Health inspection·October 6, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and interviews with staff it was determined that the facility failed to follow physician orders regarding breakfast during dialysis days for one of two residents reviewed (Resident 34) and monitor weights for one out of 24 residents reviewed (Resident 48). Residents Affected - Few Findings include: Review of Resident 34's diagnosis list revealed an active diagnosis of Chronic Kidney Disease Stage 5 (kidneys have lost the ability to filter waste from an individual's blood). Review of Resident 34's orders revealed an active order for 'Dialysis (blood purifying treatment given when kidney function is not optimum.) days/times: Tuesday/Thursday/Saturday with a start date of August 7, 2023. Review of Resident 34's clinical record revealed an active order for Early breakfast due to dialysis schedule with a start date of August 7, 2023. Further review of Resident 34's clinical record revealed a care plan intervention of DIALYSIS: Specify appointment days Tuesday-Thursday-Saturday. Have ready to leave by 5:00am. Dialysis bag meals with an implementation date of August 5, 2023. Review of Resident 34's clinical record revealed a progress note dated August 26, 2023 at 6:22 a.m. stating Resident left for dialysis this AM not having received breakfast. Multiple calls made down to the kitchen with no answer. RN Supervisor made aware and called kitchen, spoke with staff and was told kitchen staff would bring up a breakfast for resident, though nothing came up and resident left for dialysis. Interview conducted with the Director of Nursing (DON) on October 4, 2023, at approximately 11:15 a.m. confirmed that Resident 34 did not receive breakfast on August 26, 2023 prior to leaving for dialysis. Resident 48 was admitted to the facility on [DATE], with the diagnosis of congestive heart failure (Congestive heart failure (CHF) is a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply. Blood and fluids collect in your lungs and legs over time). Review of the Physician orders for daily weights on July 20, 2023, and state to notify the physician if the resident gains two to three pounds overnight or 5 pounds in one week to monitor for fluid Page 1 of 9 395224 395224 10/06/2023 Hamilton Arms Center 336 South West End Avenue Lancaster, PA 17603

F 0684 retention (CHF). Level of Harm - Minimal harm or potential for actual harm Further clinical record review revealed Resident 48's weight on August 17, 2023, was 171 and on August 18, it was 175.2 (an increase of 4.5 pounds). There was no documentation that the physician was notified. On August 23, a weight of 175 pounds was recorded on August 24 it was 177 lbs. (an increase of 2 pounds) was recorded with no further documentation that the physician was notified. On September 1, 2023, the resident weight was 174.4 pounds on September 2, a weight of 177.8 (an increase of 3.4 pounds) was recorded. No further documentation that the physician was notified. On September 7, 2023, a weight of 180 pounds was recorded and is a 5.6-pound increase. No further notes stating the physician was notified of this increase. Residents Affected - Few Review of the clinical record revealed a nursing note for September 10, 2023, that Resident 48 was requesting an as needed aerosol treatment for complaints of cough/shortness of breath. Resident was tolerating treatment when resident's eyes closed and slumped over in bed. Provided physical stimuli, tapping on feet, rubbing chest . Call was placed to 911. Review of hospital records dated September 10, 2023, revealed the resident presented in the emergency room with a cough and shortness of breath. Resident 48 was given Lasix and diuresised (the increase of urine production) 16 pounds. An interview with the Director of Nursing on October 6, 2023, at 9:30 a.m. revealed that the facility had no further documentation and failed to notify the physician of the weight gain on all the dates mentioned above. The facility failed to ensure that physician orders were followed regarding early breakfast for Resident 34 and weights being monitored for Resident 48. 28 Pa Code: 211.5(f) Clinical records 28 Pa Code: 211.12(d)(1) Nursing services 395224 Page 2 of 9 395224 10/06/2023 Hamilton Arms Center 336 South West End Avenue Lancaster, PA 17603

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that sufficient and competent nursing staff were engaged to review resident charts and ensure labs were drawn for one of one resident reviewed (Resident 24). Findings include: Review of Resident 24's diagnosis list revealed an active diagnosis of Paroxysmal Atrial fibrillation (type of irregular heartbeat). Review of Resident 24's clinical record revealed progress note dated June 4, 2023 at 3:54 p.m. indicating Resident noted to have missed Coumadin dose x 3 days. [MD] notified and order received to give resident Coumadin 4 mg (miligrams) PO (by mouth) this evening, resume current dose for June 4, 2023, June 5, 2023, June 6, 2023, and June 7, 2023, and to draw a PT/INR (test is used to see if your blood is clotting normally and if warfarin/coumadin is effective in treating clotting disorders) on June 8, 2023. Resident assessed and with no ill effects. NHA notified by phone. DON notified by phone. Resident's daughter, [NAME], notified by phone. Interview conducted on October 6, 2023, at approximately 10: 15 a.m. with Licensed nurse, Employee E5, who is author of the progress note, indicated that staff failed to review Resident 24's clinical record to ensure labs were completed. Review of Resident 24's clinical record revealed the PT/INR blood draw was not performed as directed by physician. Interview conducted with Registered nurse, Employee E4 on October 6, 2023, at approximately 10:45 a.m. reported that night shift is responsible for checking Epic (form of electronic medical record system) that is used by lab services to ensure that labs were drawn and document the results and contact the resident's physician if necessary. Interview conducted with the Director of Nursing (DON) on October 6, 2023, at approximately 12:10 p.m. confirmed the information noted above. The Director of Nursing provided surveyor with documentation of in-service training of Coumadin/INR Process along with updates to the facilities patients on coumadin which states 2. Any resident on coumadin should have a separate order stating the following Resident is on coumadin please check for any new orders or labs. This will be pushed out for all shift charge nurses to sign off on. 28 Pa. Code 211.12 (a)(c)(d)(4)(5) Nursing Services. 28 Pa. Code 201.18 (e)(1)(2)(3)(6) Management 395224 Page 3 of 9 395224 10/06/2023 Hamilton Arms Center 336 South West End Avenue Lancaster, PA 17603

