Health inspection·July 20, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observations, review of facility policies, and interviews with residents and staff, it was determined that the facility failed to provide residents with the opportunity to file grievances anonymously for two of two nursing units observed (First Floor and Second Floor nursing units). Findings include: During an interview, on July 18, 2023, at 10:30 a.m. a group of five alert and oriented residents (Residents 27, 36, 1, 28, 31) stated that they did not know who the grievance official was at the facility and they did not know where the grievance process was posted. Observation, on July 18, 2023, at 11:02 a.m. of the main lobby and first floor nursing unit areas revealed that there was no information posted regarding the facility's grievance process, the grievance officer or how to file a grievance. Continued observation, on July 18, 2023, at 11:10 a.m. of the second floor nursing unit revealed that the facility Grievance/Complaint Procedure was posted in the hallway near the elevator. Review of the Grievance/Complaint Procedure undated, revealed, Please fill in this form and submit to the Charge Nurse who will see that it is forwarded to the Social Worker, who will assign a facility representative to investigate. The Grievance/Complaint Procedure listed the social worker's name and contact information as the grievance official. Further observation revealed that there were no grievance forms available and that there was no box to place grievance forms anonymously. Observation on July 18, 2023, at 11:15 a.m. and interview with the Nursing Home Administrator confirmed that no grievance information was posted on the first floor nursing unit, that there were no grievance forms available and that there was no box to place grievance forms anonymously. Interview on July 18, 2023, at 11:24 a.m. Employee E3, Director of Social Worker, stated that grievance forms were located at the nurses station and the residents could ask staff for a grievance form. Employee E3, Director of Social Worker, confirmed that there were no grievance forms available or a box for residents to be able to file grievances anonymously. The facility failed to provide residents the opportunity to file grievances anonymously. 28 Pa Code 201.29 (b) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395952 If continuation sheet Page 2 of 6 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 395952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naamans Creek Country Manor 1194 Naamans Creek Road Boothwyn, PA 19061 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor weight loss for one of three residents reviewed for nutrition (Resident 18). Residents Affected - Few Findings include: Review of facility policy, Weighing of Residents, undated, revealed that if the resident exhibits a weight change of 3 lbs. from the previous weight (weights under 100 lbs.), the resident shall be re-weighed within 24 hours and the re-weight shall be recorded. Review of Resident 18's weights revealed on April 5, 2023, the resident was recorded as weighing 79 lbs. On April 7, 2023, the resident was recorded as weighing 73.4 lbs., which is a 7.09% loss in two days. Further review of Resident 18's weights revealed the resident was not weighed again until April 14, 2023. Further review of Resident 18's weights revealed on May 10, 2023, the resident was recorded as weighing 78.2 lbs. On June 12, 2023, the resident was recorded as weighing 71.6 lbs., which is an 8.06% loss in one month. Further review of Resident 18's weights revealed the resident was not weighed again until July 6, 2023. Interview with the Registered Dietitian, Employee E6, on July 20, 2023, at 10:30 a.m. confirmed that the facility should have obtained reweights on Resident 18 within 24 hours. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa Code: 211.10(c) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395952 If continuation sheet Page 3 of 6 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 395952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naamans Creek Country Manor 1194 Naamans Creek Road Boothwyn, PA 19061 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, policy and procedure review, and staff interview it was determined the facility failed to administer as needed pain medications for appropriate pain levels for two of five residents reviewed. (Residents 2 and 42) Residents Affected - Some Findings include: Review of facility policy and procedure titled Pain Management, revised March 2022, revealed PRN (as needed) pain medication orders should include name of medication, strength, frequency, pain indication or location and pain scale (mild, moderate, severe). If there are multiple prn pain medication orders the orders must contain the necessary, pain scale clearly defining the level of pain for each use. Review of Resident 2's physician orders revealed an order dated April 26, 2023 