Health inspection·October 23, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to protect a resident from neglect that resulted in actual harm of a left humerus (upper arm) fracture for one of six residents reviewed (Resident R1). This was identified as harm for past non-compliance.Findings include:Review of facility document entitled, Abuse, Neglect, and Misappropriation dated 4/17/25, indicated neglect is the failure of the facility to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Review of Resident R1's admission record indicated she was admitted to the facility on [DATE] and readmitted on [DATE].Review of the Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 6/30/25, included diagnoses of hemiplegia of left side (paralysis or weakness on one side of the body), diabetes and a history of falls.Review of the MDS dated [DATE], Section GG: Functional Abilities, Section GG0170 indicated Resident R1was dependent on staff for bed to chair transfer.Review of Resident R1's plan of care for ADL (activities of daily living) Self Care performance - hemiplegia affecting left side dated 6/18/24, requires resident to have an assist of two for transfers and lying to sitting on the side of the bed requires an assist of two helpers.Review of Resident R1's Kardex (Listing of ADLs, continence levels, and behaviors, which generates directly from the resident care plan) utilized by nurse aide staff dated 9/30/25, indicated that Resident R1 as requiring 2 or more helpers for bed to chair transfers and lying to sitting on the side of the bed, and two persons and a mechanical lift.Review of progress note dated 9/30/25, at 4:00 p.m. indicated Resident R1 had fallen out of bed and complained of left shoulder pain. Left shoulder x-ray was ordered and the resident was given Tylenol for pain to the left shoulder.Review of facility incident report dated 9/30/25, indicated CNA was attempting to transfer resident and she slid out of bed.Review of an x-ray report dated 10/1/25, indicated Resident R1 sustained a fracture to the left humerus.Review of CNA Employee E1's statement written on 9/30/25 indicated I sat resident up at the edge of the bed waiting for help, and the force of sitting her up made her slide forward and she hit her shoulder on something while sliding and she ended up on the floor.A review of CNA Employee E1's personnel file indicated a hire date of 9/10/25, and employee E1 received competencies in the ability to confirm appropriate transfer methods per the plan of care, assisting with transfers, and transferring residents safely.Review of the facility submitted report form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 10/1/25 indicated Employee E1 attempted to transfer Resident R1 without an assist of 2 persons as required and was terminated.During an interview on 10/23/25, at 3:30 p.m. the Nursing Home Administrator confirmed that the facility failed to protect a resident from neglect that resulted in actual harm for one of six residents which resulted in actual harm of a fractured left humerus to Resident R1.On 10/3/25, the facility-initiated education for all direct care nursing staff including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Page 1 of 6 395745 395745 10/23/2025 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0600 Level of Harm - Actual harm Residents Affected - Few Nurse Aides (NAs) to ensure that ordered transfer guidelines were understood and followed appropriately.This plan included the following:-Immediate termination of NA Employee E1.-Facility completed a full house audit to ensure correct transfer statuses were documented for each resident.-Education was provided on 10/3/25, to all nursing staff on abuse and neglect.-Audits and education were reviewed with the Quality Assurance and Performance Improvement Committee for trends and outcomes.During interviews on 10/22/25 from 1:10 p.m. to 2:45 p.m., revealed the following:CNA Employee E2 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E3 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E4 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E5 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E6 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E7 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E8 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E9 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E10 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E11 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E13 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E12 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E13 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E14 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E15 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E16 confirmed the use of orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E17 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E18 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E19 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional 395745 Page 2 of 6 395745 10/23/2025 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0600 Level of Harm - Actual harm Residents Affected - Few safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E20 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E21 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E22 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E23 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E24 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.During interviews on 10/22/25, (CNA Employees E1, E2, E3, E4, E5, E6, E7, E8, E9, E10, E11, and E12), confirmed they received point of care training on 10/3/25, for bed mobility and safe transfers.The facility has demonstrated compliance with the regulations since 10/16/25.During an interview on 10/23/25, at 4:00 p.m. with the Nursing Home Administrator and Director of Nursing, and review of the facility's immediate actions, education, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring the prevention of resident neglect. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 201.20(b)(1) Staff Development.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.11(d) Resident care plan.28 Pa Code 211.12(d)(1)(2)(5) Nursing services. 395745 Page 3 of 6 395745 10/23/2025 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

