Health inspection·December 18, 2025

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on select facility recipe review, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide food that is appetizing and attractive.Findings include:During an interview with Resident 1 on December 15, 2025, at 10:24 AM, she revealed the food at the facility is terrible.A test tray was completed on December 16, 2025, at 12:26 PM, with Employee 2 (Food Service Director), The meal tray included Cheese Ravioli, [NAME] Beans, and Chicken Noodle Soup. The tray was presented on the Memory Support unit after all residents had been served. The green beans appeared to be unseasoned and, upon surveyor sensory evaluation including visual evaluation as well as taste and smell, the green beans were plain and not seasoned. Employee 2 agreed that the green beans were not seasoned upon a visual inspection and revealed she was not sure if they should be but would obtain the recipe for surveyor review. Review of facility recipe, titled Seasoned [NAME] Beans, revealed the recipe called for cut green beans, salt, pepper, and margarine. The directions further revealed simmer or steam green beans until tender, drain. Toss with margarine before serving. Season to taste. The recipe also included guidelines for specific measurements of salt, pepper, and margarine based on how many servings are made.During an interview with Employee 3 (Executive Chef) on December 16, 2025, at 1:22 PM, he revealed he would expect recipes to be followed. During an interview with Employee 2 and the Nursing Home Administrator on December 17, 2025, at 11:47 AM, they revealed their expectation that recipes should be followed. 28 Pa. Code 201.14(a) Responsibility of licensee. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395386 If continuation sheet Page 2 of 5 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 395386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethany Village Retirement Center 5225 Wilson Lane Mechanicsburg, PA 17055 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide adaptive feeding devices for two of two residents reviewed (Residents 21 and 27).Findings include: Review of facility policy, titled Adaptive (Assistive) Eating Devices, with a last approved date of December 12, 2024, revealed, in part, The Food and Nutrition Services Department (FANS) will provide adaptive eating devices or utensils as ordered by the physician to promote independence and dignity of residents at mealtime. Each resident identified as requiring special utensils and/or adaptive eating devices related to eating will be provided with such items and will have them available at all meals and snack times, as required, to maximize the resident's comfort, dignity, and independence. The FANS department will be responsible for providing the appropriate eating devices as ordered for each meal.Review of Resident 21's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and Parkinson's disease (a progressive neurological disorder that primarily affects movement).Review of Resident 21's physician orders revealed a diet order that included the Resident to have small maroon spoons, dated August 11, 2025.Review of Resident 21's clinical record revealed a progress note by the dietician dated August 12, 2025, at 12:38 PM, that indicated the Resident was to use a small maroon spoon for feeding.Review of a nutritional risk screening completed on November 20, 2025, revealed that Resident 21 feeds themself using a maroon spoon.Review of Resident 21's care plan revealed a dysphagia care plan focus area with an intervention for the Resident to use adaptive equipment, date initiated on August 12, 2025.Observation of Resident 21 on December 15, 2025, at 12:24 PM, revealed he was eating lunch and did not have a maroon spoon.Observation of Resident 21 on December 16, 2025, at 12:16 PM, revealed he was eating lunch and did not have a maroon spoon.Review of Resident 21's lunch tray tickets for December 15 and 16, 2025, revealed that it was noted on his ticket that he was to have maroon spoons.During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 18, 2025, at 10:37 AM, the DON confirmed that Resident 21 should have received his maroon spoon during lunch as ordered.Review of Resident 27's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), lack of coordination, and muscle weakness.Review of Resident 27's physician orders revealed an order for a two-handled mug, dated July 15, 2024.Review of Resident 27's clinical record revealed a progress note by the dietician dated October 29, 2025, at 6:13 AM, that indicated a two-handled mug was in use for Resident 27.Observation of Resident 27 on December 15, 2025, at 1:08 PM, revealed she was eating lunch and did not have a two-handled mug. Immediate review of her lunch meal ticket revealed that it was noted on her ticket that she was to have a two-handled mug.Observation of Resident 27 on December 16, 2025, at 8:45 AM, revealed she was eating breakfast and did not have a two-handled mug. Immediate review of her breakfast meal ticket revealed that it was noted on her ticket that she was to have a