Camp Hill Skilled Nursing and Rehabilitation Ctr

Inspectors wroteBased on facility policy review, observations, and staff interview, it was determined that the facility failed to maintain a safe, clean, comfortable and home-like environment in one of three nursing units observed.

Inspectors wroteBased on facility policy review, review of facility diet extension sheets, review of nutrition facts label, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician for six of 36 residents reviewed on a consistent carbohydrate diet (Residents 5, 8, 15, 52, 68, and 106).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen.

Inspectors wroteBased on facility policy, staff interview, and clinical record review, it was determined that the facility failed to provide an explanation of the risks and benefits of psychotropic medications use and obtain consent prior to administering psychotropic medications for one of five residents reviewed for psychotropic medication use (Resident 4).

Inspectors wroteBased on clinical record review, document review, and staff interview, it was determined that the facility failed to ensure residents are informed of the items and services that are included in nursing facility services for which the resident may not be charged and those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services for three of three residents no longer eligible for Medicare A benefits coverage reviewed (Residents 120, 121, and 122). Findings Include: Review of Resident 120's clinical record revealed an admission date to the facility on November 25, 2025. Review of Resident 120's census information revealed the most recent date of Medicare A coverage that began on December 22, 2025, and ended on December 23, 2025. [...]

Inspectors wroteBased on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure its residents receive treatment and care in accordance with professional standards of practice for one of the 24 residents reviewed (Resident 5). Findings Include: Review of the facility's policy, titled Person-Centered Care Plan, recently reviewed January 5, 2026, defined professional standards of Quality as care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. [...]

Inspectors wroteBased on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one of two residents reviewed (Resident 8).

Inspectors wroteBased on clinical record review, observation, policy review, and staff interview, it was determined that the facility failed to provide respiratory services in accordance with professional standards of practice for one of 26 residents reviewed (Resident 97) for respiratory care.

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure pain management is provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of 24 residents reviewed (Resident 86).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of one residents reviewed (Resident 7). Findings Include: Review of facility policy, titled Trauma Informed Care and Culturally Competent Care, effective May 1, 2024, revealed, Process: 6. The Center will identify triggers which may re-traumatize patients with a history of trauma. [...]

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure Medication Regimen Reviews were responded to by the attending physician or prescriber for one of five residents reviewed (Resident 4).

Inspectors wroteBased on observation, facility policy review, medical record review, and staff interviews, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of three residents reviewed (Resident 8).

Inspectors wroteBased on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for one of eight residents on transmission-based precautions reviewed (Residents 7). Findings Include:Review of facility policy, IC308 Enhanced Barrier Precautions (EBP), revised December 6, 2024, revealed that residents with a wound or indwelling medical device will be placed on EBP if they do not meet criteria to require contact precautions. Review of Resident 7's clinical record revealed diagnoses that included pressure ulcer of left heel (an injury to the skin and/or underlying tissue caused by prolonged pressure) and chronic kidney disease (gradual loss of kidney function). [...]

Inspectors wroteBased on facility policy review, clinical record review, facility documentation review, and staff interview, it was determined the facility failed to ensure each resident was free from neglect, which resulted in actual harm as evidenced by fracture of the right hip for one of three residents reviewed (Resident 1). Review of facility policy, titled OPS 300 Abuse Prohibition with a last revision date of October 24, 2022, revealed Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. [...]

Inspectors wroteBased on facility policy review, clinical record review, select facility document review, facility training records, and staff interview, it was determined that the facility failed to ensure that residents received adequate assistance to prevent falls, which resulted in harm as evidenced by a fracture of the right hip for one of three residents reviewed for falls (Resident 1). Review of facility policy titled, NSG200 Activities of Daily Living (ADLs), last revised May 1, 2023, revealed Activities of Daily Living (ADLs) were defined as, Hygiene - bathing, dressing, grooming, and oral care;.Elimination - toileting. Review of the policy purpose revealed it stated, To ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and the patient's choices and preferences. [...]

Inspectors wroteBased on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene for three of 24 residents reviewed (Residents 20, 35, and 101).

