Health inspection·May 25, 2023

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to precisely and effectively monitor hydration status for two of 16 residents reviewed (Resident's 6 and 24) Residents Affected - Some Findings include: Review of facility policy, titled Encouraging and Restricting Fluids last revised October 2010, revealed Remove the resident's water pitcher and cup from the room .The following information should be recorded in the resident's medical record: The amount (in mLs) of fluids consumed by the resident during the shift. Review of Resident 6's clinical record revealed diagnoses that included congestive heart failure (excessive body/lung fluid caused by a weakened heart muscle), hypertension (elevated/high blood pressure), and chronic kidney disease (a condition characterized by a gradual loss of kidney function). Review of Resident 6's physician orders revealed an order for an 1800 mL (mL- milliliter, unit of measure) fluid restriction per day (dining 1500 mL= 580 mL breakfast, 460 mL lunch, and 460 mL dinner; nursing 300 mL= 120 mL dayshift, 120 mL evening shift, 60 mL night shift), dated May 17, 2023. Review of resident 6's meal tray tickets of May 24, 2023, and May 25, 2023, revealed total amount of beverages listed to provide were less than the amount of fluids allowed from dietary services for each meal. Observation on May 22, 2023, at 12:07 PM, revealed two 16-ounce (unit of measure) Styrofoam cups at Resident 6's bedside, one was full and one was a quarter full of liquid, exceeding the allowed fluids on day shift from nursing services. Observation on May 24, 2023, at 9:23 AM, revealed a 16-ounce Styrofoam cup at bedside. Further observation on May 24, 2023, at 11:47 AM, revealed a 7.5 ounce can of soda and an 8 ounce glass of water on Resident 6's meal tray, which exceeds the allowed fluids from dietary services per physician order. Observation on May 25, 2023, at 10:21 AM, revealed a 16-ounce Styrofoam cup on Resident 6's tray table. Interview with Resident 6 on May 24, 2023, at 11:47 AM, revealed she often has a Styrofoam cup at her bedside and was unaware of nursing monitoring her fluid intake. Review of Resident 24's clinical record revealed diagnoses that included of end stage renal disease (failure of kidney function to remove toxins from blood), reflux disease (a return of the stomach's contents back up into the esophagus), and diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). Review of Resident 24's physician orders revealed an order for a 1500 mL fluid restriction per day (dining 1200 mL= 480 mL breakfast, 360 mL lunch, and 360 mL dinner; nursing 300 mL= 120 mL dayshift, 120 mL evening shift, 60 mL night shift), dated March 15, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395876 If continuation sheet Page 2 of 11 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 395876 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Crossings Retirement Community 1 Longsdorf Way 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 Review of Resident 24's TAR (Treatment Administration Record- documentation for treatments/medication administered or monitored) failed to reveal documentation of fluids consumed, per policy. Review of Resident 24's meal tray tickets of May 23, 2023, revealed total beverages listed to provide were less than the amount of fluids allowed from dietary services for each meal. Residents Affected - Some Observation on May 23, 2023, at 1:36 PM, revealed one 16-ounce Styrofoam cup at Resident 24's bedside full of liquid, exceeding the allowed fluids on that shift from nursing services on day shift. Observation on May 24, 2023, at 9:05 AM, revealed a 16-ounce Styrofoam cup and a 20-ounce size bottle of root beer soda at bedside. Interview with Resident 24 on May 24, 2023, at 9:05 AM, revealed she monitors her fluids on her own. Interview with Director of Nursing on May 25, 2023, at 1:45 PM, DON was informed of the concerns regarding management of fluid restrictions. No further information was provided. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.6(a)(b)(1) Dietary services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395876 If continuation sheet Page 3 of 11 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 395876 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Crossings Retirement Community 1 Longsdorf Way 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy, select facility document review, and resident and staff interviews, it was determined that the facility failed to provide a nutritionally adequate menu for one of one meals observed (May 24, 2023, lunch meal). Findings include: Interviews with residents during the initial pool process revealed concerns with consistent food portions. Review of resident council meeting minutes revealed concern that portion size of food vary each meal and aren't consistent for three out of six months reviewed. Review of the facility menu and