Health inspection·May 7, 2025

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 facility policy review, job description review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of four residents reviewed (Resident 1). Residents Affected - Few Findings Include: Review of facility policy, titled NSG122 Change in Condition: Notification of, revised July 1, 2024, revealed A center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is: .A significant change in the patient's physical mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); . or A decision to transfer or discharge the patient from the Center. Review of facility job description for the Licensed Vocational Nurse (LVN), also known as the Licensed Practical Nurse (LPN), revealed Under the direction of a Registered Nurse (RN), the Licensed Vocational Nurse delivers efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction. He/she operates within the scope of practice defined by the State Nurse Practice Act. The LVN contributes to nursing assessments and care planning, provides direct patient care, and supervises patient care provided by unlicensed staff. The job description further states that the LPN Observes conditions and reports changes in condition to RN; . Communicates pertinent data to RN and/or physician; .Consults and seeks guidance from the RN as necessary; .Participates in shift-to-shift communication between incoming and outgoing nursing staff. Review of Resident 1's clinical record revealed diagnoses that included depression, anxiety, and hypertension (elevated blood pressure). Review of Resident 1's nursing progress notes revealed a note written by Employee 1 (Licensed Practical Nurse [LPN]), dated April 22, 2025, at 6:29 AM, stating that the Resident told the nurse aide she was having chest pain and that when the nurse arrived, the Resident's vital signs were within normal limits. The note further stated that the Resident said it wasn't really a pain. [Patient] said she was AFib [atrial fibrillation-an irregular, often rapid heart rate] at hospital and thought she was again. There was no indicator of AFib again all vitals are [within normal limits]. The note continued on, stating that the Resident told the nurse aide that the nurse is doing nothing to help her and that the nurse is concerned about possible increase in Resident's confusion. Review of Resident 1's clinical record revealed no evidence that Employee 1 notified the RN or the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395451 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395451 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inners Creek Skilled Nursing and Rehabilitation Ce 100 West Queen Street Dallastown, PA 17313 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)