Health inspection·June 9, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from neglect. This neglect was evident when the facility failed to develop and implement protocols to ensure residents received necessary wound care and services through consistent in-house assessment of pressure injuries and oversight of contracted wound care practitioners; and nursing staff neglected to report abnormal findings and obtain appropriate treatments for 1 of 6 residents reviewed for acquired pressure injuries, out of a total sample of 10 residents, (#2). These failures contributed to resident #2's pressure injuries, a severe infection, and his subsequent death. Resident #2 suffered a life threatening illness, pain, discomfort permanent disfigurement, and impairment as a result of his worsening wounds until his death. On 4/09/23, ten days after admission to the facility, a nurse identified pressure injuries on resident #2's heels. The following day, a Wound Care Nurse Practitioner recommended a Podiatry consult for advanced care of the resident's wounds. The facility never arranged the Podiatry consult, and resident #2's basic pressure relieving mattress was not replaced with an appropriate specialty air mattress in a timely manner. Over the next three weeks, the wounds worsened and on 5/01/23, the Nurse Practitioner noted a new pressure injury on his left buttock. She recommended a specialty mattress that was not ordered until nine days later. The Nurse Practitioner requested a consultation with a vascular physician for the resident, but while he awaited an appointment, his wounds continued to decline. Although the Nurse Practitioner noted an odor from wound drainage, she did not order additional tests, medication, or collaborate with a physician. Resident #2's wounds developed pus-like drainage, a strong odor, and reddened edges, but none of the nurses who completed dressing changes notified the physician of the signs and symptoms of infection until 5/20/23 when the foul odor became intolerable. Resident #2 was transferred to the hospital by Emergency Medical Services personnel where he was diagnosed with sepsis, a life-threatening infection. He underwent surgery on the wounds to remove the dead and infected tissue which extended to his heel bones. Due to the resident's poor prognosis, he was admitted to a hospice center where he died two weeks later, on 6/03/23. The facility's failure to implement policies and procedures to prevent neglect and respond appropriately to potential and actual pressure injuries placed all residents who were at risk for pressure injuries at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy starting on 4/09/23. The Immediate Jeopardy was ongoing at the time of exit on 6/9/23. Findings: Page 1 of 15 106011 106011 06/09/2023 Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North Kissimmee, FL 34741

F 0600 Cross reference F607 and F686 Level of Harm - Immediate jeopardy to resident health or safety Review of the medical record revealed resident #2, an [AGE] year-old male, was admitted to the facility from the hospital on 3/30/23. His diagnoses included left humerus fracture, left hip fracture with joint replacement, generalized muscle weakness, type 2 diabetes, and dementia. Residents Affected - Few Care Services and Patient Transfer Form dated 3/20/23 revealed resident #2 had no pressure ulcers when he was discharged from the hospital to the facility. According to the National Pressure Injury Advisory Panel (NPIAP), a pressure ulcer or pressure injury .is localized damage to the skin and underlying soft tissue usually over a bony prominence. that results from prolonged pressure. An unstageable pressure injury is defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. In order for healing to occur, the necrotic or dead tissue must be removed or debrided if the wound was non-healing, draining, and/or appeared infected (retrieved on 6/19/23 from the website for National Pressure Injury Advisory Panel at www.npiap.com). On 6/07/23 at 8:32 AM, in a telephone interview, resident #2's daughter stated her father was admitted to the facility for short-term rehabilitation after hip replacement surgery. She explained her father was left in bed for most of his first week in the facility, and nursing staff began floating his heels only after the pressure injuries were identified. She stated the size of the wounds and the odor worsened, and she discussed her concerns with nurses and the Wound Care provider. She explained when she asked Certified Registered Nurse Practitioner (CRNP) G about getting a second opinion or if her father could be sent to the hospital for diagnostic imaging studies and/or debridement of his wounds, she disagreed. The daughter stated her father was eventually transferred to the hospital for sepsis related to his wounds. She stated hospital physicians tried intravenous antibiotics and surgical debridement of the wounds, but eventually offered amputation as the final option. The daughter explained the family decided against amputation due to her father's age and dementia diagnosis; instead, they chose hospice services. Review of the Minimum Data Set Discharge Return Anticipated assessment (MDS-3.0, v1.17.1) with assessment reference date of 5/20/23 revealed resident #4 had two unhealed pressure injuries that were not present on admission to the facility. On 6/07/23 at 1:40 PM, the Social Services Assistant (SSA) recalled resident #4's daughter frequently mentioned concerns about her father's worsening wounds and that she wanted to have additional testing done, but CRNP G deemed it unnecessary. The SSA stated she informed either the DON or the ADON of the concerns each time the resident's daughter brought issues to her attention. The SSA stated the DON and ADON would review the Wound Care practitioner's notes and they were going on that. On 6/07/23 at 3:26 PM, in a telephone interview, Wound Care CRNP G stated her organization was consulted when the facility identified pressure injuries on resident #2's heels. She acknowledged over the six-week period resident #2 was treated, his wounds were non-healing and did not improve. CRNP G was informed the resident's family and staff reported an odor from the wound during the resident's last ten days in the facility, which conflicted with her documentation in the medical record of no odor. CRNP G said, I never noticed an odor from the wound itself, but there was an odor from the drainage that was on the dressing. Once the wound was cleaned, it did not have an odor. When asked why she did not consider additional diagnostic tests such as wound cultures and labs when she noted an 106011 Page 2 of 15 106011 06/09/2023 Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North Kissimmee, FL 34741

