Health inspection·May 16, 2024

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff and family interview, it was determined that the facility failed to provide care or services to maintain a resident's ambulation status for two of two residents reviewed (Residents 34 and 36) and maintain strength and activity tolerance for one of two residents reviewed. (Residents 36). Residents Affected - Some Findings include: Interview with Resident 34's husband on May 13, 2024, at 1:15 PM revealed concerns that the staff were not walking her. He indicated that she should be walked every day. Clinical record review for Resident 34 revealed that she is on a restorative nursing program (nursing interventions that are implemented to maintain the resident as independently as possible) for ambulation (walking) and is to be ambulated 50-150 feet, 1-2 times with a walker, gait belt (a belt that is placed around the resident's waist so that caregivers can assist the resident with keeping their balance when walking) and assist of one, with another staff following along behind her with a wheelchair. Further clinical record review revealed that Resident 34's restorative ambulation program was not being completed and not applicable was documented for the program on April 2, 3, 5, 8, 10, 11, 12, 15, 16, 18, 19, 22, 23, 25, 26, and 30, 2024, and on May 2, 3, 5, 6, 7, 9, 10, and 13, 2024. Interview with the Nursing Home Administrator and Director of Nursing on May 15, 2024, at 2:20 PM confirmed that Resident 34's restorative program was not being completed as ordered and that they were unsure why staff were documenting not applicable. An observation of Resident 36 on May 13, 2024, at 11:59 AM revealed the resident was in bed with a family member at bedside. The family member indicated they were told therapy was going to be changing to three times a week and they are not sure if the resident is getting it and doesn't feel the [resident] is getting out of bed. The family member stated, maybe she refused. The resident stated they recently tried to walk her, and she couldn't walk. The resident stated she did not refuse therapy. The family member indicated they understood she was getting therapy five times a week, but the insurance covered days were done, and they were told it would change to three times a week. Review of an occupational therapy discharge summary for Resident 36 revealed the resident had received skilled occupational therapy services from March 22 to April 5, 2024, with therapy discharge recommendations for a restorative nursing program. There was no evidence Resident 36 refused occupational therapy services during the dates indicated for skilled services and it was noted on the discharge summary the resident tolerated the treatment well and participated readily but made limited progress due to preexisting deficits. A restorative nursing program referral dated April 5, 2024, from the occupational therapist indicated a restorative program goal to maintain bilateral upper extremity strength and activity tolerance for ease of mobility and self-care with the program to provide bilateral upper extremity assisted range of motion with a one pound weight completing three sets of 10, shoulder flexion/extension, abduction/adduction, elbow flexion/extension, internal/external rotation, and forearm supination/pronation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395756 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 395756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Juniper Village at Brookline-Rehabilitation and Sk 1950 Cliffside Drive State College, PA 16801 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a physical therapy discharge summary for Resident 36 revealed the resident received skilled physical therapy services from March 22 to April 5, 2024, due to the resident's maximum potential was achieved. It was noted the resident made significant progress throughout the course of treatment and was being referred to the restorative nursing program for ambulation. A restorative nursing referral dated April 5, 2024, completed by the physical therapist noted the goal was to maintain optimal bilateral lower extremity strength, activity tolerance, and functional independence though regular ambulation and the resident was to ambulate 10 to 50 feet two to three times in a hallway with wheeled walker and gait belt assist of one person with a wheelchair follow for a total of 15 minutes three to five days per week. A review of Resident 36's physician's orders revealed an order dated April 5, 2024, for Resident 36 to have restorative nursing, ambulate the resident 10-50 feet two to three times in hallway with a wheeled walker, gait belt, and assist of one with a wheelchair follow for 15 minutes three - five times a week. A physician's order dated April 9, 2024, for Resident 36 revealed the resident was ordered to have restorative nursing complete bilateral upper extremity assisted range of motion with a one-pound weight at three sets of 10 repetitions and to have shoulder flexion/extension, abduction/adduction, internal rotation/external rotation, elbow flexion /extension, and forearm supination/pronation for 15 minutes three to five times a