Inspection visit

InspectionMarch 20, 2025

MAJESTIC OAKS REHABILITATION AND NURSING CENTERCMS #39543128 citations on this visit

28 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 28 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on a review of the facility policy, observations, and an interview with staff, it was determined that the facility failed to ensure that the most recent Department of Health Survey results were readily accessible to residents and visitors in three of three nursing floors and lobby (Second Floor, Third Floor, and Fourth Floor). Residents Affected - Some Findings include: The facility's policy titled Examination of Survey Results, dated April 27, 2017, states, Survey reports and plans of correction are readily accessible to residents, family members, resident representatives, and the public. It further specifies under Bulletin 2: A copy of the most recent survey report and any plans of correction are kept in a binder in the resident's day room. During a resident council meeting held on March 18, 2025, at 10:30 a.m., with 12 residents (R62, R13, R35, R129, R70, R49, R6, R4, R96, R92, R93), who were identified as alert and oriented, it was revealed that the residents were unaware of the recent Department of Health Survey results. On March 19, 2025, at 9:31 a.m., a facility tour was conducted with the Director of Social Services, Employee E4, to observe the placement of the Department of Health Survey binder in the facility. Upon observing the lobby, it was noted that the Department of Health Survey results binder was outdated, with the last survey results recorded as of November 2024. Additionally, the second, third, and fourth-floor nursing units did not have survey result binders available. On March 19, 2025 at 2:45 p.m., during an interview with the Administrator, Employee E1 confirmed that the facility possessed two more recent Department of Health Survey results, but these were not included in the binder in the front lobby. 28 Pa. Code 201.14(a) Responsibility of licensee 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 29 Event ID: 395431 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with residents and staff, and review of the facility policy, it was determined that the facility failed to provide a clean, safe, comfortable and homelike environment in three of the three nursing units observed (2nd, 3rd, 4th floor Nursing Units). Findings include: A review of the facility policy titled Homelike Environment revised February 2021, revealed Residents are provided with a safe, clean and comfortable and homelike environment and encouraged to use their personal belongings to the extend possible. It further states, these characteristics include clean, sanitary and orderly environment, clean bed, bath linens that are in good condition, pleasant, neutral scents. On March 17, 2025, at 11:47 a.m., an interview with Resident R146 who lives in room [ROOM NUMBER] revealed that his mattress is peeling, and he collects the peeling material in a cup. Additionally, observation showed that there are five ceiling tiles with large brown stains. On March 17, 2025, at 11:51 a.m., an observation in room [ROOM NUMBER] reveled no restroom mirror and restroom are missing baseboard on the bottom of the wall. On March 17, 2025, at 11:58 a.m., observation in room [ROOM NUMBER] had a large picture leaning against the wall does not hang up, large brown substance that is spilled on the floor between the two beds. On March 17, 2025, at 12:16 p.m., observation next to room [ROOM NUMBER] has a hole in the tile ceiling. Day room which as across had a broken sanitizer with no cover. room [ROOM NUMBER] had a urine odor. License nurse, Employee E5 confirmed these observations. On March 17, 2025, at 12:38 p.m., a tour with the Maintenance Director, Employee E6 confirmed the above observations in room [ROOM NUMBER], 413, 404, 409 and 418 had broken baseboard that was not attached to the wall next to the entrance door and dry wall was peeling off from the wall. On March 18, 2025, at 12:09 p.m., observation in room [ROOM NUMBER] revealed a hole in the bathroom wall, exposing insulation. Drywall was also obsvered on the bathroom floor. Observations on March 17, 2025, at 12:53 p.m. in the 2nd floor dining room during the lunch time meal revealed Resident R82 and R366 were served lunch on paper plates. Interview with nurse aide, Employee E6, confirmed residents received paper products and was not sure why. Further observations on March 17, 2025, at 1:50 p.m. revealed Resident R1, in room [ROOM NUMBER]D, was served thickened juice in a Styrofoam cup. The beverage was leaking through the bottom of the cup, creating a sticky mess on the residents overbed table where he was eating. Interview with nurse aide, Employee E6, confirmed the observations and was unsure why resident was served in a Styrofoam cup. During a test tray on the 2nd floor nursing unit with the Food Service Director, Employee E5, on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 2 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some March 19, 2025, at 12:28 p.m., coffee was served in a Styrofoam cup. The Food Service Director, Employee E5, reported the kitchen is short on coffee mugs and subsequently the second floor (last unit to be served lunch) would be served in Styrofoam cups. Observations on March 20, 2025, at 12:50 p.m. revealed Resident R141 and R111, who both resided on the 2nd floor, were served coffee in Styrofoam cups. 28 Pa Code 201.18(b)(1)(3)Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 3 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a resident group interview, resident interview, review of facility policy and staff interview, it was determined that the facility failed to ensure that prompt efforts were made to resolve grievances for one of thirty-one residents (Resident R30) and effectively communicate the resolutions of grievances for 11 of thirty-one residents (R4, R6, R13, R35, R49, R62, R70, R92, R93, R96, R129) Findings include: A review of the facility policy titled Grievances/Complaints, Filing, revised on April 2023, stated under Policy Statement The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Further review, in section Policy Interpretation and Implementation, part 12, it states that The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the finding of the investigation and the actions that will be taken to correct any identified problems Review of Facility document titled Grievance Form, updated on April 6, 2017, revealed that All grievance forms must be resolved within 7 days from the original date of notification from the department that is responsible. During a Resident Council meeting on March 18, 2025 at 10:30 a.m., 11 residents (R62, R13, R35, R129, R70, R49, R6, R4, R96, R92, R93), all of whom were alert and oriented, expressed concerns that when they file grievances, the facility does not provide them with information regarding the