Health inspection·March 19, 2026

F 0692 Provide enough food/fluids to maintain a resident's health. 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 monitor hydration status to ensure proper hydration for one of two residents reviewed for hydration (Resident 11).Findings include: Review of facility policy, titled Fluid Restriction, dated October 2022, revealed, in part, The Nursing services will be responsible for tracking and documenting the total volume consumed in accordance with facility policy. Further review of facility provided policy failed to include any guidance regarding measures that nursing staff should take if a resident exceeds their ordered fluid restrictions. Review of Resident 11's clinical record revealed diagnoses that included acute on chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body) and hypertensive heart and chronic kidney disease with heart failure (a medical condition that develops from prolonged, poorly managed high blood pressure, which causes progressive damage in both the heart and kidneys). Review of Resident 11's physician orders revealed an order for regular/liberalized diet with 1500 cc fluid restriction: 800 cc from dietary and 700 cc from nursing, dated August 22, 2025. Review of Resident 11's care plan revealed a focus for Resident exhibits or is at risk for dehydration as evidence by fluid restriction/insufficient intake, dated March 23, 2025; and Resident is at nutritional risk requires therapeutic diet history of decreased oral intake, dated March 26, 2025. Interventions included, but were not limited to, offer small amounts of fluids frequently dated March 23, 2205; fluid restriction per order: 1500 ml (dietary offers 800 ml via meals) and offer/encourage fluids of choice within fluid restriction parameters, both dated March 26, 2025. Review of Resident 11's nurse aide Kardex (care plan) revealed a special instruction that Resident 11 was on fluid restrictions, but no additional information or directions were included. Review of Resident 11's dietary tray ticket revealed that Resident 11 was on a fluid restriction of 1500 ml per day and that Resident 11 could receive a maximum of 240 ml with each meal. Review of Resident 11's Medication Administration Records from August 1, 2025, through March 17, 2026, revealed the following:September 2025- Resident 11 exceeded her allotted nursing fluids on September 1 and 16, 2025.October 2025Resident 11 exceeded her allotted nursing fluids on October 1, 13, 24, 29, and 31, 2025.November 2025-Resident 11 exceeded her allotted nursing fluids on November 2, 4, 6, 9, 10, 11, 21, and 22, 2025.December 2025-Resident 11 exceeded her allotted nursing fluids on December 16, 22, 25, and 30, 2025.January 2026-Resident 11 exceeded her allotted nursing fluids on January 3, 5, 6, 7, 13, 21, 27, and 28, 2026.February 2026-Resident 11 exceeded her allotted nursing fluids on February 5, 6, 10, 11, 16, 23, and 24, 2026.March 2026- Resident 11 exceeded her allotted nursing fluids on March 7, 8, 9, 10, 16, and 17, 2026. Review or Resident 11's clinical record failed to reveal any documentation that Resident 11's physician was made aware of her exceeding her ordered nursing fluid restrictions. Further review of Resident 11's clinical record failed to reveal any documentation of fluids Resident 11 consumed from her meal trays from August 1, 2025, through March 17, 2026, and, therefore, Resident 11's total fluid consumption in each 24-hour period was not determined. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on March 19, 2026, at 11:00 AM, the DON confirmed that there was no documentation of what fluids Resident 11 consumed with her meals. She indicated that nurse aides would report to the nurse the amount of fluids they provided to a resident. She confirmed that there was no dietary fluid intake recorded with Resident 11's meal intake documentation. She confirmed that Resident 11 did exceed allotted nursing fluids on occasions and that there was no documentation to show that all Resident 11's fluids were totaled for each 24-hr period. She confirmed that she would expect staff to follow a resident's ordered fluid Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395733 If continuation sheet Page 2 of 7 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 395733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gettysburg Center 867 York Road Gettysburg, PA 17325 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 0692 restrictions and to follow-up with the physician when exceeded. 28 Pa. Code 211.12(d)(1)(2)(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: 395733 If continuation sheet Page 3 of 7 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 395733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gettysburg Center 867 York Road Gettysburg, PA 17325 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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. Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to properly label medications in one of three medications carts reviewed (South Wing Hall C cart); and failed to discard expired medications in two of three medication carts observed (South Hall B and C carts).Findings include: Review of facility policy, titled Storage of Medication, dated January 2025, revealed, in part, Medications and biologicals are stored properly, following manufacturer or provider pharmacy recommendations to keep their integrity and to support safe, effective drug administration. Note the date on the label for insulin vials and pens when first used. Review of facility policy appendix Medications with Shortened Expiration Dates, dated 2007, revealed that Lispro insulin should be discarded 28 days after opening. Observation of the South Wing B Hall medication cart on March 17, 2026, at 12:12 PM, with Employee 4 (Registered Nurse) revealed an opened haloperidol 1 ml single dose vial, which had no resident name or date indicated on the vial. The vial was laying loose in the plastic bin with insulin pens. During an immediate staff interview with Employee 4, Employee 4 confirmed that the vial was not labeled or dated and that it should have been discarded when used since it was a single dose vial. Observation of the South Wing C Hall medication cart with Employee 5 (Licensed Practical Nurse) on March 17, 2026, at 12:20 PM, revealed a lispro insulin belonging to Resident 74 which was dated as being opened on February 16, 2026; and a Lantus insulin pen belonging to Resident 5, which was opened, but not dated. The pharmacy label indicated that the Lantus pen had been dispensed from the pharmacy on March 13, 2026. During an immediate staff interview with Employee 5, Employee 5 confirmed that Resident 74's insulin pen was beyond the 28-day expiration date and should have been discarded. Employee 5 also confirmed that Resident 5's Lantus insulin pen should have been dated with an open date and indicated that she may have been the nurse that opened it and failed to date it. During a staff interview with the Nursing Home Administrator and the Director of Nursing (DON) on March 18, 2026, at 12:11 PM, the DON confirmed that she would expect medications to be labeled and stored properly, and that she expected discarded medications to be discarded when expired according to policy or manufacturer guidelines. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.9(a)(1) Pharmacy services. Event ID: Facility ID: 395733 If continuation sheet Page 4 of 7 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 395733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gettysburg Center 867 York Road Gettysburg, PA 17325 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, document review, and staff interview, it was determined that the facility failed to follow the diet extension sheets to provide a menu to meet the needs and preferences of residents on a regular diet for 79 of 79 residents reviewed on a regular diet.Findings include: Review of the facility provided diet manual, titled Diet and Nutrition Care Manual, Reviewed February 16, 2026, revealed, the regular diet should provide adequate nutrients as recommended by the Dietary Guidelines and National Research Council by using these guidelines to provide three balanced meals and up to three snacks daily. Observation of the lunch meal service on March 17, 2026, at 11:51 AM, revealed residents on a regular diet being served rotini pasta salad with a 3-ounce scoop. Review of diet extension sheets for the lunch meal to be served on March 17, 2026, revealed that residents on a regular diet are to be served 1/2 cup (4 ounces) of rotini pasta salad. Interview with the Nursing Home Administrator on March 18, at 11:50 AM, revealed that she would expect resident meals to be prepared and served in accordance with the menus that have been approved by the dietician and physician. Pa code 211.6(a)(b) - Dietary Services Event ID: Facility ID: 395733 If continuation sheet Page 5 of 7 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 395733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gettysburg Center 867 York Road Gettysburg, PA 17325 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 observations, clinical record review, facility policy reviews, and staff interviews, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for one of one dressing changes observed (Resident 92); for storage of medications on one of three medication carts observed (South Wing C Hall); and for medication administration in one of two medication administration observations (Employee 5). Findings Include: Review of facility policy, titled IC308 Enhanced Barrier Precautions, revised November 14, 2025, revealed that Enhanced Barrier Precautions expands on the use of gown and gloves beyond anticipated blood and body fluid exposures, focusing on use of gown and gloves only during high contact patient care activities that have been demonstrated to result in the transfer of MDROs (Multi Drug Resistant Organisms) to the hands and clothing of healthcare personnel, even if blood and body exposure is not anticipated. Review of facility policy, titled Section 7.11 Medication Administration Eye Drops, dated January 2026, revealed that gloves are recommended to protect both patient and provider from transmission of infectious agents and staff are to perform hand hygiene and don (apply) gloves prior to administering eye drops. Review of Resident 92's clinical record revealed diagnoses that included pressure ulcer of the right buttock, stage 4 (severe wounds that extend through the skin and underlying tissues, exposing muscle, tendon, and bone, and require immediate medical attention) and dementia (a syndrome characterized by a decline in cognitive function). Review of Resident 92's physician orders revealed an order for, Infection precautions - enhanced barrier, starting January 31, 2026. Review of Resident 92's care plan revealed a care plan focus area of, Resident is at risk for MDRO colonization/infection due to chronic wounds, revised November 18, 2025, with an intervention of, Enhanced Barrier Precautions: Use gown and gloves when performing high-contact activities: dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device (e.g. central line, urinary catheter, feeding tube, tracheostomy, or ventilator), wound care(any skin opening requiring a dressing), created January 23, 2026. Observation of Employee 1 (Registered Nurse) on March 18, 2026, at 9:41 AM, revealed Employee 1 completed ordered wound care on Resident 92's sacral pressure ulcer. Employee 1 failed to wear a gown at any time during the dressing change. Interview with the Nursing Home Administrator (NHA) on March 19, 2026, at 11:30 AM, revealed that she would expect employees to use appropriate personal protective equipment. Observation of the South Wing C Hall medication cart with Employee 5 (Licensed Practical Nurse) on March 17, 2026, at 12:20 PM, revealed that Employee 5 had her jacket stored in the bottom drawer of the medication cart along with medications. During an immediate interview with Employee 5, she confirmed that her jacket should not be in the medication cart. During a staff interview with the NHA and the Director of Nursing (DON) on March 18, 2026, at 12:11 PM, the DON confirmed that staff personal items should not be stored in medication carts. Observation of Employee 5 administering medications to Resident 127 on March 18, 2026, at 9:15 AM, revealed that she took Resident 127's inhaler and antibiotic eye drops in their boxes into the Resident's room and sat them directly on his overbed table. Employee 5 failed to apply gloves prior to administering Resident 127's antibiotic eye drops. In addition, Employee 5 failed to wear gloves when applying Resident 127's lidocaine patch. After administering Resident 127's medications, Employee 5 returned the inhaler and eye drop boxes to the medication cart and placed them in the drawer of the cart. During an immediate interview with Employee 5 after completing Resident 127's medication administration, Employee 5 confirmed that she should have placed a clean barrier on Resident 127's overbed table before setting the medication boxes down. She also confirmed that she should have worn gloves when administering the eye drops and applying the lidocaine patch. Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395733 If continuation sheet Page 6 of 7 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 395733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gettysburg Center 867 York Road Gettysburg, PA 17325 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 Level of Harm - Minimal harm or potential for actual harm During a staff interview with the NHA and DON on March 18, 2026, at 12:11 PM, the DON confirmed that Employee 5 should have worn gloves when administering Resident 127's eye drops and applying his lidocaine patch. She also confirmed that Employee 5 should have placed a clean barrier under the medication boxes. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395733 If continuation sheet Page 7 of 7