Health inspection·November 3, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of information submitted by the facility, select facility policy, select reports and clinical records and staff interviews it was determined that the facility failed to provide necessary supervision and effective safety measures to prevent an elopement by one resident (Resident 42) out of 19 sampled residents. Findings include: Review of facility policy entitled Elopement/ Unauthorized Absence Policy, last revised by the facility March 18, 2022, revealed that all residents will be assessed for the risk of elopement using the facility's Elopement Assessment on admission, quarterly, and as needed. Residents identified at risk will have interventions promptly implemented to reduce the risk of elopement. A review of the clinical record revealed that Resident 42 was admitted to the facility on [DATE], with diagnoses, which included alcohol dependence with alcohol-induced dementia, anxiety, and depression. Review of Resident 42's Elopement Risk assessment dated [DATE], indicated that the resident was physically capable of leaving the facility, was alert and oriented to person, place, and time, the resident does not wander within the facility of have a history of wandering, does not verbalize or exhibit exit seeking behavior, or has there been a previous attempt or actual elopement or unsafe wandering. Resident 42 was determined not to be at risk for elopement at that time. There was no evidence that the facility re-evaluated Resident 42's risk for elopement after October 24, 2022. A review of nursing documentation dated June 18, 2023, at 7:22 AM revealed that the resident was exhibiting behaviors, arguing with staff and was difficult to redirect. According to the documentation, the resident was continually asking why we are keeping her here and was being verbally confrontational with other residents. Review of the facility Elopement event investigation dated June 24, 2023, revealed that at approximately 1:50 PM, staff observed Resident 42 walking outside the gated garden area. The gate was left unlocked for lawn care and had not been relocked. According to the report, Resident 42 was walking back into the gated garden area when additional staff went outside to escort her back inside the facility. The resident was unable to state where she was trying to go at that time. The resident reentered the facility cooperatively and without injury, and staff immediately locked the gate. Review of an employee witness statement dated June 24, 2023, written by Employee 2, licensed practical nurse, revealed that she had let Resident 42 outside to the gazebo with the resident's books and computer. (No time was included in Employee 2's statement). Employee 4, LPN was alerted Employee 2, LPN, that Resident 42 had wandered outside into the enclosed garden area. Employee 2 then went outside and observed the resident walking back into the garden area through the unlocked gate and brought the resident back inside the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 0689 Level of Harm - Minimal harm or potential for actual harm Review of a witness statement dated June 24, 2023, written by Employee 3, nurse aide, revealed that she was approached by another staff member and told that Resident 42 was outside, on the side of the building. According to Employee 3, her and another staff member went outside to get the resident when they witnessed the resident walking back into the garden/gazebo area. Resident 42 closed the gate behind her, and housekeeping came out to lock the gate. Residents Affected - Few The facility failed to provide necessary supervision to prevent an elopement. The facility failed to complete quarterly and as needed Elopement Risk Assessment per their Elopement/Unauthorized Absence policy for Resident 42. Interview with the Director of Nursing and Nursing Home Administrator on November 3, 2023, at approximately 2:00 PM, confirmed that the facility failed to provide necessary supervision and implement effective safety measures for this resident. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: o Resident 42 had an assessment completed by registered nurse with no negative findings. Resident 42 had a wanderguard placed for safety until reviewed by IDT (interdisciplinary team). Elopement assessment and resident careplan updated. The small gate at the gazebo area was locked. o To identify like residents the facility completed a head count of all residents in the building to make sure all other residents were accounted for, new elopement assessments were completed on current residents, and the facility posted signage that residents must be accompanied by a staff member when out in the courtyard. o To prevent this from reoccurring, the DON/designee educated staff on the elopement policy, educated staff that when residents are outside of facility during nice weather, a staff member is to stay with them, and staff education provided on locking the gates when done using them. o To monitor and maintain ongoing compliance the facility will complete elopement drills on each shift now and monthly or until a period of compliance has been reached and reviewed at QAPI. The maintenance director will check outside gates to ensure they are secured weekly x 4 and monthly x2 or until a period of compliance has been reached as determined by QAPI. The facility's completion date for this plan of correction was June 26, 2023. 28 Pa. Code 211.12 (d)(5) Nursing services 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, and staff interview, it was determined that the facility failed to thoroughly assess and evaluate bladder function and implement individualized interventions to restore bladder function to the extent possible for one out of 18 sampled residents (Residents 65). Findings include: Review of Resident 65's clinical record revealed admission to the facility on June 1, 2022, and readmission on [DATE], with diagnoses that included diabetes, and hypertension. Quarterly Minimum Data Set Assessments (MDS - a federally mandated standardized assessment completed at specific intervals to define resident care needs) dated January 3, 2023, February 6, 2023, May 8, 2023, July 10, 2023, and an annual MDS dated [DATE], all indicated that the resident was cognitively intact, dependent on staff for activities of daily living (ADLs - the basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring and repositioning) and was frequently incontinent of