Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 provide intravenous (IV) care and services
according to standards of practice and plan of care for 1 of 1 resident reviewed for IV care of a total sample
of 40 residents, (#66).
Residents Affected - Few
Findings:
Resident #66 was admitted to the facility on [DATE] from an acute care hospital with diagnoses including
fractured patella, arthritis due to bacteria right knee, and Methicillin Resistant Staphylococcus Aureus
(MRSA) infection. The resident had a Peripherally Inserted Central Catheter (PICC) line present in his left
arm for antibiotics upon admission to the facility.
A PICC line is a long, thin tube that's inserted through a vein in your arm and passed through to the larger
veins near your heart A PICC line gives your doctor access to the large central veins near the heart. It's
generally used to give medications A PICC line requires careful care and monitoring for complications,
including infection and blood clots (https://www.mayoclinic.org).
On 7/12/21 at 12:10 PM, resident #66 was observed lying in bed. He had a PICC line in his right upper arm
covered with a dressing dated 7/3. The PICC line was covered with a clear dressing and the tape around
the dressing was gray and dirty. The resident said he was getting IV antibiotics by the PICC line for infection
in his right knee. He added that the nurses had not changed the PICC line dressing since 7/3, 9 days ago.
He said he wanted the dressing changed and had not refused any care to the PICC line.
A review of the resident's care plan initiated on 6/15/21 for IV Therapy included interventions to Observe
PICC site for signs and symptoms of infection/infiltration, monitor IV line for patency, flush as ordered and
prn (as needed) and dressing changes as ordered
Review of the residents' Electronic Medical Record (EMR) revealed a physician order dated 7/1/21 to, Flush
PICC line each lumen,10 ml (milliliters) NS (normal saline) every shift. Another order dated 7/1/21 read,
measure arm circumference at site every week with dressing change and every shift every 7 days. An
additional order dated 7/1/21 read, Change PICC line dressing every week (transparent dressing) every
evening shift on Thursday.
A review of the Medication/Treatment Administration Records and EMR showed no documentation the
resident's PICC line dressing was changed on 7/3 as noted on the dressing. The EMR noted the last time
the PICC line dressing was changed was 7/1/21 which did not match the date on the 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:
105872
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
105872
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/15/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Tuskawilla Nursing and Rehab Center
1024 Willa Springs Dr
Winter Springs, FL 32708
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 7/12/21 at 12:20 PM, the resident's assigned Registered Nurse (RN) C noted the resident's outdated
and soiled IV dressing. RN C could not explain what the standard of practice was regarding the frequency
of IV dressing changes and indicated she would need to check the facility policy.
On 7/12/21 at 1:06 PM, the Director of Nursing (DON) said the standard of practice was to change
transparent PICC line dressings at least every 7 days or more often if soiled. She did not explain why the
resident's PICC line dressing had not been changed. She reviewed resident #66's medical record and
noted there was no evidence that he refused his PICC line dressing change. The DON said if he refused,
the nurses should have documented in the medical record and educated the resident regarding potential for
complications such as sepsis (blood infection). The DON added, if the resident refused care the nurses on
the following shifts should have attempted to provide the needed care. She explained the nurses should
have looked at the IV site when doing the flushes and should have noticed that it was due to be changed
from 7/10 to 7/11.
On 7/13/21 at 3:39 PM, RN D said she worked on the 7-3 shift Saturday 7/10 and only documented that
resident #66 refused his medication. RN D added that she knew his PICC line dressing was due to be
changed and did not document his refusal of IV dressing change or education regarding potential for
infection. She said she did not report the resident's IV dressing needed to be changed to the oncoming shift
nurse.
On 7/14/21 at 1:08 PM, RN B said she worked the day shift on 7/10 and 7/11 and was assigned to resident
#66. RN B said she signed the Medication Administration Record (MAR) and flushed his PICC line both
days. She said the IV dressing looked soiled but the resident did not want the dressing changed at that
time. She said she did not document doing any education with the resident of potential for infection if
dressing was soiled and not changed.
