Inspection·July 14, 2023

F 0552 bed with feet flat on the floor Level of Harm - Minimal harm or potential for actual harm • Residents Affected - Some with partial/moderate assistance come to a standing position from sitting in a chair, wheelchair, or on the side of the bed • with partial/moderate assistance transfer to and from a bed to a chair or wheelchair • walk 10-150 feet with partial/moderate assistance • independently wheel 50 ft with two turns in a wheelchair The resident had an unwitnessed fall on May 15, 2022. A nursing progress note dated May 24, 2022, at 10:17 a.m. indicated that following the fall, Resident 14 had a change in mobility status. The resident was admitted to the hospital on [DATE], and returned to the facility on June 7, 2022. A physical therapy evaluation dated June 7, 2022, indicated that Resident 14 had an order to be non-weight-bearing on the right lower extremity and to follow-up with an arthroplasty (joint repair) specialist to address the right hip once medically stable. The therapy evaluation noted that the resident complains of significant pain with right hip palpation (feeling with fingers or hands during the exam) and right lower extremity movement, such as with bed mobility tasks. The resident requires the use of a total lift for treatment. No physical therapy is indicated at this time. This evaluation indicated that the resident verbalized a pain level of 8/10 and experiences pain with all functional mobility tasks, including rolling. A nursing progress note dated June 8, 2022, at 2:02 p.m., indicated that Resident 14 was referred to a community arthroplasty specialist. A physician progress note dated June 13, 2022, that indicated that the orthopedic surgeon and nurse practitioner who originally were upset that {Resident 14's} subacute chronic fracture was not dealt with in a timely manner have now deferred the case to more capable orthopedic surgeons who deal with this area. Not sure if it will be dealt surgically. Since a timeline cannot be put on whether it is subacute or chronic. Nonetheless, {Resident 14} is in no discomfort, which the resident has never been, which is well documented, as well as, the process that lead up to his hospitalization and subsequent follow up. A significant change MDS assessment, dated June 14, 2022, revealed that the resident declined in all areas of mobility. As of this date, Resident 14 was able to: • with substantial/maximal assistance roll from lying on back to left and right side, and return to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 2 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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 0552 lying on back on the bed (prior to fall in the facility level -independent) Level of Harm - Minimal harm or potential for actual harm • Residents Affected - Some not applicable to move from sitting on side of bed to lying flat on the bed (prior level -able to complete task with supervision or touching assistance) • not applicable to move from lying on the back to sitting on the side of the bed with feet flat on the floor (prior level -able to move with supervision or touching assistance) • not applicable to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed (prior level -with partial or moderate assistance) • dependent on staff to transfer to and from a bed to a chair or wheelchair (prior level -with partial or moderate assistance • walking 10-150 ft was not attempted due to medical condition (prior level -with partial or moderate assistance) • Not indicated to utilize a wheelchair or scooter (prior level -independently able to utilize wheelchair) An orthopedic surgeon consult dated July 7, 2022, at 9:30 a.m., indicated that Resident 14 needs a total hip replacement. Will discuss with the resident's physician and call with follow-up. A physician progress note dated July 14, 2022, indicated that I have a call with community arthroplasty (joint repair) surgeon today regarding patient's chronic hip pain current recommendation is to proceed with surgery. I will discuss with surgeon the resident's multiple comorbidities and medical clearance. An orthopedic consult dated August 16, 2022, indicated that Resident 14 presents for a follow-up of right hip pain. Patient fell. Diagnoses with a displaced femoral neck fracture. Since the fall patient has not been able to ambulate. Presents in a stretcher with emergency medical services. According to the consult the resident has been advised of X-Ray findings and treatment options; resident has failed conservative measures; Orthopedic Surgeons are recommending a right hip hemiarthroplasty (half joint replacement); The risks and benefits of surgery were discussed at length; Resident's questions addressed and answered; Resident to schedule appointment with community nurse practitioner one month prior to surgery; Resident advised will need preadmission testing - Labs, EKG, chest X-ray and follow-up with primary care physician for medical clearance prior to surgery. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 3 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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 0552 Level of Harm - Minimal harm or potential for actual harm A physician progress note dated August 17, 2022, revealed that I did discuss Resident 14's case with community surgeon and they are planning on surgical repair of his hip. Community surgeon did agree that his hip fracture from his original X-ray was subacute/chronic in nature and this is a chronic pathologic is unknown duration since the patient is having discomfort and inability to ambulate, we will pursue surgery the patient agrees with same. Residents Affected - Some A physician progress note dated September 7, 2022, indicated that I discussed this case with orthopedic surgeon. Since, {Resident 14} is not ambulatory and never really was and really only transferred with the help of the staff, we recommend he undergo full weight bearing with a lift on the right. He is in no pain and not complaining of pain in his hip. Community orthopedic surgeon agrees this is a chronic fracture and did not occur back with the initial workup began at our facility. No need for repairs at this time due to overall ambulatory status. At the time of the survey ending July 14, 2023, there was documented evidence that the