Health inspection·March 21, 2024

F 0623 that drains urine from the kidney). Level of Harm - Minimal harm or potential for actual harm There was no documented evidence that a written notice of Resident 57's transfer to the hospital was provided to the State Long-Term Care Ombudsman. Residents Affected - Few Interview with the Nursing Home Administator on March 21, 2024, at 11:23 a.m. confirmed that there was no written notification to the State Long-Term Care Ombudsman of the hospitalizations for Residents 24, 49 and 57, and there should have been. 28 Pa. Code 201.25 Discharge Policy. 28 Pa. Code 201.29(f)(g) Resident Rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 2 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 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 0636 Level of Harm - Potential for minimal harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on review of the Resident Assessment Instrument User's Manual and clinical records, the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set (MDS) validation report, as well as staff interviews, it was determined that the facility failed to ensure that the Care Area Assessment Process of comprehensive Minimum Data Set assessments and comprehensive assessments were completed in the required time frame for three of 36 residents reviewed (Residents 17, 68, 71). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that for admission MDS assessments, the assessment completion date and the Care Area Assessment (CAA - the process of completing an in-depth assessment of triggered, potentially problematic care areas) completion date (Item V0200B2) were to be no later than the resident's admission date plus 13 calendar days and there must be an MDS every 92 days. A comprehensive MDS assessment for Resident 17 revealed that the ARD was February 17, 2024. The MDS assessment was dated as completed on March 3, 2024, which was one day late. A comprehensive MDS assessment for Resident 68 revealed that the ARD was February 14, 2024. The MDS assessment was dated as completed on February 29, 2024, which was three days late. A comprehensive MDS assessment for Resident 71 revealed that the ARD was February 21, 2024. The MDS assessment was dated as completed on March 7, 2024, which was one day late. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on March 18, 2024, at 1:35 p.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames. 28 Pa. Code 211.5(f) Clinical Records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 3 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Potential for minimal harm Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for one of 36 residents reviewed (Resident 16). Residents Affected - Some Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 16 had an ARD of February 24, 2024, but it was not completed (Section Z0500B) until March 11, 2024, which was two days late. An interview with Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on March 18, 2024, at 1:35 p.m. confirmed that the above referenced quarterly MDS assessment was completed late. 28 Pa. Code 211.5(f) Clinical Records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 4 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of the Long-Term Care Facility Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for five of 36 residents reviewed (Residents 20, 27, 31, 58, 72). Residents Affected - Few Findings include: The Resident Assessment Instrument User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section B0700 was to be coded zero (0) if the resident was understood, one (1) if the resident was usually understood, two (2) if the resident was sometimes understood, and three (3) if the resident was rarely/never understood. Section B0800 was to be coded zero (0) if the resident could understand others, one (1) if the resident usually understood others, two (2) if the resident sometimes understands others and three (3) if the resident rarely/never understands others. Section C0100 was to be coded zero (0) if the resident is rarely/never understood or one (1) if the resident should be interviewed. Section D0100 was to be coded zero (0) No if a mood interview was not to be conducted with the resident because the resident was rarely/never understood and/or unable to respond, and one (1) Yes if a mood interview should be conducted with the resident. The RAI Manual indicated that a mood interview should be attempted with all residents. Section J0100 was to be completed after interviewing the resident regarding their pain. Section K0200 was to be completed using the resident's height and weight. A quarterly MDS assessment for Resident 20, dated February 3, 2024, revealed that the resident had clear speech, was understood, and understood others. However, Sections C, D, and K were coded with dashes (-), indicating that the areas were not assessed. A quarterly MDS assessment for Resident 27, dated February 3, 2024, revealed that Sections B, C, D, and J were coded with dashes (-), indicating that the areas were not assessed. A quarterly MDS assessment for Resident 58, dated February 22, 2024, revealed that Sections B, J, and K were coded with dashes (-), indicating that the areas were not assessed. An interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on March 18, 2024, at 1:35 p.m. confirmed that Resident 20, 27, and 58's MDS assessments were not done and that they should have been. She stated that the facility utilizes a remote RNAC that does not come to the building