Inspection·September 22, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R1's care plan for cognitive loss initiated 12/24/19, indicated for staff to approach/speak in a calm, positive/reassuring manner. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), diabetes, and high blood pressure. Section C: Cognitive Patterns indicated that a BIMS score of 15. Review of facility submitted documentation dated 8/1/23, indicated that Resident R2 reported to facility staff that Nurse Aide (NA) Employee E1 was verbally inappropriate while providing care to Resident R1. Resident R2 stated that NA Employee E1 would get upset and yell, I'm not f****** with you today! This documentation further indicated that During investigatory process, it was discovered that more than one resident was negatively impacted by NA Employee E1's inappropriate behavior. Resident R2 indicated that this employee should not work with sick people, and Resident R2 spoke up to bring attention to her behavior. Resident R1 is unable to verbalize this information. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of diabetes, hemiplegia (paralysis on one side of the body), and systemic lupus erythematosus (SLE, an autoimmune disease where the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs). Section C: Cognitive Patterns indicated a BIMS score of 15. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles), coronary artery disease (damage or disease in the heart's major blood vessels), and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Section C: Cognitive Patterns indicated that a BIMS assessment was unable to be performed due to Resident R4 being rarely/never understood. Review of Resident R4's care plan for activities initiated 9/26/22, indicated staff will promote socialization with peers. Review of facility provided investigation documents dated 8/1/23, indicated facility staff interviewed Resident R3 to learn if she had issues with any staff. Resident R3 stated: Yes, (NA Employee E1) on 2-10. Resident R3 stated she is rude, often comes to work angry, and takes it out on residents. Resident R3 stated, A lot of people have issues with her. She reported that she slams the trays down on the tray tables and she shuts (Resident R4) in and closes the door because she yells. Resident R3 reported that NA Employee E1 told another staff to put (Resident R4) in her room with the door closed if she is loud. Review of an employee statement written by Admissions Director Employee E2 on 8/1/23, stated A few weeks back I was working in activities as an activities aide, a CNA (nurse aide) by the name of (NA Employee E1's first name) brought a resident into activities by the name of (Resident R4). She was very upset about being out of her room but her roommate had just ceased to breathe therefore EMS (emergency medical services) was taking her out. I occupied her as long as I could without keeping her there against her will before taking her back to her room. When I took her back I advised (NA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395675 If continuation sheet Page 2 of 10 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 395675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waynesburg Nursing and Rehab 300 Center Avenue Waynesburg, PA 15370 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 Employee E1) that Resident R4 would like to lay down. She replied she is always wanting something/or always yelling just put her in there and shut the door. I of course did not do those things and just proceeded with my day. During a follow-up, clarification telephone interview completed on 9/13/23, at 10:25 a.m Admissions Director Employee E2 stated that she did not feel it was appropriate to seclude Resident R4 in her room, and took her back to the activities area with her. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of COPD, diabetes, and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior). Section C: Cognitive Patterns indicated a BIMS score of 13. Review of Resident R5's care plan for Activities of Daily Living Assistance related to physical limitations initiated 9/15/21, indicated that Resident R5 was dependent on extensive assistance of two staff members to transfer in and out of bed. Review of facility submitted documentation dated 9/1/23, indicated that Maintenance Director Employee E4 heard NA Employee E5 mock Resident R5 while he was complaining of back pain, saying, Oh oh oh my back hurts and Stop whining (Resident R5's first name). Immediately after, NA Employee E5 was heard, by Maintenance Director Employee E4, saying to Resident R5, I'm so tired of you. It was further documented that NA Employee E5 then went into the hallway, stating loudly, It's too f****** hot in here. Review of facility provided investigation documents dated 9/1/23, revealed a transcribed interview with Resident R5 dated 9/1/23, at 3:30 p.m. Resident R5 was asked how his care was today (9/1/23). He said it was fine, but the girl with the dark hair always comes in with an attitude. I wanted to go to bed because my back was hurting and she told me to wait. When asked if he felt safe in the facility, Resident R5 stated, Yes, really, I have no choice because I have nowhere else to go, but I feel safe. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of hemiplegia, psychotic disorder, and history of a stroke. Section C: Cognitive Patterns indicated a BIMS score of 05. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's facility diagnosis list revealed diagnoses of hemiplegia, spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness), and history of a stroke. Review of Resident R7's admission Evaluation completed on 8/24/23, at 8:31 p.m. indicated Resident R7 used a urinary pad or brief. Review of a BIMS assessment completed 9/4/23, indicated a BIMS score of 08. Review of facility provided investigation documents dated 9/1/23, revealed an interview was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395675 If continuation sheet Page 3 of 10 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 395675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waynesburg Nursing and Rehab 300 Center Avenue Waynesburg, PA 15370 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 attempted with Resident R6, but was unable to be completed due to Resident R6's cognitive status. At the time, Resident R6's roommate, Resident R7's daughter reported a concern that her mom was not changed all day and the diaper she had on fell apart when she removed it, and she reported, however the aide said she was changed. She said, you know how I know she wasn't changed? The brief that I removed was the one brief I placed on her before I left last night. We bring one of our own supplies get her ready for bed and place our own briefs on her because she is a heavy wetter, and we do not leave any here. This is why we stay here through the day and night. The nurse aide in question was NA Employee E5. This information was determined at the time of investigation into NA Employee E5 and with the statement from Maintenance Director Employee E4. Further review of investigative documents relating to issues of emotional trauma revealed the following written statement: Review of an undated employee statement written by NA Employee E3 stated I have witnessed (NA Employee E1) cuss and scream and be very nasty toward the residents. Review of the facility Report Form for Investigation of Alleged Abuse, Neglect, and Misappropriation of Property dated 8/4/23, indicated the facility substantiated the allegation of abuse, and terminated NA Employee E1. Attempts to interview NA Employee E5 went unanswered as this employee no longer works at the facility. During staff interviews conducted on 9/9/23, between 12:30 p.m. and 1:15 p.m. the following was indicated: -On 9/2/23, Registered Nurse Employee E7 indicated began providing re-education to all licensed nurses, nurse aides, and ancillary staff regarding verbal and emotional abuse, and neglect of services. This education began after identification of the abuse and was to include all staff working at the facility but was not yet completed. -NA Employees E8, E9, E10, and E11 confirmed that they had received facility provided education on types and examples of verbal and emotional abuse, and further confirmed that not providing needed services, such as leg rests when pushing a wheelchair, is neglect. -Helping Hand (Hospitality Aide) Employee E12 confirmed that he was recently hired, and was provided education on abuse and neglect. When asked if he should push a wheelchair without leg rests, he confirmed that he should not. -Licensed Practical Nurses (LPN) Employees E13 and E14 confirmed that they are aware of what constitutes verbal and emotional abuse, and that not using leg rests when pushing a resident in a wheelchair is neglect. During an interview on 9/12/23, at 8:53 a.m. the Nursing Home Administrator confirmed that the facility failed to make certain residents were free from emotional trauma two of six and neglect to provide goods and services of changing a brief. 28 Pa. Code 201.18(e)(1) Management. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395675 If continuation sheet Page 4 of 10 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 395675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waynesburg Nursing and Rehab 300 Center Avenue Waynesburg, PA 15370 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 201.20(a)(b) Staff development. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.29(a)(c)(d) Resident rights. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395675 If continuation sheet Page 5 of 10 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 395675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waynesburg Nursing and Rehab 300 Center Avenue Waynesburg, PA 15370 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 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. Based on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of staff to resident abuse or neglect for two of four residents reviewed (Resident R4 and R7). Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. Review of the facility's Abuse Policy dated 3/1/23, indicated employees must immediately report any suspected abuse or suspected incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nurse Supervisor on duty. This policy further indicated that allegations of abuse and/or neglect will be reported to the State Survey Agency within 24 hours when no serious bodily injury has occurred. Review of an employee statement written by admission Director Employee E2 on 8/1/23, stated A few weeks back I was working in activities as an activities aide, a CNA (nurse aide) by the name of (NA Employee E1's first name) brought a resident into activities by the name of (Resident R4). She was very upset about being out of her room but her roommate had just ceased to breathe therefore EMS (emergency medical services) was taking her out. I occupied her as long as I could without keeping her there against her will before taking her back to her room. When I took her back, I advised (NA Employee E1) that Resident R4 would like to lay down. She replied she is always wanting something/ or always yelling just put her in there and shut the door. I of course did not do those things and just proceeded with my day. During a follow-up, clarification telephone interview completed on 9/13/23, at 10:25 a.m Admissions Director Employee E2 stated that she did not seclude Resident R4 in her room, but took her back to the activities area with her. Admissions Director Employee E2 stated that while she did not immediately report the attempted seclusion of Resident R4, she did explain the situation when asked about it later that day. Review of an undated employee statement written by NA Employee E3 stated I have witnessed (NA Employee E1) cuss and scream and be very nasty toward the residents. During a follow-up, clarification telephone interview completed on 9/13/23, at 10:38 a.m NA Employee E3 confirmed that she had frequently heard NA Employee E1 being disrespectful toward the residents, and confirmed that she reported her concerns to the Registered Nurse Supervisor on duty. Review of facility provided investigation documents revealed an interview completed on 9/2/23, at 3:45 p.m with Resident R7's daughter. During this interview, Resident R7's daughter's reported a concern that her mom was not changed all day and the diaper she had on fell apart when she removed it, and she reported, however the aide said she was changed. She said, you know how I know she wasn't changed? The brief that I removed was the one brief I placed on her before I left last night. We bring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395675 If continuation sheet Page 6 of 10 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 395675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waynesburg Nursing and Rehab 300 Center Avenue Waynesburg, PA 15370 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 Level of Harm - Minimal harm or potential for actual harm one of our own supplies get her ready for bed and place our own briefs on her because she is a heavy wetter, and we do no leave any here. This is why we stay here through the day and night. Review of facility submitted information as of 9/10/23, failed to reveal that the allegation of neglect of Resident R7 was reported to the state survey agency. Residents Affected - Few During an interview on 9/12/23, at 8:53 a.m. the Nursing Home Administrator confirmed that the facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of staff to resident abuse or neglect for two of four residents reviewed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395675 If continuation sheet Page 7 of 10 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 395675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waynesburg Nursing and Rehab 300 Center Avenue Waynesburg, PA 15370 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 a review of clinical records, facility documents, and resident and staff interviews, it was determined that the facility failed to provide appropriate assistance to prevent falls, resulting in actual harm of a leg fracture for one of four residents reviewed (Resident R8). Findings include: Review of the facility policy Assistive Devices and Equipment dated 3/1/23 indicated the facility provides, maintains, trains, and supervises the use of assistive devices and equipment for residents. Review of the Nurse Aide (NA) Job Description dated 3/1/23, indicated the nurse aide will attend to the individual needs of the resident, which may include assistance with transferring and ambulation. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident's care needs) dated 8/12/23, revealed diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and morbid obesity (chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions). Section G: Functional Status indicated Resident R8 utilized a wheelchair for mobility. Review of a physician's order dated 8/31/23, indicated for physical therapy to evaluate Resident R8 to address muscle weakness and, contracture, and balance. Review of facility provided documentation dated 9/2/23, indicated an incident that involved Resident R8. Nurse Aide (NA) Employee E3 had assisted Resident R8 by pushing the wheelchair without leg rests, Resident R8 was unable to keep legs elevated during this transport; the legs were lowered to the floor during this transport which caused a pop being heard. Xrays were obtained which showed a fracture. Review of a physician's note signed 9/3/23, at 1:00 a.m. indicated Resident R8 was evaluated for knee pain. The note stated, the patient presents with a chief complaint of right knee pain after an incident involving their foot getting caught underneath a wheelchair while returning from the dining hall. The patient reports feeling and hearing a pop during the incident. The patient experiences pain below the knee and has limited mobility in their legs. The note further indicated that x-ray results were pending. Review of a progress note dated 9/5/23, at 12:43 p.m. indicated Resident is to have CT scan of right knee due to knee popping incident on 9/3/23. On 9/3/23, resident had x-ray or right knee. Impression: No acute bony injury. MD notified. Due to appointment being unable to be made within a timely manner, resident was sent to the hospital emergency room so the imaging could be completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395675 If continuation sheet Page 8 of 10 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 395675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waynesburg Nursing and Rehab 300 Center Avenue Waynesburg, PA 15370 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 Review of a progress noted dated 9/5/23, at 11:02 p.m. indicated Resident R8 returned from the hospital. Level of Harm - Actual harm Review of hospital discharge paperwork dated 9/5/23, indicated Resident R8 was treated for a closed fracture of right tibial plateau (an injury that fractured the bone and injure the cartilage that covers the top end of the bottom part of your knee). Residents Affected - Few Review of a physician's note created 9/6/23, at 1:08:23 p.m. indicated Resident R8 is currently experiencing pain and swelling around the knee area. Resident R8 is using an immobilizer and has been advised to remain non-weight bearing for the next six weeks. His pain medication has been changed to Lortab (a combination of acetaminophen and hydrocodone. Hydrocodone is an opioid pain medication. Acetaminophen, also called Tylenol, is a less potent pain reliever that increases the effects of hydrocodone. Lortab is used to relieve moderate to severe pain.) to be taken three times a day. Review of physician's orders indicated from 4/14/22, through 9/5/23, Resident R8 received Tramadol (a narcotic to treat mild to moderate pain) 50 mg (milligrams), with orders varying from every four to every eight hours. Review of physician's orders dated 9/5/23, indicated Resident R8 was to receive Lortab 7.5 mg - 325 mg every six hours as needed for pain. During an interview on 9/9/23, at 11:25 a.m. Resident R8 stated I was down in the cafeteria, and I ran out of oxygen. I asked the nurse to push me back to my room. I was holding my feet up, but I was having a hard time. My foot went down too far and it hit the floor. It wrapped up right underneath me. Review of facility provided documents confirmed that NA Employee E3 failed to follow the facility's wheelchair policy while transporting a resident. Attempts to further interview this employee went unanswered. During staff interviews conducted on 9/9/23, between 12:30 p.m. and 1:15 p.m. the following was indicated: -Registered Nurse Employee E7 indicated that he was currently providing education to all licensed nurses and nurse aides regarding the need to always utilize leg rests when pushing a resident in a wheelchair. This education began after the issue with the leg rests but was not yet completed. -NA Employees E8, E9, E10, and E11 confirmed that the wheelchairs should always utilize leg rests when pushing a resident in a wheelchair. -Helping Hand (Hospitality Aide) Employee E12 confirmed that he was recently hired. When asked if he should push a wheelchair without leg rests, he confirmed that he should not. -Licensed Practical Nurses (LPN) Employees E13 and E14 confirmed that they are aware that leg rests are always required when pushing a resident in a wheelchair. During an interview on 9/9/23, at 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide appropriate assistance to prevent falls, resulting in actual harm of a leg fracture for one of four residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395675 If continuation sheet Page 9 of 10 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 395675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waynesburg Nursing and Rehab 300 Center Avenue Waynesburg, PA 15370 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 28 Pa. Code 201.18(e)(1) Management Level of Harm - Actual harm 28 Pa. Code 201.20(a)(b) Staff development Residents Affected - Few 28 Pa. Code 201.29(a)(c)(d) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395675 If continuation sheet Page 10 of 10