Health inspection·July 3, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, it was determined that the facility failed to ensure resident's privacy during a medication pass while utilizing staff personal electronic devices for two of two nursing units (Ivy and Sage Nursing Units) for one of 19 sampled residents (Residents 20). Residents Affected - Some Findings include: Review of facility documentation entitled, Athens Nursing and Rehabilitation Center Orientation, revealed that all staff attend and review this orientation upon hire. The orientation documentation revealed that staff received education on the HIPPA (Health insurance Portability and Accountability) Act of 1996, confidentiality, privacy, and resident rights. HIPPA protects protective sensitive patient information from being disclosed without their consent or knowledge. A HIPPA violation is punishable by law and could be subject to fines or jail time. Residents have the right to have their personal information kept private. Interview with the Nursing Home Administrator (NHA) on July 2, 2025, at 2:200 PM confirmed that staff complete orientation and that this information was reviewed during mandatory yearly in-services as well. Review of Employee 5, LPN (licensed practical nurse), Employee 6, NA (nurse aide), and Employee 7, NA's employee file revealed Employee 5 completed their orientation/in-service training on March 6, 2025, Employee 6 completed their orientation/in-service training on September 10, 2024, and Employee 7 completed their orientation/in-service training on June 18, 2025. Observation of the Ivy nursing unit on July 2, 2025, at 9:04 AM revealed that Employee 5 was passing medications to Resident 20. Employee 5 was utilizing the facility's identified electronic documentation system (point click care, PCC) to access Resident 20's medical record to identify, administer, and chart their medications. Concurrent interview with Employee 5 revealed that they accessed Resident 20's medical record via their own personal electronic device that they bring from home to work. Employee 5 indicated that there are not enough facility supplied electronic devices on the Ivy nursing to access resident medical records to timely administer medications and document on residents; therefore, she brings her own electronic device to ensure she has access when needed. Observation of the Sage nurse's station and interview with Employee 7, NA on July 2, 2025, at 10:05 AM revealed that there were four facility supplied laptops available for staff use. When questioned if anyone had brought a personal electronic device from home to chart or document in a resident record Employee 7 indicated that they had brought their own electronic device into the facility to utilize. Interview with the NHA on July 2, 2025, at 11:45 AM confirmed there was a concern with staff accessing resident clinical records via their personal electronic devices due to HIPPA, confidentiality, and resident privacy. The NHA requested that their corporate office purchase four laptops on June 24, 2025, due to only having two laptops available at the time for six to seven NAs to chart with. At the time of the interview, the facility had not received the requested laptops Observation of the Ivy nurse's station and interview with Employee 5 on July 2, 2025, at 11:50 AM revealed that the nursing unit was supposed to have two laptops and one iPad for staff usage. Observation of the station revealed one facility supplied laptop (labeled Sage) and one facility supplied (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396137 If continuation sheet Page 2 of 13 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 396137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Athens Nursing and Rehabilitation Center 200 South Main St Athens, PA 18810 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some iPad were available. Employee 5 revealed that she was unsure where the second laptop was located. At the time of the observation, there was a personal iPad, identified to be owned by Employee 6, NA, lying on the nurse's station desk, which staff utilize to chart care and services in resident records. Review of the staffing schedule for July 2, 2025, day shift, revealed that there were eight NAs, three LPNs and one RN working to share the five facility supplied laptops and one facility supplied iPad to chart care and services in resident's clinical record. The facility was unable to ensure that resident personal and private information contained in a resident's clinical record was secure due to staff utilizing their own personal electronic devices and accessing residents clinical records. 28 Pa. Code 201.29 (c.3)(4) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396137 If continuation sheet Page 3 of 13 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 396137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Athens Nursing and Rehabilitation Center 200 South Main St Athens, PA 18810 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 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 observation and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on one of two nursing units (Sage; Residents 27 and 66). Residents Affected - Few Findings include: Observation on July 1, 2025, at 11:42 AM revealed Resident 27's room had damage to the wall next to the bathroom door. There was 10 to 12 inches of exposed drywall paper. A hand sanitizer dispenser was installed, covering a portion of the damaged area. Observation on July 1, 2025, at 11:55 AM of Resident 66 room revealed a 2-inch area of exposed drywall paper on the wall next to the bathroom door. A hand sanitizer dispenser was installed, covering a portion of the damaged area. Observation of the Sage Nursing unit hallway on July 1, 2025, at 12:05 PM revealed a painted handrail with the paint rubbed off, exposing the underlying metal. This damage