Health inspection·June 5, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan related to wound care orders for one (Resident #1) of three sampled residents. Findings included: Resident #1 was admitted on [DATE] and discharged on 04/08/2024. admission record showed diagnoses included but not limited to spinal stenosis lumbar region, spondylolisthesis lumbar region, low back pain, abnormalities of gait and mobility, and peripheral vascular disease. Review of orders showed offload heels often in bed as tolerated and skin prep heels every shift and wound consult for evaluation and treatment for issues identified. Review showed the physician orders to perform left dorsal wound care was not on the physician orders. Review of the Treatment Administration Record of April 2024 showed no documentation that left foot wound care was performed. Review of wound care specialist provider note dated 04/04/2024, showed wound left dorsal foot is a full thickness mixed and has received a status of not healing. Initial wound encounter measurements are 6 centimeters (cm) x 4 cm x no depth, are of 24 square cm. Moderate amount of serous drainage noted. No odor noted. Pain level of 3/10. The peri-wound was moist. Weeping edema, surrounding petechia of left dorsal foot. Cleanse with normal saline, apply alginate, then super-absorbent pad, wrap with rolled gauze and secure with tape daily and prn. Offload heels. Review of the nursing progress notes dated 04/04/2024 showed Resident #1 was assessed by the wound care specialist Advanced Practice Registered Nurse (APRN). Left foot was assessed due to weeping edema. Left dorsal foot 6 cm x 4 cm x 0 area of weeping edema with surrounding petechia. Arterial Ultrasound was ordered. Resident reeducated on his high risk for further skin breakdown including pressure injury. Resident voices good understanding. Review of care plans showed Edema risk to extremities as of 03/19/2024. Interventions included but not limited to treatment as ordered. During an interview on 06/05/2024 at 11:11 a.m., the Assistant Director of Nursing (ADON)/ Wound Care nurse stated the wound care specialist came in on Thursdays. The resident had weeping edema in his lower extremities. They did arterial and venous ultrasounds that were negative and they ruled out Deep Vein Thrombosis. His heels were clear. His dorsal left foot was observed by the specialist and she wrote it up as a mixed venous arterial wound, 6 cm x 4 cm x 0 depth. The wound was to be treated with super absorbent dressing due to the weeping. She stated the left dorsal foot did not have an Page 1 of 2 105248 105248 06/05/2024 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0656 open area. The area was surrounded by petechia. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/05/2024 at 1:10 p.m., the Director of Nursing (DON) was unable to locate wound care orders for the left dorsal foot. The DON stated the wound care for the foot was not performed per review of the Treatment Administration Record (TAR). The DON spoke with the (ADON)/ Wound Care nurse and said she was the staff member who normally entered the wound care orders. The DON stated he was not sure why the ADON did not follow up. Residents Affected - Few Review of the facility's policy, Documentation of Wound Treatments, implemented 12/01/2023 showed the facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. 4. Additional documentation shall include, but is not limited to: a. date and time of wound management treatments b. modifications of treatments and interventions, e. notification of physician and / or responsible party regarding wound or treatment changes. 105248 Page 2 of 2