Inspection·February 16, 2024

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records and activities programming and participation records, and resident and staff interviews, it was determined that the facility failed to provide an ongoing program of activities designed to meet the needs, interests and functional abilities of residents including two of 25 sampled residents (Residents 83 and 117). Residents Affected - Some Findings include: Review of Resident 117's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included major depressive disorder ([MDD] persistently low or depressed mood) and stage four sacral ulcer (a severe wound that extends past het skin and subcutaneous tissue, exposing muscle and bone). Review of an initial activities assessment dated [DATE], revealed that the resident enjoyed listening to oldies music and watching cooking shows on the television. Review of the resident's care plan dated November 21, 2023, revealed that the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. Approaches planned were to offer encouragement of ongoing family involvement, activities that the resident enjoys, and providing the resident with an activities calendar and weekly menu, and to notify the resident of any changes to the calendar of activities. The resident's care plan did not identify the resident's specific preferences for activities programming that she enjoys. Review of the resident's activity participation titled Documentation Survey Report v2 for January 2024 and February 2024, failed to reveal that the resident had been offered or participated in the activities the resident preferred. The participation documentation listed cognitive group, self-directed activities, and sensory stimulation and did not identify the specific programming or the resident's response to the activities. Observation of Resident 117 on February 14, 2024, at 1:42 PM, revealed that the resident was lying in bed. The resident was observed throughout the day on February 15, 2024, in her room and observed at 1:00 PM, lying in her bed. There was no observable evidence that the resident was provided with supplies/resources for independent/self-directed preferred activities. An interview with Resident 117 on February 14, 2024, at 2:21 PM revealed she does not attend group activities due spending most of her time in bed. She stated that when she sits for a long period of time it causes her pain due to her sacral wound. She stated there are activities offered but as a group, so I usually do not go. When asked if there are activities individualized to her preferences, she said no, just the group. Review of Resident 83's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included macular degeneration (deterioration of the retinal macular causing blurring and leading to vision loss) and hemiplegia/hemiparesis (weakness caused by brain damage leading to paralysis on one side of the body) due to left cerebrovascular accident ([CVA] when blood flow to a part of the brain is stopped by blockage or the rupture of a blood vessel). Review of an initial activities assessment dated [DATE], revealed that the resident enjoys music by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395103 If continuation sheet Page 2 of 10 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 395103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elan Skilled Nursing and Rehab, A Jewish Senior LI 1101 Vine Street Scranton, PA 18510 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 0679 Elvis, arts and crafts, pet and patio visits and prefers to watch the evening news on the television. Level of Harm - Minimal harm or potential for actual harm Review of the resident's care plan dated November 26, 2023, revealed that the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. Approaches were to offer encouragement of ongoing family involvement, her activity preferences, to encourage the resident to participate in group activities allowable with COVID-19 restrictions, provide individual activities related to their personal preferences to Face Time, Skype, and Google Duo visits are being offered as family and resident desire. Residents Affected - Some Review of the resident's activity participation titled Documentation Survey Report v2 for January 2024 and February 2024, failed to reveal that the resident had been offered or participated in the activities the resident preferred. The participation documentation listed cognitive group, self-directed activities, and sensory stimulation and did not identify the specific programming or the resident's response to the activities. Review of a nurses progress note dated February 5, 2024 at 10:06 AM revealed that the resident tested positive for COVID-19 and isolation droplet precautions were initiated. Observation of Resident 83 on February 14, 2018, at 1:22 PM, revealed that the resident was sitting on the bed in the resident's room with the television on. The resident was observed throughout the day on February 15, 2024, in her room, and observed at 1:00 PM, sitting on the bed in her room. There was no observable evidence that the facility provided the resident with supplies/resources for independent/self-directed preferred activities. An interview with Resident 83 on February 14, 2021, at 1:20 PM revealed that