Health inspection·September 19, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and staff interview, it was determined that the facility failed to maintain a safe, homelike environment for one of two elevators (Elevator 1). Residents Affected - Few Findings include: An observation on 9/18/24, at 2:46 p.m. revealed a broken number one button in Elevator 1, where the center of the button was missing with exposed sharp edges. An observation on 9/19/24, at 8:37 a.m. revealed that the number one button on Elevator 1 remained broken with sharp edges exposed. During an interview on 9/19/24, at 11:46 a.m. the Nursing Home Administrator confirmed that the number one button on Elevator 1 was broken with exposed sharp edges, and that the facility failed to maintain a safe, homelike environment for one of two elevators as required. 28 Pa. Code 201.18 (b)(1)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395890 If continuation sheet Page 2 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snu Armstrong CO Memorial Hosp One Nolte Drive Kittanning, PA 16201 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 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation and staff interview, the facility failed to make certain that a complaint/grievance could be filed anonymously for 13 of 13 residents. Residents Affected - Many Findings include: Review of the facility policy Grievances/Complaints Skilled Nursing Unit dated 12/1/24, indicated that any resident, family member, friend, or staff person has the right to file a complaint or grievance alleging a violation of applicable laws/regulations by the unit orally or in writing. The person filing has the right to file anonymously. During a tour of nursing unit on 9/17/24, at 9:53 a.m. a wall hanger with Resident/Family Concern Forms, was noted to be in the Activity/Dining Room, as well as at the Nurses Station. During an observation on 9/17/24, at 10:01 a.m. failed to identify a secure location for residents, family member, friend, or staff member to put a complaint or grievance anonymously. During an interview on 9/17/24, at 10:15 a.m. Nursing Home Administrator (NHA) stated, I tell them to give the form to one of my staff when they are done. When asked, If you have them give the form to your staff, is that anonymous? NHA stated, I never really thought of it that way. During an interview on 9/17/24, at 10:35 a.m. NHA confirmed that the facility to make certain that a complaint or grievance could be filed anonymously for 13 of 13 residents. 28 Pa. Code 201.29(1) Resident rights 28 Pa. Code 201.18 e (4) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395890 If continuation sheet Page 3 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snu Armstrong CO Memorial Hosp One Nolte Drive Kittanning, PA 16201 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, newly hired personnel records, and staff interviews it was determined that the facility failed to properly screen an employment by completing a state background check prior to hire for two of five personnel records reviewed (Nursing Assistant (NA) Employee E2 and Registered Nurse (RN) Employee E3). Residents Affected - Few Findings include: The facility Abuse policy dated 10/1/24, indicated that the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion. The Skilled Nursing Unit (SNU) hereby recognizes these rights and establishes the following policies and procedures to protect the rights of the resident. At the time of application, all individuals will be asked to certify that they have not been discharged from any facility. The appropriate licensing boards and registries will be checked for information related to the applicant. Review of Nursing Assistant (NA) Employee E2's personal record indicated she was hired on 7/8/24. Review of NA Employee E2's personnel record did not include a state criminal background check prior to her date of hire. During an interview on 9/17/24, at 11:45 a.m. Employment Coordinator Employee E4 confirmed that the background check was completed after Employee E2's hire date. Review of Registered Nurse (RN) Employee E3's personal record indicated she was hired on 12/11/23. Review of RN Employee E3's personal record indicated a criminal background check was completed on 12/10/23, however the criminal background check failed to indicate if RN Employee E3 had a record or no criminal record on the report. During an interview on 9/17/24, at 11:50 a.m. Employment Coordinator Employee E4 stated, I don't see the results on the criminal background check. During an interview on 9/17/24, at 2:15 p.m. Nursing Home Administrator confirmed that the facility failed to properly screen an employment by completing a state background check prior to hire for two out of five personnel records reviewed (Nursing Assistant Employee E2 and Registered Nurse Employee E3). 28 Pa Code: 201.14(a) (c)(d)(e) Responsibility of licensee 28 Pa Code: 201.19 Personnel policies and procedures 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development 28 Pa Code: 201.29 (d) Resident Rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395890 If continuation sheet Page 4 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snu Armstrong CO Memorial Hosp One Nolte Drive Kittanning, PA 16201 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one out of three residents sampled with facility-initiated transfers (Closed record (CR) Resident R12). Findings include: Review of the clinical record indicated CR Resident R12 was admitted to the facility on [DATE]. Review of CR Resident R12's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 7/17/24, indicated diagnoses of peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time. Review of the clinical record indicated CR Resident R12 was transferred to the hospital on 7/17/24 and did not return to the facility. Review of CR Resident R12's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 9/19/24, at 12:40 p.m. the Director of Nursing (DON) stated We send paperwork with the resident but as far as documentation we don't have. During an interview on 9/19/24, at 12:44 p.m. the DON confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one out of three residents sampled with facility-initiated transfers (CR Resident R12). 