Inspection·February 23, 2024

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, the facility failed to assess and implement interventions to promote wound healing for one of three residents reviewed (Resident 3). Residents Affected - Few Findings include: Clinical record review for Resident 3 revealed he was admitted to the facility on [DATE], with an unstageable pressure ulcer (a pressure injury that is not stageable due to coverage of wound by slough or stringy material and/or eschar or dead tissue) to the right buttocks. Review of a wound consultant service note for Resident 3 dated February 16, 2024, revealed the resident had a 5.5 cm (centimeter) length x 5.5 cm width x 0 cm depth unstageable pressure ulcer of the right buttocks. The ordered treatment recommendations were to cleanse the area with Normal Saline (a non-toxic fluid like the components of body fluid that does not damage healing tissues), apply collagen with silver (a wound treatment to promote healing and prevent infection) to the base of the wound, and secure with bordered foam dressing (a padded dressing with a border) daily and as needed. Review of a physician's order dated February 17, 2024, for Resident 3 revealed the nurse was to cleanse the buttocks wound with soap and water, pat dry, apply collagen matrix dressing (another name for collagen with silver) daily, and cover one time a day. Review of the above physician order did not include use of normal saline, no use of a bordered foam dressing, and no indication that it can be changed as needed (if soiled or falls off). Interview with Employee 1, licensed practical nurse, on February 23, 2024, at 11: 10 AM revealed the above ordered dressing fell off recently and a plain dry dressing was placed over the ulcer until the dressing could be changed as the wound consultant was expected sometime this date. The time of the wound consultant's visit was not confirmed. The surveyor concurrently observed Employee 1 perform the ordered treatment for Resident 3. Employee 1 removed the resident's dry dressing, which had a scant amount of dark brown drainage that looked like blood. Employee 1 used a wash basin with liquid body soap and water and washcloths from the linen cart to cleanse and pat dry the sacral ulcer. The wound was not rinsed as the soap label indicated that rinsing was not necessary. Employee 1 applied the collagen and silver dressing and covered the ulcer with a border foam gauze dressing. During an interview with the Director of Nursing on February 23, 2024, at 11:35 AM the surveyor reviewed the findings for Resident 3 that the facility did not use the order recommended by the wound consultant who was consulted to manage wound care and washcloths for general care were used to cleanse a draining wound. (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 02/23/2024 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)