Health inspection·January 9, 2025

F 0578 Review of Resident CR1's physician orders revealed the resident was ordered a DNR on [DATE], which was discontinued on [DATE], and reordered on [DATE], after a hospital leave of absence. Level of Harm - Actual harm Residents Affected - Few A review of a physician's readmission note for Resident CR1 dated [DATE], upon return from a hospital stay listed the resident as having a code status of No Code (no CPR), and that advance directives were discussed. The document does not indicate who the advance directives were discussed with, i.e., if it was the resident himself or family. A Code Status document with the same date of [DATE], was identified for the resident with DNR, and DNI (do not intubate), checked off and the sheet was signed by the physician and the nurse receiving the order. There was no resident or family signature on the form or who determined the DNR/DNI for the resident. The facility was not able to provide evidence to show Resident CR1 was ordered to have CPR administered after the resident completed the POLST indicating desired CPR on [DATE], or if the order was changed from wishing to have CPR between the [DATE], date and the order dated [DATE], as the Director of Nursing indicated in an interview on [DATE], that the facility changed electronic records in [DATE], and any current orders at the time were carried over to the new system, which is why the DNR order for the resident was dated [DATE]. A physician's readmission note dated [DATE], after the resident had another hospital leave noted the resident's code status was No Code, and per record review his code status remains DNR/DNI. The note indicated advance directives were discussed, the patient is a DNR. Again, there was no evidence as to who advance directives were discussed with and if the resident was involved or made the decision. Another Code Status sheet dated [DATE], was completed for Resident CR1, which checked off DNR and DNI for the resident and was signed by the physician and nurse receiving the order, but the form did not indicate any discussion with the resident. Resident CR1 was noted to have a change in condition beginning [DATE], with nausea, progressing to emesis from [DATE] - 7, 2025. A nursing note dated [DATE], at 2:30 PM noted the nurse was called to the resident's room to assess the resident as he was vomiting and cool to touch but alert and speaking. It was noted the nurse was unable to get a blood pressure and the provider was consulted and the decision was made to send the resident to the emergency department. Emergency services were noted as contacted. The note then indicated the resident expired at 2:20 PM as there were no respirations or apical heartrate for one full minute and emergency personnel were updated upon arrival. A physician's death pronouncement note dated [DATE], at 12:11 PM noted the resident expired at the facility on [DATE], noting the resident had worsening status in the afternoon of [DATE], and emergency services were called due to transfer to the emergency department for further evaluation, but the patient was noted by nursing to have agonal breathing, respiratory distress, and became pulseless. It was noted no code blue was called as the patient is known DNR/DNI. There was no evidence to indicate it was Resident CR1's decision to change from his desire to have CPR as the resident signed a POLST in October of 2021, indicated to become a DNR (no CPR) as orders reflected after that date, as there is no evidence to indicate a discussion actually occurred with the resident himself, or that the resident signed a new document indicating a desire to change his wishes. There was no evidence the resident became incapable to not make that decision during his stay at the facility. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on [DATE], at 3:45 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395616 If continuation sheet Page 2 of 9 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 01/09/2025 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 0578 Cross Refer F684 Level of Harm - Actual harm 483.10(c)(6)(8)(g)(12)(i)-(v) Request/Refuse/Discontinue Trmnt; Formulate Adv Dir Residents Affected - Few Previously cited deficiency [DATE] 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395616 If continuation sheet Page 3 of 9 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 01/09/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care for a resident's change in condition that resulted in death for one of six residents reviewed causing actual harm (Resident CR1). Residents Affected - Few Findings include: Closed clinical record review for Resident CR1 revealed that the resident had been a long-term resident of the facility with an admission date of [DATE]. Review of Resident CR1's closed clinical record revealed a nursing note dated [DATE], at 8:25 PM noting the resident had complaints of nausea and not feeling well. A nursing note followed dated [DATE], at 2:38 AM noting no further emesis, and a clear liquid tray was ordered for breakfast. There was no further documentation identified between the notes identified above between the evening of [DATE], through the night to [DATE], regarding the number of