F0580

D

Failure to Notify Resident Representative of Multiple Falls

Somerset, Pennsylvania Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a resident’s representative of changes in condition as required by facility policy. The facility’s notification policy dated February 4, 2026, stated that the resident’s representative would be notified when there was a change requiring notification. A quarterly MDS assessment dated July 26, 2025, showed that Resident 2 was cognitively impaired and required staff assistance for daily care, and the resident’s care plan identified a risk for falls. Nursing notes documented that on August 1, 2025, the resident fell in his room; on August 9, 2025, the resident was found on his knees in his room with a bruised elbow; and on August 15, 2025, the resident was found on the floor in his room after tripping over oxygen tubing. There was no documented evidence that the resident’s daughter, who was the power of attorney, was notified of any of these falls, and the DON confirmed in an interview that the daughter was not notified and should have been.

This failure to notify the resident’s representative of multiple fall events for a cognitively impaired resident at risk for falls constituted noncompliance with the facility’s own notification policy and with 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services.