Inspection·February 9, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on review of facility documentation, observation, and resident, family, and staff interview, it was determined that the facility failed to provide a comfortable and homelike environment on one of two nursing units reviewed (Third floor nursing unit; Residents 8, 51, and 67). Findings include: During an interview with Resident 8's family member on February 7, 2024, at 9:29 AM it was reported that the building gets too hot and sweltering, especially on warm winter days. This includes resident rooms and the lounge behind the elevator on the third floor. There are times the staff leave the front entrance doors open and when they do, there is no security. This past Christmas day was an example. Interview with Resident 67 on February 7, 2024, at 1:50 PM revealed his room is very hot and gets very hot in the afternoon and has a fan on. Concurrent observation of the thermostat in Resident 67's room revealed the thermostat read 83 degrees Fahrenheit. The surveyor then observed the thermostat in the room shared by Residents 8 and 51 and it read 82 degrees Fahrenheit. Concurrent interview with Resident 51 revealed that it was very hot in the room and the resident said she is usually cold. During an interview with the Director of Nursing and Employee 1, director of clinical services, on February 7, 2024, at 2:00 PM the surveyor reviewed the above findings about the temperatures and the resident and family reports. Review of a ERS (event reporting system, a report of unusual occurrences submitted to the Pennsylvania Department of Health) dated February 7, 2024, revealed that temperatures conducted by maintenance revealed the temperatures on the third floor ranged from 79 degrees to 86 degrees Fahrenheit. The maintenance department adjusted the heating. Review of temperature audits conducted by the facility on February 7, 2024, at 4:00 PM revealed that the temperatures recorded in Fahrenheit on the third floor ranged between 78 degrees to 83 degrees in resident rooms and 86 degrees in the unit dining room. Review of temperature audits conducted by the facility from February 7, 2024, at 6:00 PM revealed that the temperatures recorded in Fahrenheit on the third floor ranged between 77 degrees to 83 degrees in resident rooms and 79 degrees in the unit dining room. During an interview with Employee 4, [NAME] President of Facilities, on February 8, 2024, at 12:13 PM confirmed the elevated temperatures above 81 degrees Fahrenheit and indicated the boiler repair company has been in the facility since the elevated temperatures have been reported and the facility is repairing the problem including adding parts for ambient control. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 2 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 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 review of select facility policies and procedures, review of clinical record and facility documentation, and staff interview, it was determined that the facility failed to ensure that allegations of potential abuse were thoroughly investigated and reported to the appropriate agencies for two of four sampled residents (Residents 82, 84, 79, and 92). Residents Affected - Few Findings include: The facility policy entitled, Abuse Investigation and Reporting, last reviewed February 22, 2023, revealed that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The role of the investigator, the individual conducting the investigation, will, at a minimum, review the resident's medical record to determine events leading up to the incident, interview persons reporting the incident, and interview any witnesses to the incident. Guidelines used when conducting interviews include to conduct each interview separately and in a private location; and obtain witness reports in writing (either the witness will write his/her statement and sign and date it or the investigator will obtain a statement, read it back to the member, and have him/her sign and date it). All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator (or designee) to the state licensing/certification agency responsible for surveying/licensing the facility. The Administrator, or his/her designee, will provide the appropriate agencies with a written report of the findings of the investigation within five working days of the occurrence of the incident. Clinical record review for Resident 92 revealed nursing documentation dated December 13, 2023, at 8:37 PM that this resident became agitated with the nurse aide staff when that staff was redirecting her from entering another resident's room. Resident 92, .then struck another (Resident 79) in the back, when Resident 79 was also making attempts to enter the same room. Nursing documentation by Employee 7 (registered nurse) dated December 13, 2023, at 8:32 PM revealed that the registered nurse on the second floor reported to her that Resident 92 hit another resident in the back. Employee 7's documentation noted that, When staff attempted to redirect the two residents out of the room, (Resident 92) had swung at staff and inadvertently, hand lightly hit (Resident 79) in back. Interview with Employee 7 on February 7, 2024, at 10:05 AM revealed that she was the registered nurse supervisor; and that she was the supervisor on shift when the above altercation occurred between Residents 79 and 92. Employee 7 confirmed that the wording of her documentation indicated that the physical contact initiated by Resident 92 was inadvertent (therefore, would not be considered physical abuse); contrasting the registered nurse's documentation that Resident 92 struck Resident 79 (which would meet the definition of physical abuse). Employee 7 stated that she could not recall which nurse aide was on shift at the time of the incident; or if she obtained written statements from that staff. Employee 7 stated that she remembered interviewing the registered nurse and the nurse aide at the same time at the nurses' station and believed that their report was that the action was inadvertent. Employee 7 could not locate an incident investigation report in the facility's electronic medical record system. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 3 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility provided the name and telephone contact information for the nurse aide (Employee 8) working with Residents 79 and 92 on the December 13, 2023, evening shift. A telephone interview with Employee 8 on February 7, 2024, at 1:42 PM indicated that he vividly recalled the details from the one night he worked in the facility (claimed he had not been to the facility since); and the incident was between Resident 92 and Resident 79 when Resident 92 hit Resident 79. Employee 8 stated that Resident 92, got mad, and swung around and hit (Resident 79). Employee 8 stated that Resident 79 yelled, Ow! Employee 8 stated that it was his opinion that Resident 92 did not inadvertently touch Resident 79; Resident 92 intended to hit Resident 79. Employee 8 stated that Resident 92, .gritted her teeth and nailed her, she definitely intended to hit (Resident 79). Employee 8 could not recall if the facility asked him to write a statement; but he said that he spoke to the nurses that were working at the time of the incident. The surveyor requested the facility's investigation of the December 13, 2023, incident between Residents 79 and 92 during an interview with the Director of Nursing and Employee 1 (Director of Clinical Operations) on February 7, 2024, at 2:05 PM. The interview confirmed that the facility did not report the resident-to-resident physical abuse incident to the Department as required. A facility incident investigation provided by the facility for Resident 92 dated December 13, 2023, at 3:30 PM noted in the incident description that Resident 92, inadvertently struck, another resident in the back. The report noted Employee 8 (nurse aide) was a witness and recorded his statement as, I was redirecting (Resident 92) and (Resident 79) from entering (another resident's) room. (Resident 92) got mad and inadvertently touched (Resident 79). There was no handwritten statement from Employee 8; there was no indication that he signed interview notes attesting to the accuracy of the recording of his statement. Clinical record review for Resident 82 revealed a nursing progress note dated December 11, 2023, at 2:17 PM. The note indicated that Resident 82 stepped on Resident 84's foot. Resident 84 then grabbed Resident 82 by the shirt. Resident 82 then proceeded to hit Resident 84 in the face. The residents were separated. No injuries were noted. Review of the facility investigation into the event revealed a witness statement that indicated the same, that both residents were in the hallway when Resident 82 stepped on Resident 84's foot, and he grabbed resident 82 by the shift so she hit him in the face. Clinical record review revealed a nursing progress note dated January 10, 2023, at11:48 AM that indicated that Resident 82 was walking through the hallway at a fast pace and Resident 84 pushed her out of the way by her arms. The note indicated that the nurse aide stated that she did not believe there was intent to harm. Further clinical record review for Resident 82 revealed a social service progress note dated January 11, 2024, at 9:09 AM that indicated she reviewed the incident and determined the altercation was incidental, residents were redirected appropriately, and no complaints of pain or discomfort were noted from either resident. Review of the facility investigation dated January 10, 2024, at 9:40 AM revealed a witness statement that indicated Resident 84 grabbed and pushed Resident 82 out of his way because she would not move out of his way. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 4 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Employee 1, Director of Clinical Operations, on February 8, 2024, at 3:00 PM confirmed that the facility did not report the above noted Resident-to-Resident events to the appropriate agencies as required. The facility failed to thoroughly investigate and report to the appropriate agencies allegations of potential abuse. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident rights 28 Pa. Code 211.12 (d)(3) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 5 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0660 Plan the resident's discharge to meet the resident's goals and needs. 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, facility documentation, and staff and resident interview, it was determined that the facility failed to develop and implement an effective discharge planning process, which begins on admission, including resident's assessments and goals for care for one of 24 residents reviewed (Resident 90). Residents Affected - Few Findings include: Clinical record review for Resident 90 revealed that the resident was [AGE] years old and was admitted to the facility on [DATE], following a fracture of the right proximal humerus (upper arm). The surveyor requested an admission history and physical for Resident 90 and was provided with a history and physical competed by the referring hospital dated October 17, 2023. The history and physical revealed the resident lived at home prior to the hospitalization. The resident reported current drug use of marijuana and prescription drugs. Resident 90 lived with two roommates. Review of a care plan for Resident 90 dated October 23, 2023, revealed the resident concealed medications when staff administered medications. The staff were to ensure that the resident swallowed medications during the medication pass and to observe for mental status or behavioral changes when new medication is started or when there is a change in dosage. Review of a social service discharge plan completed for Resident 90 on October 24, 2023, revealed the resident wished to be discharged to live independently in an apartment. Review of an admission MDS (Minimum Data Set, a comprehensive assessment to determine resident needs) for Resident 90 dated October 26, 2023, revealed the resident had a BIMS (Brief Interview for Mental Status, a score of 13 to 15 indicates the person is cognitively intact) of 15. Review of physician progress notes for Resident 90 dated December 13, 2023, referred to the resident being opioid (narcotic) dependent and on January 3, 2024, referred to the resident as drinking a lot and was taking narcotics. Interview with Resident 90 on February 6, 2024, at 11:35 AM revealed that the resident was being discharged the following day to a hotel. The resident indicated that the facility tried to get representative payee (a payee manages benefit payments for residents incapable of managing their Social Security Income payments) but the resident cancelled it by contacting the Social Security office. Resident 90 reported being homeless. The resident lived with roommates, but they did criminal activities, so the resident went to a hotel. Resident 30 indicated wanting to be discharged and the facility wanting the resident discharged . Clinical record review for Resident 90 on February 6, 2024, at 12:30 PM revealed there were no care plans related to discharge planning and no social service notes regarding the impending discharge. In addition, clinical record review for Resident 90 revealed there were no referrals to agencies regarding drug abuse or offers of treatment