Health inspection·June 4, 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 clinical record, facility documentation, and interviews with staff, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to perform weekly skin assessments as ordered by the physician for one of six residents reviewed. (Resident R1) Residents Affected - Few Findings include: Review of facility policy titled Skin Check Policy, effective 2025, stated the facility will perform comprehensive skin checks on all residents as prescribed in their care plan, and at a minimum frequency consistent with the physician's orders (e.g., weekly, biweekly, monthly). The goal is to promptly identify changes in skin integrity and initiate appropriate interventions. Findings must be recorded in the resident's clinical record immediately after completion. Any new or worsening skin condition must be documented and reported to the attending physician and Director of Nursing immediately. Clinical record review revealed Resident R1 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus (when the body doesn't use insulin properly, resulting in unusual blood sugar levels), bilateral primary of osteoarthritis of knee (condition that affects both knee joints with cartilage damage and inflammation), and dementia. Review of physician's order, dated April 18, 2025, revealed an order for Skin care: skin and nail checks weekly, every day shift, every Tuesday. Nursing progress note, dated May 13, 2025, stated Resident R1's skin check was done after (his/her) bed bath, Resident R1 abdominal fold looks irritated and red. Further review of Resident R1's progress notes revealed no further skin assessments and no indication of skin issues noted. Review of Resident R1's clinical record revealed on May 30, 2025 Resident R1 was transferred to the hospital due to change in mental status and abnormal vital signs. Review of Resident R1's hospital documentation, dated May 31, 2025, revealed Resident R1 had an admitting diagnosis of sepsis with acute renal failure (Sepsis is a life-threatening condition caused by an intense response of your immune system to an infection. Sepsis triggers inflammation throughout your body that can result in multiple organ failure. Sepsis is the most common risk factor of acute Page 1 of 2 396120 396120 06/04/2025 Wyncote Care Center 208 Fernbrook Avenue Wyncote, PA 19095

F 0684 kidney failure. Acute kidney failure, or acute kidney injury, is a sudden loss of kidney function). Level of Harm - Minimal harm or potential for actual harm Review of Resident R1's hospital documentation, dated June 02, 2025, revealed a physician's note that stated Resident R1 says ouch when examining abdomen and left lower extremity however more severe pain when examining right lower extremity. Right lower extremity with lower leg swelling, wound of lateral lower leg without parlance/drainage. Residents Affected - Few Physician note, dated June 03, 2025, revealed right knee fluid gram stain positive for gram positive cocci (strong indicator of septic arthritis). Right ankle fluid clotted. Plan for OR today for right knee irrigation and debridement with possible right ankle irrigation and debridement (surgical procedure that involves washing out and cleaning a wound, by removing debris and dead or damaged tissue). Interview with on June 04, 2025 at 12:17 p.m. with Director of Nursing, Employee E1, revealed not being aware of any skin issues on Resident R1. Interview on June 04, 2025 at 2:05 p.m. with Registered Nurse, Employee E2, revealed that she was Resident R1's nurse on May 30, 2025, the day Resident R1 was transported to the hospital. Registered Nurse, Employee E2, was unaware of swelling or skin issues on Resident R1's right lower extremity and no nurse aides reported any concerns. Interview with Administrator, Employee E2, confirmed the facility was unable to find evidence that there was a wound present on Resident R1's right lower extremity and weekly skin assessment was not performed as ordered. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services. 396120 Page 2 of 2