknown and it was unwitnessed she stated what he's saying is starting to make sense. Review of facility submitted reports failed to reveal documentation of reporting of Resident R108's injury of unknown source as possible abuse and/or neglect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395643 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 395643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-Gl 955 Rivermont Drive Pittsburgh, PA 15207 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 0609 During an interview on 9/7/23, at 12:35 p.m. the DON confirmed the facility facility failed to report injuries of unknown source as possible abuse and/or neglect for one of two residents. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14(a)(c)(d)(e) Responsibility of licensee. Residents Affected - Few 28 Pa. Code 201.18(b)(1)(3)(e)(1)Management. 28 Pa. Code: 211.10(a) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395643 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 395643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-Gl 955 Rivermont Drive Pittsburgh, PA 15207 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 0610 Respond appropriately to all alleged violations. 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 record review, and staff interview, it was determined that the facility failed to fully investigate incidents to rule out neglect and/or abuse for one of two residents (Resident R108). Residents Affected - Few Findings include: Review of the facility's Abuse - Resident and Reasonable Suspicion of a Crime revision dated 2/7/23, stated: all allegations are thoroughly investigated. The policy further stated the individual conducting the investigation take the following actions: 1. Initiates investigation promptly and makes all applicable notifications. Assures that the administrator and DON are notified promptly of allegation and consulting. 2. Interviews and obtains written statements from complaining party and witness using facility form D165 (residents) and workplace investigation form D195 for all others 3. Notifies resident representative allegation 4. Removed alleged perpetrator (AP) immediately from situation 5. Interviews AP and obtains written statement 6. Assures that the individual being interviewed has directly responded to all allegations both in the interview, and then written statements provided 7. Separates the AP from the work and complete indefinite suspension documentation for employee unless it is determined through investigation the allegation is unsubstantiated 8. Complete incident, report event and notify practitioner 9. Obtains practitioner orders as applicable, including but not limited to, hospital, transfer and/or diagnostic testing 10. Updates residence person Centered center to care plan promptly as needed 11. Consult with interdisciplinary te a.m. for person centered care, plan updates to address the residence medical nursing, physical, mental or psychosocial needs or preference changes as a result of the abuse 12. Reviews applicable medical record information and assures, that arrangements are made for a continuation and completion of abuse investigation 13. Complies with, and performs reporting obligations to the State survey agency and law enforcement within the time constraints identified by the type of alleged abuse, and or crime against a resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395643 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 395643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-Gl 955 Rivermont Drive Pittsburgh, PA 15207 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility policy further stated, in regards to reporting an event that causes suspicion for abuse that result in seriously bodily injury (see definition) the individual shall report the suspicion immediately, but not later than two hours after forming the suspicion. Review of the Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment) suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed that Resident R108 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs), indicated diagnoses of Dementia (a group of symptoms affecting memory, thinking and social abilities), and muscle wasting and atrophy (loss of muscle leading to its shrinking, weakening, and/or stiffness). Section C, Cognitive Pattern, indicated a BIMS score of 00. Review of Resident R108's care plan initiated 8/1/23, indicated that the resident is at risk for falls/safety risk related to: cognitive impairment, history of falls and non-compliance with POC (plan of care). Review of a progress note dated 9/2/23, at 10:00 a.m. stated that the Resident R108 was found naked in the hallway with the right hand being edematous (abnormally swollen with fluid). Review of a progress noted date 9/2/23, at 7:40 p.m. stated that the right hand was swollen with +3 edema (when the swollen area pressed with a finger tip, it takes up to 30 seconds for the depression to go away) and bruising from the right thumb down to wrist. The MD (medical doctor) was notified, and an X-ray ordered. Review of a progress note dated 9/2/23, 10:14 p.m. stated the results showed a fracture to right thumb and resident was sent to the hospital. The physician progress noted dated 9/6/23 regarding the incident stated The cause of the injury is no known, though R108 does have times where she climbs out of bed and crawls on the floor. During an interview with the Assistant Director of Nursing on 9/7/23, at 11:58 a.m. he stated these are behaviors where she throws herself on the floor and were really supposed to ignore it since its attention seeking behaviors. During an interview with the Director of Nursing (DON) on 9/7/23, at 12:35 p.m. stated that these