for drug abuse upon discharge. The surveyor requested discharge planning information for Resident 90 and subsequently met with the Nursing Home Administrator and Employee 5, business office manager, on February 6, 2024, at 12:30 PM. During this time, Employee 4 provided documentation entries, which included the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 6 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few financial status, apartment application status, money the resident owed the facility, and conversations with the Social Security department and the facility social worker. The Nursing Home Administrator confirmed these records were not part of the resident's clinical record but documents in the financial record. Following the surveyor's questioning Resident 90's discharge plans, social service documentation on February 6, 2024, at 12:49 PM revealed that the social worker and business office manager met with the resident to confirm that the resident received an application for a specific apartment, and that the resident had a reservation at a local hotel from February 7 to 14, 2024, paid by the facility and a $50.00 dollar gift care for necessities or food until Resident 90's Social Security funds become available on February 8, 2024. A social service note dated February 7, 2024, at 11:08 AM revealed the resident will be seen by a physician in the community for follow up on February 8, 2024. Review of a physician discharge summary for Resident 90 dated February 7, 2024, revealed the resident got into trouble at a hotel in the area, was kicked out, was homeless, and had to be admitted to the facility. The reasons for admission were poor social support, homelessness, drug seeking, and associated abnormal behaviors. The resident wanted to be discharged and the facility provided her with some funds to rent a local hotel room. The facility failed to develop and implement an effective discharge planning process, which begins on admission, including resident assessments and goals, and the reduction of factors leading to preventable readmissions, and referrals to local contact agencies for treatment of drug dependence. 28 Pa. Code 201.18 (3)(e)(1) Management 28 Pa. Code 211.10(a) Resident care plan FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 7 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to provide bathing assistance for a resident dependent on staff assistance for one of two residents sampled for activities of daily living (Resident 71). Residents Affected - Few Findings include: Clinical record review of Resident 71's task documentation (computerized documentation completed by staff to record residents care needs and care performed) revealed that his preference for bathing was to have a shower. His shower was to be completed on Wednesdays and Saturdays during the evening shift. Review of Resident 71's current plan of care revealed that he required limited (resident is highly involved in performing the activity but receives some physical help) to extensive (resident requires weight bearing support) assistance from staff for bathing. Review of Resident 71's bathing/shower documentation for December 2023, revealed that he did not receive a shower from December 1-12, 2023, with documentation on December 1, 5, 8, and 12 indicating NA (not applicable). Review of Resident 71's bathing/shower documentation for the January 2024, revealed that he did not receive a shower from January 6-26, 2024. Documentation revealed that he refused a shower on January 24, 2024, and NA was documented for January 9, 12, 16, 19, and 23, 2024. Interview with the Director of Nursing on February 9, 2024, at 11:10 AM confirmed that there was an issue with Resident 71 getting his showers. The facility failed to provide bathing assistance for a resident dependent on staff assistance for his showers. 483.24(a)(2) ADL Care Provided for Dependent Residents Previously cited deficiency 3/24/23 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 8 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement interventions for injury prevention for one of seven residents reviewed for accident concerns (Resident 38). Findings include: Clinical record review for Resident 38 revealed an electronic medical record physician order dated January 26, 2024, to implement floor mats bilaterally (on both sides) when Resident 38 was in bed. Review of a plan of care developed by the facility to address Resident 38's risk for falls revealed interventions that included bilateral floor mats when in bed. Nursing documentation dated October 19, 2023, at 7:09 PM revealed that staff responded to Resident 38 yelling in her room. Staff found Resident 38 on the floor on the right side of her bed. Resident 38 reported that she rolled out of bed. Nursing documentation dated December 11, 2023, at 5:10 PM revealed that nurse aide staff reported to the nurse that Resident 38 was on the floor. The nurse observed Resident 38, face down, on her fall mat. Nursing documentation dated December 14, 2023, at 9:12 AM revealed staff were alerted to Resident 38's room by her yelling. Staff observed Resident 38 in the prone (lying face down) position on the fall mat. Observation of Resident 38 on February 7, 2024, at 10:40 AM revealed Resident 38 was in bed with one fall mat on the floor on the right side of Resident 38's bed. Interview with Resident 38 on the date and time of the above observation revealed that she believed that she had approximately three falls recently; however, Resident 38 could not recount the details of the falls (such as the date, time, or any resulting injuries). Observation of Resident 38 on February 9, 2024, at 11:42 AM revealed she was in bed with one fall mat on the floor on the right side of her bed. Interview with Employee 9 (nurse aide) at Resident 38's bedside on February 9, 2024, at 11:42 AM confirmed that Resident 38 only had one fall mat. Employee 9 confirmed that she was assigned to Resident 38's nursing unit that shift. Interview with Employee 6 (licensed practical nurse) at Resident 38's bedside on February 9, 2024, at 11:51 AM verified that although current physician orders instructed staff to implement a fall mat on each side of Resident 38's bed, there was only one fall mat in place. The surveyor reviewed the above findings with the Director of Nursing and Employee 1 (Director of Clinical Operations) on February 9, 2024, at 12:39 PM. 483.25(d)(1)(2) Free of Accident Hazards/supervision/devices (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 9 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0689 Previously cited deficiency 3/24/24 Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 10 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide care and services for an indwelling catheter for two of five residents reviewed for catheter concerns (Residents 7 and 55). Findings include: Clinical record review for Resident 7 revealed a physician's order dated July 17, 2023, that instructed staff to change a Foley catheter (thin, flexible, tube inserted through the urethra into the bladder to drain urine) as needed. Another physician's order dated July 17, 2023, instructed staff to irrigate the Foley catheter with 60 milliliters of normal saline as needed for blockages. A physician's order dated September 6, 2023, instructed staff to attach the Foley catheter to a leg bag (smaller bag that can be attached to the leg under clothing to conceal urine collection during the day) when he was out of bed; and to a straight drainage bag (larger urine collection bag that can be hung from the bed frame) when he was in bed. Documentation by Resident 7's urologist (doctor that specializes in the urinary and reproductive tracts) dated October 11, 2023, instructed staff to perform catheter changes monthly. Documentation by Resident 7's urologist dated January 11, 2024, instructed staff to, .continue catheter changes monthly/prn (as needed) . Review of Resident 7's TAR (treatment administration record, electronic documentation used by the facility to document the completion of physician ordered treatments) dated October and November 2023 and January 2024 revealed no evidence that staff changed Resident 7's Foley catheter during those months. During an interview with the Director of Nursing on February 8, 2024, at 10:45 AM the surveyor reviewed Resident 7's active physician order (since July 17, 2023) to change the catheter PRN; although the urologist indicated on October 11, 2023, that Resident 7 should have a catheter change monthly. Interview with the Director of Nursing on February 8, 2024, at 12:15 PM confirmed the findings that Resident 7 did not have his catheter changed monthly. A physician's order dated February 8, 2024 (following the surveyor's questioning) instructed staff to change Resident 7's Foley catheter monthly on the 11th day of the month. Observation of Resident 55 on February 6, 2024, at 2:17 PM revealed he was in bed with an indwelling urinary catheter collection bag hung from the left side of his bed. Interview with Resident 55 on February 7, 2024, at 12:01 PM revealed that he believed staff used to change his Foley catheter on a schedule; however, now it is only changed when he asks for it to be changed. Clinical record review for Resident 55 revealed a physician's order dated October 10, 2023, that instructed staff to change Resident 55's Foley catheter and collection bag once a month (on the 12th of every month) and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 11 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 55's TAR dated October through December 2023 revealed that staff changed Resident 55's Foley catheter on October 12, 2023, and December 16, 2023; however, there was no evidence that staff changed his Foley catheter during the month of November 2023. Interview with the Director of Nursing on February 8, 2024, at 12:43 PM confirmed that the facility had no evidence of a Foley catheter change between October 12, 2023, and December 16, 2023, for Resident 55. 483.25(e)(1)-(3) Bowel/bladder Incontinence, Catheter, UTI Previously cited deficiency 3/24/23 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 12 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0699 Provide care or services that was trauma informed and/or culturally competent. 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 staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care and eliminate or mitigate re-traumatization for one of one resident reviewed. (Resident 93). Residents Affected - Few Findings include: Clinical record review for Resident 93 revealed that the facility admitted her on December 8, 2023. Further review of her clinical record revealed that a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) was added to her medical diagnosis on December 13, 2023. Review of Resident 93's admission Minimum Data Set (MDS, an assessment completed by the facility at intervals to determine care needs) assessment dated [DATE], indicated PTSD was an active diagnosis for Resident 93. Clinical record review for Resident 93 on February 7, 2024, at 9:30 AM revealed that she did not have a care plan addressing trauma informed care related to her diagnosis of PTSD or her related triggers (everyday situations that cause a person to re-experience the traumatic event as if it were reoccurring). The surveyor notified the Director of Nursing (DON) on February 7, 2024, at 10:00 AM that Resident 93's clinical record did not have a care plan related to her PTSD to include trauma informed care and related triggers. Further clinical record review for Resident 93 revealed a social service progress note dated February 7, 2023, at 10:30 AM (after the surveyor notified the DON that Resident 93 did not have a care plan related to her PTSD and trauma informed care) that indicated she contacted the power of attorney for the resident regarding her PTSD diagnosis. The facility failed to identify and care plan triggers that may retraumatize Resident 93 related to her diagnosis of PTSD. 28 Pa Code 211.12 (a)(d)(3)(5) Nursing services 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.16(a) Social services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 13 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's drug regimen was free from an unnecessary antibiotic medication for one of one resident sampled (Resident 90). Residents Affected - Few Findings include: Review of a history and physical for Resident 90 dated October 17, 2023, revealed the genitourinary (a physical exam of the female internal and external urinary and reproductive system) exam was deferred (put off until a later time). Review of a nursing progress note for Resident 90 dated February 5, 2024, at 2:02 PM revealed that the physician was made aware that the resident had vaginal burning and odor. Augmentin (antibiotic to treat a bacterial infection) 875/125 milligrams was ordered to be given twice daily for seven days. Clinical record review for Resident 90 revealed that there was no related physical exam documented of the genitourinary system and that there was no details of the type of vaginal odor or signs of infection for use of an antibiotic. The antibiotic was ordered without adequate indication for its use. During an interview with the Director of Nursing on February 7, 2024, at 2:05 PM it was confirmed there was no clinical documentation to support the use of an antibiotic. 