Inspection·August 17, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on facility policy review, observations, and staff interviews, it was determined the facility failed to maintain a safe, clean, and home-like environment for 2 of 63 residents reviewed (Residents 12 and 54) and in two of two dining rooms. Findings Include: Review of facility policy, titled Meal Service and Distribution revealed, A comfortable, attractive atmosphere will be maintained in the dining room area .suggestions for a pleasant environment include use of clean, wrinkle-free tablecloths, centerpieces, background music, and placemats. Observation of the second floor dining area on August 14, 2023, at 11:49 AM, revealed 17 residents were eating meals served on trays. Further observation in the second floor dining room revealed all tables were bare without anything but the residents' trays, and no music was playing. Interview with Employee 2 in second floor dining area on August 14, 2023, at 11:51 AM, revealed residents have been eating on trays in the dining room since COVID. Observation of the third floor dining area on August 14, 2023, at 12:17 PM, revealed 27 residents were eating meals served on trays. Further observation in the third floor dining room revealed all tables were bare without anything but the residents' trays, and no music was playing. During an interview with Nursing Home Administrator (NHA) on August 16, 2023, at 2:00 PM, the surveyor revealed a concern with residents being served meals on trays and lack of a pleasant environment in the dining rooms. No further information was provided. Observation in Resident 12's room on August 15, 2023, at 9:34 AM, and on August 16, 2023, at 1:20 PM, revealed bilateral enablers were present on Resident 12's bed. Observation of the inside of the enablers bars revealed an accumulation of dried liquid, crumbs and debris. During an interview with Employee 16 (Licensed Practical Nurse) on August 15, 2023, at 9:46 AM, she acknowledged the enablers were soiled, and revealed that she was uncertain about who normally cleans them. Observation on August 17, 2023, at 10:58 AM, revealed Resident 12's enabler bars had been cleaned. During an interview with the Director of Nursing (DON) on August 17, 2023, 11:55 AM, she confirmed that the enabler bars had been cleaned, and revealed the expectation that Resident 12's enabler bars should have been clean. Observations of Resident 54's room on August 15, 2023, a 10:03 AM and 1:25 PM, and on August 16, 2023, at 9:20 AM, revealed bilateral enabler bars attached to Resident 54's bed. Observation of the left side enabler bar revealed the bar appeared dirty, with a dried, brown substance splattered on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 2 of 17 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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 0584 Level of Harm - Minimal harm or potential for actual harm enabler bar. Further observation revealed a pool of a dried, brown substance on the bottom of the enabler bar. On August 16, 2023, at 1:45 PM, the NHA and DON were made aware of the observations of Resident 54's enabler bar. Residents Affected - Some Observation of Resident 54's enabler bars on August 17, 2023, at 10:55 AM, revealed the enablers had been cleaned. During an interview with the NHA and DON on August 17, 2023, at 11:42 AM, the DON stated that she personally cleaned Resident 54's enabler bars and stated that enablers should be cleaned as needed. 28 Pa. Code 201.18(e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 3 of 17 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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 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 four of 26 residents reviewed (Residents 55, 58, 71, and 110). Residents Affected - Some Findings Include: Review of Resident 55's clinical record revealed diagnoses that included Alzheimer's Disease (a progressive mental deterioration due to generalized degeneration of the brain, characterized by memory lapses, confusion, emotional instability, and progressive loss of mental ability), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and delusional disorders (type of psychotic disorder; a delusion is an unshakable belief in something that is untrue). Review of Resident 55's current physician orders revealed an order for Quetiapine (Seroquel) (antipsychotic medication) 25 milligrams give 0.5 tablet by mouth at bedtime daily, dated February 17, 2023. Review of Resident 55'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 November 22, 2022, revealed in section N Medications, that Resident 55 had not received an antipsychotic medication in the look back period. Review of Resident 55's November 2022 Medication Administration Record revealed that they had received Quetiapine (an antipsychotic medication) 25 milligrams at bedtime daily, as per the physician's order. Review of Resident 55's Modified Annual Comprehensive MDS with the assessment reference date of February 13, 2023, revealed in Section N Medications, that the physician had indicated