Health inspection·August 18, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **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 establish clear and consistent resident wishes regarding advance directives for three of seven residents reviewed (Residents 11, 44, and 30). Findings include: A review of Resident 11's clinical record revealed that the facility admitted him on [DATE]. A physician's order dated [DATE], indicated that he was to be a full code (all resuscitation procedures will be implemented). A review of Resident 11's POLST (Physician Orders for Life-Sustaining Treatment, a document for specific medical orders to be honored by health care workers during a medical crisis) form indicated that only section A, the section that addressed whether the resident or their responsible party are choosing CPR (cardiopulmonary resuscitation) or DNR (do not attempt resuscitation) was filled out. There was no other section of the POLST form filled out to determine if Resident 11 or his responsible party wanted to utilize additional lifesaving interventions such as intubation, antibiotics, artificial hydration, or nutrition. There was no documented evidence in Resident 11's clinical record to indicate that the facility provided him or his responsible party with information on formulating an advanced directive (written instruction, such as a living will or durable power of attorney, relating to the provision of healthcare, for a time when a resident may be incapacitated and not able to make decisions). A review of Resident 44's clinical record revealed that the facility admitted him on [DATE]. A physician's order dated [DATE], indicated that he was a DNR. There was no documented evidence in Resident 44's clinical record to indicate that the facility provided him or his responsible party with information on formulating an advanced directive. Resident 44's clinical record also did not contain a POLST form. Interview with the Director of Nursing on [DATE], at 2:00 PM confirmed the above findings for Resident 11 and Resident 44. A review of Resident 30's clinical record revealed that the facility admitted her on [DATE]. A physician's order dated [DATE], indicated that she was a DNR. A review of Resident 30's POLST form indicated that only section A was filled out. There was no other section of the POLST form filled out to determine if Resident 30 or his responsible party wanted Page 1 of 16 395512 395512 08/18/2023 Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to utilize additional lifesaving interventions such as intubation, antibiotics, or artificial hydration, or nutrition. There was no documented evidence in Resident 30's clinical record to indicate that the facility provided her or her responsible party with information on formulating an advanced directive. An interview with Employee 5 (admission director) on [DATE], at 10:19 AM confirmed these findings for Resident 30. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f) Clinical Records 395512 Page 2 of 16 395512 08/18/2023 Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801

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 and resident interview, it was determined that the facility failed to provide a clean, comfortable shower room environment, and a clean homelike environment on one of two nursing units (Second Floor 200 Nursing Unit; Residents 1, 58, and 80). Findings include: Observation of Resident 58's room on August 15, 2023, at 12:08 PM revealed debris on the floor behind the resident's bed that included a large, crumpled piece of paper. The cove base to the wall located behind the bed was coming off with the sub wall visible. The plastic handrails on the resident's toilet were cracked and damaged. Observation of Resident 80's room on August 15, 2023, at 2:32 PM revealed the wall behind the bed was marred and damaged. A concurrent interview with the resident revealed the resident was unsure how long it had been this way. Observation of Resident 1's room on August 15, 2023, at 2:34 PM revealed a damaged area of wall near the heating/air conditioning unit with a golf-ball sized hole. There were pieces of the wall falling off and accumulating on the floor. Observation of the Second Floor 200 Unit shower room on August 15, 2023, at 2:40 PM revealed the following: A gray plastic bucket in a shower stall was observed with a brownish-colored liquid and debris floating in it. Four used elastic bandages were observed discarded on top of a toilet and the railing behind the toilet. 37 folded towels divided in two stacks were positioned on top of a metal, lidded garbage container adjacent to the toilet. The towels were uncovered and not protected from any debris. The metal garbage container did not have a bag and contained various debris in the bottom that included a used shampoo bottle, used, and balled up medical gloves, various unidentified debris, and an empty bag of Bugles snacks. A broken plastic clothes hamper had a broken and taped handle and another handle that was missing. The plastic where the missing handle should be attached was broken and jagged. A shower stall contained a hand-held shower spray wand that was attached to the wall by a metal holding device. The holding device was loose and coming off the wall. A second gray plastic bucket was identified in another shower stall that was three-quarters of the way filled with a yellowish, frothy liquid that had an obvious offensive odor to it. A used plastic cup and a used elastic bandage was discarded on a railing in the shower stall. 395512 Page 3 of 16 395512 08/18/2023 Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801

