Inspection·March 22, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for eight of the twelve residents reviewed (Resident R16, R21,R29, R32, R39, R44, R47, R67, R68, R127, R134, R142). Findings Include: A review of the facility policy Advanced Directives on 7/19/2023, 1/23/2024, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the medical record indicated Resident R16 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure and dementia. A review of the clinical record failed to reveal an advance directive or documentation that Resident R16 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R21 was admitted to the facility on [DATE], with diagnoses that include diabetes, high blood pressure and end stage renal disease (ESRD-kidneys no longer work). A review of the clinical record failed to reveal an advance directive or documentation that Resident R21 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R29 was admitted to the facility on [DATE], with diagnoses that include cerebral palsy (difficulty walking and affects muscles), weakness, weight loss. A review of the clinical record failed to reveal an advance directive or documentation that Resident R29 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R32 was admitted to the facility on [DATE], with diagnoses that include diabetes, depression and high blood pressure. A review of the clinical record failed to reveal an advance directive or documentation that Resident R32 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R39 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, muscle weakness and anxiety. A review of the clinical record failed to reveal an advance directive or documentation that Resident R39 was given the opportunity to formulate an Advanced Directive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 2 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 0578 Level of Harm - Minimal harm or potential for actual harm A review of the clinical record indicated Resident R44 was admitted to the facility on [DATE], with diagnoses that include diabetes, ESRD, heart failure (heart is weak and does not pump blood like it did). A review of the clinical record failed to reveal an advance directive or documentation that Resident R44 was given the opportunity to formulate an Advanced Directive. Residents Affected - Some A review of the clinical record indicated Resident R47 was admitted to the facility on [DATE], with diagnoses that include diabetes, low blood pressure and parkinson's disease (affects movement and can include tremors). A review of the clinical record failed to reveal an advance directive or documentation that Resident R47 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R67 was admitted to the facility on [DATE], with diagnoses that include End stage renal disease (kidneys no longer work), diabetes, dementia. A review of the clinical record failed to reveal an advance directive or documentation that Resident R67 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R68 was admitted to the facility on [DATE], with diagnoses that include diabetes, depression, ESRD. A review of the clinical record failed to reveal an advance directive or documentation that Resident R68 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R127 was admitted to the facility on [DATE], with diagnoses that include depression, anxiety, anemia (not enough blood). A review of the clinical record failed to reveal an advance directive or documentation that Resident R127 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R134 was admitted to the facility on [DATE], with diagnoses that include depression, heart failure and chronic obstructive pulmonary disease (COPD-blocks airflow making it difficult to breathe). A review of the clinical record failed to reveal an advance directive or documentation that Resident R134 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R142 was admitted to the facility on [DATE], with diagnoses that include anemia, orthostatic hypotension (blood pressure drops when standing up), dysphagia (difficulty swallowing). A review of the clinical record failed to reveal an advance directive or documentation that Resident R142 was given the opportunity to formulate an Advanced Directive. During an interview on 3/22/2024, at 12:32 p.m. the DON confirmed that the clinical record did not include documentation that Resident R16, R21, R29, R32, R34, R44, R47, R67, R68, R127, R134, and R142, were not afforded the opportunity to formulate Advance Directives. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 3 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 0578 28 Pa. Code 201.29 (j) Resident rights. