Health inspection·January 19, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and resident and staff interview, it was determined that the facility failed to thoroughly investigate and report an allegation of misappropriation of property to the State Survey Agency for one of one resident reviewed (Resident 16). Residents Affected - Few Findings include: Clinical record review for Resident 16 revealed a social service progress noted dated November 27, 2023, at 3:31 PM that indicated Resident 16 alleged that a couple of days before her hospitalization a tall man came to her and told her that she did not need her watch anymore and ripped it off her hand and pointed to a resident sitting down in the hallway and stated it was him. A social service progress note dated November 24, 2023, at 3:21 PM revealed that Resident 16 was missing a watch with a black face and tan strap. Her room was searched, and no watch was found. The note indicated that the hospital had no record of a watch being in her possession during her recent stay. The note also indicated that Resident 16's story changed concerning the missing item. Social Services notified Resident 16's sister of the missing watch and she said that she did not want the facility to reimburse Resident 16 for the watch stating that she had many watches at her house and would replace this one. Review of Resident 16's personal effects inventory form revealed that she did have two watches. Review of a grievance form completed by the facility dated November 23, 2023, revealed that Resident 16's room was searched, laundry was notified, and that they contacted the hospital to inquire about the missing watch. The corrective action noted that Resident 16's sister would bring her in another watch from home. Interview with the Director of Nursing and Nursing Home Administrator on January 18, 2024, at 2:20 PM revealed that the facility did not report or investigate the allegation of misappropriation of resident property because the resident kept changing her story. The facility failed to thoroughly investigate and report an allegation of misappropriation of property for Resident 16. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Page 1 of 13 395482 395482 01/19/2024 Nursing and Rehabilitation at the Mansion 1040-52 Market Street Sunbury, PA 17801

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. Based on clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice that included all the written components to the resident and/or the resident's responsible party upon transfer to the hospital for four of five residents reviewed (Residents 5, 16, 33, and 39). Findings include: Review of Resident 33's clinical record revealed that she was transferred to the hospital on December 6, 2023. The transfer notice provided by the facility to Resident 33's responsible party regarding her transfer to the hospital did not include all the required contents: State long term care appeal agency or contact and address information for the Office of the State Long-Term Care Ombudsman including email address. The notice only contained the information for the local county ombudsman office. Review of Resident 16's clinical record revealed that she was transferred to the hospital on November 12, 2023. The transfer notice provided by the facility to Resident 16's responsible party regarding her transfer to the hospital did not include all the required contents: State long term care appeal agency or contact and address information for the Office of the State Long-Term Care Ombudsman including email address. The notice only contained the information for the local county ombudsman office. Review of Resident 5's clinical record revealed that she was transferred to the hospital on October 5, 2023. The transfer notice provided by the facility to Resident 5's responsible party regarding her transfer to the hospital did not include all the required contents: State long term care appeal agency or contact and address information for the Office of the State Long-Term Care Ombudsman including email address. The notice only contained the information for the local county ombudsman office. Review of Resident 39's clinical record revealed that she was transferred to the hospital on July 27, 2023. The transfer notice provided by the facility to Resident 39's responsible party regarding her transfer to the hospital did not include all the required contents: State long term care appeal agency or contact and address information for the Office of the State Long-Term Care Ombudsman including email address. The notice only contained the information for the local county ombudsman office. Interview with Employee 8, business office manager, on January 18, 2024, at 12:46 PM confirmed the above findings for Residents 33, 16, 5, and 39. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights 395482 Page 2 of 13 395482 01/19/2024 Nursing and Rehabilitation at the Mansion 1040-52 Market Street Sunbury, PA 17801