for Oxycodone (narcotic pain reliever) with Acetaminophen (Tylenol) Tablet 5-325 MG (milligrams); Give 1 tablet by mouth every 6 hours as needed for moderate pain. Review of Resident 2's Medication administration Record for July and June 2023 revealed the resident received the medication for a pain level other than moderate a total of eight times. Review of Resident 42's physician orders revealed an order dated July 14, 2022 for Acetaminophen tablet 325 MG give two tablets by mouth every four hours as needed for mild pain; and an order dated May 20, 2023 for oxycodone HCL tablet 5 MG give one tablet by mouth every 6 hours as needed for pain, this ordered did not specify a pain level for the medication to be administered. Review of Resident 42's MAR for June and July 2023 revealed the Acetaminophen was administered 19 times for a pain rating other than mild. Further review of Resident 42's June and July 2023 MAR revealed the Oxycodone was given for a mild pain level totaling 25 times when the acetaminophen should have been administered. Interview with the Director of Nursing and the Nursing Home Administrator on July 20, 2023 at 9:30 a.m. confirmed prn pain medications were not administered as ordered and the prn pain medications for Resident 42 did not include a pain level per policy. 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395952 If continuation sheet Page 4 of 6 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 395952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naamans Creek Country Manor 1194 Naamans Creek Road Boothwyn, PA 19061 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, review of facility policies, and interviews with staff, it was determined that the facility failed to store food in accordance with professional standards for food service safety for two of two nursing units (First Floor and Second Floor nursing units). Findings include: Review of the facility policy, Food Safety-Resident Food dated June 7, 2023, revealed, the facility will be responsible for safe storage of food and beverage items. Resident food items will be labeled with the resident's name. The item will also be dated. The item will only be safe for three days. Observation on July 17, 2023, at 9:17 a.m. of the second-floor kitchen dry food storage area revealed a box that was open and left open to air of food thickener. Interview, at the time of the observation, Employee E4, Dietary Manager, confirmed that the box of thickener was left open to air and then proceeded to close the box. Observation on July 18, 2023, at 9:56 a.m. of the second-floor pantry, revealed the following: A container of cream cheese for Resident 42 that expired June 16, 2023; Two bags full of containers of food brought in by family for Resident R42 that were undated; An opened quart sized container of iced tea that expired June 28, 2023, and did not contain a resident name label; An opened quart-sized container of strawberry lemonade that expired June 24, 2023, and did not contain a resident name label; An opened two-liter bottle of soda that was undated and did not contain a resident name label; An opened container of pastries that was undated and did not contain a resident name label; An opened carton of prune juice that was undated; Four pint-sized containers of ice cream that were undated, three of which did not contain a resident name label; An opened bag of potato chips that was undated; An opened bag of cheese crackers that was undated; A loaf of bread that expired on July 8, 2023; Four one-liter bottles of Glucerna 1.5 (nutritional supplement) that expired February 1, 2023; Two one-liter bottles of Glucerna 1.5 that expired March 1, 2023; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395952 If continuation sheet Page 5 of 6 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 395952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naamans Creek Country Manor 1194 Naamans Creek Road Boothwyn, PA 19061 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Twelve eight-ounce bottles of Jevity 1.5 (nutritional supplement) that expired on July 1, 2023; Level of Harm - Minimal harm or potential for actual harm Eight eight-ounce bottles of Glucerna 1.5 that expired on July 1, 2023; and two eight-ounce bottles of Glucerna that expired on May 1, 2022. Residents Affected - Some Observation on July 18, 2023, at 10:21 a.m. of the first-floor pantry, revealed thirty-three eight-ounce bottles of Nepro (nutritional supplement) that expired on January 1, 2023. Interview with Employee E5, Chef, on July 18, 2023, at 10:24 a.m. confirmed that food was not stored properly in the pantries. Further it was confirmed by Employee E5, chef, that items were not properly labeled or dated, and the items were expired. The facility failed to ensure that food was stored properly, labeled and dated according to professional standards. 28 Pa Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395952 If continuation sheet Page 6 of 6