F 0600 Level of Harm - Immediate jeopardy to resident health or safety odor, she said, .because I did not feel like it was infected. It did not look infected. CRNP G acknowledged she could not tell by the wounds' appearance alone, but there were no labs available, and she did not order any labs or other tests. CRNP G confirmed she did not collaborate with resident #4's attending physician, or a supervising physician and/or other Nurse Practitioner from her organization. She explained she met with the Director of Nursing (DON) once weekly when she visited the facility and told her resident #4's bilateral heel wounds were getting larger. Residents Affected - Few On 6/07/23 at 12:09 PM, the DON acknowledged resident #2 developed pressure injuries on both heels after admission to the facility. She recalled a discussion with CRNP G regarding the resident needing follow-up with a vascular physician but did not remember being told about any other concerns. The DON stated she was never informed the resident's wounds had an odor or any other signs and symptoms of infection until the day he was sent to the hospital. She denied knowledge of the daughter's request for diagnostic imaging because of the worsening condition of her father's heel wounds. The DON was informed the resident's medical record did not show nursing documentation of protective boots to prevent the development of pressure ulcers. She confirmed nurses did not record the appearance of the wound including odor and drainage when daily dressing changes were completed. The DON acknowledged when resident #4's wounds were assessed and determined to be greater than stage II wounds, his pressure relieving mattress should have been replaced with an appropriate specialty mattress. The DON was not able to explain why the medical record showed an appropriate mattress was not ordered for four weeks, by which time the resident had developed another pressure ulcer. On 6/07/23 at 4:17 PM and 6/08/23 at 8:50 AM, the DON stated the facility did not have a designated wound nurse on staff. She explained the decision was made at a higher administrative level and since then, each resident's assigned nurse was expected to accompany the contracted CRNP during weekly visits on his or her resident. The DON acknowledged assigned nurses worked varied schedules, shifts, units, and hallways, and also took vacations, so there was no single nurse who had a point of reference for comparison of wound status to determine the effectiveness of treatments. The DON validated in addition to the unreported concerning appearance and odor of the wounds as described by nurses, resident #4's medical record showed his blood glucose levels trending upwards during his final weeks in the facility. She confirmed elevated blood glucose levels could be indicative of an infection, but nurses did not identify and report the trend to the attending physician. The DON stated she reviewed the medical record and discovered during the resident's final week in the facility, nurses did not follow a physician's order to report blood glucose levels above 300 milligrams per deciliter on two days. The DON acknowledged there were no labs ordered for the resident to detect a possible elevated white blood cell count, and flowsheets indicated he had a decreased appetite in that last week, another possible sign of infection. The DON stated oversight of overall wound care and services and changes in resident status was the responsibility of both her and the Assistant DON (ADON). However, the DON verified she relied on verbal and written reports from the contracted Wound Care CRNP and never assessed wounds herself. Review of the contract between the Wound Care provider and the facility dated 3/22/22, revealed the facility was responsible for obtaining services that met professional standards. Review of the facility's policy and procedure for the Prohibition of Neglect, revised on 11/01/22, revealed neglect was defined as failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The document indicated the facility would provide ongoing oversight and supervision of staff to ensure its policies and procedures were implemented as written. The policy revealed prohibition of neglect included providing qualified staff who were knowledgeable of residents' 106011 Page 3 of 15 106011 06/09/2023 Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North Kissimmee, FL 34741

F 0600 care needs. Level of Harm - Immediate jeopardy to resident health or safety On 6/08/23 at 9:59 AM, Certified Nursing Assistant (CNA) A stated about two weeks before the resident went to the hospital there was a bad smell from his wounds. She said, It was a smell in the room. I noticed as soon as I walked in. At first I thought it was a bowel movement and when I cleaned him I still smelled it, so I figured it was the heels. CNA A stated she never reported the odor to the nurse or anyone else as the smell was strong enough for them to notice. CNA A recalled resident #2 was sleepier in the last few days and did not eat as much. She stated he kept falling asleep with food in his mouth, waking up and chewing a little but falling asleep with food in his mouth. CNA A stated a few days before the resident went to the hospital, she informed Registered Nurse (RN) B that something was different with the resident, but RN B did not seem to take her concerns seriously and commented that the resident ate well for everyone else. Residents Affected - Few On 6/08/23 at 10:25 AM, RN B confirmed the pressure injuries on resident #2's heels worsened over time. She stated she did daily wound care as ordered when she was assigned to the resident and in his final week in the facility, she noted the wound drainage was yellow and had a strong odor. She recalled each time she did the dressing change that week, the odor was worse, and the yellow drainage increased. RN B explained the odor was so strong that it was noticeable from the hallway. When asked what those signs and symptoms indicated, RN B responded, That is an infection. She stated she did not notify the physician and could not explain why she did not pursue the issue. On 6/08/23 at 11:07 AM, Licensed Practical Nurse (LPN) C