Health inspection·January 29, 2026

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to thoroughly investigate a resident's injury of unknown origin for two of six sampled residents (Residents 24 and 33). Findings include The facility policy entitled Abuse Prohibition, last reviewed without changes on December 30, 2025, revealed bruises or injuries of unknown origin found on a resident by staff, or reported by the residents themselves will be investigated promptly in an effort to determine how the bruise or injury occurred and rule out potential abuse. Direction of the investigation into bruises or injuries of unknown origin will be determined by the Director of Nursing and Nursing Home Administrator after review and discussion of information presented. All investigative efforts will be documented providing chronology of the investigation, and a list of people working who could reasonably have knowledge of the incident. All statements of direct witnesses, the accused, and if able the resident should be legibly handwritten if possible. The facility shall collect, retain, and safeguard all material pertinent to the investigation of the alleged abuse incident. Clinical record review revealed the facility admitted Resident 33 on February 20, 2018. Nursing documentation dated December 18, 2025, at 2:13 PM revealed nurse aides observed a large bruise on Resident 33's left elbow and forearm during morning care, measuring 12.5 centimeters (cm) by 5 cm, and purple in color. Further review of Resident 33's clinical record revealed a care plan noting Resident 33 is at risk for impaired skin integrity. The facility added an intervention for derma sleeves to Resident 33's bilateral upper extremities at all times except with care on July 7, 2023. Review of the facility investigation into Resident 33's bruise revealed actions taken to prevent future occurrences were to apply Resident 33's derma sleeves as ordered and therapy to assess wheelchair positioning. There was no witness statements obtained related to Resident 33's bruise until January 29, 2026, after the surveyors questioning. The facility was also unable to provide documentation that therapy assessed Resident 33 for wheelchair positioning, or that they investigated if Resident 33's derma sleeves were in place as ordered. Clinical record review revealed the facility admitted Resident 24 on December 13, 2023. Nursing documentation dated December 17, 2025, at 5:38 AM revealed a nurse aide reported that while assisting Resident 24 in the bathroom, a discoloration of her abdomen was noticed. The nurse noted a large discoloration measuring 17 cm by 7.5 cm at the widest point, with small, scattered areas across Resident 24's abdomen. The nurse documented the area was light green and yellow, with light purple areas, showing signs of healing. Resident 24 was unable to explain how bruises happened due to her advanced dementia. Review of the facility investigation into Resident 24's bruises revealed there were no witness statements obtained until January 29, 2026, after the surveyors questioning. Interview with the Director of Nursing on January 29, 2026, at 9:45 AM confirmed these findings for Residents 33 and 24. The facility failed to thoroughly investigate Resident 33 and 24's bruises to rule out abuse or prevent further injuries. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 2 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assist residents with hearing aid devices for three of three residents reviewed for hearing concerns (Residents 29, 65, and 119).Findings include: Clinical record review for Resident 65 revealed an active physician order dated December 31, 2025, for staff to place hearing aids in Resident 65's bilateral ears in the morning and take them out in the evening. Review of an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 6, 2026, revealed that staff assessed Resident 65 with adequate hearing with a hearing aid. The MDS CAA (Care Assessment Area) for communication triggered for staff to develop a plan of care to address Resident 65's potential communication deficits. Review of a plan of care initiated by the facility on January 9, 2026, to address Resident 65's risk for impaired communication revealed interventions that included to ensure hearing aid(s) are in place bilaterally. Interview with Resident 65 on January 27, 2026, at 10:03 AM revealed that her hearing aids were not in her ears and the resident stated they were on her dresser furniture. Due to many personal possessions on top of her dresser furniture, the hearing aids were not readily visible. Interview with Resident 65 on January 28, 2026, at 3:27 PM revealed that her hearing aids were not in her ears and the resident stated that they were still on her dresser furniture. Resident 65 stated, they are there and I am here (in her chair across the room from her dresser). When asked if staff assist her with her hearing aids, Resident 65 stated, that would be nice. Observation of her dresser furniture on the date and time of the interview confirmed the presence of two hearing aids in a charger. Review of Resident 65's treatment administration record (TAR, the electronic documentation by licensed nursing staff for the completion of treatments) dated January 2026 revealed that staff initialed for the