Inspection·February 8, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 24 residents reviewed (Residents 25, 54, and 65). Residents Affected - Some Findings include: Review of Resident 25's clinical record on February 5, 2024, at approximately 1:00 PM, revealed diagnoses that included diabetes type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 25's Quarterly Minimum Data Set (MDS - standardized assessment tool utilized to identify a resident's physical, mental, and psychosocial needs), with an assessment reference date of December 17, 2023, revealed that section M - Skin Conditions, subsection M300 - Current Number of Pressure Ulcers/Injuries at Each Stage was coded to reflect Resident 25 had one stage II pressure ulcer (injury of the skin that is caused by pressure over a bony surface) and one unstageable pressure ulcer. Review of Resident 25's clinical record revealed that Resident 25's stage II pressure ulcer was assessed as healed as of November 13, 2024. In an electronic communication on February 8, 2024, at 8:39 AM, the Director of Nursing (DON) confirmed that Resident 25's stage II pressure ulcer was considered healed as of November 13, 2024. During a staff interview on February 8, 2024, at approximately 12:30 PM, DON revealed that Resident 25's December 17, 2023, Quarterly MDS was coded incorrectly and should not have included the stage II pressure ulcer. Review of Resident 54's clinical record revealed diagnoses that included bipolar disorder (a lifelong mood disorder and mental health condition that causes intense shifts in mood, energy levels, thinking patterns, and behaviors), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and hypertension. Review of Resident 54's Annual MDS, with the assessment reference date of April 27, 2023, revealed in Section I. Diagnoses that Resident 54's anxiety disorder was not coded; although, they were coded in Section N. Medications as receiving an antianxiety medication for all seven days of the assessment period. Review of Resident 54's Quarterly MDS with the assessment reference date of May 4, 2023, revealed in Section I. Diagnoses that Resident 54's anxiety disorder was not coded; although, they were coded in Section N. Medications as receiving an antianxiety medication for all seven days of the assessment period. Review of Resident 54's Quarterly MDS with the assessment reference date of August 4, 2023, revealed in Section I. Diagnoses that Resident 54's anxiety disorder was not coded; although, they were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395440 If continuation sheet Page 2 of 15 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 395440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camp Hill Skilled Nursing and Rehabilitation Ctr 1700 Market Street Camp Hill, PA 17011 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some coded in Section N. Medications as receiving an antianxiety medication for all seven days of the assessment period. Review of Resident 54's Quarterly MDS with the assessment reference date of August 31, 2023, revealed in Section I. Diagnoses that Resident 54's anxiety disorder was not coded; although, they were coded in Section N. Medications as receiving an antianxiety medication for all seven days of the assessment period. Review of Resident 54's Quarterly MDS with the assessment reference date of November 23, 2023, revealed in Section I. Diagnoses that Resident 54's anxiety disorder was not coded; although, they were coded in Section N. Medications as receiving an antianxiety medication for all seven days of the assessment period. During an interview with the Nursing Home Administrator (NHA) and DON on February 7, 2024, at 11:07 AM, the DON indicated that she had spoken to the Registered Nurse Assessment Coordinator and that they indicated that they did not code the anxiety disorder diagnosis because they felt the bipolar diagnosis covered the anxiety diagnosis. Further review of Resident 54's Quarterly MDS with the assessment reference date of November 23, 2023, revealed in Section N. Medications revealed that Resident 54's physician had documented that a gradual dose reduction of their antipsychotic medication was clinically contraindicated on July 6, 2023. Review of Resident 54's Quarterly MDS with the assessment reference date of December 22, 2023, also revealed in Section N. Medications revealed that Resident 54's physician had documented that a gradual dose reduction of their antipsychotic medication was clinically contraindicated on July 6, 2023. Further review of Resident 54's clinical record revealed that their physician had documented on August 10, 2023, on a pharmacist recommendation report, that a gradual dose reduction of their antipsychotic medication was clinically contraindicated. During an interview with the NHA and DON on February 8, 2024, at 12:36 PM, the DON confirmed that the most recent date of Resident 54's physician documentation of a gradual dose reduction being clinically contraindicated was not captured on Resident 