Inspection·June 13, 2024

F 0641 the Resident has any type of active cancer. Level of Harm - Minimal harm or potential for actual harm Review of Resident 26's Quarterly MDS assessment dated [DATE], revealed under Section I - Active Diagnoses, the Resident was marked yes for having cancer. Residents Affected - Few Review of Resident 26's Quarterly MDS assessment dated [DATE], revealed under Section I - Active Diagnoses, the Resident was marked yes for having cancer. Review of Resident 26's Quarterly MDS assessment dated [DATE], revealed under Section I - Active Diagnoses, the Resident was marked yes for having cancer. During an interview with the DON on June 13, 2024, at 9:17 AM, she revealed Resident 26 has been followed by the physician and gynecology for fibroids (a non-cancerous tumor in the uterus) that contribute to her abdominal pain, and that she has no record of having an active cancer diagnosis. Follow-up interview with the DON on June 13, 2024, at 11:25 AM, revealed she would expect the residents' MDS assessments to be coded accurately. 28 Pa. Code 211.5(f) Medical records 28 Pa Code 211.12 (d)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 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 facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of 23 residents reviewed (Resident 8). Findings include: Based on facility policy, titled Care Plan Policy, not dated, read, in part, Changes in the resident's condition must be reported to the MDS Assessment Coordinator (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) so that a review of the resident assessment and care plan should be made. Review of Resident 8's clinical record revealed diagnoses that included difficulty in walking and muscle weakness. Review of Resident 8's clinical record on June 11, 2024, at 9:28 AM, revealed she was discharged to the hospital on May 1, 2024, and returned to the facility on May 2, 2024. Observation of Resident 8 on June 11, 2024, at 09:49 AM, revealed her face was heavily bruised. Interview with Resident 8 on June 11, 2024, at 09:52 AM, revealed she had a fall after an appointment and went directly to the hospital on May 1, 2024. Review of Resident 8's clinical record revealed she had an MDS assessment completed after her return from the hospital on May 15, 2024. Review of Resident 8's care plan on June 11, 2024, at 1:57 PM, revealed a focus area: [Resident 8] is at risk for falls due to deconditions (decline in physical fitness), last revised April 24, 2024, with a goal Minimize [Resident 8's] risk for injury related to falls through the next review last revised March 21, 2024. Interview with the Director of Nursing on June 13, 2024, at 10:25 AM, revealed she would expect Resident 8's fall care plan to be revised that she has had a fall with injury. 28 Pa. Code 211.12(d)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 23 residents reviewed (Resident 100). Residents Affected - Few Findings include: Review of Resident 100's clinical record revealed that they were admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), and presence of cardiac pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions). Observation of Resident 100 on June 10, 2024, at 10:19 AM, revealed a pacemaker monitoring device (a device used by a cardiologist [heart specialist] to perform an electronic periodic pacemaker function test) that was noted to be plugged into the electrical outlet and turned on. Review of Resident 100's physician orders on June 11, 2024, at 12:08 PM, failed to reveal any orders regarding their pacemaker monitoring or follow-up cardiology appointments. Review of Resident 100's care plan on June 11, 2024, at 12:15 PM, revealed a care plan focus for cardiac disease related to hypertension, initiated on April 5, 2024, which included an intervention for pacemaker checks as ordered, but failed to include any safety interventions associated with the presence of the pacemaker or cardiology follow-up visits. Review of Resident 100's hospital discharge paperwork dated April 5, 2024, revealed that the Resident had a cardiology follow-up appointment on Thursday, September 12, 2024, at 1:30 PM. During an interview with the Nursing Home Administrator, Director of Nursing (DON), and Assistant Director of Nursing on June 12, 2024, at 11:10 AM, the DON indicated that Resident 100 had not had any pacemaker checks since admission as none were due to be completed. The DON further indicated that when Resident 100 returned from an appointment at the wound clinic on June 11, 2024, all their cardiac appointments including pacemaker checks were listed on the after-visit summary and nursing staff added them to Resident 100's orders. The DON confirmed that the facility knew that Resident 100 had a pacemaker at their admission on [DATE], and that nursing staff should have obtained all necessary information from Resident 100's cardiologist regarding pacemaker checks and follow-up appointments. The DON also confirmed all safety measures