Health inspection·August 27, 2024

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical and administrative record review, and interview, the facility staff failed to ensure that 2 of 3 sampled residents, Resident # 1 and #2, received the necessary care and services as related to the resident's gastrostomy tube and site and skin assessments, as evidenced by the facility failure to provide evidence that care and services were provided for a resident with a gastrostomy tube, failed to properly assess and provide evidence of care and services for a gastrostomy tube site after removal, and failed to provide evidence that weekly skin assessments were completed for residents. Residents Affected - Few The findings included: Review of the facility's policy and procedure for Administering Medications through an Enteral Tube, revised 01/2024, documented, in part, the following regarding Enteral Tube Care: 1. Cleanse enteral feeding site per the physician orders. Typically, one time per day with normal saline or soap and water. May leave enteral feeding site open to air or cover with a dry dressing as needed. 2. Change enteral feeding syringe per the physician orders. Typically, one time per day. Store in hygienic manner in the resident's room. 3. Check residual per the physician orders. Typically, every shift. Hold medications and enteral feeding if residual is greater than 60 ml and notify the physician. Review of the facility's policy regarding Standards and Guidelines: Prevention of Skin Impairments / Pressure Injury, revised 01/2024, documented, in part: Review the resident's care and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Procedure included for Risk Assessment: 1. Assess the resident on admission for existing wound risk factors. 2. Conduct a comprehensive assessment upon admission including: a. Skin integrity - any evidence of existing or developing pressure ulcers or injuries. b. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Inspect the skin when performing or assisting with personal care or ADLs. Page 1 of 4 105911 105911 08/27/2024 Westgate Health and Rehabilitation Center 2300 Village Blvd West Palm Beach, FL 33409

F 0684 a. Identify any signs of developing skin wound (i.e. nonblanchable erythema/rashes). For darkly pigmented skin, inspect. Level of Harm - Minimal harm or potential for actual harm for changes in skin tone, temperature, and consistency. Residents Affected - Few b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). c. Wash the skin after episodes of incontinence d. Reposition resident as indicated on the care plan. 1. Review of the clinical record for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction affecting left non-dominant side, and Respiratory Failure. The admission assessments documented the resident had a PEG tube (percutaneous endoscopic gastrostomy) in her abdomen. Review of the physician orders revealed the physician prescribed for the resident to receive her medications via the PEG tube. Further review of the physician orders failed to provide evidence of orders prescribing for gastrostomy tube daily care being provided to the PEG tube, and there were no orders prescribing for checking residual or providing water flush to the tube. Review of the Medication and Treatment Administration Record (MAR, TAR) for February 2024 provided evidence that the nursing staff placed their initials in the appropriate boxes to indicate the medications were administered via the PEG tube, but the administration records failed to provide evidence that the staff provided care and services to the PEG tube site. On 03/02/24 at 3:01 AM, the nurse documented, Resident vomits x 1 and had a bowel movement Resp(respirations) even and unlabored with no distress - VS (vital signs): B/P (blood pressure) 126/72, P (pulse) 82, R (respirations) 20, T (temperature) 97.9, 02 sat [oxygen saturation] 96% on room air - Head of bed elevated to prevent aspiration - ARNP [Advance Registered Nurse Practitioner] notify - Will continue to monitor. On 03/02/24 at 8:57 AM, the nurse documented, Upon observation this am, patient noted with projectile vomiting, green bile. Patient v/s taken and noted. Patient denied any pain. Bowel sounds absent. Patient md [physician] made aware orders given to send patient out to hospital, patient daughter made aware and requested a specific hospital, medics called awaiting arrival. The hospital gastroenterologist documented on 03/02/24, Impression - Nausea and vomiting secondary to migrated PEG tube distally into the jejunum causing partial obstruction. CT [computerized tomography] reports j-tube but actually this is a PEG tube placed January 2, 2024, which seems replaced with Foley Catheter and as Foley Catheter does not have external bumper migrated with her per status is into jejunum. Constipation Fecal Impaction. The Progress note further documented the physician removed the Foley Catheter and a 20 French PEG tube was placed instead and left eternal bumper at 5 cm. Another gastroenterologist progress note, addendum on 03/04/24 at 6:44 PM, documented the PEG tube was removed per patient and family request. 105911 Page 2 of 4 105911 08/27/2024 Westgate Health and Rehabilitation Center 2300 Village Blvd West Palm Beach, FL 33409

