Inspection·June 21, 2024

F 0660 Condition Pink was called and the ground were searched. Level of Harm - Minimal harm or potential for actual harm Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/1/24, indicated the resident had an unplanned discharged to home/community and his return was not anticipated the same day of his elopement. Residents Affected - Few Review of Resident R1's physician orders dated 6/1/24, failed to include an order to discharge the resident. Review of Resident R1's progress note dated 6/2/24, entered by RN, Employee E8 at 5:23 a.m. stated Resident left facility alone, on 3-11 shift on 6/1/24. He has not called or returned. Review of Resident R1's progress note dated 6/2/24, entered by RN, Employee E7 at 8:37 a.m. indicated multiple hospitals were contacted in attempts to locate the resident. He was not found at this time. The police were contacted for an update on report filed yesterday. Waiting on return call. Review of Resident R1's clinical record failed to provide further information on Resident R1's whereabouts after 6/2/24. Review of Resident R1's Hospital Records dated 6/6/24, indicated emergency medical services (EMS) found Resident R1 lying supine on the ground, unresponsive in an alley in town in the pouring rain. Resident R1 was unresponsive except for deep painful stimuli. He had an obvious compound fracture (a break or crack in your bone that is visible through your skin), with active bleeding to the right foot at the bottom of the tibia/fibula (two bones that form your lower leg) where it met the ankle. A bystander indicated Resident R1 was possibly struck by a car. The patient had a minor abrasion to the right side of his forehead. Resident R1 became combative and started swinging and not making comprehensible sounds. Police assisted in restraining the resident, and he was sedated during the course of transport to the hospital as a level one trauma (Level 1 trauma is for the most serious injuries, where trauma is often large and requires a fast response time). Review of Resident R1's Hospital Records dated 6/6/24, indicated Resident R1 was admitted to the hospital with open right distal tibia/fibula, left 12th rib fracture, and left anterior (at or near the front) shoulder dislocation after being found down in alley after being struck by vehicle. It was indicated the resident had surgery on his right leg. During an interview on 6/18/24, at 1:42 p.m. the Director of Nursing (DON) stated This gentleman kept wanting to leave AMA (Against Medical Advice-a form of discharge from the facility in which a patient chooses to leave before the treating physician recommends discharge). During an interview on 6/18/24, at 2:34 p.m. the Director of Nursing stated Resident R1 was discharged from facility same day he eloped (occurs when a resident exits to an unsupervised or unauthorized area without the facility's knowledge). The DON stated Resident R1 was discharged against medical advice. During an interview on 6/20/24, at 9:08 a.m. the DON and Nursing Home Administrator confirmed the facility failed to complete a timely and safe discharge for Resident R1. 28 Pa. Code 211.11(d)e Resident care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395883 If continuation sheet Page 2 of 14 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 395883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgh Care Center 909 West Street Pittsburgh, PA 15221 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, clinical records, and staff interviews it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of 16 residents who was identified as high risk for elopement (Resident R1). The facility failed to provide adequate supervision during smoking times for 11 of 11 residents observed (Residents R2, R3, R4, R6, R7, R8, R9, R10, R11, R12, and R13), failed to complete safe smoking assessments, maintain an updated list of current smokers, implement care plans reflective of residents' smoking needs, and have adaptive equipment needs for smoking safely. This created an Immediate Jeopardy situation for 24 of 24 residents that smoke. Findings include: Review of the facility policy Wandering and Elopements, last reviewed 4/1/24, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Residents will be screened regularly for risk for wandering and elopement. The resident's care plan will include strategies and interventions identified appropriate. Review of the facility policy Signing a Resident Out, last reviewed 4/1/24, indicated all residents leaving the premises must be signed out. Staff observing a resident leaving the premises and having doubts about the resident being properly signed out, should notify their supervisor at once. Review of the facility policy Smoking Policy, last reviewed 4/1/24, indicated it is the facility policy to allow residents to smoke in approved areas and at approved times. It was indicated any fire lighting products is prohibited to be in a resident's possession for the safety of every resident. Smoking materials (cigarettes and lighters) are to be stored at the nurse's station/front desk. Each resident that smokes will be assessed for their own individual abilities and circumstances and care planned for this ability. Residents are strongly encouraged to wear a smoking apron while smoking. The designated smoking times are for 30 minutes increments and are everyday at 10:00 a.m., 2:00 p.m., and 7:00 p.m. Review of the facility policy, Safety and Supervision of Residents last reviewed 4/1/24, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Review of Resident R1's clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses of diffuse traumatic brain injury with loss of consciousness, high blood pressure, and alcohol abuse. Review of Resident R1's Admission/Re-Admit Eval V10.6-2023 dated 5/25/24, indicated the resident had a history of elopement or an attempted elopement while at home and at the facility without informing staff. It was indicated the resident was identified as an elopement risk and a care plan for elopement must be initiated. Review of Resident R1's progress note dated 5/26/24, at 10:41 a.m. Registered Nurse, Employee E2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395883 If continuation sheet Page 3 of 14 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 395883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgh Care Center 909 West Street Pittsburgh, PA 15221 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 0689 stated resident requires frequent orienting regarding why he's in facility. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident R1's progress note dated 5/30/24, Nurse Practitioner, Employee E3 indicated the resident was deemed per psychiatry not to have capacity to make decisions. The resident was recently admitted after being found down, seizures (a sudden, uncontrolled burst of electrical activity in the brain) requiring intubation (technique doctors use to keep airway open by inserting a tube into the windpipe to keep the airway open) and intensive care unit (ICU) management. Residents Affected - Some Review of Resident R1's progress note dated 5/31/24, Registered Nurse Assessment Coordinator (RNAC), Employee E4 at 9:30 a.m. stated a licensed practical nurse (LPN) came down hall to tell this RN that resident is more confused thinks he just got here last evening and that he has address in Wilkinsburg that he needed to get today and would be leaving. Nursing Home Administration (NHA) was alerted, staff alerted to monitor his whereabouts every 10-15 minutes, front staff alerted with picture of resident. Staff will continue to monitor and intervene as necessary. Review of Resident R1's WEC: Elopement Risk Evaluation V10.1-10.2023 dated 5/31/24, at 10:15 a.m. indicated the resident was an elopement risk and the facility staff should proceed with identification of resident as an elopement risk including but not limited to wander guard placement and facility notification. It was indicated to proceed to care plan and initiate. Review of Resident R1's progress note dated 5/31/24, RN, Employee E5 at 12:44 p.m. indicated the resident was alert with obvious signs of intermittent confusion. The resident reported wanting to walk up the street to a nearby restaurant where a friend work so that he can alert her to his whereabouts. Review of Resident R1's progress note dated 5/31/24, LPN, Employee E6 at 2:06 p.m. indicated the resident attempted to go out the front doors. This write called to lobby to bring resident back to floor. Review of Resident R1's care plan dated 5/31/24, failed to identify the resident as an elopement risk and failed to initiate any interventions. Review of the facility's electronic bulletin message board dated 5/31/24, entered by the NHA stated PLEASE MAKE SURE ROUNDS ARE BEING DONE AND ALL RESIDENTS ARE ACCOUNTED FOR- WE MUST KNOW WHERE ALL RESIDENTS ARE AT ALL TIMES. NO ONE SHOULD BE ON THE SECOND OR FIRST FLOOR. PLEASE ALSO REVIEW THE UPDATED ELOPEMENT BINDERS. Review of Resident R1's progress note dated 6/1/24, RN, Employee E7 stated I was notified that resident eloped during smoke break stating that he was going to the store and never returned. Condition Pink was called, and the ground were searched. It was indicated a Condition Pink requires staff to stop what they ' re doing and assist on locating the missing resident in the facility. If the resident is not located then the DON and NHA is notified, as well as the resident's family, physician, police. Review of RN, Employee E7's witness statement dated 6/1/24, indicated she was notified that Resident R1 left the premises during smoke break. Receptionist, Employee E14 who staffs the front desk stated that he took everyone out for the break because that's what he always does. RN, Employee E7 stated she was informed the resident walked towards GetGo, I walked over there to see if resident was there, and no one had seen him. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395883 If continuation sheet Page 4 of 14 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 395883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgh Care Center 909 West Street Pittsburgh, PA 15221 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Review of Receptionist, Employee E14's witness statement dated 6/1/24, stated Staff took residents out for their 7 p.m. smoke break, while passing everyone a cigarette Resident R1 walked off. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/1/24, indicated the resident had an unplanned discharged to home/community and his return was not anticipated the same day of his elopement. Residents Affected - Some Review of Resident R1's progress note dated 6/2/24, RN, Employee E8 at 5:23 a.m. stated Resident left facility alone, on 3-11 shift on 6/1/24. He has not called or returned. Review of Resident R1's Hospital Records dated 6/6/24, indicated emergency medical services (EMS) found Resident R1 lying supine on the ground, unresponsive in an alley in town in the pouring rain. Resident R1 was unresponsive except for deep painful stimuli. He had an obvious compound fracture (a break or crack in your bone that is visible through your skin), with active bleeding to the right foot at the bottom of the tibia/fibula (two bones that form your lower leg) where it met the ankle. A bystander indicated Resident R1 was possibly struck by a car. The patient had a minor abrasion to the right side of his forehead. Resident R1 became combative and started swinging and not making comprehensible sounds. Police assisted in restraining the resident, and he was sedated during transport to the hospital as a level one trauma. Review of Resident R1's Hospital Records dated 6/6/24, indicated Resident R1 was admitted to the hospital as level one trauma with open right distal tibia/fibula, left 12th rib fracture, and left anterior (at or near the front) shoulder dislocation after being found down in alley after being struck by vehicle. It was indicated the resident had surgery on his right leg. During an interview on 6/18/24, at 9:44 a.m. Front Desk Receptionist Employee E9 stated the duties of the receptionist include answering calls, opening the door, and to keep an eye on the residents, on the ones that escape. Front desk receptionist, Employee E9 stated no residents are allowed to leave the facility unattended and during smoke breaks a designated smoke monitor is always with them. It was indicated an elopement binder is located at the front desk. During an interview on 6/18/24, at 1:01 p.m. LPN, Employee E10 stated on admission everyone gets a smoking and elopement assessment. During an interview on 6/18/24, at 1:03 p.m. Nurse Aide, Employee E11 stated during smoke breaks, the person supervising is responsible for the residents. On the weekends the Registered Nurse Supervisor must do it on the weekends. NA, Employee E11 indicated anyone that wanders, staff must keep an eye on. During an interview on 6/18/24, at 1:10 p.m. LPN Employee E12 was asked how she knows if a resident is an elopement risk and stated it usually comes in their paperwork, but a lot of times you can't see paperwork until there is a problem. LPN, Employee E12 stated any new admission gets a screening, and if identified as an elopement risk it is usually given in verbal report, there are no wrist bands or stickers to identify them. There is no wander guard system here, so that is problematic. LPN, Employee E12 stated the front desk is not supposed to not let any residents out, they must call and assist resident back where they belong. LPN, Employee E12 stated my understanding is during the week on evenings someone is there, then at nighttime the supervisor should sit at desk. Review of the facility's list of accidents and incidents for the month of June 2024, reviewed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395883 If continuation sheet Page 5 of 14 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 395883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgh Care Center 909 West Street Pittsburgh, PA 15221 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 0689 6/18/24, failed to include Resident R1's elopement that occurred on 6/1/24. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 6/18/24, at 1:39 p.m. the NHA confirmed Resident R1's elopement was not on the list of accidents and incidents for June 2024 provided by the facility. Residents Affected - Some During an interview on 6/18/24, at 1:42 p.m. the Director of Nursing (DON) stated she is unsure why Resident R1's elopement is not shown on the list of incidents and accidents. The DON brought in a folder a filled with variety of witness statements and provided seven witness statements, the DON kept the rest of folder indicating that the other statements are not pertaining to Resident R1. The DON stated This gentleman kept wanting to leave AMA (Against Medical Advice-a form of discharge from the facility in which a patient chooses to leave before the treating physician recommends discharge)-. He only had one family member, like an aunt. When I called her, she said he does this all the time. During an interview on 6/18/24, at 2:04 p.m. the Director of Nursing stated RN, Employee E7 was responsible for supervising residents when Resident R1 eloped from the facility during a smoke break on 6/1/24, and she was terminated from her attitude towards the incident. The DON, stated Resident R1 was alert and oriented although he is sickly. The DON stated the nurse wouldn ' t give him AMA, so since he didn ' t give it to him, he took himself out of here. The DON stated Resident R1 was not a smoker and sometimes residents who are not smokers go outside with smokers. During an interview on 6/18/24 at 2:16 p.m. the DON confirmed the facility failed to implement a care plan for Resident R1's elopement risk. During an interview on 6/18/24, at 2:34 p.m. the DON stated she was notified by Resident R1's family member that he was found at the hospital on 6/6/24. During an interview on 6/20/24, at 9:08 a.m. the NHA and DON indicated Receptionist, Employee E14 was the one monitoring residents during a smoke break on 6/1/24, when Resident R1 eloped. The DON indicated residents who do not smoke go outside with smokers. It was indicated Receptionist, Employee E14 no longer works at the facility because he quit showing up. Review of Resident R2's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated the resident had diagnoses of anxiety, depression, and muscle weakness. Review of Resident R2's clinical record from 1/10/24, to 6/19/24, failed to include a smoking evaluation was completed. Review of Resident R2's care plan dated 6/12/24, failed to include a care plan for smoking. During an observation on 6/18/24, at 10:21 a.m. Resident