Inspection·April 21, 2023

F 0656 Resident R1 had a BIMS score of 6. Brief Interview for Mental Status is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: Level of Harm - Minimal harm or potential for actual harm 13-15: cognitively intact Residents Affected - Few 8-12: moderately impaired 0-7: severe impairment Review of facility submitted documents, dated 4/3/23, incident report investigation indicated Resident R1 eloped from the facility 4/3/23, at approximately 10:07 a.m. Continued review indicated that Resident R1 exited out the second-floor locked door, went down the hallway towards the kitchen. Resident was later found on 4/3/23, at 10:42 a.m. (approximately 35 minutes later). During an interview on 4/19/23, at 10:00 a.m. Registered Nurse (RN) Employee E2 stated the day Resident R1 eloped, he was wandering and found by the doors down the hallway; information was not added to the care plan for potential for elopement risk. During an interview on 4/20/23, at 12:00 p.m. with Resident Family RF1 indicated that she was notified on 4/3/23, by phone stating Resident R1 was missing; Resident Family RF1 was worried about Resident R1 getting into a stairwell. Resident Family RF1 also stated that this was one of the reasons why the hospice respite stay was given, due to the increased confusion During an interview conducted on 4/19/23, at 2:30 p.m., Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the events of the facility submitted documents and confirmed Resident R1 had a diagnosis of cerebral atherosclerosis and vascular dementia, but that no wander risk was identified on admission. Elopement assessment was completed but did not identify the Resident R1 at risk for elopement. Due to this finding the Resident R1 care plan was not implemented to reflect the diagnosis of vascular dementia. The facility failed to develop a person-centered care plan related to dementia and wandering/exit- seeking behavior related to Resident R1. This failure resulted in Resident R1 subsequently eloping from the facility. 28 Pa. Code 211.10(c) Resident care polies. 28 Pa. Code: 211.11(a)(b)(c)(d) Resident care plan. 28 Pa. Code: 211.12 (c)(d)(1) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395742 If continuation sheet Page 2 of 8 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 395742 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southwestern Nursing and Rehabilitation Center 500 North Lewis Run Road Pittsburgh, PA 15122 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 - Immediate jeopardy to resident health or safety 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 facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for a resident resulting in elopement (resident leaves the premises or a safe area without the facility's knowledge). This failure created an immediate jeopardy situation for one of 93 residents (Resident R1). Findings include: A review of the State Operations Manual (SOM) defines elopement as a situation in which a resident leaves the premises or a safe area without the facility's knowledge. A review of the facility policy Elopement/ Missing Resident reviewed 10/31/22, states that the facility will provide a safe environment for all residents regardless of orientation status and to supervise those residents at risk for elopement based on the comprehensive assessment and specific care plan for each resident. Policy also states the person identifying that a resident is missing or unaccounted for immediately notifies the charge nurse or the RN supervisor. A review of the Resident Assessment Instrument 3.0 User's Manual (tool used for the completing the Minimum Data Set (MDS- periodic assessment of care needs) 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 A review of the MDS dated [DATE], indicated that the diagnoses remained current and that Resident R1 had a BIMS score of 6, which indicated severe impairment. Section GG of this MDS, which defines functional abilities, indicated resident was able to utilize a walker with assistance. Resident is mobile in a wheelchair. A review of the admission Record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included cerebral atherosclerosis ( a condition of the arteries in the brain becoming hard, thick, and narrow decreasing the blood flow to the brain) and Vascular Dementia (brain damage caused by multiple strokes). Resident admission was scheduled as a hospice respite stay due to increased behaviors, wandering at home, and Resident R1's family having difficulty taking care of Resident R1. Resident R1 then was admitted to long term care on 3/7/23. A review of the Elopement Assessment Form dated 2/23/23, indicated that Resident R1 had zero of nine total factors/contributors indicating elopement risk. Elopement form instructions indicated that just one factor identified the resident at risk for elopement. Factors that are reviewed are: 1. Does the resident have a history of or an attemped elopement while at home? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395742 If continuation sheet Page 3 of 8 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 395742 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southwestern Nursing and Rehabilitation Center 500 North Lewis Run Road Pittsburgh, PA 15122 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 2. Does the resident have a history of or attempted leaving the facility without informing staff? Level of Harm - Immediate jeopardy to resident health or safety 3. Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit or door? 4. Does the resident wander? Residents Affected - Few 5. Is the wandering behavior a pattern, goal directed (i.e. specific destination mind, going home ect)? 6. Does the resident wander aimlessly or non-goal directed (i.e. confused, moves without purpose, may enter others' rooms and explore others' belongings)? 7. Is the residents wandering behavior likely to affect the safety or well being of self/others? 8. Is the residents wandering behavior likely to affect the privacy of others? 