Health inspection·August 31, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of employee files, facility policies and procedures review, and interviews with staff, it was determined that the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property by failing to attempt to obtain information from previous employers and/or current employers for new employees for five of five employees (Employees 1, 2, 3, 4, and 5) Residents Affected - Some Findings include: Review of facility policy, titled Abuse Prohibition, revised October 24, 2022, revealed, The center will screen potential employees for a history of abuse, neglect, or mistreating patients including attempting to obtain information from previous employers and/or current employers for new employees, and checking with the appropriate licensing boards and registries. Review of Employee file for Employee 1 revealed a date of hire of July 18, 2023. Further review of the employee file failed to reveal attempt to obtain information from previous employers and/or current employers. Review of Employee file for Employee 2 revealed a date of hire of August 1, 2023. Further review of the employee file failed to reveal attempt to obtain information from previous employers and/or current employers. Review of Employee file for Employee 3 revealed a date of hire of August 8, 2023. Further review of the employee file failed to reveal attempt to obtain information from previous employers and/or current employers. Review of Employee file for Employee 4 revealed a date of hire of July 18, 2023. Further review of the employee file failed to reveal attempt to obtain information from previous employers and/or current employers. Review of Employee file for Employee 5 revealed a date of hire of June 27, 2023. Further review of the employee file failed to reveal attempt to obtain information from previous employers and/or current employers. Interview with Nursing Home Administrator on August 30, 2023, at 11:30 AM, revealed that the facility did not have any documentation of attempting to obtain information from previous and/or current employees for Employees 1, 2, 3, 4, or 5 prior to them starting to work at the facility. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 2 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 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 the resident assessment accurately reflected the resident status for five of 28 residents reviewed (Resident 8, 23, 76, 100, and 113). Residents Affected - Some Findings Include: Review of Resident 8's clinical record revealed diagnoses that included depression (feelings of severe despondency and dejection), psychosis (a mental disorder characterized by a disconnection from reality), and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 8's physician's orders revealed orders for mirtazapine tablet 7.5 milligrams give 7.5 mg by mouth at bedtime for depression, dated January 19, 2022, and quetiapine (Seroquel) oral tablet 25 milligrams give 12.5 milligrams by mouth at bedtime for Psychosis, dated April 7, 2023. Review of Resident 8's psychiatry progress notes revealed a note dated May 3, 2023, which indicated that a gradual dose reduction was not clinically advisable as benefits outweigh risks; recently stabilized mood. Previously resident with verbal aggression and occasional depressive thoughts, now resolved. Review of Resident 8's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of May 30, 2023, indicated in Section N Medications that the date the physician last documented that a gradual dose reduction was clinically contraindicated was December 23, 2022. During an interview with the Director of Nursing (DON) on August 31, 2023, at 10:42 AM, the aforementioned MDS coding concern was shared. She indicated that she would follow-up with the Registered Nurse Assessment Coordinator (RNAC). During a follow-up interview with the DON on August 31, 2023, at 1:10 PM, she indicated that the RNAC had said that she had missed the psychiatry note dated May 3, 2023, or that it may not have been on the chart when she completed the MDS; which documented the clinical contraindication for a gradual dose reduction. The DON confirmed that she would expect the MDS to have been coded accurately. Review of Resident 23's clinical record revealed diagnoses that included fracture of the lower end of the right femur (bone located in the thigh), muscle weakness, and hypertension (high blood pressure). Review of Resident 23's clinical record progress notes revealed the following: on May 2, 2023, at 3:41 PM, the Resident had returned from an outside appointment and, during the transfer of the Resident from the litter to their bed, the Resident fell from the litter onto the floor; on May 2, 2023, at 10:50 PM, the Resident was experiencing increased right knee pain and that an x-ray had been ordered after a telehealth urgent care visit; and on May 3, 2023, at 7:57 AM, the facility received the x-ray results that indicated that Resident 23 had an acute appearing femoral fracture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 3 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0641 Level of Harm - Minimal harm or potential for actual harm Review of Resident 23's Significant Change MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date of May 18, 2023, indicated in Section J Health Conditions that the Resident was documented as having no falls; which, therefore, also disabled the question regarding a major injury from a fall since the last assessment was completed. Residents Affected - Some During an interview with the DON on August 30, 2023, at 10:39 AM, the aforementioned MDS coding concern was shared. The DON indicated that she would have the RNAC look at it and provide follow-up information. During an interview with Employee 13 (RNAC) on August 30, 2023, at 1:40 PM, she confirmed that the fall with major injury should have been coded on the MDS and that a modification would be completed. During a follow-up interview with the Nursing Home Administrator (NHA) and the DON on August 30, 2023, at 1:58 PM, they both confirmed that they would expect the MDS to have been coded accurately for the fall with major injury. Review of Resident 76's clinical record revealed diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), depression (feelings of severe despondency and dejection), and osteoarthritis (degeneration of joint cartilage and the underlying bone, causing pain and stiffness especially in the hip, knee, and thumb joints) of the right shoulder. Review of Resident 76's physician orders revealed the following orders: apixaban tablet 5 milligrams (mg) give one tablet by mouth two times a day for deep vein thrombosis (blood clot) prophylaxis, dated March 4, 2022; sertraline hydrochloride tablet 50 milligrams (mg) give 50 mg by mouth at bedtime for depression, dated April 25, 2023; and tramadol hydrochloride tablet 50 milligrams (mg) Give 50 mg by mouth three times a day for pain for pain to right shoulder/arm, dated September 12, 2022. Review of Resident 76's Quarterly MDS with the assessment reference date of June 23, 2023, indicated in Section N Medications that, in the look back period, Resident 76 had received an anticoagulant for six days, an antidepressant for seven days, and an opioid for seven days. Review of Resident 76's June Medication Administration Record revealed that they had received the anticoagulant for seven days, the antidepressant for six days, and the opioid for six days. The aforementioned coding concerns were shared with Employee 13 on August 30, 2023, at 1:40 PM, for review and follow-up. During a follow-up interview with the DON on August 31, 2023, at 10:43 AM, it was noted that a modification had been completed to code the medications accurately for Resident 76's on their Quarterly MDS with an ARD of June 23, 2023. The DON confirmed that she would expect the MDS to have been coded accurately. Review of Resident 100's clinical record on August 28, 2023, revealed diagnoses that included end stage renal disease (ESRD- loss of kidney function), dependence on renal dialysis (a machine filters wastes, salts, and fluid from your blood when kidneys can no longer perform these functions naturally), and hypertension. