Health inspection·May 1, 2023

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 observations, record reviews, and interviews, the facility failed to provide treatment and care in accordance with professional standards for two (Residents #3 and #4) of three sampled residents related to the maintenance of intravenous access devices and the provision of wound care as ordered by the physician. Residents Affected - Few Findings included: 1. On 5/1/23 at 10:37 a.m., an observation was conducted of Resident #3 sitting in a wheelchair in his room. The observation revealed a triple lumen peripherally inserted central catheter (PICC) line in his right upper arm with an inclusive dressing dated 4/21. A medication pole was observed at the head of his bed opposite of where he was sitting. An empty clear intravenous bag was hanging from the pole. The resident said he was receiving an antibiotic. Resident #3 was also observed with an undated pink foam dressing near the left antecubital area. An observation and interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 5/1/23 at 10:42 a.m. She said the resident was on intravenous antibiotics and the PICC line dressing should be changed one time a day. Staff A confirmed the dressing date was 4/21 and said it should have been changed over the weekend. Staff A removed the foam dressing from the left arm of the resident with her bare hands, folded the dressing up, and confirmed the dressing should have been dated. The white foam of the dressing contained dried dark red/brown substance, the area under the dressing was a raw and wet-looking area approximately two centimeters length and width. The resident stated that it (the wound) happened about week and half ago, the nurse did it when attempting to lift the resident. A review of the admission Record indicated that Resident #3 was initially admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to unspecified organism pneumonia, chronic obstructive pulmonary disease with (acute) exacerbation, and unspecified diastolic (congestive) heart failure. The Admission/readmission progress note, dated 4/26/23 at 10:52 p.m., identified that Resident #3 had a skin tear on the left forearm. A review of Resident #3's April 2023 Medication Administration Record (MAR) identified the following administrations: - Nafcillin Sodium in Dextrose Intravenous Solution 2 gram (GM)/100 milliliter (mL) - Use 100 mL intravenously (IV) six times a day for sepsis, started 4/26 and discontinued 4/28/23. The MAR identified that this antibiotic was administered on 4/26 - 4/28/23. (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 5 Event ID: 105636 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 105636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belleair Health Care Center 1150 Ponce DE Leon Blvd Clearwater, FL 33756 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)