Health inspection·November 7, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on document review and staff interviews, it was determined that the facility failed to ensure each resident is informed of the items and services for which the resident may be charged and the amount of charges for those services at the conclusion of the Medicare A skilled services stay by issuing the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage form (SNF ABN) for two of three residents reviewed at the conclusion of the Medicare A covered stay (Residents 37 and 64). Residents Affected - Few Findings Include: Review of Resident 37's SNF Beneficiary Protection Notification Review form revealed the Resident's last covered day of Medicare Part A services to be September 22, 2023. Continued review of the form revealed the facility had not issued the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage form [SNF-ABN, CMS-10055] at the conclusion of the Medicare Part A services stay. The SNF-ABN form is the liability form issued by skilled nursing facilities as the liability notice that describes an item or service that is usually paid for by Medicare, but may not be paid because it is not medically reasonable and necessary. Review of Resident 64's SNF Beneficiary Protection Notification Review form revealed the Resident's last covered day of Medicare Part A services to be June 16, 2023. Continued review of the form revealed the facility had not issued the SNF-ABN, CMS 10055 form at the conclusion of the Medicare Part A services. An interview with Employee 4 (Social Worker) on November 6, 2023, at 10:29 AM, revealed an alternate form was used instead of the required SNF-ABN form for Residents 37 and 64. An additional interview with the Director of Nursing on November 7, 2023, at 8:41 AM, revealed an awareness that the required form had not been issued to Residents 37 and 64. 28 Pa. Code 201.14 Responsibility of licensee Page 1 of 7 395518 395518 11/07/2023 Courtyard Gardens Nursing and Rehab Ctr 999 West Harrisburg Pike Middletown, PA 17057

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 state regulations, surveyor observation, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 24 residents reviewed (Resident 27). Residents Affected - Few Findings Include: Review of the Pennsylvania Nursing Practice Act, Chapter 21.145. Functions of the LPN (Licensed Practical Nurse), revealed The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: The LPN may accept a written order for medication and therapeutic treatment from a practitioner authorized by law and by facility to issue orders for medical and therapeutic measures. Review facility policy, titled Medication Administration General Guidelines, dated 2006, revealed in section B. Administration, Step 2. Medications are administered in accordance with written orders of the attending physician. Review of Resident 27's clinical record revealed diagnoses that include low back pain between the lower edge of the ribs and the buttock and spinal stenosis (a narrowing of the spinal canal in the lower part of your back). Review of Resident 27's physician's orders on November 6, 2023, reveals a physician's order written on October 12, 2023, for Bengay ultra patch (a patch with pain relieving medication applied) for Resident 27's mid back, applied in the morning and removed in the evening daily. Review of Resident 27's MAR (Medication Administration Record) from the month of November 2023, revealed that on November 5, 2023, Employee 1 (LPN) documented that she removed the Bengay ultra patch from Resident 27's mid back. Observation of Resident 27 on November 6, 2023, at 8:02 AM, revealed Employee 2 (LPN) removed a patch from Resident 27's mid-back, dated November 5, 2023, so that she could apply the new patch that morning. Interview with the Director of Nursing on November 7, 2023, at 9:17 AM, revealed that she would expect the Bengay patch would have been removed from Resident 27's back on the evening of November 5, 2023, as ordered, by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395518 Page 2 of 7 395518 11/07/2023 Courtyard Gardens Nursing and Rehab Ctr 999 West Harrisburg Pike Middletown, PA 17057

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observations, record review, and staff interviews, it was determined that the facility failed to follow physician orders for two of 20 residents reviewed (Residents 38 and 53). Residents Affected - Few Findings Include: Review of Resident 38's clinical record revealed diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and muscle weakness. Review of Resident 38's physician orders revealed an order for Geri Sleeves BUE (bilateral upper extremities) every shift for skin protection, may remove for care and soilage, with a start date of August 3, 2023. Observation of Resident 38 on November 5, 2023, at 1:28 PM, revealed Resident 38 asleep, sitting in a common area of the hall without Geri sleeves on. Observation of Resident 38 on November 6, 2023, at 10:18 AM, revealed Resident 38 in his room, drinking out of a cup without Geri sleeves on. Observation of Resident 38 on November 6, 2023, at 1:01 PM, revealed Resident 38 asleep in the hallway, without Geri sleeves on. Interview with the Director of Nursing (DON) on November 7, 2023, at 8:39 AM, revealed she would expect physician orders to be followed. Review of Resident 53's clinical record revealed diagnoses that included Parkinson's Disease, dementia, and muscle weakness. Review of Resident 53's physician orders revealed an order for Geri sleeves to BL (bilateral) arms at all times every shift for altered skin integrity, may remove for care, with a start date of March 14, 2023. Observation of Resident 53 on November 6, 2023, at 10:24 AM, revealed Resident 53 asleep in a common area of the hall without Geri sleeves on. Interview with the DON on November 7, 2023, at 8:39 AM, revealed she would expect physician orders to be followed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395518 Page 3 of 7 395518 11/07/2023 Courtyard Gardens Nursing and Rehab Ctr 999 West Harrisburg Pike Middletown, PA 17057