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 4 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 100's physician orders revealed an order for HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro- an injection medication) four times a day for T2DM (T2DM- Type 2 diabetes mellitusdecreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells). Review of Resident 100's medical record revealed a physician note from May 1, 2023, that stated, Assessment: 3. Diabetes Mellitus Review of Resident 100's admission MDS with ARD of May 6, 2023, under Section O. Special Treatments, Procedures and Programs, revealed Resident 100 was marked no, indicating the Resident doesn't receive dialysis. Further review of Resident 100's admission MDS with ARD of May 6, 2023, under Section I: Active Diagnoses, subsection I2900, revealed Resident 100 was marked no for a diagnosis of diabetes mellitus. Review of Resident 100's Quarterly MDS with ARD of July 10, 2023, under Section O. Special Treatments, Procedures and Programs, revealed that Resident 100 was marked no, indicating the Resident doesn't receive dialysis. Further review of Resident 100's Quarterly MDS with ARD of July 10, 2023, under Section I: Active Diagnoses, subsection I2900, revealed Resident 100 was marked no for a diagnosis of diabetes mellitus. Review of Resident 100's Quarterly MDS with ARD of August 4, 2023, under Section O. Special Treatments, Procedures and Programs revealed that Resident 100 was marked no, indicating the Resident doesn't receive dialysis. Further review of Resident 100's Quarterly MDS with ARD of August 4, 2023, under Section I: Active Diagnoses, subsection I2900, revealed Resident 100 was marked no for a diagnosis of diabetes mellitus. Interview with DON on August 31, 2023, at 9:10 AM, revealed all three of Resident 100's MDS assessments were coded in error for dialysis and diabetes mellitus, and that she would expect resident assessments to be coded accurately. Review of Resident 113's clinical record on August 28, 2023, revealed diagnoses that included Unspecified protein calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets) and hypertension. Review of Resident 113's medical record revealed a nutrition note dated August 8, 2023, that stated, Resident admitted to [NAME] Hospice services for protein calorie malnutrition on 7/21/23. Review of Resident 113's Significant Change MDS with ARD of August 3, 2023, under Section I: Active Diagnoses, subsection I5600, revealed Resident 113 was marked no for a diagnosis of malnutrition. Interview with DON on August 30, 2023, at 10:17 AM, revealed she would expect Resident 113's Significant Change MDS to be coded for malnutrition. 28 Pa. Code 211.5(f) Clinical records (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 5 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0641 28 Pa. Code 211.12(d)(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: 395746 If continuation sheet Page 6 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for one of 30 residents reviewed (Resident 29) Findings include: Review of Resident 29's clinical record revealed that Resident 29 was readmitted to the facility on [DATE]. Resident 29's clinical record revealed diagnoses that included depression (feelings of severe despondency and dejection), mood disorder (a disorder in which your general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your body's ability to function), and anxiety (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Further review of Resident 29's clinical record revealed physician orders for: lorazepam oral tablet 0.5 milligrams give one tablet by mouth two times a day for anxiety, dated April 5, 2023; venlafaxine hydrochloride extended release oral tablet 150 milligrams give 150 mg by mouth two times a day for Major Depressive Disorder, dated April 5, 2023; and olanzapine oral tablet 5 milligrams give 5 mg by mouth at bedtime for Major Depressive Disorder, dated April 5, 2023. Review of Resident 29's clinical record revealed the baseline care plan for admission on [DATE], failed to reflect their mood and behavior concerns with the use of the antidepressant and antianxiety medication. This section was blank, with no concerns or interventions marked. During an interview with the Director of Nursing on August 31, 2023, at 8:55 AM, she indicated that the Resident's baseline care plan should have included her mood/behavior concerns since she was admitted with the diagnoses and was on the medications a time of admission to the facility. 28 Pa. Code 211.11(c) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 7 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, clinical record review, facility policy review, and staff and resident interviews, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's current care needs for four of 28 residents reviewed (Resident 1, 7, 38, and 80). Findings include: Review of the facility's Care Plan policy, with a revision date of September 24, 2022, under the section Updating and Revising the Care Plan: Including Resolving and Un-resolving the Focus, Goals, and Interventions, reveals that Care plans will be updated and revised as needed. Review of Resident 1's clinical record revealed diagnoses that included acute kidney failure (when your kidneys suddenly stop working) and hypertension (high blood pressure). Review of Resident 1's current physician orders revealed an order for the following: Apply [NAME] hose Q (every) AM and remove Q PM for increased edema, with an active date of July 30, 2023. Review of Resident 1's care plan (information pertaining to a resident's psychosocial, physical, and care needs) failed to include a focus area or intervention pertaining to edema or ted hose. Interview with the Director of Nursing (DON) on August 31, 2023, at 12:32 PM, revealed that they would expect edema and ted hose to be on Resident 1's care plan. Review of Resident 7's clinical record revealed a diagnoses that included chronic kidney disease (CKD - a condition in which the kidneys are damaged and cannot filter blood as well as they should) and major depressive disorder (a mental health disorder characterized by persistently depressed mood loss of interest in activities, causing significant impairment of daily life). Review of Resident 7's current physician orders revealed an order for the following: Oxygen at 2 liters per minute via NC (nasal cannula) to keep pox (pulse oximeters and oxygen saturation) above 90%, with an active date of August 3, 2023. Review of Resident 7's care plan failed to include a focus area or intervention pertaining to oxygen. Interview with DON on August 31, 2023, at 9:12 AM, revealed that they would expect Resident 7's oxygen use to have been added to the care plan. Review of