Health inspection·July 1, 2024

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observations, facility document review, clinical record review, and staff interviews, it was determined that the facility failed to provide beverages for a resident in a form to meet the resident's individual need for one of four residents reviewed (Resident 1). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and chronic obstructive pulmonary disease (COPD- a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). Review of Resident 1's current physician orders revealed a diet order dated May 14, 2024, for a regular diet, mechanical soft texture, nectar consistency liquids. Review of Resident 1's current care plan revealed an intervention dated March 9, 2024, Ensure that all beverages offered comply with diet/fluid restrictions and consistency requirements; and an intervention, revised May 22, 2024, to provide diet as ordered: mechanical soft with nectar thick liquids. Review of facility grievance log revealed that on June 3, 2024, a grievance was filed on behalf of Resident 1, stating that thin liquids were found at Resident 1's bedside when they are to be nectar thick. Review of the follow-up action taken, revealed that staff education was provided, stating When passing liquids-make sure we are following the liquid consistency that is on physician order i.e. thin, nectar, honey, pudding. Observation of Resident 1's room on July 1, 2024, at 11:00 AM, revealed a glass of what appeared to be cranberry juice, thin liquid, sitting on his bedside dresser, out of his reach. On July 1, 2024, at 11:09 AM, the surveyor showed the Director of Nursing (DON) the glass of thin liquids that was in Resident 1's room. At that time, the DON confirmed the liquid in the cup was thin and stated that it may have been thick before but it's thin now and should not have been left at the bedside. The DON notified Employee 1, who immediately removed the cup from Resident 1's room. Observation in the dining room on July 1, 2024, at 12:46 PM, revealed Employee 2 (Nurse Aide) pouring apple juice from a container labeled honey thick, and then giving the honey thick apple juice to Resident 1. Page 1 of 2 395123 395123 07/01/2024 Gardens at Camp Hill, The 46 Erford Road Camp Hill, PA 17011

F 0805 Level of Harm - Minimal harm or potential for actual harm During an interview with the DON on July 1, 2024, at 1:37 PM, the DON was made aware that Resident 1 was given honey thick apple juice during lunch. At that time, the DON stated the expectation that a resident's ordered diet and ordered liquid consistency be followed. 28 Pa. Code 211.12(d)(1)(5) Nursing services Residents Affected - Few 395123 Page 2 of 2