Health inspection·October 26, 2023

F 0641 Ensure each resident receives an accurate assessment. 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 staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 19 residents reviewed (Residents 5 and 14). Residents Affected - Few Findings Include: Review of Resident 5's clinical record revealed diagnosis that included cerebral palsy (weakness or problems with using the muscles) and hypertension (high blood pressure). Review of Resident 5's 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) dated July 21, 2023, revealed that section J1800, Any Falls Since Admission/Entry or Reentry or Prior Assessment, was marked 0, No. Review of a fall incident report dated June 24, 2023, at 11:45 AM, revealed Resident 5 had a fall in their room. Review of Resident 5's clinical nursing progress notes revealed a progress note dated June 24, 2023, at 1:09 PM, revealed that the Resident was found sitting on the floor with their back against the bed frame and feet extending in front of them. Review of Resident 5's MDS dated [DATE], revealed that section N0410. Medications Received (B. Medication received: Days: Antianxiety) was marked 0, indicating Resident 5 has not received any antianxiety medications in the last seven days of when the assessment was completed. Review of Resident 5's July 2023 Medication Administration Record revealed that Resident 5 received Lorazepam Tablet 0.5 Milligram two times a day for the entire month. Further review of Resident 5's current Medication Review Report revealed that the Resident is prescribed Lorazepam Tablet 0.5 milligram two times a day, with a start date of March 31, 2021. During an interview with the Nursing Home Administrator on October 25, 2023, at 1:53 PM, he confirmed that the fall that occurred on June 24, 2023, and the antianxiety medication not being captured on the MDS completed on July 21, 2023, were both errors and they have both been fixed. Review of Resident 14's clinical record revealed diagnoses that included thoracic spina bifida (a birth defect in which a developing baby's spinal cord fails to develop properly) with hydrocephalus (a build-up of fluid in the cavities deep within the brain), hypertension, and major depressive Page 1 of 2 396064 396064 10/26/2023 Margaret E. Moul Home 2050 Barley Road York, PA 17404

F 0641 disorder. Level of Harm - Minimal harm or potential for actual harm Review of Resident 14's quarterly MDS assessment dated [DATE], revealed that in section H, Resident 14 was coded as having an indwelling catheter (a catheter that is maintained within the bladder for the purpose of continuous drainage of urine). Further review of the MDS revealed that intermittent catheterization (insertion and removal of a catheter through the urethra for bladder drainage) is not marked, and urinary continence is coded as 9- not rated. Residents Affected - Few Review of Resident 14's current physician orders revealed an order dated August 4, 2023, for intermittent straight catheterization twice a day. Further review of Resident 14's clinical record failed to reveal any evidence that Resident 14 had an indwelling catheter at any time in the seven days prior to, and including, September 29, 2023. During an interview with the Director of Nursing (DON) on October 26, 2023, at 10:52 AM, she stated that the Resident does receive intermittent catheterization twice daily, and that Resident 14 is also sometimes incontinent of urine. In a follow-up interview with the DON on October 26, 2023, at 11:18 AM, she stated that Resident 14 did not have an indwelling catheter at any time around September 29, 2023, and stated that the MDS assessment was incorrectly coded and a modification would be completed. 28 Pa Code 211.12 (d)(3)(5) Nursing Services 396064 Page 2 of 2