Health inspection·August 17, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage appropriately, in advance of changes for Medicare covered services, to one of three residents reviewed whose Medicare coverage was discontinued (Resident 36). Residents Affected - Few Findings include: Review of Resident 36's clinical record revealed the Resident was admitted to the facility on [DATE], payor source was Medicare A. Skilled services ended on July 15, 2023, Resident 36's payor source changed to private pay at that time, and Resident 36 remained in the facility. Resident 36 was issued a Notice of Medicare Non-Coverage (NOMNC- indicates when you coverage for care is set to end) on July 11, 2023. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN, a form provides information that as of a specific date Medicare coverage ends and the specific amount of financial liability passed onto the resident) was not provided to Resident 36. The facility failed to inform Resident 36 of the basic daily rate to remain at the facility and discuss that she would be financially liable. During an interview with the Assistant Nursing Home Administrator on August 17, 2023, at 12:15 PM, it was revealed that Resident 36 should've been issued a SNF ABN notice. 28 Pa. Code 201.29(c.3)(1) Resident rights Page 1 of 17 395844 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on review of employee files, review of facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure residents were free from abuse by failing to conduct license verification for new employees for three of four employees (Employees 2, 3, and 6) Findings include: Review of facility policy, titled Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, dated 2022, revealed, The Facility will not employ or otherwise engage individuals who: Have disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. Review of Employee file for Employee 2 revealed a date of hire of June 28, 2023. Further review of the employee file failed to reveal any license verification or check with the state licensing board for disciplinary action against Employee 2's license. Review of Employee file for Employee 3 revealed a date of hire of July 20, 2023. Further review of the employee file failed to reveal any license verification or check with the state licensing board for disciplinary action against Employee 3's license. Review of Employee file for Employee 6 revealed a date of hire of July 10, 2023. Further review of the employee file failed to reveal any license verification or check with the state licensing board for disciplinary action against Employee 6's license. Interview with Nursing Home Administrator on August 17, 2023, at 11:30 AM, revealed that the facility did not have any documentation of verifying the licenses or checking with the state licensing board for any disciplinary action of Employees 2, 3, or 6 prior to them starting to work at the facility. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management 395844 Page 2 of 17 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0637 Assess the resident when there is a significant change in condition 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 that a significant change 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) assessment was completed timely after election of hospice care for two of 16 residents reviewed (Residents 29 and 32). Residents Affected - Few Findings include: Review of the Resident Assessment Instrument 3.0 User's manual (RAI - a standardized process is the basis for the accurate assessment of each nursing home resident) dated October 2021, revealed that the facility must complete a significant change MDS no later than 14 days after the effective date of the election of hospice service. Review of Resident 29's clinical record documented diagnoses that included bladder cancer, protein calorie malnutrition, and diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). Clinical record review for Resident 29 documented her physician ordered hospice care on March 10, 2023. Further clinical record review revealed a quarterly MDS assessment was completed on March 29, 2023, that documented hospice services; however, the facility failed to complete a significant change MDS as indicated by the RAI Manual. Interview with the Assistant Nursing Home Administrator (ANHA) and the Nursing Home Administrator (NHA) on August 16, 2023, at 2:23 PM, it was revealed that a significant change MDS should've been completed. Review of Resident 32's clinical record revealed diagnoses including Hypothyroidism (a condition where there isn't enough thyroid hormone in your bloodstream and your metabolism slows down) and anxiety disorder (persistent and excessive worry that interferes with daily activities). Review of Resident 32's Physician Orders on August 15, 2023, revealed that Resident 32 was admitted to Serenity Hospice on March 16, 2023, due to senile degeneration of the brain. Further clinical record review for Resident 32 revealed a quarterly MDS assessment was completed on March 1, 2023, and another quarterly MDS assessment was completed on June 1, 2023, that documented Resident 32 is receiving hospice services; however, the facility failed to complete a significant change MDS as indicated by the RAI Manual. An interview with the ANHA and the NHA on August 16, 2023, at 2:25 PM, it was revealed that a significant change MDS should've been completed. 