**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's policy, clinical records, and staff interviews, it was determined the facility failed to timely and comprehensively assess a pressure ulcer wound resulting in actual harm to one resident (Resident 2) and failed to follow physician's wound treatment orders for three of the 11 residents reviewed (Residents 2, 62, and 225). Findings include: Review of the facility's policy titled Skin Integrity, dated April 1, 2022, revealed documentation and care interventions for skin integrity including assessment/observation to be completed within the first twenty-four hours of admission/quarterly/significant change in condition using admission Nursing Evaluation. Review of Resident 2's diagnosis list revealed diagnoses including Quadriplegia (paralysis of all four extremities), Epilepsy (seizures), protein calorie malnutrition, Bipolar Disorder (psychiatric disorder) and Major Depressive Disorder (mental disorder characterized by persistent and debilitating feelings of sadness, loss of interest in activities, and other symptoms that interfere with daily life). Review of Resident 2's care plan revealed Resident 2 had a goal of Activities of Daily Living (basic, routine tasks necessary for personal care and independence) performance deficit related to functional decline and Quadriplegia. Interventions included requiring assistance of two staff persons for repositioning and turning in bed. Further review of the care plan revealed Resident 2 was totally dependent on staff for toilet use, with an intervention to check and change every two hours. Further review of the care plan revealed potential for impairment to skin integrity related to fragile skin, immobility, and incontinence. Interventions included monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to MD (physician). Review of Resident 2's weekly skin check assessment dated [DATE], revealed no new skin issues. Review of Resident 2's weekly skin check assessment dated [DATE], revealed no new skin issues. Review of Resident 2's weekly skin check assessment dated [DATE], revealed no new skin issues. Review of Resident 2's progress notes dated February 17, 2025, revealed during care, this nurse was notified that the resident had a skin tear (type of traumatic wound caused by mechanical forces like friction, blunt force trauma, or falls, resulting in the separation of skin layers) on sacrum (large, triangular bone at the base of the spine) and an abrasion (superficial rub or wearing off of the skin, usually caused by a scrape or a brush burn) right posterior (back) thigh. Review of Resident 2's second skin check assessment dated [DATE], revealed Stage 3 (serious wound that penetrates through the skin layers into the subcutaneous tissue, revealing the underlying fat) sacral/buttocks 5.0 x 10 x 2 cm (centimeters) moderate serosanguinous (type of wound drainage that contains both serous fluid [the clear, thin liquid part of blood] and blood cells) drainage, 40% slough (dead tissue that separates from the living tissue), 60% granulation tissue (fleshy, pink or red, moist tissue that forms on the surface of a wound as it heals) appears as a blister that popped. Review of Resident 2's clinical record failed to reveal documented evidence that Resident 2 had a blister on the sacrum. Interview with Licensed Employee E3 on May 29, 2025, at 11:00 a.m. revealed Resident 2 appeared to have had a blister on sacrum, however, no clinical documentation was provided to support a blister was present. This interview further revealed, Resident 2 experienced a delay in treatment by the wound consultant until March 6, 2025 as a result of the resident being out of bed or unavailable when the wound consultant was available. Interview with Director of Nursing on May 30, 2025, at 10:00 a.m. revealed Resident 2 had a history of a prior sacral wound and that a blister was present on the sacrum. No clinical documentation was provided to support either a prior sacral wound history or the presence of a blister on the sacrum. Review of Resident 2's initial wound consultation dated March 6, 2025, revealed Resident 2 had a significant past medical history of quadriplegia, mild protein-calorie malnutrition. Further review of same consultation revealed patient presents for initial evaluation of a new Stage 3 pressure ulcer of sacrum. Area has 20% slough (dead tissue within a wound, often appearing as a yellow, tan, or white fibrous material). Further review of the same wound consultation revealed Sacral wound is a Stage 3 pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 3.5 cm length x 8 cm width x 0.1 cm depth with an area of 28 square centimeters. Assessment of exposed structures limited to the breakdown of skin. No tunneling (type of wound that extends deeper into the tissue than its surface, creating a narrow channel or tunnel-like passageway) has been noted. No sinus tract (type of wound characterized by a narrow channel or passageway that extends from the surface of the skin into deeper tissues) has been noted. No undermining (wound where the edges are not attached to the underlying tissue, creating a pocket or shelf beneath the skin at the wound's edge) has been noted. There is a light amount of sero-sanguineous drainage noted which has no odor. Wound bed has 80% granulation, 20% slough; no eschar (dead tissue) and no epithelialization (process of the epidermis regenerating over a wound surface, essentially covering the wound with new skin tissue) present. Interview with Director of Nursing on May 30, 2025, at 12:00 p.m. confirmed no clinical documentation was available to support that Resident 2 had a blister on the sacrum prior to the discovery of the Stage III pressure ulcer and that no