Inspection·January 10, 2024

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 interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 19 residents reviewed (Resident 54). Residents Affected - Few Findings include: Review of Resident 54's clinical record revealed diagnoses that included palliative care, severe protein-calorie malnutrition (the state of inadequate food intake), and hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting right dominant side. Review of Resident 54's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of September 26, 2023, revealed in Section K. Swallowing/ Nutritional Status at question K.0300 Weight Loss- Loss of 5% or more in the last month or 10% or more in the last 6 Months that the Resident was coded as 1. Yes, on a physician-prescribed weight loss regimen. Further review of Resident 54's clinical record failed to reveal any documentation or order of a physician-prescribed weight loss regimen. During an interview with Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 9, 2024, at 2:00 PM, the aforementioned coding concern was shared for follow-up. During a follow-up interview with the DON on January 10, 2024, at 11:10 AM, she confirmed that the MDS was coded in error. The Resident had experienced a weight loss, but was not on a physician-prescribed weight loss regimen. She further indicated that a modification to the assessment was completed. Further review of Resident 54's clinical record revealed a progress note dated October 27, 2023, at 11:55 AM, which indicated that they had been enrolled in hospice services last evening. Review of Resident 54's current physician orders revealed an order for [NAME] Hospice, dated October 27, 2023. Review of Resident 54's Significant Change MDS with the assessment reference date of October 30, 2023, revealed in Section O. Special Treatments, Procedures, and Programs at question K1. Hospice care that Resident 53 was coded No. During an interview with the DON on January 10, 2024, at 11:10 AM, the aforementioned MDS hospice coding concern was shared for further follow-up. During a follow-up interview with the DON on January 10, 2023, at 02:00 PM, she confirmed that the MDS was coded in error for the hospice and that a modification would be completed. 28 Pa. Code 211.5(f) Clinical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395426 If continuation sheet Page 2 of 12 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 395426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier at Perry Village for Nursing and Rehab, LL 213 East Main Street New Bloomfield, PA 17068 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 19 residents reviewed (Resident 53). Residents Affected - Few Findings Include: Review of facility policy, titled IIA2: Medication Administration General Guidelines, undated, with a last review date of July 3, 2023, revealed, in part: 11) Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications; 14) For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR [medication administration record] is 'flagged' with appropriate tags. After completing the medication pass, the nurse returns to the missed resident to administer the medication; and 15) The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate. Review of Resident 53's clinical record revealed diagnoses that included personality disorder (a mental health disorder characterized by unstable moods, behavior, and relationships), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Observation of Resident 53 in their room on January 7, 2024, at 12:13 PM, revealed a clear plastic medicine cup with two small white colored capsules, two round orange colored tablets, and one round pink colored round tab. During an immediate interview with Resident 53 indicated that they knew the importance of their medications and always take them. Resident 53 also indicated that usually they [staff] do not leave them. Review of Resident 53's current physician orders failed to reveal an order that they could self-administer any of their medications. During a follow-up interview with Resident 53 on January 7, 2024, at 2:06 PM, the medicine cup of pills was no longer present. She further indicated that Employee 1 came back to see if the medications had been taken after the surveyor left room. During an interview with Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 9, 2024, at 2:00 PM, the aforementioned observation was shared. The DON confirmed that the medications should not have been left at the bedside. She also indicated that she would not consider this Resident safe for self-administration of medications. During a follow-up interview with the NHA and DON on January 10, 2024, at 12:00 PM, the DON indicated she would not consider Resident 53 safe for self-administration of medications because their mental capacity varies throughout the day and, therefore, not always competent. The DON also shared that the there are days when Resident 53 does remember clearly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395426 If continuation sheet Page 3 of 12 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 395426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier at Perry Village for Nursing and Rehab, LL 213 East Main Street New Bloomfield, PA 17068 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 0658 28 Pa. Code 201.18(b)(1) Management Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395426 If continuation sheet Page 4 of 12 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 395426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier at Perry Village for Nursing and Rehab, LL 213 East Main Street New Bloomfield, PA 17068 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents reviewed for mobility (Resident 17). Findings Include: Review of Resident 17's clinical record revealed diagnoses that included Multiple Sclerosis (MS-a disease in which the immune system eats away at the protective covering of nerves) and contractures of the right and left hands and right and left elbows. Review of Resident 17's current physician orders revealed an order dated December 17, 2023, for bilateral elbow extension splints, on with AM care and off with PM care. Review of Resident 