Inspection·May 30, 2023

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 obtain orders and change intravenous (IV) midline catheter dressings for 3 of 4 sampled residents reviewed with IV midline catheters, (#1, #2 & #3). Residents Affected - Some Findings: 1. Resident #1 was admitted to the facility on [DATE] for skilled nursing and wound care services. Her diagnoses included infected unstageable pressure ulcer on her right heel, chronic bilateral leg edema, diabetes, breast cancer, vascular dementia, and history of strokes. According to the admission Nursing Data Collection dated 4/25/23 at 10:51 PM, the resident was admitted with a right antecubital forearm IV midline. She was ordered to receive IV antibiotics for the infected pressure ulcer. A midline catheter is a small tube used to give treatments and to take blood samples. The catheter is inserted into a vein in your arm. The end of a midline, inside your body, does not go past the top of your armpit. A midline catheter can stay in place for up to 30 days. Retrieved 6/26/23 at 10:49 AM www.drugs.com/cg/midline-catheter.html Review of resident #1's medical record noted she was readmitted to the hospital for worsening of the right heel pressure wound on 5/18/23 and was discharged from the facility. Review of the resident's April and May 2023 Medication Administration Records (MARs) and Treatment Administration Records (TARs) revealed there was no orders for the IV midline dressing to be changed. There was not any documented evidence to indicate the IV midline dressing had been changed for 23 days while the resident remained in the facility from 4/25/23 until 5/18/23 On 5/20/23 at 5:45 PM, the interim Director of Nursing (DON) acknowledged there were no orders or any documentation to show resident #1's IV midline dressing had been changed while at the facility. She did not have an explanation as to what had happened. 2. Resident #2 was admitted to the facility on [DATE]. His diagnoses included Parkinson's disease, diabetes, peripheral vascular disease, urinary tract infection (UTI), hydronephrosis, and post-surgical suprapubic urinary catheter insertion. On 5/30/23 at 12:55 PM, resident #2's upper left IV midline dressing was observed with Licensed Practical Nurse (LPN) E. The clear adhesive dressing was loose on the inner side of the arm and dried reddish brown residue was visible under the dressing. The edge of the dressing on the inner aspect of his arm was peeled up and a reddish brown discolored two inch by two inch (2 x 2) gauze dressing (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 4 Event ID: 105559 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 105559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Good Samaritan Society-Kissimmee Village 1500 Southgate Drive Kissimmee, FL 34746 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)