Health inspection·February 12, 2025

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 Based on observation, record review and interview, the facility failed to provide necessary care and services to prevent, identify and properly assess wounds, for 1 of 2 sampled residents reviewed for wounds (Resident #3), as evidenced by the facility failed to identify the blister or subsequent open wound to the resident's right foot, prior to surveyor intervention; the wound care nurse failed to properly assess the wound, documenting erroneous measurements and staff nurses failed to capture the wound during skin check assessment completed on 02/11/25, the day prior to the surveyor's observation. Residents Affected - Few The findings included: Observation of wound care conducted on 02/12/25 at 10:20 AM revealed the Wound Care Nurse (WCN) performed wound care for Resident #3's left foot. At the end of the treatment, the surveyor asked the reason why the offloading boot was only applied to the left leg, as the resident was severely contracted on both legs. The WCN responded that the resident prefers to lay on the left side and that is where the wound is located, so an offloading boot is not necessary to the right leg. The WCN was asked if the resident had any wounds to the right leg or foot and replied 'no'. At this time, the resident spoke up and said, yes he had pain to the right foot. The WCN then proceeded to inspect the right foot. An open wound was noted to the right foot below the big toe, that looked like a blister that had opened up, with visible depth and yellow slough, about the size of a dime. The WCN stated he was going to contact the physician for treatment orders and that the wound provider would evaluate the resident tomorrow (Thursday). Interview with the WCN, conducted upon completion of the wound care observation, on 02/12/25 at approximately 10:30 AM, revealed the nurse had no knowledge of a previous blister or wound to the right foot and stated that he has provided the wound care to the left foot but has not inspected the right foot. He stated the wound care provider rounds weekly and inspects the resident's skin, so the blister was not present last Thursday. An interview was conducted with Staff A, Certified Nursing Assistant (CNA), assigned to care for Resident #3, on 02/12/25 at 10:37 AM. Staff A stated she has not seen the resident as of yet today, she has a heavy assignment, was attending to other residents, and did not have the resident the day before. Staff A denied knowledge of any blisters or wounds to the right foot. An interview with Staff B, Registered Nurse (RN), conducted on 02/12/25 at approximately 10:46 AM, revealed this is her regular hallway assignment, and she is not aware of a blister or wound to the (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 6 Event ID: 105474 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 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)