Health inspection·June 10, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on facility policy review, review of select facility documentation, and staff interviews, it was determined that the facility failed to ensure all alleged violations involving abuse were reported in a timely manner for two of three residents reviewed (Residents 1 and 2). Findings include: Review of facility policy, titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated April 2021, revealed If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Review of facility policy, titled Resident-to-Resident Altercations, dated December 2016, revealed All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the nurse supervisor, director of nursing services, and to the administrator. Review of facility reported incident dated June 9, 2025, revealed that the Nursing Home Administrator (NHA) was made aware on June 9, 2025, at 8:45 AM, of possible resident-to-resident sexual abuse that occurred on June 7, 2025. Review of facility's investigation revealed an interview with Employee 4 (Housekeeper) on June 9, 2025, stating that over the weekend, she observed a female resident, possibly Resident 1, in Resident 2's room and it looked like they were kissing. Employee 4 denied seeing anything else occur and stated she could not recall where the female Resident's hands were placed. Employee 4 stated she told Employee 1 (Nurse Aide) who arrived in the room and told the Residents to stop. Review of Employee 1's witness statement, undated, revealed that on Saturday June 7, 2025, at approximately 2:30 PM, Employee 4 called Employee 1 to Resident 2's room. Employee 1 wrote in her statement that she observed Resident 1 in Resident 2's room, bent over Resident 2 with her hand on his penis. Employee 1 stated she walked Resident 1 back to her room and then told the nurse what she had just witnessed. Review of facility's interview with Employee 2 (RN-Registered Nurse) on June 9, 2025, revealed that (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395270 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 06/10/2025 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)