Health inspection·January 10, 2023

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to have evidence of the written notice of transfer provided to the resident, the resident's responsible party, and the representative of the Office of the State Long-Term Care Ombudsman, for five of six residents reviewed for hospitalizations (Residents 6, 38, 169, 105, and 116). Findings include: The facility policy entitled, Transfer or Discharge Documentation, last reviewed without changes on [DATE], revealed that when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record. The policy did not include the requirement that the facility provide the resident, the resident's responsible party, and the representative of the Office of the State Long-Term Care Ombudsman, a notice in writing that included the reasons for, the effective date of, and the location the resident was transferred or discharged . Clinical record review for Resident 105 revealed nursing documentation dated [DATE], at 1:45 PM that Resident 105 was exhibiting a decreased level of consciousness and increased oxygen demand and required supplemental oxygen administration. Resident 105's heart rate was irregular. Staff contacted the physician's assistant and obtained an order to transfer Resident 105 to the emergency department for evaluation and treatment. Nursing documentation dated [DATE], at 6:06 PM revealed that the hospital admitted Resident 105 for a urinary tract infection and dehydration. Interview with the Nursing Home Administrator and the Director of Nursing on [DATE], at 2:30 PM and [DATE], at 2:30 PM, revealed that the facility could not provide a copy of the notice of transfer provided to Resident 105 and her responsible party that included the effective date of the transfer, the reasons for the transfer, or the location to which the resident was transferred. Clinical record review for Resident 116 revealed a physician's order dated [DATE], at 2:00 AM to send Resident 116 to the emergency department for evaluation and treatment for a low oxygen level and unresponsiveness. Resident 116's medical record did not include nursing documentation that recorded the details of the transfer or discharge (e.g., assessment of resident's symptoms or medical interventions attempted). Nursing documentation dated [DATE], at 1:30 AM revealed that Resident 116 left the facility with emergency management services to the hospital emergency department and that a copy of the facility's transfer notice and bed hold agreement was sent with the resident. Social services documentation dated [DATE], at 9:13 AM revealed, Notified HCR (health care representative) that a copy of the facility's bed hold policy and resident's transfer notice were sent home today. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 2 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 0623 Level of Harm - Potential for minimal harm Residents Affected - Some The surveyor requested nursing documentation that recorded the details of Resident 116's condition and [DATE], emergency transfer during interviews with the Nursing Home Administrator and the Director of Nursing on [DATE], at 2:30 PM, and [DATE], at 2:30 PM; however, the facility failed to provide this evidence. Nursing documentation dated [DATE], at 1:41 AM revealed that the registered nurse spoke to hospital staff and was informed that Resident 116 was admitted to the hospital with hypoxic respiratory failure (insufficient functioning of the respiratory organs (e.g., lungs) and oxygenation of the blood), sepsis (infection within the blood), and bilateral aspiration pneumonia (infection of the lungs precipitated by foreign matter in the lungs). A physician's discharge summary progress note dated [DATE], at 3:20 PM revealed that Resident 116 expired at the hospital on [DATE]. Interview with the Nursing Home Administrator on [DATE], at 10:13 AM revealed that the facility does not keep copies of transfer notices sent or given to residents or the residents' responsible parties. The facility could only provide a blank form that staff are to complete with the resident's specific information at the time of the transfer or discharge. The facility was unable to provide completed notices for Residents 105 and 116. Clinical record review revealed nursing documentation dated [DATE], at 1:47 AM noting the facility received a call from the lab indicating Resident 6 had a critical result of her potassium levels. Nursing staff obtained her vitals and notified the nurse practitioner, receiving an order to send Resident 6 to the emergency room for evaluation and treatment. Nursing documentation revealed that Resident 6 left the facility via ambulance at 2:15 AM. Social service documentation dated [DATE], at 6:58 AM revealed notified HCR that a copy of the facility's bed hold policy and resident's transfer notice were sent to her today. Interview with the Nursing Home Administrator on [DATE], at 2:47 PM confirmed that the facility did not keep a copy of Resident 6's transfer notice sent to responsible party. Clinical record review revealed nursing documentation dated [DATE], at 11:44 AM noting Resident 38 left the facility at 9:30 AM via emergency medical services to the emergency department for evaluation of her altered mental status. Documentation revealed HCR is aware of her transfer to the emergency room, and a copy of the facility's transfer notice and bed hold agreement were sent with the resident. Resident 38 remained in the hospital until [DATE]. Clinical record review revealed nursing documentation dated [DATE], at 1:57 PM that Resident 169 was sent to the emergency department from dialysis due to seizure like activity. Social service documentation dated [DATE], at 8:35 AM noted the facility notified HCR that a copy of the facility's bed hold policy and resident's transfer notice was sent home to him. Interview with the Nursing Home Administrator on [DATE], at 2:47 PM, confirmed that the facility did not keep a copy of Resident 38 or Resident 169's transfer notice sent to the responsible party. Interview with the Nursing Home Administrator on [DATE], at 12:10 PM confirmed that the facility does not have any process in place to notify the representative of the Office of the State Long-Term Care Ombudsman of a resident's transfer or discharge at this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 3 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 0623 28 Pa. Code 201.14(a) Responsibility of license Level of Harm - Potential for minimal harm 28 Pa. Code 201.29(a) Resident rights Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 4 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure documentation of what the resident and/or their responsible party received pertaining to the written notice of the facility bed hold policy at the time of transfer for five of six residents reviewed for hospitalization concerns (Residents 6, 38, 169, 105, and 116). Findings include: Clinical record review revealed nursing documentation dated October 27, 2022, at 1:47 AM noting the facility received a call from the