Health inspection·December 11, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for four of 21 residents reviewed (Resident 5, 14, 56, and 99).Findings Include:Review of Resident 5's clinical record revealed diagnoses that included hypertension (high blood pressure) and dysphagia (difficulty swallowing).Review of Resident 5's comprehensive care plan revealed a care plan for being at risk for elopement with an intervention for the resident to have door alarms on at all times, with an initiation date of July 15, 2025; and an intervention for a wander guard, with an initiation date of July 15, 2025. Further review of Resident 5's elopement care plan revealed an intervention for a chair alarm that was discontinued on June 25, 2025.Review of Resident 5's Significant change MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) completed on July 18, 2025, revealed in Section P0200; Alarms, B. Chair alarm was marked as being used daily, and F. Other alarms was marked as not being used.Review of Resident 5's quarterly MDS completed on October 17, 2025, revealed in Section P0200; Alarms, F. Other was marked as not being used.During an interview with the Nursing Home Administrator (NHA) on December 11, 2025, at 11:54 AM, it was revealed that Resident 5's Significant change MDS completed on July 18, 2025, and Quarterly MDS completed on October 17, 2025, were coded incorrectly, and Section P0200 F. Other should have been marked as being used daily to reflect the use of the door alarm.Review of Resident 14's clinical record revealed diagnoses that included malignant neoplasm of pelvis (cancerous tumors in the pelvic region) and encounter for palliative care (a medical visit focused on improving quality of life for serious illness, addressing symptoms [pain, anxiety, etc.], discussing goals, and supporting patients/families emotionally).Review of Resident 14's Significant change MDS dated [DATE], revealed that Section J1400. Prognosis; was coded as Code 0. No, indicating that Resident 14 was not terminally ill and was not receiving hospice services.Review of Resident 14's physician's orders revealed an order from October 6, 2025, to admit Resident 14 to hospice services.Review of Resident 14's care plan, initiated January 3, 2025, revealed the focus area of: Resident 14 is receiving hospice care related to end stage illness.An interview with the NHA on December 11, 2025, at 9:58 AM, revealed that Resident 14's MDS completed on October 16, 2025, was marked in error and that Resident 14 had been receiving hospice services at that time, so J1400 should have been coded as 1. Yes.Review of Resident 56's clinical record revealed diagnoses that included dementia (severe cognitive decline that impairs daily life, often due to brain cell damage) and anxiety (a persistent feeling of unease, worry, or fear that often interferes with daily life).Review of Resident 56's comprehensive care plan revealed a falls risk care plan with an intervention for a chair alarm, with an initiation date of November 22, 2024, and a revision date of June 29, 2025.Review of Resident 56's annual MDS completed on October 1, 2025, revealed in Section P0200; Alarms B. Chair alarm was marked as not being used. During an interview with the NHA on December 11, 2025, at 10:30 Residents Affected - Few Page 1 of 3 395426 395426 12/11/2025 Premier at Perry Village for Nursing and Rehab, LL 213 East Main Street New Bloomfield, PA 17068

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few AM, she revealed that Resident 56's annual MDS completed on October 1, 2025, was marked in error and the chair alarm should have been marked as being used daily, and that a modification MDS was being completed.Review of Resident 99's clinical record revealed diagnoses that included chronic kidney disease (irreversible loss of kidney function where damaged kidneys can't effectively filter waste and excess fluid from the blood, leading to buildup that causes swelling, fatigue, and potential heart problems, with diabetes and high blood pressure being the leading causes) and encounter for palliative care.Review of Resident 99's Significant change MDS dated [DATE], revealed that in Section J1400. Prognosis; was coded as Code 0. No, indicating that Resident 99 was not terminally ill and was not receiving hospice services.Review of Resident 99's Quarterly MDS dated [DATE], revealed that in Section J1400. Prognosis; was coded as Code 0. No, indicating that Resident 99 was not terminally ill and was not receiving hospice services.Review of Resident 99's physician's orders reveal an order from June 28, 2025, to admit Resident 99 to hospice services.Review of Resident 99's care plan initiated October 6, 2025, revealed a focus area of: Resident 99 is receiving hospice care related to end stage illness.An interview with the NHA on December 11, 2025, at 9:58 AM, revealed that Resident 99's MDS completed on June 30, 2025, and September 30, 2025, were marked in error and that Resident 99 had been receiving hospice services at that time, so J1400 should have been coded as 1. Yes.28 Pa Code 211.12 (d)(3)(5) Nursing services. 395426 Page 2 of 3 395426 12/11/2025 Premier at Perry Village for Nursing and Rehab, LL 213 East Main Street New Bloomfield, PA 17068

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 facility document review and staff interviews, it was determined that the facility failed to complete a performance review for nurse aide staff at least once every 12 months for two of five employees reviewed (Employees 1 and 2). Findings Include: Review of select facility documentation revealed that Employee 1 was hired on July 13, 2021, and Employee 2 was hired on October 15, 2024. Review of Employee 1's most recent employee performance evaluation revealed that it was dated as being completed on December 8, 2025. Review of Employee 2's most recent employee performance evaluation revealed that it was dated as being completed on December 9, 2025. During an interview with the Nursing Home Administrator on December 11, 2025, at 11:22 AM, she stated that Employee 1's prior performance evaluation was completed on October 17, 2024. She further stated that Employee 2 was hired in October 2024 and did not have any previous performance evaluations completed. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.19(2) Personnel policies and procedures Residents Affected - Few 395426 Page 3 of 3