Health inspection·December 7, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was complete to accurately reflect the resident's status for four of 27 sampled residents. (Residents 24, 89, 111, 128) Residents Affected - Few Findings include: Clinical record review revealed that Section D (Mood) of Resident 24's MDS assessment dated [DATE], was incomplete. Clinical record review revealed that Section D (Mood) of Resident 89's MDS assessment dated [DATE], was incomplete. Clinical record review revealed that Section I (Active Diagnoses) of Resident 111's MDS assessment dated [DATE], inaccurately indicated that Resident 111 did not have depression. Section N (Medications) indicated Resident 111 had received antidepressant medication. Further review of the clinical record revealed Resident 111 was admitted to the facility October 23, 2023. The physician noted at this time that Resident 111 had a diagnosis of depression and antidepressant medications were ordered. In an interview on December 7, 2023, at 10:40 a.m., the Director of Nursing confirmed that Resident 111 had the diagnosis of depression since admission to the facility and it was not noted on the MDS. Clinical record review revealed that Section N (Medications) of Resident 128's MDS assessment dated [DATE], inaccurately indicated that the resident was not on an antipsychotic medication during the seven-day review period, however review of the rresident's record revealed the resident did receive an antipsychotic (paliperidone) during the seven-day review period. In an interview on December 7, 2023, at 10:00 a.m., the Director of Nursing confirmed that Resident 128 had received an antipsychotic during the review period and it was not noted on the MDS. CFR 483.20(g) Accuracy of Assessments Previously Cited 12/1/22 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395138 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 395138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mifflin Center 500 East Philadelphia Avenue Shillington, PA 19607 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **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 develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for five of 27 sampled residents. (Residents 76, 111, 119, 134, 135) Findings include: Clinical record review revealed that Resident 76 was admitted to the facility on [DATE], and had diagnoses that included diabetes mellitus and hypertension (high blood pressure). The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated November 9, 2023, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident 76's urinary incontinence were included in the current care plan. Clinical record review revealed that Resident 111 was admitted to the facility on [DATE], and had diagnoses that included depression and diabetes mellitus. The MDS CAA summary dated October 30, 2023, noted that the resident's urinary incontinence and psychotropic drug use were to be addressed in the care plan. There was no evidence that interventions to address Resident's 111 urinary incontinence and psychotropic drug use were included in the current care plan. Clinical record review revealed that Resident 119 was admitted to the facility on [DATE], and had diagnoses that included hypertension (high blood pressure) and depression. The MDS CAA summary dated November 11, 2023, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident 119's urinary incontinence were included in the current care plan. Clinical record review revealed that Resident 134 was admitted to the facility on [DATE], and had diagnoses that included depression and chronic kidney disease. The MDS CAA summary dated November 19, 2023, noted that the resident's urinary incontinence and psychotropic drug use were to be addressed in the care plan. There was no evidence that interventions to address Resident 134's urinary incontinence and psychotropic drug use were included in the current care plan. Clinical record review revealed that Resident 135 was admitted to the facility on [DATE], and had diagnoses that included hypertension (high blood pressure) and a disorder of the bladder. The MDS CAA summary dated November 22, 2023, noted that the resident's urinary incontinence and visual function were to be addressed in the care plan. There was no evidence that interventions to address Resident 135's urinary incontinence and visual function were addressed in the current care plan. In an interview on December 7, 2023, at 9:40 a.m., the Director of Nursing confirmed there was no documented evidence that the identified care areas were addressed in the residents' current care plans. 28 Pa. Code 211.12(d)(1)(5)Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395138 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 395138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mifflin Center 500 East Philadelphia Avenue Shillington, PA 19607 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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, observation, and interview, it was determined that the facility failed to provide services to maintain adequate grooming and personal hygiene for residents unable to carry out activities of daily living for four of 27 sampled residents. (Residents 9, 26, 32, 61) Residents Affected - Few Findings include: Clinical record review revealed that Resident 9 had diagnoses that included hemiplegia (severe or complete loss of motor function on one side of the body) and traumatic brain injury. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment and required extensive staff assistance for personal hygiene. The care plan identified that Resident 9 had difficulty caring for himself due to his physical limitations and interventions included that staff assist with daily hygiene and grooming. Observations on December 5, 2023, at 11:38 a.m., and December 6, 2023, at 10:21 a.m., revealed that Resident 9's fingernails on both hands were long and jagged. Clinical record review revealed that Resident 26 had diagnoses that included peripheral vascular disease and polyneuropathy (damage to peripheral nerves). The MDS assessment dated [DATE], indicated that the resident was oriented and required extensive staff assistance for personal hygiene. The care plan identified that Resident 26 had difficulty caring for himself due to his physical limitations and interventions included that staff assist with daily hygiene and grooming. Observations on December 5, 2023, at 11:44 a.m., and December 6, 2023, at 9:35 a.m., revealed that Resident 26's fingernails on both hands were long and jagged with dirt underneath. In an interview at that time the resident stated that he preferred his nails to be kept short. Resident 26 could not recall the last time staff provided or offered nail care. Clinical record review revealed that Resident 32 had diagnoses that included a stroke and hemiplegia. The MDS assessment dated [DATE], indicated that the resident had moderate impaired cognition, usually understood others, could expressed herself sometimes, and required extensive staff assistance for personal hygiene. The care plan identified that Resident 32 had physical limitations and required staff assistance for daily hygiene and grooming. Observations on December 6, 2023, at 12:35 p.m., and on December 7, 2023, at 12:50 p.m., revealed that Resident 32's fingernails on both hands were long, jagged, and yellow. In an interview Resident 32 stated, I wish I could get these trimmed, and I don't like them like this. Clinical record review revealed that Resident 61 had diagnoses that included stroke, hemiplegia, bilateral hand contractures, and lack of coordination. The MDS assessment dated [DATE], indicated that the resident was oriented and required extensive assistance for daily hygiene and grooming. The care plan identified that Resident 61 had physical limitations and required staff assistance for daily hygiene and grooming. Observations on December 5, 2023, at 11:40 a.m., and December 6, 2023, at 12:15 p.m., revealed that Resident 61's fingernails on both hands were long and jagged, and the right palm had scratch marks and circular indentations from the fingers. Observations on December 7, 2023, at 12:40 p.m., revealed the resident's nails were short and an abrasion was present on the side of the finger. In an interview on December 5, 2023, at 11:40 a.m., the resident stated that self trimming of the nails was difficult. In an interview on December 7, 2023, at 12:40 p.m., the resident revealed that she had chewed off and filed down her nails by herself. In an interview on December 6, 2023, at 2:10 p.m., the Director of Nursing stated that nails were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395138 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 395138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mifflin Center 500 East Philadelphia Avenue Shillington, PA 19607 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 0677 to be done on resident shower days as needed. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(5) Nursing services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395138 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 395138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mifflin Center 500 East Philadelphia Avenue Shillington, PA 19607 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for two of 27 sampled residents. (Resident4, 238) Residents Affected - Few Findings include: Review of the policy entitled, General Dose Preparation and Medication Administration, last reviewed April 24, 2023, revealed staff were to obtain vital signs if necessary, and document necessary medication administration information. Clinical record review revealed that Resident 4 had diagnoses that included hypertension (high blood pressure). A physician's order dated November 14, 2023, directed staff to administer a medication (metoprolol succinate) once a day for hypertension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 180 millimeters of mercury (mm/Hg). Review of Resident 4's medication administration records (MAR) revealed that staff administered the medication 17 times in November and six times in December 2023 when the resident's SBP was less than 180 mm/Hg. In an interview on