28 Pa. Code 201.2(a) Requirements 395844 Page 3 of 17 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for four of 16 residents reviewed (Resident 29, 32, 145, and 146). Findings include: Review of Resident 29's clinical record documented diagnoses that included bladder cancer, protein calorie malnutrition, and diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). Clinical record review for Resident 29 documented her physician ordered hospice care on March 10, 2023. Review of Resident 29's care plan documented a focus area for Hospice services as of March 10, 2023, with an initiated date of July 14, 2023. During an interview with the Assistant Nursing Home Administrator and the Nursing Home Administrator (NHA) on August 16, 2023, at 2:23 PM, it was revealed that the hospice care plan for Resident 29 should've been initiated upon admission to hospice services. Review of Resident 32's clinical record revealed diagnoses that included Hypothyroidism (a condition where there isn't enough thyroid hormone in your bloodstream and your metabolism slows down) and anxiety disorder (persistent and excessive worry that interferes with daily activities). Review of Resident 32's Physician Orders on August 15, 2023, revealed that Resident 32 was admitted to Serenity Hospice on March 16, 2023, due to senile degeneration of the brain. Review of Resident 32's comprehensive centered care plan on August 15, 2023, under the focus area, revealed Resident was admitted to Serenity Hospice on March 16, 2023, due to senile degeneration of brain with an initiated and created date of July 14, 2023. An interview with the NHA on August 17, 2023, at 12:40 PM, revealed they would expect the care plan to have been created sooner than four months after hospice services have started. Review of Resident 145's clinical record revealed diagnoses that included malignant neoplasm of spinal cord (cancerous tumor of spine) and diabetes (a group of diseases that result in too much sugar in the blood [high blood glucose]). Observation of Resident 145 on August 14, 2023, at 11:45 AM, revealed the Resident lying in bed, and she had a urinary catheter. Review of Resident 145's care plan on August 16, 2023, failed to reveal any care planning for the Resident's use of a urinary catheter. During a staff interview with the Director of Nursing (DON) on August 17, 2022, at 11:36 AM, 395844 Page 4 of 17 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0656 revealed that Resident 145 did not have a care plan for her catheter use, but one would be added. Level of Harm - Minimal harm or potential for actual harm Review of Resident 146's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems) and diabetes. Residents Affected - Some Observation of Resident 146 on August 14, 2023, at 10:15 PM, revealed the Resident lying in bed, and he had a urinary catheter. Review of Resident 146's care plan on June 12, 2023, failed to reveal any care planning for the Resident's use of a urinary catheter. During a staff interview with the DON on August 17, 2022, at 11:36 AM, revealed that Resident 146 did not have a care plan for his catheter use, but one would be added. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 395844 Page 5 of 17 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide care and services necessary for care-dependent residents for two out of 16 residents reviewed (Residents 3 and 19). Residents Affected - Few Findings Include: Review of Resident 3's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and anxiety disorder (a feeling of worry, nervousness, or unease). Review of Resident 3's most recent quarterly Minimum Data Set (MDS - assessment tool utilized to identify a resident's physical, emotional, and psychosocial needs), dated August 2, 2023, revealed that under section C, Cognitive Patterns, more specifically subsection C0500. BIMS Summary Score, Resident 3 is coded to have a BIMS of 14 out of 15. Review of Resident 3's comprehensive care plan on August 15, 2023, under the Focus section for Activities of Daily Living (ADL) care, created on April 19, 2019, and initiated on March 4, 2020, revealed that Resident 3 requires one staff member to move between surfaces. Observation on August 15, 2023, at 9:32 AM, revealed Resident 3's call bell light on. Observation