Health inspection·August 8, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In a follow up interview with the Nursing Home Administrator and Employee 1, director of environmental services, on August 8, 2024, at 3:05 PM it was determined the floor guy, had retired in November 2023, and not just a few months ago, and the facility had hired someone, but they have only been able to work part-time. Employee 1 indicated in the interview that housekeeping staff complete basic cleaning of resident rooms daily to include sweeping, mopping, emptying the trash, and restocking supplies, and deep clean (pull out and clean under and behind furniture) once a month. Review of a deep room cleaning schedule Employee 1 stated was recently started indicated only 10 rooms had received a deep clean since June 28, 2024, and only six resident rooms had been stripped and waxed (complete removal of all items in the room) since February 2024, none of which belonged to the resident's noted above nor the nursing unit hallways. Employee 1 was not able to provide any additional evidence all resident rooms were deep cleaned monthly. The facility census was 136 on August 8, 2024. 483.10(i)(1)(2) Safe, clean, homelike environment Previously cited 11/3/23, and 6/10/24 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395616 If continuation sheet Page 2 of 5 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 395616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of pest control logs, and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program on two of four nursing units (Unit Two, Unit Three, Residents 3, 6, 1, and 2). Residents Affected - Some Findings include: A review of facility resident council minutes from a July 17, 2024, meeting it was noted Resident 3 stated there was a mouse in the heater of her room making messes. In an interview with Resident 3 on August 8, 2024, at 11:00 AM the resident stated she had not heard a mouse lately. In a concurrent interview with Resident 6, Resident 3's roommate who resides in the bed next to the window and heating/air conditioner unit, Resident 6 stated she has recently had mice in her room and pointed under her recliner and towards the head of the bed. Some food crumbs and paper wrappers were observed under the recliner base and towards the head of bed. Observation of the heating/air conditioner unit through the top vent revealed broken pieces of cereal and other food and debris inside the unit. Resident's 3 and 6 reside on Unit 2 of the facility. Resident 6 was admitted to the facility in April of 2024, and indicated housekeeping does come to her room to clean but could not recall any furniture being removed from her room or moved within her room to be cleaned under. The flooring in the room was blackened, and dull with a dirty appearance. Resident 6 did not recall staff ever deep cleaning or waxing her floor. In an interview with Resident's 1 and 2 who reside together on August 8, 2024, at 11:31 AM, Resident's 1 and 2 stated they have had mice in their room, and Resident 1 had even watched one come out from under the dresser and he threw a brief he had in the room over it and killed it with his cane. Resident 1 did not recall the exact date of the incident, but stated there are mice problems all over the facility. Resident's 1 and 2 stated they try to keep all their snacks in plastic containers. Resident 1 and 2 stated they continually hear staff and other residents talking about seeing mice in their rooms recently. Resident's 1 and 2 were observed to have a large amount of personal property stacked throughout their room, and the flooring appeared blackened, and dull, although they stated housekeeping did mop it. Resident's 1 and 2 did not recall any furniture being moved inside the room or taken out of the room for several months to deep clean under furniture or other belongings. In an interview with Resident 5 on August 8, 2024, at 12:09 PM who was admitted to the facility on [DATE], stated she has watched a mouse come out from under the bathroom door move around the room and go back into the bathroom (which is adjoined to another resident room) one day and then saw a mouse come out from under the bathroom door and go over to the heater/air conditioner unit under the window and never saw it come back out on another day. Resident 5 indicated one was seen just last week. An observation of the heating/air conditioning unit in Resident 5's room revealed dried food, and debris inside the unit visible through the top vent. The flooring in resident's 5's room appeared dirty, even though the resident stated housekeeping does sweep and mop the floor. The tile flooring was blackened and dull. Resident 5 could not recall any furniture such as dressers being moved for a more thorough cleaning of her room, or her heater/air conditioning unit being cleaned since her admission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395616 If continuation sheet Page 3 of 5 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 395616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745 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 0925 Resident's 1, 2, and 5 reside on Unit 3 of the facility. Level of Harm - Minimal harm or potential for actual harm A review of a pest tracking log dated May 20 - August 8, 2024, revealed 8 mouse sightings in May 2024, in various resident rooms on Units 3, and 4 of the facility, which included Resident 1 and 2's room, as well as the mail room and basement breakroom of the facility. Ten mouse sightings were reported in June 2024, to include various rooms on Units 2 and 3 of the facility including Resident 5's room as well as the kitchen area and gift shop. Thirteen reports of mice were documented in July 2024, in various resident rooms on Units 2, and 3 including Residents 3, and 6's room. To date in August 2024, five reports of mouse sighting were reported in a resident room on Unit 2, Unit 3, and the physical therapy area. Each entry in the log noted a trap was placed and a total of five mice were documented as caught. Residents Affected - Some A review of facility pest control company visits since May 2024, revealed the pest control company made visits to the facility on May 20, June 13, 17, 26, July 3, and 22, 2024. The May 20, 2024, report noted exterior bait stations were refilled and interior maintenance areas were sprayed including the kitchen. June 13, 2024, visit noted bait stations on the third floor were refilled and additional stations were added to the kitchen and that 72 glue boards were left for use by maintenance staff. June 17, 26, and July 3, again noted the refilling of bait stations. The last visit on July 22, 2024, noted spraying of the baseboards in the kitchen and some rooms in the basement and filling of the exterior bait stations. In the same noted interviews above for Resident's 1, 2, 5 and 6, the residents did not recall any additional measures to control mice in the facility other than staff placing traps. In an interview with the Nursing Home Administrator on August 8, 2024, at 1:26 PM the administrator denied any additional measures to help remedy the rodent problem in the facility that had existed in the facility for several months without improvement. The administrator indicated that there was possibly more mouse sightings due to the use of the bait stations. There was no evidence the resident rooms were deep cleaned (removal or relocation of large pieces of furniture and swept and mopped) to limit dried food or debris in the rooms, or the heating/air conditioner units were cleaned of any dried food/debris due to the potential to act as an attractant to pests. In an interview with Employee 1, director of environmental services, on August 8, 2024, at 3:05 PM, Employee 1 indicated housekeeping staff complete basic cleaning of resident rooms daily to include sweeping, mopping, emptying the trash, and restocking supplies, and deep clean (pull out and clean under and behind furniture) once a month. Review of a deep room cleaning schedule Employee 1 stated was recently started indicated only 10 rooms had received a deep clean since June 28, 2024, and only six resident rooms had been stripped and waxed (complete removal of all items in the room) since February 2024, none of which belonged to the resident's noted above. Employee 1 was not able to provide any additional evidence all resident rooms were deep cleaned monthly. The facility census was 136 on August 8, 2024. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on August 8, 2024, at 3:40 PM. 483.90(i)(4) Maintain an effective pest control program (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395616 If continuation sheet Page 4 of 5 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 395616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745 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 0925 Previously cited 3/26/24 Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395616 If continuation sheet Page 5 of 5