treatments were in place to treat a blister. This interview also confirmed Resident 2's pressure ulcer was discovered at the level of Stage III. The facility failed to timely identify a pressure ulcer prior to the progression to a Stage III causing actual harm to Resident 2. Clinical records review revealed Resident 62 was admitted to the facility on [DATE], with a diagnosis of Acute Respiratory Failure (life-threatening condition where the lungs are unable to adequately exchange gases [oxygen and carbon dioxide] in the blood, leading to insufficient oxygen delivery to the body and potentially harmful levels of carbon dioxide). Review of Resident 62's admission skin assessment failed to reveal a skin impairment to the sacrum and or the buttock area. Review of Resident 62's skin care plan developed on May 2, 2025, revealed: [Resident] has potential for impairment to skin integrity r/t (related to) muscle weakness. Stage 3 (Full thickness skin loss) left buttock. Review of Resident 62's physician's orders dated May 2, 2025, revealed an order to cleanse the wound with normal saline solution, pat dry, and cover with silicone border gauze every day shift every Tuesday, Thursday, and Saturday. Review of Resident 62's nursing skin/wound note dated May 8, 2025, at 11:29 a.m., revealed Skin assessment of buttocks. The resident states he/she had the wound for a long time. Stage 3 left buttock. 0.3 x 0.2 x 0.1 cm. Small serosanguinous (type of wound drainage that is a combination of blood and serum). 20% slough (non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture). 80% granulation. Clinical record review revealed Resident 62's Stage 3 left buttock/sacral pressure ulcer was not comprehensively assessed (size, condition) until May 8, 2025, six days after it was identified upon admission on [DATE]. Interview with the Director of Nursing conducted on May 30, 2025, at 10:00 a.m., confirmed Resident 62's identified on admission pressure ulcer was not comprehensively assessed until May 8, 2025. Clinical records review revealed Resident 225 was admitted to the facility on [DATE], with a Stage 4 (full-thickness skin and tissue loss) pressure ulcer to the sacrum (triangular bone just below the lumbar vertebrae) measuring 8.5 x 10 x 0.2 cm. with heavy serosanguinous drainage with 50% slough and 50% granulation. A wound treatment was ordered. Review of Resident 225's wound physician's consult report dated March 27, 2025, revealed a Stage 4 sacral wound, measuring 7.0 x 10 x 0.2 cm. with 40% slough. A wound care order to cleanse with wound cleanser, apply Hydrogel (water-rich dressing that maintains a moist wound environment, promoting healing and potentially reducing pain), and cover with bordered gauze (bandage with adhesive tape that holds the dressing in place) daily. Review of Resident 225's Treatment Administration Record (TAR) revealed the wound physician's treatment order for the sacrum initiated March 27, 2025 was not implemented until March 31, 2025, four days after it was ordered. Interview with licensed nurse Employee E3 was conducted on May 29, 2025, at 1:00 p.m. Employee E3 reported that she/he does weekly rounds with the wound physician. Employee E3 reported, after the wound report was reviewed by the Interdisciplinary Team, she/he was responsible for entering it as an order on the resident's electronic medical records. Employee E3 reported the order was not implemented because it was not placed as an order until March 31, 2025, because he/she just did not get to it. The above information was conveyed to the Director of Nursing on May 30, 2025, at 10:00 a.m. 28 Pa. 211.10(c) Resident care policies Previously cited 6/7/24 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 6/7/24

Based on a review of the facility's policy, clinical records, facility documentation, observation, and staff interviews, it was determined that the facility failed to comprehensively assess, monitor, provide additional interventions, and timely follow a physician's order for a wound consult of an identified skin impairment to the left heel resulting into the harm of a declined unstageable pressure ulcer (obscured full-thickness skin and tissue loss) to the left heel for one of two residents reviewed (Resident 1). Findings include: Review of the facility's policy titled Skin Integrity, dated April 1, 2022, revealed that the facility develops a routine to review residents with wounds or at-risk weekly. The DON (Director of Nursing) or designee will be responsible to implement and monitor the skin integrity program. Wound status is monitored weekly. Further review of the same policy revealed, if there is a decline in skin integrity, pressure redistribution surfaces will be reviewed, and interventions/plans of care will be updated as appropriate. The same policy revealed that the assessment/observations are to be completed within the first 24 hours of admission/quarterly/significant change of condition using the admission Nursing evaluation/Braden Scale. Review of Resident 1's diagnosis list revealed Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side (paralysis of one side of the body following a stroke), and weakness. Review of Resident 1's admission Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated December 18, 2022, revealed the resident required extensive two-person assistance with bed mobility. The resident had an indwelling catheter (flexible tube that is used to drain urine from your bladder into a bag outside your body) and was always incontinent of bowel. The same MDS assessment revealed the resident's skin was intact but was at risk for developing a pressure ulcer/injury. Review of the Braden Scale (tool used to identify patients at risk for developing a pressure