Health inspection·August 11, 2023

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Nursing Home Administrator and Director of Nursing on August 10, 2023, at 2:05 PM confirmed the above noted findings related to Resident 28's self-administration of medication form. Observation on August 10, 2023, at 10:13 AM revealed that Resident 28 asked Employee 6, Licensed Practical Nurse, for cream to her bottom. Employee 6 indicated to Resident 28 that she had some cream in her room in a cup. The facility failed to assess Resident 28 for the clinical appropriateness to self-administer topical medications. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 2 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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 provide the correct required notification to a resident whose payment coverage changed for two of three residents reviewed (Residents 29 and 31). Residents Affected - Few Findings include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. Confirm the telephone contact by written notice mailed on that same date. A review of the Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 revealed that examples of the common reasons why an extended care stay, or services may not be covered under Medicare might include the beneficiary no longer requires daily skilled care for a medical condition but wants to continue residing in the skilled nursing facility (SNF). The SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. In the blank that follows Beginning on ., the skilled nursing facility enters the date on which the beneficiary may be responsible for paying for care that Medicare is not expected to cover. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The SNF must issue this notice when there is a termination of all Medicare Part A services for coverage reasons. If after issuing the NOMNC, the SNF expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN must be issued to inform the beneficiary of potential liability for the non-covered stay. Clinical record review of census information for Resident 31 revealed that the facility provided services primarily paid for by Medicare starting May 15, 2023. Resident 31's Medicare payment for services ended May 26, 2023. A review of a CMS-10123 form provided by the facility indicated that Resident 31's last covered day of Medicare A services ended May 26, 2023. The facility did not provide a CMS-10055 form for Resident 31. The facility provided a CMS-R-131 form that the facility used in place of the CMS-10055 form. Resident 31 signed the CMS-R-131 form on May 23, 2023. The graph on the CMS website (Beneficiary Notices Initiative) stipulates that the provider types (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 3 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for the CMS-R-131 form use include independent laboratories, home health agencies, hospices, physicians, practitioners, and providers paid under Medicare Part B. The same graph instructs that skilled nursing facilities are to use the CMS-10055 form. Clinical record review of census information for Resident 29 revealed that the facility provided services primarily paid for by Medicare A starting December 16, 2022. Resident 29's Medicare payment for services ended January 27, 2023. A review of a CMS-10123 form provided by the facility indicated that Resident 29's last covered day of Medicare A services ended January 27, 2023. The facility did not provide a CMS-10055 form for Resident 29. The facility provided a CMS-R-131 form that the facility used in place of the CMS-10055 form. Resident 29's wife signed the CMS-R-131 form on January 24, 2023. The surveyor reviewed the above findings regarding the provision of the incorrect notice during an interview with the Nursing Home Administrator and the Director of Nursing on August 9, 2023, at 2:00 PM. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 4 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record review and staff interview, it was determined that the facility failed to provide written notice of transfer to residents' responsible parties for three of five residents reviewed for hospitalization concerns (Residents 2, 18, and 20). Findings include: Clinical record review for Resident 2 revealed nursing documentation dated August 2, 2023, at 3:45 AM that nurse aide staff found Resident 2 laying on the floor in his room. Resident 2 had slurred and stuttered speech. Resident 2 was not oriented to person or time, had constricted pupils, and staff called emergency medical services to transport Resident 2 to the hospital. Staff notified Resident 2's son of the transfer by telephone. Medication administration documentation dated August 2, 2023, at 9:05 AM revealed that Resident 2 was admitted to the hospital. The facility provided a letter dated August 2, 2023, addressed to Resident 2's nickname (without his legal full name or mention of his responsible party) that noted his transfer to the hospital was necessary to evaluate any possible injuries after his fall. The facility did not provide any documentation to indicate that Resident 2's responsible party received written notification of his transfer and admission to the hospital on August 2, 2023. Interview with the Director of Nursing and the Nursing Home Administrator on August 11, 2023, at 11:00 AM confirmed that the facility did not have evidence that Resident 2's responsible party received