Inspection·April 11, 2024

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 Based on observation, interview, and record review, the facility failed to ensure central venous catheter dressing was changed in accordance with professional standards of practice for 2 of 2 residents with central venous catheters, Residents #3 and #4. Residents Affected - Few Findings include: 1. Review of Resident #3's admission record showed the resident was admitted to the facility with the diagnoses including unspecified fracture of left forearm, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, arthritis due to other bacteria left elbow, atrial fibrillation, and pneumonia. During an observation on 4/11/2024 at 9:10 AM, Resident #3 was in bed with a right upper extremity peripherally inserted central catheter (PICC) line with a net stocking over the insertion site. The resident rolled down the netting. There was a gauze under a transparent dressing that was covering the insertion site. The transparent dressing was dated 4/1/2024. The dressing was curling up at the edges and the insertion site remained covered. During an interview on 4/11/2024 at 9:12 AM, Resident #3 stated, I'm in here for antibiotics because I have an infection after I broke my arm. It is an MRSA [Methicillin Resistant Staphylococcus Aureus] infection, so I needed a PICC line and antibiotics for a long time, another 6 weeks. They changed this about 10 days ago I guess. Review of Resident #3's physician order dated 3/26/2024 read, Change PICC line dressing q [every] week every day shift every Sat [Saturday] for PICC line. Review of Resident #3's Physician Orders dated 3/26/2024 reads, Monitor PICC line Q shift, inform MD ( Medical Doctor) of any abnormal findings every shift for PICC line. Review of Resident #3's Treatment Administration Record (TAR) for April 2024 showed dressing change on 4/6/2024 by Staff A, Registered Nurse (RN). Review of Resident #3's TAR for April 2024 showed that Staff B, Licensed Practical Nurse (LPN), monitored the PICC line on 4/11/2024 at 9:00 AM. 2. Review of Resident #4's admission record showed the resident was admitted to the facility with the diagnoses including discitis (an infection of the discs between the bones of the spine) in lumbosacral area, low back pain, type 2 diabetes mellitus with diabetic neuropathy unspecified, essential primary hypertension, and chronic obstructive pulmonary disease. (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 2 Event ID: 105705 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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)