Health inspection·February 21, 2025

F 0554 28 Pa. Code: 211.10(c)(d) Resident care policies. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 28 Pa. Code: 211.9(a)(1) Pharmacy services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395001 If continuation sheet Page 2 of 9 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 395001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Passavant Retirement and Healt 105 Burgess Drive Zelienople, PA 16063 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies, documents, observations and staff interviews it was determined that the facility failed to provide a non-institutional dining experience by administering medications during the breakfast meal service for two of six residents. (Resident R3 and Resident R66). Findings include: A review of facility policy Supporting the Resident's Right to Privacy and Confidentially last reviewed January 2025, indicates it is the responsibility of each employee of this community to ensure the privacy and confidentiality of each resident is protected. A review of the facility policy Medication Administration - General Guidelines last reviewed January 2025, indicates for residents not in their rooms or otherwise unavailable to receive medication on the pass, the medication administration record (MAR) is flagged. After completing the medication pass, the nurse returns to the missed resident to administer the medication. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/7/25, indicates the diagnosis of anemia (low iron in the blood), dementia (loss of intellectual functioning), and anxiety. Review of the clinical record indicated Resident R66 was admitted to the facility on [DATE]. Review of Resident R66's MDS dated [DATE], indicates the diagnosis of anemia (low iron in the blood), Hypertension (high blood pressure), and diabetes (low sugar in the blood). During an observation completed on 2/19/25, at 9:11 a.m. Resident R3 and Resident R66 were in the dining room sitting at a table for breakfast. Licensed Practical Nurse Employee E11 was observed administering medications to Resident R3 and Resident R66. During an interview completed on 2/19/25, at 9:15 a.m. LPN Employee E11 confirmed that Resident R3 and Resident R66 received their medication in the dining room and stated, they take them with their breakfast and confirmed that the facility failed to provide a non-institutional dining experience by administering medications during the breakfast meal service for two of six residents. (Resident R3 and Resident R66). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code 201.29(d) Resident Rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395001 If continuation sheet Page 3 of 9 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 395001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Passavant Retirement and Healt 105 Burgess Drive Zelienople, PA 16063 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to ensure residents medication regime was free from unnecessary psychotropic medications for two of four residents (Resident R46 and R86). Findings include: Review of facility policy medication management dated January 2025, indicated The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication -related problems on an on-going basis. Resident R46 was admitted on [DATE]. Review of Resident R46 MDS (minimum data set a periodic assessment of resident needs) dated 1/15/25, indicated a diagnosis of dementia (dementia is a term for several diseases that affect memory, thinking and the ability to perform daily activities) and depression (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Review of Resident R46 physician orders indicated to administer: Quetiapine (antipsychotic used for schizophrenia and bipolar) 25mg tablet (12. 5mg) tablet oral two times daily starting 11/30/24, for delirium. Review of Seroquel (quetiapine) medication insert indicates : indications and usage: schizophrenia, bipolar I disorder manic episode, bipolar disorder, depressive episode. Resident R86 was admitted on [DATE]. Review of Resident R86 MDS dated [DATE], indicated a diagnosis of dementia and depression. Review of Resident R86 physician orders indicated to administer: Quetiapine 25mg tablet oral hour of sleep notes: delusions-behavior. During an interview on 2/21/25, at 11:02 a.m. Director of Nursing confirmed that Resident R46 and Resident R86 diagnosis of dementia and depression were not included on the diagnosis for the medication and the facility failed to ensure residents medication regime was free of unnecessary psychotropic medication. 28 Pa. Code 211.9(k) Pharmacy services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395001 If continuation sheet Page 4 of 9 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 395001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Passavant Retirement and Healt 105 Burgess Drive Zelienople, PA 16063 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations and staff interview it was determined that the facility failed to date opened medications, and properly store/label medication in three of three medication rooms (Mountain Laurel, Tionesta, and Trillium Medication Rooms), failed to discard expired nursing supplies in one of three medication rooms (Tionesta Medication Room), and failed to properly store medications in one of three residents' medication cabinet in the resident room (Resident R77). Findings include: Review of facility policy Preparation and General Guidelines - Vials and Ampules of Injectable Medications dated [DATE], indicated opening a vial triggers a shortened expiration date that is unique for that product. It is important to record the date opened and the triggered expiration date on a multi-dose vial. Review of the facility policy Storage of Medications dated [DATE], indicated all medications dispensed by the pharmacy are stored in the container with the pharmacy label. Medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart. Observation on [DATE], at 8:44 a.m. the Mountain Laurel medication room revealed two tuberculin multi-dose vials opened and without a date. Interview on [DATE], at 8:45 a.m. Registered Nurse (RN) Employee E7 verified the two tuberculin multi-dose vials were not dated when opened as required. Observation on [DATE], at 8:53 a.m. the Tionesta medication room revealed a Novolog flex pen (prefilled pen to inject rapid-acting insulin under the skin) without a label, resident name, and was not stored in a box or individual bag as required. Further observation on [DATE], at 8:53 a.m. the Tionesta medication room revealed six Coude foley catheters (a type of urinary catheter with a curved tip that helps it pass through tight spots) with an expiration date of [DATE]. Interview on [DATE], at 8:53 a.m. Licensed Practical Nurse (LPN) Employee E8 verified the Novolog flex pen was without a label, resident name, and was not stored in a box or individual bag as required, and that the six Coude catheters were past the expiration date of [DATE]. Observation on [DATE], at 9:42 a.m. the Trillium medication room revealed one tuberculin multi-dose vial opened and without a date. Interview on [DATE], at 9:43 a.m. Registered Nurse (RN) Employee E9 verified the tuberculin multi-dose vial was not dated when opened as required. Observation on [DATE], at 9:30 a.m. of Resident R77's medication cabinet in the resident room