Health inspection·October 12, 2023

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, clinical records, facility investigation reports, a progress note and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls for one of eight residents (Residents R58). Findings include: Review of the facility policy Incident/ Accident Occurrence Reporting System last reviewed on 1/27/23, indicated that the facility electronic reporting system is in place to assist staff to report incidents for tracking. All incidents are to be investigated and witness statements obtained and the licensing entities notified if required. Review of the clinical record indicated that Resident R58 most recent re-admission to the facility on 8/2/23, with diagnoses which included dementia with behaviors, psychotic disturbance, mood disturbance and anxiety. A MDS dated [DATE], indicated the diagnoses remained current. Review of Resident R58's plan of care indicated use of a wheeled walker and assist of one or two staff if agitated. Review of Resident R58's current Physician orders indicated the same ambulation order as identified above. Review of a progress note dated 8/28/23, indicated that Resident R58 was ambulating with a Nurse Aide in his room and lost his balance and fell against his dresser causing abrasions to his right back and left mid back requiring a treatment. During an interview on 10/11/23, at 12:20 p.m., the DON confirmed the incident was not investigated to determine if proper assistance was utilized which could have potentially prevented incident. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(d) Resident care policies. 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 2 Event ID: 395688 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 395688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Village of South HI 1290 Boyce Road Pittsburgh, PA 15241 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)