physician had discussed the resident's treatment preferences, documented the preferences or discussion, or honored Resident 14's treatment or care decisions. According to the September 7, 2022 physician note, prior to the resident's fall on May 15, 2022, the resident was assessed to independently ambulate with a wheelchair. From June 7, 2022, through September 6, 2022, the resident had physician orders for non-weight bearing on the right leg extremity. A quarterly MDS assessment, dated September 20, 2022, Section GG0170 Mobility, revealed that as of this date, Resident 14 was able to: • with substantial/maximal assistance roll from lying on back to left and right side, and return to lying on back on the bed (prior to fall in the facility level -independent) • not applicable to move from sitting on side of bed to lying flat on the bed (prior level -able to complete task with supervision or touching assistance) • not applicable to move from lying on the back to sitting on the side of the bed with feet flat on the floor (prior level -able to move with supervision or touching assistance) • not applicable to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed (prior level -with partial or moderate assistance) • dependent on staff to transfer to and from a bed to a chair or wheelchair (prior level -with partial or moderate assistance) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 4 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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 0552 • Level of Harm - Minimal harm or potential for actual harm walking 10-150 ft was not attempted due to medical condition (prior level -with partial or moderate assistance) Residents Affected - Some • Not indicated to utilize a wheelchair or scooter (prior level -independently able to utilize wheelchair) A physical therapy evaluation signed on October 7, 2022, at 8:38 a.m., indicated that Resident 14 continues to complain of significant right hip pain. Patient may be having surgery in the future, but unsure of when that will be scheduled. Resident has not been walking over the last few days secondary to right lower extremity causing pain. The assessment indicated that the resident's pain level was 6/10 from September 6, 2022, through discharge of therapy services on October 6, 2022. A physician progress note dated October 17, 2022, indicated that Resident 14 is expecting he is not going to have surgery because he is not ambulating this is a chronic finding no new changes. However, there was no documented evidence that the facility had discussed the resident's treatment preferences, documented the preferences or discussion, or honored Resident 14's treatment or care decisions. Clinical record documentation dated October 18, 2022, at 2:13 p.m. indicated that the orthopedic surgeon's office, was asking if surgery was going to be scheduled for Resident 14. A follow-up note dated October 19, 2022, at 2:04 p.m. indicated that the orthopedic surgeon had a discussion with Resident 14's primary physician and his other colleagues. The entry indicated that the patient was not a surgical candidate. Will not be proceeding with right hip hemiarthroplasty (a surgical procedure that involves replacing half the hip joint). The patient can transfer from bed to chair. Weight bear as tolerated. A nursing progress note dated October 19, 2022, at 2:28 p.m., indicated that per community orthopedic surgeon, after consulting with {Resident 14's} primary physician, it was decided that the resident is not a surgical candidate with his mental issues and other medical problems. During an interview on July 11, 2023, at 9:40 a.m., Resident 14 stated, My hip hurts. I am going to have my hip operated on to help with the pain. The resident did not state when the surgery was scheduled or planned. At the time of the survey ending July 14, 2023, there was no documented evidence that the facility had discussed the resident's treatment options for right hip pain with the resident and allowed the resident to participate in the decision making for his treatment plan. During an interview on July 14, 2023, at approximately 12:00 p.m., the Nursing Home Administrator (NHA) was unable to provide evidence that Resident 14's was afforded the right to participate in his treatment, including discussions regarding potential surgery or alternate treatment options for the resident's hip pain and to address the resident's decline in functional abilities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 5 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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 0552 28 Pa. Code 201.29(a) Resident rights. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(3)(5) Nursing services Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 6 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on a review of the minutes from Resident Council meetings and resident and staff interviews, it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings, including those voiced by six of the six residents (Residents 10, 31, 42, 45, 53, 77). Residents Affected - Some Findings include: A review of the minutes from the Resident Council meetings held from August 2022 through June 2023 revealed that the residents in attendance at these meetings voiced their concerns regarding the facility's failure to consistently offer snacks in the evenings. During the January 20, 2023, Resident Council meeting, the residents relayed concerns that residents are only sometimes offered an evening snack. During the February 17, 2023, Resident Council meeting, the residents relayed concerns regarding not being offered evening snacks. During the March 27, 2023, Resident Council meeting, the residents relayed concerns regarding evening snacks. During the April 21, 2023, Resident Council meeting, the residents relayed concerns that evening snacks are still not consistently being offered. During the May 22, 2023, Resident Council meeting, the residents relayed concerns that residents are offered an evening snack only when select staff are working. During the June 20, 2023, Resident Council meeting, the residents relayed concerns about not consistently being offered an evening snack. During a group meeting held on July 12, 2023, at 10:00 a.m. with seven alert and oriented residents, all six residents reported that evening snacks are not consistently offered despite their complaints raised at Resident Council meetings over the last few months. The residents stated this issue has continued without resolution by the facility to date. The facility was unable to provide documented evidence that the facility had determined if the residents' felt that their complaints or grievances had been resolved through any efforts taken by the facility in response to the residents' expressed concerns regarding not consistently being offered snacks in the evening. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 12, 2023, at 12:30 p.m., the NHA and DON were unable to provide documented evidence that the facility had followed up with the residents to ascertain the effectiveness of the facility's efforts in resolving their complaints regarding consistently being offered evening snacks. 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 201.18 (e)(4) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 7 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and the Resident Assessment Instrument and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 18 sampled (Residents 91). Residents Affected - Some Findings included: A review of Resident 91's Discharge MDS assessment dated [DATE], Section A2100 Discharge Status revealed that Resident 82 was discharged to an acute care hospital. Review of Resident 91's clinical record revealed documentation indicating that the resident was discharged home, making the June 14, 2023, discharge MDS inaccurate. Interview with the Director of Nursing on July 14, 2023, at approximately 1:30 PM, confirmed the aforementioned MDS Assessment was inaccurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 8 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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 a review of clinical records it was determined that the facility failed to consistently implement a resident's person centered plan of care for necessary assistance with activities of daily living for one resident out of 18 sampled (Resident 244). Findings included: Clinical record review revealed that Resident 244 was admitted to the facility on [DATE] with diagnoses to include end stage heart failure, and diabetes. A review of the resident's care plan ADL self performance deficit related to weakness initiated July 27, 2021 revealed that Resident 244 required the assistance of one person for bed mobility. A review of an interdisciplinary therapy screen dated January 9, 2023 revealed that Resident 244 had a change in status for transfers, wheelchair usage, pain and bed/chair positioning. Resident 244 was placed on hospice services on January 10, 2023 related to end stage cardiac disease. A significant change minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 18, 2023 revealed, Resident 244 was cognitively intact and required maximum assistance of two staff for bed mobility and transfers. The resident's ADL care plan was revised on January 26, 2023, and the resident's bed mobility status changed to assist of two persons with bed mobility, one person required to immobilize the resident's right lower extremity as a result of a recent fracture on January 7, 2023, and application of leg brace for treatment. A review of ADL records dated January 7, 2023 through February 6, 2023 revealed that only one person assisted the resident with bed mobility on most shifts. A review of nursing documentation dated February 6, 2023, at 3:23 P.M. revealed that the resident had a recent fracture, right femur with right lower leg brace. New open area noted of right lateral knee noted with moderate bloody drainage. A subsequent nurses note dated February 6, 2023 at 6:47 PM revealed that a change in the resident's condition was noted. A bone was protruding from Resident 244's right femur fracture site. There was no evidence at the time of the survey ending July 14, 2023, that the resident's bed mobility was consistently performed with the assistance of two staff members following the resident's leg fracture, application of the leg brace and as care planned on January 26, 2023, to maintain the resident's comfort and prevent further injury to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 9 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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 28 Pa. Code 211.12 (d)(3)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 10 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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 observation, a review of clinical records and resident and staff interviews it was determined that the facility failed to ensure that a resident dependent on staff for assistance with activities of daily living received the necessary assistance to maintain good personal grooming and hygiene for one resident out of 18 sampled (Resident 1). Residents Affected - Some Findings include: A clinical record review revealed that Resident 1 was admitted to the facility on [DATE], 2021, with diagnoses of cerebral infarction (an event that causes a decrease in blood flow to the brain, commonly known as a stroke) and aphasia (a disorder that results from damage to portions of the brain that are responsible for language). A quarterly MDS (Minimum Data Set-a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment dated [DATE], revealed that the resident was moderately cognitively impaired and required one person assistance with personal hygiene. An observation and interview with Resident 1 on July 11, 2023, at 10:55 a.m. revealed that the resident had a partially outgrown beard that was inconsistent in length. The resident's beard was approximately 1.0 cm in length in the longest section. The resident stated that he wanted a shave and gestured to his beard. Resident 1 stated that he was not shaved with his morning care. An observation of Resident 1 on July 12, 2023, at 8:45 a.m. revealed the resident had not yet been shaved. An observation and interview with Resident 1 on July 13, 2023, at 10:10 a.m. revealed the resident had still not been shaved and stated that he wanted a have shave. During an interview on July 13, 2023, at 10:15 a.m., Employee 1, a nurse aide, stated that Every morning we provide personal hygiene care for residents. Employee 1 also stated that I provided personal hygiene