Inspection·April 28, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some an Other Related Condition. The Office of Long-Term Living, Department of Human Services has reviewed your information about nursing facility placement and has determined that you are a person with an ORC. Additional ORC specialized services are available for individuals who reside in a nursing facility. These services may include training, service coordination/advocacy services, peer counseling/support groups, community integration activities, equipment/assessments, and transportation to help people function as independently as possible. Based on the review of your information, the Department's determination appears below: You need specialized services at this time. Review of Resident 45's current care plan reviewed during the survey ending April 28, 2023, revealed a Focus for triggered as Level II PASRR, related to Cerebral Palsy prior to age [AGE]. date initiated: August 24, 2018; with a Goal of resident will remain stable with interventions and specialized services. The care planned intervention was to administer medication as ordered. Consider alternate strategies if/when resident refuses services/support. Monitor mood and behaviors. The resident's care plan failed to identify the individual and specific referrals made or services recommended and provided to the resident as the result of the resident's other related condition (Cerebral Palsy), and PASARR II. For a resident with a Level II determination and recommendations, the facility failed to incorporate the recommended services into the resident's care plan (Specialized services provided or arranged by the State may be provided in the NF or through off-site visits arranged by the NF, while the resident lives in the facility). The resident's PASARR II care plan also had not been reviewed or revised since initiation on August 24, 2018. Resident 45's clinical record revealed no documented evidence at the time of the survey ending April 28, 2023, that Resident 45's Level II PASARR for other related condition (Cerebral Palsy) had been coordinated with the Office of Long-Term Living to ensure that the resident received the eligible services. The facility failed to demonstrate that they had arranged for the residents to receive specialized services through off-site visits, if appropriate, to meet Resident 2 and 45's needs as identified in the residents' PASARR Level II recommendations. An interview with the Nursing Home Administrator and Director of Nursing on April 28, 2023, at 2:00 p.m. confirmed that the PA-PASARR-ID II form completed had identified Resident 2 and 45 as a target and were unable to provide evidence of coordination of services including care planning. There was no evidence at the time of the survey that the facility had timely identified and coordinated the provision of specialized services for these targeted residents. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.16 (a) Social Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395554 If continuation sheet Page 2 of 13 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 395554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest City Nursing and Rehab Center 915 Delaware Street Forest City, PA 18421 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of 18 residents sampled (Resident 2). Residents Affected - Few Findings included: A review of Resident 2's clinical record revealed that the resident was seen by wound care consultant on February 20, 2023, for treatment of chronic nonhealing venous stasis type ulcerations of both lower legs. According to the consult progress note, a culture of the resident's wound and a culture of the bone and pathology of the bone specimen was removed. The physician ordered a course of Keflex (Cefalexin, an antibiotic) 500 mg every 8 hours for 10 days. At time of clinical record review on April 26, 2023, the facility did not have the results of the wound culture, bone culture or the bone pathology results from specimens obtained on February 20, 2023. present in the resident's clinical record. Interview with the Director of Nursing on April 26, 2023, at approximately 11:30 AM confirmed that the culture results were not available in the resident's clinical record. A review of Resident 2's Medication Administration record (MAR) for the months of February 2023 and March 2023, revealed that the resident received a total of 41 doses of the antibiotic Keflex for leg ulcer infection, from February 20, 2023, through March 5, 2023. Review of a wound care consultant progress note dated March 13, 2023, revealed that the wound culture obtained on February 20, 2023, returned with a the results of Proteus mirabilis (bacteria) and Methicillin sensitive staph aureus (bacteria). According to the consultant progress note a culture and sensitivity report was available. Instructions were provided for treatment to the chronic ulcers and to return on April 10, 2023. Review of the wound care consultant note dated April 10, 2023, revealed that a culture was obtained during the visit and the resident was prescribed Keflex (Cefalexin) 500 mg and follow-up with wound clinic in 2 weeks. The culture and sensitivity reports from the wound culture were not available in the resident's clinical record at the time of review on April 26, 2023. Review of the resident's April 2023 MAR revealed that Resident 2 received 30 doses of Keflex. Review of Wound Clinic