Health inspection·November 3, 2022

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of the resident's admission for one of 26 residents reviewed (Resident 50). Findings Include: Review of Resident 50's clinical record revealed an admission date of September 19, 2022, and diagnoses that included osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) and abnormalities of gait (walking) and mobility (the ability to move or be moved freely and easily). Review of Resident 50's admission Fall Risk assessment dated [DATE], revealed that the Resident had experienced three or more falls in the last three months prior to admission, and that their fall risk score was 24. The guidelines on the Fall Risk Assessment indicated that a score of 10 or higher represents a high risk for fall. In the section of the Fall Risk Assessment titled Indicate Care Plan Action Taken, it was marked to Initiate Plan of Care. Review of Resident 50's clinical record and facility provided incident reports, it was noted that Resident 50 had a fall on September 24, 2022, at 6:15 AM, and on October 1, 2022, at 12:30 AM. Review of Resident 50's baseline care plan revealed that a care plan was not developed for their high risk of falling until October 1, 2022. During an interview with the Nursing Home Administrator, Director of Nursing, Employee 1, and Employee 2 on November 2, 2022, at 1:02 PM, Employee 1 confirmed that the admission Fall Risk Assessment was completed on September 19, 2022; which identified the Resident was at high risk for falls and that the care plan for falls was not created until October 1, 2022. The Director of Nursing indicated that she would have expected that the baseline care plan would have included falls at the time of the initial development as indicated on the admission Fall Risk Assessment. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Page 1 of 4 395518 395518 11/03/2022 Courtyard Gardens Nursing and Rehab Ctr 999 West Harrisburg Pike Middletown, PA 17057

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on policy reviews, observations, and resident and staff interviews, it was determined that the facility failed to provide respiratory services consistent with professional standards of practice for two of 21 residents reviewed (Resident 32 and 89). Residents Affected - Few Findings include: Review of facility policy titled Nebulizers - Use and Care dated June 2011 revealed After each use, wipe mouth piece with a paper towel, removing all moisture, and store in a plastic bag. Review of facility provided policy titled Oxygen therapy revised June 2019, revealed, Change the cannula, tubing, and humidifier bottle every week or more frequently, if needed. Review of Resident 32's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), dependence on supplemental oxygen, and sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). Review of Resident 32's current physician orders revealed the following orders: continuous positive airway pressure (CPAP- a machine that uses mild air pressure to keep breathing airways open while one sleeps) to be worn while sleeping with oxygen 3 liters---settings: minimum expiratory positive airway pressure (EPAP- creating pressure when exhaling, keeping airway open until next inhale of breath) is 6 cm; maximum inspiratory positive airway pressure (IPAP the inspiratory pressure when inhaling a breath) is 25 cm pressure support of 4 cm every evening and night shift dated October 14, 2022; Cleanse CPAP face mask with soapy water and rinse daily. Do on day shift after removal, dated October 11, 2022; change oxygen tubing, humidifier bottle, and mask or cannula, and rinse concentrator filter with water every night shift every Sunday, date and initial, label with resident name, make sure to change and label wheelchair oxygen tank tubing, dated May 15, 2022; Ipratropium-Albuterol Solution 0.5-2.5 MG/3 ML 3 ml inhale orally every four hours as needed for shortness of breath or wheezing via nebulizer while awake, dated March 31, 2022; and oxygen at 3 liters/minute via nasal cannula as needed and monitor oxygen saturation each shift that oxygen is used, dated March 31, 2022. Orders did not reveal that the Resident is independent in managing his oxygen and CPAP. During an interview with Resident 32 on October 31, 2022, at 10:18 AM, the following was noted: the Resident's nasal cannula for their oxygen was laying on the bed and not contained in a protective bag. It was connected to the oxygen concentrator, which was running; but the Resident was connected to their portable oxygen tank. The oxygen concentrator was noted to have gray colored, fuzzy particles on the vent on the top of the back of the concentrator; and the CPAP mask was laying on the night stand and not contained in a protective bag. During an observation of Resident 32's room on November 1, 2022, at 9:17 AM, the same findings were noted. During an observation of Resident 32's room conducted with Employee 2 on November 2, 2022, at approximately 9:27 AM, the following was noted: the nasal cannula that was connected to the running concentrator was laying on the bed and not contained in a protective bag; a nebulizer treatment mask was noted to be laying on the overbed table and not in a protective bag, and the CPAP mask remained on the nightstand and not contained in a protective bag. Resident 32 had left the facility around 8:45 395518 Page 2 of 4 395518 11/03/2022 Courtyard Gardens Nursing and Rehab Ctr 999 West Harrisburg Pike Middletown, PA 17057

