Inspection·October 2, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide care to a resident who had not received scheduled medication for one of four residents (Resident R1). Residents Affected - Few Findings include: Review of the facility policy Medication Administration dated May 2024, indicated the facility will administer all medications consistent with standard of care and prescribed by the physician/designee. Review of the facility policy Medication Incident Report dated May 2024, indicated the physician will be notified of a medication error and recommendations will be received. Review of the clinical record indicated Resident R1 was readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/22/24, included diagnoses of malnutrition (lack of sufficient nutrients in the body) and orthostatic hypotension (a sudden drop in blood pressure upon standing from a sitting or lying position). Review of Section C: Cognitive Patterns indicated Resident R1 had moderate cognitive impairment. Review of the facility diagnosis list included diagnoses of high blood pressure and paroxysmal atrial fibrillation (a type of irregular heartbeat that resolves on its own or with treatment). Review of Resident R1's blood pressure record for August 2024 revealed one assessment completed on 8/1/24. Review of Resident R1's Medication Administration Record (MAR) indicated that on 8/9/24, Registered Nurse (RN) Employee E1 documented that the following scheduled medications (scheduled at 9:00 a.m.) were provded: -2.5 milligrams (mg) Eliquis (medication to prevent blood clot formation). -2 mg Immodium (medication to treat diarrhea). -10 milliequivalents (mEq) Klor-Con (potassium supplement). -5 mg Midodrine (medication to treat orthostatic hypotension). (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 2 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 10/02/2024 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)