Health inspection·January 11, 2024

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, comfortable, and home-like environment in four resident rooms (Residents' 2, 3, 4, and 5 rooms). Residents Affected - Few Findings include: Observation in Resident 2's room on January 11, 2024, at 1:00 PM, revealed the Resident was in bed and there were items on the floor to the right and left of the recliner, crumbs on the floor under and around the Resident's bed, and, in the bathroom, there was a broken dresser drawer on the floor with several items inside. Observation in Resident 2's room on January 11, 2024, at 1:04 PM, with Employee 1 (Licensed Practical Nurse), revealed the drawer to the nightstand was observed on the bathroom floor to the left of the sink in the corner. The front of the drawer was off and laying inside the rest of the drawer, as well as a compact disc, large greeting card, and bottom portion of a plastic bottle. The nightstand to the right of the bed (facing the bed) contained all three drawers; however, the top drawer had a different handle on it. To the right of the recliner on the floor was a black plastic cape and an empty plastic food container. On the floor to the left of the recliner behind the recliner were three empty black raspberry water bottles standing upright. To the left front of the recliner was a paper bag filled with used tissue paper and other paper trash. On top of the recliner was a broken radio, a broken headset, an intact head set, and compact disc player. There were food crumbs on the floor around and under Resident 2's bed, and several spots of dried red liquid to the left side of the bed. Employee 1 left the room to retrieve a trash bag and, upon return, revealed that the housekeeper hadn't cleaned Resident 2's room for that day. Observation and interview with the Nursing Home Administrator (NHA) on January 11,2024, at 2:35 PM, in the Resident's room revealed food crumbs remained under the Resident's bed. It was revealed by the NHA that she would follow-up with housekeeping. Observation in Resident 3's room on January 11, 2024, at 11:24 AM, revealed a dried, orange liquid on the floor between the bed and the window, food crumbs and empty food wrappers on floor to the left side and under the bed, and the over bed table contained a grey film. Observation with the NHA on January 11,2024, at 2:30 PM, revealed the food crumbs were cleaned up from the floor and over bed table, however, the dried orange liquid remained on the floor. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395223 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 395223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at West Shore, The 770 Poplar Church Road Camp Hill, PA 17011 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)