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 review of facility policies and documents, clinical record review and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent a fall that resulted in the actual harm of a left humerus (upper arm) fracture for one of six residents (Resident R1). This was identified as past noncompliance.Findings include:Review of facility policy, Incidents/Accidents dated 4/17/25, indicated It is the policy of the facility to provide a safe and healthy environment for residents, visitors, and employees by minimizing possible exposure to safety hazards to the extent applicable. The facility is to ensure that residents are handled and transferred safely.Review of facility policy, Routine Resident Care dated 4/17/25, indicated It is the policy of the facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs. The facility will provide routine daily care by a certified nursing assistant (CNA) with training in rehabilitation/restorative care including maintaining proper body position and alignment and assisting with transfers. Review of clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 6/30/25, included diagnoses of hemiplegia of left side (paralysis or weakness on one side of the body), diabetes and a history of falls.Review of the MDS dated [DATE], Section GG: Functional Abilities, Section GG0170 indicated Resident R1was dependent on staff for bed to chair transfer.Review of Resident R1's plan of care for ADL (activities of daily living) Self Care performance - hemiplegia affecting left side dated 6/18/24, requires resident to have an assist of two for transfers and lying to sitting on the side of the bed requires an assist of two helpers.Review of progress note dated 9/30/25, at 4:00 p.m. indicated Resident R1 had fallen out of bed and complained of left shoulder pain. Left shoulder x-ray was ordered and the resident was given Tylenol for pain to the left shoulder.Review of facility incident report dated 9/30/25, indicated CNA was attempting to transfer resident and she slid out of bed.Review of an x-ray report dated 10/1/25, indicated Resident R1 sustained a fracture to the left humerus.Review of CNA Employee E1's statement written on 9/30/25 indicated I sat resident up at the edge of the bed waiting for help, and the force of sitting her up made her slide forward and she hit her shoulder on something while sliding and she ended up on the floor.A review of CNA Employee E1's personnel file indicated a hire date of 9/10/25, and employee E1 received competencies in the ability to confirm appropriate transfer methods per the plan of care, assisting with transfers, and transferring residents safely.Review of the facility submitted report form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 10/1/25, indicated Employee E1 attempted to transfer Resident R1 without an assist of 2 persons as required and was terminated.During interviews on 10/22/25 from 1:10 p.m. to 2:45 p.m., revealed the following:CNA Employee E2 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E3 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E4 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E5 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E6 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E7 confirmed the use 395745 Page 4 of 6 395745 10/23/2025 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0689 Level of Harm - Actual harm Residents Affected - Few of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E8 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E9 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E10 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E11 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E13 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E12 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E13 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E14 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E15 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E16 confirmed the use of orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E17 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E18 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E19 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E20 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E21 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E22 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E23 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E24 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.During interviews on 10/22/25, (CNA Employees E1, E2, E3, E4, E5, E6, E7, E8, E9, E10, E11, and E12), confirmed they received point of care training on 10/3/25, for bed mobility and safe transfers.During review of facility policy, published documents, clinical record review and staff interviews, it was determined that the facility failed to protect residents from neglect for one of six residents (Resident R1). The facility has 395745 Page 5 of 6 395745 10/23/2025 Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227

F 0689 Level of Harm - Actual harm Residents Affected - Few demonstrated compliance with the regulations since 10/16/25During an interview on 10/23/25, at approximately 3:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a left humerus (upper arm) fracture for one of six residents (Resident R1). This was identified as past noncompliance. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)( e)(1) Management.28 Pa. Code 201.29(a) Resident Rights.28 Pa. Code 211.10 (c )(d) Resident care policies.28 Pa. Code 211.12 (d)(1)(2)(5) Nursing Services. 395745 Page 6 of 6