Health inspection·November 29, 2023

F 0600 Level of Harm - Actual harm Residents Affected - Few Review of Employee 1's (Agency Nurse Aid) employee file revealed a facility document, titled Orientation Agency Staff, which included the statement, Our patients all have transfer orders in POC [Plan of Care] and you are expected to follow them. Mechanical Lifts require two (2) [person] assist AND must use the proper sling size determined by weight .All orders must be followed. If you have any questions, it is your responsibility to ask the Registered Nurse or an experienced member of the [NAME] team. Employee 1 signed the document on June 29, 2023, acknowledging he had received, read, and understood the facility policies. Review of Employee 1's employee file revealed that on September 27, 2023, Employee 1 was hired by the facility as a full time Nurse Aide employee. Employee 1 signed an acknowledgement document, acknowledging receiving the facility's employee handbook, understanding the contents of the facility employee handbook, and was provided an opportunity to ask any questions regarding the facility's policies outlined in the facility handbook. Review of the orientation skills check list revealed it also included, Safely transfers resident from bed or chair using Hoyer lift, which was demonstrated on October 4, 2023. Review of Resident 1's clinical record revealed diagnoses that included cerebral palsy (congenital disorder affecting movement, muscle tone, and/or posture) and end stage renal disease (severe decrease/inability of the kidneys to filter toxins from the blood requiring need for dialysis). Review of Resident 1's comprehensive plan of care revealed that Resident 1's care plan for assistance with ADLs included the intervention of, Transfers 2 [person] assist with full Mechanical lift (device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) to powerchair or gerichair with pressure reducing cushion when out of bed, which was initiated on March 6, 2022. Review of Resident 1's physician orders revealed an order for, Transfers 2 [person] assist with full Mechanical lift to gerichair with pressure reducing cushion when out of bed, which was ordered on February 14, 2023. Review of Resident 1's Kardex (clinical documentation developed for care givers [nurse aides, licensed practical nurses, registered nurses] from a resident comprehensive plan of care that condenses a resident's specific care needs) revealed it included, Transfers 2 [person] assist with full Mechanical lift to powerchair or gerichair with pressure reducing cushion when out of bed. Review of Resident 1's nurse aide task documentation from October 30, 2023, to November 28, 2023, revealed Resident 1 was documented as being totally depended on staff for transfers. Further, the Resident required the assistance of two staff during all transfers documented in the 30-day period between October 30, 2023, to November 28, 2023. Review of the Nurse Aide task documentation for the dates of October 30, 2023, to November 17, 2023, revealed that Employee 1 documented that Resident 1 was totally dependent for transfers with the assistance of two staff on November 1, 2, 3, 5, 7, 8, 9, 10, 11, 12, 15, and 17, 2023. Review of Resident 1's interdisciplinary progress notes revealed that Employee 2 (Registered Nurse) entered a progress note stating that on November 17, 2023 at 7:00 PM, [Employee 1 {Nurse Aide}] approached this nurse and reported that during transfer from chair to bed, resident's left leg was bumped and bent back against the bed. [Resident 1] had [complaints of] mild pain at time of incident but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396122 If continuation sheet Page 2 of 10 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 396122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055 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 0600 Level of Harm - Actual harm Residents Affected - Few had just had Tylenol approx[imately] 1 hour prior for headache. Resident was ok with having recently had Tylenol and did not want any other pain medication. Resting in bed at present with no visible injury to left leg. Review of an interdisciplinary progress note documented by Employee 3 (Registered Nurse) stated, Resident reported left upper leg 6/10 [pain] at [8:00 PM of November 17, 2023]. No apparent injury noted. Tylenol given no further complaint for the duration of the shift. Staff attempted to get resident ready for transport to dialysis at [4:30 AM]. Resident refusing citing left hip pain 7/10. Tylenol given. Left leg assess[ed] no apparent injury noted. [Physician] notified. [New order] received for X-ray left hip, left femur, left fibula[,] left tibia, left ankle and left foot . Review of an x-ray performed on Resident 1's left leg on November 18, 2023, revealed a fractured tibia (front most bone of the lower leg; also known as the shin bone). Review of Resident 1's clinical record revealed that on November 18, 2023, Resident 1 was sent to a hospital emergency department for treatment of the fractured left tibia. Review of facility investigation report revealed a witness statement, dated November 18, 2023, provided by Resident 1 which stated, .male aide picked her up without using lift from bed to wheelchair[.] [Resident 1] states she heard a 'popping' noise