Health inspection·August 15, 2025

F 0572 Give residents a notice of rights, rules, services and charges. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, facility documentation, and interviews with staff, it was determined that the facility failed to ensure that residents/resident representatives were provided facility rules in writing related to private companions unable to provide direct care for residents while in the facility, one of two resident reviewed for falls (Resident R6). Findings incldue: Review of facility policy Resident Rights, dated 2023, revealed the facility will promote and protect the rights of each resident and places a strong emphasis on individual dignity and self-determination. A written description of a Resident's Rights will be provided to the resident upon admission to the facility and upon request. The facility will adhere to state and federal regulatory requirements pertaining to Resident Rights. Review of clinical record revealed Resident R6 was admitted to the facility on [DATE], with a diagnosis that included dementia (the loss of cognitive functioning that interferes with daily life), hypertension (high blood pressure), and atrial fibrillation (abnormal heart rhythm). Review of Resident R6's clinical record revealed on April 12, 2025, Resident R6 had a fall in his/her room. Review of Resident R6's incident report revealed on April 12, 2025 Resident had a private 1:1 Aide in room to sit with resident 7a-7p; this aide walked outside the resident's room to ask the nurse to help pull the resident up, (thinking the resident needed pulled up to his bed). The nurse entered the room and found the resident laying on the floor matt to the right side of his bed and his head resting on his wheelchair wheel. The 1:1 Aide stated that she was transferring the resident from bed to wheelchair and then she lowered the resident softly to the floor. Further review of Resident R6's incident report revealed The 1:1 aide stated she transferred the resident earlier in the day without any trouble. The nurse told the 1:1 aide that the resident has dementia and needs a 2 person transfer. Interview on August 14, 2025, at 10:30 a.m. with Employee E2, Director of Nursing, confirmed the facility provides verbal information regarding private aides not being allowed to directly care for resident in the facility to residents/resident representatives, but does not provide the information in written format. 28 Pa. Code 201.29 (e) Resident rights Residents Affected - Few Page 1 of 4 396107 396107 08/15/2025 Ann's Choice 16000 Ann's Choice Way Warminster, PA 18974

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required timeframe for one of 16 residents reviewed (Residents 47).Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days. An admission MDS assessment for Resident 47, with an ARD of March 31, 2025, was completed on April 4, 2025. A quarterly MDS assessment for Resident 47, was due to be completed within 90 days from March 31, 2025. There was no evidence that the MDS assessment was completed by the facility as required. Interview with the RNAC (registered Nurse Assessment Coordinator) on August 14, 2025, at 11:14 a.m. confirmed that the quarterly MDS assessments for Residents 47, was not completed as required. 28 Pa. Code 211.5(f) Clinical Records. Residents Affected - Few 396107 Page 2 of 4 396107 08/15/2025 Ann's Choice 16000 Ann's Choice Way Warminster, PA 18974

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and interviews with staff, it was determined that the facility failed to accurately complete a resident assessment for one of 16 residents reviewed (Resident R33). Findings include:Review of Resident R33's discharge Minimum Data Set (MDS- assessment of resident care needs) dated April 29, 2025, revealed that the resident was discharged . Further review of the MDS revealed that the social security number for the resident was coded incorrectly in the MDS assessment. Interview with the Registered Nurse Assessment Coordinator, conducted on August 14, 2025, at 11:14 a.m. confirmed that social security number was coded incorrectly for Resident R33.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.5(f) Clinical Records. Residents Affected - Few 396107 Page 3 of 4 396107 08/15/2025 Ann's Choice 16000 Ann's Choice Way Warminster, PA 18974

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on QAPI (Quality Assurance and Performance Improvement) for three of three employees reviewed (Employees E4, E5 and E6).Findings include:Review of facility policy titled Health Services- Education and Training dated April 2023, revealed All health services employees will be required to complete a specific number of continuing education topics commensurate with their job classification, certification and license at the time of hire, annually, or more frequently per state/federal regulations for the service level/ department which they are assigned. Review of facility policy titled Quality Assurance Performance Improvement (QA/PI) Committee dated April 2025, revealed Education regarding this policy and procedure will be completed with appropriate personnel as needed. Ongoing training and education will be provided on an as needed basis, as determined by the employee's direct supervisor/ manager. Employee E4, Certified Nursing Assistant, had a hire date of February 16, 2021, failed to have QAPI in-service education between August 13, 2024-August 13, 2025.Employee E5, Certified Nursing Assistant, had a hire date of August 22, 2022, failed to have QAPI in-service education between August 13, 2024-August 13, 2025.Employee E6, Certified Nursing Assistant, had a hire date of June 10, 2015, failed to have QAPI in-service education between August 13, 2024-August 13, 2025.Interview with Employee E1, Assistant Nursing Home Administrator, August 15, 2025, at 9:00 am, confirmed that the facility failed to provide training on QAPI for three of three employees reviewed (Employees E4, E5 and E6).28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(6)(d) Staff development. 396107 Page 4 of 4