Health inspection·February 19, 2026

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 interview, it was determined that the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance. Findings include:Review of the facility policy Abuse Policy-Prevention and Identification, dated 4/17/25, indicated it is the facility's policy to deploy staff on each shift in sufficient numbers and assure staff assigned have knowledge of the individual residents' care needs. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS periodic assessment of resident care needs) dated 1/11/26 included diagnoses of cellulitis (bacterial infection affecting the skin's deep layers) and muscle weakness. Review of Section GG: Functional Abilities indicated that Resident R1 required dependent assistance (two or more helpers) for chair/bed-to-chair transfers.Review of an on-call physician note dated 2/5/26 at 4:12 p.m. indicated, nurse calls to report resident was being assisted back to bed earlier and hit his left leg on the edge of the bed and caused a laceration. Per nurse measurements are 6cmx 0.5x0.25. Some bleeding earlier but not currently bleeding.Review of a progress note dated 2/5/26 at 6:03 p.m. indicated, CNA alerted this nurse that resident was bleeding from left lateral leg. Upon inspection this nurse observed a 6cmx0.5cmx0.0cm laceration to the left lateral lower leg. This resident stated, ‘My leg got dragged on the side of the bed when being transferred from my wheelchair to bed'.Review of facility submitted information on 2/5/26, indicated on 2/5/26 at 4:00 p.m., [Resident R1] reported that when was being transferred from his wheelchair to his bed by CNA [nurse aid], when his left leg hit the bed and he sustained a cut. Resident was assessed by the RN (registered nurse) and telehealth was completed. First aide provided to the resident per MD (medical doctor) order. Area was cleansed and Steri strips applied and area covered with dry dressing.Review of an employee statement via phone by NA Employee E1, dated 2/5/26 indicated, transferred the resident from the wheelchair to the bed without another employee.Review of Resident R1's plan of care for ADLs (activities of daily living) Functional Status / Rehabilitation Potential, not initiated until 2/6/26, indicated that the resident will have staff assist of two with all transfers for safety. The plan of care did not indicate assist of two prior to 2/6/26.Review of the facility's plan of correction included:-Wound will be monitored for signs/symptoms of infection. -Nursing care plan updated to include any new orders. -Interventions are put into place to prevent injuries or reduce the risk of injuries for individual resident needs. -All residents are assessed on admission, quarterly and upon incident for appropriate care plan adjustments. -All incidents and accidents are tracked and trended by the quality assurance committee and reviewed for recommendations to prevent injuries. Review of facility provided education information and on-going quality assurance measures revealed facility staff received education on accident prevention, falls, and reviewing ADL information in the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395745 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 395745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Meadows Health & Rehab Center 1717 Skyline Drive Pittsburgh, PA 15227 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)