Inspection·August 29, 2024

F 0554 and make it hard to breathe), asthma, and bronchitis. Level of Harm - Minimal harm or potential for actual harm Review of Resident R281's physician order dated 8/14/24, indicated Trelegy inhaler (inhaled medication to make breathing easier) one puff in the morning. The order did not indicate self-administration of the medication. Residents Affected - Some Review of Resident R281's care plan on 8/25/24, failed to include a plan to manage/determine self-administration practices. Review of the clinical record on 8/25/24, failed to include that the facility's interdisciplinary team had determined which medications may be self-administered safely. Observation on 8/25/24, at 12:09 p.m. Resident R281 was in his recliner chair. A Trelegy inhaler was noted on the bedside stand. Interview on 8/25/24, at 12:11 p.m. Licensed Practical Nurse (LPN) Employee E6 indicated, Yeah he gives it to himself in the morning, so I just leave it in there. Review of Resident R24's clinical record indicate admission date of 8/19/24 with the diagnosis of chronic obstructive pulmonary disease (difficulty breathing), anemia (low iron in the blood) and dysphagia (difficulty swallowing). Review of Resident R24's physician order dated 8/14/24, indicated Trelegy inhaler (inhaled medication to make breathing easier) one inhalation in the morning. The order did not indicate self-administration of the medication. Review of Resident R24's care plan on 8/25/24, failed to include a plan to manage/determine self-administration practices. Review of Resident R24's clinical record on 8/25/24, failed to include that the facility's interdisciplinary team had determined which medications may be self-administered safely. Observation on 08/25/24, at 12:20 p.m. resident was sitting in her chair, the Trelegy inhaler was sitting on the bedside stand. During an interview on 08/25/24, at 12:26 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the Trelegy inhaler was on the bedside stand and Resident R24 did not have an order for self-administration. Interview on 8/25/24, at 2:00 p.m. the Director of Nursing confirmed the facility failed to determine the ability to self-administer medications for three of six residents (Residents R24, R77, and R281). 28. Pa. Code 211.12(d)(1)(2) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 2 of 16 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 395684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to revise/update care plans for two of seven residents to accurately reflect the current status of the resident (Resident R54 and R86). Findings include: A review of the facility policy Care Plan Revision Upon Status Change dated 1/16/24, indicated the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Review of Residents R54's clinical record indicates an admission date of 6/15/23. Review of Resident R54's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/28/24, indicated diagnosis of hypertension (high blood pressure), coronary artery disease (common type of heart disease) and diabetes (high sugar in the blood). Review of Resident R54's physician orders dated 7/17/23, indicate tubigrips bilateral lower extremities on in the a.m. off in the p.m. Review of Resident R54's Treatment administered record for August 2024 indicate tubigrips applied as ordered. Review of Resident R54's care plan failed to include interventions for tubigrips. Review of Residents R86's clinical record indicates an admission date of 6/11/24. Review of Resident R86's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/18/24, indicated diagnosis of congestive heart failure (inefficient myocardial performance, resulting in compromised blood supply to the body), left artificial hip joint and chronic kidney disease. Review of Resident R86's physician orders dated 8/8/24 indicate wanderguard every shift. Review of Resident R86's care plan failed to include interventions for wanderguard. During an interview on 8/28/24, at 10:10 a.m. the Nursing Home Administrator (NHA) confirmed the facility failed to revise/update Resident R54's care plan to include interventions for tubigrips and Residents R86's interventions for wanderguard. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 3 of 16 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 395684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023 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 observation, facility procedure review, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care of a medical device for one of four residents (Resident R283). Residents Affected - Few Findings include: Review of the facility procedure Closed Suction Drain with Bulb: Management dated 1/16/24, indicated to assess the closed suction drain and tube for proper functioning. Ensure patency, airtight connections, and presence of any leaks or kinks in the drainage system. Secure the drain to the patient's clothing with a safety pin. Ensure the suction device is below the level of the wound and does not pull at the insertion site. Review of the clinical record indicated Resident R283 admitted to the facility on [DATE], with the diagnoses of rib