Health inspection·September 14, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, review of the facility assessment tool, as well as resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior on two of two nursing units (first and second floor nursing units). Findings include: Review of facility assessment tool, last reviewed August 17, 2023, revealed that maintenance staff complete routine rounds of buildings to ensure structural and operational stability and usefulness. Observation in Resident 33's room on September 11, 2023, at 10:02 AM, revealed a small hole in the ceiling above Resident 33's bed. A black substance was noted around the hole. Additionally, the paint on the wall near/above the head of Resident 33's bed appeared to be bubbling and peeling. During an immediate interview with Resident 33, he revealed that there had been a leak in that area. During a later interview with Resident 33 on September 14, 2023, at 9:37 AM, he revealed that he had told someone about the water concerns, but could not recall who. He also revealed that, during the time he had been at the facility, the water damage in his room had been repaired on more than one occasion. During an interview with Employee 4 (Maintenance Director) on September 12, 2023, at 1:43 PM, he revealed that a work order for water damage in Resident 33's room was put into their work order system on September 11, 2023, and that he was not informed there was a current problem in that room prior to that time. During a later interview with Employee 4 on September 14, 2023, at 10:13 AM, he revealed that there had been past water leakage problems in Resident 33's room that had been repaired. He revealed that he did not routinely monitor this area, but no one had informed him of any present concerns in that room. During an interview with Employee 3 (Nurse Aide) on September 14, 2023, at 12:45 PM, she revealed that she was aware of water leakage concerns in Resident 33's room, but did not let anyone know about it because she figured others were aware since it had been an issue before. She confirmed that she was able to input concerns into the work orders system, but stated she was uncertain how to do this. During an interview with the Director of Nursing (DON) on September 14, 2023, at 12:28 PM, she Page 1 of 21 395428 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed that she input the leakage concern into the work order system on September 11, 2023, after hearing that there was an observed concern. She also revealed that all staff have the capability to input concerns into the work order system, and that she would expect that any staff who noted a concern would do so. Observations on September 11, 2023, at 11:17 AM; September 12, 2023, at 9:39 AM; and September 13, 2023, at 9:29 AM, revealed that multiple dark stained areas were present on the carpet in the lounge area near the 700 hall. Review of email correspondence received from the DON on September 14, 2023, at 6:41 AM, revealed that the carpet would be cleaned. During an interview with the DON on September 14, 2023, at 12:22 PM, she revealed that she was not aware of what the carpet cleaning schedule was previously, but stated that it would now be done every three months. She also agreed that the carpet looked as though it needed to be cleaned. Observation in Resident 119's room on September 11, 2023, at 12:42 PM, revealed several brown streaks and one light brown spot on the white blanket on Resident 119's bed; the bed was noted to be made. Observation in Resident 9's room on September 12, 2023, at 9:39 AM, the blue floor mat on the window side of the bed was ripped and the foam was exposed. The air conditioner wall unit had several dried light brown drips down the front and crumbs inside the front grate. Observation with DON and Nursing Home Administrator (NHA) on September 13, 2023, at 2:20 PM, in Resident 119's room, revealed the white blanket on his bed contained four dried brown streaks and a light brown dried spot. During an interview with DON on September 13, 2023, at 2:20 PM, revealed that Resident 119's blanket should be changed. Observation with DON and NHA on September 13, 2023, at 2:25 PM, in Resident 9's room, revealed the blue floor mat on the window side of the bed was torn with the foam exposed and the floor around the mat was dirty. The air conditioner wall unit had several dried light brown drips down the front and crumbs inside the front grate. During an interview with the NHA on September 13, 2023, at 2:25 PM, it was revealed that the air conditioner units are cleaned routinely, he thought quarterly, but that he would check with maintenance. Further, the DON revealed that the floor mat needs to be replaced. During an interview with Employee 4 on September 13, 2023, at 3:00 PM, it was revealed that the floor mat in Resident 9's room is being changed, and housekeeping is cleaning the air conditioner unit. It was also revealed that the air conditioner units were taken out and pressure washed recently; he wasn't sure how the unit became dirty. Interview with the NHA and DON on September 14, 2023, at 12:21 PM, revealed that Resident 119's blanket should've been changed, Resident 9's floor mat should've been replaced, and the air conditioner unit cleaned. 