application of hearing aids for Resident 65 on January 28, 2026, at 8:00 AM. During an interview with Resident 65 on January 29, 2026, at 10:35 AM Resident 65 pointed to the hearing aid charger on her dresser furniture when she was asked if she was wearing her hearing aids. Resident 65 confirmed that her hearing aids were not in her ears but in the charger on her dresser. Review of Resident 65's TAR dated January 2026 revealed that staff initialed for the application of hearing aids for Resident 65 on January 29, 2026, at 8:00 AM. Interview with Employee 6 (licensed practical nurse) on January 29, 2026, at 10:39 AM confirmed that she initialed for the application of Resident 65's hearing aids on this date, however, she did not ensure the placement of the hearing aids in Resident 65's ears. Clinical record review for Resident 29 revealed an active physician's order dated January 13, 2026, for staff to place hearing aids in his bilateral ears in the morning and place them on the charger at bedtime. Review of an admission MDS assessment dated [DATE], revealed that staff assessed Resident 29's hearing as adequate with a hearing aid. Review of a plan of care initiated by the facility on January 14, 2026, to address Resident 29's risk for impaired communication related to hearing aid use, revealed interventions that included to ensure his hearing aids were in place bilaterally. Observation of Resident 29 on January 27, 2026, at 11:02 AM revealed that he did not have hearing aids in his ears and they were in the charger on his dresser furniture. Resident 29 stated, I haven't been wearing them here. Observation of Resident 29 on January 28, 2026, at 3:30 PM revealed that he was not wearing his hearing aids, and they were observed in the charger on his dresser furniture. Observation of Resident 29 on January 29, 2026, at 10:38 AM revealed that he was not wearing his hearing aids, and they were observed in the charger on his dresser furniture. Review of Resident 29's TAR dated January 2026 revealed that nursing staff initialed that Resident 29 had his hearing aids placed in his ears at Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 3 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 8:00 AM on January 27, 28, and 29, 2026. There was no indication that Resident 29 refused the use of his hearing aids. Interview with Employee 6 on January 29, 2026, at 10:39 AM confirmed that she initialed for the application of Resident 29's hearing aids on this date, however, she did not ensure the placement of the hearing aids in Resident 29's ears. Interview with Resident 119's daughter on January 26, 2026, at 12:11 PM revealed that Resident 119 had hearing aids, but he was not wearing them when she visited the previous Friday evening. Clinical record review for Resident 119 revealed an admission MDS dated [DATE], that assessed that he had moderate difficulty hearing but did not capture that he utilized hearing aids. The MDS CAA for communication triggered for staff to develop a plan of care to address Resident 65's potential communication deficits.Review of a plan of care initiated by the facility on January 23, 2026, to address Resident 119's potential communication deficits revealed no interventions to ensure the use of his hearing aids. An active physician's order dated January 14, 2026, indicated that Resident 119 had an audiology appointment scheduled for February 26, 2026, for a hearing aid check. Review of Resident 119's physician orders and TAR revealed no directions to ensure the use of his hearing aids. Observation of Resident 119 on January 27, 2026, at 9:30 AM revealed that he was not wearing his hearing aids. Resident 119 stated that his hearing aids were in a charger on his dresser. Observation of Resident 119 on January 28, 2026, at 3:33 PM revealed that he was not wearing his hearing aids. Resident 119 confirmed that his hearing aids were in the charger on his dresser. Observation of Resident 119's room on January 29, 2026, at 10:44 AM revealed that Resident 119 was out of his room for his skilled therapy treatment, but his hearing aids were in the charger on his dresser furniture. Interview with Employee 6 on January 29, 2026, at 10:39 AM revealed that Resident 119 had hearing aids and that he typically, doesn't give problems with his (hearing aids). Employee 6 denied ensuring that he had hearing aids in place before leaving his room for his skilled therapy treatment. The surveyor reviewed the above concerns regarding hearing aid use for Residents 29, 65, and 119, during an interview with the Nursing Home Administrator on January 29, 2026, at 12:00 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services Event ID: Facility ID: 395678 If continuation sheet Page 4 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interview it was determined that the facility failed to provide the highest practicable care for implanted cardiac pacemakers for two of 24 residents reviewed (Residents 115 and 7). Findings include: Clinical record review for Resident 115 revealed an active physician order dated January 15, 2026, that the resident had quarterly appointments to check her cardiac device (pacemaker, surgically inserted medical device with wires attached to the heart for the purpose of administering electrical impulses to regulate the