Resident 38's care plan revealed diagnoses that included obstructive sleep apnea (a sleep-related breathing disorder that causes repeated disruptions in breathing during sleep), pressure ulcer of sacral region (wound that occurs when the skin and tissue are damaged by prolonged pressure), and hypertension. Review or Resident 38's physician orders revealed an order for: Apply CPAP (a type of oxygen mask) at bedtime for sleep apnea, discontinued on April 1, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 8 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0657 Further review of Resident 38's physician orders revealed no active orders for oxygen. Level of Harm - Minimal harm or potential for actual harm Review of Resident 38's clinical record revealed a medical practitioner note on June 1, 2023, that was the most recent date in Resident 38's medical record noting use of oxygen. Residents Affected - Some Observation in Resident 38's room on August 29, 2023, at 9:17 AM, revealed she was not currently on oxygen and her room did not contain any oxygen supplies. During an interview with Resident 38 on August 29, 2023, at 9:17 AM, she stated she hasn't been on oxygen for quite a while. Review of Resident 38's resident care plan revealed a focus area: the Resident has altered respiratory status related to need for oxygen and BiPAP (a type of oxygen mask), initiated April 7, 2023, without revision, with an intervention for provide oxygen as ordered, initiated April 7, 2023, without revision. Interview with the DON on August 29, 2023, at 10:17 AM, revealed she would expect Resident 38's care plan for oxygen to be resolved. Review of Resident 80's clinical record revealed the following diagnoses that included anemia (lack of blood) and peripheral vascular disease (a slow and progressive circulation disorder). Review of Resident 80's comprehensive care plan revealed a focus area of: Resident shows potential for discharge and Resident relative or representative expresses wish for discharge, with a revision date of June 12, 2023. Resident 80's care plan also revealed the following focus area of: Resident does not show potential for discharge to the community, with a revision date of August 24, 2023. Interview with the DON on August 30, 2023, at 2:31 PM, revealed that Resident 80 should only have one discharge care plan. Interview with DON on August 31, 2023, at 9:12 AM, revealed that Resident 80's care plan has been updated to indicate Resident 80 does not show potential for discharge to the community. 28 Pa. Code 211.11(d) Resident Care Plan FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 9 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, facility policy review, and resident and staff interviews, it was determined that the facility failed to provide care and services regarding showering for three of 30 residents reviewed (Residents 22, 34, and 105). Residents Affected - Few Findings Include: Review of facility policy, titled Activities of Daily Living (ADLs), Supporting, revised May 1, 2023, revealed, Documentation of ADL care is recorded in the medical record and is reflective of the care provided by nursing staff. Review of Resident 22's clinical record revealed diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). During an interview with Resident 22 on August 28, 2023, at 10:54 AM, Resident 22 stated that he is scheduled for showers twice a week, but that he doesn't always get them. Review of Resident 22's curent care plan revealed a care plan dated January 11, 2023, for ADL self-care deficit related to physical limitations, with interventions to assist with bathe/shower, as needed, and transfer with mechanical lift. Review of Resident 22's clinical record revealed he is scheduled for showers on Wednesday evenings and Saturday evenings. Review of Resident 22's shower documentation for the past 30 days, on Wednesdays, revealed on August 16, 2023, Resident 22's shower documentation is documented as not applicable; and there was no documentation that Resident 22 received a shower on August 30, 2023. Review of Resident 22's shower documentation for the past 30 days, on Saturdays, revealed no documentation that Resident 22 received a shower on August 5, 2023. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 30, 2023, at 2:22 PM, when asked about Resident 22 missing showers, the DON acknowledged that there has been staffing issues over the past two to four weeks, especially during the weekends. Review of Resident 34's clinical record revealed diagnoses that included end stage renal disease (occurs when the kidneys are no longer able to work at a level needed for day-to-day life) and peripheral vascular disease (a slow and progressive circulation disorder). Review of Resident 34's current care plan dated August 29, 2023, revealed a focus area of: ADL Self-care deficit related to ESRD, with a revision date of April 13, 2023. Further review revealed an intervention of: Assist to bathe/shower as needed, with a revision date of November 4, 2020. Review of Resident 34's electronic medical record on August 26, 2023, revealed that the Resident received a bed bath and not a shower that day. Interview with Resident 34 on August 28, 2023, at 11:30 AM, revealed that when Resident 34 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 10 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0677 Level of Harm - Minimal harm or potential for actual harm requested a shower on August 26, 2023, she was told by a staff member that it would not be possible to have a shower because there was not enough staff and that she would have to take a bed bath. Interview with the DON on August 30, 2023, at 2:19 PM, revealed that they have been having staffing problems the previous three weeks, and that Resident 34 should have received a shower. Residents Affected - Few Review of Resident 105's clinical record revealed diagnoses that included Type 2 Diabetes Mellitus and anxiety disorder. Review of Resident 105's current care plan revealed Resident 105 had a care plan dated September 8, 2023, for ADL self-care deficit related to physical limitations and requires transfers with a mechanical lift. Further review of Resident 105's clinical record revealed Resident 105 is scheduled for showers during the day on Tuesdays and Fridays. On August 30, 2023, at 12:03 PM, Resident 105's shower documentation for the past 30 days, on Tuesdays, was reviewed. There was no documentation of Resident 105 receiving a shower on August 15 or 29, 2023. During an interview with Employee 8 on August 30, 2023, at 11:44 AM, Employee 8 confirmed that Resident 105 was not showered on August 29, 2023. During an interview with the NHA and DON on August 30, 2023, at 2:22 PM, when asked about Resident 105 missing showers, the DON acknowledged that there has been staffing issues over the past two to four weeks, especially during the weekends. 