Inspection·March 19, 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 ensure an intravenous (IV) dressing was changed as ordered for 1 of 1 residents reviewed for IV therapy, of a total sample of 27 residents, (#45). Residents Affected - Few Findings: Resident #45 was admitted to the facility on [DATE] with diagnoses including infection following a procedure, superficial incisional surgical site. A care plan for IV Medication use was initiated on 3/10/25. The care plan indicated resident #45 received IV antibiotics status post exploratory surgery and drained abscess to surgical site mid lower back. Interventions included to observe IV site for possible signs/symptoms of infection or infiltrate and peripherally inserted central catheter (PICC) line care and flush as ordered. A PICC line is a long, thin tube inserted into a vein usually in your arm and passed through larger veins near your heart to give access to the larger veins for some types of medication or nutrition. A PICC line requires careful care and monitoring for complications, including infection and blood clots, (retrieved on 4/01/25 from www.mayoclinic.org). Review of resident #45's electronic medical record (EMR) revealed a physician order dated 3/14/25 which instructed licensed nurses to change injection caps weekly with PICC line dressing change every day shift every Friday for PICC line dressing. The order was cancelled 3/14/25 and another order entered to start on 3/22/25. The new order instructed licensed nurses to change injection caps weekly with PICC line dressing change every day shift, every Friday for PICC line dressing. Review of resident #45's EMR revealed a progress note dated 3/12/25 entered by Licensed Practical Nurse A which read, PICC line dressing changed. Review of the Treatment Administration Record (TAR) for March 2025 revealed documentation the IV dressing was changed on 3/14/25 by Registered Nurse B. On 3/17/25 at 10:38 AM, resident #45 was observed in bed. An IV medication bag was hanging from the IV pole. The IV site was covered with a transparent bandage with a white gauze pad underneath. The IV dressing was dated for 3/12/25. On 3/18/25 at 3:10 PM, resident #87 was observed in a wheelchair next to the bed. Transparent IV dressing with a gauze pad underneath remained in place, dated 3/12/25. (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 3 Event ID: 105556 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 105556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village on the Green 500 Village Place Longwood, FL 32779 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)