week. Review of Resident 36's restorative nursing program completion for the ambulation program for April 2024, revealed the resident was documented April 8 to 12 (Monday to Friday), 2024, as not applicable for completion of the task. One entry for five minutes was added for April 10, 2024. Resident 36 was also documented as not applicable on Monday and Tuesday April 15 and 16, and Friday, April 19, a refusal April 18, and again not applicable for completion Monday to Friday April 22 to 26, and April 29 and 30th. Resident 36's restorative program documentation for completion of the resident's upper extremity maintenance and range of motion program for April 2024, revealed only two documented refusals on April 10, and 16, and not applicable for April 12, 22, 23, 24, 25, 26, and the resident not available for April 30th. Review of Resident 36's documentation of restorative nursing program completion for May 2024, revealed the resident was documented as refusing the ambulation program on May 1, 7, 8, and 9, and not applicable for May 2, 3, 6, 10, and 13, and documented as refusing the assisted range of motion program on May 1, 7, 8, 9, 10, and not applicable on May 2, 6, and 13. The resident was documented as completing the 15 minutes on May 3, 2024. In an interview with Employee 2, restorative coordinator, and licensed practical nurse, on May 16, 2024, at 10:08 AM, the employee stated residents are referred to the restorative program by therapy, and the programs are added to the restorative nursing schedule. Employee 2 stated the restorative programs are only completed Monday thru Friday. Employee 2 indicated that a documented not applicable for restorative program completion may be due to not having the appropriate staff to be able to complete the program such as an ambulation program whereas the restorative staff doesn't have a person to assist with a wheelchair follow, etc. and there is no assistance available from the nursing staff, the program can't be completed. Employee 2 also stated restorative staff are pulled to staff other nursing care needs in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395756 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 395756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Juniper Village at Brookline-Rehabilitation and Sk 1950 Cliffside Drive State College, PA 16801 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employee 2 indicated Resident 36 had refusals of the restorative program but acknowledged the multiple documented not applicable entries for her completion. Employee 2 was also not sure why Resident 36 did not have any refusals of physical and occupational therapy but did for the restorative program. Further clinical record review of 36 revealed the resident was again referred to physical therapy on May 8, 2024, for decreased endurance when ambulating. A physical therapy evaluation dated May 8, 2024, revealed the resident was added back to physical therapy services for ambulation and transfers three times a week noting goals of sit to stand with a prior level of function as minimum assistance and the resident's baseline on May 8, 2024, as moderate assistance. The resident's prior level of assistance for ambulation was noted as 25 feet with a wheeled walked and minimum assistance with the resident's baseline on May 8, 2024, now listed zero feet and not attempted due to medical conditions or safety concerns. Resident 36 was also referred to occupational therapy services on May 10, 2024, noting new onset of compromised physical exertion level during activity, decrease in functional mobility, decrease in range of motion, decreased in strength, coordination postural alignment, falls/fall risk, bladder incontinence, bowel incontinence, reduced dynamic balance reduced static balance and activity of daily living participation. Occupational therapy again added services for Resident 36 on May 10, 2024, scheduled for three times a week, noting the resident's prior level of function for toileting hygiene, and lower body dressing, as minimum assistance and the resident's now baseline on May 10, 2024, as 100 percent dependent. The resident's ability to shower/bathe herself prior level of function was supervision/stand by assist and was assessed as moderate assistance on May 10, 2024. There was no evidence Resident 36 refused physical or occupational therapy services since the resident was placed back on the services May 8, and 10, 2024. The above information regarding Resident 36 was reviewed with the Nursing Home Administrator and Director of Nursing on May 15, 2024, at 2:00 PM. The facility failed to provide restorative services to maintain/improve Resident 34 and 36's abilities as noted. 