Inspection·May 15, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 three residents reviewed (Resident R1), relating to use of an insulin pump (wearable device that delivers insulin continuously to people with diabetes). 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 R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of care needs) dated 3/30/25, indicated diagnoses of heart failure (heart doesn't pump blood as well as it should), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and hypertension (the force of the blood against the artery walls is too high). Section C0500 a Brief Interview for Mental Status test (BIMS - is a screening test that aides in detecting cognitive impairment) indicated a score of 12, moderately impaired cognition. Review of Resident R1's hospital discharge transfer orders dated 3/25/25, indicated Humalog (insulin Lispro) a rapid-acting insulin used to manage blood sugar) 100 units/milliliter injectable solution, injectable via insulin pump - average daily dose is 90 units (max dose 100 units daily). Review of Resident R1's current care plan on 4/29/25, indicated the resident has diabetes, with a goal of remaining free from signs and symptoms of hypo/hyperglycemia (blood sugars too low/high) through the next review date. Interventions included instruction to resident on signs and symptoms of hypo/hyperglycemia, and Accu-Chek monitoring four times daily with regular insulin coverage. The care plan failed to reflect the resident had an insulin pump that was infusing continuous insulin to the resident twenty-four hours a day. Review of Resident R1's progress note dated 3/31/25, at 12:03 p.m. indicated resident was wearing an insulin pump. Resident was ordered to be given 90 units Humulin insulin to refill insulin pump; but the nurse administered Humulin 90 units subcutaneously in error and was transferred to the hospital where he was diagnosed with hypoglycemia and accidental insulin overdose. There was no documented evidence that a care plan was developed to address Resident R1's specific and individualized interventions and care needs related to the continuous use of an insulin pump. Interview with the Director of Nursing and the Registered Nurse Assessment Coordinator (RNAC) Employee E9 on 4/30/25, at 12:20 p.m., and telephonic interview on 5/15/25, at 9:19 a.m. with the Nursing Home Administrator confirmed that there was not a care plan for the insulin pump and that the facility failed to develop comprehensive care plans that included specific and individualized (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 2 of 12 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 interventions to address the care needs of residents for one of three residents reviewed (Resident R1), relating to use of an insulin pump. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 211.10(d) Resident care policies. Residents Affected - Few 28 Pa. Code: 211.12 (d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 3 of 12 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, facility policies and procedures and staff and resident interviews, it was determined that the facility failed to ensure that one of three residents (Resident R1) received treatment and care in accordance with professional standards of practice which resulted in actual harm to Resident R1, who received a medication that was not given according to the physician's orders, resulting in Resident R1 being overdosed on insulin (injectable diabetic medication) overdose and required treatment in an acute care emergency department. Residents Affected - Few Findings include: Review of the facility policy Provision of Quality Care dated 1/7/25, indicated based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans and the resident's choices. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of care needs) dated 3/30/25, indicated diagnoses of heart failure (heart doesn't pump blood as well as it should), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and hypertension (the force of the blood against the artery walls is too high). Section C0500 a Brief Interview for Mental Status test (BIMS - is a screening test that aides in detecting cognitive impairment) indicated a score of 12, moderately impaired cognition. Review of Resident R1's Nursing admission evaluation dated 3/25/25, indicated Section D Skin Integrity chronic (something that lasts a long time, often three months or more) wound left foot, and right below the knee amputation (surgical removal of a limb or part of a limb) incision with staples (used to close incisions after surgery). The skin assessment failed to indicate the presence of an insulin pump. Review of Resident R1's hospital discharge transfer orders dated 3/25/25, indicated Humalog (insulin Lispro) a rapid-acting insulin used to manage blood sugar) 100 units/milliliter injectable solution, injectable via insulin pump (wearable device that delivers insulin continuously to people with diabetes) - average daily dose is 90 units (max dose 100 units daily). Review of Resident R1's physician order dated 3/25/25, indicated Humulin R (insulin regular - a short acting insulin used to manage blood sugar) injection solution, inject 90 units subcutaneously (injecting a drug into the fatty tissue layer beneath the skin) one time a day for Diabetes Insulin Pump, max dose 100 units daily. Order was transcribed by LPN Employee E6, incorrectly from the written hospital discharge orders, was not written clearly by the admitting nurse, the physician was not questioned by the admitting nurse for clarification and the medication was not given according to the physician's written orders upon discharge from the hospital. Review of Resident R1's care plan on 4/29/25, failed to include a problem, goal, or interventions for care and management of an insulin pump. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 4 of 12 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few Interview on 4/29/25, at 9:30 a.m. the Director of Nursing confirmed, and telephonic interview on 5/15/25, at 9:19 a.m. with the Nursing Home Administrator confirmed the admission nursing evaluation dated 3/25/25, failed to identify the use of an insulin pump for Resident R1, confirmed that the admitting nurse transcribed the hospital discharge transfer order on 3/25/25, as Humulin R and not the correct medication ordered, which was Humalog, confirmed the order read subcutaneously rather than injectable via insulin pump, further confirmed that Resident R1 was given 90 units of subcutaneous Humulin R insulin as a result of these omissions and errors in transcription and administration that resulted in actual harm and that the resident was sent to the emergency room for monitoring from an insulin overdose and hypoglycemia. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 5 of 12 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **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 ensure that nursing staff have the specific competencies and skill sets necessary to provide care for a resident with an insulin pump (wearable device that delivers insulin continuously to people with diabetes), and placed one resident (Resident R1) in immediate jeopardy in which health and safety were impacted. Findings include: Interview on 4/29/25, at 9:35 a.m. the Director of Nursing (DON) indicated I don't think we have a policy for insulin pumps. Review of facility policy Competent Nursing Staff dated 1/7/25, indicated it is the policy of the facility to provide staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/30/25, indicated diagnoses of heart failure (heart doesn't pump blood as well as it should), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and hypertension (the force of the blood against the artery walls is too high). Section C0500 a Brief Interview for Mental Status test (BIMS - is a screening test that aides in detecting cognitive impairment) indicated a score of 12 moderately impaired cognition. Review of Resident R1's nursing admission evaluation dated 3/25/25, indicated Section D Skin Integrity chronic (something that lasts a long time, often three months or more) wound left foot, and right below the knee amputation (surgical removal of a limb or part of a limb) incision with staples (used to close incisions after surgery). The skin assessment failed to indicate the presence of an insulin pump. Review of Resident R1's hospital discharge transfer orders dated 3/25/25, indicated Humalog (insulin Lispro) a rapid-acting insulin used to manage blood sugar) 100 units/milliliter injectable solution, injectable via insulin pump - average daily dose is 90 units (max dose 100 units daily). Review of Resident R1's physician order dated 3/25/25, indicated Humulin R (insulin regular - a short acting insulin used to manage blood sugar) injection solution, inject 90 units subcutaneously (injecting a drug into the fatty tissue layer beneath the skin) one time a day for Diabetes Insulin Pump, max dose 100 units daily. Order was erroneously transcribed by LPN Employee E6. Review of Resident R1's care plan on 4/29/25, failed to include a problem, goal, or interventions for care and management of an insulin pump. Interview on 4/29/25, at 9:41 a.m. Registered Nurse (RN) Employee E1 indicated No. I haven't had education on an insulin pump. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 6 of 12 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Interview on 4/29/25, at 9:44 a.m. Licensed Practical Nurse (LPN) Employee E2 indicated remembering Resident R1 having an insulin pump, but admitted she only knows about the pump because a relative of hers had one. Nobody at the facility taught her about an insulin pump. She believed the pump came with insulin already inside of it. When asked how long the pump lasted before needing changed or refilled, LPN Employee E2 indicated they last a long while and that she did not know what type of insulin pump Resident R1 had or what it looked like. Residents Affected - Few Interview on 4/29/25, at 9:51 a.m. RN Employee E3 indicated she had not received education regarding an insulin pump. Recalled Resident R1 had one because she found it beeping one day and notified the resident's nurse. Indicated the pump looked like a very tiny infusion machine. Interview on 4/29/25, at 9:54 a.m. LPN Employee E4 indicated she had not received education regarding an insulin pump. Interview on 4/29/25, at 9:57 a.m. LPN Employee E5 indicated not receiving training on an insulin pump, but recalls a resident downstairs had one recently. It was LPN Employee E5's first day of orientation and that's all they could recall. Telephonic interview on 4/29/25, at 10:12 a.m. LPN Employee E6 indicated she only picked up one shift at this facility. Recalled an admission that night during her shift of 7:00 p.m. - 7:00 a.m. When asked if she was familiar with insulin pumps, she indicated not having experience with one or receiving education on it. Recalled she arrived to work at 7:00 p.m. for her first shift at the facility and they told her she had a new admission. She remembered calling the On Call doctor who said someone will come in and see the new admission in the morning. She indicated she transcribed the orders from the hospital discharge transfer orders. She indicated she did not receive any training at the facility, had to pass her medications and