F 0641 Ensure each resident receives an accurate assessment. 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 ensure complete and accurate Minimum Data Set (MDS) assessments for two of 16 residents reviewed (Residents 33 and 55). Residents Affected - Few Findings include: Review of Resident 33's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated November 7, 2023, and November 20, 2023, that indicated the facility assessed her as having moisture associated skin damage (MASD, inflammation and erosion of the skin caused by excessive moisture). Review of Resident 33's wound assessments dated October 27, 2023, November 3, 2023, November 10, 2023, November 17, 2023, and November 24, 2023, indicated that the wound care consulting company described Resident 33's wound as being full thickness skin loss, which would be considered a Stage III (wound that involves full thickness loss of the skin potentially extending into the subcutaneous tissue) pressure ulcer according to the MDS coding instructions. The facility did not complete Resident 33's November 7, 2023, and November 20, 2023, MDS correctly to accurately reflect the status of her pressure ulcer. Review of Resident 55's clinical record revealed that the facility admitted her on September 26, 2023. Resident 55 entered the facility with a diagnosis of end stage renal disease and was getting dialysis. Review of Resident 55's MDS dated [DATE], revealed that the facility did not accurately code the MDS to include her dialysis treatments. Documentation provided by the Director of Nursing on January 18, 2024, at 11:45 AM, and again on January 19, 2024, at 1:00 PM, confirmed the above MDS errors for Resident 33 and Resident 55. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services 395482 Page 3 of 13 395482 01/19/2024 Nursing and Rehabilitation at the Mansion 1040-52 Market Street Sunbury, PA 17801

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 resident and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to maintain the highest practicable care for four of 16 residents reviewed (Residents 2, 44, 5, and 47). Findings Include: Interview with Resident 2 on January 17, 2024, at 11:54 AM revealed that he has a broken back and that he gets severe pain at times. He said that he will ask for pain medication when this happens. He also indicated that it is not every day and usually only one or two times a week. Review of Resident 2's medication administration record (a form used to document medications given to the resident) revealed that he was provided pain medication six times in November 2023, four times in December 2023, and nine times in January 2024. Review of Resident 2's clinical record revealed that there was no current plan of care for his pain. Clinical record review for Resident 47 revealed a skin and wound note dated January 12, 2024, at 12:56 PM. The note indicated that Resident 47 had a Stage III sacral pressure ulcer (a sore that is caused by prolonged pressure and extends through the skin into the deeper tissue and fat). The treatment recommendations included to wash the area with soap and water, pat dry, apply Hydrogel (used on the wound to provide moisture and promote healing) to the base of the wound, and secure with bordered gauze daily. Preventative measures were to offload pressure and other recommendations were to use appropriate moisture barrier creams, provide thorough skin care for each incontinence episode, use approved briefs when indicated to manage moisture, assess often, minimize friction and shear, and continue with turning and repositioning schedule per protocol for pressure prevention. Review of Resident 47's care plan revealed no plan of care for his sacral ulcer. The Director of Nursing confirmed the above noted findings on January 19, 2024, at 1:35 PM for Residents 2 and 47. Clinical record review for Resident 44 revealed the facility admitted her on December 13, 2023. Review of the initial nursing evaluation completed on December 13, 2023, revealed Resident 44 had an open area to her right heel and an open area to her sacrum and bilateral buttocks. Review of Resident 44's admission MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated December 20, 2023, revealed Resident 44 triggered for pressure ulcer/injury and the facility made the decision to proceed to a care plan. Review of Resident 44's most recent Skin and Wound Note dated January 12, 2024, revealed Resident 44 continued with a pressure area to her right heel. Review of Resident 44's clinical record on January 19, 2024, revealed there was no plan of care addressing Resident 44's pressure areas. 395482 Page 4 of 13 395482 01/19/2024 Nursing and Rehabilitation at the Mansion 1040-52 Market Street Sunbury, PA 17801

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with the Director of Nursing on January 19, 2024, at 11:38 AM confirmed the facility never developed a care plan to address Resident 44's open areas. Clinical record review revealed a recent Skin and Wound Note for Resident 5 dated January 12, 2024, noting a deep tissue pressure injury to Resident 5's right heel measuring 7.5 by 4 centimeters. The treatment recommendations included to apply Betadine to the base of the wound, secure with ABD and rolled gauze, and change twice a day. The preventative measures included to offload pressure and elevate Resident 5's heels while in bed. Review of Resident 5's clinical record revealed the facility initiated a plan of care addressing potential skin breakdown on March 26, 2015, with the latest revision on May 15, 2022. Resident 5's plan of care did not address the pressure injury to Resident 5's right foot. The facility failed to develop and implement a comprehensive person-centered care plan to maintain the highest practicable care for Residents 2, 5, 44, and 47. 28 Pa. Code 211.12(1)(d) Nursing Services 395482 Page 5 of 13 395482 01/19/2024 Nursing and Rehabilitation at the Mansion 1040-52 Market Street Sunbury, PA 17801