lab indicating Resident 6 had a critical result of her potassium levels. Nursing staff obtained her vitals and notified the nurse practitioner and received an order to send Resident 6 to the emergency room for evaluation and treatment. Nursing documentation revealed that Resident 6 left the facility via an ambulance at 2:15 AM. Social service documentation dated October 28, 2022, at 6:58 AM revealed notified HCR (health care representative) that a copy of the facility's bed hold policy and resident's transfer notice were sent to her today. Clinical record review revealed nursing documentation dated December 2, 2022, at 11:44 AM noting Resident 38 left the facility at 9:30 AM via emergency medical services to the emergency department for evaluation of her altered mental status. Documentation revealed HCR is aware of her transfer to the emergency room, and a copy of the facility's transfer notice and bed hold agreement were sent with the resident. Resident 38 remained in the hospital until December 19, 2022. Clinical record review revealed nursing documentation dated January 2, 2023, at 1:57 PM that noted Resident 169 was sent to the emergency department from dialysis due to seizure like activity. Social service documentation dated January 3, 2023, at 8:35 AM noted the facility notified HCR that a copy of the facility's bed hold policy and resident's transfer notice was sent home to him. Interview with the Nursing Home Administrator and Director of Nursing on January 9, 2023, at 2:47 PM confirmed the facility did not keep a copy of Resident 6, Resident 38, or Resident 169's bed hold notice sent to the responsible party. The surveyor requested the facility's policies pertaining to the provision of a bed-hold notice upon the transfer of a resident to the hospital or therapeutic leave during interviews with the Nursing Home Administrator on January 9, 2023, at 2:30 PM, and via email communication January 11, 2023, at 9:32 AM. The facility policy entitled, Bed Hold Policy, last reviewed without changes on January 22, 2022, revealed that residents who are transferred or discharged to the hospital may have their beds held for them in accordance with federal, state, and facility policy. The policy did not include the facility's obligation, or process, to ensure that the resident and the resident representative received written information that specifies the duration of the state bed-hold policy or the reserve bed payment (e.g., expected costs) for a non-covered bed-hold. Clinical record review for Resident 105 revealed nursing documentation dated September 11, 2022, at 1:45 PM that Resident 105 was exhibiting a decreased level of consciousness and increased oxygen demand and required supplemental oxygen administration. Resident 105's heart rate was irregular. Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 5 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 0625 Level of Harm - Minimal harm or potential for actual harm contacted the physician's assistant and obtained an order to transfer Resident 105 to the emergency department for evaluation and treatment. Nursing documentation dated September 11, 2022, at 6:06 PM revealed that the hospital admitted Resident 105 for a urinary tract infection and dehydration. Residents Affected - Some Interview with the Nursing Home Administrator and the Director of Nursing on January 8, 2023, at 2:30 PM, and January 9, 2023, at 2:30 PM, revealed that the facility could not provide a copy of the bed-hold notice provided to Resident 105 and her responsible party. The facility provided the one-page policy referenced above; however, could not provide an individualized notice for Resident 105 at the time of her transfer to the hospital. Closed clinical record review for Resident 116 revealed a physician's order dated October 28, 2022, at 2:00 AM to send Resident 116 to the emergency department for evaluation and treatment for a low oxygen level and unresponsiveness. Nursing documentation dated October 28, 2022, at 1:30 AM revealed that Resident 116 left the facility with emergency management services to the hospital emergency department; and that a copy of the facility's transfer notice and bed hold agreement was sent with the resident. Social services documentation dated October 28, 2022, at 9:13 AM revealed, Notified HCR (health care representative) that a copy of the facility's bed hold policy and resident's transfer notice were sent home today. The surveyor requested a copy of the bed-hold notice provided to Resident 116 and her responsible party in response to her transfer to the hospital during interviews with the Nursing Home Administrator and the Director of Nursing on January 8, 2023, at 2:30 PM, and January 9, 2023, at 2:30 PM; however, the facility failed to provide this evidence. The facility provided the one-page policy referenced above; however, could not provide an individualized notice for Resident 116 at the time of her transfer to the hospital. Interview with the Nursing Home Administrator on January 9, 2023, at 10:13 AM revealed that the facility has no individualized notice pertaining to the resident's bed-hold rights. The facility could only provide the one-page policy referenced above. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(f) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 6 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and resident and staff interview, it was determined the facility failed to provide bathing per resident preference for one of four residents reviewed for activities of daily living (Resident 112). Residents Affected - Few Findings include: In an interview with Resident 112 on January 8, 2023, at 8:47 AM the resident asked the surveyor, Is there anything you can do about getting showers, I am supposed to get them twice a week. I have to wash up at the sink. I ask them, (staff), if I could get a shower and they just say it isn't your day, and I tell them I didn't get one on my day. Resident 112 could not recall the last time she had a shower, and stated she even washed her hair in the bathroom sink. Resident 112 continued to elaborate as she sat in her wheelchair, pointing to a large plastic bin sitting on top of her tall dresser that was full of toiletries, stating, I can only carry one or two bottles with me as I wheel myself into the bathroom, so that is what I use. Clinical record review for Resident 112 revealed a five-day MDS (minimum data set, an assessment completed at periodic intervals of time to determine care needs) dated November 1, 2022, revealed facility staff assessed the resident as requiring extensive assistance for transfers with one-person physical assist, extensive assistance of one personal physical assistance for personal hygiene, and physical help in part for bathing with one-person physical assist. A review of Resident 112's bathing task in the resident's clinical record revealed the resident was scheduled to receive showers on Monday and Thursday's during the 7 AM - 3 PM shift. This schedule was last updated on November 8, 2022. A review of Resident 112's bathing completion from December 10, 2022, through January 8, 2023, revealed Resident 112 was last documented as receiving a shower on December 15, 2022, and a bed bath was documented for December 10, 11, and 23, 2022. The resident was marked non-applicable for bathing on December 20, 21, 22, and 26, 2022, there was no documentation after December 26, 2022, through January 8, 2023. In an interview with the Nursing Home Administrator and Director of Nursing on January 9, 2023, at 2:30 PM there was no additional evidence available to indicate Resident 112 received a shower from December 15, 2022, through January 8th, 2023, per her preference and schedule to receive showers two days a week, for a resident dependent on staff for bathing/showering. The Nursing Home Administrator and Director of Nursing could provide no rationale as to why the resident was not showered. 