when she was lifted up. [Resident 1] states she felt paint from [her left leg]. Further review of the investigation report revealed a witness statement given by Resident 1's mother, dated November 18, 2023, which included, [Resident 1] was in her wheelchair, and asked to be put back in bed. [Employee 1] pushed [Resident 1's] chair up to the bed. [Employee 1] said ok ready here we go, scooped [Resident 1] up and was lying her down on the bed. There was a pop and [Resident 1] hollered ['my leg']. I was standing at the door when this occurred. [Resident 1's] foot was bent and leg when it popped. [Resident 1] got situated in bed and asked for pain medicine. She didn't want to be moved or the covers tight . Review of an undated, written witness statement provided by Employee 1 (Nurse Aid) revealed it stated, The incident happen[ed] on Nov[ember] 17, 2023 around 6:30 pm. I was transferring [Resident 1] from her wheelchair to her bed and in the midst of everything her left leg was bent onto the bed. Review of the available information revealed that on the evening of November 17, 2023, Employee 1 transferred Resident 1 from the wheelchair to the Resident's bed without the use a mechanical lift and assistance from a second staff; thus, neglecting Resident 1's physician order for transfer and care planned transfer status. As a result of the transfer, Resident 1 sustained a fracture to the lower left leg which required hospitalization. During a staff interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA), NHA revealed that during a verbal interview on November 18, 2023, Employee 1 acknowledged that he transferred Resident 1 by himself without the use of a mechanical lift. During the interview, the NHA and DON confirmed that as a result of the facility investigation, the actions of Employee 1 met the definition of neglect by not providing Resident 1 a transfer with a mechanical lift and two staff assistance per Resident 1's physician orders and care plan. During the abbreviated survey, the NHA and DON provided information and documentation of an immediate action plan put into place after the transfer that subsequently caused injury to Resident 1. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396122 If continuation sheet Page 3 of 10 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 396122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055 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 0600 immediate action plan was put into place on November 18, 2023. Level of Harm - Actual harm On November 18, 2023, Employee 1 was suspended pending an investigation and, subsequently, employment of Employee 1 was terminated on November 20, 2023, as a result of the facility investigation finding Employee 1 had committed Abuse. Residents Affected - Few On November 18, 2023, the facility began educating all nursing staff (Registered Nurse, Licensed Practical Nurse, and Nurse Aide) on providing transfers in accordance with a residents' physician orders, as determined by the therapy department. All facility employees were educated as of November 20, 2023. On November 22, 2023, the facility began an audit of five resident transfers to be done weekly. The audits are to ensure resident transfers are conducted in accordance with the physician orders, therapy determination, and resident care planned transfer status. The facility will continue to audit three resident transfers five times per week for three months. The results of the audit will be reviewed by the facility's Quality Assurance process. During an onsite investigation on November 28, 2023, the facility's audits and education were reviewed. Direct care staff were interviewed and confirmed that they received education and voiced understanding of the abuse policy and resident's transfer status. Observations of residents being transferred to and from bed were made and no concerns were identified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396122 If continuation sheet Page 4 of 10 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 396122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility investigation, facility policy review, clinical record review, and staff interviews, it was determined that the facility displayed past noncompliance in that they had failed to ensure staff report violations involving neglect of a resident for one of three resident records reviewed (Resident 1). Findings include: Review of facility policy, titled Abuse Reporting, last reviewed January 23, 2023, revealed the policy statement was, The facility shall protect its residents to the fullest extent possible from physical[,] verbal, sexual or mental abuse, acts of neglect, corporal punishment, involuntary seclusion and misappropriation of residents' property. As all residents have the right to be free from abuse, mistreatment, neglect or misappropriation of property. All individuals not adhering to said policy shall jeopardize their position with the facility. Review of the policies definitions section revealed the policy defined neglect as, .failure to provide oneself or the failure of a caretaker, to provide goods or services essential to avoid a clear and serious threat to a resident's physical or mental health. This may include the failure of the caretaker to provide adequate nutrition, assistance