Health inspection·May 13, 2025

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding neurological assessments for one of five residents reviewed. Residents Affected - Few Findings include: The current facility policy entitled Neurological Assessment, revealed neurological assessments are indicated following an unwitnessed fall. When assessing neurological status, always include frequent vital signs, particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures) as this may be indicative of increasing intracranial pressure. Any change in vital signs or neurological status in a previously stable resident should be reported to the physician immediately. Closed clinical record review for Resident CR1 revealed nursing documentation dated [DATE], at 10:32 PM noting Resident CR1 was found in her bathroom, face down on the floor. The registered nurse assessed Resident CR1 before moving her, noting a 4 centimeter (cm) by 3.5 cm laceration to Resident CR1's right elbow and a 0.75 by 0.25 cm laceration to her left elbow. The registered nurse assessed Resident CR1's neurological status and cleaned her lacerations with wound cleanser while applying pressure to stop the bleeding. The registered nurse called the physician on call. The on call physician ordered the nurse to hold Resident CR1's morning dose of Eliquis (medication used as a blood thinner), talk with Resident CR1's physician in the morning, and if there are any changes in Resident CR1's neurological status to send her to the emergency room. Review of the facility's investigation dated [DATE], at 9:30 PM revealed Employee 2's (nurse aide) witness statement indicated that she provided care to Resident CR1 at 9:00 PM while Resident CR1 was in bed. Employee 2's statement noted that another resident came to the nurse's station and stated Resident CR1 was on the floor in her bathroom. Nursing documentation dated [DATE], at 6:38 AM revealed Resident CR1 was found deceased at 6:34 AM and pronounced at this time. Resident CR1's death certificate indicated the main cause of death was chronic diastolic heart failure (decreased blood flow caused by high blood pressure). Review of Resident CR1's Neurological Assessment Form revealed that nursing staff completed her neurological assessments at 9:30 PM, 10:00 PM, 10:30 PM, and 11:00 PM. There were no other assessments of Resident CR1's neurological status documented. The facility failed to document neurological assessments at 12 AM, 1 AM, 3 AM, and 5 AM. (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 2 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 05/13/2025 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)