28 Pa. Code 211.2(d)(3) Medical Director 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 14 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on staff interview, it was determined that the facility failed to employ a qualified director of food and nutrition services in the absence of a full-time dietitian. Residents Affected - Few Findings include: During the initial tour of the facility's main kitchen on February 6, 2024, at 9:15 AM, Employee 3, Dietary Manager, stated that she was the dietary manager, and had been in that role since November 2023. An interview with Employee 3 on February 8, 2024, at 1:06 PM revealed she was not certified; however, the facility was discussing enrolling her in certified dietary manager courses. An interview with Employee 1, Director of Clinical Operations, on February 8, 2024, at 2:25 PM revealed the facility did employ a consultant dietitian; however, the dietitian was not full time and worked remotely 24 hours a week. Employee 1 confirmed there was no evidence that Employee 3 had any qualifications of food service manager certification/degree, or a certified dietary manager credential in the absence of a full-time dietitian. 28 Pa Code 201.18(e)(1)(6) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 15 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on review of facility documentation, observation, and resident and staff interview, it was determined that the facility failed to serve food that is palatable on one of two nursing units (Third floor nursing unit, Residents 67 and 90). Residents Affected - Some Findings include: Review of food committee meeting minutes date November 29, 2023, revealed that the residents would like more gravy over their meats. Review of food committee meeting minutes dated December 27, 2023, revealed the residents reported the pork is dry. Neither meeting minutes mentioned follow-up of the previous month's concerns. Interview and observation on February 6, 2024, at 12:00 PM with Resident 90 revealed the pork chop was tough. The pork chop was dry and very difficult to cut. There was no gravy or broth on the pork chop. Interview with Resident 67 on February 7, 2024, at 10:09 AM revealed that he is on a soft diet and received a pork chop yesterday that he could not chew. On February 8, 2024, at 11:20 AM the surveyor tested a food tray of regular consistency foods in the presence of Employee 2, nurse aide. The surveyor noted that the chicken breast was very dry and difficult to chew. There was no gravy or broth provided. Employed 2 confirmed that the chicken breast looked dry. During a meeting with the acting Nursing Home Administrator and Director of Nursing on February 8, 2024, at 2:15 PM the surveyor reviewed the above findings about food palatability. 28 Pa. Code 201.18 (b)(3)(e)(4) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 16 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to store food items and maintain equipment in a safe and sanitary manner in the facility's main kitchen. Residents Affected - Many Findings included: Initial tour of the facility's main kitchen on February 6, 2024, between 9:15 AM and 10:15 AM revealed the following: There was a significant amount of debris on top of the dishwasher. There was also a significant amount of dust accumulating on the ceiling above the dishwasher including where the clean dishes came out of the washer. A pipe just behind the dishwasher had an accumulation of dust and had a large piece of protective covering falling off the pipe. The dry storage room had a large bucket of rice with no date or expiration on the bucket. There were dried splashes on the entire wall behind the drink prep area. There was a large number of dead bugs and debris in the bottom of the ceiling light covering above the drink prep area. A plastic container holding lids for juice containers had two lids that were put away wet. There was a plastic drink pitcher with a maroon lid that has moisture in it. A blue colored drink pitcher was found on the floor under the prep table. There was a significant dust build-up on top of the knife storage rack. There was a significant build-up of dirt and debris behind the slicer. There was a significant build-up of crumbs on top of the oven. The following was observed in the utility/housekeeping closet: a puddle of water pooling on the floor, a sprinkler head had a cloth rag wrapped around the base of the sprinkler head (staff were unsure of the purpose for this), the wall was crumbling in several areas and was falling off in some places, a plastic wall covering was starting to detach from the wall, and there were numerous black dried stains covering the entirety of the back wall of the closet. The food prep area had a significant number of dried stains covering the wall above the prep area, electrical outlets, and under an overhead stainless-steel shelf. A plastic container on the shelf holding various utensils (such as ice cream scoops) had a significant number of crumbs and debris in the bottom of the container. The ceiling above the walk-in cooler and walk-in freezer was noted to have areas where caulking was hanging down from the ceiling. Cooking pans underneath the food prep area had debris and dried food on them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 17 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0812 A steamer had dried debris and stains on the side. Level of Harm - Minimal harm or potential for actual harm A fire extinguisher holding area (no fire extinguisher) had debris on the bottom of it, which included a dead moth. Residents Affected - Many The employee eyewash station on the wall had a 32 fluid ounce bottle of eyewash that expired in February 2023. There was debris on the top of the station, dust on the eyewash bottle, and dust on the seat for the bottle. A plastic container at the tray line holding multiple clean Kennedy cups (spill proof cups) had debris in the bottom of it. There were multiple splashes on the wall under the first aid cabinet. The perimeter of the floor where it met the wall in the area of the three-compartment sink, the cooler, and ice machine had a build-up of debris and dirt. There was a significant amount of dust on top of the ice machine. A wheeled cart holding coffee mugs had an excessive accumulation of debris on the bumper of the cart. There was a significant amount of dust on the ceiling over the coffee machine. A black plastic container near the tray line holding pens and a food thermometer had a significant amount of debris in the bottom of it. The electrical box near the tray line had a significant amount of dust on it. The tile wall underneath it had a significant number of stains and dried food. There was a missing