F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that
a resident with pressure ulcers received the necessary treatment and services consistent with professional
standards of practice for one of eight residents reviewed (Resident 3).
Residents Affected - Few
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 3, dated March 31, 2025, revealed that the resident was admitted to the facility on
[DATE], was cognitively intact, required maximum staff assistance for care, and had a Stage 1 pressure
ulcer.
A wound care note, dated April 7, 2025, revealed that Resident 3 had a Stage 2 pressure wound on the left
buttock.
A care plan for Resident 3, dated March 24, 2025, revealed that the resident was to have barrier cream
applied to her buttocks three times a day to prevent skin breakdown. A review of Resident 3's clinical record
revealed that there was no documented evidence that the barrier cream was applied to the resident's
buttock on March 24, 2025, during the evening shift; March 25, 2025, during the evening and night shift;
March 26, 2025, during the day, evening, and night shift; March 27, 2025, during the day and night shift;
March 28, 2025, during the day shift; March 29, 2025, during the day and night shift; March 30, 2025,
during the evening shift; March 31, 2025, during the night shift; April 2, 2025, during the evening shift; April
3, 2025, during the day shift; and April 6, 2025, during the evening shift.
An interview with the Director of Nursing on June 18, 2025, at 11:15 a.m. confirmed that there was no
documented evidence that the barrier cream was applied to Resident 3's buttock on the above dates and
times and should have been to prevent further skin breakdown to her buttock.
28 Pa. Code 211.12(d)(3)(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 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
06/20/2025
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)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility
failed to ensure that physician's orders were followed for one of eight residents reviewed (Resident 1) who
had an indwelling urinary catheter.
Findings include:
The facility's policy regarding indwelling urinary catheter's revealed that the nursing staff were to review the
physician's orders prior to inserting an indwelling urinary catheter (a tube inserted into the bladder to
continuously drain urine) or a straight catheter (a tube inserted into the bladder to obtain a sample of urine
and then removed) for a urine sample.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 1, dated April 30, 2025, revealed that the resident was cognitively intact and
required assistance from staff for her daily care needs.
A nursing note for Resident 1, dated February 19, 2025, revealed that an indwelling urinary catheter was
inserted for urinary retention; however, there was no documented evidence that a physician's order was
obtained prior to inserting the indwelling urinary catheter.
A nursing note for Resident 1, dated April 13, 2025. revealed that staff obtained a urine sample via straight
catheter; however, there was no documented evidence that staff obtained a physician's order for the
procedure.
A nursing note for Resident 1, dated May 7, 2025, revealed that staff obtained a urine sample via straight
catheter; however, there was no documented evidence that staff obtained a physician's order for the
procedure.
Interview with the Director of Nursing on June 18, 2025, at 11:14 a.m. confirmed that staff failed to obtain a
physician's order prior to inserting an indwelling urinary catheter or performing a straight catheter to obtain
a urine sample for Resident 1.
28 Pa. Code 211.12(d)(5) Nursing Services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395552
If continuation sheet
Page 2 of 2