heart rate). The appointment scheduled for February 13, 2026, at 9:00 AM was for a, remote interrogation (remote interrogation refers to the process of wirelessly collecting data from an implanted pacemaker and transmitting it to healthcare providers. This technology enables continuous monitoring of the device's performance and the patient's heart rhythm without requiring the patient to visit the clinic physically. Pacemakers equipped with remote monitoring capabilities can communicate data via Bluetooth, cellular networks, or Wi-Fi. This data includes information about the device's function, battery status, and any detected arrhythmias.) A plan of care initiated by the facility on January 15, 2026, to address Resident 115's potential for decreased cardiac output related to a pacemaker revealed no intervention related to a [NAME] pacemaker monitoring machine. Observation of Resident 115's room on January 27, 2026, at 8:51 AM revealed no medical equipment to perform a remote cardiac pacemaker assessment. Interview with Resident 115 on January 27, 2026, at 10:24 AM confirmed that she had an internal cardiac pacemaker. Resident 115 stated that she had a [NAME] machine at her home, but was told to not bring it to the facility. Resident 115 stated that she has the [NAME] machine, next to her bed at her home and that she believes that the machine does continuous monitoring of her pacemaker. Resident 115 stated that should her pacemaker malfunction, the staff at her doctor's office would call her. Resident 115 stated that, this is her second one (pacemaker), the battery got weakened after 10 years in the other one. The surveyor requested the plan of care to address Resident 115's remote pacemaker monitoring while in the facility during an interview with the Nursing Home Administrator and the Director of Nursing on January 27, 2026, at 2:00 PM. Social services documentation dated January 27, 2026, at 5:11 PM (following the surveyor's questioning) revealed that social services staff spoke with Resident 115's responsible party regarding the [NAME] pacemaker machine. Resident 115's responsible party indicated that she would bring the device to the facility the next day.Interview with the Director of Nursing on January 28, 2026, at 11:38 AM confirmed that the facility failed to arrange for the use of Resident 115's pacemaker monitoring device before the surveyor's questioning. Interview with the Nursing Home Administrator on January 29, 2026, at 9:50 AM confirmed that Resident 115's plan of care, revised January 28, 2026, now included the use of a, [NAME] transmitter in her room, however, the plan of care was missing pertinent information (e.g., necessary distance from resident to function, method of communication such as Bluetooth or Wi-Fi connectivity, schedule of monitoring such as at hour of sleep, and applicable cardiac provider's contact information). Clinical record review revealed the facility admitted Resident 7 on February 4, 2022, with diagnoses including presence of cardiac pacemaker. A current physician order-initiated on October 3, 2022, ordered Resident 7 to receive an EKG (an electrocardiogram, a noninvasive test that records the electrical activity of the heart, to diagnosis various heart conditions) every three months for his pacemaker. Further review of Resident 7's clinical record revealed a care plan-initiated February 23, 2022, noting Resident 7 has a potential for decreased cardiac output related to his pacemaker, with an intervention for an EKG every three months. Review of documentation provided by the facility of Resident 7's EKGs revealed there was no documentation of Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 5 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Resident 7 receiving an EKG from April 8, 2025, to October 5, 2025 (6 months). The facility failed to provide the highest practical care to Resident 7 related to his pacemaker. Interview with the Director of Nursing on January 29, 2026, at 10:04 AM confirmed these findings. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 6 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review and staff and resident interview it is determined that the facility failed to implement treatment and services to prevent a pressure ulcer for one of five residents reviewed for pressure ulcer concerns (Resident 3).Findings include: Observation of Resident 3 in her room on January 26, 2026, at 1:06 PM revealed that she had a left elbow protector on. Concurrent interview of Resident 3 revealed that she has a sore on her arm. She indicated that she has been dealing with if for a long time although it was healed once but opened up again. She indicated the sore was on her elbow and that she was unsure how it happened. Clinical record review for Resident 3 revealed a progress note dated May 31, 2025, at 12:02 PM that indicated Resident 3 was noted to have a skin tear to her left elbow that measured 1.0-centimeter (cm) x 1.0 cm. The area was cleansed and Opti Foam (a foam dressing with a silicone face and border) was applied. Further clinical record review revealed a physician's order dated May 31, 2025, at 11:46 AM for Resident 3's left elbow to be cleansed with normal saline solution, pat dry and apply Opti Foam dressing and to change every three days and as needed for