Health inspection·March 2, 2023

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, record review, review of the facility's protocol, Resident and staff interviews, the facility failed to implement preventive measures to prevent the development of pressure ulcers for 1 (Resident #13) of 1 resident at risk for pressure ulcer. Residents Affected - Few The findings included: The facility's Pressure Ulcer Treatment and Prevention Protocol, revised in November 2022, noted the protocol provides guidelines for the assessment of skin integrity; interventions for the prevention and treatment of impaired skin integrity; and the evaluation and modification of the plan of care related to the resident's skin integrity. Prevention and intervention measures are placed in the resident plan of care. The protocol listed the following risk factors that increase the resident's susceptibility to develop or have impaired-healing pressure injuries: Impaired/decreased mobility; co-morbid conditions; drugs that affect wound healing; impaired diffuse or localized blood flow; resident refusal of some aspects of care and treatment; cognitive impairment; exposure of skin to urinary and fecal incontinence; under nutrition, malnutrition, and hydration deficits, and a history of a healed pressure injury and its stage. Residents are assessed for pressure injury risk factors using the Braden Scale for predicting pressure sore risk. The pressure injury prevention intervention should be initiated on residents with a Braden Scale of 18 or less and/or found at high risk for pressure injury. Recommended Nursing Interventions included: Assess for nutrition and rehabilitation needs and discuss obtaining consults; Utilize repositioning techniques, heel protection, special positioning devices, and specialty beds; Provide supportive devices to support position changes; Frequency of repositioning is based on resident condition and tolerance; Protect heels and elbows with dressings or pads; The health care provider is notified and asked to reevaluate any non-healing wound after a two week period; Document reasons why interventions were not appropriate or feasible. Review of the clinical record for Resident #13 revealed an admission date of 2/2/2022 with diagnoses including but not limited to heart disease, heart failure, and high blood pressure. Upon admission, Resident #13 scored 18 on the Braden scale indicating the resident was at risk for development of pressure ulcers. The admission Minimum Data Set (MDS) assessment with an assessment reference date of 2/5/22, and the quarterly MDS dated [DATE] noted the resident's skin was intact but she was at risk for development of pressure ulcers. Resident #13 required extensive physical assistance of two persons for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). Resident #13's cognition was intact. The care plan initiated on 2/2/22 noted Resident #13 was at risk for skin breakdown (history of skin tears/fragile skin, needs extensive to total assistance with positioning, incontinent of bowel and bladder). The approaches as of 2/2/22 included to monitor the skin during routine care and toileting, report any concerns to the charge nurse or the physician for follow up; Weekly skin checks during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106062 If continuation sheet Page 2 of 4 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 106062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bentley Care Center 875 Retreat Drive Naples, FL 34110 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)

F 0686 shower/baths. Level of Harm - Minimal harm or potential for actual harm The care plan did not list any individualized approaches to prevent the development of pressure ulcers as per the facility's protocol. Residents Affected - Few Review of the weekly skin integrity assessments revealed on 10/26/2022, Resident #13 developed a right heel dark fluid filled pustule measuring 3.4 centimeters (cm) in length by 4.2 cm in width. The Registered Nurse completing the assessment noted to continue current plan of care. Review of the Medication Administration Records (MARs) from 8/2022 through 2/28/22 revealed to apply Blue Boots (pressure relieving boots) to heels at bedtime starting on 10/26/2022 after Resident #13 developed the pressure ulcer to the right heel. On 10/26/22 the care plan was updated to include Resident #13 had an unstageable (cannot see the base of the ulcer to determine the stage) to the right heel. The goal was for the unstageable to the right heel showing improvement. The care plan did not list approaches to prevent the development of additional pressure ulcers. On 10/28/22 the Registered Dietitian (RD) documented in a progress note Resident #13's had a slow decrease in weight in the past six months. Resident #13 refused [brand name] supplement. She discontinued the supplement. The note did not address the unstageable area to the right heel and nutritional interventions to promote healing. On 11/11/2022 Licensed Practical Nurse (LPN) Staff M documented in a progress note the resident's right heel bruise was leaking serosanguineous (yellowish drainage with small amount of blood) fluid. On 1/3/23 a Standard low air loss mattress (specialized mattress to help keep the skin dry, relieve pressure to prevent pressure ulcers) was added to the care plan. On 1/13/23, Resident #13 was admitted to hospice services. On 2/27/23 at 3:30 p.m., Resident #13 was observed sitting in a wheelchair with both feet on the floor. Resident #13 had a blue heel protector on the right foot. The left heel was not offloaded. Resident #13 was not able to answer questions about the right heel ulcer. She said she did not know the reason for the blue heel protector on her right foot. Resident #13's bed did not have a standard low air loss mattress on the bed as per the care plan. On 2/28/23 at 9:21 a.m., Resident #13 was observed sitting in a wheelchair with a blue boot on the right foot. The left heel was not offloaded. On 3/1/23 at 9:08 a.m., RN supervisor Staff G verified Resident #13 did not have the standard low air loss mattress as per the approach listed on the care plan on 1/3/23. She did not explain the delay in implementing the low air loss mattress to prevent further skin breakdown. On 3/1/23 at 3:54 p.m., LPN Staff N documented in a nursing progress Resident #13 had a small open area on the coccyx. The nurse documented she placed an order for an air mattress. On 3/1/23 at 2:30 p.m. Certified Nursing Assistant (CNA), Staff L, said she provided care to resident #13. She said she did not know of any specific measures to prevent skin breakdown for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106062 If continuation sheet Page 3 of 4 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 106062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bentley Care Center 875 Retreat Drive Naples, FL 34110 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)

F 0686 resident. Level of Harm - Minimal harm or potential for actual harm On 3/2/23 at 2:28 p.m., the Director of Nursing (DON) stated she would expect to have interventions on the care plan such as turning and repositioning, heel protectors, and updates to interventions on the care plan to prevent skin breakdown and promote healing. The DON confirmed on 10/26/22 Resident #13 developed a pressure ulcer to the right heel. She said she could not locate documentation of preventative measures such as turning and repositioning had been implemented for Resident #13 who was at high risk for skin breakdown. She also said she could not find documentation on 10/26/22 the care plan was updated with measures to prevent further skin breakdown and promote healing of the existing ulcer. Residents Affected - Few On 3/2/23 at 4:06 p.m., the Registered Dietitian said she did not know Resident #13 had a pressure ulcer and did not review the clinical record to determine the need for supplements. On 3/2/23 at 5:20 p.m., the Registered Dietitian documented in a progress note Resident #13 had an unstageable pressure area to the right heel. She will add [brand name supplement to help support wound management process] twice a day to aid with healing. She said Resident #13 had a history of refusing supplements but had agreed to try a strawberry shake with lunch and dinner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106062 If continuation sheet Page 4 of 4