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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 395426 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 12/11/2025 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)