R2 was observed smoking outside. Review of the facility's undated smoking list failed to include Resident R2. Review of Resident R3's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses of asthma, chronic obstructive pulmonary disease (a chronic inflammatory lung (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395883 If continuation sheet Page 6 of 14 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 395883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgh Care Center 909 West Street Pittsburgh, PA 15221 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 0689 disease that causes obstructed airflow from the lungs), and fibromyalgia (a disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue, and sleep disturbances.) Level of Harm - Immediate jeopardy to resident health or safety Review of Resident R3's clinical record from 6/13/24, to 6/19/24, failed to include a smoking evaluation was completed. Residents Affected - Some Review of Resident R3's care plan dated 6/14/24, failed to include a care plan for smoking. During an observation on 6/18/24, at 10:21 a.m. Resident R3 was observed smoking outside. Review of the facility's undated smoking list indicated Resident R3 was a smoker. Review of Resident R4's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R4's clinical record indicated a smoking assessment dated [DATE], indicated the resident requires supervision while smoking, a smoking apron, and the facility must hold cigarettes and lighter. No further smoking assessments were completed. Review of Resident R4's MDS dated [DATE], indicated the resident had diagnoses of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) and encephalopathy (an abnormality of brain function or structure). Review of Resident R4's care plan last revised 3/18/24, failed to include a care plan for smoking. During an observation on 6/18/24, at 10:21 a.m. Resident R4 was observed smoking outside without an apron. The facility failed to implement safe smoking interventions as per his most recent smoking assessment completed on 5/29/23. Review of the facility's undated smoking list failed to include Resident R4. Review of Resident R6's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R6's MDS dated [DATE], indicated the resident had diagnoses of Human Immunodeficiency Virus (HIV), anemia (deficiency of healthy red blood cells in blood), and muscle weakness. Review of Resident R6's safe smoking evaluation dated 4/16/24, indicated the resident always requires supervision and a smoking apron. Review of Resident R6's care plan dated 4/16/24, indicated the resident is a smoker and must wear a smoking vest and supervision while smoking. During an observation on 6/18/24, at 10:21 a.m. Resident R6 was observed smoking outside without an apron. The facility failed to implement safe smoking interventions as per his most recent smoking assessment completed on 4/16/24. Review of Resident R7's clinical record indicated the resident was admitted to the facility on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395883 If continuation sheet Page 7 of 14 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 395883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgh Care Center 909 West Street Pittsburgh, PA 15221 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 0689 [DATE], with diagnoses of alcohol abuse alcohol dependence with alcohol-induced persisting dementia and tobacco use. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident R7's clinical record from 6/17/24, to 6/19/24, failed to include a safe smoking evaluation was completed. Residents Affected - Some Review of Resident R7's care plan dated 6/17/24, failed to include a care plan for smoking. During an interview and observation on 6/18/24, at 10:11 a.m. Resident R7 was observed pulling his cigarettes and lighter out of his pocket. Medical Records Employee E13 stated he arrived last night and we have to get his cigarettes. Medical Records Employee E13 stated new people come all the time, smoker list changes. Medical Records, Employee E13 confirmed no current smoker list was being utilized. During an observation on 6/18/24, at 10:21 a.m. Resident R7 was observed smoking outside. Review of the facility's undated smoking list failed to include Resident R7. Review of Resident R8's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R8's care plan dated 1/29/24, indicated the resident is a smoker and requires supervision and a smoking apron while smoking. Review of Resident R8's MDS dated [DATE], indicated the resident had diagnoses of anemia, seizure disorder, and Wernicke's encephalopathy (a neurological disorder caused by the lack of thiamine (also known as vitamin B1, a water-soluble vitamin that enables the body to use carbohydrates as energy). Review of Resident R8's safe smoking evaluation dated 4/16/24, indicated the resident always requires supervision. During an observation on 6/18/24, at 10:21 a.m. Resident R8 was observed smoking outside. Review of the facility's undated smoking list failed to include Resident R8. Review of Resident R9's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses of COPD, tobacco use, and cocaine abuse. Review of Resident R9's safe smoking evaluation dated 6/11/24, indicated the resident always requires a smoking apron and supervision. Review of Resident R9's care plan dated 6/15/24, failed to include a care plan that reflected the resident's smoking needs, and adaptive equipment needs for smoking safely. During an observation on 6/18/24, at 10:21 a.m. Resident R9 was observed smoking outside without an apron. The facility failed to implement safe smoking interventions as per his most recent smoking assessment completed on 6/11/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395883 If continuation sheet Page 8 of 14 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 395883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgh Care Center 909 West Street Pittsburgh, PA 15221 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 0689 Review of the facility's undated smoking list failed to include Resident R9. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident R10's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses of Wernicke's Encephalopathy, alcohol dependence, and anemia. Residents Affected - Some Review of Resident R10's clinical record from 6/14/24, to 6/19/24, failed to include a safe smoking evaluation was completed. Review of Resident R10's care plan dated 6/17/24, failed to include a care plan for smoking. During an observation on 6/18/24, at 10:21 a.m. Resident R10 was observed smoking. Review of the facility's undated smoking list failed to include Resident R10. Review of Resident R11's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses of high blood pressure, muscle weakness, and polyneuropathy (damage to peripheral nerves). Review of Resident R11's clinical record from 6/6/24, to 6/19/24, failed to include a safe smoking evaluation was completed. Review of Resident R11's care plan dated 6/15/24, failed to include a care plan for smoking. During an observation on 6/18/24, at 10:21 a.m. Resident R11 was observed smoking outside. Review of the facility's undated smoking list failed to include Resident R11. Review of Resident R12's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R12's MDS assessment dated [DATE], indicated diagnoses of seizure disorder, muscle weakness, and osteoarthritis (inflammation of one or more joints). Review of Resident R12's smoking evaluation dated 4/16/24, failed to indicate if the resident can smoke independently or with set up, may smoke unsupervised in designated areas, or be always supervised. The summary of the evaluation was left blank and not completed thoroughly. Review of Resident R12's care plan dated 9/7/23, indicated the facility must secure smoking materials and educate resident on facility policy and procedures for smoking. During an observation on 6/18/24, at 10:21 a.m. Resident R12 was observed smoking outside. Review of Resident R13's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses of high blood pressure, intellectual disabilities, and wheezing. Review of Resident R13's smoking evaluation dated 6/18/24, indicated the resident must be always supervised. The assessment was completed six days after the resident was admitted . Review of Resident R13's care plan dated 6/13/24, failed to include a care plan for smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395883 If continuation sheet Page 9 of 14 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 395883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgh Care Center 909 West Street Pittsburgh, PA 15221 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 0689 During an observation on 6/18/24, at 10:21 a.m. Resident R13 was observed smoking outside. Level of Harm - Immediate jeopardy to resident health or safety During an observation on 6/18/24, at 10:07 a.m. Medical Record, Employee E13 left residents (Resident R2, R3, R4, R6, R7, R8, R9, R10, R11, R12, and R13.) unattended outside to go back inside the lobby to get the water cart. Residents Affected - Some During an interview on 6/18/24, at 1:03 p.m. Nurse Aide, Employee E11 stated during smoke breaks, They all need a smoking apron. That ' s the rule, they all are to have on an apron. During an interview on 6/20/24, at 9:13 a.m. the NHA and DON confirmed the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of 16 residents who was identified as high risk for elopement (Resident R1). The facility failed to provide adequate supervision during smoking times for 11 of 11 residents observed (Residents R2, R3, R4, R6, R7, R8, R9, R10, R11, R12, and R13), failed to complete safe smoking assessments, maintain an updated list of current smokers, implement care plans reflective of residents' smoking needs, and have adaptive equipment needs for smoking safely. This created an Immediate Jeopardy situation for 24 of 24 residents that smoke On 6/20/24, at 10:41 a.m., the NHA and DON were made aware that Immediate Jeopardy (IJ) existed and was provided the IJ Template at that time and a corrective action plan was requested. On 6/20/24, at 3:05 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Elopement: -All residents are being assessed to identify if they are an elopement risk or not. If identified as a risk, an elopement risk assessment will be completed by the director of nursing or designee by the end of the day 6/20/24. -All care plans will be reviewed and updated by the end of the day on 6/20/24. -Assessment and care plans for residents who are elopement risks will be completed by the Director of Nursing or Designee by the end of the day on 6/20/24. -Newly admitted residents are screened for elopement risk upon admission and care plans and assessments done accordingly. -Education began to re-educate all staff on wandering and elopement as well as Safety and Supervision of residents. Education will be conducted by the Director of Nursing or Designee prior to the start of their next scheduled shift. -Additionally, education sent to all active staff member via alert send out (Care feed) and sign off sheet