associated with the presence of a pacemaker should have been implemented at the time of Resident 100's admission and that their care plan has now been revised. During a follow-up interview with the DON on June 13, 2024, at 10:15 AM, the DON indicated that she had researched Resident 100's pacemaker checks a little further that morning. The DON said that Resident 100 was to have an electronic remote check on April 18, 2024, however, the POA had canceled it because the pacemaker monitoring device was still at Resident 100's prior assisted living facility. The DON provided a copy of an after-visit summary dated June 12, 2024, that indicated that a remote electronic pacemaker check was completed on June 12, 2024. The DON also indicated that the cardiologist's office said that if there were to be a problem with Resident 100's pacemaker, an alert would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 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 be sent to the cardiologist's office who would then contact the facility. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident Care Policies Residents Affected - Few 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 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and Resident Responsible Party and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents reviewed (Resident 91). Residents Affected - Few Findings include: Review of facility policy, titled Policy and Procedure Trauma Informed Care, last revised April 15, 2024, read, in part: Residents who display or are diagnosed with a mental disorder, psychosocial adjustment difficulty, and/or PTSD [Post Traumatic Stress Disorder] will be provided with appropriate treatment and services to attain the highest practicable level of mental and psychosocial wellbeing. Procedure . 7. When a Resident has experienced a traumatic event, The Social worker will interview the resident/resident representative regarding potential/actual triggers that may cause re-traumatization. Experiences, preferences, and/or other interventions that eliminate or mitigate triggers that may cause re-traumatization of the resident. 8. The IDT team will ensure that an individualized resident centered care plan is developed for resident that has experienced a traumatic event. The care plan will include but is not limited to the following: Identification of the stressor/past life trauma. Identification of interventions that mitigate against re-traumatization. Identify triggers that could cause re-traumatization. Review of Resident 91's clinical record revealed diagnoses that included Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. The condition may last months or years, with triggers that can bring back memories of the trauma, accompanied by intense emotional and physical reactions) and severe recurrent major depressive disorder with psychotic symptoms (a serious mental health condition that combines a depressed mood with psychosis [a disconnection from reality] that can manifest as hallucinations or delusions). During an interview on June 10, 2024, at 1:24 PM, with Resident 91's Responsible Party, it was revealed that Resident 91 suffered from PTSD from fighting in the Vietnam War and being exposed to harmful chemicals. Review of Resident 91's clinical record revealed a social services assessment dated [DATE]. The assessment indicated Resident 91's PTSD was related to fighting in a war and witnessing various acts of violence, being a prisoner of war, and being exposed to harmful chemicals while in the war. The assessor indicated active signs or symptoms of trauma and interventions were needed. Review of Resident 91's comprehensive plan of care revealed a focus area for risk for changes in mood related to dementia, depression, PTSD and is at risk for adverse effects related to use of antipsychotic and depression medication use, but failed to indicate the source of Resident 91's PTSD or any known triggers or interventions. Further review of Resident 91's clinical record failed to reveal evidence that the facility identified or attempted to identify Resident 91's PTSD triggers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 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 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a staff interview with Employee 2 (Social Services Director), on June 12, 2024, at 2:00 PM, it was revealed that she had no further information to provide and that the previous social services director had completed Resident 91's screening. During a staff interview on June 13, 2024 at 10:14 AM, with Employee 1 (Assistant Director of Nursing), in the presence of the Director of Nursing, it was revealed that the facility was unable to provide any further evidence that culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident had been provided. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code 211.12(d)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395964 If continuation sheet Page 7 of 7