that a gradual dose reduction of the antipsychotic was clinically contraindicated, with a date given of February 3, 2023. Review of physician services progress notes and pharmacy recommendations revealed that the clinical contraindication for a gradual dose reduction was dated February 2, 2023. Review of Resident 55's Quarterly MDS with the assessment reference date of May 16, 2023, revealed in Section N Medications, that they had not had any gradual dose reductions and that their physician had indicated that a gradual dose reduction of the antipsychotic was clinically contraindicated, with a date given of February 23, 2023. Review of psychiatric physician services progress notes dated February 16, 2023, revealed that their Quetiapine (an antipsychotic medication) was to be reduced to 12.5 milligrams at bedtime, daily. Review of Resident's clinical record failed to reveal any physician services progress notes dated February 23, 2023. Review of Resident 55's physician orders revealed that their current order was for Quetiapine 25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 4 of 17 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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 milligrams give 0.5 tablet by mouth at bedtime daily, dated February 17, 2023. Level of Harm - Minimal harm or potential for actual harm Review of Resident 55's Quarterly MDS with the assessment reference date of May 31, 2023, revealed in Section N Medications, that they were coded as not having a gradual dose reduction and that their physician had indicated that a gradual dose reduction of the antipsychotic was clinically contraindicated, with a date given of February 2, 2023. As stated above, Resident 55 had a gradual dose reduction of their Quetiapine on February 17, 2023. Residents Affected - Some During an interview with Employee 2 (MDS Coordinator) on August 17, 2023, at 10:39 AM, all the above coding concerns were shared. Employee 2 indicated they would follow-up on the concerns identified. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 17, 2023, at 11:43 AM, the aforementioned concerns were shared with them as well. Email communication received from Employee 2 on August 17, 2023, at 12:33 PM, indicated that corrections were completed for MDS November 11, 2022, to code the receiving of antipsychotics; February 13, 2023, to code the correct date of the clinical contraindication of a gradual dose reduction to February 2, 2023; May 16, 2023, to code the gradual dose reduction completed on February 17, 2023; and May 31, 2023, to code the gradual dose reduction completed on February 17, 2023. During an interview with the DON on August 17, 2023, at 1:04 PM, she confirmed that she would expect the MDSs to have been coded accurately. Review of Resident 58's clinical record on August 15, 2023, revealed diagnoses that included chronic conjunctivitis (chronic eye inflammation caused by an infection), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and dysphagia (difficulty swallowing). Review of Resident 58's physician orders revealed an order for Ciprofloxacin HCl Ophthalmic Solution (antibiotic eye drops) 0.3 % Instill two drops in both eyes, two times a day for chronic conjunctivitis, wait five minutes to prevent wash out, with a start date of March 15, 2023. Review of Resident 58's Quarterly MDS (Minimum Data Set- assessment tool utilized to identify resident's physical, mental, and psychosocial needs) with ARD (assessment reference date - last day of the assessment period) of March 27, 2023, revealed under Section N - Medications, Resident 58 was marked 0 of 7 days for receiving an antibiotic. Review of Resident 58's Quarterly MDS with ARD of June 27, 2023, revealed under Section N Medications, Resident 58 was marked 0 of 7 days for receiving an antibiotic. During a staff interview on August 17, 2023, at 1:32 PM, Employee 2 confirmed that Resident 58's MDS assessments with ARD of March 27, 2023, and June 27, 2023, should have included antibiotic medication for seven days and were coded incorrectly. Interview with DON on August 17, 2023, at 1:40 PM, revealed it was the facility's expectation that resident assessments are coded accurately. Review of Resident 71's clinical record on July 13, 2023, revealed diagnoses that included dry eye (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 5 of 17 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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 syndrome, dementia, and dysphagia. Level of Harm - Minimal harm or potential for actual harm Review of Resident 71's physician orders revealed an order for Ciprofloxacin HCl Ophthalmic Solution 0.3 % Instill two drops in both eyes, three times a day for blepharitis (eye inflammation), for seven Days from June 16, 2023, to June 23, 2023. Residents Affected - Some Further review of Resident 71's physician orders revealed no order for an anticoagulant medication between the dates of June 16, 2023, and June 22, 2023. Review of Resident 71's Quarterly MDS with ARD of June 22, 2023, revealed under Section N Medications, Resident 