483.24(a)(2) ADL Care Provide for Dependent Residents Previously cited deficiency 1/12/22, 11/17/22 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 7 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered treatment for one of 24 residents reviewed (Resident 83). Residents Affected - Few Findings include: Clinical record review for Resident 83 revealed a physician progress note dated January 6, 2023, at 1:54 PM that Resident 83 had increased foot edema. Resident 83 reported that his feet felt slightly uncomfortable. The documentation indicated that Resident 83 spent most of his time in a wheelchair and did not elevate his lower extremities. The prescriber indicated a plan to obtain laboratory testing, give additional diuretic medication (medication used to stimulate the body to increase urination to decrease excessive fluid retention), and use tubigrips (tubular fabric used to provide compression) to Resident 83's legs. Nursing documentation dated January 6, 2023, at 4:00 PM confirmed the receipt of a physician's order to ensure that Resident 83 had tubigrips on his bilateral lower extremities during the day and to remove them at night. A physician's order created January 6, 2023, noted that tubigrips to Resident 83's bilateral lower extremities were to start on January 7, 2023, at 7:00 AM, and that they were to be on during the day and off at night every day and evening shift. Review of Resident 83's current plan of care revealed no intervention pertaining to the use of tubigrips to manage lower extremity edema. Observation of Resident 83 with Employee 6 (nurse aide) on January 7, 2023, at 1:46 PM confirmed that Resident 83 was not wearing tubigrips on his bilateral lower extremities. Employee 6 indicated that she was not the assigned nurse aide for Resident 83 on this date and referred the surveyor to Employee 7 (nurse aide). Interview with Employee 7 on January 7, 2023, at 1:48 PM confirmed that she was Resident 83's assigned nurse aide on this date and time and revealed that she had no knowledge of the requirement to ensure Resident 83 wore tubigrips on his legs. Employee 7 verified that the intervention was not included in Resident 83's [NAME] (electronic documentation used by staff providing direct resident care) for her to implement. Review of Resident 83's TAR (treatment administration record) dated January 2023 revealed that no staff documented the application of the tubigrips for the day shift on January 8, 2023. Interview with Employee 11 (licensed practical nurse) on January 10, 2023, at 11:12 AM indicated that Resident 83 was not wearing tubigrips, that he refused them when she asked him if he wanted them. Observation of Resident 83's room with Employee 11 confirmed that there were no tubigrips available for application in his room. Employee 11 indicated that although she questioned Resident 83 if he wanted to have his tubigrips applied, she did not look for them in his room on this date or show them to him to ensure he comprehended what she referred to when he refused them. Employee 11 confirmed that she had not documented Resident 83's refusal to wear the tubigrips as of this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 8 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 - Minimal harm or potential for actual harm Review of an MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) admission assessment dated [DATE], revealed that staff assessed him as having severe cognitive impairment as evidenced by a BIMS (Brief Interview for Mental Status) score of two. The surveyor reviewed the above findings with the Director of Nursing on January 10, 2023, at 11:28 AM. Residents Affected - Few 483.25 Quality of Care Previously cited deficiency 5/12/22 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 9 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 observation, clinical record review, and responsible party and staff interview, it was determined that the facility failed to provide the highest practicable care regarding pressure ulcer assessment and treatment for one of four residents reviewed for pressure ulcer/skin alterations (Resident 7). Residents Affected - Few Findings include: In a telephone interview with Resident 7's responsible party (RP) on January 7, 2023, at 1:46 PM, the RP indicated she got a call on New Year's Day (Sunday, January 1, 2023) from facility staff that indicated her mother's sock was fused to her foot, and a day ago (January 6, 2023) she got a call that an area on the foot was now opened. An observation of Resident 7 on January 8, 2023, at 8:46 AM revealed the resident was lying in bed sleeping. A cushion was observed towards the bottom of the resident's bed pushed off to the side of the bed and the resident's legs and heels were resting on the bed. The resident was not wearing socks or shoes. A large tan colored bandage was observed on the resident's left heel. Electronic clinical record review did not reveal any evidence to correlate that a phone call was made to Resident 7's RP on January 1, 2023, or any skin assessment or documentation related to the resident's sock being fused to her foot. A review of Resident 7's paper medical chart revealed a physician communication form (a form in which facility staff use to communicate resident information/requests to the physician for review when the physician visits) dated January 1, 2023, completed by Employee 8, licensed practical nurse (LPN) indicating the resident had a DTI (deep tissue injury, an injury to underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) to her left heel measuring 4.5 centimeters (cm) by 4 centimeters, and requested skin prep twice a day, and a heels up cushion while in bed. The physician did not respond to the request on the form until January 3, 2023, with above orders OK. Further review of Resident 7's clinical record revealed a physician's order dated January 3, 2023, at 3:56 PM for the resident to have skin prep to the left heel twice a day every day and evening shift for DTI. Resident 7 had been ordered house stock moisturizer to her bilateral feet every day and evening shift for dry skin since February 11, 2022. Documentation of the skin prep to the left heel twice a day