Health inspection·May 13, 2024

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's code status was clarified for one of seven residents reviewed (Resident 5). Findings include: The facility's policy regarding Physician Orders for Life Sustaining Treatment (POLST), dated [DATE], revealed that residents would be questioned upon admission about their preferences for resuscitation in the event of cardiac or respiratory arrest. The nurse will clarify physician discussions regarding the residents' diagnoses and prognosis with the resident and/or responsible party, as well as resuscitation status, existence of Advance Directives and/or Durable Power of Attorney. A stated desire to not have resuscitation instituted in the presence of a deteriorating, irreversible medical condition will be referred to the physician for discussion of the consequences of a DNR order. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated [DATE], revealed that the resident had severe cognitive impairment. Physician's orders, dated [DATE], included an order for the resident to be a DNR (no attempt to revive in the event of cardiac arrest) and a POLST located in the resident's hard chart at the nurse's station, dated [DATE], for the resident to be a full code (to be provided CPR in the event of cardiac arrest). Interview with Registered Nurse 1 on [DATE], at 11:30 a.m. revealed that she was not certain which code status Resident 5 was to be, a full code or a DNR, since both were listed on the resident's chart as his code status. Interview with the Director of Nursing on [DATE], at 1:02 p.m. revealed that Resident 5's code status should have been clarified so that only one code status would remain on his medical chart and staff would know what to do in the case of an emergency. 28 Pa. Code 211.12(d)(1)(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: 395552 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 395552 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethlen Hm of the Hungarian Rf of America 66 Carey School Road Ligonier, PA 15658 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)