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395756 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 395756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Juniper Village at Brookline-Rehabilitation and Sk 1950 Cliffside Drive State College, PA 16801 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 Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding integrated hospice care and services for one of two residents reviewed for Hospice (Resident 10). Residents Affected - Few Findings include: Clinical record review for Resident 10 revealed that on August 9, 2023, she was admitted to Hospice related to a terminal diagnosis of sequelae of other cerebrovascular disease (complications that can develop after a stroke or other damage to the blood vessels in the brain). Review of Resident 10's current care plan revealed that the facility failed to implement an integrated plan of care with hospice services. The plan of care did not include evidence of all services that hospice will provide for the management of Resident 10's terminal illness. Resident 10's current care plan failed to identify the hospice entity providing services, the hospice disciplines that would provide her care and services, and how often. The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on May 15, 2024, at 2:05 PM. An interview with Employee 1 (social services) on May 16, 2024, at 10:50 AM confirmed the facility had no further documentation related to Resident 10's hospice services and plan of care. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395756 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 395756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Juniper Village at Brookline-Rehabilitation and Sk 1950 Cliffside Drive State College, PA 16801 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 Based on clinical record review and resident and staff interview, it was determined that that facility failed to address or implement consultant service recommendations to aid in healing skin break down and prevent pressure ulcers in one of five residents reviewed for altered skin conditions (Resident 36). Residents Affected - Few Findings include: In an interview with Resident 36, on May 13, 2024, at 11:54 AM the resident was observed lying in bed. Resident 36 stated she had an open area on her buttocks, and it hurts. The resident stated staff do put some cream on it. Clinical record review for Resident 36 revealed a skin evaluation completed by facility staff on April 9, 2024. Resident 36 was assessed as having an altered skin area on her left buttocks 0.8 cm (centimeters) in length and 0.8 cm in width and an area on her right buttocks 2.5 cm by 0.5 cm. Both areas were noted as moisture associated skin damage. Further clinical record review for Resident 36 revealed the resident was also seen by the facility's contracted wound specialists on April 9, 2024, who noted the same areas as moisture associated skin damage (MASD) and included a treatment plan, which included recommendations of a Multivitamin once daily and Vitamin C 500 mg (milligrams) twice daily for the resident's plan of care. Resident 36 continued to be followed by the wound specialist weekly on April 16, 23, 30, May 7, and 14, 2024, at the time of review. The wound specialist report dated April 16, 2024, noted the area of Resident 36's areas of MASD on the left and right buttocks and continued to recommend the Multivitamin and Vitamin C as noted above as part of the treatment plan. The wound specialist report dated April 23, 2024, noted the MASD area on the resident's left buttocks was now 1.5 cm x 1.0 cm and area on the right buttocks was now 3.1 cm x 2.0 cm. The report noted the exacerbation of the areas due to generalized decline and the resident being non-compliant with wound care. Part of the treatment plan continued to recommend the addition of the Multivitamin and Vitamin C. The wound specialist report dated April 30, 2024, noted continued exacerbation of the left buttocks area due to decline of the resident, nutritional compromise, and resident non-compliance. The treatment plan continued to note the recommendation of the Multivitamin and Vitamin C. The wound specialist report dated May 7, 2024, noted some improvement of the area on the resident's left buttocks, and right buttocks. Recommendations continued to be listed for the resident for Multivitamin and Vitamin C. The wound specialist report dated May 14, 2024, the last report available for review, noted the left buttocks area as 4.5 cm x 1.4 cm with some improvement, the right buttock area was noted as 5.0 x 2.5 x 0.1 and required debridement during the visit. The wound specialist continued to recommend a Multivitamin once daily and Vitamin C 500 mg twice daily continued. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395756 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 395756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Juniper Village at Brookline-Rehabilitation and Sk 1950 Cliffside Drive State College, PA 16801 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 Level of Harm - Minimal harm or potential for actual harm Upon review of Resident 36's clinical record there was no evidence the resident was ordered a Multivitamin or Vitamin C at any time since the April 9, 2024, wound specialist visit or subsequent visits when they continued to be recommended. There was no evidence that the recommendation was addressed with the resident's primary care physician as to whether the physician wished to implement the Multivitamin or Vitamin C or decline them. Residents Affected - Few In an interview with the Director of Nursing on May 16, 2024, at 12:15 PM it was confirmed Resident 36 was never ordered any Multivitamin or Vitamin C per the recommendations by the wound specialist as noted, nor was there any evidence the recommendations were addressed by the resident's primary physician. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing care services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395756 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 395756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Juniper Village at Brookline-Rehabilitation and Sk 1950 Cliffside Drive State College, PA 16801 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to implement a restorative nursing program as recommended by therapy to maintain range of motion for two of five residents reviewed (Residents 21 and 32). Findings include: Review of Resident 21's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated December 21, 2023, indicating that the facility assessed Resident 21 as having range of motion limitations to one side of her lower extremities. A previous MDS assessment dated [DATE], indicated that the facility assessed Resident 21 as having no range of motion limitations to her lower extremities. A physical therapy form entitled Restorative Nursing Program, dated December 19, 2023, indicated that physical therapy was implementing an ambulation program for Resident 21 to ambulate 40 to 80 feet in the hallway three to five times a week with the goal of maintaining her lower extremity strength. Review of documentation dated February 2024, March 2024, and April 2024, revealed that Resident 21 was only provided the restorative nursing ambulation three times in February 2024, four times in March 2024, and one time in April 2024. There was no documented evidence to indicate that the facility was providing the restorative nursing ambulation program per therapy recommendations. Review of a physical therapy form entitled Restorative Nursing Program, dated May 7, 2024, indicated that physical therapy was implementing a range of motion program for Resident 32 to receive passive range of motion to his lower extremities for 15 minutes three to five times a week with the goal of maintaining range of motion and to prevent progression of joint contractures. Review of documentation dated May 2024, revealed that there was no documented evidence to indicate that Resident 32 was provided the passive range of motion program since it was implemented on May 7, 2024. Interview with the Director of Nursing on May 15, 2024, at 12:50 PM confirmed the above findings for Residents 21 and 32. 28 Pa. Code 211.12 (d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395756 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 395756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Juniper Village at Brookline-Rehabilitation and Sk 1950 Cliffside Drive State College, PA 16801 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and resident and staff interview, it was determined that the facility failed ensure safe self-administration of a tube feeding to ensure acceptable parameters of nutritional status for one resident reviewed. (Resident 2) Residents Affected - Few Findings include: Interview with Resident 2 on May 13, 2024, at 1:36 PM revealed that she administers her own tube feeding. She indicated that she administers the feeding and water but not her medications. Clinical record review for Resident 2 revealed a current physician's order that was initiated on April 4, 2024, for an Enteral Feed (feeding provided through a tube into the stomach) four times a day Twocal HN (a dietary supplement) 2.0 150 ml by gastrostomy tube (a tube into the stomach), resident may self-administer. Interview with the Director of Nursing on May 14, 2024, at 2:22 PM confirmed that Resident 2 self-administers her tube feeding but not her medications. On May 15, 2024, 9:00 AM the surveyor was provided with a self-administration of medication form that was completed for Resident 2, dated July 21, 2023, with a lock date of April 3, 2024. The form addressed administration of medications with no indicators related to safely self-administer a tube feeding. Interview with the Director of Nursing on May 15, 2024, at 10:00 AM confirmed that the self-administration of medication assessment did not address indicators to ensure Resident 2 was capable of safely self-administering her tube feeding. Review of Resident 2's current care plan related to her enteral feeding failed to address self-administration of the feeding. The Director of Nursing, on May 16, 2024, at 9:56 AM confirmed that Resident 2's plan of care did not address self-administration of her tube feeding. Interview with the Director of Nursing on May 16, 2024, 9:56 AM confirmed that the facility failed to assess Resident 2's ability to self-administer her tube feeding to ensure that she maintained acceptable parameters of nutritional status. 