the resident stated the activities in the facility are not good here and that she has problems with her vision that prevents her from participating in some of the activities they have. The resident stated that she has been under isolation/droplet precautions since February 5, 2024, due to testing positive to COVID-19. The resident stated that she is lonely because her roommate had to change rooms due to the COVID infection, and she has no one to talk to and the facility has not provided her with any activities during this time. An interview with Employee 1, Life Enrichment Director, on February 15, 2024, at 10:00 AM revealed that the Documentation Survey Report v2 was the only documentation used for tracking residents' activity participation and confirmed that the activity participation failed to clearly reflect the activities offered to the residents and their response to those activities. Additionally, there was no indication of the activity programming for residents who prefer not to attend group activities and prefer one to one or self-directed activities of preference. During an interview on February 16, 2024, at approximately 11:30 AM, with the Assistant Nursing Home Administrator (ANHA) confirmed the lack of ongoing program of activities in the facility to meet the needs, interests, preferences, and cognitive and physical abilities of residents who are dependent on staff and those under isolation precautions. 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 201.18(e)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395103 If continuation sheet Page 3 of 10 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 395103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elan Skilled Nursing and Rehab, A Jewish Senior LI 1101 Vine Street Scranton, PA 18510 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 Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, information submitted by the facility, and select facility reports and staff interviews, it was determined that the facility failed to provide necessary supervision and effective safety measures to monitor the whereabouts and activities of one out of two sampled residents with wandering behavior (Resident 108) to maintain resident safety. Findings include: A review of the clinical record revealed that Resident 108 was admitted to the facility on [DATE], with diagnoses of Dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), macular degeneration, and osteoarthritis. A review of Resident 108's wander/elopement risk scale (a document used to rate an individual's risk of elopement) dated March 11, 2023, revealed that the resident scored a 10, indicating that the resident was at risk for elopement/wandering. A review of an Annual Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 17, 2023, revealed that the resident's cognition was severely impaired with a BIMS score (brief interview for mental status -section of MDS that assesses cognition) of 4 (a score of 0-7 indicates severely impaired cognition). The resident was independent with walking and used a wander/elopement alarm daily. Interventions care planned to address the resident's elopement risk were to check resident's location on inter shift rounds, and check transmitter per facility policy, dated December 26, 2022, and the resident's care plan noted that when I am wandering, please offer to me my busy box with a few favorite items (sun catcher/puzzles/water paining/word search). Radio is in my room, likes to request phone calls and offer assistance, comfort snack is coffee with sugar, dated February 24, 2023, and place photo in wanderers book, check placement of transmitter on inter shift rounds, date revised August 28, 2023. A nursing progress note dated April 19, 2023, at approximately 2:35 PM, revealed that Resident 108 was seen on the first floor (not the floor where the resident resides). She was attempting to go through the back entrance, exit doors. Her wanderguard sounded and our receptionist notified maintenance, who redirected her around to the elevator, and escorted back to the fourth floor without incident. The resident stated she was going to her grandmother's house. MD, aware, and family currently in the building and aware. New order noted for customer service 15 - minute checks for safety. Nursing documentation dated November 24, 2023, indicated that at 2:55 PM, the resident was found at the back door of the facility. Her transmitter did alert staff to her attempts to leave the building. Employee 2, a nurse aide, was coming on shift at the time, and saw Resident 108 at the door and escorted her back into the building. The resident's daughter, was also entering the building, and escorted her back to the unit with Employee 2. Emotional support was provided. The resident's care plan was revised on November 25, 2023, in response to an incident on November 24, 2023, during which the resident was found attempting to leave facility, located at the front door. The goal was that the resident's safety will be maintained, and the resident will not leave the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395103 If continuation sheet Page 4 of 10 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 395103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elan Skilled Nursing and