28 Pa code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 11 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders and care plan for three of 28 residents reviewed (Resident 1, 38, and 48). Residents Affected - Some Findings include: Review of Resident 1's clinical record revealed diagnoses that included acute kidney failure (when your kidneys suddenly stop working) and hypertension (high blood pressure). Review of Resident 1's current physician orders revealed an order for the following: Apply [NAME] hose Q (every) AM and remove Q PM for increased edema, with an active date of July 30, 2023. Review of Resident 1's August TAR (treatment administration record) revealed 15 days in August 2023 that Resident 1 did not have a ted hose administered. The following dates were left blank: August 7, 19, 20, and 26, 2023. The following dates were marked '9', which means 'other/see nurses notes': August 6, 8, 9, 10, 11, 12, 21, 22, 23, and 25, 2023. Review of Resident 1's progress notes on August 5, 2023, revealed documentation that LPN (Licensed Practical Nurse) could not find the other leg. Review of progress notes on August 7, 2023, revealed documentation that a staff member accidentally placed it in laundry. Review of progress notes on August 9, 2023, revealed the LPN could not find the Resident ted hose. Review of Resident 1's progress notes on August 10, 2023, revealed that they were awaiting ted stocking from ancillary, and it had to be reordered. Review of Resident 1's progress notes on August 11, 2023, revealed documentation that they could not find ted hose. Review of progress notes on August 12, 2023, revealed documentation that stated, 'no better fit ted hose'. Review of Resident 1's progress notes on August 13, 2023, revealed documentation that they were waiting for a new pair of ted hose for Resident 1. Review of progress notes on August 22, 2023, indicated that Resident 1 was 'sleeping longer'. Review of progress notes on August 23, 2023, indicated that Resident 1 was resting quietly in bed and was not ready to get up for the day. Review of progress notes on August 24, 2023, and August 26, 2023, revealed that Resident 1 was not getting up from bed yet. The following dates failed to indicate any progress notes pertaining to why Resident 1 did not have ted hose administered: August 6, 8, 21, and 25, 2023. Interview with the Director of Nursing (DON) on August 31, 2023, at 12:34 PM, revealed that she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 12 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0684 would expect physician orders to be followed. Level of Harm - Minimal harm or potential for actual harm Review of Resident 38's care plan revealed diagnoses that included neurogenic bowel (a condition that affects the normal function of the bowel due to a problem with the nerves), pressure ulcer of sacral region (wound that occurs when the skin and tissue are damaged by prolonged pressure), and hypertension. Residents Affected - Some Review of Resident 38's physician orders revealed an order for Skilled Charting: Colostomy [an opening in the large intestine], Document within a skilled note every shift, with a start date of July 26, 2023. Review of Resident 38's care plan revealed a focus area: Bowel- Ostomy, initiated April 7, 2023, with an intervention for change ostomy appliance as needed, initiated April 7, 2023. Interview with the DON on August 30, 2023, at 2:05 PM, revealed she would expect physician orders to be in place for changing Resident 38's colostomy bag, and that orders were now in place to change Resident 38's colostomy bag every three days and as needed. Review of Resident 48's clinical record on August 28, 2023, revealed diagnoses that included benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland) and hypertension. Review of Resident 48's medical record revealed a physician progress note, with an effective date of August 14, 2023, that stated Patient's Foley catheter dislodged .Will check post-void residual. Review of Resident 48's physician orders revealed an order for check post-void residual (urine remaining in bladder after urine output) Q (Q-every) shift. Notify provider if above 300 every shift for urinary retention for seven days, obtain post-void (urination), with a start date of August 15, 2023, and completed August 22, 2023. Review of Resident 48's TAR (Treatment Administration Record- documentation for treatments/medication administered or monitored), revealed no documentation to indicate post-void residual was assessed or documented on August 18, 2023, on the 3-11 shift; and August 16 and 17, 2023, on the 11-7 shift. Interview with the DON on August 30, 2023, at 02:11 PM, revealed she does not have any information to provide about why there is missing documentation in the order to check residual, and she would expect care and documentation to be completed per physician order. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 13 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 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. Based on clinical record review and staff interview, it was determined that the facility failed to evaluate for and implement interventions to prevent future accidents for two of four residents reviewed for falls (Residents 61 and 81). Findings include: Review of the clinical record for Resident 61 revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking and behavior) and abnormalities of gait and mobility. Review of nursing progress notes and incident report dated August 5, 2023, revealed that Resident 61 experienced an unwitnessed fall on that date that resulted in a nasal bone fracture and facial lacerations that required suturing. Review of Resident 61's care plan revealed a focus area: at risk for falls due to history of falls with a single intervention of therapy evaluation and treatment per orders. This care plan and intervention were effective August 1, 2023. Further review of Resident 61's clinical record failed to reveal evidence that the fall that occurred on August 5, 2023, was thoroughly investigated to determine root cause, that new interventions were implemented to prevent future falls, or that Resident 61's care plan was updated with these new interventions. Review of Resident 81's clinical record revealed diagnoses that included vascular dementia with behavioral disturbance (condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain that causes problems with reasoning, planning, judgment, and memory) and repeated falls. Review of nursing progress notes and incident reports revealed that Resident 81 experienced unwitnessed falls on July 23, 2023, and August 1 and 5, 2023. Further review of Resident 81's clinical record failed to reveal any documented evidence that the aforementioned falls were thoroughly investigated to determine root cause, that new interventions were evaluated to prevent future falls, or that Resident 81's care plan was updated with any new interventions. During an interview with the Director of Nursing on August 31, 2023, at 1:29 PM, she revealed that she could not locate any documentation to show the aforementioned falls for Resident 61 and 81 were reviewed or that their care plans were updated to reflect any applicable new interventions to prevent future falls. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 14 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to precisely and effectively monitor nutritional status consistent with professional standards of practice for one of 28 residents reviewed (Resident 113). Residents Affected - Few Findings include: Review of facility policy, titled Procedure: Weights and Heights last revised February 1, 2023, revealed admissions and re-admissions will be weighed within 24 hours of admission, and weights should be entered into the weights/vital signs module on the shift obtained. Review of Resident 113's clinical record on August 28, 2023, revealed diagnoses that included Unspecified protein calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets), pressure ulcer of sacral region (wound that occurs when the skin and tissue are damaged by prolonged pressure), and hypertension. Review of Resident 113's medical record revealed she was admitted to the facility on [DATE], was discharged to the hospital on June 21, 2023, and then returned to the facility from the hospital on June 27, 2023. Review of Resident 113's weight measures revealed Resident 113 weighed 143 pounds (unit of measure) on May 22, 2023, and did not have any documentation of another weight afterward until she was weighed on July 3, 2023, at 111 pounds. Interview with the Director of Nursing (DON) on August 30, 2023 at 2:08 PM, revealed it is the facility's process to weight residents upon admission and monitor weights once a week for four weeks, and then monthly unless otherwise specified. Review of Resident 113's [NAME] (an area of the clinical record for nurse aide documentation), revealed a section for Weight: DOC (document) Weekly Days, with no documentation to indicate Resident 113's weight was obtained or refused on May 29, 2023; June 5 and 12, 2023; and documentation of a refused weight measure June 19, 2023. Interview with Employee 14 (Registered Nurse) on August 31, 2023, at 10:34 AM, revealed Resident 113's [NAME] indicated she should have been weighed weekly and, if she refused her weight measure, it should have been documented. Further review of Resident 113's [NAME] revealed during the month of June 2023, Resident 113 was documented to have eaten 25 percent (unit of measure) or less of her meal and the alternate meal provided on June 1, 2, 4, 5, 8, 9, 12, 15, and 21, 2023, at breakfast; June 1, 3, 4, 5, 8, and 12, 2023, at lunch; and June 3, 4, 5, 8, 10, 13, and 20, 2023, at dinner. Interview with Employee 7 (Dietitian) on August 31, 2023 at 1:07 PM, revealed it is the facility's process to obtain weekly weights for four weeks upon admission, and she is notified by staff when residents refuse weight measures. Employee 7 stated she runs a report between the 6th and the 8th of each month to let nursing know of any weights need to be obtained; she then puts the report with the missing weights still needed in the conference room and discusses them with unit managers and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 15 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DON, two to three times per week. Employee 7 said she asked for a June 2023 weight measure each week for Resident 113 until she went out to the hospital on June 21, 2023, in which she marked her down for needing a readmission weight upon readmission to the facility. Employee 7 stated she was not made aware of any refused weight measures of Resident 113 during June. Employee 7 further revealed if a resident has a poor appetite and intake for more than a few meals, it is the facility's expectation that the dietitian is notified for a consult. Employee 7 stated she was never consulted about Resident 113's poor appetite and intake during the month of June 2023. Interview with the DON on August 31, 2023 at 1:34 PM, revealed she would expect the facility weight policy to be followed, weekly weights to be obtained and documented or documented that the resident refused a weight if applicable, and it is the facility's expectation the dietitian should be notified of weight refusals and declines in meal intakes. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 16 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for three of six residents reviewed for oxygen (Residents 22, 29, and 30). Residents Affected - Few Findings include: Review of facility policy, titled Procedure: Oxygen: Aerosol/Tracheostomy Mask/Collar, revised August 7, 2023, revealed, Provide oxygen source in room according to equipment specific procedure, if ordered .Replace entire set-up every seven days. Store in treatment bag when not in use. Review of Resident 22's clinical record revealed diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). Observation of Resident 22 on August 28, 2023, at 10:54 AM, and on August 29, 2023, at 12:12 PM, revealed Resident 22 wearing oxygen. Observations on those dates and times revealed that neither Resident 22's oxygen tubing nor the oxygen humidification bottle were labeled or dated. Review of Resident 22's clinical record revealed no physician orders to change the oxygen tubing and no documentation that Resident 22's oxygen tubing and/or humidification bottle are being changed. During an interview with the Director of Nursing (DON) on August 30, 2023, at 10:31 AM, she stated that oxygen tubing is to be changed on Sundays. Review of facility policy, titled Nebulizer: Small Volume with a last revision date of July 15, 2021, indicated, 21. Rinse SVN (small volume nebulizer), mouthpiece, and T-Piece with sterile water and dry. 21.1 Place in treatment bag labeled with patient name and date. 21.2 Replace and date the set-up daily. Review of Resident 29's clinical record revealed diagnoses that included chronic respiratory failure with hypoxia (condition that occurs when the lungs cannot get enough oxygen into the blood); chronic obstructive pulmonary disease (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations), and mild intermittent asthma (condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus which makes it difficult to breathe). Observations of Resident 29 on August 28, 2023, at 11:56 AM, and August 29, 2023, at 9:40 AM, revealed that the tubing to their nebulizer treatment was not dated, the medication chamber was still attached to the mouthpiece, and that the mouthpiece was laying directly on their nightstand. Review of Resident 29's clinical record revealed the following orders: Arformoterol Tartrate Inhalation Nebulization Solution 15 micrograms/ 2 milliliters (ml) 2 ml inhale orally via nebulizer two times a day for COPD, dated April 5, 2023; and Budesonide Inhalation Suspension 0.5 milligrams/ 2 milliliters(ml) 2 ml inhale orally two times a day for COPD, dated April 5, 2023. There were no orders noted for the dating, changing, or bagging of the nebulizer treatment. Observations were shared with the Nursing Home Administrator (NHA) and DON on August 29, 2023, at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 17 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0695 11:53 AM, for further follow-up. Level of Harm - Minimal harm or potential for actual harm During an interview with the NHA and DON on August 30, 2023, at 10:51 AM, the DON confirmed that the nebulizer treatment tubing should have been dated and bagged as indicated in the facility policy. She also indicated that the orders had been updated to reflect this. Residents Affected - Few Review of Resident 30's clinical record revealed diagnoses that included chronic obstructive pulmonary disease, pulmonary embolism (a blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream), and type 2 diabetes mellitus. Review of Resident 30's physician orders revealed an order for Monitor Oxygen at 2 LPM (liters per minuteunit of measure) via N/C (nasal cannula- medical device used for oxygen delivery) continuously every shift, with a start date June 8, 2023. Review of Resident 30's care plan revealed a focus area: The resident has altered respiratory status/Difficulty Breathing related to chronic respiratory insufficiency and continuous oxygen use, initiated June 8, 2023, with interventions for Provide oxygen as ordered, initiated June 8, 2023, and Offer bi-pap (oxygen mask) for napping and at bedtime, initiated June 12, 2023. Observation in Resident 30's room on August 28, 2023, at 11:04 AM, revealed oxygen was running at 5 liters, oxygen tubing was not dated, and a BiPAP mask was face down on nightstand, not bagged or dated. Observation in Resident 30's room on August 29, 2023, at 9:02 AM, revealed oxygen was running at 5 liters, oxygen tubing was not dated, and a BiPAP mask was face down on nightstand, not bagged or dated. During an interview with the DON on August 29, 2023 at 10:15 AM, when the surveyor revealed the concerns with Resident 30's oxygen, the DON revealed oxygen tubing should be changed weekly on Sundays and dated when changed. Observation on August 30, 2023, at 9:17 AM, revealed the oxygen tubing was dated August 29, and the BiPAP mask was bagged and placed on dresser. Interview with the DON on August 30, 2023 at 11:45 AM, revealed it is the facility's expectation for oxygen to be running per physician order, BiPAP masks to be cleaned and bagged when not in use, and oxygen tubing to be dated and changed weekly. 