was most severe at the intersection of two hallways, next to the nursing station. Dried brown liquid splatter was observed on the lower portion of the wall behind two medication carts located across from the nursing station. A vent above the nursing station contained visible dust hanging on the interior and exterior of the vent extending to the surrounding ceiling tiles. The surveyor reviewed the above findings with the Nursing Home Administrator and the Director of Nursing on July 2, 2025, at 11:58 AM. 483.10(i) Housekeeping and Maintenance Services 28 Pa. Code 201.18(b)(3)(e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396137 If continuation sheet Page 4 of 13 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 396137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Athens Nursing and Rehabilitation Center 200 South Main St Athens, PA 18810 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 0628 Level of Harm - Potential for minimal harm Residents Affected - Many Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for nine of 10 residents reviewed for hospitalizations (Residents 13, 23, 26, 28, 50, 55, 57, 64, and 66). Findings include: Clinical record review for Resident 23 revealed nursing documentation dated April 8, 2025, at 9:15 AM that noted the resident was sent to the hospital due to chest pain. Nursing documentation for Resident 23 revealed a health status note dated April 9, 2025, at 9:21 AM that noted the resident was admitted to the hospital. Nursing documentation for Resident 23 dated April 14, 2025, at 5:53 PM revealed the resident returned to the nursing facility. Clinical record review for Resident 50 revealed nursing documentation dated May 6, 2025, at 2:07 PM that noted the resident was sent to the hospital for a change in condition. Nursing documentation for Resident 50 dated May 6, 2025, at 10:45 PM revealed that the resident was admitted to the hospital. Nursing documentation for Resident 50 dated May 12, 2025, at 4:18 PM revealed that the resident returned to the facility and was transferred back to the hospital for re-evaluation. An interview with the Nursing Home Administrator on July 2, 2025, at 3:16 PM revealed the ombudsman was not notified of the transfers to the hospital for Residents 23 and 50. Clinical record review for Resident 55 revealed that they were transferred to the hospital on November 18, 2024, after there was a change in their condition. There was no documentation that the facility provided written notification to the State Ombudsman as required regarding the transfer. Clinical record review for Resident 64 revealed that they were transferred to the hospital on June 21, 2025, after there was a change in their condition. There was no documentation that the facility provided written notification to the State Ombudsman as required regarding the transfer. Clinical record review for Resident 26 revealed the resident was sent to the hospital on April 24, 2025, for a change in condition and admitted . Clinical record review for Resident 28 revealed the resident was sent to the hospital on May 26, 2025, for a change in condition and admitted . Clinical record review for Resident 57 revealed the resident was sent to the hospital on January 30, 2025, for a change in condition and admitted . There was no evidence facility staff notified the States Ombudsman of the transfers out of the facility for Residents 25, 26, and 57. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396137 If continuation sheet Page 5 of 13 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 396137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Athens Nursing and Rehabilitation Center 200 South Main St Athens, PA 18810 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 0628 Level of Harm - Potential for minimal harm Residents Affected - Many Interview the Nursing Home Administrator on July 2, 2025, at 2:08 PM revealed facility staff had not been notifying the States Ombudsman of transfers to the hospital as required. Clinical record review for Resident 13 revealed a nursing note dated June 6, 2025, at 5:35 PM indicating the resident was transferred to the hospital. There was no documentation that the facility provided the required written notification to the State Ombudsman regarding the transfer. Clinical record review for Resident 66 revealed the facility transferred him to the hospital on March 21, 2025, March 31, 2025, and April 11, 2025. There was no documentation that the facility provided the required written notification to the State Ombudsman regarding the transfer. The surveyor reviewed the above information with the Nursing Home Administrator on July 2, 2025, at 2:50 PM. The Administrator stated they do not send notifications for hospital admissions. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396137 If continuation sheet Page 6 of 13 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 396137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Athens Nursing and Rehabilitation Center 200 South Main St Athens, PA 18810 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 clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered interventions and treatments for one of 19 residents (Resident 67). Residents Affected - Some Findings include: Clinical record review for Resident 67 revealed physician orders for the following: Ordered on May 29, 2025, and discontinued on June 22, 2025, for only registered nursing (RN) staff to drain the Aspira catheter (a chest tube/catheter inserted into the lung area/cavity to drain excessive fluids) every other day on day shift. RN staff were not to exceed 1000 ml (milliliters) of fluid each time. Staff were to document the output, color, and character of drainage in a progress note, Ordered on May 29, 2025, and discontinued on June 22, 2025, for only RN staff to change the Aspira chest tube/catheter drain dressing every other day