Health inspection·March 7, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for five of 18 residents reviewed (Residents 8, 19, 49, 56, and 76). Residents Affected - Some Findings include: Review of Resident 8's clinical record revealed diagnoses that included chronic kidney disease (CKD longstanding disease of the kidneys leading to renal failure) and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). Further review of Resident 8's clinical record revealed their admission progress note dated January 2, 2024, which indicated the presence of an unstageable deep tissue injury. Review of Resident 8's Comprehensive 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 January 8, 2024, revealed in Section M. Skin Conditions at question 0300, that they had an unhealed pressure ulcer staged as an unstageable deep tissue injury that was not present upon admission. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on March 6, 2024, at 11:50 AM, the aforementioned coding concern was shared for follow-up. Email communication received from NHA on March 6, 2024, at 2:01 PM, confirmed that the MDS was coded in error and that a modification to the assessment was completed. She also indicated that she would expect the MDS to be completed accurately. Review of Resident 19's clinical record revealed diagnoses that included ischemic cardiomyopathy (the decreased ability of the heart to pump blood properly due to heart damage caused by blockages of blood vessels supplying the area) and diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high). Review of Resident 19's Quarterly MDS with the assessment reference date of February 12, 2024, revealed in Section N. Medications at question N0350, that they had received insulin (a hypoglycemic medication used to treat diabetes) injections for seven days during the assessment period. Further review of Section N. revealed at question N0415 High Risk Drug Classes, that they were not coded as having received a hypoglycemic medication. Page 1 of 14 395378 395378 03/07/2024 Quincy Retirement Community 6596 Orphanage Road Waynesboro, PA 17268

F 0641 Level of Harm - Minimal harm or potential for actual harm During an interview with the NHA and DON on March 6, 2024, at 11:50 AM, the aforementioned coding concern was shared for follow-up. Email communication received from NHA on March 7, 2024, at 11:47 AM, confirmed that the MDS was coded in error and that a modification to the assessment was completed. Residents Affected - Some During a follow-up interview with the NHA and the Assistant DON on March 7, 2024, at 12:05 PM, the NHA indicated that she would expect the MDS to be completed accurately. Review of Resident 49's clinical record on March 5, 2024, at 11:36 AM, revealed diagnoses that included type II diabetes and generalized anxiety disorder (excessive worry about everyday issues and situations). Review of Resident 49's physician orders revealed an order for Lantus Solostar (long-acting insulin) 100 units/milliliter, give eight units daily for type two diabetes with hyperglycemia (high blood sugar). Review of Resident 49's MDS section N0415 high-risk drug classes: use and indication, revealed the facility failed to indicate Resident 49's use of hypoglycemic (including insulin) medication for two MDS assessments: the comprehensive MDS dated [DATE], and quarterly MDS dated [DATE]. Review of Resident 49's medication administration record for September 2023, October 2023, December 2023, and January 2024, revealed Resident 49 received Lantus Solostar insulin during the seven day look back period for both the comprehensive MDS dated [DATE] and the quarterly MDS dated [DATE]. Email communication on March 6, 2024, at 1:09 PM, with the NHA, revealed that Resident 49's quarterly and comprehensive MDS assessments had been reviewed and modifications were made. Additional email communication on March 6, 2024, at 1:13 PM, with the NHA revealed it was the expectation of the facility for MDS assessments to be accurate. Review of Resident 56's clinical record on March 5, 2024, at 2:00 PM, revealed diagnoses that included obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract, causing urine to back up into the kidney) and bacteremia (bacteria in the bloodstream). Further review of Resident 56's clinical record revealed Resident 56 was hospitalized [DATE], until January 31, 2024, for bacteremia due to complicated urinary tract infection (UTI). Review of Resident 56's hospital discharge summary revealed urine culture results dated January 29, 2024, showing Resident 56's urine was positive for multidrug resistant Enterobacter cloacae complex (MDRO - a type of bacterium associated with healthcare-related infections). Review of Resident 56's physician progress notes revealed a history and physical dated February 1, 2024, that stated, in part, .sepsis with Enterobacter secondary to UTI . Review of Resident 56's quarterly Minimum Data Set, dated [DATE], sections I1700 Multi drug resistant organism and I1200 Septicemia, revealed the facility failed to indicate Resident 56's diagnoses of sepsis and MDRO. 395378 Page 2 of 14 395378 03/07/2024 Quincy Retirement Community 6596 Orphanage Road Waynesboro, PA 17268

