Inspection·April 11, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 10's clinical record revealed diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning), delusional disorder (a type of psychotic disorder), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 10's quarterly MDS dated [DATE], revealed a BIMS score of 99, meaning Resident 10 was unable to complete the interview and, therefore, a staff assessment was completed. Review of the staff assessment for mental status revealed that Resident 10's cognitive skills for decision making was moderately impaired. Review of Resident 1's clinical record revealed a progress note dated January 17, 2024, stating that Resident 1 was being sexually inappropriate with Resident 10 in the dining room. The note stated that Resident 1 pulled Resident 10's shirt up and had her breast in his mouth. Resident 10 was telling Resident 1 no. The note further stated that staff immediately intervened and removed both Residents. When attempting to educate Resident 1 about the inappropriate behavior, the Resident continued to repeat statements I like her. Where did she go? I want to sleep with her. Review of the incident report dated January 17, 2024, revealed a witness statement that as the staff member was walking past the day room, she noticed Resident 1 go up to Resident 10 in his wheelchair, pull up Resident 10's shirt and started sucking her breast. Resident 10 was pushing Resident 1 away from her as the staff member entered the room to remove Resident 1. Review of electronic report submission to the Pennsylvania Department of Health (State Agency responsible for receiving and reviewing allegations of abuse from Long Term Care facilities), revealed that the facility did not notify the State Agency of the incident involving Resident 1. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 10, 2024, at 1:40 PM, the NHA confirmed that the incident was not reported to the State Agency. In a follow-up interview with the NHA and DON on April 11, 2024, at 2:00 PM, the NHA stated that the incident has since been reported to the State Agency via the electronic event reporting system. Additional review of Resident 1's quarterly MDS dated [DATE], revealed a BIMS score of 9, meaning cognitive status is moderately impaired. Review of Resident 2's clinical record revealed diagnoses that included dementia, psychosis (a mental disorder characterized by a disconnection from reality), and depression. Review of Resident 2's quarterly MDS assessment dated [DATE], revealed a BIMS score of 99. Review of the staff assessment for mental status revealed that Resident 2's cognitive skills for decision making were moderately impaired. Review of facility investigation revealed that on April 5, 2024, Resident 1 and 2 were found in bed together. Review of Employee 1's witness statement dated April 5, 2024, revealed that she entered Resident 1's room to find Resident 2 lying on her back with her legs wide open, wearing a button-down shirt and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395660 If continuation sheet Page 2 of 3 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 395660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Nursing & Rehabilitation Center 1000 Claremont Road Carlisle, PA 17013 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 0609 Level of Harm - Minimal harm or potential for actual harm no pants. Resident 1 was naked, with his brief by his ankles and was lying on top of Resident 2 and they were having what appeared to be sexual relations. I did not see his penis inside of her vaginal vault. I assumed sexual intercourse was happening because [Resident 2] was holding onto [Resident 1's] hips. Residents were separated, [Resident 2] was taken to her room .[Resident 1] stayed in his room and went to bed. Residents Affected - Few Review of Employee 2's witness statement dated April 5, 2024, revealed she entered Resident 1's room and observed Resident 2 lying on the bed, on her back, with a shirt on and no bottoms. Resident 1 was lying on top of [Resident 2] naked with his brief around his ankles. He was humping her; his penis was near her pelvic area. We tried to separate them but [Resident 2] would not let go, she was holding on. We were finally able to separate them. The statement further stated that Resident 2 was then taken to her room and provided care and Resident 1 remained in his room. Review of electronic report submission to the Pennsylvania Department of Health revealed that the facility did not notify the State Agency of the incident involving Residents 1 and 2. During an interview with the NHA and DON on April 10, 2024, at 1:40 PM, the NHA confirmed that the incident was not reported to the State Agency. In a follow-up interview with the NHA and DON on April 11, 2024, at 2:00 PM, the NHA stated that the incident has since been reported to the State Agency via the electronic event reporting system. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395660 If continuation sheet Page 3 of 3