diet spreadsheet (guide as to portion sizes and food items for all diets) for the lunch meal on May 24, 2023, read, in part, serving size for ravioli [NAME] 8 ounces and serving utensil 8 ounce spoodle (a utensil midway between a spoon and a ladle); and serving size for the apple [NAME] brussel sprouts 1/2 cup and serving utensil 4 ounce spoodle. Observation of tray line on May 24, 2023, at 11:36 AM, revealed the ravioli [NAME] was served utilizing a 3 ounce spoodle mounded with food and portions were noted to vary. Further observation revealed the apple [NAME] brussel sprouts were served utilizing a 3 ounce spoodle mounded with food and portions were noted to vary. During an interview with Employee 7 (Dining Services Director) and Employee 8 (Sous Chef) on May 24, 2023, at 1:00 PM, it was revealed that the ravioli [NAME] and brussel sprouts were served utilizing a 3 ounce spoodle that was mounded with food. Surveyor questioned how the Dietary Staff knows the portions size to be served for each menu item. Employees 7 and 8 stated that the menu doesn't contain portion size information. Surveyor reviewed the extension sheets with Employees 7 and 8, which documented the serving size for the ravioli [NAME] was 8 ounces and to utilize an 8 ounce spoodle, and the serving size for the brussel sprouts was 1/2 cup and to utilize a 4 ounce spoodle. Employee 8 commented that she wasn't aware the portion sizes were documented on the extension sheets. Employee 7 verified that the facility had 8 ounce and 4 ounce spoodles available for the staff to utilize; and revealed that the correct serving utensils should've been utilized to serve the ravioli [NAME] and the brussel sprouts. Review of the recipe for ravioli [NAME] read, in part, a portion is 6 ravioli with approximately 3/4 cup vegetables and 1/2 cup sauce. Surveyor informed the Nursing Home Administrator (NHA) on May 24, 2023, at 2:30 PM, of the concern with incorrect and inconsistent portions of the alternate entrée, ravioli [NAME], and the brussel sprouts at the lunch meal on May 24, 2023. NHA questioned whether the correct portions were served despite not utilizing the correct serving utensils. Surveyor discussed residents' concerns regarding inadequate and inconsistent portions during meals. Surveyor also revealed that the portion of ravioli served was one mounded scoop, not two are three scoops. NHA provided no further information. Pa code 211.6(a)(b) - Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395876 If continuation sheet Page 4 of 11 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 395876 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Crossings Retirement Community 1 Longsdorf Way 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 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on clinical record review and observations, it was determined that the facility failed to provide food prepared in a form designed to meet individual needs for one of 16 residents reviewed (Resident 26). Residents Affected - Few Findings include: Review of Resident 26's clinical record revealed diagnoses that included Parkinson's disease (progressive disease of the central nervous system characterized by tremors, muscle weakness, and unsteady gait), dementia (irreversible, progressive, degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and hypertension (elevated/high blood pressure). Review of Resident 26's physician orders revealed an order for a regular texture diet with pre-cut meats. Review of Resident 26's care plan revealed prescribed diet of regular texture-bite size, cut meats for all meals, thin liquids. Further review of the care plan revealed the Resident requires set-up by staff to eat. Review of Resident 26's tray tickets for May 24, 2023, revealed a notation of cut meats, bite sized, for all meals. Observation of Resident 26 in the main dining area on May 24, 2023, at 1:01 PM, revealed the Resident had full sized pieces of ravioli that were not bite sized. Further observation at 1:04 PM, revealed Resident 26 with difficulty cutting ravioli and attempting to eat ravioli using a curved, adaptive fork in his right hand and his fingers on his left hand. During an interview with the Nursing Home Administrator on May 24, 2023, at 2:30 PM, the surveyor revealed the concern with Resident 26 not receiving the appropriate texture meat. No further information was provided. 