Health inspection·April 26, 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 observation, record review, review of facility's policies and procedures, and staff interview the facility failed to implement timely preventive measures and failed to alter the plan of care to include offloading of the area when a pressure ulcer developed for 1 (Resident #6) of 2 residents reviewed who developed a pressure ulcer at the facility. The lack of timely and appropriate interventions resulted in Resident #6 developing a new unstageable pressure ulcer on her right heel as well as a worsening of her previously resolved pressure ulcer on her right heel. Resident #6 now has 2 unstageable facility acquired pressure ulcers. Residents Affected - Few The findings included: On 4/25/24 at 9:50 a.m., during a wound care observation for Resident #6 performed by RN Staff C the resident was observed in bed laying slightly on her right side. Resident was awake and stated that she was ok with the nurse doing her wound care treatment at the time. Resident feet were uncovered and her left foot was observed to be laying on one pillow with her heal just slightly elevated off the bed. There was a small adhesive dressing that was coming off the left heel at the time of the observation. The nurses stated that the heel treatment had changed since the pressure ulcer was resolved for a week or two. A nurse and CNA staff B, who was assisting, lifted the resident heel up further so that it could be assessed. The nurse removed the dressing and started to assess the area. The area was noted to have a large area of redness that encompassed the entire heel. Then in the dorsal area of the heel an area about the size of a quarter was deeper red, boggy and non-blanchable. The nurse stated that she was going to call the wound care doctor and give him a report on the condition of the left heel and ask for a change in dressing. After this she got a new order she cleaned the area with normal saline apply skin prep, covered the area with a betadine-soaked dressing, covered with ABD pad (absorbant dressing) and wrap with Kerlex. After the nurse completed dressing and had it secured she plumped up the pillow under the resident lower leg so the foot would not be pressing on the bed. Next it was observed that the residents right foot was lying flat on the bed with no elevation of the foot. The nurse was asked if the right foot and heal could be looked at. The nurse stated that the heel was ok. Surveyor asked to observed Right heel. When staff CNA and Nurse picked up the lower leg and foot to reveal the right heel it was deep read encompassing the entire heal and the heel had an elongated fluid filled blister towards the right lateral side of the heel, the size of large peanut or 25 % of the heel area. The facility policy titled, Pressure Ulcer and Skin Breakdown Policy Assessment and Recognition. The nursing staff, Wound Consultant, and practitioner will assess and document an individual's significant risk for developing pressure ulcers (i.e., immobility, recent weight loss, history of pressure (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 7 Event ID: 106092 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 106092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at the Keys Nursing and Rehab 48 High Point Road Tavernier, FL 33070 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)