Inspection visit
Health inspection
18 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 18 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Many
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or
the resident's responsible party in writing of a transfer to the hospital for seven of 10 residents reviewed
(Residents 3, 34, 69, 44, 62, 45, and 10). The facility also failed to notify the Office of the State Long-Term
Care Ombudsman of a transfer to the hospital for 3 of 10 residents reviewed (Residents 34, 44, and 69).
Findings include:
A review of Resident 3's clinical record revealed that the facility transferred her to the hospital from [DATE]
to 13, 2023. There was no documented evidence to indicate that the facility provided a written notice to
Resident 3's responsible party regarding her transfer to the hospital that included the required contents:
reason for the transfer, effective date of the transfer, location to which the resident was transferred to,
contact and address (mailing and email) information for the Office of the State Long-Term Care
Ombudsman, and information (mailing and email address and telephone number) for the agency
responsible for the protection and advocacy of individuals with developmental disabilities, and a statement
of resident's appeal rights, including name, address (mailing and email) and telephone number of entity
which receives requests.
A clinical record review for Resident 34 revealed he was transferred to the hospital from [DATE] to 21, 2023,
for a change in condition and was admitted . There was no evidence to indicate that Resident 34's
responsible party was provided written notification to include the above-required contents. Further review of
facility documentation revealed there was no documented evidence that the facility notified the Office of the
State Long-Term Care Ombudsman of Resident 34's transfer to the hospital.
A clinical record review for Resident 44 revealed he was transferred to the hospital from [DATE] to 21, 2023,
for a change in condition and was admitted . There was no evidence to indicate that Resident 44's
responsible party was provided written notification to include the above-required contents. Further review of
facility documentation revealed there was no documented evidence that the facility notified the Office of the
State Long-Term Care Ombudsman of Resident 44's transfer to the hospital.
A clinical record review for Resident 69 revealed he was transferred to the hospital from [DATE], to January
2, 2024. There was no evidence to indicate that Resident 69's responsible party was provided written
notification to include the above-required contents. Further review of facility documentation revealed there
was no documented evidence that the facility notified the Office of the State
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 26
Event ID:
395379
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0623
Long-Term Care Ombudsman of Resident 69's transfer to the hospital.
Level of Harm - Potential for
minimal harm
The surveyor reviewed the above information for Residents 3, 34, 44, and 69 during an interview with the
Nursing Home Administrator Director of Nursing on March 14, 2024, at 2:20 PM.
Residents Affected - Many
Clinical record review for Resident 10 revealed that she was transferred to the hospital on December 13,
2023, for respiratory distress. There was no evidence to indicate that Resident 10's responsible party was
provided written notification to include the above-required contents.
Clinical record review for Resident 45 revealed that she was transferred to the hospital on December 27,
2023, related to pneumonia. There was no evidence to indicate that Resident 45's responsible party was
provided written notification to include the above-required contents.
Clinical record review for Resident 62 revealed that he was transferred to the hospital on October 31, 2023,
related to concerns with swelling around his dialysis (a process that helps your body remove extra fluid and
waste when your kidneys are not able to) fistula (a surgical connection that is made between and artery
and a vein for dialysis access).
There was no evidence to indicate that Resident 62's responsible party was provided written notification to
include the above-required contents.
The Nursing Home administrator confirmed the above noted findings regarding transfer notices during a
meeting on March 14, 2024, at 2:40 PM.
The surveyor reviewed the above noted findings for Residents 10, 45, and 62, during a meeting with the
Nursing Home Administrator and Director of Nursing on March 14, 2024, at 2:45 PM.
28 Pa. Code 201.14(a) Responsibility of license
28 Pa. Code 201.29(a) Resident rights
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 2 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that
the resident or resident representative received written notice of the facility's bed hold policy at the time of
transfer for six of 10 residents reviewed for hospitalizations (Residents 3, 10, 44, 45, 62, and 69).
Findings include:
Clinical record review for Resident 10 revealed that she was transferred to the hospital on December 13,
2023, for respiratory distress. There was no documentation available that the facility provided written notice
regarding a bed hold to the resident and/or the resident's responsible party upon transfer out of the facility.
Clinical record review for Resident 45 revealed that she was transferred to the hospital on December 27,
2023, related to pneumonia. There was no documentation available that the facility provided written notice
regarding a bed hold to the resident and/or the resident's responsible party upon transfer out of the facility.
Clinical record review for Resident 62 revealed that he was transferred to the hospital on October 31, 2023,
related to concerns with swelling around his dialysis (a process that helps your body remove extra fluid and
waste when your kidneys are not able to) fistula (a surgical connection that is made between and artery
and a vein for dialysis access). There was no documentation available that the facility provided written
notice regarding a bed hold to Resident 62 and/or his responsible party upon transfer out of the facility.
Clinical record review for Resident 3 revealed that she was transferred to the hospital on November 11 to
13, 2023, for a change in mental status. There was no documentation available that the facility provided
written notice regarding a bed hold to Resident 3 and/or Resident 3's responsible party upon transfer out of
the facility.
Clinical record review for Resident 44 revealed that she was transferred to the hospital on December 18 to
21, 2023, for a change in his mental status. There was no documentation available that the facility provided
written notice regarding a bed hold to Resident 44 and/or the Resident 44's responsible party upon transfer
out of the facility.
