Health inspection·May 21, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and documentation, staff and resident interview it was determined that the facility failed to protect resident from neglect for one of three residents (Resident R1). Findings include: Review of facility policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated November 2024 through November 2025, indicated: Neglect is the failure of the home, its employees, or service providers to provide goods and services to a Resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress Resident R1 was admitted to the facility on [DATE]. Resident R1 MDS (minimum data set periodic assessment of resident needs) dated 4/14/25, indicated diagnosis of Parkinson's disease ( a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance), bipolar disease (mental health condition causes extreme mood swings) and anxiety disorder. Review of facility documentation submitted to the state survey office dated 5/2/25, indicated Medical driver took 2 residents to AGH hospital for 2 different appointments, took one resident in hospital and went back to get Resident R1 out of the van when Medical Driver noticed he didn't have the lift up and tried to pull her back but she fell to the ground striking the left side. Resident R1 was immediately surrounded by paramedics and hospital staff and she was put into ER to be evaluated and treated. Review of facility documentation witness statement from Employee E1 Medical Driver indicated that the lift was not up and they confirmed that they failed to put the lift into the proper position. During an interview on 5/20/25, at 4:35 p.m. Director of Nursing (DON) confirmed that Employee E1 Medical Driver did fail to put the lift in the appropriate position, and Resident R1 did fall from the van. During an interview on 5/20/25, at 4:40 p.m. DON was informed that the facility failed to protect Resident R1 from neglect with the van lift not being in the appropriate position and Resident R1 failing form the van. Page 1 of 4 396116 396116 05/21/2025 Little Sisters of the Poor 1028 Benton Avenue Pittsburgh, PA 15212

F 0600 28 Pa. Code 201.14(a) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.10 (a) (d) Resident care policies Residents Affected - Few 396116 Page 2 of 4 396116 05/21/2025 Little Sisters of the Poor 1028 Benton Avenue Pittsburgh, PA 15212

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. 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 review and resident and staff interview it was determined that the facility failed to provide medically related social services for one of three resident reviewed (Resident R1). Residents Affected - Few Findings include: Resident R1 was admitted to the facility on [DATE]. Resident R1 MDS (minimum data set periodic assessment of resident needs) dated 4/14/25, indicated diagnosis of Parkinson's disease ( a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance), bipolar disease (mental health condition causes extreme mood swings) and anxiety disorder. Review of facility documentation submitted to the state survey office dated 5/2/25, indicated: Medical driver took 2 residents to AGH hospital for 2 different appointments, took one resident in hospital and went back to get Resident R1 out of the van when Medical Driver noticed he didn't have the lift up and tried to pull her back but she fell to the ground striking the left side. Resident R1 was immediately surrounded by paramedics and hospital staff and she was put into ER to be evaluated and treated. Review of facility documentation indicated a psychiatric progress note completed on 5/12/25, with the following concerns/recommendations: Background information: long standing Bipolar disorder, Hx of past hallucinations History of present psychiatric illness: 5/12/25, psych visit: 1 week ago fell out of a van when lift not in alignment . Resident keeps asking same questions and insist she hit her head though she didn't according to staff. Obsessing about incident. Interview with resident: Resident R1 would like to see a counselor again, especially now that she can't stop thinking about the fall out of van. States she talks about it with everyone and has a hard time not thinking about it. Impressions: Mood ok., but displays preoccupation with thoughts of recent fall, would like to talk with therapist about this so she can stop thinking over it again and again. Recommendations: Please obtain psychology counseling for Resident R1, especially in light of recent trauma in May 2025. During interview on 5/21/25, at 9:50 a.m. Social Service Employee E2 indicated that the facility 396116 Page 3 of 4 396116 05/21/2025 Little Sisters of the Poor 1028 Benton Avenue Pittsburgh, PA 15212

F 0745 Level of Harm - Minimal harm or potential for actual harm has not had a counseling service that comes in since last year, they currently do not have a counseling appointment set up for Resident R1 and the facility failed to provided medical social services for Resident R1. 28 Pa. Code 211.10(a) Resident care policies Residents Affected - Few 396116 Page 4 of 4