F 0584 There were two flies observed in the shower room. Level of Harm - Minimal harm or potential for actual harm The above information was reviewed with the Director of Nursing on August 17, 2023, at 10:05 AM. Residents Affected - Few Subsequent observation of Resident 58's room on August 17, 2023, at 10:40 AM and 3:04 PM revealed the unidentified debris and crumpled paper were still on the floor behind the bed. There were brown splash stains on the wall behind the bed. Observation of Resident 58's room on August 17, 2023, at 3:04 PM revealed the heating / air condition unit on the wall had a significant build-up of dust and debris inside the blower vents that included dried leaves and sticks. Observation of the Second Floor 200 Unit nursing unit on August 17, 2023, at 12:21 PM revealed four out of five fluorescent light covers in the hallway had a significant accumulation of debris and possibly dead flies accumulating on the bottom of the plastic covers under the lights. One of the lights had multiple brown colored splash stains. Observation of a pink supply cart on the 200 Unit nursing unit had a small garbage container with no garbage bag. The bottom of the container contained multiple unidentified debris and what appeared to be two discarded corn chips. The additional findings were reviewed on August 18, 2023, at 9:25 AM with the Director of Nursing. 28 Pa. Code 201.18 (b) (1) (3) Management 395512 Page 4 of 16 395512 08/18/2023 Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on clinical record review, staff interview, and observation, it was determined that the facility failed to timely identify and treat a pressure ulcer for one of seven residents reviewed, which resulted in actual harm (Resident 10). Residents Affected - Few Findings include: Resident 10's clinical record revealed the resident had a diagnosis of Type 1 Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to the cells for nourishment) and a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar (dead tissue) may be present on some parts of the wound bed; often includes undermining and tunneling) Pressure Ulcer of the Sacral Region (low back) on admission to the facility on October 6, 2020. Review of a fax communication to the physician for Resident 10 dated July 30, 2023, revealed the nurse reported that the resident has a lump on his back between the shoulder blades that was approximately 6 cm (centimeter) in diameter. The top of the area was slightly firm, and the bottom was soft with a slight discoloration to the left of the area. The fax indicated that the RN (registered nurse) assessed and marked the area with a black Sharpie (marker) to monitor the size. The CRNP (clinical registered nurse practitioner) replied on July 31, 2023, to monitor-comfort measures only (comfort measures, no other intervention, or medications, which are not related to making the patient more comfortable). There was no documented evidence of the RN's assessment that corresponds with this fax. Review of an LPN progress note for Resident 10 dated July 31, 2023, at 6:42 AM revealed that the CRNP was on rounds and was aware of the resident refusing morning medications and aware of the lump on his back. Staff were to continue to monitor the area due to the resident being on comfort measures only. There was no documented evidence of the CRNP assessing Resident 10's lump on his back. Review of wound specialist reports for Resident 10 revealed that he had treatment and recommendations for the wounds on the sacrum (low back), and the right and left buttocks on August 1 and 9, 2023. The wound on the upper back was not mentioned. Clinical record review for Resident 10 revealed the next note for the upper back wound was from a wound specialist dated August 15, 2023. The wound of the left upper back was classified as pressure in etiology (cause), unstageable due to necrosis (an ulcer with full thickness tissue loss that is covered by dying tissue), the duration of greater than five days, that measured 4 cm width x 0.1 cm depth, the surface area was 16 cm, with an open ulceration area of 12 cm. The wound had light serous exudate (drainage), with 25 percent eschar and 25 percent granulation (new connective tissue) tissue. The left upper back wound was not debrided (surgical removal of dead tissue for optimal healing) by the specialist because the wound was so desiccated (dried out) that debridement could not accomplish anything meaningful until worked on by moisture donator (special moisture type dressing) for some time. The specialist ordered to cleanse the wound with saline (solution like normal body fluid), apply a hydrogel (a specialized wound healing dressing that also debrides or removes dead tissue) dressing, change daily, cover with an ABD (a large, padded dressing) pad, and gauze dressing with a border. Limit resident sitting to 60 minutes, off-load wound (no weight bearing on wound), and reposition per facility protocol. During a meeting with the Director of Nursing on August 16, 2023, at 1:45 PM the surveyor asked for 395512 Page 5 of 16 395512 08/18/2023 Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801