times emesis occurred or any other details. A review of meal intakes for Resident CR1 for [DATE], revealed the resident was documented as only consuming 1-26 percent of breakfast and lunch and had refused dinner on that day. Review of meal intakes for the resident prior to [DATE], back to [DATE], revealed the resident had normally consumed at least 51% of meals and mostly 76-100 percent of meals. Resident CR1's meal intakes for [DATE], breakfast continued to be low for the resident at 0-25 percent, with lunch slightly better at 26-50 percent and dinner 51-75 percent. Resident CR1 was also documented on his bowel record of having a loose/diarrhea bowel movement on the evening of [DATE]. The resident was documented as having normal stools almost daily for several days leading up to [DATE]. There were no further nursing notes for Resident CR1 for [DATE], reflecting the decrease in meal intakes, whether his nausea had subsided, if there was any further emesis during the day of [DATE], or that the resident had a loose/diarrhea bowel movement since nausea and vomiting has been recently documented. The next nursing note for the resident was dated [DATE], at 2:13 PM, which noted the resident had emesis twice during the shift with coffee ground appearance, very foul odor, and the resident complaining overall of not feeling well. It was noted the registered nurse supervisor was notified and observed the emesis, and the resident would be monitored for increased emesis and vital sign changes. A late entry note documented by the registered nurse on [DATE], at 9:54 AM for [DATE], at 2:51 PM noted the resident was having multiple emesis during the shift, it was liquid brown in color, there was no concern for gastrointestinal (GI) bleeding, and the emesis had no coffee brown texture noted upon assessment. The note indicated GI illness was circulating around the building and the resident's provider was aware with Zofran (an anti-nausea medication) ordered and fluids encouraged. A review of Resident CR1's orders revealed Zofran was ordered on [DATE], at 10:00 PM to be administered every eight hours for nausea/vomiting for three days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395616 If continuation sheet Page 4 of 9 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 01/09/2025 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 0684 An order for the resident to have vital sign checks each shift was also identified as ordered on [DATE], at 11:00 PM. Level of Harm - Actual harm Residents Affected - Few Further review of Resident CR1's bowel records for [DATE], also revealed loose stools/diarrhea were documented for that day. Nursing documentation dated [DATE], at 8:05 PM noted the resident refused an evening snack due to nausea and vomiting. A nursing note dated [DATE], at 10:22 PM noted the resident had two extra-large emesis during the shift of dark brown liquid noting the resident consumes a chocolate nutritional supplement, and the Zofran was given. Resident CR1's bowel records also indicated the resident had a loose/diarrhea stool documented the early morning hours of [DATE]. A review of resident CR1's vital signs on [DATE], revealed the resident's blood pressure obtained at 8:49 AM as 87/49 mmHg (millimeters of mercury) with a warning indicating the Diastolic (bottom number) was low below 60, and the Systolic (top number) was low below 90. Review of Resident CR1's [DATE], medication administration record revealed a medication Lisinopril (medication used to treat high blood pressure) was ordered for the resident daily in the morning and is to be held for a Systolic blood pressure less than 110 mmHg. The Lisinopril was documented as not administered due to vitals outside parameters for administration. A correlated administration note for [DATE], at 10:38 AM noted the medication order as it appears on the medication administration record to hold for a Systolic blood pressure of less than 110 mmHg. An administration note also followed for Resident CR1 at 10:39 AM on [DATE], noting the resident's sliding scale insulin was not administered as the resident is vomiting and refusing meals. The resident's routine insulin was also noted in an administration note that followed at 10:41 AM that it was not administered as the resident was refusing meals, and an administration note at 12:03 PM that the resident's nutritional supplement was refused as the resident was vomiting. A nursing note dated [DATE], at 12:58 PM indicated Resident CR1 was assessed by the provider on that day for nausea and vomiting and the resident continued to receive Zofran every eight hours for three days, labs were to be completed the next day, and clear liquids were to be given for 24 hours. A review of Resident CR1's physician orders revealed the following orders on [DATE]: 7:00 AM encourage 120 milliliters of fluid every shift 7:00 AM clear liquids for 24 hours 12:45 PM KUB (an Xray/scan of the urinary system) 12:45 PM CBC, BMP, and LFT's (diagnostic testing of complete blood count, basic metabolic panel, and liver function testing) A review of physician assistant (PA) documentation for [DATE], for an encounter with Resident CR1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395616 If continuation sheet