Health inspection·April 19, 2024

F 0582 Interview with the Director of Nursing and the Nursing Home Administrator on April 18, 2024, at 2:00 PM confirmed the above evidence pertaining to the Medicare notices for Residents 58 and 83. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(2)(e)(1) Management Residents Affected - Some 28 Pa. Code 201.29(a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 2 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care for a resident with an indwelling central line catheter for one of 18 residents reviewed (Resident 20). Residents Affected - Few Findings include: The surveyor requested any policy pertaining to the care and services of a peripherally inserted central catheter (PICC, long, thin, tube that is inserted through a vein in the arm and passed through to a larger vein near the heart. The line requires careful care and monitoring for complications including bleeding, infection, and blood clots.) during interviews with the Nursing Home Administrator and the Director of Nursing on April 17, 2024, at 2:00 PM, and April 18, 2024, at 2:00 PM. The policies provided by the facility entitled, Removal of Central Venous Catheter, and I.V. (Multilumen CVC), last reviewed without changes on June 20, 2023, did not address the development of a plan of care, limb restriction measures (e.g., avoid blood pressures in the affected arm), or emergency procedures (e.g., what to do in the event of bleeding) necessary while the PICC line is in use. Clinical record review for Resident 20 revealed nursing documentation dated March 7, 2024, at 2:50 PM that Resident 20 arrived at the facility. The documentation did not indicate the presence of a PICC line. Nursing documentation dated March 7, 2024, at 10:45 PM revealed that Resident 20 complained of arm pain; however, the documentation did not indicate which arm (right or left) or the presence of a PICC line. Electronic Medication Administration Record documentation dated March 8, 2024, at 12:59 AM noted that staff measured the external catheter length (PICC) from the insertion site to the base of the cap as 4.25 inches or 11 centimeters. Skilled Evaluation documentation dated March 8, 2024, at 1:29 PM confirmed the presence of a PICC line. Observation of Resident 20 on April 17, 2024, at 10:34 AM revealed she had an intravenous access site in the area of her right bicep muscle. The tape meant to hold the access port tubing to her skin was only partially adhered to her skin; but a clear dressing covered the skin at the actual insertion site. Interview with Resident 20 while observing her room on April 17, 2024, at 10:34 AM revealed no indication of an emergency kit or instructions should staff identify a complication of the PICC line (such as clamps or compression dressing kits in the event of bleeding) when providing care to Resident 20. Resident 20 confirmed that this PICC line was in place at the time of her admission to the facility. Interview with Employee 6 (licensed practical nurse) on April 17, 2024, at 10:59 AM verified that there was no emergency kit in Resident 20's room. Interview and observation of Employee 6 on April 17, 2024, at 11:04 AM revealed her walking towards Resident 20's room; she stated that she was taking an emergency kit to Resident 20's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 3 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 0684 Level of Harm - Minimal harm or potential for actual harm Review of Resident 20's plans of care revealed no evidence of a plan of care that included interventions pertaining to infection control measures, emergency measures, or ongoing assessments pertaining to the PICC line. Physician orders for Resident 20 instructed staff to: Observe PICC site every two hours and as needed Residents Affected - Few Measure external catheter length on admission, weekly, and as needed every day shift every Thursday Measure the circumference of arm three inches above the PICC line insertion site on admission and weekly every day shift every Thursday Weekly dressing changes with Needless (sic) IV (intravenous) catheter cap change every day shift every Thursday Normal saline flush intravenous solution, 0.9 percent, use 10 milliliters intravenously three times a day before and after medications, or at least twice daily Change IV tubing every 24 hours every day shift (label with name/date/time) Interview with the Nursing Home Administrator and the Director of Nursing on April 18, 2024, at 2:00 PM confirmed the above findings for Resident 20. Review of Resident 20's MAR (Medication Administration Record, electronic documentation of the administration of medications) and TAR (Treatment Administration Record, electronic documentation of the administration of treatments) dated March and April 2024 revealed that staff failed to document the completion of the following medications and treatments pertaining to Resident 20's PICC line: Vancomycin (antibiotic) intravenous March 8, 16, and 22, 2024, at 8:00 AM; and April 4, 2024, at 8:00 AM Normal saline intravenous flush: March 8, 2024, at 8:00 AM March 16, 2024, at 8:00 AM March 22, 2024, at 8:00 AM April 4, 2024, at 8:00 AM or 2:00 PM Weekly intravenous dressing change: March 14, 2024, day shift April 4, 2024, day shift Measure circumference of arm weekly on day shift Thursday: March 14, 2024, day shift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 4 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 0684 March 21, 