Health inspection·December 19, 2024

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few participate in) websites, social networks, electronic bulletin boards, or other web-based applications or tools that reference facility, patients and/or patient information, share information regarding medical records, make misleading statements, display photos of patients on work premises engaged in patient care, and/or display facility photos that violate facility policy. Facility staff will not transmit any material (by upload, send, email, or otherwise) that violates any local, state, and federal laws, and regulations and/or is threatening, slanderous, libelous, or a violation of facility policy. Staff may not use facility systems to engage in solicitation during work time and/or off-duty. Staff who chose to participate in online community or other forms of social media understand that they are accountable for anything they send/post. Staff must be aware that their actions can be recorded, written about, or videotaped and quickly posted or sent. Should a staff member's comments/photographs/videos/posts violate facility policy, mission statement, or values, staff will be subject to corrective action, up to and including discharge. Review of facility documentation and video recording of a live TikTok video posted the night of November 17, 2024, into the early morning of November 18, 2024, by Employee 1, nurse aide, revealed that Employee 1 utilized her PED and showed both Resident 1 and 2's face and body during this live TikTok. Employee 1 was seen assisting Resident 1 from the bathroom with a walker and placing her in bed for the night. Employee 1 assisted Resident 2 in standing from her recliner and providing incontinence care with brief exposure to the live TikTok of the incontinence brief Resident 2 was wearing and Resident 2's groin. During the live TikTok, a reviewer immediately commented Hippa, while Employee 1 provided incontinence care to Resident 2 and exposed Resident 2's brief and groin. Employee 1 finished the incontinence care. Employee 1 read the comments and stated Hippa. Hippa is when you show them. When you're showing the client. I'm not showing the client and walked/turned away from the PED screen. Employee 1 immediately returned to the PED screen, pointed at the screen, and stated, We'll you can show the client, you just can't show the private stuff and turned back to Resident 2. Both Resident 1 and Resident 2 were easily identifiable based on their facility identification photo as their faces were visible during these interactions with Employee 1. At no time during the video recording of the live TikTok did Employee 1 inform either Resident 1 or 2 that they were being recorded nor did Employee 1 gain Resident 1 or 2's consent to record them. The video recording of Employee 1's live TikTok was a total of 17 minutes. Interview and concurrent observation on December 19, 2024, at 10:15 AM and 3:30 PM, with the Nursing Home Administrator and the Director of Nursing confirmed the above findings. 28 Pa. Code 201.29 (c.3)(4) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395031 If continuation sheet Page 2 of 7 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 12/19/2024 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 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies, facility documentation, clinical record review, and resident and staff interviews, it was determined that the facility failed to protect a resident's right to be free from mental abuse by a staff member for two of three residents reviewed causing actual harm (Residents 1 and 2). Findings include: Review of a Centers for Medicare and Medicaid Services (CMS) Memo S&C: 16-33-NH entitled, Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio/Video Recording by Nursing Home Staff, dated August 5, 2016, revealed that each resident has the right to be free from all types of abuse, including mental abuse. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or in a manner that would demean or humiliate a resident. There may be situations in which the resident is unable to express him/herself due to a medical condition and/or cognitive impairment, cannot relate what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. A lack of response by resident does not mean that mental abuse did not occur. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Examples of verbal or nonverbal conduct that may cause mental abuse, include but are not limited to nursing home staff taking photographs or recordings of residents that are demeaning or humiliating using any type of equipment and keeping or distributing them through multimedia messages or on social media networks. Review of the Social Security Act, Sections 1819(c)(1)(A)(ii) and 1919(c)(1)(A)(ii) revealed that every resident has the right to be free from mental and physical abuse. A reasonable person would not expect that they would be harmed in his/her own home or a health care facility and would experience a negative psychosocial outcome. Review of the Personal Electronic Device Usage (PED) policy last reviewed without changes on October 29, 2024, revealed that the facility will eliminate unnecessary risk created using PED's when conducting facility business by eliminating personal distractions and maintaining patient rights to privacy. The facility defined PEDs to include cell phones, smart