Reformed Presbyterian Home

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, facility submitted documents, clinical records and staff interviews, it was determined that the facility failed to make certain each resident was free from neglect by not ensuring adequate supervision and assistance for transfers for one of three residents reviewed (Resident Resident R2).Findings include:Review of facility policy Prevention of Abuse and Response dated 7/15/25, indicated neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs on an individual basis when a resident does not receive care in one or more areas (e.g., absence of frequent monitoring for a resident known to be incontinent, resulting in being left to lie in urine or feces). Review of

the clinical record indicated Resident Resident R2 was admitted to the facility on [DATE REDACTED]. Review of Resident Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/6/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and arthritis (inflammation of one or more joints, causing pain and stiffness).Review of a physician order dated 10/2/25, indicated to transfer resident with full body lift (a mechanical lift).Review of Resident Resident R2's Kardex (a snapshot of resident care needs) dated 10/8/25, indicated the resident transfers with Hoyer/full lift and assist of two staff.Review of a progress note dated 10/8/25, stated, Resident was being transferred to bed to the w/c (wheelchair). During

the transfer the Hoyer lift tilted so the CNA (Certified Nurse Aide) had to lower her to the floor. Resident was assessed. She states that she hit her head and left shoulder. When her husband came in she requested to go to the ER (emergency room) for head pain. Physician and DON (Director of Nursing) notified.Review of

a witness statement dated 10/8/25, completed by Nurse Aide (NA) Employee E1 stated, On October 8th around 1:30 p.m. I got Resident Resident R2 all cleaned up changed to get her up in the Hoyer. She was holding on and when I went to turn it towards her chair it tilted and it was falling, so I held it to slowly lower to ground.During an interview on 11/24/25, at 1:11 p.m. the Nursing Home Administrator (NHA) stated, Resident Resident R2's spouse was pressuring NA Employee E1 to get the resident into her chair because they wanted to go outside to smoke. During an interview on 11/24/25, at 2:15 p.m. the NHA and DON confirmed that the facility failed to make certain each resident was free from neglect by not ensuring adequate supervision and assistance for transfers for Resident Resident R2. 28 Pa. Code: 201.14(a) Responsibility of licensee28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa.

Code: 211.12(d)(1)(5) Nursing services.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Reformed Presbyterian Home

2344 Perrysville Avenue Pittsburgh, PA 15214

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the building using camera system. Resident ambulating safely and with recommended device (standard wheeled walker)Details of the camera system revealed the following13:14 (1:14 p.m.) Resident witnessed getting on the elevator from 3rd floor13:14 (1:14 p.m.) Resident was observed in main reception13:16 (1:16 p.m. Resident observed leaving out the front entrance ambulating with wheeled walker. Resident gets on Bus 6357 8 downtown. Review of a written statement from LW Employee E2 dated 11/1/25, stated Resident was downtown. She got on the number 8 bus. To the best of my knowledge, she was headed back (to the facility). She was unsure of her directions, so I decided to get off the bus together and escort her back into (the facility) from the bus stop up to the 3rd floor. During an interview on 11/24/25, at 10:40 a.m. Resident Resident R1 confirmed that she had left the faciity on [DATE REDACTED], and asked Are they still talking about that? I went to my apartment to get shoes and jacket. I got them then I got confused on how to get back. Then I saw [LW Employee E2] who got me on the right bus and brought me back. During an interview on 11/24/25, at 10:48 a.m. Licensed Practical Nurse (LPN) Employee E3 stated that he was working the day of the elopement, and confirmed that Resident Resident R1 had been gone about four hours before staff knew she was missing, stating She was here for lunch, and they couldn't find her at dinner. She didn't say anything to me that indicated that she was going to leave the facility. LPN Employee E3 confirmed that Resident Resident R1 had been gone from the facility for approximately seven hours before her safe return. During an interview on 11/24/25, at 2:11 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain each resident received adequate supervision that resulted in an elopement for (Resident Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Event ID:

Facility ID:

If continuation sheet