Health inspection·January 5, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few outside the facility without supervision. When he/she returned to the facility staff placed a wander guard bracelet on Resident R24 and placed Resident R24 on the second floor locked unit. Resident R24 also stated that he/she told the facility he/she would not leave the facility again without staff knowledge. Resident R24 also revealed that he/she had cut the wander guard bracelet off several times and staff would replace it but never asked him/her why he/she kept cutting it off. He/she revealed that he/she is embarrassed by the wander guard bracelet. Resident R24 stated that when he/she goes out to appointments, he/she finds the wander guard bracelet embarrassing and stated, it's my house arrest. During an interview on 1/4/2024, at 3:19 p.m. the DON (Director of Nursing) revealed that facility had no evidence of elopement assessments being completed. He/she also revealed that Resident R24 had cut off his/her wander guard bracelet on several occasions and that facility staff had replaced the wander guard bracelet. Observation on 1/5/2024, at 9:05 a.m. revealed the wander guard bracelet remained on Resident R24's left ankle. During an interview at that time, Resident R24 stated yes I still have the little box, it's embarrassing, my house arrest. Interview with Employee E1 on 1/5/2024, at 8:40 a.m. revealed that he/she has worked at the facility for one year in a full time position on the second floor locked unit. He/she revealed that Resident R24 has had no elopement episodes while he/she was working. Interview with Employee E2 on 1/5/2024, at 8:50 a.m. revealed that he/she has worked at the facility for three years in a full-time position on the second floor locked unit. He/she revealed that Resident R24 has had no elopement episodes while he/she was working. Interview also revealed that Resident R24 has verbally communicated to him/her when he/she was going out into the garden which is part of the second floor locked unit. Interview with DON on 1/4/2024, at 3:19 p.m. he/she confirmed that Resident R24 should have been reassessed for the use of the wander guard bracelet. He/she also confirmed that the use of a wander guard is not appropriate for a resident that is alert and oriented with a BIMS of 15. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395355 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at Brmc, The 200 Pleasant Street Bradford, PA 16701 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure a physician's order was completed correctly to indicate the code status as Full Code (CPR/Attempt Resuscitation) or Do Not Resuscitate (DNR/Do Not Attempt Resuscitation-Allow Natural Death) for one of 19 residents reviewed (Resident R39). Findings include: Review of a facility policy Advance Directives-Health Care Proxy, MOLST/POLST, Living Will dated [DATE], revealed All adult individuals in New York State and in Pennsylvania have the right to self-determination in Health Care and the right to express their preferences regarding health care treatment, including decisions to continue or refuse routine or major medical treatment, as well as life-sustaining treatment without which the individual is expected to die. Advance directives such as health care proxies (HCP), living wills and consents to Do Not Resuscitate (DNR) orders allow an adult to express his/her healthcare treatment preferences and wishes, in order to be prepared for those situations in which that individual may be unable to communicate for him/herself. Instructions - It is a BRMC-OGH goal to encourage Health Care Proxy completion among competent patients, and to place those documents in the permanent medical record in ambulatory, acute, and long-term care settings. For patients who are already incapacitated with no proxy, it is a goal to identify surrogate decision makers as early as possible and actively engage them in the care of those patients. Review of Resident 39's clinical record revealed an admission date of [DATE], with diagnoses that included weakness, urinary tract infection, failure to thrive, and Parkinson's disease (a disorder of the central nervous system that affects movement, often tremors). Resident R39's clinical record indicated Full Code on the Code Status Form dated [DATE], signed by Resident R39's power of attorney (POA). A physician order dated [DATE], indicated Resident R39 to be a DNR. Review of Resident R39's clinical record on [DATE], at 2:00 p.m. lacked evidence of a POLST. During an interview on [DATE], at 3:20 p.m. the Registered Nurse Assessment Coordinator (RNAC) provided Resident R39's POLST which indicated a Full Code status. The RNAC confirmed the POLST was not maintained, but should be on Resident R39's clinical record for direction of Resident R39's plan of care. During an interview on [DATE], at 3:25 p.m. the RNAC confirmed Resident R39's code status was documented in error as a DNR as a physician order and should be a Full Code as indicated by the POA and POLST. 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.10(c) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395355 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at Brmc, The 200 Pleasant Street Bradford, PA 16701 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on a review of facility policy, facility grievances, and resident and staff interviews, it was determined that the facility failed to provide acknowledgement of a complaint/grievance and actively work toward resolution of that complaint/grievance for two of 19 residents reviewed (Residents R9 and R11). Findings include: Review of the facility policy entitled, Pavilion Complaint/Grievance Policy, dated 12/28/23, revealed that the Pavilion grievance official will oversee the Pavilion grievance process, receive and track grievances through their conclusion, will lead any necessary investigation by the facility, will maintain confidentiality of all information associated with grievances, will be