was documented as completed on January 4, 5, and 6, 2023. Another skin evaluation was completed on January 5, 2023, again by Employee 8, LPN, noting the resident had a deep tissue injury to the left heel measuring 4.5 cm by 4 cm. There was no evidence Resident 7's area on her left heel was assessed by a registered nurse, physician, or wound specialist until January 6, 2023. The registered nurse noted at 8:15 PM that a nurse aide made the nurse aware that the resident's left heel had drainage on the bed sheet. The area on the left heel was assessed as having an open area measuring 4 cm by 3.5 cm, and a note was left for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 10 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 Residents Affected - Few the physician to review. A new treatment order was obtained to apply a foam dressing with a change every three days and as needed at that time, and that the daughter was made aware. An observation of Resident 7's heel on January 10, 2023, at 12:18 PM with Employee 12, infection control LPN, revealed gauze wrapped around the resident's left heel. A foam dressing was observed under the gauze. Upon removal of the foam dressing dated January 9, 2023, drainage was observed on the bandage, and the heel remained open with drainage. Drainage was also observed on the resident's sock. In an interview with the Nursing Home Administrator and Director of Nursing on January 10, 2023, at 1:00 PM it was confirmed that the area to Resident's 7's left heel identified by the LPN as a deep tissue injury on January 1, 2023, was not assessed until January 6, 2023, when the heel was open and draining. There was no evidence measures were implemented to relieve or reduce pressure to the resident's left heel until the heels up device was ordered on January 3, 2023, although observation of Resident 7 on January 8, 2023, at 8:46 AM revealed that the resident's heels were directly on the bed surface. 483.25(b)(1)(i)(ii) Treatment/svcs To Prevent/heal Pressure Ulcer Previously cited deficiency 11/17/22 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 11 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 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. Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions for a noted decline in range of motion for one of two residents reviewed (Resident 88). Residents Affected - Few Findings include: Review of Resident 88's clinical record revealed a Minimum Data Set Assessment (an assessment completed at specific intervals to determine care needs) dated May 13, 2022, and again on November 8, 2022, indicated that the facility assessed Resident 88 as having range of motion limitations to both her lower extremities. Resident 88 was previously assessed by the facility as having no limitations to her lower extremities. The facility did not assess her range of motion for the August 8, 2022, MDS assessment. There was no documented evidence in Resident 88's clinical record to indicate that the facility implemented interventions, such as therapy referrals or restorative programs to address her decline in range of motion to her lower extremities. Interview with Employee 9, physical therapist, on January 10, 2023, at 9:25 AM confirmed the above findings for Resident 88. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 12 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure appropriate application of supplemental oxygen for two of three residents reviewed for oxygen concerns (Residents 83 and 40). Residents Affected - Few Findings include: The facility policy entitled, Oxygen Administration, last reviewed without changes on January 22, 2022, revealed that staff review the resident's care plan to assess for any special needs of the resident. Steps in the procedure include to adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is administered. Check the tank to be sure it is in good working order. Observe the resident upon setup and periodically thereafter to be sure oxygen is tolerated. After completing the oxygen setup or adjustment, information recorded in the resident's medical record should include the date and time the procedure was performed, the name and title of the individual who performed the procedure, the rate of oxygen flow, and the signature and title of the person recording the data. If the resident refused the procedure, staff record the reason(s) why and the intervention taken and notify the supervisor if the resident refuses the procedure. Clinical record review for Resident 83 revealed an active physician order dated November 23, 2022, to administer supplemental oxygen at four liters per minute continuously every shift. Observation of Resident 83 on January 7, 2023, at 12:41 PM in the nursing unit's main dining room with Employee 6 (nurse aide) revealed his portable oxygen tank was empty. Employee 6 requested another staff member obtain another portable tank of oxygen for Resident 83 at that time. The second staff member returned on January 7, 2023, at 12:44 PM, with a portable tank; however, Employee 6 determined that this tank was also empty. At that time, Employee 6 left to obtain a portable oxygen tank. Observation of Resident 83 on January 10, 2023, at 11:06 AM in the nursing unit's common activity area with Employee 5 (licensed practical nurse) revealed that his portable oxygen tank liter flow was set to 0 liters per minute. Employee 5 corrected the administration flow rate to four liters per minute. The observation and interviews with Employee 5 and 11 (licensed practical nurse assigned to Resident 83's care) indicated that no staff could determine how long Resident 83 was transferred from his room oxygen concentrator and was utilizing the portable oxygen tank set to 0 liters per minute (receiving no supplemental oxygen). Interview with Employee 11 on January 10, 2023, at 11:12 AM indicated that a portable oxygen tank stays on Resident 83's chair, and the licensed nursing staff are responsible to adjust his liter flow. Employee 11 stated that the last time she saw Resident 83 he was in bed. Employee 11 stated that she had no idea when Resident 83's supplemental oxygen administration discontinued from the room concentrator. Review of Resident 83's TAR (treatment administration record, electronic documentation of the administration of physician ordered treatments) dated January 2023 revealed that no staff initialed the administration of supplemental oxygen on the day shift on January 8, 2023. The surveyor reviewed the above findings for Resident 83 with the Director of Nursing on January 10, 2023, at 11:28 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 13 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation of Resident 40 on January 7, 2023, at 11:19 AM revealed the resident was in bed with oxygen on via nasal cannula (a device used to provide supplemental oxygen through the nose). The tubing from the nasal cannula was connected to a black oxygen concentrator (a device that takes in air from the room and filters out nitrogen to provide higher concentrations of oxygen needed