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based upon clinical record review, it was determined the facility failed to provide medications as ordered by the physician and failed to coordinate with pharmacy services to find an alternative medication for unavailable medications for one of 18 residents reviewed (Resident 83). Findings include: Review of Resident 83's diagnosis list revealed diagnoses including cerebrovascular accident (CVA stroke) and cognitive deficit as a result of the CVA. Review of Resident 83's physician orders dated June 9, 2023, revealed an order for Methylphenidate (type of stimulant used to assist with cognitive deficits) HCl 5 mg (milligrams) to be administered two times per day. Review of Resident 83's progress notes for July 2023, August 2023, September 2023, and October 2023 revealed that on multiple occasions Methylphenidate was not administered related to the medication being unavailable. Further review of Resident 83's progress notes revealed multiple phone calls and messages to resident's physician to notify the physician of the unavailability of the medication. Interview with the Director of Nursing on October 5, 2023, at 10:00 a.m. revealed that the medication has been unavailable related to a nationwide shortage of the medication. Review of Resident 83's clinical record failed to reveal evidence of information from the pharmacy related to the shortage and failed to reveal evidence that Resident 83's physician and the pharmacy coordinated to attempt to find a replacement for the Methylphenidate. Review of Resident 83's progress notes dated October 6, 2023, revealed In this situation, the Department of Health expressed concern regarding a resident's medication, Ritalin, due to its unavailability on account of being on back order. The primary objective was to explore the possibility of obtaining an alternative medication to address the resident's missed doses. Upon contacting the provider, it was explained that Adderall could potentially serve as an alternative to Ritalin. However, it was clarified that Adderall also faces back-order issues, which would present the same challenges encountered with Ritalin. These challenges were attributed to unresolved matters with the Drug Enforcement Administration. To further address the situation, the resident's spouse was informed about the provider's response, as well as the conversation that took place. The spouse shared the contact information of the resident's current neurologist, providing the phone number. It was suggested that contacting the neurologist may offer additional alternatives for medication. An attempt was made to establish direct contact with the neurologist, but unfortunately, it was unsuccessful. Consequently, this information would be passed on to the incoming Nursing supervisor. The supervisor would be briefed on the situation and tasked with placing a follow-up call to the neurologist. The purpose of this call would be to obtain information regarding any additional alternative medications that could help address the current delay issue. The goal is to ensure that the resident's medication needs are met and that suitable alternatives are considered in light of the back-order situation affecting both Ritalin and Adderall. 395224 Page 4 of 9 395224 10/06/2023 Hamilton Arms Center 336 South West End Avenue Lancaster, PA 17603

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 83's Medication Administration Records (MAR) for July 2023, revealed one missed; August 2023 revealed 3 missed doses; September 2023 revealed 9 missed doses and October 2023 revealed 4 missed doses to date. The facility failed to explore alternative medications with Resident 83's neurologist, physician, and pharmacy until October 2023 when it was brought to their attention during the survey. 28 Pa. Code 201.18(a)(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy Services 395224 Page 5 of 9 395224 10/06/2023 Hamilton Arms Center 336 South West End Avenue Lancaster, PA 17603

F 0760 Ensure that residents are free from significant medication errors. 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 residents were free from significant medication errors for one of three residents reviewed (Resident 33). Residents Affected - Few Findings include: Review of Resident 33's clinical record revealed a progress note dated September 3, 2023, at approximately 6:00 p.m. stating This report serves to address medication error related to the administration of Oxycodone to resident. The error occurred during an admission process on August 30th, 2023. admitting nurse had contacted the doctor to request a script for Oxycodone 5mg, with an intended administration of 0.5 tablet every 12 hours. However, inadvertently, admitting nurse failed to document this medication order in the EMAR (electronic medication administration record). On September 3rd, 2023, while reviewing all the admissions for the past week, the admitting nurse discovered the error and immediately took corrective action. Upon further examination of Resident 33's clinical records, it was revealed Resident 33 was prescribed additional pain relief medication in the form of Acetaminophen Extra Strength Oral Tablets (Tylenol), with a dosage regimen of 2 tablets administered orally every 6 hours for the management of pain. Additional review of Resident 33's Electronic Medication Administration Record (eMar) revealed that the facility recorded the resident's pain assessments following each instance of Acetaminophen Extra Strength administration. Resident 33 consistently reported a pain score of zero after each administration. Interview was conducted with the Director of Nursing (DON) on October 4, 2023, at approximately 1:22 p.m., confirmed that Resident 33 missed 6 Oxycodone .5 mg administrations. The facility failed to ensure Resident 33 was free of significant medication errors. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395224 Page 6 of 9 395224 10/06/2023 Hamilton Arms Center 336 South West End Avenue Lancaster, PA 17603