will be signed prior to the start of employee's next shift. -Policies and/or procedures have been reviewed to ensure that staff identify all roles and responsibilities regardingsupervision and surveillance of residents as well as what to do if a resident is identified as missing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395883 If continuation sheet Page 10 of 14 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 395883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgh Care Center 909 West Street Pittsburgh, PA 15221 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 0689 -Resident R1 is no longer a resident at the facility but was located post elopement/AMA. Facility has talked with the family and the hospital and Resident R1 is safe. Level of Harm - Immediate jeopardy to resident health or safety -Elopement Risk Binder update, and staff will be educated on those identified by the end of the day on 6/20/24. Residents Affected - Some -All staff will be in-serviced on the policy for wandering and elopement and supervision starting 6/20/24. -Registered Nurse (RN) Supervisor and or/designee to audit for safe wandering throughout facility weekly for 4 weeks and then monthly for 2 months. -Findings of this audit will be discussed with the Resident Council. -The plan of correction will be monitored at the monthly Quality Assurance meeting until such 0time consistent substantial compliance has been met. Smoking: -All residents who smoke will be identified by the end of the day on 6/20/24. -Smoking assessments will be reviewed and completed/update as needed for identified smokers by the Director of Nursing or Designee by the end of the day 6/20/24. -Resident care plans and assessments will be reviewed and revised by the Director of Nursing or designee by the end of the day on 6/20/24. Revisions will be made to reflect all current supervision and safety interventions for smoking. -Education will begin immediately for all staff on the smoking policy and supervision. Education will be conducted by the Director of Nursing or Designees prior to the start of their next scheduled shift by the end of the day on 6/20/24. -Policies and/or procedures have been reviewed. -Facility will ensure that all residents are assessed for proper smoke equipment and supervision by end of the day on 6/20/24. -All smoking equipment such as lighters and cigarettes/cigars will be stored properly/safely by the end of the day on 6/20/24. -All smokers will be assessed for any injuries they may have incurred while smoking by the end of the day on 6/20/24. -All staff will be in-services on the facility policy for Resident Smoking and Supervision during times starting 6/20/24. -Nursing staff or designee will observe residents while smoking daily to ensure appropriate supervision and implementation of safety interventions as documented on the plans of care daily for 4 weeks and then monthly for 2 months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395883 If continuation sheet Page 11 of 14 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 395883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgh Care Center 909 West Street Pittsburgh, PA 15221 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 0689 -The facility will designate a smoke monitor each smoking time by the end of day on 6/20/24. Level of Harm - Immediate jeopardy to resident health or safety -The management team will oversee assigned caregivers/smoke monitors and residents during designated smoking times to ensure appropriate supervision and interventions are implemented and the plans of care are followed. Residents Affected - Some -The Director of Nursing (DON), or designee, will complete random weekly chart audits for four (4) consecutive weeks. All care plans for residents will be reviewed to ensure that appropriate interventions have been put in place to reduce risk of smoking accidents. -Findings of this audit will be discussed with Resident Council. -This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. During an observation on 6/21/24, at 10:03 a.m. the supervised smoking was observed. Facility staff were present with tackle box containing cigarettes, lighters, and smoking aprons. During an interview on 6/21/24, at 10:58 a.m., Medical Records Employee E13 indicated all residents are encouraged to wear protective aprons, however they have the right to refuse and there is an updated list of all residents that are required to wear aprons. Review of facility's immediate action plan was verified and completed on 6/21/24, at 1:01 p.m. as follows: Elopement: All residents are being assessed to identify if they are an elopement risk or not. If identified as a risk, an elopement risk assessment will be completed by the director of nursing or designee by the end of the day 6/20/24. -77/77 Residents were assessed for elopement risk. 15/77 residents were identified as an elopement risk. All care plans will be reviewed and updated by the end of the day on 6/20/24. -15/15 resident care plans were reviewed and revised as needed for elopement risk and interventions related to risk of wandering. Assessment and care plans for residents who are elopement risks will be completed by the Director of Nursing or Designee by the end of the day on 6/20/24. -77 residents were assessed for risk of elopement and 15/77 residents who were identified as a risk were care planned for interventions. Newly admitted residents are screened for elopement risk upon admission and care plans and assessments done accordingly. -1/1 newly admitted resident was screened for