17's current care plan, revealed an intervention dated March 10, 2023, for bilateral elbow extension splints, on with AM care and off with PM care. Observation of Resident 17 on January 7, 2024, at 11:47 AM, revealed Resident 17 in her room, dressed, and out of bed to her chair. Further observation revealed Resident 17 was not wearing the bilateral elbow extension splints. Additional observation of Resident 17 on January 7, 2024, at 12:25 PM, revealed Resident 17 in the hallway with her Responsible Party. Resident 17 was not wearing the bilateral elbow extension splints. On January 9, 2024, at 2:09 PM, the Nursing Home Adminstrator (NHA) and Director of Nursing (DON) were made aware of the observations of Resident 17 not wearing her splints on January 7, 2024. In a follow-up interview with the NHA and DON on January 10, 2024, at 12:03 PM, they stated that they have been unable to follow-up with the staff who was responsible for Resident 17 on January 7, 2024, as to why the splints were not in place. The NHA and DON were asked if the splints should have been in place, per order, and the DON stated that the order is for the splints to be placed after AM care. Surveyor stated that, at the time of the observation, it appeared that AM care had been done, as Resident 17 was dressed for the day and out of bed. No additional information was provided. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395426 If continuation sheet Page 5 of 12 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 395426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier at Perry Village for Nursing and Rehab, LL 213 East Main Street New Bloomfield, PA 17068 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on clinical record review and staff interview, it was determined that the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections and complications related to the use of a foley catheter (small, flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain) for one of two residents reviewed for use of a catheter (Resident 42). Findings Include: Review of Resident 42's clinical record revealed diagnoses that included paraplegia (impairment in motor or sensory function of the lower extremities) and neuromuscular dysfunction of the bladder (urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination). Review of Resident 42's physician orders revealed an order dated October 20, 2023, for a foley catheter for neuromuscular dysfunction of the bladder. Review of Resident 61's current care plan revealed that catheter care was to be done every shift. Review of available clinical documentation for the past 30 days failed to reveal evidence that catheter care was completed each shift. During an interview with the Director of Nursing on January 10, 2024, at 12:08 PM, she confirmed that there was not an order created for routine catheter care, therefore, she was not able to provide documentation that catheter care was completed. 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395426 If continuation sheet Page 6 of 12 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 395426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier at Perry Village for Nursing and Rehab, LL 213 East Main Street New Bloomfield, PA 17068 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 Based on clinical record review and staff interview, it was determined that the facility failed to ensure that assessed nutritional interventions were provided to maintain acceptable nutritional parameters for one of 19 residents reviewed (Resident 20). Residents Affected - Some Findings: Review of Resident 20's clinical record revealed diagnoses that included Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior) and acute kidney failure (when your kidneys become unable to filter waste products from your blood). Review of Resident 20's clinical record revealed a progress note entered by dietary on February 12, 2023, that indicated Resident 20 had a 17.3% weight loss within 180 days. Progress note indicated that the facility will monitor weekly weight and tolerance tube feeding for additional recommendations as needed. Review of Resident 20's clinical record revealed a progress note entered by dietary on March 20, 2023, indicating Resident 20's 17/3% weight loss within 180 days. Progress note stated that weekly weight monitoring continues. Review of Resident 20's clinical record revealed that Resident 20 weighed 145 pounds on October 5, 2023, and 129 pounds on January 7, 2024, indicating Resident 20 has had an 11.3% weight loss in that time frame. Review of Resident 20's current physician orders revealed an order to weigh patient weekly, document in point click care, with an active date of January 12, 2023. Review of Resident 20's clinical record under the weights and vitals section revealed Resident 20 was not weighed during the following weeks: February 19 and 26, 2023; March 12, 19, and 26, 2023; April 9, 16, and 23, 2023; May 14 and 21, 2023; June 11, 18, and 25, 2023; July 16 and 23, 2023; August 13, 20, and 27, 2023; September 17 and 24, 2023; October 15 and 22, 2023; November 19 and 26, 2023; and December 10, 17, and 24, 2023. Review of Resident 20's current comprehensive person-centered care plan revealed a focus area indicating Resident 20 may be nutritionally at risk, with an initiation date of March 15, 2022. Resident 20's intervention under that area indicated to complete weights as ordered, with an initiation date of March 15, 2022. During an interview with the Director of Nursing (DON) on January 10, 2024, at 1:11 PM, revealed that weekly weights were not being completed on Resident 20 due to it not being added as a task. DON revealed that the order for weekly weights was not added as a task on Resident 20's Medication administration record (MAR), therefore, it was not scheduled for anyone to do, it was just sitting in Resident 20's orders. DON revealed they would have expected weekly weights to have been completed on Resident 20 if it was added as a task in the MAR. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395426 If continuation sheet Page 7 of 12 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 395426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier at Perry Village for Nursing and Rehab, LL 213 East Main Street New Bloomfield, PA 17068 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 - Some 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 Food and Drug Administration (FDA) information review, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free of unnecessary psychotropic medications for one of five residents reviewed (Resident 35). Findings include: Review of the FDA drug safety information revealed a black box warning for quetiapine (Seroquel) (antipsychotic medication) for increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel is not approved for elderly patients with Dementia-Related Psychoses. Review of facility policy, titled Antipsychotic Medication Use, with a last revised date of December 2016, and a last review date of July 3, 2023, revealed, in part, the following: Policy Statement: Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional, psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed; 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; 2. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident or others; 3. The Attending Physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications; and 11. Antipsychotic medications will not be used if the only symptoms are one or more of the following: a. wandering; b. poor self-care; c. restlessness; d. impaired memory; e. mild anxiety; f. insomnia; g. inattention or indifference to surroundings; h. sadness or crying alone that is not related to depression or other psychiatric disorders; i. fidgeting; j. nervousness; or k. uncooperativeness. Review of Resident 35's clinical record revealed diagnoses that included Alzheimer's Dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and dementia in other diseases with unspecified severity and without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident 35's physician order history revealed an order for quetiapine fumarate (Seroquel) give 12.5 milligrams by mouth at bedtime related to dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety for two weeks, then discontinue. Review of Resident 35's September Medication Administration Record revealed the Resident received their last dose of quetiapine fumarate (Seroquel) on September 11, 2023. Review of Resident 35's care plan revealed a care plan focus for using drugs that have an altering effect on the mind characterized by problems with cardiac, neuromuscular, gastrointestinal systems as evidenced by a diagnosis of dementia with psychosis, hallucinations, delusions, with an initiated date of March 27, 2023, and a revision date of October 24, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395426 If continuation sheet Page 8 of 12 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 395426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier at Perry Village for Nursing and Rehab, LL 213 East Main Street New Bloomfield, PA 17068 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 - Some Review of Resident 35's clinical record failed to reveal a diagnosis of dementia with psychosis, hallucinations, or delusions. Review of Resident 35's clinical record failed to reveal any other documentation of any episodes or psychosis, hallucinations or delusions exhibited by Resident 35 between September 11, 2023, and October 20, 2023. Review of Resident 35's clinical record progress notes revealed a physician's progress note dated October 23, 2023, at 6:09 PM, which indicated Patient with increased behaviors, wandering and agitation since dc [discontinuation] of Seroquel; alert combative; SDAT [Senile Dementia Alzheimer's Type] with agitation resume Seroquel 25 mg HS; Failed GDR [gradual dose reduction]. Review of Resident 35's current physician orders revealed an order for quetiapine fumarate (Seroquel) 25 milligrams (an antipsychotic medication) give one tablet by mouth at bedtime related to dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dated October 23, 2023. Further review of Resident 35's clinical record and care plan failed to reveal that Resident 35's target behaviors to monitor for were not identified, and that there was no documentation that behaviors were being monitored and documented since the quetiapine fumarate (Seroquel) was ordered on October 23, 2023. Email communication received from DON on January 10, 2023, at 10:17 AM, indicated that, during Resident 35's tapering of the quetiapine fumarate (Seroquel), the Resident was noted to be refusing meds and scratching at self. She also indicated that Resident 35 began with increased agitation and exit seeking. Physician reviewed and recommended the restart of Seroquel d/t [due to] failed GDR [gradual dose reduction]. She further indicated that after 6 days of restart [Resident 35] was still noted to have behaviors including uncooperative with care. Review of Resident 35's September 2023 Point of Care documentation revealed no documentation that care was refused other than locomotion. Review of Resident 35's October 2023 Medication Administration Record revealed no documentation that medications were refused. Review of Resident 35's October 2023 Point of Care documentation revealed no documentation that care was refused. During an interview with the DON and the Regional Director of Clinical Services on January 10, 2024, at 11:10 AM, the findings of Resident 35's Point of Care documentation and Medication Administration for September 2023 and October 2023 were reviewed. During a follow-up interview with the NHA, DON, and Regional Director of Clinical Services on January 10, 2024, at 12:05 PM, the following concerns were shared: documentation indicated that Seroquel was restarted after one documented episode of wandering that was addressed with an assessment and a wanderguard being placed; there were no target behaviors identified for the use of the antipsychotic at the time it was restarted and that, as of time of meeting, there were still no target behaviors identified; review of point of care documentation and progress notes failed to reveal any documentation of any behaviors being exhibited by Resident 35 between September 11, 2023, and present; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395426 