Inspection·May 11, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **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 develop and implement comprehensive care plans to address resident's needs for two of four residents (Resident R1 and Closed Record Resident CR2). Findings include: Review of facility policy Person-Centered Care Plan dated 2/1/23, indicated: Person-centered care means to focus on the patient as the focus of control and support the patient in making their own choices and having control over their daily life. Care plan includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition and mental and psychosocial needs that are identified. Resident R1 was admitted to the facility on [DATE], with diagnosis of COPD (a group of lung diseases that block the airways and make it difficult to breathe), hereditary & idiopathic neuropathy (nerve abnormalities), and major depressive disorder (persistently depressed mood or loss of interest in activities). These diagnosis remained current from the MDS (minimum data set - a brief periodic review of resident needs ) dated 3/1/23. Review of resident orders included the following: change the foley catheter monthly #16/10cc (catheters are thin hollow tubes used to collect urine from the bladder. Urinary catheter size is determined by the external diameter of the tube. The gauge used for determine this number is known as the French Size) every evening shift starting on 13th and ending on the 14th every month, change urinary catheter as needed for obstructive uropathy, irrigate foley catheter with 60cc sterile water as needed for occlusion, and maintain foley catheter #16/10cc every shift for obstructive uropathy. During an interview with Licensed Practical Nurse (LPN) Employee E1 indicated the following: that he/she was working on another nursing unit and came over to help due to the residents nurse being busy. LPN Employee E1 took in a Nurse Aide to help because they knew that Resident R1 did like to get their catheter changed. During an interview with Registered Nurse (RN) Employee E2 indicated the following: RN Employee E2 came into Resident R1 to assist with catheter change due to Resident R1 did not like to have their catheter changed. Review of clinical record failed to include behaviors of Resident R1. CR2 was re-admitted to the facility on [DATE], with the following diagnosis of stroke (damage to the brain from interruption of blood supply), hypertension (force of the blood against the artery wall is too high) and depression (persistent sadness). These diagnosis remained consistent as of the MDS dated [DATE]. Review of Resident R2 clinical record indicated an area on coccyx on 3/9/23. Further review of clinical record failed to include a care plan for the area on CR2 coccyx. During an interview on 5/11//23 at 2:35 p.m Nursing Home Adminstrator (NHA) indicated that CR2 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 2 of 5 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 05/11/2023 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in need of a bariatric bed. Review of the clinical record failed to include any information on CR2 being care planned for a bariatric bed or being in need of a bariatric bed. During an interview on 5/11/23, at 2:11 p.m. NHA and Director of Nursing confirmed that the facility failed to implement comprehensive care plans for Resident R1 behaviors during catheter change, and for CR2 for an area on coccyx and for needing a bariatric bed. 28. Pa Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 3 of 5 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 05/11/2023 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 interview, it was determined that the facility failed to complete wound assessments on a consistent basis for one of three sampled residents with developed areas (Closed Record Resident R2). Residents Affected - Few Findings include: Closed Record Resident R2 was re-admitted to the facility on [DATE], with the following diagnosis of stroke (damage to the brain from interruption of blood supply), hypertension (force of the blood against the artery wall is too high) and depression (persistent sadness). These diagnosis remained consistent as of the MDS (minimum data set - a brief periodic assessment of resident needs) dated 1/6/23. Review of MDS dated [DATE], Section M0210 unhealed pressure ulcers/injuries indicated that Resident R2 had no unhealed pressure ulcers. Review of care plans indicated no care plan for pressure ulcer and a care plan for being at risk for skin integrity. Review of clinical progress notes indicated the following: Additional clinical notes on 3/9/23, indicated Note text: 2 areas if incontinence dermatitis noted to her Intergluteal cleft (groove between the buttocks ). Proximal (situated near the center of the body) area has dark red tissue that measures skin alteration note: .7cmL x.7cmW x .2cmD. Scant amount of blood to wound base. Surrounding skin is normal in appearance. Distal (situated away from the center) area is superficial. Dark pink moist tissue measures .5cmL x .6cmW. Surrounding skin is normal in appearance. CRNP made aware. New order received to treat them with Puracol. Family updated. 3/16/23: nutrition note resident with weight loss significant 30 days, resident weight at 245.8 BMI 37.4 indicating obese weight for height, no pressure areas noted however is followed by nursing for areas on Intergluteal cleft. 3/21/23: skin alteration note (do not use for pressure ulcer) indicated that area turned into one area. Review of clinical record failed to include any documentation for the 3/13/23, with sizing and staging. Review Closed Record Resident R2 hospital record indicated the following: Patient presented with subacute suprapubic abdominal pain, back pain, and encephalopathy; was started on Ciprofloxacin on 3/22 at Resident R2 SNF (Skilled Nursing Facility) for UTI (urinary track infection) but sent to Emergency Department on 3/23 due to ongoing confusion/lethargy. On admission was afebrile and hemodynamically stable, but with leukocytosis,(gram negative - rods most common pathogens associated with UTI's)bacteremia, and MRI spine concerning for phlegm vs diacritics/osteomyelitis. Source is most likely hematogenous spread an indwelling catheter line and a necrotic sacral pressure ulcer. Diagnosis of unstageable sacral decubitus ulcer. Pt has unstageable, necrotic pressure ulcer on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 4 of 5 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 05/11/2023 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)

F 0686 sacrum, appears to have some tunneling but unclear exactly how deep it goes. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/11/23, at 2:17 p.m. with NHA (Nursing Home Administrator) and DON (Director of Nursing), identified the area as MASD (moisture associated skin damage). Residents Affected - Few During an interview on 5/11/23, at 4:07 p.m. with NHA and DON confirmed that the facility failed to complete wound assessments on a consistent basis for Closed Record Resident R2. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 5 of 5