Health inspection·July 10, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to provide a safe, clean comfortable homelike environment for the residents. The findings included: A tour of the facility, including resident rooms, was conducted on 07/08/24 at 9:30 AM and a second tour was conducted on 07/10/24 on 12:00 PM, with the Maintenance Director and the Housekeeping Manager. They both acknowledged the following concerns that were identified had during tour: Photographic Evidence Obtained. a. room [ROOM NUMBER] A - The wheelchair arm rests, seat and back of chair were torn. b. room [ROOM NUMBER] - The floor was very dirty with debris that included the corners of the room. room [ROOM NUMBER] - The resident in bed-A stated on 07/08/24 at 9:55 AM that there had been an Ibuprofen pill on the floor that gets pushed around, which has been there a month, and it just gets moved around when they clean and mop. She said they don't clean the toilet and it is filthy with dried up bowel movement. She stataed she has told housekeeping about her concerns but nothing happens. The resident in bed-B stated at 10:00 AM, that the outside windows are so dirty, you can't look outside and the window blinds have brown and black spots on each of the slats. c. room [ROOM NUMBER] - A the blue bariatric mattress for bed-A had a large brown stain that covers the top of the mattress. d. room [ROOM NUMBER] - The resident in bed-B stated at 10:05 AM that the floor is disgusting, they never come in and clean the floors and if they do, they just push the dirty water and mop around that does not get the floor clean. e. room [ROOM NUMBER] - The resident in bed-B stated at 9:35 AM that the bedroom door won't stay open, they have to prop it up with a garbage can, her over-the-bed table is filthy. She stated they don't wipe it down and it's been filty for days if not weeks. f. room [ROOM NUMBER] - The resident in bed-B stated that he was admitted a couple of days ago and had observed a used COVID test on the window sill since he was admitted and it's still sitting on the windowsill. Page 1 of 5 105474 105474 07/10/2024 Vero Beach Care Center 1310 37th St Vero Beach, FL 32960

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few g. room [ROOM NUMBER] - The caulking around the toilet in the bathroom was discolored yellow, black and cracked. h. The door to enter and exit the Rehab Unit (SSU) sticks and was very difficult to open. On 07/08/24 at 2:50 PM in room [ROOM NUMBER], the surveyor asked the resident in bed-B if housekeeping had been in to clean. The resident stated that they only emptied the garbage cans. The surveyor observed the toilet to be dirty, the floors was also dirty, and the Advil pill remains on the floor. An interview was conducted on 07/10/24 at 11:22 AM with the Housekeeping Supervisor, who stated, I have floor techs that are responsible to sweep, mop, strip and buff the floors and take out the garbage. Then we have housekeepers who clean, sweep, wipe down the window sills, and top of AC unit, they high dust and clean the bathrooms. On 07/10/24 at 3:10 PM, the Housekeeping Supervisor stated that they went into room [ROOM NUMBER] and cleaned the room. When the surveyor went back into the room after this conversation, the pill remained on the floor in the bathroom, the toilet had not been cleaned and floor remained filthy by the AC (air conditioner) unit. The Housekeeping Supervisor went back into the room with the surveyor and acknowledged the findings. The Supervisor did not know why it was not clean. 105474 Page 2 of 5 105474 07/10/2024 Vero Beach Care Center 1310 37th St Vero Beach, FL 32960

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure nursing staff followed physician orders for blood pressure medication perimeters for 1 of 5 sampled residents (Resident #2) reviewed for medications; and failed to follow physician orders for a wound vac for 1 of 1 sampled resident reviewed for a wound vac (Resident #4) Residents Affected - Few The findings included: 1. Record review for Resident #2 revealed Resident #2 was admitted to the facility on [DATE] with diagnoses to include Hypertension (high blood pressure), Orthostatic Hypotention, Atrial Fibrillation, and History of Falling, Review of the physician orders revealed the following orders: a) Dilltiazem HCl Oral Tablet 30 MG to give 0.5 tablet by mouth every 6 hours for Hypertension. Hold if SBP(Systolic Blood Pressure) is less than 105 or HR (Heart Rate) is less than 60 (0000-midnight, 6:00 AM, 12:00 PM, and 6:00 PM). b) Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth one time a day for Hypertension. Hold for SBP [Systolic Blood Pressure] is less than 105 or HR [Heart Rate] is less than 60 - Start Date 03/15/2024 0900 - D/C Date 04/22/2024 2110 [09:00 PM]. This order was then started again on 04/30/24 and ended 05/25/24. Review of the Physicians Orders documented on the Medication Administration Record (MAR) revealed Diltiazem HCl tablet 30 MG. Give 0.5 tablet every 6 hours (0000-midnight, 06:00 AM, 12:00 PM, and 6:00 PM) for Hypertension, to hold for SBP less than 105 or HR less than 60. Start date 02/06/24. On the following dates, the systolic blood pressure (SBP) was less than 105 and the nurse documented administration to the resident for the medication Diltiazem HCl tablet 30 MG, to give .5 MG: 03/16/24, B/P (Blood Pressure) was 101/93 (06:00); B/P 102/62 (12:00 PM); 03/17/24, B/P 102/56 (12:00 PM) 03/18/24, B/P 101/66 (0000); B/P 101/66 (06:00 AM); B/P 101/66 (1:20 PM) 03/29/24, B/P 101/71 (6:00 PM) 04/06/24, B/P 104/60 (12:00 PM) 04/09/24, B/P 104/74 (6:00 PM) 04/12/24, B/P 101/56 (12:00 PM) 04/15/2,4 B/P 97/41 (6:00 PM) 04/18/24, B/P 103/60 (12:00 PM) 105474 Page 3 of 5 105474 07/10/2024 Vero Beach Care Center 1310 37th St Vero Beach, FL 32960