are behaviors for this resident. After being asked how the facility was able determine that this was a behavior if the documentation states the cause is unknown and it was unwitnessed she stated what he's saying is staring to make sense. Review of facility provided documents failed to reveal documentation investigating Resident R108's injury of known source as possible abuse and/or neglect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395643 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 395643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-Gl 955 Rivermont Drive Pittsburgh, PA 15207 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 0610 During an interview on 9/7/23, at 12:35 p.m. the DON confirmed the facility failed to fully investigate incidents to rule out neglect and/or abuse for one of two residents (Resident R108) Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14(a)(c)(d)(e) Responsibility of licensee. Residents Affected - Few 28 Pa. Code 201.18(b)(1) )(3)(e)(1)Management. 28 Pa. Code: 211.10(a) Resident care policies. 28 Pa. Code: 211.12(d)(1) )(2)(5)Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395643 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 395643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-Gl 955 Rivermont Drive Pittsburgh, PA 15207 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 of clinical records and staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and services to maintain bowel function for one of two residents (Resident R131). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is 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 Review of the facility policy Bowel Management dated 1/5/23, indicated facility staff will monitor resident bowel elimination daily and assures that follow up actions are taken by nurses. Review of the clinical record revealed that Resident R131 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 8/15/23, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), bipolar disorder (a mental condition marked by alternating periods of elation and depression), and osteoporosis (condition when the bones become brittle and fragile). -Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R131's score to be 04. -Section G Function Status, Question G0110 I, Activities of Daily Living (ADL) Assistance, Toilet Use indicated Resident R131 required physical assistance of at least one person. -Section H Bladder and Bowel, Question H0400 Bowel Incontinence indicated that Resident R131 was always continent of bowel. Review of Resident R131's facility diagnosis list failed to include a diagnosis of constipation. Review of Resident R131's plan of care for Potential for constipation related to meds and hydration initiated 7/18/23, indicated for the facility to institute bowel movement protocol for no bowel movement greater than six shifts. Review of the physician orders active in 8/1/23, through 8/17/23, indicated that Resident R131 had orders for: -Polyethylene glycol (Miralax, laxative medication to treat constipation) give 17 grams daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395643 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 395643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-Gl 955 Rivermont Drive Pittsburgh, PA 15207 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 -Senna tablet (medication used to treat constipation) give one tablet, twice daily for constipation form 8/1/23, through 8/10/23). -Senna tablet (medication used to treat constipation) give two tablets, twice daily for constipation form 8/11/23, through 8/17/23). Residents Affected - Few -Bisacodyl suppository 10mg, give one suppository daily, as needed. Review of Resident R131's bowel record for August 2023 revealed: -No bowel movement from 8/2/23, day shift until 8/6/23, day shift; Four days, 12 shifts with no bowel movement. -No bowel movement from 8/6/23, day shift until 8/10/23, day shift; Four days, 12 shifts with no bowel movement. -One small bowel movement (8/19/23) from 8/13/23, evening shift until 8/24/23, day shift; ten shifts with no bowel movement. The August 2023, medication administration record indicated the following: -Scheduled Miralax and Senna received. -Bisacodyl suppository was not administered: Review of a progress note dated 8/6/23, at 11:43 a.m. indicated that Resident R131's abdomen distended, bowel sounds hypo (hypoactive, less than expected amount of activity). Review of a progress note dated 8/6/23, at 12:51 p.m. indicated that Resident R131 was given 30 ml (milliliters) of MOM (milk of magnesia, a medication to treat constipation). The note further indicated that the MOM was not effective. Review of the physician's orders active on 8/6/23, failed to include an order to provide milk of magnesia. During an interview on 9/8/23, at 8:40 a.m. the Director of Nursing confirmed that the facility does not utilize a set bowel protocol, that each resident's bowel care is based off their physician's orders and their care plan. During an interview on 9/8/23, at 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that residents were provided appropriate treatment and services to maintain bowel function for one of two residents 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights. 28 Pa. Code 211.10(c)(d) Resident Care Policies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395643 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 395643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-Gl 955 Rivermont Drive Pittsburgh, PA 15207 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 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 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: 395643 If continuation sheet Page 9 of 9