Health inspection·November 15, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm resident's bed frame facing the corridor uncovered exposing the bag with urine to be viewed easily by all who pass by in the corridor. During an interview at the time of the observation Registered Nurse Employee E7 confirmed that the catheter bag should have a privacy cover on it. Residents Affected - Few 28 Pa. Code 211.10(c) 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: 395510 If continuation sheet Page 2 of 17 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records and facility policies, and staff interview, it was determined that the facility failed to maintain confidentiality regarding resident medical information for three of 14 residents reviewed (Residents R10, R15, and R26). Residents Affected - Few Findings include: Review of the facility policy entitled, Computer Terminals/Workstations dated 7/14/23, revealed that computer terminals and workstations will be positioned/shielded to ensure that protected health information (PHI) and facility information is protected from public view or unauthorized access, and that users may not leave their workstation/terminal unattended unless the terminal screen is cleared. Observation on 11/12/23, at 10:16 a.m. revealed that medication cart A was situated outside the nurse's station unattended (no nurses in view of the medication cart) and the computer screen was opened and facing the center of the hallway exposing Resident R15's PHI to public view and unauthorized access. During an interview on 11/12/23, at 10:18 a.m. Registered Nurse Employee E5 confirmed that the computer screen was left open and Resident R15's PHI was visible to the public and unauthorized access, and that staff are to clear/lock their screens when they leave the medication cart. Observation on 11/12/23, at 3:32 p.m. of medication administration revealed that Licensed Practical Nurse (LPN) Employee E4 situated the medication cart near resident room [ROOM NUMBER] and entered resident room [ROOM NUMBER]-B to administer medications and failed to clear/lock the computer screen and exposed Resident R10's PHI that was visible to the public and unauthorized access. During an interview at that time LPN Employee E4 confirmed that he/she is not concerned down this hall as there are no wandering residents and few visitors. Observation on 11/12/23, at 3:36 p.m. of medication administration revealed that LPN Employee E4 left the medication cart near resident room [ROOM NUMBER] and entered resident room [ROOM NUMBER]-A to administer medications and failed to clear/lock the computer screen and exposed Resident R26's PHI that was visible to the public and unauthorized access. During an interview on 11/13/23, at 2:50 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the computer screens should be secured to prevent public view and unauthorized access to resident's PHI. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 211.5(b) Medical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395510 If continuation sheet Page 3 of 17 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to ensure that a baseline care plan was developed/implemented within the required timeframe and failed to ensure that a written copy was provided to residents and resident's representatives for six of 14 residents reviewed (Residents R5, R35, R47, R50, R54, and R58). Findings include: Review of a facility policy entitled, Care Plans - Baseline dated 7/14/23, revealed, A baseline care plan will be developed within 48 hours of the resident's admission. The interdisciplinary team will . implement a baseline care plan to meet the resident's immediate care needs . And The resident and their representative will be provided a summary of the baseline care plan . Resident R5's clinical record revealed an admission date of 8/11/23, with diagnoses that included Multiple Fractures of Ribs, Dementia (symptoms affecting memory, thinking, and social skills), and Chronic Obstructive Pulmonary Disease (COPD-a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath). Review of Resident R5's clinical record lacked evidence that a baseline care plan was developed / implemented within 48 hours of admission, and that a written summary of the baseline care plan was provided to the resident and resident representative. Resident R35's clinical record revealed an admission date of 9/11/23, with diagnoses that included Dementia, Delusional Disorders (a mental illness that makes people believe false things that seem real to them), and Diabetes (a condition where the body produces insufficient amounts of insulin, causing high blood sugar). Review of Resident R35's clinical record lacked evidence that a baseline care plan was developed / implemented within 48 hours of admission, and that a written summary of the baseline care plan was provided to the resident and resident representative. Resident R47's clinical record revealed an admission date of 8/21/23, with diagnoses that included Coronary Artery Bypass Graft (CABG - a surgery that creates a new path for blood to flow around a blocked, or partially blocked, artery in the heart), COPD, and Muscle