Health inspection·May 12, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for six of 17 residents reviewed (Residents R7, R55, R30, R14, R25, and R15). Findings include: Review of facility policy entitled, Care Plan dated 11/2022, revealed that .each time a resident's condition indicates; a new care plan will be done to address the most current problem/concern and The care plan will include measurable objectives and timetables to meet each resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Review of Resident R7's clinical record revealed an admission date of 1/04/22, with diagnoses that included respiratory failure, pressure ulcer of the sacral region, bone infection of the sacral region, dementia and high blood pressure. Review of Resident R7's Quarterly Minimum Data Set (MDS-a mandated assessment of a residents abilities and care needs) assessment, dated March 22, 2023, revealed that the resident was cognitively impaired, required extensive assistance for daily care,complained of constant pain and had an indwelling urinary catheter (a tube placed and held in the bladder to drain urine). Review of Resident R7's comprehensive care plan on 5/11/23, lacked reference to Resident R7's urinary catheter and pain status. Review of Resident R55's clinical record revealed an admission date of 4/14/23, with diagnoses that included chronic kidney disease, urinary tract infection, diabetes (high blood sugar) and heart failure. Review of clinical record documentation revealed Resident R55 was started on an antibiotic on 4/23/23, for a urinary tract infection. Review of Resident R55's comprehensive care plan on 5/11/23, lacked reference to Resident R55's urinary status or urinary tract infection. Review of Resident R30's clinical record revealed an admission date of 1/25/20, with diagnoses that included dysphagia (difficulty swallowing food and/or liquids), dementia, and gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Review of clinical record documentation revealed Resident R30 had a significant weight loss (weight loss of 5% in the last 30-day and/or 10% in the last six months) of 12.98% in the last six months. Review of physician's orders revealed Resident R30 was on a pureed diet (texture modified diet) and utilized a divided plate and Kennedy cup (light weight spill proof drinking cup with straw) Review of Resident R30's comprehensive care plan on 5/11/23, lacked reference to Resident R30's nutritional status, diet orders, or adaptive equipment required for meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395401 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ball Pavilion, The 5416 East Lake Road Erie, PA 16511 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 - Some Review of Resident R14's clinical record revealed an admission date of 6/21/21, with diagnoses that included diabetes, high blood pressure, and atrial fibrillation (irregular heart rhythm that can lead to blood clots in the heart). Review of Resident R14's clinical record revealed physician's order dated 9/28/22, for Eliquis (medication to prevent blood clots) 5 milligrams (mg) by mouth twice a day, Insulin Lispro (medication used to control high blood sugar) 4 units subcutaneous (sq) four times a day before meals and at bedtime, and Lantus (medication used to control high blood sugar) 18 units sq once a day at 9:00 p.m. and physician orders dated 10/11/22, for Lantus 14 units sq once a day at 6:00 a.m. Review of Resident R14's comprehensive care plan on 5/11/23, lacked reference to Resident R14's diabetes or usage of Insulin Lispro or Lantus as well as reference to Resident R14's atrial fibrillation and usage of Eliquis. Review of Resident R25's clinical record revealed an admission date of 8/5/16, with diagnoses that included dementia, high blood pressure, and right leg deep vein thrombosis (blood clot that formed in the leg). Review of Resident R25's clinical record revealed a physician's order dated 6/29/22, for Xarelto (medication to prevent blood clots) 10 mg by mouth daily. Review of Resident R25's comprehensive care plan on 5/11/23, lacked reference to Resident R25's history of blood clots or usage of Xarelto. Review of Resident R15's clinical record revealed an admission date of 6/20/18, with diagnoses including stroke with left-sided weakness, Type 2 Diabetes (affects how the body uses glucose (sugar)), dementia, mood disturbance, and high blood pressure. Review of Resident R15's clinical record revealed a physician's order dated 3/15/22, for oxygen at two liters per minute. Review of Resident R15's comprehensive care plan on 5/11/23, lacked reference to providing supplemental oxygen. Observations on 5/09/23, and 5/12/23, revealed Resident R15 lying in bed with supplemental oxygen being administered through a nasal cannula (tubing that delivers supplemental oxygen through the nose). During an interview on 5/12/23, at 11:38 a.m. Registered Nurse Assessment Coordinator confirmed that care plans had not been developed to address Resident R7's pain or indwelling catheter, R55's urinary tract infection, R30's nutritional status, R14's insulin, or anticoagulant, R25's anticoagulant, and R15's oxygen usage. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395401 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ball Pavilion, The 5416 East Lake Road Erie, PA 16511 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 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to update and/or individualize care plans for two of 17 residents reviewed (Residents R11 and R23). Residents Affected - Few Findings include: Review of facility policy entitled, Care Plan dated 11/2022, indicated that .each time a resident's condition indicates; a new care plan will be done to address the most current problem/concern. Review of Resident R11's clinical record revealed an admission date of 12/29/21, with diagnoses that included fractured right femur, anxiety, dementia and history of falling. Review of clinical record documentation and fall investigation tool for Resident R11, revealed that he/she fell on 2/21/23, at 7:00 p.m. resulting in a right femur fracture requiring hospitalization. There was no evidence that the care plan was updated to reflect the fall and interventions. Review of Resident R23's clinical record revealed an admission date of 9/1/22, with diagnoses that included high blood pressure, fractured right femur, and dementia. Review of clinical record documentation and fall investigation tool for Resident R23, revealed that he/she fell on 1/9/23, at 7:45 p.m. resulting in a right femur fracture requiring hospitalization and surgical intervention. Review of Resident R23's care plan on 5/11/23, related to fall's reflected that resident was found on the floor on 9/9/22, and failed to reflect the 1/9/23 fall that resulted in a fracture or interventions implemented as a result of the 1/9/23, fall and/or fracture. During an interview on 5/12/23, at 11:38 a.m. the Registered Nurse Assessment Coordinator confirmed that Resident R11 and R23's fall care plan was not updated to reflect most recent fall and/or fracture. 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: 395401 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ball Pavilion, The 5416 East Lake Road Erie, PA 16511 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. Based on review of clinical records, observations and staff interview, it was determined that the facility failed to provide appropriate care regarding a urinary catheter (a tube placed and held in the bladder to drain urine) for one of 17 residents reviewed (Resident R7). Findings include: Review of Resident R7's Quarterly Minimum Data Set (MDS-a mandated assessment of a residents abilities and care needs) assessment, dated March 22, 2023, revealed that the resident was cognitively impaired, required extensive assistance for daily care, and had an indwelling urinary catheter Observations in Resident R7's room on May 10, 2023, at 9:12 a.m. and again on May 11, 2023, at 10:00 a.m. revealed that the resident's urinary drainage bag and tubing were lying on the floor without a cover over the drainage bag. Interview with the Nursing Home Administrator on May 11, 2023, at 10:10 a.m. confirmed that Resident R7's urinary drainage bag and tubing should not have been on the floor and should have a cover over the drainage bag. 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395401 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ball Pavilion, The 5416 East Lake Road Erie, PA 16511 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 review of clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and prevent the potential spread of infection regarding respiratory care equipment according to physician orders, and failed to administer supplemental oxygen as ordered for two of 17 residents reviewed (Residents R7 and R15). Residents Affected - Few Findings include: Review of a facility policy entitled, Oxygen Concentrator (device that takes air from your surroundings, extracts oxygen and filters it into purified oxygen for you to breathe) Operation dated November 2022, indicated that oxygen will be administered to residents at the rate ordered by the physician and per oxygen concentrator with humidifier unless otherwise ordered. Review of Resident R7's clinical record revealed an admission date of 1/04/22, with diagnoses that included respiratory failure, pressure ulcer of the sacral region, bone infection of the sacral region, dementia and high blood pressure. Resident R7's physician's orders dated 3/03/23, included an order for Albuterol Sulfate (medication used to open airways via nebulizer mask) nebulization solution four times a day. Resident R7 also had an order for a wound vac (vacuum machine used to remove drainage from a wound). Observations on 5/10/23, at 9:00 a.m. revealed Resident R7's wound vac machine and drainage tubing resting on top of Resident R7's nebulizer mask. During an interview on 5/10/23, at 9:35 a.m. the Director of Nursing confirmed that the nebulizer mask should be stored in a bag while not in use and the wound vac machine and drainage tubing should not have been resting on Resident R7's nebulizer mask. Review of Resident R15's clinical record revealed an admission date of 6/20/18, with diagnoses that included stroke with left-sided weakness, Type 2 Diabetes (affects how the body uses glucose (sugar)), dementia, mood disturbance, and high blood pressure. The clinical record also revealed a physician's order dated 3/15/22, for oxygen at two liters per minute via concentrator and to change the distilled water in the humidifier bottle every day on night shift. Observations on 5/09/23, and 5/12/23, revealed that Resident R15's supplemental oxygen concentrator was set at three liters per minute continuously, and that the humidifier bottle lacked distilled water. During an interview on 5/12/23, at 8:40 a.m. Licensed Practical Nurse Employee E2 confirmed that Resident R13's oxygen concentrator was not set at the correct liters per minute as ordered by the physician and that the humidifier bottle was empty. 