to assess the residents. The Long-Term Care Facility RAI User's Manual, dated October 2023, indicated that Section B was to be completed for each resident to document the resident's ability to understand and communicate with others. Section B0700 was to be coded zero (0) if the resident was understood by others, one (1) for usually understood, two (2) for sometimes understood, and three (3) for rarely/never understood. Section C was to be completed for each resident to identify his/her cognitive status. Section C0100 was to be coded No (0) or Yes (1) depending on whether a Brief Interview for Mental Status (BIMS) should be attempted with the resident and coded in Sections C0200 through C0500. The instructions for determining if a BIMS interview should be attempted indicated that if the resident was at least sometimes understood (verbally or in writing) then the BIMS interview was to be attempted with the resident. If the resident was rarely/never understood, then the BIMS interview was not to be attempted and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 5 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a Staff Assessment of Mental Status was to be completed instead and coded in Sections C0600 through C1000. The Long-Term Care Facility RAI User's Manual, dated October 2023, revealed that Section F0300 (Should Interview for Daily and Activity Preferences be conducted?) was to be coded (0) No (resident was rarely/never understood and family/significant other not available) skip to and complete F0800 Staff Assessment of Daily Activity Preference, or (1) Yes, continue to F0400 Interview for Daily Preferences. Section F0400 Interview for Daily Preferences revealed staff were to show the resident the response options and say While you are in this facility . and code (1) very important, (2) somewhat important, (3) not very important, (4) not important at all, (5) important but can't do, or no choice, and (9) no response or non-responsive for questions, (A) how important is it for you to choose what clothes to wear?, (B) how important is it to you to take care of your personal belongings or things?, (C) how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?, (D) how important is it to you to have snacks available between meals?, (E) how important is it to you to choose your own bedtime?, (F) how important is it to you to have your family or a close friend involved in discussions about your care?, (G) how important is it to you to be able to use the phone in private?, and (H) how important is it to you to have a place to lock your things to keep them safe? An Annual MDS assessment for Resident 31, dated February 15, 2024, revealed that Section B0700 was coded zero (0), indicating that the resident was understood by others. However, Section C0100 was coded (0) No, indicating that the resident was rarely/never understood by others, and Sections C0200 through C0500 (the BIMS interview) were not completed. Section F0300 and Section F0400 A, B, C, D, E, F, G and H were coded not assessed. Interview with the RNAC on March 18, 2024, at 1:35 p.m. confirmed that Section C0100 and Sections

F0300 and F0400 were coded inaccurately on the above MDS assessment for Resident 31. The RAI User's Manual, dated October 2023, revealed that Section F0300 (Should Interview for Daily and Activity Preferences be conducted?) was to be coded (0) No (resident was rarely/never understood and family/significant other not available) skip to and complete F0800 Staff Assessment of Daily Activity Preference, or (1) Yes, continue to F0400 Interview for Daily Preferences. Section F0400 Interview for Daily Preferences revealed staff were to show the resident the response options and say While you are in this facility . and code (1) very important, (2) somewhat important, (3) not very important, (4) not important at all, (5) important but can't do, or no choice, and (9) no response or non-responsive for questions, (A) how important is it for you to choose what clothes to wear?, (B) how important is it to you to take care of your personal belongings or things?, (C) how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?, (D) how important is it to you to have snacks available between meals?, (E) how important is it to you to choose your own bedtime?, (F) how important is it to you to have your family or a close friend involved in discussions about your care?, (G) how important is it to you to be able to use the phone in private?, and (H) how important is it to you to have a place to lock your things to keep them safe? An admission MDS assessment, dated February 8, 2024, revealed that Resident 72 could make herself understood and understand others and Section F0300 was coded (1) Yes, to continue to F0400 Interview for Daily Preferences; however, Section F0400 A, B, C, D, E, F, G and H were coded not assessed. Interview with the RNAC on March 18, 2024, at 1:35 p.m. confirmed that Section F0300 and F0400 were coded inaccurately on the above MDS for Resident 72. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 6 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 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 0641 28 Pa. Code 211.5(f) Clinical Records. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 7 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that baseline care plans included the information and instructions needed to provide person-centered care for four of 36 residents reviewed (Residents 77, 78, 79, 82). Findings include: The facility's policy regarding baseline care plans, dated January 15, 2024, indicated that a baseline plan of care to meet the resident's immediate needs would be developed for each resident within forty-eight hours of admission. The interdisciplinary team would review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including, but not limited to the following: initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. admission information for Resident 77 revealed that she was admitted to the facility on [DATE]. Physician's orders, dated March 14 and 15, 2024, included orders for the resident to receive 7.5 milligrams (mg) of warfarin (anticoagulant medication-blood thinner) at bedtime for atrial fibrillation (irregular heart rhythm), 40 mg of furosemide (diuretic- water pill) in the morning for heart failure, and 250 mg of Levaquin (antibiotic) one time a day for cellulitis (bacterial skin infection). Resident 77's baseline care plan (developed within 48 hours of a resident's admission and must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission), dated March 14, 2024, did not include information regarding the care or services the resident required for the treatment with an anticoagulant, diuretic, or antibiotic medication. Interview with the Nursing Home Administrator on March 20, 2024, at 12:13 p.m. confirmed that she could not find any information on Resident 77's baseline care plan regarding the treatment with an anti-coagulant, diuretic or antibiotic medication. admission information for Resident 78 revealed that she was admitted to the facility on [DATE]. Physician's orders, dated March 10, 2024, included orders for the resident to receive 15 mg of temazepam (sleeping pill ) at bedtime as needed for insomnia (trouble sleeping) and 2 liters per minute of oxygen as needed every shift for dyspnea (difficulty breathing). The Medication administration Record (MAR) for March 2024 revealed that the resident received temazepam March 11 through 19, 2024. Resident 78's baseline care plan, dated March 10, 2024, did not include information regarding the care or services the resident required for the treatment with a sleeping pill for insomnia or regarding the care and services required for the use of oxygen. Interview with the Nursing Home Administrator on March 21, 2024, at 10:32 a.m. confirmed that she could not find any information on Resident 78's baseline care plan regarding the treatment with a sleeping medication or use of oxygen. admission information for Resident 79 revealed that she was admitted to the facility on [DATE]. Physician's orders, dated March 8, 2024, included orders for the resident to receive 0.5 mg of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 8 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 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 0655 Level of Harm - Minimal harm or potential for actual harm lorazepam (anti-anxiety medication) at bedtime for anxiety (feeling of fear, dread, and uneasiness) and 40 mg of paroxetine (anti-depressant medication) daily for depression. Resident 79's baseline care plan, dated March 8, 2024, did not include information regarding the care or services the resident required for the treatment with an antianxiety or antidepressant medication. Residents Affected - Some Interview with Nursing Home Administrator on March 20, 2024, at 2:43 p.m. confirmed that she could not find any information on Resident 79's baseline care plan regarding the treatment with an anti-anxiety or anti-depressant medication. admission information for Resident 82 revealed that she was admitted to the facility on [DATE]. Physician's orders, dated March 13, 2024, included orders for the resident to receive 2.5 mg of apixaban (anticoagulant medication) twice a day following joint replacement surgery and to cleanse the skin tear on the right shin with normal saline solution (mixture of sodium chloride and water) and cover with a bordered dressing every day. Resident 82's baseline care plan, March 13, 2024, did not include information regarding the care or services the resident required for the treatment with an anticoagulant medication or regarding the care and services required for a skin tear. Interview with the Nursing home Administrator on March 20, 2024, at 12:00 p.m. confirmed that she could not find any information on Resident 82's baseline care plan regarding the treatment with an anti-coagulant medication or treatment to the skin tear. 28 Pa. Code 211.12(d)(1) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 9 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans that included specific and individualized interventions to address specific care needs for three of 36 residents reviewed (Residents 20, 27, 72). Findings include: The facility's policy regarding care plans, dated January 15, 2024, indicated that resident's care plans would be developed based on their needs. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated Feburary 3, 2024, indicated that the resident was alert and oriented and able to make his needs known. A physician's order, dated August 30, 2023, included an order for the resident to receive 2.5 milligrams (mg) Xarelto (blood thinner) two times per day. Review of Resident 20's Medication Administration Record, dated February and March 2024, revealed that the resident received Xarelto twice a day. Resident 20's care plan revealed that it did not include any information or interventions related to the resident's anticoagulant. admission information for Resident 27 revealed that the resident was admitted to the facility on [DATE], and that he had a cardiac pacemaker. A quarterly MDS assessment, dated February 3, 2024, indicated that the resident was cognitively intact and that he had a pacemaker. Physician's orders for Resident 27, dated March 1, 2024, included an order for the resident to have a pacemaker check on March 20, 2024. Resident 27's care plan revealed that it did not include any information or interventions related to the resident's cardiac pacemaker. An interview with the Nursing Home Administrator on March 19, 2024, at 11:54 a.m. confirmed that Resident 20's and 27's care plans did not include anything regarding the use of an anticoagulant or the resident's cardiac pacemaker and they should have. An admission MDS assessment for Resident 72, dated February 8, 2024, revealed that the resident was cognitively intact and received an anti-depressant, diuretic (water pill), anti-platelet (used to reduce the risk of blood clot formation), and hypoglycemic (used to treat diabetes) medications. Physician's orders, dated February 1, 2024, included orders for the resident to receive 81 mg of aspirin (anti-platelet medication) daily, 30 mg of Duloxetine (anti-depressant) daily for depression, 40 mg of furosemide (diuretic) daily for edema (swelling), 75 mg of clopidogrel bisulfate (anti-platelet) daily to prevent blood clots, 100 mg of doxycycline (anti-biotic) twice a day for prophylaxis (prevent infection), and 12.5 mg of Jardiance (hypoglycemic) daily for diabetes. There was no documented evidence that the facility had a care plan in place for Resident 72's use of an anti-platelet, anti-depressant, diuretic, antibiotic, or hypoglycemic medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 10 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Interview with the Nursing Home Administrator and Assistant Director of Nursing on March 20, 2024, at 12:00 p.m. confirmed that a care plan related to the use of an anti-platelet, anti-depressant, diuretic, antibiotic, or hypoglycemic medication was not developed. 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: 395778 If continuation sheet Page 11 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for four of 36 residents reviewed (Residents 6, 25, 57, 67). Findings include: The facility's policy regarding care plans, dated January 15, 2024, indicated that nursing staff and/or the interdisciplinary team were to update care plans as information about the residents and the residents' conditions change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated January 17, 2024, revealed that the resident was understood; could understand; was cognitively intact; had diagnoses that included osteoarthritis (degeneration of the joints), high blood pressure and anxiety; wore bilateral hearing aides; and was dependent on staff for daily care needs. Observations of Resident 6 in bed on March 18, 2024, at 11:41 a.m. revealed that her hearing aides were not in her ears. Her roommate stated that they are kept in the medication cart. A Medication Administration Record Note for Resident 6, dated December 5, 2023, indicated that, in order to prevent her hearing aides from becoming lost during the night, the nurse would collect them at bedtime and store them in the medication cart. A care plan for Resident 6, dated January 10, 2024, indicated that the resident had a communication care plan; however, it did not speak to the use of hearing aides or the need to keep them in the medication cart at night. In addition, there was no documentation reflecting the need to put them back in in the morning. Interview with Licensed Practical Nurse 1 on March 20, 2024, at 8:59 a.m. revealed that there is a task for collecting the hearing aides at night but nothing regarding putting them back in the morning. Interview with the Nursing Home Administrator on March 20, 2024, at 9:22 a.m. confirmed that Resident 6's care plan was not revised to reflect the use of hearing aides to instruct staff that they are collected in the evening, stored in the medication cart, and placed back in the resident's ears in the morning, and it should have been. A quarterly MDS assessment for Resident 25, dated January 5, 2024, revealed that the resident was cognitively intact, required moderate assistance from staff for daily care tasks, had diagnoses that included diabetes, and a care plan that indicated the resident had a Dexcom 6 (a glucose monitor that sends blood sugar results to an electronic device) attached to her abdomen, with needle changes due every ten days. Interview with Resident 25 on March 19, 2024, at 1:05 p.m. revealed that she has not had the Dexcom since she was admitted , because they do no accept that device in the facility. The resident went on to say that staff obtain accuchecks (a needle stick to obtain blood sugar results) four times a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 12 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 day. Level of Harm - Minimal harm or potential for actual harm Interview with the Nursing Home Administrator on March 19, 2024, at 2:16 p.m. confirmed that Resident 25's care plan was not revised to reflect that the she does not use a Dexcom, and it should have been. Residents Affected - Some A quarterly MDS assessment for Resident 57, dated February 15, 2024, revealed that the resident was cognitively intact, required moderate assistance from staff for daily care tasks, had a care plan that