Health inspection·July 17, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on facility policy review, facility documentation reviews, clinical record reviews, and staff interviews, it was determined the facility to ensure that each resident is free from abuse for two of six of residents reviewed (Residents 2 and 3).Review of facility policy titled OPS300 Abuse Prohibition with a last revision date of October 24, 2022, revealed [in part] the following:Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish.Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Injuries of unknown source are defined as an injury with both of the following conditions: The source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.5. Actions to prevent abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of patient property, will include: 5.2 identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur.6. Staff will identify events - such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse - and determine the direction of the investigation. This also includes patient-to-patient abuse.6.3 If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed.6.3.1 The Center will provide adequate supervision when the risk of patient-to-patient altercation is suspected.6.3.2 The Center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation.6.3.3 The patient representative and physician will be notified and any follow-up recommended will be completed (e.g., psychiatric evaluation).6.3.4 Options for room changes will be provided based on the situation.6.3.5 The Center should seek alternative placement for the patient exhibiting the abusive behavior, if warranted.6.4 Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected;8. The Center will protect patients from further harm during an investigation.8.1 Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe.8.2 Assign a representative from Social Services or a designee to monitor the patient's feelings concerning the incident, as well as the patient's involvement in the investigation;9. The Administrator or designee will:9.4 Take steps to resolve patient and family issues, concerns and allegations and clearly recording the same; and9.5 Take appropriate corrective actions. Review of Resident 2's clinical record revealed diagnoses that included heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs) and Page 1 of 5 395451 395451 07/17/2025 Inners Creek Skilled Nursing and Rehabilitation Ce 100 West Queen Street Dallastown, PA 17313

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few adjustment disorder with mixed disturbance of emotions and conduct (a mental health condition characterized by emotional and behavioral symptoms in response to a significant stressor, impacting daily functioning). Review of Resident 2's clinical record progress notes revealed a noted dated April 21, 2025, at 9:38 PM, which indicated that he stated he wanted to be moved because his roommate (Resident 3) had hit him on his arm with a reacher. Resident 2 indicated that this had not been the first time this had occurred. The note further indicated that there were no other beds available at the time of the incident and that administration and social services will discuss situation the next morning. Review of Resident 2's facility provided incident report for the resident-to-resident altercation with Resident 3 dated April 21, 2025, at 9:00 PM, revealed a note dated April 22, 2025, by the Director of Nursing which indicated Resident 2 would be evaluated for moving/changing rooms. Review of Resident 2's clinical record failed to include any documentation regarding his request to change rooms or an evaluation of such between April 15, 2025, and June 15, 2025. Review of Resident 2's clinical record progress notes revealed a note dated June 15, 2025, at 6:06 PM, which indicated he had got into a verbal/physical altercation with his roommate-Resident 3 and that he had hit his roommate-Resident 3 with his walker which also caused Resident 2 to experience a fall. Review of Resident 2's facility provided incident report dated June 15, 2025, at 4:00 PM, revealed a note dated June 16, 2025, by the Director of Nursing which indicated Resident 2 would be evaluated for a room change due to residents not getting along. Review of Resident 2's clinical record failed to include any follow-up documentation regarding his request to change rooms, evaluation of a room change, offers of a room change, or why his request could not be accommodated between April 15, 2025, and July 17, 2025. Review of Resident 3's clinical record revealed diagnoses that included heart failure, vascular dementia with other behavioral disturbances (brain damage caused by multiple strokes which causes memory loss in older adults), and post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions). Review of Resident 3's clinical record progress notes revealed a note dated April 21, 2025, at 9:53 PM, which indicated Resident 3 admitted he had struck Resident 2 with his reacher because he was bothering the staff by always putting on his call bell. Review of Resident 3's facility provided incident report for the resident-to-resident altercation with Resident 2 dated April 21, 2025, at 9:00 PM, revealed a note dated April 22, 2025, by the Director of Nursing which indicated Resident 3 verbally argued with his roommate and hit his roommate and he would be evaluated for moving/changing rooms. Review of Resident 3's clinical record failed to include any documentation regarding a room change evaluation between April 15, 2025, and June 15, 2025. Review of Resident 3's clinical record progress notes revealed a note dated June 15, 2025, at 4:54 PM, which indicated he had been struck in his right arm with a walker by his roommate-Resident 2 and that he had sustained a skin tear measuring 2 centimeters by 1 centimeter. Review of Resident 3's facility provided incident report dated June 15, 2025, at 4:00 PM, revealed a note dated June 16, 2025, by the Director of Nursing which indicated a room change evaluation would be completed for one of the residents. Review of Resident 3's clinical record failed to include any follow-up documentation regarding an evaluation of a room change between June 15, 2025, and July 17, 2025. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 18, 2025, at 3:33 PM, the NHA indicated that there were and continue to be no appropriate male beds to move Resident 2 or 3 into. The NHA said that for the first altercation they removed the reacher from Resident 2 as it was determined he did not need one and all items were to be placed in easy reach of resident. The NHA said that the facility cannot prevent all 395451 Page 2 of 5 395451 07/17/2025 Inners Creek Skilled Nursing and Rehabilitation Ce 100 West Queen Street Dallastown, PA 17313

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident-to-resident altercations, and that the facility cannot force a resident to change rooms or just medicate them for their behavioral issues. The NHA further indicated that he had multiple email communications with Resident 2's responsible party regarding a room change. The NHA indicated that he would send the email communications for surveyor review. The NHA confirmed that he nor any other staff had documented any evaluations or discussions about a room change for Resident 2 or Resident 3. He further indicated that he was not aware of any other measures the facility could have implemented to prevent the resident-to-resident altercations between these 2 residents. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.29(a) Resident rights28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 395451 Page 3 of 5 395451 07/17/2025 Inners Creek Skilled Nursing and Rehabilitation Ce 100 West Queen Street Dallastown, PA 17313