on August 15, 2023, at 9:46 AM, revealed Resident 3's call bell light turned off. Surveyor observed staff member exiting Resident 3's room at 9:47 AM. Interview with Resident 3 on August 15, 2023, at 9:49 AM, revealed Resident requested to get up out of bed. Observation of Resident 3 on August 15, 2023, at 9:49 AM, revealed that Resident 3 was lying in bed. Observation on August 15, 2023, at 10:00 AM, revealed Resident 3 lying in bed. Interview with Resident 3 on August 15, 2023, at 1:49 PM, revealed that Resident 3 was still lying in bed. Resident 3 indicated they had been in bed all day and never received assistance getting up out of bed. During an interview with Nursing Home Administrator on August 17, 2023, at 12:36 PM, revealed they would expect the call bell to be answered and responded to in a timely manner. Review of Resident 19's clinical record documented diagnoses that included left above the knee amputation. During an interview with Resident 19 on August 15, 2023, at 10:34 AM, it was revealed that at times she doesn't get a shower. It was further revealed that she didn't get a shower on August 14, 2023, on evening shift. Resident 19 stated a staff member told her she would give her a shower on Tuesday evening, because on Monday there was only one other Nursing Assistant working on evening shift. Interview with Resident 19 on August 16, 2023, at 11:38 AM, it was revealed that she requires assistance with bathing, and that she prefers to receive a shower vice a bed bath. She stated, again, that it is an issue getting a shower when only one Nursing Assistant is working on evening shift. 395844 Page 6 of 17 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's shower schedule revealed Resident 19 was scheduled for a shower on Mondays and Thursday on evening shift. Review of bathing task sheet revealed Resident 19 received a bed bath: July 22, 2023, and August 1, 2, 4, 5, 8, and 11, 2023. It was documented the Resident refused July 21, 2023, and August 8, 2023. There was no shower documentation noted for August 15, 2023. Resident 19 wasn't documented as receiving a shower in the past 30 days per Resident preference. During interview with Assistant Nursing Home Administrator (ANHA) on August 16, 2023, at 2:30 PM, it was revealed that a resident's choice for showers vice a bed bath should be honored. During an interview with the ANHA on August 17, 2023, at 8:00 AM, revealed that a preference for showers was added to Resident 19's care plan. 28 Pa Code 211.12 (d)(1)(5) Nursing services 28 Pa. Code 201.29 Resident rights 395844 Page 7 of 17 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

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 clinical record review, facility policy review, 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 of a pressure ulcer for one of 16 residents reviewed (Resident 21). Residents Affected - Few Findings Include: Review of facility policy, titled Wound Care with a revised date of October 2010, under the Documentation section revealed, The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. Review of Resident 21's clinical record revealed diagnoses that included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) and hypertension ( high blood pressure). Further review of Resident 21's clinical record revealed that Resident 21 has a stage 3 pressure ulcer on the sacral region. Review of Resident 21's current physician orders revealed the following treatment for the sacrum wound pressure ulcer: cleanse, apply packing strip to undermining at 12 o'clock, and apply dry dressing. Review of Resident 21's Treatment Administration Record (TAR) for the months of June 2023, July 2023, and August 2023, revealed no documentation of the wound care being completed on the following dates: June 14 and 18, 2023; July 5, 22, 26, 27, and 30, 2023; and August 10, 2023. During staff interview on August 16, 2023, at 2:26 PM, the Nursing Home Administrator (NHA) stated that there were a lot of agency staff working at that time and they are looking into why there are gaps in wound care being administered to Resident 21. During an interview with NHA on August 17, 2023, at 12:33 PM, revealed that she would expect wound treatment to be completed as ordered by the physician and marked off when completed in the TAR. 28 Pa. Code 211.12 Nursing services 395844 Page 8 of 17 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and resident and staff interviews, it was determined the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice for one of 16 residents reviewed (Resident 7). Residents Affected - Few Findings include: Review of Resident 7's clinical record revealed diagnoses including Diabetes Mellitus Type II (a long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and End Stage Renal Disease (occurs when the kidneys are no longer able to work at