Health inspection·November 25, 2024

F 0677 noting she requested a tub bath Tuesday mornings and shower on Friday mornings. Level of Harm - Minimal harm or potential for actual harm Review of Resident 7's task documentation for the last 30 days revealed Resident 7 did not receive any showers or tub baths. There were only six documented bed baths. Residents Affected - Few Interview with Resident 7 on November 25, 2024, at 12:04 PM revealed that Resident 7 wants showers but stated she is unable to walk. Resident 7 became emotional during the interview. The facility failed to provide assistance for residents requiring staff assistance for bathing. These findings were reviewed during a meeting with the Nursing Home Administrator and Director of Nursing on November 25, 2024, at 1:09 PM. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395589 If continuation sheet Page 2 of 7 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 395589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Carmel Senior Living Community 2616 Locust Gap Highway MT Carmel, PA 17851 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 a review of select facility policies and procedures, clinical record review, and staff and resident interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered blood sugar assessments and insulin administration for five of nine residents reviewed (Residents 1, 2, 3, 8, and 9). Residents Affected - Some Findings include: The facility policy entitled, Insulin Administration, last reviewed without changes on January 17, 2024, revealed that the purpose of the policy is to provide guidelines for the safe administration of insulin to residents with diabetes (high blood sugar). The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Characteristics and types of insulin note that the three key characteristics of insulin are the onset of action, peak effects, and the duration of effects. Rapid-acting insulin has an onset time of 10 to 15 minutes. The policy did not include instructions regarding the administration of insulin per professional standards of practice, such as the administration of fast-acting insulin with a meal. Interview with Employee 1 (licensed practical nurse, LPN) and Employee 7 (LPN) on November 25, 2024, at 7:33 AM revealed that no breakfast trays had been delivered to the Marble or Maple hallways on the nursing unit. The interview indicated that the Marble Hall meal schedule stipulated breakfast was at 7:15 AM; and the Maple Hall meal schedule stipulated breakfast was at 7:35 AM. Interview with Employee 1 on November 25, 2024, at 7:41 AM revealed that third shift (11:00 PM to 7:00 AM) staff obtained Resident 1's (who resided on the Maple Hall) blood sugar assessment and administered her insulin before leaving their shift. The interview indicated that staff documented the completion of care at 6:05 AM. The interview confirmed that Resident 1 received her insulin more than one hour ago without receiving her breakfast meal. The interview confirmed that physician orders for Resident 1 included the use of a sliding scale (physician orders for the administration of an amount of insulin based on the result of a blood glucose assessment) for insulin coverage based on a blood sugar assessment before meals. Interview with Employee 7 on November 25, 2024, at 7:33 AM revealed that third shift staff obtained blood glucose assessments for nine residents on the Marble Hall before the end of their shift. The nine residents identified included Residents 2, 3, 8, and 9. Employee 7 confirmed that if residents require insulin administration based on the blood glucose sliding scale, third shift staff administer the insulin. Interview with Resident 1 on November 25, 2024, at 11:52 AM revealed that staff typically assess her blood glucose at approximately 6:00 AM. Resident 1 stated that she may receive insulin at that time (based on the blood glucose result), and she eats her breakfast at approximately 7:30 AM. Resident 1 indicated that she may have low blood glucose results first thing in the morning for which staff will give her something sweet to eat, and staff will check the blood glucose again to determine if the number increases. Clinical record review for Resident 1 revealed a physician's order active since May 22, 2024, that instructed staff to obtain accuchecks (testing of a small amount of blood obtained through a prick (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395589 If continuation sheet Page 3 of 7 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 395589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Carmel Senior Living Community 2616 Locust Gap Highway MT Carmel, PA 17851 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 of a finger) before meals and HS (hour of sleep). Level of Harm - Minimal harm or potential for actual harm A physician's order active since May 22, 2024, instructed staff to inject six units of Insulin Aspart (Novolog FlexPen, fast acting insulin (artificially created hormone used to lower blood sugar) that begins to have an effect within 15 minutes of administration) for a blood glucose assessment of 201 to 250 before meals and at bedtime. Residents Affected - Some Review of