Health inspection·August 7, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, physician order review, nursing documentation review, wound care consultation notes, diagnostic testing, and staff interview, it was determined the facility failed to ensure care and treatment was provided in accordance with professional standards of practice and physician orders for one of five sampled residents (Resident 1). Findings include: A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses to include heart failure, diabetes and morbid obesity and a recent vascular surgery to the left groin (a surgical procedure performed in the upper thigh where the leg meets the body, involving the large blood vessels that carry blood to and from the leg, done to repair or improve blood flow that may have been narrowed, blocked, or damaged). A review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident to be cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15. A score of 13-15 indicates the resident is cognitively intact, meaning able to understand and make decisions about care. The assessment documented that the resident was admitted with a surgical wound and required staff assistance with activities of daily living. A nursing admission assessment dated [DATE], documented a surgical wound in the left groin measuring 5 cm x 2 cm x 0.3 cm, with the area noted as red and irritated. No drainage was documented at that time. Physician's admission orders dated July 18, 2025, directed staff to cleanse the left groin surgical wound with normal saline (a sterile saltwater solution commonly used for wound cleansing), pat dry, apply a dry 4x4 gauze pad, and cover with an ABD dressing (a thick, absorbent wound dressing) twice daily, morning and evening. A review of the resident's July 2025 Treatment Administration Record (TAR) revealed the above physician-ordered wound treatment was not transcribed onto the TAR. Physician progress notes dated July 20, 2025, documented that the surgical wound site had a reddish discharge. Vascular surgery, who evaluated the wound during the resident's hospital stay prior to admission, had determined the wound was not infected and ordered a dry dressing. Nursing documentation dated July 19, 2025, at 11:20 a.m., revealed the left groin surgical wound measured 4 cm x 1.5 cm with a large amount of serosanguineous drainage (a mixture of blood and clear yellow fluid commonly seen in wounds). The nurses' note stated the wound treatment was completed, with a large amount of drainage noted on the old dressing. The next available nursing documentation regarding wound care was July 22, 2025, at 1:59 a.m., stating the dressing was applied with moderate serosanguineous drainage and no signs of infection. Another nurses' note dated July 24, 2025, at 1:09 p.m., indicated the dressing was changed as ordered and the resident tolerated it well. A contracted wound care nurse practitioner assessment dated [DATE], documented that the wound now measured 1.5 cm x 1.7 cm x 4 cm deep, classified as an open, full-thickness wound. The wound bed was described as containing 30% granulation tissue (healthy red tissue that promotes healing) and 60% slough (dead tissue appearing white or yellow). The wound was draining a moderate amount of seropurulent drainage (a mixture of clear and pus-like drainage, suggesting possible infection). The wound treatment plan was updated to include cleansing with normal saline, application of Santyl (an enzymatic debriding agent used to remove dead tissue), packing with iodoform gauze (a sterile medicated gauze used for deep wounds), and covering with a 4x4 gauze and ABD pad. An ultrasound study (noninvasive imaging test that shows structures inside the body using high-intensity sound waves) of the left groin completed on July 24, 2025, revealed a fluid collection measuring 5.2 cm x 2 cm x 1.5 cm, consistent with either an abscess (a localized collection of pus due to infection) or hematoma (a localized collection of blood). The physician was notified, and an order was obtained for immediate follow-up with vascular surgery. Resident 1 was sent to the vascular surgeon on July 24, 2025, and admitted to Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395554 If continuation sheet Page 2 of 3 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 395554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest City Nursing and Rehab Center 915 Delaware Street Forest City, PA 18421 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the hospital for further treatment of the surgical wound. An interview with the Director of Nursing (DON) on August 7, 2025, at approximately 11:00 a.m., confirmed that the admission physician order for the left groin wound treatment had been entered into the physician's order section of the chart but was never transcribed onto the electronic treatment administration record. The DON stated that because the order was not transcribed, it could not be verified that the physician-ordered wound treatments were completed twice daily as prescribed. 28 Pa. Code 211.12(d)(3)(5) Nursing Services Event ID: Facility ID: 395554 If continuation sheet Page 3 of 3