Health inspection·June 13, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policy and procedures, observations and staff interview, it was determined that the facility failed to ensure residents' rights to secure and confidential personal and medical records on the ground floor of the facility and one of two nursing units (First Floor Nursing Unit North Wing). Residents Affected - Few Findings include: A review of the facility policy titled, Safeguarding and Storage of Health Information Records, last reviewed on August 21, 2024, revealed that the company will maintain reasonable administrative, technical, and physical safeguards to protect the privacy of protected health information (PHI) from use or disclosure that is a violation of federal and/or state regulations. The purpose of the policy was noted to limit unauthorized access of PHI. Further review of the facility policy revealed a section titled Procedure, that noted procedures such as the following: protect all health information records from damage, loss, destruction, or unauthorized use; limit viewing access by unauthorized personnel as well as visitors by returning records to their designated storage location or closing when not in use; limit access to all other methods of storage of health information, including medication administration record and treatment notebooks, close notebooks when not in use to limit unauthorized access; overflow or discharge records must be filed in a systemic manner, either alphabetically or numerically, in a location that ensures the privacy and security of the information; file in a secure area such as a lockable cabinet or room/office that is not shared with other staff; when discharge records are stored in alternate storage areas or with long term storage companies: limit access to only authorized personnel; ensure the security of the paper documents and protect them from elements such as moisture, water, rodents, and fire. Observation on the North Wing of the First Floor Nursing Unit on June 10, 2025, at 10:24 AM revealed a computer at the nurse's station that was logged into the resident electronic charting software. There were no staff working at the computer or present in the immediate area upon initial observation, leaving the electronic medical record logged into an unsecured area (the electronic health record is password protected and must be logged into and out of to help ensure confidentiality). Continued observation on June 10, 2025, at 10:33 AM revealed that the computer was still logged into the electronic charting software. There was no staff member observed working at the computer and multiple unidentified staff were observed walking by the open charting program. Continued observation on June 10, 2025, at 10:47 AM revealed that the computer was still logged into the electronic charting software and Employee 2, licensed practical nurse, proceeded to return to the nurse's station and sit down at the computer. Observation on North Wing of the First Floor Nursing Unit on June 11, 2025, at 10:25 AM revealed a computer at the nurse's station that was logged into the resident electronic charting software. There were no staff working at the computer or present in the immediate area upon initial observation and the residents' electronic medical record was accessible and unsecured. Employee 2's name was noted as the user logged into the charting software. Continued observation on June 11, 2025, at 10:30 AM revealed an unidentified staff member return to the nurse's station and upon surveyor questioning about the unsecured and accessible open charting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395512 If continuation sheet Page 2 of 11 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 395512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few software, the employee proceeded to summon Employee 2 who returned to the nurse's station and began working at the computer. Observation on June 12, 2025, at 10:32 AM revealed an overflowing box of papers with the lid ajar just off the main hallway that runs adjacent to the facility's main kitchen. The box was open, and the contents were unsecured and accessible to anyone passing by (upon observation, housekeeping staff were observed wheeling garbage cans by the area). Further observation revealed the box contained various medical records and clinical documentation with identifiers of residents. An interview with Employee 3, medical records, on June 12, 2025, at 10:39 AM revealed that the box contained medical records that are awaiting pick-up from a contracted off-site storage company. However, it was unclear when the storage company would be coming and could be as early as today or weeks from now. The facility failed to ensure residents' rights to secure and confidential personal and medical records. 28 Pa. Code: 201.18(e)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395512 If continuation sheet Page 3 of 11 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 395512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and staff interview, it was determined that the facility failed to provide a clean environment on one of two nursing units (Second Floor, Resident 108), and maintain facility equipment in the facility's main kitchen. Findings include: Observation on June 10, 2025, at 12:08 PM of Resident 108's room revealed a two-tiered cart beside the bed that housed a humidification machine on the top rack, a cardboard box, a stack of inverted plastic cups, and a jug of water on the bottom rack. The cart appeared soiled with dust and debris and had a dried white substance splashed on it. Observation of Resident 108's room on June 11, 2025, at 9:59 AM revealed the humidification machine was in use and the cart still appeared soiled with dust and debris and the dried white substance remained. Interview with the Nursing Home Administrator and Director of Nursing on June 12, 2025, at 2:28PM reviewed the above noted items regarding Resident 108. Observation in the facility's main kitchen on June 10, 2025, at 9:07 AM revealed multiple metal shelves inside several two-door storage