Communities At Indian Haven,

F-F638, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quarterly assessments at least every three months.

The facility's plan of correction for a deficiency regarding a failure to provide accurate resident assessments, cited during the survey ending March 21, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accuracy of assessments.

The facility's plan of correction for a deficiency regarding a failure to provide comprehensive resident care plans, cited during the survey ending March 21, 2024, and October 2, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding comprehensive resident care plans.

The facility's plan of correction for a deficiency regarding a failure to provide quality of care, cited during the survey ending March 21, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F684.

Level of Harm - Minimal harm or 28 Pa. Code 201.14(a) Responsibility of Licensee. potential for actual harm 28 Pa. Code 201.18(e)(1) Management. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 395778 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395778 B. Wing 02/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Communities at Indian Haven, 1675 Saltsburg Avenue Indiana, PA 15701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 48809 potential for actual harm Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed Residents Affected - Few to ensure that proper infection control practices were followed while administering medications for one of 43 residents reviewed (Resident 41).

Findings include:

Physician's orders for Resident 41 included orders for the resident to receive 5 mg amlodipine (a medication that is used to treat high blood pressure) that was discontinued on February 4, 2025.

Observations of Licensed Practical Nurse 1 during medication administration on February 5, 2025, at 8:00 a. m. revealed that she dropped a 5 mg tablet of amlodipine on the cart and picked it up with her bare hands, then administered the pill to Resident 41. Interview with Licensed Practical Nurse 1 at that time confirmed that she should not have touched the 5 mg tablet of amlodipine with her bare hands and administered it to

the resident.

Interview with the Nursing Home Administrator on February 5, 2025, at 10:07 a.m. confirmed that staff were not to touch residents' medications with their bare hands.

28 Pa. Code 211.12(d)(1)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 395778