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on facility policy review, facility documentation reviews, clinical record reviews, and staff interviews, it was determined the facility failed to ensure that an injury of unknown origin was investigated for one of two residents (Resident 4).Review of facility policy titled OPS300 Abuse Prohibition with a last revision date of October 24, 2022, revealed [in part] the following: 6.4 Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected;8. The Center will protect patients from further harm during an investigation.8.1 Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe.8.2 Assign a representative from Social Services or a designee to monitor the patient ' s feelings concerning the incident, as well as the patient ' s involvement in the investigation;9. The Administrator or designee will:9.4 Take steps to resolve patient and family issues, concerns and allegations and clearly recording the same; and9.5 Take appropriate corrective actions. Review of Resident 4's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), Vitamin D deficiency, muscle weakness, and gait (walking) and mobility (the ability to move or be moved freely and easily) abnormalities. Review of Resident 4's clinical record revealed a progress note dated July 7, 2025, at 12:30 PM, which indicated that Resident 4 was observed by Physical Therapy (PT) staff with a shortened right lower leg turned outward prior to their session. The PT staff promptly contacted the Registered Nurse (RN) who then assessed the resident along with a provider. The resident complained of pain in the right lower extremity and pain upon touch. The note further indicated that Resident 4 was transferred to the hospital. Review of Resident 4's hospital records provided by facility revealed that she was found to have a fracture through the surgical neck (the portion of the bone that connects the head of the femur to the shaft of the femur and is a common site for fractures) of her right femur (large bone located in upper leg) with superior migration of the distal fracture fragment with surgical intervention planned. During an interview with the NHA and DON on July 15, 2025, at 2:20 PM, the DON indicated no investigation had been completed into Resident 4's injury of unknown origin. The DON confirmed that this injury could not be considered a result from Resident 4's initial fall on June 10, 2025, because of the time lapse and nursing staff had not noted any abnormal physical assessment findings post-fall as well as the original x-rays completed right after Resident 4's fall on June 10, 2025, were negative for any fractures. In addition, the DON indicated that Resident 4 was evaluated by physical therapy on July 5, 2025, and that there were no abnormal physical assessment findings at that time. She confirmed that she was aware that Resident 4 was diagnosed with a confirmed fracture at the hospital on July 7, 2025. The DON indicated that she had talked with a family member of Resident 4 a day or two after Resident 4 was transferred to the hospital to discuss the event at which time Resident 4's family member shared that other family members of Resident 4 had transferred her to the bathroom on July 4 and 5, 2025, however, the DON confirmed that there was no documentation of any abnormal physical assessment findings of Resident 4 between July 5, and July 7, 2025, at 12:30 PM, when the Physical Therapist found Resident 4 with a shortened right lower leg turned outward prior to their session. During a follow-up staff interview with the NHA and DON on July 17, 2025, at 3:22 PM, both confirmed that the facility should have completed an investigation into Resident 4's injury of unknown origin, a fracture, should have been investigated. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.29(a) Resident rights28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 395451 Page 4 of 5 395451 07/17/2025 Inners Creek Skilled Nursing and Rehabilitation Ce 100 West Queen Street Dallastown, PA 17313

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility provided documentation review, and staff interviews it was determined that the facility failed to provide adequate supervision and assistance to prevent accidents for one of three residents reviewed (Resident 4). Review of facility policy titled NSG215 Falls Management with a last revision date of March 15, 2024, revealed 2. Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. 2.1 Adjust and document individualized intervention strategies as patient condition changes. 4.Educate staff, patient, and/or patient representative(s) as appropriate to increase awareness of 'at risk' patients and to provide possible strategies to minimize risk for falls. Review of Resident 4's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), Vitamin D deficiency, muscle weakness, and gait (walking) and mobility (the ability to move or be moved freely and easily) abnormalities. Review of Resident 4's clinical record revealed a progress note dated June 10, 2025, at 10:48 AM, that indicated she had an unwitnessed fall. The note further indicated that the nurse was sitting at the nurse's station, heard a thud, and when the nurse stood up Resident 4 was observed sitting on the floor. Review of Resident 4's care plan revealed a care plan focus for at risk for decreased ability to perform bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to limited mobility dated May 7, 2025. Interventions included, but were not limited to, be aware: poor safety awareness dated May 7, 2025; and PT [Physical Therapy] mobility recommendations: one-person assist with transfers and ambulation for safety dated May 11, 2025. Further review of Resident 4's care plan revealed a care plan focus for at risk for falls related to cognitive loss, lack of safety awareness, impaired mobility, and possible side effects of medication dated May 7, 2025. Interventions failed to include her ambulation status or level of assistance needed for safe ambulation. Review of Resident 4's Physical Therapy Discharge summary dated [DATE], revealed resident needed supervision with stand-by assistance with ambulation and no assistive device. Review of Resident 4's facility provided incident report revealed the following: Nursing Description: Resident observed walking on the unit this evening. The nurse was at the nursing station and heard a hard thump and realized that this resident had fallen on her butt. Staff did not witness her fall. The resident was unable to give a description. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 17, 2025, at 3:30 PM, the DON confirmed that Resident 4's fall care plan did not indicate her ambulation assistance status. The DON indicated she was not aware that Resident 4 was to be one assist and said that she thought there were occasions where Resident 4 had utilized a walker for ambulation. The NHA and DON both confirmed that her care plan was not followed and should have been to prevent accidents. 201.4(a) Responsibility of licensee.201.18(b)(1) Management.211.10(d) Resident care policies.211.12(d)(1)(3)(5) Nursing services. 395451 Page 5 of 5