54's quarterly MDS's with the assessment reference dates of November 23, 2023, and December 22, 2023. Review of Resident 65's clinical record revealed diagnoses that included chronic kidney disease (CKD kidneys are severely damaged and have stopped doing their job, to filter waste from your blood) and hypertension. Review of Resident 65's clinical record medical diagnosis revealed Resident 65 has a current diagnosis of other specified depressive episodes, with a created date of February 8, 2022. Resident 65's clinical record also revealed a diagnosis of adjustment disorder with mixed anxiety and depressed mood, with a created date of March 3, 2020. Review of Resident 65's current comprehensive person-centered care plan revealed a focus area (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395440 If continuation sheet Page 3 of 15 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 395440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camp Hill Skilled Nursing and Rehabilitation Ctr 1700 Market Street Camp Hill, PA 17011 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 0641 Level of Harm - Minimal harm or potential for actual harm indicating Resident 65 is at risk for changes in mood related to depression, with an initiation date of July 9, 2021. Review of Resident 65's quarterly MDS dated [DATE], under Section I Active Diagnosis, I5800. Depression was not coded, indicating Resident 65 does not have a depression diagnosis. Residents Affected - Some During an interview with the DON on February 8, 2024, at 12:30 PM, revealed Resident 65's Quarterly MDS dated [DATE], was coded incorrectly and should have been marked Yes for depression. 28 Pa. Code 211.5(f) Clinical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395440 If continuation sheet Page 4 of 15 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 395440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camp Hill Skilled Nursing and Rehabilitation Ctr 1700 Market Street Camp Hill, PA 17011 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 observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 25 residents reviewed (Residents 42, 55, and 73). Findings include: Review of Resident 42's clinical record revealed diagnoses that included dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and diabetes (a group of diseases that result in too much sugar in the blood [high blood glucose]). Review of Resident 42's progress notes from January 22, 2024, at 11:09 AM, revealed a progress note written by Employee 3 (Physician), that revealed Resident 42 had dementia and the plan of care was to, continue with supportive care. Review of Resident 42's MDS (Minimum Data Set evaluation), dated December 29, 2023, revealed in section I4800 that Resident 42 has an active diagnosis of Non-Alzheimer's dementia, meaning that the condition required and received treatment within the previous seven days. Review of Resident 42's care plan on February 5, 2024, failed to reveal any care planning for the Resident's dementia care. During a staff interview with the Director of Nursing (DON) February 8, 2024, at 9:45 AM, revealed that a care plan was developed and added to Resident 42's plan of care. She also revealed that the care plan should have been developed previously. Review of Resident 55's clinic record on February 6, 2024, at 1:05 PM, revealed diagnoses that included diabetes mellitus type 2 (DM II - body's inability to make/use insulin causing high blood sugar levels) and atrial fibrillation (fast irregular beats in the upper chambers of the heart). Review of Resident 55's physician orders revealed the following orders: morphine sulfate (opioid pain medication) oral tablet 15 milligrams, give one tablet by mouth every 12 hours for pain; insulin glargine (long-acting insulin for controlling blood sugar) subcutaneous solution, inject 16 units subcutaneously two times a day for DM; insulin lispro (short-acting insulin for controlling blood sugar), inject eight units subcutaneously one time a day for DM II and inject six units subcutaneously two times a day for DM II; furosemide (diuretic to reduce extra fluid in the body) oral tablet 20 milligrams, give one tablet by mouth two times a day for diuretic; duloxetine HCl (increases the amount of mood-enhancing chemicals in the brain) oral capsule delayed release particles 30 milligrams, give one capsule by mouth one time a day for depression; and apixaban (used to thin blood) oral tablet five milligrams, give one tablet by mouth two times a day for prevent blood clots. Review of Resident 55's comprehensive care plan revealed no care plan for the use of opioid pain medication, insulin, antidepressant medication, and anticoagulant medication. During a staff interview on February 8, 2024, at 10:04 AM, the DON revealed it was the facility's expectation that Resident 55 would have a care plan developed for the use of opioid pain medication, insulin, antidepressant medication, and anticoagulant medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395440 