responsible in issuing written grievance decision to the resident/resident representative and will coordinate with state and federal agencies as necessary in light of specific allegations. The grievance official of the Pavilion will also take immediate action to prevent potential violation of any resident right while the alleged violation is being investigated. During an interview on 1/03/24, at 10:00 a.m. Resident R9 indicated he/she discussed concerns with administrative staff about being left on the toilet for long periods of time. Resident R9 further indicated administrative staff implied the concern would be addressed, however, no resolve of the grievance had occurred. During an interview on 1/03/24, at 1:00 p.m. Resident R11 indicated he/she discussed several concerns with administrative staff such as a brace for his/her right knee, a dental appointment, cell phone usage by staff during care, and urine collection device not being emptied. Resident R11 indicated further that no resolve of the grievances had occurred. On 1/04/24 at 8:40 a.m., the Nursing Home Administrator (NHA) provided two complaints/grievances from residents/resident representatives for review and there was no evidence that the concerns were investigated, tracked through to a conclusion, and that a written grievance decision was provided to the resident/resident representative. During an interview on 1/05/24, at 10:15 a.m. the Director of Nursing confirmed that the facility lacked evidence that the complaints/grievances for Residents R9 and R11 as noted above, were investigated, tracked through to a conclusion, and that a written grievance decision was provided to Resident R9 and Resident R11. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395355 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at Brmc, The 200 Pleasant Street Bradford, PA 16701 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. Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan regarding the use of side rails for one of 17 residents reviewed (Resident R32). Findings include: Review of a facility policy entitled Resident Care Plan dated 12/28/23, indicated that the facility will develop a comprehensive care plan of care to reflect the needs of the resident, be individualized and resident driven, and utilize nursing assessments, evaluations, etc. Resident R32's clinical record revealed an admission date of 10/19/16, with diagnoses that included dementia, generalized muscle weakness, heart disease, arthritis, and limitations of activities due to disability. Current physician's orders for January 2024, indicated that Resident R32 was to have siderails up on both sides of his/her bed to promote independence with bed mobility and transfers. The clinical record lacked evidence of a care plan to address his/her side rail use. Review of Resident R32's clinical record documentation the daily use of side rails on both sides of his/her bed for November 2023, December 2023, and January 2024. Multiple observations on 1/02/24, and 1/03/24, revealed Resident R32 in bed positioned on his/her side and both half rails were in the up position. During an interview on 1/03/24, at 10:50 a.m. Registered Nurse Employee E3 confirmed that Resident R32 always has his/her side rails up on both sides of the bed. During an interview on 1/04/24, at 11:00 a.m. the Registered Nurse Assessment Coordinator confirmed there was no evidence that a care plan was developed for Resident R32's use of side rails on both sides of the bed. 28 Pa. Code 211.10(c) 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: 395355 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at Brmc, The 200 Pleasant Street Bradford, PA 16701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of facility policy and clinical records, and staff interview, it was determined that the facility failed to administer supplemental oxygen as ordered and promote cleanliness regarding respiratory care equipment according to physician orders for one of 19 residents reviewed (Resident R17). Residents Affected - Few Findings include: Review of a facility policy entitled Care of Oxygen Tubing/Nebulizer Tubing and Filters dated 12/28/23, indicated that oxygen concentrator filters will be cleaned monthly. Review of a facility policy entitled Medication Administration dated, 12/28/23, revealed that medications shall be administered in accordance with the orders of the prescribing Healthcare Practitioner, and oxygen administration must have a physician order, the order must be written on the Medication Administration Record (MAR) and the nurse is to monitor oxygen flow rate every shift. Resident R17's clinical record revealed an admission date of 1/25/14, with diagnoses that included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), heart disease, heart failure, muscle wasting, amputation of left fingers and left foot, high blood pressure, unsteady on feet, and difficulty walking. The most recent physician's order dated 12/25/23, indicated to administer oxygen at two liters per minute (LPM) through a nasal cannula (a device that gives you additional oxygen [supplemental oxygen or oxygen therapy] through your nose), as needed for shortness of breath/wheezing. The December 2023 MAR indicated that Resident R17 was receiving his/her oxygen at two LPM on two-to-three shifts daily. Observations on 1/02/24, at approximately 4:00 p.m. and on 1/03/24, at 8:50 a.m. revealed that Resident R17 was in bed and his/her oxygen concentrator filter was blowing a significant amount gray fluffy substance into the air, and the oxygen flow rate was set at one and a half LPM. During an interview on 1/02/24, at approximately 4:00 p.m. Resident R17 confirmed that he/she was supposed to receive oxygen at two LPM. During an interview on 1/03/24, at 8:55 a.m. the Nursing Home Administrator and Director of Nursing confirmed that upon opening the oxygen concentrator filter casing, the filter was covered with copious amounts of a gray fluffy substance, and had not been cleaned