Health inspection·October 27, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to develop and implement an abuse prohibition policy to ensure a complete and thorough investigation of an incident involving the potential for abuse for one of 19 residents reviewed (Resident 60). Residents Affected - Few Findings include: The policy entitled Resident Rights - Abuse and Crimes against last reviewed without changes on September 21, 2023, revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The administrator or designee is responsible for initiating an investigation as soon as reasonably practicable and completing the investigation in a timely manner. Results of all investigations of alleged violations must be reported within five working days of the incident. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source, the administrator/designee is responsible for determining what actions (if any) are needed for the protection of residents. The individual conducting the investigation should review the documentation and evidence, interview the person reporting the incident and any witnesses to the incident, and document the investigation completely and thoroughly. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator. Clinical record review for Resident 60 revealed nursing documentation dated August 24, 2023, at 1:50 AM, which indicated that while Employee 1, licensed practical nurse, was passing bedtime medications they observed a bruise on the resident's left forearm. Resident 60 was unsure how the bruise occurred but indicated potentially from showering or when another resident had entered her room unexpectedly. The bruise was scattered and measured 5.5 centimeter (cm) by 1 cm with slight redness with light purple discoloration. Staff informed the supervisor, the resident's responsible party, and physician. Review of the facility's investigation dated August 23, 2023, revealed that both aides overnight completed statements; however, neither one of them worked the previous night. Review of Employee 1's witness statement reveled that this area was not there the night prior (August 22, 2023). Review of Employee 2 and 3's, nurse aide's, witness statements revealed no knowledge of Resident 60's bruise and confirmed that neither worked the evening/night prior. There were no additional witness statements provided for Resident 60's bruise of unknown origin investigation dated August 23, 2023. Review of the facility's schedule for August 22 and 23, 2023, confirmed Employees 2 and 3 did not work in the facility on August 22, 2023. The facility did not fully investigate Resident 60's bruise of unknown origin. This surveyor reviewed this information during an interview with the Nursing Home Administrator on October 26, 2023, at 2:12 PM. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.19 Personnel policies and procedures (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395283 If continuation sheet Page 2 of 11 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 395283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Glen Healthcare and Rehabilitation Center 15 Ridgecrest Circle Lewisburg, PA 17837 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 0607 28 Pa. Code 201.29(a) Resident rights Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395283 If continuation sheet Page 3 of 11 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 395283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Glen Healthcare and Rehabilitation Center 15 Ridgecrest Circle Lewisburg, PA 17837 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 - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 19 residents reviewed (Residents 87). Residents Affected - Few Findings include: Review of Resident 87's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated October 2, 2023, indicating that the facility assessed her as being discharged to the hospital. A nursing progress noted dated September 21, 2023, at 7:55 AM indicated that Resident 87 was discharged from the facility with home health services. Interview with the Administrator and Director of Nursing on October 26, 2023, at 2:01 PM confirmed that Resident 87's MDS was coded in error for discharge status. 483.20(g) Accuracy of Assessments Previously cited 10/21/22 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395283 If continuation sheet Page 4 of 11 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 395283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Glen Healthcare and Rehabilitation Center 15 Ridgecrest Circle Lewisburg, PA 17837 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 Based on observation, clinical record review, and resident, responsible party, and staff interview, it was determined that the facility failed to provide a dependent resident assistance with nail care for one of one resident reviewed for activities of daily living (Resident 11). Residents Affected - Few Findings include: A phone interview with the responsible party for Resident 11 on October 25, 2023, at 10:41 AM revealed concerns related to the resident's fingernail care and reported the nails were long with dirt under them. The responsible party reported speaking to several people several times about the concerns, but the concerns were not corrected. Observation of Resident 11's fingernails on October 25, 2023, at 11:12 AM with Employee 8, nurse aide, revealed the resident's nails were long with obvious black colored debris noted under the right thumb and pointer finger. The resident voiced, They look terrible. A concurrent