Health inspection·November 16, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some treatment and to formulate an advance directive if he or she chooses to do so; 2) Written information will include a description of the facility's policies to implement advance directives and applicable state law; 3) If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative; 6) Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives; 8) If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a) The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision; and b) Nursing staff will document in the medical record the offer to assist and the Resident's decision to accept or decline assistance; and 18) The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). Review of Resident 54's clinical record revealed diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things) and hypertension (high blood pressure). Resident 54 was originally admitted to the facility on [DATE]. Resident 54 had a hospital stay from October 5, 2023, through October 9, 2023. Review of Resident's current physician orders revealed the following order: Full Code dated October 9, 2023. A review of Resident 54's clinical record failed to include any documentation that the facility had discussed or offered to assist them in formulating an Advance Directive upon their readmission to the facility or at any time during the past year. In addition, there was no Advance Directive present in the clinical record. During an interview with the NHA on November 15, 2023, at 9:54 AM, the NHA confirmed that she could not provide any documentation to support that Resident 54 was offered information on formulating an advance directive. Review of Resident 72's clinical record revealed diagnoses that included hypertension, atherosclerotic heart disease (build-up of cholesterol plaques in the walls of the arteries causing obstruction of blood flow), and diabetes type 1 (a metabolic disease, involving inappropriately elevated blood glucose levels requiring insulin administration to treat). Resident 72 was originally admitted to the facility on [DATE]. Resident 72 had a hospital stay from October 2, 2022, through October 4, 2022, and from December 18, 2022, through December 22, 2022. Review of Resident's current physician orders revealed the following order: Full Code dated October 5, 2022. A review of Resident 72's clinical record failed to include any documentation that the facility had discussed or offered to assist them in formulating an Advance Directive upon their readmission to the facility or at any time during the past year. In addition, there was no Advance Directive present in the clinical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 2 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the NHA on November 15, 2023, at 9:54 AM, the NHA confirmed that she could not provide any documentation to support that Resident 72 was offered information on formulating an advance directive. Review of Resident 88's clinical record revealed diagnoses that included major depressive disorder and atherosclerotic heart disease. Resident 54 was originally admitted to the facility on [DATE]. Resident 88 had a hospital stay from December 21, 2022, through December 28, 2022. Review of Resident's current physician orders revealed the following order: Full Code dated June 28, 2022. A review of Resident 88's clinical record failed to include any documentation that the facility had discussed or offered to assist them in formulating an Advance Directive upon their readmission to the facility or at any time during the past year. In addition, there was no Advance Directive present in the clinical record. During an interview with the NHA on November 16, 2023, at 11:56 AM, the NHA confirmed that she could not provide any documentation to support that Resident 88 was offered information on formulating an advance directive. 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 201.18(a)(b)(1)(d)Management 28 Pa. Code 201.29(a) Resident Rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 3 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and staff interviews, it was determined that the facility failed to maintain a clean, comfortable, and homelike environment for five of 38 residents observed (Residents 14, 114, 137, 138, and 223). Findings include: Observation of Resident 14's Broda chair (a tilt-in-space positioning chair which prevents skin breakdown through reducing heat and moisture) on November 13, 2023, at 10:04 AM, revealed the presence of a dried white substance on the left arm rest and heavy hair build-up around all four wheels. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on November 15, 2023, at 1:28 PM, the aforementioned concerns were shared. During a follow-up interview with the NHA and DON on November 16, 2023, at 11:52 AM, the NHA indicated that Resident 14's Broda chair had been cleaned. She further indicated that she would expect homelike and cleanliness concerns be addressed when identified by staff. Observations of Resident 114's room on November 13, 2023, at 11:01 AM, and November 15, 2023, at 12:35 PM, revealed that the protective rubber molding was missing from around their overbed table and that the particle board was exposed. Observation of Resident 114's wheelchair on November 13, 2023, at 12:56 PM, and November 15, 2023, at 12:35 PM, revealed the presence of visible brownish and dusty soiling down both sides and along the base. During an interview with the NHA and DON on November 15, 2023, at 1:28 PM, the aforementioned concerns were shared. During a follow-up interview with the NHA and DON on November 16, 2023, at 11:52 AM, the NHA indicated that Resident 114's chair had been cleaned and that a new overbed table was provided. She further indicated that she would expect homelike and cleanliness concerns be addressed when identified by staff. Observations of Resident 138's room and bathroom on November 13, 2023, at 10:25 AM, and on November 15, 2023, at 10:49 AM, revealed the presence of a white powdery substance on the front of their wheelchair seat; a brown colored substance on the call bell cord in bathroom; and a dried brown substance on the floor around the base of the toilet and behind the toilet. During an interview with the NHA and DON on November 15, 2023, at 1:28 PM, the aforementioned concerns were shared. During a follow-up interview with the NHA and DON on November 16, 2023, at 11:52 AM, the NHA indicated that Resident 138's wheelchair, bathroom, and pull cord were cleaned. She further indicated that she would expect homelike and cleanliness concerns be addressed when identified by staff. During initial tour on November 13, 2023, at 10:30 AM, observations included Resident 137's middle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 4 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0584 Level of Harm - Minimal harm or potential for actual harm bedside stand drawer broken, and Resident 223's top lock drawer of the bedside stand was off track and in need of repair. During an interview with the NHA on November November 15, 2023, at 1:30 PM, the bedside stand concerns were addressed, and the NHA that the bedside stands should be repaired or replaced. Residents Affected - Few 28 Pa. Code 201.18(3)(e) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 5 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical record review, review of facility incident report, and staff interviews, it was determined that the facility failed to conduct a timely and thorough investigation to rule out abuse, neglect, or mistreatment following an unwitnessed fall for one of 12 residents reviewed for falls (Resident 138). Residents Affected - Few Findings Include: Review of facility policy, titled Abuse Policy with last review date of September 23, 2023, revealed, The Facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse and neglect. The policy defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of Resident 138's clinical record revealed diagnoses that included unsteadiness on feet, repeated falls, mild cognitive impairment (a condition in which someone has minor problems with their mental abilities, such as memory or thinking), and orthostatic hypotension (form of low blood pressure that happens when standing up from lying or sitting down). Review of Resident 138's progress notes revealed a note dated September 4, 2023, at 7:15 PM, which indicated that Resident 138 was found on the floor in his room with his blanket, and that he stated he was looking for his blanket and had found it on the floor. The note further indicated that Resident 138 was noted to have a skin