Health inspection·July 20, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop an individualized care plan for one of 48 residents reviewed (Resident 50). Residents Affected - Few Findings include: The facility's policy regarding care plans, dated July 3, 2023, indicated that the facility would develop a written plan of care that was individualized for each resident's daily care routines and would be available to staff personnel who had responsibility for providing care or services to the resident. Physician's orders for Resident 50, dated June 21, 2023, included orders for the resident to have an indwelling foley catheter (a tube inserted directly into the bladder). There was no documented evidence that a care plan was developed to address Resident 50's care needs related to the indwelling foley catheter. Interview with the Director of Nursing on July 19, 2023, at 2:00 p.m. confirmed that Resident 50 did not have a care plan that addressed the care and services needed for an indwelling foley catheter. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395460 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 395460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Christ the King Manor 1100 West Long Avenue Dubois, PA 15801 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 a review of the facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to monitor a resident's blood pressure as ordered prior to medication administration for one of 48 residents reviewed (Resident 115). Residents Affected - Some Findings include: The facility's policy for administration of medication, dated July 23, 2023, indicated that medication that requires blood pressure parameters is to be obtained and charted on the medication administration record. A diagnosis record for Resident 115, dated April 17, 2023, included diagnoses of atrial fibrillation (irregular heart rhythm) and heart failure. Physician's orders for Resident 115, dated May 14, 2023, included an order for the resident to receive 3.125 milligrams (mg) of Carvedilol (Coreg), one tablet by mouth two times a day for atrial fibrillation and to hold it if the systolic blood pressure (SBP is the pressure when your heart contracts and pushes out blood) is less than 100 or the heart rate is less than 60 beats per minute. The Medication Administration Record (MAR) for Resident 115 for May and June 2023 indicated that the afternoon dose of Carvedilol was not given on May 14, 19, 29, 31 or June 4, 6, 9, 12, 2023. There was no documented evidence in Resident 115's clinical record as to why the medication was not given on the dates listed, and no documented evidence that the resident's blood pressure was taken as ordered for all afternoon doses from May 14, 2023 through June 11, 2024. Interview with the Director of Nursing on July 20, 2023, at 7:48 a.m. confirmed that there was no documented evidence to indicate why the afternoon doses of Carvedilol were not given on the dates listed, and also confirmed that the blood pressure should have been obtained and documented prior to the administration of every dose of carvedilol. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395460 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 395460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Christ the King Manor 1100 West Long Avenue Dubois, PA 15801 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure proper pain management for one of 48 residents reviewed (Resident 115). Residents Affected - Few Findings include: The facility's policy for pain management, dated July 3, 2023, indicated that the goal of pain management is to relieve the physical and psychological symptoms associated with pain while maintaining the resident's functional level. The resident is to have a plan of action formulated which may include non-pharmacological intervention and pharmacological (medication) interventions. The resident may request a non-narcotic or narcotic as ordered by the physician. When completing a pain assessment, if pain is indicated, the resident should be offered non-pharmacological intervention if appropriate. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 115, dated July 13, 2023, indicated that he was confused, had pain, had not received any non-medication interventions for pain, but did receive as-needed and routine pain medication, was unable to respond to what level of pain he had and if the pain interfered with his rest or sleep at night. A diagnosis record for Resident 115, dated April 17, 2023, included Parkinsons (degenerative disorder of the nervous system which effects the motor system) and spinal stenosis (narrowing of the spinal canal which can cause pressure on the spinal cord) of the lumbar region (lower back). A physician's order for Resident 115, dated April 17, 2023, included an order for the resident to receive one 5-325 milligrams (mg) tablet of Hydrocodone-Acetaminophen by mouth every 4 hours as needed for a pain level of 6-10 (where 1 is the least amount of pain and 10 is the most severe pain). The Medication Administration Record (MAR) for Resident 115 for May 2023 indicated that on May 1, 2023, at 10:26 p.m. and May 22, 2023, at 12:45 a.m. he was administered one 5-325 mg tablet of Hydrocodone-Acetaminophen for a pain level of 7, which was ineffective. There was no documented evidence of any other interventions being attempted, of the physician being notified, or of any further pain monitoring until May 2, 2023, at 2:15 a.m. and May 23, 2023, at 6:29 a.m. (4-6 hours later). Interview with the Director of Nursing on July 19, 2023, at 3:47 p.m. confirmed that there was no documented follow up by staff when the medication for Resident 115 was ineffective and that they should have attempted something else, notified the physician, and documented their follow up in the clinical record. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395460 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 395460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Christ the King Manor 1100 West Long Avenue Dubois, PA 15801 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure communication between a dialysis provider and the nursing staff for two of 48 residents reviewed (Residents 69, 109). Residents Affected - Some Findings include: The facility's policy regarding dialysis, dated July 3, 2023, indicated that a communication form was sent to the dialysis unit with each visit. The facility's contract, dated September 13, 2019, indicated that both parties shall ensure that there is documented evidence of collaboration of care and communication between the long-term care facility and the dialysis unit. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 69, dated June 8, 2023, indicated that she was alert and oriented; was independent with hygiene, bed mobility, and transfers; and she received dialysis. A diagnosis record for Resident 69, dated February 24, 2021, included diabetes and end-stage renal disease. Physician's orders for Resident 69, dated October 4, 2021, and her current care plan, dated August 5, 2021, indicated that she was to receive dialysis every Monday, Wednesday, and Friday at 10:00 a.m. There was no documented evidence of routine collaboration of care and communication between the long-term care facility and the dialysis unit on the days when she received dialysis services. Interview with the Director of Nursing on July 19, 2023, at 3:10 p.m. revealed that the staff send communication forms with this resident since she is alert and oriented; however, the forms are not returned daily after dialysis. Interview with the Assistant Director of Nursing on July 19, 2023, at 3:25 p.m. confirmed that there was a record of physician's orders from dialysis with recent changes, dated April 24, 2023, and July 6, 2023; however, there was no documented evidence of routine communication and collaboration of care between the long-term care facility and the dialysis unit for Resident 69. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 109, dated July 10, 2023, revealed that the resident is usually understood and understands, is cognitively intact, required extensive assist for daily care needs, received dialysis, and had diagnosis that included end-stage renal disease. Physician's orders for Resident 109, dated July 3, 2023, included an order for the resident to have dialysis every Tuesday, Thursday, and Saturday. As of July 19, 2023, there was no documented evidence of routine communication and collaboration of care between the long-term care facility and dialysis unit for Resident 109. Interview with the Director of Nursing on July 19, 2023, at 2:00 p.m. confirmed that the facility does not receive communication forms from the dialysis unit for collaboration of care and communication between the long-term care facility and dialysis unit. 28 Pa. Code 211.12(d)(3) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395460 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 395460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Christ the King Manor 1100 West Long Avenue Dubois, PA 15801 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for two of 48 residents reviewed (Residents 5, 50). Findings include: The facility's policy for fall and incident reporting, dated July 3, 2023, indicated that post fall and incident assessment charting will be completed in the resident's electronic record by the registered nurse on duty. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 5, dated June 26, 2023, revealed that the resident was usually understood and could usually understand, was cognitively impaired, required extensive assist for daily care needs, and had diagnoses that included chronic kidney disease. A fall report for Resident 5, dated February 10, 2023, at 10:39 a.m., completed by the registered nurse, revealed that the resident had a witnessed fall on February 6, 2023, at 6:15 p.m. The fall report revealed that two nurse aides reported that the resident went to stand and his legs gave out, resulting in him sliding from his recliner to the ground. Upon assessment the resident was sitting on the ground with his legs extended out in front of him. His head was resting on the recliner, the recliner was slightly elevated, and the walker was in front of him. There was no documented evidence in Resident 5's clinical record of the registered nurse's post-fall assessment. A quarterly MDS for Resident 50, dated June 3, 2023, revealed that the resident was usually understood and could understand, was cognitively impaired, required extensive assist for daily care needs, and had diagnoses that included a displaced fracture of the lateral malleolus of right fibula (bone located in the lower leg). A fall report for Resident 50, dated April 12, 2023, at 3:00 p.m., completed by the registered nurse, revealed that the resident had an unwitnessed fall in his bathroom. The resident was trying to transfer without assistance and fell. The resident's call light was not on and he was last seen by staff when they put him on the commode. He was wearing shoes and maneuvered to his right side. The resident stated that he hit his head on the wall. No bruising, bumps, or open areas were noted. The resident's skin was warm and dry. The resident had a rug burn approximately 1.0 centimeter (cm) by 1.0 cm below right knee and abrasions to left anterior thigh. He was alert and oriented to self only. The resident was anxious and was grabbing at the wall and commode trying to pull himself up. The resident was lying in front of his toilet with his head facing the doorway. He denied pain at that time. Neurological checks were intact. The resident was afebrile and his hips and pelvis were palpated with no reports of pain. His legs were equal in length with no internal rotation noted. He was moving all extremities per baseline. The resident was transferred back to his recliner via mechanical lift. There was no documented evidence in Resident 50's clinical record of the registered nurse's post-fall assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395460 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 395460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Christ the King Manor 1100 West Long Avenue Dubois, PA 15801 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 0842 Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on July 19, 2023, at 3:42 p.m. confirmed that there was no documented evidence of the registered nurse's post-fall assessments in Resident 5's and 50's clinical records. 28 Pa Code 211.5(f) Clinical records. Residents Affected - Few 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395460 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 395460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Christ the King Manor 1100 West Long Avenue Dubois, PA 15801 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 and clinical records, as well as observations and staff interviews, it was determined that the facility failed to enure proper signage related to isolation precautions was posted for one of 48 residents reviewed (Resident 108). Residents Affected - Few Findings include: The facility's policy for initiating isolation precautions, dated July 3, 2023, indicated that when isolation precautions are implemented, the licensed practical nurse or charge nurse assigned to the resident shall post the appropriate signs on the room entrance so that all personnel will be aware of the isolation precautions. The facility's policy for visitation of residents requiring isolation precautions, dated July 3, 2023, indicated that visitors must follow instructions issued by the registered nurse supervisor or charge nurse. An isolation notice requesting all visitors to speak with the nurse prior to visiting the resident will be posted at the entrance of the resident's room. A diagnosis record for Resident 108, dated June 3, 2023, included the diagnosis of a sacral pressure ulcer, Stage 4 (a wound caused by pressure which may extend into the muscle, tendon and bone). A physician's consultation note for Resident 108, dated April 12, 2023, indicated that the resident had a Stage 4 pressure ulcer and a culture from the pressure ulcer showed heavy methicillin resistant staphylococcus aureus (MRSA, a drug resistant bacteria that is difficult to treat). Physician's orders for Resident 108, dated June 3, 2023, included an order for the resident to be on contact precautions due to MRSA of the wound. Observations of Resident 108's room on July 17, 2023, at 11:01 a.m. and July 18, 2023, at 8:27 a.m. and 1:12 p.m. revealed that she had personal protective equipment (PPE) hanging on the door for use; however, there was no signage regarding isolation precautions per the facility's policy. Interview on July 18, 2023, at 1:28 p.m. with Registered Nurse 1 confirmed that she was on isolation for MRSA of the wound and that there should have been a sign on the door but was not. Interview with the Director of Nursing on July 19, 2023, at 3:01 p.m. confirmed that there should have been signage on the door about isolation. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395460 If continuation sheet Page 8 of 8