Inspection·February 2, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 policy, observations, resident and staff interview, it was determined that the facility failed to answer call bells in a timely manner for four of 20 residents (Residents R34, R57, R82, R25), failed to accommodate the residents' needs related to having access wheelchair accessible bathroom including sink and toilet for one of the two residents reviewed (Resident R72) and the use of bed rails for 2 out of 20 residents observed.(Resident R25 and Resident R18) Residents Affected - Few Findings include: Review of the facility Resident Communication System and Call Light Policy dated February 24, 2023, indicated It is the policy of the facility to provide residents with a means of communicating with staff. A call system is instilled in each resident room and toilet/bath areas. The facility responds to resident needs and requests. On January 29, 2024, at 10:30 a.m. an observation was taken place on the B unit nursing station that call bell monitor was ringing in room A8-D and was on for 23 minutes before it was answered. After it was answered an interview was held with licensed nurse, Employee E5 in room A8 where there four four residents residing. On January 29, 2024, at 10:30 a.m. an interview was conducted with licensed nurse, Employee E5 at the bedside of Resident R34 that call bell was registered on the call bell monitor screen in the nursing station but that when Employee E5 responded to the call bell, it was Resident R82 located in room A8-B bed. Further interview confirmed by Employee E5 that the call bell response time was 23 minutes and employee E5 stated I know that you don't have to tell me that. Employee E5 was not aware why the call bell was not functioning properly for bed A8D and was shut down by A8B. On January 30, 2024, at 10:12 a.m. an interview was conducted with Resident R25 who's call bell was observed to be behind the pillow and not in a reachable position. Nursing HomeAdministrator, Employee E1 confirmed the observation and readjusted the call bell so it could be in reachable position for the resident. On January 29, 2024, at 1:10 p.m. an interview was conducted with Resident R295 who reported that call bell is not being answered for a lot time especially over the weekend and night shift staff disappear on the weekend and night shift. On February 1, 2024, at 9:38 a.m. bed A8-D call bell was observed to be behind the bed not in a reachable position. Employee E15 confirmed and helped to reach the call bell to conduct the testing of the call bell. On February 1, 2024, at 9:39 a.m. a call bell monitor at the A nursing station was monitored and A8-C response time was documented in 21 minutes. When an interview was conducted with Resident R57 located in A8-C it revealed they don't answer it referring to staff. On February 1, 2024, an observation with the housekeeping Director, employee E15 confirmed that R34's call bell was on the floor, not in a reachable position and his bed was in the high position. Employee E15 stated to R34 I'll get you a call bell clip. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 2 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On January 30, 2024, at 10:02 a.m. an interview was conducted with Resident R25 which revealed railing were taken off last week, I'm unable to turn or reposition myself. On January 30, 2023, at 1:09 p.m. an interview was conducted with ADON, Employee E12 revealed that last week there was an incident with the resident who got hurt due to bed rail and all bed rails were taken off. Employee E12 further reported that this week rehabilitation department is going around and screaming residents who actually needs them. On January 30, 2024, at 1:13 p.m. an interview with Rehabilitation Director, Employee E16 who confirmed that Resident R25 does need bed rails to reposition himself in bed. Observation conducted on January 29, 2023, at 9:27 am during the tour of Unit B revealed that Resident R18 was in bed with no rails on both sides and a floor mat was on the floor mat next to Resident R18's bed. Further observation revealed that an overhead table was next to Resident R18's bed. Further on the overhead table was a phone and a Styrofoam water pitcher with a small amount of liquid inside. Further observation revealed that the top of the overhead table, and the phone was wet. Further, the floor below the overhead table and the floor mat were wet. Interview with Resident R18 conducted at the time of the observation revealed that Resident R18 used to have a bed rail on the top part of his bed which he used to turn himself whenever he needed to reach his phone from the overhead table beside his bed. Further, Resident R18 also revealed that the bed rails were removed a few days ago. And that since the bed rails was removed, he was no longer able to turn himself to reach his phone. Further Resident R18 revealed that earlier in the morning, he tried to reach for his phone on the overhead table next to his bed, he had a lot of difficulty reaching it and tipped the water pitcher over in the process and spilled water on his phone and the table. Follow-up observation of Resident R18 together with Rehab director conducted on January 30, 2024, at 1:10 p.m. revealed that resident was in bed without a bed rail as an enabler. Interview with Rehabilitation Director, Employee E16 conducted at the time of the observation revealed that Resident R18 was using a half bed rail an enabler which allowed Resident R1 to turn independently while in bed. Further interview with Employee E16 revealed that Resident R18's bedrail was removed the week before and that it was removed before he received a request from nursing to do an evaluation to determine if resident could further benefit from the use of half rail as an enabler. Further, Employee E16 revealed that the evaluation has not been completed for Resident R18 yet. Interview with conducted Rehabilitation Director, Employee E16 on January 31, 2024, at 1:20 pm revealed that he completed the evaluation for Resident R18 for safety with bed rails for use as an enabler and recommended that resident be provided with bed rail for bed mobility. Review of Resident R18's clinical record revealed that Resident R18 was admitted to the facility on [DATE], with the diagnoses of but not limited to Muscle Weakness, Type 2 Diabetes, Abnormalities of Gait and Mobility, Acute myocardial Infarction. Review of facility bed mobility documentation for January 