Inspection·December 6, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and homelike environment on one of two nursing units (First Floor, Residents 1 and 2), and facility entrance/exit area. Findings include: An observation of Resident 1's room on December 6, 2023, at 11:45 AM revealed a small section of missing floor tile to the left of the residents heating/cooling unit under the window. A built-out section of lower wall to the right of the unit extending to the closet wall was completely pulled away hanging from the wall exposing the area behind it. Concurrent observation of Resident 1's bathroom revealed several blackened areas on the tile floor and under the bathroom sink, with brown and black buildup observed around the base of the toilet. An observation of Resident 2's room on December 6, 2023, at 11:55 AM revealed black buildup/debris on the flooring where the floor meets the cove base along the front of the resident's room extending to the bathroom door area. The bathroom was observed with black buildup around the toilet base, dust/debris buildup in the corner of the bathroom under the sink area, and black smudged areas on the floor to the left of the toilet. At 12:00 PM Resident 2 was observed to be taken out of his room in a wheelchair by transport staff at which time the resident stated he was leaving for an appointment. The resident was wheeled out an exit door at the end of the 100 hall, which exits to a sidewalk towards the back of the facility that extends around to the facility's parking area. A concurrent observation of the area outside the door with Employee 1, nurse aide, revealed a sign directly outside the door that stated, Please dispose of cigarette butts in provided receptacles. A tall disposal receptacle was observed on the sidewalk a few feet away. A white towel was laid on top of a railroad tie surrounding the landscaping behind it, in front of the sign, in which Employee 1 stated someone must have put it there to sit on so they would not get wet. Four cigarette butts were observed on the ground in the area and an additional one was observed sitting on the railroad tie. Employee 1 proceeded to pick up the butts and dispose of them in the receptacle. Employee 1 indicated the area was where the facility staff smoke and where residents are transferred in and out of the facility. In an interview with the Director of Nursing at 12:05 PM she indicated facility staff are allowed to smoke in the designated area, but the facility in non-smoking for residents and resident sign that (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: 395482 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 395482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing and Rehabilitation at the Mansion 1040-52 Market Street Sunbury, PA 17801 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)