the notice of transfer. Clinical record review for Resident 18 revealed a progress note dated April 10, 2023, at 4:41 AM that indicated she was found on the floor in the bathroom in a pool of blood. She was sent out to the hospital related to being on a blood thinner. The facility did not provide any documentation to indicate that Resident 18's responsible party received written notification of her transfer and admission to the hospital on April 10, 2023. Clinical record review for Resident 20 revealed that the facility transferred him to the hospital on July 29, 2023, related to issues with his foley catheter. The surveyor requested that the facility provide evidence that Residents 2, 18, and 20 and their responsible party received written notification of the transfer during an interview with the Nursing Home Administrator and the Director of Nursing on August 9, 2023, at 2:00 PM. The facility did not provide any documentation to indicate that Resident 20's responsible party received written notification of his transfer and admission to the hospital on July 29, 2023. Interview with the Director of Nursing on August 11, 2023, at 12:45 PM confirmed that the facility did not have evidence that Resident 18 or Resident 20's responsible party received written notification of their transfer to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 5 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 28 Pa. Code 201.14(a) Responsibility of licensee Level of Harm - Potential for minimal harm 28 Pa. Code 201.29(a) Resident rights Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 6 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 - Some 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 select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to residents' responsible parties for three of five residents reviewed for hospitalization concerns (Residents 2, 18, and 20). Findings include: The facility policy entitled, Bed Hold Policy, last reviewed without changes on November 15, 2022, revealed that before transferring a resident to the hospital, the facility would provide the resident and responsible party (or family) a copy of the facility's bed hold policy and rates. The facility would hold a resident's bed placement at that designated rate as long as the resident and/or family member/responsible party authorized payment. The procedures portion of the policy indicated that the facility would type in the specific bed-hold policy and rates in that reserved section; however, there were no specific entries made by the facility specific to their rates. Clinical record review for Resident 2 revealed nursing documentation dated August 2, 2023, at 3:45 AM that nurse aide staff found Resident 2 laying on the floor in his room. Resident 2 had slurred and stuttered speech. Resident 2 was not oriented to person or time, had constricted pupils, and staff called emergency medical services to transport Resident 2 to the hospital. Staff notified Resident 2's son of the transfer by telephone. Medication administration documentation dated August 2, 2023, at 9:05 AM revealed that Resident 2 was admitted to the hospital. The facility provided a letter dated August 2, 2023, addressed to Resident 2's nickname (without his legal full name or mention of his responsible party) that noted his transfer to the hospital was necessary to evaluate any possible injuries after his fall. The notice indicated that the facility would hold Resident 2's bed during his hospitalization if payment was arranged. The notice indicated that if Resident 2's stay was covered by the continuing care community contract, the bed-hold fees were included in the monthly fee. The facility did not provide any documentation to indicate that Resident 2's responsible party received written notification of the facility's bed-hold policy at the time of transfer of Resident 2's transfer and admission to the hospital on August 2, 2023. Interview with the Director of Nursing and the Nursing Home Administrator on August 11, 2023, at 11:00 AM confirmed that the facility did not have evidence that Resident 2's responsible party received the notice of the facility's bed-hold policy. Clinical record review for Resident 18 revealed a progress note dated April 10, 2023, at 4:41 AM that indicated she was found on the floor in the bathroom in a pool of blood. She was sent out to the hospital related to being on a blood thinner. The facility did not provide any documentation to indicate that Resident18's responsible party received written notification of the facility's bed-hold policy at the time of Resident 18's transfer and admission to the hospital on April 10, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 7 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 - Some Clinical record review for Resident 20 revealed that the facility transferred him to the hospital on July 29, 2023, related to issues with his foley catheter. The surveyor requested that the facility provide evidence that Resident 2, 18, and 20's responsible party received written notification of the facility's bed-hold policy during an interview with the Nursing Home Administrator and the Director of Nursing on August 9, 2023, at 2:00 PM. The facility did not provide any documentation to indicate that Resident 20's responsible party received written notification of the facility's bed-hold policy at the time of his transfer to the hospital on July 29, 