Health inspection·December 23, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of five residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and anxiety disorder (a persistent feeling of worry, nervousness, or unease). Observation of Resident 1 on December 23, 2024, at 11:47 AM, revealed he was sitting in a dining area with other residents, and a yellow puddle consistent with urine appeared underneath his chair. Further observation in the dining area on December 23, 2024, at 12:10 PM, revealed Resident 1 wheeling away from the dining area and Employee 1 (Nurse Aide) wheeled him back over to the table where he was sitting previously, over the urine puddle. During an interview with Employee 2 (Licensed Practical Nurse) on December 23, 2024, at 1:02 PM, the surveyor revealed the concern that Resident 1 was still sitting in the dining area appearing to be incontinent of urine. Observation on December 23, 2024, at 1:09 PM, revealed Employee 3 (Nurse Aide) and Employee 4 (Nurse Aide) were wheeling Resident 1 into a shower room with incontinence care supplies and new pants. During an interview with the Director of Nursing on December 23, 2024, at 1:19 PM, she confirmed that Resident 1 was incontinent of urine, and when she spoke to Employee 1, she revealed she told Employee 3 that Resident 1 needed to be changed when she realized he was incontinent at 12:10 PM; but that Employee 3 got side tracked with other tasks and lost track of time before she was able to get to him to provide incontinence care. The surveyor revealed the concern with the lack of incontinence care until surveyor inquiry. No further information was provided. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing services Page 1 of 2 395372 395372 12/23/2024 Capitol Rehabilitation and Healthcare Center 4000 Linglestown Road Harrisburg, PA 17112

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, clinical record review, observations, and staff interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's comprehensive plan of care for one of five residents reviewed (Resident 1). Residents Affected - Few Findings include: Review of facility policy, titled Perineal Care, last revised February 2018, read, in part, The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed. Review of Resident 1's clinical record revealed diagnoses that included benign prostatic hyperplasia (BPHa condition in which the flow of urine is blocked due to the enlargement of prostate gland), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and anxiety disorder (a persistent feeling of worry, nervousness, or unease). Review of Resident 1's comprehensive care plan revealed a focus area of I have urinary incontinence, diagnosis BPH, with an intervention for check resident approximately every 2 hours and provide incontinence care as needed. Review of Resident 1's nurse aide task documentation on December 23, 2024, revealed it was documented that Resident 1 was last assisted with toileting on December 23, 2024, at 9:19 AM. Observation of Resident 1 on December 23, 2024, at 11:47 AM, revealed he was sitting in a dining area with other residents, and a yellow puddle consistent with urine appeared underneath his chair. Further observation in the dining area on December 23, 2024, at 12:10 PM, revealed Resident 1 wheeling away from the dining area and Employee 1 (Nurse Aide) wheeled him back over to the table where he was sitting previously, over the urine puddle. During an interview with Employee 2 (Licensed Practical Nurse) on December 23, 2024, at 1:02 PM, the surveyor revealed the concern that Resident 1 was still sitting in the dining area appearing to be incontinent of urine. Observation on December 23, 2024, at 1:09 PM, revealed Employee 3 (Nurse Aide) and Employee 4 (Nurse Aide) were wheeling Resident 1 into a shower room with incontinence care supplies and new pants. During an interview with the Director of Nursing (DON) on December 23, 2024, at 1:19 PM, she confirmed that Resident 1 was incontinent of urine, and she spoke with Employee 1 who stated she told Employee 3 that the Resident needed to be changed when she realized he was incontinent at 12:10 PM. The DON further revealed that Employee 3 stated she got sidetracked with other tasks and lost track of time before she was able to get to him to provide incontinence care. The surveyor revealed the concern with the lack of incontinence care until surveyor inquiry. No further information was provided. 28 Pa. Code 211.12 (d)(1)(5) Nursing services 395372 Page 2 of 2