Health inspection·July 3, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, observation, and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for two of sixteen residents (Resident R 21 and R312). Findings include: Review of the facility Resident Rights and Facility Responsibilities policy last reviewed 6/1/25, indicated it the facility's policy to comply with all Residents Rights. A listing of Resident and Facility Responsibilities for the specific state of residence, and federal rights will be provided to the resident/resident representative upon admission and when requested. Review of the clinical record indicated Resident R21 was originally admitted to the facility on [DATE], and most recently readmitted on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/17/25, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). During an observation on 7/3/25, at 9:48 a.m. Resident R21 was observed to be laying in bed. A nurse was on the far side of the bed, and had Resident R21's gown pulled up, and appeared to be observing Resident R21's stomach. At this time, neither Resident R21's privacy curtain nor room door closed, which allowed observation from the hallway. Review of the clinical record indicated Resident R312 was admitted to the facility on [DATE]. Review of Resident R312's MDS dated [DATE], did not contain diagnosis information at this time. Review of Resident R312's History and Physical (medical examination, assesses overall condition and medical history) dated 6/25/25, reveals diagnosis of anoxic brain injury after cardiac arrest (damage to the brain due to lack of oxygen), atrial fibrillation (irregular heartbeat) and diabetes. During an interview with the resident and spouse on 7/1/25 at approximately 10:30 a.m. When asking the resident and his spouse if they had any concerns related to care at the facility, the resident nodded yes and said, when I had to poop and then pointed to his spouse. Resident spouse stated approximately two days after admission, the resident engaged the call light to use the bathroom around the Page 1 of 44 395653 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0550 Level of Harm - Minimal harm or potential for actual harm time for lunch. When staff came in the room, they stated they are passing trays, its lunch time and it would have to wait until after lunch service, the staff stated, he has a brief on he can go in his brief, that is what is there for. The resident spouse offered to take the resident to the bathroom, this was not permitted. Spouse reported, the resident had to hold it as he didn't want to go in his brief. The resident nodded his head yes as his spouse was sharing their experience. Residents Affected - Few During an interview on 7/3/25, at 3:50 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to ensure that care was provided in a manner which maintained resident dignity for three of sixteen residents (Resident R21, R32 and R312). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.29(a) Resident rights. 395653 Page 2 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0579 Provide information about how to apply for and use Medicare and Medicaid benefits. Level of Harm - Minimal harm or potential for actual harm Based on observations and staff interviews, it was determined, the facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, on two of two nursing floors (First Floor and Second Floor). Residents Affected - Few Findings include: During observations completed on 7/3/25, of the First Floor and Second Floor nursing units, failed to include information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid. During observations and an interview with the Nursing Home Administrator (NHA), on 7/3/25, at approximately 8:23 a.m., the NHA confirmed that the facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, on two of two nursing floors (First Floor and Second Floor). 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management. 395653 Page 3 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews, it was determined that the facility failed to make certain that comprehensive Minimum Data Set (MDS - periodic assessment of care needs) assessments were accurate and fully completed for five of twenty-six residents (Resident R14, R22, R25, R36, and R80). Residents Affected - Some Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments dated October 2024, indicated in: Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and the assessment should be completed if the resident is at least sometimes understood. Section I: Active Diagnoses, that a diagnosis should be checked if they had had an active diagnosis for a disease or condition in the last seven days. Section K: Swallowing/Nutritional Status, to base weight on the most recent measure in the last 30 days. If the last recorded weight was taken more than 30 days prior to the assessment reference date of this assessment or the previous weight is not available, weigh the resident again. Section O: Special Treatments, Procedures, and Programs, indicated to document what services and treatments were performed while a resident of the facility and within the last 14 days. Resident R42 had an MDS completed on 4/29/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated Resident R42 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R42 is rarely understood and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R42 is rarely understood and the Resident Mood Interview assessment was not completed. Resident R57 had an MDS completed on 4/4/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated Resident R57 is usually understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R57 is rarely understood and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R57 is rarely understood and the Resident Mood Interview assessment was not completed. Resident R80 had an MDS completed on 4/3/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated Resident R80 is usually understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R80 is rarely understood and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R80 is rarely understood and the Resident Mood Interview assessment was not completed. Resident R93 had an MDS completed on 5/28/25. Review of Section B: Hearing, Speech, and Vision, 395653 Page 4 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Question B0700 indicated Resident R93 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R93 is rarely understood and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R93 is rarely understood and the Resident Mood Interview assessment was not completed. Review of Resident R22's psychiatric evaluations dated 6/17/25, included diagnoses of bipolar disorder post-traumatic stress disorder. Review of previous psychiatric evaluations included the diagnoses of bipolar disorder post-traumatic stress disorder on 12/30/24. Review of Resident R22's facility diagnosis list included bipolar disorder and post-traumatic stress disorder, both with a diagnosis date of 12/30/24. Resident R22 had an MDS completed on 4/15/25. Review of Section I: Diagnoses failed to include active diagnoses of bipolar disorder or post traumatic stress disorder. Resident R14 had an MDS completed 4/8/25, Review of Section I: Diagnoses failed to include active diagnosis of dementia with a diagnosis date of 9/29/23. Review of a physician's order dated 11/15/24, indicated Resident R25 was admitted to hospice services. Review of the clinical record confirmed that Resident R25 remained on hospice services at the time of the survey, without breaks in services. Resident R25 had an MDS completed on 5/7/25. Review of Section O: Special Treatments, Procedures, and Programs failed to indicate that Resident R25 received hospice services. Resident R203 had a MDS completed on 6/18/25. Review of Section O: Special Treatments, Procedures and Programs failed to indicate that Resident R203 received continuous oxygen therapy via a nasal cannula. Review of Resident R36's weight record revealed the following: -4/01/25 - 155.5 pounds -4/08/25 - 156 pounds -6/02/25 - 175 pounds -6/19/25 - 141.2 pounds -6/26/25 - 125.8 pounds Resident R36 had an MDS completed on 5/31/25. Review of Section K: Swallowing/Nutritional Status utilized the weight of 156 pounds, captured on 4/8/25, 53 days prior. During an interview on 7/3/25, at approximately 11:30 a.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed During an interview on 7/3/25, at approximately 3:50 p.m. the Nursing Home Administrator Director 395653 Page 5 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0641 Level of Harm - Minimal harm or potential for actual harm of Nursing confirmed that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for six of twenty-six residents (Resident R14, R22, R25, R36, R80 and R203). 28 Pa. Code: 211.5(f) Clinical records. Residents Affected - Some 395653 Page 6 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to develop and implement comprehensive care plans for resident and care needs for five of twelve residents (Resident R14, R22, R43, R73 and R85). Findings include: Review of the facility policy Comprehensive Care Plan dated 1/1/25, indicated an interdisciplinary plan of care will be established for every resident and updated in accordance with State, and Federal requirements and on an as needed basis. Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS-periodic assessment of resident care needs) dated 4/8/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery (a stroke caused by a blockage or narrowing of a blood vessel in the brain, where the specific cause of the blockage is unknown), hemiplegia (inability to move one side of the body), unspecified dementia,severe with anxiety (a condition where cognitive decline is evident, but the specific type of dementia cannot be identified). Review of Resident R14's facility diagnosis list included diabetes, cerebral infarction, hemiplegia. unspecified dementia with severe anxiety. Review of the clinical record revealed that Resident R14's comprehensive care plan initiated on 4/8/25, failed to include plans of care with goals and interventions for dementia care. Review of active diagnoses list revelaed dementia diagnosis was made on 9/29/23. Review of the clinical record indicated Resident R22 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness), anxiety, and depression. Further review confirmed that bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and post-traumatic stress disorder (PTSD, mental health condition triggered by experiencing or witnessing a terrifying event) were not included as diagnoses. Review of Resident R22's facility diagnosis list included bipolar disorder and post-traumatic stress disorder, both with a diagnosis date of 12/30/24. Review of Resident R22's psychiatric evaluations dated 6/17/25, included the diagnoses of bipolar disorder post-traumatic stress disorder. Review of previous psychiatric evaluations included the diagnoses of bipolar disorder post-traumatic stress disorder on 12/30/24. Review of Resident R22's comprehensive care plan initiated on 7/10/24, failed to include plans of care with goals and interventions developed for bipolar disorder post-traumatic stress disorder. 