Pennwood Nursing And Rehabilitation Center Llc

F-F695

28 Pa. Code 201.18( e) (1)Management

28 Pa. Code211.12(c )(d)(3) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 68 395883 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395883 B. Wing 04/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Burgh Care Center 909 West Street Pittsburgh, PA 15221

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 49469 potential for actual harm Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed Residents Affected - Many to

prevent cross contamination during a dressing change for one of three residents (Resident Resident R22) failed to prevent cross contamination during a medication pass for two of three residents (Resident Resident R9 and Resident R12) and failed to ensure an infection control surveillance plan was implemented and staff and residents were tested in accordance with national standards.

Findings include:

Review of the facility policy Administering Medication last reviewed 9/18/24, indicate staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precaution, etc. ) for the application if medications.

Review of the facility policy Handwashing/Hand Hygiene last reviewed 9/18/24, indicate the facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personal, residents, and visitors.

Review of the CDC (Center for disease control) Fact Sheet Enhanced Barrier Precaution indicates everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high contact activities including but not inclusive to providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy and wound care: any skin opening requiring a dressing.

Review of the Respiratory Virus Outbreak Toolkit dated 11/14/25, indicated sick health care personnel should stay home until they are fever free for 24 hours without fever-reducing medication. Test anyone showing signs or symptoms of a respiratory illness. Droplet precautions should be implemented for a resident diagnosed with influenza. An outbreak is considered over' when 14 days have passed since the last resident tested positive or became symptomatic (if no positive test). Any new infections in a resident would restart the 14-day countdown. Upon identification of an outbreak, a line list is completed to collect information about all ill cases (residents and staff). Each ill resident or staff member's information should be entered and information should be updated daily during the outbreak for all cases.

Review of the facility policy Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents dated 9/18/24, revealed the infection preventionist is responsible for establishing and overseeing screening and monitoring efforts. All surveillance findings are collected and reviewed daily by the infection preventionist.

Review of the facility policy Coronavirus Disease (COVID-19) - Testing Staff dated 9/18/24, staff are instructed to report symptoms of COVID-19 for further management and test as soon as possible. During an outbreak testing approaches may consist of contact tracing or facility-wide testing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 68 395883 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395883 B. Wing 04/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Burgh Care Center 909 West Street Pittsburgh, PA 15221

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 0880 During an observation completed on 4/2/25, at 12:38 p.m. during a dressing change for Resident Resident R22 the following cross contamination opportunities were observed. Upon entering Resident Resident R22's room Licensed Level of Harm - Minimal harm or Practical Nurse (LPN) Employee E11 placed a garbage bag on the over bed tray table, she exited the room potential for actual harm and returned with a yellow disposable gown retrieved from the over the door bin and placed it on the dresser

in front of Resident Resident R22's TV. LPN Employee E11 placed the dressing supplies on top of it. LPN Employee Residents Affected - Many E11 then donned her personal protective equipment (PPE). LPN Employee E11 removed the soiled dressing and placed into the garbage bag on the over bed table, she then removed her gown and gloves placed into garbage bag, washed her hands applied new gloves and continued to cleanse the wound without utilizing any other PPE. LPN Employee E11 placed the soiled supplies into the garbage bag removed her gloves washed her hands and again donned her PPE to complete the dressing change. Upon completion of dressing change LPN Employee E11 removed her PPE placed into the garbage bag, rolled up the gown from

the TV stand and also placed into the garbage bag. LPN Employee E11 exited the room and failed to clean

the bedside table or the TV stand.

During an interview completed on 4/2/25, at 1:00 p.m. LPN Employee E11 confirmed not cleaning the overbed table or dresser surfaces utilized in the dressing change prior to or after. Using a yellow gown as a clean field and failing to utilize PPE during the complete dressing change.

During a medication pass completed on 4/1/25, at 8:57 a.m. LPN Employee E9 was preparing medications for Resident Resident R7, LPN Employee E9 was utilizing a washcloth that appeared to be wet for hand hygiene. The washcloth was in a side compartment of the medication cart. LPN Employee E9 indicated the washcloth had hand sanitizer on it. Resident Resident R7 requested to hold her senna for this day. LPN Employee E9 removed the senna from the medication cup using her bare hands and handed the cup to the resident. After administering Resident Resident R7's eye drops LPN Employee E9 utilized the washcloth to perform hand hygiene and returned it to

the side compartment of the medication cart.

During an interview completed on 4/1/25, at 9:13 a.m. LPN Employee E9 confirmed she removed Resident Resident R7's senna with her bare hands and competed hand hygiene by wiping her hands with washcloth drenched

in hand sanitizer and returning the washcloth to the side of the medication cart.

During a medication pass completed on 4/1/25 at 9:24 a.m. LPN Employee E1 was preparing medications for Resident Resident R9, LPN Employee 1 was utilizing the residents medication punch cards, LPN Employee E1 punched the medication into his bare hands prior to placing it into the medication cup. While preparing medications for Resident Resident R12, LPN Employee E1 removed a bottle of Iron supplement from the stock medications. While removing the lid, it was dropped to the floor he picked the lid of the floor and placed it back onto the bottle and stored in the medication cart, no hand hygiene was observed and LPN Employee E1 continue to prepare the remaining medications for Resident Resident R12.

During an interview completed on 4/1/25, at 10:07 a.m. LPN Employee E1 confirmed placing medications into his bare hands, placing the lid back on the bottle after it had fallen to the floor and not completing hand hygiene.

Review of information submitted to the Department of Health on 1/3/25, revealed Resident Resident R281 tested positive for COVID-19. It was indicated the resident returned on 1/4/25, with isolation protocol in place.