tear/abrasion to his right elbow (for which a treatment was provided), and that he was placed back in bed and was using the urinal. Review of facility provided incident report for Resident 138's fall on September 4, 2023, at 7:15 PM, indicated in the section of the report titled Nursing Description, that the Resident was found on the floor in doorway. Review of the section of the report titled Resident Description, revealed the following: Resident stated he needed to urinate and requested assistance to the toilet. Resident states that assistance was denied by the aide and that he should use his urinal in bed. It further stated, Resident insisted on using toilet as usual and attempted to ambulate to toilet independently and fell. In the section titled Description of Action Taken it was documented aide assigned should position self in assigned area hallway and not congregate with other aides in resident common area. During an interview with the Nursing Home Administrator (NHA) on November 16, 2023, at 9:35 AM, the aforementioned accident documentation discrepancy between Resident 138's progress notes and the incident report was shared. NHA was questioned at that time if the event had been investigated as a potential neglect allegation. She indicated that she would have to look into this concern and get back to me. During a follow-up interview with the NHA and Director of Nursing (DON) on November 16, 2023, at 11:45 AM, it was again requested that any additional information regarding this incident be provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 6 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for review, including staff education about the aide assigned should position self in assigned area hallway and not congregate with other aides in resident common area. During a follow-up interview with the NHA and DON on November 16, 2023, at 1:33 PM, the DON provided a copy of notes from a phone interview with the Aide that was working on the evening the fall occurred, which was dated for November 16, 2023, at 1:05 PM. These notes indicated that the Aide did not recall the Resident's incident, but that they always use two staff with Resident contact. The notes further indicated that the Aide never told the Resident to use the urinal instead of assisting him to the bathroom. The NHA and DON both confirmed that no investigation for possible neglect was completed at the time of the September 4, 2023; however, the NHA indicated that all incidents are reviewed in their morning meeting. DON indicated that they are trying to get a process together for a more thorough review of incidents with the team members. NHA further indicated that the Unit Manager addressed the concern at the time it occurred as stated in the incident report, but that they had no other documentation to provide and that this Unit Manager was no longer employed at the facility. 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: 395223 If continuation sheet Page 7 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure a significant change assessment (change to hospice status) was completed for one of 38 residents reviewed (Resident 18). Residents Affected - Few Findings include: A review of Resident 18's clinical record on November 14, 2023, revealed diagnoses that included Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Atrial Fibrillation (irregular and rapid heart-beat). Review of the clinical record for Resident 18 on November 14, 2023, revealed the Resident was ordered a consult with the hospice service (special kind of care that provide comfort, support, and dignity at the end of life) on July 21, 2023. On July 25, 2023, the facility completed a Significant Change Minimum Data Set (MDS - periodic assessment of resident's needs), but the significant change MDS was not coded for hospice under Section O. Special Treatments, Procedures, and Programs. On August 5, 2023, the physician wrote an order for an evaluation and treatment with the hospice service. There was no significant change MDS completed after that date or before the next Quarterly MDS assessment. Review of the Quarterly MDS completed in October 2023 revealed it was coded for hospice under Section O. Special Treatments, Procedures, and Programs. During an interview with the Nursing Home Administrator (NHA) on November 15, 2023, at 1:30 PM, the NHA confirmed a significant change assessment should have been completed and coded for hospice status. 28 Pa. Code 211.12(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 8 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0641 Ensure each resident receives an accurate assessment. 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 interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for six of 39 residents reviewed (Resident 4, 72, 77, 138, 143, and 151). Residents Affected - Some Findings Include: Review of Resident 4's clinical record revealed diagnoses that included Multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Review of Resident 4's MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated August 21, 2023, revealed that section M0150. Risk of Pressure Ulcers/Injuries (Is this resident at risk of developing pressure ulcers/injuries?) was marked 0. No. Further review of Section M0300. C1. Number of Stage 3 pressure ulcers was marked 1, indicating Resident 4 has one stage 3 pressure ulcer. Review of Resident 4's MDS dated [DATE], revealed that section M0150. Risk of Pressure Ulcers/Injuries (Is this resident at risk of developing pressure ulcers/injuries?) was marked 1. Yes. Review of Resident 4's MDS dated [DATE], revealed that section M0150. Risk of Pressure Ulcers/Injuries (Is this resident at risk of developing pressure ulcers/injuries?) was marked 1. Yes. Review of Resident 4's comprehensive centered care plan on November 15, 2023, at 11:21 AM, revealed Resident 4 is at risk for further breakdown in skin relating to incontinence, dermatophytosis, cardiovascular alterations, muscle spasms, hypothyroid, general weakness, prefers to spend most all time in bed, non-ambulatory, multiple sclerosis, history osteomyelitis sacral region, contractures and chronic pain, and has a stage 3 pressure ulcer to left gluteus, with a revision date of January 4, 2023. Review of Resident 4's Healing Partners Wound Assessment Report revealed Resident 4 was evaluated on November 14, 2023, and has a stage 3 pressure ulcer located on the left gluteus. During an interview with the Nursing Home Administrator (NHA) on November 16, 2023, at 11:48 AM, revealed that she would have expected the risk of pressure ulcers to have been captured on Resident 4's August 21, 2023, MDS and that a modification has been initiated. Review of Resident 72's clinical record revealed diagnoses that included depression, unspecified psychosis (a mental disorder characterized by a disconnection from reality), generalized anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), unspecified mood affective disorder (marked disruptions in mood), unsteadiness on feet, and repeated falls. Review of Resident 72's physician orders revealed an order for Abilify tablet (aripiprazole - an antipsychotic medication used to treat psychosis) give 5 milligrams by mouth one time a day, dated February 27, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 9 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 72's clinical record revealed a pharmacy recommendation for a gradual dose reduction (GDR) of their Abilify, which was reviewed and signed by the physician on March 2, 2023; which indicated that an attempted GDR is likely to result in impairment of function or increased distressed behavior. Review of Resident 72's Annual MDS dated [DATE], revealed in Section N Medications at Subsection

N0450. Antipsychotic Medication Review at question D. Physician documented GDR as clinically contraindicated was coded Yes, and Question E. Date Physician documented as clinically contraindicated was coded February 22, 2023. Review of Resident 72's Quarterly MDS dated [DATE], revealed in Section N Medications at Subsection

N0450. Antipsychotic Medication Review at question D. Physician documented GDR as clinically contraindicated was coded Yes, and Question E. Date Physician documented as clinically contraindicated was coded February 22, 2023. Review of Resident 72's Quarterly MDS dated [DATE], revealed in Section N Medications at Subsection