revealed a multi-dose nasal spray, and multi-dose eye drop container were not dated when opened as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395001 If continuation sheet Page 5 of 9 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 395001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Passavant Retirement and Healt 105 Burgess Drive Zelienople, PA 16063 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 0761 required. Level of Harm - Minimal harm or potential for actual harm Interview on [DATE], at 9:31 a.m. LPN Employee E10 verified the multi-dose nasal spray, and multi-dose eye drop container were not dated when opened as required. Residents Affected - Few Interview on [DATE], at 2:00 p.m. Director of Nursing 2 (DON 2) confirmed the facility failed to date opened medications, and properly store/label medication in three of three medication rooms (Mountain Laurel, Tionesta, and Trillium medication rooms), failed to discard expired nursing supplies in one of three medication rooms (Tionesta medication room), and failed to properly store medications in one of three residents' medication cabinet in the resident room (Resident R77). 28 Pa. Code: 211.9(a)(1)(2)Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395001 If continuation sheet Page 6 of 9 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 395001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Passavant Retirement and Healt 105 Burgess Drive Zelienople, PA 16063 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (A binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not.) for one of five residents (Resident R67). Residents Affected - Few Findings include: Review of the admission record indicated Resident R67 was admitted to the facility on [DATE]. Review of Resident R67's Binding Arbitration Agreement indicated that the resident signed the document on 1/13/25. Review of Resident R67's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/20/25, indicated the diagnoses of Non-Alzheimer's Dementia (dementia caused by other diseases with symptoms forgetfulness, limited social skills, and impaired thinking abilities that interfere with daily functioning), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and Parkinson's disease (disorder of the nervous system that results in tremors). Section C0500 BIMS (Brief Interview for Mental Status - a screening test that aides in detecting cognitive impairment) indicated a score of 12 (score of 8-12 indicated moderately impaired). Review of Resident R67's care plan dated 1/13/25, indicated the resident has problems that limit his ability to perform activities of daily living related to Parkinson's disease, and dementia. Review of Resident R67's care plan dated 1/14/25, indicated wandering/elopement (leaving a designated area without permission) resident is sometimes confused, wanders, may try to leave, is at risk for injury, and getting lost. Interview on 2/20/25, at 9:20 a.m. Marketing Coordinator, Employee E13 confirmed the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for one of five residents (Resident R67). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395001 If continuation sheet Page 7 of 9 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 395001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Passavant Retirement and Healt 105 Burgess Drive Zelienople, PA 16063 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 potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure droplet precautions were ordered and a care plan implemented for one of three residents (Resident R40), and failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for one of six household kitchen areas (Mountain Laurel Neighborhood). Residents Affected - Few Findings include: Review of the facility policy COVID-19 Plan dated January 2025, indicated the facility will make every attempt to reduce the risk of transmission of COVID-19 in order to protect those it serves, its personnel, volunteers and visitors. In the event transmission does occur, prompt detection and effective triage and isolation of infectious residents are essential to prevent unnecessary exposure. Transmission-based precautions are the second tier of basic infection control and are used in addition to standard precautions for residents with known or suspected infections. There are three types of transmission-based precautions contact, droplet, and airborne. Review of the clinical record indicated Resident R40 was admitted to the facility on [DATE]. Review of Resident R40's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/22/25, indicated the diagnoses of coronary artery disease (CAD-limits blood flow to the heart muscle), hypertension (high blood pressure), and diabetes (high sugar in the blood) Review of R40's clinical notes dated 2/18/25, at 7:23 p.m. indicate resident exhibits a heavy wet nonproductive cough. Physician notified of condition and initiated new orders that included but not inclusive to a rapid covid (faster results but less sensitive) test, PCR (a small amount of coronavirus genes can be detected) test and chest x-ray. During an observation completed on 2/19/25 at 10:42 a.m. signage for droplet precautions and personal protective equipment was noted to Resident R40's door. Review of Resident R40's current physician orders on 2/19/25, failed to include an order for droplet precautions. Review of Resident R40's care plan on 2/19/25, failed to include droplet precautions for care and management of the as required. During an interview completed on 2/20/25 at 12:00 p.m. the Director of Nursing confirmed physician orders were not obtained and the care plan was not updated to include droplet precaution and that the facility failed to ensure droplet precautions were ordered and a care plan implemented for one of three residents (Resident R40). Review of facility policy Infection control for Household Dining Rooms updated 2/2025, indicated that Household Assistants will disinfect the dining rooms to ensure that residents who eat in the dining room are safe. Nothing is stored beneath the sink area in the kitchen. During an observation on 2/19/25, at 12:45 p.m., of the Mountain Laurel Neighborhood Kitchen area, revealed 15 boxes of disposable gloves and 15 compact disk cases stored under the kitchen sink. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395001 If continuation sheet Page 8 of 9 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 395001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Passavant Retirement and Healt 105 Burgess Drive Zelienople, PA 16063 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an additional observation with Household Coordinator (HHC) Employee E6 at 12:50 p.m., the above observation of items found under the sink of the Mountain Laurel Neighborhood Kitchen was confirmed, and Employee E6 confirmed that the facility failed to provide a safe and sanitary environment to prevent the potential for cross contamination for one of six household kitchen areas. During an interview on 2/21/25, at 2:30 p.m., Nursing Home Administrator confirmed that the facility failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for one of six household kitchen areas (Mountain Laurel Neighborhood). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(3) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395001 If continuation sheet Page 9 of 9