Health inspection·November 10, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete cart. This writer heard a loud thud followed by the resident yelling for assistance. This writer and nurse aide immediately went down hall and upon entering, the resident was observed to be sitting on the floor between the commode and the sink. Resident stated, I was trying to get back into by wheelchair. Review of Resident R4's hospital dated 10/14/25, stated per nursing home staff, the resident had an unwitnessed fall last night. They put him back into bed. It was revealed around 4 a.m. the facility notified the Nurse Practitioner who recommended the resident was sent to the Emergency Department because the resident was on Eliquis (blood thinning medication). During an interview on 11/9/25, at 2:48 p.m. RN Supervisor, Employee E15, if an incident occurs the physician and family are notified immediately. RN, Supervisor, Employee E15 confirmed the facility failed to timely notify a physician after a resident had a fall. During an interview on 11/10/25, at 9:52 a.m. Registered Nurse, Employee E14 stated As far as hospital situation, I was unaware he was going. It was revealed the resident fell before midnight on 10/13/25, and then around 5 a.m. all the sudden the ambulance showed up, I had no idea he was going, Supervisor never notified me. RN, Employee E14 stated I am unsure if I documented a progress note. During an interview on 11/10/25, at 12:06 p.m. Nursing Home Administrator confirmed the facility failed to ensure the physician was appropriately notified of change in condition for one of four residents (Resident R4). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c)(d) Resident Care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services. Event ID: Facility ID: 395118 If continuation sheet Page 2 of 21 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 11/10/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that residents' medication regime was free from unnecessary psychotropic (a mind-altering medication) medication for one of three residents (Resident R8). Findings include: Review of facility Behavior Standard Index policy dated 5/19/25, indicated the purpose is to develop and implement behavioral plans, and medication regimes, in efforts to optimize the functional abilities of residents while monitoring for adverse side effects and improve behaviors. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/4/25, indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), anxiety, and high blood pressure. Review of Resident R8's physician order dated 7/14/25 through 10/14/25, indicated to administer Ativan (used to treat anxiety) 0.5 milligrams every six hours as needed (PRN) for three months. Review of Resident R8's physician order failed to include a 14 day stop date and there was no documented rationale by the physician for the medication to extend past 14 days for Resident R8's Ativan. Review of Resident R8's Medication Administration Record dated September 2025, indicated that residents received Ativan PRN 27 times. Review of Resident R8's Medication Administration Record dated October 2025, indicated that residents received Ativan PRN 22 times. Review of Resident R8's Progress Notes dated September and October 2025, failed to indicate any non-pharmacological interventions used prior to administering Resident R8's Ativan. During an interview on 11/9/25, at 2:56 p.m. Registered Nurse Employee E11 stated we should order psychotropic medications for 14 days and prior to giving PRN medication we would try non-pharma logical interventions (NPI) such as toileting, offering drinks or food to decrease behaviors. If you give a psychotropic medication the behaviors and NPI should be documented. During an interview on 11/9/25, at 4:15 p.m. the Chief Nursing Officer Employee E7 confirmed that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for one of three residents (Resident R8). 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.10(a) Resident care policies Event ID: Facility ID: 395118 If continuation sheet Page 3 of 21 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 11/10/2025 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 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety Based on policy, employee files, facility documents, staff interviews, it was determined that the facility failed to ensure all nursing staff were educated on abuse/neglect before working in the facility for one of five staff members (LPN, Employee E1) and two of five staff members (LPN, Employee E2 and Registered Nurse, Employee E3) annually. The facility failed to identify incidents of abuse/neglect, and timely report and investigate allegations of abuse/neglect. The facility put other residents at risk for abuse/neglect from Licensed Practical Nurse (LPN), Employee E1 by allowing the staff member to continue to work after abuse/neglect allegations were made. This failure created an immediate jeopardy situation.Findings include: Review of the facility's policy titled Resident Protection from Abuse, Neglect, Mistreatment or Exploitation review date of 5/19/25, indicated it is the policy of the facility that each of its own and operated homes treat all residents with kindness, respect and in a manner that is at all times free from any form of abuse, neglect, misappropriation of property, exploitation, or mistreatment. To protect our residents, each of our homes will implement procedures in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. The facility has developed and implemented personnel and other policies to ensure that all staff are qualified and meet all regulatory standards for hire. In addition, we screen our employed contracted prior to employment, Employed staff, upon hire and at least annually through in-service education will receive training on issues related to abuse prohibition and prevention. We provided adequate supervision of our staff to identify inappropriate behaviors and to ensure that care/services are provided safely and as needed. We provide appropriate information to our staff of those residents with potential for aggressive behavior. Abuse and neglect will be identified through various methods such as reports from employed or contracted staff, utilization of resident incident reports, review prior incidents and any patterns of staff behaviors. Allegations involving residents, visitors, employees, or any other person must be reported to the Administrator or Director of Nursing (DON) immediately. The Administrator or DON will notify the Department of Health via electronic reporting system within 24 hours of the incident and complete an on-line PB-22 if directed to do. The County Area Agency on Aging will be contacted and a verbal report of allegation of abuse will be submitted within 24 hours of the event. All written reports shall include, at a minimum, the name and age of the resident, address of resident representative, address of the home, nature of the alleged offense, and any specific comments or observations that are directly related to the alleged incident and individuals involved. All investigation will be conducted thoroughly and will attempt to gather as much factual information as possible. If a specific employee is suspected of abuse of a resident, the home shall immediately implement a plan of supervision or, where appropriate, reassignment, suspension or where appropriate, reassignment, suspension or termination of employment of the employee. The Elder Justice Care Act requires each owner, operator, employee, manager, agency, or contractor of a nursing home facility (a covered individual) to report any responsible suspicion of a crime no later than (2) hours after forming the suspicion. In addition to reporting all obligation described above, covered individuals must report any reasonable suspicion of a crime to the Department of Health and to the local police serving the community where the resident is receiving care. Review of witness statement dated 10/31/25, revealed Housekeeper, Employee E6 has worked at the facility for 13 years and since LPN, Employee E1 started on the memory impaired unit she has never seen so many die at one time. Housekeeper, Employee E6 stated I think they are given something they shouldn't be. It raises flags, and stated residents seem sedated. Review of Nurse Aide (NA), Employee E5's undated witness statement revealed, I have concerns with LPN, Employee E1, keeps people snowed. Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395118 If continuation sheet Page 4 of 21 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 11/10/2025 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and gives melatonin and Tylenol even if not ordered. Review of LPN, Employee E4's witness statement dated 10/31/25, revealed about a month ago, LPN, Employee E4 was receiving report from LPN, Employee E1 when it was reported Resident R1 was hypothermic and when asked if the resident's temperature was rechecked or a nurse was notified, LPN, Employee E1 stated a RN wasn't informed. During report LPN, Employee E1 also stated everyone gets melatonin and made references to administering everyone Tylenol. Resident R1 was found to have an abnormally low rectal temperature upon follow up. Residents were also more sedated than usual and lethargic. Residents were not fully awake or unable to eat a meal until supper time. This was the resident's daily for the whole weekend. Also, NA, Employee E5 came to me stating that LPN, Employee E1 gave everyone Tylenol and melatonin. I told aide to do the right thing and report this to the DON and Nursing Home Administrator. Review of facility documentation submitted on 11/3/25, revealed the DON was approached by staff that they had suspicions that a staff member was allegedly giving medication to all residents whether they had an order from a provider or not. Further review failed to reveal allegations of residents being sedated, unable to consume meals during the day, or increase in deaths on the memory impaired unit. During an interview on 11/5/25, at 9:56 a.m. LPN, Employee E4 revealed while receiving report from LPN, Employee E1 about a month ago, during the weekend of 9/28/25, LPN, Employee E1 instructed everyone gets melatonin. and made references to administering everyone Tylenol. LPN, Employee E4 stated residents were also more sedated than usual and lethargic, residents were not fully awake or able to eat a meal until suppertime. This was the residents condition for the whole weekend. LPN, Employee E4 stated NA, Employee E5 came to me stating LPN, Employee E1 gave everyone Tylenol and melatonin. I told the aide to do the right thing and report it. Facility nursing staff failed to report an allegation of abuse/neglect during the weekend of 9/28/25, when LPN, Employee E4 was made aware of abuse allegations. Interview conducted on 11/5/25, at 10:01 a.m. Housekeeper, Employee E6 indicated LPN, Employee E1 made the comment Monday, that she was giving everyone melatonin. Housekeeper, Employee E6 stated the weekend Resident R1 was sent out to the hospital for a change in condition, all day Saturday and Sunday residents couldn't open their eyes, eat, talk to us or anything. Housekeeper, Employee E6 stated I think something was given overnight and expressed concerns related to the increase in deaths on the memory impaired unit. I had nine people pass away just in October. Every time LPN, Employee E1 works, residents are much more tired. Interview conducted on 11/5/25, 10:15 a.m. LPN, Employee E7 stated I see a decline in residents where LPN, Employee E1 is working, but they have been here for years. A lot of them decline faster than I thought they would have. Interview conducted on 11/5/25, at 11:14 a.m. NA, Employee E8 stated sometimes LPN, Employee E1 says she is going to give them their medication, so she has a good night. They were kind of hard to wake up the next day, some wouldn't wake up, go through breakfast lunch, did get them up for supper. NA, Employee E8 stated. I worked with her twice a week and only noticed resident druggy, overly sleeping when she works the day before. During an interview on 11/5/25, at 11:24 a.m. NA, Employee E9 stated they have concerns with LPN, Employee E1. NA, Employee E9 stated, LPN, Employee E1 makes the comment, we are going to have a good night, they are going to go to bed and rest. NA, Employee E6 stated residents were sleeping the next morning, couldn't eat, couldn't get out of bed, it's been ongoing since LPN, Employee E1 has been working back there. Nursing floor staff failed to identify, correct, and intervene in situations in which allegations of abuse and neglect were reported on the Memory impaired unit since 9/28/25. During an interview on 11/6/25, at 10:19 a.m. LPN, Employee E1 was asked if they have been trained on dementia training and stated I am unsure if dementia training was completed. I am very used to working with them, worked as an aide years ago. I want them comfortable; I don't want them in pain. That's my goal. On 11/6/25, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395118 If continuation sheet Page 5 of 21 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 11/10/2025 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few a review of LPN, Employee E1's agency RN/LPN Skills List dated 5/16/25, was not signed by a clinical staff member. A review of the personnel file for Licensed Practical Nurse (LPN), Employee E1 revealed LPN, Employee E1 worked at the facility through agency from 7/23/25, to 8/17/25. There was no evidence that LPN, Employee E1 was educated on abuse prior to starting on 7/23/25. LPN, Employee E1 was hired as in-house staff on 8/26/25. During an interview on 11/6/25, at 11:30 a.m. the DON revealed LPN, Employee E1's agency skills were completed by a reference and confirmed LPN, Employee E1 failed to complete the facility's documentation required for onboarding prior to agency staff working in the facility. A review of the personnel file for LPN, Employee E2 revealed LPN, Employee E3, began working at the facility through agency on 1/18/24. There was no evidence LPN, Employee E2 was educated on abuse annually. A review of the personnel file for Registered Nurse (RN), Employee E3 revealed RN, Employee E2 began working at the facility through agency on 6/15/23. There was no evidence RN, Employee E3 was educated on abuse annually. During an interview on 11/6/25, at 2:02 p.m. the Director of Nursing (DON) stated she was made aware of allegations of abuse/neglect on 10/27/25, by Housekeeper, Employee E6. The DON confirmed the facility did not obtain witness statements until 10/31/25, for a total of 5 days after being notified of allegation of abuse. The Director of Nursing confirmed LPN, Employee E1 continued to work (on 10/29/25, 5:53 p.m. to 6:30 a.m.) after suspicions of abuse/neglect were reported. During an interview on 11/6/25, at 2:04 p.m. the DON and NHA confirmed the facility was made aware of an allegation of neglect involving LPN, Employee E1 on 10/27/25. The DON and NHA confirmed the facility failed to timely initiate an investigation, report to appropriate agencies, and suspend the alleged perpetrator immediately. During an interview on 11/6/25, at 4:08 p.