Health inspection·April 24, 2025

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services according to standards of practice and plan of care, and failed to obtain physician orders for the care and maintenance of a peripheral IV for 3 of 3 residents reviewed for IV care, of a total sample of 49 residents, (#466, #106 and #520). Residents Affected - Few Findings: 1. Resident #466 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of fracture of unspecified metatarsal left foot, peripheral vascular disease, Type 2 diabetes mellitus, urinary tract infection and sepsis. Current physician's orders indicated resident #466 had a midline IV line in his right upper arm for administration of IV antibiotics. The physician orders showed he received 1 gram (gm) of Ertapenem solution (antibiotic) intravenously daily at 9:00 PM from 4/17/25 until 4/27/25 for a bloodstream infection. A midline catheter is put into a vein by the bend in the elbow or the upper arm . a midline catheter may allow you to receive long-term intravenous medicine or treatments (retrieved on 5/02/25 from www.drugs.com). On 4/21/25 at 10:29 AM, resident #466 was sitting up in bed, an undated, transparent midline IV dressing was seen on his right upper arm. The resident stated the midline was inserted at the hospital but was unsure when. On 4/22/25 at 9:44 AM, assigned Registered Nurse (RN) C verified resident #466's IV midline dressing was undated. He explained dressing changes were based on the physician's order, usually the order was to change the dressing every week or as needed. The nurse verified the physician's order indicated the dressing was to be changed weekly on Wednesday evening. The nurse acknowledged the resident's midline dressing should have been dated with the date of the last dressing change. He acknowledged the importance of dating the dressing in preventing infection and complications. On 4/22/25 at 10:56 AM, with the Director of Nursing (DON) present, resident #466 stated his IV midline dressing had just been changed and dated with today's date. The DON stated her expectation was IV midline dressings should always be dated. 2. Resident #106 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of left femur fracture, chronic obstructive pulmonary disease and chronic respiratory failure. Review of current physician's orders revealed she had a midline IV line in her left upper arm for administration of IV antibiotics. The orders specified 1 gm of Vancomycin solution (antibiotic) Page 1 of 5 105528 105528 04/24/2025 Terrace of St Cloud, The 3855 Old Canoe Creek Road Saint Cloud, FL 34769

F 0694 Level of Harm - Minimal harm or potential for actual harm intravenously twice a day at 9:00 AM and 9:00 PM, from 4/17/25 to 4/23/25, then once a day at 9:00 AM until 5/01/25 for a wound infection of her lower left leg. Another physician order indicated, IV midline left upper arm dressing change every week, remove old dressing cleanse site with alcohol or Betadine cover with transparent dressing weekly and as needed. Monitor for s/s of infection, phlebitis, or bleeding at IV site. Once a day on Tuesday 7 AM- 3 PM. Residents Affected - Few On 4/21/25 at 11:13 AM, resident #106 was in bed, a midline IV was on her left upper arm. She stated she received IV antibiotics for a wound infection on her left leg. Resident #106's midline IV dressing was undated, and loose with the edges of the dressing lifted up from the skin. The resident stated she did not remember when the IV was inserted nor the last time the dressing was changed. On 4/22/25 at approximately 9:54 AM, RN C entered resident #106's room and confirmed the midline IV dressing now with a date of 4/16/25 written on it. The dressing was still loose at the edges lifting up from the skin, and the resident explained another nurse came in and wrote the date, but did not change the dressing. RN C acknowledged the midline IV dressing needed to be changed. On 4/22/25 at 10:50 AM, the DON stated IV midline insertions were ordered through the pharmacy and facility nurses changed the IV midline dressings based on the physician's order. She explained the facility's protocol was to change any IV dressings every Tuesday. The DON confirmed the midline IV dressing should have been dated when first inserted. She acknowledged the nurse should have changed the IV midline dressing instead of writing a date on it when they saw the dressings were undated as they would not be sure as to how long it had been in place. The Facility's Policy on Central Venous Catheter Care and Dressing Changes revised October 2024 stated in the Procedure section- to apply sterile dressing section 6 e, Label with initials and date. 3. Resident #520 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, type 2 diabetes, and pneumonia. A care plan for the presence of peripheral IV catheter was initiated on 4/23/25. The care plan indicated resident #520 was at risk for localized infection or complications. Interventions included dressing changes to IV site per orders and to observe IV site for swelling, redness, patency, leaking around site, pain and/or coolness to touch. Review of resident #520's electronic medical record (EMR) revealed a communication form from a vascular access company which indicated a peripheral IV had been placed in the resident's left arm on 4/21/25. Review of physician orders for resident #520 revealed an order dated 4/21/25 which read, May place peripheral IV line. No orders were present for monitoring or maintenance of the peripheral IV and dressing. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2025 revealed no documentation to indicate the peripheral IV and dressing had been monitored or maintained. On 4/22/25 at 10:16 AM, resident #520 was observed in bed with a transparent IV dressing on her left arm. No date was present on the dressing. Resident #520 stated she received an IV solution because she was dehydrated. 105528 Page 2 of 5 105528 04/24/2025 Terrace of St Cloud, The 3855 Old Canoe Creek Road Saint Cloud, FL 34769

