Inspection·May 16, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, and resident and staff interviews, and observations it was determined that the facility failed to provide a resident environment free of potential accidental hazards for two of six hallways (2A and 2B). Findings include. Review of the Code of Federal Regulations (CFR) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible. Review of the facility Hot Beverage Policy dated 3/10/25, indicated hot beverages have the potential to cause an injury, and will be handled carefully. Personal beverage heating devices are not permitted due to the ongoing risk of scalding and for those who may inadvertently gain access to such devices. Hot beverages will not be left unattended for resident self-service. Appropriate supervision will be provided for residents with decreased safety awareness, physical limitation and or self-feeding deficits that could place them at risk for burns/scalds. Review of the facility provided CMS-802 form (provides clinical details regarding residents) on 5/15/25, indicated the 2A and the 2B hallways had 24 residents with a diagnosis of Alzheimer's/Dementia (a progressive disease that destroys memory and other important mental functions/(a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). Observation on 5/15/25, at 10:23 a.m. of the 2B hallway indicated a three tier silver cart with three large carafes of hot beverages(coffee and hot water) and one smaller carafe of regular coffee. Condiments, disposable lids, plastic coffee mugs, and disposable lids also on the cart. The cart was positioned just outside room [ROOM NUMBER]. There were no staff in view or supervising the cart. Interview on 5/15/25, at 10:30 a.m. Nurse Aide (NA) Employee E1 indicated recently the meal carts were being delivered to the floor and the NA's had to take them to the dish room once trays were picked up after meals. Dietary brings a coffee cart up, (pointed to the coffee cart in the hallway outside room [ROOM NUMBER]) and they refurbish it. Observation on 5/15/25, at 1:05 p.m. of the 2B hallway indicated the coffee cart, unsupervised outside room [ROOM NUMBER]. Interview on 5/15/25, at 1:15 p.m. NA Employee E2 indicated residents help themselves to the cart all day. Observation on 5/15/25, at 10:35 a.m. of the 2A hallway indicated the coffee cart unsupervised in the hallway outside room [ROOM NUMBER]. Interview on 5/15/25, at 10:40 a.m. NA Employee E3 confirmed the unsupervised cart in the hallway and indicated some residents pour their own, and residents get into it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395682 If continuation sheet Page 2 of 3 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 395682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Health & Rehab Center 900 Third Ave Beaver Falls, PA 15010 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 - Minimal harm or potential for actual harm Residents Affected - Few Interview on 5/15/25, at 10:42 a.m. NA Employee E4 indicated the coffee cart needs a secure place for it because the residents access it themselves. Interview on 5/15/25, at 11:25 a.m. NA Employee E5 indicated the coffee carts were awful. Someone may get burned and residents will go floor to floor and help themselves. The coffee carts started a few weeks ago. Interview on 5/15/25, at 1:18 p.m. Registered Nurse (RN) Employee E6 indicated staff are supposed to keep the carts behind the nurses station so residents don't get hurt or for ones who have fluid restrictions, etc. Interview on 5/15/25, at 2:00 p.m. the Director of Nursing confirmed the facility failed to provide a resident environment free of potential accidental hazards for two of six hallways (2A and 2B). 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 PA Code: 201.29(a) Resident rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395682 If continuation sheet Page 3 of 3