Inspection·July 10, 2023

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 assessments accurately reflected a resident's status for one of 12 residents reviewed (Resident 6). Residents Affected - Few Findings include: Clinical record review for Resident 6 revealed a significant change MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated June 19, 2023, that assessed she received insulin injections and an anticoagulant on seven of the previous seven days. Review of Resident 6's physician orders did not include evidence of insulin or anticoagulant medications in the month of June 2023. Interview with the Director of Nursing on July 6, 2023, at 12:38 PM confirmed that the June 19, 2023, significant change MDS was incorrect; that Resident 6 did not receive any anticoagulants or insulin during the lookback periods pertinent to the June 19, 2023, significant change MDS assessment. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395356 If continuation sheet Page 2 of 15 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 395356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guy and Mary Felt Manor, Inc 110 East Fourth Street Emporium, PA 15834 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 select facility policies and procedures, clinical record review, and responsible party, resident, and staff interview, it was determined that the facility failed to provide the highest practicable care to promote pressure ulcer healing for four of four residents reviewed (Residents 2, 3, 13, and 15). Residents Affected - Some Findings include: The policy entitled Pressure Ulcer Treatment Policy and Procedure, last reviewed without changes on January 18, 2023, revealed the registered nurse will measure and document wounds at least weekly on shower assessment or wound rounding day for positive or negative changes and act accordingly. An interview with Resident 2 on July 5, 2023, at 1:11 PM revealed she had a pressure ulcer on her buttock and right thigh. A review of Resident 2's clinical record revealed Wound Healing Solutions assessed Resident 2's wounds on June 6, 2023. Wound Healing Solutions assessed Resident 2's full-thickness ulceration of her coccyx as healed, with macerated (softening and breaking down of skin) tissue. The partial thickness ulceration of Resident 2's right posterior thigh was measured as 1.5 by 0.8 by 0.1 centimeters (cm). Wound healing solutions identified a new wound on Resident 2's right buttock measuring 0.8 by 0.2 by 0.2 cm, adjacent to the coccyx ulcer. The next assessment of Resident 2's wounds was on June 20, 2023 (14 days later). Resident 2's full-thickness ulceration of her coccyx was now reopened and measured 0.5 by 0.5 by 0.1 cm. Her right posterior thigh measured 2.0 by 0.7 by 0.1 cm, and her right buttock measured 0.5 by 0.3 by 0.2 cm. An interview with Resident 3 on July 5, 2023, at 12:56 PM revealed that she had a pressure sore on her left foot and right leg stump. A review of Resident 3's clinical record revealed Wound Healing Solutions assessed Resident 3's wounds on June 6, 2023. Wound Healing Solutions assessed Resident 3's partial thickness wound on her right posterior stump (medial) 1.8 by 1.8 by 0.2 cm, full thickness wound left heel 4.8 by 4.5 by 0.2 cm, and full thickness wound of left second toe 0.6 by 0.6 by 0.2 cm. The next assessment of Resident 3's wounds was on June 20, 2023 (14 days later). An interview with the responsible party for Resident 15 on July 5, 2023, at 11:20 AM revealed the resident came to the facility with skin breakdown on her buttocks, and probably cancer has spread to her brain, and she is at the end of her life. The responsible party also indicated that the resident does not like to be repositioned in bed and only wants to lie on her back. Review of a consultation by Wound Healing Solutions for Resident 15 dated June 6, 2023, revealed the resident had wounds that healed on both buttocks and had developed a new skin ulceration over the coccyx (tailbone) that measured 3.5 cm x 3 cm x 0.1 cm. The wound was described as a partial thickness wound and moisture related. The next assessment for Resident 15 was on June 20, 2023 (14 days later), which revealed the partial-thickness ulceration was now a Stage III pressure ulcer/injury (full-thickness loss of skin) that measured 1.5 cm x 1 cm x 0.1 cm. The facility failed to provide the necessary treatment and services, consistent with professional standards of practice to promote pressure ulcer healing and prevent new ulcers from developing. An interview with the Director of Nursing on July 7, 2023, at 10:54 AM confirmed these findings for Residents 2, 3, and 15. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395356 If continuation sheet Page 3 of 15 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 395356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guy and Mary Felt Manor, Inc 110 East Fourth Street Emporium, PA 15834 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 Level of Harm - Minimal harm or potential for actual harm Clinical record review for Resident 13 revealed a progress note dated June 22, 2023, at 11:10 AM noting an assessment of the resident after a fall. A dark hard area was noted on the residents left heel noting skin prep was applied and the resident would be placed on the list for the wound care team. There was no evidence of any additional assessment at the time to determine the origin of the area to indicate if the area was a result of the fall, pressure, friction, or the size of the area. Residents Affected - Some A skin assessment dated [DATE], for Resident 13 assessed the resident as having a reabsorbed and hard right heel blister, nothing was noted on the left heel. There were no measurements of the area or interventions initiated. Resident 13 was not seen by the wound specialist until June 28, 2023, who noted an unstageable pressure area on the resident's left heel measuring 1.33 cm in area, 1.17 cm in length and 1.49 cm in width. No areas were noted on the resident's right heel. A treatment was ordered to be completed every three days to the left heel, and the wound specialist would follow up in two weeks. A skin assessment completed on Resident 13 dated July 4, 2023, assessed the resident as having a right heel blister with no measurements noted. The skin assessment did not note any area on the left heel. There was no evidence of any weekly assessment or measurements to identify any improvement, decline, or need of treatment change for the area on the resident's left heel. An observation of Resident 13's heels upon surveyor request with Employee 7, registered nurse, on July 6, 2023, at 2:28 PM revealed the resident had a treatment dressing removed from his left heel. A dark purple area was observed on the left heel. There was no evidence of any compromised area or recently healed area on the resident's right heel as the resident was noted as having a blister on the heel on assessments completed by the nursing staff dated June 27, and July 4, 2023. Employee 7 redressed the area to the resident's left heel per physician orders. No measurements or documented assessment as to the condition of the area was noted. Employee 7 indicated the facility did not have a wound nurse and a company comes in every other week to assess areas on the residents with measurements and any needed treatment changes. In an interview with the Director of Nursing on July 6, 2023, at 2:40 PM it was confirmed the facility did not have a wound nurse or the wound specialist available to assess the resident's area weekly, and Resident 13 would not be assessed by the wound specialist again until a visit the week of July 10, 2023, after the resident's initial visit on June 28, 2023. The Director of Nursing confirmed the skin assessment documentation dated June 27, and July 4, 2023, for Resident 13 inaccurately identified the area as being on the resident's right heel and not the left heel. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing care services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395356 If continuation sheet Page 4 of 15 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 395356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guy and Mary Felt Manor, Inc 110 East Fourth Street Emporium, PA 15834 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of select facility policies, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of one resident reviewed (Resident 15). Residents Affected - Few Findings include: Review of the facility policy entitled Oxygen Therapy, last reviewed without changes on January 18, 2023, revealed that oxygen therapy will be provided as ordered by the physician who will order the delivery source, the liter flow, and humidity bottle and distilled water if required or needed. The nasal cannula (prongs connected to tubing inserted in nose to deliver oxygen) tubing is to be changed every 14 days and the nurse is to place a piece of tape with the date on tubing. A physician's order dated June 10, 2021, indicated that Resident 15 was to receive oxygen by way of nasal cannula at 2 lpm (liters per minute) as needed for shortness of breath. Clinical record review for Resident 15 revealed that the resident's plan of care did not include oxygen therapy. Observation of Resident 15 on July 5, 2023, at 11:22 AM revealed that the resident was lying in bed with her eyes closed. She was receiving oxygen at 1 lpm by way of nasal cannula. The oxygen tubing had a piece of tape that was dated June 5, 2023. A humidity bottle was present on the oxygen concentrator (delivery system for oxygen). The humidity bottle was empty. Observation and interview with the Director of Nursing on July 5, 2023, at 3:45 PM confirmed that Resident 15 was receiving oxygen at 1 lpm by way of nasal cannula when 2 lpm was ordered, and the humidity bottle was to have distilled water. During an interview with the Director of Nursing on July 6, 2023, at 1:45 PM the surveyor discussed the omission of oxygen therapy in Resident 15's plan of care. 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. [NAME] 211.11 (c)(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395356 If continuation sheet Page 5 of 15 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 395356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guy and Mary Felt Manor, Inc 110 East Fourth Street Emporium, PA 15834 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. Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to regularly assess a resident's entrapment risk from the use of bed rails for one of six residents reviewed for accident hazards (Resident 1). Findings include: The facility policy entitled, Bed Rails/Entrapment, last reviewed without changes on January 18, 2023, noted that maintenance evaluates all beds annually to ensure that all entrapment zones are within FDA (Food and Drug Administration) recommendations. Observation of Resident 1's room on July 5, 2023, at 1:26 PM revealed bilateral assist bars mounted to the head of her bed. Clinical record review of Resident 1's Bed Zones Measurement Checklist (form utilized by the facility to document the assessment of the seven bed system entrapment zones) indicated that staff last completed an assessment of Resident 1's bed system entrapment zones on October 20, 2020. Interview with the Director of Nursing and the Nursing Home Administrator on July 6, 2023, at 1:45 PM confirmed that the facility had no evidence that staff assessed all potential entrapment zones for Resident 1 for more than two and two-thirds years since October 20, 2020. 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: 395356 If continuation sheet Page 6 of 15 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 395356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guy and Mary Felt Manor, Inc 110 East Fourth Street Emporium, PA 15834 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on review of select facility policies and procedures, facility assessment, select personnel files, observation, and staff interview, it was determined that the facility failed to complete skills competencies and/or annual performance reviews for three of three staff reviewed for staff competencies (Employees 1, 3 and 4; Resident 4). Findings include: The Facility Assessment, last updated May 15, 2023, indicated that the resident care and services correlating to the resident population included that medication administration is offered by the nursing staff. Medication management is provided by the pharmacy. Staff competencies are determined according to the amount of resident interaction required by the job role, job knowledge, skills, and abilities, and those needed to care for the resident. Competencies are based on current standards of practice and may include knowledge and a test, knowledge and return demonstration, knowledge and observed ability, knowledge and observed behavior, and annual performance evaluation. Competencies are based on the care and services needed by the resident population. The facility human resources policy entitled, Benefits, last reviewed January 18, 2023, stipulated that all employees will be evaluated on their job performance at the end of their probation period and/or annually. The criteria evaluated included skill level/competencies. The facility policy entitled, Medication Administration, last reviewed without changes on January 18, 2023, listed procedural steps that included medications will be administered in accordance with a physician's order by a licensed nurse. The nurse will consult the MAR (medication administration record) for medications to be administered to the given resident. Staff will compare the medication sheet with the label of each medication for the following: right person, right medication, right date, right time, right route, right dose, and expiration date. If there is a discrepancy, the medication will not be administered. Instructions will be verified by contacting the assigned nurse who in turn may contact the pharmacist or prescriber. Staff will compare the label with the medication sheet for a second time and a third time before administering it to the individual. Review of Employee 1's (licensed practical nurse) personnel record indicated that the facility hired him on April 21, 2020. Employee 1's last Employee Annual Evaluation was dated April 27, 2023. Review of a Medication Administration Observation competency outline completed with Employee 1 dated February 28, 2022, revealed that the steps for medication administration included to verify the medication and strength with the physician's order as transcribed on the MAR. Interview with the Director of Nursing on July 7, 2023, at 9:05 AM, revealed that the facility had no evidence of an annual medication administration competency for Employee 1 after the February 28, 2022, evaluation. Observation of a medication administration pass on July 6, 2023, at 8:08 AM revealed Employee 1 prepared Tramadol (narcotic analgesic) 50 milligrams for administration to Resident 4. The labeling on the Tramadol packaging instructed staff to administer the medication four times a day (QID). Clinical record review for Resident 4 revealed a physician's order, active since November 27, 2021, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395356 If continuation sheet Page 7 of 15 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 395356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guy and Mary Felt Manor, Inc 110 East Fourth Street Emporium, PA 15834 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 0726 that instructed staff to administer Tramadol 50 mg three times a day (TID) to Resident 4. Level of Harm - Minimal harm or potential for actual harm Interview with