Health inspection·October 30, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 review and revise comprehensive care plans to reflect the current care and services for one of 20 residents reviewed (Resident R12). Findings include: Review of a facility policy entitled, Comprehensive Care Planning, dated 12/15/22, indicated that the comprehensive care plans will periodically be reviewed and revised by a team of qualified persons as needed and after completion of each assessment. Review of Resident R12's clinical record revealed an admission date of 12/29/22, with diagnoses that included transient cerebral attack (stroke), hemiplegia (paralysis) and hemiparesis (partial paralysis) affecting left side and high blood pressure. Review of Resident R12's Quarterly MDS (MDS- periodic assessment of resident care needs) with an Assessment Reference Date (ARD) of 10/5/23, revealed that it was coded as having one Stage 2 (partial thickness, skin loss) pressure ulcer. Clinical record weekly wound documentation from a wound consultant company dated 8/4/23 through 10/14/23, all revealed the presence of a Stage 3 (full- thickness, skin loss) pressure ulcer to the sacrum. Clinical record documentation entitled Nursing Wound Documentation Record dated 7/25/23 through 10/19/23, all indicated a Stage 2 pressure ulcer to the sacrum. Review of Resident R12's skin care plan did not identify any pressure ulcers as identified in the skin / wound assessments. Resident R12's clinical record lacked evidence that the skin care plan was updated after completion of the 10/5/23, Quarterly assessment. During an interview on 10/27/23, at 11:00 a.m. the Nursing Home Administrator In-Training confirmed that Resident R12's skin care plan was not updated to reflect the resident's pressure ulcers. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395489 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 395489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Corry Manor 640 Worth Street Corry, PA 16407 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on review of facility records and resident, family members, and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for three of 20 residents reviewed (Residents R4, R5, and R17 ). Findings include: Review of the Resident Council minutes for July 2023 revealed concerns of resident meal trays are sitting too long; ice cream is melted. Resident Council Minutes for August 2023, revealed concerns of consistency of call bell positioning, filling water more frequently, asking both people in a room if they need water refilled, residents would like nursing to slow down and make sure needs are met, and better communication between shifts. Resident Council Minutes of September 2023, revealed concerns of call lights not being answered in a timely manner, trays are being left in resident rooms, food waiting on stackers in hallways for too long, staff at nursing station on their phones, not getting showers, would like more showers/preferred times, hoyer (type of mechanical lift) showers not getting done on second shift due to lack of help, and aides talking to residents about quitting, having attitudes with residents. Resident Council Minutes for October 2023, revealed concerns of call bells not answered in a timely manner, would like more showers, aides are not writing down the correct meal orders, would like to have more showers, and not sure when shower times are. During an interview on 10/25/23, at approximately 11:15 a.m. Resident R4, who was alert and oriented, verbalized that he/she does not get out of bed at times when there is not enough staff, due to he/she requires a mechanical lift which requires assistance of two staff. Resident R4 was observed in bed. Resident R4 also verbalized that bed linen does not get changed due to not enough staff. During an interview on 10/25/23, at approximately 12:15 p.m. Resident R5 's family member indicated he/she visits daily to ensure resident is fed properly and care is provided appropriately due to not enough staff for Resident R5, who is not alert and oriented. During an interview on 10/25/23, at approximately 11:45 a.m. Resident R17, who was alert and oriented, verbalized that he/she gets out of bed into a chair to eat, but would like to get back in bed after he/she is done eating. Resident R17 vocalized there is never enough staff to help get back into bed. Resident R17 indicated he/she requires a mechanical lift which requires assistance of two staff members. Resident R17 stated, I usually just stay in the chair because its time for lunch by the time they can come help me, then after luch you have to wait until the next shift comes for help. By that time my backside hurts. Resident R17 was observed in the chair at the time of interview, and wasn't assisted back into bed until about 3:30 p.m., upon observation. During an interview on 10/27/2023, at 12:45 p.m. the Nursing Home Administrator In-Training confirmed that the facility continues with numerous days below the state mandated levels for nursing hours and also continued to accept many new admission residents during the month of October 2023. 28 Pa Code 211.12(d)(4) Nursing services 28 Pa Code 201.14(a) Responsibility of licensee (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395489 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 395489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Corry Manor 640 Worth Street Corry, PA 16407 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 0725 28 Pa Code 201.18(b)(3) Management Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395489 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 395489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Corry Manor 640 Worth Street Corry, PA 16407 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 facility documents and clinical records and staff interview, it was determined that facility staff failed to maintain complete and accurate clinical records for one of 20 residents reviewed (Resident R12). Findings include: Review of Resident R12's clinical record revealed an admission date of 12/29/22, with diagnoses that included transient cerebral attack (stroke), hemiplegia (paralysis) and hemiparesis (partial paralysis) affecting left side and high blood pressure. Review of Resident R12's Quarterly MDS (MDS- periodic assessment of resident care needs) with an Assessment Reference Date (ARD) of 10/5/23, revealed that it was coded as having one Stage 2 (partial thickness, skin loss) pressure ulcer. Clinical record weekly wound documentation from a wound consultant company dated 8/4/23 through 10/14/23, all revealed the presence of a Stage 3 (full- thickness, skin loss) pressure ulcer to the sacrum. Clinical record documentation entitled Nursing Wound Documentation Record dated 7/25/23 through 10/19/23, all indicated a Stage 2 pressure ulcer to the sacrum. Resident R12's skin care plan did not identify any pressure ulcers as identified in the skin / wound assessments. Resident R12's clinical record lacked evidence that the skin care plan was updated after completion of the 10/5/23 Quarterly assessment. During an interview on 10/27/23, at 11:00 a.m. the Nursing Home Administrator In-Training confirmed that Resident R12's clinical record documentation regarding pressure ulcers had conflicting information. 28 Pa. Code 211.5 (f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395489 If continuation sheet Page 5 of 5