Health inspection·September 19, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for one of 19 residents reviewed (Resident 36). Residents Affected - Few Findings Include: Review of Resident 36's clinical record revealed diagnoses that included diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), psychosis (a mental disorder when a person has trouble telling the difference between what's real and what's not), and muscle weakness. Review of Resident 36's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) with ARD (assessment reference date- last day of the assessment period) of May 3, 2024, revealed it was coded that the Resident received one insulin injection in the past 7 days and that an insulin order had changed in the past 7 days. Review of Resident 36's Quarterly MDS with ARD of August 2, 2024, revealed it was coded that the Resident received one insulin injection in the past 7 days Review of Resident 36's physician orders revealed a once weekly injection for diabetes, but failed to reveal any orders for insulin during the ARD lookback period for the aforementioned assessments. Further review of Resident 36's Quarterly MDS with ARD of August 2, 2024, revealed in Section N0450. Antipsychotic Medication Review it was coded no under Has a gradual dose reduction (GDR) been attempted? (GDR- stepwise decreasing of a dose of medication to determine if symptoms, conditions, or risks can be managed by a lower dose). Also, that the next section Date of last attempted GDR was disabled due to the response to the previous section. Review of Resident 36's clinical record revealed a Psychiatry Note dated September 10, 2024, noting a GDR of Resident 36's Seroquel (antipsychotic medication) had been completed on July 17, 2024. During an email correspondence with the Nursing Home Administrator and Director of Nursing (DON) on September 17, 2024, at 1:43 PM, the surveyor questioned if Resident 36's MDS assessments were accurate related to insulin use and GDR. Follow-up interview with the DON on September 18, 2024, at 10:32 AM, revealed Resident 36's MDS assessments were coded inaccurately for those sections, and she would expect resident MDS assessments Page 1 of 5 395518 395518 09/19/2024 Courtyard Gardens Nursing and Rehab Ctr 999 West Harrisburg Pike Middletown, PA 17057

F 0641 to be coded accurately. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.5(f) Medical records Residents Affected - Few 395518 Page 2 of 5 395518 09/19/2024 Courtyard Gardens Nursing and Rehab Ctr 999 West Harrisburg Pike Middletown, PA 17057

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 21 residents reviewed (Residents 18, 69, and 81). Findings include: Review of facility policy, titled Care Plans, last reviewed December 28, 2023, read, in part, This facility will develop and maintain a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that include but are not limited to those identified in the comprehensive assessment. The plan of care will be reviewed in an ongoing manner and progress or lack thereof toward established goals will be documented within the medical record of the resident. If appropriate, the care plan will be revised as needed. Review of Resident 18's clinical record revealed diagnoses of muscle weakness (a lack of muscle strength) and disorders of phosphorus metabolism (a condition where blood phosphate levels are too low. Symptoms include muscle weakness, bone softening, and altered mental state). Review of Resident 18's electronic medical record revealed the diagnosis of post-traumatic stress disorder (PTSD) was added to her medical diagnoses on October 24, 2023. Review of Resident 18's physician orders on September 17, 2024, revealed an order for heel protectors to be worn while Resident in bed, with a start date of April 3, 2024. Review of Resident 18's care plan on September 17, 2024, revealed a care plan with a focus area of, Resident 18 is at risk for impaired skin integrity, including pressure injury, related to incontinence and decreased mobility: with a revision date of September 15, 2024. There is no mention of Resident 18's need for heel protectors anywhere in the care plan. Interview with the Director of Nursing (DON) on September 18, 2024, at 12:33 PM, revealed that Resident 18's care plan to contain instructions to apply heel protectors to Resident 18's heels when the Resident is in bed. Review of Resident 69's clinical record revealed diagnoses that included hypertension (high blood pressure) and peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage, or spasms in a blood vessel). Review of Resident 69's current physician orders revealed an order for foam boots when in bed every shift for preventative, with a start date of January 7, 2023. Review of Resident 69's care plan on September 17, 2024, revealed a care plan with a focus area of, Resident 69 is at risk for impaired skin integrity, including pressure sores, related to decreased mobility, incontinence, and history of pressure wounds; with a revision date of June 15, 2023. The care plan failed to mention Resident 69's need for foam boots on that focus area or anywhere on the care plan. 395518 Page 3 of 5 395518 09/19/2024 Courtyard Gardens Nursing and Rehab Ctr 999 West Harrisburg Pike Middletown, PA 17057