recalled on 5/20/23, she entered resident #2's room to speak to RN B and noted she was performing wound care. LPN C said, I smelled the odor as soon as I entered the room. I looked at the wound and noticed the periwound area was red and there was yellow drainage. The odor was overwhelming. I was there for less than a minute and it was actually strong enough that I chose to leave the room. LPN C explained the odor, redness and yellow drainage were definitely signs and symptoms of infection so she told RN B she would call the attending physician. LPN C stated she was not assigned to the resident during the previous week but recalled overhearing staff mention that he was lethargic, weak, and had a decreased appetite in the previous days. On 6/08/23 at 11:24 AM, LPN D recalled over time, the drainage from resident #2's wound changed to a cream and tan color, the wound edges were red, and it developed a strong odor. She confirmed she did not notify the physician and said, I didn't document on the wound. I just click the computer to say I followed the order. LPN D stated on the last day she did the dressing change, approximately eight days before the resident was sent to the hospital, the odor was very bad and there was more drainage that had progressed to a yellow color. She confirmed she did not report her findings to the DON or the physician; instead, she continued to apply the wound treatment as ordered. LPN D acknowledged the signs and symptoms she described were associated with a wound infection and explained she did not report to anyone as she assumed CRNP G was aware of the condition of the wounds. On 6/08/23 at 1:30 PM and 6/09/23 at 3:29 PM, in telephone interviews with resident #2's attending physician, he stated he would have expected all staff involved in the resident's care to inform him of any changes in condition. He verified foul odors, redness, purulent drainage, and elevated blood glucose levels were all signs of infection. He stated he was not aware resident #2 had these issues during the two weeks preceding his transfer to the hospital. The attending physician confirmed he was never asked to collaborate with the Wound Care CRNP regarding the worsening status of the wounds. On 6/09/23 at 12:08 PM, the ADON stated her responsibilities included staff education. She 106011 Page 4 of 15 106011 06/09/2023 Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North Kissimmee, FL 34741

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few explained she had been on staff for about six months but had not yet been able to focus on wound care education or participated in wound rounds or wound observations. The ADON confirmed failure of nurses to conduct thorough wound assessments, report concerns, and obtain appropriate orders would be neglectful of the resident's care needs. She confirmed any abnormal or unexpected findings identified during wound care should be reported to a nursing supervisor, documented on a change in condition note, and reported to the physician. The ADON acknowledged consistency was essential for effective wound management, and this was not currently possible as there were no designated facility nurses who were knowledgeable of residents' wounds. She explained nursing documentation was important for identification of changes between the contracted providers' rounds. On 6/09/23 at 11:05 AM, in a telephone interview, the facility's Medical Director stated to his knowledge, the CRNPs reported to physicians who critiqued and reviewed their work. He explained nurses should have contacted the attending physician regarding any problems noted between the Wound Care CRNP's visits. When informed the facility did not assign a nurse to weekly rounds with the CRNP, and no member of nursing management visualized and monitored wound status, the Medical Director stated it warranted a recommendation. He acknowledged it was a standard of practice and his expectation that nurses would record findings noted during wound care, especially if there were signs and symptoms of infection. 106011 Page 5 of 15 106011 06/09/2023 Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North Kissimmee, FL 34741

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its Neglect prohibition policy and procedures related to an allegation of inadequate wound care services that led to a transfer to a higher level of care for 1 of 6 residents reviewed for acquired pressure injuries, out of a total sample of 10 residents, (#2). Residents Affected - Few Findings: Cross reference F600 and F686. Review of the medical record revealed resident #2, an [AGE] year-old male, was admitted to the facility from the hospital on 3/30/23. His diagnoses included left humerus fracture, left hip fracture with joint replacement, generalized muscle weakness, type 2 diabetes, and dementia. A data collection form dated 3/31/23 revealed on admission, resident #2's skin assessment showed a left hip surgical incision and no pressure injuries. Review of the medical record revealed a change in condition progress note dated 4/09/23 that revealed resident #2 developed pressure injuries on his heels. A skin and wound assessment progress note dated 4/10/23 revealed a Wound Care specialist, Certified Registered Nurse Practitioner (CRNP) G assessed the resident to evaluate and treat his heel wounds. The left heel wound measured 3.68 centimeters (cm width) x 3.37 cm (length) x 0.3 cm (depth), and the right heel wound measured 3.46 cm x 2.74 cm x 0.2 cm. The CRNP G's progress note dated 5/15/23 revealed over a five-week period, resident #2's wounds increased in size and progressed in stage. The note indicated the left heel wound measured 5.89 cm x 6.17 cm x 0.1 cm and the right heel wound measured 3.11 cm x 4.11 cm x 0.1 cm. Review of the medical record revealed resident #2 had change in condition and nursing progress notes dated 5/20/23 by Registered Nurse B noted resident #2's heel wounds were red around the edges, had yellow and brown drainage, and a strong odor. Licensed Practical Nurse C wrote she notified the resident's attending physician of the signs and symptoms of infection in the wounds with a change in his level of consciousness, and the physician ordered emergency transfer to the hospital. On 6/07/23 at 1:40 PM, the Social Services Assistant (SSA) recalled resident #4's daughter frequently mentioned concerns about her father's worsening wounds and she wanted additional testing done, but CRNP G deemed it unnecessary. The SSA