F 0686 Level of Harm - Actual harm Residents Affected - Few additional information on Resident 10's unstageable pressure area of the left upper back specially questioning why a lump was identified when it possibly met the definition of a DTI (DTI, deep tissue injury is an unstageable pressure area either a Stage III, full thickness tissue loss, but bone, tendon, or muscle is not exposed, or Stage IV; as a result of an injury to the underlying tissue below the skin's surface from prolonged pressure in an area of a body). The surveyor also asked for RN or CRNP/physician assessments of the left back from when the area was discovered on July 30, 2023, and any prior to August 15, 2023, when it was evaluated by the wound specialist. There was no documented evidence of a full assessment of the upper back wound that identified it as blanchable (area of redness that disappears on applied pressure) or not blanchable (area of redness that does not disappear on applied pressure, indicative in determining a pressure area). The National Pressure Advisory Panel defines unstageable pressure injuries as a purple or maroon localized area or discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, or boggy, or warmer or cooler than adjacent tissue. Review of a late entry RN progress note for Resident 10 created on August 16, 2023, at 4:08 PM for August 11, 2023, at 4:01 PM revealed that the LPN asked the RN to assess the red lump on the resident's upper back. The RN assessed it as the beginning of skin breakdown. The area was cleansed, and protective foam was applied. The RN alerted the nursing staff and informed the wound doctor. The RN will have the resident physically seen by the wound doctor and will create a new treatment plan for the area. The RN repositioned the resident to the side to alleviate pressure on the area. The resident was educated on the importance of getting repositioned. Observation of the dressing change to Resident 10's upper back was performed by Employee 9, RN, on August 17, 2023, at 11:11 AM. The resident was repositioned by two staff for the dressing change. The dressing was saturated with serosanguineous (pink and tan in color) drainage. The upper back wound was to the left of the backbone and not between the shoulder blades as described in the fax communication to the CRNP on July 30, 2023. Immediately after the dressing change, the surveyor asked Employee 9 if skin alteration records were completed as the facility did not have pressure ulcer assessments for Resident 10 prior to August 15, 2023. Concurrent interview with Employee 9, revealed that skin alteration records are used by floor staff to monitor non-pressure related wounds and she uses them to monitor pressure wounds that are followed by the wound specialist. The forms were in Employee 9's office. The surveyor was provided with skin alteration records. Review of a skin alteration record completed by an LPN for Resident 10 dated July 30, 2023, revealed that a foam pad was placed on the red lump on the upper back. This skin alteration record had three columns for documentation. The first area was on the left of the page and dated August 7, 2023, and in the center of the page was the second area, which was dated July 30, 2023, and the third area was blank. The column dated August 7, 2023, indicated the dark pink/red tissue was present by checkmark and the foam was in place, and keep monitoring per CRNP. There was no corresponding physician order or documentation on the TAR, (TAR, treatment administration record) that a foam pad was applied. Further review of skin alteration records for Resident 10 revealed that on August 11, 2023, the upper back wound measured 5 cm x 5 cm and was without drainage. The resident had pain at the site. The form indicated the RN asked the wound specialist to see the resident on the next visit. 395512 Page 6 of 16 395512 08/18/2023 Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801

F 0686 There was no documented evidence of the need for nurse aides to reposition Resident 10 off his left upper back until recommended by the wound specialist on August 15, 2023. Level of Harm - Actual harm Residents Affected - Few The facility's failure to initially assess and treat Resident 10's left upper back wound resulted in harm. The facility failed to fully assess the upper back lump on July 30, 2023, and failed to provide off-loading in which the area increased in size and worsened to an unstageable pressure ulcer on August 15, 2023. There was no documented evidence of an RN assessment (only a note by LPN that the RN assessed) until 11 days later when the RN determined the wound needed evaluation and treatment by a wound specialist. These issues were discussed with the Director of Nursing on August 17, 2023, at 1:45 PM. 483.25(b)(1)(i)(ii) Treatment/Svcs to Prevent/Heal Pressure Ulcers Previously cited 7/28/22 28. Pa. Code 211.12(d)(1)(2)(3) Nursing services 395512 Page 7 of 16 395512 08/18/2023 Sunbury Skilled Nursing and Rehabilitation Center 901 Court 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 Based on review of select facility policy and procedures, clinical record review, and resident and staff interview, it was determined that the facility failed to maintain an acceptable parameter of nutritional status for one of six residents reviewed for nutrition concerns (Resident 18). Residents Affected - Few Findings include: The policy entitled Weights and Heights, last reviewed without changes on October 28, 2022, revealed that residents are weighed upon admission, and/or readmission, then weekly for four weeks, and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary care team. The purpose of the policy is to obtain a baseline weight and identify significant weight change, determine possible causes of significant weight change, and obtain