Page 5 of 9 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 01/09/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few on [DATE], revealed the resident was noted as seen for evaluation of nausea and vomiting and the PA was asked to see the resident after having developed symptoms of nausea and vomiting yesterday, ([DATE], even though the nausea and vomiting started on [DATE]), and upon evaluation had vomited once on [DATE], prior to the visit. The resident indicated to the PA that his bowels were moving normally, and he did not have a fever. It was noted staff reported the resident had coffee ground emesis on [DATE], however, the registered nurse reported it was slightly brown in color but did not feel it was coffee ground emesis. The PA noted the resident's blood sugar was over 200 for the day and his blood pressure from 1/6 was 132/69 mmHg. The encounter note indicated the PA reviewed the most recent facility's vitals for the resident and due to the discrepancy reports on the coffee ground emesis would check the CBC, BMP, LFT's, continue the Zofran, clear liquid diet, check KUB given slightly hypoactive bowel sounds, and recheck on [DATE], after KUB was reviewed. The time of the PA's visit was not indicated on the encounter visit report although per interview with the Director of Nursing on [DATE], at 3:45 PM indicated the PA reported she had visited the resident around 11:00 AM on [DATE]. The note was electronically signed by the PA on [DATE], at 2:49 PM. A nursing note dated [DATE], at 2:30 PM noted the nurse was called to Resident CR1's room as the resident was again vomiting and cool to tough. He was alert and speaking. The resident's blood sugar was noted as high at 476 mg/dL, and the provider was consulted, and the decision was made to send the resident to the emergency department for further evaluation. It was noted emergency medical services was called, and the resident expired at 2:20 PM, noting emergency medical services was updated upon arrival. An additional note from the PA with an encounter date of [DATE], electronically signed by the PA on [DATE], at 12:41 PM, noted a few hours after the PA had seen Resident CR1, the registered nurse came to the PA's office indicating the resident had several more episodes of vomiting since she has seen him and seemed to be declining. The registered nurse reported the resident's color did not look good and the resident seemed diaphoretic, also reporting his blood pressure was low. The registered nurse reported that there were a few spots of bright red blood on the resident's sheet but on assessment concluded it to be from a sacral wound. The PA advised to call emergency medical services and have the resident transferred to the emergency department. The PA noted the registered nurse then called her moments later and reported the resident was not responsive and had signs of respiratory distress, the nurse confirmed the resident did have a pulse and the resident's code status was reviewed and confirmed the resident was a do not resuscitate/do not intubate. The nurse was advised if the resident still had a pulse to call 911. It was noted the nurse called again a few moments later and reported 911 had been called; however, the resident was now pulseless and ceased to breathe. Emergency staff arrived just after they hung up the phone, and the nurse pronounced the resident. A physician's note dated [DATE], at 12:11 PM as a death pronouncement noted the resident's date of expiration was [DATE], with a cause of death as aspiration pneumonia, acute hypoxic respiratory failure, with secondary diagnosis listed of diabetes type 2, peripheral vascular disease, ventral hernia, neurogenic bladder, major depressive disorder, and intellectual disability. The note only referenced on [DATE], the resident was noted to have nausea and vomiting, and a GI virus had been affecting other residents in the facility. It noted symptoms continued [DATE], and the resident was evaluated by the medical team and noted to be at baseline mental state, stating he was feeling nauseous and tired. It was noted there had been some concerns of coffee ground emesis but on further evaluation of emesis by nursing was not found to be the case, more consistent with bilious/stomach acid. It was noted later that afternoon the resident had a worsening of status, emergency services were called for transfer to the emergency department, and unfortunately while they were enroute the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395616 If continuation sheet Page 6 of 9 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 01/09/2025 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 0684 noted to have agonal breathing, respiratory distress, became pulseless, and no code blue (emergency alert for a patient in cardiac arrest) was called as the patient was a known do not resuscitate/do not intubate. Level of Harm - Actual harm Residents Affected - Few There was no evidence the PA or the resident's physician was made aware Resident CR1's nausea and vomiting had actually started as documented late on [DATE] into the early morning hours of [DATE], as the PA referenced in the note as symptoms started on [DATE], per staff, or that the either was aware the resident