395428 Page 2 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0584 28 Pa. Code 201.14(a) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility Residents Affected - Some 395428 Page 3 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm 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 three of 29 residents reviewed (Residents 50, 83, and 108). Residents Affected - Few Findings include: Review of Resident 50's clinical record revealed diagnoses that included dementia, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident 50's quarterly MDS assessment (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), dated June 14, 2023, revealed that in Section N, it was coded that a gradual dose reduction (GDR) of Resident 50's antipsychotic medication was last attempted on January 16, 2022. Review of Resident 50's clinical record revealed that Resident 50 last had a GDR of his antipsychotic medication attempted on July 26, 2022. On September 14, 2023, at 10:28 AM, the Director of Nursing (DON) stated that a modification was being done to the MDS to correct the last attempted GDR date to July 26, 2022. Review of Resident 83's clinical record revealed diagnoses that included Type 2 diabetes (A chronic condition that affects the way the body processes blood sugar) and peripheral vascular disease (a slow and progressive circulation disorder). Review of Resident 83's clinical record revealed a fall investigation report dated November 20, 2022. Review of Resident 83's Quarterly Minimum Data Set (MDS) (a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment) with an assessment reference date of December 12, 2022, revealed in section J 1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment was marked '0. No', indicating Resident 83 has not had any falls since the prior Quarterly MDS with an assessment reference date of September 12, 2022. In email correspondence received from the DON on September 14, 2023, at approximately 6:23 AM, revealed that it was a clerical error when entering the MDS information and a modification MDS has been completed to capture the fall for Resident 83. Review of Resident 108's clinical record revealed diagnoses that included vascular dementia with behavioral disturbance (condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain that causes problems with reasoning, planning, judgment, and memory) and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Review of Resident 108's May 12, 2023, quarterly MDS assessment revealed that it was coded to 395428 Page 4 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0641 indicate that a GDR of Resident 108's antipsychotic medication was last attempted on January 13, 2023. Level of Harm - Minimal harm or potential for actual harm Review of Resident 108's January 2023 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed orders for Risperidone 0.25 mg (antipsychotic medication) every day shift, and Risperidone .50 mg at bedtime. Further review revealed that the order for 0.25 mg every day shift was discontinued on January 9, 2023 (not January 13, 2023, as coded on Resident 108's MDS). Residents Affected - Few Review of Resident 108's August 9, 2023, comprehensive MDS revealed that it was coded to indicate that a GDR of Resident 108's antipsychotic medication was last attempted on August 4, 2023. Review of Resident 108's August 2023 MAR, prior to the date of the assessment, revealed an order for Risperidone 0.5 mg at bedtime. Further review failed to reveal any reduction in the dosage or frequency of Resident 108's antipsychotic medication. In email correspondence received from the DON on September 14, 2023, at 1:08 PM, she confirmed that Resident 108's May 2023 and August 2023 MDS assessments would be corrected. 28 Pa Code 211.12 (d)(3)(5) Nursing Services 395428 Page 5 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 29 residents reviewed (Resident 26 and 46). Residents Affected - Few Findings include: Review of Resident 26's clinical record revealed diagnoses that included anxiety (intense, excessive, and persistent worry and fear about everyday situations) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 26's current care plan revealed a care plan for the use of an antidepressant medication, citalopram (Celexa), and that a gradual dose reduction (GDR) was done of the citalopram on March 20, 2023. Review of Resident 26's clinical record, including physician orders, revealed that a GDR of the citalopram was done on March 20, 2023, to 5 mg (milligrams) once a day. Further review revealed that the citalopram was increased to 10 mg, once a day, on July 12, 2023. Review of Resident 26's care plan failed to reveal the subsequent increase of the citalopram on July 12, 2023, after the GDR on March 20, 2023. In an email correspondence from the Director of Nursing (DON) on September 14, 2023, at 10:28 AM, she stated that Resident 26's care plan has been updated regarding the GDR of the citalopram. Review of Resident 