F 0641 Level of Harm - Minimal harm or potential for actual harm Email communication on March 7, 2024, at 10:31 AM, with Employee 2 (Registered Nurse Assessment Coordinator), revealed that Resident 56's quarterly MDS had been reviewed and modifications were made. Email communication on March 7, 2024, at 12:28 PM, with the NHA revealed it was the expectation of the facility for MDS assessments to be accurate. Residents Affected - Some Review of Resident 76's clinical record revealed diagnoses that included CKD and diabetes mellitus type II. Review of Resident 76's Comprehensive MDS with the assessment reference date of December 18, 2023, revealed in Section N. Medications at question N0350 that they had received insulin injections for seven days during the assessment period. Review of Resident 76's physician orders failed to reveal any orders for insulin. During an interview with the NHA and DON on March 6, 2024, at 11:55 AM, the aforementioned coding concern was shared for follow-up. Email communication received from the NHA on March 6, 2024, at 4:04 PM, confirmed that the MDS was coded in error and that a modification to the assessment was completed. She also indicated that she would expect the MDS to be completed accurately. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395378 Page 3 of 14 395378 03/07/2024 Quincy Retirement Community 6596 Orphanage Road Waynesboro, PA 17268

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 21 residents reviewed (Residents 8, 19, and 56). Findings include: Review of facility policy, titled Care Planning, with a last review date of December 7, 2023, revealed, in part: Presbyterian Senior Living will comprehensively evaluate and re-evaluate a resident's need for service and develop a plan to promote their highest practicable level of functioning as set forth by our Mission Statement as well as State and Federal guidelines . 10. The care plan will be updated electronically as needed; and 11. The care plan will be reviewed and evaluated for intervention effectiveness no less than quarterly. Review of Resident 8's clinical record revealed diagnoses that included chronic kidney disease (CKD longstanding disease of the kidneys leading to renal failure) and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). Review of Resident 8's care plan revealed a care plan problem for a pressure ulcer related to a deep tissue injury to the left heel, dated February 5, 2024. Further review of Resident 8's clinical record revealed that their pressure ulcer was resolved on February 20, 2024. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on March 6, 2024, at 11:50 AM, the above care plan concern was shared for further follow-up. An email communication received from the NHA on March 6, 2024, at 2:01 PM, confirmed that the care plan should have been revised when the pressure ulcer resolved. Review of Resident 19's clinical record revealed diagnoses that included ischemic cardiomyopathy (the decreased ability of the heart to pump blood properly due to heart damage caused by blockages of blood vessels supplying the area) and the presence of an automatic (implantable) cardiac defibrillator (pacemaker). Review of Resident 19's physician orders revealed an order to completed a pacemaker device remote check, dated September 19, 2023. Review of Resident 19's care plan failed to reveal any documentation of the presence of the defibrillator/pacemaker, the intervention of testing, or any safety measures needed. During an interview with the NHA on March 7, 2024, at 9:30 AM, the above concern was shared for further follow-up. During a follow-up interview with the NHA and Employee 2 (Registered Nurse Assessment Coordinator 395378 Page 4 of 14 395378 03/07/2024 Quincy Retirement Community 6596 Orphanage Road Waynesboro, PA 17268

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [RNAC]) on March 7, 2024, at 12:04 PM, Employee 2 confirmed that the pacemaker was not care planned and the care plan had been revised. The NHA confirmed that she would expect care plans to be comprehensive. Review of Resident 56's clinical record on March 5, 2024, at 2:00 PM, revealed diagnoses that included obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract, causing urine to back up into the kidney) and bacteremia (bacteria in the bloodstream). Further review of Resident 56's clinical record revealed Resident 56 was hospitalized [DATE], until January 31, 2024, for bacteremia due to complicated urinary tract infection (UTI). Review of Resident 56's hospital discharge summary revealed urine culture results dated January 29, 2024, showing Resident 56's urine was positive for multidrug resistant Enterobacter cloacae complex (MDRO [multi-drug resistant organism] - a type of bacterium associated with healthcare-related infections). Review of Resident 56's comprehensive plan of care revealed the facility failed to update the comprehensive care plan to include the new identification and diagnosis of an MRDO in the urine. During a staff interview March 7, 2024, at 12:02 PM, with the NHA and Employee 2, Employee 2 revealed Resident 56's care plan had been reviewed and updated. Email communication March 7, 2024, at 12:28 PM, with the NHA revealed it is the facility's expectation that the care plan would have been updated timely. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 395378 Page 5 of 14 395378 03/07/2024 Quincy Retirement Community 6596 Orphanage Road Waynesboro, PA 17268

