Health inspection·June 19, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Pennsylvania's Nursing Practice Act, clinical records, and staff interviews, it was determined that the facility failed to clarify physician's orders for one of four residents reviewed (Resident 2). Residents Affected - Few Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 17, 2024, indicated that he was understood and able to understand, required partial to moderate assistance with personal hygiene care, had diagnoses that included acute respiratory failure, and was receiving oxygen. Physician's orders for Resident 2, dated June 11, 2024, included an order for the resident to receive oxygen at two liters per minute at bedtime for pneumonia. A physician's note for Resident 2, dated June 12, 2024, indicated that the resident continue with oxygen at two liters per minute via nasal cannula (a small flexible tube used to deliver extra oxygen into your nose). A nursing note for Resident 2, dated June 17, 2024, at 3:20 p.m., revealed that the resident was receiving oxygen via nasal cannula and was not experiencing shortness of breath. Review of vital sign records for Resident 2, dated June 2024, revealed that on June 12 at 3:57 p.m., June 13 at 10:13 a.m., June 14 at 3:34 p.m., June 16 at 3:53 p.m., and June 17 at 4:18 p.m. the resident was receiving oxygen via nasal cannula. Observations of Resident 2 on June 19, 2024, at 9:05 a.m. revealed that the resident was sitting in a wheelchair in his room with oxygen being provided via nasal cannula at two liters per minute. Interview with Resident 2 and his wife on June 19, 2024, at 12:54 p.m. revealed that the resident had been receiving oxygen throughout the day and night since his readmission on [DATE]. Interview with the Director of Nursing on June 19, 2024, at 1:29 p.m. confirmed that the resident (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: 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 06/19/2024 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)