58 was marked 0 of 7 days for receiving an antibiotic, and was marked 7 of 7 days for receiving an anticoagulant. Email correspondence with DON on August 16, 2023, at 4:01 PM, revealed Resident 71 was on antibiotic eye drops during look-back for ARD June 22, 2023, and that Employee 2 should not have coded anticoagulant and should have coded antibiotic. Interview with DON on August 17, 2023, at 11:51 PM, revealed it was the facility's expectation that the resident assessment would be coded accurately. Review of Resident 110's clinical record revealed diagnoses that included dementia with behavioral disturbance and delusional disorder (disorder in which a person holds fixed false beliefs and is unable to tell what is real from what is imagined). Review of Resident 110's June 2023 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed an order, effective June 1, 2023, for Risperdal (antipsychotic medication) at bedtime, and an order for Risperdal daily, effective June 3, 2023. Review of psychiatric service provider progress notes dated April 20, 2023, revealed that a gradual dose reduction of Resident 110's psychoactive medication (to include Risperdal) was not recommended at that time due to ongoing clinical treatment for anxiety and delusional disorder. Review of Resident 110's June 7, 2023, and June 26, 2023, quarterly MDS assessments revealed that neither assessment was coded to indicate that the practitioner had documented that a gradual dose reduction of antipsychotic medication was contraindicated. During an interview with the DON on August 17, 2023, at 11:56 AM, she deferred to the MDS coordinator. During an interview with Employee 2 on August 17, 2023, at 12:40 PM, she acknowledged that the progress note written by the psychiatric provider on April 20, 2023, could be interpreted as meeting the criteria to be coded on the MDS that the practitioner documented that an antipsychotic gradual dose reduction was contraindicated. 28 Pa. Code 211.5(f) Clinical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 6 of 17 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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 - Few 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 review of clinical records and staff interviews, it was determined that the facility failed to ensure that the resident's care plan was updated/revised to reflect the resident's specific care needs for three of 26 residents reviewed (Resident 36, 39, and 71). Findings include: Review of Resident 36's clinical record revealed diagnoses that included morbid obesity (obesity in which the person weighs 80-100 pounds over their ideal body weight) and protein-calorie malnutrition (nutritional status in reduced availability of nutrients leads to changes in body composition and function). Review of Resident 36's progress note dated July 20, 2023, by Employee 3 (Clinical Dietary Director) indicated Resident 36 had a significant weigh loss of 13 pounds (5.1%) over the past month and that this weight loss was beneficial. Review of Resident 36's care plan revealed a care plan focus for nutritional risk, dated May 31, 2023. The care plan revealed no revisions indicating the significant weight loss experienced by Resident 36 as stated above. It was noted that one of the care plan goals indicated it would be beneficial for [Resident 36] to gradually lose weight through next review date, with a revision date of June 1, 2023. Email communication was sent to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 16, 2023, at 9:34 PM, to inform them of the care plan concern and additional information was requested. During an interview on August 17, 2023, at 11:40 AM, with the NHA and DON, the DON indicated that she had spoken to Employee 3 and that Employee 3 indicated that they had not care planned the significant weight losses and that they were updating the care plan. The DON confirmed that she would expect the care plan to have been updated if the Resident had a significant weight loss. During an interview with Employee 3 on August 17, 2023, at 1:30 PM, Employee 3 indicated that they had updated the care plan for the significant weight loss, and that they had not done so prior since it was documented on Resident 39's care plan that weight loss would be beneficial. Employee 3 did confirm that Resident 39 had experienced a significant weight loss. Review of Resident 39's clinical record revealed diagnoses that included obesity (disorder involving excessive body fat that increases the risk of health problems) and chronic obstructive pulmonary disorder (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations). Review of Resident 39's progress notes revealed the following notes: 1) note dated April 28, 2023, by Employee 3 that indicated Resident 39 had experienced a significant weight loss of 18.8 pounds (11.7%) in one month and a significant weight loss of 22 pounds (13.4%) over the past six months; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 7 of 17 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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 