a level needed for day-to-day life). An interview with Resident 7 on August 14, 2023, at 12:00 PM, revealed that the Resident attends dialysis every Tuesday, Thursday, and Saturday from 10:00 AM to 3:30 PM. Review of Resident 7's current physician orders on August 14, 2023, revealed that Resident 7 is ordered to have dialysis every Wednesday, Friday, and Sunday. An interview with the Nursing Home Administrator (NHA) on August 16, 2023, at 2:26 PM, revealed that Resident 7 attends dialysis every Tuesday, Thursday, and Saturday, and the physician order was changed to the correct days. An interview with the NHA on August 17, 2023, at 1:35 PM, revealed that Resident 7 was attending dialysis while at the hospital prior to arriving at the nursing facility every Wednesday, Friday, and Saturday, and the order was received from there. NHA revealed that, since Resident 7 was admitted to the facility on [DATE], they have been going to dialysis every Tuesday, Thursday, and Saturday. 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.12 (d) (5) Nursing services 395844 Page 9 of 17 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure there were sufficient staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for eight of 16 residents reviewed (Residents 3, 4, 7, 17, 19, 23, 26, and 30). Findings Include: During the initial pool process on August 14, 2023, Residents 3, 7, and 17 expressed concern to the survey team about call bell response time and/or staffing. Review of resident council meeting minutes and interviews with Residents 4, 19, 23, 26, and 30 during the group meeting, revealed concerns with call bell response times and insufficient staff. Review of Resident 3's clinical record revealed diagnoses including hypertension (elevated blood pressure) and anxiety disorder (a feeling of worry, nervousness, or unease). Review of Resident 3's most recent quarterly Minimum Data Set (MDS - assessment tool utilized to identify a resident's physical, emotional, and psychosocial needs), dated August 2, 2023, revealed that under section C, Cognitive Patterns, more specifically subsection C0500. BIMS Summary Score, Resident 3 is coded to have a BIMS of 14 out of 15. Review of Resident 3's comprehensive care plan on August 15, 2023, under the Focus section for Activities of Daily Living (ADL) care created on April 19, 2019, and initiated on March 4, 2020, revealed that Resident 3 requires one staff member to move between surfaces. Observation on August 15, 2023, at 9:32 AM, revealed Resident 3's call bell light on. Observation on August 15, 2023, at 9:46 AM, revealed Resident 3's call bell light turned off. Surveyor observed staff member exiting Resident 3's room at 9:47 AM. Interview with Resident 3 on August 15, 2023, at 9:49 AM, revealed the Resident requested to get up out of bed. Observation of Resident 3 on August 15, 2023, at 9:49 AM, revealed that Resident 3 was lying in bed. Observation on August 15, 2023, at 10:00 AM, revealed Resident 3 lying in bed. Interview with Resident 3 on August 15, 2023, at 1:49 PM, revealed that Resident 3 was still lying in bed. Resident 3 indicated they had been in bed all day and never received assistance getting up out of bed. Interview with six residents during group held with resident council on August 16, 2023, at 10:30 AM, revealed concerns with call bells not being answered in a timely manner. Review of facility resident council minutes from May 2023, June 2023, and July 2023 revealed 395844 Page 10 of 17 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0725 concerns that call bells are not being answered in a timely manner. Level of Harm - Minimal harm or potential for actual harm During an interview with the Nursing Home Administrator (NHA) on August 17, 2023, at approximately 12:37 PM, revealed that she would expect call bells to be answered in a timely manner. Residents Affected - Some Review of Resident 19's clinical record documented diagnoses that included left above the knee amputation. During an interview with Resident 19 on August 15, 2023, at 10:34 AM, it was revealed that, at times, she doesn't get a shower because there isn't enough staff. It was further revealed that she didn't get a shower on August 14, 2023, on evening shift. Resident 19 stated a staff member told her she would give her a shower on Tuesday evening, because on Monday there was only one other Nursing Assistant working on evening shift. Interview with Resident 19 on August 16, 2023, at 11:38 AM, it was revealed that she requires assistance with bathing, and that she prefers to receive a shower vice a bed bath. She stated, again, that it is an issue getting a shower when there isn't enough Nursing Assistants working on evening shift. Review of bathing task sheet revealed Resident 19 had not received a shower in the past 30 days, only bed baths. Review of the facility