Health inspection·July 7, 2025

F 0684 Level of Harm - Actual harm Residents Affected - Few Nursing Note Late Entry: Resident Alert and Oriented assessment completed, no s/s of acute distressed noted. Resident encouraged to continue to stay hydrated. The Late Entry progress note was created on June 25, 2025, at 10:56 AM. Review of Resident 1's progress note titled Late Entry, dated June 23, 2025, at 11:12 PM, read, Late Entry: Note Text: Evaluation of resident completed. Resident shows no s/s of pain or distress. [He/She] denies needs or concerns at this time. The Late Entry progress note was created on June 25, 2025, at 11:19 AM. Review of Resident 1's progress notes revealed a Late Entry dated June 24, 2025, at 8:19 PM, that read Late Entry: Note Text: Resident offered room change; however, resident declined room change at this time. Resident shows no s/s of discomfort or distress and verbalizes understanding to contact staff for any needs or concerns. The Late Entry progress note was created on June 25, 2025, at 11:20 AM. Review of Resident 1's progress note on June 24, 2025, at 6:00 PM, revealed a new order for Acetaminophen (Tylenol) 650 mg by mouth every six hours as needed for Elevated Temperature. A progress note on June 24, 2025, at 7:58 PM, nursing documented Prior to Writer's arrival resident was assisted from [his/her] room, then placed into [his/her] wheelchair and provided a different location X2 and encouraged fluids. After much encouragement. Resident was found back in [his/her] in bed. Upon entering resident's room, call light was not on. Room temperature 87 F (Fahrenheit), personal fan oscillating nearby resident. A progress note date June 24, 2025, at 8:00 PM, revealed the charge nurse documented Writer was alerted by assigned nurse that resident was under respiratory distress. Writer assessed; Resident had medium sized emesis. Increased temperature (Tylenol was administered). Skin warm and intact. Resident is lethargic, Resident has shortness of breath, lung sounds clear, and no cough present, pulse oxygen 90% at room air. Unable to follow simple commands, increased restlessness (reaching into the air and involuntary extremity movements), and no verbal responses. Vital signs as noted in PCC [Point Click Caredocumentation system]. Writer obtained a verbal order from [Certified Registered Nurse Practitioner] to send to hospital for eval (evaluation) and treat. An additional progress note on June 24, 2025, at 8:25 PM, read Resident ask to me get out bed and this write put on [his/her] chair, room so hot. Resident stayed on [his/her] wheelchair about 15 minutes and put [himself/herself] in bed. I get up again to stay in hallway because room too hot and after a while [he/she] put [himself/herself] again in bed. I put my persona fan in [his/her] room and take [his/her] temp (temperature), and it was 103.3 and I put ice pack and administered Tylenol 650 mg, and it was effective and with normal range. Then resident mental status was changed and vomit twice and [his/her] temp went up again about 103.4. I call supervisor for further action to be taken. I was with resident all times until the EMS [Emergency Medical Services] arrived because resident was at risk of fall. Additional review of Resident 1's clinical record failed to reveal assessments specific to the risk of hyperthermia or documentation of Resident 1's vital signs, including temperature, pulse (heart rate), respiratory rate, blood pressure and oxygen saturation when the facility was aware of the elevated temperatures. Review of Resident 1's hospital emergency department admission documentation revealed, per EMTs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395074 If continuation sheet Page 2 of 4 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 395074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Rehabilitation and Nursing Center 1205 South 28th Street Harrisburg, PA 17111 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 Level of Harm - Actual harm [Emergency Medical Technicians] patient is coming from [facility] where [he/she] was found to be altered for the past 2 hours. [He/She] is in acute respiratory distress on arrival. Patient is critically ill. Unable to provide a history. Patient is very ill appearing. [He/She] is extremely hot to the touch. Even the urine in [his/her] Foley bag that we inserted on arrival feels very warm to the touch. Residents Affected - Few Also, Patient was critically ill on arrival. [He/she] is blood pressure was 80/34 [normal is 120/80] with a temperature of 107.1 Fahrenheit. [He/She] was clearly in acute respiratory distress. During Resident 1's assessment in the emergency department, Resident 1 was intubated (medical procedure where a tube is inserted into the body, most commonly through the mouth or nose and into the trachea [windpipe] to maintain an open airway. This is often done to assist breathing, deliver medication, or provide anesthesia. The tube can be connected to a ventilator to help the patient breathe, especially in cases of respiratory failure or during surgery). Resident 1 was subsequently admitted to the Intensive Care Unit (ICU). Review of the emergency department's clinical impressions dated June 25, 2025, at 12:24 AM, revealed the following diagnoses to include Hyperthermia and Acute respiratory failure. According to additional hospital record review, staff consulted with Resident 1's court-appointed guardian, and The decision was made to transition the patient to comfort care with compassionate extubation (removing an endotracheal tube (ETT), which is the last step in liberating a patient from the mechanical ventilator. Comfort measures orders (actions taken to alleviate pain, suffering, and discomfort in a person who is seriously ill or nearing the end of their life. These measures focus on providing physical, emotional, and spiritual support to ensure a peaceful and dignified passing) were placed after discussing with the whole team. Interviews conducted with the Nursing Home Administrator (NHA) on June 26, 2025, at approximately 10:00 AM, revealed the facility to be experiencing a breakdown of its heating and cooling system. Review of Resident 1's progress notes for June 2025 revealed no evidence of a decline in Resident 1's clinical status, including any abnormal vital signs or respiratory distress prior to the elevated temperatures. Vital signs documented during an assessment on June 17, 2025, revealed vital signs as follows: Temperature: 97.9 °F, Blood Pressure: 128/67, Pulse: 68 bpm, O2 Saturation: 97 and Respiratory Rate: 18 Breaths/min. An interview with the Director of Nursing on June 26, 2025, at 2:00 PM, revealed that staff were instructed to document late entries in the clinical record to capture all assistance provided to the residents during the emergent situation regarding the hot temperatures in the building. The interview also revealed the possibility Resident 1 was already ill and the elevated building temperatures did not help his/her current condition. Interview conducted with the NHA on July 7, 2025, at 1:42 PM, provided no additional information related to Resident 1's hospitalization and status. The facility was unable to provide documentation of vital signs for Resident 1 when the faciity noted the elevated temperature on the nursing unit. The progress notes entered for Resident 1 prior to the change in condition were entered after the Resident was sent to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395074 If continuation sheet Page 3 of 4 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 395074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Rehabilitation and Nursing Center 1205 South 28th Street Harrisburg, PA 17111 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 Level of Harm - Actual harm Residents Affected - Few There was no evidence that the facility monitored and assessed Resident 1 for hyperthermia after becoming aware of the elevated temperatures on the nursing unit. The facility failed to provide care and services in accordance with professional standards, resulting in a significant decline in Resident 1's health status, as evidenced by hyperthermia and acute respiratory failure, leading to emergency treatment, hospitalization admission, and subsequent comfort care. 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 211.12 (d) (1) (3) (5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395074 If continuation sheet Page 4 of 4