F 0695 Level of Harm - Minimal harm or potential for actual harm AM for an outside appointment. Employee 2 confirmed that the nasal cannula, CPAP mask, and the nebulizer treatment should be bagged, but also shared that the Resident probably finished it before they left for their appointment, and that the nurse had not been back yet to clean it and place in the protective bag. Employee 2 further confirmed that the oxygen concentrator needed cleaned and indicated that they would get it all taken care of. Residents Affected - Few Review of Resident 32's Medication Administration Record for November 2022, revealed that there was no documentation of the Resident receiving a nebulizer for the month of November thus far. During a follow-up interview with Employee 2 on November 2, 2022, at 10:32 AM, Employee 2 indicated that the nebulizer treatment was cleaned and bagged; the nasal cannula was bagged; the CPAP mask was bagged; and the concentrator was cleaned. She further indicated that the Resident often refuses the CPAP and that they would be following up with the MD. During an interview with the Nursing Home Administrator (NHA), Director of Nursing, Employee 1, and Employee 2, on November 2, 2022, at 1:19 PM, Employee 2 confirmed that the concentrator vent area was dusty and had to be cleaned, and that she bagged items accordingly. The Director of Nursing confirmed that she would expect the items to be bagged when not in use. During exit conference with the NHA, Employee 1, and Employee 2, on November 3, 2022, at approximately 1:00 PM, Employee 2 indicated that although the items were not placed in the protective bags at the time of the observations, there were protective bags present in the room. Employee 2 further indicated that Resident 32 is independent with his oxygen and CPAP. It was shared that the concern remains because, as staff are in and out of room throughout the day, the items could be placed in their protective bags. Review of Resident 89's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) 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). Observation of Resident 89 on November 2, 2022, at 9:55 AM, revealed the Resident lying in bed sleeping. Further observation revealed their oxygen concentrator sitting beside the bed with oxygen tubing attached to it. The oxygen tubing was dated September 2, 2022. Review of Resident 89's current physician's orders on November 2, 2022, revealed an order for supplemental oxygen, via nasal canula, at 2 liters per minute, as needed, to keep SPO2 (a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry) greater than 90%. Further review revealed a current physician order to change oxygen tubing, humidifier bottle, and nasal canula night shift every Thursday and date and label with the resident's name. Review of Resident 89's Medication Administration Record/Treatment Administration revealed that staff documented that on September 8, 15, 21, and 29, 2022 and October 6, 13, 20 and 27, 2022 that the oxygen tubing was changed. Review of Resident 89's care plan on November 2, 2022, at 10:00 AM, revealed a care plan with a focus of oxygen use related to chronic obstructive pulmonary disease; and an intervention of continuous oxygen use for respirator comfort, 2 liters at rest and 4 liters with ambulation and bedtime. 395518 Page 3 of 4 395518 11/03/2022 Courtyard Gardens Nursing and Rehab Ctr 999 West Harrisburg Pike Middletown, PA 17057

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the Employee 2 on November 3, 2022, at 9:00 AM, it was revealed that the expectation is that the oxygen tubing would be changed weekly, and that the facility policy would be followed. Also, Employee 2 revealed that she would expect the care plan to be updated to reflect current physician's orders for Resident 89's care. During an interview with the Nursing Home Administrator on November 3, 2022, at 9:00 AM, it was revealed that he would exprect the facility policy to be followed. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 395518 Page 4 of 4