2024, day shift Level of Harm - Minimal harm or potential for actual harm April 4, 2024, day shift Measure external catheter length on day shift Thursday: Residents Affected - Few March 14, 2024, day shift March 21, 2024, day shift April 4, 2024, day shift Change intravenous tubing every day shift: March 8, 2024, day shift March 11, 2024, day shift March 14, 2024, day shift April 4, 2024, day shift The surveyor reviewed the above treatment and medication omissions for Resident 20 during an interview with the Nursing Home Administrator and the Director of Nursing on April 19, 2024, at 11:58 AM. 483.25 Quality of Care Previously cited deficiency 5/23/23 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 5 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation and staff interview, the facility failed to maintain an environment free of potential accident hazards in the beauty shop. Residents Affected - Some Finding: Observation of the facility on April 17, 2024, at 11:31 AM revealed that the beauty shop door was open, and no employees were in the beauty shop. Further observation of the beauty shop revealed there was a large bottle of shampoo, conditioner, and hair color, all with warning labels. There were also two pairs of hair-cutting shears, a razor, a curling iron plugged in, and warm to the touch, and a tart burner with hot melted liquid. The surveyor tested the temperature of the water the in hair washing station revealing the water was 121.6 degrees Fahrenheit. The hairdresser returned to the beauty shop at 11:56 AM. Interview with Employee 4 (beautician) on April 17, 2024, at 11:56 AM revealed that she was in a resident's room doing their hair. She stated that she also transports the residents to and from the beauty shop and she wasn't aware that she needed to secure the beauty shop when leaving. 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 6 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 0699 Provide care or services that was trauma informed and/or culturally competent. 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 and resident interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of five residents reviewed for mood/behavior (Resident 32). Residents Affected - Few Findings include: Clinical record review for Resident 32 revealed a diagnosis of Chronic Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) since admission on [DATE]. During an interview with Resident 32 related to his diagnosis of PTSD on April 16, 2024, at 10:37 AM revealed that loud noises and bright lights trigger him. Resident 32 stated that loud noises startle him related to his time in combat. A review of Resident 32's admission minimum data set (MDS, an assessment completed by the facility at intervals to determine care needs) assessment dated [DATE], indicated PTSD was an active diagnosis for Resident 32. Further review of Resident 32's care plan identified he had a diagnosis of PTSD. There were no identified triggers (everyday situations that cause a person to re-experience the traumatic event as if it was reoccurring). An interview with the Nursing Home Administrator and Director of Nursing on April 18, 2024, at 2:16 PM confirmed these findings. The facility failed to identify and care plan triggers that may retraumatize Resident 32 related to his diagnosis of PTSD. 28 Pa Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 7 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of one resident reviewed (Resident 31). Residents Affected - Few Findings include: Clinical record review for Resident 31 revealed the facility admitted him on March 30, 2023, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 31's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 27, 2023, indicated that the facility assessed Resident 31 as having a diagnosis of dementia and determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 31's current care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss, which should reflect family involvement in development. The findings were reviewed with the Administrator and Director of Nursing on April 17, 2024, at 2:15 PM. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 8 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on clinical record review and staff interview, it was determined that the facility failed to ensure the consultant pharmacist reviewed the drug regimen of each resident and reported any irregularities to the attending physician monthly for two of five residents reviewed for potentially unnecessary medications (Residents 26 and 24). Findings include: Clinical record review for Resident 26 revealed a Medication Regimen Review document (form the facility utilizes to document the monthly medication regimen review by the consultant pharmacist) that indicated the consultant pharmacist identified a potential medication irregularity that Resident 26 should be evaluated for a gradual dose reduction of her antianxiety medication, Xanax, on November 26, 2023. The same Medication Regimen Review document indicated that the consultant pharmacist identified that Resident 26 should be evaluated for a gradual dose reduction of her antidepressant medication, Effexor, on December 26, 2023. Resident 26's clinical record did not contain evidence that a physician received the report pertaining to the Xanax medication until December 26, 2023. There was no evidence in Resident 26's medical record that the physician received a report pertaining to the Effexor medication. The surveyor reviewed the above concerns pertaining to Resident 26 during an interview with the Nursing Home Administrator and the Director of Nursing on April 19, 2024, at 12:34 PM. Clinical record review of the Medication Regimen Review document for Resident 24 indicated there was no monthly review completed for February 2024. Further review of Resident 24's clinical record revealed no evidence the consultant pharmacist reviewed Resident 24's drug regimen in February 2024. The Nursing Home Administrator and Director of Nursing confirmed these findings during an interview on April 19, 2024, at 10:52 AM. 