Health inspection·April 6, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical records, and staff interview, it was determined that the facility failed to complete weekly wound assessments for one of four sampled residents with developed areas (Resident R35). Residents Affected - Few Findings include: The facility Protocol for skin integrity and wound management policy, last reviewed on 1/2023, indicated that when a wound develops, the nurse will assess, measure, stage and document findings on the wound observation tool. Weekly routine assessments will be done by a licensed nurse. The facility pressure injury/ skin breakdown clinical protocol policy, last reviewed on 1/2023, indicated that the nurse will assess and document an individual's significant risk factors for developing pressure injuries. Monitoring of the wound will occur with each dressing change and weekly by the wound nurse. Review of Resident R35's admission record indicated she was admitted on [DATE]. Review of Resident R35's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs), dated 1/18/23, indicated that her diagnoses included right tibia fracture, depressive disorder, hyperlipidemia, overactive bladder, and hypertension. Review of Resident R35's care plans dated 1/17/2023, indicated that the licensed nurse will assess her skin weekly. Review of Resident R35's wound observation tool (assessment used to document wound observations) dated 2/28/23, indicated that Resident R35 had a wound to her right heel measuring 0.5 centimeters (cm) x 0.5 cm with no measurable depth. Review of Resident R35's nurse progress notes, physician documentation and wound observation assessments did not include an assessment for the week of 3/13/2023. During an interview on 4/5/23, at 9:59 a.m. Registered Nurse (RN) Employee E1 stated that Resident R35 wound is scheduled to be assessed every week. The wound nurse does a wound assessment every Tuesday. The wound nurse is Registered Nurse (RN) Wound nurse Employee E2. We do skin assessments when residents get a shower. During an interview on 4/5/23, at 10:06 a.m. Registered Nurse (RN) Wound nurse Employee E2 stated (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 4 Event ID: 395001 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 395001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Passavant Retirement and Healt 105 Burgess Drive Zelienople, PA 16063 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)