Health inspection·December 9, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure complete and accurate records for 1 of 4 residents, Resident #6, reviewed for intravenous medication management.Findings include: Review of Resident #6's nursing admission assessment dated [DATE] read, Section 12. Intravenous Access Devices: 1. Does the resident have a vascular device in place? Yes. What type of device is present? a) PICC [peripherally inserted central catheter] Line. Review of Resident #6's physician order dated 11/06/2025 read, PICC line can be removed at the end of IV [intravenous] [NAME] [antibiotics]. Review of Resident #6's physician order dated 11/6/2025 read, Piperacillin Sod-Tazobactam [antibiotic] solution reconstituted 3-0.375 GM [gram] use 3.375 gram intravenously [IV] every 6 hours for ESBL [extended-spectrum beta-lactamase] Pseudomonas until 12/05/2025 05:59. Review of Resident #6's care plan dated 11/05/2025 read, Focus: [Resident #6's name] is at risk for complications r/t [related to] receiving IV therapy. Currently has (central) IV line located (LUE) [left upper extremity]. Is receiving (IV ABX) [intravenous antibiotics] for the treatment of: (ESBL/Pseudomonas). Interventions: Administer IV (fluids/meds) as ordered, observe for effectiveness and for adverse SEs [side effects]. Perform IV flushes as ordered. Change IV tubing per protocol. Perform IV site care as ordered, observe site for sx/sx [signs/symptoms] of infection/infiltration; notify physician if noted. Labs as ordered; report findings to physician and pharmacy prn [as needed]. Vital signs as ordered and PRN. Encourage resident to notify staff of pain at IV site upon onset. Observe for sx/sx of fluid volume overload; report to physician if noted. Review of Resident #6's health status note dated 12/07/2025 read, Removed IV at 1700 [5:00 PM] on 12/7/25. Review of Resident #6's physician orders revealed there were no orders for PICC line dressing changes. Review of Resident #6's medication administration record and treatment administration record for November 2025 and December 2025 revealed there was no documentation that PICC dressing changes were completed. During an interview on 12/09/2025 at 3:24 PM, Staff A, LPN [licensed practical nurse] Unit Manager reviewed Resident #6's admission Summary and physician orders with the surveyor, and stated, [Resident #6's name] had a PICC line when she came in. We have to select the orders when residents come in with a PICC line. It's not an automatic order, but we go to the batch orders to select which ones we need. Normally I would order to change the dressings, order flushes, and observe for signs and symptoms of infection. If there is an order for a PICC dressing change, it would be on the MAR [medication administration record] for the nurse to document. Nurses do the PICC line dressing changes. I would expect the nurses to look at the date on the PICC dressing when they are assessing it. I expect the nurses to know that PICC dressings should be changed every seven days. If there is no order, I expect the nurses to put in an order and document that they changed the dressing. I do try to check on the nurses' documentation. I can't say I did or didn't forget to put in the order for the PICC dressing change. Review of the policy and procedure, titled, PICC IV Line, with an issue date of 4/01/2022, read, (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: 105434 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 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza Health and Rehab 4842 SW Archer Road Gainesville, FL 32608 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)