fractures, atrial fibrillation (irregular heart rhythm), heart failure (heart doesn ' t pump blood as well as it should), s/p cholecystitis with possible perforation (gallbladder inflammation and possible rupture), and placement of a percutaneous drain (a plastic tube placed into the body, usually the abdomen, to drain infected fluids). Review of Resident R283's physician order dated 8/21/24, indicated JP Drain (Jackson Pratt a plastic tube placed into the body): Empty drain every shift and document drainage (right abdomen). Review of Resident R283's care plan dated 8/22/24, indicated JP drainage catheter will be free of complications through next review. Review of Resident R283's progress note dated 8/26/24, indicated JP drain output was 30cc (cubic centimeters) of dark green bile (a fluid produced by the liver that helps digest fats). Observation on 8/25/24, at 1:35 p.m. Resident R283 was out of bed in a stationary, recliner chair and the JP drain was dangling over the right-side arm of the chair. Observation on 8/27/24, at 10:04 a.m. Resident R283 was out of bed in wheelchair and the JP drain was dangling to the right side down in the wheelchair. Interview on 8/27/24, at 10:04 a.m. Resident R283 indicated it's sore and it's pulling on her skin. Interview on 8/27/24, at 10:08 a.m. Registered Nurse (RN) Employee E5 indicated he would look for a pin to anchor the drain to Resident R283's clothing. Interview on 8/27/24, at 11:00 a.m. the Director of Nursing confirmed the facility failed to make certain that residents were provided appropriate treatment and care of a medical device for one of four residents (Resident R283). 28 Pa. Code 211.10(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: 395684 If continuation sheet Page 4 of 16 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 395684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that residents received treatment and care in accordance with standards of practice and obtain physician orders regarding the dressing displacement for one of three residents (Resident R100). Residents Affected - Few Findings include: Review of the facility policy Negative Pressure Wound Therapy (NPWT-wound vac- used to draw out fluid and infection from a wound to help it heal) dated 1/16/24, indicated to avoid leaving the NPWT device off for more than two hours. If this occurs, remove the old dressing and initiate an NPWT dressing or apply an alternative absorptive dressing as prescribed by the practitioner. Review of the clinical record indicated Resident R100 admitted to the facility on [DATE], with the diagnosis of sepsis (extreme response to an infection), depression, and pressure ulcer of the sacral region (a triangular bone that connects the spine with the hip and pelvic cavity. Review of Resident R100's physician orders dated 8/8/24, indicate wound vac to sacrum, setting 125 millimeters of mercury (mm/hg) continuous. Review of Resident R100's physician orders failed to include orders for displacement of the wound vac device. During an interview on 8/28/24, at 2:05 p.m. Licensed Practical Nurse (LPN) Employee E4 confirmed the facility failed to follow standards of practice and obtain physician treatment orders for dressing displacement for one of three residents (Resident R100). 28 Pa. Code 211.10(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: 395684 If continuation sheet Page 5 of 16 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 395684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023 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 - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that appropriate treatment and services were provided for five of seven residents with a urinary catheter (a hollow, flexible tube that collects urine from the bladder and leads to a drainage bag) (Resident R38, R63, R78, R93 and R99). Findings include: Review of facility policy Indwelling Catheter Use and Removal dated 1/16/24, indicated if an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards and practice of resident care policies and procedures that include but are not limited to: . Keeping the catheter anchored to prevent excessive tension on the catheter. . Securement of the catheter to facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder. Review of Resident R38's clinical record indicate re-admission to facility on 8/23/24, with the diagnosis of heart failure (heart doesn't pump the way it should), atrial fibrillation (abnormal heartbeat), and diabetes (high sugar in the blood) Review of Resident R38's physician orders dated 8/10/24, indicate urinary catheter. Observation on 08/25/24, at 12:00 p.m. Resident R38's urinary drainage bag did not have a dignity/privacy cover. During an interview on 8/25/24, Licensed Practical Nurse (LPN) Employee E 1 confirmed Resident R38's urinary drainage bag did not have a dignity/privacy cover. Review of Resident R63's clinical record indicate an admission date of 9/4/19. Review of Resident R63's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/12/24, indicated diagnoses of hypertension (high blood pressure), Parkinson's disease (long term degenerative neurological