28 Pa. Code 211.10(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: 395756 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 395756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Juniper Village at Brookline-Rehabilitation and Sk 1950 Cliffside Drive State College, PA 16801 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by two of three residents reviewed (Residents 8 and 10). Residents Affected - Few Findings include: Clinical record review for Resident 8 revealed the facility admitted him on June 27, 2022, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 8's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated June 9, 2023, indicated that the facility assessed Resident 8 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 8's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 10 revealed the facility admitted her on August 7, 2023. Resident 10's admission MDS dated [DATE], indicated that the facility assessed Resident 10 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 10's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on May 15, 2024, at 2:05 PM. Interview with Employee 1 (social services) on May 16, 2024, at 10:50 AM confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Residents 8 and 10's dementia and cognitive loss. 483.40(b)(3) Dementia Treatment and Services Previously cited 5/18/23 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395756 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 395756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Juniper Village at Brookline-Rehabilitation and Sk 1950 Cliffside Drive State College, PA 16801 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure dental concerns were addressed for one of three residents reviewed (Resident 27 ). Residents Affected - Few Findings include: Clinical record review for Resident 27 revealed a wellness progress note dated March 30, 2024, at 4:00 PM that indicated she was found chewing on a piece of her own tooth but had no complaints of pain. There was no follow-up documentation to this in Resident 27's clinical record. Further clinical record review revealed a wellness progress noted dated May 3, 2024, at 10:31 AM that indicated Resident 27's spouse declined dental services. Interview with the Director of Nursing on May 15, 2024, at 12:41 PM revealed that there was no evidence that Resident 27's spouse was made aware that she was found to be chewing on a piece of her own tooth on March 30, 2024, or if they addressed Resident 27 being seen by a dentist due to this. Clinical record review revealed a progress note dated May 15, 2024, at 11:31 AM that indicated Resident 27's husband was made aware of the broken tooth and agreed to allow the dental hygienist see Resident 27 for one visit that is to occur on May 16, 2024. The facility failed to ensure Resident 27's husband was made aware of her dental concerns in order to make an informed decision regarding her dental care. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.15(a) Dental services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395756 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 395756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Juniper Village at Brookline-Rehabilitation and Sk 1950 Cliffside Drive State College, PA 16801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner in the facility's main kitchen. Residents Affected - Some Findings include: An observation of the facility's main kitchen on May 13, 2024, at 10:40 AM revealed the following: The dish machine and several black utility carts in the dish machine area were observed with white buildup. Food service staff working in the area indicated there is a problem with limescale buildup from the water and they have water softeners that seem to sometimes be working and sometimes not. The staff members also indicated they use a limescale remover in the dish machine itself once a week, but the problem remains. A ceiling light cover in the dish room area was covered with dried food/liquid splatter. A large stack of resident meal serving trays was observed on a cart in the dish washing area that food service staff just completed washing. The plastic trays were significantly discolored and stained and contained cracks, broken edges, and pieces of plastic that were worn/broken off on the bottoms of the tray surfaces. A large industrial floor mixer was observed not in use and uncovered. Dust and debris were observed on the interior of the mixing bowl. A panini press on a preparation counter in the corner of the kitchen contained buildup of dried food. The white tile wall surrounding the area where the panini press was located was covered in dried orange and brown food splatter. The lower shelf of a preparation table under the pot/pan storage area where plastic bins and equipment were stored was covered in dust and debris. A tan foot pedal garbage can located next to the pot/pan storage area was observed with dried brown liquid runs and dried food on the exterior of the can. The lower shelf liners in the dry storage area where multiple food products were stored had a buildup of dust and debris. The flooring under shelving units that surrounded the perimeter of both the walk-in cooler and walk-in freezer was observed with food debris. A soiled glove, coffee filter, and dried food was observed under the ice machine. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on May 14, 2024, at 1:30 PM. 28 Pa. Code 201.14 (a) Responsibility of licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395756 If continuation sheet Page 12 of 12