Clinical record review for Resident 69 revealed that she was transferred to the hospital on December 28,
2023, to January 2, 2024. There was no documentation available that the facility provided written notice
regarding a bed hold to Resident 69 and/or Resident 69's responsible party upon transfer out of the facility.
The facility failed to provide written notice of their bed hold policy at the time of transfer for Residents 3, 10,
44, 45, 62, and 69. The Nursing Home administrator confirmed the above-noted findings related to bed hold
notices during a meeting on March 14, 2024, at 2:40 PM.
28 Pa. Code 201.14(a) Responsibility of licensee
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 3 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on clinical record review and staff interview, it was determined that the facility failed to implement a
comprehensive person-centered care plan regarding cognitive loss and psychotropic medication use with
behaviors for two of 22 residents reviewed (Resident 64 and 75).
Findings Include:
Review of Resident 64's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment
done at specific intervals to determine care needs) dated May 12, 2023, revealed that the facility assessed
Resident 64 as having cognitive loss and determined that a plan of care would be developed to address her
cognitive loss.
Review of Resident 64's current plan of care revealed that the facility did not develop a plan of care to
address her cognitive loss until March 12, 2024.
Interview with the Director of Nursing on March 15, 2024, at 9:32 AM, confirmed the above findings for
Resident 64.
Clinical record review for Resident 75, revealed her current physician orders to include the following
psychoactive (medications that affects how the brain works and causes changes in mood, awareness,
thoughts, feelings or behavior) medications: Xanax (a medication used to treat anxiety) 0.5 milligrams three
times a day, Olanzapine (a medication used to treat schizophrenia), and Bupropion HCI (a medication used
to treat depression).
Review of Resident 75's current plan of care revealed that the facility did develop a personalized care plan
for Resident 75 that identified her targeted behaviors and individualized interventions related to her mood
and behaviors.
Interview with Employee 7, Social Services, on March 15, 2024, at 10:31 AM, confirmed the above findings
related to Resident 75.
The Nursing Home Administrator was made aware of the concerns related to Resident 75's care plan on
March 15, 2024, at 12:30 PM.
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 4 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on review of select facility policies, clinical record review, and staff and resident interview, it was
determined that the facility failed to invite and ensure resident and responsible party attendance and to hold
care plan conferences for three of 22 residents reviewed (Resident 8, 62, and 66).
Findings include:
Clinical record review for Resident 8 revealed that the facility documented a care plan note on February 15,
2023, to review and revise her plan of care. There was no documentation after February 15, 2023, that the
facility completed a care plan meeting or invited Resident 8 and/or her responsible party to care plan
meetings.
Clinical record review for Resident 66 revealed that the facility completed a quarterly MDS MDS (Minimum
Data Set, an assessment tool completed at specific intervals to determine resident care needs) on January
16, 2024, and indicated that she was capable. The facility indicated that she was her own responsible party.
On October 17, 2023, the facility documented a care plan meeting to review and revise her plan of care
with Resident 66 and her sister attending. There was no documentation after October 17, 2023, that the
facility completed a care plan meeting or invited Resident 8 and/or her responsible party to care plan
meetings.
During an interview with Resident 62, and his wife, on March 12, 2024, at 10:50 AM, the wife indicated that
they were to attend a meeting at 11:00 the same day. She presented an invitation and it was noted that the
meeting was a care plan meeting. She indicated that the facility holds care plan meetings once a year.
There was no clinical documentation prior to the scheduled meeting of March 12, 2024, at 11:00 AM to
indicate that the facility completed a care plan meeting or invited Resident 62 and/or her responsible party
to care plan meetings within the past year.
Interview with Employee 7, Social Services on March 15, 2024, at 12:45 PM, confirmed that she did not
invite or hold any other care plan meetings over the past year with Resident 62.
Interview with the Nursing Home Administrator on March 15, 2024, at 8:43 AM and 11:25 AM confirmed the
above findings.
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 5 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to
provide the highest practicable care regarding physician-ordered vital signs, medications, and interventions
for two of 22 residents (Residents 8 and 52) and integrated hospice care and services for two of four
residents reviewed (Residents 34 and 75).
Residents Affected - Some
Findings include:
Clinical record review for Resident 8 revealed a current physician order for staff to place an air mattress on
her bed and monitor the air mattress every shift to ensure the pump setting was 220 (pounds) alternating
pressure for skin protection.
Observation of Resident 8's air mattress on March 12, 2023, at 9:54 AM, March 13, 2024, at 11:21 AM, and
March 14, 2024, at 8:28 AM and 10:45 AM revealed that her air mattress pump setting was 380 pounds.
Further clinical record review for Resident 8 revealed a physician order for staff to administer Detemir
insulin 100 unit/milliliter 37 units subcutaneously (just under the skin) daily for diabetes. Staff were to hold
the insulin if Resident 8's blood sugar was less then 100 mg/dl (milligrams/deciliter).
Review of Resident 8's January, February, and March 2024 MAR (medication administration record, a form
to document medication administration) revealed that there was no documentation that staff were
monitoring Resident 8's blood sugars as ordered.
Clinical record review for Resident 52 revealed a current physician order place a wide air mattress on his
bed and monitor the air mattress every shift to ensure the pump setting was 450 (pounds) alternating
pressure.
Observation of Resident 52's air mattress on March 12, 2023, at 9:37 AM and 3:05 PM revealed that his air
mattress pump setting was 540 pounds.