had loose stools identified in bowel records also beginning [DATE], and significantly decreased intakes of meals due to nausea and vomiting beginning [DATE], not one day before on [DATE]. The PA's note did not reflect being made aware of the resident's significant decrease in blood pressure as it was obtained on [DATE], in the morning at 8:49 AM as the PA's note reflected the resident's blood pressure from the day before ([DATE]) in normal range in the visit on [DATE]. The PA did not reference being made aware of any low blood pressure until the later encounter with the registered nurse on [DATE], as noted above when the resident rapidly declined in the afternoon. Facility staff were not able to provide any evidence to the surveyor to indicate Resident CR1's providers were made aware the resident's change in condition began late on [DATE], greater than 24 hours prior, and not [DATE], as indicated in provider reports. Additional diagnostics were not ordered until [DATE], after the PA visited the resident. There was no evidence of any follow up to the resident's condition on [DATE], as emesis was noted in the very early morning hours, the resident had loose stools documented, and the resident's meal intakes reflected significant decline for the day with refusal of dinner, until emesis was documented on [DATE]. Resident CR1 expired on [DATE], at 2:20 PM prior to any of the ordered diagnostic testing being completed. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on [DATE], at 3:45 PM. Cross Refer F578 483.25 Quality of Care Previously cited deficiency [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395616 If continuation sheet Page 7 of 9 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 01/09/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on staff interview and clinical record review, it was determined that the facility failed to ensure that a medication was available in a timely manner for two of four residents reviewed for medication availability concerns (Residents CR1 and 2). Findings include: Closed clinical record review for Resident CR1 revealed a physician's order dated August 7, 2024, for the resident to be administered insulin glargine (a long-acting insulin medication used to control blood sugar levels) to be administered/injected via an insulin pen 30 units two times a day for a diagnosis of diabetes (a disease effecting the body's ability to control blood sugar levels). Resident CR1 was also ordered blood sugar checks before meals and at bedtime for use of sliding scale insulin. Review of Resident CR1's medication administration record for January 2024, revealed Resident CR1's evening dose of routine insulin glargine noted above for January 3, 2025, was identified as not administered. A corresponding medication administration record note dated January 3, 2025, at 8:26 PM noted the insulin was not administered as it was unavailable. Review of Resident CR1's vital sign blood sugar check on January 3, 2025, at 8:23 PM revealed the resident's blood sugar was documented as 227 milligrams (mg)/deciliter (dL), which was flagged as a high level as it exceeded 99 mg/dL in the vital check system. In an interview with the Director of Nursing on January 9, 2025, at 1:22 PM it was revealed the insulin glargine was marked unavailable due to not arriving from the pharmacy in time for administration. There was no evidence any facility staff contacted Resident CR1's physician regarding not being able to administer the resident's evening dose of insulin due to unavailability on January 3, 2025, and the resident's blood sugar level was high at 227 mg/dL. There was no evidence the resident received any alternative to the missed dose of the insulin glargine. A nursing note dated January 4, 2025, at 4:59 AM (the next morning) noted the resident's blood sugar level had significantly increased and was 449 mg/dL and the on-call physician was notified and ordered a one-time dose of rapid/fast acting insulin to be administered to the resident. A recheck of the resident's blood sugar level at 7:46 AM was decreased to 95 mg/dL. Clinical record review for Resident 2 revealed a physician's order dated September 11, 2024, for the resident to have a lidocaine external patch (pain reliever) applied to the right hip topically daily in the morning for pain. Review of Resident 2's medication administration record for January 2025, revealed the resident was marked as not having the lidocaine patch administered on the morning of January 7, 2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395616 If continuation sheet Page 8 of 9 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 01/09/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm A corresponding administration note for Resident 2, dated January 7, 2025, at 8:20 AM noted the lidocaine patch was on order. Interview with the Director of Nursing on January 9, 2025, at 3:45 PM revealed the patch was not available to be administered to the resident. Residents Affected - Few The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on January 9, 2025, at 3:45 PM. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (d)(1)(3) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395616 If continuation sheet Page 9 of 9