Inspection·April 22, 2025

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 review of clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of five residents reviewed (Resident 2). Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 2, dated April 7, 2025, indicated that the resident was sometimes understood and able to sometimes understand others, was dependent on staff for personal hygiene care, and was always incontinent of urine and bowel. An incontinence care plan for Resident 2, dated July 4, 2023, revealed that the resident was to have barrier cream applied every shift and after every incontinent episode. Physician's orders for Resident 2, dated June 29, 2023, revealed that triad (barrier) cream was to be applied every shift and after each incontinent episode as needed. A wound care note for Resident 2, dated March 26, 2025, revealed that the resident was seen by wound care due to redness in the perineal region and denudement (missing the outer layer of skin). New orders were received to ensure that physician's orders were being followed to apply barrier cream every shift and as needed. Interview with Resident 2 on April 22, 2025, at 9:50 a.m. revealed that the staff apply cream every shift; however, they do not apply barrier cream after episodes of incontinence. Interview with Licensed Practical nurse 5 on April 22, 2025, at 2:01 p.m. confirmed that the Triad barrier cream was only applied every shift, and it was not applied after incontinent episodes per care plan and physician's order. A review of Resident 2's clinical record revealed no documented evidence that the Triad Cream was applied on first shift on March 1, 2, 4, 5, 6, 8, 14, 20, 21, 25, 29, and 30, 2025; on second shift on March 25 and 30, 2025; and third shift on March 5, 11, 19, and 20, 2025; and no documented evidence that it was applied after each incontinent episode as needed. Interview with the Director of Nursing on April 22, 2025, at 1:56 p.m. confirmed that Resident 2 did not have barrier cream applied as ordered by the physician. 28 Pa. Code 211.12(d)(1)(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 3 Event ID: 395985 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 395985 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Midtown Oaks Health & Rehab Center 1020 Green Avenue Altoona, PA 16601 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)