disorder), and neurogenic bladder (bladder dysfunction). Review of Resident R63's physician orders dated 5/10/24, indicate urinary catheter. During an observation on 8/25/24, Resident R63 was in bed with her urinary drainage bag in a wash basin on the floor. During an interview on 8/25/24, at 11:37 a.m. LPN Employee E2 confirmed Resident R63's urinary drainage bag was in a wash basin on the floor. Review of Resident R78's clinical record indicate an admission date of 7/11/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 6 of 16 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 395684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023 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 - Some Review of Resident R78's MDS dated [DATE], indicated diagnoses of cancer, Hypertension (high blood pressure), and obstructive uropathy (blockage of urinary flow). Review of Resident R78's physician orders dated 8/5/24, indicate urinary catheter. During an observation on 8/26/24, resident R78 was sitting in his chair in the common area, his urinary drainage bag was sitting in his lap. During an interview on 8/26/24, Registered Nurse (RN) Employee E3 confirmed Resident R78's urinary drainage bag was in his lap and moved it to below his bladder. Review of Resident R 93's clinical record indicate admission date of 7/2/24, with the diagnosis of atrial fibrillation (abnormal heartbeat), obstructive uropathy (blockage of urinary flow), and anemia (low iron in the blood. Review of resident R93's physician orders dated 8/5/24, indicate urinary catheter. During an observation on 8/25/24, at 11:10 a.m. Resident R93 was sitting in his chair, his urinary drainage bag did not have a dignity/privacy cover. During an interview on 8/25/24, at 11:35 a.m. LPN Employee E2 confirmed Resident R93's urinary drainage bag did not have a dignity/privacy cover. Review of Resident R99's clinical record indicate an admission date of 11/24/22. Review of Resident R99's MDS dated [DATE], indicated diagnoses of anemia (low iron in the blood), obstructive uropathy (blockage of urinary flow), and hypertension (high blood pressure) Review of Resident R99's physician orders dated 6/20/24, indicate urinary catheter. During an observation on 8/5/24, at 11:29 a.m. Resident R99 was in his bed, his urinary drainage bag did not have a dignity/privacy cover. During an interview on 08/25/24, at 11:37 a.m. LPN Employee E2 confirmed that Resident R99's urinary drainage bag did not have a dignity/privacy cover. 28 Pa. Code 211.10(c)(d) Resident Care Policies 28 Pa. Code 211.12 (d)(2) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 7 of 16 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 395684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for two of eight residents reviewed (Residents R38 and R281), and failed to care plan use and management of respiratory equipment for two of three residents (Resident R5 and R6). Residents Affected - Few Findings include: Review of facility policy Oxygen Concentrator dated 1/16/24, indicated that oxygen is administered under orders of the attending physician, except in the case of an emergency. Review of Resident R5's clinical record indicated admission to the facility on 3/14/24, with the diagnoses of heart failure (heart doesn't pump blood as well as it should), Parkinson's Disease (disorder of the nervous system that results in tremors), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R5's physician orders dated 5/11/24, indicated: -Change CPAP/BIPAP (a continuous positive airway pressure machine used to keep airways open while you sleep/a positive airway pressure machine when breathing in and breathing out) mask and filter every night shift every three months. -Check and ensure CPAP/BIPAP mask and water chamber is cleaned daily. Machine is wiped down with damp cloth every day. -Check CPAP/BIPAP headgear and tubing are cleaned every day shift. Review of Resident R5's progress note dated 8/26/24, indicated resident currently resting in bed, CPAP on per orders. Review of Resident's care plan dated 6/27/24, failed to include interventions and goals for use and management of the CPAP/BIPAP machine. Interview on 8/27/24, at 2:30 p.m. the Director of Nursing confirmed Resident R5's care plan failed to include use and management of the CPAP/BIPAP machine. Review of the clinical record indicated Resident R6 was admitted to the facility 1/10/18, with the diagnoses of cerebral infarction (occurs when a blood vessel in the brain is blocked, leading to inadequate blood supply and oxygen to brain cells), major depressive disorder, and dementia (loss of cognitive functioning which interferes with a person's daily life and activities). Review of Resident R6's current physician orders dated 8/23/24, indicated Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer two times a day for sob (shortness of breath) for 2 Weeks, and Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 4 hours as needed for Shortness of Breath. Further review of current physician orders indicated for respiratory status to be monitored every shift, initiated 7/27/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 