recently, and that the oxygen flow rate was set for one and a half LPM, and that Resident R17 was ordered two LPM. 28 Pa. Code 211.10(c) 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: 395355 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at Brmc, The 200 Pleasant Street Bradford, PA 16701 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records and facility policy, and staff interviews it was determined that the facility failed thoroughly review and assess the use of bed rails prior to their use and review the risk versus benefits of using bed rails with the resident's representative and obtain informed consent for the installation and use of bed rails prior to the installation for two of 19 residents reviewed (Residents R32 and R67). Findings include: Review of a facility policy entitled Side Rails and Use of ½ Side Rails dated 12/28/23, indicated that half side rails may be utilized to assist a resident with bed mobility and transfers or to assist the resident with bed controls but only after an individual Side Rail assessment is completed on admission, quarterly, annually, and as needed. Resident R32's clinical record revealed an admission date of 10/19/16, with diagnoses that included dementia, generalize muscle weakness, heart disease, arthritis, and limitations of activities due to disability. Review of current physician's orders for January 2024, revealed Resident R32 was to have siderails up on both sides of his/her bed to promote independence with bed mobility and transfers. Review of Resident R32's clinical record documentation revealed daily use of side rails on both sides of his/her bed for November 2023, December 2023 and January 2024 Further review of Resident R32's clinical record revealed no evidence of that an individual Side Rail assessment was completed upon admission, quarterly, annually, or as needed, and lacked the required informed consent from the resident/representative for the use of side rails prior to installation. Multiple observations on 1/02/24, and 1/03/24, revealed Resident R32 in bed positioned on his/her side and both half side rails were in the up position. Review of Resident R67's clinical record revealed an admission date of 9/14/23, with diagnoses that included Down Syndrome (genetic condition that causes mild to serious physical and developmental problems), long-term kidney disease, malnutrition, and embolism and thrombosis (clots get stuck in an artery and block blood flow, the blockage starves tissues of blood and oxygen). Review of current physician's orders for January 2024, revealed Resident R67 was to have siderails up on both sides of his/her bed to promote independence with bed mobility and transfers. The clinical record revealed a care plan addressing self-care deficit and included an intervention to use half rails during the provision of care and included access to bed controls. Review of Resident R32's clinical record documentation revealed daily use of side rails on both sides of his/her bed for December 2023, and January 2024. Further review of Resident R67's clinical record revealed an incomplete individual Side Rail assessment dated [DATE] (upon admission) and lacked the required quarterly Side Rail assessment and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395355 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at Brmc, The 200 Pleasant Street Bradford, PA 16701 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 0700 informed consent from the resident/representative for the use of side rails prior to their installation. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/04/24, at 1:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed there was lack of evidence that the required periodic side rail assessments were completed, and that informed consents were not obtained from the resident/representative for the use of side rails prior to installation. Residents Affected - Few 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395355 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at Brmc, The 200 Pleasant Street Bradford, PA 16701 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of clinical records and facility policy and staff interview, it was determined that the facility failed to prevent the potential for cross contamination during a dressing change for one of 19 residents (Resident R32). Residents Affected - Few Findings include: Review of a facility policy entitled Standard Precautions dated 12/28/23, revealed that staff are expected to change their gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms, and remove gloves promptly after use, before touching non-contaminated items and environmental surfaces. Observation of wound care on 1/03/24, at 3:12 p.m. revealed that Registered Nurse (RN) Employee E3 performed hand hygiene and donned (put on) clean gloves; removed the soiled dressing containing a moderate amount of exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation); picked up the multi-use bottle of wound cleanser; applied wound cleanser solution to two, four inch by four inch cotton gauzes; cleansed the wound of a moderate amount of exudate; opened the sealed package of wound dressing (Promogran- cellulose, collagen and silver dressing); used scissors to cut the Promogran to the size of the wound bed; opened the sealed package of Allevyn (dressing indicated for exudate absorption in wound care); applied the Allevyn to the wound; obtained a wound label and used a pen to write the date on the label. During an interview at that time RN Employee E3 confirmed that he/she didn't know if staff was supposed to change gloves and cleanse hands during dressing changes when going from dirty to clean areas. During an interview on 1/04/24, at 1:50 p.m. the Director of Nursing confirmed that staff are to change gloves and perform hand hygiene after removing soiled dressings, and after wound cleansing if exudate present. 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: 395355 If continuation sheet Page 9 of 9