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility failed to ensure one of five agency staff members were educated on abuse prior to their start date (LPN, Employee E1), and failed to ensure two of five agency staff members were educated on abuse annually (LPN, Employee E2 and RN, Employee E3). During a second attempted phone interview on 11/7/25 at 9:32 a.m. NA, Employee E5 was unavailable for interview. On 11/7/25, at 12:41 p.m., the NHA and DON were made aware of Immediate Jeopardy (IJ) related to abuse and neglect. The NHA was provided with the IJ Template, the facility failed to ensure all nursing staff were educated on abuse/neglect prior to working in the facility and annually. The facility failed to identify incidents of abuse/neglect, and report and investigate allegations of abuse/neglect timely. The facility put other residents at risk for abuse/neglect from Licensed Practical Nurse (LPN), Employee E1, was allowed to continue to work after allegations were made. A corrective action plan was requested. On 11/7/25, at 3:40 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: -Current medical records will be reviewed for any signs of abuse/neglect from the last 30 days. All interview able residents will also be interviewed for any signs and/or symptoms of abuse and/or neglect. If any is found abuse policy will be followed and an investigation and reporting will begin immediately. This will be completed by Monday, 11/10/25. -All staff will be interviewed for allegations of abuse/neglect that have not been reported in the last 30 days by the DON and/or designee. If any are identified, investigations and reporting will begin immediately. This will be completed by Saturday 11/8/25. -Education will be completed by the Chief Nursing Officer to the Director of Nursing and Nursing Home Administrator on immediate reporting of any allegation/neglect by 11/7/25. -Education will be completed by the Chief Nursing Officer to the Director of Nursing and Nursing Home Administrator on the immediate suspension of an employee with an allegation of abuse/neglect by 11/7/25. -Education to be completed by the DON/Designee to Licensed Nursing Staff both in house and agency on the appropriate medication administration and following Physician's orders by Monday, 11/10/25, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395118 If continuation sheet Page 6 of 21 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 11/10/2025 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few or prior to their next scheduled shift. An audit of each resident's Medication Administration Record (MAR) and Treatment medication Record (TAR) will be completed to ensure medications and treatments have been administered/given as ordered for the last 30 days. -NHA and/or designee will review the Abuse/Neglect Policy and will update if needed. This will be completed by 11/7/25. -All house staff and agency staff will be educated on the abuse/neglect policy and reporting abuse by the DON and/or designee prior to their next shift worked. This will be completed by Monday, 11/10/25. -All audits and policy changes related to immediate jeopardy will be reviewed at an ad hoc Quality meeting by Monday, 11/10/25. Review of 95 of 95 resident clinical records for incidents or allegations of abuse or neglect, 3 of 95 had concerns for abuse/neglect, 1 of the 3 were already reported and an investigation for the other two were immediately initiated. 31/95 Residents were interviewed to see if any concerns about abuse were present. No residents indicated concerns of abuse when interviewed. An audit of resident's Medication Administration Record and Treatment Administration Record revealed 95/95 residents were reviewed, which identified 84/95 residents had concerns related to failing to sign off orders. Failing to sign off physician orders on Mar/TAR was added to abuse training and education was provided for all staff. 54/63 agency staff were interviewed as of 11/9/25 for allegations of abuse/neglect that have not been reported in the last 30 days. 54/54 agency staff members failed to have any concerns. 106/130 in-house staff members were interviewed to see if any incidents of abuse failed to be reported in last 30 days. No new incidents of abuse/neglect were identified through interviews. All staff are required to be interviewed for instances of abuse/neglect that were not reported in last 30 days, prior to the start of their next shift. Any incidents will be reported and investigated timely. Education was completed by Chief Nursing Officer to Director of Nursing and Nursing Home Administrator on 11/7/25, to immediately report any incidents that seriously compromise quality assurance or patient safety. Education was completed by Chief Nursing Officer to Director of Nursing and Nursing Home Administrator on 11/7/25, to immediately suspend an employee with an allegation of abuse/neglect. The NHA and DON signed and dated education. An audit of resident's Medication Administration Record and Treatment Administration Record revealed 95/95 residents were reviewed, which identified 84/95 residents had concerns related to staff failing to document physician orders were completed in the clinical record. Failing to sign off physician orders on MAR/TAR was added to abuse training and education was provided for all staff. 26/32 agency licensed nursing staff and 17/26 licensed nursing staff were educated on MAR/TAR and physician orders. All licensed nursing staff, not educated, must verify education on physician orders and MAR/TARs prior to the start of their next shift. Abuse/Neglect Policy was reviewed on 11/7/25, no revisions were made. Reportable Events Notification Policy and was reviewed with no revision made on 11/7/25. 106/130 in-house staff were educated on abuse/neglect policy and reporting. 54/63 agency staff members were educated on abuse/neglect and reporting. During in person interviews completed on 11/9/25, at 12:23 p.m. 14/14 interdisciplinary staff members confirmed they were educated on types of abuse/neglect, to report immediately, and who to report to. During phone interviews completed on 11/9/25, at 12:51 p.m. 14/14 staff confirmed education on types of abuse, when to report, and who to report to. All staff are required to verify education prior to the start of their next shift. Audits of all 95/95 current residents were conducted on the progress notes for evidence of abuse or neglect. 3/95 had concerns for abuse/neglect, 1 of the 3 were already reported and an investigation for the other two were immediately initiated. 31/95 Residents were interviewed to see if any concerns about abuse were present. No residents indicated concerns of abuse when interviewed. Ad Hoc Meeting was conducted on 11/8/25, no changes were made related to abuse and reporting policy. Audits of clinical records revealed two incidents of abuse/neglect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395118 If continuation sheet Page 7 of 21 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 11/10/2025 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete which were reported The Immediate Jeopardy was lifted on 11/9/25, at 2:41 p.m. when the action plan implementation was verified. During an interview on 11/10/25, at 12:05 p.m. the NHA, Chief Nursing Officer, Employee E10, Clinical Operations Specialist, Employee E11 confirmed that the facility failed to ensure all nursing staff were educated on abuse/neglect before working in the facility and annually. The facility failed to identify incidents of abuse/neglect, and timely report and investigate allegations of abuse/neglect. The facility put other residents at risk for abuse/neglect from Licensed Practical Nurse (LPN), Employee E1 by allowing the staff member to continue to work after allegations were made. This failure resulted in an immediate jeopardy situation. 