Health inspection·September 28, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm 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 observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for two of 24 residents reviewed (Residents 8 and 59). Residents Affected - Some Findings include: Review of Resident 8's clinical record contained diagnoses included adult failure to thrive, dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), and muscle weakness. Observation on September 25, 2023, at 9:53 AM, in the hallway near the second floor nursing desk, revealed Resident 8 was in her tilt/recline wheelchair, and both blue plastic arm covers contained a light brown film. Observation with the Director Of Nursing (DON) on September 28, 2023, at 12:05 PM, in the dining room, revealed Resident 8 was in her tilt/recline wheelchair, and both blue plastic arm covers contained a light brown film. During an interview on September 28, 2023, at 12:05 PM with the DON, it was revealed that Resident 8's tilt/recline wheelchair arm covers should be cleaned. Review of Resident 59's clinical record contained diagnoses that included dementia and muscle weakness. Observation in Resident 59's room on September 25, 2023, at 10:20 AM, revealed a blue floor mat observed alongside of the wall noted to have an one inch tear on the dark blue side of the mat, and the blue coloring is faded and worn to a light red color in two areas. Observation in Resident 59's room on September 28, 2023, at 12:10 PM, with the DON, revealed there was an one inch tear on the dark blue side of the mat. During an interview on September 28, 2023, at 12:10 PM, with the DON, revealed that the floor mat would be replaced. 28 Pa. Code 201.18 (e)(1)(2.1)Management Page 1 of 17 395123 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined the facility failed to complete a comprehensive assessment after a significant change in condition for one of 24 residents reviewed (Resident 81). Residents Affected - Few Findings include: Review of resident 81's clinical record revealed diagnoses that included dysphasia (swallowing difficulties) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 81's current physician orders revealed an order for Homeland Hospice, due to unspecified protein calorie malnutrition, with an order date of August 23, 2023. Review of Resident 81's comprehensive care plan revealed, under the focus area, that Resident was admitted to Hospice services on August 16, 2023, due to unspecified severe protein-calorie malnutrition, with an initiation date of August 16, 2023. Review of Resident 81's MDS assessments (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), revealed that a significant change MDS was not completed when Resident 81 was admitted to hospice. During an interview with the Nursing Home Administrator (NHA) on September 27, 2023, at 8:59 AM, the NHA confirmed that a significant change MDS had not been completed for Resident 81 and has been initiated as of that day, September 27, 2023. 28 Pa code 211.12(d)(1)(3)(5) Nursing services 395123 Page 2 of 17 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

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 two of 24 residents reviewed (Residents 52 and 62). Residents Affected - Some Findings include: Review of Resident 52's clinical record on September 25, 2023, at approximately 11:00 AM, revealed diagnoses that included type II diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 52's Quarterly Minimum Data Set (MDS - assessment tool utilized to identify a resident's physical, mental, and psychosocial needs), with an assessment reference date of July 27, 2023, revealed that section N.; 0410 was coded to reflect that Resident 52 had received an antibiotic medication for the prior seven days. Review of Resident 52's clinical record revealed that Resident 52 did not receive an antibiotic medication during the July 27, 2023, MDS assessment look back period. During an electronic communication with the Nursing Home Administrator (NHA) on September 27, 2023, at 9:34 AM, the NHA confirmed that the Quarterly MDS was coded incorrectly for Resident 52. Review of Resident 62's clinical record on September 26, 2023, at approximately 10:15 AM, revealed diagnoses that included emphysema (damage of the lung tissue which decreases gas exchange) and type II diabetes mellitus. Review of Resident 62's clinical record revealed that Resident 62 entered into Hospice care on April 6, 2023. Review of Resident 62's Quarterly MDS, with an assessment reference date of July 7, 2023, revealed that Section O.; 0100 - K(2) was coded to reflect that Resident 62 was not receiving Hospice care. During an electronic communication with the NHA on September 27, 2023, at 9:34 AM, the NHA confirmed that the Quarterly MDS was coded incorrectly for Resident 62. 