Inspection·August 4, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm During an interview on 8/04/23, at 10:47 a.m. the Director of Nursing confirmed that there was no evidence that the facility asked Resident R10 about going to the hospital, changing rooms, and no evidence of a Power of Attorney document in the clinical record. 28 Pa. Code 201.29 (j) Resident rights Residents Affected - Few 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395901 If continuation sheet Page 2 of 8 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 395901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Titusville Nursing and Rehab 81 Dillon Drive Titusville, PA 16354 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to invite residents and/or representatives to care plan meetings and failed to review and revise comprehensive care plans to reflect the current necessary care and services for four of 17 residents reviewed (Residents R18, R28, R32, and R59). Findings include: Review of a facility policy entitled, Goals and Objectives, Care Plans dated 5/25/2023, indicated that goals and objectives are reviewed and/or revised when the desired outcome has not been achieved. Review of a facility policy entitled Resident Participation Assessment/Care plans policy dated 5/23/2023, revealed that The resident/representative's right to participate in the development and implementation of his/her plan of care includes the right to: (3) a. Participate in the planning process., (7) A seven day advance notice of the care planning conference is provided to the resident and his or her representative. Review of Resident R18's clinical record revealed an admission date of 12/30/22, with diagnoses that included Type 2 Diabetes (chronic condition that affects the way the body processes blood glucose [sugar]), heart failure, heart disease, high blood pressure and a history of a stroke. Resident R18's clinical record lacked any evidence of resident/resident representative being invited or attending a care plan meeting. Review of Resident R32's clinical record revealed an admission date of 1/6/21, with diagnoses that included major depressive disorder, hypokalemia (a condition when your blood level of potassium is low), schizophrenia (impaired thinking process), and localized edema (swelling in one area of the body) Review of Resident R32's clinical record revealed a care plan conference meeting invitation on 3/31/23. Review of Resident R32's clinical record lacked evidence that he /she and/or resident representative had attended the care plan conference meeting. During an interview on 8/1/23, at 2:34 p.m. Resident R32 disclosed that he/she had not attended care plan meeting. During an interview on 8/3/23, at 9:50 a.m. the Social Services Director indicated that the care plan invitation and care plan meeting would be documented in the resident's clinical record. Review of Resident R59's clinical record Resident R59 clinical record revealed an admission date of 3/31/23, with diagnoses that included congestive heart failure (a condition where the heart becomes weak that leads to a build up of fluid in the lungs and surrounding body tissue), hyperlipidemia (high cholesterol), and cerebral infarction (a blockage of blood flow to the brain) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395901 If continuation sheet Page 3 of 8 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 395901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Titusville Nursing and Rehab 81 Dillon Drive Titusville, PA 16354 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 Review of Resident R59's clinical record lacked evidence that he/she and/or the resident representative was invited/attended the care plan conference meetings. During an interview on 8/1/23, at 11:00 a.m. Resident R59 disclosed that he/she had not attended and/or been invited to a care plan meeting. Residents Affected - Some During an interview on 8/3/23, at 9:50 a.m. the Social Service Director indicated that the care plan invitation and care plan meeting would be documented in the resident's clinical record. Resident R59's clinical record lacked evidence that Resident R59 or R59's representative was invited to and/or attended a care plan meeting. During an interview on 8/3/23, at 11:50 a.m. the Social Services Director confirmed there was no evidence that Residents R18 and R59 had attended care plan meetings or been invited to care plan meetings and no evidence of Resident R32 attending the care plan meeting. Review of Resident R28's clinical record revealed an admission date of 11/30/22, with diagnoses that included Type 2 Diabetes, long-term irregular heartbeat, need help with personal care, and artificial left knee, a care plan entitled, Shows potential for discharge and patient, relative or representative expresses wish for discharge dated 12/06/22, included the goal will be discharged to home when clinical and rehabilitation goals are met. Further review of Resident R28's clinical record revealed a departmental progress note dated 5/18/23, indicating that Resident R28 lived alone in an apartment and planned to return there, however he/she requires 24-hour care which is not available, and he/she must be able to transfer without the use of a lift. Review of a Physical Therapy Discharge summary dated [DATE], indicated that Resident R28 had attained his/her highest practical level and was to be discharged to the long-term care setting. During an interview on 8/03/23, at 9:04 a.m. the Social Services Director confirmed that Resident R28 was not able to go home due to requiring the use of a mechanical lift and lack of caregivers in the home, and that Resident R28's discharge care plan should have been updated to reflect that status. During an interview on 8/03/23, at 9:40 a.m. Physical Therapy Employee E1 confirmed that Resident R28 was discharged from therapy services on 5/18/23, and did not achieve the necessary physical requirements to safely discharge home with home health services. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395901 If continuation sheet Page 4 of 8 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 395901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Titusville Nursing and Rehab 81 Dillon Drive Titusville, PA 16354 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 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, and resident and staff interview, it was determined that the facility failed to update the resident's discharge plan to reflect changes in determining the resident's potential for discharge, involve the interdisciplinary team, involve the resident and representative, and update the comprehensive care plan and discharge plan in response to information received from referrals for one of 17 residents (Resident R28). Residents Affected - Few Findings include: Review of Resident R28's clinical record revealed an admission date of 11/30/22, with diagnoses that included Type 2 Diabetes (chronic condition that affects the way the body processes blood glucose [sugar]), long-term irregular heartbeat, needs help with personal care, and artificial left knee. Resident R28's care plan