care for {Resident 1} this morning. I wash residents' faces, assist with brushing hair, brush the resident's teeth, and offer shaving. During the interview, Employee 1, confirmed that I did not shave {Resident 1} this morning, but I do plan on going back later today to assist with shaving. A clinical record review revealed that staff noted the completion of the the resident's personal hygiene nursing task (how the resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands, and excluding baths and showers) on July 10, 11, 12, and 13 of 2023. On each of these occasions, staff noted that the resident required extensive assistance with personal hygiene nursing task During an interview on July 13, 2023, at approximately 11:00 a.m., the Nursing Home Administrator (NHA) reported that residents are only offered shaving on shower days (twice weekly) and that Resident 1 often refuses his shower. The NHA was not able to provide evidence that Resident 1 was provided the necessary services to maintain good grooming and personal hygiene and at the frequency preferred by the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 11 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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 28 Pa. Code 211.12 (d)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 12 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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 0697 Provide safe, appropriate pain management 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 a review of clinical records and select facility policy and staff and resident interview, it was determined that the facility failed to provide individualized effective pain management for one resident out of 18 sampled (Resident 14). Residents Affected - Few The findings include: A review of the facility's current Pain Management policy, last reviewed by the facility on January 29, 2023, revealed that the facility will help residents attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being, and to prevent or manage pain, the facility will recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. The facility's policy also stated that interventions for pain management will be incorporated in the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. A clinical records review revealed Resident 14 was admitted to the facility on [DATE], with diagnoses to include Schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), Dementia (a group of thinking and social symptoms that interfere with daily functioning), and chronic hip pain. An annual comprehensive MDS (Minimum Data Set-a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment dated [DATE], indicated that the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status). The resident had physician orders for Acetaminophen Tablet 325 mg 2 tablets by mouth every 4 hours as needed for mild pain since admission March 10, 2021, and an a physician order for non-pharmacological interventions to be utilized prior to administering as needed pain medications. During an interview on July 11, 2023, at 9:40 a.m., Resident 14 stated, My hip hurts. I am going to have my hip operated on to help with the pain. The resident did not state when the surgery was scheduled or planned. Resident 14 had a fall on May 15, 2022, while in the facility. After the fall, the resident was no longer able to independently ambulate and was on non-weight bearing orders for the right lower leg extremity from June 2022 until September 2022. Resident 14's attending physician and community orthopedic surgeon initially recommended hip replacement for the injury, but after consultation, it was determined that Resident 14 was not a surgical candidate. Resident 14's Medication Administration Record (MAR) for August 2022, indicated that staff administered two Acetaminophen 325 mg tablets on ten occasions for mild pain and once for moderate pain during the month. The August 2022 MAR also revealed no evidence that non-pharmacological interventions were attempted as ordered by the physician prior to administering prn Acetaminophen 325 mg on August 25, 26, 29, and 30, 2022. On September 7, 2022, a physician order was noted for the resident to be full weight bearing with a 1-inch heel lift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 13 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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 0697 Level of Harm - Minimal harm or potential for actual harm The resident's September 2022 MAR revealed an increase in the resident's use of the prn Acetaminophen, revealing that staff administered two Acetaminophen 325 mg tablets on 14 occasions for mild pain and twice for moderate pain. There was also no evidence that non-pharmacological interventions were attempted, as ordered by the physician, prior to administering Acetaminophen 325 mg on September 3 or 11, 2022. Residents Affected - Few A physical therapy evaluation dated October 7, 2022, at 8:38 a.m., indicated that the resident continues to complain of significant right hip pain. Patient may be having surgery in the future, but unsure of when that will be scheduled. Resident has not been walking over the last few days secondary to right lower extremity causing pain. The assessment indicated that the resident's pain level was 6/10 (a scale of 0 being no pain and 10 being the most severe) from September 6, 2022, through discharge of therapy services on October 6, 2022. There was no documented evidence that the facility had fully assessed, and addressed, the resident's increased pain during physical therapy services from September 6, 2022, through September 16, 2022. On September 16, 2022, the physician ordered Acetaminophen 500 mg two tablets to be taken by mouth two times a day for pain management. However, the resident's pain remained 6/10 through the end of therapy services on October 6, 2022, despite the increase in pain medication. There was no documented evidence of additional pain relieving modalities developed and implemented to address Resident 14's increased pain and the development of alternate measures to manage the resident's hip pain when it was determined that he was not a candidate for surgery. During an interview on July 14, 2023, at approximately 12:00 p.m., the Nursing Home Administrator (NHA) was unable to provide evidence