provided staffing information revealed that on day and evening shift on July 8, 2023, the census was 40 residents and only two nurse aides worked the full shift to provide care and services to those residents. Continued review revealed that, on day shift on July 30, 2023, the census was 43 residents and only two nurse aides worked the full shift to provide care and services. Further review of staffing information revealed that on July 2, 2023, on day and evening shifts, the census was 37 residents and only one licensed practical nurse (LPN) worked a full shift to provide medication and treatments. On July 5, 2023, on evening shift, the resident census was 37 and only one LPN worked that shift. On July 30, 2023, the resident census was 43 and only one LPN worked on day shift and a full shift on evening shift. On August 10, 2023, the resident census was 39 and only one LPN worked on evening shift. On August 13, 2023, the resident census was 39 and only one LPN worked a full shift on day shift. Review of facility staffing for night shift, revealed that on July 4, 8, and 31, 2023, and August 3, 5, and 10th through the 16th, 2023, there was only one LPN that worked with a resident census of 36-41 residents. During an interview with the NHA on August 17, 2023, at 12:36 PM, the staff to resident ratio was confirmed. 395844 Page 11 of 17 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0725 Level of Harm - Minimal harm or potential for actual harm During interview with Assistant Nursing Home Administrator on August 16, 2023, at 2:30 PM, it was revealed that a resident's choice for showers vice a bed bath should be honored. It was also revealed that the facility has been working to hire additional staff. 28 Pa code 211.12(a)(d)(4) Nursing Services Residents Affected - Some 395844 Page 12 of 17 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on document review and staff interview, it was determined that the facility failed to complete a performance review of every nurse aide at least once every 12 months for five of five nurse aide performance evaluations reviewed (Employees 7, 8, 9, 10, and 11). Residents Affected - Some Findings Include: Review of annual performance reviews for the following Nursing Assistant Employees 7, 8, 9, 10, and 11 revealed no annual performance reviews were completed. During an interview with Assistant Nursing Home Administrator on August 17, 2023, at 8:50 AM, it was revealed that the facility doesn't have proof that performance reviews were completed for the aforementioned employees. 28 Pa. Code 201.19 Personnel policies and procedures 395844 Page 13 of 17 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, observation, staff interview, and clinical record review, it was determined that the facility failed to ensure a medication error rate of less than five percent (two errors in 28 observations, 7.14%). Residents Affected - Few Findings include: Review of facility provided policy, titled Administering Medications, revised April 2019, revealed, Medications are administered in accordance with prescriber orders. Review of Resident 195's current physician's orders on August 16, 2023, at 8:45 AM, revealed a current physician's order for Aspirin 81 mg oral tablet chewable to be administered daily. Further review failed to reveal any physician's order for enteric coated Aspirin. Further review of Resident 195's current physician orders revealed a current order for Budesonide/Formoterol 80/4.5 inhaler, two inhalations orally two times a day, rinse mouth after use. During observation of medication administration on August 16, 2023, at 8:30 AM, Employee 6 was observed preparing a medication for Resident 195. At that time, Employee 6 prepared one 81 mg tablet of enteric coated aspirin and administered it to Resident 195. Further observation revealed Employee 6 administering Resident 195's Budesonide/Formoterol 80/4.5 inhaler (a class of drugs known as corticosteroids. It works by reducing the irritation and swelling of the airways). Following administration of the inhaler, Employee 6 did not instruct Resident 195 to rinse her mouth out. During an interview with the Nursing Home Administrator on August 16, 2023, at 2:15 PM, she revealed that she would have expected Employee 6 to give the medications as they were ordered by the physician. Based on two medication errors observed out of a possible 28 opportunities, the facility medication error rate was a calculated 7.14 percent. 