26's care plan revealed a revision was made on September 14, 2023, to include the increase of the citalopram. Review of Resident 46's clinical record revealed diagnoses of dementia (a range of conditions that affect the brain's ability to think, remember, and function normally) and diabetes mellitus (group of diseases that result in too much sugar in the blood [high blood glucose]). Observation of Resident 46 on September 11, 2023, at 9:37 AM, revealed the Resident lying in bed. Resident 46's call bell was lying on the floor, three feet to the left of her bed, under her roommate's bed. Review of a physician evaluation for Resident 46 from July 18, 2023, revealed, she is significantly vegetative at this point. Review of Resident 46's care plan on September 12, 2023, revealed a care plan for: Resident 46 has an ADL (activities of daily living) self-care performance deficit related to muscle weakness, ambulatory dysfunction, lack of coordination, abnormal posture, feeding difficulties, muscle wasting and atrophy of lower extremities; with an intervention of: call bell in reach, with a date initiated of June 8, 2016. Review of Resident 46's care plan, on September 12, 2023, revealed a care plan for: Resident 46 has 395428 Page 6 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the potential for an ineffective breathing pattern, risk for aspiration related to dementia; with an intervention of: keep call bell within easy reach, with a date initiated of February 27, 2018. Review of Resident 46's care plan on September 12, 2023, revealed a care plan for: Resident 46 has a communication problem related to hearing deficit and dementia; with an intervention of: call bell within reach, encourage Resident to call for assistance, with a date initiated of May 19, 2023. Review of Resident 46's care plan on September 12, 2023, revealed a care plan for: Resident 46 has a chronic decline in intellectual functioning characterized by; deficit in memory, judgment, decision making, and thought process related to dementia, with a date initiated of May 19, 2023. Interview with the DON on September 14, 2023, at 8:20 AM, revealed that Resident 46's care plan should have been updated because she is no longer able to use her call bell, and that it will be changed to reflect that. 28 Pa. Code 211.12(d)(5) Nursing services 395428 Page 7 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 29 residents reviewed (Resident 111). Residents Affected - Few Findings Include: Review of Resident 111's clinical record revealed diagnoses that included dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 111's nursing progress notes revealed a note, dated August 10, 2023, stating that an assessment was completed for use of a wanderguard bracelet (a monitoring device used to help ensure safety. Safety then depends upon the ensuring the alarm is activated and staff respond to the alarm when a patient or resident attempts to leave a safe area). The note further stated that Resident 111 has expressed no desires to leave the facility and has not made any attempts to leave. The physician provided an order to discontinue the use of the wanderguard at that time. Review of Resident 111's most recent quarterly 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), dated September 8, 2023, revealed a BIMS (brief interview for mental status) score of 13, meaning Resident 111 is cognitively intact. Observation of Resident 111 on September 12, 2023, at 12:55 PM, and on September 13, 2023, at 9:33 AM, revealed the Resident did not have a wanderguard in place. During an interview with Resident 111 on September 13, 2023, at 9:33 AM, he confirmed that he does not have a wanderguard and stated, they came in and cut it off. Resident 111 could not remember the exact time the wanderguard was removed, but stated it was prior to that week. Review of Resident 111's Treatment Administration Record (TAR), dated August and September 2023, revealed that staff were documenting on every night shift, through September 12, 2023, that they were checking on the function of Resident 111's wanderguard. On September 14, 2023, at 8:19 AM, the Director of Nursing (DON) was made aware of the staff documentation checking the wanderguard, when the wanderguard was not in place. She stated that the wanderguard order was not discontinued until September 13, 2023, when the facility checked all current wanderguard orders after a different Resident eloped. In a follow-up interview with the DON on September 14, 2023, at 12:03 PM, she stated that the order was not discontinued when the wanderguard was removed, and that staff should not have been documenting on the wanderguard after it was removed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395428 Page 8 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, resident and staff interview, and policy review, it was determined that the facility failed to ensure two of 29 residents reviewed were provided care and services regarding hygiene and bathing (Resident 75 and Resident 83). Residents Affected - Some Findings include: Review of the facility's Activities of Daily Living (ADLs) Policy, last revised in March 2018, indicated that Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care). Review of Resident 75's clinical record revealed diagnoses that included unspecified dementia (mild memory disturbance due to known physiological condition) and chronic kidney disease (CKD - when your kidneys are moderately damaged and are not working as well as they should to filter waste from your blood). During the initial tour of the facility on September 11, 2023, at approximately 10:15 AM, an interview with Resident 75 revealed that she does not always receive showers on scheduled shower days. Review of Resident 75's comprehensive plan of care revealed that Resident 75 was care planned for: Activity of Daily Living (ADL) self-care performance deficit with the intervention of, Bathing: The resident requires staff participation with bathing/shower, dated January 18, 2020. Review of Resident 75's ADL-Bathing/shower schedule revealed Resident 75 is to have showers provided by staff on Wednesdays and Saturdays on day shift. Review of Resident 75's ADL-Bathing task sheet documentation revealed that on Saturday, August 19, 2023, and Saturday, September 2, 2023, staff documented Not Applicable, indicating that no shower was provided to the Resident. In email correspondence received from the Director of Nursing (DON) on September 14, 2023, at approximately 6:23 AM, it was revealed that the aides have no explanation as to why they marked Not applicable. During a further interview on September 14, 2023, at approximately 12:14 PM, the DON revealed they would expect residents to receive showers on scheduled shower days. Review of Resident 83's clinical record revealed diagnoses that included Type 2 diabetes (A chronic condition that affects the way the body processes blood sugar) and peripheral vascular disease (a slow and progressive circulation disorder). During initial tour of the facility on September 11, 2023, at approximately 11:12 AM, an interview with Resident 83 revealed that she does not always receive showers on scheduled shower days. Review of Resident 83's comprehensive plan of care revealed that Resident 83 was care planned for: ADL self-care performance deficit with the intervention of, Bathing: The resident requires staff 395428 Page 9 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0676 participation with bathing/shower, dated January 31, 2022. Level of Harm - Minimal harm or potential for actual harm Review of Resident 83's ADL-Bathing/shower schedule revealed Resident 83 is to have showers provided by staff on Mondays and Thursdays on evening shift. Residents Affected - Some Review of Resident 83's ADL-Bathing task sheet documentation revealed that on Monday, August 14, 2023; Monday, August 28, 2023; Thursday, August 31, 2023; and Monday, September 11, 2023, staff documented Not Applicable, indicating that no shower was provided to the Resident. In email correspondence received from the Director of Nursing (DON) on September 14, 2023, at approximately 6:23 AM, it was revealed that the aides have no explanation as to why they marked Not applicable. During a further the interview on September 14, 2023, at approximately 12:14 PM, the DON revealed they would expect residents to receive showers on scheduled shower days. 28 Pa code 211.12(d)(1)(5) Nursing services 395428 Page 10 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

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 of the clinical record, observation, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 32 residents reviewed (Residents 9 and 59). Residents Affected - Some Findings include: Review of facility policy, titled Medication Administration- General Guidelines, not dated, read, in part, medications are administered in accordance with written orders of the attending physician. Review of Resident 9's clinical record documented diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) and dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking). Review of Resident 9's physician orders included: Humalog (insulin Lispro, fast-acting insulin that helps control the blood sugar spikes that happen naturally when you eat) inject 6 unit subcutaneously (under the skin) before meals related to diabetes mellitus, hold for fasting blood sugar below 120 milligrams/deciliter (mg/dl - unit of measure), dated June 6, 2023; insulin Glargine (long-acting insulin stabilizes blood sugar levels over an extended time) inject 36 unit subcutaneously in the morning related to diabetes mellitus, dated June 7, 2023. Review of Resident 9's August 2023 Medication Administration Record (MAR - documentation of medication administration) documented that Humalog was administer when blood sugar was below 120 ml/dl on the following: at 6:30 AM on August 16, 2023; at 11:30 AM on August 26, 2023; and at 4:30 PM on August 17 and 30, 2023. Further review of the August 2023 MAR documented that Glargine insulin was documented 28, insulin not required, on August 2, 5, 8, 22, 23, and 31, 2023. On the aforementioned dates, the Resident's blood sugar levels were documented to be below 