If continuation sheet Page 5 of 15 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 395440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camp Hill Skilled Nursing and Rehabilitation Ctr 1700 Market Street Camp Hill, PA 17011 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 Review of Resident 73's clinic record on February 6, 2024, at 12:37 PM, revealed diagnoses that included depressive episodes (feeling sad, irritable, empty) and venous thrombosis (condition that occurs when a blood clot forms in a vein). Review of Resident 73's physician orders revealed orders for the following: escitalopram oxalate (antidepressant) oral tablet 20 milligrams, give one tablet by mouth one time a day for depression; bupropion HCl (antidepressant) oral tablet 75 milligrams, give one tablet by mouth one time a day for depression; and apixaban (anticoagulant) oral tablet five milligrams, give one tablet by mouth two times a day for prevent blood clots. Review of Resident 73's comprehensive care plan revealed no care plan for the use of antidepressant and anticoagulant medications. During a staff interview on February 8, 2024, at 10:04 AM, the DON revealed it was the facility's expectation that Resident 73 would have a care plan developed for the use of antidepressant medication and anticoagulant medication. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395440 If continuation sheet Page 6 of 15 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 395440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camp Hill Skilled Nursing and Rehabilitation Ctr 1700 Market Street Camp Hill, PA 17011 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 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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 24 residents reviewed (Residents 51 and 65). Residents Affected - Few Findings include: Review of facility policy, titled OPS416 Person-Centered Care Plan, dated November 28, 2016, with a last review date of January 17, 2024, revealed, in part, 7. Care plans will be: .7.2. Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. Review of Resident 51's clinical record revealed diagnoses that included end-stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis), peripheral vascular disease (disease of the vascular system that results in decreased blood flow to the extremities), and hypertension (high blood pressure). Review of Resident 51's care plan revealed a care plan focus for a right heel pressure ulcer, with a last revision date of October 7, 2022. Review of Resident 51's clinical record revealed that their pressure ulcer to the right heel resolved on December 20, 2023. During an interview with the Nursing Home Administrator and Director of Nursing (DON) on February 7, 2024, at 11:25 AM, the aforementioned concern was shared. The DON indicated that this was a recurrent issue for Resident 51, and that she would review Resident 51's record to determine if the Resident currently had a wound or not. In a follow-up email communication received from the DON on February 8, 2024, at 8:34 AM, she confirmed that Resident 51's wound had resolved on December 20, 2023, and that it should not have been currently care planned. Review of Resident 65's clinical record revealed diagnoses that included chronic kidney disease (CKD kidneys are severely damaged and have stopped doing their job, to filter waste from your blood) and hypertension. Review of Resident 65's clinical record medical diagnosis revealed Resident 65 had a current diagnosis of other specified depressive episodes, with a created date of February 8, 2022. Resident 65's clinical record also revealed a diagnosis of adjustment disorder with mixed anxiety and depressed mood, with a created date of March 3, 2020. Review of Resident 65's current physician orders revealed that Resident 65 is not prescribed any medication for depression. Further review of Resident 65's clinical record revealed a discontinued order for Sertraline Hydrochloride Oral Tablet 25 milligram, with an end date of October 14, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395440 If continuation sheet Page 7 of 15 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 395440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camp Hill Skilled Nursing and Rehabilitation Ctr 1700 Market Street Camp Hill, PA 17011 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 Review of Resident 65's current comprehensive person-centered care plan revealed a care plan focus area that indicated Resident 65 is at risk for adverse effects related to use of antidepressant, with an initiation date of July 12, 2021. During an interview with the DON on February 8, 2024, at 12:30 PM, revealed that they would have expected Resident 65's comprehensive person-centered care plan relating to their antidepressant use to have been updated. 42 CFR 483.21(b) Comprehensive Care Plans 28 Pa. Code 211.11(d)(e) Resident care plan 28 Pa. Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395440 If continuation sheet Page 8 of 15 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 395440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camp Hill Skilled Nursing and Rehabilitation Ctr 1700 Market Street Camp Hill, PA 17011 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 24 residents reviewed (Resident 51). Residents Affected - Some Findings include: Review of Resident 51's clinical record revealed diagnoses that included end-stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis), dependence on renal dialysis (external filtering of the blood performed by a machine by removing the blood and replacing it), and adult failure to thrive (a past history of weight loss of more than five percent, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction). Review of Resident 51's physician orders revealed an order for daily weights, dated April 18, 2023. Review of Resident 51's weights in their electronic health record revealed that their daily weights were not recorded as ordered on the following dates: April 19 and 29, 2023; May 27 and 28, 2023; June 24, 28, and 29, 2023; July 2, 22, and 26, 2023; August 1, 4, 6, 17, and 19, 2023; September 2, 3, 4, 12, and 20, 2023; [DATE], 28, 29, and 31, 2023; November 1, 2, 5, 6, 8, 11, 12, 25, 26, and 29, 2023; December 9, 12, 13, 14, 20, 21, 26, and 29, 2023; and January 1, 6, 7, 15, 17, 18, 20, 27, 28, and 29, 2024. Review of Resident 51's Treatment Administration records revealed the following: April 2023: the weight was signed as obtained on the 19th, and was not signed or coded as a reason for not obtaining on the 29th; May 2023: the weight was signed as obtained on the 27th, and was not signed or coded as a reason for not obtaining on the 28th; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395440 If continuation sheet Page 9 of 15 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 395440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camp Hill Skilled Nursing and Rehabilitation Ctr 1700 Market Street Camp Hill, PA 17011 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 0684 Level of Harm - Minimal harm or potential for actual harm June 2023: the weight was signed as obtained on the 24th and 29th, and was coded as other/see notes on the 28th (the note indicated that the aides were not able to check weight with hoyer); July 2023: the weight was signed as obtained on the 2nd and 26th, and was not signed or coded as a reason for not obtaining on the 22nd; Residents Affected - Some August 2023: the weight was signed as obtained on the 1st, 4th, 6th, 17th, and 19th; September 2023: the weight was signed as obtained on the 2nd and 12th, and was coded as other/see notes on the 3rd, 4th, and 20th (notes indicated that on the 3rd the Resident was sleeping, on the 4th the Resident was out at dialysis, and on the 20th unable to take it passed on to next shift); October 2023: was signed as obtained on the 10th, and was not signed or coded as a reason for not obtaining on the 1st, 28th, 29th, and 31st; November 2023: was signed as obtained on the 2nd, 5th, 8th, 25th, and 29th, and was not signed or coded as a reason for not obtaining on the 1st, 6th, 11th, 12th, and 26th; December 2023: was signed as obtained on the 12th, 13th, 14th, and 29th, and was not signed or coded as a reason for not obtaining on the 9th, 21st, and 26th, and was coded as other/see notes on the 20th (note indicated, in part, hoyer unavailable MD aware; and January 2024: was signed as obtained on the 1st, 6th, 27th, and 28th, and was not signed or coded as a reason for not obtaining on the 7th, 15th, 17th, 18th, 20th, and 29th. Further review of Resident 51's weight data revealed the following: 1) January 5, 2024, the Resident weighed 204.2 pounds; 2) no weights were documented as indicated above on January 6, 7, or 8, 2024; 3) January 9, 10, 11, 2024, the Resident weighed 158 pounds (a loss of 46.2 pounds); 4) no weight was documented as indicated above on January 12, 2024; 5) January 13, 2024, the Resident weighed 160.2 pounds; 6) no weights were documented as indicated above on January 14 or 15, 2024; 7) January 16, 2024, the Resident weighed 160.8 pounds; and 8) no weights were documented as indicated above on January 17 or 18, 2024. Review of Resident 51's clinical record progress notes revealed a nutrition/weight progress note confirming Resident 51's weight dated January 5, 2024, at 12:20 PM, by the dietician, which indicated, in part, Note Text: Weight Warning: Value: 204.2 Vital Date: 2024-01-05 11:43 AM .Triggering for +22.8% weight gain 12/6 weight compared to 1/5 weight . Weight remains in 203-206# range 12/19 to present. Unsure of etiology of large weight gain. May be prone to wt {weight} flux {weight fluctuations} 2/2 {secondary to} fluid status/dialysis/diuretic. On daily weights. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395440 If continuation sheet Page 10 of 15 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 395440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camp Hill Skilled Nursing and Rehabilitation Ctr 1700 Market Street Camp Hill, PA 17011 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Further review of Resident 51's clinical record progress notes revealed that there were no other weight/nutrition notes by the dietician from January 5, 2024, until January 18, 2024, at 1:53 PM, which indicated, in part, Note Text: Weight Warning: Value: 160.8 Vital Date: 2024-01-16 14:59:00.0 {2:59 PM} .Triggering for -21.8% weight loss 12/19 weight compared to 1/16 weight .Unsure of etiology of large weight gain- was 160.7# {pounds} 12/18, 205.6# {pounds} 12/19 and has been in 200s 12/19 to 1/5 weights, now with weight loss. Weight has been in upper 150s and low 160s 1/9 to present .Continues on daily weights. Will continue to observe weight pattern. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on February 7, 2024, at 11:24 AM, the aforementioned concerns were shared and additional information was requested regarding daily weights not being completed as ordered, especially January 5-9, 2024, and follow-up regarding their weight loss. During another interview with the NHA and DON on February 8, 2024, at 10:16 AM, the aforementioned concerns were again shared and additional information was requested regarding daily weights not being completed as ordered, especially January 5-9, 2024, and follow-up regarding their weight loss. During a follow-up interview with the NHA and DON on February 8, 2024, at 12:39 PM, the DON confirmed that the daily weights should have been obtained as ordered or documentation present indicating why they were not obtained. During a final interview with the NHA and DON on February 8, 2024, at 1:40 PM, the DON indicated that she had been reviewing Resident 51's weights and comparing them with what was entered on the dialysis sheets and that it did not appear they had weighed 200 pounds. Review of the sheets that she was reviewing revealed that most of these weights were being documented by the dialysis center. It was shared again that the dietician's documentation confirmed the weights and did not indicate that they were inaccurate. The DON confirmed that Resident 51's weight loss which was first noted on January 9, 2024, was not addressed by the dietician or nursing staff until January 18, 2024. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395440 If continuation sheet Page 11 of 15 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 395440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camp Hill Skilled Nursing and Rehabilitation Ctr 1700 Market Street Camp Hill, PA 17011 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one residents reviewed (Resident 51). Residents Affected - Some Findings Include: Review of facility policy, titled NSG253 Dialysis: Hemodialysis (HD) - Communication and Documentation, with a last review date of January 17, 2024, indicated, in part, Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments received at a certified dialysis facility. 1. Prior to a patient leaving the Center for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record or the state required form and send with the patient to his/her HD facility visit. 2. Following completion of the HD, the dialysis facility nurse should complete and return the form and return it or other communication to the Center with the patient. 3. Upon return of the patient to the Center, a licensed nurse will: 3.1 Review the certified dialysis facility communication; 3.2 Evaluate/observe the patient; and 3.3 Complete the post-hemodialysis treatment section on the Hemodialysis Communication Record or state required form. 4. Notify the certified dialysis facility if the form is not returned with the patient and ask that it be faxed to the Center. 4.1 Document notification of certified dialysis facility regarding return of form or other communication. Review of Resident 51's clinical record revealed diagnoses that included end-stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis) and dependence on renal dialysis (external filtering of the blood performed by a machine by removing the blood and replacing it). Review of Resident 51's physician orders revealed an order for Dialysis on Mondays and Fridays, dated December 14, 2023. Further review of Resident 51's physician order history revealed they have been receiving renal dialysis since approximately August 6, 2021. Review of Resident 51's hard chart failed to reveal completed hemodialysis communication forms for the following dates: June 16, 2023, (the form did not have a Resident's name on the form; the facility section did not include a weight and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature) July 7, 2023, (form had no resident name, no weight, no facility staff signature, and dialysis section was completely blank); July 31, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); August 4, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395440 If continuation sheet Page 12 of 15 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 