on day shift. Ordered on June 5, 2025, and discontinued on June 22, 2025, for only RN staff to change the Aspira chest tube/catheter drain connecting valve weekly on day shift. Clinical record review for Resident 67 revealed there was no documentation that RN staff drained the Aspira catheter on June 2, 4, 8, 12, 16, and 18, 2025. Upon further review, licensed practical nursing (LPN) staff documented completion of draining the Aspira catheter on June 10 and 14, 2025. There was no documentation that RN staff changed the Aspira catheter dressing on June 2, 4, 8, 12, 16, and 18, 2025. Upon further review, LPN staff documented completion of the Aspira catheter dressing on June 10 and 14, 2025. There was no documentation that RN staff changed the Aspira catheter connecting valve on June 12 and 19, 2025. Upon further review, LPN staff documented completion of the Aspira catheter connecting valve change on June 5, 2025. Review of staffing education for Aspira catheter drains revealed that the facility educated RN staff on May 29, 2025. There was no documentation that the facility educated LPN staff on Resident 67's Aspira catheter. The above information was reviewed during an interview on July 3, 2025, at 9:50 AM with the Director of Nursing. 483.25 Quality of Care Previously cited 6/14/24 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396137 If continuation sheet Page 7 of 13 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 396137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Athens Nursing and Rehabilitation Center 200 South Main St Athens, PA 18810 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement interventions related to fall prevention for two of six residents reviewed (Residents 7 and 46). Residents Affected - Few Findings include: Clinical record review for Resident 7 revealed a diagnosis list that included the following: unsteadiness on feet, dementia (a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons), abnormalities of gait and mobility, and muscle weakness. Clinical record review for Resident 7 revealed a quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated May 6, 2025, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 4, which indicated severe cognitive impairment. Current physician orders for Resident 7 dated April 28, 2025, at 10:30 PM indicated the resident was to have a bed/chair alarm and check placement and function every shift. Review of Resident 7's care plan revealed that the resident is at risk for falls related to limited mobility and dementia. An intervention included a chair alarm. Nursing documentation dated May 1, 2025, at 10:16 AM revealed an interdisciplinary note for a fall risk meeting that noted Resident 7 had a fall on April 28, 2025. The root cause was noted as self-transferring from the wheelchair to the bed. An intervention was to place a chair alarm. Observation of Resident 7 on July 1, 2025, at 1:58 PM and 3:20 PM revealed the resident was in a wheelchair. Continued observation revealed the resident was able to self-propel the wheelchair and was mobile in the hallway and his room. There was no observed chair alarm on the wheelchair. The alarm was observed hanging on the resident's dresser next to the bed. Interview with Employee 4, licensed practical nurse, on July 1, 2025, at 3:29 PM revealed that Resident 7 should have a chair alarm on his wheelchair. Employee 4 proceeded to take the alarm hanging on the resident's dresser, power it on, and placed it on Resident 7's wheelchair. The above information for Resident 7 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 2, 2025, at 11:30 AM. Clinical record review for Resident 46 revealed a physician's order dated March 18, 2025, for staff to implement a chair alarm (a pressure sensitive device that alarms when a person moves and releases the pressure on the alarm) and to check for function and placement every shift. Observation of Resident 46 on the following dates and times revealed that they were seated in a wheelchair but did not have a chair alarm per their physician order: July 1, 2025, 11:14 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396137 If continuation sheet Page 8 of 13 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 396137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Athens Nursing and Rehabilitation Center 200 South Main St Athens, PA 18810 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 0689 July 2, 2025, 8:52 AM, 9:20 AM, 9:25AM, and 12:06 PM Level of Harm - Minimal harm or potential for actual harm Concurrent interview with Employee 5, licensed practical nurse, during the July 2, 2025, 9:25 AM observation confirmed that Resident 46 did not have a chair alarm while seated in their wheelchair. Residents Affected - Few The surveyor reviewed this information during an interview with the Nursing Home Administrator and Director of Nursing home on July 2, 2025, at 11:35 AM 483.25(d)(1)(2) Free of Accident Hazards/supervision/devices Previously cited deficiency 5/8/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396137 If continuation sheet Page 9 of 13 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 396137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Athens Nursing and Rehabilitation Center 200 South Main St Athens, PA 18810 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on staff interview, it was determined that the facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. Residents Affected - Many Findings include: During an interview on July 1, 2025, at 10:10 AM, Employee 2, registered dietitian indicated she was only employed at the facility three days a week (not full-time). Concurrently, Employee 1, dietary manager, indicated she was not a certified dietary manager, certified food service manager, did not have a national certification for food service management and safety, and did not hold a degree in food service management. In