Health inspection·October 31, 2024

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to provide resident privacy on one of two medication carts (Dogwood Medication cart). Residents Affected - Few Findings include: Review of facility policy entitled Resident Rights Privacy & Confidentiality dated 7/5/24, indicated The facility limits access to any medical records to staff and consultants who provide direct care to the resident. And All records - medical, personal, financial or social service - will be safe-guarded at all times to insure confidentiality. Observation on Dogwood Hall on 10/29/24, at 11:13 a.m. revealed a medication cart sitting in the hallway against the wall with an open computer on top of the medication cart and resident health information visibly facing into the hallway. Continued observations revealed several visitors, residents and staff who walked past the visible health record information until the nurse returned to the medication cart at 11:25 a.m. During an interview on 10/29/24, at 11:25 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that he/she left the medication cart with the computer open and did not cover resident health information that was on the computer on top of the medication cart. LPN Employee E1 also confirmed that resident information is to be covered when not within view. 28 Pa. Code 201.14(a) Responsibility of licensee 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 8 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 10/31/2024 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS-periodic assessment of resident care needs) for two of 18 residents reviewed (Resident R29 and R16 ). Residents Affected - Few Findings include: Review of Resident R29's clinical record revealed an admission date of 3/15/22, with diagnoses that included multiple sclerosis (a disease resulting in nerve damage that disrupts communication between the brain and the body), benign prostatic hyperplasia (type of prostate enlargement resulting in slow or backflow of urine), spastic hemiplegia(condition that causes tightness and involuntary contractions in the limbs and extremities on one side of the body) and weakness. Review of Resident R29's clinical record revealed a physician's order dated 7/12/24, for a Texas catheter (type of external condom catheter to collect urine) to be placed on at bedtime and remove in morning. Review of the MDS dated [DATE], Bowel and Bladder Section H0100 Appliances revealed to check all that apply. Documentation on the MDS for H0100 revealed Resident R29 was marked for having an external catheter and an indwelling catheter. During an interview on 10/30/24, at 1:15 p.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed that the resident did not have an indwelling catheter. The RNAC also confirmed that Section H0100 of the MDS dated [DATE], was incorrectly coded for Resident R29 regarding an indwelling catheter. Resident R16's clinical record revealed an admission date of 1/25/23, with diagnoses that included Type II diabetes (condition where the pancreas does not make enough insulin), dysphagia (difficulty swallowing), and cognitive communication deficit (difficulty communicating). Resident R16's physician's order summary revealed that an Ozempic injection (an antihyperglycemic injection used to help control blood sugar, which is not classified as an insulin) was ordered by the physician on 9/5/24. The Quarterly MDS dated [DATE], Medications Section N0350A indicated that Resident R16 received insulin one time during the seven day look back period. During an interview on 10/30/24, at 12:13 p.m. the Corporate RNAC confirmed that Section N - Medications category N0350A Insulin of the Quarterly MDS dated [DATE] was incorrectly coded for Resident R16 and should have been zero days. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395619 If continuation sheet Page 3 of 8 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 10/31/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to update a care plan for one of 18 residents reviewed (Resident R29). Residents Affected - Few Findings include: Review of a facility policy entitled Formation of the Resident Care Plan dated 7/5/24, indicated that, care plans are periodically reviewed and revised by a team of qualified persons after each assessment. Review of Resident R29's clinical record revealed an admission date of 3/15/22, with diagnoses that included multiple sclerosis (a disease resulting in nerve damage that disrupts communication between the brain and the body), benign prostatic hyperplasia (type of prostate enlargement resulting in slow or backflow of urine), spastic hemiplegia(condition that causes tightness and involuntary contractions in the limbs and extremities on one side of the body) and weakness. Review of Resident R29's clinical record revealed a physician's order dated 7/12/24, for a Texas catheter (type of external condom catheter to collect urine) to be placed on at bedtime and removed in morning. Review of clinical record documentation for Resident R29 revealed there was no evidence that the care plan was updated to reflect the Texas catheter. During an interview on 10/30/24, at 1:15 p.m. the Registered Nurse Assessment Coordinator confirmed that Resident R29's care plan was not updated to reflect the Texas catheter. 28 Pa. Code 201.14(a) Responsibility of licensee 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 4 of 8 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 10/31/2024 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 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 and facility policies, facility documentation, and staff interview, it was determined that the facility failed to administer medications as ordered by the physician for one of 18 residents reviewed (Resident R1). Residents Affected - Few Findings include: Review of facility policy entitled Medication Administration dated 7/5/24, indicated All nurses must possess an awareness of responsibility to follow physician's orders precisely . Review of facility policy entitled Sliding Scale Insulin Coverage dated 7/5/24, indicated Nurse verifies type and amount of insulin to be given, and administers it. and Nurse will record in the EMAR the date, time, fingerstick blood sugar level and the amount of insulin administered. Review of Resident R1's clinical record revealed an