a baseline height. Interview with Resident 18 on August 15, 2023, at 11:11 AM revealed the resident reported she had lost weight. Review of Resident 18's current care plan revealed the resident is at risk for changes in nutritional status related to a history of malnutrition, Crohn's disease (inflammatory bowel disease), multiple food intolerances, and weight fluctuations. Clinical record review for Resident 18 revealed assessments of her weights as follows: February 2, 2023, 120.4 pounds March 1, 2023, 120.4 pounds April 1, 2023, 120.4 pounds May 2, 2023, 121.6 pounds June 3, 2023, 121.6 pounds July 2, 2023, 121.6 pounds July 30, 2023, 108.0 pounds August 1, 2023, 107.6 pounds Resident 18 experienced a 12.8 pound, 10.6 percent significant weight loss, in 6 months, and a 14 pound, 11.5 percent severe weight loss in one month. There was no evidence Resident 18's weight loss was addressed by the registered dietitian or physician as of August 18, 2023, nor any evidence Resident 18's physician or registered dietitian was made aware of Resident 18's severe weight loss until notified by the surveyor. An interview with the Director of Nursing on August 18, 2023, at 1:41 PM revealed that Resident 18 was weighed on July 30, 2023, and again on August 1, 2023, to ensure accuracy of the weights. However, the Director of Nursing was unaware if the physician or dietitian were notified or aware of the 395512 Page 8 of 16 395512 08/18/2023 Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801

F 0692 weight loss and would have to check. Level of Harm - Minimal harm or potential for actual harm An interview with the Director of Nursing on August 18, 2023, at 1:48 PM revealed that staff did not notify the physician or dietitian of the weight loss because the weight loss does not trigger in Point Click Care (the facility's electronic health record) so notifications were not made. Residents Affected - Few 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395512 Page 9 of 16 395512 08/18/2023 Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interview, the facility failed to ensure each resident is provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of two residents reviewed (Resident 88). Findings include: Clinical record review for Resident 88 revealed the resident was admitted to the facility on [DATE], and has a diagnosis of Down Syndrome (a genetic condition that affects the way the brain and body develop, leading to developmental delays (delays in motor function, speech, language, thinking, and social skills), ID (ID, intellectual disability, below average intelligence and set of life skills before the age of 18), and an increased risk for certain medical issues). During a meeting with the Director of Nursing on August 16, 2023, at 1:45 PM the surveyor requested to see the determination letter (letter determining if specialized services such as training, treatments, therapies, and related services to help people with an intellectual disability function as independently as possible) and what specialized services were offered to the resident. The determination letter was not in the electronic medical record or hard copy of the medical record. During an interview with Employee 7, social service director, on August 17, 2023, at 9:42 AM she informed the surveyor that she is new to the facility and found the determination letter in the social service office. Concurrent review of the determination letter dated June 15, 2022, from the Department of Human Services revealed that Resident 88 was determined eligible for the level of services provided by a nursing facility, the Department has determined that the resident may be admitted to a nursing facility, and that the resident requires ID/MR (intellectual disability/mental retardation) specialized services. If specialized services are required, they will be determined through further assessment by the County ID office. A representative from the County ID program would be contacting the resident to explain this determination and other services they may be eligible to receive. If they had questions about this, please contact our office. Review of a care plan for Resident 88 revealed that she is a target (a resident who is eligible to receive specialized services) related to ID initiated August 24, 2021. The only intervention indicated that social services was to assess the resident for psycho-social well-being. There was no evidence of specialized services in the care plan. Concurrent interview with Employee 7 revealed there was no documentation in Resident 88's medical record of specialized services, and if specialized services were accepted by the resident or declined by the resident. A nursing progress note for Resident 88 dated June 11, 2023, at 1:45 revealed the nurse was called to the resident's room. The resident was soiled, soaked, and refusing care. After the nurse left the room to allow the resident tine to think about getting washed and changed, Resident 88 waved a fellow resident into her room asking for the garbage bag from her garbage can. The fellow resident handed it to Resident 88 as the resident thought she was sick. Resident 88 took the plastic bag and put 395512 Page 10 of 16 395512 08/18/2023 Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it over her head. The fellow resident yelled for staff help. A nurse aide quickly entered Resident 88's room and Resident 88 took down the bag from her head. Resident 88 was assisted out of bed with three staff while swinging and kicking a staff. Care was