28 Pa. Code 201.29 (a) (c.3) (2) Resident rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395890 If continuation sheet Page 5 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snu Armstrong CO Memorial Hosp One Nolte Drive Kittanning, PA 16201 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 - Minimal harm or potential for actual harm Residents Affected - Few 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 clinical records, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two of two residents (Closed Record (CR) Residents R7 and R12). Findings include: Review of the clinical record indicated CR Resident R7 was admitted to the facility on [DATE]. Review of CR Resident R7/'s MDS (Minimum Data Set, periodic assessment of resident care needs) dated 9/16/24, indicated coronary artery disease (damage or disease in the heart's major blood vessels), high blood pressure, and seizures. Review of the clinical record indicated CR Resident R7 was discharged to home on 9/16/24. Review of CR Resident R7's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of Long-Term Care Ombudsman for the discharge to home on 9/16/24. Review of the clinical record indicated CR Resident R12 was admitted to the facility on [DATE]. Review of CR Resident R12's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 7/17/24, indicated diagnoses of peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time. Review of the clinical record indicated CR Resident R12 was transferred to the hospital on 7/17/24 and did not return to facility. Review of CR Resident R12's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of Long-Term Care Ombudsman for the hospitalization on 7/17/24. During an interview on 9/19/24, at 12:44 p.m. Nursing Home Administrator (NHA) stated, We don't send anything to the Ombudsman. I haven't sent anything since before the COVID pandemic started. During an interview on 9/19/24, at 2:10 p.m. the NHA confirmed that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two of two residents (CR Residents R7 and R12). 28 Pa. Code 201.29 (a) (c.3) (2) Resident rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395890 If continuation sheet Page 6 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snu Armstrong CO Memorial Hosp One Nolte Drive Kittanning, PA 16201 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of two resident hospital transfers (Closed Record (CR) Resident R12). Findings Include: Review of the clinical record indicated Resident 12 was admitted to the facility on [DATE]. Review of CR Resident R12's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 7/17/24, indicated diagnoses of peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time. Review of the clinical record indicated CR Resident R12 was transferred to the hospital on 7/17/24 and did not return to the facility. Review of CR Resident R12's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 7/17/24. During an interview on 9/19/24, at 2:15 p.m. Nursing Home Administrator (NHA) stated, We don't have a policy on bed holds because we don't do bed holds here. During an interview on 9/19/24, at 2:20 p.m. the NHA confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for one of two resident hospital transfers (CR Resident R12). 28 Pa. Code: 201.29(b)(d)(j) Resident rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395890 If continuation sheet Page 7 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snu Armstrong CO Memorial Hosp One Nolte Drive Kittanning, PA 16201 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents who require dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) service receive such services consistent with professional standards of practice by failing to obtain a contract with a dialysis facility for one of three residents reviewed (Resident R68). Residents Affected - Few Finding include: Review of the clinical record indicated Resident R68 was admitted to the facility on [DATE], with active diagnoses of dependence on renal dialysis, unspecified fall, and gastroesophageal reflux disease (GERD a condition that occurs when stomach contents leak into the esophagus and cause irritation). Review of a physician order dated 9/8/24, indicated Resident R68 received dialysis every Monday, Wednesday, and Friday. During an interview on 9/18/24, at 12:30 p.m. the Nursing Home Administrator (NHA) stated that the facility did not have a contract with the dialysis facility for Resident R68 to receive dialysis services. During an interview on 9/18/24, at 12:30 p.m. the NHA confirmed that the facility failed to ensure residents who require dialysis service receive such services consistent with professional standards of practice by failing to obtain a contract with a dialysis facility as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code:201.18(b)(1) Management. 