The surveyor reviewed the above information during an interview on March 14, 2024, at 10:45 AM and 1:21
PM and March 15, 2024, 10:20 AM with the Nursing Home Administrator and Director of Nursing.
Clinical record review for Resident 75 revealed that she was on Hospice related to a terminal diagnosis of
malignant neoplasm of the endometrium (a disease in which cancer cells form in the tissues of the lining of
the uterus).
Review of Resident 75's current care plan revealed that the facility failed to implement an integrated plan of
care with hospice services. The plan of care did not include evidence of all services that hospice will
provide for the management of Resident 75's terminal illness.
Resident 75's current care plan failed to identify the hospice entity providing services, the hospice
disciplines that would provide her care and services, and how often.
Interview with Employee 7 (social services) confirmed the above-noted finding related to Resident 75's
hospice services and plan of care during an interview on March 15, 2024, at 10:30 AM and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 6 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0684
Level of Harm - Minimal harm
or potential for actual harm
confirmed that she updated Resident 75's care plan with hospice information after the surveyor brought this
to her attention at 8:30 AM on March 15, 2024.
Clinical record review revealed the facility admitted Resident 34 to hospice on December 30, 2023, due to a
terminal diagnosis of end-stage dementia with a poor prognosis.
Residents Affected - Some
Review of Resident 34's current care plan revealed that the facility failed to implement an integrated plan of
care with hospice services. The plan of care did not include evidence of all services that hospice will
provide for the management of Resident 34's terminal illness.
Interview with Employee 7 on March 15, 2024, at 10:32 AM confirmed the above-noted findings for
Resident 34. Resident 34's plan of care failed to delineate who was to provide for the physical,
psychosocial, spiritual, and emotional needs of Resident 34.
483.25 Quality of Care
Previously cited 11/2/23 and 3/3/23
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 7 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, observation, and staff interview, it was determined that the facility failed to assess
and implement treatment and services to prevent development and promote healing of pressure ulcers for
four of six residents reviewed for pressure ulcer concerns (Residents 15, 22, 34 and 260).
Residents Affected - Some
Findings include:
Clinical record review for Resident 15 revealed wound clinic documentation date of March 14, 2024, which
indicated that he had a chronic pressure ulcer on his left buttock measuring 2 centimeters by 2 centimeter
by 3 centimeters.
Resident 15's current physician order revealed that staff was to place an air mattress to his bed, ensure
that it was set at 150 pounds, and provided alternating pressure.
Observation of Resident 15 on March 12, 2024, at 10:01 AM revealed that he was in bed and his air
mattress was set at 660-750 pounds.
Clinical record review for Resident 22 revealed that the facility admitted her on September 25, 2023, with
diagnoses of paraplegia (paralyzed lower extremities), a non-pressure chronic ulcer to her back,
osteomyelitis, and extradural and subdural abscess. An admission assessment dated [DATE], revealed that
Resident 22 had an unstageable pressure ulcer on her left buttock measuring 14.5 centimeters by 9
centimeters with eschar (blackened dead tissue).
On March 8, 2024, staff documented that Resident 22 weighed 220.8 pounds.
Resident 22's current physician orders indicated that staff was to place a pressure relieving mattress to her
bed and monitor that it was functioning every night shift.
Observation of Resident 22 on March 13, 2024, at 9:44 AM, March 14, 2024, at 1:10 PM revealed that she
was in bed and her air mattress was set at 100 pounds.
Clinical record review for Resident 260 revealed that the facility admitted her on February 22, 2024, with
diagnoses of rhabdomyolysis (damaged tissue releases protein and electrolytes into the blood resulting in
potentially permanent disability). An admission assessment dated [DATE], revealed that Resident 260 had
an open wound on her right hip measuring 8 centimeters by 2 centimeters with slough (yellow/white dead
tissue).
On March 12, 2024, staff documented that Resident 260 weighed 159.4 pounds.
Resident 260's current physician orders indicated that staff was to place an air mattress to her bed and
check inflation and patency every shift.
Observation of Resident 260 on March 12, 2024, at 9:53 AM and March 13, 2024, at 9:50 AM revealed that
she was in bed and her air mattress was set at 620 pounds.
This surveyor reviewed the above information with the Nursing Home Administrator and the Director of
Nursing on March 14, 2024, at 1:10 PM.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 8 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Clinical record review for Resident 34 revealed the facility admitted him on May 22, 2023. Review of
Resident 34's nursing skin evaluation on August 30, 2023, revealed no skin impairments were observed.
The nursing skin evaluation dated September 6, 2023, noted Resident 34's current skin condition changed
and a pressure sore was noted on Resident 34's right heel. There was no further assessment, or
interventions implemented related to the identified pressure ulcer on Resident 34's heel until September
11, 2023.
Nursing documentation dated September 11, 2023, at 10:24 AM, noted a nurse was in to assess Resident
34's heels for potential deep tissue injuries. The nurse assessed Resident 34's left heel measuring 1 by 1.5
centimeters, and the left heel was not blanchable, or open. The nurse assessed Resident 34's right heel
measuring 4 by 6 centimeters, and the right heel was open with serosanguinous drainage.
The facility did not assess and implement interventions timely to address the pressure area identified on
Resident 34's right heel on September 6, 2023.
Interview with Employee 9 (assistant director of nursing) on March 15, 2024, at 8:51 AM confirmed these
findings. She could provide no further documentation that the facility assessed and implemented
interventions to address Resident 34's identified pressure ulcer when identified on September 6, 2023.