December 7, 2023, at 9:50 a.m., the Director of Nursing (DON) confirmed that the medications were administered outside established parameters for Resident 4. Clinical record review revealed that Resident 238 had diagnoses that included hypertension. On November 25, 2023, the physician ordered staff to administer a blood pressure medicine (metoprolol tartrate) twice a day. Staff were not to administer the medication if the resident's SBP was less than 90 mm/Hg or if the heart rate (the number of times a heart beats in one minute) was less than 60. Review of Resident 238's November and December 2023 MARs revealed that staff administered the medication 22 times with no documentation that the blood pressure and heart rate was assessed prior to medication administration per physician's order. In an interview on December 7, 2023, at 1:20 p.m., the DON confirmed there was documented evidence that the blood pressure and heart rate were taken prior to medication administration per physician's order. CFR 483.25 Quality of Care Previously cited 12/1/22 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395138 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 395138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mifflin Center 500 East Philadelphia Avenue Shillington, PA 19607 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on facility policy review, clinical record review, and observation, it was determined that the facility failed to provide proper catheter care to prevent the risk of infection for two of four sampled residents who utilized an indwelling urinary catheter (a flexible tube that drains urine from the bladder). (Resident 32, 54) Findings include: Review of the facility policy entitled, Catheter: Indwelling Urinary last reviewed April 2023, revealed that a urinary catheter system should be inspected to ensure connections are secure, the tubing should be kept off the floor, and the emptying spigot of the Foley catheter bag system should not be in contact with non-sterile surfaces. Clinical record review revealed that Resident 32 had diagnoses that included neuromuscular dysfunction of the bladder and a history of a stroke with residual left-sided upper and lower extremity weakness. According to the Minimum Data Set (MDS) assessment, dated August 24, 2023, the resident had an indwelling urinary catheter in place. On December 6, 2023, from 12:35 p.m. until 1:03 p.m., Resident 32 was observed in a wheelchair in front of the 300 unit nurse's station. The tubing of the urinary catheter was wrapped around the front right wheel of the wheelchair, touching the floor. Resident 32 was moving the wheelchair repeatedly rolling over the catheter tubing. The Director of Nursing, LPN2, and NA2, walked by and engaged in conversation with Resident 32 and none of them attempted to adjust the catheter tubing. At 1:03 p.m., the resident was moved into the dayroom and the catheter tubing was still in contact with the floor. On December 7, 2023, from 12:48 p.m. until 12:54 p.m., Resident 32 was observed sitting in front of the 300 unit nurse's station with catheter tubing on the floor. LPN2 was present, but did not attempt to secure the tubing. Clinical record review revealed that Resident 54 had diagnoses that included neuromuscular bladder dysfunction and paraplegia. According to the MDS assessment, dated August 30, 2023, the resident had an indwelling catheter in place. A physician's order dated July 13, 2023, directed staff to perform indwelling catheter care every shift and as needed. On December 5, 2023, from 10:55 a.m. until 1:15 p.m., Resident 54 was observed lying in bed with the catheter tubing draining into a large urine collection bag hung on the bedframe. The draining spigot of the collection bag, used to empty urine out of the bag, was unlatched from the secure holder. From 10:15 a.m. until 12:49 p.m., the spigot was in direct contact with the bed. From 12:49 p.m. until 1:15 p.m., the bed was raised by Resident 54, the spigot remained unsecured and was hanging from the Foley bag. The unlatched spigot was visible when looking at the resident from the hallway. LPN2 walked by the resident's room and did not attempt to secure the spigot. 28 Pa. Code 211.10(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: 395138 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 395138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mifflin Center 500 East Philadelphia Avenue Shillington, PA 19607 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, facility policy review, and staff interview, it was determined that the facility failed to store food in a sanitary manner in the dietary department and on one of four nursing units. (Cherry Tree Lane) Findings include: Observations during the kitchen tour on December 5, 2023, at 10:00 a.m., revealed that inside the Ice Cream Freezer, there were multiple areas of dried food debris on the wall and on the bottom. There was a leaf on the bottom of the freezer. There were two utensil drawers containing clean utensils. One drawer had a food scoop with dried food debris in it. The other drawer had dried food