Health inspection·May 10, 2024

F 0689 Total Dependence: 59 of 90 times (approximately 66%). Level of Harm - Actual harm Extensive Assistance: 25 of 90 times (approximately 28%). Residents Affected - Few Limited Assistance: 6 of 90 times (approximately 6%). Review of a progress note dated 5/5/24, at 10:10 p.m. revealed, Called to Nursing Unit by nursing. Resident sitting on the floor next to her bed. 2 CNAs (nurse aides) had just transferred her to bed using the Hoyer lift. The CNA was changing her because she was incontinent of urine; she was turned onto her left side and slid off the bed and landed on her buttocks with her knees bent; resident stating My left knee is broken resident wiggles toes and can move feet. Unable to lift legs which is the resident's baseline. resident stating 10/10 pain to left knee; no swelling or bruising; no open areas; resident unable to move; [Provider] notified; Order received to transfer resident to the Emergency department for evaluation. Review of facility provided information/documentation dated 5/6/24, indicated On 5/5/24 at approx. 10:10 pm while CNA (nurse aide) was providing incontinence care, in bed, while resident was rolled to her left side, her legs slid off of the mattress. CNA was unable to lift resident's legs back into bed due to lymphedema (the build-up of fluid in soft body tissues) and obesity and assisted resident to the floor. Resident landed on her knee and buttocks and complained of left leg pain. Resident was immediately assessed by nurse. Family and MD notified. Review of a statement written by Nurse Aide (NA) Employee E1 dated 5/6/24, revealed I [NA Employee E1] 3-11 shift witness. My resident [Resident R1] slid off the bed while doing the resident care. Today. 03-5th-2024 (5/6/24) Sunday at 10:00 p.m. Me [NA Employee E1] and my co-worker [NA Employee E2] transferred [Resident R1] to her bed using Hoyer lift after that, my coworker [NA Employee E2] had to go attend her residents on C-Hall. I helped [Resident R1] to roll to her left side holding the bed rails, which she usually does. I changed her. I was about to be done she wet the bed again and I had to change the entire bed. I tugged the bed set underneath her. She started screaming, I am going to fall so I tried to pull her back but she was too big for me to pull her. I ran in front of her, her left side and there wasn't so much I could do so I helped her land on a floor her leg she was on her knee and she straightened it out but she was complaining about her left leg pain. I notified the charge nurse. Review of hospital documentation dated 5/6/24, at 2:12 a.m. indicated an x-ray of the left knee was completed, which revealed a fracture of the distal femoral diaphysis (fracture of the lower portion of the upper leg bone). During a follow-up, clarification interview completed on 5/10/24, at 12:27 p.m. NA Employee E1 confirmed that she was the only staff member providing care to Resident R1 when she slid from the bed. NA Employee E1 stated that she was on the side of the bed closest to the room window. She confirmed that Resident R1 was rolled away from her, and due to Resident R1's size, she was unable to reach over her to provide incontinence care, and had to be positioned behind her to reach to clean her. NA Employee E1 stated that when Resident R1 began to slide from the bed, she ran to the other side of the bed to try to catch her, and began yelling out for other staff to assist her. NA Employee E1 stated that no other staff heard her yell, and she was unable to keep Resident R1 from fully sliding to the floor. NA Employee E1 also stated it is not usual for a resident to be rolled away from the person providing care; normally she doesn't ever do that when providing care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396124 If continuation sheet Page 2 of 3 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 396124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Point Healthcare Residence 200 Adams Ave Pittsburgh, PA 15243 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 interview with NA Employee E2 on 5/10/24 at 1:00 p.m., confirmed that residents should be rolled towards the person providing care. Level of Harm - Actual harm Residents Affected - Few During an interview on 5/10/24, at approximately 1:30 p.m. the Nursing Home Administrator in training confirmed that the facility failed to provide appropriate assistance to prevent falls, resulting in actual harm of a leg fracture for Resident R1. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.20(a)(b) Staff development 28 Pa. Code 201.29(a)(c)(d) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396124 If continuation sheet Page 3 of 3