28 Pa. Code 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing services. Event ID: Facility ID: 395118 If continuation sheet Page 8 of 21 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 11/10/2025 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on review of state laws, facility policy and facility documents, and staff interviews, it was determined the facility failed to identify and timely report criminal allegations of abuse/neglect to local law enforcement and required agencies to protect residents for one of five staff members Licensed Practical Nurse (LPN, Employee E1). This failure created an immediate jeopardy situation. Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. If the suspected abuse is sexual abuse, serious bodily injury, or suspicious death, the law requires additional reporting to the Department of Aging and local law enforcement. Review of the State Operations Manual, Appendix PP revised 7/23/25, revealed the facility must develop and implement written policies and procedures that ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.(i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements.(A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility.(B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Review of the facility policy titled, Resident Protection from Abuse, Neglect, Mistreatment or Exploitation review date 5/19/25, indicated it is the policy of the facility to identify abuse/neglect through various methods such as reports from employed or contracted staff, utilization of resident incident reports, review prior incidents and any patterns of staff behaviors. Allegations involving residents, visitors, employees, or any other person must be reported to the Administrator or Director of Nursing (DON) immediately. The Administrator or DON will notify the Department of Health via electronic reporting system within 24 hours of the incident and complete an on-line PB-22 if directed to do. The County Area Agency on Aging will be contacted and a verbal report of allegation of abuse will be submitted within 24 hours of the event. All written reports shall include, at a minimum, the name and age of the resident, address of resident representative, address of the home, nature of the alleged offense, and any specific comments or observations that are directly related to the alleged incident and individuals involved. All investigation will be conducted thoroughly and will attempt to gather as much factual information as possible. The Elder Justice Care Act requires each owner, operator, employee, manager, agency, or contractor of a nursing home facility (a covered individual) to report any responsible suspicion of a crime no later than (2) hours after forming the suspicion. In addition to reporting all obligations described above, covered individuals must report any reasonable suspicion of a crime to the Department of Health and to the local police serving the community where the resident is receiving care. Review of facility investigation documentation including witness statement dated 10/31/25, revealed Housekeeper, Employee E6 has worked at the facility for 13 years and since LPN, Employee E1 started on the memory impaired unit she has never seen so many die at one time. Housekeeper, Employee E6 stated I think they are given something they shouldn't be. It raises flags, and stated residents seem sedated. Review of Licensed Practical Nurse (LPN), Employee E4's witness statement dated 10/31/25, revealed about a month (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395118 If continuation sheet Page 9 of 21 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 11/10/2025 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few ago, LPN, Employee E4 was receiving report from LPN, Employee E1 on 9/28/25, when it was reported Resident R1 was hypothermic and when asked if the resident's temperature was rechecked or a nurse was notified, LPN, Employee E1 stated a RN wasn't informed. During report LPN, Employee E1 also stated everyone gets melatonin and made references to administering everyone Tylenol. Resident R1 was found to have an abnormally low rectal temperature upon follow up. Residents also were more sedated than usual and lethargic. Residents were not fully awake or unable to eat a meal until supper time. This was the residents' daily behavior for the whole weekend. Also, NA, Employee E5 came to me stating that LPN, Employee E1 gave everyone Tylenol and melatonin. I told aide to do the right thing and report this to the DON and Nursing Home Administrator. Review of the facility's investigation revealed an undated document titled by Nurse Aide (NA), Employee E5's name revealed, I have concerns with LPN, Employee E1. She keeps people snowed and gives Tylenol/Melatonin even if not ordered. I can tell a difference when LPN, Employee E1 works from when another nurse works in the resident's behaviors. They just want to sleep. It was revealed on normal days without LPN, Employee E1, Resident R5 yells out and when LPN, Employee E1 is there the resident does not. Review of facility documentation submitted on 11/3/25, revealed approached by staff that they had suspicions that a staff member was allegedly giving medication Melatonin to all residents whether they had an order from a provider or not. Facility failed to report criminal allegations of residents being sedated, unable to consume meals during the day, and increase in deaths on the memory impaired unit. During an interview on 11/5/25, at 10:01 a.m. Housekeeper, Employee E6 stated LPN, Employee E1 made the comment Monday, that she was giving everyone melatonin. Housekeeper, Employee E6 stated the weekend Resident R1 was sent out to the hospital for a change in condition, all day Saturday and Sunday residents couldn't open their eyes, eat, talk to us or anything. Housekeeper, Employee E6 stated I think something was given overnight and expressed concerns related to the increase in deaths on the memory impaired unit. I had nine people pass away just in October. Every time LPN, Employee E1 works, residents are much more tired. During an interview on 11/5/25, 10:15 a.m. LPN, Employee E7 stated I see a decline in residents where LPN, Employee E1 is working, but they have been here for years. A lot of them decline faster than I thought they would have. During an interview on 11/5/25, at 11:14 a.m. NA, Employee E8 stated sometimes LPN, Employee E1 says she is going to give them their medication, so she has a good night. They were kind of hard to wake up the next day, some wouldn't wake up, go through breakfast lunch, did get them up for supper. NA, Employee E8 stated. I worked with her twice a week and only noticed resident druggy, overly sleeping when she works the day before. During an interview on 11/5/25, at 11:24 a.m. NA, Employee E9 11/5/25, stated they have concerns with LPN, Employee E1. It was revealed LPN, Employee E1 makes the comment, we are going to have a good night, they are going to go to bed and rest. NA, Employee E6 stated residents were sleeping the next morning until 6 p.m., couldn't eat, couldn't get out of bed, it's been ongoing since LPN, Employee E1 has been working back there. During a phone interview on 11/6/25 at 9:12 a.m. NA, Employee E5 was unavailable for interview. During an interview on 11/6/25, at 11:05 a.m. the Nursing Home Administrator and Director of Nursing were asked for evidence the facility reported allegations of abuse/neglect to Area Agency on Aging (AAA). Review of facility documentation revealed the Area Agency on Aging was notified on 11/6/25, at 12:40 p.m. a total of 10 days since the facility was made aware of abuse/neglect allegations. During an interview on 11/6/25, at 2:03 p.m. the Director of Nursing confirmed they were made aware of allegations involving LPN, Employee E1 on 10/27/25. The DON and NHA confirmed the facility failed to timely initiate an investigation, report to appropriate agencies. NHA and DON confirmed the facility had not reported the allegations to police when it was made aware on 10/27/25, a total of 10 days later. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395118 If continuation sheet Page 10 of 21 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 11/10/2025 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few DON stated it was Hearsay and gossip when asked why the facility failed to report the allegations. During a second attempted phone interview on 11/7/25 at 9:32 a.m. NA, Employee E5 was unavailable for interview. On 11/7/25, at 12:41 p.m., the NHA and DON were made aware that Immediate Jeopardy (IJ) existed. The NHA was provided with the IJ Template, the facility failed to identify and timely report serious abuse/neglect allegations to local law enforcement and required agencies. This failure created an immediate jeopardy situation. A corrective action plan was requested. During an interview on 11/7/25, at 1:32 p.m. the Chief Nursing Officer (CNO), Employee E10 stated I was told this Friday, and I know the DON knew. I was at another facility, and I immediately came here and started the investigation. On 11/7/25, at 2:38 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: -Review of current residents' medical records will be reviewed for signs of abuse/neglect within the last 30 days by the DON and/or designee. All interviewable residents will be interviewed for any signs and/or symptoms of abuse and/or neglect. If any allegations of abuse/neglect are found, abuse policy will be followed, and an investigation and reporting will begin immediately. This will be completed by Monday, 11-10-25. -Staff will be interviewed for review of abuse/neglect allegations that have not been reported to the DON and/or designee. If any allegations are identified, investigation and reporting will begin immediately. This will be completed by Saturday, 11-8-25. -Review of Electronic event report for neglect allegation will be updated by the DON/designee to accurately reflect concern for Nurse giving Tylenol and Melatonin to all residents on the memory unit whether there is an order or not thus causing potential harm. This will be completed by 11-7-25. -Area of aging was notified on 11-6-25. State Police were notified on 11-6-25. -NHA and/or designee will review Abuse/Neglect Policy, Incidents and Accidents Policy, and reporting criteria and will update if needed. This will be completed by 11-7-25. -All house staff and agency staff will be educated on the abuse/neglect policy and reporting abuse by the DON and/or designee prior to their next shift worked. This will be completed by Monday, 11-10-25. -All residents who have had an allegation of abuse/neglect in the last 30 days will be audited by the DON and/or designee to ensure that it was reported appropriately and timely. This will be completed by 11-8-25. -All audits and policy changes related to IJ 609 will be reviewed at an Ad hoc Quality meeting by Monday, 11-10-25. Review of 95 of 95 resident clinical records for incidents or allegations of abuse or neglect was conducted for evidence of abuse or neglect. 3/95 had concerns for abuse/neglect, 1 of the 3 were already reported and an investigation for the other two were immediately initiated. 31/95 Residents were interviewed to see if any concerns about abuse were present. No residents indicated concerns of abuse when interviewed. An audit of resident's Medication Administration Record and Treatment Administration Record revealed 95/95 residents were reviewed, which identified 84/95 residents had concerns related to failing to sign off orders. Failing to sign off physician orders on Mar/TAR was added to abuse training and education was provided for all staff. On 11/9/25, the facility resubmitted the ERS report to include the concern for LPN, Employee E1 giving medications without an order and the allegation of increased deaths on the memory impaired unit. Area of Aging and the State Police were notified on 11/6/25. A review of facility documentation revealed a trooper arrived on-site at the facility on 11/7/25, at 5:00 p.m. Abuse/Neglect Policy was reviewed on 11/7/25, no revisions were made. Reportable Events Notification Policy was reviewed with no revision made on 11/7/25. 106/130 in-house staff were educated on abuse/neglect policy and reporting. 54/63 agency staff members were educated on abuse/neglect and reporting. During in person interviews completed on 11/9/25, at 12:23 p.m. 14/14 interdisciplinary staff members confirmed they were educated on types of abuse/neglect, to report immediately, and who to report to. During phone interviews completed on 11/9/25, at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395118 If continuation sheet Page 11 of 21 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 11/10/2025 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 2:00 p.m. 14/14 staff confirmed education on types of abuse, when to report, and who to report to. All staff are required to verify education prior to the start of their next shift. Facility completed review of clinical records and facility incidents for the past 30 days to audit all allegations of abuse/neglect to ensure accurate reporting was completed. Facility identified 2 allegations of abuse/neglect during audit and reported them to Department of Health and initiated an investigation. Ad Hoc Meeting was conducted on 11/8/25, no changes were made related to abuse and reporting policy. Audits of clinical records revealed two incidents of abuse/neglect which were reported. The Immediate Jeopardy was lifted on 11/9/25, at 2:41 p.m. when the action plan implementation was verified. During an interview on 11/10/25, at 12:05 p.m. the NHA, Chief Nursing Officer, Employee E10, Clinical Operations Specialist, Employee E11 confirmed that the facility failed to identify and timely report criminal allegations of abuse/neglect to local law enforcement and required agencies for one of five staff members (Licensed Practical Nurse (LPN), Employee E1). This failure created an immediate jeopardy situation. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services. Event ID: Facility ID: 395118 If continuation sheet Page 12 of 21 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 11/10/2025 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, resident record review, and staff interviews, it was determined that the facility failed to follow professional standards of practice when documenting for one of eight residents. (Resident R4).Findings include: Resident R4 was admitted to the facility on [DATE], with diagnoses of anxiety, muscle weakness, and high blood pressure. Review of the clinical record physician order dated 6/3/25, indicated Resident R4 was ordered assist with toileting and hygiene every two hours and as needed. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/4/25, indicated diagnoses of anxiety, muscles weakness, and high blood pressure. Question C0500 BIMS Summary Score revealed Resident R4's score to be 4, severe impairment. Section GG-Functional Abilities-revealed the resident required substantial/maximal assistance with toileting transfers and hygiene. and with sit to stand. Review of Resident R4's late entry progress note effective 10/13/25, entered on 10/22/25, by Nursing Home Administrator, stated at approximately 11:30 p.m. this nurse was standing at the med cart in the hall when a loud bang was heard this writer and CNAs on unit immediately went down the hall resident noted to be found sitting on the floor beside the commode. Resident stated, I was trying to get back into my wheelchair Resident told this writer he got dizzy prior to falling he stated he hit his head on the wall and complained of a headache. Resident assessed immediately. Residents noticed that they had a skin tear on right inner forearm, approximately 8x8 RN cleaned and dressed, no other visible injuries noted. Vital signs stable. Neuro checks started prior to the protocol. No other complaints of pain besides having a slight headache. Resident assisted back to bed with assistance x2. RN supervisor aware. Family made aware. Physician notified. During an interview on 11/9/25, at 2:48 p.m. Registered Nurse Supervisor, Employee E15 stated other staff shouldn't enter a note for someone else. During an interview on 11/9/25, at 3:06 p.m. the Chief Nursing Officer, Employee E10 confirmed the Nursing Home Administrator is not a nurse and the facility failed to follow professional standards of practice when documenting for one of eight residents. (Resident R4). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c)(d) Resident Care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395118 If continuation sheet Page 13 of 21 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 11/10/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical record, and staff interview, it was determined that the facility failed to ensure a resident is provided non-pharmacological interventions and an assessment prior to administering as needed pain medications for one of seven residents (Resident R1).Findings include: Review of facility policy Pain Assessment and Management dated 5/19/25, indicated all residents are screened for the presence of pain evaluated periodically for the presence of pain. Observe residents who are cognitively impaired/comatose or who have difficulty communicating for physical signs of pain including: grimaces, frowning, crying, change in behavior, loss of function, decreased activity level, resistance to care, agitation, eating or sleeping poorly to evaluate. Balance interventions for pain management with an adequate response to provide comfort while maintaining functional status and quality of life. Document screening for presence of pain, assessment of pain, interventions and resident's response, and physician notification and response, if indicated. Review of the facility policy Resident Change in Condition or Status dated 5/19/25, revealed it is the policy of the facility promptly addressing all resident changes in condition and managing them in compliance with all applicable standards of care. When a resident exhibits a change in condition from their baseline, the licensed nurse assigned to the resident will do the following: provide any necessary physical assessment to determine underlying cause, review any available diagnoses, request assistance from other staff as necessary, and ensure timely notification to charge nurse, physician, and family. Documentation must be provided in the resident record regarding: any assessment of the resident and findings, all applicable interventions, and all communication. All documentation provided must indicate the time at which it happened. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/10/25, indicated diagnoses of anxiety, Alzheimer's disease, and high blood pressure. Review of a physician order dated 4/28/23, indicated to administer 325 mg Acetaminophen, give two tablets by mouth every six hours as needed for pain. Review of Resident R1's September 2025 Medication Administration Record revealed the as needed medication was administered on 9/27/25, at 11:16 p.m. by Licensed Practical Nurse (LPN), Employee E1 for 7/10 pain. A further review revealed the residents did not receive any other PRN Acetaminophen for the month of September. Review of Resident R1's clinical record on 9/27/25, failed to include evidence a physical assessment or vital signs were obtained for the resident's change in condition (increased pain). There was no evidence non-pharmacological interventions were implemented prior to administering the acetaminophen for pain. A review of Resident R1's clinical record revealed LPN, Employee E1 reassessed Resident R1's pain on 9/28/25, at 2:01 a.m. and the resident pain was zero. A review of progress note dated 9/28/25, at 7:40 a.m. revealed nursing notified the Certified Registered Nurse Practitioner (CRNP), that the resident had a change in condition. The resident's rectal temperature was 93.5, heart rate was 48, and blood pressure was 100/50. Nurse reports the resident was unresponsive and did not move or speak when the nurse was assessing the resident or when rectal temperature was taken. Significant concern related to heart rate and temperature. The nurse spoke to family, and they would like the resident sent to the emergency room. Review of Resident R1's clinical record on 9/28/25, revealed Resident R1 was admitted to the hospital for alerted mental status and a urinary tract infection. During an interview on 11/5/25, at 10:47 a.m. LPN, Employee E4 stated There have been a few incidents, I followed [LPN, EmployeeE1], and there were things I had to immediately bring to the RN supervisor's attention. LPN, Employee E5 stated on one occasion, Resident R1 usually never gets Tylenol for pain and is unable to verbalize pain. Prior to Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395118 If continuation sheet Page 14 of 21 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 11/10/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete administering Tylenol, pain is assessed by looking for any indicators like guarding or grimacing. For a change in a resident's condition, physical assessment, vitals, and notification to physician and family must be completed. It was indicated Resident R1 typically screams out and has behaviors. During report on the morning of 9/28/25, LPN, Employee E1 notified LPN, Employee E4 that Resident R1 temps were low. It was indicated LPN, Employee E1 stated it was around 5:00 a.m. when [he/she] first noticed the resident was diaphoretic, cold, clammy, so LPN, Employee E1 turned the fan off. It was revealed a RN Supervisor was not notified. During an interview on 11/5/25, at 12:40 p.m. LPN, Employee E1 stated prn medications are given anytime resident needs it for pain or anxiety. If unable to determine pain, assess based on non-verbal cues, the way they act. When I give PRN, it has option to put progress note attached to medication depending on what's going on, I will add to progress note more info as to why. LPN, Employee E1 stated If change in condition, contact RN immediately. LPN, Employee E1 stated Resident R1's baseline was confused, really unable to tell any of needs. It was indicated Resident R1 was assessed for pain by non-verbal cues, she was yelling out, clutching fists, facial expressions, breathing labored, resident occasions yells out. LPN stated if I gave it, it was the way she was clenching fist. Those are things I would watch with her. Non-pharm interventions must be documented. LPN, Employee E1 stated I honestly don't remember when asked if non-pharmological interventions were implemented and documented prior to administering Resident R1 