Health inspection·June 30, 2023

F 0623 28 Pa. Code 201.29(a) Resident rights Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William Penn Nursing and Rehab 163 Summit Drive Lewistown, PA 17044 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on clinical record review and staff interview, it was determined that the facility failed to provide an accurate written notice of the facility's bed-hold policy to the resident and the resident's responsible party for one of three residents reviewed for hospitalization concerns (Resident 8). Findings include: Clinical record review for Resident 8 revealed nursing documentation dated May 15, 2023, at 6:15 AM that staff transferred Resident 8 to the emergency room for testing due to a change in condition. Nursing documentation dated May 15, 2023, at 7:41 PM revealed that Resident 8 was admitted to the hospital due to a right frontal lobe infarct (CVA, stroke, brain injury due to a bleed or blood clot). Review of Resident 8's payment sources while at the facility revealed that the facility admitted her on May 10, 2023, following a motor vehicle accident; and that the payment source for her stay was an automobile insurance plan. The Census Payment Sources documentation indicated that the facility stopped billing on May 15, 2023, and resumed billing to the automobile insurance plan on May 18, 2023 (Resident 8's readmission date to the facility). Review of a Bed-Hold Notification form for Resident 8 revealed that the purpose of the notification was to inform residents and/or their representatives of rights regarding the resident's stay in the facility when the resident must be hospitalized . The form noted that each payer/insurance such as Medicare, Medical Assistance (Medicaid), Security Blue, VA (Veterans Administration), or private pay had established policies regarding bed-holds specifying the number of bed-hold days allowed and the cost to hold the bed during that time. The form stipulated that, Information on each of these payers and their bed-hold policy information is listed .The option below that is specific to you and your payment source at this time has been checked. The form included a checkmark for Pennsylvania Medical Assistance (Medicaid) that indicated that Resident 8's bed would be held for 15 consecutive days at no cost to her while hospitalized because of Pennsylvania Medical Assistance allowances. The form indicated that Resident 8 signed and dated this form on May 15, 2023. Interview with Employee 4 (business office manager) on June 29, 2023, at 4:05 PM confirmed that Pennsylvania Medicaid was not Resident 8's payer source on May 15, 2023, and that the facility did not consider Resident 8 on a bed-hold status when she was transferred to the emergency room on May 15, 2023. The interview confirmed that the facility's billing discharged Resident 8 on May 15, 2023, and re-admitted her following her hospitalization. An interview with the Nursing Home Administrator on June 30, 2023, at 10:45 AM confirmed the above findings for Resident 8. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(f) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William Penn Nursing and Rehab 163 Summit Drive Lewistown, PA 17044 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 clinical record review and resident and staff interview, it was determined that the facility failed to assist a dependent resident with bathing assistance consistent with her preferences for one of three residents reviewed for concerns with activities of daily living (Resident 89). Residents Affected - Few Findings include: Interview with Resident 89 on June 27, 2023, at 2:12 PM revealed that staff told her that she could not receive showers because she had an indwelling Foley catheter (flexible tubing inserted through the urethra to the bladder to drain urine). Resident 89 confirmed that she would like a shower as her bathing preference. Clinical record review of a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], revealed that staff assessed Resident 89 as dependent on the physical assistance of one staff for bathing. A significant change MDS assessment dated [DATE], assessed Resident 89 as totally dependent on the physical assistance of two staff for bathing. Bathing records dated February and March 2023 indicated that Resident 89 received showers on February 5, 12, 19, 26, 2023 and March 5, 12, 19, 26, 2023. Bathing records dated April, May, and June 2023, indicated that Resident 89 was provided only assistance with a bed bath. Nursing documentation dated March 20, 2023, at 1:44 PM revealed that staff inserted a Foley catheter because of Resident 89's inability to void her urine effectively. A physician's order discontinued the indwelling Foley catheter on March 24, 2023. Nursing documentation dated March 28, 2023, at 