Health inspection·December 2, 2024

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 facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident or the resident's representative was notified about a transfer to the hospital and changes in medication orders for one of four residents reviewed (Resident 1). Findings include: The facility's policy regarding residents' rights, dated November 21, 2024, revealed that the facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there is a need to alter treatment significantly or when there is a decision to transfer the resident from the facility. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 1, 2024, revealed that the resident had moderate cognitive impairment, required assistance from staff for daily care needs, and had diagnoses that included epilepsy (chronic brain disorder that causes seizures) and gastrointestinal stromal tumor (type of cancer that begins in the digestive system). A nursing note for Resident 1, dated November 9, 2024, at 3:18 p.m., revealed that the resident was acting different and was not responding to staff. The resident was transported to the hospital for evaluation. A nurse's note, dated November 9, 2024, at 3:18 p.m., revealed that Resident 1 was admitted to the hospital with a diagnosis of status epilepticus (prolonged seizure). There was no documented evidence that a representative for the resident was notified of the resident's transfer to the hospital. Physician's orders for Resident 1, dated November 24, 2024, included an order for the resident to receive 500 milligrams (mg) of Keppra (medication used to control seizures) two times a day. Physician's orders, dated November 26, 2024, included an order for the resident to receive 20 mg of Pantoprazole (medication used to treat heartburn and certain other conditions caused by too much acid in the stomach) at bedtime. There was no documented evidence that Resident 1 or a representative of Resident 1 was notified about the above-mentioned medication changes. Interview with the Director of Nursing on December 2, 2024, at 2:51 p.m. confirmed that neither Resident 1 nor a representative for Resident 1 was notified about the changes in the above-mentioned medications, and that a resident representative was not notified of the resident's transfer to the Page 1 of 2 395610 395610 12/02/2024 Richland Nursing and Rehab 349 Votech Drive Johnstown, PA 15904

F 0580 hospital on November 9, 2024. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(3)(5) Nursing Services. Residents Affected - Few 395610 Page 2 of 2