28 Pa. Code:211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395890 If continuation sheet Page 8 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snu Armstrong CO Memorial Hosp One Nolte Drive Kittanning, PA 16201 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure a medication regime was free from potentially unnecessary medication for two of four residents reviewed (Residents R71 and R74). Findings include: Review of facility policy Psychopharmacologic Drugs dated 11/23, indicated in accordance with Federal regulations, Unit) will ensure that residents who have not used psychopharmacologic drugs are not given these drugs unless such therapy is necessary to treat a specifically diagnosed condition and is clearly documented in the clinical record. The resident's physician provides a justification for the continued use of the drug and the dose of drug is clinically appropriate. Review of the clinical record indicated Resident R71 was admitted to the facility on [DATE], with diagnoses of hyperlipidemia (high levels of fat in the blood), weakness, and atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat). Review of Resident R71's physician order's dated 9/11/24, indicated he was prescribed the following medications: - Duloxetine 60 milligrams (mg) daily (an antidepressant medication) - Zolpidem 5 mg at bedtime (a sedative/hypnotic medication) Review of Resident R71's clinical record failed to reveal documented evidence from the physician of the clinical necessity for the administration of Duloxetine and Zolpidem. Review of the clinical record indicated Resident R74 was admitted to the facility on [DATE], with diagnoses of atrial fibrillation, diabetes (too much sugar in the blood), and cirrhosis of the liver (chronic damage leading to scarring and liver failure). Review of Resident R74's physician order's dated 9/13/24, indicated he was prescribed the following medications: - Trazodone 50 mg at bedtime (an antidepressant medication) Review of Resident R74's clinical record failed to reveal documented evidence from the physician of the clinical necessity for the administration of Trazodone. During an interview on 9/19/24, at 12:05 p.m. the Director of Nursing (DON) confirmed that Residents R71 and R74 did not have documented evidence from the physician of the clinical necessity for the administration of psychotropic medications and stated, I guess the coders need to catch up. During an interview on 9/19/24, at 12:05 p.m. the DON confirmed that the facility failed to ensure a medication regime was free from potentially unnecessary medication for two of four residents as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395890 If continuation sheet Page 9 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snu Armstrong CO Memorial Hosp One Nolte Drive Kittanning, PA 16201 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 required. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.9(a)(1) Pharmacy services. 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: 395890 If continuation sheet Page 10 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snu Armstrong CO Memorial Hosp One Nolte Drive Kittanning, PA 16201 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on review of facility documents and staff interview, it was determined that the facility failed to submit direct care staffing information in the Payroll-Based Journal (PBJ) system for one of three quarters reviewed (Quarter 1). Findings include: Review of the PBJ staffing data reports revealed that the facility did not submit data for Quarter 1 (October 1, 2023, through December 31, 2023). During an interview on 9/19/24, at 11:19 a.m. the Nursing Home Administrator confirmed that the facility failed to submit direct care staffing information in the Payroll-Based Journal system as required. 28 Pa. Code 201.14(a) Responsibility of licensee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395890 If continuation sheet Page 11 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snu Armstrong CO Memorial Hosp One Nolte Drive Kittanning, PA 16201 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on a review of facility policy, plans of correction, and the results of the current and former surveys, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: Review of facility policy Quality Assurance and Performance Improvement Program dated 9/24, indicated the methodology for achieving outcomes includes monitoring, tracking, identifying and measuring, prioritizing performances and deficiencies, developing and implementing corrective action of performance improvement activities, monitoring/revaluating the effectiveness of the corrective action/performance activities and revising if needed. Data is collected from multiple sources and comparative data is reviewed and analyzed to determine the need for further evaluation. The data collected is reviewed by the Quality Assurance Team as well as the Administrator, Director of Nursing (DON), and Medical Director. The Administrator, Medical Director, and DON are accountable for identifying any indicators for opportunity or concern. The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending 10/19/23, revealed that the facility would maintain compliance with cited nursing home regulations. The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending 10/19/23, identified a deficiency related to failing to maintain a safe, homelike environment, related to Elevator 1 having a broken number one button with sharp exposed edges. The facility's plan of correction for the survey ending 10/19/23, indicated a work order would be placed with maintenance to repair the broken number one button on Elevator 1. The Administrator will monitor that the button is intact twice a week for 30 days and weekly for another 30 days. The facility safety officer will continue to monitor once a month on safety rounds. All audit findings will be reported at the quarterly QAPI meeting. The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending 10/19/23, revealed a deficiency related to failing to make certain a grievance