12:11 PM revealed that Resident 89 had decreased urinary output, that staff notified a physician of Resident 89's change in condition, and that new physician orders included the insertion of a Foley catheter. Resident 89's clinical record confirmed the provision of showers before she utilized a Foley catheter and the provision of bed baths when she had a Foley catheter. The surveyor reviewed the above findings for Resident 89 during interviews with the Nursing Home Administrator and the Director of Nursing on June 28, 2023, at 2:00 PM, and June 29, 2023, at 2:00 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William Penn Nursing and Rehab 163 Summit Drive Lewistown, PA 17044 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, clinical record review, and resident and staff interview, it was determined that the facility failed to assess and implement interventions regarding weight loss for two of five residents reviewed (Residents 99 and 8). Residents Affected - Few Findings include: The policy entitled Weight Assessment and Intervention last reviewed March 16, 2023, noted that the interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for residents. The assessment information will be analyzed by the multidisciplinary team and conclusions made regarding: the resident's target weight, approximate nutrient needs such as calorie and protein, and whether and to what extent weight stabilization or improvement can be anticipated. The policy indicated that any weight change of five percent or more since the last weight assessment will be addressed by the Dietitian. There was no guidance in the policy as to what time frame the Dietitian would address a weight loss. The policy also did not provide guidance regarding the expected time frame that facility staff would notify a resident's physician and responsible party of a significant or severe weight change. The policy further indicated that the threshold for significant unplanned and undesired weight loss will be based on the following criteria: One month, five percent weight loss is significant, greater than five percent is severe Three months, 7.5 percent weight loss is significant, greater than 7.5 is severe Six months, 10 percent weight loss is significant, greater than 10 percent is severe Review of Resident 99's clinical record revealed that nursing staff weighed him on December 1, 2022, at 202.6 pounds. Nursing staff weighed him on June 3, 2023, at 181 pounds, which would be a 10.66 percent severe weight loss in six months. There was no documented evidence in Resident 99's clinical record to indicate that the facility identified his severe weight loss, completed a nutritional assessment, made changes to his plan of care for nutrition, or notified the dietitian or his physician. Interview with the Administrator and Employee 6, registered dietitian, on June 30, 2023, at 9:43 AM confirmed the above findings for Resident 99. Observation of Resident 8 on June 27, 2023, at 1:14 PM during the lunch meal, revealed she was in bed with her meal tray on her overbed table in front of her; however, she was not eating. Interview with Resident 8 on the date and time of the observation indicated that her stomach would not allow her to eat. Resident 8 stated, .it's not easy when you don't feel like it, it's not that easy. Clinical record review for Resident 8 revealed the facility admitted her on May 10, 2023, she was hospitalized from [DATE] to 18, 2023, and readmitted to the facility on [DATE]. Nursing documentation dated May 11, 2023, at 2:18 PM revealed that a weight assessment for the first two days after Resident 8's admission was not completed because Resident 8 did not want to get out of bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William Penn Nursing and Rehab 163 Summit Drive Lewistown, PA 17044 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 There was no indication that staff made another attempt to weigh Resident 8 until May 14, 2023. Level of Harm - Minimal harm or potential for actual harm Review of weight assessments available in Resident 8's medical record revealed the following findings: May 14, 2023, at 9:20 AM, 162.0 pounds Residents Affected - Few May 18, 2023, at 4:18 PM, 166.1 pounds May 29, 2023, at 10:22 AM, 143.8 pounds (a 22.3-pound, 13.42 percent severe loss in 11 days) June 2, 2023, at 12:26 PM, 137.4 pounds (a 6.4-pound, 4.45 percent continued loss in the four days since the previous weight assessment) June 5, 2023, at 1:20 PM, 136.8 pounds June 12, 2023, at 2:11 PM, 137.0 pounds Nursing documentation dated May 29, 2023, at 2:18 PM indicated that the registered nurse was informed of Resident 8's weight loss. The writer noted that she completed an assessment for dehydration ( .Lips do not appear dry. Normal skin turgor, no tenting. BP (blood