for oxygen therapy) sitting on the floor beside the resident's bed. There was no date on the resident's oxygen tubing to indicate when the tubing was last changed. The oxygen concentrator and air filter on the back of the concentrator were covered in dust. The above information regarding Resident 40's oxygen was reviewed with the Nursing Home Administrator and Director of Nursing on January 8, 2023, at 2:50 PM. 483.25(i) Respiratory/tracheostomy Care and Suctioning Previously cited deficiency 1/12/22 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 14 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address dementia and cognitive loss displayed by one of one resident reviewed (Resident 6). Residents Affected - Few Findings include: Clinical record review for Resident 6 revealed the facility added a dementia diagnosis on April 7, 2022. Review of a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated November 6, 2022, indicated that the facility assessed Resident 6 as having the diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. Review of Resident 6'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. Interview with the Director of Nursing on January 10, 2023, at 9:55 AM confirmed the above findings for Resident 6. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa Code 211.11(d) Resident care plan FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 15 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to ensure reconciliation of medications upon discharge for two of three residents reviewed (Residents 15 and 116). Findings include: The policy entitled Transfer or Discharge Documentation, last reviewed on [DATE], indicates that when a resident is transferred or discharged from the facility, the disposition of the medications will be documented in the medical record. Review of Resident 15's closed clinical record revealed that she was discharged from the facility on [DATE]. Resident 15 had current physician orders for Morphine (a narcotic used to treat pain) 5 mg (milligrams) every four hours as needed for pain and Haldol (medication used to treat mental or mood disorders) 2 mg every four hours for agitation or restlessness. Review of Resident 15's controlled substance log for Morphine indicated that there was 12 milliliters of medication left when Resident 15 was discharged . There was no documentation on Resident 15's controlled medication log to indicate where the remainder of the Morphine went. There was no documented evidence in Resident 15's closed clinical record to indicate the disposition of the remainder of the Haldol medication. Interview with the Administrator and Director of Nursing on [DATE]. 2022, at 1:16 PM confirmed the above findings for Resident 15. Closed clinical record review for Resident 116 revealed a physician's order dated [DATE], at 2:00 AM to send Resident 116 to the emergency department for evaluation and treatment for a low oxygen level and unresponsiveness. Nursing documentation dated [DATE], at 1:30 AM revealed that Resident 116 left the facility with emergency management services to the hospital emergency department. A physician discharge summary progress note dated [DATE], at 3:20 PM revealed that Resident 116 expired at the hospital on [DATE]. Resident 116's closed clinical record contained no evidence of a recapitulation of the medications routinely administered to Resident 116 at the time of her transfer from the facility to the hospital including those listed below: Lisinopril 10 mg tablets (medication used to lower blood pressure) Levalbuterol HCL nebulizer solution (inhaled medication used to reduce wheezing and shortness of breath) Interview with the Director of Nursing on [DATE], at 11:35 AM revealed that the facility was waiting for the consultant pharmacy provider to forward what he had for Resident 116's medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 16 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 0755 Level of Harm - Minimal harm or potential for actual harm recapitulation. The interview confirmed that the facility had no evidence that the recapitulation of medications was completed upon Resident 116's transfer to the hospital or when the facility was made aware of Resident 116's death while at the hospital more than two months earlier. 28 Pa. Code 211.9 (k) Pharmacy services Residents Affected - Some 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 17 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on clinical record review, review of select facility policies, and staff interview, it was determined that the facility failed to ensure an appropriate and timely physician response to consultant pharmacist recommendations for four of five residents reviewed (Residents 38, 80, 104, and 105). Findings include: The policy entitled Consultant Pharmacist Monthly Reports, last reviewed without changes on January 22, 2022, revealed the consultant pharmacist provides administration a monthly report reviewing the facility's use of medication. Reports are acted upon by nursing and medical staff. After the reports are acted upon, administration reviews and reports to verify that sufficient action has been taken on the reports. Clinical record review for Resident 38 revealed a Consultant Pharmacist Medication Regimen Review dated February 17, 2022, that requested Resident 38's physician consider gradual dose reductions of Resident 38's Zyprexa (anti-psychotic) and Omeprazole (used to treat certain stomach and esophagus problems). Resident 38's physician responded on March 1, 2022, and she checked the box that she disagreed with the pharmacist's recommendations and failed to document any rationale. Clinical record review for Resident 38 revealed a Consultant Pharmacist Medication Regimen Review dated May 11, 2022, that requested Resident 38's physician clarify Resident 38's Xarelto (blood thinner) order to include with meal, and a gradual dose reduction of her Zyprexa. Resident 38's physician responded on May 24, 2022, and she checked the box that she disagreed with the pharmacist's recommendations and failed to document any rationale. Clinical record review for Resident 38 revealed a Consultant Pharmacist Medication Regimen Review dated July 11, 2022, that requested Resident 38's physician clarify Resident 38's Xarelto order to include with dinner. Resident 38's physician responded July 19, 2022, and she checked the box that she disagreed with the pharmacist's recommendations and failed to document any rationale. The facility was unable to provide documentation that the consultant pharmacist reviewed Resident 38's medications for March and June 2022. Interview with the Director of Nursing on January 9, 2023, at 3:10 PM confirmed these findings. The Nursing Home Administrator and Director of Nursing were made aware of the concerns with Consultant Pharmacist Medication Regimen Reviews during a meeting on January 9, 2023, at 2:30 PM. The facility failed to ensure timely and appropriate physician response to Consultant Pharmacist Medication Regimen Reviews. Clinical record review for Resident 