Inspectors wroteBased on observations, clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure treatment and services, consistent with professional standards, to promote healing and prevent infection for two of six residents reviewed for pressure ulcers (Residents 16 and 325).

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for three of five residents reviewed for limited range of motion (Residents 35, 40, and 50).

Inspectors wroteBased on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen and one of three nourishment areas.

Inspectors wroteBased on review of clinical record review, review of select facility documentation, and staff interview, it was determined that the facility failed to provide the required notices to the resident or their representatives following the end of their Medicare coverage for two of three residents reviewed for beneficiary notices (Residents 28 and 108).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for two of three discharged residents reviewed (Residents 105 and 106).

Inspectors wroteBased on facility policy review, review of incident investigation documentation, and staff interview, it was determined that the facility failed to report the results of an abuse investigation within the specified timeframes for one of one abuse incidents reviewed.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 24 residents reviewed (Residents 8 and 36).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop comprehensive care plans for two of 27 resident records reviewed (Residents 29 and 47). Findings Include: Review of Resident 29's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and anxiety disorder (mental health conditions that involve persistent and excessive feelings of fear or worry). Review of Resident 29's current physician orders revealed an order for Buspirone hydrochloride (HCL) tablet 15 milligram (MG) - give one tablet by mouth two times a day for anxiety, with an original active date of July 19, 2024. Review of Resident 29's current physician orders revealed an order for Duloxetine HCL capsule delayed release particles 60 MG -give one capsule by mouth one time a day for depression, with an original active date of July 20, 2024. [...]

Inspectors wroteBased on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the residents right to participate in the care planning process for one of 24 residents reviewed (Resident 19), and failed to review and revise the resident plan of care for one of 24 residents reviewed (Resident 50).

Inspectors wroteBased on review of the clinical record and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 24 residents reviewed (Residents 71 and 88).

Inspectors wroteBased clinical record review, hospital record review, and staff interview, it was determined that the facility failed to ensure the physician provided orders for the resident's immediate care and needs for one of 24 residents reviewed (Resident 325).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain an accurate accounting of the final disposition of medications upon discharge for two of three closed records reviewed (Residents 105 and 107). Findings Include: Review of facility policy, Disposal of Medication Waste, revised July 1, 2024, revealed, Medications that cannot be returned to the pharmacy, discharged with the patient, or donated will be placed in medication disposal bins labeled .controlled substance waste. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon timely for two of five residents reviewed for unnecessary medications (Residents 29 and 74).

Inspectors wroteBased on observations, facility policy review, review of medication data sheets, and staff interviews, it was determined that the facility failed to discard expired medications in one of three medication carts (Arcadia); and failed to properly label drugs and biologics in one of three medication carts (3rd floor short hall cart).

Inspectors wroteBased on clinical record review, observations, facility policy review, and staff interview, it was determined that the facility failed to implement infection control practices to help prevent the development and transmission of infectious diseases for one of one treatment cart observed (Third floor treatment cart).

Inspectors wroteBased on clinical record review, laboratory result review, facility policy review, and resident and staff interviews, it was determined that the facility failed to ensure the facility's Antibiotic Stewardship Program was implemented for one of two residents reviewed for antibiotic use (Resident 98).

Inspectors wroteBased on facility policy review, observations, clinical record review, staff interviews, and facility documentation review, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for four of 12 residents reviewed (Residents 4, 9, 10, and 12).

Inspectors wroteBased 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 three of 24 residents reviewed (Residents 25, 54, and 65).

Inspectors wroteBased on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 25 residents reviewed (Residents 42, 55, and 73).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 24 residents reviewed (Resident 51).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one residents reviewed (Resident 51). Findings Include: Review of facility policy, titled NSG253 Dialysis: Hemodialysis (HD) - Communication and Documentation, with a last review date of January 17, 2024, indicated, in part, Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments received at a certified dialysis facility. 1. Prior to a patient leaving the Center for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record or the state required form and send with the patient to his/her HD facility visit. [...]

Inspectors wroteBased on review of the clinical record, policy review, and staff interviews, it was determined that the facility failed to ensure that the clinical record accurately reflected the resident preference for code status for one of 24 residents reviewed (Resident 18).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 24 residents reviewed (Residents 51 and 65).