Health inspection·August 31, 2023

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified about a significant change in condition for one of three residents reviewed (Resident 2), resulting in a delay in treatment. Residents Affected - Few Findings include: The facility's policy regarding physician notification, dated March 2, 2023, revealed that upon identification of a resident who has clinical changes, change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to the physician as indicated. An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and are needs) for Resident 2, dated July 20, 2023, indicated that the resident was cognitively impaired, had behaviors, required extensive assistance with daily care needs, including transfers and ambulation (walking), had a history of falls, and had diagnoses that included dementia. A nursing note, dated July 26, 2023, at 8:58 p.m. revealed that Resident 2 attempted to walk in the dining room after sitting in a chair. The resident was assessed and had no injuries. Nursing notes, dated July 26, 2023, at 8:53 p.m. through July 28, 2023, at 8:00 p.m. revealed that Resident 2 was able to move her left and right leg, had no verbal expressions of pain, and did not grimace, withdraw or show other non-verbal signs of pain. A physical therapy note, dated July 25, 2023, at 3:59 p.m revealed that Resident 2 ambulated 50 feet with a wheeled walker and assist of two staff. A physical therapy note, dated July 26, 2023, at 2:16 p.m. revealed that Resident 2 ambulated 25 feet with a wheeled walker and assist of two staff. A physical therapy note, dated July 27, 2023, at 2:25 p.m. revealed Resident 2 had increased agitation with the request of lower extremity movement and refused to stand or ambulate, and on July 28, 2023, at 4:12 pm. the resident refused to ambulate and was easily agitated. A physical therapy note, dated July 30, 2023, at 12:45 p.m. revealed that Resident 2 was able to stand for 15 seconds and then sat down abruptly. She was fearful of falling and complained of pain in the right lower extremity. The note indicated that nursing was aware. On August 1, 2023, at 4:50 p.m. Resident 2 stated, I don't feel well and guarded her right lower extremity but was unable to specifically locate and rate her pain. There was no documented evidence that the physician was notified about the resident's change in condition. Page 1 of 2 396132 396132 08/31/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0684 Level of Harm - Minimal harm or potential for actual harm A nursing note, dated August 3, 2023, at 3:54 p.m. revealed that the resident complained of pain to the physicial therapist, the physician was notified, and an x-ray of the right hip was ordered. An x-ray result, dated August 3, 2023, revealed the resident had a fractured right femur (large bone of the leg). Residents Affected - Few Interview with the Director of Nursing on August 31, 2023, at 1:29 p.m. confirmed that the physician was not notified of Resident 2's change in condition and should have been. She indicated that she was not aware of the physical therapy notes on July 30 and August 1, 2023. 28 Pa. Code 211.12(d)(5) Nursing services. 396132 Page 2 of 2