104 revealed no evidence of a consultant pharmacist review for August 2022. Clinical record review for Resident 105 revealed no evidence of a consultant pharmacist review for August 2022. Resident 105's clinical record contained no evidence of a consultant pharmacist review for September 2022, as the consultant pharmacist documented on September 13, 2022, that Resident 105 was, noted to be in hospital. Resident 105's clinical record indicated that she was in the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 18 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some from September 1 through 10, 2022, and September 17 through 30, 2022. Resident 105's clinical record indicated no consultant pharmacist review for more than three months between July 11, 2022, and October 24, 2022. The surveyor reviewed the above findings for Residents 104 and 105 during an interview with the Nursing Home Administrator and the Director of Nursing on January 9, 2023, at 2:30 PM. Clinical record review for Resident 80 revealed no evidence of a consultant pharmacist review on Resident 80's medications for March 2022. Clinical record review for Resident 80 revealed a consultant pharmacist review form dated April 7, 2021, requesting if Resident 80's Trazodone for insomnia could be considered for a gradual dose reduction, was not addressed by the physician until June 16, 2022, as dated on the form. Clinical record review for Resident 80 revealed a consultant pharmacist review recommendation form dated May 8, 2022, recommending evaluation of the resident's Aripiprazole (anti-psychotic) use regarding the resident's diagnosis for use. The physician did not respond to the recommendation until June 15, 2022. Clinical record review for Resident 80 revealed a consultant pharmacist review recommendation form dated June 4, 2022, with a recommendation for consideration of a gradual dose reduction of the resident's Pantoprazole (used to treat acid reflux). The pharmacist then followed with a recommendation dated July 11, 2022, again requesting consideration of a gradual dose reduction of Resident 80's Pantoprazole. The physician did not respond to the June 4, 2022, recommendation until August 22, 2022, at which time the physician agreed to a reduction in the medication. The physician did not respond to the July 11, 2022, recommendation until September 14, 2022, at which time the physician agreed and discontinued the medication. Clinical record review for Resident 80 revealed a consultant pharmacist recommendation dated December 6, 2022, for Resident 80's Citalopram (antidepressant) to be considered for a gradual dose reduction. The physician did not respond to the recommendation until January 9, 2023. The facility failed to ensure Resident 80 received a monthly pharmacist review of medications and timely response from the physician to the pharmacist recommendations as noted above. The above information regarding Resident 80's pharmacy reviews and physician response was reviewed with the Nursing Home Administrator and Director of Nursing on January 10, 2023, at 1:15 PM 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.2(a)(k) Physician services 28 Pa. Code 211.12(d)(3) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 19 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for two of six residents reviewed (Residents 72 and 105). Findings include: The policy entitled Antipsychotic Medication Use, last reviewed on January 22, 2022, indicates that the need to continue PRN (as needed) orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. The policy provided by the facility does not specify that staff will document targeted behaviors prior to the administration of PRN psychotropics, nor does it indicate that nursing staff will attempt non-pharmacological interventions prior to the administration of a PRN psychotropic. Review of Resident 72's clinical record revealed a physician's order dated November 30, 2022, for nursing staff to administer Ativan (a medication used to treat anxiety) 0.5 mg (milligrams) every six hours as needed for agitation. The physician order did not include the duration of the PRN Ativan order. Resident 72's clinical record did not include evidence to indicate that Resident 72 practitioner documented a rationale for the extended order of Ativan. Review of Resident 72's MAR (Medication Administration Record, a form used to document the administration of medications) dated December 2022, indicated that nursing staff administered the Ativan to Resident 72 10 times. There was no documented evidence in Resident 72's clinical record to indicate that nursing staff attempted non-pharmacological interventions when administering the Ativan on December 5, 13, 17, 26, and 29, 2022. There was no documented evidence in Resident 72's clinical record to indicate that nursing staff documented targeted behaviors prior to the administration of Ativan on December 1, 13, or 26, 2022. Interview with the Administrator and Director of Nursing on January 9, 2023, at 2:34 PM acknowledged the above findings for Resident 72. Clinical record review for Resident 105 revealed a physician's order dated December 23, 2022, for nursing staff to administer Ativan 0.5 mg every 12 hours as needed for agitation and anxiety. The physician's order did not include the duration of the PRN Ativan order. Resident 105's clinical record did not include evidence to indicate that Resident 105's practitioner documented a rationale for the extended order for the Ativan medication beyond 14 days. Interview with the Nursing Home Administrator and the Director of Nursing on January 8, 2023, at 2:30 PM and January 9, 2023, at 2:30 PM confirmed the above findings for Resident 105. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.10(a) 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: 395767 If continuation sheet Page 20 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 100, 6, and 65). Residents Affected - Few Findings include: The facility's medication error rate was 9.68 percent based on 31 medication opportunities with three medication errors. Review of the current manufacturer's guidelines for Flonase (a nasal spray to treat allergies) nasal spray indicates that patients should blow their nose gently to clear nostrils then close one nostril and spray nozzle into the opposite nostril. Observation of a medication administration on January 7, 2023, at 8:24 AM revealed Employee 8, licensed practical nurse, administered Flonase to Resident 100. Employee 8 administered two sprays of the Flonase to both sides of Resident 100's nose. Employee 8 did not close one nostril while administering the Flonase into the other nostril nor provide instructions to Resident 100 to do so. Interview with Employee 8, on January 7, at 10:29 AM confirmed the above findings for Resident 100 and indicated that she was not aware to close the opposite nostril when administering. Interview with the Administrator and the Director of Nursing, on January 8, 2023, at 2:30 PM acknowledged the above findings for Resident 100. Observation of a medication