28 Pa code 211.12(d)(1)(5) Nursing services 395123 Page 3 of 17 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on resident observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident comprehensive plan of care was reviewed and revised for three of 24 residents reviewed (Residents 45, 62, and 292). Findings include: Review of Resident 45's clinical record revealed diagnoses that included history of stroke (damage to the brain from interruption of its blood supply), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), and dysphagia (difficulty swallowing). Observation in Resident 45's room on September 25, 2023, at 11:20 AM, revealed a bottle of Glucerna (diabetic meal replacement formula) was being administered via a feeding pump. Review of Resident 45's September 2023 physician orders included Glucerna 1.5 at 65 milliliters per hour (ml/hr - unit of measure) for 16 hours on at 6:00 AM and off at 10:00 PM, with a start date of June 24, 2023. Review of Resident 45's care plan documented a focus area for tube feeding required to assist the Resident in maintaining nutritional status related to failure to eat related to dementia and history of stroke, date initiated May 4, 2021, and revision February 8, 2023. Inventions included: Tube feeding: Jevity (high fiber meal replacement formula) 1.5 85 ml/hr for 16 hours, date initiated May 4, 2023, and revision dated February 8, 2023. During an interview on September 27, 2023, at 2:00 PM, with the Nursing Home Administrator (NHA), it was revealed that the care plan documented the incorrect tube feeding formula. During an interview with Employee 4 on September 28, 2023, at 10:15 AM, it was revealed that there were supply issues with obtaining Glucerna and, during that timeframe, the tube feeding order was changed to Jevity. The Resident did experience an increase in blood sugars, so when Glucerna was available, it was reordered and the care plan must not have been updated. Review of Resident 62's clinical record on September 26, 2023, at approximately 10:15 AM, revealed diagnoses that included emphysema (damage of the lung tissue which decreases gas exchange) and type II diabetes mellitus. Review of Resident 62's comprehensive plan of care revealed that Resident 62's care plan for skin integrity, which was revised on August 24, 2023, included the use of a foley catheter (tube inserted into the bladder through the urethra to facilitate bladder emptying). Review of Resident 62's physician orders revealed that Resident 62's foley catheter was discontinued on July 13, 2023. During an electronic communication with the NHA on September 28, 2023, at 8:46 AM, the NHA 395123 Page 4 of 17 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some confirmed that Resident 62's care plan should have been updated and that the foley catheter use should have been removed from the Resident care plan. Review of Resident 292's clinical record revealed diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and gastro esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining). Observation of Resident 292 during the initial tour of the facility on September 25, 2023, at approximately 2:32 PM, revealed there was an oxygen concentrator in the Resident's room beside their bed. Review of Resident 292's discontinued physician's orders revealed the Resident had an order for Oxygen (O2) at 2 Liters Per Minute (LPM) via nasal cannula, with a start date of September 18, 2023, and a discontinued date of September 19, 2023. Further review of Resident 292's current physician's orders revealed an order for O2 at 2 LPM as needed for shortness of breath, with a start date of September 20, 2023, and a discontinue date of indefinite. Review of Resident 292's care plan on September 26, 2023, at approximately 1:50 PM, failed to include mention of Resident 292's oxygen use on a focus or intervention area. An interview with the NHA on September 17, 2023, at 11:59 AM, revealed that Resident 292's oxygen use was a one-time thing and the Resident refuses to keep it on. Further interview with NHA on September 17, 2023, at 1:48 PM, revealed that oxygen use has been added to Resident 292's care plan as an intervention, documented as oxygen as needed. 28 Pa code 211.12(d)(1)(3)(5) Nursing services 395123 Page 5 of 17 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on clinical record review, facility policy review, and staff interview, it was determined the facility failed to ensure a medication reconciliation of medications, record of disposition of medications, and documentation of medications dispensed was conducted upon discharge for one of three discharged residents reviewed (Resident 88). Findings include: Review of facility policy, titled Discharge With Medication, effective date of July 1, 2023, revealed it stated it was the facility's policy that, Medications are sent with the resident upon discharge from the facility only under conditions that protect the resident and assure compliance with applicable state laws. Review of section, titled Procedures, revealed in subsections A, F, H, and I stated, Medications may be sent with the