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident's physician's discharge summary included all required documentation for two of three residents reviewed for discharge (Residents 83 and 85). Findings include: Review of facility policy, titled Physician Services, with a last approved date of [DATE], revealed 13. The physician, CRNP [Certified Registered Nurse Practitioner], or PA [Physician Assistant] must complete a Discharge Summary that includes a recapitulation of the resident stay and pertinent instructions for continuity of care upon discharge. Review of Resident 83's clinical record on [DATE], at approximately 10:00 AM, revealed Resident 83 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease (progressive and irreversible neurological disease that causes decreased control of the nervous system resulting in stiffness, slowing of movement, and uncontrolled bodily movements) and respiratory syncytial virus (RSV - virus that infects the respiratory system that causes mild cold-like symptoms that can be severe in elderly adults). Review of Resident 83's clinical record revealed that Resident 83's family elected hospice services after admission on [DATE]. Further review of the clinical record revealed that hospice services were started for Resident 83 on [DATE]. Review of Resident 83's clinical record revealed that between [DATE] and 8, 2023, Resident 83's health declined, and it was documented that Resident 83 exhibited less responsiveness, audible chest congestion, labored breathing, and loss of gag-reflex. Review of Resident 83's clinical record revealed that on [DATE], Resident 83 expired. Review of Resident 83's death certificate, signed and dated [DATE], revealed it documented Resident 83's immediate cause of death as acute cardiopulmonary collapse, with underlying causes of, pneumonia and rsv bronchitis. Review of Resident 83's physician discharge summary, signed [DATE], revealed it stated, Patient expired on [DATE] .dementia/[A]lzheimers. Review of available clinical documentation revealed Resident 83 had not previously been diagnosed with Alzheimer's dementia and did not expire as a result of Alzheimer's dementia. Further, the physician's discharge summary did not include a recapitulation of the Resident's stay that included course of illness and treatment, including the hospice admission, nor did it include accurate diagnosis information. As of [DATE], at 1:15 PM, the facility had no further information to provide. Review of Resident 85's clinical record revealed diagnoses that included Parkinson's disease (a 395378 Page 6 of 14 395378 03/07/2024 Quincy Retirement Community 6596 Orphanage Road Waynesboro, PA 17268

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few long term degenerative disorder of the central nervous system that mainly affects the motor system), encephalopathy (broad term for any brain disease that alters brain function or structure), and muscle weakness. Review of Resident 85's clinical record revealed that they were transferred to the hospital on [DATE], that the Resident declined to hold their bed at the facility, and was, therefore, discharged . Review of Resident 85's physician discharge summary, signed [DATE], revealed it stated, Patient admitted to hospital, dropped behold. The only other information included on this discharge summary were the diagnoses of confusion and ambulatory dysfunction (difficulty walking). The discharge summary failed to include a recapitulation of the Resident's stay that included course of illness and treatment. During an interview with the Nursing Home Administrator (NHA) and the Assistant Director of Nursing on [DATE], at 12:09 PM, the concern with the discharge summary was shared. The NHA indicated that she would review. Email communication received from the NHA [DATE], at 12:30 PM, indicated that she felt the summary was based on the physician's / nurse practitioner's assessment and that, although it was brief, it seemed to meet the regulation to her. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(xi) Medical records 395378 Page 7 of 14 395378 03/07/2024 Quincy Retirement Community 6596 Orphanage Road Waynesboro, PA 17268

