Inspection·November 30, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Interview on 11/30/23, at 2:15 p.m. the Nursing Home Administrator confirmed the facility failed to maintain a clean homelike environment for four of eight resident rooms (Resident room [ROOM NUMBER]B, room [ROOM NUMBER]B, room [ROOM NUMBER]B, and room [ROOM NUMBER]B). 29 Pa. Code 201.29 (j) Resident Rights Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 2 of 12 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 11/30/2023 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident clinical records, facility policy and staff interviews it was determined the facility failed to provide care and treatments related to dialysis care for one of two residents (Resident R10), and failed to provide consistent and complete communication with the dialysis center for two of two residents (Resident R10 and R245). Residents Affected - Some Findings include: Review of the facility policy Hemodialysis Catheters - Access and Care of dated 10/4/23, indicated the AV fistula (arteriovenous fistula - a connection made by a surgeon of an artery to a vein for vascular access for dialysis) to prevent infection and clotting, keep the access site clean at all times, do not use the access limb to take blood pressure, do not use the access site limb to take blood samples, administer IV fluid or give injections, check for signs of infection at the access site while providing routine care and at regular intervals, and palpate the site to feel the thrill (a vibration caused by blood flowing through the fistula), or use a stethoscope (an instrument used to hear sounds produced within the body) to hear the whoosh or bruit (a whooshing sound that can be heard in the fistula) of blood flow through the access. Review of the facility policy Care of Central Dialysis Catheters dated 10/4/23, indicated the central catheter site must be kept clean and dry at all times. Bathing and showering are not permitted with this device. Catheter lumens (the tubes that come out of the skin) should be capped and clamped when not in use. The nurse should document every shift the following: location of the catheter, condition of dressing (interventions if needed), any part of report from dialysis nurse post dialysis being given and observations post dialysis. Review of the facility policy Dialysis Hemodialysis (HD) - Communication and Documentation dated 10/4/23, indicated the center staff will communicate with the dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis treatments received at the dialysis facility. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data set (MDS - a periodic assessment of care needs) dated 11/15/23, indicated the diagnoses of End Stage Renal Disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), high blood pressure, and anemia (the blood doesn ' t have enough healthy red blood cells). Section O-0100 J indicated dialysis while a resident. Review of Resident R10's physician orders on 11/28/23, at 1:00 p.m. failed to indicate orders for the care and monitoring of an access device for hemodialysis. Review of Resident R10's care plan dated 8/28/23, indicated do not draw blood or take blood pressure in arm with graft. Review of Resident R10's Hemodialysis Communication Records indicated 21 of the last 23 hemodialysis communication sheets were incomplete either prior to leaving the facility, entries during care at the dialysis center, and assessments upon return to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 3 of 12 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 11/30/2023 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 11/28/23, at 1:10 p.m. Registered Nurse (RN) Manager Employee E2 confirmed the facility failed to provide consistent and complete communication with the dialysis center for Resident R10 on 21 of 23 days. Review of Resident R10's physician orders on 11/28/23, at 1:00 p.m. failed to indicate orders for the care and monitoring of an access device for hemodialysis. Review of Resident R10's care plan dated 8/28/23, indicated do not draw blood or take blood pressure in arm with graft. Review of Resident R10's Hemodialysis Communication Records indicated 21 of the last 23 hemodialysis communication sheets were incomplete either prior to leaving the facility, entries during care at the dialysis center, and assessments upon return to the facility. Interview on 11/28/23, at 1:10 p.m. Registered Nurse (RN) Manager Employee E2 confirmed the facility failed to provide consistent and complete communication with the dialysis center for Resident R10 on 21 of 23 days. Observation of Resident R10's right arm on 11/28/23, at 1:05 p.m. indicated the presence of an AV fistula and a tessio catheter to the chest. Interview with Resident R10 on 11/28/23, at 1:06 p.m. indicated the right arm device no longer works, the catheter in his chest can be used, and the AV fistula is now in his left thigh and it was used for dialysis treatment this past Monday. Interview with the Director of