Health inspection·June 16, 2023

F 0656 Review of the clinical record indicated Resident R148 was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of the MDS dated [DATE], indicated diagnoses of pneumonia (severe inflammation of the lungs from an infection), respiratory failure (a serious condition where the lungs cannot get enough oxygen into the blood), and dependence on supplemental oxygen. Residents Affected - Some Review of physician's orders indicated current orders to titrate oxygen to maintain oxygen saturation (the amount of oxygen present in the blood) above 90%. Observation and interview of Resident R148 on 6/12/23, revealed the resident was receiving oxygen at 3 liters per minute via nasal cannula. Review of Resident R148's care plan last reviewed 6/12/23, failed to include a plan of care related to the use of oxygen therapy. During an interview on 6/16/23, at 11:03 a.m. the Director of Nursing (DON) confirmed the facility failed to develop comprehensive care plans to meet resident care needs for Residents R35 and R148. Review of clinical record indicated that Resident R246 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], indicated diagnoses of cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain), hypertension (high blood pressure in the arteries), and dysphagia (difficulty swallowing). Review of physician order dated 6/7/23, revealed that Resident R246 is to be NPO (receive nothing by mouth). Review of Resident R246's nutrition care plan revealed interventions that included honoring food preferences, monitoring oral intake of food and fluid, and providing necessary assistance at mealtime and between meals. During an interview on 6/16/23, at 12:02 p.m. the DON confirmed that the facility failed to develop a comprehensive care plan to meet resident care needs of four of 16 residents. 28 Pa. Code: 211.11(a)(b)(c)(d) Resident care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395164 If continuation sheet Page 2 of 9 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 395164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St John Specialty Care Center 500 Wittenberg Way Mars, PA 16046 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, resident observations and interviews, clinical record review, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care for three of five residents (Residents R35, R148, and R152). Residents Affected - Some Findings include: Review of the facility's policy Oxygen Via Concentrator dated 8/31/2022, indicated the facility will verify physician orders for oxygen therapy and that oxygen tubing will be changed every 2 weeks and as needed. Review of the clinical record indicated Resident R35 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 6/8/23, indicated diagnoses of pneumonia (severe inflammation of the lungs from an infection), bronchitis (inflammation of the lining of the tubes that carry air to and from the lungs), and respiratory failure (a serious condition where the lungs cannot get enough oxygen into the blood). Observation and interview of Resident R35 on 6/14/23, at 11:09 a.m. revealed the resident was receiving oxygen at 3 liters per minute via a nasal cannula (an oxygen delivery device consisting of a lightweight tube which on one end splits into two prongs which are placed in the nostrils). Review of the clinical record failed to reveal a current physician order for Resident R35 to receive oxygen therapy and a current order to change oxygen tubing per facility policy. During an interview on 6/16/23, at 10:35 a.m. the Assistant Director of Nursing (ADON) confirmed there was no order for oxygen therapy and no order to change oxygen tubing per facility policy. Review of the facility's policy Oral Inhalation and Nebulizer Administration dated 8/31/22, indicated the facility will disconnect the T-piece, mouthpiece, and medication cup when the nebulizer treatment is complete, store the equipment in a plastic bag with the resident ' s name and the date on it, and change equipment and tubing per facility policy. Review of the clinical record indicated Resident R148 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], indicated diagnoses of pneumonia (severe inflammation of the lungs from an infection), respiratory failure (a serious condition where the lungs cannot get enough oxygen into the blood), and dependence on supplemental oxygen. Review of physician's orders dated 6/12/23, indicated a current order to titrate oxygen to maintain oxygen saturation (the amount of oxygen present in the blood) above 90%. Review of physician's orders dated 6/9/23, indicated a current order for ipratropium-albuterol nebulizer solution (an inhaled medication used to treat and prevent symptoms of wheezing, shortness of breath, and difficulty breathing) two times daily. Observation and interview of Resident R148 on 6/13/23, at 10:13 a.m. revealed the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395164 If continuation sheet Page 3 of 9 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 395164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St John Specialty Care Center 500 Wittenberg Way Mars, PA 16046 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some receiving oxygen therapy at 3 liters per minute via a nasal cannula and the nebulizer machine was on the bedside table with the T-piece, mouthpiece, and medication cup assembled and sitting on top of the machine while not in use. Observation and interview of Resident R148 on 6/14/23, at 10:32 a.m. revealed the resident was receiving oxygen therapy at 3 liters per minute via a nasal cannula and the