dislodgement or drainage. On June 9, 2025, the order was changed to cleanse left elbow with normal saline, pat dry, apply Opti Foam dressing every five days. The treatment to Resident 3's left elbow was documented as completed. There were no further progress notes or assessments addressing the area on Resident 3's left elbow until a skin and wound progress note was completed by Employee 7, registered nurse/wound nurse, on July 14, 2025, at 2:24 PM. The skin/wound note indicated that Employee 7 was asked to see Resident 3 related to the area on her left elbow not improving. The note indicated that staff reported an odor and drainage on the old dressing. The area now measured 2.5 x 2.5 cm x 0.3 cm. The wound nurse cleansed the area with normal saline, applied medical grade honey (a sterilized honey used in wound healing), and Max orb Silver (a highly absorbent dressing) and covered with Opti foam. The treatment was ordered to be changed daily. The note also indicated that the staff reported that Resident 3 has been noted to be leaning to the left side while in her wheelchair. A skin and wound note dated July 17, 2025, at 11:05 PM revealed that Resident 3 was seen on wound rounds by the nurse practitioner for a facility acquired stage four pressure ulcer (a severe, full-thickness wound extending through skin to expose muscle, bone, or tendons) to the left elbow. The note also indicated that the resident's arms are contracted, which applied pressure to her left elbow when sitting in her wheelchair. The elbow was debrided (removal of damaged tissue) due to unstable eschar (layer of dead tissue that forms over wounds). When the eschar was removed and the wound bed was cleaned out the bone was directly palpable. The note also indicated that the wound measured 2.5 cm x 2.4 cm x 0.8 cm and had a moderate amount of purulent drainage. The note indicated that Resident 3 should use elbow protectors to minimize pressure, friction, and shear to the bony area. Further clinical record review revealed that Resident 3 was never ordered an elbow protector until October 1, 2025. Interview with the Director of Nursing and employee 7 on January 29, 2026, at 9:00 AM confirmed the above noted findings that Resident 3's area on her left elbow was debrided and noted to be a stage four, and that there was no documentation indicating an elbow protector was ordered and put in place for Resident 3 until October 1, 2025. They also confirmed that there was no documentation on the condition of Resident 3's skin tear from May 31, 2025, until July 14, 2025, when Employee 7 was consulted because the wound was noted to be bigger in size with an odor. The facility failed to implement pressure relieving interventions to prevent a pressure area on Resident 3's left elbow. The nursing home administrator was made aware of the above noted concerns related to Resident 3's pressure ulcer on January 29, 2026, at 11:30 AM. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(ii)(iv)(ix) Medical records 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 7 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 211.12(d)(1)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 8 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion (ROM) for one of three residents reviewed for ROM concerns (Resident 3). Findings include: Clinical record review revealed the facility admitted Resident 3 on March 11, 2025. Resident 3's admission MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated March 17, 2025, revealed that the resident had no impairments of her upper extremities. Review of her MDS for the dates of May 8, 2025, August 5, 2025, and September 26, 2025, revealed that Resident 3 had no impairment of her upper extremities. Review of her annual MDS dated [DATE], noted staff assessed Resident 3 as having impairment to ROM of one side of her upper extremities. Further clinical record review for Resident 3 revealed that a passive range of motion program (PROM, movement of a body part by another to maintain a resident's ability) was initiated to her bilateral upper extremities on July 24, 2025, and a splint was ordered to her left hand on October 1, 2025. Review of Resident 3's PROM program documentation for the months of November and December 2025, and January 1-26, 2026, revealed the followings dates that her PROM program was not documented as being done: November 21, 24, and 30, 2025, dayshift. December 1, 3, 5, and 6, 2025, evening shift and December 5, 9, 14, and 29, 2025, dayshift. January 6, 15, and 25, 2025, evening shift and January 2, 10, 11, 15, 16, 24, 25, and 26, 2026, dayshift. The above noted information was reviewed with the Director of Nursing on January 29, 2026, at 1:00 PM. The Nursing Home Administrator was made aware at 1:15 PM. The facility failed to ensure that Resident 3 received her ordered PROM program in order to prevent decline or maintain her range of motion. 