official is posted with contact information and that he facility had a policy and procedure for grievances that met federal guidelines. The facility's plan of correction for the survey ending 10/19/23, indicated a notice was posted in the Activity/Dining room and at the nurse's station stating the name of the grievance officer including contact information. The complaint/grievance policy has been revised to meet and address federal regulation §483.10(j)(4). Staff will be educated with a read and sign. The Administrator will monitor weekly for four weeks and once a month for three months to ensure that the grievance information is posted. All audits will be reported at the quarterly QAPI meeting. The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending 10/19/23, identified a deficiency related to failing to implement required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395890 If continuation sheet Page 12 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snu Armstrong CO Memorial Hosp One Nolte Drive Kittanning, PA 16201 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 0867 infection control measures during a dressing change observation. Level of Harm - Minimal harm or potential for actual harm The facility's plan of correction for the survey ending 10/19/23, indicated all appropriate staff will be re-educated via a read and sign of the correct procedure for Infection Control processes during dressing changes including hand hygiene, changing of gloves, prevention of cross contamination, appropriate use of PPE (protective personal equipment) and decontamination of equipment. Based on availability of dressing changes, the DON or designee will observe a dressing change three times a week for two weeks, then weekly for four weeks, then monthly for 3 months to assure proper infection control techniques are followed. Results of the observations will be reported at the quarterly QAPI meeting. Residents Affected - Few During an interview on 9/19/24, at 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed recurring deficiencies. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395890 If continuation sheet Page 13 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snu Armstrong CO Memorial Hosp One Nolte Drive Kittanning, PA 16201 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for one of three quarterly meeting (October 2023 thru December 2023). Residents Affected - Few Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) Program policy dated 9/1/24, indicated that the facility is committed to maintaining an effective and comprehensive QAPI program that is data driven and focuses on outcomes of care and quality of life. The QAPI program is a multidisciplinary team approach. Review of Quality assurance and performance improvement sign in sheets and attendance records from meeting held on 1/15/24, QAPI quarterly meeting did not indicate that the facilities Medical Director and Director of Nursing attended a quarterly meeting. During an interview on 9/19/24, at 1:52 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members as required. 28 Pa Code: 201.18(e)(1)(2)(3)(4) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395890 If continuation sheet Page 14 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snu Armstrong CO Memorial Hosp One Nolte Drive Kittanning, PA 16201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policies, clinical record review, observation, and staff interviews, it was determined the facility failed to follow proper use of personal protective equipment (PPE) for one of five residents (Resident R65). Residents Affected - Few Findings include: Review of facility policy Infection Control Plan dated 11/1/23, indicated the goal of the facility is to maintain a comprehensive infection control program to ensure that the facility has a functioning coordinated process in place to reduce the risks of infections in residents. Review of Center for Disease (CDC) definition for Enhanced Barrier Precautions (EBP, a type of special isolation when providing direct care to a resident): The use of isolation gown and gloves during high-contact resident care activities including wound care. Review of the clinical record indicated that Resident R65 was admitted to the facility on [DATE]. Review of Resident R65's clinical record indicated diagnoses of cellulitis (bacterial skin infection), weakness, and urinary tract infection (infection in any part of the kidneys, bladder or urethra). Review of a physician order dated 9/13/24, indicated surgical wound to left shin, left lower leg wound, wash daily with hibiclens (a skin cleanser to help reduce bacteria that potentially can cause disease), pat dry, apply mupirocin (an antibiotic cream) to edges of wound, dress with xeroform (a fine mesh gauze that maintains a moist wound environment), wrap with kerlix(a gauze bandage roll), and secure with tape. Review of Resident R65's clinical record indicated resident was on EBP for surgical wound. During an observation of a dressing change on 9/18/24, at 1:47 p.m. Licensed Practical Nurse (LPN) Employee E5 entered Resident R65's room without donning (putting on) isolation equipment prior to entering room. LPN Employee E5 performed a dressing change and failed to wear a gown, as indicated. During an interview on 9/18/24, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to follow proper use of PPE for one of five residents (Resident R65). 28 Pa. code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code: 211.10 (d) Resident care policies. 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services. 28 Pa. Code: 211.11(a) Resident care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395890 If continuation sheet Page 15 of 15