Inspection·April 4, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations and staff interviews it was determined that the facility failed to maintain a homelike environment one nursing unit for 23 of 23 residents residing on that unit (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20 , R21, R22 and R23) residents. Findings include: Based on review of facility policy Condition of Participation dated 1/3/23, indicated that .the building housing the organization provides a functional, sanitary and comfortable environment. During observations on 4/4/23, from 10:11 a.m. to 11:00 a.m. the following was observed: Resident R1/R2: Doors to room and bathroom with scratches, base board appeared to be grey at the bottom. Resident R3/R4: Doors to room and bathroom with scratches black marks, wall paper with black marks with scratches, base board appeared to be grey at bottom. Resident R5/R6: Door to room with scratches Resident R7/R8: Base board appeared to be grey at the bottom. Resident R9/R10: Door to room and bathroom had scratches/black marks on them, base board appeared to be grey at the bottom. Resident R11/R12: Doors for room and bathroom had scratches/black marks on them. Resident R13/R14: Doors for room and bathroom had scratches/black marks on them, base board appeared to be grey at the bottom. Resident R15/R16: Door for room with scratches/black marks, wallpaper peeling, base board appeared to be grey at the bottom. Resident R17/R18: Door for room and bathroom had scratches/black marks on them, wallpaper had scratches, base board appeared to be grey at the bottom. (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: 395783 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 395783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peters Township Post Acute 113 West McMurray Road McMurray, PA 15317 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)