Health inspection·November 7, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident, the responsible party, and long-term care ombudsman in writing regarding the reason for hospitalization for seven of 35 residents reviewed (Residents 1, 19, 22, 27, 29, 53, 64). Findings include: A nursing note for Resident 1, dated September 27, 2024, at 12:52 a.m. revealed that the resident was admitted to the hospital with congestive heart failure (a medical condition where the heart is unable to pump enough blood to meet the body's needs). There was no documented evidence that a written notice of Resident 1's transfer to the hospital was provided to the emergency contact or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 19, dated September 24, 2024, at 1:07 a.m., revealed that the resident was admitted to the hospital with urinary tract infection and possible pneumonia. There was no documented evidence that a written notice of Resident 19's transfer to the hospital was provided to the resident's emergency contact or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 22, dated September 27, 2024, at 1:21 a.m., revealed that the resident was admitted to the hospital with hypoosmolarity hyperglycemic state (high blood sugar). There was no documented evidence that a written notice of Resident 22's transfer to the hospital was provided to the resident's responsible party or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 27, dated September 22, 2024, at 5:54 p.m., revealed that the resident was lethargic and disoriented when talking, the physician was notified, and the resident was transferred to the hospital for evaluation. The resident was admitted to the hospital with pneumonia. There was no documented evidence that a written notice of Resident 27's transfer to the hospital was provided to the resident's responsible party or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 29, dated June 1, 2024 at 6:43 a.m., revealed that the resident was admitted to the hospital with sepsis. There was no documented evidence that a written notice of Resident 29's transfer to the hospital was provided to the resident's responsible party or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 53, dated June 3, 2024, at 8:33 p.m., revealed that the resident was admitted to the hospital with aspiration pneumonia (an infection of the lungs caused by inhaling saliva, food, liquid, and/or vomit). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some There was no documented evidence that a written notice of Resident 53's transfer to the hospital was provided to the resident's responsible party or long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 64, dated July 21, 2024, at 9:58 a.m., revealed that the resident was transferred to the emergency room for evaluation after a change in mental condition. There was no documented evidence that a written notice of Resident 64's transfer to the hospital was provided to the resident's responsible party or long-term care ombudsman regarding the reason for transfer. Interview with the Director of Nursing on November 6, 2024, at 9:23 a.m. confirmed that the facility did not provide a written notice to Residents 1, 19, 22, 27, 29, 53, 64; the resident's emergency contacts/responsible parties; or the long-term care ombudsman when the residents were transferred to the hospital. 28 Pa. Code 201.25 Discharge Policy. 28 Pa. Code 201.29(f)(g) Resident Rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident and/or the resident's representative at the time of a transfer for five of 35 residents reviewed (Residents 1, 22, 27, 29, 53). Findings include: A nursing note for Resident 1, dated September 27, 2024, at 12:52 a.m. revealed that the resident was admitted to the hospital with congestive heart failure (a medical condition where the heart is unable to pump enough blood to meet the body's needs). There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 1. A nursing note for Resident 22, dated September 27, 2024, at 1:21 a.m., revealed that the resident was admitted to the hospital with hypoosmolarity hyperglycemic state (high blood sugar). There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 22. A nursing note for Resident 27, dated September 22, 2024, at 5:54 p.m., revealed that the resident was lethargic and disoriented when talking, the physician was notified, and the resident was transferred to the hospital for evaluation. The resident was admitted to the hospital with pneumonia. There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 27. A nursing note for Resident 29, dated June 1, 2024, at 6:43 a.m., revealed that the resident was admitted to the hospital with sepsis. There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 29. A nursing note for Resident 53, dated June 3, 2024, at 8:33 p.m., revealed that the resident was admitted to the hospital with aspiration pneumonia (an infection of the lungs caused by inhaling saliva, food, liquid, and/or vomit). There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 53. Interview with the Director of Nursing on November 6, 2024, at 9:23 a.m. confirmed that the facility did not provide a bed-hold notice to Residents 1, 22, 27, 29, 53 or to the resident's responsible parties when the residents were transferred to the hospital. 28 Pa. Code 201.14(a) Responsibility of Licensee. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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 0625 28 Pa. Code 201.18(b)(3) Management. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument (RAI) User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set (MDS) assessments for three of 35 residents reviewed (Residents 3, 9, 29). Residents Affected - Few Findings include: The Resident Assessment Instrument User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section N0350 Insulin (medication used to lower blood sugar) was to be coded if the resident received insulin during the seven-day look-back period. Section N0350A was to be coded with the number of days the resident received insulin injections during the look-back period. Physician's orders for Resident 3, dated September 11, 2024, included an order for the resident to receive 1.8 milligrams (mg) of Victoza (non-insulin medication used to treat diabetes) subcutaneously (beneath the skin) one time a day. Review of the Medication Administration Record (MAR) for Resident 3, dated September 2024, revealed that the resident received Victoza every day during the look-back period. An admission MDS assessment for Resident 3, dated September 17, 2024, revealed that Section N0350A was coded, indicating that the resident received receive insulin. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on November 6, 2024, at 12:05 p.m. confirmed that Victoza was not an insulin and the MDS assessment for Resident 3 was coded incorrectly. The RAI User's Manual, dated October 2023, revealed that Section N0410F (1) (Antibiotic Medications) was to be coded if the resident received an antibiotic medication during the seven-day assessment period. Physician's orders for Resident 9, dated December 13, 2023, included an order for the resident to have 1 percent silver sulfadiazine (Silvadene-topical antibiotic) applied to his buttocks and scrotum every day and evening for redness. The resident's Treatment Administration Records (TAR's) for August 2024 revealed that the resident received Silvadene twice a day during the look-back period. A quarterly MDS assessment for Resident 9, dated August 19, 2024, revealed that Section N0410F(1) was coded (0), indicating that the resident did not receive any antibiotic medications during the seven days of the assessment period. Interview with the RNAC on November 6, 2024 at 12:05 p.m. confirmed that the MDS assessment for Resident 9 was coded incorrectly. The RAI User's Manual, dated October 2023, revealed that Section N0415J Hypoglycemic Medications (medications used to treat diabetes) was to be coded if the resident took the medication during the seven-day look-back period. Section N0415J Hypoglycemic (including insulin) Medication Review was to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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 0641 be coded (1) if the resident received the medication during the look-back period. Level of Harm - Minimal harm or potential for actual harm Physician's orders for Resident 29, dated June 4, 2024, included an order for the resident to receive 40 units Glargine insulin at bedtime and 7 units every morning, and an order, dated June 5, 2024, for the resident to receive insulin coverage before meals and at bedtime based on her blood sugar reading. Residents Affected - Few Review of the Medication Administration Record (MAR) for Resident 29, dated September 2024, revealed that she received insulin every day during the look-back period. An annual MDS assessment for Resident 29, dated September 11, 2024, revealed that Section N0415J was not coded, indicating that the resident did not receive a hypoglycemic medication. Interview with the RNAC on November 6, 2024 at 12:05 p.m. confirmed that the MDS assessment for Resident 29 was coded incorrectly. 28 Pa. Code 211.5(f) Clinical Records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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 Residents Affected - Few 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, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was created to reflect the resident's specific care needs for two of 35 residents reviewed (Residents 19, 82). A facility policy regarding care plans, dated August 27, 2024, revealed that care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives were derived from information contained in the resident's comprehensive assessment. A facility policy regarding tobacco-free policy, dated October 29, 2024, revealed that the facility was tobacco free, and the facility prohibits the possession and/or storage of all smoking/smokeless tobacco materials. However, any resident admitted to the facility prior to the effective date of this policy would be Grandfathered into the prior policy and procedure. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated October 2, 2024, revealed that the resident was cognitively intact, was clearly understood and able to understand others, required assistance with care needs, and had a diagnosis of quadriplegia (condition that causes a complete or severe loss of motor function in all four limbs). Observations and interview of Resident 19 on November 7, 2024, at 9:04 a.m., revealed that the resident was lying in bed using a tablet. On this over-bed table was a can of smokeless tobacco pouches and a Styrofoam cup with a tissue and brown substance inside. The resident confirmed that he used smokeless tobacco. Interview with the Director of Nursing on November 7, 2024, at 12:02 p.m. confirmed that Resident 19 did not have a care plan developed to reflect the resident's use of smokeless tobacco, and should have. Physician's orders for Resident 82, dated November 3 and 5, 2024, included orders for the resident to receive 1 gram of meropenem (antibiotic) intravenously (IV - directly into a vein) every 12 hours until November 11, 2024. Physician's