resident on discharge if ordered by the prescriber. The prescriber should list the medications to be released upon discharge .Discharge medication information is listed in the order summary report in [the electronic health record] .The resident or responsible party should sign the Medication Release Form as proof of chain of custody .The nurse should document the number of doses of each medication discharged to the patient or responsible party on the Medication Disposition form and indicate that they are released to the customer. Review of Resident 88's clinical record on September 28, 2023, at approximately 10:00 AM, revealed diagnoses that included congestive heart failure (CHF - thickening of the heart muscles with decreases the efficiency of the heart when pumping blood to the rest of the body) and type II diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment). Review of Resident 88's clinical record revealed Resident 88 was discharged from the facility to home on August 11, 2023. Review of Resident 88's discharge paper work, including interdisciplinary progress notes, physician discharge progress note, and medication disposition record, revealed no medication reconciliation of all pre- and post-discharge medications was completed. Review of the physician's discharge progress note revealed no information regarding Resident 88's medications at the time of discharge was documented in the provider note. Further, Resident 88's discharge medication disposition record did not list specific medications, the amount of medications being dispensed upon discharge, or administration directions nor times of the medications being dispensed to Resident 88 upon discharge. Finally, review of available documentation revealed that there was no signature of Resident 88 or Resident 88's Responsible Party on Resident 88's medication disposition form. During an electronic communication with the Nursing Home Administrator (NHA) on September 29, 2023, at 1:32 PM, NHA revealed facility staff should have completed a medication reconciliation and disposition form as stated in the facility policy. 395123 Page 6 of 17 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0661 28 Pa code 211.12(d)(1)(5)Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395123 Page 7 of 17 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, policy review, and resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for one of 24 residents reviewed (Resident 47). Residents Affected - Few Findings include: Review of Facility provided policy, titled Activities of Daily Living (ADLs), Supporting, revised March 2018, revealed, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident 47's clinical record revealed diagnoses that included hypertension (high blood pressure) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 47's most recent 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), completed on August 4, 2023, revealed that Resident 47 has a BIMS (brief interview for mental status) of 15, indicating that the Resident is cognitively intact. Further review of Resident 47's most recent Quarterly MDS, completed on August 4, 2023, under section G - Functional Status, more specifically G0120. Bathing, revealed that the Resident requires total dependence on staff to assist with bathing with minimum two persons physical assist under support provided. Interview with Resident 47 during initial tour of the facility, on September 25, 2023, at approximately 11:09 AM, revealed that the Resident does not always get showers on her scheduled shower days. Resident 47 also revealed that they would prefer showers, but do not always get offered to take showers. Review of Resident 47's ADL-Bathing task sheet for the past 30 days revealed that Resident 47 was given a bed bath on the following days: September 6, 9, 13, 16, 20, and 23, 2023. On August 30, 2023, it was marked 'Not applicable'. Resident 47 received a shower on September 27, 2023. Review of Resident 47's ADL-Bathing support provided task sheet for the past 30 days revealed that the Resident was provided a one person physical assist on the following days: September 6, 9, 13, 23, and 27, 2023. Interview with the Director of Nursing on September 27, 2023, at approximately 12:01 PM, revealed that they are not sure why Not Applicable was marked on Resident 47's ADL bathing task sheet and that there is ongoing education with staff occurring on marking the correct coding. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395123 Page 8 of 17 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on review of facility documentation, observation, and resident and staff interviews, it was determined that the facility failed to provide an ongoing program of activities designed to meet the needs, interests, and functional abilities of residents for two of two nursing floors (First and Second floor nursing units). Residents Affected - Some Findings include: During resident interviews on September 25, 2023, at approximately 10:30 AM, Resident 17 reported that the facility cancels activities frequently. Further, during the resident interviews, Resident 52 also stated that the facility has canceled multiple activities. An interview with the residents who participated in the Resident Council group meeting on September 26, 2023, at 1:15 PM, revealed that 14 out of 14 residents in group revealed activities do not occur daily or as scheduled by the facility. Review of the facility's September 2023 Activity Calendar revealed that trivia is scheduled on the first floor on September 27, 2023, at 2:00 PM. Observation on the first floor on September 27, 2023, at 2:17 PM, revealed no activities occurring on the first floor as scheduled. Interview with residents sitting in the dining room painting a picture at 2:17 PM on September 27, 2023, revealed that they were not aware of trivia occurring that day or time, and confirmed it was not happening. Review of the facility's September 2023 Activity Calendar revealed that the morning news was scheduled for September 28, 2023, at 10:30 AM. Multiple observations made on the first and second floor on September 28, 2023, between 10:32 AM and 10:40 AM, revealed that there was no morning news occurring in the facility as scheduled. Review of the facility's current admission Agreement, under section G. Quality of Life Services/Activity Services, revealed, the facility provides an ongoing activities program designed to meet the interests of, and support the physical, mental, and psychosocial well-being of residents by encouraging both independence and interaction in the community. An interview with the Nursing Home Administrator (NHA) on September 28, 2023, at 12:55 PM, revealed that they are in the process of hiring more activity employees and that, when the Activity Director or assistant is not available to run the scheduled activities, the back-up plan is for Nurse Aides to assist with running the activities; but direct care comes first so they have not been able to assist with activities. NHA acknowledged that it is a problem that activities are not occurring as scheduled and is working on a resolution. 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.10(d) Resident care policies 395123 Page 9 of 17 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, policy review, staff interview, and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer received care consistent with professional standards of practice for one of 24 Residents reviewed (Resident 50). Residents Affected - Few Findings include: A review of the facility wound care policy, titled Dry/Clean Dressings, last reviewed August 2023, stated, after cleaning the wound and applying treatment, apply the ordered dressing and secure; label with date and initials on top of dressing. A review of the clinical record for Resident 50 on September 28, 2023, revealed clinical diagnoses that included quadriplegia (paralysis of all four extremities, including the trunk) and stage IV sacral pressure ulcer (ulcer involving loss of skin layers, exposing muscle and bone of the large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity). A review of Resident 50's physician orders dated September 2023, included an order for wound care to the sacrum every day and evening shift. Observation of wound care on September 28, 2023, at 10:40 AM, revealed the dressing that was removed from the sacral wound was not dated or initialed. Employee 6 (Licensed Practical Nurse) confirmed the dressing she removed was not dated or initialed, as required per policy. During an interview with the Nursing Home Administrator and Director of Nursing on September 28, 2023, at 11:30 AM, they agreed that Resident 50's dressing should have been dated and initialed as stated in the policy. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services 395123 Page 10 of 17 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the pharmacy contract, medication guide review, clinical record review, and staff interviews, it was determined that the facility failed to provide pharmaceutical services to accurately acquire, receive, dispense, and administer drugs to meet the needs of each resident, which resulted in one resident not receiving their seizure medication and suffering from a seizure, for one of 24 residents reviewed (Resident 240). Findings include: Review of the Pharmacy Products and Services agreement, dated February 1, 2018, read, in part, the pharmacy shall provide pharmacy products to the facility and its residents in a prompt and timely manner. The facility will order exclusively from Pharmacy all pharmacy products and services required for individual residents. Pharmacy may assign its rights and delegate its duties and obligations under the Agreement to any other licensed entity which is owned, directly or indirectly, provided that Facility is within the geographic service area of such assignee. Review of Resident 240's clinical record revealed