resolution after the investigation is completed. Review of Resident R30's clinical record revealed that Resident R30 was admitted to the facility on [DATE] with diagnoses of but not limited to Heart Failure, Cellulitis (bacterial infection of the skin and the tissue beneath the skin), and Type 2 Diabetes (failure of the body to produce insulin). Review of R30's MDS (Minimum Data Set- assessment of resident care needs) Section C- Cognitive Problems, dated January 23, 2025, revealed that the Resident had a BIMS (Brief interview for metal status) score of 15 (intact cognitive response). Interview with Resident R30 on March 18, 2025 at 10:03 am, revealed Resident R30 was missing clothing. Resident stated that clothing was taken to be washed and never returned to her. The resident filed a grievance, but it has not been resolved and she has been using hospital gowns because she doesn't have any other belongings with her. Review of Resident R30's Grievance Form, dated February 25, 2025, confirmed the clothing was sent to laundry in a bag labeled with her name and room number on it and was not returned to the resident. Further review, under Plan for Resolution stated Social worker met with Resident R30 who picked a new outfit out of catalog. Follow up interview with Resident R30 on March 19, 2025 at 10:25 am, revealed over 2 weeks ago, Social Worker met with Resident to choose items out of catalog. Resident confirmed that items were selected and provided to the social worker for purchase. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 4 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0585 Interview with Social Worker, Employee E3 on March 19, 2025 at 10:39 am, confirmed that grievance was placed on February 25, 2025. Further confirmed clothing has not been ordered. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(3) Management Residents Affected - Few 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 5 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to identify the placement of beds against the wall as a restraint and failed to assess the functional status of an individual resident to determine the use of the restraint for one of 31 residents reviewed. (Residents R5). Residents Affected - Few Findings Include: Review of facility policy titled Use of Restraints, revised 2017, revealed the definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which staff applied it given that resident's physical condition (i.e, side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. Clinical record review revealed Resident R5 was admitted to the facility May 24, 2022 with a diagnosis that included but not limited to hemiplegia and hemiparesis affecting left non-dominant side (muscle weakness on one side of the body), acute respiratory failure (inability of lungs to exchange oxygen and carbon dioxide properly, causing insufficient oxygen in the blood), and abnormal posture. Observation on March 18, 2025 at 9:28 a.m. revealed Resident R5 lying in bed and the bed (right side) against the wall. Review of Resident R5's nursing progress note, dated February 4, 2025 at 9:36 a.m., revealed resident bed will be adjusted and padded to avoid resident irritating wound by rubbing it against the wall Review of Resident R5's nursing progress note, dated February 18, 2025 at 7:54 a.m., revealed during change of shift around 11:15 p.m. resident was heard calling for 3-11 nursing aide. When nurse entered the room, resident was found on the floor in a fetal position between the bed and the wall. Resident aware of the fall, but not how it happened in detail. Further review of Resident R5's nursing progress note, dated February 18, 2025 at 11:01 a.m., revealed resident bed was against the wall. Resident pushed with legs pushing bed away from wall. Resident fell between bed and wall. The resident was returned to bed via mechanical lift. Interview on March 18, 2025 at 9:30 a.m. with Licensed Practical Nurse, Employee E7, confirmed Resident R5's bed was against the wall. 28 Pa. Code 211.8(e)(f) Use of Restraints. 28 Pa. Code:211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 6 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 - Minimal harm or potential for actual harm Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to perform Elder Abuse and Resident Rights training upon hire for one of five personnel files reviewed (Employee E4). Residents Affected - Few Findings Include: Review of the personnel file for Cook, Employee E4 on March 20, 2025 at 12:02 pm revealed employee hire date on December 5, 2024. Further review indicated that there was no documented evidence for completion of Elder Abuse training upon hire. An interview was conducted with Business Office/ HR, Employee E5, on March 20, 2025 at 12:13 pm, confirmed Employee E4's Elder Abuse training incomplete. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.19(8) Personnel policies and procedures FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 7 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, it was determined that the facility failed to notify the representative of the Office of the State Long Term Care Ombudsman for one of 31 residents sampled who were transferred to the hospital. (Resident R102). Finding includes: Resident R102 was initially admitted to the facility on [DATE], diagnosed with spastic quadriplegic (partial or complete paralysis of all limbs), cerebral palsy (condition that affect movement and posture), major depressive and anxiety disorder, dysphagia (difficulty swallowing). On July 7, 2024, Resident R102 had an unplanned transfer to the hospital and a surgical gastrostomy (a surgical tube place in the abdominal wall and into the stomach used to provide nutrients and medications when a person cannot eat or drink adequately) was performed. Further review of the resident's clinical record revealed on December 18, 2024 Resident R102 had an unplanned transfer to the hospital due to stomach pain. On March 20, 2025, at 11:43 a.m., the Nursing Home Administrator confirmed that no written notices of the transfers was given to the State Long Term Care Ombudsman upon transfer out of the facility for Resident R102. 