§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
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Observations:
Based on closed clinical record review and staff interview it was determined that the facility failed to implement interventions to promote pressure ulcer healing for one of two residents reviewed (Resident CR1).
Findings include:
Closed clinical record review for Resident CR1 revealed that the facility admitted her from the hospital on May 14, 2026.
Review of nursing documentation from hospital staff dated May 13, 2026, at 12:42 PM indicated that Resident CR1 had a skin wound on her coccyx (last bone at the base of the spine) that, "looks like a skin tear to coccyx."
Resident CR1 discharged from the hospital on May 14, 2026, at 1:46 PM.
Hospital discharge summary documentation dated May 14, 2026, did not include an assessment of the coccyx wound (e.g., size, color, drainage) or physician orders for treatment.
Nursing documentation dated May 14, 2026, at 3:59 PM revealed that Resident CR1 arrived at the facility with a, "wound on the sacrum (triangular bone at the base of the spine above the coccyx) that has been ongoing, per resident." There was no description of the wound or indication of treatment interventions.
A facility electronic Admission/Re-admission Evaluation assessment dated May 14, 2026, noted that Resident CR1 had a "Sacrum wound," however, there was no description of the site (e.g., stage, size, color, drainage).
A facility electronic Skin Observation/check assessment dated May 14, 2026, noted an area of skin integrity alteration on the coccyx; however, included no other description.
A physician's order dated May 15, 2026, at 1:52 PM (almost 24 hours after Resident CR1's admission to the facility) instructed staff to, "Cleanse coccyx wound with normal saline, pat dry. Apply medical grade honey to base of wound, zinc oxide (a mineral compound used to protect and support skin recovery; acts as a physical shield, soothing irritated skin and allowing underlying damage to heal naturally) to peri wound (area around wound). Cover with bordered gauze one time only for wound care for one day and every day shift for wound care and as needed for if dressing becomes wet, soiled or dislodged."
Review of Resident CR1's TAR (treatment administration record, electronic documentation completed by licensed staff for the completion of treatments) dated May 2026 revealed that staff initialed completion of the coccyx treatment for the first time on May 15, 2026, at 4:22 PM.
Review of documentation by the facility's contracted wound consultant provider for a service date of May 18, 2026, noted Resident CR1 had a pre-existing ulcer of the sacrum for less than 30 days, the previous treatment included barrier cream, and the previous care for the wound was provided by a hospitalist. The assessment of the wound on Resident CR1's sacrum was described as a stage III (stage III pressure ulcers involve full-thickness tissue loss where the epidermis and dermis (top two layers of skin) are completely lost, and the wound extends into the fat layer), 3 cm (centimeters) by 1.5 cm by 0.2 cm, with exposed subcutaneous tissue (the deepest layer of skin, composed primarily of fat and connective tissue), 100 percent slough (unhealthy, non-viable, tissue), and the peri wound area was intact, with erythema (redness) and fragile. The planned wound treatment was changed to hydrogel (water-rich, gel-based dressings that maintain a moist environment to promote healing, relieve pain, and support tissue repair) with zinc oxide to peri wound and secured with bordered gauze daily.
Review of Resident CR1's TAR dated May 2026 revealed that staff did not implement the new wound treatment orders; but continued to treat Resident CR1's sacral wound with the medical grade honey until her transfer to the hospital on May 21, 2026.
The surveyor confirmed the above findings regarding Resident CR1's pressure ulcer treatment with the Nursing Home Administrator and the Director of Nursing on June 8, 2026, at 3:15 PM.
483.25(b)(1)(i)(ii) Treatment/svcs to Prevent/heal Pressure Ulcer
Previously cited deficiency 12/12/25
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 07/22/2026
F686
1.Unable to retro correct deficient practice for resident CR#1.
2. DON or designee will complete an audit of initial skin assessments on all new admissions in the past 30 days to identify any new residents who have been admitted with pressure ulcers to ensure thorough assessment to include measurements. DON or designee will audit most recent wound care providers' recommendations to ensure that recommendations or new orders have been implemented.
3. Licensed nursing staff will be educated on facility policy related to Pressure Ulcer/Injury Risk Assessment/Skin Checks and the importance of reviewing all wound care providers' recommendations and implementation.
4. DON or Designee will audit new admissions weekly x 8 weeks to verify that any identified pressure ulcers have documentation to include wound measurements and will review all wound care provider recommendations to ensure recommendations have been initiated. The results of the audits will be reviewed by the QAPI committee x 3 months.
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