Health inspection·March 7, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 2 residents, Resident #60 reviewed for peripherally inserted central catheter/mid-line device. Residents Affected - Few Findings include: Review of resident #60's clinical record documented the resident was admitted [DATE] with diagnosis that included respiratory failure, congestive heart, and pleural effusion (fluid in the tissue of the lungs). During an observation on 3/4/2024, at 9:18 AM of Resident #60 it showed a peripherally inserted central catheter/mid-line device (PICC/MID) line in the resident's upper left arm. There was a clear dressing over the site that was dated 2/22/2024. During an observation on 3/4/2024, at 2:22PM of Resident #60 it showed a PICC/MID line to the resident's left upper extremity. There was a clear dressing over the site that was dated 2/22/2024. During an interview on 3/4/2024 at 9:18 AM Resident #60 stated, That line was placed when I was admitted to the facility and the dressing has not been changed since it was placed. Review of Resident #60's physician orders dated 2/22/2024 read, Midline to LUE [left upper extremity]. Change midline dressing every week and as needed, ensure dressing is initialed and dated. Once a day on Thu [Thursday] 7:00 AM - 3:00 PM. Measure external catheter length of midline with each dressing change. Once a day on Thu 7:00 AM - 3:00 PM. Measure upper arm circumference midline site Q [every] week with each dressing change. Once a day on Thu 7:00 AM - 3:00 PM. Monitor LUE midline site Q shift and PRN [as needed] for indications of infection or infiltration such as redness, drainage, swelling, etc. Notify MD [Medical Doctor] as indicated every shift. Observe Midline insertion site and dressing every shift. Ensure dressing is dated and initialed, every shift. Review of Resident #60's Medication Administration Record (MAR) for the period of February 22, 2024, through March 6, 2024, did not contain documentation the midline dressing change and measurements were conducted as ordered by the physician. During an interview on 3/6/2024 at 1:41 PM Staff D, License Practical Nurse (LPN) stated, Intravenous catheters dressings should be changed every 3 days. During an interview on 3/6/2024 at 1:53 PM Staff E, Registered Nurse (RN) stated PICC/MID lines are (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: 105769 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 105769 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Lake City 560 SW McFarlane Ave Lake City, FL 32055 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)