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 (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 3 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 01/15/2026 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)