orders, dated November 1, 2024, included an order for the IV catheter be flushed with a minimum of 10 cubic centimeters (cc's) of 0.9 percent sodium chloride (sterile salt water solution) every shift and before and after medication administration, and to measure the circumference in centimeters (cm) of the upper arm at the peripherally inserted central catheter (PICC line - a type of catheter that is inserted through a peripheral vein and used long-term to administer medications and/or fluids) insertion site every shift and as needed. Resident 82's Medication Administration Record (MAR) for November 2024 revealed that the resident received IV meropenem on November 3 through 7, 2024; had her PICC line flushed with normal saline solution every shift and before and after each administration; and had the circumference of her upper arm measured every shift. There was no documented evidence that a care plan was developed to address Resident 82's PICC line and need for IV antibiotics. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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 Interview with the Director of Nursing on November 7, 2024, at 9:52 a.m. confirmed that there was no documented evidence that a care plan was developed for the care of Resident 82's PICC line and the need for antibiotics. 28 Pa. Code 201.24(e)(4) admission Policy. Residents Affected - Few 28 Pa. Code 211.12(d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer treatments were provided to prevent infection for one of 35 residents reviewed (Resident 19). Residents Affected - Few Findings include: A facility policy regarding pressure ulcer/skin breakdown clinical protocol policy, dated August 27, 2024, revealed that the physician would authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings, and applications of topical agents, if indicated for type of skin alteration. A facility policy regarding handwashing/hand hygiene policy, dated August 27, 2024, revealed that staff were to use alcohol-based hand rub containing at least 62 percent alcohol or, alternatively, soap and water after handling clean or soiled dressings and gauze pads. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated October 2, 2024, revealed that the resident was cognitively intact, was clearly understood and able to understand others, required assistance with care needs, had a diagnosis of quadriplegia (condition that causes a complete or severe loss of motor function in all four limbs), and had one facility-acquired Stage III pressure ulcer (full-thickness tissue loss that extends into deeper tissue and fat). A pressure ulcer investigation for Resident 19, dated August 21, 2024, revealed that there was an open area on the left inner heel. Resident 19 indicated that his heels were rubbing against the back of his foot rest on the wheelchair. Physician's orders for Resident 19, dated October 18, 2024, included an order to cleanse the left heel with wound cleanser, then apply 500 unit/gram bacitracin antibiotic to the base of the wound, apply collagen to base of wound, secure with border dressing (an absorptive dressing bordered with adhesive) twice a day and as needed. Observations of wound care on November 7, 2024, at 9:48 a.m. revealed that Licensed Practical Nurse 2 used hand sanitizer, put on gown and gloves, removed the old dressing, sprayed wound cleanser on a gauze, and cleansed the wound. The gloves were visibly wet from the wound cleanser. After removing the soiled dressing and cleaning the wound, Licensed Practical Nurse 2 did not change gloves or perform hand hygiene. Using the same gloves Licensed Practical Nurse 2 applied the bacitracin and the collagen to the base of the wound, applied the boarded gauze, and wrapped the heel with Kerlix. Interview with Licensed Practical Nurse 2 on November 7, 2024, at 10:00 a.m. confirmed that she was to perform hand hygiene between dirty and clean tasks during wound care. Interview with the Infection Preventionist on November 7, 2024, at 10:09 a.m. confirmed that she would expect staff to change gloves and perform hand hygiene between dirty and clean tasks. 28 Pa. Code 211.12(d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician-ordered contracture management interventions were provided as care planned for one of 35 residents reviewed (Resident 65). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated August 2, 2024, revealed that the resident was cognitively impaired, required extensive assist assistance from staff for personal hygiene, and had diagnosis that included hemiplegia/hemiparalysis (a medical condition that causes weakness or paralysis on one side of the body). Resident 65's care plan, dated March 5, 2024, indicated that the resident was to always have a rolled towel in her left hand, except during a.m. and p.m. care, and it was to be checked for placement and integrity. Physician's orders for Resident 65, dated June 5, 2024, revealed the resident was to always have a rolled towel in her left hand, and it was to be checked every shift for placement and integrity. Observations on November 4, 2024, at 9:32 a.m. and at 10:51 a.m. revealed that the resident did not have a rolled towel in her left hand as ordered. Interview with Nurse Aide 3 on November 4, 2024, at 10:57 a.m. revealed that the resident did not have a rolled towel in her left hand as ordered, and she should have. Interview with the Director of Nursing on November 5, 2024, at 10:00 a.m. confirmed that Resident 65 is to always have a rolled towel in her left hand, except during morning and evening care. 28 Pa. Code 211.12(d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to complete safety assessments for one of 35 residents reviewed (Resident 47) who used an air mattress. Findings include: A facility policy regarding support surface guidelines, dated August 27, 2024, indicated that the facility would follow the guidelines for the assessment of appropriate pressure-reducing and relieving devices for residents at risk for skin break down. Support surfaces were critical to pressure ulcer prevention and general safety include pressured redistribution, moisture control, shear reduction, and life expectancy. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 47, dated June 29, 2024, revealed that the resident was usually understood, could usually understand others, was cognitively impaired, required assistance from staff for care needs, had a Stage 3 pressure ulcer (full thickness skin loss into the lower layers of skin) on admission, and received hospice services. Observations on November 7, 2024, at 9:33 a.m. revealed that Resident 47 was lying in bed and the bed was equipped with an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on Resident 47's bed. Interview with the Director of Nursing on November 7, 2024, at 12:02 p.m. confirmed that there were no assessments for potential safety hazards prior to the air mattress being placed on the resident's bed and there should have been. Hospice staff placed the mattress and did not inform the facility. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that long-term intravenous catheters were flushed and arm circumference was measured as ordered for one of 35 residents reviewed (Resident 82). Residents Affected - Few Findings include: The facility's policy regarding flushing central and midline catheters (a tube placed in a vein that can be used to deliver fluids and/or medications), dated August 27, 2024, revealed that when a resident was ordered intravenous medication, a 10 milliliter (ml) saline flush (a method used to clean a catheter of blood or medication) was to be administered before each medication was infused. Physician's orders for Resident 82, dated November 1, 2024, included an order for the peripherally-inserted central catheter (PICC line - a type of catheter that is inserted through a peripheral vein and used long-term to administer medications and/or fluids) be flushed with a minimum of 10 cubic centimeters (cc's) of 0.9 percent sodium chloride (sterile salt water solution) every shift, before and after medication administration, and to measure the circumference in centimeters (cm) of the upper arm at the PICC insertion site every shift and as needed. Physician's orders for Resident 82, dated November 3 and 5, 2024, included orders for the resident to receive 1 gram of meropenem (antibiotic) intravenously (IV - directly into a vein) every 12 hours until November 11, 2024. Resident 82's Medication Administration Record (MAR) for November 2024 revealed that the resident received IV meropenem on November 3 through 7, 2024; however, there was no documented evidence that staff flushed the resident's PICC line with normal saline solution every shift, before and after each medication administration, or that they measured the circumference of the resident's upper arm on November 2, 3, and 7, 2024. Interview with the Director of Nursing on November 7, 2024, at 9:52 a.m. confirmed that there was no documented evidence that Resident 82's PICC line was flushed every shift, before and after each medication administration, or that the resident's upper arm was measured on November 2, 3 and 7, 2024. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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 0711 Level of Harm - Minimal harm or potential for actual harm Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the physician wrote a progress note for each visit for one of 35 residents reviewed (Resident 15). Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated August 16, 2024, indicated that the resident was cognitively intact and required maximum assistance from staff for care. A nurse's note for Resident 15, dated March 5, 2024, at 3:30 p.m., revealed that the resident was seen by the physician regarding her increased behaviors in the evening and increased meanness towards her family and spoke with the physician at length; however, there was no documented evidence of a provider's progress note in the clinical record. A nurse's note for Resident 15, dated March 14, 2024, at 2:09 p.m., revealed that the resident was examined by the physician at bedside; however, there was no documented evidence of a provider's progress note in the clinical record. A nurse's note for Resident 15, dated August 15, 2024, at 7:05 p.m., indicated that the resident's daughter was concerned about her mother and wanted her seen by the doctor. A physician's list of rounds, dated August 20, 2024, revealed that Resident 15 was seen by the doctor on August 15, 2024; however, there was no documented evidence of a provider's progress note in the clinical record. Interview with the Director of Nursing on November 7, 2024, at 1:52 p.m. confirmed that there were no physician's notes in the clinical record for Resident 15 on the dates listed. She also stated that the physician is very behind in his notes and they have to call the office if they need them. 28 Pa. Code 211.5(f) Clinical Records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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 review of facility policies, clinical records, and pharmacy labels for medications, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled and dated for one of 35 residents reviewed (Resident 19). Findings include: A facility policy regarding medication ordering and receiving from pharmacy policy, dated August 27, 2024, revealed that improper and inaccurate labeled medications were rejected and returned to the dispensing pharmacy. Medication labels were not to be altered, modified, or marked in any way by nursing personnel. If the physician's directions for use change or the label was inaccurate, the nurse may place a change or order - check chart label on the container indicating there is a change in directions for use, taking care not to cover important label information. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated October 2, 2024, revealed that the resident was cognitively intact, was clearly understood and able to understand others, required assistance with care needs, had a diagnosis of quadriplegia (condition that causes a complete or severe loss of motor function in all four limbs), and was taking opioid medication (narcotic medication). Physician's orders for Resident 19, dated September 26, 2024 included an order for the resident to receive 5-325 milligrams of hydrocodone-acetaminophen (narcotic pain medication) at bedtime for pain and every six hours as needed for moderate pain (4-6 out of 10). Observations of the B wing medication cart on November 6, 2024, at 2:15 p.m. revealed that the hydrocodone-acetaminophen medication card for Resident 19 had instruction to give one tablet every six hours as needed for pain with + HS written on the label in pen. There was no sticker on the medication label to indicate a change in order. Interview with Licensed Practical Nurse 4 at the time of the observation revealed that she was unsure why the label was written on with pen, as staff were not to alter the label unless there is a sticker added when the order changes. Interview with the Nursing Home Administrator on November 6, 2024, at 2:53 p.m. confirmed that the medication label that came from pharmacy for Resident 19's hydrocodone-acetaminophen should not have been altered. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for two of 35 residents reviewed (Residents 24, 45). Findings include: Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 28 residents reviewed (Resident 24). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated July 5, 2024, indicated that the resident was cognitively impaired, was dependent on staff assistance for daily care needs, had a diagnosis of depression. Physician's orders for Resident 24, dated October 22, 2024, included orders for the resident to receive 0.5 mg of 2mg/ml Lorazepam (a medication to treat anxiety) every four hours as needed. Review of Resident 24's Medication Administration Record (MAR) for October 2024 revealed that the resident received 0.5 mg of lorazepam on October 25, 2024, at 1:56 a.m. and 4:29 a.m. Review of Resident 24's controlled drug accountability sheet for a 30.0 ml bottle of lorazepam (2mg/ml) revealed that the total amount remaining on October 25, 2024, at 4:29 a.m. was documented as 25.0 ml; however, observations of the bottle on November 6, 2024, at 1:42 p.m. revealed that there was 29.0 ml remaining in the bottle. Interview with Director of Nursing on November 7, 2024, at 8:43 a.m. confirmed that the amount remaining in the bottle was documented incorrectly. A quarterly MDS assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 45, dated October 11, 2024, revealed that the resident was cognitively intact. Resident 45's [NAME], undated, revealed that he preferred a shower. Resident 45's shower log, dated September and October 2024, revealed that there were 18 opportunities for a shower; however, only one shower was documented. An interview with Resident 45 on November 4, 2024, at 11:08 a.m. revealed that he receives his showers twice per week. Interview with the Director of Nursing on November 6, 2024, at 10:21 a.m. revealed that Resident 45's shower record was not in their charting system correctly; therefore, the staff could not accurately chart the resident's showers. 28 Pa. Code 211.5(f) Clinical Records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plan of correction for a State Survey and Certification (Department of Health) survey ending December 7, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending November 7, 2024, identified repeated deficiencies related to a failure to ensure that Minimum Data Sets (MDS, a mandated assessment of a resident's abilities and care needs) assessments were accurate upon submission, develop individualized care plans, and properly store and label medications. The facility's plan of correction for a deficiency regarding a failure to ensure that MDS's were accurate upon submission, cited during the survey ending December 7, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to accurate MDS assessments. The facility's plan of correction for a deficiency regarding the development of a comprehensive person-centered care plan, cited during a survey ending December 7, 2023, revealed that audits would be completed. The results of the current survey, cited under F656, revealed that the QAPI committee was ineffective in correcting deficient practices related to the development of a comprehensive person-centered care plan. The facility's plan of correction for a deficiency regarding storing/labeling medications properly, cited during the survey ending December 7, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to storing/labeling medications properly. Refer to F641, F656, F761. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 If continuation sheet Page 17 of 17