N0450. Antipsychotic Medication Review at question D. Physician documented GDR as clinically contraindicated was coded No. Review of Resident 72's Quarterly MDS dated of November 8, 2023, revealed in Section N Medications at Subsection N0450. Antipsychotic Medication Review at question D. Physician documented GDR as clinically contraindicated was coded No. During an interview with Employee 2 (Registered Nurse Assessment Coordinator) on November 15, 2023, at 10:46 AM, Employee 2 indicated that the Resident 72's August 8, 2023 and November 8, 2023, MDSs were coded inaccurately regarding the physician documentation of clinical contraindication to a GDR of Resident 72's ordered antipsychotic. She further indicated that for the March 3, 2023, and May 30, 2023, assessments, she had used the documentation date from the psychiatrist consult instead of the most recent date given by Resident 72's attending physician. During an interview with the NHA and DON on November 15, 2023, at 1:18 PM, the NHA confirmed that Resident 72's MDSs were coded inaccurately and that modifications were being completed. She further indicated that she would expect the MDSs to have been coded to reflect a true and accurate assessment of a resident's status. Further review of Resident 72's clinical record revealed that they had a fall on June 13, 2023. Review of Resident Review of Resident 72's Quarterly MDS dated [DATE], revealed in Section J Health Conditions at subsection J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment was coded 0 or None. Email communication was sent to the NHA and DON on November 16, 2023, 12:26 PM, to share the MDS coding concern related to falls for Resident 72. During an interview with the NHA and DON on November 16, 2023, at 1:39 PM, the NHA confirmed that Resident 72's MDS was coded inaccurately for falls and that a modification was being completed. She further indicated that she would expect the MDSs to have been coded to reflect a true and accurate assessment of a resident's status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 10 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0641 Level of Harm - Minimal harm or potential for actual harm Review of Resident 77's clinical record revealed diagnoses that included major depressive disorder, anxiety disorder, and symbolic dysfunction. Review of Resident 77's physician orders revealed an order for aripiprazole 10 milligrams by mouth one time a day, dated July 7, 2022. Residents Affected - Some Review of Resident 77's clinical record revealed that their physician had reviewed this medication for a GDR on March 2, 2023, and documented that a GDR was not possible clinically without a negative effect on the underlying psychiatric illness and added no GDR at this time. Review of Resident 77's Modification of Quarterly/Medicare 5 Day MDS dated [DATE], revealed in Section N Medications at Subsection N0450. Antipsychotic Medication Review at question D. Physician documented GDR as clinically contraindicated was coded Yes and at Question E. Date Physician documented as clinically contraindicated was coded July 15, 2022. Review of Resident 77's Annual MDS dated [DATE], revealed in Section N Medications at Subsection

N0450. Antipsychotic Medication Review at question D. Physician documented GDR as clinically contraindicated was coded Yes, and at Question E. Date Physician documented as clinically contraindicated was coded July 15, 2022. Review of Resident 77's Quarterly MDS dated [DATE], revealed in Section N Medications at Subsection

N0450. Antipsychotic Medication Review at question D. Physician documented GDR as clinically contraindicated was coded NO. Email communication was sent to the NHA and the DON on November 15, 2023, at 4:04 PM, the aforementioned coding concerns were shared for further follow-up. During an interview with the NHA and DON on November 16, 2023, at 11:41 AM, the NHA confirmed that Resident 77's MDSs were coded inaccurately and that modification were being completed. She further indicated that she would expect the MDSs to have been coded to reflect a true and accurate assessment of a resident's status. Review of Resident 138's clinical record revealed diagnoses that included unsteadiness on feet, repeated falls, mild cognitive impairment (a condition in which someone has minor problems with their mental abilities such as memory or thinking), and orthostatic hypotension (form of low blood pressure that happens when standing up from lying or sitting down). Further review of Resident 138's clinical record revealed that they had a fall on August 26, 2023, which resulted in a head laceration; a fall on October 8, 2023, which resulted in an abrasion; and a fall on October 28, 2023, which resulted in an abrasion. Review of Resident 138's Quarterly MDS dated [DATE], revealed in Section J Health Conditions at subsection J1900 B. Number of falls since admission or Prior assessment - Injury (except major) was coded None. During an interview with the NHA and DON on November 16, 2023, at 11:45 AM, the NHA confirmed that Resident 138's MDS was coded inaccurately and that a modification was being completed. She further indicated that she would expect the MDSs to have been coded to reflect a true and accurate assessment of a resident's status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 11 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 143's clinical record on November 14, 2023, at approximately 9:30 AM, revealed diagnoses that included hypertension (elevated/high blood pressure) and chronic kidney disease stage 3 (moderate decrease in the ability of the kidneys to filter toxins from the blood). Review of Resident 143's clinical record revealed that on June 25, 2023, Resident 143 suffered a fall at the facility. Review of Resident 143's admission MDS with an assessment reference date of June 28, 2023, revealed that section J1800, Has the resident had any falls since admission or the prior assessment (OBRA or PPS), which ever is more recent? revealed it was answered, No; which did not capture the fall sustained on June 25, 2023. Review of Resident 143's clinical record revealed Resident 143 suffered a fall at the facility on July 14, 2023. Review of Resident 143's Discharge - Return Anticipated MDS, assessment reference date of August 2, 2023, revealed Section J1800, Has the resident had any falls since admission or the prior assessment . was answered, No; which did not capture the fall sustained on July 14, 2023. During a staff interview on November 16, 2023, at approximately 11:30 AM, NHA revealed that Resident 143's admission and Discharge Return Anticipated MDSs should have been coded to capture Resident 143's falls. Review of Resident 151's clinical record revealed diagnoses that included protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and muscle weakness (weakness of the muscles without a known cause). Review of Resident 151's Modification of Significant Change MDS dated [DATE], revealed that Section J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent, indicated the Resident had one fall with major injury in the defined lookback period. Review of Resident 151's Modification of Significant Change MDS dated [DATE], revealed that Section J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent, indicated the Resident had one fall with major injury in the defined lookback period. Review of facility provided fall reports failed to reveal any falls with major injury during the lookback periods for either MDS completed on August 16, 2023, or September 11, 2023. Review of Electronic Medical Records failed to reveal any falls with major injury during the lookback periods for either MDS completed on August 16, 2023, or September 11, 2023. Interview with the NHA on November 16, 2023, at 10:30 AM, revealed that she agreed that Resident 151 had no falls with major injury during the lookback periods for the August 16, 2023, MDS or the September 11, 2023, MDS, and they should have been coded to indicate that. 28 Pa Code 211.12 (d)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 12 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for four of 38 residents reviewed (Residents 22, 59, 69, and 72). Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, with a last revision date of September 2022, and a last review date of September 23, 2023, revealed: A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident 22's clinical record revealed diagnoses that included hypertension (high blood pressure), personal history of COVID, chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure), and personal history of urinary tract infections (UTIs). Review of Resident 22's care plan on November 16, 2023, at 12:09 PM, revealed the following care plan focuses: COVID positive, with an initiated date of September 22, 2023; and has UTI, with an initiated date of October 24, 2023. Review of Resident 22's physician orders and clinical record progress notes failed to reveal any documentation that they were currently being treated for either of the aforementioned diagnoses. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on November 16, 2023, at 11:40 AM, the aforementioned concerns were shared. During a follow-up interview with the NHA and DON on November 16, 2023, at 1:44 PM, the DON confirmed that the care plan should have been updated when the infections resolved, and that they will update Resident 22's care plan accordingly. Review of Resident 59's clinical record revealed diagnoses that included Post-Traumatic Stress Disorder (PTSD - a mental health condition that develops following a traumatic event), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized anxiety disorder (a disorder characterized by a feeling of worry, nervousness, or unease) Review of Resident 59's clinical record revealed a psychiatric progress note from December 16, 2022, that stated, History of Present Illness he describes his family life as being abandoned. his father doesn't want him, and he abusive to him, mom not involved, siblings are not involved. he does not have any meaningful friendships because of being in here. Past Psychiatric History Anxiety disorder, Depressive disorder, history of Suicide attempt one attempted to suicide as a youth. Primary Diagnosis: Major Depressive Disorder, recurrent, unspecified, Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, Chronic. Further review of Resident 59's clinical record revealed psychiatric visits with the Resident on April 19, 2023, and August 4, 2023, noting his past trauma and a diagnosis of PTSD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 13 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0657 Review of Resident 59's care plan on November 13, 2023, failed to reveal a care plan for PTSD. Level of Harm - Minimal harm or potential for actual harm Email correspondence with the NHA on November 14, 2023, at 1:50 PM, the surveyor inquired about Resident 59's PTSD diagnosis and care plan. Residents Affected - Some Review of Resident 59's care plan on November 15, 2023, at 9:30 AM, revealed a care plan had been added with a focus area of PTSD childhood trauma. Interview with the NHA on November 16, 2023, at 11:54 AM, revealed she would expect Resident 59 to have a care plan for PTSD. Review of Resident 69's clinical record revealed diagnoses that included muscle weakness and diabetes mellitus type 2 (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). Review of Resident 69's care plan on November 13, 2023, revealed a focus area of: The resident has an ADL (activities of daily living) Self Care Performance Deficit related to weakness and physical limitations, contracture (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) of left Hand, last revised June 7, 2023, with an intervention for Patient to use double fisted mug with spout lid for all meals, initiated March 15, 2023. Observation of Resident 69 in her room on November 13, 2023, at 11:21 AM, revealed a regular mug on Resident's bedside table. Observation of Resident 69 in her room on November 14, 2023, at 11:40 AM, revealed she was eating lunch and had regular cups and mugs. During the observation, the surveyor inquired if the Resident uses two handle mugs, and she replied I haven't needed those for a while. Email correspondence with the NHA on November 14, 2023, at 1:50 PM, the surveyor inquired if Resident 69 requires two handle mugs. Email response received from NHA on November 15, 2023, at 6:44 AM, revealed that the mug was removed from her care plan and nurse aide task documentation. Interview with the NHA on November 15, 2023, at 2:05 PM, revealed she would expect Resident 69's care plan to be updated to reflect that she no longer requires a two handle mug. Review of Resident 72's clinical record revealed diagnoses that included unsteadiness on feet, repeated falls, and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 72's care plan on November 14, 2023, at approximately 1:30 PM, revealed that Resident 72 had a care plan focus for falls with interventions that included, but were not limited to, bed clip alarm and fall mat to open side of bed, both with an initiated date of October 21, 2023. Observation of Resident 72's room on November 15, 2023, at 12:25 PM, failed to reveal the presence of a fall mat to either side of the bed or a bed clip alarm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 14 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the NHA and DON on November 15, 2023, at 2:15 PM, the aforementioned observation was shared. Email communication received from the NHA on November 16, 2023, at 6:14 AM, included a revised care plan and a copy of an Interdisciplinary Team review progress note, with a created date of November 15, 2023, and an effective date of October 25, 2023, that indicated, Due to resident being independent with transfers and ambulation and having increased migraines, a bed tab alarm and fall mats are not an appropriate fall intervention. Intervention for 10/20 fall: encourage resident to toilet after dinner. Review of Resident 72's care plan received from the NHA on November 16, 2023, at 6:14 AM, revealed that the fall mat and bed clip alarm interventions had been removed from the care plan, and the intervention of encourage the Resident to toilet after dinner was added, but was dated with an initiated date of October 20, 2023. During an interview with the NHA and DON on November 16, 2023, at 11:37 AM, the concern was shared that the printed copy of Resident 72's care plan on November 14, 2023, indicated that the fall mat and clip alarm were interventions to reduce falls and that there was no intervention of encourage the Resident to toilet after dinner; however, the care plan received via email on November 16, 2023, at 6:14 AM, had the fall mat and bed clip alarm removed and the intervention of encourage the Resident to toilet after dinner added, with a date of October 20, 2023. The NHA confirmed that she would have expected Resident 72's care plan to have been revised at the time of the actual change in their care. 42 CFR 483.21(b) Comprehensive Care Plans 28 Pa. Code 211.11(d)(e) Resident care plan 28 Pa. Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 15 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 38 residents reviewed (Resident 88). Residents Affected - Few Findings Include: Review of Resident 88's clinical record revealed diagnoses that included atherosclerotic heart disease (build-up of cholesterol plaques in the walls of the arteries causing obstruction of blood flow) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 88's physician orders revealed an order for Metoprolol Tartrate Tablet 50 MG, Give 1 tablet by mouth one time a day related to essential hypertension, Do not crush; Hold for Systolic Blood Presure <120 Give with food or immediately after meal, with a start date of July 21, 2023. Review of Resident 88's MAR (Medication Administration Record - documentation for medication/treatment administered or monitored), revealed that Resident 88's Metoprolol medication was administered when it should have been held on the following dates: July 23, 25, 27, and 28, 2023; August 1, 4, 5, 13, 15, 17, 19, 23, and 26, 2023; September 4, 10, and 25, 2023; October 22, 2023; and November 12, 2023. Interview with the Director of Nursing on November 15, 2023, at 2:00 PM, revealed he would expect the medication not to be administered on those dates since there was a physician order to hold them. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 16 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to provide assistance with activities of daily living for dependent residents for six of 33 residents reviewed (Resident 15, 17, 55, 69, 88, and 94). Residents Affected - Some Findings include: Review of Resident 15's clinical record on November 15, 2023, at approximately 9:00 AM, reveled diagnoses that included diabetes mellitus type 2 (decreased ability of the body to utilize insulin for the transfer of glucose from the blood into the cells for nourishment) and congestive heart failure (CHF decreased ability of the heart to pump blood through the body). Review of Resident 15's Nurse Aide Tasks documentation revealed Resident 15 was scheduled to have a shower or bed-bath every Monday and Thursday during the evening shift. Review of the documentation revealed that Resident 15 did not receive a shower or bed bath on Thursday, November 9, 2023, and Monday, November 13, 2023. Review of Resident 17's clinical record revealed diagnoses that included contracture of muscle (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) and arthritis (a disorder causing joint pain, swelling, and stiffness). Interview with Resident 17 on November 13, 2023, at 11:17 AM, revealed she does not always get showers and that it depends on which staff members are working. Observation of Resident 17 on November 13, 2023, at 11:17 AM, revealed she had quarter inch length facial hair on her chin. Observation of Resident 17 on November 14, 2023, at 9:45 AM, revealed she had quarter inch length facial hair on her chin. Review of Resident 17's Nurse Aide Tasks documentation revealed Resident 17 was scheduled to have a shower every Wednesday and Saturday during the evening shift. Review of the documentation revealed that Resident 17 did not receive a shower or bed bath on Wednesday October 25, 2023, and Saturday November 11, 2023. During an email correspondence with the Nursing Home Administrator (NHA) on November 14, 2023, at 1:50 PM, the surveyor inquired about Resident 17's facial hair and missing shower documentation. The NHA replied to the email on November 15, 2023, at 6:44 AM, and stated staff were to address Resident 17's facial hair and bathing. Interview with the NHA on November 15, 2023, at 2:03 PM, revealed she is unable to provide documentation to indicate that Resident 17 received a shower on the aforementioned dates. Review of Resident 55's clinical record on November 15, 2023, at approximately 9:30 AM, revealed diagnoses including diabetes mellitus type 2 and hypertension (elevated/high blood pressure). Review of Resident 55's Nurse Aide Tasks documentation revealed Resident 55 was scheduled to have a shower or bed-bath every Monday and Thursday during the evening shift. Review of the documentation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 17 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0677 Level of Harm - Minimal harm or potential for actual harm revealed that Resident 55 did not receive a shower or bed-bath on Thursday, November 9, 2023, and Monday, November 13, 2023. Review of Resident 69's clinical record revealed diagnoses that included muscle weakness and diabetes mellitus type 2. Residents Affected - Some Review of Resident 69's Nurse Aide Tasks documentation revealed Resident 69 was scheduled to have a shower every Tuesday and Friday during the evening shift. Review of the documentation revealed that Resident 69 did not receive a shower or bed-bath on Tuesday October 24, 2023; Friday November 3, 2023; and Friday November 10, 2023. Interview with the NHA on November 15, 2023, at 2:03 PM, revealed she is unable to provide documentation to indicate that Resident 69 received a shower on the aforementioned dates. Review of Resident 88's clinical record revealed diagnoses that included muscle weakness and adult failure to thrive (a decline seen in older adults, typically those with multiple chronic medical conditions) Interview with Resident 88 on November 13, 2023, at 11:33 AM, revealed he does not always get showers per his preferred shower schedule. Review of Resident 88's Nurse Aide Tasks documentation revealed Resident 88 was scheduled to have a shower or bed-bath every Wednesday and Saturday during the evening shift. Review of the documentation revealed that Resident 88 did not receive a shower or bed-bath on Wednesday October 21, 2023; Saturday October 21, 2023; Wednesday November 1, 2023; and Wednesday November 8, 2023. Interview with the NHA on November 15, 2023, at 2:01 PM, revealed she is unable to provide documentation to indicate that Resident 88 received a shower on the aforementioned dates. Review of Resident 94's clinical record on November 13, 2023, at approximately 1:00 PM, revealed diagnoses that included end stage renal disease (severe decrease of the kidneys ability to filter toxins from the blood resulting in the need for dialysis) and hypertension. During a Resident interview on November 14, 2023, at approximatley 10:45 AM, Resident 94 expressed concerns that staff do not provide showers or baths at times. Review of Resident 94's Nurse Aide Tasks documentation revealed that Resident 94 was scheduled to have a shower or bed-bath every Wednesday and Saturday during the day shift. Review of the documentation revealed that Resident 94 did not receive a shower or bed bath on Wednesday, November 1, 2023, and Wednesday, November 8, 2023. During a staff interview on November 16, 2023, at approximately 1:35 PM, Director of Nursing revealed there was no indication that Residents 15, 55, and 94 received a shower or bed-bath on the aforementioned dates. 28 Pa code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 18 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide care and services to promote healing and prevent worsening of pressure ulcers for one of four residents reviewed for pressure ulcers (Resident 143). Residents Affected - Few Findings include: Review of Resident 143's clinical record on November 14, 2023, at approximately 9:30 AM, revealed diagnoses that included hypertension (elevated/high blood pressure) and chronic kidney disease stage 3 (moderate decrease in the ability of the kidneys to filter toxins from the blood). Review of consultative wound specialist documentation for Resident 143 revealed that, upon assessment on November 14, 2023, Resident 143 had a stage 4 pressure ulcer (wound of the skin produced by pressure over a bony prominence that extends to the bone and/or other connective tissue) to the left dorsal foot and a stage 3 pressure ulcer (wound of the skin produced by pressure over a bony prominence that extends through the skin to the deeper tissue but does not reach muscle or bone). Review of Resident 143's physician's orders revealed an order dated August 17, 2023, for Resident 143 to have heel lift boots (cushioned medical boot that helps to alleviate pressure on the foot, heel, and ankle to help prevent and promote healing of pressure ulcers) on both feet during every shift. During wound dressing change observations on November 15, 2023, at approximately 11:45 AM, Resident 143 was observed in bed. During the observation, it was observed that Resident 143 did not have a heel lift boot applied to the left foot. There was no heel lift boot observed laying in Resident 143 bed or in the general vicinity of Resident 143. During a staff interview on November 16, 2023, at approximately 11:30 AM, Director of Nursing (DON) revealed that Resident 143 had two sets of heel lift boots. It was further revealed that staff removed Resident 143's left heel boot at some point to have it cleaned and that it was not replaced with the second heel boot at that time. During the interview, DON revealed it was the facility's expectation that the second available heel boot wound have been placed on the Resident. 28 Pa code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 19 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to answer a dietary consult in response to weight loss to maintain adequate nutritional status for one of 38 residents reviewed (Resident 88). Residents Affected - Few Findings include: Review of facility policy, titled Weight Assessment and Intervention, last revised March 2019, revealed, Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Physician and Dietitian .The Dietitian and/or Certified Dietary Manager will review the individual weight records to follow individual weight trends over time, making recommendations as appropriate. Review of Resident 88's clinical record revealed diagnoses that included adult failure to thrive (Adult FTT a decline seen in older adults, typically those with multiple chronic medical conditions), dementia (irreversible, progressive, degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and type 2 diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). Interview with Resident 88 on November 13, 2023, at 2:03 PM, when the surveyor inquired if the Resident has lost weight at the facility, Resident 88 replied Yes, I have lost weight. Review of Resident 88's medical record revealed a weight loss of 8 pounds from September 3, 2023, to October 5, 2023. Review of Resident 88's nursing progress notes revealed a note on November 1, 2023, that stated, Message received from [Employee 3 (Medical Doctor)] regarding resident's weight loss. Order received for Dietary Consult, GI (Gastroenterology) consult for any Malignancy (worsening of a condition) work up, Cardiology follow up .Appointment request for GI faxed to Transport. Review of Resident 88's physician orders revealed an order for Dietary Consult: Weight loss, with a start date of November 1, 2023. Review of Resident 88's care plan revealed a focus area of: Resident may be nutritionally at risk