Weakness. Review of Resident R47's clinical record lacked evidence that a baseline care plan was developed / implemented within 48 hours of admission, and that a written summary of the baseline care plan was provided to the resident and resident representative. Resident R50's clinical record revealed an admission date of 9/25/23, with diagnoses that included Fracture of Lower End of Left Radius (Bone in lower arm), Fracture of Right Olecranon Process (part of the ulna in the lower arm, near the elbow), and Parkinson's Disease (a condition that affects the brain, causing problems with movement, balance, and coordination, with symptoms such as tremors, slowness, stiffness, difficulties speaking, and swallowing). Review of Resident R50's clinical record lacked evidence that a baseline care plan was developed / implemented within 48 hours of admission, and that a written summary of the baseline care plan was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395510 If continuation sheet Page 4 of 17 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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 0655 provided to the resident and resident representative. Level of Harm - Minimal harm or potential for actual harm Resident R54's clinical record revealed an admission date of 10/17/23, with diagnoses that included Pneumonia due to Inhalation of Food and Vomit,COPD, and Dysphagia (Difficulty swallowing), Residents Affected - Some Review of Resident R54's clinical record lacked evidence that a baseline care plan was developed / implemented within 48 hours of admission, and that a written summary of the baseline care plan was provided to the resident and resident representative. Resident R58's clinical record revealed an admission date of 11/8/23, with diagnoses that included Chronic Venous Hypertension (Weak veins in the legs that cannot return the blood from the legs back to the heart) with Bilateral Venous Leg Ulcers (Slow-healing sores in both lower legs caused by pooling of oxygen-poor blood), and Diabetes. Review of Resident R58's clinical record lacked evidence that a baseline care plan was developed / implemented within 48 hours of admission, and that a written summary of the baseline care plan was provided to the resident and resident representative. During an interview on 11/14/23, at 10:59 a.m. Registered Nurse Employee E6 confirmed that the baseline care plans were not developed / implemented within 48 hours and there was no evidence that a written summary of the baseline care plan was provided to Residents R5, R35, R47, R50, R54, R58 and their representatives. 28 Pa. Code 201.24 (e)(4) Admissions Policy FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395510 If continuation sheet Page 5 of 17 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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 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 interview, it was determined that the facility failed to develop a comprehensive care plan for one of 14 residents reviewed (Resident R50). Residents Affected - Few Findings include: Review of facility policy entitled Care Plans, Comprehensive Person-Centered dated 7/14/23, stated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident R50's clinical record revealed an admission date of 9/25/23, with diagnoses that included a fracture of the left lower arm bone, fracture of a right arm bone, and Parkinson's Disease (a condition that affects the brain, causing problems with movement, balance, and coordination, with symptoms such as tremors, slowness, stiffness, difficulties speaking, and swallowing). Resident R50's clinical record revealed a physician's order dated 10/5/23, that identified Maintain ROM [Range of Motion - a term used to describe how far you can move a joint or muscle in various directions] brace locked at 90 degrees. No ROM to right elbow. Wrist and finger ROM in therapy Review of Resident R50's comprehensive care plan lacked reference to nursing staff not being permitted to perform ROM or the use of a ROM brace to the right elbow and the brace being locked at 90 degrees and in place at all times. During an interview on 11/15/23, at 2:15 p.m. Director of Nursing confirmed that the resident's care plan had not been developed to address Resident R50's ROM restrictions to the right elbow, wrist, and fingers and use of the ROM brace to the right elbow. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395510 If continuation sheet Page 6 of 17 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of clinical records, and staff interviews, it was determined that the facility failed to provide dining assistance for one of 14 residents reviewed (Resident R19). Residents Affected - Few Findings include: Review of Resident R19's clinical record revealed an admission date of 9/13/21, with diagnoses that included malnutrition, kyphosis (exaggerated, forward rounding of the upper back), need for assistance with personal care, muscle weakness, and palliative care. The clinical record revealed a physician's order date 9/30/23, to admit to Hospice due to severe protein calorie malnutrition. Review of a care plan entitled ADL Self Care Performance