Health inspection·September 25, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and interviews with staff, it was determined that the facility did not maintain complete and accurate medical records for four of four records reviewed related to catheter care and urinary continence. (Residents R1, R2, R4, and R5). Findings include: Review of clinical documentation revealed that Resident R1 was admitted to the facility on [DATE], and had diagnoses of fracture of right tibia, fracture of left tibia, fracture of left fibula, and morbid obesity. Review of the resident's clinical record revealed that she utilized an indwelling urinary catheter (a tube inserted into the bladder through the urethra in order to assist in emptying it of urine, and which stays in place for an extended period of time). Review of Nurse Aide documentation of bladder function for the time period of September 13, 2024, through September 24, 2024, revealed that available options for documenting the resident's urinary continence included Continent (having sufficient voluntary bladder control) , Incontinent (having insufficient voluntary bladder control), Did Not Void, Continence Not Rated Due To Indwelling Catheter, Continence Not Rated Due To Condom Catheter (a condom-like device which is placed on the penis to collect urine through a tube and into a collection bag as it is passed), Continence Not Rated Due To Urinary Ostomy (where a surgical opening is made into the bladder through the abdomen), Resident Not Available, Resident Refused, And Not Applicable. Continued review revealed the following instances where documentation was incorrect or incomplete: On September 14, no documentation was found for night shift (11:00 p.m.-7:00 a.m.) or day shift (7:00 a.m.-3:00 p.m.). On September 15, at 1:57 p.m., the resident was documented as incontinent. No documentation was found for night shift. On September 16, at 8:07 p.m., the resident was documented as continent. No documentation was found for night shift. On September 17, at 6:59 a.m., the resident was documented as continence not rated due to urinary ostomy. At 1:48 p.m., the resident was documented as incontinent. On September 18, at 10:34 a.m., the resident was documented as continent. No documentation was Page 1 of 4 395432 395432 09/25/2024 Holland Center for Rehabilitation and Nursing 280 Middle Holland Road Holland, PA 18966

F 0842 found for night shift or day shift. Level of Harm - Minimal harm or potential for actual harm On September 19, at 6:03 a.m., the resident was documented as continence not rated due to urinary ostomy. At 11:05 a.m., the resident was documented as incontinent. Residents Affected - Some On September 20, at 12:06 p.m., the resident was documented as incontinent. No documentation was found for night shift. On September 22, at 12:26 p.m., the resident was documented as incontinent. At 5:58 p.m. the resident was documented as continent. On September 23, at 8:39 p.m., the resident was documented as incontinent. On September 24, at 6:12 a.m., the resident was documented as incontinent. Observation of the resident on September 25, 2024, at 12:45 p.m. revealed that Resident R1 was still utilizing her urinary catheter. Review of clinical documentation revealed that Resident R2 was admitted to the facility on [DATE], and had diagnoses of obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow where the built up urine flows backward into the kidney), benign prostatic hyperplasia (commonly known as an enlarged prostate), and urinary tract infection. Review of the resident's clinical record revealed that he utilized an indwelling urinary catheter. Review of Nurse Aide documentation of bladder function for the time period of September 12, 2024, through September 24, 2024, revealed the following instances where documentation was incorrect or incomplete: On September 12, at 5:48 p.m., the resident was documented as incontinent. No documentation was found for night shift. On September 13, at 5:19 a.m., at 2:28 p.m., and at 5:48 p.m., the resident was documented as incontinent. On September 14, at 5:34 a.m., and at 2:12 p.m., the resident was documented as incontinent. At 2:13 p.m. and at 4:56 p.m., the resident was documented as continent. On September 15, at 7:08 p.m., the resident was documented as continent. On September 16, at 10:50 a.m., and at 8:40 p.m., the resident was documented as incontinent. No documentation was found for night shift. On September 17, at 6:59 a.m., the resident was documented as continence not rated due to urinary ostomy. At 6:11 p.m., the resident was documented as incontinent. No documentation was found for night shift. On September 18, at 8:21 p.m., the resident was documented as incontinent. No documentation was found for night shift. 395432 Page 2 of 4 395432 09/25/2024 Holland Center for Rehabilitation and Nursing 280 Middle Holland Road Holland, PA 18966