administration pass for Resident 65 on January 7, 2023, at 8:53 AM revealed Employee 5 (licensed practical nurse) administered one spray of Flonase nasal spray into Resident 65's left nostril immediately followed by one spray into Resident 65's right nostril. Employee 5 did not suggest to Resident 65 that he blow his nose before the procedure; nor did she close the right nostril before administering the medication into the left nostril and vice versa. Employee 5 repeated the procedure to administer a second spray to Resident 65's left nostril followed by a second spray to Resident 65's right nostril. Observation of a medication administration pass for Resident 6 on January 7, 2023, at 9:12 AM revealed Employee 5 administered one spray of Flonase nasal spray into Resident 6's left nostril immediately followed by one spray into Resident 6's right nostril. Employee 5 did not suggest to Resident 6 that she blow her nose before the procedure; nor did she close the alternate nostril when administering the nasal spray as exhibited by the technique used for Resident 65. Employee 5 repeated the technique to administer a second spray into Resident 6's left then right nostrils. Interview with Employee 5 on January 7, 2023, at 9:16 AM confirmed that she did not hold one nostril closed when spraying the alternate nostril for either Resident 65 or 6. Employee 5 confirmed that she did not prompt either resident to blow their nose before administering the nasal sprays. The surveyor reviewed the above concerns regarding Resident 6 and 65's Flonase administration during an interview with the Nursing Home Administrator and the Director of Nursing on January 8, 2023, at 2:30 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 21 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 0759 28 Pa. Code 211.10(a) Resident care policies Level of Harm - Minimal harm or potential for actual harm 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: 395767 If continuation sheet Page 22 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 0791 Provide or obtain dental services for each resident. 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 to coordinate and provide dental services to meet the needs for one of three residents reviewed for dental concerns (Residents 40). Residents Affected - Few Findings include: In an interview with Resident 40 on January 7, 2023, at 11:29 AM the resident was observed to have many missing teeth. Resident 40 stated her mouth is very painful and she has many teeth that have broken off at the gums, and she stated, not only does it look awful, but it also makes her talk funny. Clinical record review for Resident 40 revealed the resident received dental services on June 24, 2021, at which time the dentist noted, Patient requests remaining teeth be extracted to alleviate discomfort they cause her and so she can have dentures constructed to help her eat and speak better. Referred below to oral surgeon for extractions of remaining dentition. The next evidence of dental services for Resident 40 revealed a dental report dated September 28, 2022, (greater than 15 months since the June 2021 visit), which noted, patient not yet seen by an oral surgeon, referred again below to have oral surgeon extract remaining teeth, after extractions will preauthorize dentures. Further review of Resident 40's clinical record revealed a progress note dated September 29, 2022, at 8:25 AM which noted: writer called Susquehanna oral health and facial surgery for appointment. Appointment is scheduled for January 24, 2023, at 2 PM. There was no evidence to indicate the facility made attempts or scheduled Resident 40 for the referred visit to the oral surgeon as indicated on the June 24, 2021, dental report until after the September 28, 2022, visit. In an interview with Employee 13, social services, on January 9, 2023, at 12:15 PM she indicated that after talking with the resident after the June 2021, visit, the resident decided not to pursue the oral surgeon at that time. Employee 13 confirmed there was no documented evidence indicating the resident did not want to follow up with an oral surgeon between June 2021, and the September 2022, dentist visits. In a follow up interview with Resident 40, the resident stated she did not recall stating she did not want to see the oral surgeon after the June 2021, dental visit and that it was a really long time until she saw the dentist after that. Resident 40 stated she could not stand her broken and missing teeth, only at that time they didn't hurt like they do now. Both Resident 40's dental visits (June 24, 2021, and September 28, 2022) noted annual routine dental visits. Clinical record review revealed the resident utilizes a state medical assistance program as her payor source for the facility, which authorizes coverage for routine dental exam/services every six months. In an interview with the Nursing Home Administrator and Director of Nursing on January 10, 2023, at 9:54 AM they confirmed there was no additional evidence as to why Resident 40 was not provided with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 23 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 0791 Level of Harm - Minimal harm or potential for actual harm the follow up to the oral surgeon referral on June 24, 2021, until September 29, 2022, when the appointment was scheduled, or as to why Resident 40 was not offered routine dental services more frequent than annually as her payor source allows. 483.55 (b)(1)-(5) Routine/ Emergency Dental Services in Nursing Facilities Residents Affected - Few Previously cited deficiency 1/12/22 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: 395767 If continuation sheet Page 24 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 the equipment in a sanitary manner in the facility's main kitchen. Residents Affected - Many Findings include: An observation of the facility's main kitchen on January 7, 2023, at 8:30 AM, revealed the following: A metal sink located in the coffee station area was covered in brown stains. A garbage can located under the sink had dried brown spills covering the lid. The garbage cans have a foot pedal mechanism for opening that was non-functional. Two light green colored wash racks were observed sitting on a shelf below the coffee station. The racks contained debris, dried brown spills, and a buildup of a white flaky substance on several areas of the racks. The racks contained several empty clear pitchers and lids that contained significant brown staining. Dried brown splatter was observed on the wall behind the shelf. The lower shelf of a metal stand with wheels located by the condiment/silverware station, holding metal beverage carafes on the lower shelf was observed dirty with dust and debris and sticky to touch. A two-door upright cooler beside the coffee station contained debris buildup on the interior tray slides. The interior base of the cooler contained dried debris, sheet trays sitting directly on the bottom interior of the cooler with plastic containers of food stored on them, contained dried