28 Pa. Code 211.12(d)(1)(2)(3)(5)Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 18 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 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 clinical record review and staff interviews, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice and the comprehensive person-centered care plan for one of 28 residents reviewed (Resident 100). Residents Affected - Few Findings include: Review of Resident 100's clinical record on August 28, 2023, revealed diagnoses that included end stage renal disease (ESRD- loss of kidney function), dependence on renal dialysis (a machine filters wastes, salts, and fluid from your blood when kidneys can no longer perform these functions naturally), and hypertension (high blood pressure). Review of Resident 100's physician orders revealed an order for: Dialysis site observation every shift and as needed every shift for monitoring, with a start date of April 30, 2023. Review of Resident 100's TAR (Treatment Administration Record- documentation for treatments/medication administered or monitored), revealed no documentation to indicate Resident 100's dialysis site was observed on June 21, 2023, July 14, 2023, and August 11, 2023, on day shift; June 12, 2023, July 24, 2023, and August 18, 2023, on evening shift; and July 3 and 18, 2023, and August 11, 2023, on night shift. Interview with the Director of Nursing (DON) on August 30, 2023, at 10:19 AM, revealed she would expect physician orders to be followed and documentation to be complete. Review of Resident 100's care plan revealed a focus area of: The resident needs dialysis hemodialysis related to ESRD, last revised July 5, 2023, with an intervention for: Do not draw blood or take blood pressure in arm with graft left arm, initiated July 3, 2023. Review of Resident 100's medical record revealed documentation that blood pressures were taken in Resident 100's right arm on July 5, 7, 14, 16, 19, and 29, 2023; and August 6, 7, 12, 13, 23, 25, and 28, 2023. Interview with the DON on August 30, 2023, at 10:21 AM, revealed she would expect blood pressure measures not to be taken or documented in Resident 100's left arm related to his dialysis access. 28 Pa Code 211.5(f) Clinical records 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 19 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on resident and staff interviews, facility documents review, and facility policy review, the facility failed to ensure the facility had sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services for three of 30 residents reviewed (Residents 22, 34, and 105). Findings Include: Review of facility policy, titled Activities of Daily Living (ADLs), Supporting, revised May 1, 2023, revealed, Documentation of ADL care is recorded in the medical record and is reflective of the care provided by nursing staff. Review of Resident 22's clinical record revealed diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). During an interview with Resident 22 on August 28, 2023, at 10:54 AM, Resident 22 stated that he is scheduled for showers twice a week, but that he doesn't always get them. He stated that he is told that there is not enough staff to assist him with his showers. Review of Resident 22's clinical record revealed he is scheduled for showers on Wednesday evenings and Saturday evenings. Review of Resident 22's shower documentation for the past 30 days, on Wednesdays, revealed on August 16, 2023, Resident 22's shower documentation is documented as not applicable; and there is no documentation that Resident 22 received a shower on August 30, 2023. Review of Resident 22's shower documentation for the past 30 days, on Saturdays, revealed no documentation that Resident 22 received a shower on August 5, 2023. During an interview with Employee 8 on August 30, 2023, at 11:44 AM, Employee 8 could not say for certain that Resident 22 missed showers due to staffing, but stated that other residents have missed showers because there isn't enough help to assist. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 30, 2023, at 2:22 PM, when asked about Resident 22 missing showers, the DON acknowledged that there has been staffing issues over the past two to four weeks, especially during the weekends. Review of Resident 34's clinical record revealed diagnoses that included end stage renal disease (occurs when the kidneys are no longer able to work at a level needed for day-to-day life) and peripheral vascular disease (a slow and progressive circulation disorder). Review of Resident 34's current care plan, dated August 29, 2023, revealed a focus area of: ADL Self-care deficit related to ESRD, with a revision date of April 13, 2023. Further review revealed an intervention of: Assist to bathe/shower as needed, with a revision date of November 4, 2020. Review of Resident 34's electronic medical record on August 26, 2023, revealed that the Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 20 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0725 received a bed bath and not a shower that day. Level of Harm - Minimal harm or potential for actual harm Interview with Resident 34 on August 28, 2023, at 11:30 AM, revealed that when Resident 34 requested a shower on August 26, 2023, she was told by a staff member that it would not be possible to have a shower because there was not enough staff and that she would have to take a bed bath. Residents Affected - Some Interview with the DON on August 30, 2023, at 2:19 PM, revealed that they have been having staffing problems the previous three weeks, and that Resident 34 should have received a shower. Review of Resident 105's clinical record revealed diagnoses that included Type 2 Diabetes Mellitus and anxiety disorder. Further review of Resident 105's clinical record revealed Resident 105 is scheduled for showers during the day on Tuesdays and Fridays. On August 30, 2023, at 12:03 PM, Resident 105's shower documentation for the past 30 days, on Tuesdays, was reviewed. There was no documentation of Resident 105 receiving a shower on August 15 or 29, 2023. During an interview with Employee 8 on August 30, 2023, at 11:44 AM, Employee 8 confirmed that Resident 105 was not showered on August 29, 2023. Employee 8 stated there was not enough staff to assist Resident 105 to shower on his scheduled shower day on August 29, 2023. During an interview with the NHA and DON on August 30, 2023, at 2:22 PM, when asked about Resident 105 missing showers, the DON acknowledged that there has been staffing issues over the past two to four weeks, especially during the weekends. 