Health inspection·January 8, 2026

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined the facility failed to complete a comprehensive assessment after a significant change in condition for one of 22 residents reviewed (Resident 7).Findings include:Review of Resident 7's clinical record revealed diagnoses that included hemiplegia (paralysis affecting one side of the body) and protein calorie malnutrition (a severe nutritional deficiency from not getting enough protein and energy [calories], leading to muscle loss, weakness, impaired immunity, and organ problems). Review of Resident 7's Hospice Certification and Plan of Care revealed that Hospice care was started on October 3, 2025. Review of Resident 7's Minimum Data Set (MDS) (an assessment tool) revealed that there have not been a Significant Change MDS completed since Resident 7 entered Hospice care on October 3, 2025, when the significant change had occurred.Interview on January 8, 2026, at 11:30 AM, with the Nursing Home Administrator, revealed that the Significant Change MDS should have been completed within the 14-day period after the change in Resident 7's status.28 Pa Code 211.12(d)(1)(5) Nursing services Residents Affected - Few Page 1 of 2 395677 395677 01/08/2026 Sarah A Todd Memorial Home 1000 West South Street Carlisle, PA 17013

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 two of 22 residents reviewed (Resident 10 and 72).Findings Include:Review of Resident 10's clinical record revealed diagnoses that included chronic kidney disease (when a disease or condition impairs kidney function, causing kidney damage to worsen over several months or years) and dementia (the loss of cognitive functioning that interferes with a person's daily life and activities).Review of Resident 10's clinical record revealed an elopement risk assessment was completed on November 21, 2025, and determined Resident 10 was at risk for elopement.Review of Resident 10's care plan revealed that the Resident was at risk for elopement and had an elopement monitor to right ankle, with an initiation date of November 21, 2025.Review of Resident 10's physician orders revealed an active order for the Resident to have an elopement bracelet, with an initiation date of November 21, 2025.Review of Resident 10's clinical record revealed a nursing progress note written on November 26, 2025, at 9:50 PM, that Resident 10 was displaying exit seeking behaviors by trying to get outdoors, looking for keys, and wandering.Review of Resident 10's MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated November 27, 2025, revealed that Section E0900. Wandering - Presence & Frequency; has the Resident wandered - is marked as 0, indicating the behavior was not exhibited during the look back period.During an interview with the Nursing Home Administrator (NHA) on January 8, 2026, at 10:20 AM, revealed that Resident 10's MDS dated [DATE], was coded inaccurately and should have captured Resident 10's wandering behavior.Review of Resident 72's clinical record revealed diagnoses that included dementia and anxiety (a mental health condition that causes fear, dread, and other symptoms that are out of proportion to the situation).Review of Resident 72's clinical record revealed that the Resident had a fall on October 23, 2025, that resulted in no injury; a fall on November 3, 2025, that resulted in skin tears to the right forearm and elbow; and a fall on December 9, 2025, that resulted in a bruise on top of the Resident's right hand, measuring 6.5 centimeters by 6.5 centimeters.Review of Resident 72's MDS dated [DATE], revealed that Section J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment, A. No Injury was marked as having two are more, and B. Injury was marked as having one.During an interview with the NHA on January 8, 2026, at 10:20 AM, revealed that Resident 72's MDS dated [DATE], was coded inaccurately and should have reflected Resident 72 having two falls with injury and one fall with no injury.28 Pa. Code 211.5(f) Clinical records28 Pa Code 211.12 (d)(3)(5) Nursing Services Residents Affected - Few 395677 Page 2 of 2