395653 Page 7 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of the clinical record indicated Resident R73 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), diabetes, and depression. Residents Affected - Some Review of Section F: Preferences for Customary Routines and Activities indicated that it is very important to Resident R73 to do things with groups of people. During on observation on 7/1/25, at 3:17 p.m. Resident R73 was noted to be in her room alone, seated next to her bed, without the television on or music playing. During on observation on 7/2/25, at 1:23 p.m. Resident R73 was noted to be in her room alone, seated next to her bed, without the television on or music playing. Review of a psychiatric evaluations dated 6/17/25, included the diagnoses of bipolar disorder post-traumatic stress disorder. Review of previous psychiatric evaluations included the diagnoses of bipolar disorder post-traumatic stress disorder on 12/30/24. Review of Resident R73's comprehensive care plan initiated on 1/28/25, for Activities included a plan of care for, [Resident R73] is dependent on staff for activities, cognitive stimulation, and social interaction due to -------------------. Review of the clinical record indicated Resident R43's was originally admitted on [DATE]. Review of Resident R43's MDS assessment (Minimum Data Set: MDS - a periodic assessment of care needs) dated 5/12/25, indicated diagnoses included atrial fibrillation (irregular heart rhythm), morbid (severe) obesity (obesity associated with a higher risk of serious health issues), and diabetes. Further review confirmed that depression (mood disorder, affects how you feel, think, and behave) was not included as a diagnosis. Review of Section D: Mood D0150 indicated Resident R43 reported feeling down, depressed, or hopeless two to six days over the last two weeks. Review of Section E: Behavior E0200 indicated the following behaviors have not been exhibited: A. physical behaviors directed toward others (hitting, kicking, pushing, grabbing, abusing others sexually). B. verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others). C. other behavioral symptoms not directed toward others (self-harm behavior verbal/vocal symptoms like screaming). Review of Resident 43's progress notes from 1/1/25 thru 6/30/25 revealed Resident 43's summary of documented behavior events on the following dates. 1/7/25 resident yelling at staff regarding staffing. 2/15/25 resident yelling to get him out of bed, requesting specific staff. 3/1/25 resident yelling and called 911 for his electric wheelchair (facility removed for safety and maintenance) a manual chair provided and explained to resident prior to the 911 call. 3/12/25 resident yelling and verbally aggressive to staff for taking too long to respond. 395653 Page 8 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0656 Level of Harm - Minimal harm or potential for actual harm 4/9/25 resident verbally aggressive to Resident R61 and Resident R43 placed hand on Resident R61's wheelchair and moved the resident causing Resident R61 to express frustration and anxiety. 4/27/25 resident yelling and verbally abusive to staff for someone to do his laundry, resident begins making barking noises at the nurse supervisor. Residents Affected - Some 4/27/25 resident agitated, Resident R43 was chasing a female Resident R61 down the hall. 5/2/25 resident yelling at the nursing assistant and attempting to hit the nursing assistant with his wheelchair. 6/7/25 resident yelling obscenities toward staff and stated he was going to throw self out of bed if they don't get him up now, resident reportedly slid out of bed to the floor. Resident R43 informed staff he will do this again. 6/21/25 resident yelling and verbally abusive to staff for how they provide his care. Resident went to the nursing supervisor's office and Resident R43 began punching at the door and screaming obscenities at the nursing supervisor. Review of Resident R43's History and Physical (medical examination, assesses overall condition and medical history) dated 7/4/23, reveals a diagnosis of depression. Review of Resident R43's physician progress note dated 9/7/23 the resident is on cymbalta for depression and suicidal thoughts from November of 2022. Review of Resident R43's comprehensive care plan initiated on 10/28/23, failed to include plans of care with goals and interventions developed for depression. Resident R43's psychosocial well-being care plan goal edited on 4/24/25 will not harm self or others secondary to socially inappropriate disruptive behavior as described. Review of the clinical record indicated Resident R85 was admitted to the facility on [DATE]. Review of Resident R85's Minimum Data Set (MDS-periodic assessment of resident care needs) dated 4/1/25, included diagnoses of cancer of the colon, chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), depression. Review of Resident R85's facility diagnosis list included cancer of the colon, COPD, and depression. Review of the clinical record revealed that Resident R85's comprehensive care plan initiated on 4/22/25, failed to include plans of care with goals and interventions for hospice care and oxygen therapy. Review of the clinical record revealed orders were placed on 8/15/24, 12/10/24, and 6/17/24, for the resident to receive hospice evaluation and treatment. Further review of the clinical record revealed an order on 8/24/24, for resident to start oxygen therapy 2-4liters per minute via nasal cannula when necessary for shortness of breathe. During an interview on 7/3/25, at approximately 4:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to develop and implement comprehensive care plans for resident and care needs for five of twelve residents. 395653 Page 9 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0656 28 Pa. Code: 211.10(d) Resident care policies. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 211.12 (d)(5) Nursing Services. Residents Affected - Some 395653 Page 10 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility documents, clinical records, and staff interview, it was determined that the facility failed to ensure that the Activities Director accurately completed, and/or directed or delegated the accurate completion of the activities component of the comprehensive assessment and failed to attempt to obtain information on resident preferences from family, significant others, or staff interviews for residents with severe cognitive impairment for 28 of 28 residents (Residents R8, R13, R14, R15, R16, R24, R29, R42, R45, R54, R59, R62, R65, R66, R72, R73, R81, R82, R88, R90, R91, R93, R96, R206, R210, R211, R310, and R311). Residents Affected - Some The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the Life Enrichment Director job description indicated the Director will, Perform administrative requirements, such as completing necessary forms, reports, attending meetings, trainings, consulting, etc., and submitting information to the Administrator or others, as required. Review of the RAI Manual, Section F: Preferences for Customary Routine and Activity, indicated, The intent of items in this section is to obtain information regarding the resident's preferences for their daily routine and activities. This is best accomplished when the information is obtained directly from the resident or through family or significant other, or staff interviews if the resident cannot report preferences. Review of the questions in Section F of the comprehensive assessment include: -How important is it to you to choose what clothes to wear? -How important is it to you to take care of your personal belongings or things -How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? -How important is it to you to have snacks available between meals? -How important is it to you to choose your own bedtime? -How important is it to you to have your family or a close friend involved in discussions about your care? -How important is it to you to be able to use the phone in private? 395653 Page 11 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0680 -How important is it to you to have a place to lock your things to keep them safe? Level of Harm - Minimal harm or potential for actual harm -How important is it to you to have books, newspapers, and magazines to read? -How important is it to you to listen to music you like? Residents Affected - Some -How important is it to you to be around animals such as pets? -How important is it to you to keep up with the news? -How important is it to you to do things with groups of people? -How important is it to you to do your favorite activities? -How important is it to you to go outside to get fresh air when the weather is good? -How important is it to you to participate in religious services or practices? Each of the above questions provided the following options for answers: Very important Somewhat important Not very important Not important at all Important, but can't do or no choice No response or non-responsive During an interview on 7/3/25, at 12:20 p.m. Activities Director Employee E1 confirmed that she is responsible for completing the Activities component of the MDS comprehensive assessment. At this time, it was discussed with Activities Director Employee E1 that eight residents had been reviewed, and all eight residents had answers of Very Important documented for each of the above 16 questions. When asked if it was normal for each of the residents reviewed to have answered all the questions the same, the Activities Director confirmed that those were the answers told to her in the interviews and stated that possibly the eight chosen for review happened to be the same. Review of facility census information revealed that when the survey began, there were 106 residents present in the