Health inspection·January 2, 2026

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, the facility's abuse prohibition policy, select facility-provided investigative documentation, staff interviews, and direct observation, it was determined that the facility failed to ensure that one resident (Resident C2) was free from physical abuse perpetrated by another resident (Resident CR1), for one out of eleven residents sampled for abuse prevention.Findings include: A review of a facility policy entitled Abuse Policy last reviewed by the facility on April 22, 2025, indicated that residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Further review of a facility policy entitled One-to-One Supervision Guidelines last reviewed April 22, 2025, indicated it was the responsibility of the staff assigned to provide one to one continuous observation, and under the supervision and guidance of the nursing supervisor, and must keep the resident within the line or vision and within reach, and not be left alone (not even with family). A review of Resident CR1's clinical record revealed admission to the facility on December 10, 2025, with diagnoses to include intraspinal abscess (swelling and infection involving the spinal cord area) and granuloma (a localized area of inflammation that forms around infection or foreign material), chronic pain due to trauma, panic disorder (an anxiety disorder characterized by sudden and recurrent episodes of intense fear or discomfort), generalized weakness, and difficulty walking. A review of Resident CR1's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 16, 2025, indicated the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates intact cognition or no cognitive impairment). A review of Resident C2's clinical record revealed admission to the facility on June 6, 2022, with diagnoses that included cerebral palsy (a condition affecting movement and muscle coordination caused by early brain development changes), unspecified intellectual disability (a condition limiting intellectual functioning and independent living skills), conduct disorder (a pattern of aggressive or disruptive behaviors), and mood affective disorder (a condition affecting emotional regulation). A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was severely cognitively impaired with a BIMS score of 4, severe cognitive impairment.A review of Resident C2's comprehensive, person-centered care plan initiated on December 15, 2023, identified behavioral symptoms related to cognitive impairment, including sliding or placing self on the floor, impulsive actions, attention-seeking behaviors, thrusting self from the chair Page 1 of 7 395464 395464 01/02/2026 Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few without warning, spitting, inappropriate verbal and physical behaviors, combative behavior during care, and yelling at others. To address these identified behaviors and reduce the risk of unsafe interactions, the facility developed interventions that included continuous one-to-one supervision, supervision during social and recreational activities, avoidance of environmental stimuli such as conversations, television, or radio programming that could trigger or escalate behaviors, referral to psychological or psychiatric services as indicated, and administration of medications as prescribed. A review of facility-provided investigative documentation completed by Employee 1 a Registered Nurse Supervisor and dated December 28, 2025, at 4:00 PM, indicated that Resident CR1 exited his room and approached the nurses' station, reporting that music being played on a laptop was bothering him. According to the documentation, Resident CR1 then removed the external speaker from the computer and threw it onto the floor. The documentation further indicated that Resident C2, who was identified as being on one-to-one supervision at the time, spit on Resident CR1, after which Resident CR1 spit back at Resident C2. The documentation reflected that Resident CR1 encouraged Resident C2 to repeat the behavior, and Resident C2 spit on Resident CR1 again. While staff attempted to redirect and separate Resident C2, the documentation indicated Resident CR1 began striking Resident C2 in the face multiple times. The investigative documentation further reflected that Resident C2 was taken to his room; however, Resident CR1 continued attempting to gain access to Resident C2's room by pushing on the door while a supervisor held it closed. The documentation indicated both residents were eventually separated and Resident CR1 returned to his room. Immediate actions documented by the facility included contacting the police department by calling 911, maintaining one-to-one supervision for Resident C2, and notifying both residents' attending physicians and representatives. The documentation further indicated that the incident was reported to appropriate protective authorities and that the facility initiated an abuse investigation. The documentation reflected Resident C2 was transported to the hospital for further evaluation and treatment, and Resident CR1 was also transported to the hospital and did not return to the facility. A review of emergency department provider documentation dated December 28, 2025, at 9:51 PM indicated diagnostic testing and imaging were completed for Resident C2, with final results that may represent an acute nondisplaced nasal fracture, defined as a possible crack in the nasal bone without displacement. A review of a written witness statement completed by a Licensed Practical Nurse, Employee 2 dated December 28, 2025, with no time indicated, reflected that at approximately 4:45 PM the nurse was administering medications while music was playing through an external speaker at the nurses' station. The statement indicated Resident C2 was in the hallway listening to