that the facility consistently attempted non-pharmacological interventions prior to administering prn pain medications or evidence of a reassessment of the resident's pain management needs. for Refer F552 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 14 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 18 sampled residents (Resident 67). Residents Affected - Few Findings include: A review of Resident 67's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included Parkinson's disease [is a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement], dementia with behavioral disturbances [is a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning] and psychotic disorder with hallucinations [illnesses that affect the mind and impact thinking clearly, make good judgments, respond emotionally, communicate effectively, understand reality, and behave appropriately], communication deficits, and a history of multiple falls. A review of the resident's current care plan in effect at the time of the survey ending July 14, 2023, revealed no documented evidence that the facility had developed an individualized person-centered plan for the resident's dementia care, which maximized the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety and using individualized, non-pharmacological approaches to care, including purposeful and meaningful activities that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. An interview with the Director of Nursing (DON) on July 13, 2023, at approximately 1:30 PM, confirmed the facility failed to develop and implement an individualized person-centered plan to address the resident's dementia diagnosis. 28 Pa Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 15 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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, review of select facility policy and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and two resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Review of a facility policy titled Use and Storage of Food Brought in by Family or Visitors that was last reviewed on January 27, 2023, indicated food must be handled in a way to ensure the safety of the resident. The facility may refrigerate, label, and date prepared items in nourishment refrigerator and that food must be consumed by the resident within 3-days. The initial tour of the kitchen was conducted with the facility's Certified Dietary Manager (CDM) on July 11, 2023, at 9:30 AM, and revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness. The wire spice rack, mounted to the wall near the cook's area, had debris and dust adhered to the surface. Below the spice rack, there was a mounted knife rack that had debris and dust accumulated on the rack. In the dish room, several ceiling tiles were observed coated with food splatter and were ill-fitting in select areas. The mounted wall fans inside of the dish room and in the kitchen area had an accumulation of dust. The juice station dispenser gun felt sticky and had an accumulation of product on the inside of the dispenser. In of the 100 hallway nourishment room there were two opened gallons of milk and two poured beverages from resident meal trays that did not have a discard date noted. In the 400 hallway nourishment room there were two opened gallons of milk and a takeout container of meatballs dated July 9, 2023. Interview with the facility's Registered Dietitian (RD) confirmed that the container of meatballs should have been discarded and that the manufacturer's date on the gallons of milk was the date that the staff should reference for discarding. Interview with the Director of Nursing (DON) on July 13, 2023, at 11:55 AM, confirmed that all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 16 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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 opened items should have an open date and that any opened containers should be discarded within 3-days. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18 (e)(2.1) Management Residents Affected - Many 28 Pa. Code 211.6 (f) Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 17 of 18 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 395260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carbondale Rehabilitation and Healthcare Center 10 Hart Place Carbondale, PA 18407 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **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 coordination of hospice services with facility services to meet the individual resident's needs for the management of the terminal illness for two out of two residents reviewed receiving hospice care (Residents 73, 15). Findings include: A review of the clinical record revealed Resident 73 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's disease (a progressive disease that destroys memory) and dementia (a group of thinking and social symptoms that interfere with daily functioning). The resident was admitted to hospice services on March 22, 2023, for senile degeneration of the brain. A review of Resident 73's current plan of care in effect at the time of the survey ending July 13, 2023, revealed no evidence that the resident's plan of care was integrated with hospice services to demonstrate coordination of care and services to meet the resident's needs related to the care of the terminal illness on a daily basis. A clinical record review revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's disease (a progressive disease that destroys memory) and dementia (a group of thinking and social symptoms that interfere with daily functioning). A clinical record review revealed that Resident 15 was admitted to hospice services on November 11, 2022, for end-stage Alzheimer's Disease. A review of Resident 15's current plan of care in effect at the time of the survey ending July 13, 2023, revealed no evidence that the resident's plan of care was integrated with hospice services to demonstrate coordination of care and services to meet the resident's needs related to the care of the terminal illness. During an interview with the Director of Nursing (DON) on July 13, 2023, at approximately 1:10 p.m., she confirmed the above residents' care plans were not integrated or coordinated with hospice services. 28 Pa. Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 18 of 18