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 9 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, review of select manufacture's guidelines, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 24 and 132). Residents Affected - Few Findings include: The facility's medication error rate was 7.69 percent based on 26 medication opportunities with two medication errors. Review of the package insert for the BD AutoShield Duo safety pen needle, dated June 2014, indicates that when using the safety pen needle, the needle should be checked to ensure it is attached correctly by dialing up two units of insulin, pointing the pen up, and pressing the thumb button. If liquid does not appear, change the needle, and repeat the steps. If liquid is present, then users are directed to then dial up the prescribed dose of insulin. Observation of a medication administration pass on April 16, 2024, at 11:45 AM revealed Employee 1, licensed practical nurse, preparing to administer Insulin Aspart Flexpen (type of insulin to treat diabetes) to Resident 132. Employee 1 attached the safety pen needle, then dialed up two units of the insulin on the pen and administered it to Resident 132. Employee 1 did not ensure the safety pen needle was attached correctly or dial up two units to ensure that the liquid appeared before administering the insulin to Resident 132. Observation of a medication administration pass on April 16, 2024, at 12:00 PM revealed Employee 1 preparing to administer Humalog Kwikpen (type of insulin to treat diabetes) to Resident 24. Employee 1 attached the safety pen needle, then dialed up six units of the insulin on the pen and administered it to Resident 24. Employee 1 did not ensure the safety pen needle was attached correctly or dial up two units to ensure that the liquid appeared before administering the insulin to Resident 24. Interview with Employee 1 on April 16, 2024, at 12:15 PM confirmed the above findings for Residents 24 and 132. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 10 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interviews, it was determined that the facility failed to maintain food service equipment in a sanitary manner and proper working order in the facility's main kitchen. Residents Affected - Some Findings include: An observation in the facility's main kitchen on April 16, 2024, at 10:06 AM revealed the following: The hood system (exhaust vent panels) over the stove/cooktop area contained thick visible dust buildup throughout. Observation of the dishwasher on April 16, 2024, at 10:18 AM revealed that the dishwasher was running to clean breakfast dishes. The dishwasher gauge revealed the wash temperature was 126 degrees Fahrenheit. There was no sanitizing agent connected to the dishwasher. Employee 5 (dietary manager) acknowledged the low wash cycle on the dishwasher. Review of the kitchen's Dish Machine Temperature Log revealed the wash temperature was not meeting the required temperature since March 31, 2024. The log noted, If temps of the dishwasher wash cycle fall below 150 degrees notify the dietary manager and maintenance.Dish Further review of the Dish Machine Temperature log revealed the following wash cycle temperatures: March 31, 2024-breakfast 125, lunch 124, and dinner 127 degrees Fahrenheit April 1, 2024- breakfast 125, lunch 126, and dinnner130 degrees Fahrenheit April 2, 2024- breakfast 126, lunch 124, and dinner126 degrees Fahrenheit April 3, 2024- breakfast 126, lunch 126 degrees Fahrenheit, and dinner was not documented April 4, 2024- breakfast 136, lunch 130, and dinner129 degrees Fahrenheit April 5, 2024- breakfast 124, lunch 126, and dinner134 degrees Fahrenheit April 6, 2024- breakfast 126, lunch 124, and dinner136 degrees Fahrenheit April 7, 2024- breakfast 124, lunch 126, and dinner131 degrees Fahrenheit April 8, 2024- breakfast 132, lunch 134, and dinner135 degrees Fahrenheit April 9, 2024- breakfast 126, lunch 124, and dinner134 degrees Fahrenheit April 10, 2024- breakfast 126, lunch 126, and dinner136 degrees Fahrenheit April 11, 2024- breakfast 122, lunch 124, and dinner122 degrees Fahrenheit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 11 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 0812 April 12, 2024- breakfast 120, lunch 122, and dinner126 degrees Fahrenheit Level of Harm - Minimal harm or potential for actual harm April 13, 2024- breakfast 126, lunch 134, and dinner120 degrees Fahrenheit April 14, 2024- breakfast 124, lunch 136, and dinner136 degrees Fahrenheit Residents Affected - Some April 15, 2024- breakfast 124, lunch 124, and dinner130 degrees Fahrenheit Review of the maintenance order dated April 1, 2024, revealed that the dishwasher was overflowing and not getting up to temperature. The order revealed that the drain was fixed, and this did not fix the wash cycle temperature. A company was contacted, and it was noted they would be in to look at it. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on April 17, 2024, at 2:05 PM. The facility had a company come in and fix the rinse temperature issue after the surveyor discussed the concern on April 18, 2024. 28 Pa. Code 201.14(a) Responsibility of licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 12 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 Based on review of select facility policies and procedures, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions for three of 18 residents reviewed (Residents 23, 20, and 51); and ensure hygienically clean resident laundry processing in the main laundry. Residents Affected - Some Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of Resident 51's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated March 14, 2024, that indicated the facility assessed Resident 51 as having a long occurring pressure ulcer and using an indwelling urinary catheter. Review of Resident 51's current physician orders revealed that nursing staff are to care for an open pressure ulcer twice a day and continue to utilize an indwelling urinary catheter for wound healing. There was no documented evidence in Resident 51's clinical record to indicate that the facility implemented the use of EBP. Observation of Resident 51's room on April 17, 2024, at 12:10 PM revealed no evidence that nursing staff should be using EBP when performing high-contact activity for Resident 51. Interview with the Administrator and Director of Nursing on April 17, 2024, at 2:33 PM confirmed that the facility has not implemented EBP for any current residents that would require it. Observation of Resident 23's room on April 16, 2024, at 11:51 AM did not indicate the implementation of any transmission-based precautions necessary to enter the room or provide care to the resident. Interview with Resident 23 on the date and time of the observation confirmed that he required the use of an indwelling Foley (urinary) catheter. The urinary collection bag was observed on the right side of Resident 23's bed. Interview with Employee 6 (licensed practical nurse) on April 17, 2024, at 11:02 AM indicated that she was the professional nurse assigned to Resident 23's care on that date and time; however, she was not aware that Resident 23 required any enhanced barrier precautions. Interview with the Nursing Home Administrator and the Director of Nursing on April 17, 2024, at 2:00 PM confirmed that the facility had not developed a policy to implement enhanced barrier precautions for residents with indwelling devices like catheters and/or intravenous access. The interview confirmed that there were no residents in the facility on enhanced barrier precautions. Interview with Employee 9 (registered nurse/infection control prevention coordinator) on April 18, 2024, at 12:10 PM confirmed that the facility had not implemented enhanced barrier precautions for those residents with an indwelling medical device until following the surveyor's questioning. Employee 9 indicated that she completed education with staff after implementation of the policy following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 13 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 the surveyor's questioning. Level of Harm - Minimal harm or potential for actual harm Review of Resident 23's clinical record revealed that the facility initiated a plan of care on April 18, 2024, to address his enhanced barrier precautions related to his Foley catheter. Residents Affected - Some Interview with Resident 20 on April 17, 2024, at 10:31 AM revealed that she had hip surgery, developed an infection in the hip joint after she returned home, was hospitalized , and was admitted to this facility for intravenous antibiotic therapy. Resident 20 denied that staff utilized personal protective equipment (e.g., isolation gown or gloves) when providing routine care like assistance with hygiene or the administration of medications. Resident 20 stated that staff use gloves and a mask when changing the dressing to her right arm PICC site (peripherally inserted central catheter, PICC, long, thin, tube that is inserted through a vein in the arm and passed through to a larger vein near the heart. The line requires careful care and monitoring for complications including bleeding, infection, and blood clots). Observation of Resident 20 on April 17, 2024, at 10:34 AM revealed she had an intravenous access site in the area of her right bicep muscle. The tape meant to hold the access port tubing to her skin was only partially adhered to her skin; but a clear dressing covered the skin at the actual insertion site. Observation of her room on the date and time of the interview revealed no evidence of enhanced barrier precautions. Interview with Employee 6 on April 17, 2024, at 10:59 AM indicated that she was the professional nurse assigned to Resident 20's care on that date and time; however, she was not aware that Resident 20 required any enhanced barrier precautions. Review of Resident 20's plans of care revealed no evidence of a plan of care that included enhanced barrier precautions. Electronic Medication Administration Record documentation dated March 8, 2024, at 12:59 AM noted that staff measured the external catheter length (PICC) from the insertion site to the base of the cap as 4.25 inches or 11 centimeters. Skilled Evaluation documentation dated March 8, 2024, at 1:29 PM