indicated the resident was at risk for urinary tract infections and sepsis (a life threatening infection in the blood), and had diagnoses that included chronic kidney disease with recent left nephrostomy tube placement (a tube placed in the kidney to drain urine). Physician's orders for Resident 57, dated January 18 and 21, 2024, respectively, included orders for staff to flush the nephrostomy tubing with 5-10 cc sterile saline as needed for blockage and to change the nephrostomy collection bag every night shift on Sunday. There was no documentation on Resident 57's, care plan regarding the orders to flush the nephrostomy tubing with 5-10 cc sterile saline as needed for blockage and to change the nephrostomy collection bag every night shift on Sunday. Interview with the Nursing Home Administrator on March 19, 2024, at 2:16 p.m. confirmed that Resident 25's care plan was not updated to reflect that staff were to flush the nephrostomy tubing and change the nephrostomy collection bag every Sunday as ordered, and it should have been. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 67, dated January 20, 2024, indicated that the resident was cognitively intact and required assistance of staff for daily care needs. A care plan for Resident 67, dated November 20, 2023, indicated that the resident had a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) care plan and an intravenous (a way of giving a drug or other substance through a needle inserted into a vein) medication care plan. Physician's orders, dated January 15, 2024, included an order to discontinue the urinary catheter. Physician's orders, dated February 12, 2024, included an order to discontinue intravenous medication. There was no documented evidence to reflect that Resident 67's care plan was updated to reflect that the urinary catheter and intravenous medication was discontinued. Interview with the Nursing Home Administrator on March 20, 2024, at 2:04 p.m. confirmed that Resident 67's care plan was not updated to reflect that the urinary catheter and intravenous medication was discontinued and it should have been. 28 Pa. Code 201.24(e)(4) admission Policy. 28 Pa. Code 211.12(d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 13 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for two of 36 residents reviewed (Residents 57, 63). Residents Affected - Few Findings include: The facility's policy regarding implementation of physican orders indicated that changes to the plan of care will be recorded, communicated, and implemented as ordered by the medical provider. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 57, dated February 15, 2024, revealed that the resident was cognitively intact, required moderate assistance from staff for daily care tasks, had a care plan that indicated the resident was at risk for urinary tract infections and sepsis (a life threatening infection in the blood), and had diagnoses that included chronic kidney disease with a left nephrostomy tube (a tube placed in the kidney to drain urine) placed in January. Physician's orders for Resident 57, dated February 12, 2024, included orders for staff to check the nephrostomy tube for patency every eight hours. A nursing note, dated March 9, 2024, for Resident 57 indicated that the resident's nephrostomy tube sutures were out and the tube was out approximately seven to eight centimeters. On March 9, 2024, the resident was started on Keflex (an antibiotic). The following day blood was noted in her nephrostomy tube and drainage bag, and the resident was then sent to the hospital to replace the nephrostomy tube. A review of Resident 57's clinical record revealed that the patency of the nephrostomy tube was not assessed for one eight-hour period on February 16, 19, 22, 25, 26, and March 6, 12, 18, 2024. Interview with Licensed Practical Nurse 2 on March 20, 2024, at 10:41 a.m. confirmed that Resident 57's clinical record indicated that staff did not assess the patency of the nephrostomy tube per physician orders. She further indicated that it is very important to do so especially because the resident has a history of her sutures coming out, and assessing the patency of the tube every eight hours can help prevent overall complications with the nephrostomy tube. Interview with the Nursing Home Administrator on March 20, at 11:10 a.m. confirmed that Resident 57's nephrostomy tube should have been checked for patency every eight hours as per physican's orders. A quarterly MDS assessment for Resident 63, dated January 20, 2024, revealed that the resident was cognitively intact and required assistance of staff for daily care needs. Resident 63 had a diagnosis of Type 2 Diabetes Mellitus. Physician's orders for Resident 63, dated January 19, 2024, included orders for the resident's blood sugar to be checked before meals. The resident's Medication Administration Record (MAR) for February 2024 revealed that the resident's blood sugar level on February 19 at 4:00 p.m. was 486 mg/dl, on February 20 at 7:30 a.m. was 414 mg/dl, on February 24 at 7:30 was 457 mg/dl and 11:00 a.m. was 429 mg/dl, and on February 25 at 7:30 a.m. was 433 mg/dl. However, there was no documented evidence that the physician was notified about the resident's elevated blood sugars. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 14 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 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 Interview with the Director of Nursing on March 21, 2024, at 11:15 a.m. confirmed that there was no documented evidence that the physician was notified about Resident 63's elevated blood sugars. 