Inspection·December 5, 2024

F 0580 indicated that Resident 44 had not exhibited any signs or symptoms and was acting his normal self. Level of Harm - Minimal harm or potential for actual harm Review of Resident 44's clinical record revealed a nursing progress note written by Employee 4 (Registered Nurse) dated November 8, 2024, at 7:00 AM, that indicated Dayshift RN [Registered Nurse] updated to possible ingestion of OTC ES [extra strength] Tylenol and in to assess the resident. Resident placed on alert charting to monitor for any s/s [signs and symptoms] of discoloration/yellow hue to skin, any c/o [complaints of] N(ausea) & V(omiting) or not feeling well, any c/o abdominal pain, or new onset of confusion. RN called MD and awaiting response for possible need of blood work to determine what acetaminophen level is or other orders at this time. Residents Affected - Few Review of Resident 44's clinical record revealed a nursing progress note written by Employee 5 (Registered Nurse) dated November 8, 2024, at 7:34 AM, that indicated MD made aware of possible OTC medication ingestion and that staff are uncertain how much medication was taken. He was also made aware that resident does not have any visible symptoms of toxicity at this time. See new orders to send resident to ED for Toxicity workup. The note further indicated that Employee 5 had a discussion with Resident 44 about the over-the-counter medications in his room, the physician's order to send him to the hospital for an evaluation, and that he agreed to go after discussion. Review of Resident 44's facility provided incident report dated November 7, 2024, at 11:30 PM, completed by Employee 4 indicated that it was prepared based on staff interviews, revealed that a nurse aide had reported to the 3-11 RN Supervisor that Resident 44 had a bag of pills on him and that the nurse aide had witnessed him take a handful of them. It further indicated that Resident 44 told the nurse aide that they were candy and that when the RN arrived in Resident 44's room, the RN witnessed Resident 44 attempting to place the plastic bag of pills in the bedside drawer. The incident report further indicated that the DON was notified on November 8, 2024, at 4:53 AM, and that Resident 44's physician was notified on November 8, 2024, at 7:42 AM. During a staff interview with the Nursing Home Administrator (NHA) and DON on December 5, 2024, at 9:45 AM, the DON indicated that staff had reached out to her about the incident and that staff had monitored him throughout the night and he had no negative outcomes nor any signs or symptoms of toxicity noted. The DON further indicated that the dayshift RN came in and did her due diligence and notified the MD of the occurrence and that was when orders were received to send out to be evaluated. The DON indicated that Resident 44 was sent to the hospital and all testing was negative and he was sent back to the facility with no new orders. The NHA indicated that they have no proof that he in fact took the Tylenol since he called it candy. She said that the daughter did admit that she brought him in Tylenol as well as Tic Tacs. NHA indicated that she met with Resident 44's family because they were upset that the over-the-counter medication was taken away from him. The NHA said she explained the safety/process of self-administering medications when in a facility. During a staff interview with Employee 6 (Registered Nurse) on December 5, 2024, at 11:41 AM, Employee 6 indicated that they were working the morning of November 8, 2024, and that they had received report on Resident 44 from Employee 3 regarding the medication incident. Employee 6 indicated that they could not recall if Employee 3 said they had notified Resident 44's physician of the possible ingestion of an unknown amount of Tylenol. Employee 6 said that they felt inclined to let Resident 44's physician know about what had happened. Employee 6 said that it was discussed with the physician about having labs drawn at the facility, but the physician was concerned regarding the amount of time it would take to get the results back and, therefore, the physician ordered Resident 44 to be sent to the emergency department for an evaluation. Employee 6 indicated that Employee 5 (Registered Nurse) was also present that morning. (continued on next page) 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 12/05/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a staff interview with Employee 5 on December 5, 2024, at 11:50 AM, Employee 5 indicated that Employee 3 confirmed during shift report that they had not notified Resident 44's physician of the possible medication ingestion of an unknown amount of Tylenol and that Employee 3 gave no rationale as to why they did not call Resident 44's physician at the time of the incident. Employee 5 indicated that as soon as they were made aware of the incident in shift report they along with Employee 6 immediately notified Resident 44's physician. During a staff interview with the NHA on December 5, 2024, at 11:59 AM, the NHA indicated that, according to their facility policy, they have 24 hours to notify the physician and that Resident 44's physician was notified within that timeframe. The NHA indicated that Resident 44 was monitored and no significant change in his condition. The NHA indicated that she felt that there was no urgent situation to report as they could not confirm that Resident 44 actually took the medication. The concern was discussed that Employees 5 and 6 (Registered Nurses) indicated that both felt the physician should have been notified at the time of the occurrence and that Employees 2 and 3 (Registered Nurses) had not reported it to Resident 44's physician. In addition, the concern was shared that when Resident 44's physician was finally made aware of the incident approximately 8 hours after it had occurred, he ordered Resident 44 to be sent to the emergency department for evaluation. 