Health inspection·May 1, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on a review of clinical records and staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about a change in condition for one of 27 residents reviewed (Resident 25). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated March 29, 2024, indicated that the resident was understood and could understand, was cognitively intact, and independent for care. A care plan for Resident 25, dated January 24, 2024, indicated that the physician must be notified of all refusals of medication. Physician's orders for Resident 25, dated January 25, 2024, included an order for the resident to receive Cefdinir (a medication that destroys bacteria) twice a day for 11 doses. Physician's orders for Resident 25, dated November 15, 2023, included an order for Miacalcin nasal spray (a medication to treat the thinning of bones) 1 unit daily at 8:00 a.m. A review of the electronic medication administration record (MAR), dated January, February, and March 2024, for Resident 25 revealed that the resident refused her morning medication on January 3, 21, 23, 26, 2024; February 2, 25, 27, 2024; and March 3, 7, 15, 26, 2024. There was no documented evidence that the physician was notified of the refusals on the above dates. Interview with the Director of Nursing on April 30, 2024, at 11:54 a.m. confirmed that there was no documented evidence that Resident 25's physician was notified about the refusals of morning medications on the dates listed. 28 Pa. Code 211.12(d)(3) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 2 of 11 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 395387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton County Medical Center 214 Peach Orchard Road McConnellsburg, PA 17233 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop a comprehensive care plan related to the use of anticoagulant medication for one of 27 residents reviewed (Resident 40). Findings include: The facility's policy regarding care plans, dated March 13, 2024, indicated that an individualized comprehensive care plan will be developed by the interdisciplinary team within 21 days of admission for each resident. The care plan will include focus issues, problems and needs (social, emotional, psychological, physical, behavioral, rehabilitation, cultural, spiritual, nutritional, leisure, prevention of decline in condition, ect.) that have been identified through resident involvement, direct observation, coordination of discipline observations and assessment. As each issue, problem or need is added to the care plan, a date will be recorded with the issue to document the specific time when the issue was identified. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated March 19, 2024, revealed that the resident had clear speech, was understood and could understand, was severely cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included pulmonary embolism (blood clot in lungs) requiring long-term use of anticoagulant (blood-thinning medications) medications. Current physician's orders for Resident 40 included an order for the resident to receive 5 mg of Apixaban (blood thinning medication) twice a day for a pulmonary embolism. There was no documented evidence that a care plan was created for the use and risks of anticoagulant medications. Interview with the Director of Nursing on May 1, 2024, at 2:16 p.m. confirmed that a care plan had not been created for Resident 40's use of anticoagulant medications. 28 Pa. Code 211.12(d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 3 of 11 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 395387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton County Medical Center 214 Peach Orchard Road McConnellsburg, PA 17233 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for four of 27 residents reviewed (Residents 25, 30, 39, 40). Findings include: A facility policy regarding plans of care, dated March 13, 2024, revealed that the care plan will be reviewed and revised by the interdisciplinary team at least quarterly, or more often as changes occur, by nursing staff to include new orders, resident's individual preferences, effective interventions, etc. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated March 19, 2024, revealed that the resident was understood and could understand, could ambulate (walk) on the unit independently, and had diagnoses that included non-traumatic brain dysfunction (a brain injury not caused by external physical force or trauma exerted on the head), and dementia, requiring her placement on a locked unit. The resident's care plan regarding behaviors, revised January 24, 2024, revealed that the resident was at risk for injury related to behaviors. If Resident 25 presented with behaviors staff were to ensure the resident was safe and reapproach at a different time. Nursing notes for Resident 25, dated March 24, 2024, revealed that she was seeing a man named [NAME], who did not exist, and was concerned that staff needed to find him. Nursing notes for Resident 25, dated April 29, 2024, revealed that the resident was concerned about the naked people in the courtyard and was adamant that they were there. There was no documented evidence that Resident 25's care plan was revised to include her delusional thoughts or interventions to address them. Interview with the Director of Nursing on April 30, 2024, at 11:57 a.m. confirmed that Resident 25's care plan was not revised to include her delusional thoughts or interventions to address them. A quarterly MDS for Resident 30, dated March 12, 2024, indicated that the resident had clear speech, understood, could understand, was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included Alzheimer's disease. A nursing note, dated August 3, 2023, revealed that Resident 30 fell and hit his head, was bleeding from a laceration on the back of the head, and said that he was trying to pick something up off the floor. An interdisciplinary team note for Resident 30, dated August 4, 2023, revealed that the resident was reaching for something, lost his balance, and fell. Occupational therapy was to screen Resident 30 for the use of a reacher tool. An occupational therapy evaluation for Resident 30, on August 4, 2023, revealed the resident was assessed for safety and independence with reacher. Therapy staff notified staff in the communication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 4 of 11 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 395387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton County Medical Center 214 Peach Orchard Road McConnellsburg, PA 17233 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 0657 book for reacher to be placed at the bedside to prevent falls. Level of Harm - Minimal harm or potential