2) note dated May 30, 2023, by Employee 3 that indicated Resident 39's weight had been stable over the past month, but had a significant weight loss of 21.5 pounds (13.1%) over the past six months; 3) note dated June 14, 2023, by Employee 3 that indicated Resident 39 had experienced a two pound gain over the past month, and that had experienced a 18.1 pound beneficial weight loss; Residents Affected - Few 4) noted dated July 15, 2023, by Employee 3 that indicated Resident 39 had lost 16.6 pounds (10.3%) between March 9, 2023, and April 9, 2023, and that their weight had been stable since April 9, 2023; and 5) note dated August 10, 2023, by Employee 3 that indicated Resident 39 was exhibiting a significant weight loss of 8.6 pounds over the past month, a significant weight loss of 25.6 pounds over the past 6 months, and a 7 pound weight loss since July 18, 2023. Review of Resident 39's care plan revealed a focus for nutritional risk, dated September 22, 2021. Care plan review revealed no revisions indicating the significant weight losses experienced by Resident 39 as stated above. It was noted that one of the care plan goals indicated it would be beneficial for [Resident 39] to gradually lose weight through next review date, with a revision date of July 31, 2023. Email communication was sent to the NHA and DON on August 16, 2023, at 9:34 PM, to inform them of the care plan concern and additional information was requested. During an interview on August 17, 2023, at 11:40 AM, with the NHA and DON, the DON indicated that she had spoken to Employee 3 and that Employee 3 indicated that they had not care planned the significant weight losses, and that they were updating the care plan. The DON confirmed that she would expect the care plan to have been updated if the resident had a significant weight loss. During an interview with Employee 3 on August 17, 2023, at 1:30 PM, Employee 3 indicated that they had updated the care plan for the significant weight loss, and that they had not done so prior since it was documented on Resident 39's care plan that weight loss would be beneficial. Employee 3 did confirm that Resident 39 had experienced significant weight losses. Review of Resident 71's clinical record on August 15, 2023, revealed diagnoses that included dry eye syndrome, dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and dysphagia (difficulty swallowing). Review of Resident 71's Quarterly MDS (Minimum Data Set- assessment tool utilized to identify residents' physical, mental, and psychosocial needs) with ARD (assessment reference date- last day of the assessment period) of June 22, 2023, revealed Section G: Activities of Daily Living (ADL) Assistance, subsection, H. Eating - how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (e.g. Tube feeding, total parenteral nutrition, IV fluids administered for nutrition or hydration), Resident 71 was coded as requiring extensive assistance with one-person physical assist, which was a decline in ability from her April MDS assessment. Review of Resident 71's care plan revealed a focus area of [Resident 71] has an ADL (Activities of Daily Living) self-care performance deficit related to decreased strength and endurance, dementia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 8 of 17 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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 pain, impaired mobility, and anxiety, with an intervention stating [Resident 71] is able to feed self after set up, last revised April 8, 2022. Interview with DON on August 17, 2023, at 1:46 PM, revealed she would expect the care plan to be updated to reflect resident 71's eating decline and care needs. Residents Affected - Few 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(3) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 9 of 17 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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, observations, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided, in accordance with professional standards of practice, that would meet each resident's physical, mental, and psychosocial needs for four of 28 residents reviewed (Residents 12, 50, 54, and 63). Residents Affected - Some Findings Include: Review of Resident 12's clinical record revealed diagnoses that included history of traumatic brain injury (an external mechanical force such as a violent blow to the head, which causes the brain to not function properly) and abnormal posture. Review of Resident 12's physician orders revealed an order, dated December 10, 2022, for gerisleeves (cloth sleeves worn on the arms to prevent skin irritation or injury) to bilateral arms when up in wheelchair. Review of Resident 12's current care plan revealed an intervention, dated August 23, 2022, for Resident 12 to wear gerisleeves on both arms when in her wheelchair. Observations on August 15, 2023, at 9:34 AM and at 1:34 PM, and on August 16, 2023, at 11:59 AM and at 1:20 PM, revealed Resident 12 was in her wheelchair. Resident 12 was not wearing gerisleeves. During an