nebulizer machine was on the bedside table with the T-piece, mouthpiece, and medication cup assembled and sitting on top of the machine while not in use. Review of the clinical record failed to reveal a current order to change the oxygen tubing and the nebulizer equipment and tubing. During an interview on 6/15/23, at 12:28 p.m. Registered Nurse (RN) Employee E1 confirmed the nebulizer set up was assembled and not stored per facility policy while not in use. When asked how does staff know when to change the oxygen tubing and nebulizer set ups, RN Employee E1 stated, there should be an order on the profile to change respiratory equipment. The admission nurse enters this order and the ADON does it if the admission nurse forgets. During an interview on 6/16/23, at 10:55 a.m. the ADON confirmed there was no order to change oxygen tubing and no order to change nebulizer equipment and tubing per facility policy. Review of the clinical record indicated Resident R152 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dependence on supplemental oxygen. Review of physician's orders dated 6/9/23, indicated current orders to titrate oxygen to maintain oxygen saturation >90%. Review of physician's orders dated 6/3/23, indicated current orders for Albuterol (a medication that is inhaled to make breathing easier by relaxing the muscles in the lungs and widening the airway) inhalation every six hours as needed for wheezing. Review of physician's orders dated 6/14/23, indicated current orders for DuoNeb inhalation solution (an inhaled medication used to treat and prevent symptoms of wheezing, shortness of breath, and difficulty breathing) every four hours for three days for shortness of breath. Observation and interview of Resident R152 on 6/12/23, at 11:29 a.m. revealed the resident was receiving oxygen therapy at 3 liters per minute via a nasal cannula. Observation and interview of Resident R152 on 6/15/23, at 12:24 p.m. revealed the resident was receiving oxygen therapy at 3 liters per minute via a nasal cannula and the nebulizer machine was sitting on the bedside table with the T-piece, mouthpiece, and medication cup assembled and sitting on top of the machine while not in use. Review of the clinical record failed to reveal a current order to change the oxygen tubing and the nebulizer equipment and tubing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395164 If continuation sheet Page 4 of 9 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 395164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St John Specialty Care Center 500 Wittenberg Way Mars, PA 16046 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm During an interview on 6/15/23, at 12:26 p.m. RN Employee E1 confirmed the nebulizer set up was assembled and not stored per facility policy while not in use. During an interview on 6/16/23, at 11:03 a.m. the ADON confirmed there was no order to change oxygen tubing and no order to change nebulizer equipment and tubing per facility policy. Residents Affected - Some 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services 28 Pa. Code: 211.12(d)(3) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395164 If continuation sheet Page 5 of 9 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 395164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St John Specialty Care Center 500 Wittenberg Way Mars, PA 16046 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly label and date food products, and verify the sanitizing temperature of the dish machine in the Main Kitchen (Main Kitchen), and properly monitor refrigerator temperatures, and properly store food products in one of three nursing unit pantries ([NAME]) and failed to properly date food and monitor food for expiration dates in three of three nursing unit pantries ([NAME], Wellstep, and Creekside), which created the potential for food borne illness. Findings Include: Review of the facility policy Food Storage: Sanitation and Infection Control last reviewed 3/23/23, indicated that all products are labeled and dated with the receiving date. Review of the facility policy Dishwashing and Pot Washing Procedures: Sanitation and Infection Control last reviewed 3/23/23, indicated that setting the right temperature for the commercial dishwasher is critical to ensure property sanitized cookware, dishes, and utensils to prevent foodborne illness. Dishwasher temperatures are maintained per manufacturer's guidelines and in accordance with nationally recognized standards of practice. Dish machine temperatures are checked and recorded before use for each meal cleanup period. Review of the facility policy Food Brought into Resident's Room from Outside Sources last reviewed 3/23/23, indicated that foods or beverages brought in from outside will be labeled with the resident ' s name and room number. Nursing will date the food with the date the item(s) was brought to the community for storage. Food or beverage in the original container that is past the manufacturer's expiration date will be discarded by nursing staff. Nursing staff will monitor resident's room, household pantry, and refrigeration units for food and beverage disposal. All refrigeration units will have internal thermometers to monitor temperatures. All units must be maintained at internal temperatures that are deemed safe for food storage. During an observation in the Main Kitchen walk-in refrigerator, on 6/12/23, at 9:55 a.m., a plastic wrapped package of meat was observed with no label or date. During an interview with the Food Service Director Employee E2 confirmed that the facility failed to properly