Inspection·November 4, 2021

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, policy review, resident and staff interview the facility failed to have documentation of physician's orders for follow up care of surgical incision for 1(Resident #246) of 5 residents reviewed with wounds. Residents Affected - Few The findings included: Facility policy #205, revised 12/20, titled, Wound and pressure Injury Assessment, Treatment and Prevention, defined surgical wound as a physical disruption of the skin caused by a cutting instrument. Policy stated, . Comprehensive assessments must be completed by the registered nurse and documented in the clinical record . Call physician for wound care/dressing change orders if none available on admission . Surgical wound . Dressing as per surgeon orders . Document daily on progress and healing . Alert MD [Physician] to any changes . On 11/1/21 at 10:53 a.m., Resident #246 was observed in wheelchair with left leg elevated. Surgical wound with visible staples to left knee observed. Resident #246 said he was concerned he had the staples for 16 days. The Resident said he knew they should come out in 10 days to 2 weeks. The Resident said, They haven't told me anything about when they will come out. I don't want to get an infection or something. On 11/2/21 at 12:10 p.m., Resident #246 was observed in bed, staples continued to left knee surgical site, resident remained unaware of when they would be removed. On 11/2/21 review of the clinical record revealed on 10/13/21 Resident #246 had a left knee arthroplasty (Surgical reconstruction or replacement of joint). The record had no physician orders for management of surgical incision, including the removal of the staples. On 11/2/21 at 3:50 p.m., in an interview Licensed Practical Nurse (LPN) Staff A said the care of the staples are based on the individual physician's orders. Upon review of the clinical record, LPN Staff A said she was unable to find any information or physician orders addressing the resident's staples to left knee surgical site. On 11/2/21 at 4:00 p.m., Charge Nurse RN Staff B, reviewed Resident #246 electronic medical record and confirmed she was unable to find documentation of physician's orders for follow up care of the surgical incision and staples for Resident #246's left knee. (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: 105779 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 105779 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthpark Care Center 16131 Roserush Court Fort Myers, FL 33908 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)