Health inspection·May 1, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record and staff interview it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 10 residents reviewed (Resident 3 and 10). Residents Affected - Few Findings include: Review of Resident 3's clinical record revealed diagnosis to include heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs) and hypertension (high blood pressure). Review of Resident 3's clinical record revealed they were admitted to the facility on [DATE], and discharged home on March 16, 2024. Review of Resident 3's physician orders revealed an order for bath/shower twice weekly every Tuesday/Friday 7:00 AM-3:00 PM shift, with an active date of March 6, 2024. Review of Resident 3's March 2024 Treatment Administration Record revealed the resident received a shower on March 12, 2024. Review of the facility's policy titled, Weight Protocol - Garden and Northwood Healthcare, with an effective date of January 10, 2023, revealed 'Those to be automatic weekly weights - those on tube feed, those with pressure ulcers, new admits for four weeks, and those less than 100 pounds.' Review of Resident 3's discontinued physician orders revealed an order for weekly weights for four weeks then monthly, with a start date of March 6, 2024. Review of Resident 3's clinical record revealed they were weighed on March 6, 2024, weighing 169.0 pounds. During an interview with the Director of Nursing (DON) on May 1, 2024, at 1:12 PM, she confirmed Resident 3 was only weighed on March 6, 2024, and revealed Resident 3 should have been weighed on March 13, 2024, as ordered. During an interview with the DON on May 1, 2024, at 1:15 PM, revealed Resident 3's bath/shower order was entered incorrectly, therefore Resident 3 did not receive a shower on March 8, 2024, or March 15, 2024. Page 1 of 2 395347 395347 05/01/2024 Oak Hill Center for Rehabilitation and Nursing 1020 North Union Street Middletown, PA 17057

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the Nursing Home Administrator on May 1, 2024, at 3:05 PM, revealed she would have expected Resident 3 to have received a shower as ordered, and to have been weighed as ordered. Review of Resident 10's clinical record revealed diagnosis to include heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of Resident 10's clinical record revealed they were admitted to the facility on [DATE]. Review of Resident 10's current physician orders revealed an order for weekly weights for four weeks then monthly, with an active date of April 12, 2024. Review of Resident 10's clinical record revealed they were weighed on April 12, 2024, weighing 112.0 pounds, and again on May 1, 2024, weighing 110.6 pounds. During an interview with the Director of Nursing on May 1, 2024, at 1:15 PM, she revealed residents normally get weighed on the date of their admission, and again the day after their admission, and then once a week for four weeks. During an interview with the Nursing Home Administrator on May 1, 2024, at 3:05 PM, she revealed she would have expected Resident 10 to have been weighed as ordered. 395347 Page 2 of 2