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 4 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on the facility policy, observations, Resident group meeting and staff interview, it was determined that the facility failed to provide residents access to grievance forms, failed to provide the right to file grievances anonymously, and failed to post the name of the Grievance Official for residents to file a grievance orally (meaning spoken) for 155 of 155 residents at the facility. Findings include: A review of the facility grievance procedure policy last reviewed on 1/23/24, with a previous review date of 7/19/23, indicated that all concerns can be written and placed in the concern form collection box and five locations identified or residents can seek out Administration team or staff member with concerns. Concerns presented to the Administrator is typically responded to within 72 hours. The posted procedure indicated the second previous Administrator as the grievance officer. Review of the facility Resident admission Packet indicated that the facility follows the resident rights of being able to file a grievance. During an observation on 3/19/24, from 9:00 a.m. through 10:00 a.m. throughout the facility there was no grievance forms found in the bins identified as the grievance forms in any of the identified areas on the grievance procedure. During a group interview on 3/20/24, at 10:15 a.m., Residents R100, R101, R102, R103 and R104 indicated they did not know how to file a grievance and were never told they could, where the forms are or how to file an anonymous grievance. During an interview on 3/20/24, at 12:40 p.m., the Nursing Home Administrator and Director of Nursing indicated that the facility currently has no grievance officer information posted and forms are not available to file a grievance. 28 Pa. Code: 201.18(e)(4) Management. 28 Pa. Code: 201.29(a)(j) Resident rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 5 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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, review of resident council meeting minutes, facility concern/grievance log and clinical records, and resident and staff interviews, it was determined that the facility failed to investigate potential abuse and/or neglect for three of 35 residents(Resident R209, R302 and R37). Residents Affected - Some Findings include: Review of the facility Abuse Prohibition policy reviewed on 1/23/24, with a previous review date of 7/19/23, indicated that the facility Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, injuries of unknown origin, etc. The facility will protect the residents from further abuse during investigation and the investigation will begin within 24 hours. All allegations will be reported to the state agencies in accordance with state law. Review of the clinical record indicated Resident R209 was admitted to the facility on [DATE], with diagnoses which included sepsis(infection), breast cancer, cute kidney failure, acute pulmonary edema (too much fluid in the lungs causing shortness of breath). Resident R209 had required a intravenous line to her heart for her antibiotics for an infection of her chest wall which also required a wound treatment. An MDS(Minimum Data Set-a periodic assessment of resident care needs) dated 2/26/24, indicated the diagnoses remained current. Review of Resident R209's Order Summary Report dated from 2/20/24, through 3/31/24, indicated Resident R209 required her left chest port to be cleansed with saline solution, patted dry, packed with iodoform(a strip embossed with iodine) and covered with s sterile dressing twice a day. Review of Resident R209's Treatment Administration Record (TAR) the treatment had not been completed from 2/23/24, evening shift through 2/27/24, dayshift, missing missing six treatments. Review of the clinical record indicated that Resident R302 was admitted to the facility on [DATE], with diagnoses of a fracture of her left leg, lung disease, malnutrition, communication deficit with constipation and diarrhea both identified. Resident R302 was on stool softeners. An MDS dated [DATE], indicated the diagnoses remained current. Review of a grievance placed by CMS Immediate Advocacy Program dated 2/6/24, indicated that the nursing Home Administrator and Director of Nursing were notified of a concern placed related to Resident R302 being left to sit in a soiled brief for an extended time. During an interview on 3/22/24, at 10:02 a.m., the Director of Nursing confirmed that the facility failed to identify the concern as neglect, failed to investigate the concern and failed to notify the state agencies as required. Review of the clinical record indicated that Resident R37 was admitted to the faiclity on 8/11/22, with diagnoses which included heart failure, traumatic brain injury, cirrhosis of the liver with intermittent ascites related to disease. An MDS dated [DATE], indicated the diagnoses remained current. During the Resident Council meeting on 3/20/24, at 1015 a.m., Resident R37 stated that he had continued neck pain and headaches after he had another resident fall onto him from behind while he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 