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, observations, clinical record review, 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 one of 18 residents reviewed (Resident 19). Residents Affected - Some Findings include: Review of facility policy, titled Wound Care, with a last approved date of December 12, 2023, revealed, in part: Care of wounds is provided in accordance with current research and practice guidelines in order to facilitate healing and/or provide comfort and symptom control as appropriate. Review of Resident 19's clinical record revealed diagnoses that included diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high), ischemic cardiomyopathy (the decreased ability of the heart to pump blood properly due to heart damage caused by blockages of blood vessels supplying the area), and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). Observation of Resident 19 on March 4, 2024, at 1:38 PM, revealed the presence of dressings to their bilateral (both) lower legs. Review of Resident 19's physician orders revealed the following orders: cleanse open areas to lower legs, cover with Xeroform (a non-adherent type dressing), ABD (absorbent type dressing), and kling (a gauze type wrap) then apply ACE wraps (elastic type wrap), change every three days and as needed for soiling/lifting, dated January 22, 2024; and an order to cleanse open areas to lower legs, cover with Xeroform, ABD, and kling then apply ACE wraps change every three days and as needed for soiling/lifting, dated November 29, 2023. Review of Resident 19's clinical record under section titled Skin Condition, revealed it did not include any identified areas to their legs. Review of Resident 19's clinical record nurses notes from November 29, 2023, through March 5, 2024, at approximately 9:30 AM, revealed that there were various notes indicating that their dressings were intact or changed, but the notes failed to include any description of Resident 19's actual skin appearance. Review of Resident 19's physician progress note dated February 8, 2024, revealed that it did not include any assessment or documentation of Resident 19's skin condition on their bilateral lower extremities. Review of Resident 19's care plan revealed a problem for a chronic skin condition of dry skin that flakes off and exposes wounds, dated February 19, 2024, with no identified goal, and one intervention to apply treatment to legs as ordered, dated February 19, 2024. During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Assistant Director of Nursing (ADON) on March 6, 2024, at 11:55 AM, the aforementioned concerns were shared for further follow-up and additional information was requested. 395378 Page 8 of 14 395378 03/07/2024 Quincy Retirement Community 6596 Orphanage Road Waynesboro, PA 17268

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the ADON on March 6, 2024, at 2:02 PM, she indicated that she does not follow Resident 19 on her weekly wound rounds. She said that the nurses assigned to Resident 19 complete the dressing changes. Again, the concern was shared that there was no documentation of an assessment or evaluation of the condition or appearance of Resident 19's legs to identify if or what was present on their legs. ADON then indicated that the physician would be in tomorrow and could take a look at them to see what they are. It was, again, shared that there was no documentation of any assessment of Resident 19's skin condition to their bilateral lower legs from November 2023, through present. Email communication received from NHA on March 6, 2024, at 4:01 PM, included a copy of a progress note dated March 6, 2024, that indicated it was a late entry from March 4, 2024. This progress note indicated that Resident 19's treatment was provided to their bilateral lower legs. In addition, the note indicated that Resident 19's bilateral lower legs remained reddened with multiple scattered open areas from the top of right foot to their mid lower right thigh, and left leg from mid shin to upper knee; both with scattered open areas draining small serosanguinous (thin, slightly yellow fluid with a pink tinge) drainage. During an interview with the NHA and ADON on March 7, 2024, at 12:08 PM, the ADON indicated that they do not do skin sheets for chronic skin conditions. The concern was shared that the March 6, 2024, nurse's note indicated multiple scattered open areas with no measurements. She indicated that Resident 19 has a chronic skin condition in which skin flakes off and creates open areas, some of which could be very small in nature. She confirmed that there was no documentation of the size of the identified multiple open areas, and that she would expect staff to document a full evaluation or an assessment of these areas in their notes with dressing changes so that the effectiveness of the treatments could be determined and appropriate follow-up completed. As of March 7, 2024, at 1:15 PM, the facility had provided no other additional information. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 395378 Page 9 of 14 395378 03/07/2024 Quincy Retirement Community 6596 Orphanage Road Waynesboro, PA 17268

