Health inspection·July 31, 2024

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 policies, resident clinical records, documentation provided by the facility and staff interview, it was determined that the facility failed to ensure that a resident was free from neglect, which resulted in a skin tear requiring a treatment for one of four residents ( Resident R7). Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR §483.12. Freedom from Abuse, Neglect, and Exploitation defined neglect as the failure of the facility, 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. Review of facility policy Preventing Resident Abuse last reviewed on 5/24, indicated that residents will not be subject to physical, mental, etc. abuse. Annual training of all employees will be conducted to ensure the knowledge of the abuse policy. Policies and procedures have been developed to document the facilities philosophy regarding the elderly. The policies are reviewed and revised as needed to comply with current regulations and standards of care. Close scrutiny of incident reports for targeted residents or trending is completed. The alleged abuser will be informed of the allegation and removed from the area. They will be asked to prepare a statement and may be placed on leave, pending the outcome of the investigation. Review of the facility policy Incident/ Event Report, last reviewed on 5/24, indicated that the facility will track the treatment and evaluation of incidents such as skin tears, lacerations, bruises and falls to formulate preventive practices. Review of the clinical record indicated that Resident R7 was admitted to the facility on [DATE], with diagnoses which included dementia with other behavioral disturbances, atrial fibrillation( irregular heart beat), a pacemaker, difficulty walking, prescience of an artificial heart valve prescience of artificial knees and left hip and malnutrition. Review of the Minimum Data Set (MDS - periodic assessment of a resident's abilities and care needs) dated 6/4/24, indicated the diagnoses remained current. Review of physician orders indicated Resident R7 requires assistance of two for care provided while she is in bed. Review of a progress note dated 4/18/24, indicated that Nurse Aide (NA) Employee E 1 told Licensed Practical Nurse (LPN) Employee E2 that around 5:30 a.m., doing rounds she was turning resident and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 396124 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 07/31/2024 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)