Health inspection·May 8, 2024

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 closed clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding surgical incision assessments and treatments for one of 4 residents reviewed (Resident CR1). Residents Affected - Few Findings include: The policy entitled Wound Treatment Guidelines, provided as the policy in effect for the facility as of March 1, 2024, indicated that the facility will report any changes to the surgeon such as drainage, pain, redness, or warmth. The policy did not indicate how often the facility will assess a surgical incision for signs and symptoms of infection. Review of Resident CR1's closed clinical record revealed that the facility admitted him on March 1. 2024. An admission nursing assessment dated [DATE], indicated that Resident CR1 was admitted with a thoracic (an area on the spine below the neck to below the shoulder blades) incision with 25 staples with black crusted drainage present. A nursing note dated March 1, 2024, at 2:45 PM indicated that Resident CR1's thoracic incision had redness and warmth to the surrounding skin. There was no documented evidence to indicate that the facility notified Resident CR1's surgeon regarding the redness and warmth to his thoracic incision. Review of Resident CR1's discharge summary from the hospital dated March 1, 2024, indicated that the facility was to transport him to a follow up visit with his neurosurgeon on March 8, 2024, for staple removal. Review of a handwritten note from Resident CR1's neurosurgeon's follow up visit revealed that the facility is to KEEP HIM OFF HIS INCISION!!! There was also an order for the facility to start using Allevyn foam (a protective barrier for skin alterations) every three days on Resident CR1's thoracic incision for protection. There was no documented evidence that the facility initiated a change to his turning and repositioning schedule to keep Resident CR1 off his incision, nor documented evidence to indicate that any protective barrier was being used on Resident CR1's thoracic incision after his visit with neurosurgery on March 8, 2024. A Weekly Skin Assessment dated March 10, 2024, indicated that Resident CR1 had two surgical incisions and that they are well approximated. There was no documented evidence to indicate that Resident CR1's thoracic incision was assessed for signs and symptoms of infection or pressure related injury. A Weekly Skin Assessment dated March 17, 2024, indicated that Resident CR1 did not have any impaired skin integrity and there was no mention of his incisions. There was no documented evidence to indicate that Resident CR1's thoracic incision was assessed for signs and symptoms of infection or pressure relate injury. Nursing documentation dated March 18, 2024, at 9:45 AM revealed that Resident CR1's thoracic incision was open with a large amount of brown drainage. A neurosurgery consult progress note dated March 18, 2024, at 2:45 PM indicated that Resident CR1's thoracic incision dehisced (when the incision opens) due to ongoing pressure and that Resident CR1 will now require a wound vac system (a would treatment that creates negative pressure for wound healing). The facility failed to appropriately assess and implement physician recommended treatment orders for Resident CR1's incision. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 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 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 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 During a phone interview on May 8, 2024, at 1:30 PM the above findings were reviewed with the Administrator and Director of Nursing. Level of Harm - Minimal harm or potential for actual harm 483.25 Quality of Care Residents Affected - Few Previously cited 2/2/24 28 Pa. Code 211.10 (a)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 3 of 3