Health inspection·March 26, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - 11:25 AM - The wall next to Resident 7's bed had numerous dried brown spots. The floor at the base of the wall had areas of dried liquid. The heater next to the toilet in Resident 7's bathroom was badly rusted and the metal was disintegrating in some areas. Multiple tiles were missing from the floor next to the toilet. The safety/towel bars were noted to have corrosion, as did the leg of the sink counter. Dried brown spots were present on the floor coming out of the bathroom. A clear plastic bucket with a dried brown substance was sitting on the bathroom windowsill. During an interview with Resident 2 on March 26, 2025, at 10:49 AM, she expressed concern with the cleanliness of her room and bathroom. During a tour on March 26, 2025, at 12:00 PM, with the Director of Nursing, the aforementioned areas were observed, and she acknowledged the concerns. During an interview with the Nursing Home Administrator on March 26, 2025, at 12:39 PM, he confirmed that the was aware of the aforementioned concerns. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395123 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 395123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011 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 Based on policy review, clinical record review, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to provide care and services in accordance with professional standards of practice to ensure the resident's highest level of well-being for one of four residents reviewed (Resident 11). Residents Affected - Few Findings include: Review of facility policy, Medication Administration, undated, revealed, Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label .Residents are identified before medication is administered. Methods of identification include: a. Checking identification band, b. Checking photograph attached to medical record, c. If necessary, verifying resident identification with other facility personnel .Medications supplied for one resident are never administered to another resident. Review of Resident 11's clinical record revealed diagnoses that included Cauda Equina Syndrome (occurs when the bundle of the nerves at the lower end of the spinal cord are compressed causing pain, numbness, and incontinence) and infection of intervertebral disc (located between the vertebrae in the spine). Further review of Resident 11's clinical record revealed the following nursing progress note dated February 24, 2025, this writer was with orientation prepared resident medication. gave wrong resident the medication. notified supervisor, np [Nurse Practitioner], notified resident representative. [Nurse Practitioner] ordered vss q [Vital sign each] shift, monitoring bleeding x 3 days. Per email correspondence received from the Director of Nursing (DON) on March 26, 2025, at 11:35 AM, the following medications were provided in error to Resident 11 on February 24, 2025: Cholecalciferol Oral Tablet 50 MCG (vitamin supplement), cyanocobalamin Sublingual Tablet Sublingual 5000 mcg (vitamin B12), Iron 325 mg (supplement), Magnesium lactate 84 mg (mineral supplement), Mag ox 800 mg (supplement), Apixaban 2.5 mg (anticoagulant), Lasix 40 mg (diuretic), Keppra 500mg (anticonvulsant), Senna plus (laxative), and Metoprolol 25 mg (treats high blood pressure and other heart problems). Review of facility incident report and supporting documentation dated February 24, 2025, revealed that Employee 1 (Registered Nurse), who was being oriented by Employee 2 (Licensed Practical Nurse), prepared and administered the incorrect medications to Resident 11. Further review revealed that following the incident, Employee 1 and Employee 2 were re-educated by the DON and disciplinary action was taken. During an interview with the DON and Nursing Home Administrator on March 26, 2025, at approximately 12:45 PM, they were made aware of the concern with Resident 11's medication administration error. The DON revealed that an internal plan of correction was completed following this incident. Review of Resident 11's February 2025 Treatment Administration Record (TAR) revealed that following the incident, an order was written effective February 24, 2025, to monitor her vital signs each shift for three days. Further review of the TAR revealed that this was documented as being completed. No abnormal vital signs were recorded. It was also noted that Resident 11 was monitored for side effects, including bleeding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395123 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 395123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011 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 - Minimal harm or potential for actual harm Residents Affected - Few Following Resident 11's medication error, the facility reviewed incident reports for the two weeks preceding the error, and none were found. No medication error reports were present since the time of Resident 11's medication error on February 24, 2025. Review of an education sign-in sheet revealed that education was provided to licensed nursing staff on the Ten Rights of medication administration on March 10, 2025. A Medication Administration Test was administered to attendees on that date. Review of facility audits revealed that a medication administration competency checklist was completed during medication pass observation for two nurses during the weeks of February 24, 2025, and March 10, 2025, and four were completed during the week of March 19, 2025. Observations made and resident and staff interviews conducted during the onsite survey on March 26, 2025, failed to reveal any concerns with medication administration errors. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395123 If continuation sheet Page 4 of 4