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F0580
D

Failure to Notify Resident Representative of Changes in Condition and Care

Hollidaysburg, Pennsylvania Survey Completed on 09-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely notification of a resident representative regarding significant changes in a resident's condition and care. Specifically, for a resident with severe cognitive impairment and a diagnosis of dementia, there was no documented evidence that the resident's representative was informed about an in-house optometry consult, the ordering of new glasses, the development and progression of a skin blister, or the initiation of a new antibiotic medication for cellulitis. The facility's policy required timely notification to families and representatives about changes in medical condition and care, but this was not followed in these instances. A grievance was filed by the resident's representative after the resident's glasses went missing and were replaced, but the representative had not been notified of the optometry visit or the order for new glasses. Additionally, clinical documentation showed the resident developed a blister that later became non-intact, and a new antibiotic was ordered, yet there was no evidence of family notification. The DON confirmed that there was no documentation of notification and acknowledged that the family should have been informed of these events.

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