interview with the Director of Nursing (DON) on August 17, 2023, at 11:56 AM, she revealed the expectation that Resident 12 should have been wearing the gerisleeves. Review of Resident 50's clinical record revealed diagnoses that included pressure ulcer of right heel (wound that occurs when the skin and tissue are damaged by prolonged pressure), osteomyelitis (infection of the bone), and diabetes mellitus (DM - a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). Review of Resident 50's physician orders revealed an order for Strict pressure relief to BLE [bilateral lower extremities]. Bilateral multipodus boots when in bed every shift related to nonpressure chronic ulcer of unspecified heel and midfoot with unspecified severity, with a start date of May 18, 2023. Review of Resident 50's care plan revealed a focus area: [Resident 50] is at risk for skin breakdown related to impaired mobility, DM, incontinence, pressure ulcers, noted osteomyelitis to right ankle with actual skin breakdown, initiated May 15, 2023, and last revised on August 4, 2023, with an intervention for Bi-lateral multipodus boots while in bed, initiated May 16, 2023. Observation of Resident 50 in his room on August 15, 2023, at 1:15 PM, revealed the Resident was laying in bed and his multipodus boots were sitting in his wheelchair, beside his bed. Interview with Resident 50 on August 15, 2023, at 1:17 PM, revealed he does not refuse to wear his boots, but, depending on which nurse aide is working, they sometimes take them off before he gets into bed. Interview with the DON on August 17, 2023, at 11:51 AM, revealed she would expect Resident 50 to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 10 of 17 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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 wearing his multipodus boots in bed per physician order and per his care plan. Level of Harm - Minimal harm or potential for actual harm Review of Resident 54's clinical record revealed diagnoses that included hypertension (elevated blood pressure), Type 2 Diabetes Mellitus, and end stage renal disease (ESRD- when the kidneys no longer work as they should to meet the body's needs). Residents Affected - Some Review of Resident 54's physician orders revealed an order dated July 17, 2023, for hipsters at all times (impact-absorbing pads over the critical hip fracture area minimize potential damage that can occur from a fall). Review of Resident 54's current care plan revealed an intervention dated July 17, 2023, for hipsters at all times, may remove for care. Observation of Resident 54 on August 14, 2023, at 1:11 PM, revealed Resident 54 in his room alone, in bed, asleep, wearing only a shirt and a brief. Resident 54 was not observed to be wearing hipsters. Observation of Resident 54 on August 15, 2023, at 9:30 AM, revealed Resident 54 in his room alone, in bed, wearing only a brief. Resident 54 was not observed to be wearing hipsters. During an interview with Employee 5 (Licensed Practical Nurse) on August 16, 2023, at 10:13 AM, Employee 5 stated that she is unsure why Resident 54 was not wearing his hipsters on August 14 or 15, 2023. She stated they may have been soiled, as some of the hipsters were being laundered. On August 16, 2023, at 1:45 PM, the Nursing Home Administrator (NHA) and DON were made aware of Resident 54 not wearing his hipsters on the aforementioned dates and times. In a follow-up interview with the NHA and DON on August 17, 2023, at 11:42 AM, the DON stated that Resident 54's hipsters got soiled during an incontinence episode, and they were being laundered. When asked if the facility had extra hipsters to be provided during a situation like that, she stated the facility does have extra hipsters, but they were all used up. No additional information was provided. Review of Resident 63's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients needed for health), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 63's care plan revealed a focus area: nutritional risk related to mechanical diet, reflux, dementia, hyperlipidemia (high cholesterol), dysphagia (difficulty swallowing), depression, chronic kidney disease (a condition characterized by a gradual loss of kidney function), and hypertension (high blood pressure), last revised May 19, 2023, with an intervention for provide a water pitcher at bedside to promote fluid intake, initiated March 24, 2022. Observation in resident 63's room on August 15, 2023, at 9:44 AM, revealed no water pitcher at bedside or anywhere in Resident 63's room. Further observation in Resident 63's on August 15, 2023, at 12:39 PM, revealed Resident 63 during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 11 of 17 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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 Level of Harm - Minimal harm or potential for actual harm lunch meal, no water pitcher at bedside, and the only beverage was an 8-ounce (unit of measure) milk on the lunch tray. Observation in Resident 63's room on August 16, 2023, at 9:54 AM, revealed no water pitcher at bedside or anywhere in Resident 63's room. Residents Affected - Some Further observation on August 15, 2023, at 12:45 PM, revealed Resident 63 during lunch meal, no water pitcher at bedside, and the only beverage was an 8-ounce (unit of measure) milk on the lunch tray. Interview with DON on August 17, 2023, at 11:48 AM, revealed she would expect the care plan to be followed and Resident 63 to have a water pitcher at bedside to promote fluid intake. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 12 of 17 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **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 residents receive appropriate treatment and services to prevent urinary tract infections and complications related to the use of a foley catheter (small, flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain) for one of two residents reviewed for use of a catheter (Resident 61). Findings Include: Review of Resident 61's clinical record revealed diagnoses that included malignant neoplasm of prostate (prostate cancer) and obstructive and reflux uropathy (blockage of tubes that carry urine that can cause swelling or damage to the kidneys). Review of Resident 61's physician orders revealed an order dated July 6, 2022, for a foley catheter for neurogenic bladder (bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves) and obstructive and reflux uropathy. Review of Resident 61's current [NAME] (resident daily care guide) revealed that catheter care was to be done every shift and as needed. Review of task documentation for the period of July 18, 2023, through August 16, 2023, revealed that it was not documented that Resident 61 received catheter care on each shift on the following dates: July 18, 19, 24, 29, and 31, and August 8 and 15, 2023. No refusals were documented. During an interview with the Director of Nursing on August 17, 2023, at 11:53 AM, she revealed that the facility policy does not address frequency of catheter care, but the standard of care would be for catheter care to be provided each shift (three times per day). 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 13 of 17 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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 five of five nurse aides reviewed (Employees 9, 10, 11, 12, and 13). Residents Affected - Some Findings Include: Review of select facility documentation revealed that Employee 9 was hired on July 18, 2011; Employee 10 was hired on June 21, 2011; Employee 11 was hired on March 16, 2021; Employee 12 was hired on July 21, 2021; and Employee 13 was hired on December 30, 2021. During an interview with the Nursing Home Administrator on August 16, 2023, at 2:05 PM, he confirmed that no annual performance evaluations were completed for the aforementioned Employees since before June 2022. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 14 of 17 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that it was free from a medication error rate of five percent or greater based on two medication errors out of 29 opportunities. Residents Affected - Few Findings include: Observation of medication administration on August 16, 2023, at 9:11 AM, revealed Employee 5 (Licensed Practical Nurse) administering magnesium oxide 400 milligrams to Resident 173. Review of Resident 173's current physician orders revealed the following order: Magnesium 250 milligrams give one tablet by mouth in the morning related to disorders of magnesium metabolism, dated August 15, 2023. During an interview with Employee 5 on August 16, 2023, at 10:47 AM, Employee 5 verified the order and confirmed that she should have given the 250 milligrams instead of 400 milligrams. Observation of medication administration on August 16, 2023, at 9:11 AM, revealed Employee 5 administering Cymbalta 20 milligrams, one capsule, to Resident 98. Review of Resident 98's current physician orders revealed the following order: Cymbalta oral capsule give 80 milligrams by mouth in the morning related to major depressive disorder, dated May 26, 2023. During an interview with Employee 5 on August 16, 2023, at 10:47 AM, the medication blister packaging was reviewed again and it was noted on the medication identification label that four capsules were to be administered. Employee 5 verified the order and confirmed that they only gave one capsule. They also indicated that they would give the three additional capsules. During medication administration observation there were two errors and 29 opportunities\, resulting in a medication error rate of 6.9%. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 16, 2023, at 1:33 PM, they were made aware of the medication errors observed and Employee 5's interview. During a follow-up interview with the NHA and DON on August 17, 2023, at 11:43 AM, the DON confirmed that she would expect medications to be administered per physician orders. 