Health inspection·December 3, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and documentation, staff and resident interviews it was determined that the facility failed to protect residents from neglect for one of three residents (Resident R1).Findings include: Review of facility policy Abuse, Prevention of Resident Abuse, Neglect, Mental Abuse, Reports of Theft, Exploitation and Misappropriation of Property dated 8/18/25, indicated the facility will provide a safe and secure environment for all residents and will protect a resident's right to be free from any form of abuse, mental abuse, neglect, reports of theft, exploitation or misappropriation of resident property. Review of the facility policy Falls, Resident Treatment of dated 8/18/25, indicated all residents who fall will be evaluated immediately for injury. When a resident is found on the floor do not move resident until a licensed nurse examines the resident. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's physician orders revealed an order dated 8/5/25, that indicated resident may transfer and ambulate (move about) with supervision. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 8/24/25, indicated diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), depression, and difficulty swallowing. Review of Resident R1's progress note dated 8/24/25, at 10:35 a.m. stated the following: Called to evaluate resident. History of fall on 8/19/25 with no apparent injury. Resident found in bed, appeared to be in pain. On evaluation, left leg had very significant swelling along entire femur (upper leg) area, ecchymosis (bruise) along entire posterior (back) hip and upper femur area that extended into groin, external rotation, and shortening. Positive pain response (yell out and grimace) to palpation (touching) of femur and hip, and with attempts to log roll. Resident unable to do any bed mobility on his own. Resident medicated for pain with Tylenol ( a pain reliever) and call placed to doctor. Resident to have hospice evaluation tomorrow for general decline. Per staff, he was able to stand and pivot on both [NAME] (lower extremities- legs) yesterday. Review of Resident R1's progress note dated 8/24/25, at 7:37 p.m. stated Call placed to hospital, patient was admitted with left hip fracture. Review of a written statement from Licensed Practical Nurse (LPN) Employee E1 dated 8/24/25, stated This LPN removed resident's BLE (bilateral lower extremities (both legs) ACE wraps (an elastic compression bandage) around 7:00- 7:15 p.m. [on 8/23/25] while resident's family was visiting. BLE were at baseline for resident. No pain noted. After family left Nurse Aide (NA) Employee E2, and NA Employee E3 put resident in bed. This LPN was not made aware of any falls or anything. Review of a written statement from NA Employee E4 dated 8/24/25, stated While providing morning care, I noticed his [Resident R1] leg was turned out and seemingly shorter than the right leg. I began providing peri care (washing anal, and genital areas) and while removing his brief I noticed his left thigh and groin was swollen with bruising to the outer hip, inner thigh, and groin. This occurred at approximately 10:00 a.m. on 8/24/25, and I immediately alerted his nurse. Review of a written (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395164 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 395164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St John Specialty Care Center 500 Wittenberg Way Mars, PA 16046 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)