Health inspection·April 22, 2025

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview completed on 4/22/25, at 11:30 a.m. Resident R1 was up, appeared well groomed and was sitting in her chair next to her bed. Upon asking how she is treated by the staff she replied fine so far and continued to state there was one girl who was very rough my care, my bum still hurts they are using cream on it. Upon asking if she could recall when this occurred she replied about three weeks ago, when I was on the lower floor. Resident began to get tearful and continued to express the event that occurred. Resident R1 stated I think her name was [NAME], I have never had anyone abuse me like that. Resident R1 continued to say she used a washcloth, it was like rape I have not have anyone ever treat me like that, she put it in my bum. There was another Nurse Aid (NA) in the room while this happened he told her to back up and get away from me Resident R1 further stated the police came in and took my statement. They had a doctor come in to see me, I'm real jumpy, I will never be ok again in my mind, the feelings inside me are not only physical but part of me is gone. Oh her name was NA Employee E6, she also did it to the lady across the hall from me. Resident was tearful when giving the information of this event, she stated It helps to talk about it I can let it all out Review of facility reported event (ERS-event reporting system) factual description indicated that on 4/7/25, the Director of Nursing (DON) was approached by two NA's to report concerns with Resident R1, staff reported that the resident was handled very roughly by another NA, they felt the action was inappropriate. Resident R1 reported to the DON and Social Worker that she had been hurt by the female NA who had been providing her care prior to her 3:00 p.m. smoke break. Resident reported that it felt like an ice scraper was being used on her buttocks to clean her bowel movement. Resident reported that she was screaming at the NA to stop, and that the NA seemed to be in a really bad mood and was swinging me around in the bed ResidentR1 felt this interaction was humiliating and very painful. Review of the facility reported follow up action in ERS indicated: NA suspended immediately pending investigation. Staff statements obtained. Resident assessed by the DON and Licensed Practical Nurse (LPN) for injury to buttocks /peri area. No redness or bruising identified, but resident complains of burning pain. Resident provided with stock barrier cream for comfort and was previously medicated with as needed pain medication. Verbal report made to local state police, awaiting state trooper arrival at facility to provide full report of incident. Resident will be followed by facility SW to monitor emotional wellbeing. PB-22 to be submitted. Review of Resident R1's behavior progress note dated 4/8/25, at 1:22 p.m. created by LPN Employee E3 indicates: Resident very tearful, asked to speak with her guardian. Resident states she was sexually abused yesterday and doesn't know what she did to deserve it. Resident says If something isn't done about her I'm going to call the policy and press charges. Resident also reports feeling unsafe and that she doesn't want to trust anyone to provide incontinence care on her. Staff on hall today permitted to provide care. During an interview completed on 4/22/24, at 11:02 a.m. upon asking LPN Employee E3, if she recalled the behavior note completed on 4/8/25, at 1:22 p.m. concerning Resident R1's concerns and if she reported the allegation of sexual abuse to anyone stated I don ' t remember who I told, it would have been on the daylight shift and was told just to watch her. During an interview completed on 4/22/25, at 12:30 p.m. The DON stated I was never made aware of that, I have not read that note and was never made aware of the sexual allegation, just the physical allegation that was in the investigation, the sexual allegation was not investigated. When I interviewed Resident R1 she did not make that accusation, she reported that the female NA hurt her, stating it felt like an ice scrapper was being dragged on her butt. If I was aware I would have offered addition services and confirmed that the facility failed to implement written policies and procedures to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395118 If continuation sheet Page 2 of 3 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 395118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Chicora 160 Medical Center Road Chicora, PA 16025 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 0607 ensure a complete and thorough investigation of an allegation of sexual abuse for one of four residents (Resident R1). Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14(a) Responsibility of licensee Residents Affected - Few 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12(c)(d)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395118 If continuation sheet Page 3 of 3