Inspection·August 10, 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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure each resident the right to formulate an advance directive for three of 17 residents reviewed (Residents 1, 28, and 212). Findings Include: Review of facility policy, titled Advanced Directives Protocol, undated, revealed Upon admission during Your Path Meetings, advance directives will be discussed with resident and/or resident representative to determine if any advance directives have been chosen .Advance directives will be reviewed at minimum annually according to MDS schedule. Review of Resident 1's clinical record revealed Resident 1's most recent admission to the facility was on April 12, 2023, with diagnoses that included paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs) and Diabetes Mellitus Type 2. Further review of Resident 1's clinical record revealed no documentation of an advance directive or documentation of facility staff discussion with the Resident and/or Resident Representative regarding the right to formulate an advance directive. Review of Resident 28's clinical record revealed Resident 28 was admitted to the facility on [DATE], with diagnoses that included peripheral vascular disease (PVD- a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and heart failure. Further review of Resident 28's clinical record revealed no documentation of an advance directive or documentation of facility staff discussion with the Resident and/or Resident Representative regarding the right to formulate an advance directive. During an interview with the Nursing Home Administrator (NHA) on August 8, 2023, at 1:20 PM, he stated that advance directives are reviewed with Residents at time of admission. He stated they are also sometimes reviewed during the care plan meetings, but that isn't always consistent. In a follow-up interview with the NHA on August 9, 2023, at 2:35 PM, he confirmed that there is no documentation of an advance directive for Residents 1 or 28, and no evidence that Residents 1 or 28 and/or their Representatives were offered the right to formulate an advance directive. Review of the clinical record for Resident 212 on August 8, 2023, revealed she was admitted to the (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 8 Event ID: 395785 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 395785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health & Rehabilitation Center 102 Chandra Drive Duncannon, PA 17020 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)