8 of 16 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 395684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R6's recapitalization of physician orders dated 4/24/24, indicated Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 6 hours as needed for Shortness of Breath and 3 milliliter inhale orally via nebulizer at bedtime for sob (shortness of breath), which was discontinued 8/23/24. Review of Resident R6's care plan dated 3/26/24, failed to include interventions and goals for use and management of respiratory breathing treatments. During an interview on 8/28/24, at 1:50 p.m., Resident Nurse Assessment Coordinator (RNAC) Employee R11 confirmed that Resident R6's care plan failed to include use and management of nebulization breathing treatments. Review of the clinical record indicated Resident R281 was admitted to the facility on [DATE], with the diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), asthma, and bronchitis. Review of Resident 281's physician order dated 8/14/24, indicated night nurse to check every week if oxygen used, to make sure filter is cleaned and oxygen tubing and humidifier has been changed every night shift. Oxygen at four liters per minute. Review of Resident R281's progress note dated 8/21/24, indicated no respiratory complications noted with oxygen on via nasal cannula. Observation on 8/25/24, at 12:09 p.m., Resident R281 was noted to have oxygen via nasal cannula on, the concentrator flow rate indicated three liters per minute and the oxygen tubing or humidification was not dated as required. Interview on 8/25/24, at 12:10 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed the concentrator was on the incorrect flow rate of three, instead of four as ordered, and that there were not dates on the oxygen tubing or humidification as required. Review of the clinical record indicate Resident R38 was re-admitted to facility on 8/23/24, with the diagnosis of heart failure (heart doesn't pump the way it should), atrial fibrillation (abnormal heartbeat), and diabetes (high sugar in the blood). Review of Resident R38's physician orders dated 8/23/24, indicate oxygen at 3 liters per minute. Review of physician orders dated 8/16/24, indicated night nurse to check every week on (Fridays), if oxygen used, to make sure filter is cleaned and oxygen tubing and humidifier has been changed. every night shift every 7 days. Review of progress notes dated 8/23/2024, 9:44 p.m., respirations easy and nonlabored on oxygen via nasal canula. Observation on 08/25/24, at 12:00 p.m. Resident R38 was noted to have oxygen on per nasal canula the oxygen tubing failed to be labeled with a date. During an interview on 8/25/24, Licensed Practical Nurse (LPN) Employee E1 confirmed Resident R38's oxygen tubing was not labeled with a date as required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 9 of 16 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 395684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Interview on 8/29/24, at 1:30 p.m. the Nursing Home Administrator (NHA) Director of Nursing (DON) confirmed the facility failed to maintain sanitary conditions of respiratory equipment for two of eight residents reviewed (Residents R38 and R281), and failed to care plan use and management of respiratory equipment for two of three residents (Resident R5 and R6). Residents Affected - Few 28. Pa. Code 211.12(d)(1)(2) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 10 of 16 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 395684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician and failed to notify the physician of missed medications for one of four residents (Residents R335). Residents Affected - Few Findings include: Review of the facility policy Unavailable Medications dated 1/16/24 indicated the facility maintains a contract with a pharmacy provider to supply the facility with routine, as needed (PRN), and emergency medications. A supply of commonly used medications is maintained in house for timely initiation of medications. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable, notify physician of inability to obtain medication upon notification or awareness that the medication is unavailable. Obtain alternative treatment orders and/or specific order for monitoring resident while medication is on hold. Review of the clinical record indicated Resident R335 was a new admission to the facility on 8/24/24, with the diagnosis of restless leg syndrome (nervous system disorder that causes a severe urge to move legs), cellulitis (infection of skin), and lymphedema (tissue swelling). During an interview on 8/25/24 at 12:25 p.m. Resident R355 stated he did not receive his medication for his legs for two nights. Review of Resident R335 physician orders dated 8/24/24, indicate ropinirole oral tablet extended release give 12 mg by mouth at bedtime for restless leg syndrome (RLS) in addition to 6mg tablet. Review of Resident R335's medication administration record dated 8/24/24, and 8/25/24, indicates ropinirole marked as 9 (9 is code for other/see nursing notes). Review of Resident R355's nursing notes dated 8/24/24, at 11:44 p.m. indicate medication not available. Review of Resident R355's nursing notes dated 8/25/24, at 8:20 p.m. indicate medication not available. Review of Resident R355's clinical record failed to reveal the physician was notified that Resident R355 did not receive his ropinirole medication on 8/24/24 and 8/25/25. A review of the facility current emergency medication current contents indicates ropinirole 0.5mg twenty doses available. During an interview 8/27/24, at 11:48 a.m. the Director of Nursing (DON) confirmed the facility failed to follow physician orders for medication administration and to notify the physician of missed medication for one of four residents reviewed (Resident R355). 