provided and Resident 88 was placed on 1:1 observation until the ambulance arrived to transport her to the hospital for evaluation. A nursing progress note for Resident 88 dated June 11, 2023, at 10:37 PM revealed the resident returned from the hospital and was treated for a urinary tract infection and antibiotics were started. Clinical record review for Resident 88 revealed that she was seen by psychiatric services on May 28, 2023, June 5, 13, 19, 2023, and July 3 and 31, 2023, for depression, anxiety, and medication management of antidepressants and antianxiety medications. Recommendations for 1:1 observation, every 15-minute observations, and hourly observations were made by psychiatric services and followed by the facility staff. Clinical record review for Resident 88 revealed a significant weight loss of 8.34 pounds in one month. The weight record for Resident 88 revealed she weighed 248.1 pounds on July 11, 2023, and weighed 227.4 pounds on August 14, 2023. Clinical record review for Resident 88 revealed that she was hospitalized from [DATE] to 27, 2023, for hyponatremia (low sodium levels). During hospitalization, the resident refused all oral intake and a PEG tube (PEG, a percutaneous endoscopic gastrostomy, a surgical placement of tube into the stomach from the abdominal wall for feeding). There was no documented evidence that the facility had communication from the County ID office regarding the specialized services for Resident 88 and there was no documented evidence that the facility contacted the County ID office for this assessment or made contact when the resident had a decline in mood and behavior to provide the specialized ID services the resident required to maintain the highest practicable physical, mental, and psychosocial well-being. During an interview with the Director of Nursing on August 18, 2023, at 12:45 PM the surveyor reviewed the findings for Resident 88. 28 Pa. Code 211.12(d)(1)(2)(3) Nursing services 395512 Page 11 of 16 395512 08/18/2023 Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a safe and sanitary condition in the facility's main kitchen. Findings included: Initial tour of the facility's main kitchen on August 15, 2023, between 9:09 AM and 9:50 AM with Employee 4, Dietary Manager, revealed the following: A package of yellow cake mix, fudge brownie mix, tortilla shells, and a bag of toasted oats located in the dry goods storage area were all open with no open date noted on the packages. A clear plastic storage container with a lid on it had several items that included straws and various snack food items (cookies and oatmeal creme pies). Multiple snacks and straws in the container were wet to the touch with no obvious origin of the moisture. A bag of lettuce and a package of American cheese located in a refrigerator were open with no open date noted on the packages. The lid on a large garbage can was broken and cracked. There were dead flies and a significant accumulation of dust build up on the windowsill adjacent to the milk storage cooler. There was dust and a white powdery substance on top of the microwave. Hand towels were stored in a black bin that was sticky and covered in dust. There were cobwebs hanging from the ceiling adjacent to the stove. There was an accumulation of dust on the ice machine. Observed ceiling vents had a significant accumulation of dust build up on the grates and surrounding ceiling tiles. A sprinkler head above the mixer had a significant accumulation of dust. Two dish dollies holding clean dishes had an accumulation of dust and debris on the base area that held the clean dishes. A stainless steel rack in the dishwasher area that held various food storage items had a significant accumulation of dust on it especially near the top of the rack. The bottom shelf that held multiple plastic food trays and other items had no protective barrier to prevent contamination from floor debris or mop water and chemicals used for floor cleaning from contaminating the items beings stored on the bottom shelf. A large, suspended grate above the dishwasher had a significant accumulation of dust. 395512 Page 12 of 16 395512 08/18/2023 Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801

F 0812 Level of Harm - Minimal harm or potential for actual harm The windowsill adjacent to the dishwasher next to where the clean dishes exit the dishwasher had dead bugs and a significant accumulation of dust on it. There was an accumulation of dirt and food debris under the steam table especially near the receptacle where it was plugged in. Residents Affected - Many Observation of a delivery person on August 15, 2023, at 9:43 AM revealed the person entered the main kitchen at least twice to deliver various boxed food items. The delivery person had hair and a full beard. The delivery person did not don a hairnet or beard cover. Upon questioning Employee 4 whether a hairnet and beard cover were required for visitors, she verbalized that she would have to check. There were multiple large cobwebs hanging off the ceiling area of the dock above the outside entrance to the kitchen. The above information was reviewed with the Director of Nursing on August 17, 2023, at 10:10 AM. Observation of the resident tray deliveries on the 200 nursing unit on August 17, 2023, at 12:16 PM revealed a food cart that had a significant accumulation of dirt, debris, and stains on the base / bumper area at the bottom perimeter of the cart. A portion of the rubber bumper was coming off the cart. Four of four resident food tray carts observed