2024 revealed that Resident R18 required limited to extensive assistance for bed mobility Review of Resident R18's quarterly MDS dated [DATE], revealed that section C0500, BIMS brief interview for mental status) Summary Score revealed a score of 13 suggesting that resident was cognitively (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 3 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few intact. Section GG - Functional Abilities and Goals, A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed, was coded 02 (Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). Section G0110. Activities of Daily Living (ADL) Assistance A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture was coded 3- Extensive assistance (resident involved in activity; staff provide weight-bearing support) under Self-Performance and was coded 3 -Two+ persons physical assist, under Support. Review of Resident R18's self-care deficit care plan initiated on September 8, 2023, revealed that under interventions: evaluate resident for adaptive equipment, promote independence and dignity. Further review of Resident R18's clinical record revealed no documented evidence or reason for removing Resident R18's half bedrail that he was using for bed mobility. Further, Resident R18's half bed rail was removed before an evaluation was conducted by the occupational therapy to determine the appropriateness of the use of a half bed rail causing Resident R1 to loose his ability to function at his highest practicable function. On January 30, 2024, at 1:35 p.m. an interview was conducted in room A4 with Resident R 72 and who had a friend visiting Resident R28. Resident R72 reported that she/he was moved to room A6 on January 27, 2024, due to her roommate being on hospice and unable to perform her independent daily hygiene because her wheelchair does not pass thru the restroom due to the structure of the toilet being in her way. Resident R72 reported that she has not brushed her teeth since her move, washed her hands, or washed her face due to the not having accommodation to get to the sink with her wheelchair. Resident R72 further reported they didn't even ask me if I would like to change my roommate. It happened last Friday referring to January 27, 2024. Resident R72's further stated CNAs (nurse aides) barely have time to get me dressed and leave to the next resident. Surveyor made observation that the structure of the restroom in room A6 was not accommodating Resident R72 due to the having enough walking space but not having enough of space to pass by the toilet to get to the sink using a bariatric wheelchair. Resident had a commode next to her bed as a way to use the restroom. Resident R72 further reported after the move I approached Director of Nursing, Employee E2 and she didn't even allowed me to speak, but said it's already done, I felt like she treated me like a child and walked away. Resident R28 also reported that her room B33 is also structured the same way and she/he is unable to get to the sink. I can't recall when the last time was I brushed my teeth. On January 30, 2024, at 1:53 p.m. surveyor spoke to the Nursign Home Administrator and Director of Nursing, Employee E2 and reported the concern immediately. On January 30, 2024, at 2:15 p.m. an interview was held in room A6 with Rehabilitation Director, Employee E16 who confirmed that Resident R72 is no weight bearing. The resident had both toes amputed therefore she/he was consider no weight bearing. The resident was able to transfer herself with visual assistance and needed the toilet bars to support her when using the toilet. Resident R72 does need to be in a different room where she could have an entrance to the restroom from the sink side to use her sink, and toilet independently. Employee E16 did confirm that commode which was next to the bedside of the resident was not appropriate as it's a temporary item for short term for resident who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 4 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have c-deff infection (bacteria present in the large intestine, watery diarrhea 10-15 times a day) or diarrhea, but as it was given to Resident R72 to use for permanent. Employee E16 further reported we encourage residents to have independence with their hygiene and Resident R72 is able to be independent with appropriate accommodations. On January 30, 2024 at 2:25 p.m. a nursing assistant, Employee E3 was interviewed regarding Resident R72 and her hygiene. Employee E3 reported when Resident R72 was moved form A5 to A6 room I noticed right away that she/he was not able to brush her teeth, hands independently even to get to the sink because the way the restroom structure. I notified DON, Employee E2 and advised we need to move Resident 72 to room A7 because of the toilet being structure on the other side and giving Resident R72 access to the sink . DON reported absolutely not because there's a resident who is short term resident and Resident R72 needs to be moved to with a short term resident. Another option was provided to Resident R14 but that room had the same structure of the restroom as room A6 and Resident did not want to move into A14 because there was a roommate who did not speak English. Employee E3 further reported I asked her to move from A5 to A6 but Resident R72 did not wanted to move but she/he did not mind as long as the structure of the restroom would be the same as in A5. However, I'm just an aide at the end of the day and I need to do what my higher up tell me to do. Clinical record was conducted for Resident R72 which revealed admission date on January 5, 2024 from the hospital with diagnosis of muscle weakness, morbid (severe obesity due to excess calories), other acute osteomyelitis left ankle and foot, type 2 diabetes with mild nonproliferative diabetic retinopathy with macular edema bilateral, legal blindness as defined in USA, dependence on renal dialysis, hypertensive heart and chronic kidney diseases with heart failure and stage 1 through stage 4 chronic kidney disease, difficulty in walking, chronic embolism and thrombosis of unspecified vein, peripheral vascular diseases, anemia in chronic kidney and hypertension. Review of the Resident R72's Minimal Data Set assessment dated [DATE], indicated that a Brief Interview for Mental Status (BIMS) score of 15 which revealed that the resident was cognitively intact. Physical Evaluation dated January 6, 2024 noted No WB (weight baring) order from hospital notes, however, patient reports she is able to WANT for transfers n surgical shoe. Transfer = CGA:Sit -Stand +SBA. It further notes that Resident R72 difficulty in walking. Transfer Goal: Patient will safely perform functional transfers with modified Independence for correct use of Assitive Devise, for proper positioning before/during transfer, for correct hand/foot placement, for safe maneuvering in small spaces and for safety while turning in order to facilitate increased participation with functional daily activities and return to prior level of functional abilities. 