Inspection·August 8, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. 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, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R80).Findings include: Review of facility policy Call Lights: Accessibility and Timely Response dated 1/7/25, indicated staff will ensure the call light is within reach of resident and secured, as needed. Review of the clinical record indicated Resident R80 was admitted to the facility on [DATE]. Review of Resident R80's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/2/25, indicated diagnoses of high blood pressure, reduced mobility, and repeated falls. During an observation on 8/4/25, at 11:05 a.m. Resident R80 was sitting in a recliner in their room. The call bell was placed on Resident R80's bed, out of the resident's reach. During an interview on 8/4/25, at 11:25 a.m. Licensed Practical Nurse Employee E1 confirmed Resident R80's call bell was not accessible and unavailable for use to the resident and that the facility failed to accommodate Resident R80's call bell needs. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.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: 395684 If continuation sheet Page 2 of 15 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 08/08/2025 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 0575 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observations and staff interview it was determined that the facility failed to have complete contact information for the State Long Care Ombudsman program posted at the facility.Findings include: During an observation on 8/8/25, from 10:07 a.m. to 10:38 a.m. poster were noted on bulletin boards in three places for the ombudsman but they did not have the name, address and correct email listed. During an interview on 8/8/25, at 11:25 a.m. the NHA was informed that the ombudsman postings failed to have complete contact information State Long Care Ombudsman program. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(3) Management Event ID: Facility ID: 395684 If continuation sheet Page 3 of 15 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 08/08/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review and staff interviews, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for one of four residents (Resident R10).Review of facility policy Use of Psychotropic Medication(s) date 1/3/25, indicated that residents only receive psychotropic medications when other nonpharmacological interventions are clinically ineffective. Additionally, these medications should only be used to treat the resident's medical symptoms and not used to discipline or staff convenience, which would deem it a chemical restraint. A psychotropic drug is any drug that affects brain activities associated with mental processes and behaviors. Psychotropic medications are the be used only when a practioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to medication(s).Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE].Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/26/25, indicated diagnoses of humerus (upper arm) fracture, protein-calorie malnutrition, and diabetes mellitus (group of diseases that affect how the body used blood sugar (glucose)).Review of Resident R10's Medication Administration Record (MAR) for July 2025, indicated Lorazepam oral tablet (a psychotropic medication used to treat anxiety) 1 milligram, give 1 tablet by mouth every four hours as needed for severe anxiety, initiated 6/5/25, and discontinued 7/16/25.Review of Resident R10's current physician order dated 7/16/25, indicated to administer Lorazepam tablet (a psychotropic medication used to treat anxiety) 0.5 milligram, give 0.5 milligram by mouth every eight hours as needed (PRN) for anxiety.Review of Resident R10's current care plan indicated use of psychotropic medication for anxiety and depression, with interventions to monitor for side effects and effectiveness every shift; Monitor/document/report as needed any adverse reactions of psychotropic medications.Review of Resident R10's MAR dated July 2025 through August 2025, indicated that resident received Lorazepam PRN (as needed) 10 times per order.Review of Resident R10's current physician order dated 5/16/25, indicated to administer Duloxetine HCl Capsule Delayed Release Particles (a psychotropic medication used to treat anxiety and nerve pain) 60 milligrams, give 1 capsule by mouth in the morning for neuropathy.Review of Resident R10's clinical record failed to indicate any documented non-pharmacological interventions used by staff prior to administering Resident R10's Lorazepam PRN. Further review of Resident R10's clinical record revealed no evidence that the facility had implement side effect or behavior monitoring for psychotropic medication use.During an interview on 8/7/25, at approximately 1:05 p.m., the Director of Nursing (DON) confirmed that the facility did not have documentation of non-pharmacological interventions used prior to administering of as needed psychotropic medication. DON also confirmed that the facility did not have side effect monitoring nor behavior monitoring in place for the safe and effective use of Resident 10's psychotropic medication use.28 Pa Code: 201.14(a) Responsibility of licensee.28 Pa. Code 211.5(f) Medical records.