120 ml/dl. Review of Resident 9's September 2023 MAR: Glargine insulin was documented as 28, insulin not required, on September 2, 5, 7, 9, and 11, 2023. On the aforementioned dates, the Resident's blood sugar levels were documented to be below 120 ml/dl. During an interview with the Director of Nursing (DON) on September 14, 2023, at 12:20 PM, it was revealed that the physician orders weren't followed. Humalog should've been held when blood sugars were below 120 ml/dl, and the Glargine shouldn't of been held. Review of the clinical record for Resident 59 revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a group of disease that cause airflow blockage and breathing-related problems) and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). Review of Resident 59's physician orders revealed an order on August 22, 2023, for the Resident to be out of bed for all meals/before meals due to risk of aspiration. Review of Resident 59's comprehensive care plan revealed that Resident 59 was care planned for: The 395428 Page 11 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident has nutritional problem or potential nutritional problem, with an intervention of Out of bed for all meals/before meals due to risk of aspiration, dated August 22, 2023. Observation of Resident 59 on Monday, September 11, 2023, at approximately 12:35 PM; Tuesday, September 12, 2023, at approximately 12:33 PM; and Wednesday, September 13, 2023, at approximately 12:31 PM, revealed the Resident was in bed eating lunch. In email correspondence received from the DON on September 14, 2023, at approximately 6:23 AM, revealed the orders were not scheduled properly in Point Click Care (PCC) for them to show up on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). Further interview with the DON on September 14, 2023, at approximately 12:16 PM, revealed she would expect physician orders to be correctly written and followed. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(a)(c) Resident care policies 395428 Page 12 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on review of clinical records, facility policy review, observations, and staff interviews, it was determined that the facility failed to provide restorative nursing care for range of motion devices for one of 29 residents reviewed (Resident 12). Findings include: Review of the facility's Resident Mobility and Range of Motion Policy, last revised in July 2017, indicated that residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Review of Resident 12's clinical record revealed diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and chronic obstructive pulmonary disease (COPD - a group of disease that cause airflow blockage and breathing-related problems). Review of Resident 12's physician orders reveal an order on August 28, 2023, for a left resting hand splint, donned with morning cares, doffed with evening or as tolerated. Review of Resident 12's Occupational Therapy evaluation and plan of treatment document from August 1, 2023, to August 30, 2023, reveal a recommendation for a resting hand splint. Observation of Resident 12 on September 11, 2023, at approximately 1:20 PM; September 12, 2023, at approximately 12:14 PM; and September 13, 2023, at approximately 12:25 PM, revealed the Resident sitting in her room, not wearing a hand splint. In email correspondence received from the Director of Nursing (DON) on September 14, 2023, at approximately 6:23 AM, revealed the order for the hand splint was not scheduled properly in Point Click Care for it to show up on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). Further interview with the DON on September 14, 2023, at approximately 12:15 PM, revealed that they would expect physician orders to be followed. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 395428 Page 13 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations in a timely manner for five of five residents reviewed for unnecessary medications (Residents 9, 26, 50, 108, and 111). Findings Include: Review of facility policy, titled Medication Regimen Review (Monthly Report), last reviewed January 2023, revealed, The consultant pharmacist reviews the medication regimen of each resident at least monthly . Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's (active record) and reported to the Director of Nursing, and/or prescriber as appropriate. Recommendations are acted upon and documented by the facility staff and or the prescriber. Review of Resident 9's clinical record documented diagnoses that included gallstones (a small hard crystalline mass formed abnormally in the gall bladder), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), and dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking). Review of Resident 9's monthly medication regimen reviews revealed that recommendations were made May 17, 2023, to discontinue ondansetron every six hours as needed for nausea and vomiting due to the Resident 9 not using it in the previous 30 days. The recommendation wasn't addressed in May 2023. The Pharmacy resubmitted the same recommendation June 14, 2023, the physician responded