confirmed the presence of a PICC line. Review of Resident 20's clinical record revealed that the facility initiated a plan of care on April 18, 2024, to address her enhanced barrier precautions related to her intravenous medications/fluids. A physician's order dated April 18, 2024 (following the surveyor's questioning), instructed staff to implement, Enhanced Barrier Precautions: Gown and gloves for high contact resident care, add face shield for catheter care r/t (related to) PICC every shift. The facility policy entitled, Infection Control and Laundry Services, last reviewed without changes on June 20, 2023, revealed that the purpose of the policy was to outline standard operating procedures pertaining to the handling of clean linens and soiled linens within the scope of daily resident care. Linens and personal laundry are handled in such a manner as to reduce the ability of cross contamination and staying within recommended CDC Infection Control guidelines. The policy did not stipulate any procedure used to ensure that laundry is hygienically cleaned (e.g., chemical, thermal, or mechanical/agitation). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 14 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 The CDC (Centers for Disease Control and Prevention) Best Practices for Linen and Laundry Management note that the effectiveness of the laundering process depends on many factors, including: Level of Harm - Minimal harm or potential for actual harm Time and temperature Residents Affected - Some Mechanical action Water quality (pH, hardness) Volume of the load Extent of soiling Model/availability of commercial washers and dryers The resource specifically stipulated to, Always use and maintain laundry equipment according to manufacturer's instructions. Best practices for laundering soiled linen included: Follow instructions from the washer/dryer manufacturer. Use hot water (158-176 degrees Fahrenheit for 10 minutes) and an approved laundry detergent Use disinfectant on a case-by-case basis, depending on the origin of the soiled linen (e.g., linens from an area on contact precautions) Dry linens completely in a commercial dryer. Observation of the facility's main laundry department on April 19, 2024, at 11:38 AM with Employee 8 (laundry/housekeeping supervisor) and the Nursing Home Administrator revealed that Employee 8 had processed loads of resident laundry on that date; however, Employee 8 was unable to indicate how water temperatures in the laundry department are monitored, the weight capacity of the facility's washing machines (e.g., 60 pounds), if the chemicals used for laundry processing included the use of a sanitizing agent, or if the Xtreme Oxygen Bleach product located by the equipment was used in every load of laundry processed (e.g., every load of personal laundry and not just for whites). The Nursing Home Administrator indicated that she would contact the facility's chemical vendor to ascertain the pathogens inactivated by the chemicals used, if any. The facility was unable to provide this information during the onsite survey. Employee 8 contacted a previous laundry department supervisor via telephone on April 19, 2024, at 11:45 AM who (via speakerphone) stated that the facility utilizes a system of hot water to ensure that laundry is hygienically clean. She stated that the facility's chemical vendor indicated that it would be appropriate for water temperatures to be 150 degrees Fahrenheit during laundry processing; however, no staff could locate any water temperature logs or equipment (e.g., thermometer) used to assess water temperatures in the department. During an interview with the Nursing Home Administrator on April 19, 2024, at 1:20 PM the Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 15 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 - Some Home Administrator provided a laundry service audit dated March 11, 2024, from the facility's laundry chemical provider that stipulated the water temperatures reached 155 to 157 degrees Fahrenheit and that the washing machines had a 60-pound capacity. The interview confirmed that the facility had no mechanism in place to ensure that staff did not overload the machines during laundry processing (e.g., a scale to ensure no more than a 60-pound load processed at one time), that the facility had no evidence that hot water temperatures reached those stipulated by the CDC, or that any chemicals used in the laundry processing sanitized fabrics. The interview also confirmed that the policy provided did not stipulate the method of washing used to ensure hygienically cleaned laundry. 28 Pa. Code 201.18(b)(3)(d)(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 16 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on review of select facility policies and procedures, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure the administration of a COVID-19 immunization for one of five residents reviewed for immunization concerns (Resident 45). Findings include: The facility, COVID19 Immunization/Booster Informed Consent, is a form utilized by the facility to document the provision of education regarding the risks and benefits of the vaccine, the resident's history of previous vaccinations, and documentation of consent by the resident/resident's responsible party for the administration of the vaccine. The facility policy entitled, Core Infection Prevention and Control Measures, last revised October 23, 2023, revealed that the