Review of Resident Resident R281's clinical record failed to include an order for isolation for COVID-19.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 68 395883 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395883 B. Wing 04/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Burgh Care Center 909 West Street Pittsburgh, PA 15221

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 0880 During an interview on 4/4/25, at 8:54 a.m., the IP, Employee E8 stated, I am still just learning what to do. IP Employee E8 started this role in January 2025. IP, Employee E8 became certified as of 3/27/25. IP, Level of Harm - Minimal harm or Employee E8 stated the facility has not had an outbreak of COVID since 1/1/25, until now. When asked potential for actual harm during an outbreak, how often are tests completed, IP, Employee E8 stated I got the dates written down, I don't want to guess. When asked how do you determine when the facility is no longer in an outbreak for Residents Affected - Many COVID, IP, Employee E8 stated I think 21 days is the timeframe.

A review of facility documentation on 4/4/25, at 9:04 a.m. failed to include a line listing for COVID-19 and Influenza.

During an interview on 4/5/25, at 9:25 a.m. Director of Clinical Operations, Employee E24, confirmed the facility failed to implement COVID and Influenza monitoring, tracking, and testing in accordance with state and federal guidance.

During an observation an interview on 4/4/25, at 9:56 a.m. LPN, Employee E28 was observed coughing and stated I was up all night coughing, all my joints are aching. LPN, Employee E28 stated I told HR Employee E27 and the DON and they did not tell me to test for COVID, I can do it now.

During an interview on 4/5/25, at 11:22 a.m. the DON was asked which days the facility conducts testing

during a COVID outbreak and stated there are no specific days, twice a week. When asked how does the facility determine when the facility is no longer in an outbreak for COVID, it was indicated the completion of negative testing, unless they extend past day 10. If positive after day 10, then testing is extended if showing signs and symptoms of infection.

During an interview on 4/5/25, at 4:45 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the facility failed to ensure an infection control surveillance plan was implemented and staff and residents were tested in accordance with national standards.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(b)(1)(e)(1) Management.

28 Pa. Code 211.12 (d)(1)(2)(3) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 68 395883 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395883 B. Wing 04/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Burgh Care Center 909 West Street Pittsburgh, PA 15221

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 46337 potential for actual harm Based on review of the facility's infection control policies and procedures and staff interview, it was Residents Affected - Many determined that the facility failed to implement an antibiotic stewardship program for ten of ten months (June 2024 through February 2025).

Findings include:

Review of facility policy Antibiotic Stewardship Program Policy dated 9/18/24, indicated the purpose of the facility's antimicrobial stewardship program is to monitor the use of antibiotics in the residents. If an antibiotic is ordered the indications for use will be included.

Review of the facility's Infection Control surveillance for October 2024 through February 2025, failed to include documentation to indicate that antibiotic monitoring was completed.

During an interview on 4/4/25, at 8:51 a.m., the IP (infection preventionist) Employee E8 was unable to provide antibiotic monitoring from June 2024 until September 2024. October 2024 through February 2024 failed to include documentation including diagnoses and responses to indicate that antibiotic monitoring was completed. IP, Employee E8 stated, I am still just learning what to do. IP Employee E8 started this role in January 2025.

During an interview on 4/4/25, at 11:22 a.m. the Nursing Home Administrator and Director of Nursing (DON) confirmed that the facility failed to implement an antibiotic stewardship program for ten of ten months (June 2024 through February 2025).

28 Pa. Code: 211.10(c)(d) Resident care policies.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 68 395883 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395883 B. Wing 04/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Burgh Care Center 909 West Street Pittsburgh, PA 15221

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 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 46337

Residents Affected - Many Based on a review of select facility policy and staff interview, it was determined the facility failed to designate

a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections (January 2025 to March 2025).

Findings included:

The Centers for Medicare and Medicaid Services regulation S483.80(b)(3) states the facility must designate one or more individuals as the infection preventionist who are responsible for the facility's Infection Prevention and Control Program. The IP (infection preventionist) must work at least part-time at the facility, physically work onsite in the facility, have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field, cannot be an off-site consultant or perform the IP work at a separate location.

During an interview on 4/4/25, at 8:51 a.m., the IP, Employee E8 stated, I am still just learning what to do. IP Employee E8 started this role in January 2025. IP, Employee E8 became certified as of 3/27/25.

During an interview on 4/4/25, at 11:22 a.m. the Nursing Home Administrator and Director of Nursing (DON) confirmed the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections (January 2025 to March 2025).

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(1) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 68 395883 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395883 B. Wing 04/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Burgh Care Center 909 West Street Pittsburgh, PA 15221

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 0944 Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Level of Harm - Minimal harm or potential for actual harm 49469

Residents Affected - Many Based on review of facility policy, facility documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for five of five staff members (Employee E21, E26, E27, E28, and E29).

Findings include:

Review of facility education documents for the year 2024, revealed the following concerns:

Review of Nurse Aide (NA) Employee E21's facility provided information did not include training on QAPI.

Review of NA Employee E26's facility provided information did not include training on QAPI.

Review of NA Employee E27's facility provided information did not include training on QAPI.

Review of NA Employee E28's facility provided information did not include training on QAPI.

Review of NA Employee E29's facility provided information did not include training on QAPI.

During an interview 4/4/25, at 2:30 p.m. Human Resource (HR) Employee E30 confirmed that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for five of five staff members. (Employee E21, E26, E27, E28, and E29).

28 Pa Code: 201.14 (a) Responsibility of licensee.

28 Pa Code: 201.18 (b)(1) Management.

28 Pa Code: 201.20 (a) Staff development.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 68 395883