28 Pa. Code 201.18(b)(1)(3) Management
28 Pa. Code 211.5(f)(ii)(iv)(ix) Medical records
28 Pa. Code 211.10(a)(d) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 9 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
Based on clinical record review and staff interview, it was determined that the facility failed to provide
services to maintain a resident's range of motion (ROM, movement of the body to maintain a resident's
ability) for three of 10 residents reviewed (Residents 69, 66, and 20).
Findings include:
Interview with Resident 69 on March 12, 2024, at 10:24 AM revealed that he wants to go home. He stated
that the staff tell him he needs to be able to walk to be discharged home. Resident 69 indicated that staff do
not help him improve his walking.
Clinical record review revealed that Resident 69 was discharged from physical therapy on January 5, 2024.
Review of the physical therapy discharge summary revealed Resident 69's prognosis was good with
consistent staff follow-through. Physical therapy's discharge recommendations included a restorative
nursing program to facilitate Resident 69 maintaining his current level of performance and to prevent a
decline in his ambulation and transfers.
Review of Resident 69's clinical record revealed he was not currently on a restorative nursing program.
Review of Resident 69's Documentation Survey Report dated February 2024, documented an intervention
for staff to ambulate with Resident 69 to Sycamore Nursing Station with his walker and limited assistance of
one staff following with his wheelchair. There was no documentation of the restorative nursing program after
February 2, 2024.
Interview with Employee 8 (physical therapy assistant, director of therapy) on March 15, 2024, at 10:58 AM
confirmed the above findings. Employee 8 could provide no further documentation as to why Resident 69's
restorative nursing program was discontinued.
Clinical record review for Resident 20 revealed a current care plan for staff to provide ROM (range of
motion) to her BLLE (bilateral lower extremities) and BLUE (bilateral upper extremities) twice daily (BID).
Review of task documentation for Resident 20 for January and February 2024, revealed that staff did not
document completion of the restorative task on the following dates:
January 13 and 26, 2024, day shift
January 24, 2024, evening shift
February 8, 15, and 20, 2024, day shift
February 10, 13, and 18, 2024, evening shift
Clinical record review for Resident 66 revealed a current care plan for staff to provide a restorative nursing
program for her activities daily of living (ADLs, daily resident care and services) with limited assistance for
her upper body and extensive assistive for her lower body BID, restorative nursing to ambulate from the foot
of her bed to the central bathroom with a front wheel walker with extensive assist of one staff member and
the wheelchair to follow BID, AROM (active range of motions)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 10 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0688
to BLLE BID, and restorative nursing for transfers with extensive assistance of one staff member BID.
Level of Harm - Minimal harm
or potential for actual harm
Review of task documentation for Resident 66 for January, February, and March 2024, revealed that staff
did not document completion of the restorative task on the following dates:
Residents Affected - Few
ADL'sJanuary 5 and 6, 2024
February 10, 2024, day shift
February 2, 10, and 13, 2024, evening shift
March 1 and 8, 2024, day shift
AmbulationJanuary 5 and 6, 2024, day shift
February 10, 2024, day shift
February 2, 10, and 13, 2024, evening shift
March 1 and 8, 2024, day shift
AROMJanuary 5 and 6, 2024, day shift
February 10, 2024, day shift
February 2, 10, and 13, 2024, evening shift
March 1 and 8, 2024, day shift
TransfersJanuary 5 and 6, 2024, day shift
February 10, 2024, day shift
February 2, 10, and 13, 2024, evening shift
March 1 and 8, 2024, day shift
The surveyor reviewed the above information on March 14, 2024, at 2:30 PM with the Nursing Home
Administrator and Director of Nursing.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 11 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0688
CFR 483.25(c)(2) Mobility
Level of Harm - Minimal harm
or potential for actual harm
Previously cited 3/3/23
28 Pa. Code 211.12(d)(1)(5) Nursing services
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 12 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on clinical record review, and staff interview it was determined that the facility failed to thoroughly
investigate a resident elopement for one of 22 residents sampled (Resident 44)
Residents Affected - Few
Findings include:
Clinical record review revealed the facility admitted Resident 44 on September 1, 2023. Review of Resident
44's care plan initiated on September 2, 2023, revealed that Resident 44 is a high risk for elopement.
Nursing documentation dated December 11, 2023, at 10:59 AM revealed Resident 44 followed a staff
member off the locked dementia unit. Documentation revealed staff were alerted by the physical therapist
that Resident 44 was on another hall. The physical therapist attempted to get Resident 44 back into the
dementia unit when Resident 44 grabbed the handrail in the hallway and would not let go. Documentation
revealed that it took three staff members to get Resident 44 back to the dementia unit. The documentation
further revealed that Resident 44 was having delusions and was noted to be sitting by the locked door to
the unit.
Interview with the Nursing Home Administrator, Director of Nursing, and Employee 9 (assistant director of
nursing) on March 15, 2024, at 8:27 AM, revealed that the facility did not have an investigation into
Resident 44's elopement off the locked dementia unit. Further interviews revealed they do not know how
Resident 44 got out of the locked dementia unit. The Nursing Home Administrator confirmed the facility
could not provide any further documentation that facility staff was interviewed, and educated, or that
maintenance checked that the door lock was functioning properly.