interview with Employee 8 revealed the fingernails may be long because the resident is a diabetic and staff would have to check with the nurse prior to trimming. Clinical documentation for Resident 11 dated October 12, 2023, at 2:13 PM revealed the resident Requires complete assistance with ADLs (activities of daily living). Clinical record review for Resident 11 revealed a comprehensive Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated August 25, 2023, that indicated the resident had a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident had cognitive impairment. The MDS further noted the resident requires extensive assistance of one staff member to maintain personal hygiene. The current care plan for Resident 11 revealed the resident had a self-care deficit related to the medical history and staff were to help complete any task that the resident is unable to do independently. A review of the recent activities for Resident 11 revealed a group activity titled Glam on September 24, 2023, at 2:09 PM that was marked as S for resident attendance. An interview with Employee 9, Activities Director, on October 26, 2023, at 2:26 PM indicated that Glam is an activity where residents get their nails filed and painted. The S documented for Resident 11 indicated the resident was sleeping. There were no additional Glam activities noted for Resident 11 since that date. The above information for Resident 11 were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on October 25, 2023, at 2:23 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395283 If continuation sheet Page 5 of 11 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 395283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Glen Healthcare and Rehabilitation Center 15 Ridgecrest Circle Lewisburg, PA 17837 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medications for one of 19 residents reviewed (Resident 70). Residents Affected - Some Findings include: Clinical record review for Resident 70 revealed a current physician's order dated March 2, 2023, for staff to administer Oxybutynin Chloride (for incontinence) 2.5 milligrams (mg) every day by mouth for one week (March 9, 2023) then stop. Observation of a medication administration pass on October 24, 2023, at 9:00 AM with Employee 7, licensed practical nurse, revealed that she administered Oxybutynin 2.5 mg by mouth to Resident 70. Review of Resident 70's clinical documentation revealed that staff continued to administer Resident 70's Oxybutynin until after the surveyor identified the concern on October 26. 2023. The surveyor reviewed the above information during an interview on October 26, 2023, at 10:00 AM with the Nursing Home Administrator. 483.25 Quality of Care Previously cited 10/21/22 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395283 If continuation sheet Page 6 of 11 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 395283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Glen Healthcare and Rehabilitation Center 15 Ridgecrest Circle Lewisburg, PA 17837 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. Based on clinical record review and staff interview, it was determined that the facility failed to provide physician ordered services to maintain a resident's range of motion for one of four residents reviewed (Residents 19). Findings include: Clinical record review for Resident 19 revealed a current 's order for staff to provide restorative continuous AROM (active range of motion, movement of the body in an attempt to maintain a resident's ability) with assistance as needed (PRN) to her bilateral (BL) shoulders, elbows, and wrists for two sets of 10 repetitions each and restorative continuous PROM (passive range of motion) to her BL knees and ankles for three sets of 10 repetitions each. Review of task documentation for Resident 19 for August, September, and October 2023, revealed that staff did not document completion of the restorative task on the following dates: AROM BL Shoulders, Elbows, and Wrists August 29, 2023 September 4, 6, 16, and 29, 2023 October 17, 2023 PROM BL Knees and AnklesAugust 29, 2023 September 6, 16, and 29, 2023 October 17, 2023 The surveyor reviewed the above information on October 26, 2023, at 2:22 PM with the Nursing Home Administrator and Director of Nursing. 483.25(c)(1)-(3) Increase/prevent Decrease In Rom/mobility Previously cited 10/21/22 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395283 If continuation sheet Page 7 of 11 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 395283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Glen Healthcare and Rehabilitation Center 15 Ridgecrest Circle Lewisburg, PA 17837 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent falls and/or injuries for one of seven residents reviewed (Resident 60). Residents Affected - Few Findings include: Clinical record review for Resident 60 revealed a current physician's order for staff to check the (motion) alarm to ensure that it is intact to the door to decrease intrusions in the room by other residents. Observation of Resident 60 on the following dates and times revealed that the motion alarm did not sound upon entry to her room: October 24, 2023, at 9:47 AM and 10:02 AM October 25, 2023, at 10:45 AM October 26, 2023, at 10:21 AM Concurrent interview on October 26, 2023, at 10:21 AM with the Director of Nursing (DON) confirmed that Resident 60's motion alarm did not sound upon entry to her room. The DON replaced Resident 60's alarm. 