28 Pa. Code 201.29(h) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 8 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on review of clinical records, interview with staff and review of facility policy, it was determined that the facility did not ensure revisions were made to the PASRR (Pre-admission Screening and Resident Review) application to include mental health diagnoses for 2 out of 2 residents reviewed. (Resident R71, R98) Findings include: Review of the facility policy titled Preadmission Screening and resident Review (PASRR) policy last revised October 2023 revealed New admissions and readmissions are screened for mental disorders (MD), intellectual disability (ID) or related disorders (RD) per the Medicaid Pre-admission Screen for all potential admission, regardless of payer source, to determine if the individual meets the criteria for a MD, IM, RD. Review of Resident R71's PASRR completed on July 27, 2023, indicated that Resident R71 only had a mental health condition of Mood Disorder and Major Depressive Disorder. Review of R71's clinical record revealed on August 31, 2023, obtained a medical diagnosis Psychosis (is a mental health condition characterized by a disconnection from reality), physiological condition, Psychotic disorder, Suicidal Behavior and Psychotic disorder with Delusions. A review of Resident R98's PASRR completed on June 6, 2022, indicated that Resident R98 had a mental health condition of bipolar and schizoaffective disorder. A review of the Resident diagnosis revealed that he also had anxiety disorder as of August 11, 2023. Interview with the facility Social Worker, Employee E4 on March 19, 2025, at 10:36 a.m., confirmed that the PASSR forms for Residents: R71 and R98, should have been updated with the additional updated mental health diagnosis. 28 PA Code 211.10 (c) Resident Care Policies 28 PA Code 211.5(f)(viii) Medical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 9 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility documents, clinical records, and interview with staff, it was determined the facility failed to develop a comprehensive care plan and interventions to address resident care needs for Resident R37's diagnosis of diabetes, Resident R115 respiratory care, Resident R97 mood, R75 and R136 psychotropic medication, for five of 31 residents reviewed (Resident R37, R115, R136, R97, and R75). Findings include: Review of facility policy titled Care Plan, Comprehensive Person-Center revised March 2022, revealed the a comprehensive, person-center care plan that includes measurable objectives and timetable to meet the resident's physical psychosocial and functional needs is developed and implemented for each resident. Review of Resident R37's clinical record revealed the resident was admitted to the facility on [DATE], diagnosed with Diabetes (failure of the body to produc insulin) with orders for insulin and Accu-Cheks three times a day at 8:00 a. m., 12:00 p.m. and 5:00 p.m. Further review of Resident R37 clinical record failed to develop a care plan related to Resident R37 diagnosis of diabetes. On March 20, 2025 at 10:00 a.m the Director of Nursing confirmed a care plan was not developed for Resident R37's diagnosis of Diabetes. A review of a clinical record for Resident R115 revealed an admission on [DATE], with a diagnosis of diffuse traumatic brain injury. A review of the physician order dated February 17, 2025 oxygen as needed to maintain 02 (oxygen) level above 92% at 2 /min via N/C (nasal cannula) PRN (as needed) SOB (shorthness of breath) every shift. On March 17, 2025, at 12:06 p.m., it was observed that Resident R115 had oxygen set at 2.5 liters per minute via nasal cannula. A review of the comprehensive care plan dated last revised February 14, 2025, did not reveal a care plan for oxygen therapy. On March 19, 2025, at 2:14 p.m. the Director of Nursing, Employee E2 confirmed there was no care plan for oxygen therapy for Resident R115. A review of the clinical record for Resident R136 revealed an admission date of July 12, 2024, with diagnoses including dementia (severity unspecified), without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression. A review of the physician's order dated November 1, 2024, shows that Resident R136 was prescribed Seroquel 50 milligrams (mg) oral tablet as an antipsychotic medication. On March 19, 2025, at 10:03 a.m. an interview with the unit manager, Employee E3 confirmed that there was no comprehensive care plan developed for the antipsychotic medication for Resident 136. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 10 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R75's clinical record revealed an admission on [DATE] with a diagnosis of bipolar disorder and anxiety disorder. Review of Resident R75's clinical record revealed a physician order dated March 4, 2025, Alprazolam (used to treat anxiety and panic disorders) 0.5mg three times a day and Aripiprazole (used to treat agitation) 15 mg daily. Continued review revealed a physician order dated February 5, 2025, Lamotrigine (helps to prevent extreme mood swings related to bipolar) 10 0mg twice daily. Interview with Resident R75 revealed resident expressing concerns about non-interest in activities and appearing in an anxious mood. Further review of Resident R75's clinical record revealed a physician note dated March 9, 2025, stating in Assessment and plan section (part 5), Bipolar disorder with psychotic features/confusion/anxiety: Continue current treatment per Medicine team. Patient currently managed on Lamotrigine 100 mg Q (every) 12H (hours), Aripiprazole 15 mg a day, Xanax 0.5 mg 3 times a day, and Sertraline 200 mg every day. Encouraged to follow up with Psych. Maintain fall and safety precautions. Continue supportive measures. Continue to reassure, redirect and reorient patient. Patient is at high risk for falls related to poor safety insight and judgment. Encouraged use of assistive devices. Encouraged activity and engagement. We will continue to monitor in conjunction with the nursing team and discuss any issues identified with Internal Medicine. Review of Resident R75's comprehensive care plan dated March 7, 2025, did not reveal a care plan for any behavioral health diagnoses of bipolar disorder or anxiety disorder. Interview with Assistant Director of Nursing, Employee E13 on March 20, 2025 at 9:45am, confirmed there was no care plan in place for behavioral health diagnoses of bipolar disorder or anxiety disorder. Review of Resident R97's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 6, 2025, revealed the resident was admitted to the facility on [DATE], had moderate cognitive impairment, and diagnoses of non-Alzheimer's dementia and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). Further review of Resident R97's MDS dated [DATE], revealed the resident scored a 17 under section D Mood which can be interpreted as moderately severe depression. Review of Resident R97's clinical record revealed a psychiatry assessment dated [DATE], by Psychiatric Mental Health Nurse Practitioner (PMHNP), Employee E8, that revealed Resident R97 expressed feeling anxious and depressed. Review of Resident R97's comprehensive care plan revealed no documented evidence a care plan was developed to address the diagnosis and care needs for a resident with a mood disorder. 