facility. Review of the clinical records revealed that 100 residents had been admitted to the facility long enough to have a comprehensive assessment completed. Review of the comprehensive assessments revealed the following: Activities Director Employee E1 completed 66 of the 100 assessments for Section F. -(3) assessments have differing answers for the above 16 questions. These assessments were 395653 Page 12 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0680 completed in July and August 2024. Level of Harm - Minimal harm or potential for actual harm -(1) assessment was documented as Not Assessed -(1) assessment had all answers documented as Somewhat Important Residents Affected - Some -(61) assessments, 92.4%, had all answers documented as Very Important Registered Nurse Employee E2 completed 17 of the 100 assessments for Section F. -(7) assessments have differing answers for the above 16 questions. -(10) assessments, 58.8%, had all answers documented as Very Important Registered Nurse Assessment Coordinator Employee E3 completed 15 of the 100 assessments for Section F. -(3) assessments have differing answers for the above 16 questions. -(1) assessment was not completed -(11) assessments, 73.3%, had all answers documented as Very Important Employee E4 completed one of the 100 assessments for Section F, with all answers documented as Very Important. Employee E5 completed one of the 100 assessments for Section F, with all answers documented as Very Important. Review of the clinical record indicated Resident R8 had an Annual MDS completed on 12/11/24, with a BIMS score of 06. Review of Section F, documented as completed by the Registered Nurse Employee E2, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R13 had an admission MDS completed on 1/22/25, with a BIMS score of 00. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R14 had a Significant Change MDS completed on 11/19/24, with a BIMS score of 05. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R15 had an Annual MDS completed on 3/5/25, with a BIMS score of 02. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. 395653 Page 13 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0680 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the clinical record indicated Resident R16 had a Significant Change MDS completed on 2/18/25, with a BIMS score of 03. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R24 had an admission MDS completed on 3/19/25, with a BIMS score of 00. Review of Section F, documented as completed by the Registered Nurse Employee E2, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R29 had a Significant Change MDS completed on 9/24/24, with a BIMS score of 04. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R42 had an Annual MDS completed on 4/29/25, with a BIMS assessment unable to be completed due to the resident being rarely understood. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R45 had an Annual MDS completed on 4/8/25, with a BIMS score of 04. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R54 had a Significant Change MDS completed on 1/15/25, with a BIMS score of 05. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R59 had an Annual MDS completed on 7/30/24, with a BIMS assessment unable to be completed due to the resident being rarely understood. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R62 had an Annual MDS completed on 2/26/25, with a BIMS score of 04. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R65 had an admission MDS completed on 8/12/24, with a BIMS score of 05. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R66 had an admission MDS completed on 5/30/25, with a BIMS score of 00. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. 395653 Page 14 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0680 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the clinical record indicated Resident R72 had an admission MDS completed on 4/3/25, with a BIMS score of 00. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R73 had an Annual MDS completed on 4/30/25, with a BIMS score of 00. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R81 had a Significant Change MDS completed on 9/3/24, with a BIMS score of 00. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R82 had an admission MDS completed on 1/23/25, with a BIMS score of 00.Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R88 had an Annual MDS completed on 6/10/25, with a BIMS score of 05. Review of Section F, documented as completed by the Registered Nurse Assessment Coordinator Employee E3, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R90 had an admission MDS completed on 1/11/25, with a BIMS score of 00. Review of Section F, documented as completed by the Registered Nurse Employee E2, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R91 had an admission MDS completed on 5/24/25, with a BIMS score of 04. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R93 had a Significant Change MDS completed on 2/28/25, with a BIMS assessment unable to be completed due to the resident being rarely understood. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R96 had an admission MDS completed on 4/25/25, with a BIMS score of 00. Review of Section F, documented as completed by the Registered Nurse Assessment Coordinator Employee E3, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R206 had an admission MDS completed on 4/25/25, with a BIMS score of 00. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. 395653 Page 15 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0680 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the clinical record indicated Resident R210 had an admission MDS completed on 6/22/25, with a BIMS score of 07. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R211 had an admission MDS completed on 6/20/25, with a BIMS score of 06. Review of Section F, documented as completed by the Registered Nurse Assessment Coordinator Employee E3, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R310 had an admission MDS completed on 6/14/25, with a BIMS score of 00. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R311 had an admission MDS completed on 6/12/25, with a BIMS score of 04. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. During an interview on 7/3/25, at approximately 4:00 p.m. the Nursing Home Administrator was informed that the facility failed to ensure that the Activities Director accurately completed, and/or directed or delegated the accurate completion of the activities component of the comprehensive assessment and failed to attempt to obtain information on resident preferences from family, significant others, or staff interviews for residents with severe cognitive impairment. 395653 Page 16 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility review of policy, manufacturer's instructions, clinical records and staff interviews, the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for six of 22 residents (R2, R11, R58, R73, R86, and R94). Residents Affected - Some Findings Include: Review of facility policy Diabetic Protocol dated 6/1/25, previously dated 1/1/25, 1/1/24, indicated provider and staff will work together to give appropriate treatment to manage diabetes. The provider will follow up on any acute episodes associated with significant blood glucose level changes and deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. The staff will identify and report complications such as hypoglycemia. Review of the facility Hypoglycemia Policy dated 6/1/25, previously dated 1/1/25, 1/1/24, indicated nursing personnel are responsible for recognizing signs and symptoms of hypoglycemia and responding accordingly. When acute hypoglycemia is suspected, assess mental status (alert, drowsy, uncooperative, or unconscious) and use glucometer to determine the resident's blood sugar level. A blood glucose of 70 mg/dL or less may indicate the need for intervention. If there are no provider orders for specific treatment do the following: -If the resident is conscious and treatment is indicated, give 1 tube of dextrose gel (15 grams). -After 15 minutes, repeat blood sugar and if still under 70 mg/dL, repeat glucose gel. -After 15 minutes repeat blood sugar. If above 70 mg/dL, give a snack of protein and a carbohydrate (ex. ½ sandwich with bread and a protein or crackers and a protein.) Monitor until stable. -If the resident is drowsy or unconscious or is unable or unwilling to consume anything orally, administer glucagon 1 mg subcutaneously. Monitor the resident for 15 minutes after treatment. -If, after 15 minutes, the resident is conscious and able to consume orally, give a snack of a protein and a carbohydrate (ex. ½ a sandwich with bread and a protein or crackers and a protein). Monitor until stable; -If, after 15 minutes the resident still cannot consume anything orally, repeat glucagon 1 mg subcutaneously and call 911. Further review of the policy failed to reveal procedures in the event of a resident experiencing hyperglycemia. Review of the Facility assessment dated [DATE], indicated the facility will provide care for residents diagnosed with diabetes. Review of the United States Food and Drug Administration prescribing information for basaglar insulin (insulin glargine, a long-acting injectable medication to diabetes) dated 12/2015, indicated 395653 Page 17 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0684 basaglar insulin begins to work several hours after administration, the maximum effect of basaglar insulin is approximately 12 hours after administration, and works over 24 hours to lower blood sugar levels. Level of Harm - Immediate jeopardy to resident health or safety Review of the glucometer manufacturer's instructions indicated Low refers to less than 20 mg/dl, and High refers to greater than 600 mg/dl. Residents Affected - Some Review of the clinical record indicated that Resident R73 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/30/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of a physician order for Blood glucose parameters dated 4/17/25, indicated If resident blood glucose 70< initiate Hypoglycemic protocol and Notify MD (Doctor of Medicine). If resident blood glucose 400> Notify MD. Review of Resident R73's plan of care for diabetes dated 4/14/25, indicated Labs as ordered by doctor. Contact md with any abnormalities. Follow facility routines for hypo/hyperglycemic episodes. Review of Resident R73's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up.: 5/29: 539 5/28: 409 5/24: 411 5/21: 453 5/14: 462, notified 8 hours later 5/13: 540 5/11: 565 5/11: 445 5/08: 489 4/30: 412 4/29: 425 4/03: 517 Review of the physician's order dated 6/6/24, indicated to provide insulin lispro on a sliding 395653 Page 18 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0684 scale before meals and at bedtime. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident R73's meal consumption record on 8/25/24, indicated Resident R73 had consumed 50-75% of her lunch. Consumption was documented at 11:01 a.m. Residents Affected - Some Review of Resident R73's blood sugar record indicated a blood sugar assessment on 8/25/24, at 11:55 a.m. of 371. Review of Resident R73's medication administration record for August 2024, indicated Resident R73 received 10 units of insulin lispro, the appropriate amount for a blood sugar of 371, if the blood sugar was assessed prior to eating. Review of a progress note dated 8/25/24, at 3:22 p.m. indicated Resident R73 was not responding to voice, was cold and clammy, and had a decreased level of consciousness. Resident R73's blood sugar was assessed at this time, noted to be 31. Resident R73 was transferred to the hospital by emergency services. Review of a progress note dated 8/25/24, at 10:14 p.m. indicated Resident R73 was admitted to the hospital for hypoglycemia. Review of hospital discharge paperwork dated 8/31/24, indicated, [Resident R73] was found by staff at [facility] with a sugar of 20. Review of a progress note dated 10/6/24, at 4:10 p.m. indicated that Resident R73 had fallen in her room. A blood sugar value was not documented in the note. Review of a progress note dated 10/6/24, at 5:38 p.m. indicated that Resident R73 had fallen in the hall. Resident was walking on the unit and fell. No injuries noted. While taking her vitals, staff noted that her CBG was 523. Resident has a fx (fracture) to R (right) shoulder from a fall about a month ago which is not completely healed. Son requested that she be sent to [hospital] to have her R shoulder evaluated and elevated blood sugar. MD notified. 911 called for transport. Review of hospital discharge paperwork dated 10/6/24, indicated Resident R73's reason for the emergency room visit was a fall, with the diagnosis of hyperglycemia. Review of the clinical record indicated that Resident R11 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and chronic kidney disease (gradual loss of kidney function). Review of physician orders dated 5/25/24, indicated Resident R11 received rapid acting insulin: with breakfast (7:00 a.m. - 10:00 a.m.), with lunch (11:00 a.m. - 12:00 p.m.), and with afternoon med pass (4:00 p.m. - 6:00 p.m.), If CBG <60 give 0 units. 60-100 give 8 units. If CBG >100, give 16 units. Review of Resident R11's plan of care for diabetes initiated 7/26/23, indicated for staff to Monitor for signs of hyperglycemia (blood glucose > 140mg/dl) and administer medications per physician's orders. 395653 Page 19 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Review of Resident R11's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up: 6/27: 480 6/24: 403 Residents Affected - Some 6/17: 533 6/17: 421 6/07: 421 6/07: 508 5/27: 490 5/24: 501 5/24: 430 5/22: 356 5/12: 360 5/11: 400 5/06: 388 5/05: 360 5/04: 369 5/08: 489 4/27: 357 4/18: High 4/15: 424 Review of Resident R11's blood sugar level on 5/29/25 indicated that at 8:26 p.m. Resident R11's blood sugar level was 515, and at 11:19 p.m. was 444. Review of a progress note written by Registered Nurse Supervisor Employee E9 dated 5/29/25, at 11:47 p.m. indicated, Call placed to on call provider for [doctor] in reference to resident blood glucose reading of 515, received 33u (units) of basaglar insulin, recheck performed and blood glucose 444. Spoke with on call physician, given order to transfer resident to ER for evaluation due to elevated blood glucose levels. 395653 Page 20 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of hospital discharge paperwork dated 5/30/25, indicated Resident R11 was seen in the emergency room for hyperglycemia and a urinary tract infection. Review of the physician notification sheet dated 5/29/25, indicated for Resident R11, Returning, had elevated (upward pointed arrow) BGM. During an interview on 7/2/25, at approximately 2:00 p.m. the Director of Nursing confirmed that basaglar insulin would not have an appreciable effect on Resident R11's elevated blood sugar level. Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of a physician order dated 4/2/25, indicated for Resident R2 to sliding scale insulin coverage with meals, and to notify the MD if Resident R2's CBG is less than 60 or greater than 340. Review of Resident R2's plan of care dated 6/13/25, for diabetes indicated Labs as ordered by doctor. Contact md with any abnormalities. Follow facility routines for hypo/hyperglycemic episodes. Review of Resident R2's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up: 6/24: 460 6/24: 387 6/24: 389 6/21: 451 6/20: 394 6/18: 346 6/13: 414 6/03: 401 6/03: 435 5/28: 413 5/28: 477 4/23: 395 4/08: 402 395653 Page 21 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0684 4/08: 516 Level of Harm - Immediate jeopardy to resident health or safety Review of the clinical record indicated that Resident R58 was admitted to the facility on [DATE]. Residents Affected - Some Review of the MDS for Resident R58 dated 6/4/25, included diagnoses of diabetes, acquired absence of right leg below knee (amputation below right knee), unspecified intracranial injury without loss of consciousness (injury to the brain without loss of consciousness, might experience confusion, headache or amnesia). Review of a physician order dated 6/18/25, indicated for Resident R58 a sliding scale insulin coverage with meals, and to notify the MD if Resident R58's CBG is less than 60 or greater than 341. Review of Resident R58's plan of care dated 5/6/25, for diabetes indicated Labs as ordered by doctor. Contact md with any abnormalities. Follow facility routines for hypo/hyperglycemic episodes. Review of Resident R58's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up: 6/29: 371 6/27: 368 6/10: 394 6/04: 434 5/29: 406 5/27: 390 5/24: 395 5/23: 381 5/19: 359 4/29: 401 4/23: 355 4/22: 358 4/20: 373 4/09: 378 4/07: 386 4/01: 350 395653 Page 22 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0684 Review of the clinical record indicated that Resident R86 was admitted to the facility on [DATE]. Level of Harm - Immediate jeopardy to resident health or safety Review of the MDS for Resident R86 dated 6/3/25, included diagnoses of diabetes, high blood pressure, osteomyelitis of vertebrae, thoracic region (bone infection in the middle back). Residents Affected - Some Review of a physician order dated 4/17/25, indicated for Resident R86 a sliding scale insulin coverage with meals, and to notify the MD if Resident R86's CBG is less than 60 or greater than 340. Review of Resident R86's plan of care dated 5/8/25, for diabetes indicated Labs as ordered by doctor. Contact md with any abnormalities. Follow facility routines for hypo/hyperglycemic episodes. Review of Resident R86's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up: 6/10: 350 6/04: 351 5/04: 350 5/03: 396 4/19: 403 4/19: 366 4/19: 371 4/17: 388 4/11: 345 4/05: 371 Review of the clinical record indicated that Resident R94 was admitted to the facility on [DATE]. Review of the MDS for Resident R94 dated 6/3/25, included diagnoses of diabetes, history of falling, fracture of left femur (a break in the long bone in upper leg). Review of a physician order dated 4/17/25, indicated for Resident R94 a sliding scale insulin coverage with meals, and to notify the MD if Resident R94's CBG is less than 70 or greater than 350. Review of Resident R94's plan of care dated 5/15/25, for diabetes indicated Labs as ordered by doctor. Contact md with any abnormalities. Follow facility routines for hypo/hyperglycemic episodes. Review of Resident R94's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up: 6/20: 360 395653 Page 23 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0684 6/10: LOW (no repeat conducted) Level of Harm - Immediate jeopardy to resident health or safety 6/07: 419 Residents Affected - Some 4/18: 417 5/10: LOW (no repeat conducted) 4/18: 403 The Nursing Home Administrator (NHA) and the DON were made aware that an Immediate Jeopardy situation existed for residents on 7/1/25, at 12:50 p.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time. On 7/1/25, at 2:30 p.m. an acceptable Corrective Action Plan was received which included the following interventions: After record review, it was determined that [the facility] failed to notify the physician of blood sugars out of range timely for six residents and care plans were absent or did not include approaches for diabetic emergency management. Immediate Actions: -Resident R73, R11, R2, R94, R86, R58 was assessed by the Director of Nursing on 07/01/2025 at 1325. Residents R73, R11, R2, R94, R86, and R58 had no s/s hyperglycemia at that time. -Education was initiated on 07/01/2025 with facility RN's and LPN's on the Diabetic Protocol, the Hypoglycemia policy, and the Resident Change in Condition policy to include hyperglycemia is a change in condition, and notifications to the physician of blood sugars out of range. The facility is currently not using any agency staff. Moving forward, if any agency RN or LPN need to be utilized, they will be educated on the diabetic protocol before their first day of work. -On 07/01/2025, Residents R73, R11, R2, R86, R58's blood sugars were reviewed from the past 24 hours to ensure none were out of range without physician notification. -On 07/01/2025, an ad hoc QAPI committee meeting was held, and the medical director was made aware of the findings. Like Residents: -Current residents with diabetes have the potential to be affected. Current residents with diabetes were reviewed on 07/01/2025 by the DON to determine if blood sugars were out of range and none were noted out of range. Correction of System: -Root cause analysis completed by the center QAPI committee on 07/01/2025 and determined failure to follow the Resident Change in Condition policy led to the allegation. 