The facility failed to thoroughly investigate Resident 44's elopement.
483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices
Previously cited 03/03/2023.
28 Pa. Code 201.18 (e)(1) Management
28 Pa. Code 211.10(d) Resident care policies
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 13 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to
provide appropriate respiratory care and services for one of two residents reviewed (Resident 8).
Residents Affected - Few
Findings include:
According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer)
equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to
clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap
and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip
lock bag.
Clinical record review for Resident 8 revealed a current physician order for staff to change their oxygen
tubing and bag for their CPAP (continuous positive airway pressure, a device to help treat sleep apnea)
tubing weekly on Friday during night shift.
Observation of Resident 8's Oxygen concentrator on March 12, 2024, at 9:56 AM and March 13, 2024, at
1:51 PM, revealed that their oxygen tubing was dated March 1, 2024 (12 days prior) and her CPAP mask
was lying on top of the bedside stand unbagged. Concurrent interview with Employee 10, licensed practical
nurse, during the March 13, 2024, at 1:51 PM observation it was identified that an additional oxygen tubing
with the date March 8, 2024, and a clean bag was located inside another bag hanging on Resident 8's
bedside stand. Employee 10 confirmed that the March 1, 2024, dated oxygen tubing continued to be in use
for Resident 8 at the time of the observation.
The surveyor reviewed the above information for Resident 8 during observation and interview with the
Director of Nursing and the Nursing Home Administrator on March 14, 2023, at 2:17 PM.
28 Pa. Code 211.10 (c)(d) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing Services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 14 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
Based on clinical record review, resident and staff interview, it was determined that the facility failed to
ensure the highest practicable pain management for one of six residents reviewed (Resident 103).
Residents Affected - Few
Findings include:
Clinical record review for Resident 103 revealed that the facility admitted her on January 30, 2024. An
admission note dated January 30, 2024, at 3:22 PM, indicated that nursing staff oriented her to the facility
and the key locations. There was no documented evidence in the admission note to indicate Resident 103
was experiencing any pain.
Review of Resident 103's medication admission orders revealed that she was transferred from the hospital
with an order for nursing staff to administer Norco (a combination drug containing acetaminophen and a
narcotic pain reliever) 5 mg/325mg (milligrams) one tablet every six hours for moderate to severe pain.
Interview on March 12, 2024, at 11:53 AM, with Resident 103 revealed that she had to wait for 59 minutes
for a pain pill upon her admission and was in excruciating pain. There was no documented evidence in
Resident 103 clinical record to indicate Resident 103 verbalized her pain level to nursing staff upon her
admission to the facility.
A nursing note dated January 30, 2024, at 10:22 PM, indicated that Resident 103's medications were not
available to administer and that she was having severe pain to her left foot. The note indicated that she was
medicated with her own pain medication. The note did not indicate Resident 103's level of pain, nor did it
indicate how long she was in pain. There was no documented evidence to indicate what medication was
administered, by whom, or its effectiveness for Resident 103's pain level.
Review of the facility's list of medications available to use in their Cubex (a medication storage system for
use when medications are not available by pharmacy) revealed that Norco 5mg/325mg was available for
use. There was no documented evidence to indicate that nursing staff used the available Norco in the
facility's Cubex system.
Interview with Employee 1, registered nurse, on March 14, 2024, at 3:18 PM, revealed that she was the
supervisor during the shift of Resident 103's admission. Employee 1 indicated that she misread the Cubex
list of available medications and didn't realize that Resident 103's prescribe pain medication of Norco was
available to administer.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 15 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0726
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way
that maximizes each resident's well being.
Based on the review of facility documentation, four employee files and staff interviews, it was determined
that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets
related to the care and assessment of resident tracheostomy, peg tube, and catheter care.
Findings include:
A review of the facility documentation revealed that the facility had six residents with urinary catheters
(insertion of a tube into the bladder to remove urine), one resident with a tracheostomy (a surgical airway
management procedure that consists of making an incision on the anterior aspect of the neck and opening
a direct airway through an incision in the trachea), and two residents with peg tubes (medical procedure in
which a tube is passed into resident's stomach through the abdominal wall, most commonly to provide a
means of feeding).
A request for nursing staff competencies for tracheostomy, peg tube, and catheter care revealed the facility
was unable to provide any.
The findings were reviewed with the Nursing Home Administrator and Director of Nursing on March 14,
2024, at 2:55 PM confirmed the facility could provide no documentation that ensured nurses have specific
competencies and skill sets to care for the residents' needs listed above.
28 Pa Code 201.20(a) Staff development
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 16 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0730
Observe each nurse aide's job performance and give regular training.
Level of Harm - Minimal harm
or potential for actual harm
Based on staff interviews and review of facility documentation, it was determined that the facility failed to
ensure that nurse aides received an annual performance review for three of three nurse aides reviewed
(Employees 3, 4, and 5).
Residents Affected - Many
Findings Include:
Review of the facility's list of active nurse aide staff revealed Employee 3 had a hire date of November 15,
2022. Employee 3 should have had an annual performance review by November 15, 2023.
Employee 4 had a hire date of November 15, 2022. Employee 4 should have had an annual performance
review by November 15, 2023.
Employee 5 had a hire date of November 15, 2022. Employee 5 should have had an annual performance
review by November 15, 2023.
Requests to review Employees 3, 4, and 5's performance reviews revealed no documented evidence that
the facility completed the reviews at least once every 12 months.
