Health inspection·January 15, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on review of facility policy and Food Committee meeting minutes, and resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve resident grievances regarding cold food. Findings include: The facility's policy regarding food quality and palatability, dated March 18, 2024, revealed that food will be palatable, attractive, and served at a safe and appetizing temperature. Food Committee meeting minutes for January through August 2024 and October through December 2024 indicated that the residents were receiving cold food. A meeting with a group of residents on January 13, 2025, at 11:15 a.m. revealed that the residents have been served food that was cold and unpalatable. They stated that they have requested food that is served at the correct temperature. They stated that this had been occurring for at least one year. Interview with Director of Dietary on January 14, 2025, at 12:14 p.m. confirmed that she was aware that residents complained about cold food, and that it was brought up during the Food Committee meetings. She stated that she did not address the issue because the food that was temped in the kitchen was at the correct temperatures. 28 Pa. Code 201.29(i) Resident Rights. 28 Pa. Code 211.12(d)(5) Nursing Service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 2 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on a review of policies, clinical records, personnel files, and investigative reports, as well as interviews with staff, it was determined that the facility failed to ensure that the abuse policy was followed for one of 30 residents reviewed (Resident 28), and failed to complete a professional licensure verification with the Pennsylvania State Board of Nursing prior to hire for one of four employees reviewed (Registered Nurse 1). Residents Affected - Few Findings include: The facility's abuse policy, dated March 18, 2024, indicated that no employee may at any time commit an act of physical, psychological, or emotional abuse; neglect; mistreatment and/or misappropriation of property against any resident, and persons applying for employment with the center will be screened for a history of abuse, neglect, exploitations, or misappropriation of resident property, including but not limited to employment history, criminal background check, abuse check with appropriate licensing board and registries prior to hire, and licensure or registration verification prior to hire. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 28, dated November 25, 2024, revealed that the resident was cognitively intact and was dependent on staff for all daily care needs. Investigation documents provided by the facility for Resident 28, dated October 31, 2024, revealed that on October 31, 2024, Nurse Aide 3 was overheard telling Resident 28 to shut up. The facility determined that Nurse Aide 3 did tell the resident to shut up and was subsequently terminated. Interview with the Director of Nursing on January 14, 2025, at 11:04 a.m. revealed that Nurse Aide 3 did not follow the facility's abuse policy when she told Resident 28 to shut up. The personnel file for Registered Nurse 2 revealed that she was hired on September 10, 2024, and as of January 13, 2025 (four months after hire) a professional licensure verification with the Pennsylvania State Board of Nursing had not been completed. Interview with Director of Human Resources on January 15, 2025, at 2:47 p.m. confirmed that there was no documented evidence to indicate that Registered Nurse 2's professional licensure was verified with the State Board of Nursing prior to the nurse's hire date. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 3 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on review of facility policy and clinical record reviews, and staff interviews, it was determined that the facility failed to notify the resident, responsible party, and Ombudsman, in writing, regarding the reason for hospitalization for two of 30 residents reviewed (Residents 68, 70). Findings include: The facility policy for Transfer/Discharge Notification, dated March 18, 2024, revealed that before a resident is transferred or discharged , the facility will notify the resident and resident representative of the transfer or discharge and the reason for the move in writing and will send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 68, dated November 7, 2024, indicated that the resident was cognitively intact and required assistance from staff for daily care needs. A nursing note for Resident 68, dated October 28, 2024, at 3:42 a.m. revealed that the resident complained of difficulty breathing. Despite interventions she continued to have difficulty breathing and requested to go to the emergency department, and she was transferred to the hospital. There was no documented evidence that a written notice of Resident 68's transfer to the hospital was provided to the resident's responsible party and the Ombudsman regarding the reason for transfer. A quarterly MDS assessment for Resident 70, dated November 14, 2024, indicated that the resident was cognitively impaired and was dependent on staff for daily care needs. A nursing note for Resident 70, dated April 3, 2024, at 10:40 p.m., revealed that the resident had a fall from her chair and had a bleeding laceration to the back of her head, and she was transferred to the hospital. There was no documented evidence that a written notice of Resident 70's transfer to the hospital was provided to the resident's responsible party and the Ombudsman regarding the reason for transfer. Interview with the Nursing Home Administrator on January 15, 2025, at 9:41 a.m. confirmed that the facility did not provide a written notice to the residents, the residents' responsible parties, or the Ombudsman when Residents 68 and 70 were transferred to the hospital. 28 Pa. Code 201.25 Discharge Policy. 