pressure) elevated, but pt (patient) trends high periodically, other VSS (vital signs stable). Foley patent, draining clear yellow urine. No complaints voiced by pt.). The above documentation did not include an assessment of any other nutritional parameters (e.g., meal intake percentages, resident's need for assistance, resident preferences, or protein or caloric needs). The documentation did not indicate notifications to the physician, dietitian, or Resident 8's responsible party. The documentation did not indicate the initiation of any new interventions in response to the identified 22.3-pound, 13.42 percent, severe weight loss. A physician's order originally written on May 18, 2023 (Resident 8's readmission to the facility), was automatically implemented as scheduled on June 1, 2023, that decreased Resident 8's weight assessments from weekly to monthly. A physician's progress note dated June 2, 2023, at 8:38 PM included no reference to Resident 8's severe weight loss. The practitioner noted that the resident reported a fair appetite, and that there were no concerns voiced by nursing staff, Resident 8 was stable, and that there were no new orders on that date. Nursing documentation by the Nursing Home Administrator on June 5, 2023, at 10:24 AM indicated that the interdisciplinary team reviewed Resident 8's weight loss. The documentation included that Resident 8's, intakes vary greatly .some meals she eats 50-75 percent of meals, other meals refused or eats very little .MD (physician) notified of wt (weight) loss, per MD, new order for Ha1C (Hemoglobin A1c, HbA1c, blood test that tells you your average level of blood sugar over the past 2 to 3 months) .Will liberalize diet . Progress note documentation dated June 7, 2023, at 4:57 PM was the first indication that a qualified dietary professional (registered dietitian) assessed Resident 8's severe weight loss (to include protein and caloric needs) since May 29, 2023, and the facility implemented nutritional dietary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William Penn Nursing and Rehab 163 Summit Drive Lewistown, PA 17044 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 supplements. Level of Harm - Minimal harm or potential for actual harm Interview with the Nursing Home Administrator and the Director of Nursing on June 28, 2023, at 2:00 PM indicated that the facility did not employ a dietitian at the time of Resident 8's finding of severe weight loss on May 29, 2023. The interview indicated that a new dietitian started the first week of June 2023. Residents Affected - Few Interview with the Director of Nursing and the Nursing Home Administrator on June 29, 2023, at 2:00 PM confirmed that the facility had no expectation that staff perform a re-weight assessment when a severe change in weight assessments is identified to ensure the accuracy of the findings. The interview also confirmed that the facility had not weighed Resident 8 since June 12, 2023, to monitor the ongoing effectiveness of interventions implemented on June 5, 2023. Interview with the Nursing Home Administrator and Employee 6 (registered dietitian) on June 30, 2023, at 9:54 AM confirmed that there was no assessment by a qualified dietary professional completed on Resident 8 (to include caloric, protein, and fluid needs) and Resident 8 had no nutritional supplements ordered for the nine days from May 29, 2023, to June 7, 2023, during which Resident 8 was identified to have lost a total of 29.3 pounds (17.6 percent) from her weight assessment on May 18, 2023. The Nursing Home Administrator stated that it would be her expectation that nursing staff assess a resident who is identified to have a severe weight change; however, neither the Nursing Home Administrator nor Employee 6 would state what that assessment should include. The Nursing Home Administrator was also unable to state the expectation for nursing staff to timely notify a resident's physician, responsible party, or the dietitian in the event of an identified severe weight loss (e.g., within 24 hours or within one week). The interview indicated that the facility's system is that the electronic weight documentation program will alert the registered dietitian the next day of a significant weight loss. The interview confirmed that there was no registered dietitian employed by the facility on May 29, 2023, to receive the alert for Resident 8. In the event of the absence of a dietitian, the Nursing Home Administrator and the facility's administration would address daily significant weight loss alerts during morning meeting; however, the Nursing Home Administrator was unable to provide evidence that this occurred for Resident 8 after Monday, May 29, 2023's, weight until the following Monday on June 5, 2023. 