28 Pa. Code 211.12(d)(1)(5) Nursing services Event ID: Facility ID: 395678 If continuation sheet Page 9 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with wound treatments and foley catheters, for four of four employees reviewed for competencies (Employees 2, 3, 4, and 5).Findings include: A review of the facility documentation revealed that the facility had a total of 17 residents with indwelling urinary catheters (insertion of a tube into the bladder to remove urine) and 28 residents with dressing changes (treatment to and changes in the covering of wounds). A request for nursing staff competencies for dressing changes and catheter care revealed the facility was unable to provide competencies for these for Employees 2 and 3 (licensed practical nurses), and Employees 4 and 5 (registered nurses). The findings were reviewed with the Nursing Home Administrator and Employee 1 (registered nurse/staff development) on January 29, 2026, at 10:05 AM. They confirmed the facility could provide no documentation that ensured Employees 2, 3, 4, and 5 had specific competencies and skill sets to care for the resident needs listed above. 28 Pa. Code 201.20 (a) Staff Development Event ID: Facility ID: 395678 If continuation sheet Page 10 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 clinical record review and staff interview, it was determined that the facility failed to ensure an appropriate physician response to a pharmacy recommendation for one of five residents reviewed (Resident 19). Findings include: Clinical record review for Resident 19 revealed a consulting pharmacist report dated June 28, 2025, requesting a gradual dose reduction or a documented rationale for declining for Resident 19's Escitalopram (a medication used to treat depression) 5 mg daily. Resident 19's physician declined the recommendation on July 3, 2025, indicating that the resident's targeted symptoms returned or worsened after the most recent gradual dose reduction and that the continued use is in accordance with the current standard of practice and a gradual dose reduction attempt at this time would likely impair Resident 19's function or cause instability. Interview with the Director of Nursing on January 29, 2026, at 12:42 PM revealed that the facility was unable to provide documentation that a previous dose reduction was attempted and unsuccessful. The facility failed to ensure an appropriate physician response to Resident 19's pharmacy review as noted above. 483.45(c)(4) Pharmacy reviewPreviously cited 2/28/25 28 Pa. Code 211.9 (d)(k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services Event ID: Facility ID: 395678 If continuation sheet Page 11 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure the administration of pneumococcal immunizations for two of five residents reviewed for immunization concerns (Residents 87 and 119).Findings include: The facility policy entitled, Vaccination of Residents, last reviewed December 30, 2025, revealed that all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. All new residents shall be assessed for current vaccination status upon admission. The facility policy entitled, Pneumococcal Vaccine Policy, last reviewed December 30, 2025, revealed that all residents will be offered the pneumococcal vaccine per Centers for Disease Control and Prevention (CDC) guidelines to aid in preventing infections and pneumonia. Pneumococcal vaccines include Pneumococcal Polysaccharide (Pneumovax 23, PPSV23), Pneumococcal Conjugate (Prevnar 13, PCV13), and Pneumococcal 21 (PCV21). On admission, residents will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, provided the vaccine unless it is medically contraindicated, the resident and/or responsible party refuses the vaccine, or prior documentation of the vaccination status is provided. Administration of the vaccine will be completed in accordance with the current CDC guidelines. Current CDC guidelines available at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html include that based on shared clinical decision-making, adults 65 years or older have the option to get the PCV20 or PCV21 immunization. They can get the PCV20 or PCV21 if they have received both the PCV13 at any age and the PPSV23 at or after the age of [AGE] years old. The CDC job aide available at https://www.cdc.gov/vaccines/hcp/admin/downloads/job-aid-SCDM-pneumococcal-508.pdf meant to assist vaccine providers in discussions with older adults considering a PCV20 or PCV21 vaccination, notes that adults [AGE] years of age or older have the option to receive supplemental PCV20 or PCV21 (not both) if they previously completed the pneumococcal vaccine series with both PCV13 and PPSV23 and meet the following criteria: previously received one dose of PCV13 at any age, and previously received all recommended doses of PPSV23 (including 1 dose of PPSV23 at or after [AGE] years of age). The determination to administer a PCV20 or PCV21 is based on a shared clinical decision-making (SCDM) process between a patient and their health care provider. Increased risk of exposure to PCV20 or PCV21 serotypes may occur among people who are living in nursing homes or other long-term care facilities. Protection against disease from both PCV13 and PPSV23 is expected to decrease over time. Clinical record review for Resident 87 revealed that the facility admitted her on January 5, 2026. Review of Resident 87's immunization audit report revealed that she received the PPSV23 on June 4, 2013, when she was [AGE] years old. Resident 87 received the PCV13 vaccine on July 17, 2020, more than five years before her admission to the facility. Review of a Vaccination Questionnaire revealed that Resident 87's responsible party