with activities of daily living, health related services .medical services for the person unable to care for him/herself . Activities of Daily Living (ADLs) are defined as activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. Review of the policy subsection, titled Protection, revealed it stated, Immediately upon report of an abuse situation, the employee shall be released of duties affecting the alleged abused resident. The resident shall be monitored, and documented nursing checks shall be conducted as the situation warrants ensuring resident safety and freedom from retaliation. Policy subsection, titled Investigation, stated, All allegations of abuse shall be thoroughly investigated. All incidents shall be investigated via but not limited to the following .House Supervisor / ADON [Assistant Director of Nursing] / DON [Director of Nursing] shall document intake of allegation of abuse .Allegations of abuse shall be reported to the DON and Administrator plus appropriate state agencies as required by PA Law .In addition, all reported bruises or injuries of unknown etiology shall also be investigated by the Director of Nursing via evaluation, interview with resident if possible and completion of incident report . Review of facility's job description for Registered Nurse (Charge Nurse), revealed Essential Duties: Resident Care Duties, stated that the Registered Nurse, Reports all incidents immediately to appropriate supervisor or DON, and, Reports suspected abuse immediately per [NAME] Subacute policy and applicable federal, state and local regulations . Review of Resident 1's clinical record on November 28, 2023, at approximately 9:30 AM, revealed diagnoses that included cerebral palsy (congenital disorder affecting movement, muscle tone, and/or posture) and end stage renal disease (severe decrease/inability of the kidneys to filter toxins from the blood requiring need for dialysis). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396122 If continuation sheet Page 5 of 10 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 396122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 1's comprehensive plan of care revealed that Resident 1's care plan for assistance with ADLs included the intervention of, Transfers 2 [person] assist with full Mechanical lift to powerchair or gerichair with pressure reducing cushion when out of bed, which was initiated on March 6, 2022. Review of Resident 1's physician orders revealed an order for, Transfers 2 [person] assist with full Mechanical lift to gerichair with pressure reducing cushion when out of bed, which was ordered on February 14, 2023. Review of Resident 1's Kardex (clinical documentation developed for care givers [nurse aides, licensed practical nurses, registered nurses] from a resident comprehensive plan of care that condenses a resident's specific care needs) revealed it included, Transfers 2 [person] assist with full Mechanical lift to powerchair or gerichair with pressure reducing cushion when out of bed. Review of facility investigation report revealed a witness statement, dated November 18, 2023, provided by Resident 1 which stated, .male aide picked her up without using lift from bed to wheelchair[.] [Resident 1] states she heard a 'popping' noise when she was lifted up. [Resident 1] states she felt paint from [her left leg]. Review of an interdisciplinary progress note documented by Employee 3 (Registered Nurse) on November 18, 2023, at 8:31 AM, revealed Employee 3 stated, Resident reported left upper leg 6/10 [pain] at [8:00 PM of November 17, 2023]. No apparent injury noted. Tylenol given no further complaint for the duration of the shift. Staff attempted to get resident ready for transport to dialysis at [4:30 AM]. Resident refusing citing left hip pain 7/10. Tylenol given. Left leg assess[ed] no apparent injury noted. [Physician] notified. [New order] received for X-ray left hip, left femur, left fibula[,] left tibia, left ankle and left foot . Review of the interdisciplinary progress notes revealed a note from Employee 3 (Registered Nurse), which was created on November 18, 2023 at 9:11 AM with an effective date of November 17, 2023 at 9:00 PM, which stated, At the start of the shift [November 17, 2023, at approximately 8:00 PM] [Resident 1] reported that she was transported from her chair to bed without the use of a mechanical lift. Resident stated that the left leg was 'bent backwards', during transport from chair to bed. Left leg assessed. No apparent injury noted at the time of the assessment. Bruising noted on left shin. Resident denied that left shin hit any surface during transport to bed. Resident denied pain to area of left shin . Review of available facility documentation revealed Employee 3 did not inform the DON or the NHA that Resident 1 was injured as a result of a transfer that was not performed per Resident 1's physician's orders or according to Resident 1's comprehensive plan of care. During the staff interview with NHA and DON, DON confirmed that Employee 3 did not notify the DON of Resident 1's report that Employee 1 transferred Resident 1 without the use of a lift, which resulted in injury to the left leg. During the staff interview, DON revealed that Employee 4 (Registered Nurse) reported to the DON after Resident 1's x-ray revealed a fracture of the lower