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to implement interventions and provide adequate supervision to prevent a fall for one of three residents reviewed for falls that resulted in harm (Resident 5). This deficiency is cited as past non-compliance. Findings include: Clinical record review revealed the facility admitted Resident 5 on March 26, 2015. Review of Resident 5's plan of care initiated on March 26, 2015, indicated that Resident 5 is at risk for falls related to her diagnosis of Alzheimer's dementia, history of falls, syncope, and noncompliance with assistance with transfers. Nursing documentation dated October 5, 2023, at 2:45 PM revealed the Director of Nursing was called to the front porch by staff asking for nursing assistance. Documentation revealed that upon reaching the porch the Director of Nursing was notified that Resident 5 had wheeled herself off the porch and down the steps. Resident 5 was noted to be lying on the ground on her left side with blood from the left side of her head. Nursing documentation noted Resident 5 complained of head and right arm pain. Documentation further revealed that 911 was called and EMS staff reported that Resident 5 would be transferred to the emergency room under a trauma alert. Further review of Resident 5's clinical record revealed she was admitted and remained in the hospital from [DATE] to 9, 2023. Review of the hospital discharge summary from October 9, 2023, revealed Resident 5 was admitted with a large forehead laceration with exposed bone, as well as a large hematoma of the left upper extremity extending from the elbow to the hand, along with swelling and a hematoma to the right knee. The summary indicated that sutures were used to close the head laceration and she was diagnosed with a fracture of her left ring finger. Nursing documentation dated October 11, 2023, at 11:48 AM revealed the physician's assistant was made aware of Resident 5's increased right leg pain and the facility requested an x-ray, as only her knee was x-rayed at the hospital. Nursing documentation dated October 12, 2023, at 10:05 AM revealed the physician's assistant and physician reviewed Resident 5's x-ray and noted she needed to be evaluated at the emergency room for a nondisplaced fracture of her distal right femur. Review of the facility's investigation into Resident 5's fall revealed that it occurred while Resident 5 was with other residents outside on a porch activity. Resident 5 was noted to be in her wheelchair approximately 25 feet away from the end of the porch. The investigation indicated Resident 5 self-propelled herself off the end of the porch. The activity aide was assisting another resident when she heard Resident 5's alarm sounding. Resident 5's wheelchair was noted to be at the top of the porch steps tipped over and the activity aide notified nursing staff that Resident 5 had fallen down the steps. The investigation revealed there were 20 residents on the porch with the activity aide. 395482 Page 6 of 13 395482 01/19/2024 Nursing and Rehabilitation at the Mansion 1040-52 Market Street Sunbury, PA 17801

F 0689 Level of Harm - Actual harm Residents Affected - Few The facility investigation did not determine if Resident 5's wheelchair brakes were engaged at the time of the incident. The activity aide was unable to state if the brakes were engaged or not. Review of the Director of Maintenance's witness statement revealed an inspection was completed on Resident 5's wheelchair and determined all the hardware on the wheelchair worked properly, stating Resident 5's wheelchair would not move forward or backward if the brakes were applied. Further review of Resident 5's clinical record revealed her most recent MDS (Minimum Data Set, an assessment at specific intervals to determine care needs) dated October 16, 2023, revealed staff assessed Resident 5 as dependent to wheel 50 feet. An interview with the Director of Nursing on January 19, 2024, at 2:40 PM revealed that Resident 5 is physically capable of self-propelling, but due to her cognition, and visual deficits, staff coded her as dependent. The facility failed to implement interventions and provide adequate supervision to prevent a fall for Resident 5. These findings were reviewed in an interview with the Director of Nursing on January 19, 2023, at 2:52 PM. The quality assurance team met and developed a safety plan regarding porch activities on October 9, 2023. The plan included the facility will keep a staff/volunteer ratio of one staff to 10 residents while outside, and if at any time more staff is needed to immediately notify staff members in the facility. A retractable gate was placed on the porch on October 9, 2023, and will be closed when residents are attending a porch activity. Education was initiated on October 6, 2023, educating staff regarding brakes being applied to residents' wheelchairs when seated in an area. The Nursing Home Administrator or designee planned to audit porch activities for three months and as needed thereafter to ensure that the safety plan does not need to be updated or revised related to safety concerns. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395482 Page 7 of 13 395482 01/19/2024 Nursing and Rehabilitation at the Mansion 1040-52 Market Street Sunbury, PA 17801