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: 395778 If continuation sheet Page 15 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 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 - Some 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 review of policies and clinical records, as well as staff interviews, it was determined that monitoring of the resident's restorative nursing programs for range of motion and transferring did not reflect the resident's progress toward program goals for two of 36 residents reviewed (Residents 3, 14). Findings include: The facility's policy regarding restorative nursing, dated January 15, 2024, revealed providing nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. The restorative nursing care programs are designed and designated to assist the resident in achieving and maintaining an optimal level of self-care and independence. Reassessment of progress, goals, and duration/frequency was part of the care plan process. Documentation of reassessment in the medical record with evidence of periodic evaluation was completed by a licensed staff member (at least quarterly). Documentation should include the following: If and how the resident has participated overall in the procedure or any changes in the resident's ability to participate in the procedure. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 5, 2023, revealed that the resident was understood, understands, and had a diagnosis which included dementia and Parkinson's disease. A care plan for the resident, dated April 6, 2023, revealed that the resident was on a nursing rehab/restorative transfer program, and that the resident will transfer from his bed to his power chair with one assist from staff. Staff was to cue the resident to sit back into his chair and use a folding wheeled walker. However, there was no documented evidence in Resident 3's clinical record of a periodic evaluation of the progress or lack of progress toward meeting the resident's goals being completed by a licensed staff member at least quarterly. A quarterly MDS assessment for Resident 14, dated February 5, 2024, revealed that the resident was understood, understands, and had a diagnosis which included Cerebral Vascular Accident (CVA commonly referred to as a stroke) with hemiplegia (paralysis to one half of the body). A care plan for the resident, dated August 25, 2022, revealed that the resident was on a nursing rehab/restorative for passive range of motion (the joints are moved by another person) to her bilateral upper extremities and staff was to complete three sets of 10 reputations. A care plan, dated September 15, 2023, revealed that the resident was on a nursing rehab/restorative for passive range of motion to her lower extremities each a.m. and p.m. to prevent contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) and skin injury. However, there was no documented evidence in Resident 14's clinical record of a periodic evaluation of the progress or lack of progress toward meeting the resident's goals being completed by a licensed staff member at least quarterly. Interview with the Nursing Home Administrator on March 20, 2024, at 12:23 p.m. confirmed that there was no documented evidence in Resident 3's and Resident 14's clinical records of a periodic evaluation of the progress or lack of progress toward meeting the resident's goals being completed by a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 16 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 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 licensed staff member at least quarterly. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(3)(5) Nursing Services. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 17 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to administer pain medications as ordered by the physician for two of 36 residents reviewed (Residents 78, 82). Residents Affected - Some Findings include: The facility's policy regarding pain medications, dated January 15, 2024, indicated that staff were to administer pain medications as ordered by the physician. Physician's orders for Resident 78, dated March 11, 2024, included orders for the resident to receive 5-325 milligram (mg) tablet of hydrocodone-acetaminophen (narcotic pain medication) every twelve hours as needed for a pain rating of 6 to 10 (on a scale of 1-10, with 10 being the worst pain). Resident 78's Medication Administration Record (MAR) for March 2024 revealed that staff administered hydrocodone-acetaminophen for a pain rating that was less than six on March 14 at 8:39 p.m., March 15 at 10:09 p.m., and March 19 at 7:51 p.m. Physician's orders for Resident 82, dated March 18, 2024, included orders for the resident to receive 5 mg of oxycodone (narcotic pain medication) every four hours as needed for a pain rating of 6 to 10. Resident 82's MAR for March 2024 revealed that staff administered oxycodone for a pain rating that was less than six on March 14 at 8:24 p.m., March 15 at 8:46 p.m., March 18 at 11:46 a.m. and 7:49 p.m., March 19 at 5:58 p.m., and March 20 at 7:24 a.m. An interview with the Nursing Home Administrator on March 21, 2024, at 10:32 a.m. confirmed that Resident 78's hydrocodone-acetaminophen and Resident 82's oxycodone were not administered as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 18 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for one of three nurse aides reviewed (Nurse Aide 3). Residents Affected - Few Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation for Nurse Aide 3 was due February 13, 2024. As of March 21, 2024, there was no documented evidence that the annual performance evaluation was completed as required for Nurse Aide 3. Interview with the Human Resource Director on March 21, 2024, at 11:38 a.m. confirmed that she could not provide evidence that the annual performance evaluation for Nurse Aide 3 was completed as required. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(c) Staff Development. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 19 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 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. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 36 residents reviewed (Residents 63). Findings include: The facility's policy regarding controlled substances, dated January 31, 2024, indicated that accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance was administered, the licensed nurse administering the medication was to immediately enter the following information on the accountability record and Medication Administration Record (MAR): date and time of administration, amount administered, remaining quantity, and the initials of the nurse administering the dose, completed after the medication is actually administered. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 63, dated January 20, 2024, revealed that the resident was cognitively intact and required assistance of staff for daily care needs. Current physician's orders for Resident 63 included an order for the resident to receive 5-325 mg of Oxycodone (narcotic pain reliever) every eight hours as needed for severe pain. The resident's MAR for February 2024 indicated that one dose of Oxycodone was signed-out for administration to the resident on February 18 at 8:28 a.m. and 4:48 p.m. The resident's controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for February 2024 indicated that one dose of Oxycodone was signed-out for administration to the resident on February 11 at 6:00 a.m., February 12 at 3:30 p.m., February 15 at 12:45 p.m., February 17 at 4:45 p.m., and February 21 at 11:40 a.m. However, the resident's clinical record, including the MAR controlled drug record and nursing notes, contained no documented evidence that the signed-out doses of Norco were actually administered to the resident on these dates and times. Interview with the Director of Nursing on March 21, 2024, at 11:15 a.m. confirmed that there was no documented evidence that staff administered signed-out doses of Oxycodone to Resident 63 on the above dates and times. 28 Pa. Code 211.9(a)(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 20 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 20 residents reviewed (Resident 20). Residents Affected - Some Findings include: The facility's medication administration policy, dated January 15, 2024, revealed that medications were to be administered as prescribed. Manufacturer's instructions for Aspart, revised February 2015, indicated that the medication should be administered within five or ten minutes of a meal. Physician's orders for Resident 20, dated December 9, 2023, included orders for the resident to receive 10 units of insulin Aspart (fast-acting insulin) in the morning before breakfast, 10 units before lunch, and 10 units before dinner. Medication Administration Records (MAR) for Resident 20 for January, February, and March 2024 revealed that he received his insulin at 9:00 a.m., 10:00 a.m. and 3:00 p.m. However, meal times were 8:10 a.m. for breakfast, 11:40 a.m. for lunch, and 4:40 p.m. for dinner. Resident 20's insulin administration was not within five to ten minutes of receiving his meal. Interview with the Director of Nursing on March 20, 2024, at 2:18 p.m. confirmed that Resident 20 was not receiving his insulin per the manufacturer's instructions and that he should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 21 of 22 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 395778 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and staff interviews, as well as medication package inserts, it was determined that the facility failed to discard expired medication in one of two medication rooms reviewed (Medication room [ROOM NUMBER]), failed to discard multiple bags of outdated IV (fluid that is administered into the vein) stock solution, and failed to administer insulin as per manufacture's instructions. Findings include: The facility's policy regarding medication storage, dated [DATE], revealed that the facility would not use outdated drugs or biologicals. Observations in Medication room [ROOM NUMBER] on [DATE], at 9:10 a.m. revealed that one Forteo (a man-made hormone that stimulates new bone growth) injection pen was labeled with an expiration date of [DATE], and there were five 100 cc bags of outdated IV stock solution, two that expired in [DATE] and three that expired in [DATE]. Interview with Registered Nurse 4 on [DATE], at 9:20 a.m. confirmed that the Forteo injection pen and the five IV solution bags were expired and should have been discarded. Interview with the Nursing Home Administrator on [DATE], at 2:15 p.m. confirmed that the medication injection pen and the five IV solution bags were outdated and should have been discarded. 28 Pa. Code 211.9(a)(1) Pharmacy Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395778 If continuation sheet Page 22 of 22