The Sanctuary At Tuttle Crossing

Review of the plan of care dated 09/22/25 for Resident #40 revealed the resident was at risk for/had an actual alteration in skin integrity related to being admitted with a pressure ulcer to the sacrum with an intervention including, but not limited to, providing treatments per physician's orders.

Review of the Skin Risk assessment dated [DATE] for Resident #40 revealed the resident was at high risk for skin breakdown.

Review of the pressure ulcer admission assessment dated [DATE] for Resident #40 revealed a sacrum unstageable pressure ulcer measured 4 centimeters (cm) by 6 cm by undetermined depth.

Review of the physician order dated 09/22/25 for Resident #40 revealed an order to clean the sacral wound with wound wash, pat dry, cover with foam border dressing and change every three days and as needed.

The order was discontinued on 09/25/25.

Review of the Wound Physician #1500 note dated 09/23/25 revealed Resident #40 had a sacrum stage four pressure ulcer measured 5.5 cm by 7 cm by 1 cm with a treatment order for Mesalt with a gauze dressing daily and as needed.

Review of the physician order dated 09/23/25 for Resident #40 revealed an order for Mesalt with a gauze dressing daily and as needed.

Interview on 12/23/25 at 9:44 A.M. with the Director of Nursing (DON) verified Resident #40 had two active orders for the sacrum stage IV pressure ulcer from 09/23/25 through 09/25/25. 3.Review of the medical record for Resident #50 revealed an admission date of 05/18/22.

Diagnoses included, but were not limited to, systolic heart failure, chronic kidney disease stage three, peripheral vascular disease and personal history of transient ischemic attack and cerebral infarction without residual deficits.

Review of the Skin Risk assessment dated [DATE] for Resident #50 revealed the resident was at high risk for skin breakdown.

Review of Resident #50's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact.

The resident was assessed to require total dependence for toilet hygiene, shower/bathing, bed mobility, and transfers.

This resident was assessed to be at risk for developing pressure ulcers and to have two stage three pressure ulcers currently.

Review of the plan of care, revised 12/02/25, for Resident #50 revealed actual skin alterations related to the sacrum and right ischium pressure ulcers with interventions including, but not limited to, wound treatments per orders.

Review of the Wound Physician #1500 note dated 12/02/25 for Resident #50 revealed a sacrum stage three pressure ulcer measured 4.5 centimeters (cm) by 0.6 cm by 0.2 cm and a right ischium stage three pressure ulcer measured 1 cm by 1.7 cm by 0.2 cm with treatments for both to be Hydrocolloid paste (triad) twice a day and as needed.

Review of the physician orders dated 12/04/25 for Resident #50 revealed for the sacrum and right ischium stage three pressure ulcers to use Hydrocolloid paste (triad) twice a day and as needed.

Interview on 12/23/25 at 9:43 AM with the Director of Nursing (DON) verified Resident #50 did not have a treatment order for the sacrum and right ischium stage three pressure ulcers from 12/02/25 through 12/04/25.

Review of the undated facility policy titled Pressure Injury Prevention and Management revealed evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present.

This deficiency represents non-compliance investigated under Complaint Number 2685037 and Complaint Number 2669759.

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