on June 20, 2023, and the medication was discontinued. During an interview with the Director of Nursing (DON) on September 13, 2023, at 2:00 PM, revealed that she would expect pharmacy recommendations to be responded to prior to the next month's review. Review of Resident 26's clinical record revealed diagnoses that included anxiety (intense, excessive, and persistent worry and fear about everyday situations) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 26's monthly medication regimen reviews revealed that recommendations were made in January 2023. Review of Resident 26's clinical record revealed no evidence of what the recommendation was nor the physician's response to the recommendation. On September 14, 2023, at 1:37 PM, the Nursing Home Administrator (NHA) stated that they were unable to locate Resident 26's January pharmacy recommendation. Review of Resident 50's clinical record revealed diagnoses that included dementia, major depressive disorder, and anxiety. Review of Resident 50's monthly medication regimen reviews revealed that recommendations were made in November 2022 and July 2023. 395428 Page 14 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0756 Level of Harm - Minimal harm or potential for actual harm Review of Resident 50's clinical record revealed no evidence of what the recommendation was in November 2022, nor the physician's response to the recommendation. Review of Resident 50's pharmacy recommendation dated July 17, 2023, revealed that the physician did not respond to the recommendation until September 11, 2023. Residents Affected - Some During an interview with the DON on September 14, 2023, at 12:07 PM, she stated that the physician should have acted upon the July 2023 recommendation sooner than September 11, 2023. During an interview with the NHA on September 14, 2023, at 1:37 PM, he stated that Resident 50's November 2022 pharmacy recommendation was unable to be located. Review of Resident 108's clinical record revealed diagnoses that included vascular dementia with behavioral disturbance (condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain that causes problems with reasoning, planning, judgment, and memory) and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Review of Resident 108's pharmacy medication regimen reviews revealed that one was completed on May 17, 2023, and a recommendation was made at that time. Review of Resident 108's clinical record revealed no evidence of what the pharmacy's recommendation was in May 2023, nor the physician's response to the recommendation. In email correspondence received from the DON on September 14, 2023, at 1:08 PM, she revealed that she was unable to locate any information regarding the pharmacy recommendation that was made for Resident 108 in May 2023. Review of Resident 111's clinical record revealed diagnoses that included dementia and major depressive disorder. Review of Resident 111's monthly pharmacy reviews revealed that recommendations were made in November 2022 and July 2023. Review of Resident 111's clinical record revealed no evidence of what the recommendation was in November 2022, nor the physician's response to the recommendation. Review of Resident 111's pharmacy recommendation dated July 15, 2023, revealed that the physician did not respond to the recommendation until September 11, 2023. On September 14, 2023, at 8:19 AM, the DON stated the physician should have responded to the July 2023 recommendation prior to September 11, 2023. On September 14, 2023, at 10:28 AM, the DON stated Resident 111's pharmacy recommendation with physician response for November 2022 was unable to be located. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 395428 Page 15 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy review, product labeling review, and staff interviews, it was determined that the facility failed to store food under sanitary conditions in the main facility kitchen and in two of two nursing unit nourishment refrigerators (first and second floor). Findings include: Review of facility policy, titled Storage Areas undated, revealed, Food should be dated as it is placed on the shelves. Date marking to indicate the date or day by which a ready-to-eat .All refrigerator units are always kept clean and in good working condition .Temperatures for refrigerators should be between 35-39 degrees F. Thermometers should be checked at least two times each day using the Refrigerator/ Freezer Temperature Log .Every refrigerator must be equipped with an internal thermometer .All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded. Review of facility policy, titled Food from Outside Sources revised December 14, 2017, revealed that visitors/family members must label food and beverages with the resident's name, room number and date, and perishable foods must be marked with a use-by date that is three days from the date brought into the facility. Observation in the main kitchen on September 11, 2023, starting at 9:37 AM, revealed the following: - in the walk-in refrigerator: a case of fresh peppers, undated. One pepper was observed to have a spot of