left leg. During the interview, DON revealed that Employee 1 was able to begin his shift at the facility at approximately 7:30 AM, and worked until the DON suspended Employee 1 after initiating an investigation at approximately 11:40 AM on November 18, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396122 If continuation sheet Page 6 of 10 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 396122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Based on the facility investigation and review of Resident 1's clinical record, it was identified that Employee 3 failed to notify the DON, or any other administrative staff, that Employee 1 has neglected to follow Resident 1's transfer status as ordered by the physician and indicated in the comprehensive plan of care; which resulted subsequently in a fracture of Resident 1's lower left leg. On November 18, 2023, Employee 1 was suspended pending an investigation and, subsequently, employment of Employee 1 was terminated on November 20, 2023, as a result of the facility investigation finding Employee 1 had committed Abuse. During the abbreviated survey, the NHA and DON provided information and documentation of an immediate action plan put into place after the Employee 3 failed to notify via the chain of command (DON, NHA) of an incident that resulted in Resident pain and/or possible injury. On November 18, 2023, the facility began educating all nursing staff (Registered Nurse, Licensed Practical Nurse, and Nurse Aide) on reporting to supervisor or administration complaints of pain, or reports of care or transfers that may have resulted in injury, and documentation of an assessment by the registered nurse when ever there is suspected injury. Finally, the education included that investigations must be started immediately if and when there is a suspicion of abuse. During an onsite investigation on November 28, 2023, the facility's audits and education were reviewed. Direct care staff were interviewed and confirmed that they received education and voiced understanding of the abuse policy and resident's transfer status. Observations of residents being transferred to and from bed were made and no concerns were identified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396122 If continuation sheet Page 7 of 10 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 396122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility investigation, facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility displayed past noncompliance in the failure to follow the plan of care and provide the required assistance during a transfer, resulting in harm as evidenced by a leg fracture, for one of three resident records reviewed (Resident 1). Findings include: The facility's expectations for direct care staff states, Our patients all have transfer orders in POC [Plan of Care] and you are expected to follow them. Mechanical Lifts require two (2) [person] assist AND must use the proper sling size determined by weight .All orders must be followed. If you have any questions, it is your responsibility to ask the Registered Nurse or an experienced member of the [NAME] team. Review of Resident 1's clinical record revealed diagnoses that included cerebral palsy (congenital disorder affecting movement, muscle tone, and/or posture) and end stage renal disease (severe decrease/inability of the kidneys to filter toxins from the blood requiring need for dialysis). Review of Resident 1's comprehensive plan of care revealed that Resident 1's care plan for assistance with activities of daily living included the intervention of, Transfers 2 [person] assist with full Mechanical lift (device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) to powerchair or gerichair with pressure reducing cushion when out of bed, which was initiated on March 6, 2022. Review of Resident 1's physician orders revealed an order for, Transfers 2 [person] assist with full Mechanical lift to gerichair with pressure reducing cushion when out of bed, which was ordered on February 14, 2023. Review of Resident 1's Kardex (clinical documentation developed for care givers [nurse aides, licensed practical nurses, registered nurses] from a resident comprehensive plan of care that condenses a resident's specific care needs) revealed it included, Transfers 2 [person] assist with full Mechanical lift to powerchair or gerichair with pressure reducing cushion when out of bed. Review of Resident 1's nurse aide task documentation from October 30, 2023, to November 28, 2023, revealed Resident 1 was documented as being totally dependent on staff for transfers. Further, the Resident required the assistance of two staff during all transfers documented in the 30-day period between October 30, 2023, to November 28, 2023. Review of the Nurse Aide task documentation for the dates of October 30, 2023, to November 17, 2023, revealed that Employee 1 documented that Resident 1 was totally dependent for transfers with the assistance of two staff on November 1, 2, 3, 5, 7, 8, 9, 10, 11, 12, 15, and 17, 2023. Review of Resident 1's interdisciplinary progress notes revealed that Employee 2 (Registered Nurse) entered a progress note stating that on November 17, 2023 at 7:00 PM, [Nurse Aide] approached this nurse and reported that during transfer from chair to bed, resident's