food debris. The interior of the right-side door was observed with dried substance, which appeared to have run down the door. The metal base and frame of the bread rack contained a buildup of dust and debris. The white plastic covering on the lower shelf of a wire metal shelving unit located beside the bread rack contained dust and debris. A table mounted can opener in the food preparation area contained dried food buildup on the blade and area surrounding the blade. Two food preparation tables were observed with white paper sheets on the lower shelves acting as a cover on the shelf with books, pans, and other equipment sitting on top of them. The exposed shelf area on the tables contained visible dust and were sticky to touch. A juice dispensing machine located in the preparation area was observed on a table with a metal rack below. The metal rack below was observed with dust build up throughout the rack itself. Two boxes of juice concentrate were observed on the metal rack with plastic tubing attached and connected to the juice machine. Three additional tubes were observed coming from the machine and were hanging from the metal rack. The ends were not connected to any juice product. All the tubing was sticky to touch and observed with multiple colors of dried substance on the tubing, and dust stuck on the tubes. The connector ends were hanging, soiled, not in use, and not covered. One of the tubes not connected to any juice product was observed with a brownish colored liquid filling the tube. Concurrent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 25 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 interview with Employee 10, dietary manager, revealed he was not sure what juice was in the tube, and when the last time a box of juice was connected to the exposed ends. A wire metal rack shelf with pots and pans stored on it in next to the steamer area was sticky to touch and covered with dust stuck on the metal spokes. A ceiling vent directly above the pan rack was observed with dust hanging from it. The tilt kettle was observed with chunks of dried food and dried spills on the right side of the kettle. A roll-a-way cooker stationed by the prep table contained a dried tan colored substance splattered all over the interior base of the cooler. Two three tier metal carts were observed in the dry storage area holding recipe books, trash bags, case of oats, case of corn bread mix, and some canned items. The shelves of both carts contained dust and debris. The walk-in cooler located outside the building, contained a speed rack with several sheet tray pans stored on it. One empty tray sitting on the rack contained dried spills and debris. A pan was filled with a tan colored meat, of which Employee 10 identified as sliced turkey was observed on a tray on the rack. There was no evidence as to what the product was, when it was placed there, or when it expired. A tray at the top of the rack contained three pieces of meat, covered in saran wrap, and labeled roast beef 12/28. Employee 10 stated they were cooked prior and now pulled from the freezer to use. Review of a cool down log revealed an entry for roast beef dated December 28, 2022. There was no evidence to indicate when the roast beef cooked on December 28, 2022, that Employee 10 identified in the cooler was frozen, and if so when it was pulled from the freezer, or when it needed used by, as nine days had already passed since it was cooked. The dish room was observed with dried spills and debris covering the flooring area by the clean out station. There were no staff working in the dish room and Employee 10 indicated no washing had been done yet that morning. The baseboard and walls of the dish room including under the clean out station area were observed with dried splatter throughout the dish room. Fifteen dishwashing racks lined up on the clean end of the dish machine were observed worn, and with white flaky buildup covering several spots on the racks. A cart containing what Employee 10 identified as clean equipment observed in the dish room was observed with eight tan colored resident meal trays. The trays were discolored and stained, and one tray contained a broken corner. Three brown dollies were observed lined up along the dish room wall, which Employee 10 indicated were also clean. Two of the dollies contained several racks stacked on them with plastic coffee mugs. The dish racks were also worn and contained a flaky white debris in several areas of the rack. The bases of the dollies contained dried noodles, and other dried food debris, and dried liquid spills. The above observations of the main kitchen were reviewed with the Nursing Home Administrator and Director of Nursing on January 8, 2023, at 2:45 PM. 42 CFR 483.60(i) (1)-(3) Food Procurement, Store-Sanitary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 26 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 Previously cited 1/12/22 Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.6 (c) Dietary services Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 27 of 28 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 395767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on clinical record review and staff interview, it was determined that the facility failed to offer, or provide education regarding the benefits, risks, and potential side effects with the COVID-19 vaccine for three of five residents reviewed for immunizations (Residents 19, 46, and 87). Findings include: Clinical record review revealed the facility admitted Resident 19 on October 13, 2022. Further review of Resident 19's clinical record revealed no documentation that Resident 19 was offered or received the COVID-19 vaccine, or that the facility provided the resident or resident's responsible party education regarding the benefits, risks, and potential side effects of the vaccine. Clinical record review revealed the facility admitted Resident 46 on June 26, 2022. Further review of Resident 46's clinical record revealed no documentation that Resident 46 was offered or received both doses of the COVID-19 vaccine, or that the facility provided the resident or resident's responsible party education regarding the benefits, risks, and potential side effects of the vaccine. Clinical record review revealed the facility admitted Resident 87 on September 6, 2022. Further review of Resident 87's clinical record revealed no documentation that Resident 87 was offered or received the COVID-19 vaccine, or that the facility provided the resident or resident's responsible party education regarding the benefits, risks, and potential side effects of the vaccine. During an interview with Employee 12 (infection preventionalist) on January 10, 2023, at 11:12 AM she confirmed the above findings and stated the facility had no further documentation indicating they offered, or provided education regarding the benefits, risks, and potential side effects with the COVID-19 vaccine to Residents 19, 46, and 87. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395767 If continuation sheet Page 28 of 28