entitled, Shows potential for discharge and patient, relative or representative expresses wish for discharge dated 12/06/22, included the goal will be discharged to home when clinical and rehabilitation goals are met. Review of Resident R28's clinical record revealed a departmental progress note dated 5/18/23, that indicated Resident R28 lived alone in an apartment and planned to return there, however he/she requires 24-hour care which is not available and he/she must be able to transfer without the use of a lift, and a Physical Therapy Discharge summary dated [DATE], indicated that Resident R28 had attained his/her highest practical level and was to be discharged to the long-term care setting. Resident R28's clinical record lacked documentation regarding changing and/or updating Resident R28's discharge plan, and lacked evidence of including the interdisciplinary team and resident/representative in updating the discharge plan. During an interview on 8/01/23, at 2:32 p.m. Resident R28 confirmed that he/she had caregivers at home before coming into the facility and was trying to find home health caregivers so he/she can go back home. During an interview on 8/03/23, at 9:04 a.m. the Social Services Director confirmed that Resident R28 was not able to go home due to requiring the use of a mechanical lift and lack of caregivers in the home, and that Resident R28's discharge plan should have been updated. During an interview on 8/03/23, at 9:40 a.m. Physical Therapy Employee E1 confirmed that Resident R28 was discharged from therapy services on 5/18/23, and did not achieve the necessary physical requirements to safely discharge home with home health services, did not qualify for 24-hour care at home, and that Resident R28 was not safe to discharge home with services. During an interview on 8/04/23, at 9:47 a.m. Social Services Director confirmed that there was no evidence that the change in the discharge plan was discussed with the interdisciplinary team, Resident R28, and his/her representative. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical records (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395901 If continuation sheet Page 5 of 8 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 395901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Titusville Nursing and Rehab 81 Dillon Drive Titusville, PA 16354 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 0660 28 Pa. Code 211.11(e) Resident care plan 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: 395901 If continuation sheet Page 6 of 8 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 395901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Titusville Nursing and Rehab 81 Dillon Drive Titusville, PA 16354 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 facility policy and facility grievances, and staff interviews it was determined that the facility failed to properly and safely administer resident medications on two separate incidents for one of 17 residents (Resident R3) Residents Affected - Few Findings include: Review of facility policy dated 5/25/23, entitled Medication Administration General Guidelines indicated that Medications are to be administered at the time they are prepared. The policy further indicated that The resident is always observed after administration to ensure that the dose was completely ingested. Review of facility policy dated 5/25/23, entitled Documentation of Medication Administration, indicated that a nurse documents all medication administered to each resident on the resident's Medication Administration Record (MAR), it further indicated that the reason why a medication or medications not administered should be documented. Review of a facility grievance form dated 5/29/23, revealed that a family member found a cup of medications at Resident R3's bedside when the family member came to visit on 5/29/23, at 3:30 p.m. Review of a facility grievance dated 6/22/23, revealed that on 6/22/23, Resident R3 had received their morning medications twice by two different nurses. Review of Resident R3's admission record revealed an admission date of 4/01/22, with diagnoses that included dementia, heart disease, high blood pressure, atrial fibrillation and diabetes. Review of a quarterly Minimum Data Set (MDS-a periodic assessment of resident care needs) assessment for Resident R3, dated 5/19/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) that identified she had severely impaired cognition. Review of Resident R3's MAR for May 2023, identified that Resident R3 was administered all of their medications on 5/28/23 and 5/29/23, even though a medication cup full of medications was found at Resident R3's bedside stand on 5/29/23, at 3:30 p.m. by a family member. A nurse's note dated 6/22/23 at 9:42 a.m. revealed that Resident R3 was given a double dose of her morning medications and a nurse's note dated 6/23/23 at 10:46 p.m. revealed that Resident R3 was doing well post medication overdose; No ill effects. During an interview on 8/03/23, at 10:20 a.m. the Director of Nursing (DON) confirmed that Resident R3's medications should not have been left alone in the room for the resident and should not have been documented as administered. The DON also confirmed that on 6/22/23, Resident R3 did receive two doses of their morning medications in error. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)(1)(d) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395901 If continuation sheet Page 7 of 8 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 395901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Titusville Nursing and Rehab 81 Dillon Drive Titusville, PA 16354 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 - Few 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. Based on review of facility policy and grievances and staff interviews, it was determined that the facility failed to properly administer resident medications for one of 17 residents (Resident R3) Findings include: Review of facility policy dated 5/25/23, entitled Medication Administration General Guidelines indicated that Medications are to be administered at the time they are prepared. The policy further indicated that The resident is always observed after administration to ensure that the dose was completely ingested. Review of Resident R3's clinical record revealed an admission date of 4/01/22, with diagnoses that included dementia, heart disease, high blood pressure, atrial fibrillation and diabetes. Review of a quarterly Minimum Data Set (MDS-a periodic assessment of resident care needs) assessment for Resident R3, dated 5/19/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) and had severely impaired cognition. Review of a facility grievance form dated 5/29/23, revealed that a family member found a cup of medications at Resident R3's bedside when the family member came to visit on 5/29/23, at 3:30 p.m During an interview on 8/03/23, at 10:20 a.m. the Director of Nursing confirmed that Resident R3's medications should not have been left alone in the room for the resident. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395901 If continuation sheet Page 8 of 8