Health inspection·April 15, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide comprehensive skin assessments that are consistent with professional standards of practice, to promptly identify changes to promote healing of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 1). Residents Affected - Few This deficiency is cited as past noncompliance Findings include: A review of the facility policy titled, Skin Integrity and Wound Management, dated October 15, 2024, revealed that, a comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin and wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revision to the plan of care as needed. Notify Medical Director, Director of Nursing, and Administrator, if deviation from protocol is requested by the physician, advanced practice provider, managed care company, or others. Review of the policy revealed a section titled, Practice Standards, that indicated the licensed nurse will evaluate any reported or suspected skin changes or wounds, perform and document skin inspection on all newly admitted and readmitted patients weekly thereafter, and with any significant change of condition; and complete a wound evaluation upon admission or readmission, new in-house acquired, weekly, and with unanticipated decline in wounds. Clinical record review for Resident 1 revealed a diagnoses list that included unspecified protein calorie malnutrition (when the body does not receive enough protein and calories to maintain a healthy status), Type 2 diabetes mellitus with chronic kidney disease (when the body does not properly use sugar that leads to high blood sugar levels that also negatively impacts the kidneys (two bodily organs that filter the blood), and generalized muscle weakness. Review of Resident 1's current care plan revealed the resident has cognitive loss as evidenced by a low BIMS (Brief Interview for Mental Status) and forgetfulness secondary to the resident's medical history. An attempted interview with the resident on April 15, 2025, at 2:55 PM revealed the resident was cognitively impaired and unable to complete the interview with the surveyor. A physician's order for Resident 1 dated February 3, 2025, instructed staff to perform a body audit (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: 395512 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 395512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunbury Skilled Nursing and Rehabilitation Center 901 Court 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)