wall tile and a broken wall tile. The walk-in cooler had an expired five-pound container of sour cream with a best by date of 1/30/2024. There was a gallon container of mustard with a use by date written as 1/31/24. The walk-in freezer had an excessive amount of paper debris and food debris under the shelving racks. The above information was reviewed during a walk through of the kitchen with Employee 3, Dietary Manager, on February 6, 2024, at 10:18 AM. The above findings were reviewed with the Director of Nursing and Employee 1, Director of Clinical Operations, on February 7, 2024, at 2:38 PM. 28 Pa. Code 201.14(a) Responsibility of licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 18 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation and staff interview, it was determined that the facility failed to properly contain and dispose of garbage. Residents Affected - Many Findings include: Observation of the main dumpsters outside of the kitchen dock entrance on February 6, 2024, at 10:10 AM revealed the following: There was debris and garbage on the ground surrounding the facility's two dumpsters that included: a large piece of balled up tin foil, multiple small pieces of cardboard, broken glass, food condiment packets, and a balled-up medical glove. The area between the dumpsters and the dock had a pile of garbage that included various paper products, a discarded water bottle, dead leaves, and various food packaging containers. There was a bag of lids open and spilled on the ground behind one dumpster. The dumpster lid was found open with garbage visible in the dumpster and there were no staff noted near the dumpster at the time of the findings. There were pieces of dried food on top of the dumpster. A cardboard box was found broken apart and laying in a pile of snow. The entrance to the kitchen at the dock next to the dumpsters had a large amount of debris in the perimeter where the dock met the wall. There was a discarded partially smoked cigarette butt. There was an accumulation of cobwebs on the walls, ceiling, and an active air vent above the entrance to the kitchen. The above information was reviewed during a walk through of the kitchen with Employee 3, Dietary Manager, on February 6, 2024, at 10:18 AM. The above findings were reviewed with the Director of Nursing and Employee 1, Director of Clinical Operations, on February 7, 2024, at 2:38 PM. 28 Pa. Code 201.14(a) Responsibility of licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 19 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on a review of the facility's water management program and staff interview it was determined that the facility failed to assess the building's water system for waterborne pathogen risk; and implement measures to monitor and prevent the growth of opportunistic pathogens within the facility's water system. Residents Affected - Few Findings include: The CDCs (Centers for Disease Control and Prevention) current Water Management Program Toolkit, Practical Guide to Implementing Industry Standards, indicated that many buildings need a water management program to reduce the risk for Legionella (bacteria that can grow and spread in water systems and can cause a serious type of pneumonia (lung infection) known as Legionnaires' disease) growing and spreading within their water system and devices. Developing and maintaining a water management program is a multi-step process that requires continuous review. Steps to building an effective Legionella water management program include: A description of the building's water system using flow diagrams and a written description to include details like connections to the municipal water supply, how water is distributed, and location of water heaters/boilers. Identification of potentially hazardous conditions such as areas where water temperature could promote Legionella growth or where water flow might be low. Control measures (such as heating, adding disinfectant, or cleaning) that include where and how to monitor them. Control limits are the maximum value, minimum value, or range of values that are acceptable for the control measure. Determine what corrective actions or contingency responses to take when control measures are outside the control limits established. Interview with Employee 10 (multi-facility corporate maintenance director) and Employee 11 (maintenance assistant) on February 8, 2024, at 12:28 PM revealed that the facility does not have a maintenance director at this time; the previous maintenance director was no longer employed at the facility. Employee 10 stated that he is the maintenance director at another facility within Highlands Healthcare and Rehabilitation Center's multi-facility organization; and that he would answer questions pertaining to this corporation's expected practices. Employee 10 stated that, per Department of Environmental Protection standards, a facility that is supplied by a city water system is to test water samples monthly via chlorine testing and pH (numeric value used to express how acidic a solution is) testing. Employee 10 confirmed that Highlands Healthcare and Rehabilitation Center is supplied water through a city water system. Employee 10 repeatedly stated that the facility's water management program manual was outdated and did not reflect the most current corporate policies and procedures. Employee 10 stated that the available manual did not include numeric ranges deemed acceptable for chlorine and pH testing results. Logbook Documentation, Water Systems: Chlorine Residual Test, logs dated July, August, September, October, November, and December 2024 (marked done on-time by the previous maintenance director) and January and February 2024 (marked done on-time by Employee 11), included pH values. Each value result was documented as, low. There were no comments or actions documented on the logs to indicate any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 20 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 measures to correct identified low results. Level of Harm - Minimal harm or potential for actual harm Interview with Employees 10 and 11 indicated that the facility could not stipulate if the numeric values listed were a pH testing result or a chlorine residual testing result. The facility could not provide acceptable numeric ranges to determine if the findings were acceptable. Employees 10 and 11 were unable to provide any evidence that the building water system was assessed for potential areas where Legionella and other opportunistic waterborne pathogens could grow and spread. Residents Affected - Few The surveyor reviewed the above concerns regarding the facility's water management program during an interview with the Director of Nursing and Employee 1 (Director of Clinical Operations) on February 8, 2024, at 2:42 PM. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control Previously cited deficiency 3/24/23 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 21 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents' medical records included documentation that residents' representatives were provided education regarding the risks and benefits of immunizations for three of five residents reviewed for immunization concerns (Residents 88, 22, and 92); and that residents received the pneumococcal vaccine for two of five residents reviewed for immunization concerns (Residents 88 and 91). Residents Affected - Some Findings include: The facility policy entitled, Influenza Vaccine, last reviewed February 22, 2023, indicated that all residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility will provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives). Prior to the vaccination, the resident (or resident's legal representative) will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education will be documented in the resident's medical record. A resident's refusal of the vaccine and reason for refusal will be documented on the Informed Consent for Influenza Vaccine and documented in the electronic health record. The facility policy entitled, Pneumococcal Vaccine, last reviewed February 22, 2023, indicated that all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Before receiving a pneumococcal vaccine, the resident or legal representative will receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education will be documented in the resident's medical record. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per the facility's physician-approved pneumococcal vaccination protocol. Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. For residents who receive the vaccines, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. Clinical record review for Resident 88 revealed nursing documentation dated September 28, 2023, at 1:25 PM that the facility admitted her to the second-floor secured nursing unit. The documentation indicated that Resident 88 was oriented to person, noted to have current/history of behaviors, and was at risk for elopement. Review of hospitalization documentation dated September 25, 2023 (before Resident 88's admission to the facility) listed Resident 88's principal problem as Alzheimer's dementia (disease with a group of symptoms that affects memory, thinking and interferes with daily life). The documentation noted that Resident 88 presented with an altered mental status in the setting of Alzheimer's dementia. In August 2023, Resident 88 was involuntarily admitted to a psychiatric treatment hospital for confusion and acute psychosis (sudden break from reality with delusions and hallucinations). Social services were in contact with county aging services to coordinate needs of Resident 88's safe discharge. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 22 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 Social services documentation dated September 29, 2023, at 8:57 AM revealed that the facility sent all admission documentation to the county's office of aging. Profile information available for Resident 88 indicated that the county's office of aging representative was her responsible party. Residents Affected - Some A quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 4, 2024, assessed a BIMS (Brief Interview for Mental Status, intended to determine the resident's attention, orientation, and ability to register and recall new information and if the resident has signs and symptoms of delirium) score of seven (indicating severe cognitive impairment) for Resident 88. Clinical record review of influenza and pneumococcal vaccination information for Resident 88 revealed staff documented, Consent Refused, for the influenza vaccination. The electronic medical record contained no information pertaining to a history of pneumococcal vaccines. Review of an Influenza Vaccination - Informed Consent/Declination form dated November 28, 2023, indicated that the facility obtained Resident 88's signature to refuse the influenza vaccine. The facility could not provide evidence that Resident 88's responsible party was given education regarding the risks and benefits of the influenza and pneumococcal vaccinations; or that Resident 88's responsible party refused the vaccinations for Resident 88 (given Resident 88's incapacity to be her own responsible party for medical decisions). Clinical record review for Resident 91 revealed profile information that listed a sister-in-law as Resident 91's power of attorney (POA) for finances and care and as her responsible party. A responsible party/POA consent form dated October 4, 2023, indicated that Resident 91's sister-in-law gave consent for the facility to administer a pneumococcal vaccine (PCV20) to Resident 91. Resident 91's clinical record contained no evidence that Resident 91 ever received the PCV20 vaccine. Clinical record review for Resident 22 revealed that the facility admitted her on April 6, 2023. Resident 22's profile information listed a guardian as her emergency contact and responsible party. Guardianship documentation contained in Resident 22's medical record dated November 3, 2021, indicated that a court of law found clear and convincing evidence that Resident 22 was deemed a totally incapacitated person due to intellectual disabilities; and that an attorney assumed the role of guardian for her. Immunization history documentation in Resident 22's electronic medical record indicated that consent was refused for the Prevnar 20 (pneumococcal) and influenza vaccines. Review of an Influenza Vaccination - Informed Consent/Declination form dated September 20, 2023, indicated that the facility obtained Resident 22's signature to refuse the influenza vaccine on September 20, 2023. Review of a Pneumococcal Vaccination - Informed Consent form dated January 25, 2024, indicated that the facility obtained Resident 22's signature to refuse the pneumococcal vaccine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 23 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 - Some The facility could not provide evidence that Resident 22's responsible party was given education regarding the risks and benefits of the influenza and pneumococcal vaccinations; or that Resident 22's responsible party refused the vaccinations for Resident 22 (given Resident 22's incapacity to be her own responsible party for medical decisions). Clinical record review for Resident 92 revealed that the facility admitted her on December 1, 2023, with diagnoses that included Alzheimer's dementia and psychotic disorder with delusions. Profile information indicated that Resident 92's sister was her emergency contact and responsible party. An Influenza Vaccination - Informed Consent/Declination form and a Pneumococcal Vaccination - Informed Consent/Declination form dated December 5, 2023, indicated that verbal consent was refused by Resident 92's POA/sister for both the influenza and pneumococcal vaccinations; however, no facility staff signed and dated the documentation. Electronic communication with the Director of Nursing on February 8, 2024, at 5:05 PM reviewed the above concerns regarding Residents 22, 88, 91, and 92's immunization history. Interview with the Director of Nursing and Employee 1 (Director of Clinical Operations) on February 9, 2024, at 12:39 PM confirmed the above findings for Residents 22, 88, 91, and 92. The facility had no additional information to provide. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 24 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 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 review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents' representatives received education regarding the risks and benefits of the COVID-19 vaccination; and that residents' responsible parties were given the opportunity to accept or refuse the COVID-19 vaccination for residents incapable of making medical decisions independently for two of five residents reviewed for immunization concerns (Residents 22 and 88). Findings include: The facility policy entitled, Coronavirus Disease (COVID-19) - Vaccination of Residents, revised May 2023, revealed that residents who are eligible to receive the COVID-19 vaccine are strongly encouraged to do so. COVID-19 vaccine education, documentation, and reporting are overseen by the infection preventionist and coordinated by his or her designee. Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. Information is provided to the resident in a format and language that is understood by the resident or representative. Residents must sign a consent to vaccinate form prior to receiving the vaccine. The resident's medical record includes documentation that includes, at a minimum, that the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine including: samples of the education materials used; the date the education took place; and the name of the individual who received the education. The policy did not indicate how the facility would provide education or obtain consent for a resident who is deemed incapable of making medical decisions independently. Clinical record review for Resident 88 revealed nursing documentation dated September 28, 2023, at 1:25 PM that the facility admitted her to the second-floor secured nursing unit. The documentation indicated that Resident 88 was oriented to person, noted to have current/history of behaviors, and was at risk for elopement. Review of hospitalization documentation dated September 25, 2023 (before Resident 88's admission to the facility) listed Resident 88's principal problem as Alzheimer's dementia (disease with a group of symptoms that affects memory, thinking and interferes with daily life). The documentation noted that Resident 88 presented with an altered mental status in the setting of Alzheimer's dementia. In August 2023, Resident 88 was involuntarily admitted to a psychiatric treatment hospital for confusion and acute psychosis (sudden break from reality with delusions and hallucinations). Social services were in contact with county aging services to coordinate needs of Resident 88's safe discharge. Social services documentation dated September 29, 2023, at 8:57 AM revealed that the facility sent all admission documentation to the county's office of aging. Profile information available for Resident 88 indicated that the county's office of aging representative was her responsible party. A quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 4, 2024, assessed a BIMS (Brief Interview for Mental Status, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 25 of 26 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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 intended to determine the resident's attention, orientation, and ability to register and recall new information and if the resident has signs and symptoms of delirium) score of seven (indicating severe cognitive impairment) for Resident 88. Review of Resident 88's electronic immunization history revealed that consent for the Moderna COVID-19 Spikevax vaccine (2023) was refused. A COVID-19 Vaccine (2023-2024 Formulation) Screening and Consent/Declination form indicated that the facility obtained Resident 88's signature to refuse the COVID-19 vaccine on November 28, 2023. The facility could not provide evidence that Resident 88s' responsible party was given education regarding the risks and benefits of the COVID-19 vaccination; or that Resident 88's responsible party refused the vaccination for Resident 88 (given Resident 88's incapacity to be her own responsible party for medical decisions) Clinical record review for Resident 22 revealed that the facility admitted her on April 6, 2023. Resident 22's profile information listed a guardian as her emergency contact and responsible party. Guardianship documentation contained in Resident 22's medical record dated November 3, 2021, indicated that a court of law found clear and convincing evidence that Resident 22 was deemed a totally incapacitated person due to intellectual disabilities; and that an attorney assumed the role of guardian for her. Immunization history documentation in Resident 22's electronic medical record indicated that consent was refused for the COVID-19 Moderna Spikevax (2023) vaccine. Review of a COVID-19 Vaccine (2023-2024 Formulation) Screening and Consent/Declination form indicated that the facility obtained Resident 22's signature to refuse the COVID-19 vaccine on October 6, 2023. The facility could not provide evidence that Resident 22's responsible party was given education regarding the risks and benefits of the COVID vaccine; or that Resident 22's responsible party refused the vaccination for Resident 22 (given Resident 22's incapacity to be her own responsible party for medical decisions). Electronic communication with the Director of Nursing on February 8, 2024, at 5:05 PM reviewed the above concerns regarding Residents 22 and 88's COVID-19 immunization history. Interview with the Director of Nursing and Employee 1 (Director of Clinical Operations) on February 9, 2024, at 12:39 PM confirmed the above findings for Residents 22 and 88; the facility had no additional information to provide. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 26 of 26