Nursing on 11/28/23, at 1:15 p.m. confirmed the facility did not have physician orders to monitor the failed right arm device, the tessio catheter to the chest, and the AV fistula to the left thigh and failed to provide care and treatments related to dialysis care for one of two residents (Resident R10). Review of Resident R245's clinical record indicated the resident was admitted to the facility on [DATE]. Diagnoses included end stage renal disease and dependence on renal dialysis. Review of Resident R245's current physician orders dated 11/30/23, indicated dialysis treatments on Tuesday, Thursday and Saturday, effective 11/21/23, check dialysis form prior to departure in a.m. to make sure entire form is completed, and check dialysis book upon return from the facility and complete nurse section. Review of Resident R245's care plan initiated 11/18/23, included a care focus of renal failure/insufficiencies with interventions to coordinate dialysis care with dialysis treatment center. Review of Resident R245's progress note dated 11/21/23, indicated the resident's vital signs were taken prior to dialysis. Review of Resident R245's Hemodialysis Communication Records indicated a hemodialysis communication sheet was not completed prior to leaving the facility, entries during care at the dialysis center, and assessments upon return to the facility. During an interview on 11/30/23, at 11:35 a.m. Registered Nurse (RN) Unit Manager Employee E4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 4 of 12 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 11/30/2023 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some confirmed the facility failed to provide consistent and complete communication with the dialysis center for Resident R245 on 11/21/23. Interview on 11/30/23, at 2:15 p.m. the Director of Nursing confirmed the facility failed to provide care and treatments related to dialysis care for one of two residents (Resident R10), and failed to provide consistent and complete communication with the dialysis center for two of two residents (Resident R10 and R245). 28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services. 28 Pa. Code 211.10 (c) Resident Care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 5 of 12 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 11/30/2023 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 0760 Ensure that residents are free from significant medication errors. 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, manufacturer's recommendations, observation, clinical record and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of two residents (Resident R45). Residents Affected - Few Findings include: Review of facility policy, Insulin Pens dated 10/4/23, indicated practice standards included insulin pens (pens that come preloaded with insulin- a medication used to control blood sugar) be primed prior to each use to prevent the collection of air in the insulin reservoir (a place where something is kept). Review of manufacturers guidelines for Insulin Lispro (a short acting, manmade version of human insulin) indicated to prime the Pen before each injection. Priming the Pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the Pen is working correctly. If the Pen is no primed before each injection, the resident may get too much or too little insulin. Review of admission record indicated Resident R45 admitted to the facility on [DATE]. Review of Resident R45's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/10/23, indicated the diagnoses of anemia (blood doesn't have enough healthy red blood cells), high blood pressure, and diabetes (too much sugar in the blood). During a medication administration observation on 11/27/23, at 12:18 p.m. Licensed Practical Nurse (LPN) Employee E1 indicated Resident R45 required Lispro two units subcutaneously injected, dialed the Novolog pen to two units, then injected Resident R45, failing to prime the needle prior to administration. During an interview on 11/27/23, at 12:20 p.m. LPN Employee E1 indicated she was not aware of the practice to prime the needle prior to administration. During an interview on 11/27/23, at 12:35 p.m. Registered Nurse Manager (RN) Employee E2 confirmed that LPN Employee E1 failed to prime the Lispro pen when administering insulin and confirmed the facility committed a significant medication error for one of two residents reviewed (Residents R45). 