6 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 - Some seated in his wheelchair. Resident R37 stated t happened around Christmastime. He went on to state he had xrays which did not show anything and a CT scan that the facility had not told him the results and the doctor had not come back in to review with him. He stated that he feels like his hearing is worse now also. Review of a progress note dated 12/24/23, indicated Resident R37 was examined by the Medical Director and told him about the incident and that's when xrays were ordered. During an interview on 3/20/24, at 2:16 p.m., the Director of Nursing stated that an incident report and investigation was not completed as Resident R37 had a brain injury and we decided his memory could be cloudy. Review of Resident R37's xray report of the cervical spine dated 12/26/23, indicated that a fracture could not be excluded and a repeat xray and CT scan were recommended. During a review of the clinical record, the CT scan report had not been obtained by the facility. During a phone interview with the Medical Director on 3/21/24, at 10:00 a.m., the Medical Director stated that he remembered Resident R37's conversation and that he had reviewed the CT scan at the hospital and it showed arthritis and no fracture. The facility then received the report to provide to the survey team, the CT scan had been completed on 1/26/24. During an interview on 3/21/24, at 10:20 a.m., the DON stated that the facility failed to investigate the incident although Resident R37's continued pain and recollection of the incident never changed. 28. Pa Code 201.14(a) Responsibility of licensee. 28. Pa Code 201.18(b)(1)(e )(1) Management. 28. Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 7 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and resident and staff interviews, it was it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for four of four residents (Resident R20, R45, R83, and R145). Residents Affected - Some Findings include: Review of Resident R20's admission record indicated he was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 3/7/24, included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and a seizure disorder. Review of an active physician order dated 3/10/24, indicated Resident R20 should have ACE wraps applied to both legs, on in the morning and off at the hour of sleep. During an observation on 3/20/24, at approximately 11:35 a.m. Resident R20 had his ACE wraps applied in the direction from the knees to the toes. Review of Resident R45's admission record indicated she was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and high blood pressure. Review of a physician order dated 1/20/24, indicated Resident R45 should have ACE wraps applied to both lower extremities every morning and off at the hour of sleep. During an observation on 3/20/24, at approximately 11:40 a.m. Resident R45 failed to have ACE wraps applied. Review of Resident R83's admission record indicated she was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included coronary artery disease and high blood pressure. Review of a physician order dated 3/9/24, indicated Resident R83 should have ACE wraps applied to both lower extremities every morning and off in the evening. During an observation on 3/20/24, at approximately 11:43 a.m. Resident R83 had her ACE wraps applied in the direction from the toes to the knees, and then in the direction from the knees to the toes again. During an interview and observation on 3/21/24, at approximately 11:25 a.m. Resident R83 stated that she had removed the ACE wrap on her left leg due to it being painful from being too tight. Observation of the right leg revealed that the ACE wrap was applied tightly, particularly over the ankle, with significant swelling both above and below the ankle. Review of Resident R145's admission record indicated he was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 8 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 0684 Level of Harm - Minimal harm or potential for actual harm Review of the MDS dated [DATE], included diagnoses of malnutrition (lack of sufficient nutrients in the body) and high blood pressure. Review of a physician order dated 2/27/24, indicated Resident R145 should have compression stockings applied to both lower extremities every morning and off at the hour of sleep. Residents Affected - Some During an observation on 3/20/24, at approximately 11:42 a.m. Resident R145 was noted to have fluid seeping through his compression stocking on outer side of the lower left leg. Further observation of the stocking revealed a circle of dried fluid larger than the current area of seepage. During an observation on 3/21/24, at approximately 11:15 a.m. Resident R145 was noted to have fluid seeping through his compression stocking on outer side of the lower left leg. Further observation of the stocking revealed areas of dried fluid. During an interview on 3/21/24, at 11:17 a.m. Unit Manager Employee E1 confirmed that Resident R145 had seepage present on his compression stockings and that it appeared that new stockings were not applied when the previous were soiled. During an interview on 3/22/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to make certain that residents were provided appropriate treatment and care for four of four 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. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 9 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed and failed to identify needs for increased nutrition for one of five residents (Residents R78). Residents Affected - Few Findings include: Review of Centers for Medicare and Medicaid Services GUIDANCE §483.25(g) indicated that significant weight loss is defined as: 5% or greater in one month 7.5% or greater in three months 10% or greater in six months Altered Nutrient intake, absorption, and utilization: Poor intake, continuing or unabated hunger, or a change in the resident's usual intake that persists for multiple meals, may indicate an underlying condition or illness. Examples of causes include, but are not limited to: -An inadequate amount of food or fluid, including insufficient tube feedings. -Diseases and conditions such as cancer, diabetes mellitus, advanced or uncontrolled heart or lung disease, infection and fever, liver disease, kidney disease, hyperthyroidism, mood disorders, gastrointestinal disorders, pressure injuries or other wounds, and repetitive movement disorders (e.g., wandering, pacing, or rocking). Review of the clinical record indicated Resident R78 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- periodic assessment of resident care needs) dated 2/19/24, included diagnoses of dysphagia following cerebral infarction (difficulty swallowing following a stroke) and malnutrition (lack of sufficient nutrients in the body). Section K: Swallowing / Nutritional Status revealed the use of a feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) while a resident. Review of Resident R78's plan of care for the Need for feeding tube/ potential for complications of feeding tube use related to dysphagia initiated 2/15/24, indicated that Resident R78 is to consume nothing by mouth. Review of Resident R78's plan of care for Alteration in nutritional status initiated 2/19/24, included the goal that Resident R78 will maintain adequate nutritional status as evidenced by maintaining weight within (90)% of (current body weight). On 3/16/24, an order was placed to document Resident R78 ' s weight one time only for three days with the notation that This schedule will appear on the administration record as of the specified start date and will remain until administered or the schedule's end date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 10 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a Dietary Screening for Malnutrition, At Risk for Malnutrition, Morbid Obesity dated 2/14/24, indicated Resident R78 was as risk for malnutrition. An additional screening was initiated on 3/1/24, but showing as incomplete. Review of a Nutritional Assessment dated 2/14/24, indicated Resident R78 did not receive any nutrition by mouth, and utilized a nasogastric tube for tube feeding. An additional screening was initiated on 3/1/24, but showing as incomplete. Review of Resident R78's weight record since admission [DATE]) revealed the following weights: 2/13/24 205.0 pounds 3/19/24 171.8 pounds a loss of 16.20% in 35 days. Review of nurse practitioner's progress notes dated 2/14/24, 2/21/24, 2/27/24, 3/1/24, 3/4/24, 3/13/24, and 3/15/24, all included the verbiage, Based on my clinical judgement, the following statements most accurately reflects this patient's current nutritional status. Pt is at risk for protein malnutrition. Dysphagia s/p (status post) CVA (cerebral vascular accident, stroke), currently on TF (tube feed) for nutrition. Current weight is 205# on 2/13/24 with BMI (body mass index) of 27.8. Review of a nutrition note completed by Registered Dietician Employee E3 on 3/18/24, at 4:55 p.m. revealed Weight is 205# on 2/13/24. No weight changes noted. During an interview with the DON and Dietician Employee E6 on 3/21/24, at 2:16 p.m., indicated that weights are generally done on admission then weekly times four then monthly unless there is a concern then adjusted accordingly. During an interview on 3/21/24, at 2:19 p.m., the Director of Nursing and Dietician Employee E6 confirmed that Resident R7,should have been placed on weekly weight assessments upon admission, and further confirmed that Resident R78's weight loss was not addressed in a timely manner. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 11 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, Centers for Disease Control (CDC) documents, observations, and staff interview, it was determined that the facility to make certain that medications and medical supplies were properly stored and/or disposed of on one of two nursing units (Second-Floor Nursing Unit). Findings include: Review of the facility policy Storage and Expiration Dating of Medications, Biologicals dated [DATE], indicated the facility should ensure that: -Medications and biologicals are stored in an orderly manner. -External use medications and biologicals are stored separately from internal use medications and biologicals. -Medications and biologicals that have an expired dated on the label are stored separate from other medications until destroyed or returned to the pharmacy or supplier. Review of the CDC's NIOSH (National Institute for Occupational Safety and Health) List of Antineoplastic and Other Hazardous Drugs in Healthcare, 2016 dated [DATE], indicated that conjugated estrogens are Known to be human carcinogens. During an observation of the Second-Floor Nursing Unit on [DATE], at 11:31 a.m. the following was observed in the medication room and in the medical supply room: (13) feeding pump bags, with an expiration date of [DATE]. (20) packages of Xeroform (dressing impregnated with petrolatum and an antimicrobial compound) with an expiration date of 06/2022. (24) packages of Xeroform with an expiration date of 01/2023. (1) package of Xeroform with an expiration date of 08/2023. (7) packages of Xeroform with an expiration date of [DATE]. (13) colostomy bags with an expiration date of [DATE]. (8) colostomy wafers with an expiration date of [DATE]. (1) package of Fibracol (collagen wound dressings) with an expiration date of [DATE]. (7) packages of Fibracol with an expiration date of [DATE]. (2) packages of Fibracol with an expiration date of [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 12 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 0761 (1) Molnlycke Melgisorb (gelling fiber dressing) with an expiration date of [DATE]. Level of Harm - Minimal harm or potential for actual harm (1) urethral catheter, with an expiration date of [DATE]. (8) packages of Hydrofera Blue (antibacterial foam dressing) an expiration date of [DATE]. Residents Affected - Some (1) package of Hydrofera Blue an expiration date of [DATE]. (1) Urinary catheter stabilizer with an expiration date of 04/2022. (1) Urinary catheter stabilizer with an expiration date of 02/2023. (25) packages of Steri-strips (skin closure adhesive strip) with an expiration date of 06/2021. (1) Intravenous (IV) access start kit with an expiration date of [DATE]. (1) Sterile field towel with an expiration date of 10/2015. (1) Sterile dressing change kit, open to air, with an expiration date of [DATE]. (1) Sorbaview Shield (clear covering for IV access) with an expiration date of 05/2023. (1) Sorbaview Shield with an expiration date of 05/2023. (7) packages of lubricating jelly with an expiration date of 03/2023. During an observation of the 2nd A/B Hall Treatment Cart stored in the medical supply room, it was noted that the drawer containing treatment supplies was divided into four sections. Top, left section: (1) tube of triamcinolone (prescription skin cream) for Resident R112, opened, undated, not in a bag. (1) tube of triamcinolone for Resident R112, opened and undated. (1) tube of Santyl (prescription wound ointment) for Resident R40, opened, undated, not in a bag. (1) tube of Premarin conjugated estrogen (prescription vaginal cream), for Resident R96, opened, undated, not in a bag. A Hazardous Drug sticker was affixed to the tube. Top, right section: (1) tube of lidocaine cream (prescription pain relief cream) for Resident R300, opened, undated, not in a bag. This resident discharged from the facility on [DATE]. (1) tube of Venelex (prescription ointment for pressure wounds) without a resident name, opened, undated, not in a bag. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 13 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 0761 (1) empty box of Santyl for Resident R40, with the tube next to the box, opened, undated, not in a bag. Level of Harm - Minimal harm or potential for actual harm Bottom, right section: Residents Affected - Some (1) tube of hemorrhoid cream, with a room number written on it for the first floor, opened, undated, not in a bag. (1) tube of hemorrhoid cream, without a name or room number written on it, opened, undated, not in a bag. (1) tube of Santyl for Resident R40, opened, not in a bag. (1) tube of Nystatin (antifungal) cream for Resident R17, opened, undated, not in a bag. Additionally, observed in other drawers in the cart were: (1) tube of Mupirocin ointment (prescription antibacterial ointment), for Resident R301, opened, undated, not in a bag, with an expiration date of 12/2022. This resident discharged from the facility on [DATE]. (1) tube of moisturizing cream for Resident R37, opened, not in a bag. This resident has not resided on the Second-Floor nursing unit since [DATE]. (1) package of rolled gauze, not in