28 Pa. Code 211.6(d) Dietary services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William Penn Nursing and Rehab 163 Summit Drive Lewistown, PA 17044 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents reviewed for medication concerns (Resident 14). Findings include: The facility policy entitled, Psychotropic Medication Use, last reviewed without changes on March 16, 2023, stipulated that residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms to identify underlying causes. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions) unless clinically contraindicated, to discontinue these medications. When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts an evaluation of the resident. The evaluation will attempt to clarify whether: other causes for symptoms (including symptoms that mimic a psychiatric disorder) have been ruled out; signs and symptoms are clinically significant enough to warrant medication therapy; a particular medication is clinically indicated to manage the symptoms or condition; and the actual or intended benefit of the medication is understood by the resident/representative. The National Institute of Mental Health defines psychosis as a collection of symptoms that affect the mind, where there has been some loss of contact with reality. During an episode of psychosis, a person's thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not. People with psychosis typically experience delusions (false beliefs, for example, that people on television are sending them special messages or that others are trying to hurt them) and hallucinations (seeing or hearing things that others do not, such as hearing voices telling them to do something or criticizing them). Other symptoms can include incoherent or nonsense speech and behavior that is inappropriate for the situation. Clinical record review for Resident 14 revealed a current medication regime that included the administration of the antipsychotic Seroquel, 25 mg (milligrams) two times a day related to unspecified psychosis since December 21, 2021. Resident 14's medication regime also included: Zoloft (antidepressant), 50 mg once daily for depressive disorders (active since February 11, 2023) Cymbalta (antidepressant) 120 mg once daily for depressive disorders (active since October 9, 2021) Trazodone (antidepressant) twice daily as 25 mg during the day and 50 mg in the evening for depressive disorders (active since November 30, 2022) Depakote (anticonvulsant sometimes used to treat mood disorders) which was increased from 125 mg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William Penn Nursing and Rehab 163 Summit Drive Lewistown, PA 17044 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 0758 twice daily to 250 mg twice daily for complaints of increased depression on June 27, 2023. Level of Harm - Minimal harm or potential for actual harm Psychiatric documentation by a certified registered nurse practitioner (CRNP) dated November 12, 2021, instructed staff to start Resident 14's Seroquel at 25 mg at hour of sleep. The documentation did not include a diagnosis of psychosis. The documentation indicated that Resident 14 was agitated, restless, anxious, angry, and constricted, but he was alert and oriented to person and place and that he was not a danger to himself or others. Residents Affected - Few Psychiatric documentation dated December 17, 2021, indicated that Resident 14 stated that he missed his dog and wife and that he presented with poor insight regarding memory issues and that he admitted to feeling angry. Resident 14 remained alert and oriented to person and place. The CRNP instructed staff to increase Resident 14's Seroquel to 25 mg twice daily. Psychiatric documentation dated November 30, 2022, indicated Resident 14 was seen for psychiatric follow up for a history of anxiety disorder, mood disorder, and depression. The history of his present illness listed dementia. Resident 14 continued to have some anxiety but he felt mentally stable. Although Resident 14 reported feeling, .down at times due to his situation, he had a good appetite and was sleeping better. Resident 14's mental exam was that he was well groomed, alert, cooperative, with clear speech, appropriate mood, and without delusions or hallucinations. The practitioner's impression was that Resident 14 continued to have mild depression and anxiety symptoms but was overall stable. His mood irritability was addressed by his Trazodone and Depakote. The plan noted to, continue Seroquel 25 mg PO (by mouth) bid (twice daily) for dementia related behaviors. A consultant pharmacist review on June 2, 2022, requested the physician consider reviewing Resident 14's Seroquel and Trazodone medications for a possible gradual dose reduction (GDR) as within the first year a psychotropic medication is initiated a gradual dose reduction must be attempted in two