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/23/25 at 2:44 PM, resident #520 was observed in bed, the transparent IV dressing remained in place. The dressing was now dated 4/22/25. On 4/24/25 at 10:13 AM, resident #520 was observed in bed with her husband at bedside. The IV dressing remained in place. Resident #520 stated the IV infusion had been discontinued but she was not aware why she still had the IV. On 4/24/25 at 10:14 AM, RN B and the Assistant Director of Nursing (ADON) confirmed resident #520 had a peripheral IV. RN B and the ADON could not locate physician orders to monitor and/or maintain the IV. On 4/24/25 at 10:22 AM, the DON stated a peripheral IV was usually removed within 72 hours of insertion. She could not locate an order for care, maintenance nor for removal of the IV. The DON confirmed resident #520 should have a physician's order for monitoring and maintenance of the IV and IV site. At 10:40 AM, the DON acknowledged the peripheral IV should have been removed and there should have been an order to monitor the IV and change the dressing as needed. The DON acknowledged without orders, nurses would not be prompted to check the IV site and dressing, including documentation of their findings. 105528 Page 3 of 5 105528 04/24/2025 Terrace of St Cloud, The 3855 Old Canoe Creek Road Saint Cloud, FL 34769

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow infection control practices to prevent the development, transmission and potential spread of infection by not adhering to proper contact precautions for 1 of 2 residents reviewed for isolation precautions, (#56); and failed to ensure acceptable standards of practice were implemented when performing blood glucose monitoring and administration of injectable medication for 1 of 6 residents observed during medication administration, (#64); of a total sample of 49 residents. Residents Affected - Few Findings: 1. On 4/21/25 at 11:25 AM, resident #56's door had a sign indicating contact isolation precautions were implemented. Inside the resident's room, the biohazard waste receptacle for used personal protective equipment (PPE) was located in the middle of the resident's room between resident #56's and her roommate's dressers. In order to dispose of soiled PPE, the wearer would have to walk past resident #56's bed and dresser in order to dispose of soiled PPE. Personal protective equipment refers to protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness, (retrieved on 5/02/25 from www.fda.gov/medical). Resident #56 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Hospital paperwork dated 3/20/25 revealed swelling, a rash and fluid-filled blister like formation to her right upper extremity due to possible infiltration of a corrosive IV medication. An admission note from 3/28/25 listed a wound to the inside bend of resident #56's right elbow. Review of the results for a lab test of resident #56's right arm wound dated 4/15/25 revealed multiple microorganisms identified inside the wound including staphylococcus aureus (staph). A nursing progress note from 4/16/25 revealed the resident was placed on contact precautions due to staph in her right middle arm wound. Staph or a Staph infection is caused by staphylococcus bacteria. This bacteria can cause a staph infection which can be deadly if the bacteria invade deeper into your body. The Centers for Disease Control recommend that nursing home residents with multi-drug resistant organisms such as staph be placed on contact isolation to prevent further transmission of the bacteria, (retrieved on 5/02/25 from www.mayoclinic.org). On 04/23/25 at 11:48 AM, the Infection Preventionist (IP) nurse revealed disposal for soiled PPE should be located near the resident's exit door. The IP nurse confirmed resident #56's biohazard waste disposal box was located in the middle of the resident's room between the two residents. She confirmed contact precautions for resident #56 were to prevent the transmission of the staph organism from her to other residents. She acknowledged removing PPE and walking back through the resident's environment for disposal was a break in isolation. The facility policy revised October 2018 entitled, Infection Prevention and Control Program indicated an infection prevention and control program was established and maintained to provide a safe, and sanitary environment. The policy detailed the program should help prevent the development and transmission of communicable disease and infections. 105528 Page 4 of 5 105528 04/24/2025 Terrace of St Cloud, The 3855 Old Canoe Creek Road Saint Cloud, FL 34769