ulcer) dated December 14, 2022, revealed Resident 1 was moderately at risk for developing a pressure ulcer. Review of Resident 1's potential for impairment to skin integrity care plan developed on December 13, 2022, revealed the following interventions: Avoid scratching and keep hands and body parts from excessive moisture; Encourage good nutrition and hydration; Identify/document potential causative factors and resolve where possible; Monitor/document location, size and treatment of skin injury; Use caution during transfer and bed mobility; Incontinence care and preventative skin care; Keep skin dry and clean; Monitor labs; Pressure reduction mattress; Treatment as ordered, and Use draw sheet or lifting device to move the resident. Review of the nursing progress notes dated February 23, 2023, at 7:39 a.m., revealed: Left heel pressure ulcer/, boggy heel. The supervisor was made aware and will place a consult for foot care, with a bilateral heel protector in place, complained of pain/discomfort, and was placed on the 24-hour report to continue to monitor. Review of Resident R1's clinical record revealed a wound care consult for the left heel was ordered by the physician on February 23, 2023. Review of Resident R1's clinical record failed to reveal a comprehensive skin assessment completed for the skin impairment identified on the left heel. Nursing assessment failed to reveal size, appearance, color, and stage (if applicable) of the left heel pressure ulcer. Clinical records revealed the intervention documented in the progress note of February 23, 2023, a bilateral heel protector, was not applied. The facility was unable to provide documented evidence that the heel protector was placed on resident's heel after the wound was identified. Clinical records review also revealed that Resident 1's skin care plan was not updated with the interventions. Clinical records review revealed that the wound care consult ordered on February 23, 2023, was not done until March 20, 2023, which was 25 days after the consult was ordered by the physician. Clinical records review failed to reveal the identified left heel skin impairment was monitored or checked weekly. Review of the physician's order dated March 16, 2023, revealed an order for a Santyl (topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin) to the left heel then cover with bordered gauze. Review of the care plan developed on March 16, 2023, revealed Resident has an unstageable pressure ulcer to the left heel due to immobility. Clinical records review failed to reveal an assessment of the identified unstageable pressure ulcer to the left heel. Observation of the wound was conducted on March 20, 2023, at 11:00 a.m., with licensed nurse Employee E3. Resident 1 was laying in bed, with both heels touching the pillow placed under the legs. Employee E3 reported that the wound doctor saw the resident earlier that morning (unable to indicate exact time). Observation revealed left heel wound did not have a dressing, the wound was covered with 100% black necrotic eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound). Employee E3 reported the wound was unstageable and measured 2.2 x 2.0 cm (centimeter) in size. Interview was conducted with the Director of Nursing, and the Regional Clinical Director Employee E4 on March 20, 2023, at 11:52 a.m. The Director of Nursing indicated any identified skin impairment should be assessed and documented with the following: measurement, stage, color, area, and drainage. The Director of Nursing stated, she/he identified Resident 1's left heel unstageable ulcer when she/he provided a shower/bath to the resident on March 16, 2023. Review of the facility's documentation, Resident Concern Report dated March 16, 2023, revealed a family's concern regarding the resident's hygiene and skin integrity. Findings and disposition revealed: Shower was provided to the resident, left heel wound was identified. Treatment placed with heel protection. Air mattress applied, wedge protection to the left side. Interview conducted with the Director of Nursing and Employee E4 on March 20, 2023, at 1:00 p.m. confirmed the left heel skin impairment initially identified on February 23, 2023, as pressure ulcer/, boggy heel was not comprehensively assessed, interventions were not implemented, order for a wound care consult was not completed until March 20, 2023, and failed to provide reason for the delay. The Director of Nursing confirmed the left heel skin impairment identified on February 23, 2023, was not routinely monitored or assessed and the resident skin care plan was not updated. The Director of Nursing reported a shower and a skin check were performed on March 16, 2023, after receiving a concern from the resident's family. The Director of the Nursing indicated the unstageable wound observed during the shower was covered with 90% black eschar, with slight bleeding, and measured approximately 3 x 3 cm in size. Treatment was ordered, and a care plan was updated on March 16, 2023. Late documentation of the left heel unstageable wound assessment was done on March 20, 2023. The facility failed to comprehensively assess, implement interventions, follow a physician's order for a wound consult timely, and monitor the left heel ulcer/, boggy heel initially identified on February 23, 2023, resulted in harm of a declined pressure ulcer to the left heel after addressing a family's skin integrity concern on March 16, 2023. 28 Pa Code 201.18 (b)(1) Management Previously cited 9/21/22, 10/12/22, 2/6/23 28 Pa Code 211.10 (d) Resident care policies Previously cited 2/6/23 28 Pa Code 211.12(d)(1)(5) Nursing services Previously cited 9/21/22, 10/12/22, 2/6/23 28 Pa. Code: 211.5(f) Clinical records Previously cited 9/21/22, 2/6/23