Health inspection·October 19, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observations, clinical record review, and staff interview, it was determined that the facility failed to provide the necessary treatment and services consistent with professional standards of practice for the prevention of a pressure ulcer for one of five residents reviewed for pressure ulcers (Resident 3). Residents Affected - Few Findings include: Clinical record review for Resident 3 revealed that the facility admitted her on August 28, 2024, with a diagnosis of a fractured right lower leg. Review of Resident 3's admission MDS (Minimum Data Set, an assessment completed by the facility at intervals to determine care needs), dated September 1, 2024, revealed that she required extensive assistance with bed mobility, transfers, and toilet use. The MDS also indicated that she was at risk for pressure ulcer development but currently did not have any pressure ulcers. A nursing progress note dated September 23, 2024, at 11:04 AM revealed that Resident 3 had some openings on her bilateral buttocks, and she will not lay in bed to get off the areas. The note indicated that she denied pain and that she had a ROHO cushion (a cushion used to prevent pressure) on her chair and a gel cushion on her wheelchair. There was no description of the open areas, and no assessment was documented. A wound note date September 24, 2024, at 3:28 PM revealed that the wound nurse was alerted to open areas on Resident 3's bilateral buttocks. The wound nurse and the physician's assistant observed the area and noted that Resident 3 had Stage 3 pressure ulcers (a deep wound that involves full thickness tissue loss, but does not expose bone tendon or muscle) to both the left and right buttock. The note also indicated that both the areas were new open areas. The measurement of the right open area was 0.6 centimeters (cm) x 2.0 cm x 0.2 cm and the left measured 3.5 cm x 4.0 cm x 0.2 cm. The note indicated Resident 3 would be added to the list to be seen by the wound care consultant this week for an evaluation. A wound note dated September 26, 2024, at 12:37 PM revealed that the wound consultant evaluated the two new Stage 3 pressure ulcer injuries on Resident 3's left and right buttock. The measurements were unchanged. The current treatment order was to cleanse with normal saline solution, apply hydrogel, and cover with bordered gauze daily and as needed for soilage or dislodgement. Pressure relieving cushions were in place to seating areas. Review of the wound consulting progress note dated September 26, 2024, at 4:54 PM revealed that Resident 3 had a new Stage 3 pressure ulcer on her right buttock that measured 2 cm x 2.5 cm x 0.2 cm. The wound base was 100% granulation (tissue that indicates the wound is healing). The wound exudate (the fluid that is secreted from the wound) was a moderate amount of serosanguineous (drainage consisting of serum and blood) drainage. The left buttock had a new Stage 3 pressure ulcer that measured 2 cm x 4.5 cm x 0.2 cm. The wound base was 100% granulation. The wound exudate was a moderate amount of serosanguinous drainage. A wound progress note date October 9, 2024, at 7:53 AM revealed that the Stage 3 pressure ulcer injury on Resident 3's left buttock was resolved and the right buttock measured 0.3 cm x 1.0 cm x 0.2 cm and was improving. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395379 If continuation sheet Page 2 of 3 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 10/19/2024 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 - Few A wound progress note dated October 15, 2024, at 1:00 PM revealed that the Stage 3 pressure ulcer injury on Resident 3's right buttock was resolved. There was no documentation in the clinical record to indicate that Resident 3's pressure ulcers on her left and right buttock were noted by staff at a Stage 1 (the skin is red but unbroken), even though she required staff assistance with her activities of daily living. Interview with the Director of Nursing and the Nursing Home Administrator on October 19, 2024, at 3:30 PM confirmed the above noted findings that there was no evidence in Resident 3's clinical record that her pressure ulcers on her left and right buttocks were discovered by staff at a Stage 1. The facility failed to identify Resident 3's pressure ulcers on her left and right buttocks at an earlier stage resulting in Stage 3 pressure ulcers to both. 483.25(b)(1)(i)(ii) Treatment/svcs to Prevent/heal Pressure Ulcer Previously cited deficiency 3/15/2024 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing care services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395379 If continuation sheet Page 3 of 3