separate quarters (with at least one month between attempts) unless contraindicated. After the first year a GDR must be attempted annually unless clinically contraindicated. The physician declined to decrease or discontinue either the Seroquel or the Trazodone medications on June 23, 2022, with the rationale, .as doing so would most likely result in increased depression and behaviors. The surveyor requested that the facility provide any evidence that Resident 14 exhibited target behavioral symptoms of psychosis during an interview with the Nursing Home Administrator and the Director of Nursing on June 29, 2023, at 2:00 PM. Review of the tracking of Resident 14's socially inappropriate/abusive behaviors provided by the facility dated December 2022 - June 28, 2023, revealed that he had zero episodes documented by staff. Interview with Employee 7 (social services) and the Nursing Home Administrator on June 30, 2023, at 9:32 AM confirmed that there was no evidence of symptoms of psychosis (such as hallucinations or delusions) when the Seroquel was started. Resident 14 was identified as exhibiting yelling, cursing, and that he was angry. There was no evidence that the consultant pharmacist requested another GDR of the Seroquel medication since June 2, 2022. There was no evidence that Resident 14 ever failed an attempt at a GDR of the Seroquel medication since its initiation in November 2021. There was no evidence provided by the facility that Resident 14 ever exhibited delusions or hallucinations that were symptoms of a psychosis disorder. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William Penn Nursing and Rehab 163 Summit Drive Lewistown, PA 17044 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, review of select manufacturer's guidelines, and staff and resident interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 6, 70, 80, and 41). Residents Affected - Some Findings include: The facility's medication error rate was 14.81 percent based on 27 medication opportunities with four medication errors. Observation of a medication administration pass on June 27, 2023, at 12:14 PM revealed Employee 5, licensed practical nurse, preparing to administer Humalog (a medication that treats diabetes) KwikPen (a multidose administration pen) 100 units per milliliter to Resident 6. Employee 5 attached a disposable needle to the Humalog KwikPen and dialed up two units of the insulin and administered the medication to Resident 6. Review of the manufacturer's guidelines indicated that the Humalog KwikPen should be primed prior to each injection by turning the dose knob to two units and dispersing the medication to ensure the pen is working correctly and to get rid of any air that may be in the needle and cartridge. Employee 5 did not prime the disposable needle prior to administering the medication to Resident 6. Observation of a medication administration pass on June 27, 2023, at 12:04 PM revealed Employee 5 preparing to administer Novolog (a medication that treats diabetes) FlexPen (a multidose administration pen) 100 units per milliliter to Resident 70. Employee 5 attached a disposable needle to the Novolog FlexPen and dialed up eight units of the insulin and administered the medication to Resident 70. Review of the manufacturer's guidelines indicated that the Novolog FlexPen should be primed prior to each injection by turning the dose knob to two units and dispersing the medication to ensure the pen is working correctly and to get rid of any air that may be in the needle and cartridge. Employee 5 did not prime the disposable needle prior to administering the medication to Resident 70. Observation of a medication administration pass on June 27, 2023, at 12:09 PM revealed Employee 5 preparing to administer Humulin R U-500 (a medication that treats diabetes) KwikPen (a multidose administration pen) 500 units per milliliter to Resident 80. Employee 5 attached a disposable needle to the Humulin R U-500 KwikPen and dialed up 40 units of the insulin and administered the medication to Resident 80. Review of the manufacturer's guidelines indicated that the Humulin R U-500 KwikPen should be primed prior to each injection by turning the dose knob to five units and dispersing the medication to ensure the pen is working correctly and to get rid of any air that may be in the needle. Employee 5 did not prime the disposable needle prior to administering the medication to Resident 80. Interview with Employee 5 on June 27, 2023, at 12:15 PM confirmed the above findings for Residents 6, 70, and 80. Observation of a medication administration pass on June 28, 2023, at 8:45 AM with Employee 8 (licensed practical nurse) revealed that the medications prepared for administration to Resident 41 included delayed release Omeprazole (medication used to block stomach