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The resident was discharged from the hospital and readmitted to the facility on [DATE]. The admission nursing note on 03/04/24 at 10:19 PM did not provide any assessment or documentation regarding the resident's PEG tube site. The admission summary, dated [DATE] at 11:31 PM, documented the following: a skin assessment was done, no skin issue noted, the exception of skin tag noted to left upper scapula and peg removal site, dressing is clean and dry, no drainage, no irritation nor swollen noted. Review of the twenty-one physician progress notes from 03/06/24 through 05/31/24 documented the same notation for skin - no rash or lesions abdominal dressing was C/D/I [clean, dry and intact]. Further review of the physician orders did not provide documentation of physician prescriptions prescribing for care, dressing changes and/or treatment to the site of the recently removed PEG tube. An interview was conducted on 08/27/24 at approximately at 3:15 PM with the Licensed Practical Nurse, Staff A. Staff A was the nurse who sent the resident to the hospital on [DATE] with nausea and vomiting. She stated when she came on duty, the resident was sitting in a wheelchair, and she noticed she had vomited and had the green bile on her clothing. She had assessed the resident and did not hear any bowel sounds. She called the physician, and he said to send the resident out to the hospital and then she called the resident's daughter, who requested to send the resident to a specific hospital. The surveyor asked Staff A regarding the care and services for the PEG tube. She stated the resident ate by mouth and medications (meds) were by the PEG tube. She stated the PEG tube dressing would have been done on the night shifts. She confirmed she did not see a physician order for the care and services for the PEG tube. The surveyor asked about what the PEG tube site looked like post hospitalization. She stated she doesn't specifically remember but confirmed the assessment did not provide a thorough picture of the site and did not verify whether the site was open or closed. She stated if the site was opened, it would usually close within 2 weeks. The surveyor explained that the documentation was misleading because the initial nursing note documented the dressing was clean and dry. The nurses were not completing the weekly skin checks; and the skin checks completed did not provide information on the PEG tube site. Review of the Nurse Practitioner's notes were the same and were documenting there was an abdominal dressing that was clean and dry for over 2 and 1/2 months after the resident returned to the facility. An interview was conducted on 08/27/24 beginning at approximately 3:45 PM with the Advance Registered Nurse Practitioner (ARNP) who stated she normally would check the G-tube dressings to ensure staff are performing the dressing changes. She stated she would prescribe the care and services of dressing changes, flushes, and to check residual for the G-tubes. She did not know what happened with Resident #1 and there not being orders regarding care and services for the resident during her stay in the facility. The surveyor asked the ARNP about the PEG tube site once it was removed because all her notes were the same and documented that the dressing was C/D/I [Clean, Dry, and Intact]. The surveyor inquired whether the site was open or closed upon admission and thereafter. The ARNP was unable to confirm the appearance of the PEG tube site upon admission and during the resident's 2nd admission to the facility. She again stated that she normally would have lifted the dressing to view the area. She stated that once a PEG tube is removed, the amount of time when the site closes varies but it will usually close within two weeks. She confirmed that the site, if open, would need a daily dressing change and need monitoring for signs of infection, etc. She further stated that she would 105911 Page 3 of 4 105911 08/27/2024 Westgate Health and Rehabilitation Center 2300 Village Blvd West Palm Beach, FL 33409

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few normally prescribe for daily dressing changes until the area closed. She confirmed that this was not done for Resident #1, and she further confirmed that the skin assessment on progress notes were carried over and not changed. Further review of the clinical record for Resident #1 revealed the staff failed to complete the weekly skin assessments for the resident. Review of the plan of care revealed a concern as, The resident is at risk for skin impairment r/t (related to) diabetes, neuropathy, risk for malnutrition, use of anticoagulant/antiplatelet medications, weakness/decreased mobility, s/p (status post) tracheostomy. The interventions included: .Skin checks weekly and as indicated; Report any s/s of skin breakdown to MD/wound team as indicated. Review of the assessment completed for the resident revealed the facility completed an assessment on admission. There were no further weekly skin assessments until 03/06/24 (3 weeks later, the readmission to the facility after a 4-day hospitalization). The next weekly skin assessment was completed on 04/14/24 (more than 5 weeks later). The next weekly assessment was completed on 05/03/24 (over 2 weeks later). An interview was conducted on 08/27/24 at approximately 3:15 PM with Staff A. She stated that when the admission assessments are completed it is placed in the computer and the computer will generate the task of performing the weekly assessments. She had no explanation why the assessments were not completed. 2. Review of the clinical record for Resident #2 revealed the resident was admitted to the facility on [DATE] with a diagnosis of Osteomyelitis of the Vertebrae, Sacral and Sacrococcygeal region. The admission assessment documented a Stage IV pressure in the sacrum and left upper quadrant PEG tube. The 06/07/24 Wound Evaluation identified a Stage IV sacrum wound measuring 4.2 x 3 x 1.2 cm. Further review of the assessments for the resident revealed a 06/10/24, 06/17/24 and 06/24/24 weekly skin assessments. After the resident was readmitted to the facility on [DATE] after a brief hospitalization, a 07/06/24 weekly skin assessment documented the sacrum wound and noted ongoing treatment to her sacrum and left knee. There was no other acute skin alterations noted. Further review of the clinical record on 08/27/24 failed to provide evidence of additional weekly skin assessments completed for the resident after the date of 07/06/24 (over 7 weeks). Review of the 07/07/24 5-day Minimum Data Set Assessment (MDS) documented the resident is at risk for the development of pressure ulcers and the resident had 1 Stage IV unhealed pressure ulcer. A skin observation for Resident #2 was conducted on 08/27/24 at 2:05 PM with the Certified Nursing Assistants, Staff B and Staff C. The observation revealed a dressing on the sacrum dated 08/27/24. There were no further skin issues identified at this time. 105911 Page 4 of 4