Health inspection·March 5, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records and staff interview, it was determined that the facility failed to inform a resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for one of five sampled residents (Resident R1). Residents Affected - Few Findings include: Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs), dated 12/3/24, indicated she had diagnoses included end stage renal disease (permanent condition in which the kidneys are no longer able to filter waste from the blood), dementia (progressive decline in cognitive abilities, such as memory, thinking, problem-solving, and judgment) and chronic kidney disease. Further review of the MDS indicated the resident's BIMS (Brief Interview for Mental Status assessment was 10 indicating moderately impairment. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of physician orders dated 8/17/24 Mirtazapine Oral Tablet , Give 30 mg at bedtime for mood. Review of physician orders dated 11/9/24 Mirtazapine Oral Tablet , Give 45 mg at bedtime for mood. Review of Resident R1's nurse progress notes November 2024-December 2024 revealed no evidence that the resident's daughter or other representatives was notified of the new order, discussed the advantage and disadvantage of medication increase and alternative options. Interview with Director of Nursing (DON) on 3/5/25, at 12:30 p.m., DON confirmed that the facility did not inform a resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for Resident R1 as required. 28 Pa Code 201.29(j) Resident rights. Page 1 of 2 395790 395790 03/05/2025 Seneca Place 5360 Saltsburg Road Verona, PA 15147

F 0552 28 Pa. Code 211.12(d)(1) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395790 Page 2 of 2