Resident 1's MAR (Medication Administration Record, electronic documentation of the administration of medications) dated November 2024, revealed that Employee 2 (LPN) initialed completion of an accucheck assessment scheduled for 7:00 AM, before meals and at bedtime, for Resident 1. The staff documented Resident 1's blood glucose was 220. Resident 1's MAR indicated that Employee 3 (LPN) administered six units of Insulin Aspart to Resident 1. The medical reference, Drugs.com, noted that Insulin Aspart is a fast-acting insulin that starts to work about 15 minutes after injection. Instructions included in the reference list that whenever you use Insulin Aspart, be sure to eat a meal within five to 10 minutes. Review of nurse staffing schedules indicated that Employees 2 and 3 worked November 24, 2024, at 11:00 PM to November 25, 2024, at 7:00 AM. Resident 1 received her accucheck assessment and fast-acting insulin more than one hour before her breakfast meal. Clinical record review for Resident 2 revealed active physician orders for staff to inject Fiasp (Insulin Aspart) per a sliding scale before meals and at bedtime that indicated no medication for a blood glucose less than 201. Review of Resident 2's MAR dated November 2024 revealed that Employee 2 documented a glucose assessment (scheduled for 6:00 AM) as 99. Employee 4 (LPN) documented that no insulin was administered, no insulin required, for Resident 2's 7:00 AM scheduled dose of Fiasp. Drugs.com noted that Fiasp insulin should be given as, Inject the dose within five to 10 minutes before a meal. Observation of Resident 2 on November 25, 2024, at 7:53 AM, revealed he was in bed, without a breakfast tray, appearing to be asleep. Review of nurse staffing schedules indicated that Employee 4 worked November 24, 2024, at 11:00 PM to November 25, 2024, at 7:00 AM. Staff obtained Resident 2's blood glucose assessment more than 53 minutes before his breakfast meal delivery service. Observation and interview with Resident 3 on November 25, 2024, at 8:03 AM revealed that she had not received her breakfast meal. Resident 3 stated that staff obtained her blood glucose assessment before her shower that morning. Interview with Employee 5 (nurse aide) in Resident 3's room on November 25, 2024, at 8:04 AM indicated that she gave Resident 3 her shower at approximately 6:35 AM that morning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395589 If continuation sheet Page 4 of 7 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 395589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Carmel Senior Living Community 2616 Locust Gap Highway MT Carmel, PA 17851 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Clinical record review for Resident 3 revealed a physician's order dated July 16, 2024, that instructed staff to inject 15 units of Novolog Mix 70/30 Suspension in the morning. Drugs.com indicated that Novolog 70/30 suspension is a combination of a fast-acting insulin and an intermediate-acting insulin. This combination insulin starts to work within 10 to 20 minutes after injection, peaks in two hours, and keeps working for up to 24 hours. The resource instructed to use this medicine within 15 minutes before or after the start of a meal. A physician's order dated March 14, 2024, instructed staff to inject Fiasp insulin per a sliding scale before meals and at bedtime. The sliding scale instructed staff to administer two units of Fiasp insulin for a blood glucose of 151 to 200. Review of Resident 3's MAR dated November 2024, revealed that Employee 4 documented the administration of the Novolog Mix 70/30, scheduled for 6:30 AM, with a blood glucose assessment of 185. Employee 4 also documented the administration of two units of Resident 3's Fiasp insulin per her sliding scale. Resident 3 received her blood glucose assessment and fast-acting insulin approximately one and one-half hours before her breakfast meal. Observation and interview with Resident 8 on November 25, 2024, at 8:00 AM revealed that he had not received his breakfast meal. Resident 8 stated that staff obtained his blood glucose assessment approximately 5:25 AM and his reading was 95. Resident 8 stated that he did not receive insulin in response to his blood glucose assessment. Clinical record review for Resident 8 revealed a physician's order dated October 31, 2024, that instructed staff to obtain a blood glucose assessment before meals and at bedtime. Staff are instructed to inject Insulin Aspart per a sliding scale for blood glucose assessments of 151 or greater. Review of Resident 8's November 2024, MAR indicated that Employee 4 initialed that no insulin was required for a blood glucose assessment of 95. The assessment and insulin administration were scheduled for 7:00 AM. Staff obtained Resident 8's blood glucose assessment and determined no need for administration of fast-acting insulin, greater than one hour before his breakfast meal. Interview with Resident 9 on November 25, 2024, at 7:49 AM revealed that staff obtain her first accucheck assessment at approximately 5:00 AM daily and then another one at approximately 11:00 AM daily. Resident 9 stated that her accucheck that morning was low, .91, or something like that, and