deficit dated 9/14/21, included an intervention for staff to assist Resident R19 with eating. Resident R19's most recent Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) dated 10/13/23, Section GG0130A was coded as requiring substantial/maximal assistance with eating. Observations on 11/12/23, at 1:30 p.m. and 11/13/23, at 12:51 p.m. revealed that Resident R19 was in bed with the head of the bed elevated and Resident R19 was slumped forward with the over-the-bed tray table containing his/her uneaten lunch meal at forehead level. During an interview on 11/13/23, at 1:16 p.m. Licensed Practical Nurse Employee E1 confirmed that someone should have been feeding the resident long before this. During an interview on 11/13/23, at 1:23 p.m. the Dietary Manager identified that the cart with the lunch trays left the kitchen approximately 12:15 p.m. 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395510 If continuation sheet Page 7 of 17 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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 review of facility documents, clinical records, and staff interviews, it was determined that the facility failed to maintain current information related to Hospice services for one of 14 residents reviewed (Resident R19). Residents Affected - Few Findings include: Review of a Hospice services agreement dated 9/13/19, and provided by the facility on 11/14/23, indicated that the facility and Hospice will coordinate the development of a plan of care, Hospice shall assume professional management responsibility for Hospice services including establishment of the plan of care, and Hospice shall provide the most recent plan of care to the facility. Resident R19's clinical record revealed an admission date of 9/13/21, with diagnoses that included malnutrition, kyphosis (exaggerated, forward rounding of the upper back), need for assistance with personal care, muscle weakness, and palliative care. The clinical record also revealed a physician's order dated 9/30/23, to admit to Hospice services for severe protein calorie malnutrition. Review of Resident R19's clinical record revealed a lack of evidence of a Hospice plan of care. During an interview on 11/14/23, at 4:04 p.m. the Nursing Home Administrator confirmed there was no Hospice plan of care provided to the facility. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395510 If continuation sheet Page 8 of 17 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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 facility policies and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of 14 residents reviewed (Resident R58). Residents Affected - Few Findings include: Review of a facility policy dated 7/14/23, entitled, Oxygen Administration (a process that extracts and purifies oxygen from the surrounding air for a resident to breathe) revealed preparation instructions that identified Verify that there is a physician's order for this procedure. Review of Resident R58's clinical record revealed an admission date of 11/8/23, with diagnoses that included Chronic Venous Hypertension (condition of weak veins in the legs that cannot return the blood from the legs back to the heart) with Bilateral Venous Leg Ulcers (slow-healing sores in both lower legs caused by pooling of oxygen-poor blood), and Diabetes (a condition where the body produces insufficient amounts of insulin, causing high blood sugar). Review of Resident R58's clinical record revealed a physician's order dated 11/8/23, that identified Oxygen via Nasal Canula (a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen) 2 lpm (liters per minute) continuous every shift. Observation on 11/13/23, at 10:26 a.m. revealed Resident R58 in bed with his/her supplemental oxygen in place and the oxygen concentrator liter flow was set at 4 lpm. During an interview on 11/13/23, at 11:45 a.m. Registered Nurse Employee E6 confirmed that Resident R58 was receiving oxygen continuously at 4 lpm and not in accordance with the physician's order dated 11/8/23, for oxygen at 2 lpm continuously. 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395510 If continuation sheet Page 9 of 17 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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 - Few 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 review of facility policy, observations, and staff interviews, it was determined that the facility failed to prevent the opportunity for unauthorized access of medications on two of two medication carts (Carts A and B) and failed to label multi-dose insulin (medication to treat elevated blood sugar levels) pens with the date they were opened in one of two medication carts (Cart B). Findings include: Review of a facility policy entitled Security of Medication Cart dated 7/14/23, indicated that staff must secure the medication cart during the medication pass to prevent unauthorized entry, medication carts must be always locked when out of the nurse's view, and when the medication cart is not being used it must be locked and parked at the nurse's station. Review of a facility policy entitled Administering Medications dated 7/14/23, indicated