Health inspection·September 17, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, review of clinical record, review of facility provided documentation and interview with resident and staff, it was determined that facility did not ensure a resident received treatment and care in accordance with professional standards of practice related to heat therapy for one of five residents reviewed. (Resident R1)Findings include:Review of facility policy ‘Hydrocollator - therapy,' revised November 7, 2022, indicates that hydrocollator temperature should be checked daily (therapeutic temperature range is 150-170 degrees Fahrenheit. This is the responsibility of therapy department.Further review of policy indicates the following: 10. Place hot pack in cover holder/envelope.11. wrap the hot pack in layers of toweling and place on the resident /patient's affected area.12. check the resident/patient's skin as indicated after application to ensure skin integrity.13. if skin presents with redness or is hot to the touch add another 2 layers of toweling for safety.14. skin should be routinely checked.17. report any injury or excessive redness to nursing immediately and fill out an incident report if indicated.18. document the patient's response to treatment and the need for continued skilled intervention.Review of Resident R1's clinical record revealed that R1, a [AGE] year old male resident was found to have a left shoulder blister on September 5, 2025, measuring 3.5cm length by 2.0cm in width; the resident explained that that it happened during a prior physical therapy session where a heating pad was put on it after he complained of left shoulder pain.Review of facility provided documentation revealed that on September 5, 2025, the facility became aware that Resident R1 sustained a blister on the left shoulder after using a heating pad from the hydrocollator. Resident R1 was noted to receive heat therapy to the left shoulder on September 2, 2025. Per therapist and resident statements, all the time of usage on September 2, 2025, there was no evidence of injury .Interview with physical therapy associate, Employee E3, on September 15, 2025 at 12:45 pm, revealed that redness was noted on resident's left shoulder after heat therapy treatment on September 2, 2025. No complaint of pain or discomfort voiced by resident post treatment.Further interview with physical therapy associate, Employee E3 revealed that while administering heat therapy to Resident R1 on September 2, 2025 - heat pack was placed in envelope, wrapped in two layers of towels, placed on resident's left shoulder and skin was checked after treatment - not after initial application, and not checked routinely as per facility's policy/ protocol.Review of facility provided statement from Resident R1 on September 5, 2025, indicated that he did not experience any pain post treatment on September 2, 2025, until Friday, September 5, 2025, while getting dressed - he had pain in left shoulder.Interview with Nurse aide, Employee E5, on September 15, 2025, at 1:55 pm, revealed no indication that skin concerns were noted during Resident R1's scheduled bath/shower time on Wednesday, September 3, 2025, evening shift.Further review of facility provided documentation revealed that temperature in the hydrocollator was not checked daily as per their policy, on the following dates: September 1, 2025 through September 4, 2025, August 2, 2025, August 3, 2025, August 9, 2025, August 10, 2025, Residents Affected - Few Page 1 of 2 395380 395380 09/17/2025 Saunders Nursing and Rehabilitation Center 100 Lancaster Avenue Wynnewood, PA 19096

F 0684 Level of Harm - Minimal harm or potential for actual harm August 16, 2025, through August 31 2025.Facility did not ensure to complete daily hydrocollator temperature checks and did not ensure to accurately assess and report skin changes as per policy. 28 Pa Code 211.12(d)(1)(2)(3)(5) Nursing services28 Pa Code 211.10(a)(d) Resident care policies Residents Affected - Few 395380 Page 2 of 2