Inspection·September 5, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and staff interview, it was determined that the facility failed to maintain a safe and home-like environment for one of three nursing units observed. (C wing)Findings Include: On September 2, 2025, at 12:02 p.m., observation conducted on C wing of the bathroom of Resident R80's room, revealed that the covering of the heater/cooler- outlet- was not properly fixated to the heater/cooler- outlet and the rusted metal pieces were exposed around the base of the wall. The same observation was noted on September 3, 2025, at 10:01 a.m., on September 4, 2025, at 10:31 a.m., and on September 5, 2025, at 9:31 a.m.On September 2, 2025, at 12:22 p.m., observation made of the hallway in front of Resident R8's room revealed that the covering of the heater/cooler- outlet- was not properly fixated to the heater/cooleroutlet and the rusted metal pieces were exposed around the base of the wall. The same observation was noted on September 3, 2025, at 10:11 a.m.Interview and observations made with the Assistant Director of Nursing on September 5, 2025, at 9:47 a.m., confirmed the above findings.28 Pa. Code 207.2 (a) Administration responsibility Event ID: Facility ID: 395259 If continuation sheet Page 2 of 7 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 09/05/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility policy and interviews with staff, it was determined that the facility did not ensure a care plan was developed for one of twenty-two residents reviewed. (Resident R57)Findings Include: Review of facility policy titled, Comprehensive Care Planning Policy with a revision date of March 20, 2025 states, Policy- An interdisciplinary plan of care will be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. Further review of the policy revealed, Procedure- the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. These plans will be focused on resident choices and abilities with the intent of maintaining and improving resident functional abilities and quality of life. Interview held with Resident R57 on September 3, 2025 at 12:41 p.m. During the resident interview the resident talked about feeling frustrated and down about not being able to get help from staff for his incontinence care. Review of Resident R57's clinical record revealed the resident was admitted to the facility on [DATE] with a diagnosis on Major Depressive Disorder from July 31, 2020. Further review of the resident's clinical record revealed the resident has a Brief Interview for Mental Status (BIMS) assessment completed on May 27, 2025 with a score of 14 indicating the resident is cognitively intact. Interview with licensed nursed Employee E6 on September 3, 2025 at 1:04 p.m. revealed the resident is incontinent. An interview with the Assistant Director of Nursing, Employee E3 on September 5, 2025 at 12:23 p.m. revealed the resident did have depression. Employee E3 confirmed the above findings, that Resident R57's care plan did not include a focus area for the diagnosis of depression. 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Event ID: Facility ID: 395259 If continuation sheet Page 3 of 7 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 09/05/2025 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 review of clinical records, facility policy, and staff and resident interviews, it was determined that the facility failed to ensure residents received quality care related to incontinence care for and medication administration for three of twenty-one residents reviewed (R5, R57, R114) Residents Affected - Some Findings include: Review of facility policy “Medication Administration/ Disposition”, revised September 2023, revealed medications should be administered in a safe and timely manner, and as prescribed. Facility staff involved in the administration of resident care will be knowledgeable of the policies and procedures regarding pharmacy services including medication administration. Medications, both prescription and non-prescription, shall be administered under the orders of the attending physician or the physician's designee. Clinical record review revealed Resident R5 was admitted to the facility on [DATE] with a diagnosis that included Rhabdomyolysis (muscles break down and release toxins into blood and kidneys), hypertension (high blood pressure), and congestive heart failure (condition that happens when your heart can't pump blood well enough to meet the body's needs). Interview with Resident R5 on September 3, 2025 at 9:40 a.m. revealed he/she has been receiving his/her evening medication late. Review of Resident R5 medication administration record (MAR) from August 20, 