phones, and smart devices. The policy indicated that while in the clinical environment, conducting facility business, and for staff members that are within listening distance or view of a patient, resident, and/or guest, all PEDs should be turned off .and only permitted during designated breaks and during assigned meal periods. Staff are only permitted to use their PED in designated area (such as a break room), and in a manner intended to prevent disruption and prevent patient privacy. A staff's failure to abide by this policy and/or applicable state, local, and federal law, may result in corrective action in accordance with facility policy. Review of the Social Networking policy last reviewed without changes on October 29, 2024, revealed that knowledge sharing through social networking (including all social media sites) is recognized as critical for the facility. Facility staff must protect patient information and follow the facility's code of conduct. Without prior consent, staff should not independently establish (or otherwise participate in) websites, social networks, electronic bulletin boards or other web-based application or tools that reference facility, patients and/or patient information, share information regarding medical records, make misleading statements, display photos of patients on work premises engaged in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395031 If continuation sheet Page 3 of 7 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 12/19/2024 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 0600 Level of Harm - Actual harm Residents Affected - Few patient care, and/or display facility photos that violate facility policy. Facility staff will not transmit any material (by upload, send, email, or otherwise) that violates any local, state, federal laws, and regulations and/or is threatening, slanderous, libelous, or a violation of facility policy. Staff may not use facility systems to engage in solicitation during work time and/or off-duty. Staff who chose to participate in online community or other forms of social media understand that they are accountable for anything they send/post. Staff must be aware that their actions can be recorded, written about, or videotaped and quickly posted or sent. Should a staff member's comments/photographs/videos/posts violate facility policy, mission statement, or values, staff will be subject to corrective action, up to and including discharge. Clinical record review for Resident 1 revealed that the facility completed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) on November 13, 2024, which indicated that she was severely cognitively impaired. Clinical record review for Resident 2 revealed that the facility completed an initial MDS on August 28, 2024, which indicated that she was moderately cognitively impaired. Review of facility documentation and recording of a live TikTok video posted the night of November 17, 2024, into the early morning of November 18, 2024, by Employee 1, nurse aide, going by the username of Pxxxxx or Pxxx94 (not the real usernames) revealed the following: The recording of the live TikTok post started as Employee 1 entered Resident 1's room after placing her PED on the heater ledge in Resident 1's room prior to leaving the resident room. Employee 1 walked past the PED, then looked back and directly into the phone screen, and stated Did I miss anything chico? Employee 1 read a comment posted to the live video and responded to the comment. Employee 1 then moved out of view of the live TikTok and returned past the PED with a resident brief, unfolding it as she passed. She then proceeded to Resident 1's bathroom area, out of view of the PED, but within listening distance, and stated, Alright hun .you ready to get up, you ready to go back to bed? to which Resident 1 responded yeah along with another indiscernible mumbling statement, and audibly sighed. Employee 1 completed what was perceived to be incontinence care to Resident 1 based on the actions heard off camera. Off camera, Employee 1 asked Resident 1 Can you hold it? Resident 1 mumbled indiscernibly then stated yeah giggled, and said Oh, I see. Employee 1 requested that Resident 1 Put your hand right here. Resident made unintelligible statements, sighs, and mumbling as Employee 1 stated, Alright honey, flushed the toilet, and assisted Resident 1, clothed in a hospital gown that was tied once in the back, to ambulate with a walker from the bathroom area that was offscreen, and into full view of the live TikTok recording via Employee 1's PED. Employee 1 prepped Resident 1's bed while Resident 1 stood beside the bed holding onto her walker, then stated Alright sweety, and assisted Resident 1 to back up to the side of her bed, pull her hospital gown up enough to side down on the side of the bed, stating Go ahead honey, and helped Resident 1 sit down. When Resident 1 sat down on the side of the bed, she was just off to the right side of the live TikTok viewing area. Employee 1 then assisted Resident 1 with getting into bed by swinging Resident 1's bare legs up and onto her bed and into view of the live TikTok video. Employee 1 covered Resident 1 up with a sheet and comforter. Employee 1 stated, There you go, to which Resident 1 indicated thank you. Employee 1 responded your welcome turned off Resident 1's overbed light, placed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395031 