Health inspection·April 18, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on a review of the Pennsylvania Professional Nursing Practice Act, facility policy and procedure, clinical records review, and staff interview, it was determined the facility failed to ensure that staff met the professional standards upon identifying a skin impairment for one of three residents reviewed (Resident 39). Residents Affected - Few Findings include: The Professional Code, Title 49, Professional and Vocational Standards (Pennsylvania Professional Nursing Practice Act), Chapter 21.145(a) states that the Licensed Nurse is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, and experience in nursing competency. The nurse participates in the planning, implementing, and evaluating nursing care, using focused assessment in settings where nursing takes place. A review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, undated, revealed that the nursing staff would assess and document an individual's significant risk factors for developing pressure sores. In addition, the nurse shall describe and document/report the following: a full assessment of the pressure sore, including location, stage, length, width, and depths, and the presence of exudates or necrotic (dead) tissue. A review of Resident 39's care plan developed on November 22, 2022, revealed the following interventions: Inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness; and check the body for breaks in the skin and treat promptly as ordered by the physician. A review of the nursing progress notes dated March 11, 2025, at 12:11 p.m., revealed that nursing was notified by the wound team that a new unstageable wound was observed on the resident's left heel measuring 2.0 x 2.6 x 0.1 cm. The same note revealed that there was a dressing applied to the wound which was not dated or initialed. A review of the facility's investigation titled New Pressure Injury, dated March 11, 2025, at 11:37 a.m., revealed that during wound rounds, an unstageable wound measuring 2.0 x 2.6 x 0.1 cm was found on the resident's left heel. Staff statement of licensed Employee E3, dated March 11, 2025, revealed the following statements I was notified by the wound team that resident has an unstageable wound on [his/her] left heel. I was also informed that [he/she] has a dressing on, but it wasn't dated so we have no idea how long it had been on for. An interview with licensed nurse Employee E4 was conducted on April 18, 2025, at 8:44 a.m. Employee E4 reported that all treatment medications, dressing, and supplies are all kept in the treatment cart or medication room which is always locked with access only to the nurses. (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 5 Event ID: 395917 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 395917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brinton Manor Nursing and Rehabilitation Center 549 Baltimore Pike Glen Mills, PA 19342 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)