Inspection·January 22, 2025

F 0600 was no care plan in place indicating the presence of such behaviors. Level of Harm - Actual harm A review of a facility investigative report dated January 19, 2025, at 1:15 PM revealed Resident 3, a cognitively intact resident was observed by staff performing oral sex on Resident 2, a cognitively impaired resident. A review of the investigative reports and witness statements confirmed that Employee 2 nurse aide (NA) and Employee 3, nurse aide (NA) both witnessed the event and immediately reported to the nurse, Employee 1 registered nurse (RN). When questioned Resident 3 admitted to engaging in the act, stating that Resident 2 had initiated the interaction, although Resident 2, due to her severe cognitive impairment, could not have consented to or initiated sexual behavior. Residents Affected - Few A review of a statement from Resident 3, which did not indicate the date or time it was obtained, revealed that Resident 3 went into Resident 2's room to offer her roommate, some yogurt. Resident 3 stated that Resident 2 was moaning as if she needed a drink. He indicated that he went into the bathroom to get her some water, and upon returning, Resident 2 grabbed his hand and pulled him toward her and started to touch the front of his pants. Resident 3 indicated they began to kiss. Resident 3 stated that Resident 2 had her brief off, so he placed his head between her legs for a few seconds. He stated the staff came in, saw what was happening and he confirmed he immediately got up and left the room. A review of nursing documentation written by Employee 1, RN dated January 19, 2025, at 1:15 PM indicated she was notified by Employee 2 NA that Resident 3 was engaged in inappropriate behavior with Resident 2. When Resident 3 was asked what he was doing, he got up and walked out of the room. Resident 2 was observed lying on her mattress with her incontinence brief removed. When asked if someone hurt her, Resident 2 moaned yes. A body audit was conducted revealing no signs of bruising, marks or bleeding. State police were notified, and an investigation was initiated. Resident 2 was sent to the hospital for a rape kit examination. Resident 3 was separated from this resident and placed on one-to-one observation to ensure residents' safety and provide continuous supervision of this resident. A telephone interview with Employee 2, NA on January 22, 2025, at 1:00 PM revealed she was assigned to Resident 2 on January 19, 2025. Employee 2 stated that she asked Employee 3, NA for assistance with Resident 2's care. When they entered Resident 2's room, the privacy curtain was drawn, and they noticed sneakers sticking out from underneath the curtain. Employee 2 indicated she and Employee 3 then moved around the curtain and observed Resident 3 face positioned between Resident 2's legs. She also noted that Resident 2's brief had been removed and was placed to the side. When asked if Resident 2 would have been capable of removing the brief on her own, Employee 2 responded that she could not. She explained that while Resident 2 had a history of attempting to rip off her brief, the brief tabs were not torn. Instead, the tabs had been carefully undone, and the brief had been intentionally placed to the side. Employee 2 further stated when asked Resident 3 what he was doing, he got up and left the room. She observed that Resident 2 appeared distraught. Employee 2 stated she then helped resident to get dressed and escorted her to the dining room for monitoring. An interview with Employee 3 on January 22, 2025, at 12:12 PM revealed that on January 19, 2025, she had returned from her break when Employee 2 approached her and asked her for assistance with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395929 If continuation sheet Page 2 of 3 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 395929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeview Healthcare & Rehab Center 200 Pennsylvania Avenue Shenandoah, PA 17976 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 0600 Level of Harm - Actual harm Residents Affected - Few care. The Resident 2 Employee 3 stated it was approximately 1:00 when they entered the residence room and noticed a pair of sneakers sticking out from under the privacy curtain. She indicated she then walked around the curtain and observed Resident 2 lying on the bed with her brief removed and saw Resident 3's face positioned between Resident 2's legs. Employee 3 stated that she and Employee 2 immediately yelled What are you doing! At that point, Resident 3 got up and walked out of the room. Employee 3 followed Resident 3 out of the room while Employee 2 stayed with Resident 2. Employee 3 immediately reported the incident to Employee 1 RN on duty. Employee 3 further stated she later returned to Resident 2's room and helped her get dressed and assisted her to the dining room. When asked whether Resident 2 would have been able to reach up to pull Resident 3 toward her or grab him, Employee 3 responded no. She explained that Resident 2 requires assistance with. Activities of daily living and would not have the strength to perform such activities. Multiple attempts were made to interview Resident 3 throughout the day on January 22, 2025, however, the resident was asleep during each attempt. A review of legal records indicated, Resident 3 is facing charges of Indecent Assault on a Person with Mental Disabilities, with a preliminary hearing scheduled for February 6, 2025. Resident 2 is cognitively impaired and did not possess the ability to consent to sexual acts with Resident 3. Applying the reasonable person concept, in the case of Resident 2, who is unable to cognizant speak for herself due to severe cognitive impairment, and the assessment of how most people would react to the situation of being sexually abused by Resident 3, Resident 2 would have been negatively affected by Resident 3's actions. An interview with the Nursing Home Administrator on January 22, 2025, at approximately 3:00 PM confirmed that the facility failed to ensure that Resident 2 was free from sexual abuse perpetrated by Resident 3. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12(c)(d)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395929 If continuation sheet Page 3 of 3