Progress Notes dated April 24, 2023, revealed that a culture was obtained and the wound care consultant noted and will consider antibiotics targeted to pathogens isolated. A review of culture and sensitivity report dated April 26, 2023, revealed that the wound culture specimen had moderate bacterial growth of Proteus Mirabilis, a moderate bacterial growth of Pseudomonas Aeruginosa, and moderate bacterial growth of Enterococcus Faecalis. The sensitivity (report to indicate what antibiotic will treat the infection) report for Proteus Mirabilis, Pseudomonas Aeruginosa, and Enterococcus Faecalis did not include Keflex (Cefalexin) as a treatment option. There was no physician documentation to indicate the clinical necessity of initiating antibiotic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395554 If continuation sheet Page 3 of 13 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 395554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest City Nursing and Rehab Center 915 Delaware Street Forest City, PA 18421 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few treatment with Keflex to treat the residents' leg ulcer infections prior to receiving the results of the culture and sensitivity tests. Interview with the Director of Nursing on April 28, 2023, at 12:45 PM, confirmed that the administration of Keflex was not clinically justified for treatment of Resident 2's leg ulcer infections and that the facility failed to timely obtain culture and sensitivity results from wound clinic as part of their antibiotic stewardship and to demonstrate the resident's clinical need for antibiotic therapy. Refer F775 28 Pa. Code 211.2 (a) Physician services 28 Pa. Code 211.9 (k) Pharmacy Services 28 Pa. Code 211.5 (h) Clinical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395554 If continuation sheet Page 4 of 13 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 395554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest City Nursing and Rehab Center 915 Delaware Street Forest City, PA 18421 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record and staff interview, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary drugs by failing to clinically justify the use of an antihistamine medication for treatment of anxiety that is contraindicated in the elderly due to anticholinergic adverse side effects for one resident out of 18 sampled residents (Resident 5). Findings include: Review of Resident 5's clinical record revealed that she was [AGE] years old and initially admitted to the facility on [DATE], with diagnoses to have included dementia [is the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities], anxiety, and Parkinson's disease [a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement]. Resident 5's quarterly Minimum Data Set [(MDS) is a federally mandated standardized assessment process completed periodically to plan resident care), dated December 12, 2022, revealed that the resident was severely cognitively impaired. Review of a Psychiatric Evaluation and Consultation that was completed by the psychiatric nurse practitioner (NP) on January 16, 2023, revealed that Resident 5 was presenting with increased anxiety after the recent discontinuation of Alprazolam [(Xanax) an antianxiety agent used to treat anxiety and panic disorders] and noted that her behaviors were stable although the resident presented with falls. The CRNP's plan was to start Hydroxyzine [(Vistaril/Atarax) is in the drug class of antihistamine type and antianxiety agent that is used to treat itching caused by allergies and can be used for the short-term treatment of nervousness and tension that may occur with certain mental/mood disorders (such as anxiety); it is a sedating drug and may cause confusion and over sedation in the elderly] 10 mg twice per day for anxiety. Review of physician's order dated January 17, 2023, at 4:34 AM, revealed an order for Hydroxyzine HCL Tablet 10 mg, give 1 tablet by mouth two times a day for diagnosis of anxiety. Review of Resident 5's clinical record from January 2023, through the survey ending April 28, 2023, revealed that the resident continued to exhibit signs and symptoms of anxiety such as repetitive statements of wanting to go home with her granddaughter and increased agitation. Review of the resident's clinical record failed to reveal justification for the continued use of an anticholinergic medication Hydroxyzine HCL that was noted in the 2019 American Geriatrics Society Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults as highly anticholinergic and that clearance was reduced with advanced age and tolerance develops when used as hypnotic and risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity. Interview with the director of nursing (DON) on April 26, 2023, at 10:00 AM, confirmed the facility failed to ensure that Resident 5's medication regime was free from unnecessary medications, anticholinergic drug, for the management of anxiety in a resident with diagnosis of dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395554 If continuation sheet Page 5 of 13 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 395554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest City Nursing and Rehab Center 915 Delaware Street Forest City, PA 18421 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 0758 28 Pa. Code 211.9(a) (1)(k) Pharmacy Services Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.2(a) Physician