Health inspection·February 14, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of Resident 1's physician orders revealed an order, dated February 4, 2025, for Full Code, meaning if Resident 1 is found unresponsive and without a pulse, CPR (cardiopulmonary resuscitation) is to be performed. Review of Resident 1's POLST form (Pennsylvania Orders for Life-Sustaining Treatment), revealed that if Resident 1 was found without a pulse and not breathing, Resident 1's wishes were for CPR/attempt resuscitation. Resident 1 signed the POLST form on February 4, 2025. The POLST form was also signed by Resident 1's physician. Review of Resident 1's progress notes revealed a note, written by Resident 1's nurse, Employee 1 (Licensed Practical Nurse), dated February 7, 2025, stated that at approximately 8:40 PM, Employee 1 was informed by a nurse aide that Resident 1 did not appear to be himself. Employee 1's note stated that upon assessment, Resident 1 appeared pale and with tachypnea (rapid breathing). The note further stated that Resident 1's blood glucose was 64 (normal is 70-99), blood pressure 86/44 (normal 120/80), temperature 97.1, respiratory rate 38 (normal 12-20). No pulse was documented and Employee 1 stated she was unable to obtain an oxygen saturation. The note further stated that Employee 1 immediately notified the nursing supervisor and supplied oxygen to the Resident at 2 L (liters). Review of Resident 1's progress notes revealed a note, written by the RN (registered nurse) supervisor, Employee 3, dated February 7, 2025. The note stated that at approximately 8:45 PM, Resident 1's nurse asked Employee 3 to check on Resident 1. Upon assessment, Resident 1 was noted to be pale, sweaty, short of breath and his respiratory rate was 30. The note stated Resident 1 was talking but with labored breathing and he denied pain. Vital signs at this time were documented as temperature 97.1, heart rate 101 (normal 60-100), blood pressure 86/44, unable to obtain an oxygen saturation and oxygen was applied at 4 L via nasal cannula. Employee 3 notified Resident 1's physician and an order was received to transfer Resident 1 to the hospital and 911 was called. Further review of Employee 3's progress note stated that she was then called to the room by a nurse aide who stated that Resident 1 was unresponsive. The note further stated that Resident 1 was found unresponsive and without a pulse. EMS (emergency medical services) arrived and CPR was initiated. Resuscitation efforts continued without success and Resident was pronounced deceased at 9:21 PM. During a telephone interview with Resident 1's nurse, Employee 1 (Agency LPN), on February 12, 2025, at 10:11 AM, Employee 1 stated that she was at the nursing station and was told that Resident 1 wasn't looking good. She stated she immediately went to assess the Resident and stated that he didn't look good. Employee 1 stated that she assessed the Resident, took his vital signs and informed the RN supervisor (Employee 3). Employee 1 stated that Employee 3 assessed Resident 1 and at this time, he was responsive. Employee 1 stated that Employee 3 notified the physician and called 911 and that Employee 1 put oxygen on Resident 1. Employee 1 stated she was unable to recall anything else that happened after that. Employee 1 stated she did not know who started chest compressions. Employee 1 was asked if she was in the room when EMS arrived or went into the room after EMS was already there, and she replied I can't recall at this very moment. Employee 1 was unable to provide any additional information at that time, stating I can't remember everything that happened and I'm trying to remember everything accurately. Review of Employee 1's CPR certification revealed she was issued her CPR certification in [DATE], with an expiration date of [DATE]. During a telephone interview with Employee 2 (Nurse Aide) on February 12, 2025, at 11:50 AM, she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395270 If continuation sheet Page 2 of 6 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 395270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Park Nursing and Rehabilitation 700 Walnut Bottom Road Carlisle, PA 17013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some stated that Resident 1 was having trouble breathing so she notified Resident 1's nurse, Employee 1. She stated that Employee 1 came into the room to assess Resident 1. She stated Employee 1 then notified Employee 3, who also assessed Resident 1, who was still responsive at this time. Employee 2 stated that Employee 3 made the comment Let me call his family and see what they want done with him. Employee 2 stated there was confusion, as Resident 1 was wearing a bracelet on his arm that said DNR but his POLST said to perform CPR. Employee 2 stated that Resident 1 may have come back from the hospital with the DNR band in place, as she wasn't aware of the facility using those bands. Employee 2 stated she then left Resident 1's room to tend to her other residents and she thinks that Employee 1 was still in Resident 1's room at that time. Employee 2 stated she was not present when EMS arrived and was not present when CPR was started. During a telephone interview with Employee 3 (Agency RN) on February 12, 2025, at 1:33 PM, she stated that she assessed Resident 1 upon the request of Employee 1. Employee 3's assessment revealed that Resident 1 was having difficulty breathing, but he was responsive, talking and had a pulse. Employee 3 instructed Employee 1 to put Resident 1 on oxygen while she went out to call the physician. Employee 3 stated that Employee 1 was then asking where all of the supplies were for the oxygen and that another employee had to get the oxygen tank for Employee 1. Employee 3 stated the physician ordered Resident 1 to be sent to the hospital. Employee 3 stated she was then questioning Resident 1's code status. She stated that Resident 1's physician order said full code and the POLST said to perform CPR but Resident 1 was wearing a DNR bracelet and in his electronic clinical record, it said full code but had special instructions underneath the full code that said DNR with limited interventions. Employee 3 stated that Resident 1 had a recent hospital stay, being readmitted to the