facility will provide residents and their family/POA information on the COVID vaccines on admission and will be given the opportunity to receive the vaccine in the facility. Residents will be educated on the current recommended vaccine through the CDC and will be offered the vaccine at least yearly or with any new boosters. Definition of fully vaccinated is changed to, up to date, with all current recommended vaccine doses. The current CDC recommendations for COVID-19 vaccinations stipulate that people aged 12 years and older who got previous COVID-19 vaccine(s) before September 12, 2023, should get one updated Pfizer-BioNTech, Moderna, or Novavax COVID-19 vaccine. Clinical record review for Resident 45 revealed immunization history information that indicated that she received a COVID-19 immunization on February 13, 2021, March 6, 2021, October 12, 2021, August 16, 2022, and October 27, 2022. A COVID19 Immunization/Booster Informed Consent signed by Resident 45 on April 27, 2023, and a COVID19 Immunization/Booster Informed Consent signed by Resident 45's daughter on November 2, 2023, gave permission for the facility to administer the COVID19 vaccination series/booster. There was no evidence in Resident 45's clinical record that she received a COVID-19 immunization after October 27, 2022. Interview with Employee 9 (registered nurse infection control prevention coordinator) on April 18, 2024, at 3:39 PM confirmed that there was no evidence Resident 45 received a COVID-19 immunization after October 27, 2022. Employee 9 indicated that information under Resident 45's immunization tab within her electronic clinical record documented that staff noted Resident 45 refused the vaccine; however, there was no COVID19 Immunization/Booster Informed Consent document or progress note to support that. The information referred to included an electronic signature by Employee 7 (registered nurse) dated February 14, 2024. During an interview with Resident 45 on April 19, 2024, at 11:18 AM, she stated, no, not a bit, when asked if she was opposed to receiving a COVID-19 vaccine. Interview with Employee 7 on April 19, 2024, at 11:30 AM, indicated that her documentation recorded (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 17 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on February 14, 2024, confirmed that a consent was obtained for Resident 45 to receive the COVID-19 immunization; not that Resident 45 refused the immunization. Interview with the Nursing Home Administrator and the Director of Nursing on April 19, 2024, at 11:58 AM revealed that the facility could not identify a staff member that documented Resident 45 refused a COVID-19 immunization. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 18 of 19 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 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to perform an accurate assessment for possible entrapment with the use of specialized mattress and side rails for one of six residents reviewed (Resident 51). Findings include: The policy entitled Side Rail Policy and Procedure, last reviewed on June 20, 2023, indicates that when side rail usage is deemed appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment. The policy does not specify what the facility will utilize when the assessments would indicate that side rails are not appropriate or safe. Observation of Resident 51's bed on April 17, 2024, at 10:37 AM revealed that her bed had bilateral half side rails up on each side of her bed. Resident 51 had an air mattress in place that easily shifted side to side leaving a larger gap between the side rail and the mattress depending on what side the mattress was shifted too. Review of Resident 51's clinical record revealed that the facility admitted her on November 15, 2022, with a diagnosis of Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 14, 2024, indicated that the facility determined that she scored a 5 on the BIMS (Brief Interview for Mental Status, a tool used to screen and identify the cognitive condition of residents). A score of 0 to 7 suggests severe cognitive impairment. Resident 51 has a current physician's order dated May 1, 2023, that indicates the facility is to utilize an air mattress. Review of Resident 51's side rail assessment form dated March 12, 2024, indicated that the facility assessed her as having fluctuating levels of consciousness but not an alteration in safety awareness due to cognitive impairment. The assessment also indicated that Resident 51 has a history of falls. Review of Resident 51's side rail entrapment assessment dated [DATE], indicated that the facility identified that Resident 51 is using a special mattress that fits securely without shifting, despite the surveyor observation of the mattress shifting. Interview and observations with Employee 2, occupational therapist, on April 18, 2024, at 10:59 AM confirmed that Resident 51's mattress does shift from side to side and is not secured. Employee 2 also indicated that for the March 12, 2024, assessment she did not physically enter Resident 51's room to measure entrapment zones, and that she based the side rail entrapment assessment for Resident 51 on the typical bed frame and mattress being used in the facility. The surveyor reviewed the above information during an interview with the Administrator on April 18, 2024, at 12:00 PM. 28 Pa Code 211.12(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395101 If continuation sheet Page 19 of 19