Health inspection·October 13, 2023

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 review of select facility policies and procedures, review of clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of one resident reviewed (Resident 3). Residents Affected - Few Findings include: The policy entitled Abuse Policy, last reviewed on August 29, 2023, indicates that the facility describes an injury of unknow origin as an injury that was not observed by any person, cannot be explained by the resident, and a suspicious location not generally vulnerable to trauma. The policy does not specify how the facility will specifically rule out abuse when an injury of unknown origin occurs. Review of Resident 3's clinical record revealed a nursing care plan indicating that she needs the help of two staff members to use a mechanical lift to transfer her out of bed. Resident 3 is not self-ambulatory. A nursing note dated October 6, 2023, at 6:30 PM indicated that staff noted a bruise to the top of Resident 3's left foot measuring 5 cm (centimeters) by 4 cm. The note further described the bruise as green and blue (indicating an older bruise up to five days). Review of the facility's investigation into Resident 3's bruised left foot revealed a witness statement form indicating that for investigations regarding a bruise, the facility is to collect staff statements from the previous three days prior to its discovery. The facility only collected two staff members on the same shift it was discovered, one who reported it and another who didn't see it. There was no documented evidence to indicate the facility collected staff statements for the three days prior to Resident 3's discovery of her bruise. There was also no other documented evidence to indicate the facility thoroughly investigated the possible cause of the bruise to rule out the potential for abuse and/or neglect. Interview with Employee 1, consultant, on October 13, 2023, at 11:00 AM confirmed the above findings for Resident 3. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395614 If continuation sheet Page 2 of 6 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 395614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rolling Hills Healthcare and Rehabilitation Center 17350 Old Turnpike Road Millmont, PA 17845 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 - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for three of three residents reviewed (Residents 13, 37, and 46). Findings include: Review of Resident 13's clinical record revealed that the facility transferred him to the hospital on August 8, 2023. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 13's transfer to the hospital. Review of Resident 37's clinical record revealed that the facility transferred him to the hospital on June 20, 2023, and again on September 17, 2023. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 37's transfers to the hospital. Review of Resident 46's clinical record revealed that the facility transferred the resident to the hospital on August 31, 2023, at 7:50 AM. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 46's transfer to the hospital. Interview with Employee 3, social worker, on October 12, 2023, at 1:04 PM confirmed the above findings and indicated that she had not sent any transfer notices to the Office of the State Long-Term Care Ombudsman for any resident transfers. Employee 3 indicated that she was faxing the local Ombudsman office, but also could not provide documented evidence that it occurred. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395614 If continuation sheet Page 3 of 6 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 395614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rolling Hills Healthcare and Rehabilitation Center 17350 Old Turnpike Road Millmont, PA 17845 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 clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding the care of a pacemaker for one of one resident reviewed with a pacemaker (Resident 12). Residents Affected - Few Findings include: Clinical record review revealed Resident 12 was admitted to the facility on [DATE]. Clinical record review of Resident 12's diagnoses list included a left bundle branch block (a disease that impacts or disrupts the electrical impulse that causes the heart to beat). Clinical record review for Resident 12 revealed hospital documentation that noted the resident had a pacemaker implanted in October 2018. A current care plan for Resident 12 indicated the resident had cardiac disease related to the left bundle branch block and an intervention included, pacemaker checks as ordered. A review of the current physician orders for Resident 12 revealed no current orders related to pacemaker checks; however, an order dated October 28, 2018, noted cardiology consult as needed. A review of Resident 12's clinical record revealed no pacemaker checks. An interview with the Nursing Home Administrator on October 13, 2023, at 12:45 PM, and Employee 2, licensed practical nurse, on October 13, 2023, at 1:00 PM reported Resident 12 refused the pacemaker check appointments. Upon the surveyor asking for documentation to support this, the only documentation provided by the facility was a form titled Resident Refusal of Appointment dated September 2, 2020, for a cardiology appointment and the reason for refusal noted Resident refusing to wear a mask to go on appointment. An interview with Employee 2 on October 13, 2023, at 1:13 PM revealed a box for a [NAME] device (a device used for remote follow-up after implantation of a pacemaker) was found with Resident 12's name in the supply room of the facility; however, the device was not in the box or visible in the resident's room. Employee 2 was further observed advising Resident 12 that the facility was going to make an appointment to get the pacemaker checked and the resident stated, Oh, ok. The facility failed to provide the highest practicable care regarding Resident 12's pacemaker follow-up checks and it was unclear when the last pacemaker check occurred. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395614 If continuation sheet Page 4 of 6 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 395614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rolling Hills Healthcare and Rehabilitation Center 17350 Old Turnpike Road Millmont, PA 17845 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on clinical record review, review of facility investigation, and staff interview, it was determined that the facility failed to thoroughly investigate an accident regarding an elopement and implement interventions to prevent recurrence for one of one resident reviewed (Resident 51). Findings include: Review of Resident 51's clinical record revealed nursing documentation dated September 21, 2023, at 4:56 PM indicating that nursing staff called Resident 51's representative to discuss Resident 51's elopement. Nursing documentation dated September 21, 2023, at 5:08 PM indicated that Employee 5, cook, received a text message from a neighbor indicating that an older lady was standing in front of her house. v Employee 5 drove to the neighbor's house and found Resident 51 in front of the neighbor's garage. Employee 5 brought Resident 51 back to the facility in her personal vehicle at approximately 4:25 PM with no apparent injuries. Review of the facility's investigation into Resident 51's elopement revealed that according to witness statements, Resident 51 was last seen at the nursing station in her wheelchair around 3:30 PM, with her pressure sensor chair alarm in place. The investigation indicated that prior to Resident 51's elopement, her chair alarm did not sound. There was no documented evidence in the facility's investigation that the facility determined why Resident 51's pressure sensor chair alarm did not sound prior to her elopement, or that a witness statement was collected from Employee 5 who was a key staff member in Resident 51's elopement. A progress note included in Resident 51's elopement investigation from the Interdisciplinary Team effective September 22, 2023, indicated that the keypad to the door that Resident 51 exited was reactivated and staff education/disciplinary action for nurse aides on completing rounds and alarm checks. There was no documented evidence to indicate that the facility determined why the keypad to the door was not activated or not working, if the facility completed a facility wide sweep of other doors with alarms to ensure proper functioning, or that the facility performed staff education or disciplinary action regarding not completing rounds and alarm checks. Interview with Employee 1, consultant, on October 12, 2023, at 2:50 PM confirmed the above findings for Resident 51. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.10(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395614 If continuation sheet Page 5 of 6 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 395614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rolling Hills Healthcare and Rehabilitation Center 17350 Old Turnpike Road Millmont, PA 17845 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by three of three residents reviewed (Residents 4, 42, and 49). Residents Affected - Some Findings include: Clinical record review for Resident 4 revealed the facility admitted her on September 9, 2021, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of a significant change Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 21, 2023, indicated that the facility assessed Resident 4 as having the diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 4's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 42 revealed the facility admitted her on March 12, 2021, with diagnosis including Dementia. A review of Resident 42's Minimum Data Set assessment dated [DATE], indicated that the facility assessed Resident 42 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 42's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 49 revealed the facility admitted her on February 25, 2022, with diagnosis including Dementia. A review of Resident 49's Minimum Data Set assessment dated [DATE], indicated that the facility assessed Resident 42 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 49's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The findings were reviewed with the Director of Nursing, Nursing Home Administrator, and Employee 1 (consultant) on October 12, 2023, at 11:30 AM. Further interview with Employee 1 on October 13, 2023, at 9:35 AM confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Residents 4, 42, and 49's dementia and cognitive loss. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa Code 211.11(d) Resident care plan FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395614 If continuation sheet Page 6 of 6