stated she informed either the DON or the ADON of the concerns each time the resident's daughter brought issues to her attention. The SSA recalled after resident #2 was sent to the hospital, his daughter and son-in-law came to the facility and met with her, the Social Services Director (SSD), the Administrator, and DON. The SSA stated the resident's family asked if the facility wrote up a grievance about their concerns related to inadequate care of her father's pressure injuries. The SSA provided an incomplete grievance form dated 5/26/23 that she initiated on the day of the meeting and an email written by the SSD. The SSA explained the email was sent to the Wound Care organization and detailed the concerns raised by resident #2's daughter regarding improper wound care and services which resulted in significant harm. The SSA acknowledged the complaints made by resident #2's daughter were significant and possibly met the definition of neglect because they referred to necessary care and services not provided. 106011 Page 6 of 15 106011 06/09/2023 Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North Kissimmee, FL 34741

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's policy and procedure for the Prohibition of Neglect, revised on 11/01/22, revealed the facility would provide protections for the health and welfare of each resident. The document defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The document indicated the facility would provide ongoing oversight and supervision of staff to ensure its policies and procedures were implemented as written. The policy revealed prohibition of neglect included providing qualified staff who were knowledgeable of residents' care needs. The document indicated an immediate investigation was required in response to an allegation of Neglect, to include interviews of all involved persons or those who had knowledge of the allegation, and detailed documentation of the investigation. The policy specified reporting guidelines that included immediate reporting, not later than two hours, to State agencies, adult protective services, and/or law enforcement if the allegation involved serious bodily injury. Necessary post-investigation actions were to include analysis to determine why Neglect occurred and .how care provision will be changed and/or improved to protect residents receiving services. On 6/07/23 at 1:59 PM, the Administrator confirmed resident #2's daughter came to the facility and met with her on 5/26/23. She acknowledged the daughter informed her of concerns regarding wound care and services her father received in the facility, specifically from CRNP G. The Administrator validated she was the facility's Risk Manager and her responsibilities included determining if an occurrence was potentially abuse or neglect, completing a thorough investigation, and reporting to the required agencies. She explained the purpose of adhering to the policy and procedure was to protect all residents from abuse and neglect. The Administrator stated she did not perceive the concerns expressed by resident #2's daughter as a reportable allegation of neglect as it involved a contracted provider and not facility staff. She explained she did not collect statements from staff, interview CRNP G, or report the allegation of neglect to the required State agencies. When asked if the facility was ultimately responsible for the well-being of its residents, the Administrator did not respond. She stated the facility was responsible for reaching out to provider groups or consultants as indicated by the SSD's email, regarding care they provided for the residents. The Administrator stated a representative from Department of Children and Families came to the facility on 6/02/23 and informed her their agency received an allegation of neglect related to wound care services for resident #2, and she initiated an investigation only after that visit. 106011 Page 7 of 15 106011 06/09/2023 Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North Kissimmee, FL 34741

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent the development and worsening of pressure injuries; failed to provide wound care services consistent with professional standards of practice; and failed to identify and treat signs and symptoms of wound infection for 2 of 6 residents reviewed for acquired pressure injuries, out of a total sample of 10 residents, (#2 and #4). These failures contributed to resident #2's pressure injuries, a severe infection, and his subsequent death. Resident #2 suffered a life threatening illness, pain, discomfort, permanent disfigurement, and impairment as his wounds worsened until his death. Residents Affected - Few On [DATE], ten days after admission to the facility, a nurse identified pressure injuries on resident #2's heels. The following day, a Wound Care Nurse Practitioner recommended a Podiatry consult for advanced care of the resident's wounds. The facility never arranged the Podiatry consult, and resident #2's basic pressure relieving mattress was not replaced with an appropriate specialty air mattress in a timely manner. Over the next three weeks, the wounds worsened and on [DATE], the Nurse Practitioner noted a new pressure injury on his left buttock. She recommended a specialty mattress that was not ordered until nine days later. The Nurse Practitioner requested a consultation with a vascular physician for the resident, but while he awaited an appointment, his wounds continued to decline. Although the Nurse Practitioner noted an odor from wound drainage, she did not order additional tests, medication, or collaborate with a physician. Resident #2's wounds developed pus-like drainage, a strong odor, and reddened edges, but none of the nurses who completed dressing changes notified the physician of the signs and symptoms of infection until [DATE] when the foul odor became intolerable. Resident #2 was transferred to the hospital by Emergency Medical Services personnel where he was diagnosed with sepsis, a life-threatening infection. He underwent surgery on the wounds to remove the dead and infected tissue which extended to his heel bones. Due to the resident's poor prognosis, he was admitted to a hospice center where he died two weeks later, on [DATE]. The facility's failure to implement policies, procedures, and clinical guidelines related to promotion of skin integrity and prevention of pressure injuries placed all residents who were at risk for pressure injuries at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was ongoing at the time of exit on [DATE]. Findings: Cross reference F607 and F600. 1. Review of the medical record revealed resident #2, an [AGE] year-old male, was admitted to the facility from the hospital on [DATE]. His diagnoses included left humerus fracture, left hip fracture with joint replacement, generalized muscle weakness, type 2 diabetes, and dementia. Care Services and Patient Transfer Form dated [DATE] revealed resident #2's primary diagnosis when he was discharged from the hospital was left hip surgery. He was alert, oriented and followed instructions, and was deemed to have good rehabilitation potential. The document showed resident #2 had no pressure ulcers. 106011 Page 8 of 15 106011 06/09/2023 Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North Kissimmee, FL 34741