music, and Resident CR1 made statements about changing the music. The statement further reflected that Resident C2 requested the music be turned up due to difficulty hearing. According to the statement, Resident CR1 exited his room into the hallway near the nurses' station, and the nurse observed shouting and banging before witnessing Resident CR1 strike Resident C2 and attempted to spit in Resident C2's face. The statement indicated the external speaker was observed on the floor approximately fifteen feet from the nurses' station and Resident C2's eyeglasses were knocked off during the physical interaction. The statement further reflected that the nurse intervened by positioning herself between the residents as Resident CR1 continued attempting to approach Resident C2. The statement indicated Resident CR1 swung at staff, yelled profanities, and accused staff of lying. The supervisor was paged and responded immediately, both residents were separated, Resident C2 was taken to his room, and Resident CR1 continued attempting to access Resident C2's room, requiring staff to barricade the door to prevent further contact. A review of a written witness statement completed by Employee 3, a Nurse Aide assigned to provide one-to-one supervision for Resident C2, dated December 28, 395464 Page 2 of 7 395464 01/02/2026 Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2025, at 4:45 PM, reflected that Resident C2 and Employee 3 were at the nurses' station listening to music and watching videos. The statement indicated Resident CR1 approached staff and stated the music was bothering him. According to the statement, Resident CR1 removed the speaker from the computer and threw it onto the floor. The statement further reflected that Resident C2 spit on Resident CR1, Resident CR1 spit back, and encouraged Resident C2 to repeat the behavior. The statement indicated Resident C2 repeated the behavior and attempted to pull away, after which Resident CR1 struck Resident C2 in the face multiple times. The statement reflected the nurse aide called for assistance, and additional staff responded to separate the residents. A review of emergency department provider documentation dated December 28, 2025, indicated imaging results that may represent an acute nondisplaced nasal fracture, defined as a possible crack in the nasal bone without displacement. The documentation did not identify functional decline, neurological impairment, or lasting injury. A review of follow-up specialty documentation revealed that Resident C2 was evaluated by an ear, nose, and throat (ENT) physician on December 30, 2025, due to emergency department findings that identified a possible nondisplaced nasal fracture, defined as a potential crack in the nasal bone without displacement. The ENT consultation documented that the resident exhibited no changes in breathing, normal airway function, and no clinical indication for medical or surgical intervention at that time. The physician documented that the resident was advised to return for further evaluation only if symptoms worsened. The documentation further reflected that no worsening symptoms were reported, and the resident was observed without visible bruising. During on-site survey conducted on January 2, 2026, at 2:15 PM, Resident C2 was observed seated in a wheelchair outside of his room, across from the nurses' station, with a lunch tray placed on a bedside table and independently eating. At the time of observation, no staff member was present providing one-to-one supervision as required by the resident's care plan and the facility's One-to-One Supervision Guidelines. The assigned nurse aide (Employee 4) was observed seated behind the nurses' station at a computer, and Resident C2 was not maintained within the staff member's direct line of vision or within reach, as required by facility policy. During an interview conducted on January 2, 2026, at 2:18 PM, Employee 4, nurse aide confirmed Resident C2 required one-to-one supervision and reported being assigned to provide that supervision. Based on the facility's investigative documentation and written witness statements, Resident C2 was identified as requiring one-to-one supervision at the time of the resident-to-resident physical altercation on December 28, 2025. However, the facility's documentation did not consistently demonstrate that one-to-one supervision was effectively maintained during the incident, as evidenced by Resident CR1's ability to approach, engage, and physically strike Resident C2 prior to staff intervention. An attempt was made by the surveyor to contact the assigned nurse aide (Employee 3) to obtain clarification regarding supervision at the time of the incident; however, the nurse aide did not respond to surveyor contact attempts. The subsequent observation on January 2, 2026, revealed continued noncompliance with the facility's one-to-one supervision policy for Resident C2, demonstrating the facility was unable to consistently implement required supervision interventions intended to prevent unsafe resident-to-resident interactions. During an interview with the Director of Nursing on January 2, 2026, at 3:30 PM, the surveyor reviewed the findings related to the resident-to-resident physical altercation and the observations regarding one-to-one supervision. The Director of Nursing confirmed Resident C2 required one-to-one supervision per the care plan and facility policy. The facility failed to demonstrate consistent implementation of required one-to-one supervision for Resident C2, limiting the facility's ability to ensure the resident was protected from physical abuse by another resident. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 395464 Page 3 of 7 395464 01/02/2026 Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255