28 Pa. Code 201.18(e)(1) Management 28 Pa Code 211.10(d) Resident care policies (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 11 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0656 28 Pa. Code 211.12 (c)(d)(1) Nursing Services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 12 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 staff interviews, and review of resident records determined the facility failed to document to ensure one resident (Resident R102) received treatment and care in accordance with professional standards of practice when the facility failed to properly assess and document a change of condition per physician orders for one of 31 records reviewed. (Resident R102) Residents Affected - Few Findings include: Review of Resident R102's clinical record revealed that the resident was initially admitted to the facility on [DATE], with the diagnoses of spastic quadriplegic cerebral palsy, major depressive and anxiety disorder, dysphagia (difficulty swallowing), and had a gastrostomy (a surgical tube place in the abdominal wall and into the stomach used to provide nutrients and medications when a person cannot eat or drink adequately). Review of Resident R102 quarterly MDS (an assessment of residents' needs) dated December 29, 2024, indicated Resident R102 was completely dependent on staff for all activities of daily needs including bed mobility bathing and daily hygiene, with contractures to both sides of his upper and lower body. Review of Resident R102's care plan for chronic pain included interventions to assess for pain every shift for characteristics such as quality, severity, location, onset, duration, precipitating or relieving factors and to provide non-pharmacological relief such as repositioning. Review of Resident R102's physician orders instructed to assess for pain every day and night shift, indicate pain score (0 thru 10, 10 being the worst pain) provide nonpharmacological interventions document the interventions attempted. If no relief, provide medications as ordered, reassess within the hour of administration. Review of the electronic medication administration (EMAR) Licensed Practical Nurse Employee E15 documented during the day shift on December 18, 2024, the resident was experiencing severe pain of 9/10. Further review of the clinical revealed no documented evidence nonpharmacological interventions were attempted, nor if medications was provided and/or reassessed within the hour for effectiveness. Continue review of the physician orders instructed to document every day and night shift if the resident is verbally crying out and to provide any additional documentation needed in progress notes. During day shift, on December 18, 2024, the same licensed nurse documented Resident R102 was verbally crying out. Further review of the resident's clinical record failed to provide any additional documentation as instructed by the physician. 28 Pa Code 211.10(c) Resident care policies 28 Pa. Code:211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 13 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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, review of clinical record, and staff interview it was determined that the facility failed to provide pressure ulcer treatment, consistent with professional standards of practice, for one of three residents reviewed for pressure ulcers (Resident R18). Residents Affected - Few Findings Include: Review of facility policy Pressure Ulcers/Skin Breakdown revised April 2018 revealed the nurse should describe and document/report a full assessment of the pressure ulcer including location, stage, length, width, and depth. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. Review of Resident R18's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 18, 2025, revealed the resident had diagnoses of peripheral artery disease (narrowing of arteries which results in reduced blood flow to head, arms, stomach and legs), diabetes mellitus (metabolic disorder that affect how the body uses blood sugar), paraplegia (a form of paralysis that primary affects the lower part of the body), and stage four pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) to the sacrum. Continued review of Resident R18's quarterly MDS revealed the resident was at risk for developing pressure ulcers and that the resident had a stage four pressure ulcer to the sacrum that was present on admission to the facility. Review of Resident R18's comprehensive care plan revised March 17, 2025, revealed the resident was at risk for and had actual skin breakdown to the sacrum (stage 4 pressure ulcer) and left lower extremity (stage 3 pressure ulcer - full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue). Interventions dated June 11, 2024, included to assess the wound for signs and symptoms of infection, increased drainage, or odor. Review of Resident R18's clinical record revealed the resident was hospitalized from [DATE], through February 25, 2025, for an infection of the sacral pressure ulcer. Review of the hospital records revealed during Resident R18's hospital stay, the resident developed a new pressure ulcer on the left knee that received wound care. Further review of Resident R18's clinical record revealed a nursing admission/readmission evaluation dated February 25, 2025. Review of section c skin integrity within the nursing admission/readmission evaluation noted that Resident R18 had impaired skin integrity to the sacrum, left thigh (rear), and left ankle (outer). The assessment was incomplete as the sections to identify the type, stage, and measurements of the pressure ulcers was left blank. Review of Resident R18's clinical nursing notes and physician assessment revealed no documented evidence the wounds were assessed for the type of injury, the pressure ulcer stage, or a description of the pressure ulcers characteristics. Review of Resident R18's clinical record revealed the resident was re-hospitalized from [DATE], through March 7, 2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 14 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of R18's nursing admission/readmission evaluation, section c skin integrity dated March 7, 2025, noted that Resident R18 only had impaired skin integrity to the sacrum. The assessment was incomplete as the sections to identify the type, stage, and measurements of the pressure ulcers was left blank. Review of Resident R18's clinical nursing notes and physician assessment revealed no documented evidence the wounds were assessed for the type of injury, the pressure ulcer stage, or a description of the pressure ulcers characteristics. Review of Resident R18's clinical record revealed a wound note dated March 13, 2025, that indicated the resident had a stage 3 pressure ulcer of the left lower extremity and a stage 4 pressure ulcer of the sacrum. Interview on March 20, 2025, at 12:45 p.m. with the Assistant Director of Nursing, Employee E13, confirmed inaccurate/incomplete wound assessments. Assistant Director of Nursing, Employee E13, confirmed that there was no documented assessment of Resident R18's left lower extremity wound until March 13, 2025. Further interview confirmed Resident R18's nursing admission/readmission evaluation dated March 7, 2025, was inaccurate and did not include the skin impairment of the left lower extremity. 