28 Pa. Code: 201.29(j) Resident rights. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 5 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on clinical record reviews and resident and staff interviews, it was determined that the facility failed to support and accommodate a resident's choices and preferences for one of two residents reviewed (Resident R72). Findings include: Review of Resident R72's quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated January 12, 2024, revealed that the resident was cognitively intact. Review of Resident R72's clinical record revealed an admission date on January 5, 2024 with the resident's diagnoses of muscle weakness, morbid (severe obesity due to excess calories), other acute osteomyelitis left ankle and foot, type 2 diabetes with mild nonproliferative diabetic retinopathy with macular edema bilateral, legal blindness as defined in USA, dependence on renal dialysis, hypertensive heart and chronic kidney diseases with heart failure and stage 1 through stage 4 chronic kidney disease, difficulty in walking, chronic embolism and thrombosis of unspecified vein, peripheral vascular diseases, anemia in chronic kidney and hypertension. Physical Evaluation dated January 6, 2024, noted No WB (weight bearing) order from hospital notes, however, patient reports she is able to want for transfers in surgical shoe. On January 30, 2024, at 1:35 p.m. an interview was conducted in room A4 with Resident R72 who reported that she/he was moved to room A5 on January 27, 2024, to accommodate her as the roommate was on hospice. With the room transfer Resident R72 was unable to perform her independence of daily hygiene as it was not wheelchair accessible bathroom. Resident R72 further reported they didn't even ask me if I would like to change my roommate. It happened last Friday referring to January 27, 2024. Resident R72 further reported after the move I approached Director of Nursing, Employee E2 and she didn't even allow me to speak, but said it's already done, I felt like she treated me like a child and walked away. On January 30, 2024, at 1:53 p.m. an interview with Administrator and Director of Nursing, Employee E2 revealed that both were not aware that Resident R72 had no wheelchair bathroom accommodation in the current room where she was moved. On January 30, 2024, at 2:25 p.m. a nursing assistant, Employee E3 was interviewed revealed when Resident R72 was moved from A3 to A4 room I noticed right away that she/he was not able to brush her teeth, hands independently even to get to the sink because the way the restroom structure. I notified DON, Employee E2 and advised we need to move Resident 72 to room A7 because of the toilet being structure on the other side and giving Resident R72 access to the sink . DON reported absolutely not because there's a resident who is short term resident and Resident R72 needs to be moved to with a short-term resident. On January 30, 2024, 2:45 p.m. an interview was held with Resident R72's prior roommate, Resident R309 who reported I didn't request a private room and didn't mind Resident R72 to be my roommate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 6 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On January 30, 2024, 3:06 p.m. an interview was held with Social Worker Director, Employee E19 who reported that room change was completed by the policy of offering Resident R72 a room change. Room Change notification dated January 27, 2024, revealed the reason for the room change room management under comments roommate not doing well. Needed privacy with multiple families. Discussed with resident and she agreed. However, based on the resident's statement and nursing aid the room change was not changed to accommodate Resident's R72 wheelchair bathroom accommodation. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 7 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain the confidentiality of residents' medical information and phone communication on two of six nursing units (A unit). Residents Affected - Few Findings include: During a screaming observation on January 29, 2024, at 1:25 p.m. the medication cart used by Licensed Nurse, Employee E5 outside of room A15 on the A unit was left unattended with the computer screen open with identifiable information so any passerby could see resident personal and confidential information. On January 29, 2024, at 1:28 p.m. Employee E12, Assisting Director of Nursing was asked to do an observation in room A15 with Resident R295 and came across the medication cart, recognized the unattended cart and lowered the top screen of the computer. It was confirmed by ADON that licensed nurse, Employee E5 was not near on the A wing unit & hallway, but in some resident's room administering medication. Employee E12 ADON confirmed the observation of medication cart being unattended. 28 Pa. code: 211.5(b) Clinical records. 28 Pa. Code: 201.29(i) Resident Rights 28 Pa. Code: 211.12(d)(3) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 8 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and interviews with residents and staff, it was determined that the facility failed to ensure that one resident remained free from abuse of 20 residents reviewed. (Resident R3) Findings include: Review of facility policy, Pennsylvania Resident Abuse revised August 30, 2023, revealed that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Further review revealed that it is the facility policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. Further review of facility policy revealed that facility staff must immediately report all such allegations to the administration . Review of Resident R3's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated December 22, 2023, revealed that the resident was admitted to the facility on [DATE], and had a BIMS score of 15, indicating cognitive intactness. Interview with Resident R3 was