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the DON on September 19, 2024, at 10:22 AM, she revealed she would expect Resident 69's foam boots to be on the care plan. Review of Resident 81's clinical record revealed diagnoses that included rheumatoid arthritis (an autoimmune disease that causes inflammation and damage in your joints and other body system), chronic pain, and muscle weakness. Interview with Resident 81 on September 16, 2024, at 9:55 AM, revealed she wears her splint at night to help with her rheumatoid arthritis. Review of Resident 81's physician orders revealed an order for Carrot splint to left hand at bedtime, off in AM-- skin checks every shift, every shift for skin integrity related to rheumatoid arthritis, with a start date of August 1, 2024. Review of Resident 81's care plan on September 17, 2024, revealed care plans for assistance with activities of daily living and chronic pain related to arthritis, but failed to reveal notation of her carrot splint. During an interview with the DON on September 18, 2024, at 12:26 PM, she revealed she would expect Resident 81's carrot splint to be on her care plan. 28 Pa. Code 211.12(d)(3)(5) Nursing services 395518 Page 4 of 5 395518 09/19/2024 Courtyard Gardens Nursing and Rehab Ctr 999 West Harrisburg Pike Middletown, PA 17057

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for one of four residents reviewed for pressure ulcers (Resident 69). Residents Affected - Few Findings include: Review of the facility policy, titled Skin Integrity Interventions and Protocol for The Middletown Home, last reviewed on December 28, 2023, revealed that interventions for pressure ulcer preventions include: Implement pressure-relieving measures for residents at risk, including: frequent repositioning, use of pressure-reducing mattresses and cushions, proper skin care, including cleansing and moisturizing, adequate nutrition and hydration, and management of incontinence. Review of Resident 69's clinical record revealed diagnoses that included hypertension (high blood pressure) and peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage, or spasms in a blood vessel). Review of Resident 69's current physician orders revealed an order for foam boots when in bed every shift for preventative, with a start date of January 7, 2023. Observation of Resident 69 on September 16, 2024, at 9:57 AM, revealed Resident 69 was lying in bed, and their foam boots were on the floor beside the bed, not on the Resident. Observation of Resident 69 on September 16, 2024, at 1:19 PM, revealed Resident 69 was lying in bed, and their foam boots were on the floor beside the bed, not on the Resident. Observation of Resident 69 on September 18, 2024, at 10:14 AM, revealed Resident 69 was lying in bed, and their foam boots were on the floor beside the bed, not on the Resident. Review of Resident 69's clinical record revealed no progress notes documented by staff indicating that Resident 69 refused to wear their foam boots or requested them to be taken off during the dates and times above. Review of Resident 69's care plan on September 17, 2024, revealed a care plan with a focus area of, Resident 69 is at risk for impaired skin integrity, including pressure sores, related to decreased mobility, incontinence, and history of pressure wounds; with a revision date of June 15, 2023. The care plan failed to mention Resident 69's need for foam boots on that focus area or anywhere on the care plan. During an interview with the Director of Nursing (DON) on September 19, 2024, at 10:22 AM, she revealed she would expect Resident 69's foam boots to be on the care plan, and that she spoke to staff on Resident 69's hall who said that Resident 69 will kick their foam boots off, but staff could document in progress notes on Resident 69's clinical record when they are taken off. DON revealed they could change Resident 69's physician order to include: foam boots as tolerated. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395518 Page 5 of 5