Pottstown Skilled Nursing And Rehabilitation Cente
Inspection Findings
F-Tag F0686
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm or potential for actual harm
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physicians' orders for wound treatments were implemented for three of five sampled residents. (Residents 1, 2, 3) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included diabetes and kidney disease. On August 21, 2025, a physician ordered that staff clean the resident's pressure sore that was located on the second right toe with saline (wound cleaner) and apply one layer of Xeroform (sterile gauze to cover wounds) and an ABD (abdominal pad for large wounds), and wrap with a Kling (flexible bandage) every day on day shift and as needed. A review of Resident 1's Treatment Administration Record (TAR) revealed that there was no evidence that staff provided treatment on September 3, 9, and 10, 2025. Clinical record review revealed that Resident 2 had diagnoses that included hemiplegia and hemiparesis (paralysis on one side of the body) and hypertension (high blood pressure).
On June 17, 2025, a physician ordered that staff apply amlactin (medicated skin lotion) to his left toes and foot in the morning to scaly skin to avoid heel wound. A review of Resident 2's TAR revealed that there was no evidence that staff administered the treatment on August 24, 25, 26, and 30, 2025, September 1, 5, 6, 10, and 11, 2025. Clinical record review revealed that Resident 3 had diagnoses that included heart failure and atrial fibrillation (abnormal heart rhythm). On August 28, 2025, a physician ordered that staff clean the resident's pressure sore that was located on the spine with saline, then dry, and cover with foam (wound dressing), and change every three days on day shift and as needed. A review of Resident 3's TAR revealed that there was no evidence that staff provided treatment on September 3 and 10, 2025. In an interview conducted on September 12 at 1:45 p.m., the Administrator confirmed that their was no evidence that the residents received wound treatments as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Residents Affected - Few
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
Event ID:
Pottstown Skilled Nursing and Rehabilitation Cente in POTTSTOWN, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in POTTSTOWN, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Pottstown Skilled Nursing and Rehabilitation Cente or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.