left leg was bumped and bent back against the bed. [Resident 1] had [complaints of] mild pain at time of incident but had just had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396122 If continuation sheet Page 8 of 10 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 396122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Tylenol approx[imately] 1 hour prior for headache. Resident was ok with having recently had Tylenol and did not want any other pain medication. Resting in bed at present with no visible injury to left leg. Level of Harm - Actual harm Residents Affected - Few Review of an interdisciplinary progress note documented by Employee 3 (Registered Nurse) stated, Resident reported left upper leg 6/10 [pain] at [8:00 PM of November 17, 2023]. No apparent injury noted. Tylenol given no further complaint for the duration of the shift. Staff attempted to get resident ready for transport to dialysis at [4:30 AM]. Resident refusing citing left hip pain 7/10. Tylenol given. Left leg assess[ed] no apparent injury noted. [Physician] notified. [New order] received for X-ray left hip, left femur, left fibula[,] left tibia, left ankle and left foot . Review of the clinical record revealed that X-ray results were positive for left leg fibula and tibula (lower leg bones) fracture. On November 18, 2023, that facility initiated an investigation into Resident 1's fractured left leg. Review of investigation revealed a statement from Resident 1. Resident 1 stated that a male aide picked her up without using lift. States she heard a popping noise when she was lifted up and that she felt pain. Review of the statement obtained from Resident 1's mother, who was in the room during the incident, stated that Resident 1 was in her chair and asked to be put back to bed. Employee 1 (Nurse Aide) pushed the chair up to the bed and said ok ready here we go, scooped [Resident 1] up and was laying her down on the bed. There was a pop and [Resident 1] [NAME][e]d my leg. Further review of the facility investigation revealed a statement from Employee 2 (Registered Nurse) dated November 18, 2023, that stated that Employee 1 (Nurse Aide) approached the nurse stating that Resident 1 was requesting something for pain. He continued to say that, during a transfer from chair to bed, [Resident 1's] left leg bent back slightly and she said it hurt. Employee 2 told Resident 1 that she just had Tylenol and asked the resident if she was ok and she said yes. Employee 2 stated that no visible injuries were observed to left leg at that time. Review of the statement obtained from the facility from Employee 1 (Nurse Aide) stated, I was transferring [Resident 1] from her wheelchair to her bed and in the midst of everything her left leg was bent onto the bed. The investigation concluded that on the evening of November 17, 2023, at approximately 6:30 PM, Employee 1 transferred Resident 1 without the use of a mechanical lift (Hoyer) and second person assist as ordered by the physician and included in Resident 1's comprehensive plan of care. Instead, Employee 1 lifted Resident 1 out of her wheelchair with his arms and placed Resident 1 in bed, at which time Resident 1's left leg and left foot were bent behind the Resident. As a result, Resident 1 suffered a fracture to the lower left leg, specifically a fracture of the fibula and tibula of the left leg. During the abbreviated survey, the Nursing Home Administrator (NHA) and Director of Nursing (DON) provided information and documentation of an immediate action plan put into place after the transfer that subsequently caused injury to Resident 1. The immediate action plan was put into place on November 18, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396122 If continuation sheet Page 9 of 10 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 396122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few On November 18, 2023, Employee 1 was suspended pending an investigation and, subsequently, employment of Employee 1 was terminated on November 20, 2023, as a result of the facility investigation finding Employee 1 had committed Abuse. On November 18, 2023, the facility began educating all nursing staff (Registered Nurse, Licensed Practical Nurse, and Nurse Aide) on providing transfers in accordance with a residents' physician orders, as determined by the therapy department. All facility employees were educated as of November 20, 2023. On November 22, 2023, the facility began an audit of five resident transfers to be done weekly. The audits are to ensure resident transfers are conducted in accordance with the physician orders, therapy determination, and resident care planned transfer status. The facility will continue to audit three resident transfers five times per week for three months. The results of the audit will be reviewed by the facility's Quality Assurance process. During an onsite investigation on November 28, 2023, the facility's audits and education were reviewed. Direct care staff were interviewed and confirmed that they received education and voiced understanding of the abuse policy and resident's transfer status. Observations of residents being transferred to and from bed were made and no concerns were identified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396122 If continuation sheet Page 10 of 10