F 0684 04/19/24, B/P 102/64 (12:00 PM). Level of Harm - Minimal harm or potential for actual harm On the following dates, the Systolic Blood Pressure (SBP) was less than 105 and the nurse documented administration to the resident for the medication Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG 1 tab. Residents Affected - Few 03/18/24 B/P 101/66 (09:00 AM) 04/18/24 B/P 103/60 (09:00 AM). An interview on 07/10/24 at 1:15 PM with the DIrector of Nursing (DON), who was asked to review and verify on the for Resident #2 for the Diltiazem and the Metoprolol. The DON confirmed the medicaitons should have been held. She acknowledged the findings. 2. Record review for Resident #4 revealed a diagnoses to include Sepsis, Pressure Ulcer of Sacral and Right Buttocks, and Dementia. Review of a physician's progress note dated 05/11/24 documented the resident was recently hospitalized for an infected sacral ulcer resulting in sepsis, and IV (intravenous) antibiotics were initiated. The resident underwent excisional debridement into the muscle and fascia of the right hip ulcer and sacral decubitus ulcer on 03/23/24. Review of the Physician's Orders documented the following: - Wound Vac - Apply Wound Vac to left upper thigh wound at 125mmhg. Cleanse area with NS [normal saline], pat dry, apply skin prep to peri wound, apply wound vac 3x [times] weekly and PRN [as needed]. OK to use green or black foam. Every day shift every Monday, Wednesday, and Friday for wound care and as needed for wound care Start date 05/10/24. Review of the Treatment Administration Record (TAR) for May 2024 revealed the physician order for the Wound Vac did not have any nurses' initials documenting the care was provided to the resident. During interviews with the nurses who were assigned to Resident #4 on the Monday, Tuesday and Wednesday of the following week, they all acknowledged that they did not provide any care relating to the wound vac. Review of the daily staffing from 05/09/24 to 05/15/24 documented the Wound Care Nurse (WCN) worked on 05/09/24, 05/10/24 and on 05/13/24 but also documented she had 'called off' on Monday 05/13/24 and there was no replacement marked on the daily staffing form. An interview was conducted on 07/09/24 at 8:45 AM with the Staff L, the current Wound Care Nurse, who stated she began about a month ago. When asked where she would document wound care, she stated she documents in the PCC (Point Click Care-electronic record) or in the TAR (Treatment Administration Record), if no change in wound and no issues with wound, she doesn't put a note. Every week there are rounds with nurse practitioner she (practitioner) measures the wound and describes it. She emails them to me (WCN). The nurses on the floor are responsible if the wound care nurse is not available. We have a weekend wound care nurse. She stated that 3 nurses called off on 07/05/24 so she was on the floor and didn't do wound care. A telephone interview was conducted on 07/10/24 at 8:39 AM with the previous WCN who no longer works for the facility. She stated she saw Resident #4 one time on 05/10/24 because she ended up being out the following week but that all nurses are responsible for changing the wound vac and pads. She 105474 Page 4 of 5 105474 07/10/2024 Vero Beach Care Center 1310 37th St Vero Beach, FL 32960

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was asked if the wound vac was on the resident when he arrived, and stated they (hospitals) do not release patients with wound vac from the hospital. The facility had the wound vac when the resident was admitted but it wasn't put on until I saw him the next day. The admitting nurse should have put it on but wanted to wait until I saw him. The wound vac stays on the resident and is changed on Monday, Wednesday, and Friday. You take the appliance completely off and if the canister is full, you would change it or just change it once a week. When I saw him the next day, the dressing on the wound was saturated and approximately 6 oz (ounces) of drainage. It took an hour to clean him up, he had feces up and down his back. I am sure if no one saw him the following week the wound vac would have been full. She stated that she put the order in, and her notes would be in comment in TAR or progress note. An interview was conducted on 07/10/24 at 10:43 AM with the Director of Nursing (DON) who brought the surveyor a document that showed the resident had a wound vac. The surveyor stated, I know he had a wound vac, I am looking to see if the orders were followed. She stated the progress notes documented the wound vac was intact, on and functioning. The surveyor asked where the documentation was that showed the dressing was changed and orders followed. The DON did not have an answer. An interview was conducted on 07/10/24 at 10:50 AM with Staff K, Registered Nurse / Unit Manager who stated, nurses are responsible if the wound care nurse is not available. The wound care nurse works Monday to Friday but the week of 05/13/24, she was not working. An interview was conducted on 07/10/24 at 11:01 AM with Staff J, LPN (Licensed Practical Nurse), who acknowledged she had Resident #4 on Wednesday 05/15/24. Staff J stated, To my understanding, the wound care nurse takes care of the wound vac every day. We are not trained in it. We just check it if malfunctioning, beeping. If it was, we would have to reach out to whoever takes care of it. If I have a question, I can call the wound nurse. She stated that the spouse refused for anyone to provide care to the resident on that Wednesday and wanted him transferred to the hospital. An interview was conducted on 07/10/24 at 11:27 AM with Staff M, LPN who acknowledged she was assigned as wound care nurse on 05/15/24. She stated that any nurse can do wound care, you learn this in school. Instead of putting me on the cart, they put as wound care. When asked where she documents her wound care, she stated everyone is different. I never saw this resident because I was being yelled at by the spouse. A telephone interview was conducted on 07/10/24 at 12:37 PM with Staff I, LPN, who acknowledged she had Resident #4 on Monday 05/13/24. Staff I stated, I did not do any wound care with this resident. We usually have a wound care nurse do everything. I do not take care of the wound vacs; I need a refresher course on wound vac. I only dealt with wound vacs in clinicals. Went to school in 2020. 105474 Page 5 of 5