Health inspection·January 22, 2026

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 record review, and interview, the facility failed to ensure that a newly admitted resident received timely, consistent, and properly documented dermatologic treatment in accordance with professional standards of practice and the comprehensive, person-centered care plan for two of three residents reviewed for wound care, of a total sample of six residents, (#6, and #2). 2. Resident #2 was admitted to the facility on [DATE] for nerve pain. The Minimum Data Set Quarterly assessment dated [DATE] noted resident #2 was cognitively intact, required partial to moderate assistance with activities of daily living, and was occasionally incontinent. Residents Affected - Few Review of resident #2's care plan dated 8/18/25 revealed a focus for a pressure ulcer to open area, buttocks. Interventions included to complete weekly skin checks and measure length, width, and depth, if possible. Resident #2 had a care plan dated 8/18/25 for risk for skin impairment. Care plan interventions included monitor/observe skin while providing routine care, nutritional supplements/diet as ordered, preventative skin treatments as ordered, skin checks weekly and provide incontinence care promptly. Review of physician orders dated 8/16/25, with no stop date, included cleanse bilateral lower legs with normal saline, pat dry, and wrap with dry dressing for wound care-abrasion. The order specified staff to monitor site for signs of infections until healed, every evening shift for wound care. Review of the Treatment Administration Record (TAR) for the physician order dated 8/18/25 to 8/31/25 revealed a missing treatment on 8/20/25. Review of physician orders dated 8/18/25 for wound care in between buttocks. The order specified to cleanse the area with 1/4 Dakins and apply zinc oxide every shift. The TAR for the wound care in between buttocks order from 8/18/25 to 8/31/25 revealed missing treatments for 8/24/25 nightshift, 8/30/25 dayshift, and 8/31/25 dayshift. A physician orders dated 8/21/25 with no stop date– for wound Care-Abrasion: Cleanse (bilateral lower legs) with NS, pat dry, and wrap with dry dressing. Monitor site for signs/of infections until healed. Every dayshift for wound care. The TAR for the physician order 8/18/25 to 8/31/25 revealed missing treatments on 8/23/25 and 8/30/25. On 1/22/25 at 3:15 PM, the Wound Care Nurse (WC), stated her responsibilities were for residents who needed treatment for stage three or greater pressure wounds (deeper, open wounds). She stated the 'cart nurses' (staff nurses) provided regular treatment for wounds stage two and less (less serious wounds). On 1/22/25 at 12:40 PM, LPN revealed her responsibilities as the 'cart nurse'. She stated she Page 1 of 3 106123 106123 01/22/2026 Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940

F 0684 Level of Harm - Minimal harm or potential for actual harm completed wound assessments weekly and provided wound treatments when ordered. She further stated that if there were any issues she would let the wound care nurse know or her nurse manager. LPN1 confirmed she cared for resident #2 and provided wound care. She stated she always got her treatments completed by the end of her shift and would let the next shift know or manager if unable to complete. Residents Affected - Few Findings: Review of resident #6's medical record revealed she was admitted to the facility from an acute care hospital on [DATE]. The record showed she had limited communication ability, and she required limited assistance for mobility. Review of the admission assessment showed the resident was admitted with a rash on both feet that had been present for several weeks. A dermatology consultation on 01/13/2026 noted diagnosis of tinea pedis (fungal infection). On 01/13/2026, the dermatologist, prescribed Ketoconazole cream two percent to be applied daily to both feet until resolved. On 01/22/2026 at approximately 1:16 PM, the dermatologist, confirmed she prescribed the Ketoconazole cream to be applied daily to both feet. She stated that failure to apply the cream as ordered could result in worsening fungal infection and secondary complications. On 01/21/2026 at approximately 1:45 PM, Licensed Practical Nurse (LPN) B initially stated she applied the cream to the resident's belly button and documented the application. Upon further interview, LPN B clarified the cream was intended for the resident's feet and acknowledged that she misspoke. During the interview, LPN B showed the tube of Ketoconazole cream in the treatment cart labeled with the resident's name and dated 01/13/2026. The Ketoconazole tube was unopened. When asked how she had been applying the cream when the tube was not opened, LPN B stated that she had thrown a tube away earlier that morning and that the tube observed was a new tube. She verified that medications were not shared between residents and that refills were only obtained from the pharmacy. On 01/21/2026 at approximately 12:17 PM, LPN A stated the tube should last approximately three weeks if applied daily to both feet. She stated only one tube of Ketoconazole cream had been obtained from the pharmacy and it had not been reordered or refilled as it was only ordered one week ago, on 1/13/26. On 01/22/2026 at approximately 12:39 PM, LPN C confirmed she applied Ketoconazole cream to the top of the resident's feet that day. LPN C stated the tube had not been refilled and would last approximately two and a half to three weeks. LPN C confirmed that medications were not shared between residents. On 01/22/2026 at approximately 2:00 PM, LPN D confirmed the Ketoconazole cream had never been refilled since the order was placed on 01/13/2026. LPN D reiterated that medications were not shared between residents, and a new pharmacy order was required if the medication ran out. Family interviews on 01/21/2026 at 4:00 PM and 01/22/2026 at 10:51 AM confirmed the resident had not received the prescribed cream for several days after her admission. The resident's daughters expressed concern regarding the resident not receiving her treatment, emphasizing the dermatologist had ordered daily application. They stated they felt the missed treatments placed their mother at risk for worsening infection and skin breakdown. 106123 Page 2 of 3 106123 01/22/2026 Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940

F 0684 Attempts to contact the Pharmacy Consultant on 01/22/2026 at approximately 12:59 PM and 1:21 PM were unsuccessful. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 106123 Page 3 of 3