Employee 1 on July 6, 2023, at 9:55 AM verified Resident 4's Tramadol had been ordered as TID since November 26, 2021; however, every card of Tramadol available in the medication cart for Resident 4's administration included instructions to administer QID. The dates on the available Tramadol medication labeling indicated the following pharmacy fill dates: Residents Affected - Some One card, with one of 28 tablets left, dated February 17, 2023 Three cards, with 28 tablets, dated May 12, 2023 Three cards, with 28 tablets, dated June 9, 2023 The pharmacy continued to fill Resident 4's Tramadol's prescription with incorrect medication labeling since February 2023. Staff who administered the 27 doses of the Tramadol medication from the packaging filled by pharmacy on February 17, 2023, failed to identify and/or correct that the labeling did not match the active physician order for Resident 4. Review of Employee 4's (registered nurse) personnel record revealed that the facility hired her on August 4, 2021. Interview with Employee 2 (business manager/human resources) on July 7, 2023, at 10:10 AM revealed that there was no evidence of an annual employee evaluation for Employee 4. Review of a Medication Administration Observation competency outline for Employee 4 revealed that more than a year had elapsed since the last competency assessment was completed on March 28, 2022. Review of Employee 3's (licensed practical nurse) personnel record revealed that the facility hired her on August 10, 2021. Employee 3's last Employee Annual Evaluation was dated August 12, 2022. Review of a Medication Administration Observation competency outline for Employee 3 revealed that more than a year had elapsed since the last competency assessment was completed on March 12, 2022. Interview with the Director of Nursing on July 7, 2023, at 9:39 AM revealed that all licensed nursing staff perform medication administration duties as part of their job duties. The interview confirmed that the facility had no evidence of a medication administration competency for Employees 1, 3, and 4 at least annually. 28 Pa. Code 201.20(a) Staff development 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395356 If continuation sheet Page 8 of 15 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 395356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guy and Mary Felt Manor, Inc 110 East Fourth Street Emporium, PA 15834 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents reviewed (Resident 10). Findings include: Review of Resident 10's clinical record revealed a physician's order dated March 20, 2023, for staff to administer Lorazepam (generic name of Ativan, medication used to treat anxiety) oral concentrate 2mg/ml (milligrams/milliliter), 0.5 ml every four hours PRN (as needed for anxiety). Review of Resident 10's clinical record revealed a physician's order dated March 31, 2023, for staff to administer Ativan 0.5 mg two times a day. Review of Resident 10's Medication Administration Record (MAR, form used to document the administration of medications) revealed the resident received Lorazepam PRN on the following dates in 2023: March 20 at 7:50 PM March 23 at 12:51 AM March 28 at 6:39 AM, 11:19 AM, and 7:34 PM March 31 at 9:05 PM April 8 at 4:40 AM and 12:58 PM April 10 at 8:42 PM April 18 at 2:31 PM April 19 at 2:31 AM and 1:50 PM April 23 at 6:00 PM May 7 at 3:47 PM July 2 at 3:28 PM During a meeting with the Nursing Home Administrator and Director of Nursing on July 5, 2023, at 3:29 PM the surveyor asked for the documented rational for the PRN lorazepam being used beyond 14 days with the duration of the medication. During an interview with the Director of Nursing on July 6, 2023, at 8:44 AM it was confirmed that the PRN lorazepam did not have a 14 day stop date nor was there a documented rationale to indicate the continued use and the duration for the PRN medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395356 If continuation sheet Page 9 of 15 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 395356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guy and Mary Felt Manor, Inc 110 East Fourth Street Emporium, PA 15834 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 0758 28 Pa. Code 211.9(a)(1)(k) Pharmacy services Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395356 If continuation sheet Page 10 of 15 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 395356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guy and Mary Felt Manor, Inc 110 East Fourth Street Emporium, PA 15834 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure accurate labeling of medications for one of two residents observed for medication administration (Resident 4). Findings include: The online resource https://www.webmd.com/drug-medication/what-are-the-7-rights-of-medication, instructed to always triple-check that you are giving the right medication to the right person. After confirming that you have the right individual, read the medication's label, and review the resident's charts to confirm you are going to give the correct medication. Along with giving the right medication comes giving the right dose. You will be able to find the right dose on the individual's chart alongside the form that the