services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395554 If continuation sheet Page 6 of 13 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 395554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest City Nursing and Rehab Center 915 Delaware Street Forest City, PA 18421 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 0775 Keep complete, dated laboratory records in the resident's record. Level of Harm - Minimal harm or potential for actual harm Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure that results of laboratory studies were present on the resident's clinical record for one resident out of 18 sampled (Resident 2) Residents Affected - Few Findings included: A review of Resident 2's clinical record revealed that the resident was seen wound care consultant on February 20, 2023, for treatment of chronic non-healing venous stasis type ulcerations of both lower legs. According to the consultant's progress note, a culture of the resident's wound and a culture of the bone and pathology of the bone specimen was removed. The physician ordered a course of Keflex (Cefalexin, an antibiotic) 500 mg every 8 hours for 10 days. At time of clinical record review on April 26, 2023, the results of the wound culture, bone culture and bone pathology results from specimens obtained on February 20, 2023, were not present on the resident's clinical record. Review of a wound care consultant progress note dated March 13, 2023, revealed that the wound culture obtained on February 20, 2023, returned with a the results of Proteus mirabilis (bacteria) and Methicillin sensitive staph aureus (bacteria). According to the consultant progress note a culture and sensitivity report was available. Review of the wound care consultant progress note dated April 10, 2023, revealed that a culture was obtained during the visit and the resident was placed on Keflex (Cefalexin) 500 mg and follow-up with wound clinic in 2 weeks. The results from the wound culture obtained on April 10, 2023, were not available in the resident's clinical record at the time of the survey ending April 28, 2023. Interview with the Director of Nursing on April 26, 2023, at approximately 11:30 AM confirmed that the culture results were not available in the resident's clinical record. Refer F 757 28 Pa. Code 211.5 (f) Clinical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395554 If continuation sheet Page 7 of 13 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 395554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest City Nursing and Rehab Center 915 Delaware Street Forest City, PA 18421 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, a review of select facility policy and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and two of three resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Review of a facility policy titled Dating of Food Policy indicated that that all foods are dated so the growths of food borne illnesses are prevented. All food must be dated upon opening and dietary staff were responsible for monitoring expiration dates of food when they conduct the weekly cleaning of the refrigerator area. If the item is not eaten on the 3rd day, the item will be thrown away. Any food items, such as Jell-O, pudding, or fruit, must be dated to include the month and day the food was placed in the container. The facility policy entitled Food from Outside revealed that perishable foods with a use by date, which is 3-days from the date that it was brought into the facility. The initial tour of the kitchen was conducted with the facility's Certified Dietary Manager (CDM) and Registered Dietitian (RD) on April 25, 2023, at 9:15 AM, that revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness: Upon entering the walk-in cooler, the center floor tiles were observed to be missing grout and were loose, lifting off the sub-flooring. Observation of the walk-in freezer revealed that there were open bags of chicken patties and sausage patties that did not have an open date listed on the packaging. Further observations of the walk-in freezer revealed that the dual freezer fan lacked a cover and the blades were exposed. The CDM stated that a few months ago, maintenance staff removed the fan cover due because it was bent. Observations of the walk-in produce cooler revealed a 5 lbs. container of open cottage cheese that was dated by the facility that it was opened on April 20, 2023, but the listed manufacturer's best if used by date noted on the container was March 31, 2023. Observation of the walk-in produce cooler revealed a 32-ounce container of chopped garlic in water that was dated by the facility that it was opened on January 10, 2023, but the listed manufacturer's best if used by date on the container was November 20, 2022. There was a quart of liquid eggs that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395554 If continuation sheet Page 8 of 13 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 395554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest City Nursing and Rehab Center 915 Delaware Street Forest City, PA 18421 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 was opened and not dated. Level of Harm - Minimal harm or potential for actual harm Observation of the dry storage area revealed an uncovered open case of lasagna noodles, that were not covered, or labeled or dated. Residents Affected - Many Cobwebs were observed inside