Health inspection·January 29, 2024

F 0686 Level of Harm - Minimal harm or potential for actual harm 14. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage. 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). Residents Affected - Few 16. Use dry gauze to pat the wound dry. 17. Apply the ordered dressing and secure with tape or bordered dressing per order. (Note: Use non-allergenic tape as indicated.) Label with date and initials to top of dressing. 18. Discard disposable items into the designated container. 19. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. 20. Reposition the bed covers. Make the resident comfortable. 21. Place the call light within easy reach of the resident. 22. Clean the bedside stand. 23. Wash and dry your hands thoroughly. 24. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. Review of Resident 1's clinical record revealed diagnoses of pressure ulcer of sacral region (skin ulcer caused by excess pressure) and pressure ulcer of the right hip (skin ulcer caused by excess pressure). Observation of a dressing change to Resident 1's sacrum and right hip on January 29, 2024, at 10:55 AM, revealed that Employee 1 (Registered Nurse) failed to establish a clean field on Resident 1's overbed table and, instead, sat his dressing change supplies directly on the overbed table. Further observation of the dressing change at that time revealed Employee 1 removed the old dressing from Resident 1's sacral wound and laid it on the Resident's bed. For the remainder of the time Employee 1 was completing the dressing changes, he continued to lay all of the used dressing supplies and used gloves on Resident 1's bed. Further observation of the dressing change at that time revealed Employee 1 cleansed the sacral wound with wound cleansing solution, remove his gloves, reapplied new gloves without completing hand hygiene, and then cleansed Resident 1's right hip wound. Further observation of the dressing change at that time revealed Employee 1 applied Silvadene (wound care solution) to Resident 1's sacral skin tear, and then immediately applied gauze soaked in Dakins (wound care solution) to Resident 1's pressure ulcer on his right hip without completing hand hygiene or applying new gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 2 of 3 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 01/29/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Further observation of the dressing change at that time revealed that, when Employee 1 was finished with Resident 1's dressing changes, Employee 1 removed all the dirty dressings and used supplies that had been laying on Resident 1's bed and put them into the garbage can at Resident 1's bedside. Employee 1 failed to remove the garbage bag containing soiled wound dressings and dressing supplies from Resident 1's room. Residents Affected - Few Further observation at that time revealed that Employee 1 left Resident 1's room and failed to clean Resident 1's overbed table that he had used to set up his dressing change supplies. Interview with the Nursing Home Administrator on January 29, 2024, at 12:48 PM, revealed that she would expect the facility policy to be followed during dressing changes. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 3 of 3