for actual harm Interview and observation of Resident 30 on April 30, 2024, at 12:13 p.m. revealed that he was sitting in his wheelchair watching television, the reacher was on his recliner, and the resident said he uses it to pick up things. Residents Affected - Some There was no documented evidence that the fall care plan was updated to reflect the use of a reacher as an intervention for fall prevention. Interview with the Director of Nursing on May 1, 2024, at 9:42 a.m. confirmed that Resident 30's care plan was not updated to reflect her current interventions for fall prevention and should have been. An admission MDS for Resident 39, dated February 26, 2024, revealed that the resident had clear speech and required either extensive assistance or was dependent on staff for his care needs, and had diagnoses that included dementia and Parkinson's. A nursing note for Resident 39, dated February 19, 2024, revealed that the resident was admitted from another nursing care facility and that the resident used Continuous Positive Airway Pressure (CPAP - a machine used to treat obstructive sleep apnea and other types of sleep-disorders) nightly. A care plan for Resident 39, dated February 19, 2024, revealed that the resident used CPAP. Physician's orders for Resident 39, dated March 22, 2024, included an order to discontinue the CPAP and start oxygen at two liters per minute (LPM) at night and as needed during the day and naps. There was no documented evidence that Resident 39's care plan was updated to indicate that the CPAP was discontinued or that the resident was to start the use of oxygen at night and as needed during the day and naps. Interview with the Director of Nursing on April 30, 2024, at 11:00 a.m. confirmed that Resident 39's care plan should have been updated to show that the CPAP was discontinued, and that the resident was to start the use of oxygen at night and as needed during the day and naps. A quarterly MDS for Resident 40, dated March 19, 2024, indicated that the resident had clear speech, understood, could understand, was severely cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included Alzheimer's disease. A care plan for Resident 40, dated July 18, 2023, indicated that the resident had a potential for behaviors due to dementia and anxiety. A nursing note, dated December 17, 2023, revealed that Resident 40 verbalized she wanted to shoot herself and alert charting was started to monitor her for suicidal ideation. A nursing note, dated February 20, 2024, revealed that Resident 40 verbalized that she wanted to be dead and would be better off dead. A nursing note, dated February 21, 2024, revealed that Resident 40 verbalized negative thoughts, did not have a plan to hurt herself, and needed to watch what she said out loud. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 5 of 11 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 395387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton County Medical Center 214 Peach Orchard Road McConnellsburg, PA 17233 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A behavioral health service consult, dated February 21, 2024, revealed that the Resident 40 was seen due to her negative thoughts and not wanting to live any more, and to follow up with her in two weeks. A nursing note, dated March 23, 2024, revealed that Resident 40 verbalized that she wanted to die. There was no documented evidence that the care plan was updated to reflect Resident 40's suicidal ideation comments or for the use of behavioral health services. Interview with the Director of Nursing on May 1, 2024, at 2:16 p.m. revealed that Resident 40's care plan was not updated to reflect her suicidal ideation and use of behavioral health services. 28 Pa. Code 211.12(d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 6 of 11 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 395387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton County Medical Center 214 Peach Orchard Road McConnellsburg, PA 17233 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that appropriate treatment and services were provided to prevent the development of pressure ulcers for one of 27 residents reviewed (Resident 39). Residents Affected - Few Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated February 26, 2024, revealed that the resident was usually understood, could usually understands others, was frequently incontinent of bowel and bladder, had diagnoses that included Parkinson's disease and dementia, and had one Stage 2 pressure injury (a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) that was not present upon admission. A nursing note for Resident 39, dated February 19, 2024, revealed that the resident was admitted from another nursing care facility and that the resident had a small red mark to his right posterior thigh from his brief. A care plan for Resident 39, dated February 19, 2024, revealed that the resident was at risk for impaired skin integrity. A nursing note for Resident 39, dated February 24, 2024, revealed that at 3:05 a.m. the writer received a call from the licensed practical nurse that this resident had a blister to his leg. There was a 30 centimeter (cm) by 7 cm water blister to his left upper/inner thigh in the area of where the incontinent brief would normally be present. A nursing note for Resident 39, dated February 25, 2024, at 10:56 a.m. and completed as an addendum to the nursing note dated February 24, 2024, revealed that the serum-filled blister measured 1.5 cm x 3.0 cm x 0.0 cm. The resident's brief was checked at this time and noted with proper placement. A nursing note at 1:39 p.m. revealed that the serum-filled blister drained when the resident got up to go to the bathroom. A nursing note for Resident 39, dated February 26, 2024, revealed that the interdisciplinary team review of the blister to the resident's left leg revealed that the root cause was related to the brief placement, and that the intervention was to evaluate the placement of the brief and to reposition appropriately for comfort, as well as apply skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) to the blister. However, there was no documented evidence that Resident 39's brief was evaluated and/or that preventive interventions were started when a red mark caused by the brief was identified on February 19, 2024, and progressed to a blister on February 24, 2024. Interview with the Director of Nursing on May 1, 2024, at 2:15 p.m. confirmed that there was no documented evidence that Resident 39's brief was evaluated and/or that preventive interventions were started when an area of concern was identified on February 19, 2024, and progressed to a blister on February 24, 2024. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 7 of 11 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 395387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton County Medical Center 214 Peach Orchard Road McConnellsburg, PA 17233 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on a review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for two of 27 residents reviewed (Residents 40, 42). Findings include: The facility's policy on wheelchairs, dated March 13, 2024, indicated that all wheelchairs being utilized for transport purposes should be equipped with leg rests and utilized when residents are being transported. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated March 19, 2024, revealed that the resident had clear speech, understood, could understand, was severely cognitively impaired, required assistance from staff for daily care needs, used a wheelchair, and had diagnoses that included Alzheimer's disease. Observation of Resident 40 on April 29, 2024, at 11:17 a.m. revealed that the resident was sitting in a wheelchair while being transported to her room from the dining/community room by Licensed Practical Nurse 4. There were no footrests on her wheelchair to prevent her feet from dragging during transport. Interview with Licensed Practical Nurse 4 at that time revealed that she was unsure if footrests were needed since Resident 40 was able to self propel. Interview with Licensed Practical Nurse 4 on April 29, 2024, at 11:38 a.m. confirmed that the resident should have had footrests on her wheelchair to prevent injury during transport. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated February 6, 2024, revealed that the resident was cognitively intact and required assistance for daily care needs, including transfers and locomotion. Observation of Resident 42 on May 1, 2024, at 9:12 a.m. revealed that the resident was sitting in a wheelchair while being transported to her room from the shower room by Nurse Aide 5. There were no footrests on her wheelchair to prevent her feet from dragging during transport. An interview with Nurse Aide 5 on May 1, 2024, at 9:17 a.m. confirmed that the resident should have had footrests on her wheelchair to prevent injury during transport. An interview with the Director on Nursing on May 1, 2024, at 2:26 p.m. confirmed that footrests should have been used when transporting Residents 40 and 42 in their wheelchairs. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 8 of 11 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 395387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton County Medical Center 214 Peach Orchard Road McConnellsburg, PA 17233 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of a list of nurse aides provided by the facility and the nurse aides' personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for two of five nurse aides reviewed (Nurse Aides 6, 7). Residents Affected - Few Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, annual performance evaluations were due between April 13, 2023, and June 6, 2023. However, there was no documented evidence that annual performance evaluations were completed as required for Nurse Aides 6 and 7. Nurse Aide 6 had a hire date of April 13, 2021. Nurse Aide 6's personnel file revealed that she had a performance evaluation completed on December 15, 2023. However, there was no documented evidence that her annual performance evaluation was completed as required in April 2023. Nurse Aide 7 had a hire date of June 6, 2022. Nurse Aide 7's personnel file revealed that she had a performance evaluation completed on December 28, 2023. However, there was no documented evidence that her annual performance evaluation was completed as required in June 2023. Interview with the Nursing Home Administrator May 1, 2024, at 9:37 a.m. confirmed that she could provide no evidence that annual performance evaluations were completed as required for the above nurse aides. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(c) Staff Development. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 9 of 11 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 395387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton County Medical Center 214 Peach Orchard Road McConnellsburg, PA 17233 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety. Residents Affected - Many Findings include: The facility's policy regarding food safety, dated March 13, 2024, indicated that food needs to be stored in clear plastic containers covered with a lid, labeled with the name of the food, dated with a prepared date, and a use by date. The item can also be wrapped, dated, and labeled so that the food item was air tight. Observations in the walk-in freezer on April 29, 2024, at 9:45 a.m. revealed opened and unlabeled bags of corn with peppers and onions, green beans, hamburger patties, and hash browns that were not in a clear plastic container. Interview with the Dietary Manager at the time revealed that staff should be using a label maker to put a sticker on the food item when a new container is opened. Observations in the walk-in refrigerator on April 29, 2024, at 9:45 a.m. revealed that there was a five-pound plastic container of cottage cheese opened and unlabeled; a three-pound container of whipped cream cheese spread opened, undated, and with a best by dated of March 21, 2024; and a 64-ounce container of almond milk opened, unlabeled, with a best by date of April 15, 2024. Interview with the Dietary Manager at the time indicated that the dates are best by dates and not expiration dates, and that the containers should be labeled with the date when opened. 28 Pa. Code 211.6(f) Dietary Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 10 of 11 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 395387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton County Medical Center 214 Peach Orchard Road McConnellsburg, PA 17233 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct and/or maintain compliance with quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) for the survey ending June 28, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending May 1, 2024, identified repeated deficiencies related to notification of changes and nurse aide performance review. The facility's plans of correction for deficiencies regarding notification of changes in resident condition, cited during the survey ending June 28, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F580, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. The facility's plans of correction for deficiencies regarding annual nurse aide performance evaluations, cited during the survey ending June 28, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F730, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. Refer to F580 and F730 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 11 of 11