Health inspection·November 9, 2023

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or the resident's responsible party in writing of a transfer to the hospital for four of eight residents reviewed (Residents 6, 26, 32, and 65). Findings include: A review of Resident 26's clinical record revealed that the facility transferred him to the hospital from [DATE] to 19, 2023, for a change in condition, and he was admitted . There was no documented evidence to indicate that the facility provided a written notice to Resident 26's responsible party regarding his transfer to the hospital that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address (mailing and email) information for the Office of the State Long-Term Care Ombudsman, and information (mailing and email address and telephone number) for the agency responsible for the protection and advocacy of individuals with developmental disabilities, and a statement of resident's appeal rights, including name, address (mailing and email) and telephone number of entity which receives requests. A clinical record review for Resident 65 revealed he was transferred to the hospital from [DATE] to November 1, 2023, for a change in condition and was admitted . There was no evidence to indicate that Resident 65's responsible party was provided written notification to include the above-required contents. An interview with Employee 4 (admissions coordinator) revealed that the facility staff contacted the residents' representatives verbally, but confirmed they did not provide the transfer notices in writing for Residents 26 and 65. Review of Resident 6's clinical record revealed that she was transferred to the hospital on August 9, 2023, after going to a cardiology appointment. There was no documented evidence to indicate that the facility provided a written notice to Resident 6 or her responsible party regarding her transfer to the hospital that included the required contents as stated above. Interview with the Administrator and Director of Nursing on November 9, 2023, at 9:00 AM confirmed the above findings for Resident 6. Clinical record review for Resident 32 revealed that they were transferred to the hospital on October 6, 2023, after there was a change in their condition. There was no documentation that the facility provided written notification to the resident or the resident's responsible party regarding the transfer that included the required contents as noted above. The surveyor reviewed the above information for Resident 32 during an interview with the Director of Nursing on November 9, 2023, at 9:33 AM. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395031 If continuation sheet Page 2 of 6 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 395031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven Place Rehabilitation and Nursing Center 24 Cree Drive Lock Haven, PA 17745 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed hold policy to the resident or responsible party for three of eight residents reviewed for hospitalizations (Residents 6, 26, and 65). Findings include: Review of Resident 6's clinical record revealed that she was admitted to the hospital on [DATE], after going to a cardiology appointment. Resident 6 was in the hospital until August 15, 2023. There was no documented evidence in Resident 6's clinical record to indicate that the facility provided her, or her responsible party written information on the facility's bed hold policy. Interview with the Administrator and Director of Nursing on November 9, at 9:00 AM confirmed the above findings for Resident 6. A review of Resident 26's clinical record revealed that the facility sent him to the hospital from [DATE] to 19, 2023. There was no documented evidence in Resident 26's clinical record to indicate that the facility provided him, or his responsible party written information on the facility's bed hold policy. Clinical record review for Resident 65 revealed that the facility sent him to the hospital from [DATE] to November 1, 2023. There was no documented evidence in Resident 65's clinical record to indicate that the facility provided him, or his responsible party written information on the facility's bed hold policy. An interview with Employee 4 (admission coordinator) on November 9, 2023, at 9:05 AM confirmed the above findings for Residents 26 and 65. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(f) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395031 If continuation sheet Page 3 of 6 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 395031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven Place Rehabilitation and Nursing Center 24 Cree Drive Lock Haven, PA 17745 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate completion of a resident assessment for two of 24 residents reviewed (Resident 22 and 49). Residents Affected - Few Findings include: Clinical record review for Resident 22 revealed an admission Minimum Data Set Assessment (MDS, an assessment completed at specific intervals by the facility to determine care needs of the resident) dated October 4, 2023, that indicated he was on a ventilator (a machine that is used to push air in and out of the lungs to assist with breathing), while a resident in the facility. Interview with Employee 5, Registered Nurse Assessment Coordinator (RNAC), on November 7, 2023, at 12:52 PM revealed that Resident 22 was not on a ventilator while a resident at the facility and that this was a coding error. The Nursing Home Administrator and Director of Nursing were made aware the MDS coding error related to Resident 22 during a meeting on November 8, 2023, at 11:02 AM. Review of Resident 49's clinical record revealed an MDS dated [DATE], indicating that the facility assessed him as having a psychotic disorder. There was no documented evidence in Resident 49's clinical record to support a diagnosis of psychotic disorder. Interview with Employee 3, RNAC, on November 8, 2023, at 1:45 PM confirmed that Resident 49's MDS dated [DATE], was coded in error for having a psychotic disorder. The facility failed to complete an accurate MDS assessment for Resident 22 and 49. 28 Pa. Code 211.5(f)(ix) Medical Records 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395031 If continuation sheet Page 4 of 6 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 395031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven Place Rehabilitation and Nursing Center 24 Cree Drive Lock Haven, PA 17745 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide care, consistent with physician orders, for the administration of supplemental oxygen for one of one resident reviewed for oxygen use (Resident 6). Residents Affected - Few Findings include: Review of Resident 6's clinical record revealed a physician's order dated October 20, 2023, for nursing staff to administer 4 Liters of oxygen per minute via nasal cannula (a tubing that connects the flow of oxygen to the resident's nose) every day and night shift related to her chronic obstructive pulmonary disease. The physician's order indicated that the oxygen may be removed as needed for toileting and bathing. There was no addendum in Resident 6's physician's order to indicate that nursing staff were to change the liter flow of the oxygen based on titration levels. Observation on November 7, 2023, at 9:36 AM revealed Resident 6's oxygen was running at 1.5 liters per minute. Observation on November 7, 2023, at 12:15 PM revealed Resident 6's oxygen was running at 1.5 liters per minute. Observation on November 8, 2023, at 9:37 AM revealed Resident 6's oxygen was running at 2 liters per minute. Interview with Employee 2, licensed practical nurse, on November 8, 2023, at 9:39 AM confirmed the above observation. Employee 2, then reviewed Resident 6's physician orders to confirm Resident 6's oxygen should be running at 4 liters per minute. The facility failed to provide supplemental oxygen as ordered by Resident 6's physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395031 If continuation sheet Page 5 of 6 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 395031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven Place Rehabilitation and Nursing Center 24 Cree Drive Lock Haven, PA 17745 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. Based on observation, review of select policies and procedures, and staff interview, it was determined that the facility failed to secure medications and biologicals on one of two nursing units (First Floor Nursing Unit). Findings include: Review of the policy entitled Storage of Medications, last reviewed July 17, 2023, indicates that medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. The medication supply is only accessible to licensed personnel. Observation on November 9, 2023, at 9:11 AM revealed the following tubes of biologicals on top of a medication cart: Multiple tubes Triamcinolone cream (a prescription steroid cream used to treat skin diseases) Multiple tubes of Voltaren cream (used to treat arthritic pain) Nystatin powder (a prescription powder used to treat fungal infections) Metronidazole vaginal gel (a prescription medication used to treat vaginal fungal infections) Employee 1, licensed practical nurse, approached the medication cart during the surveyors observations at 9:12 AM, and indicated that the creams were on top of the cart because she was getting ready to do treatments. Employee 1 then walked away from the medication cart, down a hallway and out of line of sight of the medication cart. The biologicals were left on top of the medication cart accessible to non-licensed staff, visitors, and residents. Employee 1 returned to the medication cart at 9:14 AM and started to put the biologicals away into the cart. Employee 1 indicated at this time she was told to lock them up, and that she was still catching on. Interview with the Director of Nursing on November 9, 2023, at 9:30 AM, acknowledged the above observations. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395031 If continuation sheet Page 6 of 6