Inspection·January 15, 2025

F 0580 28 Pa. Code 201.14(a) Responsibility of Licensee. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 If continuation sheet Page 2 of 6 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 01/15/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of seven residents reviewed (Resident 2). Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 20, 2024, revealed that the resident was understood, could understand others, and had a Crohn's disease (a chronic inflammatory bowel disease that causes inflammation in the digestive tract), diabetes (a chronic disease that occurs when the body can not produce or use insulin properly, resulting in high blood sugar levels), and hemiplegia (a neurological condition that causes paralysis or weakness on one side of the body). The resident's clinical record revealed that Resident Family Member 2 (son) and Resident Family Member 3 (daughter-in-law) were the resident's emergency contacts and were interested family members. A nursing note for Resident 2, completed by Registered Nurse 1 and dated January 6, 2025, at 8:00 a.m., revealed that Resident Family Member 3 was at the nurses' station stating, I want her sent out. Upon assessment, the resident was awake, alert, and oriented to self. Resident 2 stated that she was in the emergency room. Her skin was warm and dry, her cheeks were ruddy. She was afebrile (no increased temperature), and her vital signs were stable. Physician 2 was made aware, and no new orders were received. There was no documented evidence in the clinical record to indicate that Resident 2 was sent to the hospital per Resident Family Member 3's (daughter-in-law) request. Interview with Physician 2 on January 14, 2025, at 1:42 p.m. revealed that when he received a text regarding Resident 2, he gave an order to send the resident out to the hospital at that time. He then received a text that said the resident was not going out to the hospital. He indicated that he was not aware of what changed as to why they did not send her out to the hospital at that time. Interview with the Regional Director of Clinical Services 5 on January 14, 2025, at 2:05 p.m. confirmed that the resident was not sent out to the hospital on January 6, 2025. Interview with Registered Nurse 1 on January 14, 2025, at 2:30 p.m. revealed that Resident Family Member 3 came to her and told her that she thought that the resident was having a stroke. She indicated that she went back to assess the resident and saw that the resident was not in any distress. She indicated that she did not see anything that would indicate a stroke. She indicated that before she was able to get the order in to send the resident out to the hospital the Director of Nursing came out and said that she was going to go back and assess the resident. When she came back, she said they are not sending the resident out. She indicated that she did not put the order in the electronic medical record because the Director of Nursing said that they were not sending her out, so why put the order in. She indicated that she contacted the resident's son that she had all the paperwork and that she was going to send his mother out to the hospital. Interview with the Director of Nursing on January 14, 2025, at 3:03 p.m. revealed that someone came to her office and indicated that Resident 2 was being sent out to the hospital. They said that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 If continuation sheet Page 3 of 6 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 01/15/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm family went to Registered Nurse 1 and told her that the resident was a little off. So, she went back to see the resident. She indicated that she sat on the bed and spoke with the resident, and the resident did not look to be in any distress. She then told Registered Nurse 1 to go and do her assessment and then to notify the physician and the resident's family. She indicated that she went back to her office and had very little involvement after that. Residents Affected - Few Interview with Licensed Practical Nurse 3 on January 14, 2025, at 3:15 p.m. revealed that he worked over from the night shift that night and he was waiting to do count with Registered Nurse 1 when someone came up to Registered Nurse 1 indicating that Resident 2 did seem like herself. Registered Nurse 1 asked me to go with her because she was relatively new to the facility and does not know all the residents. The resident thought she was in the emergency room. So, they returned to the nurses' station and Registered Nurse 4, who was the night shift supervisor, was still there, so she began helping Registered Nurse 1 with the transfer paperwork for the resident. He indicated that when he was leaving around 8:00 a.m. he was under the impression that they were sending the resident to the hospital. Interview with Registered Nurse 4 on January 14, 2025, at 3:28 p.m. revealed that she gave report to Registered Nurse 1 when she came in for the daylight shift. Then someone came up to Registered Nurse 1 and indicated that Resident 2 was incoherent and wanted her sent out to the hospital and that that person was going to call someone. Registered Nurse 1 then went back to assess the resident and when she came back, she was trying to get papers around to send her out to the hospital, so Registered Nurse 4 helped her. The Director of Nursing was there, and she went back to see the resident. When the Director of Nursing returned, she indicated that she thought the resident did not need to be sent out. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 If continuation sheet Page 4 of 6 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 01/15/2025 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 - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of facility policies and 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 seven residents reviewed (Resident 2). Findings Include: The facility's policy regarding charting and documentation, dated July 25, 2024, indicated that documentation in the medical record will be objective, complete, and accurate. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 20, 2024, revealed that the resident was understood, could understand others, and had Crohn's disease (a chronic inflammatory bowel disease that causes inflammation in the digestive tract), diabetes (a chronic disease that occurs when the body can not produce or use insulin properly, resulting in high blood sugar levels), and hemiplegia (a neurological condition that causes paralysis or weakness on one side of the body). The resident's clinical record revealed that Resident Family Member 2 (son) and Resident Family Member 3 (daughter-in-law) were the resident's emergency contacts and were interested family members. A nursing note for Resident 2, completed by Registered Nurse 1, dated January 6, 2025, at 8:00 a.m., revealed that Resident Family Member 3 was at the nurses' station stating, I want her sent out. Upon assessment, the resident was awake, alert, and oriented to self. She stated that she was in the emergency room. Her skin was warm and dry, cheeks ruddy. She was afebrile (no increased temperature), and her vital signs were stable. Physician 2 was made aware, and no new orders were received. A statement completed by Registered Nurse 1, dated January 9, 2025, revealed that on January 6, 2025, at approximately 8:00 a.m. she entered Resident 2's room due to Resident Family Member 3 stating she felt that the resident was having a stroke. The resident was lying in bed with no visible signs of distress. The resident was awake, alert, her smile was symmetrical, her tongue was mid-line, her hand grasps and pedal pulses equal and strong. Her vital signs were stable. She then spoke with Resident Family Member 2 when he called in, informed him of the assessment, and that if there was something they can treat there, they would do so. A statement completed by the Director of Nursing, dated January 9, 2025, revealed that approximately 8:30 a.m. on January 6, 2025, she was notified that the family was questioning if Resident 2 should be transferred to the hospital. She walked back to the resident's room to visualize her status. At that time, she was alert and oriented and talking and did not appear to be in any distress. The Director of Nursing conferred with Registered Nurse 1, who stated that she assessed the resident, and she also did not see that the resident was in any distress. Interview with Physician 2 on January 14, 2025, at 1:42 p.m. revealed that when he received a text regarding Resident 2, he gave an order to send the resident out to the hospital at that time. He then received a text that said the resident was not going out to the hospital. He indicated that he was not aware of what changed as to why they did not send her out to the hospital at that time. There was no documented evidence that the assessments of Resident 2 by Registered Nurse 1 and the Director of Nursing, or the physician's orders to send the resident to the hospital were in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 If continuation sheet Page 5 of 6 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 01/15/2025 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 resident's clinical record. Level of Harm - Minimal harm or potential for actual harm Interview with the Regional Director of Clinical Services 5 on January 14, 2025, at 2:05 p.m. revealed that they spoke with Registered Nurse 1 regarding the morning of January 6, 2025, as well as had her write a statement after a family member voiced a grievance. Registered Nurse 1's statement indicated that she was assessing for a stroke and she was asked why that part of the assessment was not documented in the medical record. Registered Nurse 1 told them that she forgot to go back into the electronic medical record to update her note. She also confirmed that the physician's order for Resident 2 to be sent out to the hospital was not in the resident's clinical record and that Registered Nurse 1's assessments from her statement were not in the clinical record. Residents Affected - Few Interview with Registered Nurse 1 on January 14, 2025, at 2:30 p.m. she indicated that she went back throughout her shift to re-evaluate the resident on January 6, 2025. She confirmed that she did not put the physician's orders for her to be transferred out to the hospital or her re-evaluation assessments throughout her shift in the electronic medical record for Resident 2, as well as go back in to update her note from January 6, 2025, with her assessment finding as stated in her statement from January 9, 2025. 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 6 of 6