Interview with the Nursing Home Administrator on March 14, 2023, at 10:50 AM confirmed that
performance evaluations were not completed.
28 Pa. Code 201.19(2) Personnel policies and procedures
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 17 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0744
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and staff interview, it was determined that the facility failed to develop and implement
an individualized person-centered care plan to address dementia and cognitive loss displayed by four of
five residents reviewed (Residents 33, 50, 8, and 75).
Residents Affected - Some
Findings include:
Clinical record review for Resident 33 revealed the facility admitted her on October 22, 2023, with diagnosis
including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere
with daily life) with other behavior disturbances. A review of Resident 33's admission Minimum Data Set
Assessment (MDS, a form completed at specific intervals to determine care needs) dated September 1,
2023, indicated that the facility assessed Resident 33 as having a diagnosis of dementia. The facility
determined that a care plan for dementia and cognitive loss would be developed.
A review of Resident 33's care plan revealed that there was no indication that the facility had developed and
implemented a person-centered care plan to address the resident's dementia and cognitive loss.
Clinical record review for Resident 50 revealed the facility admitted her on October 1, 2020, with diagnosis
including Dementia. A review of Resident 50's most recent MDS dated [DATE], indicated that the facility
assessed Resident 50 as having a diagnosis of dementia. The facility determined that a care plan for
dementia and cognitive loss would be developed.
The findings were reviewed with the Nursing Home Administrator and Director of Nursing on March 13,
2024, at 2:35 PM. The facility had no further documentation that the facility developed and implemented
individualized person-centered care plans to address Resident 33 and 55's dementia and cognitive loss.
Clinical record review for Resident 8 revealed that she was admitted to the facility on [DATE]. Resident 8's
physician diagnosed her with Dementia on November 2, 2016. An annual MDS completed on January 8,
2024, revealed that the facility indicated that she had Dementia and determined that a care plan for
dementia and cognitive loss would be developed.
Review of Resident 8's care plan revealed that there was no documentation of an individualized Dementia
care plan.
Clinical record review for Resident 75 revealed that she was admitted to the facility on [DATE], with
diagnosis including dementia.
Review of Resident 75's most recent comprehensive MDS dated [DATE], revealed that the facility
determined that a care plan for cognitive loss and dementia would be developed.
Review of Resident 75's current care plan revealed that there was no evidence of an individualized
dementia care plan.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 18 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0744
Level of Harm - Minimal harm
or potential for actual harm
The surveyor reviewed the above information regarding Resident 75, during an interview on March 15,
2024, at 8:46 AM with the Nursing Home Administrator.
28 Pa Code 211.12 (d)(1)(3)(5) Nursing services
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 19 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on clinical record review, review of select policies and procedures, and resident and staff interview, it
was determined that the facility failed to ensure accurate acquiring and dispensing of medications for one of
22 residents reviewed (Resident 103).
Findings include:
The policy entitled Remedi, Pharmacy Contact Info, last reviewed on December 4, 2023, indicates that for
any new admissions, facility staff must call the pharmacy for any new admissions orders. The pharmacy will
not automatically send medications from a facsimile.
The policy entitled Medications brought to the facility by the resident last reviewed on December 4, 2023,
indicates that if a medication is not available and have been determined to be essential to the resident's life,
the Director of Nursing and nursing staff along with the support of the attending physician to ensure that the
medication has been ordered by the resident's physician.
Review of Resident 103's medication admission orders revealed that she was transferred from the hospital
with an order for nursing staff to administer Norco (a combination drug containing acetaminophen and a
narcotic pain reliever) 5 mg/325mg (milligrams) one tablet every six hours for moderate to severe pain. A
nursing note dated January 30, 2024, at 3:22 PM, indicated that Resident 103 was admitted and oriented to
the facility.
Interview on March 12, 2024, at 11:53 AM, with Resident 103 revealed that none of her pills were here
when she was admitted . Resident 103 also indicated that she had to wait for one of her pain pills because
the facility didn't have it on hand, and that she took one of her own pills that she brought to the facility.
A nursing note dated January 30, 2024, at 10:22 PM, indicated that Resident 103's medications were not
available to administer and that she was having severe pain to her left foot. The note indicated that she was
medicated with her own pain medication. There was no documented evidence to indicate that Resident
103's physician was made aware that she brought her own medication, nor if nursing staff ensured it was a
medication ordered by her physician.
Review of Resident 103's Medication Administration Record (MAR, a form used to document the
administration of medications) dated January 2024, revealed that her physician ordered Allegra (for
allergies), Combigan (treats eye diseases), and Mirapex (treats restless leg syndrome) were not
administered for the 8:00 PM dose. There was no documented evidence in Resident 103's clinical record to
indicate if nursing staff called the pharmacy as required or why the medications were not administered.
Interview with the Administrator and Director of Nursing on March 14, 2024, at 2:00 PM, confirmed the
above findings for Resident 103, and could not provide further documented evidence to indicate why her
medications were not administered as ordered.
28 Pa. Code 211.9 (a)(1)(d)(e)(4)(k) Pharmacy services
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 20 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that
the resident's attending physician addressed and responded appropriately to pharmacy recommendations
for four of six residents reviewed (Resident 64, 33, 50, and 75) and failed to ensure that the consulting
pharmacy identified potential appropriateness for psychoactive medications for one of six residents
reviewed (Resident 64).
