Health inspection·July 25, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that resident records were complete and accurate for 3 of 3 residents reviewed, Residents #1, #5 and #6. Findings include: 1) Review of Resident #1's admission record showed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses that included stage 4 pressure ulcer of right heel, need for assistance with personal care, spastic hemiplegia affecting left nondominant side, lower leg contracture of muscle, left elbow contracture, and dementia. Review of Resident #1's physician order dated 6/26/2024 read, Cleanse open area of the left lateral foot with normal saline, apply piece of Derma Blue foam with silver to open area, and cover with a silicone foam dressing three times per week, every day shift Mon [Monday], Wed [Wednesday], Fri [Friday] for wound healing for 30 days. Review of Resident #1's TAR for July 2024 revealed no entry documented for the left lateral foot wound care on Friday, 7/5/2024. Review of Resident #1's physician order dated 6/26/2024 read, Cleanse open area of the right medial ankle with normal saline, apply piece of Derma Blue with silver to open area, and cover with a foam dressing three times per week, every day shift Mon, Wed, Fri for wound healing for 30 days. Review of Resident #1's TAR for July 2024 revealed no entry documented for the right medial ankle wound care on Friday, 7/5/2024. Review of Resident #1's physician order dated 6/26/2024 read, Cleanse open area of right heel with wound cleanser, apply Derma Blue foam with silver, foam dressing, ABD [abdominal] pad, and wrap with kerlix three times per week, every day shift every Mon, Wed, Fri for wound healing. D/C [Discontinue] Date: 07/11/2024. Review of Resident #1's TAR for July 2024 revealed no entry documented for the right heel wound care on 7/5/2024. Review of Resident #1's physician order dated 7/12/2024 read, Cleanse open area of the left lateral foot with normal saline, apply Anasept gel, and cover with island gauze dressing daily, every day shift for wound healing for 30 days. Page 1 of 3 105638 105638 07/25/2024 Parklands Care Center and Rehab 1000 SW 16th Ave Gainesville, FL 32601

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of Resident #1's Treatment Administration Record (TAR) for July 2024 revealed no entry documented for the left lateral foot wound care on 7/12/2024, 7/15/2024, 7/18/2024, 7/20/2024, 7/21/2024, and 7/23/2024. Review of Resident #1's physician order dated 7/12/2024 read, Cleanse open area of the right medial ankle with normal saline, apply Anasept gel, ABD pad, and wrap with kerlix daily, every day shift for wound healing for 30 days. Review of Resident #1's TAR for July 2024 revealed no entry documented for the right medial ankle wound care on 7/12/2024, 7/15/2024, 7/18/2024, 7/20/2024, 7/21/2024 and 7/23/2024. Review of Resident #1's physician order dated 7/12/2024 read, Cleanse open area of the right heel with wound cleanser, apply Anasept gel, ABD pad, and wrap with kerlix daily, every day shift for wound healing for 30 days. Review of Resident #1's TAR for July 2024 revealed no entry documented for the right heel wound care on 7/12/2024, 7/15/2024, 7/18/2024, 7/20/2024, 7/21/2024 and 7/23/2024. 2) Review of Resident #5's admission record showed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses that included chronic multifocal osteomyelitis, stage 4 pressure ulcer of sacral region, and type 2 diabetes mellitus. Review of Resident #5's physician order dated 6/17/2024 read, Cleanse depression of sacrum with Vashe, apply collagen sheet with silver (PURACOL) into depression of sacrum, place droplet of Vashe on cotton ball, place cotton ball in depression of sacrum daily and as needed, every day shift for odor control and wound healing for 30 days. Review of Resident #5's TAR for July 2024 revealed no entry documented for sacral wound care on 7/1/2024, 7/3/2024, 7/6/2024, and 7/11/2024. 3) Review of Resident #6's admission record showed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses that included paraplegia, type 2 diabetes mellitus, stage 3 pressure ulcer of left buttock, and stage 4 pressure ulcer of sacral region. Review of Resident #6's physician order dated 7/12/2024 read, Cleanse open area with normal saline, apply Betadine, and cover with an island gauze dressing daily and as needed, every day shift for wound healing of the left third toe. D/C Date: 07/23/2024. Review of Resident #6's TAR for July 2024 revealed no entry documented for the left third toe wound care on 7/20/2024. Review of Resident #6's physician order dated 7/12/2024 read, Cleanse open area with normal saline, apply Derma Blue foam with silver, ABD pad, and secure with retention tape, every day shift for wound healing of the right ischium for 30 days. Review of Resident #6's TAR for July 2024 revealed no entry documented for the right ischium wound care on 7/20/2024. Review of Resident #6's physician order dated 7/12/2024 read, Cleanse open area with normal saline, 105638 Page 2 of 3 105638 07/25/2024 Parklands Care Center and Rehab 1000 SW 16th Ave Gainesville, FL 32601

F 0842 Level of Harm - Minimal harm or potential for actual harm apply Derma Blue foam with silver, ABD pads, and secure with tape, every day shift for wound healing for 30 days. Apply to Sacrum. Review of Resident #6's TAR for July 2024 revealed no entry documented for sacral wound care on 7/15/2024 and 7/20/2024. Residents Affected - Many Review of Resident #6's physician order dated 7/12/2024 read, Cleanse open area with normal saline, apply Derma Blue foam with silver, pad with ABD, and secure with retention tape, every day shift for wound healing of the left buttock for 30 days. Review of Resident #6's TAR for July 2024 revealed no entry documented for the left buttock wound care on 7/15/2024 and 7/20/2024. Review of Resident #6's physician order dated 7/13/2024 read, Cleanse open area with normal saline, apply oil emulsion and cover with an island gauze daily, every day shift for wound healing of the right, dorsal, lateral, fourth toe, for 30 days. Review of Resident #6's TAR for July 2024 revealed no entry documented for the right, dorsal, lateral, fourth toe wound care on 7/15/2024 and 7/20/2024. During an interview on 7/25/2024 at 1:45 PM, Staff A, Licensed Practical Nurse (LPN), Wound Care Nurse, stated, I completed the wound care as ordered. I just have not been charting all the care that I provided. I do not always have access to a computer. During an interview on 7/25/2025 at 2:38 PM, the Director of Nursing stated that wound care was provided but not documented, and it was her expectation that wound care would be documented when provided. Review of facility policy and procedure titled Charting and Documentation revised in July 2017 read, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation . 2. The Following information is to be documented in the resident medical record . c. Treatments or services performed . 7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided. b. The name and title of the individual(s) who provided the care. 105638 Page 3 of 3