395440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camp Hill Skilled Nursing and Rehabilitation Ctr 1700 Market Street Camp Hill, PA 17011 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 0698 Level of Harm - Minimal harm or potential for actual harm August 9, 2023, (facility section only had two questions completed, did not include vital signs and weight, and was not signed by a staff member and the dialysis section was completely blank); September 18, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); Residents Affected - Some September 25, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); October 6, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); October 16, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); October 20, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights and that an additional medication was given with no signature); October 30, 2023, (facility section did not include vital signs, weight, or a staff signature); November 6, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); November 13, 2023, (facility section did not include vital signs, weight, or a staff signature and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); November 22, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); November 27, 2023, (facility section did not include vital signs, weight, or a staff signature); December 1, 2023, (form did not contain Resident's name and the facility section was blank); December 4, 2023, (facility section was blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); December 8, 2023, (facility section did not include vital signs, weight, or a staff signature and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights and that an additional medication was given with no signature); December 11, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); December 15, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); December 22, 2023, (facility section did not include vital signs, weight, or a staff signature and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395440 If continuation sheet Page 13 of 15 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 395440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camp Hill Skilled Nursing and Rehabilitation Ctr 1700 Market Street Camp Hill, PA 17011 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 0698 the dialysis section of the form was completed but no signature was present); Level of Harm - Minimal harm or potential for actual harm December 24, 2023, (facility section was partially completed, did not include weight, and was not signed and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); Residents Affected - Some December 29, 2023, (the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); January 5, 2024, (form did not contain Resident's name and the facility section was blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); January 8, 2024, (form did not contain Resident's name and the facility section was blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); January 12, 2024, (facility section only contained vital signs and weight indicating it was from January 11th, 2024, and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights and that an additional medication was given with no signature); January 15, 2024, (the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); January 22, 2024, (the facility section was completed but there was no staff signature and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); January 26, 2024, (the facility section was completed but indicated the weight was obtained on January 25, 2023, and there was no staff signature and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); and January 29, 2023, facility section only included vital signs and no signature and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature). In addition, there were three dialysis communication forms located in Resident 51's chart that had no name or dates in which the facility section was completely blank, and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature. There was also one dialysis communication forms located in Resident 51's chart that included the Resident's name with the facility section of form completely blank, and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature. During an interview with the Nursing Home Administrator and Director of Nursing (DON) on February 8, 2024, at 10:11 AM, the DON confirmed that the dialysis communication sheets should be completed in their entirety. 28 Pa Code 211.5(f) Clinical records (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395440 If continuation sheet Page 14 of 15 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 395440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camp Hill Skilled Nursing and Rehabilitation Ctr 1700 Market Street Camp Hill, PA 17011 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 0698 28 Pa. Code 211.12 (d)(1)(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: 395440 If continuation sheet Page 15 of 15