Health inspection·September 4, 2025

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Seroquel. A nursing note for Resident 5, dated May 27, 2025, at 2:11 p.m. revealed that Certified Physician's Assistant (CRNP- registered nurse with advanced education and training who can diagnose, treat and prescribe medication) with psychiatric services was called and updated with the resident's increased agitation and a medication change was ordered to add 50 mg of Seroquel twice daily in addition to the 250 mg of Seroquel daily in the evening. Physician's orders for Resident 5, dated May 27, 2025, included an order for the resident to receive two 25 mg tablets of Seroquel to equal 50 mg twice daily related to dementia with agitation. There was no documented evidence in the resident's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Seroquel. Interview with the Director of Nursing on September 4, 2025, at 3:25 p.m., confirmed that a nursing note, dated May 15, 2025, at 1:30 p.m. and a nursing note, dated May 27, 2025, at 2:13 p.m. indicated that Resident 5's representative was notified of the dosage changes to Seroquel; however, there was no documented evidence in the resident's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased doses of Seroquel. Event ID: Facility ID: 395592 If continuation sheet Page 2 of 4 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 09/04/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based on a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for two of 5 residents reviewed (Residents 1 and 5). Findings Include: The facility policy related to the use of psychotropic medications, dated April 23, 2025, indicated that residents will only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Nonpharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 30, 2025, revealed that the resident was severely cognitively impaired, was sometime understood, could sometimes understand, received antipsychotic and antianxiety medications, and had diagnoses that included dementia and anxiety. A skilled nursing facility psychiatric visit, dated March 25, 2025, indicated that Resident 1 was seen for ongoing agitation, was up yelling, and was difficult to redirect at night. Nonpharmacological interventions were to be used for this resident. Physician's orders for Resident 1, dated May 19, 2025 and June 11, 2025, revealed that the resident was to receive 0.25 milligrams (mg) of Alprazolam (a psychotropic medication) every eight hours as needed for anxiety. Review of Resident 1's Medication Administration Record (MAR) for May and June 2025, revealed that the resident received 0.25 mg of Alprazolam on May 19 at 2:41 p.m., on May 20 a.m at 10:17 a.m., on May 21 at 2:50 a.m., on June 11 at 1:50 p.m, on June 17 at 12:20 a.m., and on June 19 at 11:30 p.m. A review of Resident 1's clinical record revealed no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed Alprazolam on the above-mentioned dated and times. Interview with the Director of Nursing on September 4, 2025, at 2:54 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted prior to administering as needed Alprazolam to Resident 1 on the above-mentioned dates/times. An admission MDS assessment for Resident 5, dated May 13, 2025, revealed that she was cognitively impaired, required assistance with care needs, received antipsychotic, antianxiety, and antidepressant medications (psychotropic medications) and had diagnoses that included dementia, depression, and anxiety. Physician's orders for Resident 5, dated May 9, 2025, revealed that the resident was to receive 0.5 milligrams (mg) of Lorazepam (a psychotropic medication) every eight hours, may use three times daily, as needed for anxiety. Physician's orders for Resident 5, dated May 24, 2025, included an order for the resident to receive 0.5 mg of Lorazepam three times daily as needed for anxiety. Physician's orders for Resident 5, dated May 27, 2025, June 8, 2025, and June 24, 2025, included orders for the resident to receive 0.5 mg of Lorazepam every eight hours as needed for anxiety. Physician's orders for Resident 5, dated July 10, 2025, July 24, 2025, July 30, 2025, revealed that the resident was to receive 0.5 mg of Lorazepam every eight hours, may use three times daily, as needed for anxiety. Physician's orders for Resident 5, dated August 8, 2025, and August 25, 2025, revealed that the resident was to receive 0.5 mg of Lorazepam every eight hours as needed for anxiety. Review of Resident 5's Medication Administration Record (MAR) for May, 2025 through August, 2025, revealed that the resident received 0.5 mg of Lorazepam on May 10 at 1:20 p.m.; May 14 at 11:20 p.m.; May 18 at 10:01 a.m.; May 23 at 5:58 p.m.; May 27 at 7:15 p.m.; May 28 at 8:15 a.m.; May 31 at 3:38 p.m.; June 2 at 8:33 a.m.; June 3 at 8:11 a.m.; June 6 at 3:56 p.m.; June 10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395592 If continuation sheet Page 3 of 4 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 09/04/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete at 3:43 p.m.; June 14 at 4:10 p.m.; July 10 at 5:48 p.m.; July 29 at 12:05 p.m.; August 14 at 2:15 p.m.; August 21 at 12:14 p.m.; and August 25 at 2:22 p.m. Review of Resident 5's clinical record, revealed no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed Lorazepam on the above-mentioned dated and times. Interview with the Director of Nursing on September 4, 2025, at 3:25 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted prior to administering as needed Lorazepam to Resident 5 on the above-mentioned dates/times. 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code: 211.9(a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(5) Nursing services. Event ID: Facility ID: 395592 If continuation sheet Page 4 of 4