Normandie Ridge

Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to provide care and services consistent with professional standards to promote healing and prevent worsening of pressure injuries for one of two residents reviewed for pressure injuries (Resident 71).Findings include:Review of facility policy, titled Skin Management and Injury and Prevention, last reviewed July 30, 2025, revealed the policy statement was, B. A resident with impaired skin integrity receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent avoidable skin integrity issues from developing.

Subsection I. stated, All resident alterations in skin integrity will be tracked weekly in the [Electronic Medical Record] and reviewed and documented weekly until resolved.Review of Resident 71's clinical record revealed diagnoses that included acute congestive heart failure (decreased ability of the heart to effectively pump blood throughout the body) and unspecified atrial flutter (irregular heart rate).Review of Resident 71's clinical record revealed that upon re-admission to the facility from a hospital stay on August 8, 2025, Resident 71's sacral area was identified as having intact, dry skin.Review of Resident 71's interdisciplinary progress notes revealed that on August 16, 2025, at 2:48 PM, Employee 4 (Licensed Practical Nurse [LPN]) documented Resident 71 had an open area to left upper buttocks that was approximately 1.0 centimeter (cm - metric unit of measure) by 0.7 cm.

The wound bed was documented as having yellow slough (dead cells and/or tissue).

The progress note stated that the supervisor was made aware.

Further review of the clinical record revealed no progress note or assessment of the newly identified wound was completed by a Registered Nurse. Resident 71's physician's orders, revealed that an order was started to cleanse the wound with Normal Saline Solution (NSS), apply medical honey and cover with boarder gauze.Review of Resident 71's clinical record revealed that the electronic skin/wound assessment tracking form was not initiated until August 25, 2025.

Review of Resident 71's clinical record failed to reveal a documented wound assessment (including but not limited to wound size, characteristics, or changes and or improvement) for Resident 71's sacral wound between August 16 and 25, 2025 (total of 9 days).Between the dates of August 16 and 25, 2025, Resident 71 was transferred to a hospital emergency department on August 21, 2025, at approximately 1:04 PM due to abnormal blood laboratory values, and returned to the facility on August 21, 2025, at approximately 7:50 PM.

Review of Resident 71's clinical record revealed no reassessment of Resident 71's skin upon return to the facility.On August 25, 2025, at 11:24 AM, Employee 5 (Registered Nurse) documented a wound assessment.

According to the wound assessment, Resident 71's sacral wound measured 5.33 cm in length by 1.42 cm in width.During a staff interview on September 26, 2025, at approximately 2:30 PM, the Nursing Home Administrator confirmed that there was no documented wound assessment completed for Resident 71's sacral wound between August 16 and 25, 2025. As of the interview, the facility had no further information to provide.28 Pa code 211.12(d)(1)(3)(5) Nursing services.

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.

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