28 Pa code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 21 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually and that in-service education was provided based on the outcome of these reviews for two of five nurse aides reviewed (Employees 9 and 10). Residents Affected - Few Findings Include: Review of select facility documentation revealed that Employee 9 was hired on June 13, 1995, and Employee 10 was hired on July 22, 1994. Review of employee performance evaluations for Employees 9 and 10 revealed that one was completed on June 15, 2022, for Employee 9, and one was completed on March 15, 2022, for Employee 10. During an interview with the Director of Nursing on August 31, 2023, at 1:27 PM, she confirmed that no additional performance evaluations were completed within the prior 12 months for either Employee 9 or 10. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 22 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to manage the final disposition of controlled substances for one of two closed records reviewed (Resident 122). Findings Include: Review of facility policy, titled Disposal/Destruction of Expired or Discontinued Medication, revised [DATE], revealed, Controlled substances may not be returned to the Pharmacy, unless refused at the time of the delivery Facility should destroy controlled substances in the presence of a registered nurse and a licensed professional or in accordance with Facility policy or Applicable Law. Destruction of controlled medications should be documented on the controlled medication count sheet and signed by the registered nurse and witnessing licensed professional who should record: Quantity destroyed; Date of destruction; and Signature of registered nurse and Licensed professional. Review of Resident 122's clinical record revealed Resident 122 passed away on [DATE]. Review of Resident 122's physician orders at the time of death included an active order for Morphine Sulfate 5 mg (opiate/controlled substance) every four hours for comfort. Further review of Resident 122's clinical record revealed no evidence of any final disposition of the controlled substance to show how much of the medication remained, if any, or whether the remaining medication was destroyed in the presence of two licensed staff members. During an interview with the Director of Nursing on [DATE], at 1:27 PM, she revealed that she was unable to locate documentation of this medication disposition. 28 Pa. Code 211.9(j.1)(3)(4) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 23 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observations and staff interviews, it was determined that the facility failed to provide food at portion sizes to meet the nutritional needs of residents and ensure the menu was followed for one of one meal observed (lunch meal, August 30, 2023). Findings include: Review of the menu and diet extension sheet (menu items based on individual diets) for August 30, 2023, lunch meal, revealed the pureed diet texture should be served a 4 ounce (unit of measure) portion of mixed vegetables and sweet potatoes. Observation of tray line on August 30, 2023, at 12:47 PM, revealed Employee 12 used a red handled scoop to serve puree mixed vegetables and pureed sweet potatoes. Interview with Employee 6 (Dietary Manager) on August 30, 2023 at 12:55 PM, revealed the scoop used on tray line for pureed sweet potatoes and pureed mixed vegetables were 2 ounce scoops. Observation of tray line meal service on August 30, 2023 at 12:31 PM, revealed the dietary department ran out of sweet potatoes after five meals were served for the Arcadia unit, the remaining resident's that were allowed the regular sweet potato side were served instant mashed potatoes. Observation of Employee 6 on August 30, 2023 at 12:31 PM, revealed Employee 6 prepping instant mashed potatoes. Employee 6 poured instant mashed potatoes directly out of the container without measuring into the pan and mixed them with hot water; no other ingredients were added. Review of facility recipe for mashed potatoes revealed milk and margarine should be added to the mashed potatoes. Interview with Employee 6 on August 30, 2023, at 1:08 PM, revealed he did not add margarine or milk to the mashed potatoes for the sake of time to get the food out. Interview with the Director of Nursing on August 31, 2023, at 2:11 PM, revealed it is the facility's expectation that food and beverages served to residents should be prepared following facility recipes and be served at appropriate portion sizes specified by the menu extension sheets. Pa code 211.6(a)(b) - Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 24 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility forms and menus, observations, completion of a meal test tray, and resident and staff interviews, it was determined that the facility failed to provide food and beverages that were at an appetizing appearance, flavor, and temperature. Residents Affected - Few Findings include: Review of facility document, titled Food and Nutrition Services Test Tray Evaluation, last revised May 1, 2023, revealed that hot food and beverages should be served above 140 degrees Fahrenheit (F - a unit of measure) and chilled food and beverages should be served at or below 55 degrees F. Multiple resident interviews on August 28, 2023, and August 30, 2023, revealed residents voiced concerns with the temperature, taste, and appearance of the food during meal service. During an interview with Resident 57 on August 28, 2023, at 10:12 AM, Resident 57 stated the food is not good and the temperature of the food is not hot enough for her. Interview with Resident 38 on August 28, 2023, at 10:19 AM, revealed the food is horrible and cold. Interview with Resident 423 on August 28, 2023, at 10:57 AM, revealed the food tastes bland like old TV dinners. Interview with Resident 69 on August 30, 2023, at 12:59 PM, revealed I didn't eat the chicken it was fried too dark. Observation of tray line meal service on August 30, 2023 at 12:09 PM, revealed the breading on the fried chicken was dark. A Test Tray was completed on August 30, 2023, at 1:06 PM, utilizing lunch tray served from tray line in the main facility kitchen. A test tray was served and placed in a closed food cart for approximately two minutes prior to being delivered to Arcadia dining room area (other trays for room service being delivered here also at that time). The Test Tray included: fried chicken, mashed potatoes, mixed vegetables, cornbread, pears, hot tea, and orange juice. Temperatures taken by Employee 6 revealed the following: fried chicken was 129 degrees F, not acceptable mashed potatoes were 139 degrees F, not acceptable mixed vegetables were 119 degrees F, not acceptable pears were 58.8 degrees F, not acceptable orange juice was 56.7 degrees F, not acceptable; and hot tea was 136.7 degrees F, not acceptable On August 30, 2023, at 1:06 PM, when the surveyor tasted the fried chicken, the chicken tasted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 25 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few overcooked and the breading tasted burnt; when the surveyor tasted the mashed potatoes they tasted bland. Observation of tray line meal service on August 30, 2023 at 12:31 PM, revealed the dietary department ran out of sweet potatoes after five meals were served for the Arcadia unit, the remaining resident's that were allowed the regular sweet potato side were served instant mashed potatoes. Observation of Employee 6 (Dietary Manager) on August 30, 2023 at 12:31 PM, revealed Employee 6 prepping instant mashed potatoes. Employee 6 poured instant mashed potatoes directly out of the container without measuring into a pan and mixed them with hot water; no other ingredients were added. Review of facility recipe for mashed potatoes revealed milk and margarine should be added to the mashed potatoes. Interview with Employee 6 on August 30, 2023, at 1:08 PM, revealed he did not add margarine or milk to the mashed potatoes for the sake of time to get the food out. Interview with the Director of Nursing on August 31, 2023, at 2:11 PM, revealed it is the facility's expectation that food and beverages served to residents should be prepared following facility recipes and be at appetizing appearance, flavor, and temperatures. 