of the cabinet containing the emergency food supply. On the lower shelf of a cook's preparation table, dishes were stored a clear storage bin. The lid of this bin was dirty and debris had accummulated on the lid. Splattered food particles were observed inside the microwave. Observation of the white ceiling fans that were over food preparation areas revealed that the fans were coated with dust. Observation of the dish room area revealed a metal shelf located over the 3-compartment sink that was dusty and debris had accumulated on the shelf. Large and small plastic food containers, identified as clean, were stored on the shelf and there were dirty rags on the shelf next to the clean containers. Observation of the 2nd unit lunch tray service on April 25, 2023, at 11:55 AM, revealed that the 4-ounce bowls of fruit cocktail that were being served as the dessert. When the items were delivered to the resident units they were not covered or in a closed delivery cart. Observations of the 2nd Unit Pantry Area on April 25, 2023, at 12:15 PM, revealed that there were 5 bowls of portioned cold dry cereal that were not labeled or dated. The ice scoop container lid was dirty and the water inside the container appeared to be discolored a greyish color. Observation of the inside of the refrigerator revealed a half of a peanut butter and jelly sandwich that was hard to the touch and not labeled or dated. Inside of the freezer there was an ice pack stored that was used for resident treatment. Observations of the 1st Unit Pantry Area on April 25, 2023, at 12:35 PM, revealed that there was a dirty resident tray from breakfast on the countertop. Inside of the refrigerator, there was an assorted cheese platter with a handwritten discard date of June 24, 2023. However, the use by date on the platter was earlier than the date written on the package. On top of the refrigerator there was a red stain with dust and debris coating the surface. Observation of lunch meal tray pass on April 26, 2023, at 11:45 AM, revealed that the 4-ounce bowls of mandarin oranges were being served as the dessert were not covered and opened to air during delivery. During a follow up visit to dietary department during lunch tray line services on April 27, 2023, at 11:20 AM, revealed that coconut cream cake was uncovered on the resident trays and remained uncovered during delivery to residents on the unit. Interview with the Nursing Home Administrator on April 26, 2023, at 2:00 PM, confirmed that the dietary department and unit pantry areas were to be maintained in a sanitary manner and that food/beverages should be stored and served in a sanitary manner. 28 Pa. Code 211.6 (f) Dietary services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395554 If continuation sheet Page 9 of 13 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 395554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest City Nursing and Rehab Center 915 Delaware Street Forest City, PA 18421 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 28 Pa. Code 207.2(a) Administrator's responsibility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395554 If continuation sheet Page 10 of 13 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 395554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest City Nursing and Rehab Center 915 Delaware Street Forest City, PA 18421 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the facility's infection control tracking logs and policy and staff interviews it was determined that the facility failed to maintain a comprehensive program to monitor the development and spread of infections within the facility and plan preventative measures accordingly, failed to store resident care equipment in a manner to deter the spread of infection and failed to appropriately dispose of PPE after use. Residents Affected - Many Findings include: A review of the current facility policy Infection Control Program Overview, dated as reviewed by the facility April 21, 2023, revealed that the purpose of the facility Infection Control Program is to provide a safe, sanitary and comfortable environment, to help prevent the development and transmission of communicable infections and to improve antibiotic use. The facility adheres to the mission and goals set forth in the infection control program. The infection prevention and control plan is a comprehensive process that addresses preventing, identifying, reporting, investigating and controlling infections and communicable diseases and monitoring judicious use of antibiotics to individuals. A review of the facility's infection control data revealed that the facility's infection control tracking did not reflect evidence of a functioning tracking system to monitor and investigate causes of infection and manner of spread. There was no documented evidence of a system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner. A review of the facility's infection control data revealed that the facility's tracking included the following information: July 2022: 4-respiratory infections August 2022: 1- urinary tract infection, 5- skin infections September 2022: 1- urinary tract infection October 2022: 4-urinary tract infections,4 -skin infections November 2022: 8-skin infections, 1-urinary tract infection and 1- respiratory infections. December 2022: 5-urinary tract infections and 2- respiratory infections. January 2023: 2- urinary tract infection February 2023: 2-urinary tract