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Event ID: Facility ID: 395684 If continuation sheet Page 4 of 15 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 08/08/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of six residents sampled with facility-initiated transfers (Residents R11, R42, R143, and R201), and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of six resident hospital transfers (Residents R4, R11, and R143).Findings include: Review of facility policy Transfer and Discharge (including AMA) dated 1/7/25, indicated for a transfer to another provider, for any reason, the following information must be provided to the receiving provider: Contact information of the practitioner who was responsible for care of the resident; Resident representative information, including contact information; Advance directive information; All other information necessary to meet the resident's needs, which includes, but may not be limited to: resident status, diagnoses and allergies, medications (including when last received), and most recent relevant labs, other diagnostic test, and recent immunizations All special instructions and/or precautions for ongoing care, as appropriate; The resident's comprehensive care plan goals Document assessment findings and other relevant information regarding the transfer in the medical record. Review of facility policy Bed Hold Notice dated 1/7/25, indicated in the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/19/25, indicated diagnoses of muscle wasting, constipation, and dependence on supplemental oxygen. Review of the clinical record indicated Resident R4 was transferred to the hospital on 7/9/25, and did not return to the facility. Review of Resident R4's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 7/9/25. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 5 of 15 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 08/08/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Review of Resident R11's MDS dated [DATE], indicated diagnoses of reduced mobility, constipation, and chronic pain. Review of the clinical record indicated Resident R11 was transferred to the hospital on 5/27/25, and returned to the facility on 6/2/25. Residents Affected - Some Review of Resident R11's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of Resident R11's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 5/27/25. Review of the clinical record indicated Resident R42 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R42's MDS dated [DATE], indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), anemia (too little iron in the body causing fatigue), and anxiety (a feeling of worry, nervousness, or unease). Review of the clinical record indicated Resident R42 was transferred to the hospital on 2/21/25, and returned to the facility on 2/26/25. Review of Resident R42's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 8/8/25, at 9:19 a.m. the Director of Nursing (DON) confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for Resident R42. Review of the clinical record indicated Resident R143 was admitted to the facility on [DATE]. Review of Resident R143's MDS dated [DATE], indicated diagnoses of anemia (too little iron in the blood), muscle wasting, and need for assistance with personal care. Review of the clinical record indicated Resident R143 was transferred to the hospital on 3/21/25, and returned to the facility on 3/24/25. Review of Resident R143's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 6 of 15 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 08/08/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Review of Resident R143's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 3/21/25. Review of the clinical record indicated Resident R201 was admitted to the facility on [DATE]. Residents Affected - Some Review of the clinical record indicated Resident R201 was transferred to the hospital on 8/6/25. Review of Resident R201's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, specific instructions for ongoing care, and all information necessary to meet the resident's specific needs at the receiving facility including a list of current medications. During an interview on 8/7/25, at 2:14 p.m. the Nursing Home Administrator confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for three of six resident hospital transfers (Residents R4, R11, and R143). During an interview on 8/7/25, at 2:51 p.m. the DON confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for Residents R5, R11, and R201. 