elopement risk and care plan was not needed to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395883 If continuation sheet Page 12 of 14 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 395883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgh Care Center 909 West Street Pittsburgh, PA 15221 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 0689 update because he was not identified as an elopement risk. Level of Harm - Immediate jeopardy to resident health or safety Education began to re-educate all staff on wandering and elopement as well as Safety and Supervision of residents. Education will be conducted by the Director of Nursing or Designee prior to the start of their next scheduled shift. Residents Affected - Some -106/106 staff were educated on the wandering and elopement as well as safety and supervision of residents. Staff were educated where to find Elopement binder of all residents identified as elopement risk and what code is called if resident is discovered missing. 17/17 Staff interviewed in-person confirmed they were educated on the Safety and supervision of residents. 6/6 interviews conducted via phone confirmed staff were educated on importance of supervising residents. 62/106 staff confirmed they received the education prior to the start of their shift. The facility will ensure staff sign off that they were educated prior to the start of their shift. Additionally, education sent to all active staff member via alert send out (Care feed) and sign off sheet will be signed prior to the start of employee's next shift. -106/106 staff were provided education regarding where to find elopement risk binder, code pink, and what to do if resident goes missing on 6/20/24, via alert send out. Staff were provided with policies on wandering and elopements, safety, and supervision of residents, and signing residents out. Policies and/or procedures have been reviewed to ensure that staff identify all roles and responsibilities regarding supervision and surveillance of residents as well as what to do if a resident is identified as missing. -106/106 staff were provided education regarding where to find elopement risk binder, code pink, and what to do if resident goes missing. Staff were educated on wandering and elopements, safety, and supervision of residents, and signing residents out. Resident R1 is no longer a resident at the facility but was located post elopement/AMA. Facility has talked with the family and the hospital and Resident R1 is safe. -Resident R1 will not be returning to facility. Elopement Risk Binder update, and staff will be educated on those identified by the end of the day on 6/20/24. -Review of Elopement Binder on 6/21/24, at 12:22 p.m. revealed a total of 15 residents were identified as an elopement risk. A picture of the resident and their first and last name is listed in the binder. An elopement binder is located at each nursing station and the front desk. All staff will be in-serviced on the policy for wandering and elopement and supervision starting 6/20/24. -106/106 staff were in-serviced on the policy for wandering and elopement and supervision on 6/20/24. Registered Nurse (RN) Supervisor and or/designee to audit for safe wandering t[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395883 If continuation sheet Page 13 of 14 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 395883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgh Care Center 909 West Street Pittsburgh, PA 15221 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed effectively manage the facility to prevent the elopement of a resident and effectively manage the facility to ensure that proper supervision, assessments, and interventions were provided to ensure safe smoking for residents as required. Residents Affected - Many Findings include: The signed job description for Nursing Home Administrator dated 12/4/23, indicated the purpose of this position is to manage the facility in accordance with current federal, state, and local standards governing long-term facilities and to ensure that the highest degree of quality care is provided to the residents at all times. The signed job description for Director of Nursing dated 3/29/24, indicated the purpose of this position is to plan, organize, develop, and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility to ensure residents receive the highest degree of quality care. Based on the findings in this report that identified that the facility failed make certain each resident received adequate supervision which resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of 16 residents who were identified as high risk for elopement (Resident R1) which placed residents in Immediate Jeopardy. The facility failed to complete safe smoking assessments, maintain an updated list of current smokers, implement care plans reflective of residents' smoking needs, and have adaptive equipment needs for smoking safely. This created an immediate jeopardy situation for all residents. The NHA and The DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 6/21/24, at 2:06 p.m. the NHA and DON confirmed they failed to effectively manage the facility to prevent the elopement of a resident and to effectively manage the facility to make certain that proper supervision, assessments, and interventions were provided to ensure safe smoking for residents as required. Refer to F689. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 207.2 (a) Administrator's responsibility. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395883 If continuation sheet Page 14 of 14