Health inspection·December 26, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or resident's representative was notified of changes in condition and new physician's orders for one of three residents reviewed (Resident 1). Findings include: The facility's policy regarding communication of health status/notification of family, dated October 12, 2023, indicated that the facility was to notify the resident and/or the resident's family/responsible party of any changes in resident's condition, including new physician orders or changes in current orders. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 9, 2023, indicated that the resident was cognitively intact, required assistance from staff with daily care tasks, had an indwelling urinary catheter (a flexible tube inserted into the bladder through the urethra or suprapubically to allow for urine drainage), and had diagnoses that included acute cystitis (infection or inflammation of the bladder) and hematuria (blood in the urine), obstructive and reflux uropathy (a condition that affects the urinary tract due to blockage or backflow), heart failure, and protein-calorie malnutrition (inadequate food consumption). A nursing note for Resident 1, dated November 7, 2023, at 5:09 a.m., revealed that the resident had not voided (urinated) in seven hours and had suprapubic (lower abdomen) tenderness and distention. A physician's order for straight catheterization (a thin tube that drains urine from the bladder) was received and the procedure was performed. However, there was no documented evidence that the resident or the resident's family/responsible party was notified about her change in condition and new orders. A nursing note for Resident 1, dated November 8, 2023, at 1:44 p.m., revealed that the resident did not void that shift and her bladder appeared to be full on palpation. A physician's order was received to insert an indwelling urinary catheter, and the procedure was completed. However, there was no documented evidence that the resident or the resident's family/responsible party was notified about the new orders. A nursing note for Resident 1, dated November 14, 2023, at 2:32 p.m., revealed that the resident was evaluated by doctor due to an increase in swelling to her left lower extremity and received a new order for Zaroxolyn (a water pill) for five days and on the sixth day the resident had lab work ordered. However, there was no documented evidence that Resident 1 or her family/responsible party was Page 1 of 2 396132 396132 12/26/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0580 notified about the resident's change in condition and new orders. Level of Harm - Minimal harm or potential for actual harm A nursing note for Resident 1, dated November 28, 2023, at 8:11 a.m., revealed that the resident had an ongoing deep tissue injury (a pressure-related injury under intact skin) to her left heel. Physician's orders, dated November 28, 2023, included an order for Liquacel (a protein supplement) 30 milliliters two times a day for 14 days for wound healing or until the wound heals. However, there was no documented evidence that Resident 1 or her family/responsible party was notified about the new orders. Residents Affected - Some A physician's progress note for Resident 1, dated December 5, 2023, at 8:58 p.m. revealed that the resident was seen at the request of nursing staff for a moist cough and rhonchi (abnormal lung sounds). Physician's orders, dated December 5, 2023, included an order for a chest x-ray to rule out pneumonia (a lung infection). However, there was no documented evidence that Resident 1 or her family/responsible party was notified about the resident's change in condition and new orders. A nursing note for Resident 1, dated December 8, 2023, at 4:10 p.m., revealed that resident received a physician's order for a liver ultrasound. A nurse's note, dated December 9, 2023, at 11:22 p.m., and a physician's order, dated December 9, 2023, revealed that resident was scheduled to receive the ultrasound on December 12, 2023, and was to have nothing by mouth after midnight until the time of the test. However, there was no documented evidence that Resident 1 or her family/responsible party was notified about the resident's new orders. A nursing note for Resident 1, dated December 10, 2023, at 5:50 p.m., revealed that the resident had a large amount of creamy, yellow-colored fluid from her vaginal area and on exam, the vaginal area had mild erythema (redness caused by inflammation) and residual discharge. A physician's order was obtained for a culture and sensitivity of vaginal drainage, and an order was given for Diflucan 150 milligrams daily for five days. However, there was no documented evidence that Resident 1 or her family/responsible party was notified about the resident's change in condition and new orders. A physician's order for Resident 1, dated December 19, 2023, included that the resident was ordered a computed tomography (CT) scan of the abdomen/pelvis. However, there was no documented evidence that Resident 1 or her family/responsible party was notified about the new orders. Interview with the Director of Nursing on December 26, 2023, at 2:35 p.m. confirmed that there was no documented evidence that Resident 1 or her family/responsible party was notified about the above changes in conditions and/or new orders. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 396132 Page 2 of 2