Inspection·February 21, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on review of the Pennsylvania Code Title 49. Professional and Vocational Standards, facility job descriptions, clinical records, facility documents, and staff interviews, it was determined that the facility failed to follow nursing standards of practice to ensure medications are obtained from pharmacy in a timely manner for one of 12 residents reviewed (Resident R1). Residents Affected - Few Findings include: Review of Pennsylvania Code Title 49. Professional and Vocational Standards 21.145. Functions of the Licensed Practical Nurse (LPN), (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place and 21.11. General functions of the Registered Nurse (RN) (a)(4) stated, Carries out nursing care actions which promote, maintain and restore the well-being of individuals and (b) The RN is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and (d) The Board recognizes standards of practice and professional codes of behavior, as developed by appropriate nursing associations, as the criteria for assuring safe and effective practice. Review of facility job descriptions for LPNs and RNs revealed both are expected to utilize nursing knowledge and skills in the safe implementation of basic preventative therapeutic and rehabilitative nursing care of assigned resident as evidenced by documentation and observation of positive resident care outcomes, perform delegated nursing functions using established procedures, policies, guidelines and standards as observed by the registered nurse, and administer treatments, medications, and diets accurately. Review of Resident R1's clinical record revealed an admission date of 10/30/2024, with diagnoses that included dementia (a group of thinking and social issues that interfere with daily living), parkinsonism (a central nervous system disorder that affects movements), and anxiety. Resident R1's clinical record progress notes documented that on 11/04/2024, Resident R1 was tired and had a fever. He/she was tested for COVID, with positive results. At that time, the physician was contacted, and an order was received to give Paxlovid (300/100) (an antiviral medication used to treat mild to moderate COVID) oral tablet therapy give two tablets by mouth two times a day for COVID starting on 11/05/2024, for five days. Review of facility documents from pharmacy dated 11/1/2024, through 11/7/2024, revealed that the Paxlovid was never received from the pharmacy for Resident R1. Review of additional facility documents revealed six LPNs, and one RN failed to ensure the pharmacy was faxed the original order for the Paxlovid and failed to follow-up with the pharmacy once realizing the Paxlovid was ordered in the medication administration record for Resident R1 but was not available for several days. During an interview on 2/19/2025, at approximately 1:00 p.m. the Director of Nursing and the Regional Director of Clinical Operations confirmed that the Paxlovid ordered for Resident R1 was never received from the pharmacy, due to nursing staff's failure to fax the original order to the pharmacy and nursing staffs' failure to follow-up with the pharmacy regarding the status of the medication delivery. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395607 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 395607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippenville Nursing and Rehab 21158 Paint Boulevard Shippenville, PA 16254 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 0658 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395607 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 395607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippenville Nursing and Rehab 21158 Paint Boulevard Shippenville, PA 16254 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, facility documents, and staff interview, it was determined that the facility failed to follow physician's orders related to a medication order resulting in a delay in treatment for one of 12 residents reviewed (Resident R1). Residents Affected - Few Findings include: Review of Resident R1's clinical record revealed an admission date of 10/30/2024, with diagnoses that included dementia (a group of thinking and social issues that interfere with daily living), parkinsonism (a central nervous system disorder that affects movements), and anxiety. Resident R1's clinical record progress notes documented that on 11/04/2024, Resident R1 was tired and had a fever. He/she was tested for COVID, with positive results. At that time, the physician was contacted, and an order was received to give Paxlovid (300/100) (an antiviral medication used to treat mild to moderate COVID) oral tablet therapy give two tablets by mouth two times a day for COVID starting on 11/05/2024, for five days. Review of facility documents from pharmacy dated 11/1/2024, through 11/7/2024, revealed that the Paxlovid was never received from pharmacy for Resident R1, therefore not administered during that time. During an interview on 2/19/2025, at approximately 1:00 p.m. the Director of Nursing and the Regional Director of Clinical Operations confirmed that the Paxlovid was never delivered from the pharmacy, causing a delay in treatment for Resident R1. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395607 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 395607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippenville Nursing and Rehab 21158 Paint Boulevard Shippenville, PA 16254 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, clinical records, facility documents, and staff interviews, it was determined that the facility failed to maintain complete and accurate clinical records for one of 12 residents reviewed (Resident R1). Findings include: Review of facility policy entitled, Administering Medications dated 2/18/2025, revealed The individual administering the medication initials the resident's medication administration record (MAR) on the appropriate line after giving each medication and before administering the next ones. Review of the facility policy entitled, Change in a Resident's Condition or Status dated 2/18/2025, revealed The nurse will notify the resident's attending physician on call when there has been a need to transfer the resident to a hospital/treatment center . Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: it is necessary to transfer the resident to a hospital/treatment center .The nurse will record in the resident's medical record information relative to the changes in the resident's medical/mental condition or status. Review of the facility policy entitled Charting and Documentation dated 2/18/2025, revealed The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident . Review of Resident R1's clinical record revealed an admission date of 10/30/2024, with diagnoses that included dementia (a group of thinking and social issues that interfere with daily living), parkinsonism (a central nervous system disorder that affects movements), and anxiety. Resident R1's clinical record progress notes documented that on 11/04/2024, Resident R1 was tired and had a fever. He/she was tested for COVID, with positive results. At that time, the physician was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395607 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 395607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippenville Nursing and Rehab 21158 Paint Boulevard Shippenville, PA 16254 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 contacted, and an order was received to give Paxlovid (300/100) (an antiviral medication used to treat mild to moderate COVID) oral tablet therapy give two tablets by mouth two times a day for COVID starting on 11/05/2024, for five days. Resident R1's MAR revealed that Resident R1 received his/her Paxlovid on 11/6/2024, at 8:00 p.m., and on 11/8/2024, at 8:00 p.m. Review of facility documents from pharmacy dated 11/1/2024, through 11/7/2024, revealed that the Paxlovid was never received from pharmacy for Resident R1, therefore the documentation in the MAR was inaccurate. Resident R1's clinical record progress notes documented that on 11/08/2024, he/she was Out at ER [emergency room]. There was no documented evidence in Resident R1's clinical record regarding Resident R1's change in condition and/or assessment that resulted in him/her being transferred to the ER. Additionally, Resident R1's clinical record lacked evidence that the physician, resident representative, emergency transport, and receiving emergency department were contacted regarding Resident R1's change in condition. During an interview on 2/19/2025, at approximately 1:00 p.m. the Director of Nursing and the Regional Director of Clinical Operations confirmed that the Paxlovid was never received from the pharmacy, therefore the documentation on the MAR for Resident R1 was inaccurate and that clinical record lacked evidence that Resident R1's change in condition and/or assessment that resulted in him/her being transferred to the ER and that the physician, resident representative, emergency transport, and receiving emergency department were contacted regarding Resident R1's change in condition was documented in the clinical record. 28 Pa. Code 211.5(f)(xiii)(ix) Medical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395607 If continuation sheet Page 6 of 6