Health inspection·January 5, 2024

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 clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 16 sampled residents. (Resident 10) Residents Affected - Few Findings include: Clinical record review revealed that Resident 10 had diagnoses that included congestive heart failure, diabetes mellitus, dementia, and peripheral vascular disease. On November 20, 2023, the physician ordered that staff administer a medication (Lasix) if the resident gained more than three pounds in one day to treat the resident's swelling in her legs. Review of Resident 10's weights revealed that on December 7, 2023, Resident 10 weighed 134 pounds (lbs). On December 8, 2023, the resident weighed 145 lbs, indicating a nine pound weight gain. On December 15, 2023, the physician ordered for staff to weigh the resident three times a week and administer Lasix if the resident gained more than three pounds when weighed on Monday, Wednesday, or Friday. On December 25, 2023, the resident weighed 140 lbs and on December 27, 2023, she weighed 145 lbs, indicating a five pound weight gain. A review of the December 2023, Medication Administration Record revealed that there was no evidence that staff administer the Lasix as ordered on December 8, 2023, or December 27, 2023. In an interview on January 5, 2024, at 10:15 a.m., the Director of Nursing confirmed that Resident 10 did not receive the Lasix as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395252 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 395252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at York Terrace, The 2401 West Market Street Pottsville, PA 17901 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)