28 Pa. Code 211.12 (d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 15 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 clinical records and facility policies and procedures, observations of care and services, and interviews with staff, it was determined that the facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for two of 31 residents reviewed. (Resident R115 and R63). Residents Affected - Few Findings included: A review of the facility policy titled Oxygen Administration dated October 2023, stated The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. A review of a clinical record for Resident R115 revealed an admission on [DATE], with a diagnosis of diffuse traumatic brain injury. A review of the physician order dated February 17, 2025, oxygen as needed to maintain O2 level above 92% at 2 Liter per min via nasal cannula, PRN for shortness of breath, every shift. A review of the physician order dated February 19, 2025, revealed Oxygen Concentrator cleaning schedule 11-7 during weekly tubing change, remove filter on back wash with soap and water allow to dry and replace one time a day every Wednesday. On March 17, 2025, at 12:06 p.m., it was observed that Resident R115 had oxygen set at 2.5 liters per minute via nasal cannula. The oxygen tubing was not labeled. Licensed nurse, Employee E5, confirmed these observations and reported that the setting should be 2 liters. She then adjusted the oxygen to 2 liters. Clinical record review revealed Resident R63 was admitted to the facility on [DATE] with a diagnoses that included but not limited endocarditis (infection caused by bacteria that enter the blood stream and settle in the heart lining, a heart valve, or a blood vessel), acute and chronic respiratory failure (inability of lungs to exchange oxygen and carbon dioxide properly, causing insufficient oxygen in the blood), and muscle weakness. Review of Resident R63's physician orders, dated September 4, 2024, revealed an order for weekly oxygen tubing change. Observation on March 18, 2024 at 9:24 a.m. revealed Resident R63 had a label on her oxygen tubing dated February 27, 2025. Interview on March 18, 2025 at 9:28 a.m. with Licensed Practical Nurse, Employee E7, confirmed Resident R63's oxygen tubing had a date of February 27, 2025 and should be changed and dated weekly. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 16 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview with resident and staff and review of clinical records and facility policy it was determined that the facility failed to appropriately assess residents for use of bedrails and failed to ensure correct installation, use and maintenance of bed rails were maintained for two of 31 resident records reviewed (Resident R37 and R77). Findings include: Review of Resident R37 medical diagnosis revealed the resident was admitted to the facility on [DATE], identified lacking coordination, reduced mobility, abnormal posture and a need for assistance with personal care. Resident R37 was assessed as a fall risk and care planned to encourage the resident to use handrails/ siderails or assistive devices properly and to maintain the call bell within the resident's reach for preventing falls and accidents, dated January 10, 2025. During an interview on March 18, 2025, at 1:00 p.m. Resident R37 stated he did not like his bedrails and moved the bedrails to show how loose they were attached to his bed. During an interview on March 19. 2025 at 10:33 a.m., the Maintenance Director Employee E12 confirmed and stated Resident R37's bedrails were tightened because they were loose. The Maintenance Director also explained that he does not put bedrails on the beds without an order from the Director of Nursing or therapy. Interview with the Third floor Unit Manager, Registered Nurse Employee E11 on March 19, 2025, at 12:07 p.m. confirmed there were no physician orders for bedrails. We need to request the assessment from therapy for bedrails and there isn't one. Review of Resident R77 medical diagnosis revealed the resident was admitted to the facility on [DATE], identified with muscle weakness, difficulty with walking , a need for assistants with persons care and was a fall risk. On March 20, 2025 at 1:52 p.m. Resident R77 reported that her railings were very loose and she's not using them. The resident stated she didn't know why they were there because they don't help her get out of bed. Review of Resident R77 admission's assessment for bedrails dated November 27, 2024, indicated the resident was alert and oriented x3, did not use the side rails to achieve independence with bed mobility, was not assessed for entrapment risk from the side rails prior to their use, and did not request the side rails. Further review of Resident R77 clinical file revealed no physician orders allowing Resident R77's bed rails On March 20, 2025, at 1:26 p.m. the Director of Nursing was made aware of the above findings . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 17 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 28 Pa. Code: 201.14 (a) Responsibility of licensee. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 211.12 (d) (1)(3)(5) Nursing services. 28 Pa. Code 211.10(c)(d) Resident care policies. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 18 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that one resident, who displayed mental disorder or psychosocial adjustment difficulty, received treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for one of four residents reviewed for mood/behavior (Resident R97). Findings Include: Review of Resident R97's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 6, 2025, revealed the resident was admitted to the facility on [DATE], had moderate cognitive impairment, and diagnoses of non-Alzheimer's dementia and depression. Further review of Resident R97's MDS dated [DATE], revealed the resident scored a 17 under section D Mood which can be interpreted as moderately severe depression. Review of Resident R97's clinical record revealed a psychiatry assessment dated [DATE], by Psychiatric Mental Health Nurse Practitioner (PMHNP), Employee E8, that revealed Resident R97 expressed feeling anxious and depressed. Staff reported resident showed intermittent behavioral disturbances such as agitation and restlessness. Further review of the psychiatry assessment dated [DATE], revealed PMHNP, Employee E8, recommended to start Resident R97 on Buspar (anti-anxiety medication) 7.5 milligrams (mg) two times per day to support anxiety. Review of Resident R97's clinical record revealed a follow-up psychiatry assessment dated [DATE], by Psychiatric Mental Health Nurse Practitioner, Employee E8, which indicated Resident R97 reported feeing sad about the state of the world and having visual hallucinations. Further review of the psychiatric assessment dated [DATE], PMHNP, Employee E8, indicated staff had not started Resident R97 on Buspar as recommended at the last visit on March 10, 2025, to support anxiety. Review of Resident R97's clinical record revealed no documented evidence the facility implemented the Buspar as the Psychiatric Mental Health Nurse Practitioner, Employee E8, recommended. Interview on March 19, 2025, at 1:20 p.m. with Registered Nurse, Employee E9, confirmed the facility did not implement the medication as recommended. 