28 Pa. Code 211.12(d)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395876 If continuation sheet Page 5 of 11 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 395876 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Crossings Retirement Community 1 Longsdorf Way 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to provide adaptive feeding devices for one of 16 residents reviewed (Resident 23). Residents Affected - Few Findings include: Review of Resident 23's clinical record documented diagnoses that included: Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and lack of coordination. Observation of Resident 23 in the dining room on May 22, 2023, at 12:25 PM, Resident 23 was eating his meal off of a regular plate. Additional observation on May 24, 2023, at 12:40 PM, revealed Resident 23 was in his room, eating his lunch meal off of a regular plate. Review of Resident 23's May 2023 physician orders included a scoop plate (a plate with curved, elongated rim that makes it easier to put food on a spoon or fork for those with limited dexterity or fine motor skills) for all meals, with a revision date of April 10, 2023. Review of Resident 23's care plan included a focus area at risk for nutritional problem related to Parkinson's, dementia, osteoarthritis ( a type of arthritis that occurs when flexible tissue at the ends of bones wears down), initiated October 10, 2022. Interventions included a scoop plate at all meals, initiated May 9, 2023. Review of Resident 23's [NAME] (informational system used as a quick reference for information pertaining to resident care needs) documented scoop plate at all meals, updated May 24, 2023. Review of Resident 23's tray tickets for breakfast, lunch, and dinner failed to document use of a scoop plate. During an interview with the Nursing Home Administrator on May 24, 2023, at 2:30 PM, surveyor revealed the concern with Resident 23 not receiving a scoop plate at two observed lunch meals. No further information was provided. 28 Pa code 211.6(b)(d) - Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395876 If continuation sheet Page 6 of 11 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 395876 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Crossings Retirement Community 1 Longsdorf Way 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, review of facility policy, and staff interview, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen and in one of one nourishment pantry. Findings include: Review of facility policy, titled Food and Supply Storage, revised January 2023, read, in part, cover, label, and date unused portions and open packages of food. Store dry and staple items at least 18 inches below sprinklers. Store bulk materials in a food grade container with a tight fitting lid, label both the lid and the container, and hang the scoop. Review of facility policy, titled Ice Handling, revised January 2021, read, in part, use a scoop to remove ice from the storage bin into the receptacle used for serving. Store the scoop in a self-draining container, in an area protected from contamination. The scoop cannot be stored in the ice bin, unless the container for the scoop is placed in a way that doesn't allow the ice scoop handle to come in contact with the ice. Wrap foods tightly to prevent cross contamination. Observation on May 22, 2023, at 9:32 AM, in the kitchen dry storage room, revealed one case of napkins and several boxes of straws were stored on the top shelf and were less than 18 inches from the sprinkler head. Observation on May 22, 2023, at 9:35 AM, in the kitchen walk-in freezer, revealed two one gallon plastic bags of frozen pulled pork were open, not securely closed, and were not date marked. During an interview with Employee 7 on May 22, 2023, at 9:35 AM, it was revealed that the two bags of pulled pork should be securely closed and marked with a label to include a date. Observation on May 22, 2023, at 9:37 AM, in the kitchen walk-in refrigerator revealed the following items were stored on the top shelf and were less than 18 inched from the sprinkler head: once case of spring mix lettuce and two full sheet pans of cheesecake. During an interview with Employee 7 on May 22, 2023, at 9:37 AM, it was revealed that the walk-in refrigerator is new and that the floor is elevated, leaving less head space on the top shelf, and the staff aren't accustom to the reduced head space. It was acknowledged that the items on the top shelf in the walk-in refrigerator were too close to the sprinkler head and needed to be moved. Items on the shelf directly below the sprinkler head were moved; however, items on the top shelf of the remaining racks remained in place. It was also revealed that the aforementioned boxes in the dry storeroom were too close to the sprinkler head and needed to be moved. The case of napkins and boxes of straws on the shelf directly below the sprinkler head were moved; however, items on the top shelf of the remaining racks remained in place. Observation in the kitchen on May 22, 2023, at 9:40 AM, revealed bulk bins of rice and flour contained a scoop inside the bin, resting on the rice/flour. During an interview with Employee 7 on May 22, 2023, at 9:40 AM, it was revealed that the scoops should not be stored inside the bins. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395876 If continuation sheet Page 7 of 11 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 395876 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Crossings Retirement Community 1 Longsdorf Way 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 0812 Level of Harm - Minimal harm or potential for actual harm Observation in the kitchen on May 22, 2023 at 9:42 AM, the ceiling above the pat and pan storage area and above the tray line contained a dark grey fuzzy substance. During an interview with Employee 7 on May 22, 2023, at 9:42 AM, it was revealed that the maintenance has a schedule to clean the ceiling and the vents on the ceiling. Residents Affected - Some Observation on May 22, 2023, at 9:44 AM, revealed the hand sink faucet had a solid stream of water running from it and wasn't able to be shut off; and the faucet on the right side of the three-compartment sink contained a drip and wasn't able to be shut off. During an interview with Employee 7 on May 22, 2023, at 9:44 AM, it was revealed that work orders have been submitted to maintenance. Observation in the nourishment pantry on May 22, 2023, at 9:53 AM, revealed the following: two of two ice coolers contained an ice scoop inside resting on/in the partially melted ice; inside of the microwave contained dried on food particles; and inside the refrigerator contained two thawed chocolate nutritional shakes and two thawed vanilla nutritional shakes that weren't date marked with a thaw or pull date (the product is to be used within 14 days of thawing). During an interview with Employee 7, on May 22, 2023, at 9:53 AM, it was revealed that the scoops shouldn't be stored inside the ice bins, the microwave needs to be cleaned, and nutritional shakes are delivered to the pantry on a tray and the tray is marked with a pull date. It was revealed that the full tray of shakes, on the above shelf contained a thaw date. Surveyor noted that the shakes on the tray were frozen and the two chocolate and two vanilla shakes were thawed. Surveyor informed Nursing Home Administrator (NHA) of the aforementioned dietary concerns on May 24, 2023, at 2:25 PM. NHA revealed that maintenance has work orders for the leaking faucets and has a schedule for cleaning ceilings in the kitchen; however, if they need to be cleaned outside of the routine schedule, maintenance should be notified. It was also revealed that items were removed from beneath the sprinkler heads. 28 Pa code 211.6(b)(d) - Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395876 If continuation sheet Page 8 of 11 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 395876 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Crossings Retirement Community 1 Longsdorf Way 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on staff interviews, policy review, Centers for Disease Control guidelines, and documents reviewed for implementation of a water management program, it was determined the facility failed to implement their water management program for the prevention, detection, and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease [a serious type of pneumonia]). Residents Affected - Many Findings include: During an interview with Employee 1 (Maintenance Technician) on May 25, 2023, at 9:00 AM, Employee 1 indicated they were not aware of a water management program and that the facility was on township water and the township completes all required testing. They further indicated that the township does testing weekly and the facility receives an annual report of findings. Employee 1 also conveyed that the township water authority would notify facility and all community members utilizing the township water source of any identified water concerns. During a follow-up interview with Employee 1 on May 25, 2023, at 09:40 AM, Employee 1 indicated that, when they called the township water authority, they were told that they do not test for Legionella as they are not required and that the annual report is released in June every year. Therefore, the facility had no current report to provide. During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Assistant Director of Nursing (ADON) on May 25, 2023,at approximately 9:45 AM, the above information was shared. Weekly township testing reports were requested as well as the facility water management policy/program. During a follow-up interview with the NHA, DON, and ADON on May 25, 2023, at approximately 12:35 PM, the NHA indicated that he had followed-up with the township regarding testing and that they, again, confirmed that they do not test for Legionella as they are not required to do so. He further indicated that they had looked for a policy and that the facility only has a very generic policy for water management. This policy was requested for review at that time. During an interview with Employee 1 and Employee 2 (Maintenance Director) on May 25, 2023, at approximately 12:50 PM, revealed that they had notified the company that maintains the campus swimming pool and they indicated that they could test for them, but the vendor did not really feel it was necessary as Legionella