do the admission on her own. She indicated she was not aware she entered the incorrect insulin type and that she was not aware she wrote the insulin to be injected subcutaneously in error, rather than to refill the pump. Review of Resident R1's progress note dated 3/31/25, at 12:03 p.m. indicated resident was wearing an insulin pump. Resident was ordered to be given 90 units Humulin insulin to refill insulin pump; but the nurse administered Humulin 90 units subcutaneously in error and was transferred to the hospital where he was diagnosed with hypoglycemia and accidental insulin overdose. Review of LPN Employee E6's employee file failed to include evidence of orientation to the facility, Interview on 4/29/25, at 2:00 p.m. the Director of Nursing confirmed LPN Employee E6, and the facility nursing staff were not trained on insulin pumps. Confirmed LPN Employee E6 was not trained on facility processes, admission process, transcribing physician orders from hospital discharge papers, transcribed the incorrect insulin type in the admission orders, and this resulted in a negative resident outcome. On 4/29/25, at 2:03 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware that Immediate Jeopardy (IJ) existed, NHA was provided the IJ Template, that placed one resident (Resident R1) in immediate jeopardy in which health and safety were impacted, and a corrective action plan was requested. On 4/29/25, at 4:01 p.m., an acceptable Corrective Action Plan was received which included the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 7 of 12 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 following interventions: Level of Harm - Immediate jeopardy to resident health or safety Immediate Action: Resident was sent out to the hospital for evaluation regarding insulin medication error and returned to the facility in stable condition. Resident R1 has been discharged from the facility with no plans to return. Residents Affected - Few The root cause of the event was that the facility failed to educate licensed staff on insulin pump usage, admission process, and transcribing physician orders from hospital discharge paperwork. Residents: -Residents will be audited by the DON or designee to identify specialty equipment by 4/29/25. If specialty equipment is identified, the staff will obtain physician orders. Care plans will be updated to include specialty equipment (if applicable) by 4/29/25. -admission assessments for residents admitted from 3/25/25, to present will be audited for special equipment specifically insulin pumps and/or continuous glucose monitors by the DON or designee by 4/29/25. -Physician orders from discharge paperwork for residents admitted from 3/25/25, to present will be audited for accuracy by DON or designee by 4/29/25. System Correction: -Pre-admission resident screening will be conducted by the Admissions Director (AD) or designee to identify any special equipment. Special equipment needs will be communicated to the nursing team prior to resident admission. AD will be educated on this process by the NHA or designee by 4/29/25. Licensed nursing staff (including agency) will be educated on the following: -Pre-admission resident screening will be conducted by the AD or designee to identify any special equipment. Special equipment needs will be communicated to the nursing team prior to resident admission. -Assessing residents upon admission for special equipment including insulin pumps/continuous glucose monitors (CGM's). -Obtaining physician orders for specialty equipment. -Accurate order transcription and admission red lining processes (a process to double check accuracy of orders). -Care plan updates on specialty equipment (insulin pumps/CGM's). -The DON or designee will educate licensed nursing staff (including agency) on updated processes by 4/30/25, or before the start of their next scheduled shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 8 of 12 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few -Facility policy on medication administration updated and reviewed to include specialty equipment, obtaining physician orders, and updating care plans. Monitoring: -Audits of new resident admission assessments will be conducted by the DON or designee weekly for four weeks, monthly for two months to ensure assessments, redlining, and orders are completed and accurate. Findings of audits will be submitted through facility Quality Assurance and Performance Improvement (QAPI) program. Next QAPI meeting scheduled for 5/1/25. Interview on 4/30/25, at 10:50 a.m. RN Employee E6 indicated she wasn't familiar with insulin pumps prior to receiving training, and that Resident R1's insulin pump was beeping and she asked him what it was. Resident R1 (with a BIMS of 12) educated RN Employee E6 on the insulin pump. RN Employee E6 drew up the insulin and Resident R1 showed RN Employee E6 how to fill the pump with the insulin. Telephonic interview on 4/30/25, at 11:29 a.m. LPN Employee E7 verified she received education on insulin pumps, facility processes, admission process and transcribing physician orders from hospital discharge papers. Telephonic interview on 4/30/25, at 11:37 a.m. LPN Employee E8 verified she received education on insulin pumps, facility processes, admission process and transcribing physician orders from hospital discharge papers. Review of the Abatement plan on 4/30/25, indicated: -Resident R1 was sent out to the hospital and later returned. Has since discharged home status post physical and occupational therapy and wound care. -The root cause of the event was listed as the facility failed to educate licensed staff on insulin pump usage, admission process, and transcribing physician orders from hospital discharge paperwork. -The DON completed a house audit on 84 of 84 residents in house for specialty equipment needs. No new residents identified. -New Admissions (20 residents) assessed for special equipment since 3/25/25, completed. -New Admissions (20 residents) physician order audit for accuracy and no discrepancies found. -AD was in-serviced on pre-admission screening for special equipment prior to acceptance to facility including, life vest, insulin pump, CGM's, pacemakers, etc. -Facility policy updated to include specialty equipment having physician orders and care plans reflective of equipment. -Facility professional nurses 27 of 27 received education. -Agency professional nurses 17 of 17 received education. Total professional staff 44. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 9 of 12 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 -Interviewed nine of nine professional staff in house on 4/30/25, who verified they received training. Level of Harm - Immediate jeopardy to resident health or safety -Six professional nurses confirmed via phone on 4/30/25, 11:39 a.m. Residents Affected - Few -Audit forms completed per plan, next QAPI, May 1, 2025. -Total of 15 verified receiving education. -No additional equipment needs were identified through the abatement process. The Immediate Jeopardy was lifted on 4/30/25, at 12:03 p.m. when the action plan was verified. During an interview on 4/29/25, at 2:03 p.m. the NHA and DON confirmed that the facility failed to ensure that nursing staff have the specific competencies, and skill sets necessary to provide care for a resident with an insulin pump, and placed one resident (Resident R1) in immediate jeopardy in which health and safety were impacted. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 10 of 12 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for one of three residents which created an actual harm of an accidental insulin overdose and acute care emergency room visit for Resident R1. Residents Affected - Few Findings include: Review of the facility policy Medication Administration dated 1/7/25, indicated medications are administered by licensed nurses, as ordered by the physician and in accordance with professional standards of practice. Ensure that the six rights of medication administration are followed: right resident, right drug, right dose, right route, right time, and right documentation. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of care needs) dated 3/30/25, indicated diagnoses of heart failure (heart doesn't pump blood as well as it should), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and hypertension (the force of the blood against the artery walls is too high). Section C0500 a Brief Interview for Mental Status test (BIMS - is a screening test that aides in detecting cognitive impairment) indicated a score of 12, moderately impaired cognition. Review of Resident R1's Nursing admission evaluation dated 3/25/25, indicated Section D Skin Integrity chronic (something that lasts a long time, often three months or more) wound left foot, and right below the knee amputation (surgical removal of a limb or part of a limb) incision with staples (used to close incisions after surgery). The skin assessment failed to indicate the presence of an insulin pump. Review of Resident R1's hospital discharge transfer orders dated 3/25/25, indicated Humalog (insulin Lispro) a rapid-acting insulin used to manage blood sugar) 100 units/milliliter injectable solution, injectable via insulin pump - average daily dose is 90 units (max dose 100 units daily). Review of Resident R1's physician order dated 3/25/25, indicated Humulin R (insulin regular - a short acting insulin used to manage blood sugar) injection solution, inject 90 units subcutaneously (injecting a drug into the fatty tissue layer beneath the skin) one time a day for Diabetes Insulin Pump, max dose 100 units daily. Order was transcribed by LPN Employee E6. Review of Resident R1's progress note dated 3/31/25, at 12:03 p.m. indicated resident was wearing an insulin pump. Resident was ordered to be given 90 units Humulin insulin to refill insulin pump; but Licensed Practical Nurse (LPN) Employee E10 administered Humulin 90 units subcutaneously in error and Resident R1 was transferred to the hospital where he was diagnosed with hypoglycemia and accidental insulin overdose. Review of LPN Employee E10's witness statement dated 3/31/25, indicated Statement is in regard to wrong dose medication. Resident R1 was ordered 90 units subcutaneously one time a day for diabetes insulin pump maximum dose 100 units daily. When she read the order, she thought Resident R1 was supposed to get 90 units subcutaneously daily in one dose. The insulin pump was empty, so she just (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 11 of 12 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 Level of Harm - Actual harm administered subcutaneously from how she read the order at 8:50 a.m. Around 11:00 a.m. on 3/31/25, the wound nurse alerted LPN Employee E10 that Resident R1 was groggy. LPN Employee E10 then explained what she did, and the supervisor was made aware of the mistake. Resident was then sent to the emergency room per physician order. Residents Affected - Few Interview on 4/29/25, at 9:30 a.m. the Director of Nursing, and telephonic interview on 5/15/25, at 9:19 a.m. with the Nursing Home Administrator confirmed the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for one of three residents which created an actual harm of an accidental insulin overdose and acute care emergency room visit for Resident R1. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 12 of 12