Health inspection·May 8, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding pressure injury risk for one of four residents reviewed (Resident CR1). Findings Include: Review of Resident CR1's closed clinical record revealed a Minimum Data Set Assessment (MDS, an assessment done at specific intervals to determine care needs) dated March 7, 2024, revealed that the facility assessed Resident CR1 as being at risk of developing pressure ulcers and/or injury and indicated that a care plan regarding this risk would be developed. Review of Resident CR1's plan of care revealed that the facility did not develop a plan of care to address his risk of pressure ulcer and/or injury until April 3, 2024, two days after his discharge from the facility. The above findings were reviewed and acknowledged during a phone interview with the Administrator and Director of Nursing on May 8, 2024, at 1:30 PM. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Page 1 of 3 395678 395678 05/08/2024 Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701

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. 395678 Page 2 of 3 395678 05/08/2024 Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701

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 395678 Page 3 of 3