related to diagnoses of Type 2 diabetes mellitus, dementia, Adult FTT, Vitamin Deficiency, Depression, Vegetarianism. History of significant weight changes, with an intervention for, Dietitian consult as needed, dated July 20, 2022. Review of Resident 88's clinical record on November 14, 2023, at 1:00 PM, revealed a Nutritional Risk assessment dated [DATE], and the status was in progress. Further review of Resident 88's Nutritional Risk assessment dated [DATE], revealed the only information loaded into the note was it was marked as a quarterly assessment under assessment type, the Resident's most recent height measurement, and his weight measure from October 5, 2023. Review of Resident 88's clinical record revealed the last dietitian note in his medical record was effective August 2, 2023, and created on August 10, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 20 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0692 Level of Harm - Minimal harm or potential for actual harm Email correspondence with the Nursing Home Administrator (NHA) on November 14, 2023, at 1:50 PM, the surveyor inquired about Resident 88's dietary consult. Email response received from NHA on November 15, 2023, at 6:44 AM, revealed that she emailed the dietitian about the consult. Residents Affected - Few Review of Resident 88's medical record on November 15, 2023, at 9:00 AM, revealed the Nutrition Risk assessment dated [DATE], was signed and locked on November 14, 2023, at 8:14 PM. Further review of Resident 88's Nutrition Risk assessment dated [DATE], revealed a comprehensive nutrition assessment with a new dietary intervention of large portions ordered to diet to encourage intake. Interview with the NHA on November 15, 2023, at 2:03 PM, revealed she would expect the physician order for a dietary consult to be answered timely prior to 13 days after it was ordered. When the surveyor inquired if the NHA would expect for the consult to be answered within one week; she answered, yes. 28 Pa Code 211.6(d) - Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 21 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, clinical record review, policy review, and staff interview, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of 39 residents reviewed (Resident 8). Residents Affected - Few Findings include: Review of the facility's Oral Inhalation Administration Policy, last reviewed September 2023, revealed under the Nebulizer section, W. When equipment is completely dry, store in a plastic bag with the resident's name and date on it, and X. Change equipment and tubing every seven days. Review of Resident 8's clinical record revealed diagnosis that included chronic kidney disease (CKD - a condition in which the kidneys are damaged and cannot filter blood as well as they should) and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Review of Resident 8's current physician orders reveal an order for Ipratropium-Albuterol Solution 0.5-2.5 milligrams / 3 milliliters two times a day one vial inhale orally for shortness of breath and wheezing, with a start date of November 26, 2022. During an observation of Resident 8 on November 13, 2023, at 10:32 AM, revealed Resident 8's nebulizer machine sitting on their bedside stand, not bagged, with the tubing dated November 6, 2023. Observation on November 14, 2023, at 9:43 AM, revealed Resident 8's nebulizer machine on their bedside stand, not bagged, with the tubing dated November 6, 2023. Observation on November 15, 2023, at 10:08 AM, revealed Resident 8's nebulizer machine on their bedside stand, not bagged, with the tubing dated November 6, 2023. Observation on November 16, 2023, at 9:21 AM, revealed Resident 8's nebulizer machine sitting on their bedside stand, not bagged, with the tubing dated November 6, 2023. Review of Resident 8's comprehensive centered care plan on November 15, 2023, at 11:45 AM, failed to include Resident 8's nebulizer use. Review of Resident 8's comprehensive centered care plan on November 16, 2023, at 9:30 AM, revealed the following interventions have been added, with a date initiation of November 16, 2023: Changed nebulizer and oxygen tubing weekly and as needed, and change nebulizer tubing weekly and as needed. During an interview with the Nursing Home Administrator on November 16, 2023, at 11:39 AM, revealed that she would have expected Resident 8's nebulizer to have been bagged each day, the tubing to have been changed weekly, and the nebulizer to have been on Resident 8's care plan prior to November 16, 2023. 28 Pa. Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 22 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for four of 39 residents reviewed (Residents 72, 77, 88, and 96). Findings include: Review of facility policy, titled Medication Regimen Review (Monthly Report), reviewed September 2023, revealed, The prescriber accepts and acts upon recommendations or rejects and provides and explanation for disagreeing. Review of Resident 72's clinical record revealed diagnoses that included depression, unspecified psychosis (a mental disorder characterized by a disconnection from reality), generalized anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), unspecified mood affective disorder (marked disruptions in mood), and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 72's clinical orders revealed an order for lorazepam 0.5 milligrams give by mouth three times a day related to Generalized Anxiety Disorder, dated October 5, 2022. Review of Resident 72's clinical record revealed documentation by the pharmacist that they had completed a monthly Medication Regimen Review on June 14, 2023, made recommendations, and to review Clinical Pharmacy Report. The note further indicated in the Additional Comments section: Lorazepam GDR (gradual dose reduction) eval. Review of Resident 72's clinical record failed to reveal any documentation that the physician had reviewed or acted upon this recommendation. Email communication was sent to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on November 14, 2023, at 12:43 PM, requesting pharmacy recommendation report for June 14, 2023, with physician response. During an interview with the NHA and DON on November 15, 2023, at 1:18 PM, Resident 72's pharmacy recommendation with physician response for June 14, 2023, was again requested. During an interview with the NHA and DON on November 16, 2023, at 12:13 PM, Resident 72's pharmacy recommendation with physician response for June 14, 2023, was again requested. During a follow-up interview with the NHA and DON on November 16, 2023, at 1:59 PM, the NHA confirmed that she could not provide Resident 72's pharmacy recommendation report with physician response from June 14, 2023. She further indicated that she would expect these to be completed in a timely manner and be in the Resident's chart when completed. Review of Resident 77's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a type of progressive lung disease characterized by long term respiratory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 23 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0756 symptoms and airflow limitations) and sleep apnea (intermittent airflow blockage during sleep). Level of Harm - Minimal harm or potential for actual harm Review of Resident 77's clinical orders revealed an order for Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 MCG (micrograms)/ACT (activated) one inhalation orally one time a day for COPD, dated July 24, 2023. Residents Affected - Some Review of Resident 77's clinical record revealed documentation by the pharmacist that they had completed a monthly Medication Regimen Review on September 14, 2023, made recommendations, and to review Clinical Pharmacy Report. The note further indicated in the Additional Comments section: Breo-rinse mouth. Review of Resident 77's clinical record failed to reveal any documentation that the physician had reviewed or acted upon this recommendation, and the current order did not include instructions to rinse mouth after use. Email communication was sent to the NHA and DON on November 14, 2023, at 12:43 PM, requesting Resident 77's pharmacy recommendation report for September 14, 2023, with physician response. During an interview with the NHA and DON on November 15, 2023, at 1:18 PM, Resident 77's pharmacy recommendation with physician response for September 14, 2023, was again requested. During an interview with the NHA and DON on November 16, 2023, at 12:13 PM, Resident 77's pharmacy recommendation with physician response for September 14, 2023, was again requested. During a follow-up interview with the NHA and DON on November 16, 2023, at 1:59 PM, the NHA confirmed that she could not provide Resident 77's pharmacy recommendation report with physician response from September 14, 2023. She further indicated that she would expect these to be completed in a timely manner, and be in the Resident's chart when completed. Review of Resident 88's clinical record revealed diagnoses that included Gastroesophageal reflux disease (GERD - occurs when stomach acid frequently flows back into the tube connecting your mouth and stomach [esophagus]) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 88's Electronic Medical Record revealed a pharmacy review form dated February 7, 2023. Further review revealed that the pharmacist made a recommendation to change the time of Resident 88's pantoprazole to 30-60 minutes before breakfast. Further review of Resident 88's record failed to reveal any response from the physician, and that the order was never changed from an administration time of 9:00 AM, with a start date of January 23, 2023. Review of posted facility meal times revealed Resident 88's hall is served breakfast from 8:00 AM to 9:00 AM. Interview with the DON on November 16, 2023, at 1:20 PM, revealed that they do not have the physician's response to the pharmacy recommendation made on February 7, 2023, for Resident 88. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 24 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 96's clinical record revealed diagnoses that included anxiety (a feeling of fear, dread, and uneasiness) and major depressive disorder. Review of Resident 96's Electronic Medical Record revealed a pharmacy review form dated October 8, 2023. Further review revealed that the pharmacist made a recommendation for a trial GDR (gradual dose reduction) of Resident 96's Zoloft (antidepressant medication). Further review of Resident 96's record failed to reveal any response from the physician. Interview with the DON on November 16, 2023, at 10:30 AM, revealed that they do not have the physician's response to the pharmacy recommendation made on October 8, 2023, for Resident 96. 28 Pa. Code 211.10(c) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 25 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on clinical record review and staff interview, it was determined that the facility failed to ensure residents were free from unnecessary antipsychotic medication for one of five residents reviewed for unnecessary medications (Resident 143). Findings include: Review of Resident 143's clinical record on November 14, 2023, at approximately 9:30 AM, revealed diagnoses that included hypertension (elevated/high blood pressure) and chronic kidney disease stage 3 (moderate decrease in the ability of the kidneys to filter toxins from the blood). Review of Resident 143's physician orders revealed that on June 22, 2023, Resident 143 was ordered Seroquel (an antipsychotic medication used to treat schizophrenia and other mental health disorders) 50 milligrams (mg - metric unit of measure) twice a day with the indication for use documented as unspecified encephalopathy (broad term used for a disease that alters functioning of the brain). Review of Resident 143's clinical record revealed a Consultant Pharmacist Communication to Physician (also referred to as a medication regimen review), dated July 14, 2023. Review of the medication regimen review revealed the pharmacist's communication to the physician for the physician to clarify the diagnosis for the Seroquel as encephalopathy was not an appropriate diagnosis for the medication per Centers for Medicare and Medicaid Services. As a result of the pharmacist's recommendation, the attending physician changed the diagnosis for the Seroquel order to bipolar disorder, which was recorded in Resident 143's electronic physician orders as, Schizoaffective disorder, bipolar type, which is a condition defined by psychotic symptoms such as hallucinations, delusions, as well as symptoms of a mood disorder such as periods of mania and/or depression. Review of Resident 143's clinical record, including pre-admission hospital records, revealed no indication or clinical assessment to diagnose Resident 143 with schizoaffective disorder. Further review of Resident 143's clinical record, including pre-admission hospital records, revealed no indication of hallucinations, delusions, mania, or depressive symptoms. During a staff interview on November 16, 2023, at approximately 1:35 PM, Director of Nursing revealed he was unable to identify a clinically appropriate rationale for the diagnosis and for the use of an antipsychotic medication at that time. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 26 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews, and clinical record review, it was determined that the facility failed to ensure that it was free from a medication error rate of five percent or greater based on two medication errors out of 31 opportunities. Residents Affected - Few Findings include: Observation of medication administration on November 15, 2023, at 8:42 AM, revealed Employee 1 (Licensed Practical Nurse) administering Symbicort Aerosol 80-4.5 MCG/ACT (Budesonide-Formoterol Fumarate) Inhaler and diclofenac sodium gel 1% to Resident 7. Review of Resident 7's physician orders revealed orders for Symbicort Aerosol 80-4.5 MCG/ACT (Budesonide-Formoterol Fumarate) two puffs (an inhaled medication) for acute respiratory failure with hypoxia (condition that occurs when the lungs cannot get enough oxygen into the blood) with specific directions to rinse mouth and spit after administration; and diclofenac sodium gel 1% apply to bilateral knees topically two times a day with specific directions to apply four grams for generalized osteoarthritis (degeneration of joint cartilage and the underlying bone, causing pain and stiffness especially in the hip, knee, and thumb joints). Employee 1 was not observed to provide Resident 7 with water or to instruct her to rinse and spit after the Symbicort inhaler was administered. Employee 1 was also not observed to measure the diclofenac sodium gel 1% to obtain and administer the ordered dose of four grams. Employee 1 just squirted a small unmeasured amount on her gloved hand and applied it to Resident 7's knee. During an interview with Employee 1 on November 15, 2023, at approximately 9:02 AM, Employee 1 confirmed that she should have had Resident 7 rinse her mouth after the inhaler was administered as directed in the order. She further confirmed that she should have measured the diclofenac sodium gel to obtain the ordered dose. She said that there is usually a paper ruler located in the box with the gel cream to measure by, but that there was not one in the box. During medication administration observation there were two errors and 31 opportunities, resulting in a medication error rate of 6.45%. During an interview with the Nursing Home Administrator (NHA) on November 15, 2023, at 9:58 AM, the aforementioned medication errors were shared. The NHA confirmed that she would expect meds to have been administered as per physician orders and that special instructions or directions would be followed. 28 Pa. Code 211.9 (a)(1) Pharmacy Services 28 Pa. Code 211.12 (d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 27 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on record review, staff interview, and policy review, it was determined that the facility failed to ensure documentation of controlled medication disposition and reason for one of three closed records reviewed (Resident 168). Findings include: Review of facility policy, titled Disposal of Medications and Medication-Related Supplies, last reviewed March 2023, confirms that disposition of the medication and reason for the disposition should be documented on the Resident's controlled substance record. A review of the clinical record for Resident 168 on November 15, 2023, revealed that the Resident was transferred to the hospital on October 7, 2023, and passed away at the hospital October 8, 2023. A review of the closed record controlled substance forms revealed the Resident was receiving Tramadol (controlled pain medication) 50 milligrams and had 17 tablets remaining at the time of transfer. The licensed staff failed to document the disposition (how the medication was disposed) or reason why the medication was disposed. A review of the closed record controlled substance forms revealed the Resident was receiving A/B/H Gel (a topical controlled pain medication made up of Ativan 0.5 mg, Benadryl 12.5 mg, and Haldol 0.5 mg) and had 42 syringes remaining at the time of transfer. The licensed staff failed to document the disposition (how the medication was disposed) or