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few According to the National Pressure Injury Advisory Panel (NPIAP), a pressure ulcer or pressure injury .is localized damage to the skin and underlying soft tissue usually over a bony prominence. that results from prolonged pressure. Pressure injuries are classified or staged according to the severity of the wounds (retrieved on [DATE] from the website for National Pressure Injury Advisory Panel at www.npiap.com). Review of resident #2's hospital record revealed a Physical Therapy progress note dated [DATE]. The document described the resident as high risk for skin breakdown due to recent surgery and immobility, and included instructions to turn and reposition him every two hours. An admission Data Collection form dated [DATE] revealed resident #2 was admitted to the facility on [DATE] at 7:00 PM. The admission nurse noted the resident had a left hip surgical incision with staples, a left arm sling, and an old surgical scar on his right knee, The form indicated the resident's pressure ulcer risk score was 12 which deemed him to be at high risk. Review of the admission Minimum Data Set (MDS) assessment (MDS-3.0. v1.17.1) with assessment reference date (ARD) of [DATE] revealed resident #2 had a Brief Interview of Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The MDS assessment indicated the resident did not reject evaluation or care necessary to achieve the resident's goals for health and well-being. He required extensive assistance of two staff for bed mobility, was totally dependent on one staff member for toilet use and personal hygiene and was always incontinent of bowel and bladder. The document revealed the resident had a surgical wound and no pressure injuries. The MDS assessment showed the resident had pressure reducing devices for his bed and chair but was not on a turning and repositioning program. Review of the medical record revealed resident #2 had a care plan for activities of daily living self-care performance deficit, initiated on [DATE]. The interventions included skin inspections by nurses and Certified Nursing Assistants (CNAs) to observe for concerns such as redness or open areas and report to nurses. The care plan directed nursing staff to turn and reposition the resident in bed each shift and as necessary but did not specify every two hours as indicated in the hospital record. A care plan for potential for skin impairment and risk for pressure areas, initiated on [DATE], included goal that resident #2 would maintain or develop clean and intact skin. The interventions included pressure relieving / reducing mattress, identify and eliminate causative factors and report abnormalities, failure to heal, [signs and symptoms] of infection.weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. The facility's policy and procedure regarding pressure injury risk assessment, effective [DATE], revealed the most common site of a pressure injury was where a bone was near the surface of the body such as the heels. The guidelines indicated if pressure injuries were not treated promptly, they rapidly increase in size, and often become infected. The document read, Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Staff were expected to perform routine skin inspections daily or every other day as needed. Review of the medical record revealed resident #2's weekly skin assessment was not completed on [DATE]. Daily skilled nursing notes from [DATE] to [DATE] revealed nurses described resident #2's skin as warm and/or dry, but there was no documentation that thorough routine daily skin evaluations were conducted. The progress notes did not include any references to offloading heels or use of 106011 Page 9 of 15 106011 06/09/2023 Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North Kissimmee, FL 34741

F 0686 protective boots to prevent skin breakdown. Level of Harm - Immediate jeopardy to resident health or safety A change in condition progress note dated [DATE] revealed when resident #2's weekly skin assessment was completed, three days after it was due, staff discovered resident #2 had pressure injuries on his heels. Residents Affected - Few A skin and wound assessment progress note dated [DATE] revealed Wound Care specialist, Certified Registered Nurse Practitioner (CRNP) E saw resident #2 to evaluate and treat his heels. The document showed there were no concerns regarding the pulses and circulation in the resident's legs. The note indicated the resident had stage III pressure ulcers which involved full thickness tissue loss on both heels. The left heel wound measured 3.68 centimeters (cm) width x 3.37 cm length x 0.3 cm depth, and was described as acquired in house, with 50% healthy granulation tissue, and 50% slough / eschar or dead tissue. The medical record indicated the resident's right heel wound was also acquired in the facility, measured 3.46 cm x 2.74 cm x 0.2 cm, had 70% granulation tissue, 30% slough / eschar. Both heels had macerated periwound tissue that was soft and moist due to prolonged exposure to moisture, moderate amounts of pink to light red or serosanguinous drainage, and no odor. CRNP E's recommendations included offloading the resident's heels, applying protective heel boots, reducing pressure to bony prominences, and providing additional assistance with repositioning. The wound note read, Recommend Podiatry Consult for advanced care of lower extremity, staff aware. Review of resident #2's medical record revealed no physician order for a Podiatry consult nor any progress notes to show the recommendation was noted and discussed by the clinical team. A care plan for