Health inspection·April 17, 2025

F 0623 emergency room for evaluation and treatment. Level of Harm - Minimal harm or potential for actual harm There was no documented evidence that a written notice of Resident 23's transfer to the hospital was provided to the State Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital on March 9, 2025, Residents Affected - Few Interview with the Director of Nursing on April 15, 2025, at 12:25 p.m. confirmed that there was no documented evidence that a written notice of Resident 8's and 23's transfer to the hospital was provided to the State Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of Licensee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 2 of 10 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 04/17/2025 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 - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to revise/update the care plan for one of 25 residents reviewed (Resident 37). Findings include: The facility's policy regarding care plans, dated March 6, 2025, indicated that nurses and interdisciplinary team members were responsible for updating the resident's care plan to reflect changes in the resident's status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated September 7, 2024, indicated that the resident was cognitively intact, usually understood and understands, required assistance from staff for his daily care needs, and had diagnoses that included end-stage renal disease. A care plan, dated August 7, 2023, revealed that Resident 37 had a hemodialysis catheter (a type of catheter used for vascular access during hemodialysis treatment that is typically inserted into a large vein, such as the jugular or femoral vein, to facilitate the removal and return of blood during hemodialysis sessions) in place. Nursing notes for Resident 37, dated November 6, 2023, indicated that on that day, he had a left upper arm fistula (connection between an artery and a vein to facilitate dialysis) placed at the hospital. Nursing notes, dated May 8, 2024, indicated that on May 7, 2024, the resident had his hemodialysis catheter removed. Interview with the resident on April 15, 2024, at 2:02 p.m. indicated that his hemodialysis catheter was removed and now he has a fistula in his left arm. Interview with the Director of Nursing on April 15, 2025, at 3:25 p.m. confirmed that Resident 37's care plan should have been updated to reflect the fact that the resident's hemodialysis catheter was removed in May 2024 and was now using a fistula for dialysis treatment. 28 Pa. Code 201.24(e)(4) admission Policy. 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 10 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 04/17/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 25 residents reviewed (Resident 8). Residents Affected - Some Findings include: A facility policy regarding administering medication, dated August March 6, 2025, revealed that staff were to administer medications that were ordered by the physician; to ensure the right resident received the right medication at the right time. Medication given to a resident shall be prescribed by the physician. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated March 25, 2025, indicated that the resident was cognitively intact, required assistance from staff for care needs, had diagnoses that included Type I diabetes (unable to produce insulin needed to regulate blood sugar), and was administered insulin (medication to lower blood sugar). Physician's orders for Resident 8, dated January 10, 2025, included an order for the resident to receive Insulin Admelog (Lispro- a rapid-acting insulin) based on a sliding scale (the amount of insulin is based on the result of a fingerstick blood sugar test) before meals and bedtime. The sliding scale for before meals included giving 3 units of insulin for a blood sugar of 151-200 milligrams per deciliter (mg/dL); 6 units for a blood sugar of 201-250 mg/dL; 9 units for a blood sugar of 251-300 mg/dL; 12 units for a blood sugar of 301-350 mg/dL; and 15 units for a blood sugar of 351-400 mg/dL. The sliding scale for bedtime included giving 0 units of insulin for a blood sugar of 151-200 mg/dL; 2 units for a blood sugar of 201-250 mg/dL; 3 units for a blood sugar of 251-300 mg/dL; 4 units for a blood sugar of 301-350 mg/dL; and 5 units for a blood sugar of 351-400 mg/dL. Special instruction that were included indicated that the dosages of insulin for before meals and bedtime were different and to read the entire scale before administering. Review of the Medication Administration Record (MAR) for Resident 8, dated March and April 2025, revealed that on March 18, 2025, at 7:59 p.m. the resident had a blood sugar of 258 mg/dl and was administered 9 units when 3 units of Admelog was ordered; on March 19, 2025, at 8:24 p.m. the resident had a blood sugar of 268 mg/dl and was administered 9 units when 3 units of Admelog was ordered; on March 20, 2025, at 7:41 p.m. the resident had a blood sugar of 173 mg/dl and was administered 3 units of Admelog when the insulin should have been held as ordered; on March 31, 2025, at 7:56 p.m. the resident had a blood sugar of 202 mg/dl and was administered 6 units when 2 units of Admelog was ordered; on April 3, 2025, at 7:56 p.m. the resident had a blood sugar of 160 mg/dl and was administered 3 units when the insulin should have been held as ordered; on April 7, 2025, at 7:42 p.m. the resident had a blood sugar of 161 mg/dl and was administered 3 units when the insulin should have been held as ordered; and on April 15, 2025, at 8:14 p.m. the resident had a blood sugar of 204 mg/dl and was administered 6 units when 2 units of Admelog was ordered. Interview with the Director of Nursing on April 16, 2025, at 9:25 a.m. confirmed that Resident 8's bedtime insulin was not administered as physician ordered for the dates listed above. 