F0580

E

Failure to Notify Resident Representatives of Changes in Condition and Care

Milton, Pennsylvania Survey Completed on 03-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify residents’ representatives or responsible parties of changes in condition or care, as required by facility policy and state regulations. The facility’s policy titled “Change in Condition,” dated 6/1/25, states that the resident, attending physician, and representative must be notified of changes in the resident’s medical or mental condition and/or status. Surveyors reviewed clinical records and staff interviews and determined that this notification did not occur for three of seven residents reviewed, all of whom had severe cognitive impairment and therefore relied on their representatives for information and decision-making.

For one resident with diagnoses including hypertension, dementia, and traumatic brain injury, the MDS showed severe cognitive impairment. Progress notes documented multiple significant clinical events: a large episode of emesis on 1/3/26; a report on 1/7/26 of a small amount of blood in the stool; an episode on 3/5/26 of full body tremors and slurred speech with MD notification via communication paper; and multiple episodes of large, projectile brown emesis on 3/15/26 treated with Zofran. In each of these instances, review of the progress notes did not show any documentation that the resident’s representative or responsible party was notified of these changes in condition.

For a second resident with dysphagia and Alzheimer’s disease and severe cognitive impairment, a progress note on 2/9/26 documented vomiting, holding of medications, and MD notification, but there was no documentation that the resident’s representative was notified. Weight change notes showed a five‑pound loss between 11/17/25 and 12/17/25, a 7.7% loss by 2/9/26 with continued decline in oral intake and a recommendation for an enhanced diet, and a 10.4% loss by 3/6/26 with continued dietary interventions; however, there was no documentation that the representative was notified of the ongoing weight loss. For a third resident with coronary artery disease, diabetes, and dementia and severe cognitive impairment, progress notes documented episodes of diarrhea on 12/17/25, excoriation to the sacrum and groin later that day, abnormal stool characteristics and a new liver profile lab order on 12/22/25, and continued loose stools on 1/9/26. In each of these events, the progress notes lacked evidence that the resident’s representative or responsible party was notified. The Nursing Home Administrator and DON confirmed that the facility failed to notify representatives for these three residents.