pressure injuries to both heels was initiated on [DATE] with goals including the resident's pressure injury will show signs of healing and have minimal risk of infection. The interventions directed nursing staff to apply the wound treatments ordered by the physician and monitor for effectiveness, assess and record wound healing, apply protective booties, follow policies and procedures to promote skin integrity, and document and report changes in skin condition. The document indicated resident #2 still required a pressure relieving device on his bed as noted in his admission care plan for risk for pressure injuries; however, it did not specify the type of mattress required to promote healing of the stage III wounds. The medical record revealed resident #2 was assessed weekly from [DATE] to [DATE] by another Wound Care specialist, CRNP G. Review of the wound care progress notes revealed on [DATE], one week after discovery and initial assessment, resident #2's heel wounds had worsened from full thickness stage III to unstageable pressure injuries. The note indicated the left heel wound had increased in size and measured 3.72 cm x 4.43 cm x 0.1 cm and the right heel wound measured 2.32 cm x 2.26 cm x 0.1 cm. An unstageable pressure injury is defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. In order for healing to occur, the necrotic or dead tissue must be removed or debrided if the wound was non-healing, draining, and/or appeared infected (retrieved on [DATE] from the website for National Pressure Injury Advisory Panel at www.npiap.com). A progress note dated [DATE] revealed CRNP G assessed resident #2's wounds and determined they were still unstageable. The note indicated the left heel wound measured 4.41 cm x 4.06 cm x 0.1 cm and the right heel wound measured 2.24 cm x 2.24 cm x 0.1 cm. Both wounds had serosanguinous drainage and no odor. CRNP G's recommendations included an arterial Doppler study of the resident's legs. This test uses ultrasound technology to detect blood clots and narrowed arteries that cause circulatory 106011 Page 10 of 15 106011 06/09/2023 Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North Kissimmee, FL 34741

F 0686 issues (retrieved on [DATE] from www.my.clevelindclinic.org). Level of Harm - Immediate jeopardy to resident health or safety On [DATE], CRNP G's progress note showed both wounds were larger and continued draining but had no odor. The left heel wound measured 5.27 cm x 5.89 cm x 0.1 cm and the right heel wound measured 3.64 cm x 4.27 cm x 0.1 cm. The document revealed a repeat recommendation for the arterial Doppler study. CRNP G also identified a newly acquired stage II pressure ulcer with partial thickness skin loss on resident #2's left buttock and recommended a specialty bed for pressure reduction and offloading. Residents Affected - Few Review of resident #2's bilateral lower extremity Doppler study dated [DATE] revealed a conclusion of suspected mild peripheral vascular disease. A nursing progress note dated [DATE] revealed resident #2's bilateral heel wound care was completed, and the nurse noted the wound edges were red. On [DATE], CRNP G assessed resident #2's wounds and noted his left buttock wound was healed, but his heels remained unstageable and had increased amount of serosanguinous drainage with no odor. CRNP G's documentation did not show a finding of periwound redness. The left heel wound had macerated edges and measured 5.05 cm x 5.15 cm x 0.1 cm and the right heel wound had increased in size to 4.71 cm x 4.23 cm x 0.1 cm. CRNP G gave treatment orders for Calcium Alginate, an enzymatic debridement agent, to be used on the pressure injuries, and skin protectant around the edges of the wounds. She recommended a consultation with a vascular specialist physician. A nursing progress note dated [DATE] revealed resident #2 complained of pain during wound care. Review of the medical record revealed no additional nursing progress notes for April and [DATE] to reflect documentation of the appearance and status of the resident's wounds during daily dressing changes. Review of the medical record revealed a physician order for a low air loss specialty mattress dated [DATE], nine days after CRNP G recommended the intervention. On [DATE], CRNP G's progress note indicated the left heel wound was larger, measuring 5.89 cm x 6.17 cm x 0.1 cm and the right heel wound measured 3.11 cm x 4.11 cm x 0.1 cm. CRNP G noted there was no odor from the wounds. Review of the medical record revealed resident #2 had change in condition and nursing progress notes dated [DATE] by Registered Nurse (RN) B showed resident #2's heel wounds were red around the edges, had yellow and brown drainage, and a strong odor. LPN C wrote she notified the resident's attending physician of the signs and symptoms of infected wounds, and a change in his level of consciousness. A physician order dated [DATE] revealed instructions to send resident #2 to the hospital Emergency Department due to signs and symptoms of infection of his unstageable bilateral heel wounds. On [DATE] at 8:32 AM, in a telephone interview, resident #2's daughter stated her father was admitted to the facility for short-term rehabilitation after hip replacement surgery. She explained she visited him in the facility every day and recalled when he developed wounds on his heels. The resident's daughter stated her father was left in bed for most of his first week in the facility, and nursing staff began floating his heels only after the pressure injuries were identified. She stated the 106011 Page 11 of 15 106011 06/09/2023 Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North Kissimmee, FL 34741

