Health inspection·June 6, 2024

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observations, facility document review, and resident and staff interviews, it was determined that the facility failed to provide a therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) for the lunch meal on June 5, 2024, for three of three residents on a renal diet (Resident 1, 3, and 12) and two of two residents reviewed for a consistent carbohydrate diet (Residents 2 and 4). Findings include: Review of the facility meal extension sheets for June 5, 2024, revealed that residents on a renal diet (a diet to control potassium, phosphorus, sodium, protein for kidney health) were to be served a half a cup of seasoned beets instead of a half a cup of stewed tomatoes; and a half a cup of fruit sherbet instead of a half a cup of chocolate ice cream. Further review of the facility meal extension sheets for June 5, 2024, revealed that residents on a consistent carbohydrate diet (a diet designed to keep blood sugar levels stable by eating the same amount of carbohydrates every day) were to receive a dinner roll. Review of Resident 1's clinical record revealed diagnoses that included end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis) and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). Review of Resident 1's physician orders revealed an order for a renal diet, dated May 10, 2024. Observation of Resident 1's meal tray and tray ticket on June 5, 2024, at 12:24 PM, revealed that the Resident was on a renal diet and was to receive a half cup of seasoned beets. Resident 1 had stewed tomatoes in place of the seasoned beets. Interview with Employee 1 (Dietary Aide) who was serving the food on the unit where Resident 1 resides on June 5, 2024, at 12:28 PM, revealed that they did not have seasoned beets on the tray line to serve. Review of Resident 2's clinical record revealed diagnoses that included diabetes mellitus type II and chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure). Review of Resident 2's physician orders revealed an order for a consistent carbohydrate diet, dated May 30, 2024. Page 1 of 3 395733 395733 06/06/2024 Gettysburg Center 867 York Road Gettysburg, PA 17325

F 0803 Level of Harm - Minimal harm or potential for actual harm Observation of Resident 2's meal tray and tray ticket on June 5, 2024, at 12:30 PM, revealed that the Resident was on a consistent carbohydrate diet and was to receive a dinner roll. Resident 2 did not have a dinner roll present on their tray at time of delivery. Review of Resident 3's clinical record revealed diagnoses that included CKD and diabetes mellitus type II. Residents Affected - Some Review of Resident 3's physician orders revealed an order for a renal diet, dated January 17, 2024. Review of Resident Council Meeting minutes for February 27, 2024, revealed that Resident 3 questioned why their renal diet was not always being followed. The minutes also indicated that the Dietary Manager said she would educate dietary staff on making sure that the Resident receives what they are supposed to be receiving on their meal trays. Observation of Resident 3's meal tray and tray ticket on June 5, 2024, at 12:35 PM, revealed that the Resident was on a renal diet and was to receive a half cup of seasoned beets and a half cup of fruit sherbet. Resident 3 had stewed tomatoes in place of the seasoned beets and chocolate ice cream instead of the fruit sherbet. During observation, Resident 3 stated, they never follow my renal diet. Review of Resident 4's clinical record revealed diagnoses that included diabetes mellitus type II and CKD. Review of Resident 4's physician orders revealed an order for a consistent carbohydrate diet, dated March 12, 2018. Observation of Resident 4's plate and tray ticket on June 5, 2024, at 12:36 PM, revealed that the Resident was on a consistent carbohydrate diet and was to receive wheat bread only. Resident 4's plate had a dinner roll in place of the wheat bread. Resident 4 stated, I don't always get wheat bread. Review of Resident 12's clinical record revealed diagnoses that included diabetes mellitus type II and CKD. Review of Resident 12's physician orders revealed an order for a renal diet, dated May 22, 2024. Review of facility grievance log for June 2024, revealed that a grievance had been received on June 3, 2024, from Resident 12 and their significant other, which indicated that their renal diet was not being followed as they felt Resident 12 was receiving too many potatoes. Interview with Employee 2 (Dietary Manager in Training) on June 5, 2024, at 12:45 PM, she indicated that no beets were prepared for the lunch meal and confirmed that Residents 1, 3, and 12 were not provided the seasoned beets as their ordered diet indicated. She further indicated that they were available in the kitchen, but offered no information as to why they were not prepared for the lunch meal. She also indicated that fruit sherbet was available and could not answer why Resident 3 did not receive it. During an interview with the Nursing Home Administrator (NHA) on June 5, 2024, at 2:45 PM, the aforementioned observations and interviews were shared. The NHA confirmed that she would expect residents to receive their ordered therapeutic diets. 395733 Page 2 of 3 395733 06/06/2024 Gettysburg Center 867 York Road Gettysburg, PA 17325

F 0803 Pa code 211.6(a) Dietary Services Level of Harm - Minimal harm or potential for actual harm Pa code 211.10(c) Resident Care Policies Pa code 211. 12(d)(5) Nursing Services Residents Affected - Some 395733 Page 3 of 3