Health 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. Page 1 of 2 105779 105779 11/04/2021 Healthpark Care Center 16131 Roserush Court Fort Myers, FL 33908

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/2/21 at 4:30 p.m., in an interview, the Director of Nursing (DON) said the surgical staples can be removed at the facility or at the follow-up appointment. The DON confirmed the facility should have communicated with the surgeon to find out when he wanted the staples removed. The DON said, We missed it and I will add surgical wound site management to the performance improvement plan (PIP) I currently have for wounds. I recognize it is a problem that none of the staff confirmed what the treatment plan was for this resident. 105779 Page 2 of 2