28 Pa. Code 211.12 (d)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 19 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of clinical records, facility policy, and staff and resident interviews, it was determined that the facility failed to ensure the timely acquisition and administration of a prescribed medication to meet the needs of one of 31 residents reviewed (Resident R16). Findings include: A review of Resident 16's clinical record revealed Resident R16 was admitted to the facility September 1, 2022 , with diagnoses that included but not limited to congestive heart failure (condition that happens when your heart can't pump blood well enough you meet the body's needs), alcoholic polyneuropathy (damage to the nerves caused by excessive alcohol consumption), and generalized anxiety disorder. On March 18, 2025 at 12:10 p.m. interview with Resident R16 revealed Resident R16 was experiencing anxiety due to a recent event that occurred in his personal life. Resident R16 stated the physician ordered Ativan and he did not receive it for 3 days due to the medication not being available. Review of Resident R16's nursing progress note, dated February 11, 2025 at 1:25 p.m., revealed resident is able to express his emotions; grief and informed this nurse he will be dealing with a lot of anxiety over the next few days. Physician notified and Ativan 0.5 mlligrams (mg) by mouth twice a day was ordered. Order placed in residents record and pharmacy notified to contact physician for script. Review of physician's orders, dated March 12 2025, revealed the physician prescribed Ativan 0.5 mg to be given by mouth twice a day for 3 days. Review of Resident R16's MAR (medication administration record) revealed Ativan 0.5 mg was given on March 14, 2025 at 1:08 p.m. On March 19, 2025 at 10:30 a.m. interview with Employee E10, Registered Nurse, stated the pharmacy did not approve the script in a timely manner and that is why there was a delay is Resident R16 receiving his medication. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.9 (f)(2) Pharmacy services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 20 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations during dining and resident interviews it was determined that the facility failed to serve food that was palatable and attractive to meet resident needs for 20 of 20 residents reviewed (Resident R62, R13, R35, R129, R70, R49, R6, R4, R96, R92, R93, R30, R9, R120, R122, R81, R108, R83, R58, and R139). Residents Affected - Some Findings Include: During a Resident Council meeting on March 18, 2025, at 10:30 a.m. with 11 alert and oriented residents (R62, R13, R35, R129, R70, R49, R6, R4, R96, R92, R93) residents reported that the chicken being served is dry. Review of the facility menu revealed chicken was on the menu for lunch on March 18, 2025. Observations on March 18, 2025, at approximately 12:30 p.m. on the 2nd floor nursing unit during the lunch time meal revealed the following: Observations and interview at 12:38 p.m. revealed Resident R30 refused to eat the chicken served for lunch because it was dry. Observations and interview at 12:50 p.m. revealed Resident R9 and R120 refused to eat the chicken because it was served cold. Observations and interview at 12:51 p.m. revealed Resident R122 refused to eat the chicken because it was served dry. Observations at 12:53 p.m. revealed Resident R81 was being fed lunch by nurse aide, Employee E16. Interview with nurse aide, Employee E16, reported Resident R81 spit the chicken out and refused to eat it. Interview at 12:55 p.m. with alert and oriented Resident R108 revealed the chicken was hard as a rock and that the resident could not finish eating it. Interview at 12:56 p.m. with alert and oriented Resident R83 revealed the chicken was served dry. Observations and interview at 12:57 p.m. revealed Resident R92 had an un-eaten thin, overcooked piece of chicken on her plate. Resident R92 reported being unable to cut the chicken and subsequently not being able to eat it. Interview at 12:58 p.m. with alert and oriented Residents R58 and R139 revealed the chicken was served very dry and was inedible. 28 Pa. Code 211.10(c) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 21 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff and resident interviews it was determined that the facility failed to provide a substitute for a resident who requested a meal alternative and failed to serve foods that accommodate a residents allergies for two of 26 residents reviewed during dining (Resident R97 and R6). Findings Include: Review of Resident R97's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 6, 2025, revealed the resident was admitted to the facility on [DATE], had moderate cognitive impairment, and had a diagnosis of malnutrition (deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients). Observations on March 17, 2025, revealed an always available menu dated February 18, 2025, posted on the wall on the 2nd floor nursing unit located next to the elevators. For the lunch and dinner meal, a hamburger was listed as an alternative option that could be requested by calling the kitchen. Observations on March 17, 2025, at 1:15 p.m. revealed Resident R97 did not eat his lunch. Resident R97 stated he wasn't in the mood for what was served and subsequently requested a hamburger. During an interview on March 17, 2025, with Unit Clerk, Employee E17, the surveyor informed the employee that Resident R97 requested a hamburger for lunch. Unit Clerk, Employee E17, called the kitchen to request a hamburger for Resident R97. Unit Clerk, Employee E17, reported that the kitchen stated they could not make a hamburger for Resident R97 and to let the resident know hamburgers would be on the menu the next day. Clinical record review revealed Resident R6 was admitted to the facility November 21, 2023 with a diagnosis that included but not limited to multiple sclerosis (disease that causes breakdown of the protective covering of nerves), chronic obstructive pulmonary disease (airway disease that restricts breathing), and muscle weakness. Review of Resident R6's dietary orders, dated February 7, 2025, revealed a lactose restricted diet. Review of Resident R6's care plan, dated November 27, 2023, revealed resident has a nutritional problem or potential nutritional problem related to lactose and tolerance, requiring a therapeutic diet. Intervention included providing Resident R6 with a lactose restricted diet. Interview on March 18, 2025 at 9:30 a.m. with Resident R6 revealed she does not receive a lactose diet. Resident R6 further stated her meals include cheese and milk, which causes her to have loose bowel movements. Observation on March 19, 2025 at 12:05 p.m. revealed Resident R6 was served cheese on top of chicken. 