Health inspection·July 27, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, clinical record review, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of three dining rooms (both 300 unit dining areas), and four of 46 resident rooms (Resident 7, 8, 35, and 51's rooms). Findings include: Observations in the 300 unit main and auxiliary dining areas on July 24, 2023, at 10:40 AM, and on July 26, 2023, at 10:50 AM and at 1:40 PM, revealed that an accumulation of dried food debris was present on the surface of several dining chairs. The chairs were observed to be in use by residents during meal times. During an interview with Employee 4 on July 24, 2023, at 10:40 AM, she confirmed that the chairs needed to be cleaned. During a tour of the unit with the Nursing Home Administrator (NHA) on July 26, 2023, at 1:40 PM, she acknowledged that the chairs needed to be cleaned. During an additional interview with the NHA on July 27 2023, at 10:05 AM, she revealed that the spoke with housekeeping staff and made a plan to clean the chairs that day. Observation of Resident 7's room on July 24, 2023, at 11:23 AM, revealed gouges in the paint on the closet doors and the bathroom door frame, as well as an overbed table with edging missing and cork exposed. Observation in Resident 8's bathroom on July 24, 2023, at 1:54 PM, revealed that the wall to left of toilet near the base of the door frame, there was a hole in the wall. The baseboard was pulled away and the size of the hole started at the floor and was approximately seven inches high (at the largest point) and 15 inches long. During an interview with Resident 8 on July 24, 2023, at 1:54 PM, it was revealed that she does utilize the bathroom. Observation in Resident 8's bathroom on July 26, 2023, at 12:58 PM, revealed the aforementioned hole remained in the wall. Observation of Resident 35's room on July 24, 2023, at 11:40 AM, revealed that the wood trim along Page 1 of 18 395247 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the inside of the door frame was separated from the wall with approximately five nail heads exposed under the separated wood trim. Observations were shared with the NHA and Director of Nursing on July 26, 2023, at 1:15 PM. During a follow-up interview with the NHA on July 27, 2023 at 9:55 AM, in regards to the environmental concerns for Resident 7's and Resident 35's room, the NHA indicated that these items had been identified and a work order had been initiated. The surveyor requested any additional information that the facility could provide. During another follow-up interview with the NHA on July 27, 2023, at approximately 12:15 PM, the NHA indicated that she had started making environmental rounds with environmental services in the last month. She provided audit sheets some were dated and others were not. The concerns identified during observations above were not noted on these sheets. She further indicated that the identified concerns for Resident 7 and Resident 35 were being addressed. Observation in Resident 51's room on July 24, 2023, at 10:37 AM, revealed the chair rail at the head of the bed was missing 3/4 of the length of the wall, and brown dried glue was visible. During an interview with Resident 51 on July 24, 2023, at 10:37 AM, it was revealed that the chair rail had been missing since she was admitted . Review of Resident 51's clinical record revealed she had resided in that same room since November 4, 2022. Observation in Resident 51's room on July 26, 2023, at 12:58 PM, revealed the chair rail at the head of the bed remained missing. During an interview with the NHA on July 26, 2023, at 2:00 PM, the surveyor revealed concerns regarding Resident 8's bathroom wall and Resident 51's wall at the head of her bed. No further information was provided at that time. During an interview with the NHA on July 27, 2023, at 10:29 AM, it was revealed that staff have the ability to enter areas that need repaired into the facility's work order system. It was also revealed that environmental rounds are completed weekly and any areas of concern are documented. NHA did acknowledge that the chair rail in Resident 51's room is being repaired that day, and the wall in Resident 8's bathroom does need to be repaired. 28 Pa. Code 207.2(a) Administration responsibility 395247 Page 2 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on facility policy, review of facility investigation documentation, and staff interview, it was determined that the facility failed to ensure all alleged violations involving abuse were reported immediately for one of three residents reviewed for abuse (Resident 66). Findings include: Review of facility policy, titled Abuse Prohibition and Protection revised November 28, 2016, revealed, All reports of alleged or suspected abuse must be reported to the Administrator immediately. Review of facility's electronic incident report submission dated April 13, 2023, revealed that it was reported by Employee 5 that, while Employee 5 and 6 (Nurse Aides) were providing care to Resident 66 on April 12, 2023, the Resident became combative and Employee 6 said to Resident 66, If you hit me I'll be the last woman you'll hit because you'll leave in a body bag. Review of Employee 5's witness statement dated April 13, 2023, revealed that the alleged incident occurred the previous evening, on April 12, 2023, around 8:30 PM. Further review of the facility's electronic incident report submission revealed that Employee 5 first reported the incident the following day to the Director of Nursing on April 13, 2023, at 1:00 PM. During an interview with the Nursing Home Administrator on July 27, 2023, at 10:05 AM, she acknowledged that Employee 5 did not report the allegation of verbal abuse timely and that individual and staff-wide training was completed as a result. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services 395247 Page 3 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined the facility failed to complete a comprehensive assessment after a significant change in condition for one of 26 residents reviewed (Resident 35). Residents Affected - Few Findings include: Review of Resident 35's clinical record revealed diagnoses that included anoxic brain injury (injury to the brain that occurs when the oxygen supply to the brain is compromised or interrupted) and encounter for palliative care (specialized medical care for people living with a serious illness). Further review of Resident 35's clinical record revealed that they were admitted to hospice services on June 4, 2023. Review of Resident 35's Minimum Data Set's (MDS- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that there was not a significant change MDS completed when Resident 35 was admitted to hospice. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on July 26, 2023, at 1:08 PM, the NHA confirmed that the significant change MDS was not completed after Resident 35 was admitted to hospice and that it should have been completed. 28 Pa Code 211.12(d)(1)(5) Nursing services 395247 Page 4 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for six of 26 residents reviewed (Resident 22, 35, 44, 61, 75, and 84). Residents Affected - Some Findings Include: Review of Resident 22's clinical record on July 25, 2023, revealed diagnoses that included dysphagia (difficulty swallowing), protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients), and diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). Review of Resident 22's speech therapy evaluation dated June 29, 2023, under evaluation of oral and pharyngeal swallow function, revealed cough to clear throat post swallow. Review of Resident 22's admission MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) with an assessment reference date of June 29, 2023, revealed that Section K: Swallowing / Nutritional Status was not assessed to indicate that Resident 22 had coughing during meals. Review of Resident 22's 5-Day MDS with an assessment reference date June 29, 2023, revealed that Section K: Swallowing / Nutritional Status was not assessed to indicate that Resident 22 had coughing during meals. Email correspondence with Nursing Home Administrator (NHA), when the surveyor revealed the concern with the MDS not being coded for a swallowing problem related to coughing with meals, the NHA replied Understood- thank you. During a staff interview on July 26, 2023, at approximately 1:00 PM, NHA revealed it was the facility's expectation that the Resident MDS would be coded accurately for Resident 22's swallowing problem. Review of Resident 35's clinical record revealed diagnoses that included anoxic brain injury (injury to the brain that occurs when the oxygen supply to the brain is compromised or interrupted) and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 35's Quarterly MDS with the assessment reference date (last day of the assessment period) of May 15, 2023, indicated In Section P: Restraints and Alarms that, in the seven days prior to the assessment reference date, Resident 35 had a restraint coded as other and that it had been used less than daily. Further review of Resident 35's clinical record revealed no orders for a restraint and no documentation that indicated that a restraint was used. Observations of Resident 35 on July 24, 2023, at 12:01 PM, and on July 26, 2023, at 1:25 PM, revealed no use of a restraint. 395247 Page 5 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the NHA and Director of Nursing (DON) on July 26, 2023, at 01:12 PM, the concern regarding the coding of a restraint was shared. The NHA indicated that she believed it was coded in error, but she would look into the concern. During a follow-up interview with the NHA on July 27, 2023, at 9:55 AM, the NHA confirmed that the MDS was coded for a restraint in error and that a modification was completed. The NHA also confirmed that she would expect the MDS to have been coded accurately. Review of Resident 44's clinical record revealed diagnosis that included gastro-esophageal reflux disease (a common condition in which the stomach contents move up into the esophagus) and congestive heart failure (CHF - a chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident 44's Quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated June 6, 2023, revealed that Section K0510. Nutritional Approaches, part D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol) was marked that Resident 44 had received a therapeutic diet in the