Inspection·July 25, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to notify the physician and begin treatment timely related to a change in a resident's condition, and obtain a physician's order/clarification for the use of an assistive device for two of 17 residents reviewed (Residents R4 and R25). Residents Affected - Few Findings include: Review of facility policy entitled, Change in a Resident's Condition or Status dated 3/28/24, indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition. Resident R4's admission record revealed an admission date of 4/1/22, with diagnoses that included dementia (condition with symptoms that affect memory and thinking), atrial fibrillation (irregular heart rate), and type II diabetes (condition of insufficient production of insulin). Review of a nursing note dated 7/20/24, at 6:01 p.m. indicated that the physician was faxed information regarding white patches in Resident R4's mouth. Continued review of Resident R4's clinical record revealed a nursing note dated 7/22/24, at 11:40 a.m. indicating that the physician's office was contacted regarding white patches on Resident R4's tongue and mouth. A nursing note dated 7/23/24, at 12:03 p.m. indicated an order was received for Nystatin Mouth/Throat Suspension (a medication used to treat a fungal infection in the mouth) Give 5 milliliters by mouth three times a day (8:00 a.m., 1:00 p.m., and 5:00 p.m.) for thrush swish and spit. Nursing notes dated 7/23/24, at 1:31 p.m. and 7/23/24, at 4:18 p.m. revealed that Resident R4 did not receive the Nystatin Mouth/Throat Suspension as ordered due to it not being delivered to the facility. Review of Resident R4's July 2024 Medication Administration Record revealed Resident R4 received his/her first dose of Nystatin Mouth/Throat Suspension on 7/24/24, during the 8:00 a.m. medication pass, this was approximately 86 hours after the white patches on his/her mouth and tongue were observed. During an interview with the Director of Nursing (DON) on 7/24/24, at 12:20 p.m. it was confirmed that there was a delay in treatment regarding Resident R4's change in condition and that nursing staff should have called the physician on Saturday 7/20/24, rather than faxing the physician with the resident condition concerns. Resident R25's clinical record revealed an admission date of 1/16/24, with diagnoses that included (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 8 Event ID: 395901 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 395901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Titusville Nursing and Rehab 81 Dillon Drive Titusville, PA 16354 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)