conducted on January 30, 2024, at 10:54 a.m. revealed that the nurses call the resident a racist. Resident R3 stated to the surveyor that he voiced an allegation of verbal abuse to the Physician, Employee E14, on January 18, 2024, during noon; and to the Assistant Director of Nursing (ADON), Employee E12, on January 18, 2024, in the evening. An interview was conducted with the Physician, Employee E14, on January 31, 2024, at 2:57 p.m. Employee E14 stated that on January 18, 2024, at approximately 12:00 p.m. Resident R3 was telling me he was being accused of being racist by nursing staff and that the nurses were making other inappropriate racial accusations towards the resident. Employee E14 further stated, I didn't report it . I ignored it . I blew it off and confirmed that he failed to recognize and report verbal abuse. The above-mentioned findings and abuse training for the physician, Employee E14, was requested during an interview with the facility administration, which was conducted on January 31, 2024, at approximately 3:30 p.m. On February 1, 2024, at 11:20 a.m. the facility provided three copies of Child abuse Identification and Reporting certificate for Employee E14. During an interview with the facility administrator, Employee E1, on February 1, 2024, at 12:14 a.m. the administrator confirmed that the Physician, Employee E14, signed the abuse policy training that morning. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(c) Management (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 9 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0600 28 Pa Code 201.29(c) Resident rights 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: 395259 If continuation sheet Page 10 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and interview with staff, it was determined that the facility did not ensure that resident assessments accurately reflected resident status related to discharge for one of four closed records reviewed (Resident R302). Residents Affected - Few Findings include: Review of the discharge MDS assessment (Minimum Data Set, a periodic assessment of resident care needs) for the resident dated December 20, 2023, revealed that in section A, Identification Information, it was documented that the resident was discharged to an Planned. Interview with the MDS Coordinator, Employee E10, on February 1, 2024, at 12:16 p.m. confirmed that Resident R302's discharge should have been coded as Unplanned as the resident only been at the facility for two days and did not complete the rehabilitation. The discharge status had been coded in error. February 2, 2024, at 12:40 p.m. it was confirmed by the Administrator, Employee E1 that Resident R302's MDS was coded in error. 28 Pa. Code 211.5(f) Clinical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 11 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on review of Pennsylvania's Nursing Practice Act, facility policies, interviews and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that treatments and medication were performed in accordance with professional practices for one of one residents reviewed (Resident 295). Residents Affected - Few Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals. On January 30, 2024, 1:10 p.m. an interview was held with Resident R295 who reported that I have pain during my care, there's not enough powder for my soreness in my butt anal area. Resident R295 reference a Nystatin medication powder that was on her tray and said it's almost out and I need this for nursing assistance when they do my care to provide. Resident R295 confirm that nursing assistance when provide incontinence administer prescribed Nystatin medication powder. On January 29, 2024, at 1:28 p.m. Employee E12 Assisting Director of Nursing was asked to come make observation of Nystatin powder to be on the Resident R295's tray and based on the physician order dated January 24, 2024, for apply to under b/l breasts topically every shift for fungal rash for 14 days not for anal area. Employee E12 confirmed the observation and took away the powder. On January 29, 2024, at 2:14 p.m. an interview was held with License nurse, Employee E6 who confirmed that Resident R295 has a anal rash she does allow nursing aides, (CNAs) to administer Nystatin medication powder when they are providing incontinence as it's a burden to go in and out of the medication storage where the medication is accessible. Employee E6 confirmed that she delegated the administration of the medication to the nursing aide. Resident 295's clinical record revealed admission to the facility on January 21, 2024, with muscle weakness, gastro-esophageal reflux disease without episodes (chronic condition characterized by the backward flow of stomach acid and occasionally bile into the esophagus, leading to irritation, inflammation, and various symptoms), hypothyroidism (medical condition characterized by an underactive thyroid gland, which fails to produce sufficient thyroid hormones to meet the body's needs) abdominal distension (increase in the girth or size of the abdomen, often resulting from the accumulation of gas, fluid, or solid masses within the abdominal cavity). Review of nursing notes upon admission dated on January 21, 2024, mentioned dry scaly skin with BLLE (bilateral left leg) redness. ABD (abdominal) folds, under b/l (bilateral) breast redness ad B/L buttocks redness. Review of Resident R295's physician order revealed an order dated January 24, 2024, for Nystatin powder to apply to under b/l breasts topically every shift for fungal rash for 14 days not for anal area. Continued review of physician orders revealed Nystatin-Triamcinolone external cream 100000-o.1 Unit/GM-% was prescribed on January 22, 2024 to apply to b/l buttock, abdomen fold topically two times a day for irritation redness itching for 10 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 12 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0658 28 Pa. Code 211.10(c) Resident care policies Level of Harm - Minimal harm or potential for actual harm 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: 395259 If continuation sheet Page 13 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, review of facility documents and interview with staff, it was determined that the facility failed to ensure that a physician's orders was followed related a psychotropic medication one of four closed records reviewed. (Resident R302) Residents Affected - Few Findings include: Review of the closed record