admission date of 4/9/24, with diagnoses that included Diabetes (a health condition that caused by the body's inability to produce enough insulin), Hypertension (high blood pressure), and Hemiplegia (a condition where a person is paralyzed and unable to move one side of their body). Review of Resident R1's physician's orders revealed an order dated 4/9/24, for Insulin Lispro (medication to treat diabetes and control blood sugar levels) 100 Units per Milliliter Subcutaneous (an injection placed just under the skin) four times a day for sliding scale (a scale to determine how much insulin to give based on the blood glucose results) 70-130 0 units, 131-180 1 unit, 181-240 = 2 units, 241-300 3 units, 301-350 4 units four times a day for diabetes. Review of Resident R1's September 2024, and October 2024, Medication Administration Record's (MAR) revealed Resident R1's Blood Glucose Monitoring (BGM) at breakfast on 9/18/24, was 161 and documentation on the MAR was 0 for insulin given. Review of MAR's for Hour of Sleep (HS) on 9/11/24, BGM was 211; on 9/18/24, BGM was 242; on 9/19/24, BGM was 240; on 9/25/24, BGM was 271; and on 10/16/24, BGM was 337. The MAR's lacked documentation of the amount of insulin administered in accordance with the physician's order. Interview with the Director of Nursing on 10/30/24, at 1:00 p.m. confirmed that Resident R1's Insulin Lispro was not administered in accordance with physician's orders. He/she also confirmed that Resident R1's insulin should have been administered in accordance with the physician's order. 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 5 of 8 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 10/31/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to administer routine oxygen as ordered for one of 18 residents reviewed (Resident R31). Residents Affected - Few Findings include: Review of facility policy entitled Medication Administration dated 7/5/24, indicated All nurses must possess an awareness of responsibility to follow physician's orders precisely . Review of Resident R31's clinical record revealed an initial admission date of 7/5/24, with diagnoses that included malignant neoplasm of the right bronchus or lung (lung cancer), atrial fibrillation (irregular heartbeat), and low back pain. Resident R31's clinical record revealed a physician's order dated 7/31/24, indicating Resident R31 was to be on routine oxygen set at 2 liters per minute via nasal canula. Resident R31's Medication Administration Record (MAR) for September 2024 and October 2024 revealed that he/she did not have his/her routine oxygen in place as ordered by the physician on every shift on 9/1/24, 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/7/24, 9/8/24, 9/9/24, 9/10/24, 9/11/24, 9/12/24, 9/13/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/22/24, 9/23/24, 9/24/24, 9/25/24, 9/26/24, 9/27/24, 9/28/24, 9/29/24, 9/30/24, 10/1/24, 10/2/24, 10/3/24, 10/4/24, 10/5/24, 10/6/24, 10/7/24, 10/8/24, 10/9/24, 10/10/24, 10/11/24, 10/12/24, 10/13/24, 10/14/24, 10/15/24, 10/16/24, 10/17/24, 10/18/24, 10/19/24, 10/20/24, 10/21/24, 10/22/24, 10/23/24, 10/24/24, 10/25/24, 10/26/24, 10/27/24, 10/28/24, and 10/29/24. During an interview on 10/30/24, at 1:43 p.m. Licensed Practical Nurse Employee E3 confirmed that Resident R31's routine oxygen order was not being administered as ordered by the physician on the shifts and dates listed above. 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 6 of 8 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 10/31/2024 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Some Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on facility requirements according to the Affordable Care Act (ACA), review of Payroll Based Journal (PBJ) Staffing Data Reports, and staff interview, it was determined that the facility failed to electronically submit accurate direct care staffing information for one of the last four quarters (Quarter One of 2024). Findings include: Review of Section 6106 of the ACA requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data to the Centers for Medicare and Medicaid Services (CMS). First quarter reporting includes data from October 1st through December 31st. Review of PBJ staffing data reports for fiscal year first quarter 2024 revealed the facility triggered for No RN hours on 12/17/23, 12/23/23, 12/24/23, 12/25/23, and 12/31/23, and Failed to have Licensed Nursing Coverage 24 hours/day on 12/16/23, 12/17/23, 12/23/23, 12/24/23, 12/25/23, 12/30/23, and 12/31/23. Review of staffing documentation on 12/17/23, 12/23/23, 12/24/23, 12/25/23, and 12/31/23, revealed the facility did have RN hours and on 12/16/23, 12/17/23, 12/23/23, 12/24/23, 12/25/23, 12/30/23, and 12/31/23, the facility did have Licensed Nursing Coverage 24 hours/day, indicating the facility failed to submit accurate PBJ information as required by the ACA. During an interview on 10/31/24, at 10:41 a.m. the Scheduler Employee E2 confirmed that the PBJ report for Quarter One for 2024 was submitted inaccurately. 28 Pa. Code 201.18(b)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395619 If continuation sheet Page 7 of 8 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 10/31/2024 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of facility records and staff interview, it was determined that the facility failed to assure required attendance of the Medical Director to Quality Assurance and Performance Improvement (QAPI) Committee meetings for one of four quarterly QAPI Committee meetings (September 2024). Residents Affected - Few Findings include: A facility policy entitled Quality Assurance and Process Improvement (QAPI) Program and Committee dated 7/5/24, indicated the QAPI committee shall meet at least quarterly and will include feedback from the Medical Director. Review of the QAPI Committee Attendance Records from April 2024 through October 2024 revealed no evidence on the attendance sign-in sheets for the required QAPI meetings that the Medical Director was in attendance for the September 2024 meeting. During an interview on 10/31/24, at 11:13 a.m. the Nursing Home Administrator confirmed the facility lacked evidence that the Medical Director attended the quarterly QAPI Committee meeting as required for the September 2024 meeting. 28 Pa. Code 201.18(e)(1)(3) 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 8 of 8