F 0600 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a)(c) Resident Rights. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(5) Nursing Services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395464 Page 4 of 7 395464 01/02/2026 Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255

F 0610 Respond appropriately to all alleged violations. 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, the facility's abuse prohibition policy facility-provided documentation, and resident and staff interviews, it was determined the facility failed to ensure allegations of abuse were thoroughly investigated, corrective actions implemented, and results reported to the State Survey Agency within five working days, in accordance with regulatory requirements and facility policy, for 1 of 10 residents reviewed (Resident 1).Findings included:A review of the current facility policy titled Abuse Policy revealed the policy stated each resident has the right to be free from abuse, neglect, misappropriation of resident property (wrongful taking or use of a resident's belongings), and exploitation (improper use of a resident for personal gain) as defined in regulation. The policy defined abuse as the willful (deliberate) infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish (severe emotional distress). The policy further defined willful to mean the individual acted deliberately, not that the individual intended to cause injury or harm. The policy defined mental abuse as humiliation, harassment, threats of punishment, or withholding of treatment or services. The policy indicated if an individual has a reasonable suspicion that a crime has been committed against a resident, a report must be submitted to law enforcement and the State agency in accordance with the Elder Justice Act (federal law requiring owners, operators, employees, or contractors of federally funded long-term care facilities to report any reasonable suspicion of a crime against a resident within 2 hours if serious bodily injury is involved, or within 24 hours if no serious bodily injury is involved, to the State Survey Agency and local law enforcement). The policy further revealed if any individual observed or suspected resident abuse, an immediate report should be obtained including names of individuals involved, date and time of incident, type of abuse, and names of witnesses. The policy revealed once an allegation of potential abuse is received, the facility will investigate immediately. If the allegation involves an employee, the investigator conducts an interview, obtains a statement, and suspends the accused individual pending the outcome of the investigation. The policy indicated such suspension would remain in place until the investigation is completed. The policy indicated that when staff suspect a crime has occurred against a resident, they must report the incident to the State Survey Agency and local law enforcement. The policy further detailed that staff must report suspicion of a crime to the State Survey Agency and at least one local law enforcement entity within the required time frames by email, fax, or telephone. The policy specified that if the event results in serious bodily injury, the staff member shall report the suspicion immediately but no later than 2 hours after forming the suspicion. If the event does not result in serious bodily injury, the staff member shall report the suspicion no later than 24 hours after forming the suspicion. The policy further revealed the facility will assist staff in reporting suspicions of a crime using the Crime Reporting Form at the time the facility becomes aware of the suspicion that the report will be submitted to the State Survey Agency and local law enforcement within required time frames, and that the facility shall maintain a record of these reports. Clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses including vascular dementia with psychotic disturbance (loss of thinking ability caused by impaired brain blood flow) and primary insomnia (chronic difficulty sleeping). The resident's comprehensive person-centered plan of care initiated on May 10,2024, and revised on December 19, 2024, indicated the resident had behaviors related to impaired psychiatric/mood status due to dementia. The interventions included providing a calm, safe environment when emotional or frustrated and allowing time to voice feelings. The interventions also included approaching the resident in a calm, positive reassuring manner, and redirecting the Residents Affected - Few 395464 Page 5 of 7 395464 01/02/2026 Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident as needed. Review of Resident 1's Annual MDS (Minimum Data Set, a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], revealed the resident had a BIMS score of 0 (Brief Interview for Mental Status is a tool used to evaluate cognitive impairment and assist with dementia diagnosis), which indicated that the resident had severe cognitive impairment. A review of Resident 2's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included vascular dementia (cognitive impairment caused by reduced blood flow to the brain) and insomnia (difficulty sleeping). Additionally, the resident had severe cognitive impairment and utilized a wheelchair for mobility as indicated by the Annual MDS assessment dated [DATE], as evidenced by a BIMS score of 2 (score of 00-07 indicates severe cognitive impairment). A review of facility-provided documentation revealed that on January 18, 2026, at approximately 8:00 PM, an incident occurred involving Resident 1 and Resident 2. The documentation included a written witness statement by Employee 1 (Nurse Aide), which indicated Employee 2 (Licensed Practical Nurse) engaged in a verbal argument with Resident 1 and threw a cup of water into Resident 1's face, followed by a second cup of water. The statement