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few size of the wounds increased and his nurses noted a very bad odor. The daughter stated she discussed her concerns with nurses and the Wound Care provider. The daughter stated she became aware that despite the strong smell, the Wound Care documented there was no odor. She stated she asked the Wound Care nurse if her father could be sent to the hospital for debridement of his wounds, but CRNP G disagreed. The daughter recalled on [DATE], RN B contacted her to report that her father did not eat breakfast or lunch that day, and . that he looked bad, and the wound odor was worse. She explained her father was transferred to the hospital as a sepsis emergency and required intravenous antibiotics and surgical debridement of his heel wounds. She said, They told me it was already down to the bone and his situation was terminal. Resident #2's daughter stated her father remained in the hospital for one week before he was transferred to a hospice inpatient unit where he died. On [DATE] at 12:09 PM, the Director of Nursing (DON) confirmed resident #2 was at high risk for skin impairment due to immobility after hip surgery and her expectation was for staff to offload his heels with pillows and obtain an order for skin protectant for the heels if indicated, as the goal was to prevent pressure injuries rather than cure them. She explained resident #2 should have had skin inspections by CNAs every shift during care, daily full body skin assessments by nurses who completed skilled nursing notes, and once weekly assessments by a nurse. The DON confirmed resident #2's weekly skin assessment was not completed on schedule, and by the time it was done he had acquired pressure injuries on both heels which had gone unnoticed by CNAs and nurses who cared for him. The DON explained all the mattresses in the facility were appropriate for residents with stage II pressure injuries. She acknowledged once resident #2 was diagnosed with stage III pressure injuries, his mattress should have been upgraded to a specialty air mattress. The DON validated the medical record showed an appropriate mattress was ordered on [DATE], one month after the bilateral heel pressure injuries were identified, and more than a week after he developed a stage II pressure injury on his buttock. Review of the facility's equipment rental invoices for April and [DATE] revealed no evidence a specialty mattress was ordered and designated for resident #2. On [DATE] at 9:59 AM, CNA A stated for the first two weeks in the facility resident #2 was mostly in bed and she provided bed baths. She recalled after approximately two weeks, the resident's daughter requested showers for her father and staff started getting him out of bed. CNA A stated about two weeks before the resident went to the hospital there was a bad smell from his wounds. She said, It was a smell in the room. I noticed as soon as I walked in. At first I thought it was a bowel movement and when I cleaned him I still smelled it, so I figured it was the heels. CNA A sated she never reported the odor to the nurse or anyone else as the smell was strong enough for them to notice. On [DATE] at 10:25 AM, RN B stated she was regularly assigned to care for resident #2 and recalled the pressure injuries on his heels worsened over time. She explained he wore soft booties but usually drew his legs up and his heels pressed into the mattress. RN B stated she returned from vacation on Monday [DATE] and immediately noticed an odor and yellow drainage from the resident's wounds. She stated she informed the Wound Care CRNP verbally that day. RN B stated she was next assigned to resident #2 on Friday [DATE]. She said, .the wound odor was worse. It was so bad, it smelled in the room and the hallway. The daughter asked me to change the dressing that Friday and the odor was worse. When I took the dressing off the drainage was more yellow, dressing was saturated. RN B stated she informed the DON at some point but did not inform the physician. She recalled she was assigned to the resident again on Saturday [DATE] and noticed the odor was even worse than the day before, and resident #2 was not very responsive. On [DATE] at 11:07 AM, Licensed Practical Nurse (LPN) C recalled on [DATE], she entered resident 106011 Page 12 of 15 106011 06/09/2023 Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North Kissimmee, FL 34741

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few #2's room to speak to RN B and noted she was performing wound care. LPN C said, I smelled the odor as soon as I entered the room. I looked at the wound and noticed the periwound area was red and there was yellow drainage. The odor was overwhelming. I was there for less than a minute and it was actually strong enough that I chose to leave the room. LPN C explained the odor, redness and yellow drainage were definitely signs and symptoms of infection so she told RN B she would call the attending physician. On [DATE] at 11:24 AM, LPN D recalled resident #2's daughter was present on two occasions when she did his dressing change and commented the wounds did not look good. She could not recall the date, but remembered the drainage from the wound was cream to tan-colored and the wound edges were red. LPN D stated she did not notify the physician, instead she told the resident's daughter she would mention it to Wound Care CRNP G on her next visit. LPN D said, I didn't document on the wound. I just click the computer to say I followed the order. She recalled on the day she attempted to speak to CRNP G, the practitioner stopped her and stated she had already spoken to the resident's daughter regarding the wounds. LPN D looked at her datebook and stated she thought she last did the resident's dressing change on Friday [DATE]. She described the wound odor that day as very bad but said she did not report it to anyone and continued to apply the treatment as ordered. LPN D acknowledged resident #2 exhibited signs and symptoms of a wound infection. Review of the facility's policy and procedure for wound dressings dated [DATE], instructed nurses to complete a wound assessment whenever a soiled dressing was removed. The document read, This includes a visual check and comparing and evaluating the smell, amount of blood or ooze (excretions) and their color, and the size of the wound.If the site has not improved as expected, then the treating physician or the senior charge nurse must be informed so they too can evaluate it and consider changing the care plan. The policy indicated nurses were to document wound assessment findings in the medical record. On [DATE] at 3:26 PM, in a telephone interview, Wound Care CRNP G stated she initially assessed resident #2 on [DATE] to evaluate his left hip surgical wound. She explained she conducted a full skin assessment noted no other areas of concern on his body. CRNP G stated the resident was at high risk for skin breakdown and she would have expected preventative measures to have been initiated on admission including floating his heels and regular skin evaluations according to the facility's policy. She stated her organization was consulted when the facility identified pressure injuries on the resident's heels, and by the time she saw him, a week after CRNP E's initial