Health inspection·December 10, 2024

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 interview, policy review and record review, the facility failed to assess a resident's skin under a knee immobilizer to prevent a pressure injury for 1 of 5 sampled residents (Resident #1). Residents Affected - Few The findings included: The facility policy Titled Skin Assessment and revised on 10/01/22 documented in part: 1. A full body or head to toe skin assessment will be conducted by a Registered Nurse upon admission/readmission and weekly thereafter. The assessment may also be performed after a change in condition or after a newly identified pressure injury. The facility policy titled, Pressure Injury Prevention and Management, revised on 10/03/24, documented in part: The facility is committed to the prevention of avoidable pressure injuries. Avoidable means the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident clinical condition and risk factors, define and implement interventions that are consistent with resident needs, resident goals and professional standards of practice. Record review revealed on 10/19/24, Resident #1 was transferred from a hospital to the facility. She had diagnosis to include unspecified Fracture of Lower end of Left Femur with encounter for closed fracture with routine healing, Pleural Effusion, Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease, Muscle Weakness, Difficulty in Walking, Muscle Wasting and Atrophy, Malnutrition, Hypothyroidism, Non-rheumatic Aortic Valve, Periprosthetic Fracture around internal prosthetic left knee joint, Hyperlipidemia, and pain in right hip. Resident #1's admission MDS (Minimum Data Set) assessment dated [DATE] documented the resident had a BIMS (Brief Interview for Mental Status) score of 5, indicating severe cognitive impairment. Further record review revealed Resident #1 arrived at the facility with a left knee immobilizer to secure her knee movements following a fracture of the lower end of her left femur. On 11/18/24 a pressure injury was found under Resident #1 left knee immobilizer after drainage was (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: 106075 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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)