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12 (c)(1)(3) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 11 of 16 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 395684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to properly store medical supplies and biologicals in one of four medication rooms (Blankenbuehler medication room). Findings include: A review of the facility policy Medication Storage in the Facility last reviewed 1/16/24, indicates medications are to be stored safely, securely, and properly. A review of the facility policy Date Marking for Food Safety last reviewed 1/16/24, indicates the individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. During an observation on 8/26/24, at 11:08 a.m. of the Blankenbuehler Medication Room the following was observed under the sink: . One container of Micro-kill bleach wipes . One gallon of distilled water During an observation on 8/26/24, at 11:08 a.m. of the Blankenbuehler Medication Room, the following was observed in the resident pantry refrigerator: . One opened bag of cheddar cheese cubes, not marked with date/time opened. . Two box of AA batteries . One box of 9 Volt batteries . One box of AAA batteries During an interview on 08/26/24, at 11:14 a.m. Registered Nurse (RN) Employee E3 confirmed the above observations. 28. Pa. Code: 211.10 (c) Resident care policies. 28. Pa. Code: 211.12 (d)(1)(2)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 12 of 16 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 395684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy, observations and staff interview, it was determined that the facility failed to properly label food products in the dry storage area and maintain sanitary conditions in the dish room and kitchen which created the potential for cross contamination in the designated main kitchen. Findings include: Review of the facility policy Date Marking for Food Safety dated 1/16/24, indicated the facility adheres to date marking system to ensure the safety of ready-to-eat, time/temperature control for food safety. During an observation of the main designated kitchen on 8/25/24 at 10:00 a.m, at the following was observed: - 1 bag of life cereal- no label or date - 2 boxes of pineapple juice- no dates - 1 bag of elbow pasta-no date - 2 boxes of [NAME] Buddy-no date - 1 box of Oatmeal Cream Pie- no date - 1 box of Fudge Rounds-no date Walk in Freezer-(1) bag of meat- no label or date Walk in cooler-(3)crates of drinks, stored on the floor During an observation of the main designated kitchen on 8/25/24, at 10:15 a.m. the following was observed: (1) Wall fan's above clean side of dishwasher, brown debris (1) Floor fan clean side of dishwasher, brown debris During an interview on 8/25/24 at 10:25 a.m., Dietary Supervisor Employee E10 confirmed that the facility failed to properly label and date food products and maintain sanitary conditions which created the potential for food borne illness. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.6(c) Dietary services. 28 Pa. Code: 201.14(a) Responsibility of license FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 13 of 16 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 395684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, Centers for Disease Control (CDC) documents, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for one of two residents with an enteral feeding (Resident R96), and failed to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R93). Residents Affected - Few Findings include: Review of the facility policy Enhanced Barrier Precautions (EBP) dated 1/16/24, indicated EBP - conditions to address with precautions includes wounds, indwelling medical devices (central lines, dialysis catheters feeding tubes, and tracheostomy/ventilator tubes), even if the resident is not known to be infected or colonized with a multi drug resistant organism (MDRO). Gowns and gloves are to be worn during high contact activities such as device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. Review of the CDC's Frequently asked Questions about Enhanced Barrier Precautions in Nursing Homes document dated 6/28/24, indicated the safest practice would be to wear a gown and gloves for any care (e.g., dressing changes) or use (e.g., injecting, or infusing medications or tube feeds) of the indwelling medical device. It may be acceptable to use gloves, alone, for some uses of a medical device that involve only limited physical