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A facility policy revised on March 2024 with information for different types of isolation indicated under the section for contact precautions, a gown and gloves were required on every entry into the resident's room and waste disposal for PPE should be located near the exit of the resident's room. 2. Resident #64 was admitted to the facility on [DATE] with an admitting diagnosis of end stage renal disease with dependence on dialysis, hypertension, and type 2 diabetes mellitus. On 4/23/25 at 8:57 AM, Licensed Practical Nurse (LPN) A prepared to perform medication administration for resident #64. LPN A entered the room and swabbed resident #64's finger with an alcohol swab. The nurse pricked resident #64's finger with a lancet, obtained a drop of blood from the finger and placed it on the test strip which was previously inserted into the glucometer. LPN A did not don gloves when he performed the blood sugar check. LPN A then removed the cap of the insulin pen, swabbed the rubber seal, and attached the needle to the pen. LPN A swabbed the site on resident #64's abdomen and administered the injection, without sanitizing his hands or applying gloves. LPN A then disposed of the lancet, the bloody test strip and the used needle in the sharps container. He left the resident's room without sanitizing his hands and proceeded to his medication cart where he placed the glucometer back into the top drawer of the medication cart without disinfecting the device. The Centers for Disease Control, recommended health care providers should wear gloves during blood glucose testing or any other procedure that involved potential exposure to blood or bodily fluids. They recommended if blood glucose meters were used to test multiple patients the device should be cleaned and disinfected after every use to prevent the spread of blood and infectious agents, (retrieved on 5/02/25 from www.cdc.gov/injection-safety). On 4/23/25 at 9:38 AM, the Director of Nursing (DON) explained they did not have individual glucometers for each resident and expected nurses to disinfect the glucometers after each resident. Nurses should use the appropriate cleaning solution prior to placing the glucometer back on the cart. The DON confirmed nurses were expected to wear gloves as best practice when checking blood sugars and/or administering injections, as they had potential to encounter blood and bodily fluids. She acknowledged LPN A did not follow this policy/procedure and required re-education. On 4/23/25 at 1:21 PM, LPN A confirmed he did not wear gloves when checking resident #64's blood sugar or when he administered insulin by injection. He acknowledged he knew the proper infection control procedure for blood glucose monitoring and insulin injection required the use of gloves when potentially encountering bodily fluids. He stated he should have disinfected the glucometer before placing it back into the medication cart. The facility's policy and procedure revised September 2014 entitled, Blood Sampling - Capillary (finger stick) indicated the purpose of the procedure was to guide the safe handling of capillary-blood sampling devices to prevent the transmission of bloodborne diseases to residents and employees. The section titled, General Guidelines detailed that blood glucose meters should always be cleaned and disinfected between use. The section entitled, Steps in the Procedure, listed the steps including, wash hands, don gloves, clean and disinfect reusable equipment after each use. The procedure continued, remove gloves, and wash hands. The facility policy dated 2024 entitled Administering Medications indicated staff were to follow established facility infection control procedures such as hand washing and wearing gloves during the administration of medications. 105528 Page 5 of 5