Health inspection·October 24, 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 clinical record review and staff interview it was determined that [NAME] Skilled Nursing and Rehabilitation Center failed to ensure that residents were assessed and monitored to prevent pressure ulcers for one of one residents reviewed (Resident R72). Residents Affected - Few Findings include: Review of Resident R72's clinical record revealed resident was admitted on [DATE]. Further review of clinical record revealed Resident 72's diagnoses include; Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), Vascular Dementia (lack of blood carrying oxygen and nutrient to a part of the brain, causing problems with reasoning, planning, judgment, and memory); Malnutrition; and Abnormalities of gait. Review of Resident R72's clinical record revealed most recent Braden Scale (assessment of risk of developing pressure ulcers) dated June 15, 2023 which indicated resident was considered High Risk to develop pressure ulcer/wound. Review of Resident R72's clinical record revealed a care plan addressing skin integrity. Further review of care plan revealed interventions initiated on April 17, 2023 of barrier cream to peri area (skin between the genitals and the anus) and buttocks; encourage fluids; encourage repositioning as needed; and use assistative devices as needed. Additional review of Resident R72's skin integrity care plan revealed an intervention added on October 23, 2023 of Administer treatment per physician orders. Review of Resident R72's clinical record including Tasks documentation for showers failed to reveal documented showers on designated shower days of Tuesday/Thursdays for previous 30 days. Further review of Resident R72's clinical record revealed most recent showers recorded for September 26 and September 29, 2023. Review of Resident R72's September 2023 and October 2023 Medication Administration Record (MAR)/Treatment Administration Record (TAR) revealed body audits occurred on September 5, 2023; September 12, September 19, September 26, October 3, and October 10, 2023. Further review of Resident R72's clinical record including September 2023 and October 2023 MAR/TAR failed to reveal documetnation of the administration of barrier cream to resident's peri area/buttocks to prevent pressure wounds. (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: 395685 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 395685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wallingford Skilled Nursing and Rehabilitation Cen 115 South Providence Road Wallingford, PA 19086 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)