Findings include:
Review of Resident 64's clinical record revealed a physician order dated September 22, 2022, for nursing
staff to administer Zoloft (used to treat depression) 150 mg (milligrams) every day for schizoaffective
disorder (a combination of symptoms of schizophrenia and bipolar disorder).
A consultant pharmacy review dated September 1, 2023, indicated that Resident 64 has been on the
current dose of Zoloft since September 2022 and that her physician review the current dose and should
consider a gradual dose reduction. There was no documented evidence that Resident 64's physician
addressed the consultant pharmacist's recommendation. Resident 64 continued to get the 150 mg of Zoloft
for an additional two months before a gradual dose reduction was attempted.
Review of Resident 64's clinical record revealed a nursing progress noted dated November 13, 2023, that
indicated her attending physician was going to write an order for nursing staff to decrease her dose of
Seroquel (a medication that treats mental disorders) to 12.5 mg in the morning and 25 mg in the evening.
Review of the order dated November 13, 2023, indicated the above changes.
Review of Resident 64's Medication Administration Record (MAR, a form used to document the
administration of medications) dated November 2023 revealed that in addition to the above orders changes
for Resident 64's Seroquel, the nurse transcribing the order also entered an order for an additional 50 mg of
Seroquel to be given in the morning. There was no documented evidence to indicate that Resident 64's
attending physician authorized the extra 50 mg of Seroquel.
A consultant pharmacy review was conducted on November 17, 2023, with no recommendations for
Resident 64's attending physician. The consultant pharmacist did not identify that Resident 64 was
receiving an extra 50 mg of Seroquel that her physician did not order.
Interview with the Director of Nursing on March 15, 2024, at 9:32AM confirmed the above findings for
Resident 64.
A consultant pharmacy review dated December 19, 2023, requested Resident 33's physician consider
ordering a Lipid Panel (a blood test that can measure the amount of cholesterol in your blood), CBC
(complete blood count, is a blood test used to look at overall health), BMP (basic metabolic panel, a test
that measures eight different substances in your blood), and Vitamin D level. There was no documented
evidence that Resident 33's physician addressed the consultant pharmacist's recommendation from
December 19, 2023.
A consultant pharmacy review dated January 22, 2024, indicated Resident 33 has an order for Seroquel
with an indication of dementia. The consultant pharmacist requested Resident 33's physician change the
indication for Resident 33's Seroquel to depression. There was no documented evidence that
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 21 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0756
Resident 33's physician addressed the consultant pharmacist recommendations from January 22, 2024.
Level of Harm - Minimal harm
or potential for actual harm
A consultant pharmacy review dated December 19, 2023, noted Resident 50 has four psychotropic
medication orders for at least three to 12 months that are now potentially due for a gradual dose reduction
based on CMS guidelines. The consultant pharmacist requested Resident 50's physician evaluate if
Resident 50 is a candidate for gradual dose reduction and consider a reduction in the total daily dose of
any of the four psychotropic medication orders. There was no documented evidence that Resident 50's
physician addressed the consultant pharmacist's recommendation from December 19, 2023.
Residents Affected - Some
Interview with Employee 9 (assistant director of nursing) on March 14, 2024, at 1:02 PM confirmed the
above findings for Residents 33 and 50.
A consultant pharmacy review dated November 22, 2023, noted that Resident 75 had an order for
Olanzapine (a medication used to treat schizophrenia, bipolar disorder, and depression). The consulting
pharmacist requested that the physician change the indication for use to depression. Resident 75's
physician addressed the recommendation on November 28, 2023. He declined to change the indication for
use marked the box that indicated to continue the zyprexa order with the current indication and that he was
aware that olanzapine is not FDA approved for agitation/hallucination but the benefits to the resident
outweights any potential adverse side effect risks. He also documented under the physician reponse area
that the resident is on hospice with metastatic cancer. The physician failed to provide an appropriate
indication for use of the medication Olanzapine for Resident 75.
Interview with Employee 9, on March 15, 2024, at 11:00 AM confirmed the above noted finding related to
Resident 75.
28 Pa. Code 211.9 (d)(k) Pharmacy services
28 Pa. Code 211.12(d)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 22 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on clinical record review and staff interview, it was determined that the facility failed to ensure a
resident's medication regime was free from potentially unnecessary medications for three of five residents
reviewed (Residents 2, 8, and 64).
Findings include:
Clinical record review for Resident 8 revealed current physician orders for Seroquel (for bipolar disorder) 75
milligrams (mg) by mouth (PO) at bedtime (HS), Seroquel 50 mg PO twice daily (BID), Depakote sprinkles
(for bipolar disorder) 125 mg two capsules PO daily (QD) and one capsule PO BID, and Duloxetine (for
Depression) 60 mg PO QD.
Resident 8's physician ordered the every shift staff to monitor her for dry mouth, constipation blurred vision,
disorientation/confusion, difficulty urinating, hypotension (low blood pressure), dark urine, yellow skin,
nausea and/or vomiting, lethargy drooling, tremors, disturbed gait, increased agitation, restlessness, and/or
involuntary movement of the mouth or tongue. Staff were to document Y if monitored and none of the above
were observed or N if monitored and any of the above was observed, select chart code other/see nurses
notes and progress note findings related to bipolar disorder and Depression.