395653 Page 24 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some -To prevent recurrence, the Director of Nursing initiated education with facility RN's and LPN's on 07/01/2025 on the Diabetic Protocol, the Hypoglycemia policy, and the Resident Change in Condition policy to include hyperglycemia is a change in condition and notification of the physician of blood sugars out of range. RN's and LPN's that were not on duty received education via phone and will receive in person education on their next scheduled shift. -Moving forward any new RN's and LPN's hired will be educated on the Resident Change of Condition policy, the Diabetic Protocol, and the Hypoglycemia policy in orientation by the Director of Nursing/ designee. Monitoring: -To monitor and maintain compliance, the Director of Nursing/ designee will review blood sugars daily x 2 weeks, 3x a week x 2 week and then weekly x 2 weeks to determine if any blood sugars were out of range and notifications made. If notification not documented, the physician will be contacted at the time of discovery and notified and new orders implemented as needed. -To monitor and maintain compliance, new admissions/ readmissions with diabetes will be reviewed by the DON/ designee to ensure a care plan is implemented for diabetes including approaches for diabetic emergency management 5 x a week for 2 weeks, then weekly x 3 weeks. -Results of the audits will be forwarded to the center QAPI committee for review and recommendations. On 7/2/25, care plans for affected residents were reviewed, and confirmed they were corrected to show goals and interventions related to diabetes and blood glucose monitoring. On 7/2/25, the whole house audit was reviewed by surveyors, revealing its completion and accuracy. During interviews beginning at approximately 8:30 a.m. on 7/2/25, four of four LPNs on duty were able to describe the correct procedure for documenting, monitoring, and needs of notification for blood sugars outside of the ordered parameters. During interviews beginning at approximately 1:30 p.m. on 7/2/25, one of one RN on duty was able to describe the correct procedure for documenting, monitoring, and needs of notification for blood sugars outside of the ordered parameters. The Immediate Jeopardy was removed on 7/2/25, at 11:08 p.m. when the action plan implementation was verified. During an interview on 7/3/25, at approximately 3:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for six of 22 residents. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. 395653 Page 25 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights or act upon weight changes for four of twelve residents (Residents R14, R36, R66, and R94). Residents Affected - Few Finding include: Review of the facility policy, Resident Policy dated 6/1/25, and 1/1/25, indicated it is the policy of the facility to obtain weights routinely in order to monitor nutritional health over time. Each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified, or as ordered. Review of Resident R14's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS-periodic assessment of care needs) assessment dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), cerebral infarction due to unspecified occlusion or stenosis of cerebral artery (a stroke caused by a blockage or narrowing of a blood vessel in the brain, where the specific cause of the blockage is unknown), hemiplegia (loss of motor skills on one side of the body), unspecified dementia, severe with anxiety (a cognitive decline is evident, but the specific type of dementia cannot be identified). Review of physician's order dated 2/4/25, indicated for the facility to obtain Resident R14's weight monthly, on the first of the month. Review of Resident R14's weight record from 2/7/25, through 6/6/25, revealed the following: 2/7/25: 188.4 pounds 3/1/25: 189.3 pounds 4/1/25: 189.3 pounds 5/1/25: 188.0 pounds 6/6/25: 217.0 pounds No further notes were documented after 6/6/25. Review of Resident R14's clinical record indicated that on 6/9/25, Resident R14's weight was captured by Optum Healthcare, and the nurse practitioner note stated, per facility documentation she has gained 29# x1 month-needs reweighed, weights had been stable at 188 pounds previously. Review of Resident R14's clinical record indicated as of 6/6/25, Resident R14's weight was not captured by the physcian or the registered dietitian. 395653 Page 26 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0692 Review of the clinical record indicated Resident R36 was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of the minimum MDS dated [DATE], included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), anemia (too little iron in the body causing fatigue), and history of a stroke. Residents Affected - Few Review of Resident R36's weight record revealed the following: -4/01/25 - 155.5 pounds -4/08/25 - 156.0 pounds -6/02/25 - 175.0 pounds -6/19/25 - 141.2 pounds -6/26/25 - 125.8 pounds Review of progress notes from 6/19/25, through 7/3/25, failed to include documentation that Resident R36's weight loss was verified as accurate or addressed by the physician or registered dietitian. Review of a nurse practitioner note dated 6/17/25, at 10:27 p.m. failed to include information that Resident R36's documented weight loss was evaluated for accuracy or addressed. This note was electronically signed by MD Employee E6 on 6/21/25, at 10:28 p.m. Review of a physician's 60 day recapitulation note dated 7/1/25, at 10:14 a.m. indicated, No concerns from staff. This note failed to include information that Resident R36's documented weight loss was evaluated for accuracy or addressed. Review of Resident R66's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R66's MDS dated [DATE], included diagnoses of metabolic encephalopathy (a brain dysfunction caused by an underlying medical condition that disrupts the body's metabolism), chronic obstructive pulmonary disease (COPD-a group of progressive lung disorders characterized by increasing breathlessness), dementia(a group of symptom that affects memory, thinking and interferes with daily life), and diabetes(a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of physician's orders dated 5/26/25, through 6/29/25, and 5/28/25, through 7/1/25, indicated for the facility to obtain Resident R66's obtain weight on admission, then weekly x 4 weeks, once a day on Tuesday. Review of Resident R66's weight record from 5/27/25, through 6/26/25, revealed the following: 5/27/25: 168.8 pounds 5/29/25: 168.8 pounds 6/3/25: 166.0 pounds 395653 Page 27 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0692 6/5/25: 154.6 pounds Level of Harm - Minimal harm or potential for actual harm 6/6/25: 175.4 pounds 6/12/25: 173.0 pounds Residents Affected - Few 6/17/25: 170.0 pounds 6/19/25: 166.0 pounds 6/24/25: 150.6 pounds 6/26/25: 147.0 pounds No further notes were documented after 6/26/25. Review of Resident R66's clinical record indicated that on 6/12/25, Resident R66's weight was captured by Licensed Nutrition Health Aide (LNHA) with clinical note stating, Current weight-175.4, Are there any concerns with the residents weight:-No, If Yes, please note weight concerns-NA, Does the resident have supplementation ordered-No. Review of Resident R66's clinical record indicated as of 6/26/25, Resident R66's weight was not captured by the physcian or the registered dietician. Review of Resident R94's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R94's MDS dated [DATE], included diagnoses of dementia, fracture of left femur (break in the long bone in the upper part of the leg), history of falling, diabetes. Review of physician's orders dated 2/27/25, through 3/12/25 and 3/17/25, through 4/20/25, obtain weight upon admission then weekly x 4 weeks. Review of physician order dated 6/19/25, stated to weigh monthly 1x a day the 1st of every month. Review of Resident R94's weight record from 2/27/25, through 6/6/25, revealed the following: 2/27/25: 103.6 pounds 3/6/25: Not taken 3/11/25: 117.0 pounds 3/18/25: 103.0 pounds 3/25/25: 109.0 pounds 4/1/25: 109.0 pounds 4/8/25: 106.0 pounds 395653 Page 28 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0692 6/6/25: 139.4 pounds Level of Harm - Minimal harm or potential for actual harm No further notes were documented after 6/6/25. Residents Affected - Few Review of Resident R94's clinical record indicated as of 6/6/25, Resident R94's weight was not captured by the physcian or the registered dietitian. During an interview on 7/3/25, at 1:22 p.m. the Medical Director, Employee E6 confirmed that the nursing staff leaves him information in a binder regarding weights, he reviews this information during his assessments of the residents but acknowledged that no documentation occurred as to a plan of care for the weight gain/weight loss of five of twelve residents. During an interview on 7/3/25, at 2:55 p.m. the Registered Dietetic (DTR) Employee E10 confirmed that the facility failed to properly monitor weight and nutrition status by failing to obtain weights or act upon weight changes for five of twelve residents. 395653 Page 29 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for one of three sampled residents (Resident R203). Residents Affected - Few Findings include: The facility policy Oxygen Administration (all routes) Policy last reviewed 6/1/25 and 1/1/25, indicated licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider. In an emergency situation, clinicians may administer oxygen and obtain a provider's order as soon as practicably possible after patient stabilization or transfer. Review of Resident R203's admission record indicated she was admitted on [DATE]. Review of Resident R203's Minimum Data Set (MDS -a periodic assessment of resident care needs) dated 6/18/25, indicated that she had diagnoses that included diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), COPD (Chronic Obstructive Pulmonary Disease- a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), obstructive and reflux uropathy (two distinct conditions where one blocks the flow of urine and the other causes urine to back up into the kidneys), high blood pressure. Review of Resident R203's orders, baseline care plan and admission MDS revealed that the resident's need for oxygen was not captured. During observations on 7/1/25 at 9:30 a.m. Resident R203 observed with nasal cannula in place and oxygen set to 4 liters per minuted then 7/3/25 at 11:30 a.m. Resident R203 was observed with a nasal cannula in place, clinical record documented that oxygen was on for both observations. During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 7/3/25 at approximately 2:30 p.m. confirmed that the facility failed to provide clinician competence with administering oxygen via the specified route, obtaining an order by a provider, care planning the resident according to diagnoses relevant to oxygen usage and capturing oxygen need on MDS. 28 Pa. Code 201.29(i) Resident Rights. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395653 Page 30 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of three residents (Residents R20 and R61). Residents Affected - Few Findings include: Review of the facility policy Hemodialysis Care Policy dated 1/1/25 and 6/1/25, indicates communication between the dialysis provider and facility staff will occur before and after each hemodialysis treatment and as needed. Pre-dialysis process: document assessment in the Dialysis Communication Tool vital signs, pre-treatment weight (unless performed at dialysis) medication adminstered before treatment, time of last meal, fluid intake and any additional alerts or information. Tool to be sent with resident to dialysis. Post-dialysis process: receive report from dialysis provider and or review Dialysis Communication Tool documentation by dialysis provider. Information post-dialysis will include: vital signs, post-treatment weight (unless to be completed by skilled nursing facility), lab draws and/or results, medication administered during or after treatment, any new orders, additional alerts or information, meal and/or fluids consumed at dialysis. Review of the admission record indicated Resident R20 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident R20's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/21/25, indicated diagnoses offend stage renal disease (condition where kidneys lose the ability to remove waste and balance fluids), intellectual disabilities, anemia (too little iron in the blood), and dependence on renal dialysis (treatment to replace the function of the kidneys). Review of Resident R20's physician orders dated 5/3/25, indicated dialysis: Monday, Wednesday, and Friday at [dialysis vendor]. Chair time scheduled at 11:15 a.m. Review of Resident R20's current care plan indicated dialysis three times a week, treatments as scheduled: Monday, Wednesday, and Friday at [dialysis vendor]. Chair time at 11:15 a.m. Dialysis folder (communication) to be given to driver, not resident. Resident has her own separate folder she can color/write in. Review of Resident R20's dialysis communication forms indicated the following: 7/2/25 and 6/30/25 dialysis communication forms were incomplete. 6/27/25 dialysis form failed to be present. 6/25/25 and 6/23/25 dialysis communication forms were incomplete. 6/20/25 dialysis forms failed to be present. 6/18/25, 6/16/25, 6/13/25, 6/11/25, 6/7/25, 6/4/25 and 6/2/25 dialysis communication forms were incomplete. 395653 Page 31 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0698 Review of the admission record indicated Resident R61 was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident R61's MDS dated [DATE], indicated diagnoses of right below the knee amputation, high blood pressure, anemia (too little iron in the blood), and dependence on renal dialysis (treatment to replace the function of the kidneys). Residents Affected - Few Review of Resident R61's physician orders dated 2/24/25 and 4/24/25, indicated dialysis: Monday, Wednesday, and Friday at dialysis vendor. Chair time scheduled at 6:30 a.m. Review of Resident R61's current care plan indicated dialysis three times a week, treatments as scheduled: Monday, Wednesday, and Friday at dialysis vendor. Chair time at 6:30 a.m. Review of Resident R61's dialysis communication forms indicated the following: 6/30/25, dialysis form failed to be present. 6/13/25, 6/18/25, and 6/25/25 dialysis communication forms were incomplete. 5/2/25 and 5/7/25, dialysis form failed to be present. 5/5/25, 5/9/25, 5/14/25, 5/23/25, 5/23/25, 5/26/25, and 5/28/25 dialysis communication forms were incomplete. (April 2025 resident was hospitalized ) 3/10/25 and 3/24/25 forms failed to be present. 3/5/25, 3/14/25, and 3/17/25 dialysis communication forms were incomplete. Interview on 7/3/25, at 1:00 p.m. the Director of Nursing confirmed the facility failed to make certain consistent dialysis communication was maintained for two of three residents (Residents R20 and R61). 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(2)(3) Nursing services 395653 Page 32 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review facility documents, clinical records, and staff and resident interviews it was determined that the facility failed to ensure the physician reviewed the resident's total program of care for one of eight residents (Resident R36).Findings include:Review of the Facility assessment dated [DATE], previously dated 2/27/25, indicated the facility will ensure resident health and safety by assessing needs and matching those needs to facility staff and other resources. Review of the facility provided, Medical Director's Responsibilities Checklist indicated that the Medical Director (MD Employee E6) will coordinate medical care in the facility and ensure the appropriateness and quality of medical care and medically related care.Review of the clinical record indicated Resident R36 was admitted to the facility on [DATE].Review of the minimum MDS dated [DATE], included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), anemia (too little iron in the body causing fatigue), and history of a stroke.Review of Resident R36's weight record revealed the following:-4/01/25 - 155.5 pounds-4/08/25 - 156 pounds-6/02/25 - 175 pounds-6/19/25 - 141.2 pounds-6/26/25 - 125.8 poundsReview of progress notes from 6/19/25, through 7/3/25, failed to include documentation that Resident R36's weight loss was verified as accurate or addressed by the physician or registered dietician.Review of a nurse practitioner note dated 6/17/25, at 10:27 p.m. failed to include information that Resident R36's documented weight loss was at 10:28 p.m. Review of a physician's 60 day recap note dated 7/1/25, at 10:14 a.m. indicated, No concerns from staff. This note failed to include information that Resident R36's documented weight loss was evaluated for accuracy or addressed.During an interview on 7/3/25, at 1:22 p.m. MD Employee E6 stated that he relies on nursing staff to put information in the communication log regarding weight changes, but during his recap visits he reviews all available information.During an interview on 7/5/25, at approximately 4:00 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure the physician reviewed the resident's total program of care for one of eight residents.28 Pa. Code; 211.12(a)(c)(d)(1)(3)(5) Nursing Services.28 Pa. Code 211.2(a) Physician Services28 Pa. Code: 211.5 (f)(g)(h) Clinical records. 395653 Page 33 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health services to maintain the highest practicable well-being for one of eight residents (Resident R43). Findings include: The facility Behavior Management Program policy reviewed on 1/1/25 and 6/1/25, includes, the facility will assess and track a behavior(s) that negatively impacts each resident regarding their quality of life. The interdisciplinary team (IDT) will conduct record review. The IDT will review newly identified behaviors during risk rounds to ensure appropriate documentation in in place for new behaviors and/or different behaviors for a resident. The IDT will conduct a clinical record review. The IDT will complete behavior/psychotropic review form and identify the root cause for the behavior utilizing the behavioral management care paths. The resident with identified behaviors will be followed at the weekly resident review meetings. The weekly review meetings the IDT will discuss interventions, medication management, staff education and update/imitate care plans and document in clinical record. Review of Resident R43's admission record indicated he was originally admitted on [DATE]. Review of Resident R43's Minimum Data Set (MDS - a periodic assessment of care needs) assessment dated [DATE], indicated diagnoses included atrial fibrillation (irregular heart rhythm), morbid (severe) obesity (obesity associated with a higher risk of serious health issues), and diabetes. Review of Resident R43's History and Physical (medical examination, assesses overall condition and medical history) dated 7/4/23, reveals a diagnosis of depression (mood disorder, affects how you feel, think, and behave). Review of Resident R43's physician orders dated 8/16/23 Resident R43 was ordered Cymbalta (antidepressant used to treat major depressive disorder, anxiety and chronic pain). Review of Resident R43's physician progress note dated 9/7/23 the resident is on Cymbalta for depression and suicidal thoughts from November of 2022. Review of Resident R43's MDS completed on 5/12/25 Section D: Mood D0150 indicated Resident R43 reported feeling down, depressed, or hopeless two to six days over the last two weeks. Review of Section E: Behavior E0200 indicated the following behaviors have not been exhibited: A. physical behaviors directed toward others (hitting, kicking, pushing, grabbing, abusing others sexually). B. verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others). C. other behavioral symptoms not directed toward others (self-harm behavior verbal/vocal symptoms like screaming). Review of Resident 43's progress notes from 1/1/25 thru 6/30/25 revealed Resident 43's summary of documented behavior events on the following dates. 1/7/25 resident yelling at staff regarding staffing. 395653 Page 34 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0740 2/15/25 resident yelling to get him out of bed, requesting specific staff. Level of Harm - Minimal harm or potential for actual harm 3/1/25 resident yelling and called 911 for his electric wheelchair (facility removed for safety and maintenance) a manual chair provided and explained to resident prior to the 911 call. Residents Affected - Few 3/12/25 resident yelling and verbally aggressive to staff for taking too long to respond. 4/9/25 resident verbally aggressive to Resident R61 and Resident R43 placed hand on Resident R61's wheelchair and moved the resident causing Resident R61 to express frustration and anxiety. 4/27/25 resident yelling and verbally abusive to staff for someone to do his laundry, resident begins making barking noises at the nurse supervisor. 4/27/25 resident agitated, Resident R43 was chasing a female Resident R61 down the hall. 5/2/25 resident yelling at the nursing assistant and attempting to hit the nursing assistant with his wheelchair. 