infections and 2- respiratory infections. March 2023: 8-skin infections, 5-urinary tract infections and 9- respiratory infections. The facility's infection control tracking log revealed no documented evidence of detailed data (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395554 If continuation sheet Page 11 of 13 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 395554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest City Nursing and Rehab Center 915 Delaware Street Forest City, PA 18421 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 collection that could be used by the facility to track these infections and to identify any potential trends contained in the tracking data. The data did not include resident room location or the infectious organism. There was no documented evidence at the time of the survey that based on the available tracking data that the facility had identified any possible trends in order to implement specific interventions to prevent the spread of any of the infections. Residents Affected - Many There was no documentation by the facility of the any of the infections resolution date, symptoms, complete culture information for any of the infections noted in the facility's monthly infection control tracking logs and the treatments required, if any. It could not be determined if any of the noted infections required the implementation of isolation protocols. There was no indication that the limited data that was compiled was then evaluated to determine what could be done to prevent the spread or recurrence of infection. During an interview conducted on April 28, 2023, at approximately 11 AM the facility's Infection Preventionist confirmed that the facility's infection control tracking was incomplete and failed to include the necessary details to conduct routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections (i.e., HAI and community-acquired), infection risks, communicable disease outbreaks, and to maintain or improve resident health status and to track staff for adherence to infection control policies and procedures and the potential need to for corrective action. An observation on April 25, 2023, at 10:00 a.m. in the shared resident bathroom in resident room [ROOM NUMBER] revealed an empty, uncovered urine collection container drying on the top of the toilet in the residents' bathroom. Clear liquid droplets were visible on the sides of the container. The urine container was not labeled with a resident's name. An additional observation on April 27, 2023, at 10:15 a.m. in the the shared resident bathroom of resident room [ROOM NUMBER] an empty, uncovered urine collection container was again drying on top of the toilet in the residents' bathroom. Liquid droplets were visible on the sides of the urine collection graduate and the container was not labeled with a resident's name. During an interview on April 27, 2023, at 11:10 a.m. with the Director of Nursing and the Infection Control Preventionist, the DON stated that the urine collection container should not be left drying on the back of the toilet A review of a CDC (Centers for Disease Control) document updated July 12, 2022 entitled Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to prevent spread of Multidrug resistant organisms revealed required PPE donning and doffing when in isolation include, gloves and gown, don before room entry, doff before room exit. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or providing care for another resident in the same room. Observation on April 27, 2023, at approximately 10:45 AM revealed clean PPE stored in over the door bags of the resident rooms identified as yellow isolation rooms on the first floor (Rooms 103-2, 108-2, 114-2, 115-2, 129-2). There was a large garbage can located in the hallway of this unit. During an interview on April 27, 2023 at 11 AM., Employee 1 (a nurse aide) stated that in the resident yellow isolation rooms, the PPE is stored in the outside of the room door in a hanging storage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395554 If continuation sheet Page 12 of 13 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 395554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest City Nursing and Rehab Center 915 Delaware Street Forest City, PA 18421 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 bag. Employee 1 stated that she dons clean PPE outside the room in the hallway, then enters the resident room, performs resident care, doffs the used PPE in the doorway within resident's room then steps out into the hallway and walks to the trash can in the hallway to dispose of the soiled PPE. Employee 1 stated that there were no trash cans located inside the resident rooms or immediately outside the yellow rooms to dispose of the used PPE. Residents Affected - Many Observation on April 27, 2023, at 11:15 AM revealed that staff doff the used PPE in the resident's room then leave the room and walk down the resident hallway, a designated neutral zone, carrying the used PPE and discard the soiled in the garbage can in the hallway. During an interview with the Infection Preventionist and the DON on April 27, 2023, at 11:30 AM, the DON confirmed that the used PPE should be discarded in the resident room prior to leaving the resident room. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(a)(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395554 If continuation sheet Page 13 of 13