28 Pa Code 211.9(a)(1) Pharmacy Services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 4 of 10 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 04/17/2025 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 0760 28 Pa. Code 211.12(d)(1)(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: 395387 If continuation sheet Page 5 of 10 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 04/17/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility failed to discard expired medical supplies in two of two medication rooms reviewed (Overly Meadows and [NAME] Trails). Findings include: Observations in the Overly Meadows medication room on [DATE], at 11:22 a.m. revealed that there were six 24 gauge angiocatheters (small teflon tubing inserted into the vein to administer fluids or medication) that expired [DATE]; one 18 gauge needle expired on [DATE]; and one 25 vial box of 20 cc's each normal saline solution that expired on [DATE]. Interview with Licensed Practical Nurse 1 on [DATE], at 11:26 a.m. confirmed that the above angiocatheters, needles and syringe should not have been in circulation in the medication room if they were expired. Observations in the [NAME] Trails medication room on [DATE], at 12:20 p.m. revealed that there were nine 24 gauge IV catheters that expired [DATE]; two 20 gauge IV catheters that expired [DATE]; twenty- seven 22 gauge IV catheters, 26 that expired [DATE], and one that expired [DATE]; four 18 gauge needles that expired [DATE]; and one 10 cc syringe that expired [DATE]. Interview with Licensed Practical Nurse 2 on [DATE], at 12:25 p.m. confirmed that the above angiocatheters, needles and syringe should not have been in circulation in the medication room if they were expired. Interview with the Nursing Home Administrator on [DATE], at at 12:46 p.m. confirmed that the intravenous catheters, needles and syringe should not have been in circulation in the medication rooms if they were expired, and they were. 28 Pa. Code 211.9(a)(1) Pharmacy Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 6 of 10 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 04/17/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on review of hospice contracts, facility policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two of 25 residents reviewed (Residents 27, 36) who received hospice services. Findings include: An agreement between the facility and a hospice provider (provider of end-of-life services), dated March 9, 2018, revealed that it was the responsibility of the hospice to provide information to the skilled nursing facility to include plan of care, Benefit of Election form (a form used to formally enroll a patient in hospice care), advance directives, certification and recertification of terminal illness (a form signed by the resident's hospice physician and specific to each patient), names and contact info of hospice personnel, instructions for access of hospice 24 hour on-call system, hospice medication information, hospice and attending orders. The facility's policy regarding hospice care (specialized care that provides physical comfort and emotional, social and spiritual support for people nearing the end of life), dated March 6, 2025, revealed that residents electing to receive hospice services will be referred to the hospice agency of choice, and care will be coordinated with the nursing home through the interdisciplinary care planning process. Nursing will communicate with hospice in coordinating the resident's overall care and incorporate hospice care into the resident's care plan. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated February 6, 2025, revealed that the resident was usually understood, could usually understand others, had diagnoses that included heart failure (occurs when the heart can not pump enough blood to meet the body's needs), and adult failure to thrive (a syndrome characterized by a decline in a person's overall health, function, and well-being, often accompanied by symptoms like weight loss, decreased appetite, and cognitive impairment), and received hospice care. A care plan, dated January 31, 2025, revealed that the resident had an anticipated decline due to the progression of the disease process, with a less than six months life expectancy. A nursing note for Resident 27, dated January 31, 2025, revealed that the resident was admitted to the facility this afternoon and that the resident was receiving hospice care. A hospice provider care plan for Resident 27, for the hospice certification period of February 23, 2025, through April 23, 2025, revealed that the hospice nurse would visit the resident two times per week for six weeks, then one time a week for one week and would make four as needed visits for any changes in condition. As of April 17, 2025, there was no documented evidence that Resident 27's clinical record and/or the hospice provider's clinical record contained the Hospice Benefit of Election form and communication from the contracted hospice provider after March 14, 2025. An admission MDS assessment for Resident 36, dated March 18, 2025, revealed that the resident was sometimes understood, could sometimes understand others, had a diagnoses that included cerebral vascular accident (CVA - commonly known as a stroke) with hemiplegia (paralysis on one side of the body), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 7 of 10 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 04/17/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few aphasia (a language disorder that results from damage to the brain's language centers, affecting the ability to speak, understand language, and read or write), and adult failure to thrive, and received hospice care. A care plan, dated March 12, 2025, revealed that the resident has an anticipated