Health inspection·June 28, 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. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified about a significant change in condition for one of 25 residents reviewed (Resident 22). Findings include: The facility's weight policy, dated March 14, 2023, indicated that a registered nurse (RN) assessment would be completed on significant weight changes, and the physician would be notified of the resident's change in physical condition. Review of Resident 22's clinical record revealed a weight on May 7, 2023, of 178 pounds and a weight on June 6, 2023, of 167 pounds, which indicated an 11-pound weight loss in 30 days. A nutritional assessment note written by the dietician for Resident 22, dated June 12, 2023, indicated that the resident had a significant weight loss of 6.18 percent in the past 30 days. A nursing note for Resident 22, dated June 13, 2023, revealed that a RN assessment was completed for significant weight loss. However, there was no documented evidence that the physican was notified of the resident's significant weight loss. Interview with Registered Nurse Supervisor 5 on June 27, 2023, at 3:13 p.m. and the Nursing Home Administrator on June 28, 2023, at 9:51 a.m. confirmed that Resident 22's physician was not notified about the significant weight loss. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. 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 4 Event ID: 395387 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 395387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton County Medical Center 214 Peach Orchard Road McConnellsburg, PA 17233 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)