gave, permission to administer pneumococcal vaccinations per the CDC guidelines, on January 5, 2026. Resident 87 could receive either the PCV20 or PCV21 per current CDC guidelines as more than five years had elapsed since her last pneumococcal immunization. Interview with Employee 7 (registered nurse/infection preventionist) on January 29, 2026, at 11:46 AM revealed that she believed that Resident 87 received all appropriate pneumococcal vaccinations since she received the PCV13 and PPSV23 and did not identify that she should be given the option to get the PCV20 or PCV21 immunization per CDC current guidelines. Employee 7 confirmed that there is no evidence that Resident 87 was offered either the PCV20 or PCV21, or that she and her physician discussed the appropriateness of the PCV20 or PCV21 vaccines based on her previous pneumococcal immunizations and her current risks in the long-term care facility. Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 12 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Clinical record review for Resident 119 revealed that the facility admitted him on January 14, 2026. Review of Resident 119's immunization audit report revealed that he received the PPSV23 on October 28, 2010, when he was [AGE] years old. Resident 119 received the PCV13 vaccine on December 28, 2018, more than five years before his admission to the facility. Review of Resident 119's Vaccination Questionnaire revealed that staff obtained verbal declination of additional pneumococcal immunizations from Resident 119's daughter on January 14, 2026; due to the reason that Resident 119, .received pneumonia vaccines per CDC guidelines. Interview with Employee 7 on January 29, 2026, at 11:46 AM revealed that she believed that Resident 119 also received all appropriate pneumococcal vaccinations since he received the PCV13 and PPSV23 and did not identify that he should be given the option to get the PCV20 or PCV21 immunization per CDC current guidelines. Employee 7 confirmed that there is no evidence that Resident 119's daughter was educated that a PCV20 or PCV21 immunization may be appropriate based on current CDC guidelines, Resident 119's previous pneumococcal immunization history, and his current risks in the long-term care facility. The surveyor reviewed the above concerns regarding Resident 87 and 119's pneumococcal immunizations during an interview with the Nursing Home Administrator and the Director of Nursing on January 28, 2026, at 2:30 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Event ID: Facility ID: 395678 If continuation sheet Page 13 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on a review of select facility policies and procedures and staff interview it was determined that the facility failed to maintain documentation related to staff COVID-19 vaccination that included at a minimum that staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine, that staff were offered the COVID-19 vaccine, or information on obtaining COVID-19 vaccine, for one of one employee reviewed for COVID-19 vaccination (Employee 8).Findings include: The facility policy entitled, COVID-19-Covid Plan, last reviewed without changes on December 30, 2025, revealed that the facility would vaccinate residents and health care professionals (HCP) against SARS-CoV-2 (COVID-19) as part of their plan's core principles. The facility would encourage everyone to remain up to date with all recommended COVID-19 vaccine doses. HCP should be offered resources and be counseled about the importance of receiving the COVID-19 vaccine. Interview with Employee 8 (environmental services director) on January 29, 2026, at 10:50 AM revealed that she believed that she was up to date with all her recommended COVID-19 immunizations. Employee 8 stated that it was important to her to have all available immunizations as she had medical conditions that put her at risk for infections. Employee 8 presented a COVID-19 immunization card to the surveyor that indicated that her last COVID-19 immunization was in 2022. Employee 8 stated that she received additional vaccines from Employee 7 at the facility, but her card had not been updated. Interview with Employee 7 (registered nurse/infection preventionist) on January 29, 2026, at 11:20 AM revealed that data submitted to NHSN (Centers for Disease Control and Prevention's National Healthcare Safety Network) confirmed that Employee 8 had no additional COVID-19 immunizations after October 17, 2022. Employee 7 denied administering a COVID-19 immunization to Employee 8 and that she likely administered an influenza immunization to Employee 8. Employee 7 confirmed that the facility had no evidence that Employee 8 was offered resources or was counseled about the importance of receiving ongoing COVID-19 vaccines, the risks and benefits of the vaccines, or was offered a COVID-19 immunization after October 17, 2022. Employee 7 confirmed that the facility had no process to obtain ongoing COVID-19 immunization data for staff after initial information is obtained during the hiring process to ensure accurate COVID-19 vaccine status of staff and related information is submitted to the NHSN as required. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1) Nursing services Event ID: Facility ID: 395678 If continuation sheet Page 14 of 14