28 Pa. Code 201.29(f)(g) Resident Rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 4 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that appropriate parties were notified about the facility's bed-hold policy upon transfer to the hospital for two of 30 residents reviewed (Residents 68, 70). Findings include: The facility policy for Bed Hold Notice, dated March 18, 2024, revealed that in accordance with state and federal law the facility provides written notice of its bed-hold information to each resident and resident representative. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 68, dated November 7, 2024, indicated that the resident was cognitively intact and required assistance from staff for daily care needs. A nursing note for Resident 68, dated October 28, 2024, at 3:42 a.m., revealed that the resident complained of difficulty breathing. Despite interventions she continued to have difficulty breathing and requested to go to the emergency department, and she was transferred to the hospital. There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 68. A quarterly MDS assessment for Resident 70, dated November 14, 2024, indicated that the resident was cognitively impaired and was dependent on staff for daily care needs. A nursing note for Resident 70, dated April 3, 2024, at 10:40 p.m., revealed that the resident had a fall from her chair and had a bleeding laceration to the back of her head, and she was transferred to the hospital. There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 70. Interview with the Nursing Home Administrator on January 15, 2025, at 9:41 a.m. confirmed that there was no documented evidence that a bed-hold notice was issued to Residents 68 and 70 or their responsible parties and there should have been. 28 Pa. Code 201.25 Discharge Policy. 28 Pa. Code 201.29(f)(g) Resident Rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 5 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for one of 30 residents reviewed (Resident 29). Findings include: The facility's policy regarding care plans, dated March 18, 2024, indicated that an individualized person-centered plan of care will be established by the interdisciplinary team with the resident or resident representative to the extent practicable and will be updated in accordance with state and federal regulatory requirements. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated December 14, 2024, revealed that she was cognitively impaired, was dependent on staff for activities of daily living, and had a diagnoses that included dementia and high blood pressure. A consult note for Resident 29 from the wound doctor, dated January 7, 2025, revealed that the consultant company was signing off on the resident and that she has no open wounds at this time. The current care plan for Resident 29, dated July 9, 2024, revealed that the resident has pressure ulcer to right heel. Interview with the Director of Nursing on January 15, 2025 at 12:49 p.m. confirmed that Resident 29's pressure ulcer was healed and that her care plan should have been discontinued. 28 Pa. Code 201.24(e)(4) admission Policy. 28 Pa. Code 211.12(d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 6 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on clinical record reviews and resident and staff interviews, it was determined that the facility failed to provide adequate, ongoing activities designed to meet the needs of residents for seven of 30 residents reviewed (Residents 3, 14, 20, 24, 36, 63, 66). Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated December 6, 2024, indicated that the resident was cognitively intact and was dependent on staff for daily care needs, and that it was very important for the resident to be provided with books to read, be involved in group activities, participate in favorite activities, and participate in religious activities. A quarterly MDS assessment for Resident 14, dated December 11, 2024, indicated that the resident was cognitively intact and dependent on staff for daily care needs, and that it was very important for the resident to listen to music, participate in favorite activities, go outside when the weather is nice, and participate in religious activities. A quarterly MDS assessment for Resident 20, dated December 30, 2024, indicated that the resident was cognitively intact, required partial assistance from staff for daily care needs, and that it was very important for the resident to listen to music, be around animals, participate in favorite activities, go outside when the weather is nice, and participate in religious activities. A quarterly MDS assessment for Resident 24, dated December 1, 2024, indicated that the resident was cognitively intact, required maximum assistance from staff for daily care needs, and that it was very important for the resident to listen to music, participate in favorite activities, and go outside when the weather is nice. A quarterly MDS assessment for Resident 36, dated December 21, 2024, indicated that the resident was cognitively intact, was dependent on staff for daily care needs, and that it was very important for the resident to be able to have books to read, listen to music, keep up with the news, do activities with groups of people, and participate in favorite activities. A quarterly MDS assessment for Resident 63, dated December 19, 2024, indicated that the resident was cognitively impaired, was independent with daily care needs, and that it was very important for the resident to participate in favorite activities, do actives in groups of people, and participate in religious activities. An annual MDS assessment for Resident 66, dated November 8, 2024, indicated that the resident was cognitively intact, was dependent on staff for all care needs, and that it was very important for the resident to listen to music, do activities with groups of people, participate in favorite activities, and to go outside when the weather is nice. Resident council meeting minutes from January 2025 revealed that the residents were upset because activity hours were cut and they did not have as many activities, and they wanted them back. A review of the activity calendars for October and November 2024 revealed that the residents had three to four activities per day during the week and three activities per day on the weekends. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 7 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Activity calendars for December, 2024 and January 2025 revealed that the residents had two to three activities during the weeks and two activities on the weekends. Sunday activities were Sunday social and church. Observations of the Sunday Social activity on January 12, 2025, in the activities room consisted of residents sitting around a table, there were no refreshments provided, and residents were quiet and spoke very little. An interview with a group of Residents on January 13, 2025, at 11:15 a.m. revealed that the residents would like more activities. They stated that two of the activity aides were recently let go, and their activities have been cut in half. They would like more bingo, music, and religious activities. Their bingo is very important to them because they get points during bingo, and they are allowed to purchase items with those points. The residents stated that some residents do not have family who can bring them special items, and by cutting bingo back these residents are no t able to get these items. They stated they only have half as many activities during the week and very little on weekends. Interview with Resident 66 on January 15, 2025, at 1:45 p.m. revealed that she was upset that bingo was decreased and that church during the week was cut. She stated, What do they want us to do, stare at the walls like we are in a prison? The activities are the only things we have to do here. Interview with the Activity Director on January 13, 2025, at 12:41 p.m. revealed that two activity staff were recently let go, and that her hours were cut back. She stated that she was aware the residents were requesting more activities like bingo, music, and church, but it is difficult to schedule them with the cut in her hours and the loss of activites staff. 28 Pa. Code 201.24(e)(4) admission Policy. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 8 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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 Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for two of 30 residents reviewed (Residents 40, 53). Residents Affected - Some Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated November 13, 2024, revealed that the resident was cognitively intact, was independent with daily care needs, had diagnoses that included high blood pressure, diabetes, and Parkinson's. Current physician's orders for Resident 40 included orders for the resident to receive 10 milligrams of Cetirizine at bedtime every Monday and Thursday for allergies, 100 micrograms of Synthroid daily for hypothyroidism (when the thyroid gland does not make enough thyroid hormones), 17 grams of Miralax daily for constipation, 30 milligrams of Diltiazem twice a day for high blood pressure, and 500 milligram of Tylenol twice a day for left knee pain. A review of Resident 40's Medication Administration Records (MAR's) for December 2024 revealed no documented evidence that the medications were administered as ordered on December 3, 9, 10, 12, 16, 18, 21, and 24, 2024. Interview with Resident 40 on January 14, 2025, at 11:41 a.m. revealed that he has not been receiving his medications per the physician orders. An interview with the Director of Nursing on January 14, 2025, confirmed that Resident 40's MAR revealed no documented evidence to indicate that the medications were administered on the dates listed above. An admission MDS for Resident 53, dated December 3, 2024, revealed that the resident was cognitively impaired, required assistance with daily care needs, had diagnoses that included diabetes (a disease that interferes with blood sugar control), high blood pressure, and a stroke. Physician's orders for Resident 53, dated November 27, 2024, included orders for accuchecks every morning and at bedtime and to notify the physician if the blood sugar was less than 60 mg/dL or greater than 400 mg/dl. A review of the MAR for Resident 53, dated December 2024, revealed that on December 1, 2024, at 9:00 p.m. the resident's blood sugar was 32 mg/dl and on December 2, 2024, at 6:00 a.m. the resident's blood sugar was 41 mg/dl. There was no documented evidence that the physician was notified of these low blood sugars as ordered. Interview with the Director of Nursing on January 15, 2025, at 10:15 a.m. confirmed that the physician was not notified of Residents 53's low blood sugars mentioned above, and he should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 9 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's transfer status was followed for one of 30 residents reviewed (Resident 68). Residents Affected - Few Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 68, dated November 7, 2024, revealed that the resident was cognitively intact, required two-person assistance for transfers, and had diagnoses of acute respiratory failure and muscle weakness. A nursing note for Resident 68, dated December 20, 2024, at 10:45 a.m. revealed that the resident was being transferred from the bed to a wheelchair by one nurse aide when the resident became weak and was slowly lowered to a sitting position on the floor. Resident was wearing black sneakers and was assessed, no injuries were found and there were no complaints of pain. Interview with the Nursing Home Administrator on January 15, 2025, at 9:41 a.m. confirmed that Resident 68 was transferred by one staff member and she should have been transferred by two staff members. 