reason why the medication was disposed. During an interview with the Nursing Home Administrator (NHA) on November 16, 2023, at 12:00 PM, she confirmed that policy should be followed and the disposition and reason for disposition should have been documented on the controlled substance form. 28 Pa. Code 211.12(d)(1)(5)Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 28 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on resident and staff interviews, policy review, and record review, the facility failed to assist residents in obtaining routine and emergency dental services for one of 39 residents (Resident 4). Residents Affected - Few Findings include: Review of the facility's Dental Examination/Assessment Policy, last reviewed September 2023, revealed that residents should be offered dental services as needed and, upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist. Review of Resident 4's clinical record revealed diagnoses that included Multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). During an interview with Resident 4 on November 13, 2023, at 10:13 AM, Resident 4 stated that he was not currently wearing his dentures because he only has them for his top teeth and is still waiting to get them for his bottom teeth. Resident 4 pointed to his TV stand and showed the surveyor a green case that his top denture was in. Review of Resident 4's clinical record revealed a dental consult dated March 9, 2022, the treatment notes stated that Resident 4 lost both his upper complete denture and lower partial denture and would like new ones to be fabricated as he has difficulty chewing and eating without his teeth. The recommended treatment included for Resident 4 to have fabrication of full upper denture and fabrication of partial lower denture completed. Review of Resident 4's clinical record revealed a dental consult dated July 13, 2022, for denture step 1: impression for a upper complete denture. Review of a dental consult dated September 2, 2022, revealed it was for denture step 3 for Resident 4. Review of Resident 4's clinical record and dental consults provided no further documentation regarding Resident 4's lower partial dentures. Electronic mail received from the Nursing Home Administrator (NHA) on November 16, 2023, at 6:19 AM, revealed a document showing Resident 4 on the list to see the dentist on the next scheduled visit, which was November 22, 2023, and had a written note at the bottom that they will electronically mail a request for the dentist to evaluate Resident 4's dentures. During and interview with the NHA on November 16, 2023, at 11:38 AM, revealed she would have expected Resident 4's lower partial dentures to have been acted upon if the recommendation was made in March 2022. Pa.Code 211.5(a) - Dental Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 29 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on resident and staff interviews, policy review, observations, and clinical record review, it was determined that the facility failed to implement infection control practices to prevent the transmission of infectious disease for one of one resident reviewed for transmission based precautions (Resident 105); failed to maintain a data collection system of surveillance for three of 12 months reviewed (December 2022, January 2023, and April 2023); and failed to maintain an effective infection control program related to the preparation and administration of medications to one of three Residents observed (Resident 7). Residents Affected - Some Findings include: Review of the facility policy titled, Infection Control, last reviewed September 2023, revealed the facility will maintain a monthly line list of residents with infections for trending and outbreak potential, follow-up review of lab data is compared, and a monthly review is completed to identify trends to facilitate infection control surveillance. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and health-care associated infections, to guide appropriate interventions and required reporting, and to prevent future infections. The infection control line list for the past 12 months was requested on November 13, 2023. During a review of the facility's monthly infection control logs the December 2022, January 2023, and April 2023 were unable to be provided by the facility. The facility did have QAPI notes that verified the facility had infections during these months, but only the number of infections was documented. During an interview with the Nursing Home Administrator (NHA) on November 16, 2023 at 12:00 PM, the NHA confirmed the monthly infection control line list data should be maintained and the December 2022, January 2023, and April 2023 data is unable to be found. Review of facility policy titled, Isolation - Categories of Transmission-Based Precautions, last revised September 2022, the policy statement was, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Further review revealed policy section, Policy Interpretation and Implementation section 2 stated, Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. Section 5 stated, When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution .The signage informs the staff of the type of CDC precaution(s), instructions for use of [personal protective equipment] PPE, and/or instructions to see a nurse before entering the room . Review of Resident 105's clinical record on November 13, 2023, at approximately 2:00 PM, revealed diagnoses that included necrotizing fasciitis (type of aggressive skin infection that causes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 30 of 31 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church 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 0880 necrosis/death of cells) and hypertension (elevated/high blood pressure). Level of Harm - Minimal harm or potential for actual harm During a resident interview on November 13, 2023, at approximately 12:00 PM, Resident 105 indicated that Resident 105 had a wound of the right leg and foot, which had an infection that Resident 105 was actively taking antibiotic medications for. Residents Affected - Some Review of Resident 105's physician orders revealed an active order dated September 27, 2023, for Transmission based precautions - Contact precautions, for the indication of Necrotizing fasciitis. Resident 105 also had an order for Keflex (an antibiotic) 500 milligrams (mg - metric unit of measure) three times a day for osteomyelitis, which was started on November 9, 2023, and scheduled to be completed on November 15, 2023. Review of Resident 105's clinical record revealed that Resident 105 had an open wound to the lower right leg and an open wound to the lower right foot, and was being followed by infectious disease for an infection of the wound and bone. During multiple observations from an initial observation on November 13, 2023, at approximately 12:00 PM, to November 16, 2023, at approximately 11:40 AM, no indication of contact precautions was observed to be posted at Resident 105's room. During the observations, it was also observed that no PPE was made available at, or near Resident 105's room. During a staff interview on November 16, 2023, at approximately 11:30 AM, NHA and Director of Nursing (DON) revealed they believed there was signage and PPE on Resident 105's door as appropriate; however, at approximately 11:40 AM, it was confirmed that no signage or PPE was placed at Resident 105's door. During the interview, NHA was informed of the observations. During a medication pass observation on November 15, 2023, at June 29, 2022, at approximately 8:45 AM, Employee 1 was observed preparing medications to administer Resident 7. When Employee 1 was emptying one of the plastic pouches (sealed pouch used by pharmacy to dispense the medications) into the medication cup, one small, white, round pill fell onto the top of the medication cart, landing on Employee 1's report sheet. Employee 1 was observed using the lateral sides of their hands cupped together to pick up the pill, placed it in the medication administration cup with the other pills, and administered the medications to the resident. During an interview with Employee 1 on November 15, 2023, at 9:00 AM, Employee 1 confirmed that they should not have touched the medication with her hands. During an interview with NHA on November 15, 2023, at approximately 9:58 AM, the NHA that Employee 1 should not have touched the medication with their hands and should have discarded the medication they dropped and gotten a new one. 28 Pa Code 201.14(a)(c)Responsibility of licensee 28 Pa code 211.12(c)(d)(1)(2)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 31 of 31