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 7 of 15 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 08/08/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of residents for one of two residents reviewed (Resident R84), relating to visual impairment.Findings include: Review of the facility policy Comprehensive Care Plans dated 1/7/25, indicated that the comprehensive, person-centered care plan included measurable objectives and time frames, to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified to meet the resident's needs. Review of the clinical record revealed that Resident R84 was admitted to the facility on [DATE]. Review of Resident R84's MDS (Minimum Data Set, periodic assessment of care needs) dated 7/20/25, indicated diagnoses of hip fracture, depression, and migraine. Section B1000. Vision revealed the resident's ability to see in adequate light was highly impaired. Review of Resident R84's progress note dated 8/1/25, stated the resident was legally blind-staff to assist in belongings within reach. Review of Resident R84's care plan on 8/5/25, failed to include a care plan for the resident's visual impairment. During an interview on 8/6/25, at 12:45 p.m. Licensed Practical Nurse (LPN), Employee E5 confirmed Resident R84 failed to have a care plan for the resident's visual impairment. Interview with the Director of Nursing and the Nursing Home Administrator on 8/6/25, at 12:49 p.m. confirmed the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of residents for one of two residents reviewed (Resident R84), relating to visual impairment. 28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12 (d)(5) Nursing Services. Event ID: Facility ID: 395684 If continuation sheet Page 8 of 15 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 08/08/2025 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, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers for one of five residents (Resident R5). Residents Affected - Few Findings include: Review of facility policy Wound Treatment Management dated 1/7/25, 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. Treatments will be documented on the Treatment Administration Record (TAR). Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/11/25, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and hyperlipidemia (high levels of fat in the blood). Review of a physician order dated 7/1/25, indicated to cleanse coccyx (tailbone) wound with NSS (normal sterile saline), apply collagen particles (used to promote new tissues growth) to wound bed followed by medical grade honey (a gel used to promote wound healing), place calcium alginate (a highly absorbent dressing) in wound bed over the honey and cover wound with a large bordered gauze every day shift for wound. Review of Resident R5's July 2025 TAR indicated the treatment was not documented as completed during the day shift on 7/6/25. Review of a physician order dated 7/16/25, indicated to cleanse coccyx wound with NSS, apply calcium alginate, collagen particles, medical grade honey, house antifungal ointment to peri (surrounding) wound every day. Cover with a bordered gauze dressing every day shift for wound. Review of Resident R5's July 2025 TAR indicated the treatment was not documented as completed during the day shift on 7/24/25. During an interview on 8/8/25, at 1:12 p.m. Licensed Practical Nurse (LPN) Wound Nurse Employee E3 confirmed that the facility failed to make certain Resident R5 received proper treatment for a pressure ulcer as required. 28 Pa. Code 201.18 (b)(1) Management.28 Pa. Code 211.10 (c)(d) 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 9 of 15 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 08/08/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of facility documentation, review of clinical records, and staff interview, it was determined that the facility failed to identify and assess a resident for smoking safety in a timely manner for one of two residents (Resident R89).Findings include: Review of the facility policy Resident Smoking dated 1/7/25, indicated that all residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS (Minimum Data Set- periodic assessment of resident care needs) assessment process. Residents who smoke will be further assesses, using a smoking assessment tool designated by the facility, to determine whether or not supervision is required for smoking, or of the resident is safe to smoke at all. Review of Resident R89's clinical record revealed documentation from the hospital dated 2/3/25, that resident is a smoker and smokes one pack of cigarettes per day, and has been smoking for the past 40 years. Review of clinical record revealed that Resident R89 was admitted to the facility on [DATE]. Review of clinical record revealed a history and physical completed by the physician on 2/18/25, that indicated that Resident R89 uses tobacco products at least daily and smokes 1 pack of cigarettes per day. Review of Resident R89's MDS dated [DATE], indicated diagnoses of high blood pressure, peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Section J1300 stated yes to current tobacco use. Review of Resident R89's clinical record revealed that a Smoking- Safety Screen was completed on 3/24/25, and indicated that resident would like to smoke two to five cigarettes per day in the mornings, and evenings, and that resident requires supervision to smoke. Review of Resident R89's plan of care revealed interventions for smoking were initiated on 4/2/25. During an interview on 8/7/25 at 10:29 a.m. the Nursing Home Administrator (NHA) confirmed that the facility does allow smoking. The NHA confirmed that Resident R89's Smoking - Safety Screen was not completed in a timely manner, as it was completed on 3/24/25, five weeks after her 2/17/25 admission, and that care plan interventions were not implemented un 4/2/25. During an interview on 8/8/25 at 11:45 a.m. the Nursing Home Administrator confirmed that the facility failed to properly identify Resident R89 as a smoker upon admission, and that the facility failed to timely assess and care plan Resident R89 for smoking safety. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Event ID: Facility ID: 395684 If continuation sheet Page 10 of 15 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 08/08/2025 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications for one of four residents (Resident R171) the pharmacy driver left medications unattended and unsecured during a delivery during one observation. Findings include: Review of the facility Medication Storage in the Facility policy dated 1/7/25, stated medications and biologicals are stored safely, securely, and properly following manufactures recommendations or those of the supplier. The medication supply is only accessible to licensed nursing personal, pharmacy personnel, or staff members lawfully authorized to administer medications. Review of Resident R171's admission record indicated she was admitted [DATE], with diagnosis that included pulmonary hypertension, atrial fibrillation (irregular heartbeat), and polycythemia vera (rare type of blood cancer). During an observation on 8/4/25, at 1:12 p.m. the following was observed on Resident' R171's bedside dresser.-(1) tube of Muscle Rub-Methyl salicylate/menthol-(1) bottle Nystatin-100,000 units per gram, 30 gram bottle -(1) bottle Deep Sea Premium Saline bottle During an interview on 8/4/25, at 1:15 p.m. Registered Nurse, Employee E8 confirmed the above observations and that the facility failed to properly store medications for Resident R171. During an observation on 8/7/25, at 12:05 p.m. three bins of unsecured medications from pharmacy were observed left on a utility cart in the hallway. A total of 333 resident medication cards were observed throughout the three bins. During an interview on 8/7/25, at 12:09 p.m. Pharmacy Driver, Employee E9 indicated they were in the middle of restocking medication carts. Pharmacy Driver, Employee E9 confirmed three bins of medications were left unsecure in the hallway. During an interview on 8/7/25, at 12:11 p.m. the Director of Nursing confirmed the facility failed to properly store medications for one of four residents (Resident R171) and the pharmacy driver left medications unattended and unsecured during a delivery during one observation. 28 Pa. Code: 201(a) Responsibility of licensee.28 Pa. Code: 211.9(a)(1)(k) Pharmacy services.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. Event ID: Facility ID: 395684 If continuation sheet Page 11 of 15 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 08/08/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.A review of facility policy Food Safety and Sanitation dated 1/3/25, indicated all local, state and federal standards and regulations are followed in order to assure a safe and sanitary food service department. During an observation on 8/4/25, at 10:55 a.m., of the walk-in cooler in the main kitchen, conducted with Dietary Supervisor (DS) Employee E2, revealed that the cold air condenser unit had a build-up of dust, grime, and dark colored debris around the fan covers and the area of the condenser immediately around the fans. DS Employee E2 confirmed observation by surveyor when viewed. During an interview on 8/4/25, at 10:57 a.m., DS Employee E2 confirmed that the facility failed to properly maintain kitchen equipment, walk-in cooler, in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management. Event ID: Facility ID: 395684 If continuation sheet Page 12 of 15 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 08/08/2025 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 review of facility policies and clinical records, observations, and staff interviews, it was determined that the facility failed to properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for two of two residents (Residents R5 and R143), and failed to ensure enhanced barrier precautions (EBP) were implemented for two of three residents (Resident R10 and R40). Findings include: Residents Affected - Few Review of facility policy Enhanced Barrier Precautions dated 1/3/25, indicated the facility will implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). Enhanced barrier precautions may be implemented for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. During an observation on 8/4/25, at 10:50 a.m. Resident R5 had a small personal refrigerator in their room. The temperature log had data recorded for 8/1/25, but no documented temperatures for 8/2/25, and 8/3/25. During an observation on 8/4/25, at 10:56 a.m. Resident R143 had a small personal refrigerator in their room. The temperature log had data recorded for 8/1/25, but no documented temperature for 8/2/25, and 8/3/25. During an interview on 8/4/24, at 10:58 a.m. Licensed Practical Nurse (LPN) Employee E1 stated, The temperatures are supposed to be done on the day shift and usually the next shift will get them if it's missed. During an interview on 8/4/25, at 11:33 a.m. LPN Employee E1 confirmed that the facility failed to properly monitor a resident's personal refrigerator to ensure that food is properly stored and maintained for Residents R5 and R143. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/26/25, indicated diagnoses of humerus (upper arm) fracture, protein-calorie malnutrition, and diabetes mellitus (group of diseases that affect how the body used blood sugar (glucose)). Section M0210, Unhealed Pressure Ulcers/Injuries was coded 1, indicating current number of unhealed pressure ulcer/injuries. Review of Resident R10's Skin and Wound Evaluation dated 7/28/25, revealed that a Stage III (full-thickness skin loss) pressure ulcer was developed in-house on 6/11/25 to Resident R10's coccyx (commonly known as the tailbone - small, triangular bone located at the bottom of the vertebral column); current measurements - length 1.3 centimeters, width 0.7 centimeters, and depth 0.1 centimeters. Review of Resident R10's current physician order dated 7/7/25, indicated to cleanse: coccyx wound with NSS (normal saline solution), apply Santyl (prescription medicine that removes dead tissue from wounds) nickel thick layer to wound bed followed by calcium alginate (wound care treatment for the management of highly draining wounds). Apply Magic Mix (Lidocaine gel 3%, Triamcinolone 0.25%, Nystatin cream, Zinc oxide 40%, 1:1:1:2) to peri wound (skin around the wound that is affected by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 13 of 15 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 08/08/2025 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 wound). Cover with a bordered foam, every day shift for wound. Level of Harm - Minimal harm or potential for actual harm Review of Resident R10's clinical record and direct observation of Resident R10's room on 8/6/25, revealed no evidence that the facility implemented Enhanced Barrier Precautions (EBP) for Resident R10 due to current pressure ulcer. Residents Affected - Few During an interview on 8/6/25, at 10:00 a.m., Infection Preventionist (IP) Employee E4 confirmed that the facility failed to implement EBP's for Resident R10. Review of the admission record indicated Resident R40 was admitted to the facility on [DATE]. Review of R40's MDS dated [DATE], included diagnoses of anemia (the blood doesn't have enough healthy red blood cells), malnutrition, and muscle wasting. Review of Resident R40's physician order dated 8/2/25, indicated to implement contact isolation precautions due to ESBL (E. Coli) of the urine. During an observation on 8/6/25, at 8:16 a.m. contact isolation signage was posted at the entrance of Resident R40's door. Licensed Practical Nurse Employee E7 entered Resident R40's room without a gown and failed to wash their hands. LPN Employee E7 administered Resident R40's medication without any PPE (personal protective equipment). During an interview on 8/6/25, at 8:43 a.m. the IP Employee E4 confirmed the facility failed to enter the correct order for isolation and implement isolation precautions for Resident R40. IP Employee E4 confirmed Resident R40's order for isolation should have been enhanced barrier precautions. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.10 (d) 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 14 of 15 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 08/08/2025 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to complete Influenza vaccination consent and administer the Influenza vaccination in a timely manner for one of five residents (Resident R3).Findings include: Review of facility policy Infection Prevention and Control Program dated 4/28/25, indicated all residents and employees will be offered the influenza vaccine. Between October 1st and March 31st each year, the influenza vaccine shall be offered. The resident or employee will be provided information and education regarding the benefits and potential side effects. Education shall be documented in the residents or employee's medical record. Review of the admission record indicated that Resident R3 was admitted to the facility on [DATE]. Review of R3's Minimum Data Set (MDS-periodic assessment of care needs) dated 1/7/25, included diagnoses of high blood pressure, anemia (too little iron in the body causing fatigue), and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Review of Resident R3's immunization record failed to include evidence the resident was offered and received the influenza vaccination for the 2024-2025 flu season. During an interview on 8/7/25, at 10:30 a.m. the Director of Nursing confirmed that the facility failed to complete Influenza vaccination consent and administer the Influenza vaccination in a timely manner for one of five residents (Resident R3). 28 Pa. Code 211.5(f) Clinical records Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395684 If continuation sheet Page 15 of 15