revealed that Resident 302 was admitted to the facility on [DATE], and discharged on December 20, 2023, with a bipolar disorder current episode manic severe with psychotic features (a mental health condition characterized by episodes of mania (or hypomania) and depression. When someone experiences a manic episode with psychotic features, it means they are in a state of elevated mood, energy, and sometimes psychosis). Review of hospital records indicated that Resident R302 was prescribed Quetiapine 25 milligrams (mg) tablet commonly known as Seroquel take 1.5 tablets, 37.5 mg total by mouth 3 times a day. Last time given December 18, 2023, to treat agitation. Review of the clinical record at the facility did not indicate that this medication was ordered by the facility physician, nor a continuation of care was followed for resident admitted from hospital, related to psychotropic medication. Review of Nurse practitioner, Employee E21's progress notes dated December 19, 2023 revealed bipolar d/o (disorder). There was no other note related to continuation or discontinue for psychotropic medicationQuetiapine. On February 2, 2024, at 11:42 p.m. an interview was conducted with the Director of Nursing, Employee E2, who reported that facility's protocol is to get Resident R302's psychiatry consultation before prescribing psychotropic medication. Further review of clinical record indicated Resident R302 had a psychiatry consultation on December 20, 2024 which resulted with the following recommendations Bipolar disorder current episode manic severe with psychotic features Recommendations and Plan:-Continue Melatonin 10 mg HS ( at night)-Continue Namenda 5 mg BID (twice a day)-Continue supportive care, anticipate needs-Bipolar disorder stable, monitor behavior, will f/u (follow up) as needed. Chart review/Staff discussion: There was no documentation to continue or discontinue Quetiapine. On February 2, 2024, at 12:05 p.m. a telephone interview was held with physician, Employee E22 who confirmed that the protocol when the residents gets admitted to the hospital shall continue all of the hospital medications until the facility physician evaluates the resident and makes the necessary changes. The facility should have provided the prescribed of Quetiapine 25 mg tablet commonly known as Seroquel take 1.5 tablets (37.5 mg total by mouth 3 times a day to the Resident R302. Employee E22 confirmed the above medication should have been provided. 28 Pa. Code 201.29 (d) Resident's rights 28 Pa. Code 211.12 (c) Nursing services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 14 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 28 Pa. Code 211.12(d)(3) Nursing services 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: 395259 If continuation sheet Page 15 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical record, observations, and interviews with staff and residents, it was determined that the facility failed to administer a resident's tube flushes per physician orders for one of one resident reviewed receiving enteral nutrition. (Resident R79). Findings include: Review of facility policy titled, Enteral Feeding Tube Policy dated, December 22, 2023, revealed that tube flushes must be performed according to physician direction or, n the absence of an order . Further review revealed that the enteral tube sites will be monitored daily and observed for drainage quantity, odor, and appearance. Review of Resident R79's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including malnutrition (occurs when the body doesn't get enough nutrients) and had a feeding tube (PEG- abdominal). Review of nutrition progress notes for Resident R79 revealed a note dated, December 20, 2023, which stated that the resident not receiving tube feeding or IV. Further review revealed that the resident received water flushes to maintain PEG tube patency. A review of physician orders revealed an enteral order dated, January 18, 2024, flush peg tube with 120 mL of water every 12 hours; every shift to maintain patency. Observations of Resident 79's peg tube on February 2, 2024, at 11:43 a.m. revealed that the feeding tube was cluttered with dried dark brown contents on the inside of the tube. The feeding tube was observed a darkened brown color and no longer clear. The tube had dark brown debris on the outside of the tube and on the tube clip. Interview with Resident R79 on February 1, 2024, at 11:43 a.m. revealed that the tube had been clogged with dried, dark brown clumps for weeks. Resident R79 stated that when a nurse aide came to flush the tube only one time, last week, and that the resident told the nurse aide that she wanted the tube cleaned before a water flush because it is dirty, and the gunk will go inside me. Interview with the Licensed Practical Nurse, Employee E11, during the time of the observation, on February 1, 2023, at 11:43 a.m., confirmed that the resident's tube was clogged with what appeared to be dried up, dark brown, feeding formula and that the tube has not been flushed for weeks. Employee E11 confirmed that the outside of the feeding tube and clip contained brown colored debris and acknowledged the unsanitary tube feeding conditions and infection control concerns. Further interview confirmed that tube feeding flushes were not provided for Resident R79 according to physician orders and that the administration documentation was not accurate. Interview with the Nurse Supervisor, Employee E5, on February 1, 2024, at 12:01 p.m., confirmed that Resident R79's tube feeding was clogged with dark brown clumps on the inside of the tube and dark brown debris on the outside of the feeding tube, and acknowledged that the dark brown clumps appeared to be dried up formula. Further interview revealed that the formula must've dried out over several weeks as it appeared dark brown in color. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 16 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0693 Further review of Resident R79's clinical record failed to reveal documentation of Resident R79 refusing water flushes. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.10 (a) Resident care policies Residents Affected - Few 28 Pa. Code 211.12 (c) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 17 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and interviews with staff, it was determined that the facility failed to provide mental health services to a resident with a mental disorder for one of 20 residents reviewed (Resident R302). Review of the closed record revealed that Resident 302 was admitted to the facility on [DATE], and discharged on December 20, 2023, with a bipolar disorder current episode manic severe with psychotic features (is a mental health condition characterized by episodes of mania (or hypomania) and depression. When someone experiences a manic episode with psychotic features, it means they are in a state of elevated mood, energy, and sometimes psychosis). Hospital record indicated Resident R302 had a prescription of Quetiapine 25 mg tablet commonly known as Seroquel take 1.5 tablets (37.5 mg total by nouth 3 times a day. Last time given December 18, 2023, to treat agitation. Review of the clinical record at the facility did not indicate that this medication was ordered by the facility physician, nor a continuation of care was followed for resident admitted from hospital, related to psychotropic medication. Further review of clinical file indicated a nurse practitioner, Employee E21 evaluated Resident R302 on December 19, 2023 and bipolar d/o was mentioned with no assessment or mentioned about mental health bipolar treatment or to continue or discontinue the need for psychotropic medication. On February 2, 2024, at 11:42 p.m. an interview was conducted with the director of nursing, Employee E2 who reported that facility physician did ordered and the protocol is to get Resident R302 psychiatry consultation before prescribing psychotropic medication. Further review of clinical file indicated Resident R302 had a psychiatry consultation on December 20, 2024 which resulted with the following recommendations Bipolar disorder current episode manic severe with psychotic features Recommendations and Plan:-Continue Melatonin 10 mg HS-Continue Namenda 5 mg BID-Continue supportive care, anticipate needs-Bipolar disorder stable, monitor behavior, will f/u as needed Chart review/Staff discussion: There was no documentation to continue or discontinue Seroquel. On February 2, 2024, at 12:05 p.m. a telephone interview was held with physician, Employee E22 who confirmed that the protocol when the residents gets admitted to the hospital shall continue all of the hospital medications until the facility physician evaluates the resident and makes the necessary changes. The facility should have provided the prescribed of Quetiapine 25 mg tablet commonly known as Seroquel take 1.5 tablets (37.5 mg total by mouth 3 times a day to the Resident R302. Employee E22 confirmed the above medication should have been provided. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa Code 211.12(d)(1) Nursing services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 18 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0742 28 Pa Code 211.12(d)(5) Nursing services 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: 395259 If continuation sheet Page 19 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, clinical record review and resident and staff interview, it was determined that the the faciltiy failed to provide a diet in accordance with resident's preference for one of 20 residents reviewed. (Resident R43) Finding include: Review of physician's order for Resident R43 revealed an order for LCS (limited concentrated sweets) Double Protein diet, Regular texture, thin consistency with an order date of February 4, 2023. Review of Resident R43's lunch meal ticket dated January 29, 2024, revealed that diet order was Regular double protein, low concentrated sweets, thin liquids. Further, meal ticket indicated a note stating: 2X Protein, no beets regular milk. Interview with Resident R43 conducted on January 29, 2024, 12:03 p.m. revealed that she doesn't get the right amount of food. Further Resident R43 revealed that she was supposed to get double protein but only gets one portion. Observation of Resident R43's meal tray conducted at the time of the interview revealed that there was one bun with a grayish brown patty in the bun with fries on the side. Further, there was a small bowl of lettuce, a small carton of low-fat milk, 118ml cup of apple juice and two cups of coffee. Interview with Food Service Director, Employee E9 conducted on January 29, 2024, at 12:14 a.m. confirmed that Resident R43 only had one bun with meat. Further, Employee E9 also confirmed that the one bun with meat is equivalent to one serving of protein Interview with facility dietician Employee E20 conducted on January 29, 2024, at 12:27 pm confirmed that resident was on double protein. Further dietician revealed that Resident R43 needs the double protein and that as long as its ordered, it has to be provided to her and that she should have been provided with double protein. 28 Pa. Code 211.10(c) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 20 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Residents Affected - Many Finding include: An initial tour of the Food Service Department was conducted on January 29, 2024, at 9:55 a.m. with Employee E9, Food Service Director, which revealed the following: Observations in the receiving area revealed piles of cardboard and leaves at the receiving enterance door which allowed pest harborage (conditions or place where pests can obtain water or food, nest, or obtain shelter). Further observation in the receiving area revealed significant amount of cigarette buds (50-100 count), at the door. Interview with the Food Service Director conducted on January 29, 2024, at approximately 10:26 a.m. confirmed the above mentioned findings. Further interview revealed that the food receiving area was also a smoking area for staff and acknowledged that the cigarette buds should have been cleaned up to maintain sanitary conditions in the food receiving area. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.14(a) Responsibility of Licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 21 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. 