483.25(d)(1)(2) Free Of Accident Hazards/supervision/devices Previously cited 10/21/22 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395283 If continuation sheet Page 8 of 11 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 395283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Glen Healthcare and Rehabilitation Center 15 Ridgecrest Circle Lewisburg, PA 17837 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate treatment and services regarding bladder incontinence for one of two residents reviewed (Resident 4). Findings include: The policy entitled Urinary Incontinence-Clinical Protocol, last reviewed on September 21, 2023, indicates that the facility's physician will look for findings related to continence, categorize the incontinence as urge, stress, overflow, or functional, and will address the treatable causes of urinary retention and incontinence. The policy further indicates that nursing staff will identify, and document circumstances related to the incontinence, and based on assessment of the category and causes of incontinence, will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. Review of Resident 4's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated September 19, 2023, that indicated that the facility assessed her as being frequently incontinent of bladder, and that a urinary toileting program has not been attempted. The facility also assessed Resident 4 as being able to understand others, be understood, having adequate vision and hearing. The MDS dated [DATE], also indicated that the facility assessed Resident 4 as only needing the supervision of one staff member for bed mobility, transfers, walking in her room, and toilet use. There was no documented evidence in Resident 4's clinical record to indicate that the facility's physician or nursing staff assessed Resident 4 to determine the type of urinary incontinence, or to develop an individualized toileting program or plan of care. Interview with the Administrator on October 27, 2023, at 9:15 AM confirmed the above findings for Resident 4. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395283 If continuation sheet Page 9 of 11 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 395283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Glen Healthcare and Rehabilitation Center 15 Ridgecrest Circle Lewisburg, PA 17837 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner in the facility's main kitchen and on one of six nursing units (Evergreen Nursing Unit). Findings include: A tour of the facility's main kitchen with Employee 4 (Kitchen Operations Manager) and Employee 5 (General Manager) on October 24, 2023, at 9:03 AM revealed the following concerns: The ceiling in the dishwashing area had a section of chipped and missing paint. A concurrent interview with Employee 4 revealed it was unclear what had damaged the ceiling. There was an accumulation of debris on the floor under the stainless steel shelves adjacent to the dishwasher against the wall. An outside entrance leading to the dumpsters had a barrel full of grease positioned on a pallet adjacent to a storm drain. There was a large accumulation of dead leaves under the pallet. The lid was partially ajar, and grease was visible at the lip of the barrel. Employee 5 reported the grease was from the facility fryers and it was unclear how long it had been there. A large stick of butter was found open in a walk-in cooler. There was no open date noted. A Hershey's chocolate syrup bottle was open in the dry goods storage area. There was no open date. A manufacturer's note directly on the bottle indicated to refrigerate after opening. The Nursing Home Administrator and Director of Nursing were notified of the above findings on October 25, 2023, at 2:33 PM. Observation of the food serving area in the dining room on the Evergreen Nursing Unit on October 24, 2023, at 11:04 AM revealed various dried stains and dried splashes on eight panes of the windows located behind the food service area. Observation of the pantry area on the Evergreen Nursing Unit on October 26, 2023, at 11:58 AM revealed the following: There were various items found on the floor under the ice machine that included: a can of soda, packaged cookies, a granola bar, food wrappers, a balled-up napkin, five packaged graham cracker snack packs, a fruit bar, a pen, a plastic cup, and a triggered mouse trap There were dried, brown colored stains on the wall behind the trash can with an accumulation of coffee grounds on the floor behind the trash receptacle. There was an accumulation of debris under the cooler and four cans of soda. A wood cupboard had a knife on top of it that had the blade wrapped in a paper towel covered in dust and a dry-rotted rubber band. There was also a packaged fruit snack bar discarded on top of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395283 If continuation sheet Page 10 of 11 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 395283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Glen Healthcare and Rehabilitation Center 15 Ridgecrest Circle Lewisburg, PA 17837 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 cupboard. Level of Harm - Minimal harm or potential for actual harm The Nursing Home Administrator and Director of Nursing were notified of the findings from the Evergreen Nursing Unit on October 26, 2023, at 2:07 PM. Residents Affected - Some 483.60(i)(1)(2) Food Procurement. store/prepare/serve Sanitary Previously cited 10/21/22 28 Pa. Code 201.14(a) Responsibility of licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395283 If continuation sheet Page 11 of 11