Rehab, A Jewish Senior LI 1101 Vine Street Scranton, PA 18510 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 facility unattended through the next review date with the target date April 18, 2024 Level of Harm - Minimal harm or potential for actual harm A review of a change in condition note dated November 24, 2023, at 4:30 PM, indicated a change in condition assessment was completed related to the resident attempted elopement out the back entrance. Found at doorway and escorted back to fourth floor. No injuries noted. and at 5:30 PM, the MD was notified of the incident. Changes and updates were made to the keyed entrance/exit codes on the unit. Residents Affected - Few A review of an incident report entitled Event of Known Origin (Other than Fall) dated November 24, 2023, at 2:55 P.M., revealed that Resident 1 had been found at the rear lobby door without injury and that the entrance/exit elevator codes had been changed, and that every 15-minute safety checks were initiated. A review of Employee 2's witness statement dated November 24, 2023, indicated that the employee was approaching the door to enter for her shift. The employee saw the resident walk out of the 2nd set of doors to the parking lot. Resident 108 was walking with another woman along with an employee behind them. The resident was stopped at the door by Employee 2, and the resident's daughter as they were entering. Together, they escorted the resident back into the building and notified the supervisor. A review of facility incident follow up, dated November 24, 2023, revealed that the administrator was alerted immediately, and went to the area to investigate. Employee 4 (receptionist) was on duty, thought the alarm was going off because a resident was coming in from the outside with a family member. Employee 4 (receptionist) had seen Resident 108 in the past, but thought she was with her family and did not verbally verify who she was and who was accompanying her. The resident's code alert was tested and found to be functioning, the lobby door was tested and found to be working properly. A request for maintenance to determine if the elevator code for the 4th floor unit could be changed. Camera footage was reviewed and showed a family member of another resident from 4th floor was leaving the building at 2:48 PM. The lobby door closed behind her. At 2:53:51 PM Resident 108 was seen at the lobby exit door and code alert bracelet worn prevented the door from opening, alarm sounded. At the same time, 2 visitors arrived at the door with Resident 108 to go out (exit), and 1 staff member Employee 3, a nurse aide, and a visitor arrived at the door to come in from the outside. Employee 4 (receptionist) went to the door and disarmed the door. Resident 108 walked through the first door with the other 2 visitors into the vestibule and stepped out to the mat at the second door going out of the vestibule at the same time another staff member, Employee 2 was walking into the door into the vestibule with the resident's daughter. Resident 108 was returned to unit without incident. Employee 3, nurse aide and Employee 4, receptionist, stated they thought Resident 108 was going out with family as she had her coat and purse, and was speaking with the 2 visitors as they walked through the first door into the vestibule, which is why Employee 4 (receptionist) turned off the alarm system. In response to the incident, reception staff educated, in-serviced, on their responsibility when the alarms go off, (identifying the resident, who is accompanying the resident) prior to resetting the code. All elevator codes have been changed to all elevators to the 4th floor, and all staff have been educated, in-serviced on the new codes, and to visibly observe the elevator doors close to ensure no unauthorized residents are on the elevators before walking away. Signs have been posted for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395103 If continuation sheet Page 5 of 10 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 395103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elan Skilled Nursing and Rehab, A Jewish Senior LI 1101 Vine Street Scranton, PA 18510 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 Residents Affected - Few staff not to share the codes with family/visitors, and for family/friends to ask, request, access from a staff member for the elevators to exit the floor. A review of information submitted by the facility dated November 24, 2023, indicated that Resident 108 had left the nursing unit unattended, unsupervised by staff, on the elevator and proceeded to the main lobby as stated. The Assistant Nursing Home Administrator (Asst. NHA) on February 15, 2024, stated during interview at approximately 1:10 PM, that Resident 108 had not exited the 2nd set of doors into the parking lot, but rather was in-between the inner and outer doors (the vestibule). Interview with the Asst. NHA on February 16, 2024, at approximately 10:05 AM, confirmed that staff were not aware of Resident 108 leaving the nursing unit until the resident was observed attempting to exit the facility at the lobby doors. 