facility on [DATE], and, at that time, changed his POLST, indicating he wanted CPR. She stated although the POLST said CPR, the bracelet and the special instructions in the chart were misleading. Employee 3 stated she then called the Director of Nursing (DON) to apprise her of Resident 1's change in condition and to question the code status. Employee 3 stated the DON instructed her to follow the POLST. Employee 3 then stated that as she was on the phone with the DON, she observed EMS had arrived in the building and were down at the end of the hallway. At this same time, she stated a nurse aide called out to her to come to Resident 1's room. Employee 3 stated she immediately entered Resident 1's room and found that he was unresponsive, warm, not breathing and had no pulse. Employee 3 stated that at that time, EMS arrived and they started chest compressions. She stated CPR was performed but was unsuccessful and Resident was pronounced deceased . During this interview, Employee 3 was asked where Employee 1 was during this time and what her role was. Employee 3 stated she didn't know where Employee 1 was and stated that she was not in Resident 1's room when Employee 3 went back in his room and found him unresponsive. Employee 3 stated she did not feel there was a delay in Resident 1's care but she did have a concern that it was mostly agency staff present. Review of facility's staffing deployment sheet, dated February 7, 2025, for evening shift, revealed that one of one RNs was agency and two of four LPNs were agency staff. During a telephone interview with Emergency Response Personnel 1 (ERP) on February 12, 2025, at 2:02 PM, she stated that EMS was dispatched to a call at the facility for someone who was having trouble breathing. She stated that upon arrival, there was nobody at the door to meet them and let them in. She stated they had to ring the door bell and wait, and it was a painter who was in the building who let them in. She stated that upon arrival to the nursing unit, she observed the charge nurse (Employee 3), on the phone and looking through a chart. She stated that upon entering the Resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395270 If continuation sheet Page 3 of 6 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 395270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Park Nursing and Rehabilitation 700 Walnut Bottom Road Carlisle, PA 17013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some room, no staff were present in the room. ERP 1 stated that Resident 1 felt warm and they placed him on the monitor, which said PEA (pulseless electrical activity- a life-threatening condition where the heart's electrical activity is present but there is no pulse). ERP 1 stated that she initiated chest compressions. EPR 1 then stated that an unidentified staff member was standing in the Resident's doorway. EPR 1 asked her if she could help do chest compressions. She stated the employee looked away shyly and left the room. EPR 1 stated she continued with compressions until a nurse from a different unit came to assist and relieve her. EPR 1 stated she was then able to assist her partner to place an intraosseous line (IO-a hollow needle inserted into the bone marrow to deliver fluids, medications, and blood products), start an airway, and give medications. She stated they continued resuscitation for approximately 25 minutes before terminating efforts and pronouncing the Resident deceased . Email correspondence received on February 12, 2025 at 3:06 PM, ERP 2 stated no one was in the room when they arrived to Resident 1's room. During a telephone interview with Employee 4 (Nurse Aide) on February 12, 2025, at 3:34 PM, she stated that when EMS arrived, there were no staff members present in Resident 1's room. She stated that she thought the RN and LPN were confused about what to do, because Resident 1 was wearing a DNR bracelet. Employee 4 stated that after EMS arrived, nurses from other units came to assist with compressions. In a follow-up telephone interview with Employee 3, on February 13, 2025, at 8:40 AM, she stated that after she found Resident 1 to be not breathing and without a pulse, she ran out of the room to get the code cart. When Employee 3 was asked why she didn't immediately start chest compressions, she stated because EMS was right there, she didn't know if any of the nurse aides, or any of the agency staff, would know where the crash cart was, and she did not know where Resident 1's nurse, Employee 1, was. Employee 3 stated that Employee 1 was not involved in Resident 1's resuscitation efforts. The facility failed to ensure that Resident 1 was free from neglect and provided the necessary emergency services. Employee 1 was assigned to work on the unit that Resident 1 resided on. She was aware of the Resident's decline during her assessment and that EMS was called for transport to the hospital. There was no evidence that Employee 1 followed up with Resident 1 to check his status. When Resident 1 was found without a [NAME] or respirations and CPR was initiated, Employee 1 did not assist and staff on the unit did not know where she was. Additionally, when Employee 3 found Resident 1 without a pulse, she did not immediately start CPR, instead she left the room to obtain the Crash cart. During the onsite survey on February 13, 2025, at 1:16 PM, in an interview with Employee 5 (LPN, agency) stated that she did not know where the crash cart or emergency equipment is located, and she would ask a RN where they are located. She also revealed she would look for a resident's code status on the POLST form. During an interview with Employee 6 (LPN, agency) on February 13, 2025, at 1:20 PM, she stated her first time at the facility was a couple of months ago and she had been working at the facility this week and last week. She further revealed she did not know where the oxygen room was and knew where the crash cart was on the other unit she usually works on, but not on the unit she was currently working. She revealed that in the event of an emergency, she would run to the other unit to get the crash cart and notify to Registered Nurse on duty. She stated she would look for code status in physician orders and in the hard chart. She stated she had not received