fuzzy white substance; a case of green cabbage with a use by date of September 8, 2023; an open, undated bag of shredded lettuce; and an open, partially used, undated bag of celery stalks. - in the walk-in freezer: a container (lid not totally sealed) of ham and green beans with a use by date in April 2023; a container of chicken cacciatore with a use by date in June 2023; a container of pork riblets with a use by date in June 2023; and a tray of macaroni and cheese with a use by date of July 31, 2023. During an immediate interview with Employee 2 (Dietary Director), he revealed that he would dispose of the aforementioned items. Observation in the second floor nourishment refrigerator on September 11, 2023, at 9:57 AM, revealed the following: - An open and undated container of Ready Care brand thickened lemon water. Observation of the instructions noted on the container revealed the product was to be used within seven days once opened. - Four open and undated containers of Hormel brand Thick and Easy clear hydrolyte thickened water. Observation of the instructions on the container noted the product was to be used within 10 days once opened. - A half gallon on Swiss brand ice tea labeled with a receipt date of April 19, 2023, and a sell 395428 Page 16 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0812 by date of May 4, 2023. Level of Harm - Minimal harm or potential for actual harm - An open and undated bottle of Ocean Spray brand apple juice. - A sub sandwich in a brown paper bag labeled with a resident name, undated. Residents Affected - Some - Two plastic containers of pasta labeled with a resident's name, undated. - A plastic tub containing sandwiches, labeled with a resident's name and dated July 29, 2023. A visible black substance was noted on the sandwiches. - A large brown spill was noted in the bottom of the refrigerator. - A container of food, marked with a resident's name, in a shopping bag, undated. - A whipped topping container filled with an unknown food substance, white fuzzy spots noted on top of the food, dated May 25, 2023. - Pre-packaged container of strawberry shortcake, undated. - A container of noodles and corn, labeled with resident name, dated August 2. - A container of baked beans and other items, marked with resident name, undated. - A white takeout container with unknown contents, visible black spots present on food, labeled with resident name, undated. - No temperature log was noted in or around the refrigerator. Employee 6 (Licensed Practical Nurse) was informed of the findings in the second floor nourishment refrigerator on September 11, 2023, at 10:12 AM. She confirmed that nursing labels drinks and food brought from visitors. She stated that she would take care of the aforementioned concerns in the refrigerator and would inform Employee 2 (Dietary Director) of the findings. Observation in the first floor nourishment refrigerator on September 11, 2023, at 10:16 AM, revealed the following: - No thermometer was noted in the refrigerator. No temperature log was noted in or around the refrigerator. - An open, partially consumed [NAME] brand ice cream cake, not labeled or dated. - A Splenda brand carton of tea, opened, labeled with resident name, undated. - A container of Thirster brand prune juice, opened, undated. - Spills were present in the bottom of the refrigerator. Employee 7 (Licensed Practical Nurse) was informed of the findings in the first floor nourishment 395428 Page 17 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some refrigerator on September 11, 2023, at 10:24 AM. She stated that she would take care of the aforementioned concerns. During a follow-up interview with Employee 2 on September 11, 2023, at 2:45 PM, he revealed that he disposed of the produce in the refrigerator, and had instituted a new process for dating and labeling of produce. During a later interview with Employee 2 on September 13, 2023, at approximately 11:40 AM, he revealed that he placed a thermometer in the first floor nourishment refrigerator and put temperature monitoring logs in place for both nourishment refrigerators. During an interview with the Nursing Home Administrator on September 14, 2023, at 12:30 PM, he revealed the expectation that food should be stored and/or disposed of according to policy. During an additional interview on that date at 1:37 PM, he confirmed that temperature logs were not being maintained for the nourishment refrigerators, but have been put into place. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 395428 Page 18 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