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 and review of clinical record and staff and resident interviews, it was determined that the facility failed to ensure a resident and resident's representative had the capacity to understand the terms of a binding arbitration agreement for 4 of 5 residents reviewed (Residents R72, R86, R29, R59). Residents Affected - Few Findings include: On October 30, 2024, at 1:22 p.m. an interview was held with Resident R86 who reported when asked if arbitration agreement was explained. R86 responded not really explained I remember signing but I didn't understand it, no on explained to me about 30 days or what arbitration process was. Review of the resident's Minimum Data Set (assessment of resident care needs), indicated that a Brief Interview for Mental Status (BIMS) dated December 7, 2023, revealed Resident R86 had a BIMS score indicated 15 - cognitively intact. Review of Resident R86's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated she signed the document on admission on [DATE]. On October 30, 2024, at 1:39 p.m. an interview was held with Resident R72 reported not really explained not that I remember explained to me when asked if arbitration agreement was explained. Review of the resident's MDS, indicated that a Brief Interview for Mental Status (BIMS) dated January 4, 2024, indicated Resident R70 had a BIMS score indicated 15 - cognitively intact. Review of Resident R72's Binding Arbitration Agreement indicated that the document was signed on admission on [DATE]. On January 31, 2024, at 11:00 a.m. a Resident Council Meeting was held with seven alert and oriented Residents (R31, R59, R29, R69, R3, R78, R42). During the question about if arbitration agreement has been explained to resident during admission Resident R29 reported I never signed anything like that referencing arbitration agreement. Resident R59 reported I did not know what I was signing. Review of Resident R29's MDS, indicated that a Brief Interview for Mental Status (BIMS) dated November 19, 2023, indicated Resident R29 had a BIMS score indicated 15 - cognitively intact. Review of Resident R59's MDS, indicated that a Brief Interview for Mental Status (BIMS) dated December 15, 2023 indicated Resident R59 had a BIMS score indicated 15 - cognitively intact. Review of Resident R29's Binding Arbitration Agreement indicated she signed the document on admission on [DATE]. Review of Resident R59's Binding Arbitration Agreement indicated she signed the document on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 22 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0847 admission on [DATE]. Level of Harm - Minimal harm or potential for actual harm On January 31, 2024, at 11:50 a.m. an interview with admission Director, Employee E4 who educates residents upon Arbitration process reported that when residents come in, I take the iPad and go over everything following the verbiage by reading the arbitration agreement paragraph by paragraph to residents. When asked if Employee E4 explains arbitration agreement in a form and manner including a language that the resident or his/her representative understands, the response of Employee E4 was I do not tell them in my own language I read the paper agreement to them. When asked what is arbitration? Employee E4 responded sue any damages and will use mediator vs going into the court. When asked if anything else is mentioned to see if Employee E4 covers the right of not requiring biding arbitration as a condition of admission or right to revote the contract within the 30 days? Employee E4 responded from the top of my hand I can't recall. Residents Affected - Few 28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 23 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 observations, review facility policy and review of facility documents and interview with staff, it was determined that the facility did not maintain an effective infection prevention program related to hand hygiene during wound care observation and medication administration for five of eight residents observed. (Residents R295, R4, R84, R48, R65 and R8) Residents Affected - Few Findings: Review of facility policy on hand hygiene with most recent revision date of May 3, 2023, under section Policy: Hand washing is the most important component for preventing the spread of infection. Use of gloves does not replace the need for hand cleaning by either hand rubbing or hand washing. Under section procedure. #1. Proper hand washing technique is to be accomplished when visibly dirty or contaminated with proteinaceous material, or visibly soiled with blood or other body fluids, or if exposure to potential spore forming organisms is strongly suspected or proven. And after using the restroom. #2. Referable to use an alcohol-based rub for routine hand antisepsis in all other clinical situations described in item 3A to 3F listed below. If hands are not visibly soiled. Alternatively wash hands with soap and water. #3. Perform hand hygiene: a. Before and after having contact with residents. b. After removing gloves. C. before handling an invasive device regardless of whether or not gloves are used for resident care. D. after contact with body fluids or secretions, mucous membranes, non-intact skin and/or would dressings. e. If moving from a contaminated body site to a clean body site during resident care. f. After contact with inanimate object including medical equipment in the immediate vicinity of the resident. Review of Resident R 295's clinical record revealed that Resident R295 was admitted to the facility on [DATE], with diagnoses of Muscle Weakness, Type 2 Diabetes Mellitus, Morbid Obesity, Cellulitis of the right and left lower limb, Chronic Venous Hypertension with Ulcer to Both Lower Extremity. Review of Resident R295's physician orders revealed an order for Nystatin-Triamcinolone External Cream 100000-0.1 UNIT/GM-% (Nystatin-Triamcinolone) Apply to b/l buttock, abdomen fold topically two times a day for irritation redness itching for 10 Days-Start Date-January 23, 2024. Observation of Resident R295's environment prior to the start of the wound care conducted February 1, 2024, at 10:45 am revealed an overhead table with water cups, a computer tablet and other items on top of the overhead table. Wound care observation for Resident R295 conducted on February 1, 2024, at 10:58 a.m. with Licensed nurse, Employee E17 and Unit Manager, Employee E5 revealed that Employee E17 was wearing the same gloves she used to prepare the dressing supplies. Further, while preparing and setting-up the wound care supplies for Resident R295, Employee E17 placed the dressing supplies on the overhead table without disinfecting the table or without using a clean drape and a barrier between the table and the dressing supplies. Further, cups, computer tablet and other items were on top of the overhead table wound care supplies. Further observation revealed that Licensed nurse, Employee E17 proceeded to pick up the Nystatin-triamcinolone cream using her left hand and while