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services for urinary catheters consistent with the resident's comprehensive plan of care for one of six residents reviewed for urinary catheters (Resident 63). Findings include: Review of Resident 63's clinical record on March 4, 2024, at approximately 1:00 PM, revealed diagnoses that included chronic kidney disease (CKD - decreased ability of the kidneys to filter toxin from the blood and produce urine) and osteomyelitis (infection of the bone) with sepsis (life threatening condition that results in dysfunction of the immune system entering the blood stream and causing inflammation in organs through out the body). Review of Resident 63's clinical record revealed Resident 63 utilized a urostomy (surgical opening to the bladder through the skin) with a catheter for urine elimination. Review of Resident 63's comprehensive plan of care revealed that Resident 63 had a care plan with the identified problem of, [Resident 63] has an ostomy to divert urine [related to] urostomy. Review of the goal of care plan revealed the goal was, [Resident 63] will have urinary diversion managed appropriately: drainage appropriate amount, type, color, odor, stoma correct size, pink free of breakdown and infection, surrounding skin free of breakdown, rash and infection. Review of the care plan interventions revealed one of the interventions for nursing staff were to, Check/record drainage (amount, type, color, odor). Observe for leakage. Review of Resident 63's clinical record revealed that staff were not recording the characteristics (amount, type, color, odor) of the urine drained from the urostomy bag. During a staff interview on March 7, 2024, at approximately 11:15 AM, Nursing Home Administrator confirmed that staff were not recording Resident urine characteristics and added that there was no physician order to do so. 28 Pa code 211.12(d)(1)(5) Nursing services 395378 Page 10 of 14 395378 03/07/2024 Quincy Retirement Community 6596 Orphanage Road Waynesboro, PA 17268

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free of unnecessary psychotropic medications for one of six residents reviewed for unnecessary medications (Resident 61). Findings include: Review of facility policy, titled Management of Behavioral or Psychological Symptoms of Dementia-BPSD with or without Antipsychotic, with a last approved date of December 22, 2023, revealed the following, in part: The FDA [Food and Drug Administration] Black Box Warning Regarding Atypical & Conventional Antipsychotic in Dementia states, 'Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo; Residents/families/representatives should be involved in discussions about potential approaches to address behaviors and about the potential risks and benefits of a psychopharmacological medication (e.g., FDA black box warnings), the proposed course of treatment, expected duration of use of the medication, use of individualized approaches, plans to evaluate the effects of the treatment, and pertinent alternatives. The discussion should be documented in the resident's record; and D. Monitoring of behaviors/antipsychotic use through community At Risk committee at least annually with IDT to include pharmacist reviews of medication use. 1. Include gradual dose reduction attempts and results.' Review of facility policy, titled Medication Orders: IB3: Stop Orders, with a last review date of December 7, 2023, indicated, in part: A. The following medications, whether the order is for routine or as needed (PRN) use, are stopped automatically after the indicated number of days, unless the prescriber specifies a different number of doses or duration of therapy to be given. 7) PRN psychotropic medication orders - 14 days. Review of Resident 61's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning); anxiety (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in daily activities). Review of Resident 61's current physician orders on March 6, 2024, at approximately 10:15 AM, revealed an order for haloperidol (an antipsychotic medication), give 1 milligram as needed every 12 hours for behaviors, dated February 8, 2024, with no stop date indicated. During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON), on March 6, 2024, at 11:48 AM, the concern was shared that an antipsychotic medication was ordered PRN with no 14-day stop date implemented or documentation as to why the order was extended beyond 14 days. Additional information was requested. Email communication received from the DON on March 6, 2024, at 12:53 PM, indicated that Resident 61's routine Haldol was discontinued on February 8, 2024. The DON further indicated that Resident 61 had a history of significant behaviors, but that the facility staff and Resident 61's hospice provider felt that the routine dose could be discontinued and the PRN Haldol could be added in case it was 395378 Page 11 of 14 395378 03/07/2024 Quincy Retirement Community 6596 Orphanage Road Waynesboro, PA 17268