label and date food products. During an observation in the Main Kitchen dish room, on 6/13/23, at 1:15 p.m. it was revealed that the facility does not verify the final rinse temperature of the dish machine by running a temperature test strip through the dish machine to verify the operating condition of the dish machine. During an interview on 6/13/23, at 1:32 p.m., the Food Service Director Employee E2 confirmed that the facility failed to make certain the final rinse temperature of the dish machine was operating properly to sanitize the equipment. During an observation on the [NAME] Nursing Unit Pantry on 6/16/23, at 10:10 a.m., the following was noted: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395164 If continuation sheet Page 6 of 9 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 395164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St John Specialty Care Center 500 Wittenberg Way Mars, PA 16046 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 -The small refrigerator contained a plastic container of salad with no date. Level of Harm - Minimal harm or potential for actual harm -Refrigerator temperature log for the small refrigerator was absent. -A case of applesauce was stored underneath the sink. Residents Affected - Many -Baskets of prepackaged snacks were stored without dates. -Three packages of Fig Newtons were found to be past the manufacture ' s expiration date of 6/12/23. During an interview on 6/16/23, at 10:20 a.m., Clinical Manager Registered Nurse Employee E3, and the Director of Nursing (DON) confirmed that the facility failed to properly date foods, monitor and record refrigerator temperatures, properly store food, and failed to dispose of expired food products. During an observation on the Wellstep Nursing Unit Pantry on 6/16/23, at 10:30 a.m., the following was noted: -Baskets of prepackaged snacks were stored without dates. -Four packages of sugar free cookies were found to be past the manufacture ' s expiration date of 6/1/23. During an interview on 6/16/23, at 10:42 a.m., the DON confirmed that the facility failed to properly date food and dispose of expired food products. During an observation on the Creekside Nursing Unit Pantry on 6/16/23, at 10:50 a.m., the following was noted: -Baskets of prepackaged snacks were stored without dates. -Six packages of sugar free cookies were found to be past the manufacturer ' s expiration dates of 6/1/23, and 6/15/23. During an interview on 6/16/23, at 10:54 a.m., the DON confirmed that the facility failed to properly date food and dispose of expired food products. 28 Pa. Code: 211.6 (c)(d)(f) Dietary Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395164 If continuation sheet Page 7 of 9 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 395164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St John Specialty Care Center 500 Wittenberg Way Mars, PA 16046 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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on abuse and neglect prevention for two of ten staff members (Employees E4 and E5). Findings include: Review of the Facility Assessment dated 9/28/22, indicated facility staff will complete annual mandatory training on abuse, neglect, misappropriation, and exploitation. The facility Abuse, Prevention of Abuse, Neglect, Mental Abuse, Reports of Theft, Exploitation and Misappropriation of Property policy dated 8/31/22, indicated all employees are required to participate in mandatory annual educations relative to resident rights and training relating to abuse. Review of Nurse Aide (NA) Employee E4's education record indicated she was hired on 1/7/16. Review of NA Employee E4's training record for 1/7/22, through 1/7/23, did not include training on abuse and neglect. Review of Registered Nurse (RN) Employee E5's education record indicated she was hired on 2/26/19. Review of RN Employee E5's training record for 2/26/22, through 2/26/23, did not include training on abuse and neglect. During an interview on 6/14/23, at 2:37 p.m. the Nursing Home Administrator confirmed that the facility failed to provide documentation of training for abuse and neglect prevention for two of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395164 If continuation sheet Page 8 of 9 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 395164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St John Specialty Care Center 500 Wittenberg Way Mars, PA 16046 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 0949 Level of Harm - Potential for minimal harm Residents Affected - Some Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on behavioral health and dementia for two of ten staff members (Employeees E4 and E5). Findings include: Review of the Facility Assessment dated 9/28/22, indicated all nursing staff will have training on Alzheimer's/Dementia/Cognitive Impairments. Review of Nurse Aide (NA) Employee E4's education record indicated she was hired on 1/7/16. Review of NA Employee E4's training record for 1/7/22, through 1/7/23, did not include training on behavioral health and dementia. Review of Registered Nurse (RN) Employee E5's education record indicated she was hired on 2/26/19. Review of RN Employee E5's training record for 2/26/22, through 2/26/23, did not include training on behavioral health and dementia. During an interview on 6/14/23, at 2:37 p.m. the Nursing Home Administrator confirmed that the facility failed to provide documentation of training on behavioral health and dementia for two of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395164 If continuation sheet Page 9 of 9