Tylenol on 9/27/25. During an interview on 11/5/25, at 1:28 p.m. the DON confirmed that the facility failed to ensure a resident is provided with non-pharmacological interventions and an assessment prior to administering pain medications as needed for one of seven residents (Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c)(d) Resident Care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services. Event ID: Facility ID: 395118 If continuation sheet Page 15 of 21 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 11/10/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, and staff interviews, it was determined that the facility failed to implement fall prevention interventions and conduct post fall monitoring for one of four residents (Resident R4).Findings include: Review of the facility policy Resident Change in Condition or Status dated 5/19/25, revealed it is the policy of the facility promptly address all resident changes in condition and to manage them in compliance with all applicable standards of care. When a resident exhibits a change in condition from their baseline, the licensed nurse assigned to the resident will do the following: provide any necessary physical assessment to determine underlying cause, review any available diagnoses, request assistance from other staff as necessary, and ensure timely notification to charge nurse, physician, and family. Documentation must be provided in the resident record regarding: any assessment of the resident and findings, all applicable interventions, and all communication. All documentation provided must indicate the time at which it happened. Resident R4 was admitted to the facility on [DATE], with diagnoses of anxiety, muscle weakness, and high blood pressure. Review of the clinical record physician order dated 6/3/25, indicated Resident R4 was ordered assist with toileting and hygiene every two hours and as needed. Review of Resident R4's care plan dated 6/4/25, revealed the resident was a high risk for falls related to confusion, deconditioning, gait/balance, and psychoactive drug use with a history of falls. Interventions include always using bed/chair alarm, anticipating and meeting the residents' needs. The care plan also included the following interventions: Assist me with toileting, catheter care or check or incontinence at least every two hours and provided with care as needed. Check me for incontinence at least once every two hours and promptly clean me for any incontinence episodes. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/4/25, indicated diagnoses of anxiety, muscles weakness, and high blood pressure. Question C0500 BIMS Summary Score revealed Resident R4's score to be 4, severe impairment. Section GG-Functional Abilities-revealed the resident required substantial/maximal assistance with toileting transfers and hygiene. and with sit to stand. Review of the facility's incident report revealed Registered Nurse (RN), Employee E13 stated This RN was informed by nurse on memory lane unit that a resident had fallen just then, upon entering his room noticed him sitting on the floor between the sink and toilet in his bathroom, he stated he was trying to get up from using the toilet when he lost his balance/fell back hitting his head, he is alert, skin tear about 9millimeter (mm) x 8 mm to right forearm/actively bleeding, xeroform and dressing applied to area. Patient able to move all limbs, complaints of pain to back of head and feeling dizzy, neurological checks started, this RN notified his step daughter/POA and discussed the above, no indication of needing to go to hospital at this time, range of motion is good, no other opening noted to his skin/no redness at this time, no pain to pelvis reported by resident at this time. Will place call to on call for physician, resident encourage to call staff when he needs help. Not part of the Medical Record was written at the bottom of the incident report. A further review of Resident R4's incident report revealed the resident's family member was notified on 11/2/25 (a total of 20 days later), at 2:14 p.m. and the physician was notified on 10/16/25, at 2:27 p.m. (a total of 3 days later). Review of RN, Employee E14's witness statement dated 10/14/25, stated at approximately 11:30 p.m. this writer was standing in the hallway at the medication cart. This writer heard a loud thud followed by the resident yelling for assistance. This writer and nurse aides immediately went down hall and upon entering, the resident was observed to be sitting on the floor between the commode and the sink. Resident stated, I was trying to get back into by wheelchair. Review of Resident R4's late entry progress note effective (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395118 If continuation sheet Page 16 of 21 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 11/10/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 10/13/25, entered on 10/22/25, by Nursing Home Administrator, stated at approximately 11:30 p.m. this nurse was standing at the med cart in the hall when a loud bang was heard this writer and CNAs on unit immediately went down the hall resident noted to be found sitting on the floor beside the commode. Resident stated, I was trying to get back into my wheelchair Resident told this writer he got dizzy prior to falling he stated he hit his head on the wall and complained of a headache. Resident assessed immediately. Resident noted to have a skin tear on right inner forearm approximately 8x8 RN cleaned and dressed, no other visible injuries noted. Vital signs stable. Neuro checks started prior per protocol. No other complaints of pain besides having a slight headache. Resident assisted back to bed with assistance x2. RN supervisor aware. Family made aware. Physician notified. A review of Resident R4's clinical record on 10/13/25, and 10/14/25, failed to include evidence that a physical assessment was completed by a Registered Nurse or documentation Q15 minute checks were initiated. During an interview on 11/9/25, at 2:48 p.m. RN Supervisor, Employee E15 stated residents that they are ordered transfer and assist with toileting, it is expected the Nurse Aides (NA) to stay with the resident. If a fall is unwitnessed or the resident hits their head, a body assessment must be completed and documented to ensure there are no injuries, and then neurological checks are started. The physician and family are notified. An assessment must be entered into the incident report, and a progress note should be entered timely, right after the resident was assessed. RN Supervisor, Employee E15 stated no one should enter a note for someone else. RN Supervisor, Employee E15 confirmed neuro checks first began on 10/14/25, 8:15 p.m. for Resident R4's fall that occurred on 10/13/25. The facility failed to implement neuro checks in a timely manner after an unwitnessed fall.\ During an interview on 11/10/25, at 9:52 a.m. Registered Nurse, Employee E14 stated the nurse aide took Resident R4 to the bathroom, and the residents tried to take themselves off. As far as hospital situation, I was unaware he was going. It was revealed the resident fell before midnight on 10/13/25, and then around 5 a.m. all the sudden the ambulance showed up, I had no idea he was going, Supervisor never notified me. RN, Employee E14 stated I am unsure if I documented a progress note. During an interview on 11/10/25, at 12:06 p.m. Nursing Home Administrator confirmed that the facility failed to implement fall prevention interventions and conduct post fall monitoring for one of four residents (Resident R4). 