two-handled mug.Observation of Resident 27 on December 16, 2025, at 12:39 PM, revealed she was eating lunch and did not have a two-handled mug. Immediate review of her lunch meal ticket revealed that it was noted on her ticket that she was to have a two-handled mug.During a staff interview with Employee 1 (Licensed Practical Nurse) on December 16, 2025, at 12:44 PM, Employee 1 indicated that the kitchen has not provided Resident 27 with a two-handled mug in at least a month. Employee 1 further indicated that she was not aware that it was still part of Resident 27's orders since Resident 27 had not received them with her meals. During a staff interview with the NHA and DON on December 17, 2025, at 12:27 PM, the DON confirmed that Resident 27 should have received her two-handled mug as ordered. 28 Pa. Code 201.18(b)(1) Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395386 If continuation sheet Page 3 of 5 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 395386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethany Village Retirement Center 5225 Wilson Lane Mechanicsburg, PA 17055 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 0810 Management.28 Pa. Code 211.10(c) Resident care policies.28 Pa. Code 211.12(d)(2)(3)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395386 If continuation sheet Page 4 of 5 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 395386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethany Village Retirement Center 5225 Wilson Lane Mechanicsburg, PA 17055 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen.Findings include:Review of facility policy, titled Food Storage- Dry Goods last reviewed November 19, 2025, read, in part, The Dining Services Director or designee ensures that the storage will be neat, arranged for easy identification, and date marked as appropriate.Review of facility policy, titled Food Storage: Cold last reviewed November 19, 2025, read, in part, A written record of daily temperatures is recorded. The Dining Services Director/Cook(s) ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination.Observation in the main kitchen on December 15, 2025, at 9:54 AM, revealed one bin of sugar that was not labeled or dated. Observation of reach in cooler 1 on December 15, 2025, at 9:56 AM, revealed one pan of beef not dated, one bin of meat sauce not dated, and one container of tomato paste labeled use by December 10, 2025. Observation of the dry storage area on December 15, 2025, at 10:04 AM, revealed one bag of linguini pasta open without an open date, one bag of spaghetti pasta open without an open date, and one bag of ditalini pasta open without an open date. Observation of the walk-in freezer on December 15, 2025, at 10:06 AM, revealed one bag of sausage links not dated, one open bag of tater tots not dated, and one container of orzo soup dated use by November 12, 2025, that was left open to air and not properly sealed. Observation of reach-in cooler 2 on December 15, 2025, at 10:08 AM, revealed one lemon sliced and not dated, and one bin of cucumbers not dated. During an interview with Employee 2 on December 15, 2025, at 10:22 AM, she revealed a contributing factor to lack of labeling and dating is that the foodservice department at the facility has been dealing with staffing issues, as they are currently down 10 FTEs (full-time equivalents- a unit of measurement used to represent the number of full-time hours worked by all employee). Review of February 2025 dish machine temperature logs revealed temperatures failed to be recorded at all meals on February 7, 20, 21, 22-26, and 28; and at dinner on February 1-6, 8-13, and 27. Review of March 2025 dish machine temperature logs revealed temperatures failed to be recorded on March 21-24 and 28 at dinner. Review of May 2025 dish machine temperature logs revealed temperatures failed to be recorded at all meals on May 1, 3-5, 18, and 19; at Breakfast on March 9, 16, 23, 30, and 31; at lunch on May 9, 16, 17, 23, 30, and 31; and at Dinner on May 8, 10 22, 27, and 29. Review of June 2025 dish machine temperature logs revealed temperatures failed to be recorded at all meals on June 1, 13-15, 20, and 27-29; and at Dinner on June 9, 12, and 16-19.Review of July 2025 temperature log for Breakfast refrigerator revealed the temperature log was blank from July 18-31. Review of July 2025 temperature log for Breakfast reach-in revealed the temperature log was blank from July 1-22.Dish machine temperature logs were unavailable for review from August 2025 -October 2025. Review of dish machine temperature logs provided for November 2025 revealed the only temperatures available for review were from November 10-21, 2025. During an interview with Employee 2 and the Nursing Home Administrator on December 17, 2025, at 11:37 AM, revealed it was their expectation that expired items are discarded, foods items are labeled and dated per facility policy, and that kitchen equipment is utilized in accordance with professional standards.28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.6(f) Dietary services Event ID: Facility ID: 395386 If continuation sheet Page 5 of 5