F 0692 Provide enough food/fluids to maintain a resident's health. 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 assess and implement interventions regarding weight gain for one of six residents reviewed (Resident 4). Residents Affected - Few Findings include: Review of Resident 4's clinical record revealed he had a diagnosis of congestive heart failure since his admission to the facility in 2019. Documentation indicated that nursing staff weighed him on July 6, 2023, to be 164 pounds. Nursing staff weighed him on January 10, 2023, to be 183 pounds, which would be a 11.59 percent significant weight gain in six months. Resident 4's current body weight would put him into the overweight category for body mass index. There was no documented evidence in Resident 4's clinical record to indicate that nursing staff assessed Resident 4 for edema related to his diagnosis of congestive heart failure. A nutritional risk assessment dated [DATE], and again on December 6, 2023, indicated that Resident 4's usual body weight was between 172 and 178 pounds. A dietary note dated January 8, 2024, indicated that Resident 4's current body weight is considered a planned and desirable weight gain. There was no documented evidence in Resident 4's nutritional care plan to indicate that he was on a physician guided weight gain program. Review of Resident 4's nutritional care plan revealed that he was at nutritional risk and that his goals were to not exhibit signs and/or symptoms of dehydration and to eat greater than 50 percent of his meals. There was no mention of weight gain goals or interventions as to how a desired weight gain would be obtained, how much he should gain, or how long it should take. Review of Resident 4's physician orders and progress notes revealed no physician orders regarding a weight gain program, nor progress notes to indicate he was on a physician involved weight gain program. Information provided by the Director of Nursing on January 19, 2023, at 11:36 AM could provide no additional documented evidence and confirmed the above findings for Resident 4. 483.25(g)(1) Acceptable Parameters of Nutrition Previously cited 2/10/23 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395482 Page 8 of 13 395482 01/19/2024 Nursing and Rehabilitation at the Mansion 1040-52 Market Street Sunbury, PA 17801

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 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 one of one resident reviewed (Resident 40). Residents Affected - Few Findings include: Clinical record review for Resident 40 revealed the facility admitted her on October 25, 2018, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 40's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 2, 2023, indicated that the facility assessed Resident 40 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 40'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. The findings were reviewed with the Director of Nursing on January 19, 2023, at 11:30 AM. The Director of Nursing confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Resident 40's dementia and cognitive loss. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 395482 Page 9 of 13 395482 01/19/2024 Nursing and Rehabilitation at the Mansion 1040-52 Market Street Sunbury, PA 17801

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and staff interview, it was determined that the facility failed to secure medications and biologicals on one of two nursing units (First Floor Nursing Unit). Findings include: Observation of the first-floor nursing unit on January 18, 2024, at 8:51 AM revealed the medication room door with keys inserted into the doorknob. This surveyor was able to enter the room using an easy turn of the keys and push the door open. Medications were on the counter to include prescription intravenous antibiotics, two Flonase nasal sprays (treats allergies), Ventolin inhaler (used to treat respiratory problems), Acidophilus (a probiotic) and Alka seltzer. Above the sink was an unlocked cabinet that contained multiple bottles of over-the-counter medications that including but not limited to Acetaminophen (pain reliever), Melatonin (sleep aid), Magnesium, Vitamin D, Zinc, Iron, Diphenhydramine (treats allergies) and Deep-Sea Nasal Spray (treats nasal dryness). The medication room continued to be left unattended and accessible to non-licensed staff, residents, and visitors until 9:04 AM, at which time Employee 1, licensed practical nurse, removed the keys from the door. This surveyor was able to be inside the medication room for five minutes without anyone coming in or being aware that anyone was inside. Observation on January 18, 2024, at 9:10 AM revealed an open treatment cart near the first-floor nursing station. The treatment cart contained wound care supplies to treat skin and wound issues such as Dermasyn wound dressing, hydrocortisone, ketoconazole (antifungal), and Ivermectin (anti-parasitic medication). Interview with Employee 1 on January 18, 2024, at 9:16 AM confirmed that the medication room should not have the keys in the door, and that the treatment cart should be locked when not attended too. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services 395482 Page 10 of 13 395482 01/19/2024 Nursing and Rehabilitation at the Mansion 1040-52 Market Street Sunbury, PA 17801

