Health inspection·September 28, 2023

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on review of select facility documentation, clinical record review as well as resident and staff interviews, it was determined that the facility failed to ensure sufficient staffing to meet resident need on two of four nursing units (200 and 400 hallways). Findings include: Review of Resident 1's clinical record revealed diagnoses that included spinal stenosis (narrowing of the spinal canal which may result in pain, numbness and loss of motor control) and chronic pain. Review of Resident 1's care plan revealed she required assistance from one person when bathing. Further review revealed Resident 1 was to be offered a shower first, then a bed bath if she refused a shower. During an interview with Resident 1 on September 26, 2023, at 9:50 AM she stated she was not getting her showers timely due to staffing. Review of nurse aide task sheets for the 200 hallway revealed that Resident 1 was scheduled for a shower on Tuesday and Friday evenings. Review of Resident 1's shower documentation for August 28 - September 26, 2023, revealed that on three scheduled shower dates it was documented that Resident 1 was given a bed bath, and on two scheduled dates it was marked as Not Applicable. Review of clinical documentation revealed that no refusals of showers were noted on these dates. During a later interview at 12:40 PM, Resident 1 revealed that she preferred showers, and would not have turned one down if offered. Resident also revealed that she did not receive bed baths from the staff, instead she washed herself up in her bathroom. During an interview with Employee 1 on September 26, 2023, at 9:30 AM Employee revealed that sometimes showers do not get done due to staffing deficits, and at times the residents who require more assistance get left until last. During an interview with Residents 7 and 8 on September 26, 2023, at 10:05 AM they revealed that they do not always receive their showers in a timely manner due to staffing concerns, and that when there is only one nurse aide assigned to the hallway, they don't have time to give showers. Resident 8 also indicated that she requires assistance with showering since she is paralyzed on one side. Page 1 of 3 395247 395247 09/28/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 7's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and spinal stenosis. Review of Resident 7's care plan revealed that Resident 7 required assistance from one staff person while bathing. Review of nurse aide task list for the 400 hallway revealed that Resident 7 was scheduled to receive a shower on Wednesday and Saturday evenings. Review of Resident 7's shower documentation for August 28 - September 26, 2023, revealed that on four scheduled shower dates it was marked as Not Applicable. Review of clinical documentation revealed that no refusals of showers were noted on these dates. Review of Resident 8's clinical record revealed diagnoses that included hemiplegia and hemiparesis following intracranial hemorrhage affecting left side (inability to move, severe weakness, or rigid movement on either the right or left side of the body resulting from bleeding within the skull) and epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors). Review of nurse aide task list for the 400 hallway revealed that Resident 8 was scheduled to receive a shower on Monday and Thursday daylight shifts. Review of Resident 8's shower documentation for August 28 - September 26, 2023, revealed that on two dates it was marked as Not Applicable. Review of clinical documentation revealed that no refusals of showers were noted on these dates. During an interview with Employee 2 on September 26, 2023, at 10:25 AM, Employee revealed that they have been by themselves on a unit several times, and when this happens, it is difficult to get residents washed and dressed. Employee 2 stated that showers can't get done when assigned alone. Employee 2 also stated that when unable to give a shower, shower documentation is left blank or marked as Not Applicable. During an interview with Employee 3 on September 26, 2023, at 10:30 AM Employee stated that staffing had been bad for a while and licensed staff were having to assist the nurse aides with a lot of direct care. During an interview with Employee 4 on September 26, 2023, at approximately 10:40 AM Employee stated that staffing is awful on the weekends, and that some showers scheduled in the evening can't get done due to staffing. During an interview with Employee 5 on September 26, 2023, at 1:30 PM revealed Employee revealed that staffing is a concern, especially on evening shift. During an interview with the Nursing Home Administrator on September 26, 2023, at 2:28 PM she revealed that the plan was to revamp the shower schedule based on staffing in the evening so that more showers could be provided during the day. In email correspondence received from the Nursing Home Administrator on September 28, 2023, at 2:02 PM she revealed that she interviewed the staff and residents about showers and felt the facility 395247 Page 2 of 3 395247 09/28/2023 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0725 was following their policy. She also revealed that she felt staffing difficulties were not affecting resident care. Finally, she confirmed that the facility would be adjusting the schedules to meet resident preferences. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14(a) Responsibility of licensee. Residents Affected - Few 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395247 Page 3 of 3