medication comes in. In addition to following the seven medication administration rights, there are three checks that you must perform. Read the individual's chart three times before letting your resident take their medication: before you prepare the medication, while you prepare the medication, and when returning or discarding the container. Review of the Medication Administration Observation competency outline completed with Employee 1 (licensed practical nurse) dated February 28, 2022, revealed that the steps for medication administration included to verify the medication and strength with the physician's order as transcribed on the medication record (MAR, electronic documentation of the administration of medications). The facility policy entitled, Safe Medication Administration, last reviewed without changes on January 18, 2023, revealed that the steps for procedures for administration within the Medication Administration Guidelines did not instruct staff to ensure the medication labeling matched the physician order/prescriber dosing instructions before dispensing a medication. Medication Dispensing is defined as an act by a practitioner or a person who is licensed in this state to dispense medications under the Pharmacy Act (63 P.S. 390-1-390-13) entailing the interpretation of an order for a medication and, under that order, the proper selecting, measuring, labeling, packaging, and issuance of the medication for a resident or for a service unit of the facility. The Pharmacy Act (63 P.S. 390-1-390-13) Chapter 27. State Board of Pharmacy, 27.12(b)(3), stipulated that the pharmacist shall ensure that the label of the container in which a nonproprietary drug is dispensed or sold pursuant to a prescription complies with the labeling requirements of 27.18, Standards of practice. The standards of practice listed in 27.18 included a drug not in unit dose shall be labeled to indicate the resident name, drug name, drug strength, dosing instructions, and lot number. The facility policy entitled, Medication Administration, last reviewed without changes, listed procedural steps that included medications will be administered in accordance with a physician's order by a licensed nurse. The nurse will consult the MAR for medications to be administered to the given resident. Staff will compare the medication sheet with the label of each medication for the following: right person, right medication, right date, right time, right route, right dose, and expiration date. If there is a discrepancy, the medication will not be administered. Instructions will be verified by contacting the assigned nurse who in turn may contact the pharmacist or prescriber. Staff will compare the label with the medication sheet for a second time and a third time before administering (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395356 If continuation sheet Page 11 of 15 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 395356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guy and Mary Felt Manor, Inc 110 East Fourth Street Emporium, PA 15834 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 0761 it to the individual. Level of Harm - Minimal harm or potential for actual harm Observation of a medication administration pass on July 6, 2023, at 8:08 AM revealed Employee 1 prepared Tramadol (narcotic analgesic) 50 milligrams for administration to Resident 4. The labeling on the Tramadol packaging instructed staff to administer the medication four times a day (QID). Residents Affected - Few Clinical record review for Resident 4 revealed a physician's order, active since November 27, 2021, that instructed staff to administer Tramadol 50 mg three times a day (TID) to Resident 4. Interview with Employee 1 on July 6, 2023, at 9:55 AM verified Resident 4's Tramadol had been ordered as TID since November 26, 2021; however, every card of Tramadol available in the medication cart for Resident 4's administration included instructions to administer QID. The dates on the available Tramadol medication labeling indicated the following pharmacy fill dates: One card, with one of 28 tablets left, dated February 17, 2023 Three cards, with 28 tablets, dated May 12, 2023 Three cards, with 28 tablets, dated June 9, 2023 The pharmacy continued to fill Resident 4's Tramadol's prescription with incorrect medication labeling since February 2023. 483.45(g)(h)(1)(2) Label/store Drugs and Biologicals Previously cited deficiency 08/04/22 28 Pa. Code 211.9(a)(1)(2) Pharmacy services 28 Pa. Code 211.10(c) 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: 395356 If continuation sheet Page 12 of 15 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 395356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guy and Mary Felt Manor, Inc 110 East Fourth Street Emporium, PA 15834 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to arrange for routine dental care to the extent covered under the State plan for two of three residents reviewed for dental concerns (Residents 3 and 1). Residents Affected - Some Findings include: Clinical record review revealed the facility admitted Resident 3 on July 3, 2019. Interview and observation of Resident 3 on July 5, 2023, at 12:53 PM revealed her front tooth appeared broken. Resident 3 