201.14(a) Responsibility of licensee 201.18(b)(1) Management 211.12(d)(1)(2)(3)(5) Nursing service 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 12/05/2024 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 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 two of 21 residents reviewed (Residents 8 and 60). Residents Affected - Few Findings Include: Review of Resident 8's clinical record revealed diagnoses that included hypertension (high blood pressure) and anxiety (a feeling of worry, nervousness, or unease). Review of Resident 8's clinical record revealed a physician's order for Oxygen via nasal cannula to maintain saturation above 91 as needed for shortness of breath, with an active date of November 6, 2024. Review of Resident 8's clinical record revealed Resident 8 was administered oxygen via nasal cannula on November 6, 7, 8, and 9, 2024. Review of Resident 8's MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated November 11, 2024, revealed that Section O0110. C1. Oxygen therapy was marked No. During an interview with the Nursing Home Administrator (NHA) on December 4, 2024, at 6:08 PM, revealed Resident 8's MDS dated [DATE], has been modified to reflect oxygen use. Review of Resident 60's clinical record revealed diagnoses that included major depressive disorder (a serious mental illness that can affect how a person feels, thinks, and acts) and dementia (a chronic condition that causes a decline in cognitive abilities, such as thinking, memory, and reasoning, that interferes with daily life). Review of Resident 60's clinical record revealed a physician's order for Bed alarm, with an active date of November 14, 2024. Review of Resident 60's MDS dated [DATE], revealed that Section P0200. A. Bed Alarm was marked No. During an interview with the NHA on December 4, 2024, at 12:31 PM, revealed that the MDS dated [DATE], should have reflected Resident 60's bed alarm use, and a modification will be made. 28 Pa. Code 211.5(f) Medical records 28 Pa Code 211.12(d)(3)(5) Nursing services 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 12/05/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan to address the resident's medical, physical, mental, and psychosocial needs for three of 21 records reviewed (Residents 10, 60, and 75). Findings include: Review of Resident 10's clinical record revealed diagnoses that included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and hypertension (elevated blood pressure). During an interview with Resident 10 on December 2, 2024, at 12:38 PM, she stated that she is a smoker with staff supervision. Review of Resident 10's clinical record revealed a smoking contract was signed by Resident 10 on August 27, 2024, and the most recent smoking evaluation was completed on November 12, 2024, which revealed Resident 10 could smoke with supervision. Review of Resident 10's current care plan failed to reveal a smoking care plan. On December 4, 2024, at 10:58 AM, the Nursing Home Administrator (NHA) stated that a smoking care plan has been added for Resident 10 and provided the smoking care plan, with an initiation date of December 4, 2024. During a follow-up interview with the NHA on December 4, 2024, at 2:00 PM, she confirmed that a smoking care plan was not in place prior to December 4, 2024. Review of Resident 60's clinical record revealed diagnoses that included major depressive disorder (a serious mental illness that can affect how a person feels, thinks, and acts) and dementia (a chronic condition that causes a decline in cognitive abilities, such as thinking, memory, and reasoning, that interferes with daily life). Review of Resident 60's clinical record revealed they were admitted to the facility on [DATE], with a diagnosis of Alzheimer's disease as well as Dementia. Review of Resident 60's current care plan failed to reveal a dementia care plan. On December 4, 2024, at 12:31 PM, the NHA revealed a dementia care plan was added to Resident 60's care plan, with a focus area to include the Resident has impaired cognitive function/dementia or impaired thought process, with a revision date of December 4, 2024. During an additional interview with the NHA on December 4, 2024, at 2:08 PM, revealed she would have expected Resident 60's care plan to include a dementia focus area upon admission. Review of Resident 75's clinical record revealed diagnoses that included urinary retention (a condition in which you are unable to empty all the urine from your bladder) and cancer. (continued on next page) 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 12/05/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Resident 75 on December 2, 2024, at 10:08 AM, Resident 75 indicated that the Resident is a smoker and that residents who smoke must do so outside and that staff must supervise them. Review of Resident 75's clinical record revealed that the Resident had a smoking evaluation completed on June 21, 2024 (which indicated Resident 75 was a smoker); September 15, 2024 (which indicated Resident 75 was a non-smoker); and November 7, 2024 (which indicated that Resident 75 was a smoker). Review of Resident 75's clinical record revealed that the Resident had signed the facility's Smoking Contract on August 27, 2024. Review of Resident 75's care plan failed to reveal that the Resident was a smoker. Email communication received from the NHA on December 4, 2024, at 6:55 PM, indicated that Resident 75's care plan was updated to reflect their desire to smoke. During a staff interview with the NHA and Director of Nursing on December 5, 2024, at 9:33 AM, the NHA confirmed that Resident 75's care plan should have included their desire to smoke prior to yesterday. 