packaging. (5) partially used, open to air, packages of Xeroform. During an observation of the B/C Hall Treatment Cart stored in the medical supply room, it was noted that the drawer containing treatment supplies was divided into four sections. Top, left section: (2) tubes of triamcinolone for Resident R100, opened, undated, not in a bag. (2) containers of Nystatin powder for Resident R102, opened, undated, not in a bag. (1) tube of Clotrimazole cream (antifungal cream) for Resident R79, opened, undated, not in a bag. (1) tube of Bacitracin cream (antibacterial cream) for Resident R63, opened, undated, not in a bag. Bottom, left section: (1) tube of Clotrimazole cream (antifungal cream) for Resident R79, opened, undated, not in a bag. (1) tube of ammonium lactate cream (prescription skin cream) for Resident R86, opened, undated, not in a bag. Top, right section: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 14 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 0761 (1) tube of Bacitracin cream for Resident R63, opened, undated, not in a bag. Level of Harm - Minimal harm or potential for actual harm (1) tube of athlete's foot cream, with a room number written on it for the first floor, opened, undated, not in a bag. Residents Affected - Some Bottom, right section: (1) tube of Diclofenac gel (prescription pain relieving gel) for Resident R112, opened, undated, not in a bag. (1) tube of Premarin conjugated estrogen, for Resident R96, opened, undated, not in a bag. A Hazardous Drug sticker was affixed to the tube. Additionally, observed in other drawers in the cart were: (1) tube of antifungal cream, without a name or room number written on it, opened, undated, not in a bag. (1) tube of triamcinolone for Resident R63, opened and undated. (1) tube of stomahesive paste (skin barrier paste used with colostomies), without a name or room number written on it, opened, undated, not in a bag. (1) tube of triple antibiotic ointment, without a name or room number written on it, opened, undated, not in a bag. During an interview on [DATE], at approximately 12:15 p.m. Unit Manager Employee E1 confirmed the above observations. During an interview on [DATE], at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that medications and medical supplies were properly stored and/or disposed of on one of two nursing units. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 15 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of dish machine temperature/sanitation logs, observations, and staff interviews, it was determined that the facility failed to follow proper sanitation and temperature procedures for the dish machine operation allowing for the potential for cross contamination in the main kitchen for seven of nine months (July 2023, August 2023, October 2023, November 2023, January 2024, February 2024 and March 2024). Findings include: During a observation of the staff use of the low temperature dish machine, the Assistant Dietary Manager Employee E4 stated that she did not know what the temperatures of the dish machine wash should be or the sanitation level that is required to make certain the dishes and items being washed were sanitized and clean for resident use. During an review of the dish machine temperature logs from January 2024 through March 2024. The previous logs from July 2023 through December 2023 identified wash temperatures required to be 120 degrees and sanitation levels at 50 to 100 parts per million (PPM). Further review of the logs indicated the following: July 2023 6 of 31 days the wash temperature did not reach 120 degrees August 2023 the sanitizer documented level was a line from 8/1 through 8/31. October 2023 two of 31 days the wash temp was below 120 and two of 31 days the documented wash temp was not completed. on 5 of 31 days the sanitization level was not documented. November 2023, the wash temperature was 140 through the 15th then a line indicated the temp, no number. on 1 of 30 days a sanitization level was not indicated. January, February and March 2024, the log had no indication of a value that needed to be met to ensure cleanliness and sanitation levels were met. January log had 3 of 31 days of wash temp not documented or not met for breakfast. There were three days of wash temps documented for lunch and none for dinner. Sanitation levels were documented on 11 days for breakfast only. February log had not sanitation levels documented as being completed. March had no sanitation levels completed. During an interview on 3/19/24, at 9:42 a.m., Dietary Manager Employee E5 confirmed that the facility failed to to follow proper sanitation and temperature procedures for the dish machine operation allowing for the potential for cross contamination in the main kitchen for seven of nine months reviewed. 