stated that she goes to a dentist outside the facility when the facility schedules her appointments. Further review of Resident 3's clinical record revealed she saw a dentist on August 18, 2022, and then not again until May 23, 2023. Interview with the Director of Nursing on July 7, 2023, at 10:51 AM confirmed these findings and had no further information to indicate that Resident 3 received routine dental services every six months as the State plan allows. Observation of Resident 1 on July 5, 2023, at 1:34 PM revealed she was missing several teeth; however, Resident 1 had some natural teeth. Clinical record review for Resident 1 revealed progress note documentation by the facility's consultant dental provider dated November 19, 2019, indicating that Resident 1 had no new cavities and no signs of pathology. Progress note documentation on the following dates indicated that dental appointments for Resident 1 were cancelled/rescheduled: Transport documentation dated August 17, 2022, at 1:34 PM revealed that Resident 1 had an appointment for an annual dental cleaning on October 21, 2022, at 10:00 AM. Appointments documentation dated September 28, 2022, at 11:48 AM revealed that Resident 1's dental cleaning appointment was rescheduled for January 20, 2023, at 1:45pm. Appointments documentation dated December 7, 2022, at 1:24 PM revealed that Resident 1's dental cleaning appointment was rescheduled from January 20, 2023, to December 28, 2022, at 10:00 AM. Appointments documentation dated December 27, 2022, at 8:16 AM revealed that Resident 1's dental cleaning appointment for December 28, 2022, was rescheduled to February 7, 2023, at 10:00 AM. Progress note documentation from the facility's consulting dental provider dated February 7, 2023, indicated that Resident 1 had decay present on two teeth. Interview with Employee 5 (social services), on July 6, 2023, at 2:57 PM confirmed that the facility could not provide evidence that Resident 1 received appropriate routine care (e.g., dental prophy cleaning every six months); all evidence indicated that Resident 1 received one dental cleaning (February 2023) since the facility's last standard survey ending August 4, 2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395356 If continuation sheet Page 13 of 15 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 395356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guy and Mary Felt Manor, Inc 110 East Fourth Street Emporium, PA 15834 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 0791 Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on July 7, 2023, at 10:58 AM indicated that prior to February 7, 2023, the only evidence the facility had of dental services for Resident 1 was a progress note on November 19, 2019, when Resident 1 had no new cavities and no signs of pathology. The interview confirmed that the facility had no evidence that a dental professional provided services for Resident 1 from November 19, 2019, to February 7, 2023. Residents Affected - Some 483.55(b)(1)-(5) Routine/emergency Dental Srvcs in Nfs Previously cited deficiency 8/4/22 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.15(a) Dental services 28 Pa. Code 211.16(a) Social services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395356 If continuation sheet Page 14 of 15 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 395356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guy and Mary Felt Manor, Inc 110 East Fourth Street Emporium, PA 15834 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 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 and maintain equipment in a safe and sanitary condition in the main kitchen. Residents Affected - Many Findings include: An observation of the facility's main kitchen on July 5, 2023, at 11:16 AM revealed the following: A countertop deep fryer had significant yellow grease buildup on the back of the fryer basket area where it connects to the base. The walk- in freezer contained significant ice buildup around the interior of the door. Pieces of ice were observed on the freezer floor. Ice buildup was also observed on the interior wall of the walk- in cooler that sits against the walk-in freezer. Employee 6, certified dietary manager, indicated the ice accumulation has been an ongoing problem and multiple repairs have been made including changing the seals around the door, but the ice continues to accumulate. Canned products including three cans of diced tomatoes, two cans of sweet corn, three cans of sweet potatoes, five cans of tomato paste, five cans of baked beans, and four cans of carrots were observed stored on shelving in the dry storage area. There was no evidence to indicate when the products were delivered, or when they needed used by. Three cardboard boxes of paper cups and foam food containers were observed stored directly on the floor in the dry storage area. Additional boxes of disposable cups and food containers were observed stored directly on the floor in the chemical room beside bottles of cleaning solutions. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on July 6, 2023, at 2:00 PM. 28 Pa. Code 211.6 (c)(f) Dietary services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395356 If continuation sheet Page 15 of 15