that when opening a multi-dose container, the date opened is recorded on the container. Observation on 11/12/23, at 10:18 a.m. revealed that Medication Cart A was situated outside the nurse's station and no nurses were within view of the cart, and the medication cart was unlocked with the drawers facing the hallway. During an interview on 11/12/23, at 10:20 a.m. Registered Nurse (RN) Employee E5 confirmed that the medication cart must be locked when not in use. Observation on 11/12/23, at 1:10 p.m. of medication storage on Medication Cart B revealed opened multi-dose insulin pens labeled for Residents R35, R4, R6, R47, and R27 that lacked a date to identify when they were opened. During an interview at that time Licensed Practical Nurse (LPN) Employee E3 confirmed that the multi-dose insulin pens listed were not labeled with an open date and therefore could not determine the disposal date. Observation on 11/12/23, at 3:32 p.m. of medication administration on Medication Cart A, revealed that LPN Employee E4 parked the medication cart outside of room [ROOM NUMBER] and proceeded to room [ROOM NUMBER] to administer medications and failed to lock the medication cart which was left out of view and unattended in the hallway with the drawers facing the hallway. During an interview at that time LPN Employee E4 stated that he/she is not concerned down this hall as there are no wandering residents and few visitors. Observation on 11/12/23, at 3:36 p.m. of medication administration on Medication Cart A, revealed that LPN Employee E4 parked the medication cart outside of room [ROOM NUMBER] and proceeded to room [ROOM NUMBER] to administer medications and failed to lock the medication cart which was left out of view and unattended in the hallway with the drawers facing the hallway. During an interview on 11/13/23, at 2:50 p.m. the Director of Nursing and Nursing Home (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395510 If continuation sheet Page 10 of 17 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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 Administrator confirmed that the medication carts must be locked unless they are in use, and that all multi-dose containers of medications must be dated when opened to determine the disposal date. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(1) Management Residents Affected - Few 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395510 If continuation sheet Page 11 of 17 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to store food and food containers in a safe and sanitary manner in one of one nourishment refrigerators. Residents Affected - Few Findings include: Review of a facility policy entitled Food Storage-Unit Pantries/Activity Kitchens dated 7/14/23, revealed that if food items are opened, they will be discarded within three days and that the resident/family member will be notified. Review of a facility policy entitled Food Received from Outside Sources-Other than Nursing Home dated 7/14/23, indicated that foods will be labeled with the resident's name and dated on the day it is brought to the facility and discarded after three days. Observation on 11/12/23, at 10:30 a.m. revealed the nourishment refrigerator at the nurse's station contained: a pepperoni pizza labeled 11/06/23; two containers with solid white substance dated 10/19/23; 1/3 coconut cream pie- not dated; 1/2 empty bottle of Pepsi, no name, no date; quart of buttermilk with a use by date of 11/09/23; half eaten salad dated 11/06/23; small container of possible noodle soup, not dated; one small container of soup and one small container of chili not dated; and one small container of sloppy joes dated 10/31/23. During an interview at that time, Registered Nurse Employee E5 confirmed that the above listed food items should have been dated when they were put in the refrigerator and discarded three days after, and that the night shift nursing staff is responsible for monitoring and discarding unlabeled and/or out of date food items. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395510 If continuation sheet Page 12 of 17 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on review of facility policy, clinical records, and Title 49. Professional and Vocational Standards, and staff interview, it was determined that the facility failed to assure that a Registered Nurse (RN) conducted and documented a comprehensive resident wound assessment for two of 14 residents reviewed (Residents R6 and R22). Findings include: Review of the Title 49. Professional and Vocational Standards, Department of State Chapter 21, State Board of Nursing, dated 1/15/05, revealed that under Responsibilities of the RN, 21.11, General Functions. (a) The registered nurse assesses human responses and plans, implements, and evaluates nursing care for individuals or families for whom the nurse is responsible, and (b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered. Review of the 21.141 Definitions, Practice of practical nursing revealed The performance of selected nursing acts in the care of the ill, injured or infirm under the direction of the licensed professional nurse, a licensed physician