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 (continued on next page) 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 Page 1 of 2 Event ID: 105248 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)