Health inspection·December 4, 2025

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 facility policy, clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of three residents (Resident R1 and Closed Record Resident CR1).Findings include: Review of facility policy Hemodialysis dated 7/24/25, indicated the facility will ensure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The licensed nurse will communicate to the dialysis facility via telephone communication or written format, such as a dialysis communication form or other form. Ongoing assessment and oversight of the resident before, during and after dialysis treatments. Review of the admission record indicated Resident R1 was re-admitted to the facility on [DATE], with the diagnosis of End Stage Renal Disease (ESRD -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), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and seizures (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness). Review of Resident R1's current physician orders indicated dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to) every Monday, Wednesday, and Friday. Chair time 11:30 a.m. Review of Resident R1's current care plan indicated encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis Monday, Wednesday, and Friday. Review of Resident R1's dialysis record of visit forms from 9/10/25 - 9/22/25, indicated six of six visits with incomplete documentation. Review of the admission record indicated Resident CR1 was admitted to the facility on [DATE]. Review of Resident CR1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/4/25, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and dialysis. Review of Resident CR1's physician orders dated 2/17/25, indicated dialysis every Monday, Wednesday, and Friday. Chair time 11:00 a.m. Review of Resident RCR1's care plan indicated encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis three times a week. Review of Resident CR1's dialysis record of visit forms from 9/10/25 - 9/22/25, indicated six of six visits with incomplete documentation. During an interview completed on 10/14/25, at 10:48 a.m. the Director of Nursing confirmed the forms failed to be complete as listed for Resident R1 and CR1. Interview on 10/14/25, at 1:30 p.m. the Director of Nursing confirmed that the facility failed to make certain consistent dialysis communication was maintained for two of three residents (Resident R1 and Closed Record Resident CR1). 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(2)(3) Nursing services Residents Affected - Few Page 1 of 3 395883 395883 12/04/2025 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide behavioral services from outside vendors in a timely and accurate manner for two of three residents (Resident R2 and CR1).Findings include: Review of the facility policy Use of Outside Resources dated 7/24/25, indicated the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services. The facility assumes responsibility for the timeliness of the services provided by those professionals. Review of the admission record indicated that Resident R2 admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/3/25, indicated the diagnosis of high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident R2's clinical record indicated resident was at the hospital from [DATE], through 10/3/25. Further review of Resident R2's clinical record indicated a psychological services progress noted dated 10/2/2025. Start Time: 4:36 p.m. and End Time: 4:55 p.m. Interview on 10/14/25 at 1:00 p.m. the Nursing Home Administrator confirmed that Resident R2 was not in the facility on 10/2/25, as the psychological services progress note indicated. Review of the admission record indicated Resident CR1 was admitted to the facility on [DATE]. Review of Resident CR1's MDS dated [DATE], indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and dialysis. Review of Resident CR1's progress note dated 9/23/25, at 6:13 a.m. indicated Resident CR1 was pronounced dead at 4:38 a.m. Further review of Resident CR1's clinical record indicated a psychological services progress noted dated 10/2/2025. Start Time: 1:04 p.m. and End Time: 1:23 p.m. Interview on 10/14/25, at 1:00 p.m. the Director of Nursing confirmed that Resident CR1 was not in the facility on 10/2/25, as the psychological services progress note indicated, and that CR1 had passed away on 9/23/25. During an interview on 10/14/25, at 1:30 p.m. the Nursing Home Administrator confirmed the facility failed to provide behavioral services from outside vendors in a timely and accurate manner for two of three residents (Resident R2 and CR1). 28 Pa. Code 211.12(d)(3) Nursing services 395883 Page 2 of 3 395883 12/04/2025 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0844 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. Based on a review of regulations, documents submitted to the State agency and staff interviews it was determined that the facility failed to notify the State agency of a change in the facility's Medical Director at the time of the change. Findings include: Review of the facility's data indicated Doctor Employee E1 was the Medical Director effective 1/1/20. During an interview on 10/14/25, at 1:00 p.m. the Nursing Home Administrator indicated Doctor Employee E1 no longer worked there and the new Medical Director was Doctor Employee E2 effective 7/24/25. During an interview on 10/14/25, at 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to notify the State agency of a change in the facility's Medical Director at the time of the change. 28 PA Code: 201.14(a) Responsibility of licensee. 395883 Page 3 of 3