9. Has the resident been recently admitted or re-admitted (within the past 30 days) and is not accepting the situation? A review of the resident admission documents and history indicated that the resident did have at least one factor that triggered the resident as an elopement risk, despite the facility indicating there were 0. This was indicated upon admission for the initial stay for respite care prior to the decision to stay long term. A Nurse Practitioner note dated 3/4/23, indicated Resident R1 was very confused at baseline. A review of the clinical record on 4/19/23 at 10:00 a.m. indicated that the nurse practitioner saw Resident R1 on a monthly review dated 3/24/23 and revealed Resident R1's status as very confused at his baseline. A review of Resident R1's care plan dated 2/28/23, failed to show documented risks, goals or interventions related to elopement or wandering. A review of Resident R1's physician order dated 2/23/23 through the elopement date of 4/3/23, failed to show any documented orders or protocols to follow for Resident R1 in case of elopement or wandering behaviors. A review of Resident R1's progress notes dated 4/1/23 indicated: Resident does not follow commands. A review of facility provided documents, dated 4/3/23, indicated that on 4/3/23, at 10:07 a.m. the facility had a resident elopement. A review of a statement from Registered Nurse Employee E2 dated 4/3/23, indicated that Therapy Employee E1 was looking for Resident R1 for therapy. RN Employee E2 looked around the second floor nursing station then down the halls and then into the second floor rooms. Resident R1 was not able to be located. Then Registered Nurse Employee E2 went to the third floor to see if the Resident R1 was at activities. Once Resident R1 was not able to be located, RN Employee E2 notified the Assistant Director of Nursing (ADON) as directed in the policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395742 If continuation sheet Page 4 of 8 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 395742 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southwestern Nursing and Rehabilitation Center 500 North Lewis Run Road Pittsburgh, PA 15122 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 - Immediate jeopardy to resident health or safety Residents Affected - Few A review of the facility Elopement Sheet documentation dated 4/3/23, indicated that the elopement code was called at 10:07 a.m. This documentation also indicated that the Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified at 10:15 a.m. A call was placed to 911 at 10:32 a.m. when Resident R1 was still unable to be located. Documentation stated that Resident R1 was found at 10:42 a.m. in the hallway between the locked second floor doors and the kitchen. Directly outside these coded doors is a long hallway that is not part of the physical layout of the nursing home. A left out of these doors would lead to a set of double doors that would exit to a back parking lot; a right would lead down a long hallway, past a set of staff lockers, an exit to an enclosed courtyard that is staff access only, and then the kitchen. A person in this area may not come into contact with any staff until the next meal or if the nursing center would call the kitchen for a food request. During an interview on 4/19/23, at 2:00 p.m. RN Employee E2 indicated on 4/3/23, Resident R1was last seen at the end of the short hall and was brought back to the second floor nursing station and on 4/3/23, RN Employee E2 also indicated that it was witnessed that NA Employee E3 was talking with Resident R1 at 9:40 a.m. by the nurses station. During an interview on 4/19/23, at 2:45 p.m., the NHA indicated the facility does not have a wander guard system in place just locking doors that are coded and the doors do not have alarms. During an interview on 4/19/23, at 3:50 p.m., the Maintenance Director Employee E4 stated that the second floor doors that lead to the hallway that Resident R1 exited was slow closing. Maintenance Director Employee E4 also stated that after the elopement the doors were adjusted to close faster. A review of the maintenance log from 4/1/23 through 4/3/23 shows the facility did daily checks and indicated the maintenance department just checks that the doors lock; not how long the doors take to close. A review of a written statement from Nurse Aide (NA) Employee E5 dated 4/3/23, indicated they did not see Resident R1. A review of a written statement from Nurse Aide (NA) Employee E6 dated 4/3/23, indicated they did see Resident R1 by the nurses station at 8:30 a.m. A review of a written statement from Nurse Aide (NA) Employee E7 dated 4/3/23, indicated they did not see Resident R1 at all. A review of a written statement from NA Employee E8 dated 4/3/23, indicated they observed Resident R1 at 7:30 a.m., before starting to give care in a different room. During an interview on 4/20/23, at 12:00 p.m. with Resident Family RF1 indicated that she was notified on 4/3/23, by phone stating Resident R1 was missing; Resident Family RF1 was worried about Resident R1 getting into a stairwell. Resident Family RF1 also stated that this was one of the reasons why the hospice respite stay was given, due to the increased confusion. During an interview on 4/20/23, at 1:20 p.m., the NHA stated the facility did an investigation into the elopement and found the incident happened due to one of the kitchen/dietary staff going through the door and not making sure the door closed and the door not closing fast enough to limit the risk of residents eloping out of the doors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395742 If continuation sheet Page 5 of 8 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 395742 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southwestern Nursing and Rehabilitation Center 500 North Lewis Run Road Pittsburgh, PA 15122 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 - Immediate jeopardy to resident health or safety During an interview on 4/19/23, at 11:20 a.m. the NHA confirmed the facility failed to provide adequate supervision for Resident R1 resulting in elopement. This failure created an immediate jeopardy situation. During an interview on 4/19/23, at 4:18 p.m. the NHA and the DON were made aware that Immediate Jeopardy (IJ) existed for one of six residents (Resident R1) residing in the facility. The IJ template was provided to facility administration at that time and a corrective action plan was requested. Residents