Reformed Presbyterian Home

Review of 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 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 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 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 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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/24/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Reformed Presbyterian Home

2344 Perrysville Avenue Pittsburgh, PA 15214

SUMMARY STATEMENT OF DEFICIENCIES