Health inspection·April 1, 2024

F 0574 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some beneficiary and/or the representative understand the information. The need to obtain an attestation signed by the facility staff member that assisted with the change in enrollment, attesting that the beneficiary or representative requested the change and that the beneficiary or representative (as applicable) received and understood the minimum required information listed above. In cases where beneficiaries request disenrollment from PACE, LTC facilities that are contracted with PACE organizations should work directly with the PACE organization and the participant's interdisciplinary team to ensure the PACE participant receives the information required under the PACE regulations and to coordinate the transition of care, including as specified in their contract requirements. According to the CMS memo if a LTC facility cannot provide documentation of a beneficiary's request to change enrollment, this may suggest that the enrollment action was not initiated by the beneficiary or their legal representative and therefore was not legally valid. Lastly, If the facility has the beneficiary sign documentation regarding their understanding of an enrollment change, CMS will expect to find that the beneficiary's assessed cognitive function also supports an ability to understand this type of information. If CMS becomes aware of enrollment actions that the beneficiary alleges were taken without their request, consent, knowledge, and/or complete understanding, CMS will expect the facility to provide the above noted documentation to support that it appropriately assisted the beneficiary with their choice to change coverage, including that the beneficiary's cognitive function supports such decision-making. An admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) revealed that Resident 3 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact). Upon admission, the resident's primary insurance payer was noted to be Aetna Medicare Advantage, a Medicare Advantage plan. On February 1, 2024, the primary insurance payer was changed to traditional Medicare. During an interview with Resident 3 on April 1, 2024, at 12:30 PM, she stated that the Nursing Home Administrator came in and told me that I should change my insurance and that the new plan was better for me. A review of a facility form titled Medicare Advantage Disenrollment Form dated January 31, 2024, revealed a request to disenroll the resident from the resident's Medicare Advantage plan so that the resident may be covered under original Medicare benefits. A review of Resident 3's clinical record revealed no documented evidence of the date or time the resident initiated the wish or desire to disenroll from her Medicare Advantage Plan. Further, there was no documentation that the facility had assessed her cognitive function immediately prior to explaining the change in Medicare health plans and having the resident sign the disenrollment form to identify the resident's ability to understand this type of information at the present time. Clinical record review revealed that Resident 4 was admitted to the facility on [DATE], with diagnoses to include Parkinsons disease (a progressive neurological disease) and quadraplegia. A quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395464 If continuation sheet Page 2 of 7 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 395464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255 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 0574 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Upon admission, the resident's primary insurance payer was noted to be Aetna Medicare Advantage, a Medicare Advantage plan. On January 1, 2024, the primary insurance payer was changed to traditional Medicare. During an interview with Resident 4's wife (his representative) on April 1, 2024, at 1 PM she stated that in the beginning of January 2024, the social services director had approached her concerning changing her husband's insurance. Resident 4's wife stated that she did not understand the difference in the insurance plans and expressed her confusion during the interview. The resident's wife stated that she was confused when the social services director approached her about changing her husband's insurance. A review of a facility form titled Medicare Advantage Disenrollment Form dated January 31, 2024, revealed a request to disenroll the resident from the resident's Medicare Advantage plan so that the resident may be covered under original Medicare benefits. A review of Resident 4's clinical record revealed no documented evidence of the date or time the resident initiated the wish or desire to disenroll from his Medicare Advantage Plan. Further, there was no documentation that the facility had discussed the change with the resident and assured both the resident and his wife's understanding prior to signing the disenrollment form. Resident 5's quarterly Minimum Data Set assessment revealed that the resident was cognitively intact with a BIMS score of March 15 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact). Upon admission, the resident's primary insurance payer was a Medicare Advantage [NAME] Quality Options plan. On February 1, 2024, the primary insurance payer was changed to traditional Medicare. The resident was not available for interview at the time of the survey ending April 1, 2024. A review of a facility form titled Medicare Advantage Disenrollment Form dated January 31, 2024, revealed a request to disenroll the resident from the resident's Medicare Advantage plan so that the resident may be covered under original Medicare benefits. A review of Resident 5's clinical record revealed no documented evidence of the date or time the resident initiated the wish or desire to disenroll from the resident's Medicare Advantage Plan. Further, there was no documentation that the facility had assessed the resident's cognitive function immediately prior to changing Medicare health plans and having the resident sign the disenrollment form to identify the resident's ability to understand this type of information at the present time. Interview with the Business Office Manager on April 1, 2024, at 10 AM verified that the facility social workers and the Nursing Home Administrator go around to the residents to discuss their Medicare Advantage Plans and explain that straight