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 211.12 (d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395103 If continuation sheet Page 6 of 10 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 395103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elan Skilled Nursing and Rehab, A Jewish Senior LI 1101 Vine Street Scranton, PA 18510 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 accurately monitor a fluid restriction prescribed to address a resident's clinical condition and maintain fluid balance and adequate hydration status for one resident receiving dialysis (Resident 54) out of 25 sampled. Residents Affected - Few Findings include: A review of the clinical record revealed that Resident 54 was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease, diabetes, and end stage kidney disease with dependence on hemodialysis. A physician's order dated January 25, 2024, was noted for the resident to be maintained on a 1000 cc fluid restriction with the following breakdown of the fluid distribution: 7:00 AM - 3:00 PM shift nursing 240 ml. 3:00 PM - 11:00 PM shift nursing 120 ml. 11:00 PM - 7:00 AM. shift nursing 120 ml. A total of 520 ml of fluids provided by dietary each day. A review of the resident's January 2024 and February 2024 Documentation Survey Report failed to provide evidence of an accurate recording and/or accounting of the amount of fluids the resident consumed each day to assess compliance with physician ordered fluid restriction related to the resident's kidney disease and to meet the resident's hydration needs. Interview with the facility's Registered Dietitian on February 15, 2024, at approximately 11 AM confirmed that the facility did not have a process in place to monitor Resident 54's total fluid consumption for compliance to the fluid restriction. The facility was unable to confirm the amount of fluid consumed by the resident daily and if that amount of fluid consumed exceeded the physician prescribed fluid restriction or was sufficient to maintain adequate hydration. The facility was unable to provide documented evidence that this fluid restriction was maintained in accordance with physician orders. 28 Pa. Code: 211.12 (c)(d)(3)(5) Nursing services 28 Pa. Code 211.5(f) Medical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395103 If continuation sheet Page 7 of 10 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 395103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elan Skilled Nursing and Rehab, A Jewish Senior LI 1101 Vine Street Scranton, PA 18510 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of select facility policy and controlled drug shift count records, observation, and staff interviews, it was determined that the facility failed to implement procedures for reconciling and accounting for the use and administration of controlled drugs on three of five medication carts reviewed (3rd high, 3rd low, and 2nd). Finding include: A review of facility policy Controlled Medication last reviewed by the facility February 5, 2024, indicated that the policy is to ensure appropriate management and accounting of all controlled medications. All controlled medications will be counted by the on-coming and off-going licensed nurse at the change of each shift. After verification of the accuracy of the controlled substance count, both nurses will sign the Narcotic and Controlled Drug Record on the line corresponding with the appropriate date and shift. Observation of medication administration pass, on February 14, 2024, at approximately 8:25 AM, revealed Employee 5, Licensed Practical Nurse (LPN), was completing med pass on the 3rd floor high side medication cart. Upon review of the narcotic count records, entitled count form, it was revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify completion of the counts of controlled drugs in the respective medication cart on February 11, 2024 and February 13, 2024. Interview with employee 5 (LPN), confirmed the observation and acknowledged the licensed nurse are expected to sign at change of shift. A review of the narcotic count records, entitled count form, on February 14, 2024, at approximately 8:38 AM, revealed Employee 6, Licensed Practical Nurse (LPN), on the 3rd floor low side medication cart. It was observed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following dates to verify completion of the counts of controlled drugs in the respective medication cart: January 21, 2024, and February 2, 2024. Interview with employee 6 (LPN), confirmed the observation and acknowledged the licensed nurse signatures are expected to be signed at change of shift. A review of the narcotic count records, entitled count form, on February 14, 2024, at approximately 12:50 PM, revealed Employee 7, Licensed Practical Nurse (LPN), on the 2nd floor medication cart. It was discovered that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify counts of controlled drugs in the respective medication cart: January 29, 2024. Interview with employee 7 (LPN), confirmed the observation and acknowledged the licensed nurse signatures are expected to be signed at change of shift. Interview with the Assistant Nursing Home Administrator (Asst. NHA) on February 15, 2024, at approximately 11:10 AM, confirmed the observation, and that it is his expectation that nursing staff signs the narcotic count records, entitled count form, at change of shift, and that the facility failed to implement procedures for accounting for the controlled drugs. 