decline due to the progression of the disease process, with a less than six months life expectancy. A nursing note for Resident 36, dated March 12, 2025, revealed that the resident was admitted to the facility, and that the resident has been receiving hospice care for the past two months. As of April 17, 2025, there was no documented evidence that Resident 36's clinical record and the hospice provider's clinical record contained the Hospice Benefit of Election form. Interview with the Nursing Home Administrator on April 17, 2025, at 11:00 a.m. confirmed that the Hospice Benefit of Election form and Hospice nurse visit notes for Resident 27 and the Hospice Benefit of Election form for Resident 36 had to be faxed over from the contracted hospice provider and that there was no documented evidence that as of April 17, 2025, that the above information was in Resident 27's and Resident 36's clinical records and/or the hospice provider's clinical records. 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 8 of 10 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 04/17/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during wound care for one of 25 residents reviewed (Resident 23). Residents Affected - Few Findings include: The facility's policy regarding hand hygiene, dated March 6, 2025, indicated that hand hygiene is an important infection control measure to prevent illness in skilled nursing homes, and that hands should be sanitized or washed before and after the use of gloves. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated January 30, 2024, indicated that the resident was cognitively intact, was understood, could understand others, required assistance from staff for care needs, and had diagnoses that included left arm hematoma (blood clot) and sepsis (a medical emergency in response to an infection). Physician's orders for Resident 23, dated April 11, 2025, included an order to cleanse the left arm with normal saline (salt water) solution, lightly pack 1/4-inch iodoform (sterile gauze infused with antiseptic) into left forearm surgical site, cover with gauze, abdominal pad and kerlix then secure with tape. Observations on April 16, 2025, at 1:30 p.m. revealed that Licensed Practical Nurse 1 donned a gown and gloves and with scissors she removed Resident 23's left forearm dressing, cleansed the area with normal saline infused gauze, removed her gloves and without performing hand hygiene she donned new ones. Using a Q-tip she packed the wound with a 1/4-inch iodoform packing strip; covered the area with gauze, an abdominal pad, and kerlix and secured it with tape; gathered the garbage; and without removing her gloves and performing hand hygiene, Licensed Practical Nurse 1 repositioned three of the resident's pillows, then removed her gloves and washed her hands. Interview with Licensed Practical Nurse 1 on April 16, 2025, at 1:45 p.m. confirmed that while performing wound care on Resident 23, she did not perform hand hygiene after removing her gloves and donning new gloves, and did not remove her gloves and hand sanitize prior to repositioning the resident's pillows. Interview with the Director of Nursing on April 16, 2025, at 3:18 p.m. confirmed that Licensed Practical Nurse 1 should have washed her hands or sanitized them after removing her gloves and before donning new gloves, and should have removed her gloves and performed hand hygiene prior to repositioning Resident 23's pillows. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 9 of 10 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 04/17/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on review of manufacturer's direction for use, as well as observations and staff interviews, it was determined that the facility failed to ensure essential equipment was in safe operating condition in the facility's laundry area. Residents Affected - Few Findings include: A facility policy regarding chemical dispensing, dated August March 6, 2025, indicated that the automatic dispensing system was to ensure safe dispensing of chemicals for the laundry department. The automatic liquid dispensing system would dispense chemicals for the recommended amounts of detergent per the chemical manufacturer. Observations in the laundry department on April 18, 2025, at 12:50 p.m. revealed that the laundry area had two washing machines. There was a five-gallon bucket on the floor and a smaller bucket on the counter with blue liquid in it. Interview with Environmental Service Staff (ESS) 3 at the time of the observation revealed that the second washing machine's automatic feeder was not working and was not adding the detergent to the washing machine. She had to open the five-gallon bucket on the floor that had plastic tubing to the automatic feeding system, transfer some of the detergent to another bucket using a clear handled cup to put approximately 1/4 cup in the washer. This issue has been a concern for about three months, and she reported it to her supervisor. ESS 3 was the primary staff responsible for operating the facilities personal laundry. Interview with the Nursing Home Administrator on April 17, 2025, at 1:05 p.m. revealed that the Environmental Service Director was aware that the automatic detergent feeder was not working. The Environmental Service Director had contacted the company for replacement parts but was unsure when, and had no other contact with the manufacturer. Interview with the Nursing Home Administrator on April 17, 2025, at 1:35 p.m. revealed that she was unaware that the automatic feeding system was not working, there were no work orders for the repairs, and confirmed that the washing machine should be in functional order. 28 Pa. Code 201.18(b)(3) Administrator's Responsibility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395387 If continuation sheet Page 10 of 10