F 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation and staff interview, it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Residents Affected - Many Findings include: Observation on January 17, 2024, at 8:50 AM revealed that the facility's two main dumpsters in the parking lot were overfilled, and the lids were not able to close. There were at least four bags of garbage laying on the ground between the two dumpsters. Interview with Employee 2, dietary manager, on January 17, 2024, at 9:40 AM acknowledged the above observations. Subsequent interview with Employee 3, director of maintenance, on January 17, 2024, at 9:45 AM revealed that the facility does not have an alternate means of proper disposal of garbage if their dumpsters are full. 29 Pa. Code 201.18 (b)(1) Management 395482 Page 11 of 13 395482 01/19/2024 Nursing and Rehabilitation at the Mansion 1040-52 Market Street Sunbury, PA 17801

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 ensure an environment free from the potential spread of infection on one of two nursing units (First Floor and Residents 41 and 213). Residents Affected - Few Findings include: Clinical record review for Resident 41 revealed that she was on transmission-based precautions (TBP) related to a diagnosis of COVID-19. Observations of Resident 41's room on January 17, 2024, at 11:25 AM revealed a sign indicating that she was on droplet precautions (preventative steps taken by healthcare team members and staff to prevent the spread of an infection that is transmitted by coughing, sneezing, talking or close contacts with an infected person). The sign indicated that an N-95 mask (a mask that protects you from breathing in small particles in the air) is to be worn when entering the room. Observation of Employee 5 (Housekeeper) at 11:25 AM on January 17, 2024, revealed she was in Resident 41's room with a surgical mask on. Interview with Employee 6 (Housekeeping supervisor) at 11:35 AM on January 17, 2024, revealed that Employee 5 should have had an N95 mask on when she was in Resident 41's room. Observation of Employee 7, Licensed Practical Nurse (LPN) on January 18, 2024, at 8:45 AM during medication administration to Resident 213, revealed that she entered the resident's room, placed the oral medications and the topical medication on the overbed table. Employee 7 donned gloves and picked up the medication cup to administer Resident 213's oral medication to her. Resident 213 asked if the medication was extra strength Tylenol (a mild pain reliever), and Employee 7 indicated that it was not but that she would go check to see if there was an order for her to have the extra strength. Employee 7 left the room with gloves still on her hands. She went to her medication cart and used the computer to review Resident 213's orders, with the same gloves still on. Employee 7 then went back into Resident 213's room with the same unclean gloves on, administered her oral medication, repositioned her onto her left side, and applied Voltaren Gel (a gel used for arthritis pain) to her right hip. Employee 7 failed to prevent the potential spread of infection during medication administration to Resident 213. Interview with Employee 7 on January 18, 2024, at 9:35 AM confirmed the above noted findings that she failed to prevent the potential spread of infection during medication administration to Resident 213. The Director of Nursing and Nursing Home Administrator were made aware of the concerns related to infection control with Resident's 41 and 213 during a meeting on January 18, 2024, at 2:11 PM. 28 Pa. Code 201.18 (d) Management 28 Pa. Code 211.10(d) Resident care policies 395482 Page 12 of 13 395482 01/19/2024 Nursing and Rehabilitation at the Mansion 1040-52 Market Street Sunbury, PA 17801

F 0880 28 Pa. Code 211.12(d)(1) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395482 Page 13 of 13