2023. Interview with the Director of Nursing on August 11, 2023, at 12:45 PM confirmed that the facility did not have evidence that Resident 18 or Resident 20's responsible party received written notification of the facility bed-hold policy at the time they were transferred to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a)(1) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 8 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 clinical record review and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered weights for one of 16 residents reviewed (Resident 8) and regarding a change in condition for one of 12 residents reviewed (Resident 5). Residents Affected - Few Findings include: Clinical record review for Resident 8 revealed a physician's order dated December 2, 2022, that staff were to complete weekly weights on day shift every Friday. Review of Resident 8's clinical documentation revealed that staff did not complete Resident 8's weights on the following dates: December 23 and 30, 2022 February 24, 2023 April 21 and 28, 2023 May 26, 2023 June 2, 9, 23, and 30, 2023 July 7, 2023 The surveyor reviewed the above information during an interview on August 9, 2023, at 11:30 AM with the Nursing Home Administrator. Interview with Resident 5 on August 8, 2023, at 2:48 PM revealed that he was experiencing diarrhea for four or five days. Interview with Resident 5 on August 10, 2023, at 1:45 PM revealed that he felt, a little better, but still (had) diarrhea. Review of bowel elimination records for Resident 5 dated August 2023 revealed that staff documented formed/normal bowel movements on August 1, 2, 3, and 4, 2023. Staff documented loose/diarrhea bowel movements on the following dates and times: August 5, 2023, at 10:38 AM August 6, 2023, at 5:35 AM and 9:17 AM August 7, 2023, at 4:24 AM, 8:35 AM, and 9:57 PM August 8, 2023, at 1:05 AM and 9:19 AM August 9, 2023, at 10:55 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 9 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 August 10, 2023, at 4:26 PM Level of Harm - Minimal harm or potential for actual harm Review of Resident 5's active physician orders revealed that on August 7, 2023, the physician ordered the administration of Imodium A-D (medication used to treat diarrhea by slowing down the movement of the gut; decreases the number of bowel movements and makes the stool less watery) 2 mg (milligrams) every four hours as needed for diarrhea. Residents Affected - Few Review of progress note documentation available in Resident 5's clinical record revealed no evidence that nursing staff assessed Resident 5's gastrointestinal status upon the new diarrhea symptom. No nursing staff documented notification to Resident 5's physician or responsible party that Resident 5 exhibited a new symptom of diarrhea or the start of the Imodium medication. There was no evidence that staff performed routine assessments to monitor Resident 5's change in condition (e.g., signs and symptoms of dehydration or gastric upset, changes in appetite, assessments of temperature, mental status changes, etc.). There was no evidence that staff educated Resident 5 regarding increasing his fluid intake to prevent potential dehydration secondary to his loose stools. Review of Resident 5's medication administration record (MAR, electronic documentation of the administration of medications) dated August 2023 revealed that no staff administered the Imodium medication from August 7 through 10, 2023; however, staff documented withholding Resident 5's medications for loose stools as follows: August 11, 2023, at 7:34 AM, Colace (stool softener), Polyethylene Glycol (fiber laxative), and Senna-Time (stimulant laxative) August 10, 2023, at 5:49 PM, Colace and Senna-Time August 9, 2023, at 7:48 PM, Colace and Polyethylene Glycol August 6, 2023, at 4:22 PM, Colace and Senna-Time August 6, 2023, at 7:41 AM, Colace and Senna-Time Resident 5's August 2023 MAR indicated that staff administered Polyethylene Glycol on August 5 and 7, 2023, at 8:00 AM. Staff administered Resident 5's Colace at 8:00 AM and 5:00 PM on August 5 and 7, 2023. Staff administered Resident 5's Senna-Time at 8:00 AM and 5:00 PM on August 5 and 7, 2023, and at 5:00 PM on August 8, 2023. The documentation indicated that staff did not consistently hold medications that promoted bowel movements during the time Resident 5 reported diarrhea. Interview with the Director of Nursing on August 11, 2023, at 9:02 AM confirmed that the facility had no evidence of routine assessments of Resident 5 when he presented with a change in condition starting on August 5, 2023. The surveyor also reviewed concerns regarding staff administering stool softeners without administering the Imodium medication as ordered when Resident 5 exhibited diarrhea. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 10 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 - Some 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 clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion for three of five residents reviewed (Residents 14, 21, and 22). Findings include: Clinical record review for Resident 14 revealed a current care plan for staff to provide restorative active ROM (range of motion, movement of the body to maintain a resident's ability) to her bilateral upper extremities (arms, BUE) to maintain functional performance and active ROM to her bilateral lower extremities (legs, BLE) to increase strength to improve functional mobility. Review of task documentation for Resident 14 from June and July 2023, revealed that staff documented not applicable or did not document completion of the restorative task on the following dates: Active ROM to BUE: June 8, 13, 14, 17, 18, and 27, 2023 July 5, 6, 7, 11, 20, and 25, 2023 Active ROM to BLE: July 7, 2023 Clinical record review for Resident 21 revealed a current care plan for staff to provide a restorative transfer program for strengthening and passive ROM to her 3rd and 4th digits of her left hand and BUE. Review of task documentation for Resident 21 from June, July, and August 2023, revealed that staff documented not applicable or did not document completion of the restorative task on the following dates: Transfer program: June 3, 11, 14, 16, 22, 23, and 27, 2023 July 11, 15, 18, 21, and 24, 2023 August 3, 4, and 10, 2023 Clinical record review for Resident 22 revealed an Occupational therapy referral dated May 6, 2023, for staff to provide restorative passive ROM to her BUE for 2 sets x 10 BID (twice daily) Review of task documentation for Resident 22 from May, June, July, and August 2023, revealed that staff documented not applicable or did not document completion of the restorative task on the following dates: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 11 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 May 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30 and 31, 2023 Level of Harm - Minimal harm or potential for actual harm June 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 22, 23, 24, 25, 26, 27, 28, and 30, 2023 Residents Affected - Some July 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 30, 2023 August 2, 4, 7, 8, and 10, 2023 The surveyor reviewed the above information on August 9, 2023, at 2:45 PM with the Nursing Home Administrator and Director of Nursing. 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 12 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on clinical record review, observation, and staff interview, it was determined that the facility failed to thoroughly investigate incidents and implement interventions in response to falls for one of nine residents reviewed for falls (Resident 18); and ensure an environment free from potential accident hazards on one of two nursing units (first floor, Resident 28). Findings include: Clinical record review for Resident 18 revealed a nursing progress note dated March 25, 2023, at 4:40 AM that indicated she was found on the floor in the bathroom with her head partially in the shower. She had right lower back pain and two small open areas. She got up to use the bathroom and slipped. Her blood sugar was 51. A new intervention was to have Resident 18 ring her call bell for help and to provide a protein snack at bedtime. Review of the facility investigation into Resident 18's fall from March 25, 2023, at 4:40 AM revealed an incident review form dated March 29, 2023, that indicated that the potential contributing factor to the fall was that her blood sugar dropped. The new intervention would be to have the resident ring for help before getting out of bed and to eat a protein snack at bedtime. Review of Resident 18's task sheet (where daily care is recorded in the computer documentation system) revealed that the protein snack was never initiated until April 24, 2023. Review of Resident 18's nutritional services progress notes date April 18, 2023, revealed to provide increased protein snack options at bedtime. Interview with the Director of Nursing on August 11, 2023, at 11:18 AM revealed that there was no evidence that Resident 18's increased protein snacks were initiated until April 24, 2023. The facility failed to initiate a timely intervention in response to Resident 18's fall on March 25, 2023. Observation of Resident 28 on August 8, 2023, at 11:50 AM revealed she was wandering on the nursing unit. At 12:15 PM she exited the unit into the lobby. She indicated she was going to the dining room. Clinical record review for Resident 28 revealed a quarterly MDS (minimum data set, an assessment completed by the facility at intervals to determine care needs of the resident) assessment that revealed her BIMS (Brief interview for mental status) score was 3, indicating she has a severe cognitive impairment. Observation of the main lobby on August 9, 2023, at 4:03 PM revealed that one of the double doors that led to the first-floor nursing unit was propped open creating unfettered access from the nursing unit to the main lobby. The automated glass doors from the main lobby and another unlocked and unmonitored door led from the main lobby to the parking lot. No staff were present in the nursing unit hallway or facility main lobby on the date and time of the observation. Interview with Employee 9 (registered dietitian who was in an office within the main lobby) on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 13 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 August 9, 2023, at 4:04 PM revealed that she was unaware of the unsecured doors. During the interview with Employee 9 while observing the unsecured doors, Employee 1 (health care associate/main lobby receptionist) arrived in the lobby area and confirmed that she left the main lobby area unattended to perform another task on the first floor. Residents Affected - Some The unsecured and unmonitored doors presented a potential accident hazard for a wandering resident. The surveyor reviewed the above door security concerns with the Nursing Home Administrator and the Director of Nursing on August 10, 2023, at 2:00 PM. The Nursing Home Administrator confirmed that doors between the nursing unit and the main lobby should always closed and secured via a keypad. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 14 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, clinical record review, review of select facility policies and procedures, and staff and resident interview, it was determined that the facility failed to assess for the risk of bed rail entrapment for three of four residents reviewed for accident hazards (Residents 3, 4, and 5). Findings include: The facility policy entitled Bedrail, last reviewed without changes on November 15, 2022, indicated the objective of the policy was to identify and reduce safety risks and hazards commonly associated with bed rail use through interdisciplinary evaluation to determine if residents use of bed rail equipment is safe and appropriate. Technical issues such as the proper sizing of mattresses, fit and integrity of bed rails, or other design elements can affect the risk of resident entrapment risk. The facility maintenance department will establish a regular maintenance program to include regular inspection of all bed systems to include rails, frames, entrapment zones, mattresses, and operational components. The policy includes an overview of the United States Food and Drug administration's potential zones of bed entrapment as their guide for assessment and education. The policy indicated that the FDA provided dimensional recommendations for zones one through four as 80 percent of reported entrapment cases have occurred in these zones. Observation of Resident 4's bed on August 8, 2023, at 11:15 AM revealed one side against the wall and a bed rail enabler bar on the side of the bed closest to the door. Concurrent interview with Resident 4 revealed that she utilized the bed rail to help her sit up and turn. Clinical record review for Resident 4 revealed a consent form signed by her noting the risk and benefits of utilizing the bed rail. The Nursing Home Administrator (NHA) provided the surveyor with a form that she indicated was utilized to assess Resident 4's bed rail entrapment zones. The form entitled Recommendations did not have a completion date on it. The form did not assess zone 1 (area within the rail) and was marked not applicable for zone 2 (under the rail, between rails supports, or next to a single rail support) and zone 3 (between rail and mattress). The form indicated that zone 4 (under the rail, at the ends of the rail) passed. Interview with the Nursing Home Administrator on August 10, 2023, at 2:15 PM confirmed the above noted findings that the facility failed to properly assess Resident 4's bed rail enabler bar for the risk of entrapment. Observation of Resident 3's room on August 8, 2023, at 4:00 PM revealed her bed was equipped with a right-sided assist bar. Clinical record review for Resident 3 revealed an undated and unsigned entrapment zone assessment form. The form indicated that Resident 3's right-sided assist bar passed zones one through three; however, the form did not indicate an assessment for zone four. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 15 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 0700 Level of Harm - Minimal harm or potential for actual harm Observation of Resident 5's room on August 8, 2023, at 2:59 PM revealed the head of his bed was equipped with assist bars on both sides of his bed. Clinical record review for Resident 5 revealed an entrapment zone assessment form that noted a review of zone four; however, the form did not indicate an assessment of zones one through three. Residents Affected - Some Residents 3 and 5 had the same style of assist rails on their beds. The surveyor reviewed the above concerns regarding a thorough assessment of potential assist rail entrapment zones for Residents 3 and 5 during an interview with the Nursing Home Administrator and the Director of Nursing on August 10, 2023, at 2:00 PM. 28 Pa. Code 211.12 (d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 16 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 staff education records and staff interview, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for a nurse aide as required for one of three nurse aides reviewed (Employee 7). Residents Affected - Few Findings include: Review of Employee 7's, nurse aide, education records revealed that she had a hire date of May 18, 2015, with 3.75 hours of Inservice education between May 18, 2022, to May 18, 2023. An interview with the Nursing Home Administrator on August 11, 2023, at 9:35 AM confirmed the above noted findings that Employee 7 did not have the required minimum 12 hours of education over the 12-month period. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.20(a) Staff Development FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 17 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement a behavioral management plan to attain the highest practicable well-being for one of three residents reviewed for behavioral concerns (Resident 14). Findings include: Clinical record review for Resident 14 revealed that she attended a behavioral health visit on April 19, 2023, which revealed a diagnosis of major neurocognitive disorder due to Alzheimer's disease with behavioral disturbance. The nurse practitioner indicated that Resident 14 continued with aggressive behaviors towards staff and residents, that she had been refusing medications, is having poor sleep, and frequently wanders the unit until physical exhaustion, without staff being able to redirect her. The practitioner also noted Resident 14's continued paranoia. She indicated that she would see Resident 14 again in approximately eight to 10 weeks or sooner if another psychiatric need arises. Observation of Resident 14 on August 8, 2023, at 12:00 PM revealed that she was sitting on her bed and grinding her teeth. Observation of Resident 14 throughout the day on August 9, 2023, revealed that she would frequently walk/pace the nursing unit and grind her teeth. There was no documentation that indicated that Resident 14 was scheduled for or attended a follow-up visit with her behavioral health provider in June or July 2023, as requested by the nurse practitioner until after identified by the surveyor. Interview with the Director of Nursing on August 10, 2023, at 10:00 AM confirmed the above findings. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 18 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that the consultant pharmacist appropriately documented the monthly drug regimen review, and that the physician appropriately acted upon a reported irregularity for one of five residents reviewed for potentially unnecessary medications (Resident 2). Findings include: The facility policy entitled, Consultant Pharmacist Services Requirements, last reviewed November 15, 2022, revealed that regular and reliable consultant pharmacist services are provided to residents. The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. In collaboration with the facility staff, the consultant pharmacist helps to identify, communicate, address, and resolve concerns and issues related to the provision of pharmaceutical services. This includes but is not limited to helping to assure that the procedures address the needs of the residents and reflect current standards of practice and providing nationally recognized organizational information to facility staff and practitioners as needed. Specific activities include reviewing the medication regimen of each resident at least monthly, incorporating federally mandated standards of care, and documenting the review and findings in the resident's medical record. The policy did not address the expectation of a physician practitioner to appropriate respond to a consultant pharmacist recommendation. Clinical record review for Resident 2 revealed a physician's order active since his admission on [DATE], to administer Clonazepam (an anti-anxiety psychotropic medication) 1 mg (milligram) every day at bedtime for anxiety. Consultant pharmacist electronic documentation dated January 13, 2023, at 12:22 PM, noted, January drug regimen review complete, no significant finding noted. A separate written report to Resident 2's physician also dated January 13, 2023, requested that the physician consider a gradual dose reduction (GDR) of Resident 2's Clonazepam 1 mg daily at hour of sleep for a diagnosis of insomnia (the inability to fall or stay asleep). Although the consultant pharmacist documented that there was no, significant finding, he/she also documented the need to review a psychotropic medication for a gradual dose reduction on the same date. The consultant pharmacist did not correctly document whether he/she did or did not have a medication irregularity; or that one was referred to the resident's physician in the electronic medical record progress note. Resident 2's physician disagreed with the consultant pharmacist recommendation on January 19, 2023, with a rationale of long standing. The physician did not document an appropriate rationale (e.g., previously failed GDR, persistent distressing target behaviors, etc.) in the resident's medical record. Resident 2's clinical record did not contain evidence that the facility identified the target behaviors exhibited by Resident 2 due to his anxiety diagnosis. The record did not contain evidence that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 19 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility monitored the frequency of a target behavior or non-medicinal interventions used to reduce or discontinue the antianxiety medication use. Interview with the Nursing Home Administrator and the Director of Nursing on August 11, 2023, at 11:00 AM confirmed that the facility did not have evidence of the monitoring of target behaviors that supported the continuation of the Clonazepam medication; or that persistent target behaviors would clinically contraindicate the reduction of the Clonazepam medication. The facility did not have evidence that Resident 2 ever failed an attempt of a gradual dose reduction of the Clonazepam medication. 