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.29 (a) (c.3) (1) Resident rights 28 Pa. Code 211.12 (d) (1)(3)(5) Nursing services Event ID: Facility ID: 395118 If continuation sheet Page 17 of 21 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 11/10/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of four residents reviewed (Resident R6).Findings include: Review of facility policy Medication Administration-General Guidelines reviewed 5/19/25, stated medications are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. Personnel authorized to administer medication do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). Five rights- Right resident, right drug, right route and right time, and applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication is put away. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's clinical record reveal an allergy to Tylenol with an unknown severity as of 7/22/25. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/28/25, indicated diagnoses of dementia, aphasia, and malnutrition. Review of Resident R6's progress note dated 8/22/25, at 5:34 a.m. entered by Registered Nurse, Employee E12 stated resident had a temperature. Floor nurse gave [him/her] Tylenol and then realized the resident was not ordered Tylenol, and it was listed as an allergy. Vitals and assessment completed with no adverse reaction note. The Certified Registered Nurse Practitioner was notified. As needed, Benadryl was ordered but not needed. Ibuprofen was ordered as needed for fever/pain. Vitals obtained every 15 minutes for one hour then every hour for four hours for monitoring. Review of the facility incident report dated 8/22/25, revealed a witness statement entered by LPN, Employee E1 that stated Resident had a fever of 101. Gave Tylenol and realized upon charting that no Tylenol order and was listed as an allergy. Supervisor made aware of error and Nurse Practitioner called. Vital signs were done every 15 minutes for one hour then, every hour for four hours. Resident has no signs and symptoms of reaction at this time. During an interview on 11/5/25, at 12:43 p.m., Licensed Practical Nurse (LPN), Employee E1 confirmed [he/she] gave Resident R6 Tylenol without an order, and the resident had an allergy. LPN, Employee E1 stated I did not look at chart before I gave Tylenol. During an interview on 11/9/25, at 3:12 p.m. the Chief Nursing Officer, Employee E10, confirmed that the facility failed to ensure that residents are free of significant medication errors for one of four residents reviewed (Resident R6).28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c)(d) Resident Care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395118 If continuation sheet Page 18 of 21 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 11/10/2025 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage and implement the facilities abuse and neglect policy, and failed to report alleged criminal activity of a Licensed Practical Nurse (LPN) Employee E1 to the proper authorities, which created an immediate jeopardy situation for all 95 of 95 residents.Findings include: The job description for the Nursing Home Administrator dated 4/14/24, indicated the NHA is to direct the day-to-day operations of the facility in accordance with current federal, state, and local standards governing long-term care facilities and to ensure that the highest degree of resident care and services are delivered and maintained. The position is responsible for establishing and maintaining systems that are effective and efficient. Oversee all departments and department supervisors to ensure the Nursing Home is operating safely and efficiently. Operate the company in accordance with the established policies and procedures. The job description for the Director of Nursing dated 5/8/25, indicated the DON is to provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management of the nursing department. Assume accountability for the development, organization, and implementation of approved policies and procedures. Ensure compliance with all federal, state, and local regulations. Based on findings identified, the facility failed to implement the facilities Abuse and Neglect policy and failed to report alleged criminal activity to the proper authorities, which placed the residents in Immediate Jeopardy. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 11/9/25, at 4:15 p.m. the Chief Nursing Officer Employee E7 was notified that the NHA and DON failed to implement the facilities abuse and neglect policy and failed to report allegations of criminal activity, which created an immediate jeopardy situation for all residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395118 If continuation sheet Page 19 of 21 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 11/10/2025 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 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to one of five direct care facility staff reviewed (Employee E5).Findings include: Review of the facility Nursing Assistant Job Description indicated the purpose of your job role is to provide direct care to residents, under the supervision of a licensed nurse, in accordance with policies and procedures and report resident needs and concerns to a licensed nurse. Attend all in-service classes as assigned and complete assignments. During an interview on 11/9/2025, at 10:30 a.m. Chief Nursing Officer Employee E7 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2024 revealed the following concerns: Review of Nurse Aide (NA) Employee E5's facility provided information did not include training on QAPI. During an interview on 11/9/25, at 10:54 a.m. the Chief Nursing Officer Employee E7 confirmed that the facility failed to provide QAPI training to one of five direct care facility staff reviewed (Employee E5). 28 Pa. Code: 201.14(a) Responsibility of Licensee 28 Pa. Code: 201.20(a) Staff Development Event ID: Facility ID: 395118 If continuation sheet Page 20 of 21 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 11/10/2025 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to conduct the minimum 12 hours of nurse aide (NA) training per year for four of four direct care facility staff reviewed (NA Employee E5, E8, E9, and E10). Findings include: Review of the facility Nursing Assistant Job Description indicated the purpose of your job role is to provide direct care to residents, under the supervision of a licensed nurse, in accordance with policies and procedures and report resident needs and concerns to a licensed nurse. Attend all in-service classes as assigned and complete assignments. During an interview on 11/9/2025, at 10:30 a.m. Chief Nursing Officer Employee E7 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2024 revealed the following concerns: Review of NA Employee E5's facility provided information failed to include the minimum 12-hour NA annual training. Review of NA Employee E8's facility provided information failed to include the minimum 12-hour NA annual training. Review of NA Employee E9's facility provided information failed to include the minimum 12-hour NA annual training. Review of NA Employee E10's facility provided information failed to include the minimum 12-hour NA annual training. During an interview on 11/9/25, at 10:57 a.m. the Chief Nursing Officer Employee E7 confirmed that the facility failed to provide a minimum of 12 hours of NA training to four of four direct care facility staff reviewed (NA Employee E5, E8, E9, and E10), as required. 28 Pa. Code: 201.14(a) Responsibility of Licensee 28 Pa. Code: 201.20(a) Staff Development Event ID: Facility ID: 395118 If continuation sheet Page 21 of 21