Health inspection·July 5, 2023

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 select facility policy and procedures, clinical record review, and staff interview, it was determined that the facility failed to notify the resident representative of a resident's transfer to the emergency room for one of four residents reviewed for notifications (Resident CR1). Findings include: A review of the policy titled Physician and Family Member Responsible Party Notification, last reviewed without changes in April 2023, revealed that the purpose was to maintain an open line of communication regarding the resident's condition between the resident, the resident's primary physician, responsible party, and facility. The policy noted that unless otherwise instructed by the resident, the facility will notify the resident's next of kin or responsible party when the resident is involved in any accident or incident that results in an injury, there is a significant change in the resident's physical/mental/psychosocial status, and/or it is necessary to transfer the resident to the hospital. Closed clinical record review for Resident CR1 revealed a comprehensive MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated February 1, 2023, which noted that staff assessed the resident as having cognitive impairment as evidenced by a BIMS (Brief Interview for Mental Status) score of 11. Closed clinical record review for Resident CR1 revealed nursing documentation dated March 17, 2023, at 3:47 PM that noted the resident went on a leave of absence to the [NAME] Life Center at 8:10 AM, was then taken to a cardiology appointment, and then admitted to the hospital with a diagnosis of atrial fibrillation (an irregular heart rhythm that can lead to blood clots in the heart). Hospital documentation dated March 17, 2023, at 9:56 AM revealed Resident CR1 has a surgical history of a pacemaker (an implanted device in the body to control the electrical impulses of the heart) and presented to the emergency room at the request of the pacemaker clinic due to tachycardia. The documentation further noted Resident CR1 went to the pacemaker clinic for a routine appointment. At the time of the arrival in the emergency room, the resident was tachycardic (a rapid heart rate) and was hypertensive (high blood pressure). The documentation noted the resident was admitted to the hospital due to atrial fibrillation with rapid ventricular rate (RVR). There was no evidence in the clinical record to indicate that Resident CR1's emergency contact was notified at the time of the transfer of the transport to the emergency room from the cardiology appointment. (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: 395283 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 395283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Glen Healthcare and Rehabilitation Center 15 Ridgecrest Circle Lewisburg, PA 17837 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)