Affected - Few Notification on 4/19/23, at 7:52 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Resident R1 was assessed after the elopment to determine any injury, none at that time. Resident R1 elopement assessment was updated and care plan was updated accordingly. Resident Family RF1 was offered alternate placement but refused for Resident R1. Residents: Facility will re evaluate all residents to ensure elopement behaviors are identified; update the care plan as needed. Audit will be completed by 4/19/23. Facility will ensure adequate supervision/monitoring of residents identified at risk for elopement by educating staff on potential risk factors and implementing interventions per residents care plan. Education will be completed with all in house staff by 4/20/23, and all new hires and contracted staff prior working their next shift. Facility will review and/or revise elopement policy with all staff. Whole house audit was conducted by the NHA and DON on elopement risk with updated assessments done on every resident. No further residents identified to be at risk. System correction: Whole house education for all departments including nursing, maintenance, therapy, housekeeping, laundry, dietary, administrative, social services, and activities, also to include agency and hospice staff was conducted and completed regarding elopement policy, identifying signs and symptoms of residents potential for elopement, and potential risk factors and interventions for residents care plan. The maintenance department updated daily work sheet on door functioning. Education was conducted by DON or designee via telephone or in person meetings. In person education was completed on 4/19/23 through 4/20/23, with any remaining staff getting a voice message to see the DON or designee before starting shift. Elopement policy and elopement binder was updated on 4/19/23. Monitoring: Audits and timed closing of the doors were initiated by Maintenance staff and documented daily. Audits and monitoring, supervision, and interventions will be completed daily for five days, weekly for three weeks, and monthly for two months. Results and audits will be presented at the Quality Assurance Improvement Committee meeting for review and recommendations. A review of Resident R1's care plan on 4/20/23, indicated the plan of care was updated on 4/3/23, after the incident. Continued review of ten sampled charts verified the part of the plan that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395742 If continuation sheet Page 6 of 8 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 395742 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southwestern Nursing and Rehabilitation Center 500 North Lewis Run Road Pittsburgh, PA 15122 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 residents were re-evaluated for identifying elopement behaviors. Level of Harm - Immediate jeopardy to resident health or safety During an interview with RN Employee E2 on 4/20/23 at 10:00 a.m. it was confirmed that she had received the education for elopement policy, potential risk factors, interventions for resident care plans, and education on identifying signs and symptoms of resident potential for elopement. Residents Affected - Few During an interview with RN Employee E4 on 4/20/23 at 10:05 a.m. confirmed that she had received the education for elopement policy, potential risk factors, interventions for resident care plans, and education on identifying signs and symptoms of resident potential for elopement. During an interview with RN Employee E5 on 4/20/23 at 10:10 a.m. confirmed that she had received the education for elopement policy, potential risk factors, interventions for resident care plans, and education on identifying signs and symptoms of resident potential for elopement. During an interview with RN Employee E6 on 4/20/23 at 10:15 a.m. confirmed that she had received the education for elopement policy, potential risk factors, interventions for resident care plans, and education on identifying signs and symptoms of resident potential for elopement. During a phone interview with License Practical Nurse (LPN) Employee E7, that works overnight 7:00 p.m. to 7:00 a.m. shift, on 4/20/23 at 1:00 p.m. confirmed that she had received the education for elopement policy, potential risk factors, interventions for resident care plans, and education on identifying signs and symptoms of resident potential for elopement. During a phone interview with NA Employee E8, that works on the 3:00 p.m. to 11:00 p.m. shift, on 4/20/23 at 1:10 p.m. confirmed that she had received the education for elopement policy, potential risk factors, interventions for resident care plans, and education on identifying signs and symptoms of resident potential for elopement. During interviews on 4/20/23, from 9:00 a.m. through 2:00 p.m. 42 total staff employees confirmed they had received education on elopement policy, identifying signs and symptoms of residents potential for elopement, and potential risk factors and interventions for residents care plan. Total of nine staff members was called for phone interviews and all staff interviewed by phone confirmed they had received the education via phone call. Facility provided documentation and sign in sheets verifying 80 staff members have received the education in person and 41 staff members received a phone call about the education . The IJ was lifted on 4/20/23, at 2:38 p.m. when the action plan implementation was verified. During an interview on 4/20/23, at 3:00 p.m. the NHA confirmed the facility failed to provide adequate supervision for one resident resulting in elopement. This failure created an immediate jeopardy situation for one of 93 residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 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: 395742 If continuation sheet Page 7 of 8 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 395742 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southwestern Nursing and Rehabilitation Center 500 North Lewis Run Road Pittsburgh, PA 15122 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 211.12(d)(1)(2)(3)(5) Nursing services. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395742 If continuation sheet Page 8 of 8