or a licensed dentist which do not require the specialized skill, judgement and knowledge required in professional nursing. Review of the 21.145 Functions of the LPN [Licensed Practical Nurse], (a) . The LPN participates in the planning, implementation and evaluation of nursing care using the focused assessment in settings where nursing takes place. Review of a facility policy entitled, General Wound Care Policy dated 7/14/23, indicated that skin and wounds are assessed by the Registered Nurse (RN) at the time of admission/discovery and if not possible within two hours. Review of Resident R6's clinical record revealed an admission date of 12/31/20, with diagnoses that included Type 2 Diabetes (condition that affects how the body uses glucose [sugar]), chronic obstructive pulmonary disease (a lung disease that causes airflow blockage and breathing-related problems), irregular heartbeat, and high blood pressure. Review of Resident R6's ongoing wound documentation revealed the discovery of an open area located on his/her right foot (outside)on 8/13/23. The weekly wound assessments were conducted by LPN Employee E8 and lacked evidence that the wounds were assessed by an RN. Review of Resident R22's clinical record revealed an admission date of 9/01/23, with diagnoses including sepsis (systemic bacterial infection), urinary tract infection, inflammation of the bladder, and fluid overload. Review of Resident R22's ongoing wound documentation revealed the discovery of open areas located in his/her left upper arm on 8/22/23, left lower leg (outside) on 9/25/23, and the right thigh on 11/07/23, and that weekly wound assessments were conducted by LPN Employee E8 and lacked evidence that the wounds were assessed by an RN. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395510 If continuation sheet Page 13 of 17 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/14/23, at 11:41 a.m. LPN Employee E8 confirmed that there was no evidence that Residents R6 and R22's wounds were assessed by an RN, and that he/she conducts the weekly wound assessments. During an interview on 11/14/23, at 3:44 p.m. the Director of Nursing and the Nursing Home Administrator confirmed that assessing wounds was out of the LPN scope of practice, and there was no evidence of RNs assessing wounds. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395510 If continuation sheet Page 14 of 17 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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 observations, review of facility policies, manufacturer's guidelines, Pennsylvania Department of Health PAHAN 694, and clinical records, and staff interviews, it was determined that the facility failed to properly clean and prevent the potential for cross contamination during the use of a blood glucose meter (BGM-a device to collect and measure the level of glucose [sugar] in the blood) for three of 12 residents observed during the administration of medications (Residents R58, R4, and R47), prevent the potential for cross contamination during a dressing change for two of 14 residents (Residents R6 and R22), and failed to ensure SARS-CoV-2 (COVID-19) infection control protocols were followed to help prevent the development and transmission of communicable diseases and infections on one of four nursing units (East Wing). Residents Affected - Some Findings include: Review of the Pennsylvania Department of Health PAHAN 694 dated 5/11/23, instructed facilities to ensure: -health care providers (HCP) who enter the room of a patient with suspected or confirmed COVID-19 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). -limit transport and movement of the patient outside of the room to medically essential purposes. -Source control (use of respirators, well-fitting facemasks, or well-fitting cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions is recommended by those with suspected or confirmed SARS-CoV-2 infection, those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 outbreak. Review of a facility policy entitled, COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care, dated 7/14/23, indicated that staff maintain room restrictions and full TBPs ([transmission based precautions] N95 or higher-level respirator, gowns, gloves, and eye protection) for care of residents who are positive for COVID-19 until there are no new cases identified, and if a resident with confirmed or suspected COVID-19 must leave their room, they should wear a facemask (if tolerated). Review of a facility policy entitled, Blood Sampling-Capillary (Finger Sticks) dated, 7/14/23, indicated to ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident use. Review of manufacturer's guidelines for cleaning and disinfecting procedures for the blood glucose meter indicated that the meter was to be cleansed with CaviWipes (intermediate-level disinfecting wipe) towelette or an EPA-registered (antimicrobial products effective against certain blood borne/body fluid pathogens) disinfecting wipe. Review of a facility policy entitled, Handwashing/Hand Hygiene dated 7/14/23, indicated to use an alcohol-based hand rub or soap and water after removing gloves, that the use of