28 Pa. Code 201.18(b)(3) Management (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 22 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0806 28 Pa Code 211.6(a) Dietary services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 23 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations in the main kitchen and staff interview it was determined that the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. Findings include: A tour of the Food Service Department conducted on March 17, 2025, at 9:22 a.m. with Employee E5, Food Service Director, revealed the following concerns: Observations of the walk-in freezer revealed two tortillas loosely wrapped in plastic wrap with no dates. Observations of the dry storage room revealed the juices used for the juice machine were stored in this room. Two juice bags (fruit punch and orange juice) were taken out of the box and placed directly on a visibly dirty/dusty metal wrack. One juice was not hooked up (cranberry juice) and the tubing was on the floor and backed up with stagnant juice in the tubing. Observations revealed the drainpipe behind the ice machine was placed directly into the floor drain with no air gap. To prevent sewer water backup, all ice machine drains require an air gap of a few inches between the ice machine ' s drain point and the facility's drain access point. Observations were confirmed by the Food Service Director, Employee E5, throughout the duration of the kitchen tour. 201.14 (a) Responsibility of licensee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 24 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews with staff, it was determined that the facility did not ensure that that trash was properly disposed of in the receiving and dumpster area. Residents Affected - Many Findings Include: A tour of the main kitchen was conducted on March 17, 2025, at 9:22 a.m. with the Food Service Director, Employee E5. Observations revealed double doors adjacent to the main kitchen where food deliveries are accepted and lead out to where the dumpsters are stored. Observations in the receiving area outside revealed trash, food, and debris on the ground surrounding the dumpsters. On one dumpster, the lid was open, and trash was exposed. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 25 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility protocol, observations, interview ,and review of clinical records, it was determined that the facility failed to implement proper use of personal protective equipment (PPE) for one resident on enhanced barrier precautions during morning care and wound observation of 31 resident records reviewed (Resident R102). Residents Affected - Some Findings include: Review of the facility policy for Enhanced Barrier Precautions (EBP) revised December 2024 states it is used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms to residents. EBP employ targeted gown and glove use during high contact resident care activates EBP are indicated for residents with wounds and or indwelling medication devices. Resident R102 was initially admitted to the facility on [DATE], diagnosed with spastic quadriplegic cerebral palsy, major depressive and anxiety disorder, dysphagia (difficulty swallowing) , and had a gastrostomy (a surgical tube place in the abdominal wall and into the stomach used to provide nutrients and medications when a person cannot eat or drink adequately). Resident R102's had orders to use EBP and was care planned for use while maintaining tube feedings, incontinence care and wound care. On March 17, 2025, at 10:00 a.m. it was observed nursing assistant Employee E14, aide was providing incontinence care without the use of EBP. On March 18, 2025, at 11:30 a. m. during wound observation Unit manager Employee E12 provided care without the use of EBP. On March 18, 2025, at 3:36 p.m. the Assistant Director of Nursing Employee E13 was made aware and confirmed EBP use with care. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 26 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with staff and residents and review of facility policy, it was determined that the facility failed to ensure that call bells were within reach for five of 31 residents reviewed. (Resident R37, R115, R153, 109, R88 ). Residents Affected - Few Findings include: A review of the policy titled Answering Call light last revised March 2021 revealed The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Its further states under General Guideline bulletin 4. Be sure that the call light is plugged in and always functioning. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Review of Resident R37's medical diagnosis revealed the resident was admitted to the facility on [DATE], identified lacking coordination, reduced mobility, abnormal posture and a need for assistance with personal care. Resident R37 was assessed as a fall risk and care planned to encourage the resident to use handrails/ siderails or assistive devices properly and to maintain the call bell within the resident's reach for preventing falls and accidents, dated January 10, 2025. During an interview on March 18, 2025, at 1:00 p.m. Resident R37 was observed sitting in his wheelchair and the resident's call bell was out of reach found on the floor on the opposite side of the bed. The resident indicated his call bell was broke for a while until it was fixed. On March 19, 2025, at 10:33 p.m. with Resident R37, the Maintenance Director explained the call bell was never broken it was because nursing ties the cord around the bed. If someone moves the bed it pulls the cord out of the wall and it falls to the floor. No one uses the clips that are all attached to the call bell cord that can be attached to the bed covers. It was observed that during this time the maintenance director indicated Resident R37's call bell was not in the resident's reach and further found that the roommates call bell was clipped to the resident's curtain, also not in reach. A review of a clinical record for Resident R115 revealed an admission on [DATE], with a diagnosis of diffuse traumatic brain injury, adult failure to thrive, difficult in walking, muscle weakness, need for assistance with personal care, and history of falling. On March 17, 2025, at 12:14 p.m., an interview was held with Resident R115 who asked to raise his bed to a sitting position. Surveyor asked for Resident R115 to press the call bell, and it revealed that his call bell was stuck in his bedside drawer, and he was not able to reach his call bell. The surveyor pressed the call bell in room [ROOM NUMBER], but there was no response from any staff. The surveyor then went to the 4th-floor nursing station, where it was discovered that the call bell panel was sitting on the nursing desk, completely turned off and unplugged from the outlet. Licensed nurse, Employee E5 