If continuation sheet Page 4 of 7 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 12/19/2024 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 0600 Level of Harm - Actual harm Residents Affected - Few her overbed table beside Resident 1's bed, picked up dirty linens off Resident 1's floor, pulled a mesh bag off a hook on Resident 1's closet door, removed her right glove, moved out of view of the live TikTok, and then immediately returned into view. Employee 1 picked up her PED, stated Alright, that room is done while leaving Resident 1's room. Employee 1 looked directly into her PED screen and read the live TikTok comments and badges, stating Chico again with the team bracelet. Let's go [NAME]. Alright, alright, I'm about to go into the next room y'all hold on. Thank you for the follow [NAME]. Employee 1 then exited Resident 1's room into the facility hallway and stated, So I take this stuff out (holding up Resident 1's dirty linens), bring it to this bin, like that in here, put that in there, and continued walking down the hallway. While walking, Employee 1 stated, I have two more people to do showed two gloved fingers to the live TikTok screen, looked away from the PED screen and up the hallway, then back to the screen, and continued walking up the hallway and into Resident 2's darkened room. Employee 1 placed her PED on the sink counter, turned on Resident 2's light above the sink, picked up her PED, moved to the heater ledge, and placed the PED on the ledge, using a stuffed animal to prop the PED to show Resident 2's elevated legs and feet while she sat in a chair beside her bed. Resident 2's TV could be heard playing in the background and out of sight. Employee 1 moved out of the view of the live TikTok, returned with resident care supplies, including Resident 2's blue night gown, and placed them on Resident 2's bed. Employee 1 moved around Resident 2 and closer to the live TikTok on her PED, briefly glanced at the screen, and stated, Hi [NAME]. We're gonna change you, ok? Employee 1 paused beside Resident 2, turned, and looked at her PED to read the live TikTok screen comments. Employee 1 stated, Billy, thank you for liking the live, I appreciate you, turned back towards Resident 2, brushed her hair back from her face, immediately turned back to her PED screen and stated, Evelyn, I'm gonna go ahead and add you on snap in a sec. Employee 1 returned to Resident 2 and put her legs down and moved her walker in front of her, locking the walker brakes. Employee 1 moved out of view of the live TikTok screen, then returned and donned a pair of gloves, moved to the far side of Resident 2, between her bed and chair and stated, Remember, hold onto this (pointing to Resident 2's walker), turned to Resident 2's bed, opened a disposable pad and brief and placed them on Resident 2's chair. Employee 1 asked Resident 2 Ready? Resident 2 stood on her own, holding onto her walker with her left hand and pushing up off the chair with her right hand. Employee 1 indicated Now, put your hand here, and pointed to Resident 2's right handle on her walker. Resident 2 moved her right hand from the chair to the walker handle and continued to stand on very shaky legs. Employee 1 then stated, Yep, good job. As Resident 2 stood and continued standing, her face and front half of her body was in full view of the live TikTok screen. Resident 2's nightgown that she had on was pulled up to her midthigh/upper hip area, which exposed the front part of an incontinence brief that she was wearing. Employee 1 released Resident 2's brief tabs, moved from behind Resident 2 to the front side, looked towards her PED screen, and reached down, pulled Resident 2's night gown up to her belly area, fully exposed the front part of Resident 2's incontinence brief, glanced again at her PED screen, pulled the incontinence brief down, pushed it in between Resident 2 legs, briefly exposing Resident 2's groin area, and let Resident 2's nightgown fall back down to Resident 2's mid-thigh/upper hip area. Employee 1 stated, You're doing really great. A person with the user name xxx0327 (not the real username) was watching the live TikTok and immediately commented Hippa. Employee 1 continued the incontinence brief change and told Resident 2 to Keep up the good work, you're almost done. You're almost done. Honey, you're doing good. I told you you'll get strong every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395031 If continuation sheet Page 5 of 7 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 12/19/2024 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 0600 Level of Harm - Actual harm Residents Affected - Few time. As Resident 2 grunted and her leg wobbles increased, Resident 2 requested Hurry, hurry, can you hurry? Employee 1 stated, You can't sit down yet ok. You're about to be done just bear with me. Almost done. Resident 2 continued to grunt with the exertion of standing and stated, I want to sit down, I want to sit down, I want to sit down. Can I sit down? Employee 1 stated, Alright, hold on, but Resident 2, unable to stand any longer, sat down with a grunt. Resident 2 stated, I gotta sit, as she sat back down in her chair with a [NAME]. When Resident 2 sat back down in her chair, only her upper legs and knees were visible in the live TikTok screen. Employee 1 immediately removed Resident 2's current gown, placed it on the bed, then