Health inspection·August 28, 2024

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 observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident's status for two of 18 residents reviewed (Residents 49 and 74). Residents Affected - Few Findings include: Review of Resident 49's clinical record revealed diagnoses that included severe intellectual disabilities (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills) and spastic quadriplegia cerebral palsy (cerebral palsy refers to a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination. Spastic quadriplegia cerebral palsy is a form of cerebral palsy that affects both arms and legs and often the torso and face). Review of Resident 49's quarterly MDS assessment (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 29, 2024, revealed that in Section K, it was marked no or unknown for a weight loss of 5% or more in the last month or 10% or more in the last 6 months. Review of Resident 49's clinical record revealed a weight of 83 pounds on July 29, 2024, and a weight of 98.4 pounds on January 17, 2024, which is a 15.65% weight loss in 6 months. Review of Resident 49's nutrition progress note dated August 1, 2024, revealed that Resident 49's weight was down 10% in 180 days. During an interview with the Nursing Home Administrator (NHA) on August 28, 2024, at 11:49 AM, he confirmed that Resident 49's quarterly MDS was a coding error and that her weight loss should have been coded on the MDS. A review of the clinical record for Resident 74 on revealed diagnoses that include spastic quadriplegic cerebral palsy (a permanent neuromuscular disorder that affects all four limbs, the trunk, and the face) and Unspecified Psychosis (condition that affects the mind and makes it hard to tell what is real and what is not. It can cause delusions, hallucinations, and disorganized speech or behavior). A review of Resident 74's Quarterly MDS dated [DATE], revealed that Section H. Bladder and Bladder, Subsection H0100. Appliances. A. was marked yes for an indwelling catheter. Page 1 of 3 396064 396064 08/28/2024 Margaret E. Moul Home 2050 Barley Road York, PA 17404

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation of Resident 74 while in bed on August 25, 2024, at 10:00 AM, failed to reveal any catheter bag or tubing hanging on the side of his bed. During an interview with Employee 6 (Licensed Practical Nurse) on August 26, 2024, at 10:15 AM, Employee 6 informed the surveyor that Resident 74 never had an indwelling catheter. Employee 6 informed the surveyor that Resident 74 wears a condom catheter (a non-invasive device that can be used to collect urine and is considered an alternative to incontinence pads) that is connected to a urine drainage bag when the Resident is out of bed. During an interview with the NHA on August 27, 2024, at 2:00 PM, the NHA confirmed that Resident 74's June 14, 2024, MDS was marked in error for an indwelling catheter. 28 Pa. Code 201.18(b)(1)Management 28 Pa. Code 211.12(d)(1)(5) Nursing services 396064 Page 2 of 3 396064 08/28/2024 Margaret E. Moul Home 2050 Barley Road York, PA 17404

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 once every 12 months for five of five nurse aide employee files reviewed (Employees 1-5). Residents Affected - Some Findings Include: A performance evaluation or appraisal is defined as a tool to document an employee's performance over time. A review of Employee 1's information revealed a hire date of May 22, 2023. A review of Employee 1's training information revealed no annual performance evaluation. A review of Employee 2's information revealed a hire date of January 18, 2021. A review of Employee 2's training information revealed no annual performance evaluation. A review of Employee 3's information revealed a hire date of April 17, 2017. A review of Employee 3's training information revealed no annual performance evaluation. A review of Employee 4's information revealed a hire date of February 20, 2006. A review of Employee 4's training information revealed no annual performance evaluation. A review of Employee 5's information revealed a hire date of April 21, 2008. A review of Employee 5's training information revealed no annual performance evaluation. An interview with the Nursing Home Administrator on August 27, 2024, at 10:22 AM, confirmed the facility has not completed annual performance evaluations on those nurse aides. 28 Pa. Code 201.19 (2) Personnel policies and procedures 396064 Page 3 of 3