Health inspection·February 22, 2024

F 0600 28 Pa. Code 201.18(b)(1) Management. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.10(d) Resident care policies. Residents Affected - Few 28 Pa. Code 211.12(c) Nursing services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 2 of 5 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 02/22/2024 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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, document review, observations, resident and staff interviews, and facility policy review, it was determined that the facility failed to provide suprapubic catheter care and monitoring, which resulted in actual harm, as evidenced by an active infection requiring antibiotic treatment. The facility also failed to promptly initiate urology specialist recommendations for treatment of the infection for one of two residents reviewed for catheter use (Resident 2). Findings include: Review of current facility policy, titled Catheter Care, Urinary, last revised September 2014, revealed the policy purpose was to, .prevent catheter-associated urinary tract infections. Review of policy's subsection, titled Complications, revealed it included, If the resident indicates that his or her bladder is full or that he or she needs to void (urinate), notify the physician or supervisor. Review of the policy's Documentation section revealed the steps of documentation included, The following information should be recorded in the resident's medical record .The date and time that catheter care was given .The name and title of the individual(s) giving the catheter care .All assessment data obtained when giving catheter care .Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor .Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain .Any problems or complaints made by the resident related to the procedure .How the resident tolerated the procedure .If the resident refused the procedure, the reason(s) why and the intervention taken .The signature and title of the person recording the data. Review of Resident 2's clinical record revealed diagnoses that included neuromuscular dysfunction of the bladder (loss of bladder control due to brain, spinal cord or nerve problems) and hypertension (elevated/high blood pressure). Further review of Resident 2's clinical record revealed that, upon admission on [DATE], Resident 2 had a suprapubic catheter (catheter inserted into the bladder through an incision in the abdomen used to drain the bladder of urine). Review of Resident 2's physician orders revealed an order for catheter care dated October 27, 2023. The order included instructions to cleanse the suprapubic catheter site with normal saline and to apply a dry dressing every shift. However, review of Resident 2's Treatment Administration Record (TAR - record of administered treatments that prompts staff to perform and document treatments) revealed that the order for cleansing and applying a dry dressing was not on the TAR. Further review of the clinical record revealed no evidence that Resident 2's suprapubic catheter was being cleansed and a new dressing applied per physician order. During an interview with Employee 2 (Licensed Practical Nurse - LPN) on February 22, 2024, at approximately 2:10 PM, Employee 2 displayed the TAR orders that were prompted for staff to perform for Resident 2. It was observed that the ordered catheter care for Resident 2 was not present in Resident 2's TAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 3 of 5 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 02/22/2024 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 0690 Level of Harm - Actual harm Residents Affected - Few During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on February 22, 2024, at approximately 2:30 PM, they revealed that Resident 2's order for catheter care was incorrectly transcribed into the electronic health record and, therefore, did not carry over to the TAR. Review of Resident 2's clinical record revealed no evidence that Resident 2 was receiving catheter care as ordered since admission on [DATE]. Observation of Resident 2's catheter insertion site on February 22, 2024, in the presence of Employee 2, at approximately 2:25 PM, revealed Resident 2 had no dressing to the catheter insertion site. Observation revealed a moderate amount of yellow-white drainage at the catheter site and on Resident 2's brief. During the observation, Employee 2 confirmed that there was no dressing to Resident 2's catheter insertion site. Further review of Resident 2's clinical record revealed that on December 5, 2023, Resident 2 was sent to the hospital with catheter related complications. Further review of Resident 2's clinical record revealed that he was treated for a urinary tract infection. Review of Resident 2's comprehensive plan of care revealed that on December 6, 2023, a care plan was initiated with a focus of, [Resident 2] has a urinary tract infection related to catheter use. The care plan included the interventions of, Administer meds as ordered .encourage increased fluid consumption .evaluate residents response to treatment and meds .observe characteristics of urine, color, odor, sediment. Review of Resident 2's urology consultation report from December 14, 2023, revealed [Suprapubic] tube not draining for three weeks per patient report. He reports voiding out of urethra. Seen in [Emergency room] 12/5/23 and started on [ciprofloxacin] for pyelonephritis [infection of the kidneys] . The report also noted that Resident 2's suprapubic tube was blocked. Recommendations included a follow-up in one month for a catheter change. Review of Resident 2's urology consultation report from January 18, 2024, revealed no concerns, recommendations to follow-up in one month for a catheter change, and instructions to contact urology with any catheter concerns. Review of the clinical record revealed no evidence of a urology consultation report for the visit in February 2024. During an interview with the NHA and DON on February 22, 2024, at approximately 2:00 PM, a request was made for Resident 2's February 2024 urology report. At approximately 2:30 PM, DON provided a urology consultation report for Resident 2's February 15, 2024, urology appointment titled Urology Outpt Note *Final Report*. When provided, the NHA revealed that the facility sends a report of consultation form with a Resident to outside services, and typically receives the form back with information provided by the consultative service. The facility then receives a typed report from the office within 7 to 10 days. The NHA confirmed there was no report of consultation from the February 15, 2024, urology appointment for Resident 2 in his clinical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 4 of 5 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 02/22/2024 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 0690 Level of Harm - Actual harm Residents Affected - Few Review of urology consult report dated February 15, 2024, revealed, Today [Resident 2] presents for monthly [suprapubic] tube catheter changes. Further, the February 15, 2024, urology report stated, Resident 2 voided a thick pus like drainage from his urethra. There has been no urinary drainage from his [suprapubic] tube for two weeks. He reports voiding into a urinal. Bladder scan in office showed 296 [milliliters][of urine in Resident 2's bladder] and, [suprapubic catheter] tube removed with large amounts of pus-like drainage mixed with yellow urine. A new suprapubic catheter was inserted and it was noted that Resident 2 has another 25 ml of clumpy drainage. Due to pus drainage will send a urine culture and start him on antibiotics . The report also included recommendations to start ciprofloxacin twice a day for seven days, to obtain a urine culture, and to increase the catheter change to every two weeks. Review of Resident 2's physician orders failed to reveal any orders for antibiotics, urine culture, or catheter change since the February 15, 2024, urology consultation. During a Resident interview on February 22, 2024, at approximately 2:17 PM, Resident 2 expressed that he sometimes voids through his urethra into a urinal. Further, Resident 2 stated that he had not received his antibiotics that he was supposed to receive. During an interview with the DON on February 22, 2024, at approximately 3:30 PM, DON revealed that the facility did not have a urology consultation report from Resident 2's February 15, 2024, urology consultation, prior to the surveyor requesting the consult. During the interview, NHA revealed that staff should follow-up with outside consultative services when a report is not provided upon a Resident's return to the facility. The facility failed to follow facility policy, care planned interventions, and physician orders for catheter care and monitoring which resulted in failure to identify signs of infection and complications with Resident 2's suprapubic catheter. Additionally, the facility failed to implement urology recommendations to include: administration of antibiotics to treat an identified infection, obtainment of lab work, and an increase in the frequency of catheter changes. 28 Pa code 201.18(b)(1) Management 28 Pa code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395223 If continuation sheet Page 5 of 5