gloves does not replace handwashing/hand hygiene, and that the procedure for removing gloves included to perform hand hygiene after glove removal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395510 If continuation sheet Page 15 of 17 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of medication administration on 11/12/23, between 11:12 a.m. and 12:25 p.m. revealed Licensed Practical Nurse (LPN) Employee E3 performed a blood glucose monitoring using a BGM on Resident R27 and failed to cleanse the meter. Then obtained a blood glucose level with the same BGM from Resident R58, and failed to cleanse the meter, then obtained a blood glucose level with the same BGM from Resident R4, and failed to cleanse the meter, then obtained a blood glucose level with the same BGM from Resident R47. During an interview on 11/12/23, at 12:26 p.m. LPN Employee E3 confirmed that he/she usually cleans the BGM meter two-three times a day and uses alcohol pads. During an interview on 11/13/23, at 2:50 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the BGMs should be cleansed between each resident use. Review of Resident R6's clinical record revealed an admission date of 12/31/20, with diagnoses that included Type 2 diabetes (condition that affects how the body uses glucose [sugar], irregular heartbeat, and high blood pressure. A physician's order dated 11/08/23, revealed for staff to cleanse left outer foot, apply Medi-Honey (type of wound treatment) and Calcium Alginate with silver (type of wound treatment), and cover with bordered gauze. Observation on 11/14/23, at 9:54 a.m. of wound care for Resident R6 revealed that LPN Employee E8 cleansed the wound on Resident R6's left outer foot, changed gloves, and failed to perform hand hygiene, and continued to apply the new dressing. Review of Resident R22's clinical record revealed an admission date of 9/01/23, with diagnoses that included sepsis (systemic bacterial infection), urinary tract infection, inflammation of the bladder, and fluid overload. A physician's order dated 11/03/23, revealed to cleanse left calf leg wound, apply Xeroform and Alginate (wound treatments), ABD (abdominal pad), and wrap with kerlix (type of bandage). A physician's order dated 11/07/23, revealed to cleanse right thigh wound, apply Medi-Honey, 2x2's and bordered gauze. Observation on 11/14/23, at 11:05 a.m. of wound care for Resident R22 revealed that LPN Employee E8 removed the soiled dressing from Resident R22's right thigh, changed gloves, and failed to perform hand hygiene, then continued to cleanse and apply the new dressing. LPN Employee E8 removed the soiled dressing from Resident R22's left outer calf, changed gloves, and failed to perform hand hygiene, then continued to cleanse and apply the new dressing. During an interview at that time, LPN Employee E8 confirmed that he/she should have performed hand hygiene when he/she changed gloves. Review of Resident R37's clinical record revealed an admission date of 12/02/22, with diagnoses that included heart failure, COVID-19, respiratory failure, kidney failure, and history of falling, and physician's orders dated 11/12/23, for COVID isolation for 11 days (11/23/23), 11/12/23, to maintain COVID isolation precautions, and for supplemental oxygen at three liters per minute continuously. Observation on 11/14/23, at 10:43 a.m. revealed that Nurse Aide (NA) Employee E9 entered Resident R37's room (COVID precautions signage posted on the doorway) with his/her N95 mask down below the chin and failed to don (put on) a gown, eye protection and gloves. NA Employee E9 then used bare hands to switch Resident R37's oxygen tubing from the concentrator (machine that takes air from your surroundings, extracts oxygen and filters it into purified oxygen for one to breathe) to a portable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395510 If continuation sheet Page 16 of 17 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some oxygen tank on the back of the wheelchair. NA Employee E9 pushed Resident R37 out of his/her room two-thirds of the way down East Wing to the common bath area across from the centrally located nurse's station and failed to offer/apply a mask to Resident R37 for source control measures. During an interview at that time Registered Nurse Employee E2 confirmed that NA Employee E9 should have his/her N95 mask over the mouth and nose, should have donned a gown, gloves and eye protection before entering Resident R37's room, and should only remove Resident R37 from his/her room in case of emergency and offer/apply a mask to Resident R37. During an interview on 11/14/23, at 11:10 a.m. the Director of Nursing and Nursing Home Administrator confirmed that LPN Employee E8 should have performed hand hygiene when he/she changed gloves, and that NA Employee E9 should have his/her N95 mask over the mouth and nose, donned a gown, gloves and eye protection before entering Resident R37's room, and should only remove Resident R37 from his/her room in case of emergency and offer/apply a mask to Resident R37. 28 Pa. Code 201.18(1)(3) Management 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: 395510 If continuation sheet Page 17 of 17