Review of Resident 8's January, February, and March 2024 MAR (medication administration record, a form
to document medication administration) and clinical record revealed that there was no documentation that
staff were monitoring Resident 8 for the above noted physician ordered signs and symptoms or behaviors.
The surveyor reviewed the above for Resident 8 during an interview with the Nursing Home Administrator
on March 15, 2024, at 8:58 AM.
Review of Resident 2's clinical record revealed a current physician order for nursing staff to administer
Ativan (helps with anxiety) .5 mg three times a day for anxiety, Remeron (an anti-depressant) 45 mg at
bedtime for depression, and Risperdal (used to treat mental disorders) 2mg three times a day for
psychosis.
A physician order dated December 3, 2023, indicated that nursing staff were to monitor Resident 2's
behaviors such as crying, wringing of her hands, outbursts, and physical aggression. Review of Resident
2's MAR dated March 2024 revealed that there was no documented evidence that the facility was tracking
Resident 2's behaviors to determine what behavior she was exhibiting, how many episodes, or what
interventions nursing staff were using to help alleviate the behavior.
Review of Resident 64's clinical record revealed a current physician order for nursing staff to administer
Seroquel (treats depression) 12.5 mg every morning and 25 mg every evening, and Zoloft (treats
depression) 100 mg every day, both to treat her depression.
A physician order dated December 28, 2023, indicated that nursing staff were to monitor Resident 64's
behaviors such as agitation, restlessness, anger, fear, hallucinations, sadness, crying, and fatigue. Review
of Resident 64's MAR dated March 2024 revealed that there was no documented evidence
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 23 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0758
Level of Harm - Minimal harm
or potential for actual harm
that the facility was tracking Resident 64's behaviors to determine what behavior she was exhibiting, how
many episodes, or what interventions nursing staff were using to help alleviate the behavior.
The above findings for Resident 2 and 64 were reviewed with the Administrator and Director of Nursing on
March 14, 2023, at 2:00 PM.
Residents Affected - Some
28 Pa. Code 211.9(a)(1)(k) Pharmacy services
28 Pa. Code 211.10(a) Resident care policies
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 24 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 potential for actual harm
Based on observation and staff interviews, it was determined that the facility failed to prevent the potential
spread of infection to one of five residents reviewed for infection control. (Residents 10).
Residents Affected - Few
Findings include:
Observation of Resident 10's door to her room revealed a sign indicating that she was on enhanced barrier
precautions. (EBPs, precautions used to prevent the spread of multi-drug resistant organisms). The sign
indicated to use gloves and to wear a gown with device care, and listed one example of device care as a
tracheostomy ( An opening in the front of the neck with a tube inserted directly into the airway that allows a
person to breath).
Observation of Resident 10's tracheostomy care on March 14, 2024, at 8:20 AM with Employee 2, LPN
(Licensed Practical Nurse), revealed that she performed the care without putting a gown on.
Interview with the Director of Nursing on March 14, 2024, at 2:51 PM revealed that Employee 2 should
have worn a gown to perform Resident 10's tracheostomy care.
The facility failed to prevent the potential spread of a multi-drug resistant infection to Resident 10.
483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control
Previously cited 03/03/2023
28 Pa. Code 201.18 (d) Management
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 25 of 26
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Sycamore Rehabilitation and Nursing Cent
1445 Sycamore Road
Montoursville, PA 17754
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 0909
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and
mattresses must attach safely to the bed frame.
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to
perform an assessment for possible entrapment after installation of enabler bars and/or side rails for two of
two residents reviewed (Residents 22 and 66).
Findings include:
Observation of Resident 22 on March 13, 2024, at 9:41 AM revealed that she was in bed sleeping. There
was an enabler bar on the left side of her bed.
Clinical record review for Resident 22 revealed that she requested the use of enabler(s) on November 10,
2023.
There is no documentation indicating that the facility assessed Resident 22's bed to ensure that that the
enabler bar placed on Resident 22's bed was compatible with the mattress and/or bed frame utilized and
there was no documentation that the facility completed an assessment to ensure that there was not the
potential for entrapment while utilizing an enabler bar on Resident 22's bed.
Observation of Resident 66 on March 12, 2024, at 11:14 AM revealed that there were bilateral enabler bars
on her bed.
Clinical record review for Resident 66 revealed that the facility completed an assessment for the use of
enabler bars to promote independence on October 5, 2023.
There is no documentation indicating that the facility assessed Resident 66's bed to ensure that that the
enabler bars placed on Resident 66's bed was compatible with the mattress and/or bed frame utilized and
there was no documentation that the facility completed an assessment to ensure that there was not the
potential for entrapment while utilizing enabler bars on Resident 66's bed.
The surveyor reviewed the above information during an interview with the Nursing Home Administrator on
March 14, 2024, at 1:25 PM.
28 Pa Code 211.12(d)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395379
If continuation sheet
Page 26 of 26
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
18 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F726 - Nursing Services
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
F744 - A resident who displays or is diagnosed with dementia, receives the
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F909 - Conduct Regular inspection of all bed frames, mattresses, and bed
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the March 15, 2024 survey of WECARE AT SYCAMORE REHABILITATION AND NURSING CENT?
This was a inspection survey of WECARE AT SYCAMORE REHABILITATION AND NURSING CENT on March 15, 2024. The surveyor cited 18 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WECARE AT SYCAMORE REHABILITATION AND NURSING CENT on March 15, 2024?
Yes, 18 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before tran..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.