previous seven days. Review of physician's orders for Resident 44 revealed a physician's order from July 26, 2023, that Resident 44 was ordered a regular diet, puree texture, nectar consistency. Further review of the physician's orders failed to reveal any previous diet order for a therapeutic diet during the MDS look-back period. An interview with the NHA on July 27, 2023, at 10:00 AM, revealed that she agreed that Resident 44 had not had a therapeutic diet during the MDS look-back period and the MDS was going to be modified. Review of Resident 61's clinical record revealed diagnoses that included bipolar disorder (mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior) and dementia with agitation (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life). Review of Resident 61's February 2023 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed that Resident 61 received Pristiq (an antidepressant) daily (with exception of one day - February 11, 2023) during the month. Review of Resident 61's February 13, 2023, significant change comprehensive MDS revealed that it was not coded to indicate that Resident 61 received an antidepressant medication within the previous seven days. During an interview with the NHA on July 27, 2023, at 10:04 AM, she confirmed that this was missed on Resident 61's February 13, 2023 MDS. Review of Resident 75's clinical record revealed diagnoses that included dementia with behavioral disturbance and delusional disorder (disorder in which a person holds fixed false beliefs and is unable to tell what is real from what is imagined). 395247 Page 6 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0641 Level of Harm - Minimal harm or potential for actual harm Review of Resident 75's November 21, 2022, comprehensive admission MDS revealed that it was not coded to indicate that Resident 75 received an antipsychotic medication within the previous seven days. Review of Resident 75's November 2022 MAR revealed that Resident 75 received Quetiapine Fumarate (also known as Seroquel - an antipsychotic medication) daily November 16 through 21, 2023. Residents Affected - Some During an interview with the NHA on July 27, 2023, at 10:04 AM, she confirmed that this was missed on Resident 75's November 21, 2022, MDS. Review of Resident 84's clinical record revealed diagnoses that included stroke (damage to the brain from interruption of its blood supply) and encounter for palliative care (specialized medical care for people living with a serious illness). Review of Resident 84's Significant Change MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) with the assessment reference date (last day of the assessment period) of July 11, 2023, indicated in Section J: Health Conditions that in the five days prior to the assessment reference date, Resident 84 had received no as needed pain medication administration. Review of Resident 84's July Medication Administration Record revealed that they had received their ordered as needed pain medication on July 7, 2023 (three doses); July 8, 2023 (five doses); July 9, 2023 (two doses); and July 11, 2023 (three doses). Email communication received from NHA July 27, 2023, at 9:23 AM, indicated that the MDS was reviewed, and the PRN [as needed] Medication Administration was missed- we will be submitting a revision. During an interview with the NHA on July 27, 22023, at 9:52 AM, the NHA confirmed that she would expect the MDS to have been completed accurately. 28 Pa. Code 211.5(f) Clinical records 28 Pa Code 211.12 (d)(3)(5) Nursing Services 395247 Page 7 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

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 Based on facility policy, review of the clinical record, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for four of 30 residents reviewed (Residents 22, 23, 61, and 86). Residents Affected - Some Findings include: Review of facility policy, titled Catheter care, urinary last reviewed June 29, 2023, revealed, Review the resident's care plan to assess for any special needs of the resident .Maintain an accurate record of the resident's daily output, per facility policy and procedure. Review of Resident 22's clinical record on July 25, 2023, revealed diagnoses that included dysphagia (difficulty swallowing), protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients), and diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) Review of Resident 22's care plan revealed an intervention for Provide catheter care per order. Review of Resident 22's physician orders revealed an order for Provide Suprapubic Catheter care and document urine output every shift, document urine output in mls (mls- unit of measure), with a start date of June 29, 2023. Review of Resident 22's TAR (Treatment Administration Record- documentation for treatments/medication administered or monitored) revealed no documentation to indicate catheter care was completed or urine output in mls were recorded on the following dates: June 30, 2023, day shift; July 1, 2023, day shift; July 7, 2023, evening and night shift; July 9, 2023, day shift; July 10, 2023, evening shift; July 11, 2023, day shift; July 16, 2023, day shift; July 17, 2023, day shift; July 21, 2023, evening shift; and July 26, 2023, evening and night shift. During an interview with Nursing Home Administrator (NHA) on July 27, 2023, at 10:00 AM, revealed the documentation that catheter care was completed and urine output recorded were missed, and she would expect documentation and catheter care to be completed as ordered. Review of the facility policy, titled Medication Administration General Guidelines not dated, read, in part, medications are administered in accordance with written orders of the attending physician. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the MAR for that dosage administration is initialed and coded appropriately. An explanatory note is entered in the record. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. Review of Resident 23's clinical record documented diagnoses that included diabetes mellitus. Review of Resident 23's July 2023 physician orders included: metformin HCl 500 milligrams (mg-unit of measure) once a day related to type 2 diabetes mellitus, with an order date of July 14, 2023, at 8:31 AM, and a start date of July 15, 2023, at 9:00 AM. 395247 Page 8 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of Resident 23's July 2023 Medication Administration Record revealed: metformin 500 mg once daily at 9:00 AM, there was no documentation for July 15th and 16th, 2023. Review of nursing progress note dated July 17 2023, at 2:35 PM, read, in part, Metformin signed for in error at 9 AM, it wasn't given. Medication did not arrive until afternoon. Residents Affected - Some Further review of progress notes failed to reveal documentation for the Metformin not being administered or for the physician being notified of ordered medication not being administered on July 15th and 16th, 2023. During an interview with the NHA on July 27, 2023, at 10:03 AM, revealed that Metformin was stocked in the facility's automated medication dispensing cabinet and should've been administered. During an interview with the NHA on July 27, 2023, at 12:17 PM, revealed that the physician wasn't notified timely, the notification was after the fact. Review of Resident 61's clinical record revealed diagnoses that included heart failure (heart's inability to pump an adequate supply of blood) and chronic obstructive pulmonary disease (COPD - chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident 61's July 2023 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Midodrine (used to treat symptoms of low blood pressure when standing), effective October 24, 2022. Further review of the order revealed that the medication was not to be administered when Resident 61's systolic blood pressure (SBP - top number in blood pressure reading) was over 130. Review of Resident 61's March 2023, April 2023, and July 2023 MARs revealed that Midodrine was administered on the following dates when his systolic blood pressure reading was recorded as being over 130: March 2023: 5, 6, 15, 16, twice on 17, 18, 24 April 2023: 4, 17, 29 July 2023: 2, 9, 24. During an interview with the NHA on July 27, 2023, at 12:31 PM, she acknowledged that she was aware that the medication was administered outside of hold parameters. Review of Resident 86's clinical record on July 25, 2023, revealed diagnoses that included neuromuscular dysfunction of bladder (a bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves), dysphagia (difficulty swallowing), and diabetes mellitus. Review of Resident 86's care plan on July 25, 2023, revealed an intervention: Provide Catheter care as per physician order. Review of Resident 86's physician orders revealed an order for Provide Suprapubic Catheter care and document [urine] output in mls each shift, with a start date June 29, 2023. 395247 Page 9 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Further review of Resident 86's physician orders revealed an order for Cefpodoxime Proxetil Oral Tablet 200 MG (Milligrams) (Cefpodoxime Proxetil) Give one tablet by mouth at bedtime related to Urinary Tract Infection for five Days, with a start date of June 27, 2023, and Completed July 2, 2023. Review of Resident 86's TAR revealed no documentation to indicate catheter care was completed or urine output in mls were recorded on the following dates: July 1, 2023, day shift; July 7, 2023, evening and night shifts; July 9, 2023, day shift; July 10, 2023, evening shift; July 11, 2023, day shift; July 16, 2023, day shift; and July 21, 2023 evening shift. During an interview with NHA on July 27, 2023, at 10:00 AM, revealed the documentation that catheter care was completed and urine output recorded were missed, and she would expect documentation and catheter care to be completed as ordered. Review of Resident 86's physician orders revealed an order for Magnesium Oxide Oral Tablet 400 MG (milligrams) (Magnesium Oxide) Give one tablet by mouth two times a day for low magnesium level, with a start date of June, 27, 2023. Review of Resident 86's MAR (Medication Administration Record- documentation for treatments/medication administered or monitored) revealed Magnesium Oxide was not given for two of two doses on July 18, 2023. Review of Resident 86's clinical record revealed a nursing progress note on July 18, 2023, at 10:30 AM, that Magnesium Oxide was not given due to being unavailable. Further review of clinical record revealed a nursing progress note on July 18, 2023, at 6:21 PM, that Magnesium Oxide was not given due to being unavailable. Email correspondence with NHA on July 26, 2023, at 9:56 AM, revealed there is no documentation to indicate the physician was notified that Magnesium Oxide was held due to being unavailable for two doses on July 18, 2023. Interview with NHA on July 26, 2023, at 1:20 PM, revealed she would expect that the physician was notified if a dose of regularly scheduled medication is withheld. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395247 Page 10 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for one of 30 residents reviewed (Resident 22). Residents Affected - Some Findings include: Review of facility policy, titled Dressings, Dry/Clean last reviewed June 29, 2023, revealed Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs .Report information in accordance with facility policy and professional standards of practice. Review of Resident 22's clinical record on July 25, 2023, revealed diagnoses that included pressure ulcer of sacral region, stage 4 (wound that occurs when the skin and tissue are damaged by prolonged pressure), protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients), and dysphagia (difficulty swallowing). Review of Resident 22's care plan revealed an intervention for: Treatment to right and left buttock PU (PU-pressure ulcer) areas per order, monitor for effectiveness. Review of Resident 22's physician orders revealed an order to Cleanse Left buttock wound with 1/4 strength Dakins solution, lightly pack wound with silver calcium alginate, apply zinc oxide peri wound, and cover with dry dressing daily and PRN (PRN- as needed), with a start date of July 7, 2023. Review of Resident 22's TAR (Treatment Administration Record - documentation for treatments/medication administered or monitored) revealed no documentation to indicate wound treatment was completed as ordered on July 8, 9, 11, 16, 17, 19, and 20, 2023. Review of Resident 22's physician orders revealed an order to Cleanse Right buttocks wound with 1/4 strength Dakin's solution, apply santyl to open areas, and cover with dry dressing daily, with a start date July 7, 2023. Review of Resident 22's TAR revealed no documentation to indicate wound treatment was completed as ordered on July 8, 9, 11, 16, 17, 19, and 20, 2023. Review of Resident 22's physician orders revealed an order for Santyl External Ointment 250 UNIT/GM (unit of measure) (Collagenase), Apply to Right buttocks wound topically every day shift for Wound Care, with a start date of July 7, 2023. Review of Resident 22's TAR revealed no documentation to indicate wound treatment was completed as ordered on July 8, 9, 11, 16, 17, and July 19, 2023. Review of Resident 22's physician orders revealed an order for Cleanse Left gluteal region, left upper thigh, and peri area with NSS (NSS- normal saline solution), apply zinc oxide every shift, with a start date of July 6, 2023. Review of the TAR revealed no documentation to indicate wound treatment was completed as ordered on July 7, 2023, evening and night shift; July 9, 2023, day shift; July 10, 2023, evening shift; July 395247 Page 11 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 11, 2023, day shift; July 16, 2023, day shift; July 17, 2023, day shift; July 19, 2023, day shift; July 20, 2023, day shift; and July 21, 2023, evening shift. During an interview with Nursing Home Administrator on July 27, 2023, at 10:00 AM, revealed the documentation for wound care on dates in question were missed, and she would expect documentation and wound care to be completed per physician order and professional standards of practice. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395247 Page 12 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

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 on clinical record review, observation, and staff interviews, it was determined that the facility failed to provide pharmaceutical services to accurately acquire, receive, dispense, and administer drugs to meet the needs of each resident for one of 26 residents reviewed (Resident 301). Findings include: Review of Resident 301's clinical record revealed diagnoses that included anemia (condition marked by a deficiency of red blood cells or of hemoglobin in the blood) and severe protein-calorie malnutrition (the state of inadequate food intake). Review of Resident 301's physician orders from July 21, 2023, through current revealed an order for Folite Oral Tablet (Folic Acid- Vitamin D3-Mag Cit-Acetylcysteine-Ca Cit) Give 0.5 milligrams by mouth one time a day related to UNSPECIFIED SEVERE PROTEIN-CALORIE MALNUTRITION and anemia. The order had an original start date of July 21, 2023, and a revision date of July 25, 2023. During a medication pass observation on July 26, 2023, at approximately 9:20 AM, for Resident 301, Employee 4 and Employee 7 indicated that the medication was not available to administer, and Employee 7 further indicated that they would follow-up with the pharmacy. Review of Resident 301's July 2023 Medication Administration Record revealed that the medication had