acid production) 20 milligrams (mg) from the facility's stock medication supply. Observation of Resident 41 on June 28, 2023, at 8:55 AM at the time she consumed the Omeprazole medication, revealed she had a meal tray in front of her. Interview with Resident 41 on the date and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William Penn Nursing and Rehab 163 Summit Drive Lewistown, PA 17044 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 0759 time of the observation confirmed that she finished eating her breakfast ,and she ate all of it. Level of Harm - Minimal harm or potential for actual harm Interview with Employee 8 on June 28, 2023, at 8:59 AM confirmed that Resident 41 received her Omeprazole medication after she had finished her breakfast meal, and the medications are scheduled that way daily. Residents Affected - Some Interview with Employee 8 while reviewing the Omeprazole manufacturer's packaging on June 28, 2023, at 12:07 PM confirmed that the instructions for administration noted to swallow one capsule with a glass of water before eating in the morning. The online resource, www.drugs.com, noted that it is usually best to take Omeprazole one hour before meals. When omeprazole is taken with food, it reduces the amount of Omeprazole that reaches the bloodstream. The above findings were reviewed with the Administrator during an interview on June 28, 2023, at 1:45 PM. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William Penn Nursing and Rehab 163 Summit Drive Lewistown, PA 17044 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed prepare, store, and serve food, and maintain equipment in accordance with professional standards for food service safety in the facility's main kitchen and on one of two nursing units (nursing unit one). Findings include: An observation of the facility's main kitchen on June 27, 2023, at 9:50 AM revealed the following: Employee 1, cook, was observed from the entrance to the kitchen working in a preparation area with facial hair covering sides of his face, lip, and chin, uncovered. Upon walking to the preparation area, the employee had donned a beard covering. Upon concurrent interview, Employee 1 stated he had forgot about the beard guard this morning, and that he had been working since 5:30 AM. Multiple sheet tray pans were observed stored on a rack beside the ovens. The pans contained thick burnt on black buildup. A speed rack (a tall metal cart with open sides and slats to hold sheet tray pans) that contained trays of unbaked rolls, was located directly beside the three-compartment sink where pans were soaking in the compartments. An overflowing trash receptacle without a lid was also pushed up to one side of the speed rack. A Robot Coupe food processor located on the cook's preparation table was observed with a large piece of plastic broken off on the top of the base of the processor leaving a large hole to the interior of the base where metal internal components could be seen. Dried food and debris were observed on the interior components. An anti-fatigue mat on the floor in front of the cooks table was significantly covered in dried food and debris. A shelving unit outside the walk-in cooler area where pans were stored, contained a skillet with a lid on the bottom shelf. The lids were soiled, and the interior of the skillet contained debris. Multiple racks of bread products including 19 packs of hot dog rolls, 10 loaves of bread, one pack of hamburger buns, and one wide open package containing three hot dog rolls were observed outside the cooler and freezer area. Employee 1, dietary manager, indicated the products come in frozen and the staff pull them from the freezer. All items observed were thawed and contained no date to indicate when the items were pulled from the freezer or when they needed to be used by. A red dolly in the dry storage area with a box of hoagie rolls stored on it, and metal dolly beside it with ravioli cans stored on it were soiled with dirt and debris. An observation on June 28, 2023, at 12:31 PM revealed Employee 3, dietary aide, plating and serving lunch from a steam table in the hallway on nursing unit 1. Employee 3 was observed with facial hair visible from the end of the hallway. Employee 3 was wearing a beard guard covering that was observed pulled down under the facial hair area under his chin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William Penn Nursing and Rehab 163 Summit Drive Lewistown, PA 17044 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on June 28, 2023, at 2:10 PM. Level of Harm - Minimal harm or potential for actual harm 483.60 (i) Food Procure, Store/Prepare/Serve -Sanitary Residents Affected - Many Previously cited 7/14/22 28 Pa. Code 211.6 (c) Dietary services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 13 of 13