contact between the healthcare worker and the resident (e.g., passing medications through a feeding tube). This is only appropriate if the activity is not bundled together with other high-contact care activities and there is no evidence of ongoing transmission in the facility. Review of the CDC signage for EBP, that the facility is currently using, indicated wear gloves and a gown for the following high contact resident care activities: Device care or use: central line, urinary catheter, feeding tube, tracheotomy. Review of the facility policy Wound Treatment Management dated 1/16/24, indicated to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Review of the clinical record indicated Resident R96 was admitted to the facility on [DATE]. Review of Resident R96's's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/18/24, indicated the diagnoses of Parkinson ' s Disease (disorder of the nervous system that results in tremors), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and high blood pressure. Review of Resident R96's physician orders dated 7/11/24, enhanced barrier precautions due to tube, and physician order dated 7/18/24, indicated to cleanse Gastro tube (the creation of an artificial external opening into the stomach for nutritional support) site with normal saline and apply gauze dressing daily. Review of Resident R96's care plan dated 8/8/24, indicated the resident is at risk for infection related to tube. Maintain EBP. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 14 of 16 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 395684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 8/25/24, at 11:08 a.m. Resident R96's door was adorned with a EBP sign indicating wear gloves and a gown for the following high contact resident care activities: Device care or use: central line, urinary catheter, feeding tube, tracheotomy. Observation on 8/25/24, at 11:09 a.m. during medication observation with Licensed Practical Nurse (LPN) Employee E6, Resident R96 received Sinemet (Parkinson's medication) via tube per order. LPN Employee E6 failed to don a gown as per EBP safest standards according to the CDC. Interview on 8/25/24, at 11:12 a.m. LPN Employee E6 confirmed she did not don a gown according to EBP standards for tube feed care and use. Observation on 8/26/24, at 10:15 a.m., Registered Nurse (RN) Employee E9 was observed sitting on Resident R96's bed on top of used linens, leaning towards window side of the bed where Resident R96 was sitting out of the bed in a chair, holding the tube and irrigation syringe. RN Employee E9 failed to don a gown as per EBP safest standards according to the CDC. Interview on 8/26/24, at 10:18 a.m. RN Employee E9 confirmed she did not don a gown according to EBP standards for tube feed care and administration of resident's feeding bolus as she thought a gown was only required for changing or bathing residents. Interview on 8/26/24, at 2:00 p.m. the RN Infection Preventionist Employee E8 refused to confirm a gown needed donned for care and use of the tube, despite the safest practices stated by the CDC and the fact that the RN Employee E9 thought EBP was only for changing and bathing residents and was found sitting leaning on top of soiled linens of Resident R96's bed while administering the feeding. Interview on 8/26/24, at 2:00 p.m. the Nursing Home Administrator was informed that the facility failed to follow enhanced barrier precautions for one of two residents with an enteral feeding (Resident R96). Review of the clinical record indicated Resident R93 was admitted to the facility on [DATE], with the diagnosis of sepsis (extreme response to an infection), pressure ulcer of the sacral region (a triangular bone that connects the spine with the hip and pelvic cavity) and atrial fibrillation (abnormal heartbeat). Review of a physician's order dated 7/2/24, indicated to cleanse sacral wound site with Dakins (1/4 strength) external solution, then pack wound gently with moisten kerlix gauze with Dakins (1/4 strength) external solution, cover with ABD pad and secure with medfix dressing retention tape only, apply Z guard barrier to surrounding tissues, complete on day and evening shift, and PRN Displacement or Saturated. During a dressing change observation on 8/27/24 at 12:58 p.m., Licensed Practical Nurse (LPN) Employee E2 removed Residents R93's soiled dressing, cleansed the wound, and packed the wound without changing gloves and performing hand hygiene. During an interview on 8/27/24, at 1:38 p.m. LPN Employee E2 confirmed that he did remove Residents R93's soiled dressing, cleansed wound, and packed the wound without changing gloves and performing hand hygiene. 28 Pa. Code 201.14(a) Responsibility of licensee (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 15 of 16 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 395684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023 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 28 Pa. Code 201.18(b)(1) Management Level of Harm - Minimal harm or potential for actual harm 28. Pa. Code 211.12(d)(1)(2) Nursing services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 16 of 16