been documented as administered on July 22, 23, 24, and 25, 2023. During an interview with Employee 1 (Assistant Director of Nursing) on July 26, 2023, at 12:01 PM, Employee 1 indicated that she had followed-up with the facility's pharmacy and was informed that this medication was not available and, therefore, had not been delivered to the facility. Employee 1 further indicated that the pharmacy was looking to see if they could obtain the medication or they would follow-up with the physician for a change in the order. At that time, the surveyor shared the concern that staff had documented that this medication was administered on July 22, 23, 24, and 25, 2023, even though Employee 1 had just confirmed that the pharmacy did not have the medication available to provide and had not delivered this medication to the facility. Employee 1 then indicated that they would look into the concern. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on July 26, 2023, at 1:10 PM, the surveyor shared the concerns that a medication that was ordered on July 21, 2023, had not been delivered as ordered, that staff had documented the medication as being administered on July 22, 23, 24, and 25, 2023, and that there was no documentation noted prior to today that the physician had been made aware that medication was not available. The NHA indicated that she would look into it. During a follow-up interview with the NHA on July 27, 2023, at 9:50 AM, the NHA confirmed that she would have expected staff to follow-up with the pharmacy regarding the medication when it was not received at time of the original order. The NHA provided no other information. 28 Pa. Code 201.14(a) Responsibility of Licensee 211.9(a)(1)(k) Pharmacy services 395247 Page 13 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0755 211.10(c) Resident Care Policies Level of Harm - Minimal harm or potential for actual harm 211.12(d)(5) Nursing Services Residents Affected - Few 395247 Page 14 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on clinical record review and staff interviews, it was determined that the facility failed to provide nutrition services to accommodate each resident's individual preferences and dietary choices for one of 30 resident's reviewed (Resident 22). Findings include: Review of Resident 22's clinical record on July 25, 2023, revealed diagnoses that included dysphagia (difficulty swallowing), protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients), and diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) Review of Resident 22's clinical record revealed a dietary note dated June 30, 2023, that stated, [Resident 22] conveys sister prepared meals at home and a more relaxed diet was followed .Liberal diet appropriate given increased nutrient needs/inadequate oral intake/weight loss. [Resident 22] is in agreement with plan: Recommend: liberalize diet to Regular/regular texture/thin liquids. Review of Resident 22's physician orders on July 25, 2023, revealed a therapeutic diet order CCHO (CCHO -consistent carbohydrate - diabetic) 2 gm NA (2 gm NA- limited to 2 grams sodium daily). Review of Resident 22's tray tickets on July 24, 2023, revealed 2 Gram Sodium CCHO Heart Healthy diet. Review of Resident 22's clinical record on July 27, 2023, revealed a dietary note dated July 27, 2023, stating [Resident 22] does prefer liberalized diet. Recommend Change to regular/regular texture/thin liquids. Interview with Employee 2 (Dietitian) on July 7, 2023, 12:06 PM, revealed she missed following through with the diet order being changed on June 30, 2023. Interview with Nursing Home Administrator on July 27, 2023, at 12:17 PM, revealed she would expect Resident 22 would have been provided a liberal diet as of June 30, 2023, per dietitian recommendation and in accordance with Resident 22's choice and preference. 28 Pa code 211.6(b)(d) Dietary Services 28 Pa code 201.18(b)(1)(3) Management 395247 Page 15 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on policy review, observations, and staff interviews, it was determined that the facility failed to store food and equipment in accordance with professional standards for food service safety in the main kitchen and two of four pantries. Findings include: Review of facility policy, titled Policy: Dry Storage Areas last reviewed June 29, 2023, revealed Frozen foods must be maintained at a temperature to keep food frozen solid. Temperatures for the freezer should be < or = [below or equal to] 0 degrees F (F- fahrenheit) to keep food frozen solid and should be checked at least two times each day .All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use dates or discarded. Observation in the main kitchen dry storage area on July 24, 2023, at 9:38 AM, revealed one bag of macaroni pasta open and not dated, one bag of penne pasta open and not dated, and one pan of individual salad dressings not dated. Observation in the main kitchen walk-in refrigerator on July 24, 2023, at 9:43 AM, revealed one bag of lettuce opened without a label or date; one container of cheese without a label or date; one stick of margarine opened without a date; half of a bag of parmesan cheese opened and not dated; two pans of sliced ham not dated; one green