Health inspection·July 1, 2025

F 0584 A step stool splattered with brownish tan substance Level of Harm - Minimal harm or potential for actual harm · The floor with tan debris, paper wrappers and coffee stirrers. Residents Affected - Few · The windowsill had leaf debris under a plant. During an interview completed on 7/1/25, at 9:17 a.m. the receptionist Employee E2 confirmed the above observations and stated, I don ' t think housekeeping has been here they start at 8:00 a.m. During an interview completed on 7/1/25, at 9:22 a.m. the Nursing Home Administrator confirmed the above observations and that the facility failed to maintain a clean, safe, and homelike environment for one of one coffee areas (first-floor lobby). 28 Pa. code: 201.14 (b) Responsibility of licensee. 28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c) Resident Rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395300 If continuation sheet Page 2 of 4 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 395300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Perry Health & Rehab Center 9850 Old Perry Highway Wexford, PA 15090 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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, clinical records, resident interviews and staff interview it was determined that the facility failed to provide assistance with Activity of Daily Living (ADL) involving consistent shower or baths for two out of seven residents (Closed Record (CR) Resident R1 and Resident R3). Residents Affected - Few Findings include: The facility Routine Resident Care last reviewed 3/14/25, indicated it is the policy of this facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social and spiritual needs and honor resident lifestyle preferences while in the care of this facility. Providing routine daily care by a nursing assistant with specialized training including but not limited to maintaining a program for skin care. Routine care includes bathing, dressing, eating and toileting. Review of the clinical record indicated CR Resident R1 was admitted to the facility on [DATE]. Review of CR Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/25, indicated the diagnosis of anemia (low iron in the blood), gastroesophageal reflux disease (stomach contents flow back up the esophagus) and anxiety. Review of the facility shower schedule indicated that CR Resident R1 would receive showers on Tuesdays and Fridays on the daylight shift. Review of CR Resident R1's documentation survey report for June of 2025, indicated that resident's shower days are scheduled on Tuesday and Fridays on the daylight shift. Further review failed to include documentation to indicate CR Resident R1 received or refused a shower or bed bath on 6/6/25. During an interview completed on 7/1/25, at 1:40 p.m. the Director of nursing confirmed that CR Resident R1 did not receive a shower or bed bath on 6/6/25. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS assessment dated [DATE], indicated he had diagnoses that included quadriplegia (paralysis of all four limbs), neuromuscular dysfunction of the bladder (muscle and nerve concerns impacting bladder control), and anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry). Review of Resident R3's care plan dated 9/27/24, indicated that he is dependent for bathing and helper does all of the effort. Review of Resident R3's physician orders dated 2/21/25, indicated that it was ok for Resident R3 to shower. Review of Resident R3's shower documentation report and the Treatment Administration Record (TAR) for June 2025, failed to include documentation to indicate that Resident R3 received or refused a shower/bed bath on the following dates: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395300 If continuation sheet Page 3 of 4 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 395300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Perry Health & Rehab Center 9850 Old Perry Highway Wexford, PA 15090 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 0677 6/5/25 Level of Harm - Minimal harm or potential for actual harm 6/9/25 6/23/25 Residents Affected - Few During an interview on 7/1/25, at 9:15 a.m. Resident R3 stated the following: They have only one nurse aide to help shower me or to get me out on Sunday. Longest have gone without a shower was six weeks. One nurse aide is supposed to have 10-12 residents and there are a lot more residents than that on this hallway. They have a real problem with being understaffed. During an interview completed on 7/1/25, at 12:20 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide assistance with Activity of Daily Living (ADL) involving consistent shower or baths for Resident R3 as required. 28 Pa. Code: 211.12(1) Nursing services. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (2)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395300 If continuation sheet Page 4 of 4