Health inspection·January 15, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify a family representative of a change in condition for one of three residents. (Resident R1). Residents Affected - Few Findings include: A review of the facility Resident Rights last reviewed 8/30/24, indicates the resident or representative have the right to be fully informed of your medical condition. A review of Resident R1's clinical record indicates an admission date of 7/22/24, with the diagnosis of traumatic brain injury (TBI), urinary tract infection (UTI) and dysphagia (difficult swallowing). A review of Resident R1's physician progress notes dated 12/3/24, follow up for hospitalization indicate Resident R1 was treated for chronic outlet obstruction and had a foley catheter (tube inserted into the bladder to drain urine) placed which should stay in place and follow up with urology. A review of Resident R1's care plan on 1/15/25, indicated Resident R1 had a 14 french (size) with 10cc balloon (holds catheter in place in the bladder) foley catheter. Review of nursing progress note dated 11/15/24, at 9:00 p.m. indicates received notification from Nurse Aid (NA) and daughter that resident was having blood in urine. Also, brown discharge noted in resident ' s brief. No lesions or open areas noted in genital areas that could be causing brown discharge. Call placed to physician and made aware of information, stated to obtain urinalysis testing and lab work. Stated ok to straight catheterize resident if necessary. During an interview completed on 1/15/25, at 3:26 p.m. the Director of Nursing confirmed that the resident ' s representative was not notified of the new orders received on 11/15/24, for urinalysis testing, lab work and straight catheterization if necessary. Review of nursing progress note dated 12/23/24, at 2:28 p.m. indicates this morning the NA was giving the patient a shower when the patient pulled out his foley. NA immediately notified the nurse for assessment. Nurse entered the shower room and assessed the patient. Patient siting in shower chair with blood dripping from his penis that became to clot. Nurse cleaned the area. The patient stopped bleeding. Patient at the time, is not screaming or crying. The NA finished cleaning the patient and got him dressed. I notified the nurse supervisor and physician for further guidance and direction. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395164 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St John Specialty Care Center 500 Wittenberg Way Mars, PA 16046 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)