Inspection·April 24, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on closed clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding the administration of physician ordered pain medications for one of 11 residents reviewed (Resident CR1). Residents Affected - Few Findings include: Review of Resident CR1's closed clinical record revealed a physician's order dated March 23, 2024, for nursing staff to administer Morphine Sulfate 20mg/ml (milligrams/milliliter) 0.5 ml every two hours as needed for pain. A physician's order dated March 24, 2024, indicated that nursing staff were to administer Morphine Sulfate 20mg/ml, 0.75 ml every four hours around the clock for pain, scheduled to be given at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM, every day. Review of Resident CR1's Medication Administration Record (MAR, a form utilized to document the administration of medications) dated April 2024, revealed that Employee 4, registered nurse, only administered 0.5 ml of Resident CR1's Morphine Sulfate dose on April 3, 2024, at 4:47 PM and again at 8:47 PM. Resident CR1's Morphine Sulfate dose at those times should have been 0.75 ml. There was no documented evidence to indicate that Employee 4 administered any as needed Morphine Sulfate doses to Resident CR1 during her shift. Interview with the Administrator on April 24, 2024, at 9:30 AM confirmed that there were no reported medication errors for April 2024, and during a meeting on the same date at 2:30 PM, confirmed the above findings for Resident CR1. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies 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 2 of 4 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 04/24/2024 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 clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure an effective infection control program for outbreak testing and transmission-based precautions to prevent the spread of infection on one of two nursing units (3rd Floor Nursing Unit; Residents 1 and 2, Employees 1 and 2). Residents Affected - Some Findings include: Review of the policy entitled COVID-19 Testing Requirements last reviewed on May 10, 2023, indicates that a single new case of COVID-19 infection in any staff or resident should be evaluated to determine if others in the facility could have been exposed. The approach could involve either contact tracing or a broad-based approach. A broad-based approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Testing is recommended immediately, and again 48 hours after the first negative test, and if negative, again 48 hours after the second negative test. Testing should continue on affected units until there are no new cases for 14 days. The facility's current policy entitled Duration of Transmission-Based Precautions for Residents with COVID-19 Infection, indicates that residents will be on transmission-based precautions for at least 10 days since their first positive viral test or since symptoms first appeared. Review of Resident 1's clinical record revealed nursing documentation dated March 26, 2024, that indicated nursing staff tested him for COVID-19 and the results were positive. The nursing documentation for March 26, 2024, also indicated Resident 1 was symptomatic with a cough and sinus congestion. A physician's order dated March 26, 2024, indicated that nursing staff were to start droplet precautions. The droplet precautions were discontinued after only seven days on April 2, 2024. The facility did not maintain Resident 1's droplet precautions for 10 days. Review of facility submitted incidents via ERS (Event Reporting System, a web-based notification system facilities use to notify the Department of Health of reportable incidents) revealed that the facility tested Employee 1, nurse aide on March 26, 2024, for COVID-19 because she was feeling ill. Employee 1 also tested positive for COVID-19 on March 26, 2024. Employee 2, nurse aide, tested positive for COVID-19 on March 26, 2024, because she was feeling ill. Review of Resident 2's clinical record revealed that she tested positive for COVID-19 on March 28, 2024. Resident 2 was symptomatic with a cough and a low-grade temperature. There was no documented evidence in Resident 2's clinical record to indicate how long the facility kept her on transmission-based precautions. There was no physician order initiated to start or discontinue droplet precautions. The facility was not able to provide any documented evidence that either contract tracing or a broad-based approach of testing was initiated after staff and residents were identified as having symptomatic COVID-19 starting on March 26, 2024. Interview with the Administrator on April 24, 2024, at 11:30 AM revealed that the facility's infection control preventionist quit at the end of March 2024. A new infection control preventionist was hired but did not initiate facility wide COVID-19 testing until April 3, 2024. From March 26, 2024, until April 20, 2024, the facility has reported at least 55 resident and staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 3 of 4 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 04/24/2024 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 cases of COVID-19 to the Department of Health. Level of Harm - Minimal harm or potential for actual harm Interview with the Administrator and Director of Nursing on April 24, 2024, at 2:30 PM confirmed the above findings. Residents Affected - Some 483.80 Infection Control Previously cited 2/9/24 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395683 If continuation sheet Page 4 of 4