returned in front of Resident 2 (out of view of the live Tik Tok screen), picked up Resident 2's gown that Employee 1 had placed on the bed prior to the incontinence change, placed it over Resident 2's head, assisted to put Resident 2's arms into the nightgown, and moved the gown covering Resident 2's chest area. Employee 1 moved the gown out of sight of the live TikTok screen, returned to Resident 2, moved her walker out of the way, and stated, Alright honey-girl, now let's recline you. Employee 1 picked up the chair's controls and elevated Resident 2's legs while looking into the PED screen and not paying attention to Resident 2. Employee 1 read the comments and stated, Hippa. Hippa is when you show them, when you're showing the client. I'm not showing the client and walked/turned away from the PED screen. Employee 1 immediately returned to the PED screen, pointed at the screen, and stated, We'll you can show the client, you just can't show the private stuff and turned back to Resident 2. Employee 1 repositioned Resident 2's legs, walked to the sink out of view of the live TikTok video, washed her hands, and returned to the PED screen. In between the time Employee 1 made the Hippa statement, and when she returned to the live TikTok video, a person with the username Cxxxxstick (not the real username) typed, Want me to mute him? Employee 1 read and verbalized Cxxxxstick's comment of Want me to mute him? and stated, Yeah, who ever said that yeah, you can mute them and turned back towards Resident 2. A person by the username Bxxxx (not the real username) immediately commented I don't think she's showing more than just herself idk (I don't know) why u (you) be bitching. Cxxxxstick (not the real username) commented @Bxxxx (not the real username) fr (for real) tho. During these comments, Employee 1 was providing care to Resident 2, which was out of view of the live TikTok. She then put Resident 2's legs down via the electronic controls, continued care out of the view of the live TikTok and stated, Now lean over there, honey, lean on over. There you go [NAME], now all good. Now let's stand up so I can pull your gown down. Employee 1 moved Resident 2's walker back in front of her and stated, Alright honey, and assisted Resident 2 in attempting to stand; however, Resident 2 was unable to stand fully and fell back into the chair. Employee 1 moved in front of Resident 2 and stated, There you go, you're all done, and put Resident 2's feet back up. As Employee 1 was leaving she stated, Alright honey, get some sleep. Resident 2 stated, thank you and Employee 1 responded, you're welcome, picked up her phone with a gloved hand and began reading the live TikTok screen comments verbally. Employee 1 stated, Always, I think I missed what was going on. Some people to .seriously .for real. Hold on guys, I gotta go (undiscernible comment), hold on. Employee 1 carried her PED into the facility's hallway and the live TikTok video ended. Both Resident 1 and Resident 2 were easily identifiable based on their facility identification (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395031 If continuation sheet Page 6 of 7 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 12/19/2024 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 0600 Level of Harm - Actual harm photo as their faces were visible during these interactions with Employee 1. Employee 1 provided incontinence care to Resident 2 during the live TikTok screen. At no time during the video recording of the live TikTok did Employee 1 inform either Resident 1 or 2 that they were being recorded nor did Employee 1 gain Resident 1 or 2's consent to record them. Residents Affected - Few The video recording of Employee 1's live TikTok was a total of 17 minutes. The Nursing Home Administrator (NHA) received an anonymous phone call on November 18 2024, at 1:30 PM. The caller referenced this live TikTok, described Employee 1, and provided a video recording of the live TikTok to the NHA for review. Facility administration reviewed the video, initiated a facility investigation, and immediately suspended Employee 1. Review of the facility's investigation revealed that the NHA spoke with Employee 1 on November 18, 2024, at 5:15 PM. Employee 1 revealed to the NHA that she didn't know she did anything wrong and that you couldn't see residents faces. Employee 1 also validated she received a violation by TikTok, and her account was temporarily suspended. Employee 1 also admitted to doing a daily day in the life of a CNA TikTok. The facility's human resources office spoke with Employee 1 on November 19, 2024. Employee 1 confirmed that she did not inform the Residents that she was live on TikTok, that the Residents could not say yes or not if she were to ask them if she could record them, and that she thought she was doing her best to protect their privacy. Employee 1 acknowledged now that it was wrong what she did but noted that she sees videos like that all the time on TikTok. Employee 1 confirmed that someone on her live (TikTok) reported her, she doesn't know why she was reported, and doesn't receive compensation for her TikTok. Interview on December 19, 2024, at 10:15 AM and 3:30 PM with the Nursing Home Administrator and the Director of Nursing confirmed the above findings. 28 Pa. Code 201.29 (c.3)(4) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395031 If continuation sheet Page 7 of 7