only grows in very hot water, and their hot water doesn't go above 110 degrees. Employee 1 and Employee 2 further shared that they have circulator pumps on their hot water that mixes the water constantly to prevent sitting water. According to the Centers for Disease Control, Building water systems and devices that might grow and spread Legionella include: showerheads and sink faucets; cooling towers (structures that contain water and a fan as part of centralized air cooling systems for buildings or industrial processes); hot tubs; decorative fountains and water features; hot water tanks and heaters; and large, complex plumbing systems. Review of facility policy, titled Legionella Water Management Program with a last revision date of July 2017 and a last review date of January 25, 2023, revealed the following information: 1. As part of the infection prevention and control program, our facility has a water management program, which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395876 If continuation sheet Page 9 of 11 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 395876 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Crossings Retirement Community 1 Longsdorf Way 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many is overseen by our water management team; 2. The water management team will consist of at least the following personnel: a. the infection preventionist; b. the administrator, c. the medical director (or designee); d. the director of maintenance; and e. the director of environmental services; 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease; 5b. The identification of areas in water system that could encourage the growth and spread of Legionella or other waterborne, bacteria including storage tanks; water heaters; filters; aerators; showerheads and hoses; misters, atomizers, air washers, and humidifiers; hot tubs; fountains; and medical devices such as CPAP machines, hydrotherapy equipment, etc; and 5c. The identification of situations that can lead to Legionella growth such as: construction; water main breaks; changes in municipal water quality; the presence of biofilm, scale or sediment; water temperature fluctuations; water pressure changes; water stagnation; and inadequate disinfection; 5f. the control limits or parameters that are acceptable and that are monitored; 5g. a diagram of where control measures are applied; 5h. a system to monitor control limits and the effectiveness of control measures; 5i. A plan for when control limits are not met and/or control measures are not effective; 5j. documentation of the program; and 6. the water management program will be reviewed at least once a year. During a follow-up interview with the NHA on May 25, 2023, at approximately 1:10 PM, the NHA indicated that they have a water management team and that water management is part of the safety committee that meets monthly. Upon reviewing the monthly meeting minutes for February 2023 through April 2023 and the accompanying attendance sign-in sheets, it was noted that there was no discussion regarding water management and/or testing and that the NHA and the Medical Director (or designee) were not in attendance at these meetings as indicated in the facility policy. The NHA confirmed that the facility does not have a water management program in place. 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395876 If continuation sheet Page 10 of 11 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 395876 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Crossings Retirement Community 1 Longsdorf Way 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of personnel training records and staff interview, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of no less than 12 hours per year, which included dementia management and resident abuse prevention, for four of five nurse aide employee records reviewed (Employees 3, 4, 5, and 6). Findings Include: Review of personnel information revealed Employee 3's hire date was March 15, 2021; Employee 4's hire date was July 7, 2015; Employee 5's hire date was January 26, 2022; and Employee 6's hire date was October 28, 2019. Review of facility training records failed to reveal that the aforementioned Employees completed 12 hours of required annual training in the past 12 months. Further review of facility training records failed to reveal evidence that dementia management or abuse prevention training was completed by Employees 4, 5, and 6 within the past 12 months. During an interview with the Nursing Home Administrator on May 24, 2023, at 2:29 PM, he acknowledged that the aforementioned Employees did not meet the training requirements, and indicated that he did not have any additional information to provide. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.20(a)(c) Staff development 28 Pa. Code 201.29 (d) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395876 If continuation sheet Page 11 of 11