Inspection·December 27, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policies and procedures, closed clinical record, and staff interview, it was determined that the facility failed to notify a medical provider of a change in a resident's condition for one out of four residents reviewed (Resident CR1). Findings include: A review of the facility policy titled, Change in a Resident's Condition or Status, revealed a policy statement that noted the facility should promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. The policy further noted the nurse will notify the resident's attending physician or physician on call when there is a significant change in the resident's physical condition, need to alter the resident's medical treatment significantly, and/or specific instructions to notify the physician of changes in the resident's condition. A review of the facility policy titled, Oxygen Therapy, revealed that a physician must order the oxygen therapy. There were no instructions in the policy related to the titration (assess oxygenation and adjust the rate based on resident response to the treatment) of oxygen therapy. A review of the facility policy for bi-level positive airway pressure (BiPAP, is a non-invasive ventilation machine that can generate two adjustable pressure levels - Inspiratory Positive Airway Pressure (IPAP) high amount of pressure, applied when the patient inhales and a low Expiratory Positive Airway Pressure (EPAP) during exhalation). The policy noted that Bi-level also known as Bi-PAP must be ordered by a physician. There were no instructions in the policy related to troubleshooting the device or what actions to take if there are problems encountered (such as a mask leak). Closed record review for Resident CR1 revealed the resident was admitted to the facility on [DATE]. The resident had a diagnosis list that included: chronic respiratory failure with hypoxia (low oxygen levels in the body), chronic respiratory failure with hypercapnia (abnormal levels of carbon dioxide in the body), chronic obstructive pulmonary disease (COPD, a lung disease caused by obstructed airflow and breathing difficulties), sleep related hypoventilation (breathing that is not sufficient during sleep that may include breathing too shallow or too slow), chronic pulmonary edema (abnormal fluid accumulation in the lungs), and heart failure (the heart has difficulty pumping blood). (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 3 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 12/27/2024 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)