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and staff interview, it was determined that the facility failed to post daily current staffing and census for the following dates: October 31, 2023; November 1, 2, 4, and 5, 2023. Residents Affected - Some Findings include: During entrance to the facility on November 5, 2023, at approximately 9:15 AM, the posted staffing was reviewed and observed to be dated October 30, 2023, and copier detail confirmed it was printed on October 30, 2023, at 2:01 AM. During an interview with the Director of Nursing on November 6, 2023, at approximately 2:00 PM, she confirmed that the staff person who is assigned to post the daily staffing forgot to create and post the staffing for October 31, 2023; November 1, 2, 4, and 5, 2023. 28 Pa. Code 201.18(b)(1)(3) Management 395518 Page 4 of 7 395518 11/07/2023 Courtyard Gardens Nursing and Rehab Ctr 999 West Harrisburg Pike Middletown, PA 17057

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on facility policy review, observations, product label review, and staff interviews, it was determined that the facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and four of four nourishment areas. Findings include: Review of facility policy, titled Food and Nutrition Services Policies and Procedures: Storage of Goods, revealed, Remove goods from storage for which the expiration date has passed .All foods will be labeled with month/day/year received .Leftovers are to be covered, labeled, and dated with use by date .All foods must be labeled and dated. Review of facility policy, titled Food and Nutrition Services Policies and Procedures: Foods Brought by Family/Visitors, revealed, Perishable foods must be destroyed daily .All food items must be labeled with the resident's name and use by date and the date brought in and/or opened. Observation of the dry storage area on November 5, 2023, at 9:39 AM, revealed: one bag of rice open without a date; one open bag of rotini without an open date; one open bag of spaghetti without an open date; and one open bag of egg noodles without an open date. Interview with Employee 3 (Dietary Supervisor) on November 5, 2023, at 9:43 AM, revealed food containers should be labeled with an open date once opened. Observation of the walk-in freezer unit on November 5, 2023, at 9:45 AM, revealed: four pie crusts not dated; one bag of fries open and not dated; one bag of tater tots open and not dated; three slices of pizza not dated; two bags of hoagie rolls not dated; and one pan of dessert without a label or date. Observation in the main kitchen on November 5, 2023, at 9:50 AM, revealed a bin of flour dated use by October 25, 2023; and a bin of rice dated use by November 1, 2023. Observation of the walk-in refrigerator on November 5, 2023, at 9:56 AM, revealed: one container of thousand island salad dressing not dated. Observation of the second walk-in refrigerator on November 5, 2023, at 10:00 AM, revealed: one bin of celery not dated; one bag of parmesan cheese not dated; one bag of feta cheese with a use by date of October 27, 2023; and one monster energy drink open and labeled Dee. Interview with Employee 3 on November 5, 2023, at 10:01 AM, revealed employee food and beverages should not be stored in food storage areas. Observation during initial tour of the station 2 pantry area on November 5, 2023, at 10:08 AM, revealed: one container of individual jelly packets not dated; and one container of individual peanut butter packets not dated. Observation of the refrigerator and freezer temperature logs in the station 2 pantry area on November 5, 2023, at 10:09 AM, revealed temperatures failed to be recorded on September 7, 8, and 28, 395518 Page 5 of 7 395518 11/07/2023 Courtyard Gardens Nursing and Rehab Ctr 999 West Harrisburg Pike Middletown, PA 17057