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed to support hospice philosophy for end of life comfort. She further indicated that the PRN Haldol was used only once in February 2024 since the time the routine dose was discontinued. Review of Resident 61's February 2024 Medication Administration Record revealed that they received a PRN dose of the Haldol on February 27, 2024, at 8:42 PM; a total of 20 days after the order was originally written. Review of Resident 61's physician's progress note dated February 12, 2024, failed to include any documentation of Resident 61 being on Haldol or a rationale for continuing the PRN Haldol past the 14 day threshold. Email communication received from DON on March 6, 2024, at 1:19 PM, indicated that she would get the physician to put it in their progress note. Follow-up email communication sent to the DON on March 6, 2024, at 1:34 PM, reiterated the concern that this had not occurred at the time the medication was originally ordered, or at the 14-day point. Review of Resident 61's March 2024 Medication Administration Record on March 6, 2024, at 1:40 PM, revealed that they have not received any PRN doses of the Haldol thus far in March. Email communication was sent to the NHA on March 6, 2024, at 5:00 PM, requesting a copy of Resident 61's consent for the use of the antipsychotic medication (Haldol) or information to indicate that the resident's responsible party was educated on the risks versus benefits of the medication and their Abnormal Involuntary Movement Scale (a rating scale designed to measure involuntary movements known as tardive dyskinesia that can occur with the use of antipsychotic medications) screening results. During an interview with the NHA on March 7, 2023, at 9:19 AM, she indicated that they did not have any other documentation to provide. She said that there were no AIMS screenings completed and that there was no consent or documentation of risk versus benefit education with Resident 61's responsible party for the use of the Haldol at any point. She further indicated that they have processes in place for these to occur, but that they were missed for Resident 61, possibly because they were on hospice. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 395378 Page 12 of 14 395378 03/07/2024 Quincy Retirement Community 6596 Orphanage Road Waynesboro, PA 17268

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, facility policy review, and review of facility legionella guidelines, it was determined the facility failed to implement a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia)); and failed to maintain accurate infection control data. Residents Affected - Some Findings include: A review of the facility policy, titled Anticipated Increase in Legionellosis Cases Due to Seasonality, dated June 12, 2023, failed to address any baseline or annual testing in the facility for water-borne contaminants, such as Legionella. A review of the facility policy, titled Surveillance for Health-Care Associated Infections (HAI), last reviewed February 22, 2024, stated, The purpose of the surveillance of infections is to identify both individual cases and trends in the transmission of epidemiologically significant organisms and Healthcare-Associated Infections, to permit interventions to try to slow or stop the transmission of such infections. A review of the facility guidelines (toolkit developed by CDC-Centers for Disease Control), titled Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, determined the need for a water management program based on risk analysis. The facility risks, based on analysis, included being a healthcare facility where residents stay overnight and have acute or chronic problems and weakened immune systems; Residents are primarily older than 65 years; and the building has multiple rooms (housing units) with a centralized hot water system. During an interview with the Nursing Home Administrator (NHA) on March 6, 2024, at 11:00 AM, the NHA was unable to show evidence of routine environmental sample results of Legionella testing. The NHA added that the facility was having difficulty finding a local service provider to perform Legionella testing. A review of the facility infection control (IC) monthly log (data that should minimally include a resident identifier, room location, confirmed type and area of infection, treatment), dated January 2024, revealed 26 residents were listed as suspected for an infection and 8 are listed as confirmed, but the IC logs were not updated for the 26 residents to show confirmation of an infection with microbiology (laboratory/x-ray reports that confirm infection, type of bacteria, and recommended antibiotic), or that the infection was ruled out. A look back at previous months of IC data revealed the same as above. Further review of the January 2024 infection control (IC) data log revealed Resident 56 was documented as being admitted [DATE]. Resident 56 was actually admitted [DATE]. Resident 56's infection was listed as suspected, but was actually confirmed with microbiology reports for both infections in the blood and urinary tract. The organism (type of bacteria or treatment) was never documented on the IC log. During an interview with the Infection Control Preventionist (ICP) on March 7, 2024, the ICP stated that the system marks all residents as suspected and only those residents who are reported to the 395378 Page 13 of 14 395378 03/07/2024 Quincy Retirement Community 6596 Orphanage Road Waynesboro, PA 17268

F 0880 Level of Harm - Minimal harm or potential for actual harm state reporting system are marked as confirmed; therefore, the logs do not reveal all of the confirmed infections and accuracy for tracking infections. During an interview with the Nursing Home Administrator (NHA) on March 7, 2024, at approximately 11:30 AM, the NHA agreed that IC data should be accurate. Residents Affected - Some 28 Pa. Code 201.18(b)(1)(3) Management 395378 Page 14 of 14