28 Pa. Code 211.12(d)(1)(2)(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 12/05/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm 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 clinical record review and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 21 residents reviewed (Residents 1, 11, and 60). Residents Affected - Few Findings Include: Review of Resident 1's clinical record revealed diagnoses that included epilepsy (a brain condition causing recurring seizures) and multiple sclerosis (a chronic autoimmune disease that affects the central nervous system). Review of Resident 1's care plan on December 2, 2024, revealed a care plan with a focus area of, Resident has an alteration in neurological function, with an intervention of IM (intramuscular) Ativan (benzodiazepine medication) as needed for seizure activity, with a date initiated of July 3, 2024. Review of Resident 1's physician orders on December 2, 2024, failed to reveal an order for Ativan for Resident 1. Interview with the Nursing Home Administrator (NHA) on December 4, 2024, at 5:47 PM, revealed that Resident 1's Ativan was discounted in May 2024 and the care plan should have been updated at that time. Review of Resident 11's clinical record revealed diagnoses that included chronic kidney disease (a disease characterized by progressive damage and loss of function of the kidneys) and diabetes (a disease that affects how the body utilizes blood glucose). Review of Resident 11's physician orders on December 2, 2024, revealed an order for, CCHO (consistent, controlled carbohydrate), liberal renal diet with dysphagia advanced texture, and thin consistency. Review of Resident 11's care plan on December 2, 2024, revealed a care plan with a focus area of, Diet: CCHO, dysphagia advanced, thin liquids, no salt packet, with a revision date of June 27, 2023. Interview with the NHA on December 4, 2024, at 5:47 PM, revealed that Resident 11's care plan should have been updated so that it would match Resident 11's current physician's orders. Review of Resident 60's clinical record revealed diagnoses that included major depressive disorder (a serious mental illness that can affect how a person feels, thinks, and acts) and dementia (a chronic condition that causes a decline in cognitive abilities, such as thinking, memory, and reasoning, that interferes with daily life). Review of Resident 60's current physician orders revealed a diet order for regular diet, regular texture, thin consistency, with an active date of November 10, 2024. Review of Resident 60's care plan revealed a focus area which included the Resident may experience weight changes due to ordered therapeutic altered diet related to diabetes, with an initiation date of November 8, 2024. (continued on next page) 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 12/05/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm During an interview with the NHA on December 5, 2024, revealed Resident 60's care plan is incorrect as the Resident is not on a therapeutic diet, and that it should have been updated to reflect their current diet. 28 Pa. Code 211.12(d)(5) Nursing services Residents Affected - Few 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 12/05/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of four residents reviewed (Resident 44). Residents Affected - Few Findings include: Review of facility policy, titled Continuous Positive Airway Pressure, with a last review date of October 24, 2024, indicated that Continuous Positive Airway Pressure or CPAP is a medical device which uses compressed air to keep the air passage open so breathing continues normally and that CPAP must be ordered by a physician. Review of Resident 44's clinical record revealed diagnoses that included obstructive sleep apnea (intermittent airflow blockage during sleep) and asthma (condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus which makes it difficult to breathe). Observations of Resident 44 on December 2, 2024, at 10:48 AM, and December 4, 2024, at 11:14 AM, revealed the presence of a CPAP (continuous positive airway pressure which is a type of ventilator that uses mild air pressure to keep breathing airways open while one sleeps) or BiPAP (bi-level positive airway pressure which is a type of ventilator used to treat sleep apnea) machine sitting at the Resident's bedside. Review of Resident's 44's current physician orders failed to reveal an order for CPAP or BiPAP. Review of Resident 44's physician order history revealed that there was no order for CPAP or BiPAP since their admission to the facility on October 29, 2024. Review of Resident 44's nursing progress notes revealed that the Resident was documented as using CPAP on October 30 and 31, 2024; November 6, 7, 10, 11, and 12, 2024; and December 1 and 2, 2024. In addition, Resident 44 was documented as using a BiPAP on November 5, 2024. Review of Resident 44's care plan revealed that the Resident was care planned for CPAP at HS [bedtime] per order, dated October 30, 2024. Email communication received from the Nursing Home Administrator (NHA) on December 4, 2024, at 6:33 PM, indicated that Resident 44 uses BiPAP not CPAP. During a staff interview with the NHA on December 5, 2024, at 11:33 AM, the NHA confirmed that Resident 44 did not have a physician order for their BiPAP prior to yesterday and that an order should have been obtained when Resident 44's BiPAP machine was brought into the facility. 