Health inspection·September 17, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three out of nine residents (Residents R1, R2 and R3). Findings include: Review of Resident R2's admission record indicated she was originally admitted on [DATE], with diagnoses that included diabetes, anxiety disorder and fibromyalgia (chronic condition that causes widespread pain and tenderness in the body). Review of Resident R2's annual MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 8/29/24, indicated that the diagnoses were current upon review. Review of Resident R2's clinical record revealed that the resident was transferred to the hospital on 8/20/24, and returned to the facility on 9/9/24. Review of Resident R2's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for the hospitalization on 8/20/24 Review of Resident R1's admission record indicated she was originally admitted on [DATE], with diagnoses that included protein-calorie malnutrition, chronic kidney disease and cardiomegaly ( a condition where the heart is larger than normal). Review of Resident R1's admission MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 9/9/24, indicated that the diagnoses were current upon review. Review of Resident R1's clinical record revealed that the resident was transferred to the hospital on 9/13/24, and returned to the facility on 9/15/24. Review of Resident R1's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for the hospitalization on 9/13/24. Review of Resident R3's admission record indicated she was originally admitted on [DATE], with diagnoses that included anemia, respiratory disorders and spinal stenosis (narrowing of the spinal canal (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 3 Event ID: 396056 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 396056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William Penn Care Center 2020 Ader Road Jeannette, PA 15644 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)