Health inspection·August 7, 2025

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revised on April 26, 2021; enhanced, regular texture, thin liquids diet, initiated April 17, 2019, revised May 16, 2024. Observation on August 7, 2025, at 1:09 PM, revealed Resident 3 failed to receive the enhanced chocolate milk and house shake. Surveyor had asked for the guidelines for the Enriched food diet on August 7, 2025, at 3:00 PM. Per the Nursing Home Administrator (NHA), there wasn't written guidelines. When a resident is ordered enriched food diet, additional items are added to the resident's tray such as cookies, enhanced chocolate milk, or pudding. Review of Resident 4's clinical record documented diagnoses that included hemiplegia left nondominant side (paralysis or severe weakness on one side of the body) and vascular dementia. Review of Resident 4's physician orders included regular/liberalized diet, dysphagia advanced texture, standard thin liquids consistency, enhanced, may have breads, initiated October 29, 2024; fluid restriction-1920 cc daily: nursing provides day shift-240 ml, evening shift-240 ml, night shift-120 ml, and dietary provides breakfast-540 ml, lunch-480 ml, dinner-300 ml, initiated December 4, 2023. Review of Resident 4's care plan included a focus area for nutritional risk related to congestive heart failure (heart doesn't pump blood the way it should), diuretic use and frequent fluid shifts causing weight fluctuations; therapeutic diet was liberalized due to history of poor intake and texture modified diet; need for fluid restriction; significant weight loss x 1 year related to combination of declined intake/diuretic therapy, initiated November 4, 2022, and revised February 6, 2025. Interventions included nutritional treat at bedtime, initiated January 17, 2024, and revised March 1, 2024. Observations on August 7, 2025, at 1:15 PM, revealed Resident failed to receive the following items per the residents tray ticket: 8 ounces of Lactaid milk, cold cereal, and oatmeal cream cookie. Per physician order, the Resident should've received 480 ml fluid on her meal tray and she only received 240 ml (juice and Jello). Review of Resident 5's clinical record documented she was admitted to the facility on [DATE], and diagnoses that included multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves, disrupts the communication between the brain and the body), pressure ulcer sacral region and left heel, and protein calorie malnutrition. Review of Resident 5's physician orders included regular/liberalized diet, regular texture, standard thin liquids consistency for admission protocol, initiated August 2, 2025; Ensure plus with meals initiated August 6, 2025. Review of Resident 5's weight history documented 65 lb on August 2nd, 2025, and 73 lb on August 6th, 2025. Review of Resident 5's care plan included a focus area for nutritional risk related to severe malnutrition, anorexia, nutritional marasmus (a form of severe malnutrition caused by a lack of calories and protein- muscle wasting, fat depletion), initiated August 4, 2025, and created by Employee 4 (Registered Nurse). Interventions included honor food preferences within meal plan, monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake, initiated August 4, 2025. Progress note dated August 1, 2025, documented a change in appetite, Difficulty chewing, decreased fluid intake. Meal supplements ordered. Resident reported loss of appetite and difficulty chewing food, prefers soft food. Review of history and physical dated August 4, 2025, read, in part, malnutrition and multiple wounds, care plan regarding malnutrition included dietitian consult, vegetarian, nursing to encourage intake and start supplemental shakes with meals. Review of Psychiatry progress note dated August 4, 2025, read, in part, the Resident reports not wanting to eat much in the facility due to food choices and asked to speak with dietary and requested protein shakes. Resident decreased protein levels when in hospital, cachectic with severe muscle wasting, discussed dietary needs with dietitian and nurse, recommended protein supplements to dietitian. Review of note dated August 4th, 2025, documented the Resident, Resident Representative and Social Services were in attendance for the post-admission care plan, a copy of the medication list, and dietary instruction was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395451 If continuation sheet Page 2 of 3 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 08/07/2025 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete provided. The care plan was reviewed and updated. Further review of the clinical record failed to document a progress note or an initial assessment by the Registered Dietitian as of August 7th, 2025; 7 days post admission. Observation on August 6, 2025, at 12:45 PM, revealed Resident 5 failed to receive the following items per the residents tray ticket: Stuffed shells, dessert of the day (diced pears), and diet fruit cup. The Resident received orzo with tomato sauce and cheese (the cheese was not visible and the orzo appeared dry), a side salad, hot tea and 4 ounces of apple juice, and 4-ounce mighty shake. Interview with the Resident 5 on August 6, 2025, at 12:45 PM, revealed that she is vegetarian, and had provided her preferences to staff but doesn't receive what she has requested, which included Greek yogurt vanilla or plain, and cottage cheese. She also noted that was the first time she had received a supplement of any kind, which was a mighty shake (contains 220 calories and 6 grams of protein). The Resident revealed she was to be on a high protein diet, and the facility had not provided high protein foods. While at home, she consumed a nutritional drink that contained 42 grams of protein for 12 ounces, which her husband has been providing, as well as Greek yogurt and cottage cheese. It was also revealed that the yogurt the facility has provided, nonfat plain yogurt, contained only 4 grams of protein. Interview with Employee 1 (Food Service Director) on August 6, 2025, at 1:10 PM, revealed she was on vacation the previous week when Resident 5 was admitted and obtained her preferences on August 4th, 2025. The Resident didn't receive the stuffed shells due to not being available. The stuffed shells were ordered and will be delivered that week. Employee 1 formulated a vegetarian meal plan based on Resident 5's preferences to enable dietary staff a guide on what to provide if the main and alternate menu items would not suffice. Items included: plain yogurt, toast with peanut butter, grilled cheese, tomato soup, peanut butter and jelly sandwich, chef salad with extra cheese (no meat or eggs), cottage cheese and fruit plate, macaroni and cheese, stuffed shells. Employee 3 (Registered Nurse) documented to Employee 1 that she reached out to the Dietitian regarding Resident 5, and the Dietitian thought the resident required extra calories and nutritional supplements and would submit a request for an order. Review of Resident 5's Medication Administration Record (MAR- documentation of administration of physician orders) documented ensure plus with meals was administered 12:00 PM on August 6th, 2025. Observation and interview on August 7, 2025 at 12:55 PM revealed Resident 5 did not receive the Ensure plus. Interview with The Director of Nursing on August 7, 2025, at 11:30 AM, it was revealed that there are two Registered Dietitians who work remotely to provide services to the facility. It was also revealed that they don't attend care plan meetings remotely. Nutrition recommendations are communicated to the Unit Managers and they will complete a request form and place it in the physician book to be reviewed. During an interview with the NHA on August 7, 2025, at 3:30 PM, the concern regarding items missing from four resident's trays to include enhanced meal items and nutritional supplements, and lack of a timely nutrition assessment and direct communication with Resident 5 by a Registered Dietitian were communicated. No further information was provided. The facility failed to ensure physician orders and care plan interventions were followed to maintain nutritional status of four residents. The facility failed to provide timely nutritional assessment, participation in a care conference, and have direct communication with Resident 5 to provide resident-centered care for a nutritionally compromised resident. 28 Pa, Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(3) Nursing services Event ID: Facility ID: 395451 If continuation sheet Page 3 of 3