28 Pa. Code: 211.6(c)(d)(f) Dietary services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 16 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on facility policy, observation, and staff interview, it was determined that the facility failed to provide a safe and sanitary environment to help prevent the potential for cross-contamination for two of four medication carts (2nd A/B Hall Treatment Cart and B/C Hall Treatment Cart). Residents Affected - Some Findings include: Review of the facility policy Storage and Expiration Dating of Medications, Biologicals dated 1/23/24, indicated the facility should ensure that medications and biologicals are stored in an orderly manner and that external use medications and biologicals are stored separately from internal use medications and biologicals. During an observation of the 2nd A/B Hall Treatment Cart stored in the medical supply room, it was noted that the drawer containing treatment supplies was divided into four sections. Top, left section: (1) tube of triamcinolone (prescription skin cream) for Resident R112, not in a bag. (1) tube of Santyl (prescription wound ointment) for Resident R40, not in a bag. (1) tube of Premarin conjugated estrogen (prescription vaginal cream), for Resident R96, not in a bag. Top, right section: (1) tube of lidocaine cream (prescription pain relief cream) for Resident R300, not in a bag. This resident discharged from the facility on 4/13/23. (1) tube of Venelex (prescription ointment for pressure wounds) without a resident name, not in a bag. (1) empty box of Santyl for Resident R40, with the tube next to the box, not in a bag. Bottom, right section: (1) tube of hemorrhoid cream, with a room number written on it for the first floor, not in a bag. (1) tube of hemorrhoid cream, without a name or room number written on it, not in a bag. (1) tube of Santyl for Resident R40, opened, not in a bag. (1) tube of Nystatin (antifungal) cream for Resident R17, not in a bag. Additionally, observed in other drawers in the cart were: (1) tube of Mupirocin ointment (prescription antibacterial ointment), for Resident R301 not in a bag. This resident discharged from the facility on 6/21/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 17 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 0880 Level of Harm - Minimal harm or potential for actual harm (1) tube of moisturizing cream for Resident R37, not in a bag. This resident has not resided on the Second-Floor nursing unit since 4/3/23. During an observation of the B/C Hall Treatment Cart stored in the medical supply room, it was noted that the drawer containing treatment supplies was divided into four sections. Residents Affected - Some Top, left section: (2) tubes of triamcinolone for Resident R100, not in a bag. (2) containers of Nystatin powder for Resident R102, not in a bag. (1) tube of Clotrimazole cream (antifungal cream) for Resident R79, not in a bag. (1) tube of Bacitracin cream (antibacterial cream) for Resident R63, not in a bag. Bottom, left section: (1) tube of Clotrimazole cream (antifungal cream) for Resident R79, not in a bag. (1) tube of ammonium lactate cream (prescription skin cream) for Resident R86, not in a bag. Top, right section: (1) tube of Bacitracin cream for Resident R63, not in a bag. (1) tube of athlete's foot cream, with a room number written on it for the first floor, not in a bag. Bottom, right section: (1) tube of Diclofenac gel (prescription pain relieving gel) for Resident R112, not in a bag. (1) tube of Premarin conjugated estrogen, for Resident R96, not in a bag. A Hazardous Drug sticker was affixed to the tube. Additionally, observed in other drawers in the cart were: (1) tube of antifungal cream, without a name or room number written on it, not in a bag. (1) tube of triamcinolone for Resident R63, opened and undated. (1) tube of stomahesive paste (skin barrier paste used with colostomies), without a name or room number written on it, not in a bag. (1) tube of triple antibiotic ointment, without a name or room number written on it, not in a bag. During an interview on 2/21/24, at approximately 12:15 p.m. Unit Manager Employee E1 confirmed the above observations, and further confirmed that the co-mingling of multiple residents' medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 18 of 19 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 395743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carnegie Park Post Acute 1848 Greentree Road Pittsburgh, PA 15220 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 0880 and medications with different administrative routes created the potential for cross-contamination. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/22/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Infection Preventionist Employee E2 confirmed that the facility failed to provide a safe and sanitary environment to help prevent the potential for cross-contamination for two of four medication carts. Residents Affected - Some 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395743 If continuation sheet Page 19 of 19