28 Pa. Code 211.2(d)(3)(8)(9) Medical director 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 20 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medication for one of five residents selected for medication regimen review (Resident 2). Findings include: The facility policy entitled, Psychotropic (Psychoactive) Drug Documentation, last reviewed without changes on November 15, 2022, revealed that staff will document data collected on a resident's response to psychotropic drug administration and assessment of side effects to assess therapeutic value of therapy. Psychoactive drugs are used only in the resident's best interest and non-drug approaches and interventions and/or drug therapy are used whenever possible. General guidelines for assessment may include, but are not limited to, behavior patterns, causes of stressful or inappropriate behavior, stimulus for behavior to be treated, medical symptoms, resident's response to drug therapy, and whether the behavior is easily altered. The components of specifying behavior included to have the prescriber specify the medical necessity and specific targeted behavior to be treated in the order for the psychotropic drug. List the behavior to be treated, as specified by the prescriber, in the problem list of the resident's care plan. List a measurable goal for elimination of, or decrease in, the behavior in the goal column of the resident's care plan. In the approach/plan column of the resident's care plan, list the name of the drug. State where data on effectiveness and side effects will be documented according to facility policy. List other non-drug interventions to be used to reduce or eliminate the behavior. List drug holidays or the planned drug reduction schedule. Identify the behavior being treated in the licensed nurses' progress notes. Data presentation to the prescriber will include the stipulation of the behavior treated, the episodes of the behavior, the occurrence of side effects, and the response to the drug therapy. Clinical record review for Resident 2 revealed a physician's order active since his admission on [DATE], to administer Clonazepam (an anti-anxiety psychotropic medication) 1 mg (milligram) every day at bedtime for anxiety. Resident 2's clinical record did not contain evidence that the facility identified the target behaviors exhibited by Resident 2 due to his anxiety diagnosis. The record did not contain evidence that the facility monitored the frequency of a target behavior, or non-medicinal interventions used to reduce or discontinue the antianxiety medication use. Review of plans of care developed by the facility to address Resident 2's care needs revealed that goals and approaches did not include reference to the reduction or discontinuation of the anti-anxiety medication. A consultant pharmacist report to Resident 2's physician dated January 13, 2023, requested that the physician consider a gradual dose reduction (GDR) of Resident 2's Clonazepam. Resident 2's physician disagreed with the consultant pharmacist recommendation on January 19, 2023, with a rationale of long standing. The physician did not document an appropriate rationale (e.g., previously failed GDR, persistent distressing target behaviors, etc.) in the resident's medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 21 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 record. Level of Harm - Minimal harm or potential for actual harm Interview with the Nursing Home Administrator and the Director of Nursing on August 11, 2023, at 11:00 AM confirmed that the facility did not have evidence of the monitoring of target behaviors that supported the continuation of the Clonazepam medication. The facility did not have evidence that Resident 2 failed a previous attempt of a gradual dose reduction. Residents Affected - Few 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 22 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 clinical record review and staff interview, it was determined that the facility failed to provide routine dental services for one of 16 residents (Resident 22). Residents Affected - Few Findings include: Clinical record review for Resident 22 revealed that the facility contracted dental hygienist indicated the following: On October 13, 2022, noted that Resident 22's number 13 tooth had retained silver that had shifted with visible fistula noted near the apex, indicating an active infection. She recommended that a physician or dentist be consulted for a possible antibiotic and evaluation of extraction of number 13. On June 16, 2023, the hygienist again noted a concern with tooth 13. It was broken to the gum line, with some retained and loose pieces. The resident did not appear in pain, so it would be up to the family if they would like the resident to be seen by a dentist for an extraction of the remaining fractured tooth and root. There was no documentation that the facility addressed Resident 22's hygienist concerns with tooth #13 after either hygienist visit until after identified by the surveyor. This surveyor reviewed the above information during an interview on August 10, 2023, at 10:35 AM with the Director of Nursing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 23 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation and resident and staff interview it was determined that the facility failed to ensure an environment free from the spread of infection for one of 12 residents reviewed (Resident 5) and during resident laundry processing. Residents Affected - Some Findings include: Observation of Resident 5's room on August 8, 2023, at 3:04 PM revealed a facial mask stored directly on the surface of his bedside stand. The mask was not bagged or protected from potential contaminants. Interview with Resident 5 on the date and time of the observation revealed that he had not used the respiratory equipment in months, and that he used it as needed for medicinal treatments when he had difficulty breathing. Observations of Resident 5's room on August 