Health inspection·February 5, 2025

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few since the date noted on the dressing was 1/24. RN A said it should have been changed on 1/31/25 but was not done. Review of the resident's physician orders showed orders dated 1/29/25 for PICC line care that read, PICC line Right arm: Monitor for s/s (signs/symptoms) of infection, swelling, color change, pain, drainage etc. If abnormalities observed, stop use of IV site and notify physician Q (every) shift until 2/19/2025 23:59 (11:59 PM) and as needed. Change dressing within 24 hours of admission, insertion, or reinsertion and Q 7 days and PRN thereafter using sterile technique. Measure arm circumference and external length of catheter. Physician order dated 1/31/25 was for Piperacillin 3.0-375 gm IV Q 8 hrs for cystitis until 2/19/2025. Piperacillin/tazobactam is used to treat a wide variety of bacterial infections. It is a penicillin antibiotic. It works by stopping the growth of bacteria. (retrieved on 2/14/2025 from webmd.com). Review of the resident's Physician/Practitioner progress notes dated 1/30/25 revealed the physician's plan included Routine PICC care. Review of the resident's Medication Administration Record (MAR) revealed documentation on 1/30/25 that indicated the PICC line dressing was changed at 9:40 AM. The date observed on the PICC line dressing was 1/24, not 1/30/25. On 2/05/25 at 1:16 PM, observation of the resident's PICC line dressing was conducted with the East Coast Registered Nurse (RN) Unit Manager (UM). She acknowledged the dressing was dated 1/24 and stated that by protocol the PICC line dressing was to be changed weekly. The RN/UM stated a resident admitted with a Midline/PICC would have batch orders for the care of the Midline/PICC placed in the residents' Electronic Medical Records (EMR). She stated the Midline/PICC line dressing changes should be done by the resident's assigned nurse and explained the PICC dressing for resident #7 should have been changed 24 hours after his admission, and then every 7 days thereafter. On 2/05/25 at 2:20 PM, the Director of Nursing (DON) stated PICC line dressings should be changed if soiled or wet then every 7 days after admission. The resident's MAR was reviewed, and the DON confirmed that signature on 1/30/25 indicated the PICC dressing was changed. The date noted on the resident's PICC dressing was 1/24. She acknowledged the order signed off by Licensed Practical Nurse (LPN) B was for dressing change within 24 hours of admission and every 7 days and as needed thereafter. On 2/05/25 at 2:33 PM, LPN B stated the protocol was to change the PICC dressing if dirty or within 24 hours of admission. The resident's MAR was reviewed with the LPN. She acknowledged she signed the order on 1/31/24 to indicate she had checked the resident's IV access, and not that a dressing change was done. She stated a dressing change was not needed at that point, and noted the PICC dressing was normally changed by an RN not an LPN. LPN B acknowledged th the physician order she signed off on was for dressing change, and stated she should have signed off on the order that instructed staff to monitor the PICC. On 2/05/25 at 3:25 PM, the DON provided a revised policy for Central Lines. She acknowledged that since the date noted on the resident's PICC line dressing was 1/24, the dressing was not changed in the facility since the resident was admitted on [DATE]. A care plan developed for a midline located in the right arm related to infection was initiated on 1/30/25. An intervention was, IV access site maintenance: perform dressing changes, flushes, etc. as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105673 If continuation sheet Page 2 of 3 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 105673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indian River Center 7201 Greenboro Dr West Melbourne, FL 32904 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)

F 0694 ordered. Level of Harm - Minimal harm or potential for actual harm The facility's policy Central Lines issued 10/2020, and revised 02/2025 read, Change dressing routinely and per physician orders. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105673 If continuation sheet Page 3 of 3