holding the tube of Nystatin- triamcinolone cream (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 24 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with her left hand, Employee E17 touched the opening of Nystatin-triamcinolone cream opening and scooped up cream and applied it to Resident R295's buttocks. Further, observation revealed that after applying the Nystatin-triamcinolone cream to Resident R295's buttocks, Employee E17 did not wash her hands. Further, Employee E17 proceeded to touch the opening of the cream tube and scooped up more cream with the same unwashed finger without sanitizing her hands or changing her gloves and applied more cream on Resident R295's buttocks. Observation of wound treatment to Resident R295's abdomen revealed that Employee E17 touched the opening of Nystatin-triamcinolone cream opening and scooped up cream and applied it to Resident R295's abdomen. Further, observation revealed that after applying the Nystatin-triamcinolone cream to Resident R295's abdominal fold, Employee E17 did not wash her hands. Further, Employee E17 proceeded to touch the opening of the cream tube and scooped up more cream with the same unwashed finger without sanitizing her hands or changing her gloves and applied more cream on Resident R295's abdominal fold. Interview with nurse Licensed nurse, Employee E17 and Employee E5 conducted at the time of the observation confirmed that Employee E17, did not disinfect the overhead table or put a clean drape over it prior to setting up the wound care supplies on the table. Further Employee E17 and Employee E5 also confirmed that water cups, a computer tablet and other items were on the same over head table next to the wound care supplies. Further interview with Licensed nurse, Employee E17 and Unit manager, Employee E5 confirmed that employee touched the opening of Nystatin-triamcinolone cream opening and scooped up cream and applied it to Resident R295's buttocks. Further, Employee E17 and Employee E5 also confirmed that after applying the Nystatin-triamcinolone cream to Resident R295's buttocks, Employee E17 did not wash her hands. Further Employee E17 and Employee E5 also confirmed that Employee E17 proceeded to touch the opening of the cream tube and scooped up more cream with the same unwashed finger/hands without sanitizing her hands or changing her gloves and applied more cream on Resident R295's buttocks. Further, Employee E17 and Employee E5 confirmed that employee touched the opening of Nystatin-triamcinolone cream opening and scooped up cream and applied it to Resident R295's abdomen. Further, Employee E17 and Employee E5 also confirmed that after applying the Nystatin-triamcinolone cream to Resident R295's abdominal fold, Employee E17 did not wash her hands. Further Employee E17 and Employee E5 also confirmed that Employee E17 proceeded to touch the opening of the cream tube and scooped up more cream with the same unwashed finger/hands without sanitizing her hands or changing her gloves and applied more cream on Resident R295's abdominal fold. Medication administration observation conducted on January 30, 2024, at 8:55 am with Licensed nurse, Employee E18 revealed that after administering medication for Resident R87, Employee E18 proceeded to prepare and administered Resident R4's medication without sanitizing or washing her hands. Further observation revealed that Licensed nurse, Employee E18 proceeded to prepare and administered Resident R48's medication without sanitizing or washing her hands. Further observation revealed that Licensed nurse, Employee E18 went back to Resident R4 to administer another medication which Employee E18 forgot to give previously. Further, Employee E18 proceeded to prepare and administer Resident R4's medication without sanitizing or washing her hands. Further observation revealed that Employee E18 proceeded to prepare and administer Resident R82 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 25 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 without sanitizing or washing her hands. Level of Harm - Minimal harm or potential for actual harm Further observation revealed that Licensed nurse, Employee E18 proceeded to prepare and administer Resident R65's medication without sanitizing or washing her hands. Residents Affected - Few Interview with Licensed nurse, Employee E18 confirmed that she did not wash her hands between residents during medication administration. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 26 of 27 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 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on the review of facility records, observations and interviews with resident and staff, it was determined that the facility failed to ensure a sanitary environment on one three of three nursing units observed. (C unit) Finding Include: On January 29, 2024, at approximately 10:07 a.m. a significant urinal odor was detected on the C unit near room C43. On February 1, 2024, at 9:23 a.m. an observation was taken place with Housekeeping Director, Employee E15 who reported room B27 has a significant unsanitary odor. The root cause Employee E15 reported that Resident R39 and Resident R37 refuse care. Both residents agreed to take showers as it was their shower days and investigate where the significant odor was coming and prevent future reoccurrences. On February 1, 2024, at 10:03 a.m. an observation with the housekeeping Director, Employee E15 confirmed a strong urine smell in room C43 and stated, we'll get someone in here immediately. There were four male residents resigning in the room. On February 1, 2024, at 11:20 a.m. the Director of Nursing, Employee E2 revealed that Resident R39 and Resident R37 have care plans and progress notes documenting refusals of care from October 29, 2023, for Resident R37 and for Resident R39 from July 5, 2022. On February 1, 2024, at 11:25 a.m. an observation was taken place with Housekeeping Director, Employee E15 who reported that they Resident R39's mattress was disposed to outdoor as it was contaminated and saturated with significant and unsanitary urinal odor. The smell of urine significant improved with in the last two hours from the original smell. During the observations it was requested multiple times to provide to the survey team the deep schedule validation documentation from the housekeeping Director, Employee E15 for room B27 and C43 and it was not provided. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 27 of 27