§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 facility policy, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain that residents wounds were measured weekly and monitored for one of two residents reviewed (Resident R1).
Findings include:
Review of facility policy Review of facility policy "Pressure Wound Policy" dated 1/9/26, indicated the facility will make reasonable efforts to identify residents at risk for pressure injuries and implement individualized interventions intended to promote skin integrity. Resident changes in skin condition may be documented in the medical record as appropriate and consistent with facility practices.
Review of the clinical record indicated Resident R1 was admitted to the facility on 5/13/26, with diagnoses of quadriplegia, cardiac arrest, and cerebral infarction.
Review of Resident R1's progress note 5/13/26, stated the resident has no feeling in bilateral lower extremities and is not able to move bilateral lower extremities due to a spinal cord injury. Resident had an open area on buttocks.
Review of Resident R1's Braden Scale Assessment (an evidence-based, standardized assessment tool used to evaluate a patient's risk of developing pressure injuries) dated 5/13/26, revealed the resident was at a high risk for developing pressure ulcers.
Review of Resident R1's physician order dated 5/14/26, indicated to cleanse right buttock with soap &; water, apply Triad (barrier cream) to site every day and as needed for incontinence related to Moisture Associated Skin Dermatitis (MASD).
Review of Resident R1's wound note dated 5/14/26, revealed a head to toe assessment was completed and "no skin issues noted." The facility failed to timely assess and measure Resident R1's open area on buttocks.
Review of Resident R1's baseline care plan failed to include the resident's wound.
Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/20/26, indicated diagnoses were current.
Review of Resident R1's physician order dated 5/24/26, indicated to cleanse right lateral buttock with wound cleanser and pat dry. Apply Medihoney and calcium alginate to wound daily and as needed with incontinence changes, every day shift for wound care.
Review of Resident R1's clinical record failed to include documentation of an assessment and measurements of Resident R1's buttocks wound from 5/13/26, to 5/27/26.
Review of Resident R1's skin assessment dated 5/28/26, revealed the resident had an unstageable buttock wound that measured 3.2 x 3. 0 cm.
During an interview on 7/8/26, at 11:39 a.m. Registered Nurse (RN) Unit Manager, Employee E1 stated resident's wounds are assessed and measure weekly by the wound care nurse and wound care nurse practitioner.
During an interview on 7/8/26, at 11:59 a.m. Resident R1 confirmed he had a wound on his buttocks since his hospital stay and has had it since admission.
During an interview on 7/8/26, at 12:22 p.m. the Director of Nursing (DON) stated if new wound is identified, it must be reported to the cart nurse, supervisor, then the wound care nurse is notified. Wounds are assessed weekly.
During a phone interview on 7/8/26, at 1:08 p.m. Wound Care Consultant, Employee E2 stated resident's wounds are assessed weekly. Wound Care Consultant, Employee E2 confirmed Resident R1's buttock wound was not assessed weekly from admission until 5/28/26.
During an interview on 7/8/26, at 1:23 p.m. Registered Nurse, Unit Manager Employee E3 indicated the day Resident R1 was admitted to the facility she was helping out. It was indicated she usually manages the third floor. RN, Unit Manager, Employee E3 confirmed Resident R1 had a buttocks wound upon admission and failed to obtain measurements. RN, Unit Manager, Employee E3 stated she believes she mistyped the open area to be the left not right.
During an interview on 7/8/26, at approximately 2:00 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the facility failed to make certain that residents wounds were measured weekly and monitored for one of two residents reviewed (Resident R1).
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10 (c)(d) Resident care policies.
28 Pa. Code: 211.12 (d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 08/10/2026
Resident R1 no longer residents at Ivy Park Post Acute.
A whole house skin sweep will be performed by in-house staff and the help of our wound provider, Thursday, July 30th. An audit of all current wounds and if any new wounds are found on the skin sweep will be done to ensure measurements, orders and proper documentation is in place.
The director of nursing and/or designee will educate the nursing staff on wound assessment, timely documentation, monitoring and dressing changes.
The facility will audit all new admissions for 30 days to ensure skin checks are documented on admission, a second day skin check is performed, and if a wound is present that the proper assessment and orders are present. Audit results will be reviewed by the interdisciplinary team and presented at the facility's QAPI meeting. Based on the audit findings and compliance trends, the QAPI Committee will determine whether ongoing monitoring is necessary or if the audit may be discontinued.
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