Health inspection·January 8, 2026

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to meet the needs of the residents for three of three residents reviewed for the use of hipsters (Residents 1, 2, and 3).Findings include: Review of the clinical record for Resident 1 revealed clinical diagnoses that included depressive disorder (mood disorder causing persistent sadness and loss of interest affecting daily activities) and adjustment disorder (extreme emotional or behavioral reaction to a specific, identifiable stressor impacting daily functioning) and a history of falls. Review of Resident 1's Quarterly Minimum Data Set (periodic assessment and care screening) dated December 18, 2025, revealed a BIMS (brief interview of mental status) score of 11, indicating moderate cognitive impairment. Review of Resident 1's current physician orders revealed the order to encourage to wear hipsters every shift, document refusals with an effective date of November 3, 2025, and reentry of same order on January 5, 2026, because initial order was missed when reviewed by Administration. Resident 1 was care planned for risk of falls and encouraged to wear hipsters every shift, effective November 3, 2025. Observation on January 5, 2026, at approximately 11:00 AM, revealed Resident 1 not wearing any hipsters while in the resident lounge/dining area. Review of the clinical record for Resident 2 revealed clinical diagnoses that included dementia (cognitive decline of memory, thinking, and behavior interfering with daily life), atrial fibrillation (fast, irregular heartbeat), and a history of falls. Review of Resident 2's Quarterly Minimum Data Set, dated [DATE], reveals a BIMS score of 99, indicating the Resident was unable to complete interview for cognitive status. Review of Resident 2's current physician orders revealed an order to encourage to wear hipsters, document refusals with an effective date of December 5, 2025. Resident 2 was care planned for risk of falls and encouraged to wear hipsters every shift effective, August 13, 2025. Observation on January 5, 2026, at approximately 11:00 AM, revealed Resident 2 not wearing any hipsters while in the resident lounge/dining area. Review of the clinical record for Resident 3 revealed clinical diagnoses that included dementia, depressive disorder (mood disorder causing persistent sadness and loss of interest affecting daily activities), and a history of falls. Review of Resident 3's Quarterly Minimum Data Set, dated [DATE], reveals a BIMS score of 2, indicating severe cognitive impairment. Review of Resident 3's current physician orders revealed an order to encourage to wear hipsters at all times with an effective date of February 17, 2025. On January 5, 2026, a second order was written stating encourage resident to wear hipsters. Resident 3 was care planned for risk of falls and encourage to wear hipsters at all times, effective February 17, 2025. Observation on January 5, 2026, at approximately 11:00 AM, revealed Resident 3 not wearing any hipsters while in the resident lounge/dining area. During an interview with Employee 1 (Nursing Assistant) on January 5, 2026, she stated that residents do not have any hipsters in their rooms to apply. Employee 1 was asked if any of the residents refused hipsters and she replied no. Employee 1 added that she didn't get Resident 3 out of bed this Residents Affected - Few Page 1 of 3 395270 395270 01/08/2026 Forest Park Nursing and Rehabilitation 700 Walnut Bottom Road Carlisle, PA 17013

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few morning, he was already up and groomed when she arrived. During an interview with Employee 2 (Laundry) on January 5, 2026, when asked if there were any hipsters available for Residents 1, 2, and 3, Employee 2 replied, we do not have any hipsters, and later added there could be some in a washer. An interview with Employee 3 (Central Supply) on January 5, 2026, revealed multiple pairs (all sizes) of new hipsters locked in a cabinet in her office. During an interview and observations with the Director of Nursing (DON) on January 5, 2026, the DON confirmed with the surveyor that no hipsters were present in Resident 1's, 2's, or 3's rooms and stated that each resident should have two pairs each. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395270 Page 2 of 3 395270 01/08/2026 Forest Park Nursing and Rehabilitation 700 Walnut Bottom Road Carlisle, PA 17013

F 0917 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. Based on observation and staff interview, it was determined that the facility failed to provide residents with private closet space for all 46 semi-private rooms within the facility.Findings include:Observation of semi-private room closets on January 5, 2026, revealed one closet in the room with roommates' clothing touching, and personal items on the shelf and floor were intermingled because there was no partition. A tour of the semi-private rooms revealed no partition in any of the closets.During an interview with the Director of Nursing (DON) on December 5, 2026, at 2:30 PM, the DON confirmed that none of the closets have a partition to provide private closet space for residents. 28 Pa. Code 201.18(b)(2) Management 395270 Page 3 of 3