If continuation sheet Page 9 of 12 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 395426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier at Perry Village for Nursing and Rehab, LL 213 East Main Street New Bloomfield, PA 17068 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 - Some refusals of care and/or medications would not warrant the use of an antipsychotic medication; and all residents have the right to refuse medications and/or care. The Regional Director of Clinical Services indicated that Resident 35 did had behavior monitoring of sadness, withdrawn, insomnia, and somnolence in place. Surveyor shared that these had been in place since February 17, 2020, and were associated with Resident 35's antidepressant medication. It was also discussed that these are not typical behaviors to support the use of an antipsychotic. She confirmed that these are not typical behaviors for the use if an antipsychotic. Follow-up review of Resident 35's physician orders on January 10, 2023, at 1:03 PM, revealed an order dated January 10, 2024, for Behavior Monitoring: (yelling out, agitation, exit seeking) every shift. During a final interview with the DON on January 10, 2024, at 1:11 PM, the DON indicated that Resident 35's physician orders were revised for target behaviors and that she had no additional information to provide regarding target behaviors or the resumption of the quetiapine fumarate (Seroquel). She confirmed that the Resident's target behaviors should have been identified at the time the medication was ordered. She further indicated that she had no documentation to show that there were any behaviors that warranted the use of an antipsychotic occurring prior to the resumption of the quetiapine fumarate (Seroquel) on October 23, 2023. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395426 If continuation sheet Page 10 of 12 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 395426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier at Perry Village for Nursing and Rehab, LL 213 East Main Street New Bloomfield, PA 17068 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff and resident interviews, grievance review, and record review, it was determined that the facility failed to offer and/or provide dental services for one of 19 resident records reviewed (Resident 16). Residents Affected - Some Findings: Review of Resident 16's clinical record revealed diagnoses that included Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by nerves) and hypertension (high blood pressure). During an interview with Resident 16 on January 7, 2024, at 12:36 PM, Resident 16 revealed they lost their lower partial denture about six weeks ago, and it was reported to the facility. Resident 16 revealed they were not in pain, but it is hard to chew. Observation of Resident 16 on January 7, 2024, at 12:37 PM, revealed they were missing their lower partial denture and did not have it in their mouth. Review of Resident 16's comprehensive person-centered care plan revealed an intervention to complete denture care every morning and hour of sleep, with an initiation date of November 2, 2023. Review of the facilities November 2023 grievance log revealed a grievance was filed by Resident 16 on November 13, 2023, with the nature of concern being missing upper plate and lower denture. Disposition/resolution on the grievance log revealed Resident 16's room was searched and family was aware they are responsible, with a date of November 14, 2023. Review of the grievance that was filed on November 13, 2023, on behalf of Resident 16, revealed Resident 16's son called into the facility to inform that Resident 16's dentures have been missing since November 11, 2023. Steps taken to investigate the grievance indicated Resident 16's room was searched, and their empty denture cup was sitting on top of their dresser. Laundry and dietary was notified of missing denture. Review of the summary of pertinent findings revealed the family is aware if they want to replace upper plate and lower partial, they are responsible for doing so. Corrective action taken indicated the family knows they are responsible to pay for the dentures. Resolution date for the grievance was dated November 15, 2023. Review of Resident 16's clinical record revealed a progress note entered on December 15, 2023, that stated dentures have been missing for a few weeks, son wanted the facility to pay for a replacement set, the dentures were not damaged by the facility and will not be paid to replace, and son will let facility know which dentist he would like to use to replace Resident 16's dentures. Review of Resident 16's progress notes fail to include any documentation prior to December 15, 2023, regarding setting up an appointment to replace their missing dentures. During an interview with the Nursing Home Administrator (NHA) on January 9, 2024, at 1:53 PM, revealed they are still waiting to hear back from Resident 16's son on which dentist he wants Resident 16 to use. NHA revealed they did not notify or make a referral to dental within three days the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395426 If continuation sheet Page 11 of 12 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 395426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier at Perry Village for Nursing and Rehab, LL 213 East Main Street New Bloomfield, PA 17068 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 0790 Level of Harm - Minimal harm or potential for actual harm dentures were reported to be missing, and they did not have an assessment completed on the Resident to determine if Resident 16 was still able to eat or drink adequately. Review of Resident 16's current physician orders reveal an order to consult dental, podiatry, optometry, dietary - evaluate and treat as needed, with an active date of December 4, 2023. Residents Affected - Some During an interview with the NHA on January 10, 2024, at 11:59 AM, revealed the facility uses Healthdrive dental group as their dentist, and that the facility does not have a policy relating to lost or missing dentures. Pa Code 211.15(a) - Dental Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395426 If continuation sheet Page 12 of 12