any orientation to the facility, such as a facility tour or orientation to facility policies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395270 If continuation sheet Page 4 of 6 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 395270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Park Nursing and Rehabilitation 700 Walnut Bottom Road Carlisle, PA 17013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview with the Nursing Home Administrator (NHA) and DON, on February 13, 2025, at 2:55 PM, the NHA stated that when the receptionist is not present, visitors need to ring the doorbell, which is only heard in the lobby area, not at the nursing stations. She stated that visitors would then have to call the facility's main number and when someone picked up the phone, that person would then need to walk to the front door to let them in. The NHA stated that if someone is calling 911, someone should be at the door waiting for EMS to arrive. She stated that she is not sure if agency staff would know to send someone to the door to wait for EMS. At that time, the DON stated that staff are supposed to look at a resident's orders and POLST, to determine their code status. The DON stated that if there is a discrepancy, staff are instructed to go by the POLST. The NHA stated that when agency comes to the building for the first time, they are not given any orientation or tour of the facility. The facility failed to provide orientation and/or training to agency staff. They failed to ensure agency staff responded correctly to a medical emergency. This resulted in a delay in emergency services to a resident who went unresponsive, placing 48 other residents in an immediate jeopardy situation, who requested CPR be administered in the event that they were to suddenly become unresponsive and pulseless. Review of facility provided provided documentation revealed that Residents 2-49 were a full code and wanted CPR. The NHA and DON were notified of the immediate jeopardy situation on February 13, 2025, at 3:00 PM, and were provided the immediate jeopardy template. An immediate action plan was requested. On February 13, 2025, at 5:12 PM, the facility's immediate action plan was accepted, which included: DON/Designee will provide immediate orientation/education to licensed agency and facility staff currently working in the facility to include facility policies on resident code status, copy of floor plan including location of crash carts, oxygen, and other emergency supplies as well as how to meet EMS at the front door after calling 911 if receptionist is not on duty. Education will include the following information: if a resident has change in condition, the nurse refers to the order and the POLST. If there is no order and no POLST, resident is automatic full code. If resident is a full code and CPR is to be initiated, code is called immediately, All available licensed staff are to be present and CPR initiated and not stopped until EMS arrives and instructed to do so. Do not freely type a special instruction in PCC regarding code status. When a resident is admitted or readmitted to facility from the hospital, all hospital bracelets are to be removed. DON/Designee will provide orientation/education to any additional licensed agency and facility staff prior to the start of their shift to include facility policies on resident code status, copy of floor plan including location of crash carts, oxygen, and other emergency supplies as well a how to meet EMS at the front door after calling 911 if receptionist is not on duty. Education will include the following information: if a resident has change in condition, the nurse refers to the order and the POLST. If there is no order and no POLST, resident is automatic full code. If resident is a full code and CPR is to be initiated, code is called immediately, All available licensed staff are to be present and CPR initiated and not stopped until EMS arrives and instructed to do so. Do not freely type a special instruction in PCC regarding code status. When a resident is admitted or readmitted to facility from the hospital, all hospital bracelets are to be removed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395270 If continuation sheet Page 5 of 6 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 395270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Park Nursing and Rehabilitation 700 Walnut Bottom Road Carlisle, PA 17013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Human Resources Director/Designee will review schedule daily to ensure licensed agency and staff scheduled have completed the orientation or will complete prior to start of shift for new agency staff. This education/orientation will be forwarded to agencies for signatures prior to start of shift. DON/Designee will audit current resident code status to ensure the order and POLST match, there are no residents with hospital wrist bands and no special instructions in PCC regarding code status. Residents Affected - Some DON/Designee will audit 10 resident charts weekly for 2 months, then monthly for 3 months to ensure resident have code status in order and if there is a POLST that it matches the order. NHA/Designee will audit licensed agency staff for completed orientation weekly for 2 months, then monthly for 2 months. Results of audit will be reviewed by QAPI committee for any recommendations. Date of compliance will be February 14, 2025. On February 14, 2025, at 10:53 AM, the Immediate Jeopardy was lifted during an onsite survey after ensuring that the immediate action plan had been implemented. Staff interviews on February 14, 2025, revealed the facility had re-educated staff on facility policy regarding resident code status, the locations of crash carts, oxygen and other emergency supplies, the process for removal of hospital wrist band upon admission, the process for meeting emergency services at the door when the receptionist is not on duty, and abuse and neglect policies. Interviews were conducted with three RNs and three LPNs. All were able to verbalize understanding of the education points. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa Code 211.12(d)(1)(2)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395270 If continuation sheet Page 6 of 6