pepper labeled with a use by date of July 12, 2023; half of one tomato not labeled or dated; and one pan of bacon without a label or date. Observation of walk-in freezer temperature logs on July 24, 2023, at 9:54 AM, revealed temperatures in PM section of log on July 4, 2023; July 8, 2023, through July 17, 2023; and July 19, 2023, through July 23, 2023, were all out of acceptable temperature ranges. Observation of the ice machine in the main kitchen on July 24, 2023, at 10:04 AM, revealed a brown substance on the inside left and right edges of the machine, and a black substance on the top of the inside of the machine. Further observation of the ice machine revealed no air gap between the piping of the machine and the drain. Observation in the main kitchen on July 24, 2023, at 10:07 AM, revealed the three-compartment sink with filled with quat sanitizer. Employee 3 (Food Service Director) was requested to test the sanitizer concentration with testing strips. Upon testing the sanitizer, the surveyor checked the expiration date on the strip container used to test the concentration of the sanitizer, which revealed an expiration date of June 1, 2023. Observation in the main kitchen reach-in refrigerator on July 24, 2023, at 10:11 AM, revealed one container of cranberry juice dated July 11, 2023; one container of milk opened without an open date; one container of thickened apple juice opened without a date; and three containers of thickened lemon water opened without a date. Observation during initial tour of the 300 hall pantry area on July 24, 2023, at 10:11 AM, revealed: one container of individual syrup cups with a use by date of September 5, 2022; one container of crackers with a use by date of September 5, 2022; one container of ketchup with a use by date of September 5, 2022; one container of mustard with a use by date of September 5, 2022; one container of 395247 Page 16 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0812 Level of Harm - Minimal harm or potential for actual harm mayonnaise with a use by date of September 5, 2022; and one container labeled salt with a use by date of September 5, 2022, that contained sugar packets. Further observation in the refrigerator revealed four containers of juice without a label or date; and one container of punch without a label or date. Residents Affected - Some Observation during initial tour of the 200 hall pantry area on July 24, 2023, at 10:19 AM, revealed: 14 individual packs of graham crackers without a date, and five packs of animal crackers without a date. Interview with Employee 3 on July 24, 2023, at 10:30 AM, revealed that items should be labeled and dated per policy, and discarded once expired. Employee 3 also revealed the ice machine should be clean and have an air gap between the piping and drain, freezer temperatures should be at or below 0 degrees, and strips used to test sanitizer concentration should not be expired. Interview with the Nursing Home Administrator on July 26, 2023, at 1:20 PM, revealed it was the facility's expectation that expired items are discarded, food items are labeled and dated per facility policy, and food items and kitchen equipment are stored in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services 395247 Page 17 of 18 395247 07/27/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to the preparation and administration of medications to one of four Residents observed (Resident 16). Residents Affected - Few Findings include: Review of the facility policy, titled Medication Administration-General Guidelines with a last review date of June 29, 2023, revealed that the policy did not include Infection Control measures to take during medication preparation or administration if a nurse must remove a pill or capsule from the medication cup after preparation. During a medication pass observation on July 26, 2023, at approximately 8:50 AM, for Resident 16, revealed Employee 4 cleansed their hands with hand sanitizer prior to preparing the Resident's medications. Employee 4 was observed touching drawers of the medication cart, the top of the medication cart, the pill packets, pill bottles, handle of the water pitcher, the controlled substance log book, an ink pen, the keypad of the medication cart laptop computer, and the lock on the medication cart during the process of preparing Resident 16's medications for administration. Upon entering Resident 16's room to administer the medications, Resident 16 indicated that they did not wish to take the vitamins for their eyes. Employee 4 then used their fingers on their right hand to remove these two pills, and then proceeded to administer the rest of the medications (eight medications) in the pill cup. During an interview with Employee 4 on July 26, 2023, at approximately 9:35 AM, Employee 4 indicated that they should not have touched the medications with their bare fingers, and that they realized it after they had already done it. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on July 26, 2023, at 1:10 PM, the NHA indicated that she would expect a nurse to have clean hands if they were going to handle medications with her hands. 28. Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services 395247 Page 18 of 18