Inspection·May 1, 2025

F 0567 March 2025: $7,712 Level of Harm - Minimal harm or potential for actual harm April 2025: $1,989 Resident 40's income from Social Security and pension benefits totaled $10,210 during the same period: Residents Affected - Few December 2024: $2,014 January 2025: $2,049 February 2025: $2,049 March 2025: $2,049 April 2025: $2,049 According to Pennsylvania Medicaid requirements, the facility was responsible for deducting only the monthly care cost balance after applying the PNA (personal needs allowance-$45.00 before January 2025 and $60.00 after January 2025). Based on the resident's monthly income, the proper care cost charges from January 1, 2025, through April 28, 2025, should have been: December 2024: $2,014 - $45 = $1,969 January 2025: $2,049 - $60 = $1,989 February 2025: $2,049 - $60 = $1,989 March 2025: $2,049 - $60 = $1,989 April 2025: $2,049 - $60 = $1,989 Resident 40 should have been charged $1,989 each month from January 2025 through April 2025 and charged $1,969 in December 2024, totaling $9,925. A review of credits Resident 40 received from Social Security and his pension ($10,210) and calculating for the personal needs allowance for Pennsylvania ($285) it was determined the facility over charged the resident by $100.00. During an interview on May 1, 2025, at approximately 9:00 AM, the Nursing Home Administrator (NHA) confirmed Resident 40 was overcharged due to billing errors. The NHA confirmed it is the facility's responsibility to safeguard, manage, and accurately account for residents' personal funds deposited with the facility. The NHA indicated Resident 40 would be reimbursed for the overcharge. 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a) Resident rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 2 of 8 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 05/01/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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, observations, and staff interviews, it was determined the facility failed to consistently implement measures planned to promote healing, prevent worsening, and the development of pressure sores for one resident out of 23 residents sampled (Resident 57). Residents Affected - Few Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists who specialize in the diagnosis, treatment, and care of adults. The largest medical specialty organization and second-largest physician group in the United States, Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. Review of the facility policy entitled Pressure Injury Prevention and Management, last reviewed January 10, 2025, indicated the facility will provide interventions for prevention and to promote healing in accordance with evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to, redistributing pressure (such as repositioning, protecting, and/or offloading heels, etc.) and providing appropriate, pressure-redistributing support surfaces. Further review of the policy revealed the facility will provide interventions for prevention to promote healing in accordance with current standards of practice and will be provided for all residents who have a pressure injury present. The goals and preferences of the resident and/or authorized representative will be included in the plan of care, interventions will be documented in the care plan and communicated to all relevant staff, and compliance with interventions will be documented in the weekly summary charting. A review of the clinical record revealed that Resident 57 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet). A quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 57 dated April 10, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 03 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment) and revealed the resident was dependent on staff for activities of daily living of putting on/taking off footwear and was at risk for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 3 of 8 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 05/01/2025 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 0686 pressure sore development. Level of Harm - Minimal harm or potential for actual harm A review of the resident's care plan, initiated July 18, 2024, and last revised April 28, 2025, revealed a problem focus of risk for skin breakdown and actual impairment to the right heel related to fragile skin and decreased mobility. Planned interventions included use of heel-lift boots at all times (removable only during care), a pro-mat plus air mattress to bed, and a pressure redistribution cushion for the chair. Residents Affected - Few Physician orders dated November 12, 2024, directed the use of heel-lift boots at all times, allowing removal only for care. A skin integrity wound assessment dated [DATE], revealed the presence of a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) on the resident's right heel, measuring 0.3 cm (length) x 0.6 cm (width) x 0.2 cm (depth), with 50% slough (yellow/white necrotic tissue) and 50% granulation tissue (new connective tissue) and moderate serous drainage (clear or pale-yellow fluid similar to blood plasma). An observation of Resident 57 on April 29, 2025, at approximately 10:35 AM revealed the resident was in the activity hall wearing purple slippers and was identified by Employee 1 (Licensed Practical Nurse). An observation of her room revealed heel-lift boots lying on top of the Pro-mat mattress, not on the resident. A review of the resident's task report (a record of staff-documented care tasks) from April 29, 2025, indicated the heel-lift boots were documented as being on the resident, with no documentation of refusals noted. A second observation on April 30, 2025, at 10:50 AM revealed the resident sitting in her wheelchair in her room again without heel-lift boots and wearing purple slippers. At the time of the surveyor's observation, a nurse aide applied the heel-lift boots to the resident. An interview with Employee 1 (LPN) at that time confirmed the resident often removes the boots, stating: She kicks them off, and when she does, we just put the purple slippers on her. Further clinical review on April 30, 2025, revealed no documentation in the care plan regarding refusal of heel-lift boots, nor documentation of staff interventions to address such refusals. Additionally, the task report for April 30, 2025, indicated the heel-lift boots were on the resident at 9:05 AM, despite observations proving otherwise. During an interview with the Director of Nursing (DON) on April 30, at 1:10 PM, it was confirmed the facility did not consistently implement the planned interventions to promote healing or prevent the progression of the right heel pressure ulcer for Resident 57. 