was sitting at the nursing station. When asked how staff could respond to the call bell, Employee E5 confirmed that the call bell system had not been turned on, which is why she was unable to see which call bell needed to be answered. Employee E5 then plugged the call bell panel into the outlet, and it was revealed that the call bell for room [ROOM NUMBER] had been actively (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 27 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ringing for 16 minutes. During this same interview when Employee E5 came to the room and she confirmed that Resident R115's call bell was out of reach and was stuck in his bedside drawer. She assisted the resident and clipped the call bell to his bed sheets. On March 17, 2025, at 12:28 p.m. a tour on the unit with license nurse, Employee E5 revealed that Resident R109 had her call bell in front of her bed which was not reachable to the resident and Resident R153 was also not in reachable position of the call bell. It was further confirmed that both Resident's R153 and R109 are confined to their bed and require assistance with personal care. On March 17, 2025, at 1:44 p.m. a tour was conducted with the unit manager, Employee E3 who confirmed that the call bell in room [ROOM NUMBER]'s restroom was not attached to the wall. During a Resident Council meeting on March 18, 2025, at 10:30 a.m., 11 residents (R62, R13, R35, R129, R70, R49, R6, R4, R96, R92, R93), all of whom were alert and oriented, reported that when they pressed the call bell, facility staff would enter the room and turn off the bell without providing assistance. They were often told, I'm not assigned to you, I'll let your staff know, but no one would return to help. On March 19, 2025, at 9:52 a.m., a tour was conducted with the Director of Social Services, Employee E4, on the 4th-floor nursing unit. During the tour, it was observed that the call bell panel was showing an active call bell in room [ROOM NUMBER]-B for 42 minutes. Upon arriving in room [ROOM NUMBER]-B, Resident R88 was in bed and reported that they had pressed the call bell to request a change. Although Resident R88 had already been changed by a nursing aide, the call bell was still active and would not turn off. Employee E4 reported the malfunctioning call bell to maintenance. On March 19, 2025, at approximately 10:30 a.m., the Maintenance Director, Employee E6, confirmed that the call bell in room [ROOM NUMBER]-B was broken and that the entire call bell panel needed to be replaced. 28 Pa. Code 211.12(d)(1(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 28 of 29 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 395431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of facility documentation, and staff interviews it was determined that the facility failed to establish an effective pest control program in the main kitchen. Residents Affected - Many Findings Include: Review of pest control report dated March 4, 2025, revealed pest control inspected and treated the kitchen areas, storage areas, and dishwasher room for occasional invaders. Per the pest control report, mice droppings were observed in the kitchen food storage room. Pest control recommended a door sweep in the kitchen doors and replacing doors to the small room outside, next to the dumpster, as te doors are rotten. A tour of the main kitchen was conducted on March 17, 2025, at 9:22 a.m. with the Food Service Director, Employee E5. Observations revealed double doors adjacent to the main kitchen where food deliveries are accepted and lead out to where the dumpsters are stored. There was a visible gap located at the bottom of the door allowing easy access to the main kitchen for common household pests (mice, roaches, flies, ants). Observations on March 19, 2025, at 12:15 p.m. in the main kitchen revealed a significant amount of mouse droppings on top of an empty plastic rack dolly (designed for transporting dish racks) that was placed directly outside the entry for the dish room amongst the other plastic rack dolly used to store clean dishes. Observations of the mouse droppings were confirmed by the Food Service Director, Employee E5. Further observations on March 19, 2025, at 1:55 p.m. with the Food Service Director, Employee E5, revealed the facility did not follow through on recommendations made from pest control company and the small room next to the dumpsters still had rotten/broken doors with large holes at the bottom of the doors. 28 Pa. Code 201.14 (a) Responsibility of licensee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395431 If continuation sheet Page 29 of 29

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

28 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
0577GeneralS&S Epotential for harm
F577 - The resident has the right to-
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
0584GeneralS&S Epotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0585GeneralS&S Dpotential for harm
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
0604GeneralS&S Dpotential for harm
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
0607GeneralS&S Dpotential for harm
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
0623GeneralS&S Dpotential for harm
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
0644GeneralS&S Dpotential for harm
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0700GeneralS&S Dpotential for harm
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
0742GeneralS&S Dpotential for harm
F742 - Based on the comprehensive assessment of a resident, the facility must
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0804GeneralS&S Epotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0806GeneralS&S Dpotential for harm
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0814GeneralS&S Fpotential for harm
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0919GeneralS&S Dpotential for harm
F919 - Resident Call System
Make sure that a working call system is available in each resident's bathroom and bathing area.
0925GeneralS&S Fpotential for harm
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
0541GeneralS&S Epotential for harm
Install properly constructed and protected linen or trash chutes.
0918GeneralS&S Fpotential for harm
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
0923GeneralS&S Epotential for harm
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.

FAQ · About this visit

Common questions about this visit

What happened during the March 20, 2025 survey of MAJESTIC OAKS REHABILITATION AND NURSING CENTER?

This was a inspection survey of MAJESTIC OAKS REHABILITATION AND NURSING CENTER on March 20, 2025. The surveyor cited 28 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at MAJESTIC OAKS REHABILITATION AND NURSING CENTER on March 20, 2025?

Yes, 28 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide properly protected cooking facilities."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·March 20, 2025