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395401 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ball Pavilion, The 5416 East Lake Road Erie, PA 16511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and staff interviews, it was determined that the facility failed monitor the sanitizing functions of the dish machine in the main kitchen, and store food and food containers in a safe and sanitary manner in one of three nourishment refrigerators (B wing). Findings include: Review of a facility policy entitled, Dish Machine Temperatures dated July 2022, indicated that dish machine temperatures will be taken at the beginning of breakfast, dinner, supper dish runs, and any temperature that is below regulation (160-180 Fahrenheit degrees (F) wash, 180-200 F final rinse) will be reported immediately to the supervisor/coordinator on duty, and in the event that a dish machine is not working properly, paper products will be used for meal service. Review of a facility policy entitled Pantry Stock of Nursing Units and Dining Rooms dated July 2022, indicated that storage areas will be cleaned and organized as necessary. Observation on 5/09/23, at 2:00 p.m. the dish washer washing cycle reached 146 F, and final rinse cycle reached 156 F. Review of the High Temp Dish Log for May 2023, revealed that the wash cycle temperature failed to reach the minimum 160 F for the following meals; supper on 5/02/23, 5/04/23, and 5/07/23: the final rinse cycle failed to reach the minimum required 180 F on the following meals; dinner on 5/01/23, 5/03/23, 5/06/23, 5/08/23, and 5/09/23; supper on 5/02/23, 5/03/23, 5/04/23, and 5/07/23, or 12 of 26 meals documented. During an interview on 5/09/23, at 2:00 p.m. the Dietary Manager confirmed that the recorded dish washer temperatures for the above mentioned meals did not reach the minimum required 160 F for the wash cycle and 180 F for the final rinse cycle, and that dietary staff failed to notify the manager/coordinator and that meals were not provided the residents on paper products. Observations on 5/09/23, at 3:37 p.m. and 5/10/23, at 11:30 a.m. of the B wing nourishment revealed a brown dried substance splashed on middle and bottom shelves and down the left side panel of the internal refrigerator wall, and a yellow dried substance on the top door shelf. Interview on 5/10/23, at 11:30 a.m. with Registered Nurse Employee E3 confirmed the brown and yellow dried substances in the refrigerator and that the condition did not meet appropriate sanitary conditions, he/she believes that dietary staff clean it daily when they stock the refrigerator and take temperatures, and nursing staff are to clean up spills if they notice them. Interview on 5/10/23, at 12:20 p.m. with the Dietary Manager confirmed that whoever spills food/liquids in the refrigerators or finds the spilled substance should clean it up. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.6(f) Dietary services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395401 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ball Pavilion, The 5416 East Lake Road Erie, PA 16511 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 review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to prevent the potential for cross contamination during a dressing change for one of two residents with pressure ulcers requiring wound care reviewed (Resident R7). Residents Affected - Few Findings include: Review of the facility policy entitled, Dressings/Prevention of Infection, dated 11/15/2022, indicated to remove the soiled dressing, remove soiled gloves and then wash hands. Review of Resident R7's clinical record revealed an admission date of 1/04/22, with diagnoses that included respiratory failure, pressure ulcer of the sacral region, bone infection of the sacral region, dementia and high blood pressure. Review of Resident R7's physician's orders dated 3/03/23, included an order to cleanse the sacral wound and apply a wound vac (vacuum machine used to remove drainage from a wound). Observation of wound care on 5/10/23, at 9:00 a.m. revealed that the Director of Nursing moved the garbage can closer to Resident R7 with their gloved hands and then proceeded to remove the soiled dressing without removing gloves or washing hands and then continued to cleanse the wound without removing gloves or washing hands. During an interview on 5/10/23, at 9:35 a.m. the Director of Nursing confirmed he/she did not change gloves and did not complete hand hygiene when indicated. 28 Pa. Code 201.18 (b)(2) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395401 If continuation sheet Page 8 of 8