Health inspection·February 21, 2025

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy, and staff interview it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication according to the physician's parameters for two out of 19 sampled residents. (Resident 75 and 11). Residents Affected - Few Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. Review of the facility policy titled Medication Administration last reviewed by the facility on November 13, 2024, revealed that medications are administered as prescribed to all residents in a timely fashion and within prescribed parameters. Medications are administered in accordance with written orders of the attending physician. Prior to administering a medication to a resident, the nurse will verify: 1) The correct resident 2) The correct medication, dosage, and route, as per physician order 3) The correct time for the medication 4) Any special instructions are followed 5) Required parameter (s) are obtained prior to administration, as per order A review of the clinical record revealed Resident 75 was admitted to the facility on [DATE], with diagnoses to include diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and chronic kidney disease (gradual loss of kidney function). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 15, 2025, revealed that Resident 75 had moderately impaired cognition with a BIMS score of 9 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395480 If continuation sheet Page 2 of 5 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 395480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mahoning Operating LLC 397 Hemlock Drive Lehighton, PA 18235 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the physician's order dated January 4, 2025, revealed an order for Humalog injection (medication used to treat high blood glucose) 5 units twice a day and 8 units once daily, HOLD for BS<120 mg/dl (a blood sugar less than 120 mg/dl) for diabetes. A review of the physician's order dated January 19, 2025, revealed an order for Humalog injection 8 units in the morning, 12 units in the afternoon and 15 units in the evening, HOLD for BS<120 (a blood sugar less than 120) for diabetes. Review of the Medication Administration Record (MAR) for January 2025, and February 2025, revealed Resident 75's Humalog was administered on the following dates two times outside of the physician ordered parameters: January 8, 2025: 5 units of Humalog administered at 7:45 AM despite a blood glucose level of 117 (below the prescribed threshold). February 10, 2025: 8 units administered at 7:34 AM with a blood glucose level of 102. (below the prescribed threshold). During an interview on February 21, 2025, at approximately 12:30 PM, the Director of Nursing (DON) confirmed that nursing staff failed to follow the physician-ordered parameters and did not adhere to professional nursing standards during medication administration. A clinical records review revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses of Parkinson's disease, benign prostatic hyperplasia (BPH enlarged prostate), and history of COVID-19. A physician order, initially dated February 17, 2025, was noted for Midodrine (medication to treat low blood pressure) 5 mg one tablet by mouth two times a day for hypotension (low blood pressure) with instructions to hold the medication if the resident's systolic blood pressure (measures pressure inside the arteries and is the top number of a blood pressure reading) is greater than 120 mm/Hg. According to the resident's February 2025 Medication Administration Record, nursing administered Midodrine 5mg tablet on February 17, 2025, at 5:00 p.m. Further review of the MAR revealed that the medication was administered when Resident 11's systolic blood pressure was 132 mm/Hg, exceeding the prescribed threshold of 120 mm/Hg. During an interview on February 21, 2025, at approximately 1:00 p.m., the Nursing Home Administrator and Director of Nursing confirmed the medication was improperly administered, contrary to the physician's orders. The facility failed to adhere to professional standards of nursing care by not ensuring prescribed medications were administered according to the specific physician-ordered parameters for two residents. 28 Pa. Code 211.5 (f) (ix) Medical Records 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395480 If continuation sheet Page 3 of 5 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 395480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mahoning Operating LLC 397 Hemlock Drive Lehighton, PA 18235 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 select facility policies and procedures and clinical records, observations, and staff interviews, it was determined the facility failed to provide supplemental oxygen administration care consistent with professional standards of practice for three out of 19 residents sampled (Resident 2, 16, and 82). Residents Affected - Some Findings include: Review of facility policy entitled Oxygen Administration, last reviewed November 13, 2024, revealed that oxygen is administered under orders of a physician, except in the case of an emergency. Infection control measures performed during the administration of oxygen include change and date oxygen tubing and mask/cannula every two weeks and as needed. Change and date humidifier bottle every 72 hours and keep delivery devices covered in plastic bag when not in use. Observation of Resident 2 on February 19, 2025, at 10:57 a.m. revealed the resident was receiving oxygen via nasal cannula set (tube with two prongs placed in the nostrils to deliver oxygen) at 3.0 liters per minute (l/m) with humidification. The humidifier bottle, dated February 15, 2025, was empty, and the oxygen tubing was not dated as per facility policy. Observation of Resident 16 on February 19, 2025, at 10:45 a.m. revealed nebulizer tubing and mask in a clear bag on the resident's nightstand. The tubing was dated January 26, 2025-indicating that it had not been replaced for over 25 days, exceeding the recommended timeframe. Observations were confirmed by Employee 2, licensed practical nurse (LPN), on February 19, 2025, at approximately 9:30 a.m. Resident 82: On February 20, 2025, at 9:32 a.m., the resident was observed resting in bed while the oxygen concentrator was on. The nasal cannula was placed in a clear bag attached to the concentrator rather than applied to the resident. The oxygen tubing was also not dated. An interview with Employee 1, a licensed practical nurse, revealed the resident was being evaluated for discontinuation of oxygen therapy; however, a review of the resident's clinical records showed no physician order to withhold oxygen therapy, as a current order dated January 29, 2025, prescribed 2.5 liters/min via nasal cannula. Additional interview with Employee 1 on February 20, 2025, confirmed that Resident 82 was not receiving oxygen as prescribed and acknowledged the lack of a physician's order for discontinuation. Interview with Nursing Home Administrator (NHA) and the Director of Nursing on February 21, 2025, at 1:00 p.m. confirmed that nursing staff failed to adhere to facility policies concerning oxygen administration and infection control practices. The Director of Nursing further confirmed that nursing staff failed to consistently provide oxygen therapy to Resident 82 in accordance with the physician's order. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395480 If continuation sheet Page 4 of 5 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 395480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mahoning Operating LLC 397 Hemlock Drive Lehighton, PA 18235 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of facility documents and staff interview, it was determined the facility failed to ensure the Medical Director or designee attended quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for two of four quarters (April 2024 and January 2025). Residents Affected - Few Findings include: A review of QAPI Committee meeting sign-in sheets for the period of April 2024 through January 2025, revealed the Medical Director or designee was not in attendance at the quarterly QA meeting held on April 25, 2024, and January 30, 2025. Interview with the director of nursing on February 21, 2025, at 11:00 AM confirmed the Medical Director or designee failed to attend the facility's QAPI meetings on a quarterly basis. 28 Pa. Code 211.2 (d)(3)(4)(5)(6) Medical director. 28 Pa. Code 201.18 (e)(1)(3) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395480 If continuation sheet Page 5 of 5