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 upon observation, it was determined the facility failed to adequately label and store medication on two of three medication carts observed (second floor - low cart and second floor - long hall cart). Findings include: Observation of the medication cart labeled Second floor - low on October 5, 2023 at 1:00 p.m. revealed one unopened and unrefrigerated Novolog Insulin (medication used to treat high blood sugar levels) Pen; one opened and undated Lantus Insulin Pen and one opened and undated vial of Novolog insulin. Observation of the medication cart labeled Second floor - long hall on October 5, 2023 at 1:15 p.m. revealed one opened and undated Lantus Insulin pen and one unopened and unrefrigerated Humalog insulin pen. The above information was conveyed to the Director of Nursing on October 6, 2023 at 11:00 a.m. The facility failed to properly store and label medications. 28 Pa. Code 211.12(a)(d)(1)(2)(5) Nursing Services 395224 Page 7 of 9 395224 10/06/2023 Hamilton Arms Center 336 South West End Avenue Lancaster, PA 17603

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of facility policies and procedures and observation, it was determined the facility failed to provide appropriate infection control and failed to follow appropriate transmission-based precautions during medication administration and food delivery for two of two nursing units (first floor nursing unit and second floor nursing unit). Residents Affected - Some Findings include: Review of facility policy and procedure titled Administering Medications revealed Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of facility policy and procedure titled Isolation - Categories of Transmission Based Precautions Droplet Precautions - revealed Masks will be worn when entering the room. Gloves, gown, and goggles should be worn if there is risk of spraying respiratory secretions. Observation of medication administration on October 4, 2023, at 8:30 a.m. revealed Licensed Employee E3 administer medication to three residents. Two of the three residents were on Transmission Based Precautions for COVID-19. Observation of Licensed Employee E3 on October 4, 2023, at 8:31 a.m. revealed Licensed Employee E3 administer medications to Resident 57. After administration, Licensed Employee E3 did not wash hands or utilize hand sanitizer. Observation of Licensed Employee E3 on October 4, 2023, at 8:40 a.m. revealed Licensed Employee E3 administer medications to Resident 82. Resident 82 is on transmission-based precautions for COVID-19. Licensed Employee E3 did not wear a gown or goggles while administering medications to Resident 82 and did not wash hands or utilize hand sanitizer after administering the medications. Observation of Licensed Employee E3 on October 4, 2023, at 8:46 a.m. revealed Licensed Employee E3 administer medications to Resident 72. Resident 72 is on transmission-based precautions for COVID-19. Licensed Employee E3 did not wear a gown or goggles while administering medications to Resident 72 and did not wash hands or utilize hand sanitizer after administering the medications. Licensed Employee E3 then proceeded to prepare medications for the next resident scheduled to receive medications. Observations conducted at approximately 12:33 p.m. on October 4, 2023, on the first floor during food delivery revealed lapses in infection control procedures. Dietary staff was observed delivering food to a resident in room [ROOM NUMBER], who was under droplet precautions due to testing positive for COVID-19, without wearing gloves. Dietary staff left room [ROOM NUMBER] without removing her personal protective equipment (PPE) and 395224 Page 8 of 9 395224 10/06/2023 Hamilton Arms Center 336 South West End Avenue Lancaster, PA 17603

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some neglected to wash her hands. She then entered room [ROOM NUMBER], which housed another resident under droplet precautions, without using gloves. Afterward, she exited room [ROOM NUMBER], donned a pair of gloves, and returned to room [ROOM NUMBER]. At 12:34, the dietary staff exited room [ROOM NUMBER], removed all PPE, and disposed of it in the appropriate trash receptacle. Dietary staff failed to wash her hands before handling two food trays, which she handed over to another staff member for delivery to residents who were not under droplet precautions. The dietary staff left the floor before an interview could be conducted. Surveyor asked E4 RN the name of the dietary staff member, E4 did not recognize the dietary staff member and could not provide the surveyor with her name. The dietary staff member was not observed in the facility for the remainder of the survey. An interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on October 4, 2023, at approximately 1:13 p.m., revealed administration were aware of staff members failing to adhere to droplet precautions on the first floor. Administration reported corrective actions were underway, including staff reeducation. The facility failed to provide appropriate infection control measures during the administration of medications and food delivery. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services 395224 Page 9 of 9