diagnoses that included cerebral palsy (a condition marked by impaired muscle coordination typically caused by damage to the brain), seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or stated of awareness), schizophrenia (mental disorder involving a breakdown in the relation between thought, emotion, and behavior leading to faulty perception, inappropriate actions and feelings, affects a person's ability to think, feel, and behave clearly), and bipolar disorder (a mental health condition alternating periods of elation and depression). Review of pre-admission hospital documentation, dated August 30, 2023, revealed that Resident 240 was hospitalized on [DATE]. The Resident has history of seizures and home medications, including Xcopri (medication used to treat seizures) 200 milligrams (mg-unit of measure) once daily and Lamictal (medication used to treat seizures) 200mg once daily. Further review of hospital documentation revealed that Resident 240 received Xcopri 200 mg once daily and Lamictal 200 mg twice daily while in the hospital, with no seizure activity noted as of August 29, 2023. Review of Hospital After Visit Summary documented Resident 24 was hospitalized [DATE], through September 22, 2023, for self-care deficit and diagnoses including seizures. Further review of the Hospital After Visit Summary medication list included Lamictal 200 mg in the morning and evening, with last dose given September 21, 2023, at 11:06 PM; and Xcopri 200 mg every morning, with last dose given September 21, 2023, at 9:23 AM. It was noted that the aforementioned medications were not administered by the hospital the morning the Resident was discharged from the hospital to the facility on September 22, 2023. Review of Resident 240's September 2023 Physician orders included a verbal order for Xcopri 200 mg one time a day for seizures, with a start date of September 23, 2023, and a verbal order for Lamotrigine (Lamictal) 200 mg two times a day for bipolar disorder, with a start date of September 22, 2023. Review of Resident 240's September 2023 Medication Administration Record (MAR-documentation of 395123 Page 11 of 17 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0755 Level of Harm - Actual harm medication administration) included Xcopri 200 mg at 9:00 AM, start date September 23, 2023, at 9:00 AM, documented 16 (hold, see nurse's note) on September 23rd and 24th, 2023. Further review of the MAR documented Lamotrigine (Lamictal) 200 mg at 9:00 AM and 5:00 PM, start September 22, 2023, at 5:00 PM, medication was documented as administered per physician orders. Residents Affected - Few Review of progress notes dated September 22, 2023, read in part, admitted at 10:00 AM from the hospital, call placed to facility Physician (Employee 1) who was in the facility at time of Resident's arrival; and orders were reviewed and verified. Review of a progress note dated September 23, 2023, at 9:10 AM, read, in part, Xcopri 200 mg one time a day for seizures not available, supervisor aware. Progress note dated September 24, 2023, at 1:34 PM, read, in part, Xcopri 200 mg one time a day for seizures, awaiting from pharmacy. Progress note dated September 24, 2023, at 10:50 PM, read, in part, Resident had a seizure at 10:15 PM today, which lasted for three minutes. Resident has history of seizures/has routine seizure medication, Xcopri 200 mg, which he gets in the morning; however, it wasn't administered related to waiting from pharmacy. Progress note dated September 24, 2023, at 11:22 PM, read, in part, pharmacy was called regarding Resident's medication and a copy of the physician orders faxed to pharmacy; endorsed to night shift to follow-up. Progress note dated September 25, 2023, at 5:00 AM, read, in part, Resident found on floor beside left side of bed with Percutaneous Endoscopic Gastrostomy (PEG- feeding tube) tube in his hand; PEG site cleansed and a dressing was applied. Unable to understand the Resident as to what happened. Nursing Assistant provided incontinence care at 4:00 AM. At time of fall, floor was dry, brief was wet, bed was in low position and locked, the Resident was alert and responding per baseline. Resident's mother was notified, and requested he be sent out for evaluation and PEG replacement. Ambulance transported the Resident at 5:25 AM. Review of prescriptions sent to pharmacy revealed two prescriptions were sent to the contract pharmacy for Xcopri; one on September 22, 2023, for 30 tablets, and a second on September 24, 2023, for 30 tablets. Review of the physician's (Employee 1) History and Physical dated September 24, 2023, at 10:19 PM, documented a diagnosis of seizure disorder. Xcopri and Lamictal were ordered for seizures, and both orders were active. Care plan and medication list were documented as reviewed; continue current medications, management, and interventions. There was no documentation regarding Xcopri not available from the pharmacy and the Resident having missed two doses of the