Health inspection·May 9, 2025

F 0641 Ensure each resident receives an accurate assessment. 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 staff interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for six of 26 residents reviewed (Residents 4, 14, 20, 71, 75, and 81). Residents Affected - Some Findings include: Clinical record review for Resident 75 revealed a Quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated February 2, 2025. The facility staff assessed the resident as taking an anticoagulant (a medication that prevents or reduces clotting time of the blood). Further clinical record review revealed no evidence that Resident 75 was on an anticoagulant. An interview with Employee 2, registered nurse assessment coordinator (RNAC), on May 7, 2025, at 10:50 AM confirmed that Resident 75 was not on an anticoagulant during the assessment period, and this was marked in error on the MDS. The Nursing Home Administrator and Director of Nursing were informed of the above findings during a meeting on May 7, 2025, at 2:00 PM. Clinical record review for Resident 4 revealed a quarterly MDS dated [DATE]. The facility staff assessed the resident as having used a limb restraint when in a chair less than daily. Interview with Employee 2, RNAC, on May 7, 2025, at 9:20 AM revealed that Resident 4 never utilized a limb restraint, and this was an MDS coding error. Clinical record review for Resident 20 revealed a quarterly MDS dated [DATE]. The facility staff assessed the resident as having an impairment of both of her lower extremities. Clinical record review for Resident 71 revealed an annual MDS dated [DATE]. The facility staff assessed her as having an impairment of her bilateral lower extremities. Interview with Employee 6, RNAC, on May 9, 2025, at 12:10 PM revealed that Residents 20 and 71 do not have an impairment of their bilateral lower extremities, and this was marked in error on the MDS. The Director of Nursing was made aware of the concerns with Resident 20 and 71's MDS coding concerns on May 9, 2025, at 12:15 PM. Clinical record review for Resident 14 revealed a quarterly MDS dated [DATE]. The facility staff assessed the resident as having used a trunk restraint in a chair or out of bed, less than daily. Clinical record review for Resident 81 revealed a quarterly MDS dated [DATE]. The facility staff assessed the resident as having used a trunk restraint in a chair or out of bed, less than daily. Interview with Employee 2 on May 7, 2025, at 9:06 AM revealed that Residents 14 and 81 never (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 2 of 9 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 05/09/2025 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 0641 utilized a trunk restraint and that this was an MDS coding error. Level of Harm - Minimal harm or potential for actual harm The Director of Nursing was made aware of the concerns with Residents 14 and 81 MDS coding concerns on May 9, 2025, at 12:16 PM. Residents Affected - Some 483.20(g) Accuracy of Assessments Previously cited 6/25/2024 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 3 of 9 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 05/09/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Clinical record review and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident needs related to call bell response time for two of 26 residents reviewed (Residents 50 and 66). Findings include: In an interview with Resident 50 on May 6, 2025, at 12:56 PM she stated that she has waited an hour to go the bathroom. She stated that she is usually only incontinent when she rings her call bell and must wait a long time for staff to assist her. Resident 50 stated that the licensed practical nurse will come into her room and turn off her call bell stating they will let the nurse aide know but nobody comes back. Clinical record review for Resident 50 revealed her most recent annual MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) assessment dated [DATE], indicated Resident 50 was cognitively intact and occasionally incontinent of her bladder function. Resident 50 filed a grievance on January 1, 2025, stating her call bell was on for over an hour, noting she was incontinent and embarrassed. Review of Resident 50's grievance revealed no resolution to her concern. Interview with Employee 7 (social services) on May 9, 2025, at 10:43 AM confirmed these finding for Resident 50. There was no evidence of any call bell audits completed until January 14, 2025. The above call bell response times were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on May 8, 2025, at 2:00 PM. Interview with Resident 66 on May 6, 2025, at 12:15 PM revealed that he has concerns with the facility not having enough staff. He indicated that when he rings his bell to go to the bathroom or use the urinal there are not enough staff to answer it timely. He could not provide specific dates, but he indicated that it happens on all the shifts. He said that he is incontinent often because they don't answer the call bell timely. He said the that often he has to wait over 30 minutes. Review of Resident 66's MDS dated [DATE], revealed that he is always continent of bowel and frequently incontinent of bladder. The above noted concern related to Resident 66 was reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on May 8, 2025, at 2:30 PM. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(4)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 4 of 9 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 05/09/2025 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and staff interview, it was determined that the facility failed to post the daily nurse staffing information at the beginning of each shift for two of two nursing units reviewed (Nursing Unit One and Nursing Unit Two). Residents Affected - Many Findings include: Observation of the nurse staffing information posted on the wall adjacent to the main lobby of the facility on May 8, 2025, at 11:19 AM and 12:38 PM revealed a nurse staffing sheet dated May 7, 2025. Observation at the Nursing Unit Two nurse station and concurrent interview with Employee 5, licensed practical nurse, on May 8, 2025, at 11:30 AM revealed that there was no nurse staffing information posted in a prominent place at or near the nurse's station. Observation of Nursing Unit One nurse station and concurrent interview with Employee 6, social worker, on May 8, 2025, at 12:43 PM revealed that there was no nurse staffing information posted in a prominent place at or near the nurse station. An interview with Employee 8, scheduler, on May 8, 2025, at 12:53 PM revealed that the posted nurse staffing information located near the main lobby was changed to reflect the correct date of May 8, 2025. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on May 8, 2025, at 2:15 PM. 28 Pa. Code 201.18(b)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 5 of 9 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 05/09/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and staff interview, it was determined that the facility failed to properly store resident medications on one of two nursing units reviewed (Station Two Nursing Unit; Honey Creek Hall). Findings include: Observation during the medication pass on the Station Two Nursing Unit (Honey Creek Hall) on May 9, 2025, at 9:35 AM revealed a medication cart being utilized by Employee 5, licensed practical nurse. Observation of the medication cart revealed the following: There was a significant accumulation of debris and dirt including hair in the bottom of the drawers. There were several unsecured and unidentified medication tablets found in the drawer that contained the medication punch cards that included several unidentified pills: two white colored round pills, two orange colored round pills, a multi-colored capsule, and a large brown colored pill. The above findings were reviewed in a meeting with the Director of Nursing on May 9, 2025, at 9:57 AM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 6 of 9 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 05/09/2025 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 0791 Provide or obtain dental services for each resident. 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, observation, and staff and resident interview, it was determined that the facility failed to assist residents to obtain routine dental care for six of eight residents reviewed (Residents 34, 50, 95, 4, 20, and 37). Residents Affected - Some Findings include: Observation of Resident 34 on May 7, 2025, at 10:23 AM revealed that she had some natural teeth. Resident 34 was unable to be interviewed due to her current cognitive status. Clinical record review revealed the facility admitted Resident 34 on January 8, 2018, with payment sources that included the state Medicaid benefit. Further review of Resident 34's clinical record revealed that she last saw a dentist on February 13, 2020. An interview with Employee 1 (licensed practical nurse) on May 8, 2025, at 11:34 AM confirmed these findings for Resident 34. There was no other documentation that indicated Resident 34 was offered routine dental services every six months as the State plan allows. Observation and interview with Resident 50 on May 6, 2025, at 1:06 PM revealed she had her own teeth, and she stated that she couldn't remember the last time she saw a dentist. Clinical record review revealed the facility admitted Resident 50 on April 30, 2021, with payment sources that included the state Medicaid benefit. Further review of Resident 50's clinical record revealed that she last saw a dentist on March 13, 2023. Interview with Employee 1 on May 8, 2025, at 11:34 AM confirmed these findings for Resident 50. There was no other documentation that indicated Resident 50 was offered routine dental services every six months as the State plan allows. Observation of Resident 95 on May 7, 2025, at 11:27 AM revealed that she had some natural and broken teeth. Resident 95 was unable to be interviewed due to her current cognitive status. Clinical record review revealed the facility admitted Resident 95 on May 19, 2024, with payment sources that included the state Medicaid benefit. Further review of Resident 95's clinical record revealed no evidence that Resident 95 saw a dentist. Review of Resident 95's admission MDS assessment dated [DATE], revealed staff assessed Resident 95 as having obvious or likely cavity, or broken natural teeth. Interview with Employee 1 on May 8, 2025, at 11:34 AM confirmed these findings for Resident 95. There was no other documentation that indicated Resident 95 was offered routine dental services every six months as the State plan allows. The findings for Residents 34, 50, and 95 were reviewed with the Director of Nursing on May 9, 2025, at 9:55 AM and she confirmed the facility had no further evidence the above-mentioned residents received routine prophylactic dental cleanings as covered under the State plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 7 of 9 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 05/09/2025 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Clinical record review for Resident 4 revealed that the facility admitted her on September 6, 2024. Her admission MDS indicated that she is edentulous. Further clinical record review revealed that she has upper and lower dentures. There was no evidence in Resident 4's clinical record to indicate that she was offered or provided routine dental services. Clinical record review for Resident 20 revealed that the facility admitted her on May 16, 2016, with payment sources that included the state Medicaid benefit. Review of Resident 20's significant change MDS dated [DATE], revealed staff assessed her as having some or all her natural teeth. Further review of Resident 20's clinical record revealed no evidence that she was seen by a dentist or offered dental services. Clinical record review for Resident 37 revealed that the facility admitted her on May 16, 2019. Review of Resident 37's annual MDS dated [DATE], revealed that she has some or all her natural teeth. There was no evidence in Resident 37's clinical record to indicate that she was offered or provided with routine dental services. Interview with Employee 1 on May 8, 2025, at 11:34 AM confirmed these findings for Residents 4, 20, and 37. There was no other documentation that indicated Residents 4, 20, and 37 were offered routine dental services every six months as the State plan allows. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.15. Dental services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395335 If continuation sheet Page 8 of 9 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 05/09/2025 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on staff interview, it was determined that the facility failed to maintain COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network for one of one staff reviewed (Employee 3). Findings include: The surveyor requested information regarding the COVID-19 vaccination status for the facility's current employees during an interview with Employee 4 (Registered Nurse, Infection Preventionist), on May 9, 2025, at 11:00 AM. Employee 4 indicated that she has not been tracking vaccination status for staff. She also indicated that she had no evidence of offering COVID-19 vaccinations to staff because they do not ask each staff member individually as they post a sign by the time clock and in the employee breakroom indicating that if staff were interested in receiving a vaccine that they need to visit their primary care physician or local pharmacy. The Nursing Home Administrator and Director of Nursing were made aware of concerns related to staff COVID-19 vaccinations on May 9, 2025, at 11:35 AM. 28 Pa. Code 211.5(f)(i)-(xi) Medical records 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 9