Health inspection·January 14, 2021

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility policies and procedures and staff interview, the facility failed to maintain documentation of accurate skin evaluation and interventions to prevent the development of pressure injury for 1 (Resident #372) of 3 residents reviewed with wounds. Residents Affected - Few The findings included: Review of the facility's policy and procedure titled Pressure Injury Risk Assessment with a revision date of 1/7/20 revealed the purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure injury(s). The general guidelines of the policy noted Pressure injury(s) are usually formed when a resident remains in the same position for an extended period of time causing pressure or a decrease circulation (blood flow) to that area, which destroys the tissues . A pressure injury risk assessment will be completed upon admission, with each additional assessment; quarterly, annually and with significant changes .Because a resident at risk can develop a pressure injury within 2 to 6 hours of the onset of the pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure injury(s) .Skin will be assessed for the presence of developing pressure injury(s) on a weekly basis or more frequently if indicated. Review of the clinical record revealed Resident #372 was admitted on [DATE] with a diagnosis of right femur fracture and weakness. Resident #372 required assistance with personal care. On 1/11/21 at 10:00 a.m., during an interview Resident #372 said she was living independently at home, had a fall and fractured her right leg. The resident said she was receiving physical and occupational therapy at the facility. Review of the admission skin assessment dated [DATE] revealed Resident #372 had a right hip surgical site with 17 staples. The skin assessment did not document the presence of a pressure injury. Review of the admission Braden scale (tool used to predict pressure ulcer risk) revealed Resident #372 scored a 17 indicating the resident was at risk for developing a pressure injury. The MDS (Minimum Data Set) assessment with a target date of 11/9/20 revealed Resident #372 was not admitted with a pressure ulcer and required extensive physical assistance of 2 persons for bed mobility, transfer, and toilet use. The care plan (documents interventions to address the resident's needs) initiated on 11/20/20 Page 1 of 4 105738 105738 01/14/2021 Solaris Healthcare Imperial 900 Imperial Golf Course Blvd Naples, FL 34110

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documented Resident #372 was not able to complete activities of daily living independently due to a recent hip fracture. Review of the weekly skin observation dated 11/25/20 revealed documentation Resident #372 scored a 16 (at risk) on the current pressure ulcer risk score. The nurse documented none on the skin Treatment/Interventions. Review of the weekly skin observation dated 12/2/20 revealed documentation Resident #372 scored a 0 (very high risk) on the current pressure ulcer risk score. The nurse documented none on the skin Treatment/Interventions. Review of the physician's progress note dated 12/18/20 revealed Resident #372 developed a stage 2 (wound that expands into deeper layers of the skin) pressure ulcer on the buttocks midline measuring 1.6 centimeters (cm) in length by 0.5 cm in width and 0.1 cm in depth., with 20% of the wound covered in necrotic yellow slough (dead tissue). The physician documented excision of the necrotic (dead tissue) yellow slough. On 12/23/20 the nurse documented Resident #372 scored a 0 (very high risk) for a pressure ulcer, had no wound or red areas and had no skin treatment or intervention. The skin observation was not accurate and did not document the presence of the pressure ulcer acquired at the facility. On 1/14/21 at 9:12 a.m., in an interview, the Director of Nursing (DON) confirmed Resident #372 had an in house acquired pressure wound. She provided an undated, typed paper which she signed that read Pressure relieving w/c [wheelchair] cushion on admit, house barrier cream [brand name] applied since admit, added low loss air mattress with sign of skin breakdown (split in the crease started) put on by nurse. Treatment ordered. On 1/14/21 at 11:19 a.m., in an interview, the Registered Nurse (RN) designated Wound Care RN, said each nurse working is responsible to complete the weekly assigned skin observations as assigned. The RN said she does weekly wound rounds with the wound care physician. The RN said she does not review the weekly skin observations once they were completed. On 1/14/21 at 12:00 p.m., in an interview, the DON said there was no process in place for the review of the weekly skin observations to ensure they were accurate. The DON said she was aware of the missing skin observations and inaccurate documentation on the skin observation forms. On 1/14/21 at 12:13 p.m., with Resident #372's consent the wound was observed. Observed an open area to the coccyx Approximately 1.0 cm by 0.5 cm., with redness to the surrounding skin extending approximately 3.0 cm. 105738 Page 2 of 4 105738 01/14/2021 Solaris Healthcare Imperial 900 Imperial Golf Course Blvd Naples, FL 34110

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, review of the facility's policies and procedure, resident and staff interview, the facility failed to maintain appropriate infection prevention practices in the management of the urinary catheter tubing and collection bag to prevent potential contamination and infection for 2 (Resident #372 and #25) of 5 sampled residents with indwelling urinary catheters. The findings included: The facility's policy titled Catheter Care, Urinary with a revision date of 1/7/20 read The purpose of this procedure is to prevent catheter-associated urinary tract infections. The policy specified to use standard precautions when handling or manipulating the drainage system and be sure the catheter tubing and drainage bag are kept off the floor. 1. Review of the clinical record revealed Resident #372 had a Foley catheter inserted in the bladder to drain urine due to an obstruction. The MDS (Minimum Data Set) assessment with a target date of 11/9/20 revealed Resident #372 required extensive physical assistance of 2 persons for bed mobility, transfer, and toilet use. On 1/11/21 at 10:00 a.m., Resident #372 was observed in a wheelchair. The urinary drainage tubing was resting on the floor next to the wheelchair. Resident #372 said the catheter was inserted the night prior but could not recall the reason. Resident #372 was not aware the tubing of the drainage bag was on the floor and was not able to adjust the tubing without staff assistance. ** Photographic evidence obtained** On 1/11/21 at 12:46 p.m., Resident #372's urine collection bag was observed stored in a privacy bag. The privacy bag was on the floor next to the resident. ** Photographic evidence obtained** 2. Review of the clinical record revealed Resident #25 had a diagnosis of urinary retention requiring the use of a Foley catheter. Review of the laboratory results revealed on 12/25/20 Resident #25 was diagnosed with a urinary tract infection. On 1/11/21 at 11:02 a.m., Resident #25 was observed in a wheelchair. The emptying spout of the catheter's drainage bag was resting on the floor. Resident #25 was not able to provide information regarding the placement of the catheter drainage bag. On 1/13/21 at 9:00 a.m., and 1/14/21 at 9:00 a.m., Resident #25 was observed in bed. The catheter's drainage bag was resting on the metal base of the over the bed table. **Photographic evidence obtained** 105738 Page 3 of 4 105738 01/14/2021 Solaris Healthcare Imperial 900 Imperial Golf Course Blvd Naples, FL 34110

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/14/21 at 9:13 a.m., in an interview, Registered Nurse Staff A said catheter drainage bags were to be covered and off the floor. Staff A confirmed Resident #25's catheter drainage bag was not covered and was not positioned to prevent contact with the frame of the bedside table. On 1/14/21 at 9:18 a.m., in an interview, Certified Nursing Assistant Staff N said catheter drainage bags were to be off the floor and in a privacy bag. 105738 Page 4 of 4