2025 – August 26, 2025 revealed the following medications being administered late: - Atorvastatin to be given at 9:00 p.m. for hyperlipidemia o 8/22/25 documented on 8/23/25 at 12:20 a.m. - Carvedilol 3.125 mg to be given at 9:00 p.m. for hypertension o 8/21/25 documented at 12:20 a.m. - Cyclobenzaprine 5 mg to be given three times day for muscle spasm o 8/21/25 scheduled for 9:00 p.m. and documented at 12:20 a.m. - Eliquis 5 mg every 12 hours a -fib o 8/21/25 scheduled for 9:00 p.m. and documented on 8/23/25 at 12:20 a.m. The reasoning for the late medication administration was documented as “charted late”. Clinical record review revealed Resident R114 was admitted to the facility on [DATE] with a diagnosis that included hypertension, neuropathy (nerve damage that affects hands and feet), and muscle spasms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 4 of 7 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 09/05/2025 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 Level of Harm - Minimal harm or potential for actual harm Interview on September 3, 2025 at 9:55 a.m. revealed he/she has been receiving his/her evening medication late, which has resulted in poor sleep. Review of Resident R114 medication administration record (MAR) from August 20, 2025 – August 26, 2025 revealed the following medications being administered late: Residents Affected - Some - Atorvastatin 10 mg to be given at 9:00 p.m. for hyperlipidemia o 8/29/25 documented on 8/30/25 at 12:47 a.m. o 8/21/25 documented at 10:49 p.m. - Cardizem 240 mg to be given at 9:00 a.m. for hypertension o 8/27/25 documented at 10:21 a.m. o 8/30/25 documented at 11:21 a.m. - Gabapentin 600 mg three times a day for nerve pain o 8/29/25 scheduled for 9:00 a.m. given at 10:21a.m. o 8/29/25 scheduled for 1:00 p.m. given at 3:01p.m. - Glipizide 5 mg to be given at 8:00 a.m. for Diabetes Mellitus o 8/27/25 documented at 10:21 a.m. o 8/28/25 documented at 9:44 a.m. o 8/20/25 documented at 11:21 a.m. o 9/1 documented at 9:22 - Paroxetine 10 mg to be given at 9:00 p.m. for depression o 8/29/25 documented at 8/30/25 at 12:47 p.m. o 8/31/25 documented at 10:29 p.m. - Ropinirole 1 mg to be given at 9:00 p.m. for restless leg o 8/29/25 documented at 8/30/25 at 12:47 a.m. o 8/30/25 documented at 10:49 p.m. The reasoning for the late medication administration was documented as “charted late”. Resident Council meeting was held on September 4, 2025 at 10:30 a.m. with 10 residents in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 5 of 7 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 09/05/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some attendance. Three residents (R72, R100, R92) reported receiving their evening medications late/or missed doses of medications. Interview with Employee E2, Director of Nursing, on September 4, 2025 at 10:16 a.m. confirmed Resident R5 and Resident R114 MAR's were not documented in a timely manner and medications are allowed to be administered an hour before and an hour after the scheduled medication time. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 6 of 7 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 09/05/2025 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, it was determined that the facility failed to accurately display facility daily nurse staff hours as required.Findings Include:On September 5, 2025 at 10:34 a.m. observations at the front lobby area revealed staffing was posted is a spot behind the front desk receptionist on the wall in a clear sleeve. Observation of the posting revealed the posting would be difficult to access for people with mobility issues due to the height of the posting and the position behind the receptionist desk. Employee E7 the front desk receptionist, was asked if this was the only placed that the staffing was posted and Employee E7 replied, I believe so. The form in the clear sleeve on the wall was from September 4, 2025 and the form was left blank without any of the staffing information filled in. The only portion of the form that filled it was the date, written in pencil. Further observation of three wings (A, B, C) revealed there was no other staffing posted throughout the building. On September 5, 2025 at t 10:37 a.m. an interview was held with the Assistant Director of Nursing Employee E3 came into the lobby and confirmed that staffing for each shift and each day should be posted. Employee E3 stated that the overnight shift supervisor would have been responsible for posting the staffing prior to the first shirt on September 5, 2025. 28 Pa. Code 211.12 (d)(1)(3)(4) Nursing Services Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395259 If continuation sheet Page 7 of 7