documented Resident 1 then attempted to spit toward Employee 2 but instead spit on Resident 2, who became agitated and struck Resident 1 in the face. The statement documented Employee 1 removed Resident 1 from the area while Employee 2 remained to clean the spilled water. Professional standards of practice and the facility's own policy required staff to report and investigate allegations when an action could reasonably be interpreted as abusive. Even when residents exhibit behavioral symptoms such as yelling or spitting, staff are expected to use trained behavioral and de-escalation interventions. The documented action of Employee 2 intentionally throwing two cups of water into Resident 1's face constituted conduct that a reasonable person (objective standard used to evaluate how an average individual would interpret an action) could view as humiliating, distressing, or punitive in nature. Therefore, the allegation met the facility policy threshold requiring immediate reporting, investigation, and documentation to determine whether abuse occurred. During an interview on February 12, 2026, at 10:00 AM, Employee 2 LPN confirmed she threw a cup of water in Resident 1's face. Employee 2 stated that when she began her shift at 3:00 PM, she observed Resident 1 to be agitated. She stated she approached Resident 1 to administer medications, at which time Resident 1 began yelling profanities at her. Employee 2 stated she threw the water in reaction to Resident 1, after which she reported Resident 1 spit at her. Employee 2 stated she provided a statement to police regarding her encounter with Resident 1 and the physical interaction between Resident 1 and Resident 2. She stated that after speaking with police she returned to the unit to complete charting. Employee 2 stated she had previously been scheduled to leave early and departed the facility between approximately 9:30 PM and 10:00 PM but could not recall the exact time. Employee 2 stated she was not instructed to leave the facility and departed at her previously approved early time. A review of the written statement by Employee 2, provided by the facility documented Resident 1 was agitated with another resident and was using derogatory language toward that resident. The statement documented that after Employee 2 administered Resident 1 his medications, he began calling her names. The statement further documented Resident 2 was walking down the hallway when Resident 1 spit medication and water toward Employee 2, also simultaneously hitting Resident 2 with the medication/water spit combination. Employee 2 wrote she threw the water on Resident 1 out of impulse. Employee 2 then wrote that she continued to pass medications to other residents and monitored Resident 1. Review of facility-provided information revealed the facility reported the incident to police and the Area Agency on Aging as a resident-to-resident altercation. However, the facility was unable to provide documentation showing it investigated or reported the 395464 Page 6 of 7 395464 01/02/2026 Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few allegation of staff-to-resident abuse involving Employee 2 throwing water at Resident 1. During interview on February 12, 2026, at 1:55 PM, Employee 3 (Registered Nurse Supervisor) stated she became aware of the incident between approximately 8:00 PM and 8:30 PM on January 18, 2026, and directed Employee 2 to leave the floor and write a statement. She stated Employee 2 was argumentative and said the water was thrown accidentally. Employee 3 stated she did not believe it was accidental because she was informed Employee 2 filled a second cup and again threw water on Resident 1. Employee 3 stated she contacted police regarding the resident-to-resident altercation and stated Employee 2 did not return to the floor to complete her shift, despite Employee 2's statement that she returned to the floor to complete her shift. Review of Employee 2's time records showed she clocked out at 9:33 PM. Review of Resident 1's January Medication Administration Record documented Employee 2 recorded completion of an Accu-Chek (finger-stick blood sugar test) at 9:30 PM one and a half hours after the alleged incident was first documented, as indicated by her statement she returned to the floor to finish documentation. During interview on February 12, 2026, at 11:20 AM, the facility Risk Manager stated he became aware of the incident the following day and stated the facility did not report or further investigate the staff action because there was no serious bodily injury, sexual abuse, or death and therefore it was not considered reportable. When asked whether documentation existed showing the facility ruled out physical, mental, or psychosocial abuse (harm affecting emotional or psychological well-being), the facility was unable to provide such documentation. The facility was unable to provide documentation that the allegation involving Employee 2 throwing water on Resident 1 was reported to the State Survey Agency as required by facility policy. The facility was also unable to provide documentation of a complete investigation into the allegation, including evidence of interviews of all involved individuals, investigative findings, or documentation demonstrating abuse was ruled out. These findings were reviewed with the Nursing Home Administrator on February 12, 2026, at 1:10 PM. At that time, no additional documentation was provided demonstrating that a thorough investigation had been conducted or that the staff-to-resident allegation had been reported in accordance with facility policy and reporting requirements. 28 Pa. Code 201.14(a)(c) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29 (a)(c) Resident Rights28 Pa. Code 211.10(a)(d) Resident care policies.28 Pa. Code 211.12 (d)(1)(5) Nursing services. 395464 Page 7 of 7