F 0812 2023; October 2, 27, and 30, 2023; and November 3 and 4, 2023. Level of Harm - Minimal harm or potential for actual harm Further observation of the station 2 pantry area refrigerator on November 5, 2023, at 10:11 AM, revealed one carton of milk with a use by date of November 4, 2023, and the milk was leaking on the shelf; and two nutritional juice drinks not labeled with a thawed date. Residents Affected - Some Interview with Employee 3 on November 5, 2023, at 10:12 AM, revealed nutritional drinks that are received frozen should be labeled with a thawed date once pulled from the freezer, and are good for two weeks after the thawed date. Observation during initial tour of the dining room nourishment area on November 5, 2023, at 10:13 AM, revealed: one container of flaked cereal, one container of bran cereal, one container of toasted o's cereal, and one container of frosted wheat cereal, all labeled October 18, 2023. Interview with Employee 3 on November 5, 2023, at 10:16 AM, revealed the cereal containers are to be used within a week and they have been filled since October 18, 2023, and should be relabeled. Observation during initial tour of the station 1 pantry area on November 5, 2023, at 10:18 AM, revealed: one container of individual jelly packets not dated; and one container of individual peanut butter packets not dated. Further observation of the station 1 pantry area refrigerator on November 5, 2023, at 10:21 AM, revealed: one container of thickened cranberry juice with an open date of October 23, 2023, and one container of thickened water with an open date of October 28, 2023; both containers state they should be discarded seven days after opening. Observation during initial tour of the kitchenette pantry area on November 5, 2023, at 10:23 AM, revealed: four oatmeal cookies, two fudge cookies, and one brownie all not dated; and two containers of dairy creamer not dated. Further observation of the kitchenette pantry area refrigerator on November 5, 2023, at 10:25 AM, revealed: one container of potato salad for a resident labeled 10/31/23 from an outside source; one container of fruit from an outside source for a resident not labeled with residents name or date; and one container of olives from an outside source for a resident not labeled with resident's name or date. Observation of the refrigerator and freezer temperature logs in the kitchenette pantry area on November 5, 2023, at 10:27 AM, revealed temperatures failed to be recorded on September 7, 8, and 28, 2023; October 20, 27, and 30, 2023; and November 3 and 4, 2023. Interview with Employee 3 on November 5, 2023, at 10:28 AM, revealed she would expect food and beverages to be labeled and dated per facility policies and temperature logs to be filled daily. Interview with the Director of Nursing on November 6, 2023, at 2:14 PM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policies, food items are stored in accordance with professional standards, and temperature logs are filled. 28 Pa. Code 211.6(f) Dietary services 395518 Page 6 of 7 395518 11/07/2023 Courtyard Gardens Nursing and Rehab Ctr 999 West Harrisburg Pike Middletown, PA 17057

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on document review and staff interviews, it was determined the facility failed to develop a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia). Residents Affected - Many Findings include: During an interview with the Nursing Home Administrator (NHA) on November 7, 2023, at 11:00 AM, the NHA was unable to provide a policy that addressed water management or a list of water management team members. During the interview with the NHA on November 7, 2023, data was requested and unable to be provided, that would support implementation of a water management program, such as Legionella risk assessment, a water system flow chart that identifies risk areas such as, testing of shower heads, the ornamental fountain, or the pond that is active during Spring and Summer. The facility was able to provide professional water testing with a most recent date of October 26, 2023, to determine proper functioning of the cooling systems for pH (acidity or basicity), total alkalinity, calcium hardness, PTSA (ultra violet dye for monitoring cooling systems), and temperature. The facility was also able to provide professional water testing with a most recent date of October 26, 2023, to determine proper functioning two boilers for temperature, pH, hardness, molybdenum (a mineral), and sulfite; as well as cooling systems for conductivity, pH (acidity or basicity), total alkalinity, and calcium hardness. The company who performed the test made the following statement on the report, Standard water treatment is not meant to protect against health risks. The facility was able to show a form dated August 1, 2022, for a one time Legionella testing of the pond in the courtyard and one air condition intake grill in the facility that reported the detection of Legionella, but the final report did not detect the species of Legionella that affects humans and causes the disease in humans. The facility was unable to show control measures to prevent growth and spread of water-borne contaminants, no validation for routine environmental sample results of legionella testing, no monitoring of high risk areas, and no plan for when control limits are not met and/or control measures are not effective. During a final interview with the NHA on November 7, 2023, at approximately 11:00 AM, the NHA confirmed the facility hasn't developed a water management program. 28 Pa. Code 201.18(b)(1)(3) Management 395518 Page 7 of 7