Health inspection·December 2, 2025

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that in preparation for a room change, the resident and/or resident's responsible party received written notice, including the reason for the change, before the resident's room was changed for five of seven residents reviewed with a room change (Residents R1, R2, R3, R4, and R5). Findings include: Review of facility policy entitled Transfer within the care community dated 1/8/25, indicated The Social Worker will contact family members/responsible parties to discuss room changes. Review of Resident R1's clinical record revealed an admission date of 1/7/24, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypertension (high blood pressure). Review of Resident R1's documentation revealed a progress noted dated 8/26/25, that he/she was moved to a different room in the facility. Resident R1's clinical record lacked evidence that he/she was asked if they would agree to a room change and also if the resident and/or their responsible party were provided with written notification prior to the room change. Review of Resident R2's clinical record revealed an admission date of 5/10/25, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypertension. Review of Resident R2's documentation revealed a progress noted dated 8/26/25, that he/she was moved to a different room in the facility. Resident R2's clinical record lacked evidence that he/she was asked if they would agree to a room change and also that the resident and/or their responsible party were provided with written notification prior to the room change. Review of Resident R3's clinical record revealed an admission date of 3/17/25, with diagnoses that included heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues), and anxiety. Review of Resident R3's documentation revealed a progress noted dated 8/28/25, that he/she was moved to a different room in the facility. Resident R3's clinical record lacked evidence that he/she was asked if they would agree to a room change and also that the resident and/or his/her responsible party were provided with written notification prior to the room change. Review of Resident R4's clinical record revealed an admission date of 7/7/25, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat). Review of Resident R4's clinical record revealed a census line dated 8/28/25, that he/she was moved to a different room in the facility. Resident R4's clinical record lacked evidence that he/she was asked if they would agree to a room change and also that the resident and/or his/her responsible party were provided with written notification prior to the room change. Review of Resident R5's clinical record revealed an admission date of 10/18/22, with diagnoses that included diabetes, and vascular dementia (a disease that affects short term memory and the ability to think logically). Review of Resident R5's documentation revealed a progress noted dated 8/26/25, that he/she was moved to a different room in the facility. Resident R5's Page 1 of 2 395003 395003 12/02/2025 Quality Life Services - New Castle 520 Friendship Street New Castle, PA 16101

F 0559 Level of Harm - Minimal harm or potential for actual harm clinical record lacked evidence that he/she was asked if they would agree to a room change and also that the resident and/or his/her responsible party were provided with written notification prior to the room change. During an interview on 10/1/25, at 11:35 a.m. the Nursing Home Administrator confirmed that the clinical records lacked evidence of written notification regarding Residents R1, R2, R3, R4, and R5's room changes were not provided prior to their room change. 28 Pa. Code 201.14(a) Responsibility of licensee Residents Affected - Few 395003 Page 2 of 2