had various stains, debris, and dust on the tops of each cart. The above information regarding the food carts was reviewed with the Director of Nursing on August 18, 2023, at 9:45 AM. 483.60 Food Procure, Store/Prepare/Serve - Sanitary Previously cited 07/28/2022 28 Pa. Code 201.14(a) Responsibility of licensee 395512 Page 13 of 16 395512 08/18/2023 Sunbury Skilled Nursing and Rehabilitation Center 901 Court 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, review of select facility policies, and staff interviews, it was determined that the facility failed to provide an environment free from the potential spread of infection regarding the administration of eye drops for one of two residents observed for eye drop administration (Resident 75) and the facility failed to develop and implement an effective Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia). Residents Affected - Some Findings include: A review of the facility policy entitled Medication Administration: Eye (Drops and Ointments), last reviewed on October 28, 2022, revealed that prior to the administration of eye drops or ointment, the nurse is to perform hand hygiene and put on gloves. Observation of Employee 1, LPN, (licensed practical nurse), on August 17, 2023, at 8:57 AM revealed that the LPN administered Polyethylene Glycol-Propylene Glycol (lubricating eye drops) to the resident's eyes. Employee 1 cleansed her hands with alcohol-based hand sanitizer before and after the administration of the eye drops. Employee 1 did not wear gloves. A concurrent interview with Employee 1 revealed that she never wears gloves when administering eye drops. During an interview with the Director of Nursing on August 18, 2023, at 11:49 AM the surveyor revealed the findings for Resident 75. (CMS) memo Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated July 6, 2018, revealed, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. This policy memorandum applies to Long-Term Care (LTC). However, this policy memorandum is also intended to provide general awareness for all healthcare organizations. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. Develops and implements a water management program that considers the ASHRAE (American Society of Heating, Refrigerating, and Air Conditioning Engineers) industry standard and the CDC toolkit. Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions taken when control limits are not maintained. Maintains compliance with other applicable Federal, State, and local requirements. A review of the facility's water management program plan provided by the facility, dated February 14, 2019, revealed the facility will implement a water management program that includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. The facility will specify testing protocols and 395512 Page 14 of 16 395512 08/18/2023 Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. Ongoing monitoring and documentation of control measures will be accomplished by the facility maintenance director and others designated by the water management team. The results of the monitoring will be documented on logs. The water management team is responsible for scheduling, planning, conducting, and evaluating results of program validation activities including review of control monitoring data, water sampling, and testing. Water samples will be collected from the hot and cold water systems twice per year to assess the effectiveness of water system maintenance. Inspection of the building water systems will be conducted by the Maintenance Director or other designee of the water management team in accordance with control points and control limits. Plumbing fixtures in unused or unoccupied portions of the facility will be flushed twice per week by the maintenance director, or other designee of the water management team. An interview with Employee 8 (maintenance director) on August 18, 2023, at 10:50 AM revealed that he has been employed by the facility for approximately three months and has not completed any monitoring of the facility's water system for Legionella. A review of the facility's water management program binder revealed documentation that the facility's last water sample testing for Legionella was on September 22, 2022. A review of the facilities control measure log revealed the water fixtures were last flushed on December 30, 2022. The facility was unable to provide any further documentation that it implemented an effective Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella. 483.80(a)(1)(2)(4)(e)(f) Infection Control & Prevention Previously cited 7/28/22 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3) Nursing services 395512 Page 15 of 16 395512 08/18/2023 Sunbury Skilled Nursing and Rehabilitation Center 901 Court Street Sunbury, PA 17801

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 ensure residents received pneumococcal immunizations for one of five residents reviewed for immunization concerns (Resident 98). Residents Affected - Few Findings include: Clinical record review for Resident 98 revealed the facility admitted her on June 22, 2023. There was no documentation that the facility attempted to obtain an informed consent or administer the pneumococcal immunization. During an interview with Employee 2 (infection preventionalist) on August 18, 2023, at 10:53 AM it was confirmed that there was no documented evidence that Resident 98 was evaluated for or offered the pneumococcal immunization. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services 395512 Page 16 of 16