Inspection·October 17, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to assess wounds or implement interventions to prevent new or worsened pressure ulcers for two of five sampled residents with wounds. (Residents 1 and 3) Residents Affected - Few Findings include: Review of the facility policy entitled, Skin Integrity and Wound Management, last reviewed October 15, 2024, revealed that staff was to assess and document wound status weekly. The nursing assistant would observe skin daily and report any changes or concerns to the nurse. The licensed nurse would perform daily monitoring of wounds or dressings for the presence of complications or decline. Documentation was to include daily monitoring of the ulcer/wound site with or without a dressing, status of the dressing, status of the tissue surrounding the dressing, adequate control of wound associated pain, and signs of decline in wound status. Pressure injury prevention was to be implemented for identified, modifiable risk factors. Clinical record review revealed that Resident 1 had diagnoses that included diabetes, peripheral vascular disease, chronic kidney disease, and right leg cellulitis (bacterial skin infection). Review of nursing documentation revealed that on September 17, 2024, Resident 1 was noted to have a new wound on the right third toe and a treatment was ordered. Review of Resident 1's skin and wound evaluation records revealed that there was no documented evidence that staff assessed or monitored the resident's right third toe wound September 21, 22, and 24 through 30, 2024, and October 1 through 8, 2024. On October 9, 2024, nursing documented that Resident 1's left foot had an odor which resolved after being cleansed and a calloused area had fallen off. There was no documented evidence that the left foot was assessed or monitored since September 18, 2024. Clinical record review revealed that Resident 3 had diagnoses that included hypotension, fourth thoracic vertebra fracture, and sternal fracture. Review of the care plan indicated that on September 12, 2024, the resident was at risk for skin breakdown related to fragile skin, advanced age, and urinary incontinence. The intervention was for staff to provide preventative skin care. On September 14, 22, 29, and October 7, 2024, nursing documented that the resident had boggy heels (spongy tissue with a high fluid content). There was no evidence that interventions to prevent pressure ulcers were put into place until October 10, 2024, when the physician ordered for staff to apply skin prep (a liquid that forms a protective film or barrier when applied to the skin) to the left heel and to ensure that heels were offloaded. In an interview on October 17, 2024, at 3:45 p.m., the Director of Nursing confirmed that there was no documented evidence that Resident 1's wound was assessed weekly or monitored daily and that there were no interventions implemented timely for Resident 3 to prevent pressure ulcers per facility (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 2 Event ID: 395541 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 395541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sinking Spring Skilled Nursing and Rehabilitation 3000 Windmill Road Sinking Spring, PA 19608 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)