28 Pa. Code 211.10(a) 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: 395422 If continuation sheet Page 10 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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. Based on observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that there was sufficient nursing staff available to transport residents to activities and to provide licensed nursing staff in the facility's main dining area for the lunch and dinner meals. Findings include: A grievance from Resident 68, dated November 15, 2024, revealed that the resident was unable to go to activities due to nursing aides not being able to take her there. Staff were educated on the importance of ensuring residents were out of bed and transferred to their activities per each resident's preference. Review of the facility's dietary delivery times, undated, revealed that breakfast meals were to be delivered to the units from 7:00 a.m. to 8:15 a.m., lunch meals were to be delivered to the units from 12:40 a.m. to 1:00 p.m., the main dining room was to be served at 1:10 p.m., and dinner meals were to be delivered to the units from 5:00 p.m. to 6:15 p.m. Observations in the main dining room for lunch on January 12, 2025, at 1:02 p.m. revealed that only one resident was present (Resident 83). Interview with Resident 83 at that time revealed that he prefers to eat in the dining room and would prefer to eat dinner in the dining room too. Interview with a group of residents on January 13, 2025, at 11:15 a.m. revealed that they preferred to eat their meals in the dining room and were not aware that the dining room was open and available to eat in. They stopped going because they had to wait for long periods of time in the dining room for a nurse to get there. They were too hungry, and said they were served faster if they just ate in their rooms, so they stopped going. Interview with Licensed Practical Nurse 4 on January 13, 2025, at 12:19 p.m. confirmed that staff do not use the dining room because it is easier for them to serve the residents in their rooms rather than getting them all to the dining room. Interview with Dietary Manager on January 14, 2025, at 12:20 p.m. confirmed that only one resident comes to the dining room for lunch and stated the residents used to come all the time for lunch and for their monthly special breakfast. The residents really enjoyed it, but there has to be a licensed nurse in the dining room and the residents do not like waiting a long time until one is able to come. Interview with Nurse Aide 5 and Nurse Aide 6 on January 14, 2025, at 1:38 p.m. confirmed that only one resident was in the dining room for lunch, and that was because he takes himself. The other residents are served in their rooms due to staffing. They also stated that they were not able to get the residents to activities because the activity aides used to help transport the residents, but they were let go. Nurse Aides 5 and 6 said they were kept too busy with their daily care tasks. Interviews with Nurse Aide 7, Nurse Aide 8, and Nurse Aide 9 on January 14, 2025, at 1:49 p.m. revealed that they did not have enough staff to get their daily care tasks done. They were still showering residents at 12:00 p.m. and were not able to take all the residents to the dining hall that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 11 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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 wanted to go. They would have to take the residents down early and they would have to wait for one to two hours. Residents are served in their rooms. Nurse Aides 7, 8, and 9 believed it was due to staffing. Nurse aides used to have help from the activity aides but they lost two of their people. Interview with Director of Nursing on January 14, 2025, at 2:46 p.m. confirmed that the dining room is open for residents for lunch and dinner. She was not sure why the residents were not using it, and Resident 68 should have been transported to the activity by the nurse aides. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 12 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for one of three nurse aides reviewed (Nurse Aide 10). Residents Affected - Few Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation for Nurse Aide 10 was due September 24, 2024. As of January 15, 2025, there was no documented evidence that the annual performance evaluation was completed as required for Nurse Aide 10. Interview with the Director of Human Resources on January 15, 2025, at 2:03 p.m. confirmed that there was no documented evidence that the annual performance evaluation for Nurse Aide 10 was completed as required. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(c) Staff Development. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 13 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, as well as resident and staff interviews, it was determined that the facility failed to serve palatable food that was at appropriate temperatures. Residents Affected - Many Findings include: Review of food committee meeting minutes for 2024 revealed that the food is burnt, has been cold, and tasted bad. Interview with Resident 66 on January 12, 2025, at 10:47 a.m. indicated that the food tastes burnt and does not taste good, and it is cold at times. Interview with Resident 74 on January 12, 2025, at 1:22 p.m. indicated that the food is terrible and has no taste, there is too much pork, and it is cold. Observations of the kitchen's lunch meal tray line on January 14, 2025, revealed that it began at 12:10 p.m. and included macaroni and cheese, chicken, mashed potatoes, fruit cocktail, and coffee. The last tray was placed on the cart at 12:15 p.m. The cart left the kitchen and arrived on the unit at 12:16 p.m. and the last tray was removed from the cart and served at 12:27 p.m. The test tray was removed from the cart at 12:28 p.m. The macaroni and cheese was 141 degrees Fahrenheit (F), the chicken was 136.5 degrees F and dry to taste, the mashed potatoes were 136.5 degrees F and not palatable, the fruit cocktail was 61 degrees F and warm to taste, and the coffee was 138.3 degrees F. Interview with Director of Dietary on January 14, 2025, at 12:40 p.m. confirmed that the fruit cocktail was a little warmer than she liked. She stated that she had pulled it out of the refrigerator and did not put it back to keep it cold. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.6(f) Dietary Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 14 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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 0807 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Based on observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents' drink and food preferences were honored. Residents Affected - Few Findings include: Interview with a group of residents on January 13, 2025, at 11:15 a.m. revealed that they would enjoy soda, but you can only get soda now if you are sick. They have requested dippy eggs, hot dogs, sausage, kielbasa, and also asked for ice cream as a snack but were told no. One resident stated, We have no joy in our lives, we may as well be in prison. Interview with the Dietary Manager and Nursing Home Administrator on January 14, 2025, at 1:07 p.m. revealed that she is not able to purchase any of the requested drink or snack items for residents and that everything she receives was determined by corporate. She revealed that the beverages on the menu are juices and not soda, and that with the increased cost of food there is no money left to buy the requested snacks such as soda and ice cream. Residents have to purchase the items themselves. She indicated that sometimes she uses her own money to buy things. The Nursing Home Administrator revealed that they do not have hot dogs because it is a choking hazard and someone choked. The Dietary Manager indicated that there is no facility policy regarding tube meat such as hot dogs being a choking hazard. 28 Pa. Code 201.29(j) Resident Rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 15 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review facility policy, as well as observations and staff interviews, it was determined that the facility failed to store and serve food in accordance with professional standards for food service safety by failing to store and serve food under sanitary conditions. Findings include: The facility's current policy for outside food indicated that when food items are intended for later consumption the responsible facility staff member will label foods with the resident's name and current date. Frozen foods may be retained for 30 days. Observations in the main kitchen during an initial tour on January 12, 2025, at 9:17 a.m. revealed that Dietary Employee 11 was removing a cake from the cooler and his hair and beard were exposed and not covered with a hair net or beard guard. Interview with Dietary Employee 11 at that time confirmed that he should have been wearing a hair net and beard guard but he was just getting a cake out. Observations in the solarium refrigerator on January 12, 2025, at 9:35 a.m. revealed that the following items that had resident names but were open and undated or outdated: five pints of ice cream; one cup of ranch dressing; one cup of applesauce; two cups of butterscotch pudding; an eight-ounce glass of chocolate milk with a milk ring around the glass; one piece of pumpkin pie on a paper plate; a half full 16-ounce cup of applesauce; a Tupperware container with two deviled eggs that were turning to liquid and had a bad smell; one old stalk of celery; a plastic bag dated December 29, 2024, with spaghetti; one snack-sized Ziploc bag of moldy meat and cheese dated December 2, 2024; one hard sandwich roll in a Ziploc bag; one plate of grilled chicken breast and mashed potatoes; one four- ounce container of cottage cheese, dated November, 2024; three four-ounce containers of cottage cheese, dated December, 2024; one 1.3-ounce package of pepper snack sticks; and two 10-ounce containers of diet cranberry juice that were three-quarters full. There was a brown, removable substance on the refrigerator door. Interview with the Director of Nursing on January 12, 2025, at 10:22 a.m. confirmed that the food listed above should have been thrown out and that food should be labeled with the resident's name and date upon arrival per the facility's policy. Interview with the Nursing Home Administrator on January 12, 2025, at 1:58 p.m. confirmed that Dietary Employee 11 should have been wearing a hair net and beard guard while in the kitchen. 28 Pa. Code 211.6(f) Dietary Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 16 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plan of correction for a State Survey and Certification (Department of Health) survey ending February 23, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 15, 2025, identified repeated deficiencies related to a failure to ensure that grievances were resolved, care plans were revised/updated, quality of care-physician's orders were followed, nurse aide performance reviews were conducted, and food and drink preferences were honored. The facility's plan of correction for a deficiency regarding a failure to resolve grievances, cited during the survey ending February 23, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F585, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to resolving grievances. The facility's plan of correction for a deficiency regarding a failure to revise or update care plans, cited during the survey ending February 23, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to revising/updating care plans. The facility's plan of correction for a deficiency regarding quality of care, following physician's orders, cited during the survey ending February 23, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to quality of care, following physician's orders. The facility's plan of correction for a deficiency regarding a failure to conduct nurse aide performance reviews, cited during the survey ending February 23, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F730, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to conducting nurse aide performance reviews. The facility's plan of correction for a deficiency regarding a failure to honoring food and drink preferences, cited during the survey ending February 23, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F807, revealed that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 17 of 18 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 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennknoll Village 208 Pennknoll Road Everett, PA 15537 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 0867 facility's QAPI committee was ineffective in correcting deficient practices related to honoring residents food and drink preferences. Level of Harm - Minimal harm or potential for actual harm Refer to F585, F657, F684, F730, F804. Residents Affected - Some 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395422 If continuation sheet Page 18 of 18