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 review of facility policy, Centers for Disease Control guidelines, documents reviewed for implementation of a water management program, and staff interviews, it was determined the facility failed to implement their 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]). Residents Affected - Few Findings Include: Review of facility policy, titled Legionella Water Management Program, revised September 2022, revealed The purpose of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. The policy further states, The water management program includes a plan for when control limits are not met and/or control measures are not effective. According to the Centers for Disease Control, The key to preventing Legionnaires' disease is to reduce the risk of Legionella growth and spread. Building water systems and devices that might grow and spread Legionella include: showerheads and sink faucets. Review of facility provided document, titled Laboratory Certificate of Results, revealed water samples were delivered for testing on May 18, 2023. Further review of the document revealed a water sample was taken from the bathroom sink in room [ROOM NUMBER], on May 17, 2023, at 7:46 AM. The certificate revealed the results to be L. pneumophila: 20 MPN/100 ml (MPN-most probable number). Under the comment section on the certificate for room [ROOM NUMBER]'s bathroom, it was labeled PR and to see table. Review of the corresponding table at the bottom of the certificate revealed, PR-Any numerical result is a cause for concern. During an interview with the Infection Preventionist (IP) on September 14, 2023, at 8:25 AM, the IP was asked if there was any follow-up testing or treatment done based off of the results of room [ROOM NUMBER]'s bathroom sink. The IP stated she would have to follow-up with the Maintenance Director. She further stated that the facility has not had any cases of legionella. During an interview with the Nursing Home Administrator and Director of Nursing (DON) on September 14, 2023, at 12:03 PM, the DON stated that the bathroom sink faucet in that room was changed on this date and a new testing kit has been ordered to do a retest of the water in that bathroom. 28 Pa. Code 201.18(b)(1) Management 395428 Page 19 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of the facility assessment tool as well as staff interviews, it was determined that the facility failed to ensure resident equipment was maintained in a safe operating condition on one of two nursing units (first floor nursing unit). Residents Affected - Few Findings include: Review of facility assessment tool, last reviewed August 17, 2023, revealed that maintenance checks equipment during routine rounds; staff also assess equipment daily and report any items requiring repair or replacement. The assessment notes equipment includes such things as bath benches, shower chairs, bathroom safety bars, bathing tubs, sinks for residents and for staff, scales, bed scales, wheelchairs and associated positioning devices, bariatric beds, bariatric wheelchairs, lifts, lift slings, bed frames, mattresses, room and common space furniture, exercise equipment, therapy tables/equipment, walkers, canes, nightlights, steam table, oxygen tanks and tubing, dialysis chair. Observation with Employee 1 (Nursing Assistant) on September 11, 2023, at 12:31 PM, in the 300 hallway shower room revealed one shower chair. The seat belt clasp on the shower chair contained one missing tine, but the clasp did latch. During an interview with Employee 1 at the time of the observation, she revealed that the clasp has been like that for a while, and she wasn't sure if the broken clasp had been reported to the maintenance department. Employee 1 also revealed that the side rails on the shower bed in the 200 hallway shower room would not stay in the upright position. Observation with Employee 1 on September 11, 2023, at 12:35 PM, in the 200 hallway shower room revealed that the side rails on the shower bed wouldn't stay in the upright position. During an interview with Employee 1 at the time of the observation, she revealed that the side rails had been like that for a while, and she wasn't sure if it had been reported to the maintenance department. An additional observation of the shower bed stored on the 200 hallway shower room on September 12, 2023, at 12:07 PM, revealed that the side rails would not stay in the upright position. During an immediate interview with Employee 5 (Registered Nurse), after observing the shower bed, she revealed that she was not aware that the side rails did not lock, that no one had informed her of this concern, but that she would input the concern into the work order system. During an interview with Employee 4 (Maintenance Director) on September 12, 2023, at 1:43 PM, he confirmed that he repaired the shower bed and shower chair. He also revealed that he was not aware of these concerns before the current date. Additionally, he revealed that all staff have access to the work order system and can let him know of concerns that way. During an interview with the Nursing Home Administrator on September 14, 2023, at 1:37 PM, he revealed the expectation that if staff were aware of concerns, then they should report them. 28 Pa. Code 201.14(a) Responsibility of licensee 395428 Page 20 of 21 395428 09/14/2023 Northern Dauphin Nursing and Rehabilitation Center 990 Medical Road Millersburg, PA 17061

F 0908 28 Pa. Code 201.18(b)(1)(3) Management Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 207.2(a) Administrator's responsibility Residents Affected - Few 395428 Page 21 of 21