6/7/25 resident yelling obscenities toward staff and stated he was going to throw self out of bed if they don't get him up now, resident reportedly slid out of bed to the floor. Resident R43 informed staff he will do this again. 6/21/25 resident yelling and verbally abusive to staff for how they provide his care. Resident went to the nursing supervisor's office and Resident R43 began punching at the door and screaming obscenities at the nursing supervisor. Review of Resident R43's point of care history revealed on 6/7/2025, resident threatened to kill the staff member once the staff member got him out of bed. Review of Resident 43's social services notes from 1/1/25 thru 6/30/25 revealed, 2/13/25 Quarterly assessment, ARD 2/12/25. Resident is alert and oriented. Makes his needs and wants known. Understands/understood. He is independent with daily decision making. He is OOB to electric w/c daily. Needs assistance with some ADLs. Attends activities of choice. Continues to be appropriate for long term care. 4/11/25 Met with resident to see how he was doing after the incident he had yesterday with his foot and another resident. He said he was fine. Told him if he needs anything to please let me know. 4/23/25 Spoke with resident to see how he was doing after the incident the day prior. He said he was doing fine. 4/24/25 Stopped in to see resident this morning in his room to see how he was doing. He was doing good. 5/13/25 Annual ARD 5/12/25. Resident is alert and oriented. Makes his needs and wants known. Understands/understood. Independent with daily decision making. OOB to electric w/c daily. Needs assistance with some ADLs. Attends activities of choice. Continues to have behaviors at times. Continues to be appropriate for LTC. He had received his 30-day notice in March but is going through an appeal 395653 Page 35 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0740 process and waiting for the judge's decision. Level of Harm - Minimal harm or potential for actual harm Review of physician orders dated 6/21/25 indicated a consult to social services as needed prn (as needed) for aggressive/combative behavior. Residents Affected - Few Review of Resident R43's care plans dated 10/18/23, indicated resident exhibits socially inappropriate disruptive behavioral symptoms: (verbal aggression towards staff at times and episodes of touching female staff inappropriately. Resident R43's care plan did not indicate behavioral health assistance, related to the Resident R43's actions and threats of self-abuse, physical, verbal abuse, and threats to others. During an interview on 7/1/25, 8:45 a.m. Resident R43 stated, the staff say I yell at them but it's not true. With further discussion, Resident R43 reported when things are not done the way or in the time he wants them, the hollering starts. Further review of Resident R43's clinical record lacked evidence that the facility provided, attempted to provide, arrange, or request ancillary services such as behavioral health care for the resident behaviors. This includes the threats and actions taken by the resident to do harm to self, other residents, or staff. During an interview on 7/3/25, at 3:50 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to provide sufficient and timely social services to meet the residents needs for one of eight residents (Resident R43). 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(c)(d)(3) Nursing services 28 Pa. Code 211.16(a) Social services 395653 Page 36 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health services to maintain the highest practicable well-being for one of eight residents (Resident R43). Findings include: The facility Behavior Management Program policy reviewed on 1/1/25 and 6/1/25, includes, the facility will assess and track a behavior(s) that negatively impacts each resident regarding their quality of life. The interdisciplinary team (IDT) will conduct record review. The IDT will review newly identified behaviors during risk rounds to ensure appropriate documentation in in place for new behaviors and/or different behaviors for a resident. The IDT will conduct a clinical record review. The IDT will complete behavior/psychotropic review form and identify the root cause for the behavior utilizing the behavioral management care paths. The resident with identified behaviors will be followed at the weekly resident review meetings. The weekly review meetings the IDT will discuss interventions, medication management, staff education and update/imitate care plans and document in clinical record. Review of Resident R43's admission record indicated he was originally admitted on [DATE]. Review of Resident R43's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/12/25, included diagnoses of atrial fibrillation (irregular heart rhythm), morbid (severe) obesity (obesity associated with a higher risk of serious health issues), and diabetes. Review of Resident R43's History and Physical (medical examination, assesses overall condition and medical history) dated 7/4/23, reveals a diagnosis of depression (mood disorder, affects how you feel, think, and behave). Review of Resident R43's physician orders dated 8/16/23 Resident R43 was ordered Cymbalta (antidepressant used to treat major depressive disorder, anxiety and chronic pain). Review of Resident R43's physician progress note dated 9/7/23 the resident is on Cymbalta for depression and suicidal thoughts from November of 2022. Review of Resident R43's MDS completed on 5/12/25 Section D: Mood D0150 indicated Resident R43 reported feeling down, depressed, or hopeless two to six days over the last two weeks. Review of Section E: Behavior E0200 indicated the following behaviors have not been exhibited: A. physical behaviors directed toward others (hitting, kicking, pushing, grabbing, abusing others sexually). B. verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others). C. other behavioral symptoms not directed toward others (self-harm behavior verbal/vocal symptoms like screaming). Review of Resident 43's progress notes from 1/1/25 thru 6/30/25 revealed Resident 43's summary of documented behavior events on the following dates. 395653 Page 37 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0742 1/7/25 resident yelling at staff regarding staffing. Level of Harm - Minimal harm or potential for actual harm 2/15/25 resident yelling to get him out of bed, requesting specific staff. Residents Affected - Few 3/1/25 resident yelling and called 911 for his electric wheelchair (facility removed for safety and maintenance) a manual chair provided and explained to resident prior to the 911 call. 3/12/25 resident yelling and verbally aggressive to staff for taking too long to respond. 4/9/25 resident verbally aggressive to Resident R61 and Resident R43 placed hand on Resident R61's wheelchair and moved the resident causing Resident R61 to express frustration and anxiety. 4/27/25 resident yelling and verbally abusive to staff for someone to do his laundry, resident begins making barking noises at the nurse supervisor. 4/27/25 resident agitated, Resident R43 was chasing a female Resident R61 down the hall. 5/2/25 resident yelling at the nursing assistant and attempting to hit the nursing assistant with his wheelchair. 6/7/25 resident yelling obscenities toward staff and stated he was going to throw self out of bed if they don't get him up now, resident reportedly slid out of bed to the floor. Resident R43 informed staff he will do this again. 6/21/25 resident yelling and verbally abusive to staff for how they provide his care. Resident went to the nursing supervisor's office and Resident R43 began punching at the door and screaming obscenities at the nursing supervisor. Review of Resident R43's point of care history revealed on 6/7/2025, resident threatened to kill the staff member once the staff member got him out of bed. Review of Resident 43's social services notes from 1/1/25 thru 6/30/25 revealed, 2/13/25 Quarterly assessment, ARD 2/12/25. Resident is alert and oriented. Makes his needs and wants known. Understands/understood. He is independent with daily decision making. He is OOB to electric w/c daily. Needs assistance with some ADLs. Attends activities of choice. Continues to be appropriate for long term care. 4/11/25 Met with resident to see how he was doing after the incident he had yesterday with his foot and another resident. He said he was fine. Told him if he needs anything to please let me know. 4/23/25 Spoke with resident to see how he was doing after the incident the day prior. He said he was doing fine. 4/24/25 Stopped in to see resident this morning in his room to see how he was doing. He was doing good. 5/13/25 Annual ARD 5/12/25. Resident is alert and oriented. Makes his needs and wants known. Understands/understood. Independent with daily decision making. OOB to electric w/c daily. Needs 395653 Page 38 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assistance with some ADLs. Attends activities of choice. Continues to have behaviors at times. Continues to be appropriate for LTC. He had received his 30-day notice in March but is going through an appeal process and waiting for the judge's decision. Review of physician orders dated 6/21/25 indicated a consult to social services as needed for aggressive/combative behavior. Review of Resident R43's care plans dated 10/18/23, indicated resident exhibits socially inappropriate disruptive behavioral symptoms: (verbal aggression towards staff at times and episodes of touching female staff inappropriately. Resident R43's care plan did not indicate behavioral health assistance, related to the Resident R43's actions and threats of self-abuse, physical, verbal abuse, and threats to others. During an interview on 7/1/25, 8:45 a.m. Resident R43 stated, the staff say I yell at them but it's not true. With further discussion, Resident R43 reported when things are not done the way or in the time he wants them, the hollering starts. Further review of Resident R43's clinical record lacked evidence that the facility provided, attempted to provide, arrange, or request ancillary services such as behavioral health care for the resident behaviors. This includes the threats and actions taken by the resident to do harm to self, other residents, or staff. During an interview on 7/3/25, at 3:50 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to ensure a resident received appropriate behavioral health services to maintain the highest practicable well-being for one of eight residents (Resident R43). 