coolers contained exposed rusted metal in areas where the protective coating was worn off the shelves. An observation of a large dining/activity room located on the second-floor nursing unit (South end) on June 12, 2025, at 11:47 AM revealed a set of lower cabinets by the sink area with several rolling pins, mixing bowls, and measuring cups stored in it. The cabinets appeared very worn, and the interior of the cabinet doors and interior base of the cabinets was significantly soiled with brown debris, dust, crumbs, and was sticky to touch. The above information regarding the cooler shelving and second floor dining/activity area was reviewed with the Nursing Home Administrator on June 12, 2025, at 2:00 PM. 483.10(i)(1)(2) Safe/clean/comfortable/homelike Environment Previously cited 7/10/24 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395512 If continuation sheet Page 4 of 11 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 395512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801 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 clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medication parameters for one of 24 residents reviewed (Resident 317). Residents Affected - Few Findings include: Clinical record review for Resident 317 revealed a diagnosis list that included atrial fibrillation (an irregular and sometimes rapid heart rhythm that can lead to complications such as stroke and heart failure) and essential hypertension (high blood pressure). Review of Resident 317's current care plan revealed the resident is at risk for cardiovascular symptoms or complications related to low blood pressure due to medications with parameters in place. A review of the current physician orders for Resident 317 revealed an order dated March 1, 2025, for Metoprolol Succinate ER Extended Release (a medication that is used to treat high blood pressure and/or heart rate) 25 milligrams (mg) give half a tablet by mouth one time a day for hypertension. Hold for a systolic blood pressure (SBP, the top number of a blood pressure reading where the heart contracts) less than 100 or pulse less than 60. A review of the Medication Administration Record (MAR) for June 2025, for Resident 317 revealed that the Metoprolol was marked as administered outside of the physician specified parameters for the following dates: June 1, the resident's pulse was documented as 56 June 2, the pulse was documented as 56 June 9, the pulse was documented as 56 June 10, the pulse was documented as 51 June 11, the pulse was documented as 51 There was no documentation for Resident 317 why the medication was administered outside of the specific physician ordered parameters. The above information for Resident 317 was reviewed in a meeting with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 11, 2025, at 1:45 PM. Further review of Resident 317's medical record revealed that staff documented on the MAR for June 12, 2025, that the Metoprolol was administered despite a corresponding blood pressure noted as 90/54. The above information for Resident 317 for the Metoprolol administration on June 12, 2025, was reviewed in a meeting with the NHA and DON on June 12, 2025, at 2:00 PM. 483.25 Quality of Care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395512 If continuation sheet Page 5 of 11 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 395512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801 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 Previously Cited 7/10/2024 Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395512 If continuation sheet Page 6 of 11 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 395512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801 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 clinical record review, observation, and staff and resident interview, it was determined that the facility failed to ensure the availability of necessary emergency supplies for one of one resident reviewed receiving hemodialysis (Resident 15). Residents Affected - Few Findings include: In an interview and observation of Resident 15 on June 10, 2025, at 11:42 AM the resident indicated he attended dialysis outside the facility three days a week and that his access site was in his arm. Concurrent observation of Resident 15's room did not reveal any emergency supplies used to control bleeding such as sterile gauze, hemostat (a tool used to control bleeding), needleless connector, or tape in the resident's room readily available should the resident start bleeding from his dialysis access site. With the resident's permission to look inside his closet there was also no evidence of any emergency supplies in Resident 15's closet. Clinical record review for Resident 15 revealed the resident was receiving hemodialysis (a machine that performs a basic function of the kidney by cleansing the blood of impurities) three days a week outside the facility and the resident had an AV (arteriovenous) fistula (a surgically created connection between and artery and a vein) for dialysis. In a follow up observation of Resident 15's room on June 11, 2025, at 9:35 AM, Employee 1, licensed practical nurse, checked Resident 15's closet, bedside drawers, and bag the resident transported back and forth to dialysis, and could not locate emergency supplies. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on June 11, 2025, at 12:37 PM. 483.25 (I) Dialysis Previously cited 7/10/24 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395512 If continuation sheet Page 7 of 11 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 395512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801 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 clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of three residents reviewed (Resident 18). Residents Affected - Few Findings include: Clinical record review for Resident 18 revealed that the facility admitted her on May 31, 2014. A diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) was added to her clinical record on October 1, 2022. A review of Resident 18's significant change Minimum Data Set (MDS, a form completed at specific intervals to determine care needs) assessment dated [DATE], indicated that the facility assessed Resident 18 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 18's current care plan entitled, Cognitive loss as evidenced by forgetfulness related to dementia last revised on February 20, 2020, and her care plan entitled At risk for behavior symptoms due to dementia initiated on April 17, 2025, failed to identify individualized person-centered approaches to address Resident 18's dementia and cognitive loss to include indications of distress and how she communicates unmet needs such as pain, discomfort, hunger, thirst and frustration. The findings were reviewed with the Nursing Home Administrator on June 13, 2025, at 10:30 AM. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395512 If continuation sheet Page 8 of 11 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 395512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (First Floor Nursing Unit North Wing; Resident 22). Residents Affected - Few Findings include: The facility's medication error rate was 7.14 percent based on 28 medication opportunities with two medication errors. Observation of Resident 22's medication administration pass on June 12, 2025, at 9:05 AM revealed that Employee 4, licensed practical nurse (LPN), prepared the medications prior to administration. Employee 4 went to Resident 22's room and placed one drop of Brimonidine Tartrate-Timolol Ophthalmic Solution 0.2-0.5% (a medication administered via eye drops to lower the pressure in the eyes known as intraocular pressure) into each of the resident's eyes. Review of Resident 22's clinical record revealed a physician's order dated March 6, 2025, that noted Brimonidine Tartrate-Timolol Ophthalmic Solution (0.2-0.5%) instill one drop in the right eye two times a day for glaucoma (an eye condition that can lead to vision loss or blindness and is often associated with increased pressure in the eye). A follow-up interview with Employee 4 on June 12, 2025, at 9:23 AM confirmed that the drops were administered in both eyes at the time of the medication pass and are only ordered for the right eye. Employee 4 administered one lactase enzyme supplement (an enzyme to help break down lactose in milk products to help treat lactose intolerance) to Resident 22. Resident 22 did not have any food present at the time of the administration. Review of Resident 22's clinical record revealed a physician's order dated March 25, 2025, that noted Lactaid Oral Tablet (Lactase) give one tablet by mouth every day with meals at 7:30 AM/11:30 AM/4:30 PM for lactose intolerance. A review of the instructions on the bottle of the medication revealed to swallow the capsules with the first bite of dairy food, and the medication can be used every day with every meal. Resident 22's Lactaid Oral Tablet (Lactase) was not given with a meal. An interview with Employee 5, registered nurse, on June 13, 2025, at 12:01 PM revealed that Resident 22's family sometimes brings in breakfast for her. An interview with Resident 22 on June 13, 2025, at 12:03 PM revealed that the resident's family did bring in breakfast for her on June 12, 2025, and reported the time as 7:20 AM. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on June 12, 2025, at 2:00 PM. 28 Pa. Code 211.9(a)(1) Pharmacy services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395512 If continuation sheet Page 9 of 11 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 395512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801 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 0759 28 Pa. Code 211.10(a)(c) Resident care policies Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395512 If continuation sheet Page 10 of 11 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 395512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801 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. Based on observation and staff interview, it was determined that the facility failed to properly store resident medications on one of two nursing units reviewed (First Floor Nursing Unit) and failed to ensure the security of a resident's prescription for a controlled substance one of one nursing units reviewed (Second Floor Nursing Unit, Resident 45). Findings include: Observation during the medication pass on the North Hall of the First Floor Nursing Unit on June 12, 2025, at 9: 15 AM revealed a medication cart being utilized by Employee 4, licensed practical nurse. Observation of the medication cart revealed the following: There were several unsecured and unidentified medication tablets found in the bottom of the drawers that included: a brown oblong tablet, a pink colored oblong tablet, and a white colored oblong tablet. A drawer of the medication cart had a container of individually wrapped supplemental vitamin chews that contained a pink colored oblong medication tablet and a yellow colored oblong medication tablet. A concurrent interview with Employee 4 revealed that it was unclear what the unsecured medications were. The above findings were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on June 12, 2025, at 2:00 PM. Review of Resident 45's clinical record on June 12, 2025, at 12:00 PM revealed two loose prescriptions for Oxycodone (an opioid medication used to treat severe pain) 5 milligrams as needed every four hours for moderate to severe pain. One of the prescriptions was dated June 2, 2025, and the other was dated June 5, 2025. The prescriptions were not defaced, and they were easily removable from the clinical record. Resident 45's clinical record was located behind the nurse's station with all the other resident records who reside on the nursing unit. The nurse's station had a slide over lock to a door that did not require a key or code to unlock and was easily accessible to all staff The above information regarding Resident 45's prescriptions was reviewed, and the prescriptions were given to the Nursing Home Administrator on June 12, 2025, at 12:15 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395512 If continuation sheet Page 11 of 11