28 Pa. Code 211.6 (d) Dietary services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 26 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that the Quality Assurance Committee met quarterly for one of four quarters reviewed (fourth quarter 2022). Residents Affected - Few Findings include: Review of Quality Assurance Committee sign-in sheets revealed no evidence that the facility held a meeting during the fourth quarter of 2022 (October through December). During an interview with the Director of Nursing on August 31, 2023, at 11:40 AM, she confirmed that they were unable to locate information to verify a meeting was held during the aforementioned timeframe. 28 Pa. Code 201.14(a) Responsibility of licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 27 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that each resident's medical record includes documentation that indicates the resident or resident's representative was provided education regarding the benefits and potential side effects of the pneumococcal and influenza immunizations for five of five residents reviewed for immunizations (Residents 22, 23, 57, 95, and 105). Residents Affected - Some Findings Include: Review of facility policy, titled IC 601 Pneumococcal Vaccination, revised November 15, 2022, revealed, Provide the patient/representative education (Vaccine Information Statement [VIS]) regarding the benefits and potential side effects of vaccination. Answer any questions. Document education, including VIS .If patient/resident representative refuses pneumococcal vaccination, provide information and counseling regarding the benefit of vaccination (VIS). Document education . Review of facility policy, titled IC600 Influenza Immunization Program, revised May 1, 2023, revealed, If patient/health care decision maker or employee refuses influenza immunization, provide information and counseling regarding the benefit of immunization. If immunization refused, document patient's or decision maker's refusal of immunization and education and counseling given regarding the benefit of immunization . Review of Resident 22's clinical record revealed that Resident 22 refused both the pneumococcal vaccination and influenza vaccination. Further review of Resident 22's clinical record revealed no evidence that Resident 22 or Resident 22's Representative were educated on the benefits and potential side effects of the vaccinations. Review of Resident 23's clinical record revealed that Resident 23 refused the pneumococcal vaccination. Further review of Resident 23's clinical record revealed no evidence that Resident 23 or Resident 23's Representative were educated on the benefits and potential side effects of the vaccination. Review of Resident 57's clinical record revealed that Resident 57 refused the both the pneumococcal vaccination and influenza vaccination. Further review of Resident 57's clinical record revealed no evidence that Resident 57 or Resident 57's Representative were educated on the benefits and potential side effects of the vaccinations. Review of Resident 95's clinical record revealed that Resident 95 refused the pneumococcal vaccination. Further review of Resident 95's clinical record revealed no evidence that Resident 95 or Resident 95's Representative were educated on the benefits and potential side effects of the vaccination. Review of Resident 105's clinical record revealed that Resident 105 refused the influenza vaccination. Further review of Resident 105's clinical record revealed no evidence that Resident 105 or Resident 105's Representative were educated on the benefits and potential side effects of the vaccination. On August 31, 2023, at 10:31 AM, Employee 11 (Infection Preventionist) stated that she was unable to find evidence that the aforementioned Residents or their Representatives were provided education on the benefits and potential side effects of the immunizations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 28 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0883 Level of Harm - Minimal harm or potential for actual harm On August 31, 2023, at 11:38 AM, the Director of Nursing was made aware that there was no documented evidence of education for the aforementioned Residents who declined the pneumococcal and/or influenza vaccinations. No additional information was provided. 28 Pa. Code 201.14(a) Responsibility of licensee Residents Affected - Some 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 29 of 30 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 395746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Skilled Nursing and Rehabilitation Center 940 Walnut Bottom 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide evidence that education was provided to Residents on the risks and benefits of the COVID-19 vaccine for two of five residents reviewed for immunizations (Residents 22 and 23). Findings Include: Review of facility policy, titled IC604 COVID-19 Vaccination, revised June 30, 2023, revealed, Obtain consent. In situations where COVID-19 vaccination requires multiple doses, the patient/patient representative/employee/visiting HCP [Healthcare Provider] is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects associated with the COVID-19 vaccine before requesting consent for administration of any additional doses. Review of Resident 22's clinical record revealed that Resident 22 received doses one and two of the COVID-19 vaccination, and also received one booster dose. Further review revealed that Resident 22 refused additional COVID-19 boosters. Review of Resident 22's clinical record revealed no documented evidence that Resident 22 or Resident 22's Representative were educated on the benefits, risks, or potential side effects of the additional COVID-19 booster. Review of Resident 23's clinical record revealed that Resident 23 refused the COVID-19 vaccination. Further review of Resident 23's clinical record revealed no documented evidence that Resident 23 or Resident 23's Representative were educated on the benefits, risks, or potential side effects of the COVID-19 vaccination. On August 31, 2023, at 10:31 AM, Employee 11 (Infection Preventionist) stated that she was unable to find evidence that the aforementioned Residents or their Representatives were provided education on the benefits and potential side effects of the immunizations. On August 31, 2023, at 11:38 AM, the Director of Nursing was made aware that there was no documented evidence of education for the aforementioned Residents who declined the COVID-19 vaccinations. No additional information was provided. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395746 If continuation sheet Page 30 of 30