Health inspection·January 15, 2026

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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for one of three resident reviewed for pressure ulcers (Resident 2).Findings include: Review of facility policy, titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, with a last revised date of April 2018, revealed, in part, The nurse shall describe and document/report the following full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. Review of Resident 2's clinical record revealed diagnoses that included pressure induced deep tissue injury (DTI-pressure-related injury to subcutaneous tissues under intact skin) to left heel, stage 4 pressure ulcer (a pressure injury that is deep, reaching into muscle and bone and causing extensive damage) to sacrum, and paraplegia (paralysis of the lower body/legs). Review of Resident 2's current physician orders revealed the following orders: Follow-up with Wound center in 2 weeks, dated December 10, 2025; Cleanse sacral region pressure ulcer and peri wound (skin located around the perimeter of the wound) with normal saline solution; apply skin prep to peri wound skin; apply 1/4 strength Dakin's solution moistened gauze roll to wound beds/tunnel creases, cover with absorbent pads and secure with tape. Change daily on night shift and as needed for drainage saturation. May change outer absorbent pads if drainage strike through occurs, dated December 12, 2025; and weekly body audit every Monday on day shift. Complete form in electronic health record, dated January 5, 2026. Review of Resident 2's clinical record revealed that she had a Weekly Body Audit form completed on December 17, 18, and 22, 2025. These forms all failed to include any documentation of her existing pressure ulcers in Section A2. Note any areas of alterations in skin integrity. Further review of Resident 2's clinical record, including progress notes, failed to reveal any documented assessment of her wounds to include description and measurements between December 11 and 28, 2025. Review of Resident 2's clinical record revealed that she was transferred to the hospital on December 28, 2025, and remained hospitalized until January 1, 2026, when she returned to the facility. Review of Resident 2's readmission Evaluation dated January 1, 2026, indicated in Section H. Skin Evaluation that she had a pressure ulcer on her coccyx, right heel, and left heel. The sections for length, width, depth, stage, and additional observations/comments were blank. Further review of Resident 2's clinical record to include progress notes failed to reveal any documented assessments of her pressure ulcers to include description and measurements between January 1 and 13, 2026. Resident 2 was transferred to the hospital on January 13, 2026, and remained hospitalized at time of survey.During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on January 14, 2026, at 3:13 PM, the DON confirmed that Resident 2 had refused services from the in-house wound consultant. She also acknowledged that Resident 2 had allowed facility nursing staff to perform her ordered routine wound care. The DON confirmed that nursing staff probably should have completed and documented a full wound assessment to Residents Affected - Few Page 1 of 3 395270 395270 01/15/2026 Forest Park Nursing and Rehabilitation 700 Walnut Bottom Road Carlisle, PA 17013

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few include measurements on at least a weekly basis to determine if any treatment changes were needed. The DON indicated that it had been difficult to get Resident 2 to an outside wound clinic for a thorough evaluation and treatment management because of Resident 2's frequent hospitalizations. Email communication received from the NHA on January 15, 2025, at 9:48 AM, indicated that Resident 2 had a scheduled appointment on January 20 and 16, 2026; and February 5, 2026, with an outside wound clinic.During a final staff interview with the NHA on January 15, 2026, at 2:03 PM, she confirmed that she would expect nursing staff to complete a full wound assessment to include measurements at least weekly on residents with pressure ulcers. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. 395270 Page 2 of 3 395270 01/15/2026 Forest Park Nursing and Rehabilitation 700 Walnut Bottom Road Carlisle, PA 17013

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents receive appropriate treatment and services to prevent urinary tract infections in residents with a foley catheter for one of five residents reviewed (Resident 6).Findings include: Review of facility policy, titled Catheter Care, Urinary, with a last revision date of September 2014, revealed, in part, the step-by-step procedural instructions on how to perform catheter care, which included the following: Wash resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry; using a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. In addition, the policy indicated that the following information should be documented in the resident's medical record: date and time catheter care was given; name and title of individual giving the catheter care, and all assessment data obtained when giving catheter care. Review of Resident 6's clinical record revealed diagnoses that included neuromuscular dysfunction of the bladder, urinary retention (incomplete emptying of the bladder or inability to urinate), and cognitive communication deficit (a group of disorders that affect a person's ability to communicate which can cause difficulty with understanding or producing language and nonverbal communication skills such as gestures and facial expressions). Review of Resident 6's current physician orders revealed an order for an indwelling Foley Catheter (a flexible tube placed through the urethra to the bladder to drain urine) 16 French Coude with 10 cc (cubic centimeter) balloon to straight bag gravity drainage for urinary retention, dated December 11, 2025. Further review of Resident 6's clinical record revealed that his catheter was originally ordered on November 13, 2025. Resident 6's clinical record, including physician orders and treatment administration records from December 1, 2025, through January 14, 2026, failed to reveal any order or documentation of the provision of catheter care or emptying of his catheter drainage bag. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing on January 14, 2026, at 3:15 PM, the above concern was shared and the NHA indicated that she would investigate. During a final staff interview with the NHA on January 15, 2026, at 2:02 PM, she confirmed that Resident 6 did not have orders for catheter care and that he should have had them in place since the catheter was ordered. 28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services. 395270 Page 3 of 3