28 Pa Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.9 (k) Pharmacy Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395103 If continuation sheet Page 8 of 10 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 395103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elan Skilled Nursing and Rehab, A Jewish Senior LI 1101 Vine Street Scranton, PA 18510 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select facility policy, resident and staff interviews it was determined that the facility failed to ensure that resident's drug regimen was free of unnecessary antibiotic drugs for one out of five residents sampled prescribed antibiotic drugs (Resident 40). Residents Affected - Few Findings included: A review of the facility's policy titled Antibiotic Stewardship Plan with a review date of August 23, 2023, states that antibiotic resistance is a major problem, it is imperative to protect agents available by judicious antimicrobial management, which improves resident outcomes and reduces the potential development of resistant infections. The guideline principles include timely and appropriate initiation of antibiotics, appropriate administration according to evidence-based practice, monitoring the effectiveness and promoting transparency and open communication. Review of Resident 40's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of cognitive communication deficit (impaired functioning of one or more cognitive processes) and diabetes mellitus type two ([T2DM] a condition of insufficient insulin production causing high blood sugar levels). A clinical record titled JH Change in Condition Evaluation dated January 28, 2024, at 4:03 PM, revealed that {Resident 40} had a fever of 102.4 degrees Fahrenheit. All other vital signs were within normal limits, no changes were observed in her mental, functional, or behavioral status. The resident had no complaints or observations of her urinary function. The record stated that the resident was experiencing a fever and her daughter was concerned of a urinary tract infection (UTI) without any other indication. Recommendations from the provider were to obtain a urinalysis ([UA] is an analysis that includes various tests to examine the urine contents for any abnormalities that indicate a disease condition or infection), culture and sensitivity ([C & S] identifies the organisms create infections and illnesses. Sensitivity tests to identify the most effective medications to treat the illnesses or infections), and a complete blood count ([CBC]serum laboratory testing), complete metabolic panel ([CMP] serum laboratory testing), and blood cultures (serum laboratory testing), and one time of dose of Levaquin (antibiotic medication) 750 mg. Levaquin (antibiotic medication) one dose after urine sample obtained and re-evaluate after results of CBC and UA/C&S. A review of the resident's medication administration record (MAR) for the month of January 2024, revealed that the resident received one dose of Levaquin, received on January 28, 2024. A review of McGeer's Criteria dated January 29, 2024, revealed that the resident had a single symptom of fever and no other symptoms of a UTI and that the UTI criteria was not met to treat. A review of laboratory test results (U/A) dated January 28, 2024, at 5:46 PM revealed an abnormal result of small amount of esterase urine and WBC urine 20-29. A review of laboratory test results (CBC) dated January 28, 2024, at 3:06 PM revealed that the patient had a slightly elevated WBC (white blood cell) count of 11.89, but not exceeding 14,000 WBC/mm to meet McGeer's Criteria for leukocytosis (higher than normal level of white blood cells in the blood). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395103 If continuation sheet Page 9 of 10 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 395103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elan Skilled Nursing and Rehab, A Jewish Senior LI 1101 Vine Street Scranton, PA 18510 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 0757 Level of Harm - Minimal harm or potential for actual harm A review of laboratory test results (blood cultures) dated February 2, 2024, at 6:02 PM revealed that there was no growth of bacteria noted. There was no evidence of an order to obtain a urine culture and sensitivity or report of the results of a urine C & S when reviewed at the time of the survey ending February 16, 2024. Residents Affected - Few There was no physician documentation to indicate the clinical necessity of initiating antibiotic treatment with Levaquin to treat the resident's suspected urinary tract infection prior to receiving the results of a urine C&S or that a C&S was performed. Interview with the Infection Preventionist Nurse on February 16, 2024, at 11:30 AM, confirmed that the prescribing physician did not document the supporting clinical rationale for initiating antibiotics prior to receiving the results of the culture and sensitivity results identify the most effective treatment for the resident's suspected urinary tract infection. 28 Pa. Code 211.2(d)(3)(5) Medical director 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.9 (k) Pharmacy services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395103 If continuation sheet Page 10 of 10