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 Page 1 of 2 395451 395451 05/07/2025 Inners Creek Skilled Nursing and Rehabilitation Ce 100 West Queen Street Dallastown, PA 17313

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident's provider about Resident 1's complaint of chest pain. Further, there is no evidence of any diagnostic testing being done to determine if the Resident was or was not in AFib. The next progress note in Resident 1's clinical record was on April 22, 2025, at 8:52 AM, written by Employee 2 (RN). The note stated At about 0800 [8:00 AM] a CNA [nurse aide] stated the resident had called 911 and was sending herself to the hospital. The resident's friend was behind the CNA and stated she would explain what was happening while she had 911 on the phone with the operator stating to give the resident an aspirin. While this writer was attempting to find out what was happening, the friend stated the resident was having chest pain since 0530 [5:30 AM] and no one has done anything about it. This writer went into the resident's room and she was laying in the bed in no apparent distress .This writer began talking to the resident who stated she told the nurse this morning that she was having chest pain and she pointed to the left side of her chest. She stated it was more of a pressure at this time. The resident stated she was also having some SOB [shortness of breath]. The resident stated nothing was done when she first complained of the pain so she called her family who called 911. The note further stated that the Resident was transferred to the hospital and the physician was notified. Review of Resident 1's hospital records dated April 22, 2025, revealed that Resident 1 was admitted to the hospital with a pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest) and lower extremity edema (swelling). During an interview with the Director of Nursing (DON) on May 7, 2025, at 12:45 PM, she was asked if the LPN notified the RN or the Resident's provider of Resident 1's complaint of chest pain, or if she passed the information along to the next nurse during change of shift. The DON stated she would look into it but stated that she looked at the change of shift report for that day and did not see anything about Resident 1's chest pain on the report. In a follow up interview with the Nursing Home Administrator (NHA) and DON on May 7, 2025, at 1:15 PM, the DON stated that if a Resident is complaining of chest pain, the provider should be notified for any new orders or guidance. In an email correspondence from the DON on May 8, 2025, at 2:20 PM, the DON stated that she spoke to the night shift RN supervisor from April 22, 2025, who stated she was not made aware from Employee 1 about Resident 1's complaints. The DON stated she also spoke to the day shift RN, who wrote the note at 8:52 AM. That RN also stated she was unaware of Resident 1's complaints until she was told by other staff that the Resident was complaining of not feeling well, which is when the day shift RN went to assess Resident 1. No additional information was provided. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395451 Page 2 of 2