28 Pa. Code: 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 6 of 12 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 11/30/2023 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, resident interviews, staff interviews and observations it was determined the facility failed to provide the residents with food and drink that is palatable and at a safe and appetizing temperatures for two of two lunch meals observed (Lunch Meals on 11/29/23, on [NAME] Unit and Medbridge/TCU units). Residents Affected - Few Findings include: Review of facility titled Food and Nutrition Services Policies and Procedures last reviewed 11/13/23, informed foods are stored, prepared and served in a safe and sanitary manner to prevent bacterial contamination. Hazard Analysis Critical Control Points (HACCP) flow charts are used when handling, preparing, cooling, storing, reheating, and reserving food. Review of the HACCP flow chart informed the hot holding temperature for beef is 145 degrees Fahrenheit of above. Review of the HACCP flow chart in formed the hot holding temperature for vegetables, rice, pasta, legumes is 135 degrees Fahrenheit or above. Review of the HACCP flow chart informed the cold holding temperature for cold ready to eat foods is 40 degrees Fahrenheit or below. During an interview on 11/27/23, at 10:45 a.m. Resident R252 reported the food is served cold. During an interview on 11/27/23, at 1:40 p.m. Resident R11 reported the food is served cold at dinner time. During a group interview conducted on 11/28/23, at 1:30 p.m. Residents R500, R501, R502, R503, R504, R505, R506, R507, R508, R509, R510, R511 and R512 reported the meals are served cold and ice cold. Review of the Resident Council Minutes dated 11/20/23, revealed complaints/comments of residents requesting a microwave on each unit, and menu and requests ideas/suggestions of food carts that plug in to keep food warm. During a [NAME] Unit test tray observation on 11/29/23, at 11:45 a.m. the following temperatures were observed: Meat loaf - 139.5 degrees Fahrenheit Milk - 55.9 degrees Fahrenheit During a Medbridge/TCU Unit test tray observation on 11/29/23, at 12:05 p.m. the following temperatures were observed: Meat loaf - 130.2 degrees Fahrenheit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 7 of 12 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 11/30/2023 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 0804 Mashed potatoes - 125.1 degrees Fahrenheit Level of Harm - Minimal harm or potential for actual harm Milk - 56.3. degrees Fahrenheit Residents Affected - Few During an interview on 11/29/23, at 12:08 p.m. the Food Service Director Employee E confirmed the temperatures of the test tray and that the facility failed to provide the residents with food and drink that is palatable and at a safe and appetizing temperatures. 28 PA Code: 211.6(b)(c)(d) Dietary services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 8 of 12 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 11/30/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on facility policies, observations and staff interviews, it was determined that the facility failed to perform hand washing to prevent the potential for cross contamination in the Main Kitchen and failed to perform handwashing between tasks in the main dining room during meal service. Findings include: Review of the facility policy Food Handling last reviewed on 8/1/23 and 11/13/23, indicated food is prepared with a minimal of handling. Employees wear disposable gloves when handling food and are considered single-use items and are discarded when damaged, soiled, and after each use. Employees must wash their hands before putting on disposable gloves. Review of the facility policy Hand Washing last reviewed on 8/1/23 and 11/13/23, indicated handwashing is preformed before preparing or handling food, before putting on disposable gloves to begin a task that involves food, during food preparation, as often as necessary to clean soiled hands, and when moving from one task to another. During an observation of tray line service in the main kitchen on 11/27/23, from 10:55 a.m. through 12:00 p.m. the following was observed: Dietary Aide Employee E9 did not wash her hands, donned disposable gloves, removed her cell phone from her pants pocket to check the time, replaced the cell phone in her pocket, and proceeded to start tray line placing silverware on the trays wearing the same gloves and not washing her hands. Dietary [NAME] Employee E7 started tray line with disposable gloves on, removed the lids from the food and began plating foods. Dietary [NAME] Employee E7 walked away from tray line twice to walk across the kitchen to retrieve hanging portion servers, returned and continued tray line without washing her hands and changing gloves. Dietary [NAME] Employee E6 placed bottom portions of plates on heater to warm, one fell on the floor and was picked up with left hand and placed to the side. Dietary [NAME] Employee E6 removed disposable glove from left hand and continued to heat the plates with the gloved right hand. Then, without washing her hands or changing her gloves, she then left the tray line, went to the refrigerator, removed two slices of American cheese and proceeded to cook a grilled cheese. Once the grilled cheese was finished, it was plated and placed for Dietary [NAME] Employee E7 to serve. Dietary [NAME] Employee E6 then returned to tray line to resume heating plates without washing her hands and changing gloves between tasks. Dietary Aide Employee E8 did not wash his hands, donned disposable gloves, and was placing the loaded plates onto trays and loaded the food carts for delivery on the floor. When the food carts were full, he pushed the carts out to the hallway to be delivered to the units touching the food cart, and door, then returned to load more plates onto trays and load more into food carts without washing his hands or changing his disposable gloves between tasks. During an interview on 11/27/23, at 11:20 a.m. the Dietary Manager Employee E3 confirmed the facility failed to prevent the potential for cross-contamination during tray line. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 9 of 12 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 11/30/2023 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 0812 28 Pa. Code: 211.6(c)(d)(f) Dietary services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 10 of 12 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 11/30/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observation, and staff interviews it was determined that the facility failed to follow proper infection control technique during a dressing change (Resident R298). Residents Affected - Few Findings: Review of the facility policy Wound Dressings: Aseptic last reviewed 10/4/23, indicated no touch technique is a method of changing surface dressings without directly touching the wound or any surface that might come in contact with the wound. Clean gloves are used along with sterile solution/supplies/dressings that are maintained as clean. The nurse should clean and disinfect the over-bed table. Perform hand hygiene. If a break in aseptic technique occurs, stop the procedure, remove gloves, perform hand hygiene, and apply clean gloves. Unused supplies are discarded according to infection control procedure or remain dedicated to the patient and stored appropriately. During an observation of a dressing change on 11/29/23, at 10:30 a.m. with Licensed Practical Nurse (LPN) Employee E10 the following was observed: -LPN donned gloves, cleansed the scissors. -removed gloves, gathered supplies at the cart and taken into resident ' s room. -resident ' s door was closed for privacy. -LPN placed a towel on the resident ' s bed and placed supplies on towel. -LPN placed a bag containing Dakin ' s solution (antiseptic solution developed to treat infected wounds), and a bottle of wound packing on the resident ' s nightstand. -LPN washed hands and donned gloves. -old dressing was removed from left buttock wound, saline solution (a mixture of salt and water often used to clean wounds because it is gentle and does not damage the tissue) was removed from the clean towel, wound cleansed. LPN failed to cleanse hands and change gloves when moving from a dirty surface to a clean surface. -Alcohol Based Hand Sanitizer (ABHS) was used and gloves changed. - dressing supplies opened -skin prep applied around wound, treatment cut to size with scissors. -LPN reached into her pocket to get a pen, wrote initials and date on the bordered gauze, returned her pen to her pocket. -treatment was placed on wound and covered with border gauze. LPN failed to cleanse hands and change gloves when moving from a clean surface, to a dirty one, and back to the clean surface. -ABHS used and gloves changed. Towel on resident ' s bed picked up and moved to other side of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 11 of 12 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 11/30/2023 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 0880 bed for next wound. Level of Harm - Minimal harm or potential for actual harm -bag of Dakins solution and packing removed from nightstand to over-bed table. -LPN failed to cleanse the over-bed table prior to placing items. Residents Affected - Few -Dakin ' s solution placed in medicine cup and packing cut to size and placed in Dakin ' s solution using cotton-tipped applicators. -old dressing removed from right buttocks wound. saline and gauze removed from towel, wound cleansed. -LPN failed to cleanse hands and change gloves when moving from dirty surface to clean surface. -ABHS used, gloves changed. -wound dried, skin prep applied around wound edges, packing placed in wound with cotton-tipped applicator. -border gauze opened, LPN reached into her pocket for her pen, initialed and dated the border gauze, then replaced pen back in pocket. -border gauze applied to wound. LPN failed to cleanse hands and change gloves when moving from a clean surface, to a dirty one, and back to the clean surface. -bag with Dakins solution and bottle of packing was taken to cart and placed back into the treatment cart. During an interview on 11/29/23, at 11:00 a.m. LPN Employee E10 confirmed she failed to cleanse hands prior to switching between dirty and clean surfaces. During an interview on 11/29/23, at 12:20 p.m. the Nursing Home Administrator confirmed the facility failed to follow proper infection control technique during a dressing change for Resident R298. 28 Pa. Code: 211.10(d) Resident Care Policies. 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 12 of 12