Health inspection·April 2, 2024

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, clinical records, and staff interviews, it was determined that the facility failed to make certain that residents were monitored, assessed, and received the necessary services to prevent pressure ulcers from developing or worsening for one of three residents (Resident R1). Residents Affected - Few Findings include: Review of facility policy Pressure Ulcer Policy dated 12/13/23, indicated a resident who enters the facility without a pressure ulcer will not develop a pressure ulcer unless the individual's clinical condition demonstrates they are unavoidable. All residents will be assessed for pressure ulcer risk on admission, monitored weekly and reviewed quarterly and as needed. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/3/24, indicated diagnoses of high blood pressure, diabetes (high blood sugar levels), and anemia (too little iron in the blood). Section M: Skin Conditions, Question M0150 indicated Resident R1 had no unhealed pressure ulcers/injuries present on admission to the facility. Review of Resident R1's Nursing Admission/readmission Screener dated 1/30/24, indicated Resident R1 had shearing/incontinent dermatitis (inflammation of the skin) on the coccyx (center mid-buttocks region). Review of a physician order dated 2/2/24, indicated to apply Medihoney (a wound gel) to bilateral buttocks wounds topically every day and every evening shift and cover with border gauze (a self-adhering, multi-layer foam dressing). Review of a Nursing Weekly Skin and Body Review dated 2/6/24, indicated no new skin abnormalities were identified. Review of a Nursing Weekly Skin and Body Review dated 2/13/24, indicated no new skin abnormalities were identified. Review of a Skin/Wound Note dated 2/14/24, indicated Resident R1 had a Stage II Pressure Ulcer (partial thickness skin loss involving epidermis, dermis, or both) present on her buttocks, measuring 1.3 centimeters (cm) Length (L) x 1.3 cm Width (W) x 0.1 cm Depth (D). The wound had a status of not healed. Page 1 of 2 395705 395705 04/02/2024 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a Skin/Wound Note dated 2/21/24, indicated Resident R1's Stage 2 Pressure Ulcer to her buttocks measured L 4.4 cm x W 3.6 cm x D 0.1 cm. The wound had a status of not healed and that the wound was deteriorating. Review of Resident R1's Treatment Administration Record (TAR) dated February 2024, failed to reveal documentation to indicate that the dressing change to Resident R1's buttocks occurred on 2/12/24, during the day shift, 2/17/24, on the day and evening shifts, 2/18/24, on the evening shift, and 2/1924, on the day shift. During an interview on 4/2/24, at 3:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to make certain that residents were monitored, assessed, and received the necessary services to prevent pressure ulcers from developing or worsening for one of three residents (Resident R1). 28 Pa. Code:211.10(a)(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 395705 Page 2 of 2