28 Pa code 211.12(d)(1)(2)(5) Nursing services 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 12/05/2024 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observations, policy review, clinical record review, and staff interview, it was determined that the facility failed to provide adaptive feeding devices for one of 21 residents reviewed (Resident 53). Residents Affected - Few Findings include: Review of facility policy, titled Assistance with Meals, last reviewed October 2024, read, in part, adaptive devices (special eating equipment and utensils) will be provided for residents who need them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups. Review of Resident 53's clinical record revealed diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) and anxiety (a feeling of worry, nervousness, or unease). Review of Resident 53's current active physician orders included: Equipment: lip plate, and Kennedy cup with meals, with an active date of September 10, 2024. Review of Resident 53's care plan included a focus area for nutrition risk, initiated date April 28, 2022, and revised May 26, 2022; with focus areas that included Equipment: lip plate and Kennedy cup with meals, initiated date November 3, 2023. Observation on December 2, 2024, at 12:18 PM, revealed Resident 53 was delivered lunch in his room that contained a lipped plate, however, did not include a Kennedy cup. Observation on December 3, 2024, at 12:31 PM, revealed Resident 53 was delivered lunch in his room that contained a lipped plate, however, did not include a Kennedy cup. Observation on December 4, 2024, at 12:33 PM, revealed Resident 53 was delivered lunch in his room that contained a lipped plate, however, did not include a Kennedy cup. Interview with the Nursing Home Administrator on December 4, 2024, at 6:08 PM, revealed she would have expected Resident 53 to have been served a Kennedy cup with his meals. 28 Pa code 211.6(a) - Dietary 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 12/05/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and staff interview, it was determined that the facility failed to serve food in a sanitary manner during one of one tray line observations in the kitchen. Residents Affected - Few Findings include: Observation of food service tray line on December 4, 2024, at 11:54 AM, revealed that Employee 1 (Cook) was wearing gloves on both hands. Employee 1 was observed to pick up a resident tray ticket from the top of a cart next to the food service line and lay it on a resident tray. Employee 1 was then observed to open a package of hamburger buns by ripping a hole in the bag. Employee 1 was then observed to removing a hamburger bun from the package using their same gloved hands which had touched the tray ticket and the hamburger bun packaging. Employee 1 was then observed reaching into a bin, removing lettuce and tomato, and placing them on a resident plate using their same gloved hands. Observation of Employee 1 revealed that the Employee was continuing to touch tray tickets, hamburger buns, lettuce, and tomato with the same gloved hands for three additional resident trays observed. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing on December 4, 2024, at 2:26 PM, the NHA confirmed that she would expect dietary staff not to have direct contact with resident food items after having direct contact with non-food items such as tray tickets and food packaging. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 201.18(b)(1) Management 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 12/05/2024 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on facility document review and staff interviews, it was determined that the facility failed to provide evidence that Quality Assurance Committee meetings were held at least quarterly for one of four quarters reviewed (First Quarter of 2024). Residents Affected - Few Findings include: Review of all available documentation submitted by the facility revealed no evidence that the facility conducted a Quality Assurance (QA) Committee meeting during the first quarter of 2024 (January, February, March). During an interview with the Nursing Home Administrator (NHA) on December 2, 2024, at 9:41 AM, she stated that the first quarter QA meeting was held with the prior administration at the facility and that the prior administration did not provide her with the sign in sheet for the first quarter QA meeting upon their exit from the facility. In a follow-up interview with the NHA on December 5, 2024, at 10:09 AM, she again confirmed she was unable to provide evidence that the QA meeting was held during the first quarter of 2024, under the prior administration. 28 Pa code 201.18(b)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395426 If continuation sheet Page 12 of 12