Medicare might cover more skilled services, such as therapy, if the resident should need it. When asked why they are asking residents if they would like to switch without the residents initiating these requests for information or health insurance changes, the Business office manager stated that they let the residents know it is open enrollment and if they would like to review their insurance at that time. Interview with the facility's NHA April 1, 2024, at approximately 2:45 PM confirmed that facility did not have operational policies and procedures in place that outline the process of assisting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395464 If continuation sheet Page 3 of 7 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 395464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255 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 0574 beneficiaries and their representatives with their requests for changing their Medicare health care coverage. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.29 (a)(c) Resident rights 28 Pa. Code 201.18 (b)(2)(c)(e)(1)(2) Management Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395464 If continuation sheet Page 4 of 7 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 395464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255 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 and staff interviews, it was determined that the facility failed to provide maintenance services necessary to maintain a comfortable and homelike resident environment by failing to maintain comfortable water temperatures in one of two shower rooms on the area 4 resident unit and a functioning wall heating unit in resident room [ROOM NUMBER]. Findings include: Observation of resident room [ROOM NUMBER] on April 1, 2024 at 11:00 AM revealed that one of the 2 wall heating units not operational. An observation April 1, 2024 at 11:15 A.M., the area 4 shower room (in the 409-419 hallway) revealed that the shower hot water temperature was 88 degrees Farenheit and the sink hot water temperature was 80 degrees farenheit. During an interview at the time of the observation Employees 1 and 2, both nurse aides, stated that the shower and sink hot water has been cold for weeks. They stated that resident showers and personal care could not be provided in that particular shower room due to the cool water temperatures. Both employees stated that residents on this side of the unit were taken to the shower room on the opposite side of the unit for care. Interview with the administrator on April 1, 2024, at approximately 2 PM confirmed that maintenance services were to be provided to maintain comfortable water and room temperatures. 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395464 If continuation sheet Page 5 of 7 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 395464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based a review of clinical records and resident and staff interviews it was revealed that the facility failed to provide services necessary to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with bathing/showering activities of daily living for one of resident out of five reviewed (Resident 2) Residents Affected - Few Findings include: Interview with Resident 2 on April 1, 2024, revealed that the resident informed the surveyor that staff showered her the other day but this was the first shower she was showered in a while. Interview with the Director of Nursing conducted on April 1, 2024, revealed that the facility's protocol for showers is that residents are to be showered once each week. The DON stated that when a resident is showered the nurse aide documents this activity in the electronic clinical record. A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses to include hemiplegia, communication deficit and the need for assistance with personal care and grooming. A review of a quarterly MDS Assessment (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 11, 2024, revealed that the resident was moderately cognitively impaired and required extensive assistance with activities of daily living and partial to moderate assistance with showering/bathing. A review of Resident 2's plan of care dated July 11, 2024, revealed that the resident has an ADL self-care performance deficit related to disease process and required assistance with bathing. A review of Resident 2's Documentation Survey Report from March 6, 2024, through the time of the survey on March 29, 2024, revealed that the resident was showered only once during the month, on March 29, 2024. At the time of the survey ending April 1, 2024, there was no evidence that the resident had been showered or received a tub bath at least weekly from March 6, 2024 through March 29, 2024. The resident's bathing documentation dated March 6, 2024, March 15, 2024 and March 22, 2024 revealed no evidence that the resident received a shower or tub bath or had been offered a shower or tub bath and had declined. The documentation stated not applicable on each date noted. During an interview April 1, 2024, at 2 PM the Director of Nursing confirmed that the facility was unable to demonstrate that the above resident had been showered at the planned frequency, at least once a week. 28 Pa Code 211.12 (d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395464 If continuation sheet Page 6 of 7 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 395464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255 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 observation and staff interview, it was determined that the facility failed to maintain sanitary practices for managing infectious and/or hazardous waste storage on the facility grounds. Residents Affected - Some Findings include: An observation April 1, 2024 at 11 AM revealed multiple red plastic bags and closed cardboard boxes containing facility infectious waste were observed in an open storage shed located in a parking area outside the facility's kitchen. The doors of the shed were open when observed. Closer observation of the infectious waste revealed a large accumulation of dried leaves under the bags and boxes of infectious waste. During an interview April 1, 2024 at approximately 1 P.M., the Nursing Home Administrator confirmed that the infectious waste was not stored properly in the storage shed. 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395464 If continuation sheet Page 7 of 7