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395653 Page 39 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical records, resident, and staff interviews, it was determined that the facility failed to provide sufficient and timely social services to meet the residents needs for one of eight residents (Resident R43). Residents Affected - Few Findings include: Review of the facility's Social Service Job Description indicated the social worker: Plan develop, organize, implement, evaluate, supervise and direct the social services program of the community including coordination with all departments to provide suitable social services. Keep abreast of current federal and stat regulations, as well as professional standards of practice, and make recommendations on changes in policies and procedures to the administrator. Complete assessments and devise, review and revise comprehensive care plans. Ensure that all charted social service progress notes and all documentation is accurate, informative and descriptive of the services provided and of the resident's response to the services Coordinates ancillary services for the residents. Review of Resident R43's admission record indicated he was originally admitted on [DATE]. Review of Resident R43's Minimum Data Set: (MDS - a periodic assessment of care needs) dated 5/12/25, indicated diagnoses included atrial fibrillation (irregular heart rhythm), morbid (severe) obesity (obesity associated with a higher risk of serious health issues), and diabetes. Review of Resident R43's History and Physical (medical examination, assesses overall condition and medical history) dated 7/4/23, reveals a diagnosis of depression (mood disorder, affects how you feel, think, and behave). Review of Resident R43's physician orders dated 8/16/23 Resident R43 was ordered Cymbalta (antidepressant used to treat major depressive disorder, anxiety, and chronic pain). Review of Resident R43's physician progress note dated 9/7/23 the resident is on Cymbalta for depression and suicidal thoughts from November of 2022. Review of Resident R43's MDS completed on 5/12/25 Section D: Mood D0150 indicated Resident R43 reported feeling down, depressed, or hopeless two to six days over the last two weeks. Review of Section E: Behavior E0200 indicated the following behaviors have not been exhibited: A. physical behaviors directed toward others (hitting, kicking, pushing, grabbing, abusing others sexually). B. verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others). C. other behavioral symptoms not directed toward others (self-harm behavior verbal/vocal symptoms like screaming). Review of Resident 43's progress notes from 1/1/25 thru 6/30/25 revealed Resident 43's summary of documented behavior events on the following dates. 1/7/25 resident yelling at staff regarding staffing. 2/15/25 resident yelling to get him out of bed, requesting specific staff. 395653 Page 40 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3/1/25 resident yelling and called 911 for his electric wheelchair (facility removed for safety and maintenance) a manual chair provided and explained to resident prior to the 911 call. 3/12/25 resident yelling and verbally aggressive to staff for taking too long to respond. 4/9/25 resident verbally aggressive to Resident R61 and Resident R43 placed hand on Resident R61's wheelchair and moved the resident causing Resident R61 to express frustration and anxiety. 4/27/25 resident yelling and verbally abusive to staff for someone to do his laundry, resident begins making barking noises at the nurse supervisor. 4/27/25 resident agitated, Resident R43 was chasing a female Resident R61 down the hall. 5/2/25 resident yelling at the nursing assistant and attempting to hit the nursing assistant with his wheelchair. 6/7/25 resident yelling obscenities toward staff and stated he was going to throw self out of bed if they don't get him up now, resident reportedly slid out of bed to the floor. Resident R43 informed staff he will do this again. 6/21/25 resident yelling and verbally abusive to staff for how they provide his care. Resident went to the nursing supervisor's office and Resident R43 began punching at the door and screaming obscenities at the nursing supervisor. Review of Resident R43's point of care history revealed on 6/7/2025, resident threatened to kill the staff member once the staff member got him out of bed. Review of Resident 43's social services notes from 1/1/25 thru 6/30/25 revealed, 2/13/25 Quarterly assessment, ARD 2/12/25. Resident is alert and oriented. Makes his needs and wants known. Understands/understood. He is independent with daily decision making. He is OOB to electric w/c daily. Needs assistance with some ADLs. Attends activities of choice. Continues to be appropriate for long term care. 4/11/25 Met with resident to see how he was doing after the incident he had yesterday with his foot and another resident. He said he was fine. Told him if he needs anything to please let me know. 4/23/25 Spoke with resident to see how he was doing after the incident the day prior. He said he was doing fine. 4/24/25 Stopped in to see resident this morning in his room to see how he was doing. He was doing good. 5/13/25 Annual ARD 5/12/25. Resident is alert and oriented. Makes his needs and wants known. Understands/understood. Independent with daily decision making. OOB to electric w/c daily. Needs assistance with some ADLs. Attends activities of choice. Continues to have behaviors at times. Continues to be appropriate for LTC. He had received his 30-day notice in March but is going through an appeal process and waiting for the judge's decision. 395653 Page 41 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of physician orders dated 6/21/25 indicated a consult to social services as needed for aggressive/combative behavior. Review of Resident R43's care plans dated 10/18/23, indicated resident exhibits socially inappropriate disruptive behavioral symptoms: (verbal aggression towards staff at times and episodes of touching female staff inappropriately. Resident R43's care plan did not indicate behavioral health assistance, related to the Resident R43's actions and threats of self-abuse, physical, verbal abuse, and threats to others. During an interview on 7/1/25, 8:45 a.m. Resident R43 stated, the staff say I yell at them but it's not true. With further discussion, Resident R43 reported when things are not done the way or in the time he wants them, the hollering starts. Further review of Resident R43's clinical record lacked evidence that the social worker provided, attempted to provide, arrange, or request ancillary services such as behavioral health care for the resident behaviors. This includes the threats and actions taken by the resident to do harm to self, other residents, or staff. During an interview on 7/3/25, at 3:50 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to provide sufficient and timely social services to meet the residents needs for one of eight residents (Resident R43). 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.16 (a)(1) Social services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395653 Page 42 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on review of clinical records and staff interview, it was determined that the facility failed to provide documentation of medication regimen reviews (MRR) completed at least monthly for two of five residents (Resident R22 and R34). This was identified as past non-compliance. Finding include: On 7/2/25, the MRRs for Residents R22 and R34 were requested, for the months of January through June 2025. On 7/3/25, the facility provided information that the Quality Assurance and Performance Improvement (QAPI) program members had identified that pharmacy recommendations were not being completed timely. Review of the performance improvement plan developed on 4/24/25, included: -The Director of Nursing (DON) will begin to receive all pharmacy reports and recommendations. -Medical Records staff will ensure any recommendations that re received are handed directly to the ADON (Assistant Director of Nursing) or the DON. -Once the recommendation is received, it will be reviewed by a physician and returned. The ADON/DON will review and complete adjustments as necessary. -Audits will be completed monthly for three months with results reviewed by the QAPI committee. During an interview on 7/3/25, at 12:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide documentation of medication regimen reviews completed at least monthly. This was identified as past non-compliance. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.5(f) Medical records. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. 395653 Page 43 of 44 395653 07/03/2025 Woodhaven Health & Rehab Center 2400 McGinley Road Monroeville, PA 15146

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications and/or biologicals in one of two medication rooms (First Floor Medication Room). Findings include: Review of facility policy Storage and Expiration Dating of Medications and Biologicals dated [DATE], previously dated [DATE], indicated that medications and biologicals that have been retained longer than recommended by manufacturer or supplier guidelines are stored separate from other medications until destroyed. During an observation on [DATE], at 9:25 a.m. of the First Floor Medication Room the following was observed: (4) petroleum gauze dressing with an expiration date of 06/2023 (2) Aquacel Advantage dressing with an expiration date of [DATE] (3) Aquacel Extra dressing with an expiration date of [DATE] (1) tube Zinc Oxide ointment (1 ounce) with an expiration date of 04/2024 (1) Vacutainer Transfer Straw Kit with an expiration date of 01/2025 (5) Puracol Ultra Powder with an expiration date of [DATE] (2) Lemon Glycerin Swabs with an expiration date of 02/2025 (214) Povidone-Iodine prep pads with an expiration date of 12/2023 (96) Povidone-Iodine prep pads with an expiration date of 01/2025 (1) Container Iodoform Packing Strip with an expiration date of [DATE] During an interview on [DATE], at approximately 9:40 a.m. Licensed Practical Nurse Employee E8 confirmed the above items were expired. During an interview on [DATE], at approximately 4:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facililty failed to properly store medications and/or biologicals in one of two medication rooms. 28 Pa. Code: 211.9(a)(1)(j.1)(k) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 395653 Page 44 of 44