Health inspection·November 2, 2023

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Based on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide urostomy (an opening in the belly made during surgery to re-direct urine away from the damaged bladder) care and services consistent with professional standards of practice for one of one residents with a urostomy (Resident 57). Findings include: Upon request, no facility policy was provided by the Director of Nursing (DON). Review of Resident 57's clinical record revealed an admission date 10/22/18, with diagnoses of kidney failure, chronic kidney disease-stage four (kidneys are severely damaged and are not able to filter waste from the blood sufficiently), gastro-esophagus reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining), and an artificial opening of the urinary tract (urostomy). Review of Resident R57's care plan dated 10/13/23, identified an alteration in elimination as shown by the presence of a urostomy with interventions to change appliance per order. Review of Resident R57's physician order referenced on the Treatment Record, dated with a start date of 1/23/20, revealed Change urostomy Q [every] 3 days - Every 72 hours Apply ring of stoma [artificial opening] paste at opening . Review of the Resident R57's Treatment Record for October 2023 from 10/01/23, through 10/31/23, revealed Resident R57's urostomy was only changed on 10/01/23, 10/10/23, 10/20/23, and 10/22/23, or four of 31 days. Observations of Resident R57 on 10/30/23, at approximately 11:00 a.m., on 10/31/23, at approximately 10:00 a.m., and on 11/01/23, at approximately 1:00 p.m. revealed Resident 57 with a urostomy maintained. A strong odor of urine was also noted during the observations. During an interview on Tuesday, 10/31/23, at approximately 11:00 a.m. Resident 57 indicated that his/her urostomy does not get changed as ordered on Tuesdays and Saturdays weekly. Furthermore, an interview on Wednesday, 11/01/23, at approximately 1:00 p.m. revealed Resident 57's urostomy did not get changed the day prior, 10/31/23, as ordered. During an interview on 11/01/23, at 2:45 p.m. the DON confirmed that Resident R57's urostomy was not changed every three days per the physician order as noted above and failed to provide urostomy care and services consistent with professional standards of practice for Resident 57. 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395619 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 395619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rolling Fields, Inc 9108 State Highway 198 Conneautville, PA 16406 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on review of facility records, observations, and resident, family member, and staff interviews, and review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for six of 21 residents reviewed (Residents R9, R36, R40, R44, R47, and R53). Findings include: Review of the RAI manual instructions for Section C0500 Brief Interview for Mental Status (BIMS) revealed that a score of 13-15 identified a resident as cognitively intact and a score of 8-12 identified a resident as moderately impaired, and a score of 0-7 as severely impaired. Section GG0100 Prior Functioning: Everyday Activities. Indicate the resident's usual ability with everyday activities prior to the current illness, exacerbation, or injury. Review of Resident R47's MDS information identified a BIMS of 14/15 and was Dependent (helper does All of the effort Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helper is required for the resident to complete the activity), During resident interviews on 10/30/23, from 11:00 a.m. through 3:30 p.m., Resident R47 verbalized that call bell response times were a concern with wait times of an hour or more. Resident R47 indicated that he/she has to wait for assistance to go the bathroom and his/her incontinence product is typically soaked by the time staff answer his/her call light. Resident R47 also indicated it was common to wait for long periods regardless of shifts. Resident R53, with a BIMS of 11/15, verbalized that he/she would like to go to the dining room for meals. However, due to not enough staff, the dining room is not open, and residents are required to eat each meal in their rooms. Resident R47 and Resident R53 verbalized that meals are late. Observations on 10/30/23, 10/31/23, and 11/01/23, revealed the dining room was not open for resident meals. During a Resident Council meeting on 10/31/23, at approximately 10:15 a.m., four of six residents (Resident R9 with a BIMS 15/15, R36 with a BIMS 15/15, R40 with a BIMS 15/15, and R44 with a BIMS 15/15) in attendance indicated resident needs were not being met due to long call bell response times related to insufficient staffing. During an interview on 11/02/23, at 11:20 a.m. the Director of Nursing confirmed the dining room has not been open and off shifts (afternoon and midnight shift) have been a struggle to meet the resident needs due to insufficient staff. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(4) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395619 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 395619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rolling Fields, Inc 9108 State Highway 198 Conneautville, PA 16406 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly label multi-use pens of insulin with an opened and/or use by dates for one of three medication storage carts reviewed (Birch Street). Findings include: Review of the current facility policy entitled, Insulin Administration Procedure, last reviewed 11/13/2022, identified that Upon opening a new vial, make sure to write both the open and discard date on the vial with a permanent marker. Timing and loss of potency varies depending on the type of insulin, refer to the pharmacy label prior to writing discard date. Observation of medication storage cart on Birch Street, on 10/30/2023, at 3:45 p.m. revealed that multi-use pens of insulin were opened with no opened date and/or use-by date printed on the vial. During an interview with Licensed Practical Nurse Employee E1 on 10/30/2023, at the time of the observation, it was confirmed that the multi-use pens of insulin were opened and in the medication cart for use and there was no opened date and/or use-by date on the pens for staff to know if the medication was still safe for use or to discard. During an interview on 10/30/2023, at 3:45 p.m. Registered Nurse Supervisor Employee E2 confirmed that insulins in the Birch Street cart were opened with no opened date and/or use by date on the pens. It was confirmed that opened pens of insulin should have opened and/or use by dates on the pens. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395619 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 395619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rolling Fields, Inc 9108 State Highway 198 Conneautville, PA 16406 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of infection control records, facility policy, and staff interviews, it was determined that the facility failed to provide proof that a system to monitor and prevent legionella in the facility water was established. Residents Affected - Few Findings include: Upon request, no facility policy was provided by the Nursing Home Administrator (NHA). During review of infection control records, it was identified there was no written evidence of routine testing for legionella in the facility water system. During an interview with the Director of Environmental Services on 11/02/23, at 11:15 a.m. he/she indicated the facility does not complete water testing for legionella in the facility water. During an interview with the NHA on 11/02/23, at 11:20 a.m. it was confirmed the facility lacked evidence of testing for legionella in the facility water system, and the facility currently has no routine for water testing. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395619 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 395619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rolling Fields, Inc 9108 State Highway 198 Conneautville, PA 16406 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of facility employee in-service training records and staff interview, it was determined that the facility failed to assure staff completed all required mandatory trainings for the yearly Nurse Aide (NA) 12-hour mandatory trainings for the past year from December 2022 through November 2023. Findings include: Upon request, no records or evidence of mandatory in-service training for all NA's from December 2022 through November 2023, was provided for review. During an interview on 11/02/23, at 12:40 p.m. the Nursing Home Administrator confirmed that no evidence could be provided regarding NA's 12-hour mandatory in-service trainings as required. 28 Pa. Code 201.20(a)(d) Staff development FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395619 If continuation sheet Page 6 of 6