28 Pa. Code 201.18(b)(1) Management 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 4 of 8 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 05/01/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility to the extent possible for one resident out of 23 residents sampled (Resident 40). Findings include: A review of the facility policy titled Restorative Nursing Program, last reviewed by the facility on January 10, 2025, revealed it is the facility's policy to provide maintenance and restorative services designed to maintain or improve residents' ability to the highest practicable level. The restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. Residents will receive services from restorative when they are assessed to have a need for restorative nursing services. A clinical record review revealed Resident 40 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of the lung (an abnormal growth of cells characterized by uncontrolled and rapid growth, invasion of surrounding tissues, and the potential to spread to other areas of the body). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 5, 2025, revealed that Resident 40 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A care plan indicates Resident 40 exhibits a deficit in ambulation related to decreased mobility and fatigue initiated on February 16, 2025. Interventions implemented to assist Resident 40 in attaining his restorative nursing goal of ambulating with a rollator walker (a mobility device) for 50 ft include ensuring the resident is wearing appropriate footwear, instructing the resident on appropriate positioning with an assistive device, and following with a wheelchair during ambulation as recommended by skilled physical therapy. A Physical Therapy Discharge summary dated [DATE], revealed Resident 40 was discharged from physical therapy services with recommendations to implement a restorative nursing program for ambulation that includes walking 50 ft with a rollator walker and the assistance of one caregiver. During an interview on April 29, 2025, at 10:20 AM, Resident 40 indicated that physical therapy exercised with him regularly, but when his therapy services ended, no one was providing restorative ambulation services. He explained no one has walked with him in months. During an interview on April 30, 2025, at 1:00 PM, Resident 40 confirmed that no one provided restorative ambulation services today or since his physical therapy services ended over a month ago. A clinical record review revealed staff indicated Resident 40 received his restorative ambulation intervention (walking with the rollator walker for 50 ft with assistance) on 48 occasions from April 30, 2025, through April 30, 2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 5 of 8 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 05/01/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The clinical record review revealed documentation indicating Employee 3, Nurse Aide, implemented Resident 40's ambulation program on April 30, 2025, at 12:35 PM. However, during an interview on April 30, 2025, at 1:05 PM, Employee 3, Nurse Aide, confirmed she did not implement Resident 40's restorative nursing ambulation program, despite documenting on the clinical record that he received the intervention on April 30, 2025, at 12:35 PM. During an interview on April 30, 2025, at approximately 1:30 PM, the Director of Nursing (DON) confirmed it is the facility's responsibility to provide and implement restorative nursing services for residents as planned to maintain residents' mobility to the highest practicable extent possible. The DON confirmed Employee 3, Nurse Aide, inaccurately documented that she provided Resident 40 restorative nursing interventions when none were implemented. 28 Pa. Code: 211.5(f)(viii) Medical records. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 6 of 8 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 05/01/2025 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 - Few 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 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 in two of 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, last reviewed on February 10, 2025, 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. Observation during the initial tour of the kitchen with the facility's registered dietitian on April 29, 2025, at 9:40 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness: There was a heavy build-up of a black substance along the wall located under the soiled side (area where dirty dishes are slid into the dishwasher) counter space of the dishwasher. There was a build-up of debris under the ceiling light shield located in the janitor's closet. Interview with the registered dietitian at this time confirmed the kitchen was to be maintained in a clean and sanitary manner. An observation on April 29, 2025, at 11:13 AM, in the Nursing B Hall Pantry, revealed a resident food refrigerator/freezer with 5 plastic undated and unmarked containers with resident food. The refrigerator also contained the following items that were also not dated: a stick of butter wrapped in plastic, a piece of white bread in a plastic bag, a vanilla ice cream sundae with caramel, and an ice cream tub. During an interview on April 29, 2025, at 11:15 AM, Employee 2, Registered Nurse (RN), confirmed the food items identified during the observation were not dated. Employee 2, RN, explained that facility staff should date all food items when opened or received by residents or residents' families. Observation of the A Hall Nursing Unit resident pantry on April 30, 2025, at 1:30 PM revealed there was a build-up of a black substance on the end of the condensation hose (removes excess water from the ice machine) of the ice machine. Observation of the B Hall Nursing Unit resident pantry on May 1, 2025, at 9:20 AM revealed a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 7 of 8 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 05/01/2025 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 build-up of a wet black substance on the end of the condensation hose of the ice machine. Level of Harm - Minimal harm or potential for actual harm Interview with the maintenance director on May 1, 2025, at 9:25 AM confirmed that the ice machines, including the condensation hoses of the ice machines, were not cleaned and sanitized frequently enough to prevent the build-up of the black substance. Residents Affected - Few 28 Pa. Code 201.18 (e) (2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395260 If continuation sheet Page 8 of 8