debris in it. When that drawer was open, there was long strand of hair sticking out from the inside track of the drawer, close to the clean utensils. On the pot and pan rack, there was a long strand of hair where the clean items were stored. Review of the facility's policy entitled, Safe Handling for Foods from Visitors, last reviewed April 24, 2023, revealed when food was brought into the facility for the residents by visitors that staff should label foods with the resident's name. Observation of the Cherry Tree Lane unit pantry on December 6, 2023, at 11:45 a.m., revealed five bottles of opened salad dressing and four containers of Gatorade, milk, soda, and juice that were not labeled with a resident's name. The inside of the microwave was rusted and damaged. In an interview on December 6, 2023, at 12:40 p.m., the Administrator confirmed the microwave and refrigerator were used for the residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(2.1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395138 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 395138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mifflin Center 500 East Philadelphia Avenue Shillington, PA 19607 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on one of four nursing units. (400 unit) Findings include: Observations throughout the unit December 5, 2023, at 10:00 a.m. through December 6, 2023, 1:00 p.m., revealed the following: In room [ROOM NUMBER] bed C, the paint was peeling and marred. Bed D overbed table had dried liquid and food debris on the base. The HVAC vents at beds A and B were dusty and dirty. At bed C, the front of the bedside cabinet had exposed compressed board and there were gaps around the door. The wall next to the bed was marred. The bathroom intake air vent had a build up of thick dust and the walls and door were marred. The fall mat in room [ROOM NUMBER] bed B was littered with smashed food crumbs. Bed D had no light cover on the overbed light and the bedside cabinet had gaps around the door. The bathroom had no toilet paper holder and the paint was peeling on the wall. In room [ROOM NUMBER] bed A, the bedside cabinet door hinge was broken. The wall beside bed B was marred. An IV pole between bed B and D contained an empty IV bag and tubing and the pole had dried liquid at the base. In the bathroom there was no toilet paper holder and the walls and door were marred. There was a hole in the bathroom wall in room [ROOM NUMBER]. The bathroom door and wall were marred in room [ROOM NUMBER]. In room [ROOM NUMBER], next to bed A, food debris and dried liquid were observed on the floor. The bedside cabinet had cobwebs at the base. Bed B, C, D the bedside cabinet had gaps around the doors and bed D door had no handle. The bathroom wall was marred and scuffed. In room [ROOM NUMBER] bed A, there was a discarded nasal cannula and tubing laying on the floor next to the bedside cabinet. On top of the fall mat next to bed B, there was a torn piece of a brief. On the floor under the head of the bed C, there was black dirt. There was thick dust on the back of the television between beds B and D. There was dust, cobwebs, and black dirt under the head of bed of bed D. In the bathroom there was no toilet paper holder, the length of the front of the sink had exposed press board, and the door and walls were marred and scuffed. In room [ROOM NUMBER] bed C, the overbed table had food debris and dried liquid spillage. There was dust and dirt at the head of the bed on the floor. Bed D had dried liquid spillage, dust, and dirt under the head of the bed on the floor. In the bathroom, there was no toilet paper holder, the walls were marred, there were cobwebs near the floor under the sink, and a square hole in the ceiling with exposed pipes. In room [ROOM NUMBER] bed A, the overbed table had dried paper napkin remnants stuck to the surface (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395138 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 395138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mifflin Center 500 East Philadelphia Avenue Shillington, PA 19607 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and dried liquid spillage. The bedside cabinet for bed B had cobwebs at the bottom. The overbed table for bed C had dried liquid and food particles. The wall was marred and missing paint. There was an oxygen concentrator with a nasal cannula that was dusty and laying on the floor by bed D. In the bathroom there was no toilet paper holder. There were cobwebs on the walls that contained debris. The window curtains in rooms 402, 406, 408, 414, 416, and 418 were torn and and pulled out from the track. In the hallway across from the soiled utility room, the light covers were full of debris. The hand rail outside room [ROOM NUMBER] was missing the end. In the hallway across from rooms [ROOM NUMBERS], debris was observed between the windows and screens. CFR 483.90(i) Safe/Functional/Sanitary/Comfortable Environment Previously Cited 12/1/22 28 Pa. Code 201.18(b)(3) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395138 If continuation sheet Page 10 of 10