assessment, the ulcers had worsened and progressed to unstageable wounds. She explained she chose not to debride the resident's heel wounds until he was seen by a Vascular physician to determine the status of his circulation. She acknowledged over the six-week period resident #2 was treated, his wounds were non-healing and did not improve. CRNP G was informed the resident's family and staff reported an odor from the wound during the resident's last ten days in the facility, which conflicted with her documentation in the medical record of no odor. CRNP G said, I never noticed an odor from the wound itself, but there was an odor from the drainage that was on the dressing. Once the wound was cleaned, it did not have an odor. When asked why she did not consider additional diagnostic tests such as wound cultures and labs when she noted an odor, she said, .because I did not feel like it was infected. It did not look infected. CRNP G acknowledged she could not tell by the wounds' appearance alone, but there were no labs available, and she did not order any labs or other tests. She recalled when she visited the facility on [DATE], staff informed her resident #2 had been transferred to the hospital over the weekend. On [DATE] at 4:17 PM and 4:47 PM, the DON reviewed the resident's medical record and found no change in condition forms or nursing documentation of the signs and symptoms of a wound infection as 106011 Page 13 of 15 106011 06/09/2023 Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North Kissimmee, FL 34741

F 0686 Level of Harm - Immediate jeopardy to resident health or safety described by assigned nursing staff and CRNP G, until [DATE] when he was transferred to the hospital. She stated her expectation was nurses would notify her and the attending physician of such concerns between CRNP G's weekly visits, but she was never made aware of these concerns. The DON reviewed cover pages of CRNP G's weekly reports and validated there was no notification of resident #2's worsening wound status. The DON validated no labs were ordered for resident #2 during his entire stay in the facility, neither for a baseline or to monitor for signs of infection. Residents Affected - Few Review of the facility's policy and procedure for pressure injuries and skin breakdown, effective [DATE], revealed the wound nurse would collaborate with staff to .review and modify the care plan as appropriate, especially when wounds are not healing as anticipated. On [DATE] at 11:05 AM, in a telephone interview, the facility's Medical Director explained nurses should have contacted the attending physician regarding any problems noted between the Wound Care CRNP's visits. He expressed surprise that nobody reported such a strong wound odor to the DON. The Medical Director was informed although CRNP G documented no wound odor, she explained there was an odor from the drainage but not from the wound after it was cleaned. He acknowledged that once the wound was cleaned there might not be an odor, but if the drainage had an odor it should have been addressed. 2. Review of the medical record revealed resident #4 was admitted to the facility on [DATE]. Her diagnoses included acquired left heel pressure injuries and osteomyelitis or bone infection of the left ankle and foot. The Significant Change in Status MDS assessment (MDS-3.0, v1.17.1) with ARD of [DATE] revealed resident #4 had two unstageable pressure injuries that were not present on admission. The MDS assessment indicated the resident had a pressure reducing device for her bed, received pressure injury care, but was not on a turning and repositioning program. Review of the medical record revealed resident #4 had a care plan for an unstageable left heel pressure area initiated on [DATE]. The interventions included administer treatments as ordered and monitor for effectiveness, and follow facility policies for prevention and treatment of skin breakdown. Review of a nursing progress note dated [DATE] revealed resident #4 went to podiatry appointment and returned with new physician orders for her left heel wound. A physician treatment order dated [DATE] instructed nurses to clean resident #4's left heel wound with normal saline, apply Endoform, and cover with gauze wrapping three times weekly to promote wound healing. Endoform is a collagen dressing that provides an environment which promotes epithelialization and results in formation of new tissue (retrieved on [DATE] from the website, WoundSource at www.woundsource.com). The Treatment Administration Record for [DATE] revealed RN F's initials to verify she completed the dressing as ordered on [DATE] and [DATE]. On [DATE] at 12:37 PM, RN F was asked to show the treatment supplies she used to complete resident #4's wound care that morning, for reconciliation with the revised physician order. She checked both treatment carts on the unit and was not able to locate Endoform. RN F returned to the treatment cart located near resident #4's room and retrieved a bottle labeled Iodoform. Iodoform-soaked gauze strips are used to pack and treat infected wounds (retrieved on [DATE] from the website, the National 106011 Page 14 of 15 106011 06/09/2023 Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North Kissimmee, FL 34741

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Institutes of Health, National Library of Medicine, Pub Med at www.pubmed.ncbi.nlm.nih.gov). RN F said, That's what I used this morning. On [DATE] at 12:56 PM, the DON and Assistant DON (ADON) observed as RN F removed resident #4's left foot dressing and exposed a strip of Iodoform gauze, approximately three inches long, that was coiled on top of the pressure injury on her heel. Residents Affected - Few On [DATE] at 12:58 PM and 1:19 PM, the DON confirmed Iodoform was to be used in wounds that were deep enough to require packing. She validated the dressing was not the one ordered by the podiatrist and not appropriate for resident #4's wound. The DON stated her expectation was nurses would read physician orders carefully, clarify if necessary, and apply treatments as ordered. She acknowledged the error and instructed RN F to notify resident #4's attending physician, the Medical Director. Review of the Facility Assessment Tool dated [DATE], revealed the facility could provide pressure injury prevention and wound care and services. The document indicated staff competencies were based on current standards of practice and the needs of the residents. 106011 Page 15 of 15