bladder. Review of an Evaluation for Continence and Retraining/Scheduled Toileting dated February 1, 2023, indicated that the resident was incontinent and to be placed on a 72 Hour bowel and bladder tracking. The Bowel and bladder tracking continued past the 72 hours and indicated patterns of incontinence. There was no evidence that the facility had developed and implemented individualized toileting plans based on the the results of the 72 hour bowel & bladder tracking and the resident's elimination patterns. Review of Resident 65's plan of care for bladder incontinence indicated on February 1, 2023, planned measures were to assess the resident's pattern of urination and episodes of incontinence and to Implement a toileting program as indicated, and provide incontinence care as needed. At the time of the survey ending November 3, 2023, there was no additional Incontinence Evaluations or any scheduled toileting programs developed and implemented for the resident based on the resident's assessed patterns of urination and incontinence. The facility failed to thoroughly assess and evaluate bladder function and implement individualized interventions to restore bladder function to the extent possible for Resident 65. Interview with the Administrator on November 3, 2023 at 10:30 a.m. confirmed that the resident's plan of care for bladder incontinence was not implemented. The NHA verified that Resident 65 was placed on incontinence care without evidence of individualized toileting plans attempted to decrease incontinence. 28 Pa. Code 211.12 (d)(5) Nursing services 28 Pa. Code 211.10 (d) Resident care policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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 clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 19 residents (Resident 3). Residents Affected - Few Findings include: A review of the clinical record revealed that Resident 3 was admitted to the facility on [DATE], and had diagnoses, which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of the resident's current care plan, initially dated March 17, 2023, in effect at the time of the survey ending November 3, 2023, revealed no documented evidence that the facility had developed an individualized person-centered plan for the resident's dementia care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety and using individualized, non-pharmacological approaches to care, including purposeful and meaningful activities that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. An interview with the director of nursing on November 2, 2023, at approximately 2:00 PM confirmed the facility failed to develop and implement an individualized person-centered plan to address the resident's dementia. 28 Pa Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policy, observations, and staff interview, it was determined that the facility failed to ensure adherence to medication/pharmaceuticals expiration/use by dates in two of three medication storage rooms and failed to identify use by/discard dates for multidose insulin for four of 35 residents sampled (Residents 30, 40, 65, and 29). Findings include: A review of the facility's policy and procedure entitled General Dose Preparation and Medication Administration last reviewed [DATE] revealed that the facility staff should enter the date opened on the label of the medication with shortened expiration dates (i.e. insulins). The staff may enter the expiration date based on the date opened on the label of the medication with shortened expiration dates. Observations of the medication room on the E hall on [DATE], at 10:47 AM revealed 18 heparin lock flush syringe 50 units/5 ml expired [DATE]; one bottle of sodium bicarbonate 325 mg expired [DATE]; one bottle of Vitamin B12 1000 mcg expired on [DATE]; one bottle of Vitamin B12 1000 mcg expired on [DATE] and one bottle of Omnipaque oral solution expired [DATE]. Observations of the central supply room on [DATE], at 10:55 AM revealed one bottle of niacin 1000 mcg expired on [DATE] and two bottles of Vitamin B6 25mg expired [DATE]. An interview with the DON (director of nursing) on [DATE], at the time of the observations noted above confirmed the medication were expired and should have been discarded. An observation of the B hall nursing unit medication cart on [DATE], at 11:02 AM revealed the following multi-dose insulins opened for resident use but undated when first opened: Resident 30's Lantus Flex Pen 100 units/ml (insulin) and Humalog 100 units/ml insulin vial Resident 40's Novolog Flex Pen 100 units/ml (insulin) . Resident 65's two Lantus Flex Pens 100 units/ml, two Lispro insulin vials 100 units/ml, and one Humalog Flex Pen 100 units/ml . Resident 29's Humulin 70/30 100 units/ml insulin vial and Lispro Flex Pen 100 units/ml The above insulin pens and vial observed were not dated when initially opened and activated for use. An interview with Employee 1 LPN (license practical nurse) on [DATE], at approximately 11:05 AM revealed the employee stated all insulins should be dated when opened and discarded in 28 days and the employee confirmed the residents' insulins were not dated when opened. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 28 Pa Code 211.9 (a)(1)(k) Pharmacy services 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: 395493 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined facility failed to ensure coordination of Hospice services with facility services to meet the needs one each resident receiving hospice care for one out of one resident reviewed under hospice care (Resident 43). Findings include: A review of the clinical record revealed that Resident 43 was admitted to the facility on [DATE], with diagnoses of Parkinson's Disease (a condition that affects the brain and causes problems with movement, balance, and coordination) and depression. The resident was admitted to hospice services on August 10, 2023, for end stage Parkinson's Disease. Review of Resident 43's plan of care, conducted during the survey ending November 3, 2023, revealed that the resident's plan of care was not integrated with hospice services to ensure the resident's care plan identified the care and services provided by both the hospice provider and facility staff. Interiew with the Administrator on November 3, 2023, at 10:30 a.m. she confirmed that hospice care plans were not integrated with the facility plans of care. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 If continuation sheet Page 8 of 8