F 0842 Level of Harm - Minimal harm or potential for actual harm On September 19, at 6:59 a.m., at 1:20 p.m., and at 9:41 p.m., the resident was documented as incontinent. On September 20, at 6:46 a.m., and at 11:41 a.m., the resident was documented as incontinent. No documentation was found for evening shift. Residents Affected - Some On September 21, at 1:56 pm., and at 4:26 p.m., the resident was rated as incontinent. At 1:58 p.m., the resident was rated as continent. On September 22, at 5:57 a.m., and at 6:04 p.m., the resident was documented as incontinent. On September 23, at 9:20 p.m., the resident was documented as incontinent. No documentation was found for night shift. On September 24, at 4:39 a.m., the resident was documented as incontinent. At 10:41 a.m., the resident was documented as continent. Observation of the resident on September 25, 2024, at 12:32 p.m. revealed that resident R1 was still utilizing his urinary catheter. Review of clinical documentation revealed that resident R4 was admitted to the facility on [DATE], and had diagnoses of benign prostatic hyperplasia, and neuro muscular dysfunction of the bladder. Review of the resident's clinical record revealed that prior to his discharge on [DATE], he utilized an indwelling urinary catheter. Review of Nurse Aide documentation of bladder function for the time period of September 1, 2024, through September 6, 2024, revealed the following instances where documentation was incorrect or incomplete: On September 1, at 11:33 a.m., and at 8:16 p.m., the resident was documented as incontinent. No documentation was found for night shift. On September 2, at 3:25 a.m., the resident was documented as continent. At 1:52 p.m., the resident was documented as incontinent. On September 3, at 2:06 a.m., the resident was documented as incontinent. On September 4, at 6:49 a.m., the resident was documented as incontinent. No documentation was found for day shift. On September 5, at 5:26 a.m., the resident was documented as incontinent. No documentation was found for day shift or for evening shift. On September 6, no documentation was found for day shift. Review of clinical documentation revealed that resident R5 was admitted to the facility on [DATE], and had diagnoses of benign prostatic hyperplasia, malignant neoplasm (cancerous tumor) of prostate, and hematuria (blood in the urine). Review of the resident's clinical record revealed that prior to August 15, 2024, he utilized an indwelling urinary catheter. He discharged from the facility on 395432 Page 3 of 4 395432 09/25/2024 Holland Center for Rehabilitation and Nursing 280 Middle Holland Road Holland, PA 18966

F 0842 August 17, 2024. Level of Harm - Minimal harm or potential for actual harm Review of Nurse Aide documentation of bladder function for the time period of August 11, 2024, through August 14, 2024, revealed the following instances where documentation was incorrect or incomplete: Residents Affected - Some On August 11, at 2:59 p.m., the resident was documented as both continent, and continence not rated due to condom catheter. No documentation was found for night shift or for evening shift. On August 13, no documentation was found for day shift or for evening shift. On August 14, at 2:59 p.m., the resident was documented as continent. At 9:47 p.m., the resident was rated as continence not rated due to condom catheter. At 11:53 p.m., the resident was rated as incontinent. No documentation was found for night shift. On August 15, at 2:58 p.m., and at 6:46 p.m., the resident was documented as continent. At 6:44 p.m., the resident was documented as incontinent. No documentation was found for night shift. Interview with the Director of Nursing, employee E2, on September 25, 2024, at 2:15 p.m. confirmed that during the above documented time periods, each respective resident was utilizing an indwelling catheter, and that documentation should have been continence not rated due to indwelling catheter. She also confirmed that bladder function should be documented at least once per shift. 28 Pa. Code 211.12(c) Nursing service 28 Pa. Code 211.12(d)(1) Nursing service 28 Pa. Code 211.12(d)(2) Nursing service 28 Pa. Code 211.12 (d)(5) Nursing service 395432 Page 4 of 4