§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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for one of 14 residents reviewed (Resident 6).
Findings include:
The facility's pressure injury prevention and treatment policy, dated July 22, 2025, revealed that identified pressure injuries would be documented on and orders obtained from providers for treatment.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated September 11, 2025, revealed that the resident was cognitively intact, required assistance for daily care needs, and was at risk for developing pressure ulcers. A care plan for Resident 6, dated September 15, 2025, revealed that the treatments to the sacral wound were to be applied per physician orders.
A wound consultation for Resident 6, dated September 12, 2025, revealed that the resident had an unstageable pressure ulcer (non-stageable due to coverage of wound bed by slough and/or eschar) to her sacral area (lower tailbone) that measured 5.7 x 5.5 centimeters (cm).
Physician's orders for Resident 6, dated September 12, 2025, included an order for the resident to receive Triad cream (medicine used to maintain a moist environment to promote wound healing) to her sacral wound every shift.
Review of the Treatment Administration Record (TAR) for Resident 6, dated September 2025, revealed that Triad cream was only applied to the resident's sacral wound once daily from September 12 through 15, 2025.
Interview with the Assistant Director of nursing on September 23, 2025, at 12:46 p.m. confirmed that the treatment to resident's sacral wound was not applied every shift as ordered by the physician.
28 Pa. Code 211.12(d)(5) Nursing services.
| | Plan of Correction - To be completed: 11/05/2025
The submission of this plan of correction does not constitute admission or agreement on the part of the provider with the deficiencies or conclusions contained in the Statement of Deficiencies. This plan of correction is prepared and executed solely to respond to the allegation of non-compliance cited during the survey ended on September 23, 2025.
- Actions taken for the situation identified:
Facility cannot retroactively correct the situation. Physician orders for resident were reviewed and no other errors were identified. Resident 6 suffered no ill effects from failure to follow physician treatment orders.
- How the facility will act to protect residents in similar situations:
Facility baseline audit was completed to ensure that physician treatment orders are being followed as prescribed.
- System changes and measures to be taken:
The Director of Nursing/designee has educated licensed nurses on following physician/provider treatment orders as prescribed.
- Monitoring mechanisms to assure compliance:
The Director of Nursing/designee will perform physician treatment order audits to ensure they are being followed, as ordered by the physician. This audit will be completed three (3) times a week for four (4) weeks, then monthly for two (2) months. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings for additional recommendations as necessary, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure facility continues to meet quality standards.
- Date Corrective Action will be completed:
Substantial compliance is expected by November 5, 2025.
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