Inspection·July 2, 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 observations, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of 16 residents reviewed (Resident 47). Residents Affected - Few Findings include: Review of Resident 47's clinical record revealed diagnoses that included chronic kidney disease (a gradual loss of kidney function) and hyperlipidemia (high levels of fat in the blood). Review of Resident 47's clinical record revealed an active physician's order for prevalon boots on at all times every shift, with a start date of October 9, 2024. Observations of Resident 47 on June 30, 2025, at 12:15 PM and 2:16 PM, revealed the Resident was sitting in their wheelchair wearing sneakers instead of prevalon boots. Observation of Resident 47 on July 1, 2025, at 12:03 PM and 2:26 PM, revealed the Resident sitting in their wheelchair wearing sneakers instead of prevalon boots. Review of Resident 47's Medication Administration Record (MAR) for June 30, 2025, revealed that Resident 47 was marked off as having prevalon boots on during day, evening, and night shift. Review of Resident 47's MAR for July 2025, revealed the Resident was marked off as having her prevalon boots on during the day shift. Review of Resident 47's comprehensive care plan revealed a problem area for skin integrity, that the Resident is at risk for impaired skin integrity related to impaired mobility, cognitive deficits, incontinence, depression, and prescribed medications, with a problem start date of August 14, 2024, and an edited date of November 13, 2024. Further review of Resident 47's care plan revealed an approach area to wear prevalon boots at all times, with a start date of August 21, 2024, and an edited date of October 10, 2024. Review of Resident 47's clinical record revealed the Resident had a consult with a foot and ankle doctor on October 9, 2024, who gave the recommendation for the Resident to wear a prevalon boot to right foot daily at all times. Review of Resident 47's clinical record revealed a nursing progress note written on July 2, 2025, at 8:55 AM, with the following text: after reviewing prevalon boot order for the resident, 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 6 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 07/02/2025 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)