28 Pa. Code 211.9 (a)(1) Pharmacy Services 28 Pa. Code 211.12 (d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 15 of 17 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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 facility policy reviews, 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 - Some Findings include: Review of facility document, titled Meal Service and Distribution last reviewed August 2, 2023, revealed Have hot food hot and cold food cold when the tray reaches that resident. Review of facility document, titled Dining and Food Service last reviewed August 2, 2023, revealed, The dining experience will enhance the resident's quality of life and recognize the resident's needs during dining to achieve the provision of nourishing, palatable, attractive meals to meet the resident's daily nutritional and special dietary needs. Multiple resident interviews on August 14 and 15, 2023, revealed residents voiced concerns with the temperature and flavor of the food during meal service. During an interview with Resident 13 on August 14, 2023, at 10:35 AM, Resident 13 stated that sometimes the food is not always hot. Interview with Resident 30 on August 14, 2023, at 11:40 AM, revealed he is often served cold food. During an interview with Resident 34 on August 15, 2023, at 9:38 AM, Resident 34 stated that the food is not good. During an interview with Resident 36 on August 14, 2023, at 10:19 AM, Resident 36 indicated that the food was not too good; most of the time it is overcooked, and it is not always hot. Resident 36 further stated that condiments such as salt is not always on the tray. During an interview with Resident 82 on August 15, 2023, at 9:18 AM, when Resident 82 was asked about the food, he scrunched up his nose. Resident 82 stated the food was iffy and the temperature of the food is not good. Interview with Resident 84 on August 14, 2023, at 1:15 PM, revealed her family members bring her food often as facility food does not taste good and is often cold. Follow-up interview with Resident 84 on August 15, 2023, at 12:32 PM, during lunch meal, the Resident revealed the chicken was dry and salty. Immediate observation of the chicken on the plate revealed a dry appearance. During an interview with Resident 106 on August 14, 2023, at 11:02 AM, Resident 106 stated the food is not as good as it used to be. She further stated that the temperature of the food isn't to her liking, and the vegetables are often hard. Review of resident council meeting minutes from May 24, 2023, revealed residents voiced dietary concerns about potatoes and noodles needing to be cooked longer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 16 of 17 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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 Review of resident council meeting minutes from June 21, 2023, revealed residents voiced dietary concerns related to potatoes not being cooked long enough. Review of resident council minutes from July 18, 2023, revealed residents voiced concerns the iced tea needs more sugar, and the potatoes are still not being cooked long enough. Residents Affected - Some Observation of dietary tray line service on August 16, 2023, at 11:46 AM, revealed chocolate pie portions stacked on top of each other causing pie served to residents to be smashed flat on the plate with an unattractive appearance. Observation of dietary tray line service on August 16, 2023, at 12:10 PM, revealed butter parsley noodles were running low and replaced with plain, not seasoned noodles. Interview with Employee 3 (Dietary Manager) on August 16, 2023, at 12:29 PM, revealed it is the facility's expectation that hot foods and beverages are served at or above 140 degrees Fahrenheit (unit of measure), and cold foods and beverages as served at or below 41 degrees Fahrenheit. A Test Tray was completed on August 16, 2023, at 12:34 PM, utilizing lunch tray served from tray line in the main facility kitchen. A test tray was served and placed in closed food cart for approximately two minutes prior to being delivered to third floor dining room area (other trays for room service being delivered here also at this time). The Test Tray included: meatballs with mushroom gravy, noodles, broccoli and cauliflower, chocolate pie, coffee, and milk. Temperatures taken by Employee 3 revealed the following: meatballs were 136 degrees Fahrenheit, not acceptable temperature broccoli and cauliflower were 132 degrees Fahrenheit, not acceptable temperature chocolate pie was 58 degrees Fahrenheit milk was 52 degrees Fahrenheit, not acceptable temperature, and coffee was 135 degrees Fahrenheit, not acceptable temperature The test tray included the plain noodles that were bland in taste, and the chocolate pie that was smashed flat on the plate with an unattractive appearance. Interview with Employee 3 on August 16, 2023, at 12:37 PM, revealed food and beverages should be served at attractive appearance, flavor, and temperatures. Interview with the Nursing Home Administrator on August 16, 2023, at 1:57 PM, revealed it is the facility's expectation that food and beverages are served at attractive appearance, flavor, and temperatures. 28 Pa. Code 211.6 (d) Dietary services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 17 of 17