a follow up interview on July 1, 2025, at 12:00 PM the Nursing Home Administrator confirmed the facility did not employe a full-time qualified dietitian or qualified director of food and nutrition services. Cross Refer F812 28 Pa. Code 201.18(b)(1)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396137 If continuation sheet Page 10 of 13 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 396137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Athens Nursing and Rehabilitation Center 200 South Main St Athens, PA 18810 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to maintain food service equipment in accordance with professional standards for food service safety and store food in a sanitary manner in the facility's main kitchen and on two of two nursing units (Sage and Ivy). Findings include: An observation in the facility's main kitchen on July 1, 2025, at 10:10 AM with Employee 1, dietary manager, revealed the following: The interior of the water wells of the steam table were observed on (hot), with water in the compartments (wells that hold water produce the steam to keep pans of food placed above the water hot). Employee 1 indicated breakfast had been served and the breakfast pans had already been removed from the steam table. The interior base of the steam table compartments was coated in a buildup of brown film. A significant amount of food debris was also observed floating in the water of the compartments including vegetables, potatoes, and other food debris that was not served at breakfast. A two-door cooler was observed with three plastic bins on the shelf in the cooler. The bins were filled cups that had milk poured in them. The cups of milk were not covered or dated as to when they were placed there or when they needed used by. The ceiling over the dish room area contained multiple areas of rust-colored spots. A pipe extending through the dish washing area near the ceiling was covered in visible dust. The light covers over the area were dirty with blackened areas and dried food splatter. The walk-in freezer contained large chunks of ice on the floor behind the condenser area. The lower freezer shelves where food products were stored were lined with a porous wood covering presenting a risk for harboring bacteria/organisms. The dry storage area contained multiple wire rack shelving units holding food products. The lower shelves throughout the dry storage room were also lined with the same porous wood coverings. Multiple areas of the wood shelf coverings were observed with dried liquid stains in the wood. A concurrent observation of the Sage nursing unit pantry, which extends from the main kitchen to the Sage hallway was observed with a buildup of dust, debris, and dried spills on the flooring of the pantry. A large round garbage can in the area had dried food splatter in several spots on the exterior of the can. The wall behind and beside the garbage can was covered in dried food splatter from three feet up the wall to the floor. The refrigerator in the Sage pantry was soiled on the interior base and the lower vent unit at the front of the refrigerator was soiled and dusty. An observation of the Ivy nursing unit pantry on July 1, 2025, at 10:30 AM revealed the flooring in the area was blackened and dirty. The interior of a single door cooler in the pantry was soiled with dried purple liquid on the interior base of the cooler. The above findings in the main kitchen were reviewed with the Nursing Home Administrator and Director of Nursing on May 2, 2025, at 12:00 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396137 If continuation sheet Page 11 of 13 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 396137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Athens Nursing and Rehabilitation Center 200 South Main St Athens, PA 18810 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 483.60(i)(2) Store, prepare, food safe and sanitary Level of Harm - Minimal harm or potential for actual harm Previously cited 6/14/24 28 Pa. Code 201.14 (a) Responsibility of Licensee Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396137 If continuation sheet Page 12 of 13 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 396137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Athens Nursing and Rehabilitation Center 200 South Main St Athens, PA 18810 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 Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate Enhanced Barrier Precautions (EBP) for one of 24 residents reviewed (Resident 276). Residents Affected - Few Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, device care, etc. During an observation and interview with Resident 276 on July 1, 2025, at 3:07 PM an enhanced barrier sign was observed outside Resident 276's door. Resident 276 indicated that he had a urinary foley catheter (a medical device consisting of tubing inserted into the urethra to collect urine) and a chest tube (a medical device consisting of a tube inserted through the chest cavity wall to collect drainage). Resident 276's clinical record revealed an active physician's order dated June 27, 2025, that reads Enhanced barrier precautions for indwelling foley and chest tube. An observation of a chest tube dressing change on Resident 276 on July 2, 2025, at 11:16 AM revealed Employee 3, Registered Nurse, entered Resident 276's room, donned gloves, removed the dressing, and cleansed around the chest tube insertion site, changed gloves, and applied a new dressing. Employee 3 did not don a gown during this high-contact procedure, as required for EBP. The surveyor reviewed the above information with the Nursing Home Administrator and the Director of Nursing on July 2, 2025, at 12:29PM. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control 28 Pa. Code 211.12(d)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396137 If continuation sheet Page 13 of 13