medication. During an interview on September 27, 2023, at 1:45 PM, with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee 3 (Registered Nurse), it was revealed that Xcopri is a controlled medication and requires a prescription. It was also revealed that the pharmacy didn't have the medication in stock and failed to communicate that to the facility. The NHA noted that Resident 240 was ordered and administered Lamictal, which is a medication used to treat seizures and bipolar disorder, and Resident 240 was receiving the medication for seizures. The incorrect diagnoses was documented on the physician orders, per hospital discharge summary and the Physician's history and 395123 Page 12 of 17 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0755 physical. The Lamictal was being administered for seizures. Level of Harm - Actual harm During the interview, Employee 3 stated that there are two local pharmacies that the contract pharmacy should utilize if they don't have a required medication in stock. There is a process in place where the local pharmacies utilize a transportation company to deliver medications to the facility. Residents Affected - Few Review of Employee 2's (Registered Nurse Supervisor) phone statement obtained by the DON, dated September 27, 2023, revealed that he was notified the Xcopri wasn't available for administration on September 23rd, 2023; at which time, he called the pharmacy and then the physician. He obtained the prescription, sent it to the pharmacy, and confirmed the pharmacy received the prescription. He reviewed the process with the night shift supervisor to ensure the appropriate people were notified. It was revealed that on September 24, 2023, the physcian (Employee 1) was in the building and assessed Resident 240. Employee 2 stated he spoke with Employee 1 regarding Resident 240's status and his medication. On September 24, 2023, Employee 2 contacted the pharmacy again, at which point he was told Xcopri wasn't in stock and it would be delivered on September 25th, 2023. During a phone interview with Resident 240's physician, Employee 1, on September 28, 2023, at 10:30 AM, it was revealed he was not notified that the Xcopri was unavailable or that Resident 240 missed two doses. Employee 1 stated that he wouldn't of ordered another medication, his recommendation would've been to send the Xcopri perscription to another pharmacy to obtain the Xcopri as soon as possible. Xcopri prescribing medication guide, revised June 2022, read, in part, withdrawal of Xcopri - advise patients not to discontinue use of Xcopri without consulting with their healthcare provider. Xcopri should normally be gradually withdrawn to reduce the potential for increased seizure frequency and status epilepticus (seizure with 5 minutes or more of continuous clinical and/or electrographic seizure activity or recurrent seizure activity without recovery between seizures). Review of Resident 240's hospital Discharge summary dated [DATE], noted that the dislodged PEG tube was not replaced. It also noted that the dislodged PEG tube was likely accident due to fall, there was no documentation about breakthrough seizure prior to arrival {to hospital}. Further review of the discharge summary notes a history of traumatic brain injury/cognitive decline and history of seizure disorder. The hospital physician gave instructions to the facility for Resident 240 to continue taking antiseizure medication because even with medication he is low threshold [more likely] to have a breakthrough seizure because of his previous history of traumatic brain injury. During an interview on September 28, 2023, at 12:00 PM, with the NHA, it was revealed that he would expect pharmacy to contact the facility if a prescribed medication wasn't readily available. Further, the NHA stated if a substitute medication wasn't applicable, the contract pharmacy should utilize a local pharmacy to fulfill the prescription. The pharmacy failed to provide and facility failed to obtain and administer a prescribed seizure medication, which lead to one Resident missing two doses of a seizure medication and having a seizure. 28 Pa. Code 201.14(a) Responsibility of Licensee 211.9(a)(1)(4) Pharmacy services 395123 Page 13 of 17 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0755 211.10(c) Resident Care Policies Level of Harm - Actual harm 211.12(d)(5) Nursing Services Residents Affected - Few 395123 Page 14 of 17 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure that the physician documented a rationale for declination of a pharmacy review recommendation for two of 24 residents reviewed (Resident 28 and Resident 81). Findings include: Review of the facility policy, titled Medication Regimen Review (MRR), last reviewed dated 2006, revealed, Recommendations are acted upon and documented by the facility staff and or the prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. Review of Resident 28's clinical record contained diagnoses that included dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking) with behavioral disturbance, psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), anxiety (a feeling of worry, nervousness, or unease), and depression (feelings of severe despondency and dejection). Review of Resident 28's September 2023 Physician orders included Lexapro 10 milligrams (mg-unit of measure) once daily for anxiety, with a start date of October 22, 2021. Review of the pharmacy recommendation dated March 11, 2023, read, in part, gradual dose reduction for Lexapro 10 mg is due for assessment in accordance with Center for Medicare/Medicaid Services guidelines for psychopharmacological medications. The physician checked disagree, however, failed to provide a rationale for not attempting a gradual dose reduction, and the response wasn't date marked. During an interview with the Nursing Home Administrator (NHA) on September 28, 2023, at 9:00 AM, it was revealed that the Physician response to the pharmacy recommendation dated March 11, 2023, didn't contain a rationale for not attempting a gradual dose reduction for Lexapro and should have. Review of Resident 81's clinical record revealed diagnoses that included dysphasia (swallowing difficulties) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 81's May 2023 monthly medication regimen revealed the following recommendation made by the consultant pharmacist: Centers for Medicare and Medicaid Services (CMS) requires that all residents admitted to an antipsychotic medication must be evaluated for a dose reduction within 14 days of admission. This resident was admitted on : Seroquel 12.5 milligrams every 12 hours. Please evaluate. Further review of the May 2023 monthly medication regimen review revealed that the MD 1 (Physician) responded with, disagree. Further review of this form failed to reveal any rationale as to why the pharmacy recommendation was disagreed upon. Review of Resident 81's June 2023 monthly medication regiment review revealed the following recommendation made by the consultant pharmacist: This resident is receiving Aricept 5 milligram daily. Please consider increasing to Aricept 10 Milligram at bedtime to optimize treatment. 395123 Page 15 of 17 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of the June 2023 monthly medication regimen review revealed that the MD 1 responded with, disagree. Further review of this form revealed the MD 1 responded with continue, as the rationale in response as to why they disagree with the pharmacy recommendation. Review of Resident 81's August 2023 monthly medication regimen review revealed the following recommendation made by the consultant pharmacist: Please consider discharging this residents order for Melatonin as needed due to non-usage. Further review of the August 2023 monthly medication regimen review revealed that the MD 1 responded with, disagree. Further review of this form failed to reveal any rationale as to why the pharmacy recommendation was disagreed upon. An interview with the NHA on September 27, 2023, at 2:15 PM, revealed that the NHA expressed understanding on the physician needing to provide an explanation for disagreeing with the pharmacy recommendation provided. 28 Pa. Code 211.2(a) Physician services 395123 Page 16 of 17 395123 09/28/2023 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure controlled substances were contained in a permanently affixed compartment for one of one medication rooms reviewed (second floor medication room). Findings include: Review of facility policy, titled Controlled Medicine Storage, (no date) revealed it was the facility's policy for, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Review of the policy's Procedure section revealed subsections A and B stated, The director of nursing and the consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications .Scheduled controlled medications and other medications subject to abuse are stored in a locked permanently affixed compartment separate from all other medications . During medication room observations on September 26, 2023, at approximately 12:00 PM, it was observed that the refrigerator in the second floor medication room contained two plastic boxes locked with pad-locks, but neither box were permanently affixed. Observation of the contents of the two boxes revealed a combined total of 17 one milliliter (mL - Metric unit of measure) vials of lorazepam (a schedule IV controlled substance) with a concentration of two milligrams (mg - Metric unit of measure) of lorazepam per milliliter (total of 24 mg of lorazepam). During the observation, Director of Nursing confirmed that the two boxes were not permanently affixed inside the refrigerator. During an electronic communication with the Nursing Home Administrator (NHA) on September 29, 2023, at 1:32 PM, the NHA revealed the facility was not following the facility policy on controlled substance storage. 28 Pa code 211.12(d)(1)(5)Nursing services 395123 Page 17 of 17