Health inspection·July 2, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy, and grievances lodged with the facility and staff interview, it was determined that the facility failed to immediately notify the resident's interested representative of a significant change in condition for one resident out of seven sampled (Resident A1). Findings include: A review of the facility policy entitled notification of the responsible party on hospital transfers, dated as reviewed by the facility January 2024, revealed that the the facility will notify a resident's responsible party of a hospital transfer once the order has been obtained from the physician to transfer. The facility will initiate transfer when it is determined that the cannot provide services required for the resident and or if the resident and or the responsible party requests the hospital transfer be initiated The corresponding procedures were noted as: The facility will notify the incapable residents responsible party of an upcoming transfer to the hospital and or a change in condition and reason they are being sent out for evaluation. If the resident is capable and requests to not notify the family the facility will follow their wishes. If the change occurs in the off hours at night and the resident is deemed stable by a physician and or a nurse assessment the facility may wait to notify the family during waking hours, unless specified other by family member. If the resident is deemed unstable immediate notification will occur. Documentation of transfer and notification date and time shall be documented in the residents medical record. A review of the clinical record revealed that Resident A1 was admitted to the facility on [DATE], with diagnoses, which included chronic obstructive pulmonary disease, dementia, and hypertension. Review of nursing documentation dated May 21, 2024, at 11:06 AM, indicated that Resident A1 had a moist productive cough, had expectorated yellow mucous, the resident's lung sounds were noted to have some rhonchi and expiratory wheezing, temperature was 98.4 degrees Fahrenheit, and her oxygen saturation was 90% on room air. A physician order was received from the physician to complete a chest x-ray. Page 1 of 3 395104 395104 07/02/2024 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few According to nursing documentation at 1:14 PM on May 21, 2024, the resident's son (representative) was made aware of new MD [physician] orders and resident's condition. Nursing documentation dated May 22, 2024, at 4:32 AM, revealed that the resident vomited a large amount of maroon liquid with some coffee ground residual noted. According to the nursing documentation, the resident's abdomen was distended (large) but soft and non-tender, the resident's temperature was 100.5 degrees Fahrenheit (elevated), blood pressure was 86/50 mmHg (low) , her heart rate was 64, and her oxygen saturation was 79% on room air (normal is 98-100%). There was no documented evidence that the resident's respiratory rate was evaluated at that time. Nursing documentation further noted that oxygen was immediately applied via nasal cannula to increase oxygen saturation up 89-90%. A call was placed to the on-call physician who instructed the facility to continue to monitor resident for any worsening symptoms and update her physician in the AM [morning] and to update family in the AM. The facility did not notify the resident's son, her designated representative, at the time the resident had experienced a significant change in medical condition on May 22, 2024, at approximately 4:32 AM. There was no indication that the facility had ascertained if this resident's family wished to be notified of significant changes during non-waking hours, according to the facility policy indicating that the facility may wait to notify the family during waking hours, unless specified other by family member. Physician documentation dated May 22, 2024, at 10 AM, revealed that the changes in the resident's condition that occurred at 4:30 AM that morning were reviewed, current condition evaluated, and a chest x-ray and KUB (x-ray of abdomen) were ordered. Nursing documentation dated May 22, 2024, at 4:23 PM, revealed that the resident's temperature was 99.1 degrees Fahrenheit, her oxygen saturation was 90% with oxygen on via nasal cannula at 2 liters/min, no complaints of pain/discomfort were offered, no vomiting/nausea. Resident observed to have a wet, congested cough with thick yellow mucus produced. Resident in good spirits otherwise. Nursing notes dated May 22, 2024, at 5:10 PM, revealed that the KUB results indicated that the resident had Cholelithiasis (gallstones in the gallbladder). New physician orders were obtained to send the resident to the emergency room for evaluation and treatment of Cholelithiasis, abdominal distention, vomiting, pain, nausea, and elevated white blood cell count. Review of grievance submitted to the facility on May 22, 2024, at 11:32 PM via email from the resident's representative, revealed that the resident's family expressed a concern that they were not notified of the resident's significant change in condition that occurred at 4:30 AM on May 22, 2024, and that the facility waited until approximately 6:20 PM on May 22, 2024, to send the resident to the emergency room for evaluation and treatment. An interview with the Nursing Home Administrator on July 2, 2024, at approximately 11:00 AM confirmed that the facility had not previously ascertained if this resident's family wanted to be notified during non-waking hours and verified that the facility did not immediately notify the resident's designated representative of the resident's change in condition identified on May 22, 2024, at approximately 4:30 AM. 28 Pa. Code 201.29 (a)(b) Resident rights 395104 Page 2 of 3 395104 07/02/2024 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0580 28 Pa. Code 211.12 (d)(3) Nursing services Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.10 (a) Resident care policies Residents Affected - Few 395104 Page 3 of 3