she did not receive insulin per her sliding scale. Clinical record review for Resident 9 revealed an active physician's order for staff to inject Fiasp insulin per a sliding scale before meals and at bedtime for accuchecks of 151 or greater. Review of Resident 9's MAR dated November 2024, revealed that Employee 4 documented that no insulin (scheduled for 7:00 AM) was required for an accucheck assessment of 81. Staff obtained Resident 9's blood glucose assessment and determined no need for administration of fast-acting insulin, greater than one hour before her breakfast meal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395589 If continuation sheet Page 5 of 7 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 395589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Carmel Senior Living Community 2616 Locust Gap Highway MT Carmel, PA 17851 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with the Director of Nursing on November 25, 2024, at 10:50 AM confirmed that third shift (11:00 PM to 7:00 AM) staff obtain accucheck assessments, but those staff are not to start obtaining those accucheck assessments earlier than 6:00 AM. The interview confirmed that the breakfast meal does not start until after 7:00 AM; therefore, the scheduling of accucheck assessments and meal delivery predispose residents to receive accucheck assessments and rapid-acting insulin more than one hour before receipt of the breakfast meal. The surveyor reviewed the concern that licensed staff were completing accuchecks and insulin administrations one or more hours before the breakfast meal (as evidenced above) during an interview with the Nursing Home Administrator and the Director of Nursing on November 25, 2024, at 1:15 PM. Interview with the Director of Nursing on November 25, 2024, at 12:48 PM ,November 26, 2024, at 7:23 AM, and November 26, 2024, at 12:55 PM, indicated that the facility had no policy or standard of practice that directed licensed staff how to implement physician orders that included a parameter for completion before a meal (e.g., provide the care within one-half hour of the meal). 483.25 Quality of Care Previously cited deficiency 8/23/24 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395589 If continuation sheet Page 6 of 7 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 395589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Carmel Senior Living Community 2616 Locust Gap Highway MT Carmel, PA 17851 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to promote the healing of pressure ulcers for one of one resident reviewed for pressure ulcer concerns (Resident CR1). Residents Affected - Few Findings include: The facility's current policy entitled Skin and Wound Management System, revealed it is the policy to identify and assess residents with wounds and/or pressure ulcers, as well as those at risk for skin compromise. Ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes. An assessment of skin integrity is to be performed on each resident upon admission by completing a head-to-toe physical evaluation of skin condition and a risk evaluation for predicting pressure will be used to determine risk status, such as the Braden or Norton Scale. Ongoing weekly evaluations of resident skin will be completed and documented in Point Click Care. Closed clinical record review for Resident CR1 revealed the facility admitted him on September 6, 2024. Review of Resident CR1's initial nursing evaluation dated September 6, 2024, revealed a Braden score of 12, indicating Resident CR1 was high risk for skin break down. Nursing staff assessed Resident CR1's skin noting redness to his left buttock and an open area measuring 2 centimeters (cm) by 2 cm. Review of Resident CR1's nursing documentation revealed the last weekly skin assessment was completed on September 30, 2024, noting nursing staff assessed Resident CR1's left gluteal fold as unstageable slough (dead tissue within a wound, often appearing as a yellow, tan, or white fibrous material) and/or eschar (hardened, dry, black or brown dead tissue that forms a scab-like covering over deep wounds) measuring 2 cm by 3.8 cm with a scant amount of serous (clear to yellow) drainage. Nursing staff assessed Resident CR1's sacrum as unstageable slough and/or eschar measuring 4.8 by 2.6 cm with a scant amount of serous drainage. Further review of Resident CR1's closed clinical record revealed no further assessments of Resident CR1's wounds. Nursing documentation dated October 2, 2024, at 9:26 AM revealed Resident CR1 complained of his wound bleeding, and nursing staff received new orders for Resident CR1's sacral and left gluteal fold sacral injury. Nursing documentation dated October 16, 2024, at 8:28 AM revealed that Resident CR1's pressure ulcers resolved (16 days after the last assessment of Resident CR1's wounds). Interview with Employee 6 (licensed practical nurse, wound nurse) on November 25, 2024, at 11:02 AM confirmed these findings. The Nursing Home Administrator and Director of Nursing were made aware of concerns with Resident CR1's pressure ulcer concerns on November 25, 2024, at 1:05 PM. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395589 If continuation sheet Page 7 of 7