10, 2023, at 1:36 PM, and August 11, 2023, at 10:04 AM, revealed that the facial mask remained stored directly on the surface of his bedside table (unprotected from potential contaminants). Observation of Resident 5's room during an interview with Employee 8 (licensed practical nurse) on August 11, 2023, at 10:11 AM confirmed that Resident 5's respiratory equipment should be cleaned, dried, and then bagged for storage when not in use. Employee 8 removed the equipment from the room and confirmed that Resident 5 had not used respiratory equipment for as needed medication for a significant amount of time. Observation of the facility's laundry department with Employee 2 (laundry) on August 11, 2023, at 9:37 AM revealed that the facility utilized one large open area for the processing of soiled and clean laundry. There was no partition to separate the process of loading soiled laundry in washers from the process of loading cleaned laundry into dryers or storing clean laundry until covered in transport equipment. Employee 2 stated that she did not know the weight capacity of the washers in the department; and did not have equipment to weigh a load before processing it in the available washers. Employee 2 contacted Employee 3 (director of facilities) on August 11, 2023, at 9:41 AM to determine what chemicals used by the laundry department might sanitize resident laundry. Observation of Employee 2's processing of laundry on August 11, 2023, at 9:44 AM revealed that Employee 2 removed cleaned laundry from the washing machine and stored the clean laundry in an uncovered wheeled bin. Employee 2 then obtained a new load of soiled laundry and loaded the washer while within six feet of the uncovered bin of clean laundry. There was no barrier to prevent the potential contamination of the cleaned laundry during the process. Continued observation of Employee 2 on August 11, 2023, at 9:47 AM revealed that she obtained another load of soiled laundry and loaded it into another washing machine while the bin of uncovered cleaned laundry and the uncovered bin of soiled laundry were separated by only a few inches. There was no barrier to prevent the potential contamination of the cleaned laundry during the process. Interview with Employee 3 upon his arrival to the laundry department on August 11, 2023, at 9:53 AM revealed that neither he nor Employee 2 were able to identify a chemical used in the processing of laundry that would sanitize residents' personal laundry. Employee 3 called the facility's chemical supplier and confirmed that the facility did not have a system to maintain washing temperatures considered necessary to ensure that laundry is hygienically cleaned; and did not currently use a chemical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 24 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some product that would sanitize laundry to ensure it was hygienically cleaned. The interview confirmed that the facility had no method to monitor the weight of laundry loads when processed to ensure that appropriate agitation hygienically cleaned residents' laundry. The surveyor reviewed the concerns regarding the storage of Resident 5's respiratory equipment and the facility's processing of residents' personal laundry during an interview with the Director of Nursing and the Nursing Home Administrator on August 11, 2023, at 11:00 AM. 28 Pa. Code 205.26(c) Laundry 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 25 of 26 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 396092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Penn State, The 260 Lion's Hill Road State College, PA 16803 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure the administration of a pneumococcal vaccine for one of five residents reviewed for immunization concerns (Resident 27). Residents Affected - Few Findings include: The facility policy entitled, Pneumococcal Prevention, last reviewed without changes on November 15, 2022, revealed that residents will be offered the pneumococcal vaccine if they have never received the vaccine or need a pneumococcal booster. A vaccine information sheet will be given to, and consent will be obtained from, the resident or the resident advocate prior to administration of the vaccine. Clinical record review for Resident 27 revealed that the facility admitted him on June 14, 2022. Review of Resident 27's immunization history revealed no evidence of a pneumococcal vaccine. The surveyor requested information regarding Resident 27's pneumococcal vaccination, or declination of the vaccine following education regarding the risks and benefits, during interviews with the Nursing Home Administrator and the Director of Nursing on August 9, 2023, at 2:00 PM, and August 11, 2023, at 10:28 AM. The interview with the Nursing Home Administrator and the Director of Nursing on August 11, 2023, at 10:28 AM revealed that the facility believed an interview with Resident 27's wife indicated that Resident 27 received a pneumococcal vaccine; however, there was no documented evidence of Resident 27's pneumococcal vaccinations. The facility was unable to provide evidence that Resident 27, or his wife, was offered a pneumococcal immunization, received education regarding the risks and benefits of the pneumococcal vaccinations, or that Resident 27, or his wife, refused the vaccine. 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396092 If continuation sheet Page 26 of 26