28 Pa. Code 211.12(d)(1) Nursing services 395844 Page 14 of 17 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility temperature logs and records, observations, and staff interviews, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for microbial growth in food, which increased the risk of food-borne illness (Walk-in Refrigerator). Findings include: On August 14, 2023, at approximately 9:46 AM, during initial tour of the walk-in refrigerator with the Food Service Director (FSD), the surveyor observed the thermometer on the outside of the walk-in refrigerator to read 41 degrees. The thermometer on the inside of the walk-in refrigerator read 46 degrees. Interview with FSD on August 14, 2023, at approximately 9:49 AM, revealed that they have a quote submitted to get the walk-in refrigerator fixed and reached out to the maintenance director when they first became aware of the issue, which was on July 31, 2023. Review of the walk-in refrigerator temperature log for August 2023, revealed that on August 1 through August 13, 2023, the temperatures were above 41 degrees, with the highest temperature reaching 45 degrees. Review of a work proposal that was created by [NAME] Service Co (a heating, air conditioning, and refrigeration company) that is dated July 31, 2023, revealed that they submitted a quote to the facility to replace the compressor and evaporator unit in the walk-in refrigerator for $7,435.00, and that parts are available 5-7 days after ordering. The proposal was signed by the Nursing Home Administrator (NHA) on August 14, 2023, indicating that the proposal has been accepted. On August 14, 2023, at approximately 3:15 PM, the surveyor observed the FSD temp high risk foods in the walk-in refrigerator, which included meat that was temped at 47.3 degrees, milk that was temped at 45.7 degrees, and cheese that was temped at 51.9 degrees. Interview with FSD on August 14, 2023, at 3:17 PM, revealed that he does not have a problem with the temperatures in the walk-in refrigerator because it is from staff being in and out of the walk-in refrigerator all day, getting supplies for the meals. Interview with the NHA on August 17, 2023, at 12:34 PM, revealed that they would expect the temperatures for the walk-in refrigerator to be within regulation, and that the facility rented a freezer truck through Penske as of August 17, 2023. The NHA further revealed that they were in the process of transferring food from the walk-in refrigerator to the truck during the same time as the interview. 28 Pa. Code 211.6(f) Dietary services 395844 Page 15 of 17 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based staff interview, select policy review, and documents reviewed for implementation of a water management program, it was determined the facility failed to implement their 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 - Some Findings include: Review of facility provided policy, titled Legionella Water Management Program, revised July 2017, revealed, The water management program includes the following elements: f. The control limits or parameters that are acceptable and that are monitored, h. A system to monitor and control limits and effectiveness of control measures, i. A plan for when control limits are not met and/or control measures are not effective. Review of Facility provided documents on August 17, 2023, failed to reveal any water testing for Legionella or other water-borne pathogens. Interview with the Nursing Home Administrator on August 17, 2023, at 11:45 AM, revealed that the facility has not completed any water testing, but will be starting water testing with I.W. Innovations soon. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395844 Page 16 of 17 395844 08/17/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of nurse aide in-service records and staff interview, it was determined that the facility failed to ensure that Nursing Assistants received a minimum of 12 hours of in-service education training each year that include the following topics: infection control, dementia, communication, and behavioral health, for five of five nurse aide performance evaluations reviewed (Employees 7, 8, 9, 10, and 11). Findings include: Review of the facility's yearly mandatory in-service training failed to reveal documented evidence that Employees 7, 8, 9, 10, and 11 met the yearly regulatory minimum training requirements (12 hours within one year). Further review of in-service training revealed that Employees 7, 8, 9, 10, and 11 failed to complete training regarding behavioral health and communication. Furthermore, Employees 9 and 10 failed to complete training regarding infection control, and Employee 11 failed to complete dementia training. During an interview with Assistant Nursing Home Administrator on August 17, 2023, at 8:50 AM, it was revealed that competencies are completed as applicable with monthly training. It was also revealed that the facility doesn't have proof that the aforementioned staff members completed 12 hours of education in the past year, or that the appropriate/needed topics were covered. 28 Pa. Code 201.18 (b)(3)(e)(1) Management 28 Pa. Code 201.19 (2)(7) Personnel policies 28 Pa. Code 201.20 (a)(6)(d) Staff development 395844 Page 17 of 17