On 7/15/21 at 3:19 PM, RN E said he worked 7/10 and 7/11 on the 11:00 PM to 7:00 shift. He said he did
not notice the date or that the IV dressing was dirty when he flushed the line as it was dark in the residents'
room. He could not recall if the prior nurse had informed him the resident's IV dressing needed to be
changed. He could not remember if the resident had declined prior attempts to change the dressing. He
noted that PICC line dressing should be changed every 72 hours and as needed.
Attempts were made to interview RN G and F who also provided care to the resident on 7/10 to 7/11 but
the nurses did not return the calls.
The facility's policy and procedure, Central Vascular Access Device (CVAD) revised May 1, 2016 read,
Licensed nurses according to state law and facility policy. The nurse is responsible and accountable for
obtaining and maintaining competence with infusion therapy CVADs include: Peripherally Inserted Central
Catheter (PICC) The catheter insertion site is a potential entry site for bacteria that may cause a
catheter-related infection. A transparent dressing is the preferred dressing Sterile dressing change using
transparent dressing is performed: 24 hours post insertion or upon admission, at least weekly, if the
integrity of the dressing has been compromised (wet, loose or soiled)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105872
If continuation sheet
Page 2 of 4
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
105872
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/15/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Tuskawilla Nursing and Rehab Center
1024 Willa Springs Dr
Winter Springs, FL 32708
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 0695
Provide safe and appropriate respiratory care 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 ensure respiratory therapy was provided as
per physician orders for 2 of 2 residents of a total sample of 40 residents, (#23, #136).
Residents Affected - Few
Findings:
1. Review of resident #23's medical record revealed he was re-admitted to the facility on [DATE] with
diagnoses of Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure and dependence
on supplemental oxygen.
On 7/12/21 at 10:30 AM, resident #23 was observed in his room sitting up in bed. He was alert and
oriented to person, place, and time. He received oxygen via nasal cannula (NC) attached to a portable
oxygen concentrator set at 4.25 liters per minute (LPM). He said, he used oxygen because his breathing
was not good.
The resident had a care plan dated 9/5/20 for impaired gas exchange/ineffective airway clearance related to
history of COPD exacerbation, shortness of breath and wheezing at times with intervention to provide
oxygen via nasal cannula per physician orders.
On 7/12/21 at 10:40 AM, the resident's assigned Registered Nurse (RN) B checked the physician orders
and said the resident was ordered oxygen at 2 LPM. RN B said she had already given the resident's
morning medications but had not observed the oxygen concentrator's flow rate.
On 7/12/21 at 10:43 AM, the East Wing Unit Manager (UM) entered resident #23's room and checked the
setting on the oxygen concentrator. She said it was set at 4.25 LPM and the resident was not getting
oxygen as ordered. The UM then adjusted the rate to 2 LPM and asked the resident if he had adjusted his
settings. He denied changing the settings. The UM said the assigned nurse should have checked the
oxygen settings when she gave his morning medications.
On 7/12/21 at 1:15 PM, the Director of Nursing (DON) said the expectation was that nurses check the
oxygen setting every time they entered a resident's room. She explained that a resident with COPD could
become more short of breath if given too much oxygen.
2. Review of resident 136's medical record revealed she was admitted to the facility from an acute care
hospital on 7/2/21 with diagnoses of metastatic breast cancer, chronic renal failure, anemia and sepsis.
Review of the Agency for Health Care Administration (AHCA) Transfer Form 5000-3008 from the hospital
dated 7/2/21 noted Oxygen at 2 LPM continuous via NC. A physician order for Oxygen dated 7/5/21 read,
Oxygen at 2 LPM via NC and for nurses to check every shift.
On 7/13/21 at 9:45 AM, resident #136 was in her room lying in bed. She was alert and oriented to person
and place. The resident had oxygen via concentrator with the flow rate set at 1.5 LPM.
On 7/13/21 at 2:32 PM, the East Wing UM entered resident #136's room and checked the oxygen setting.
She said there was something wrong with the concentrator as the ball on the flow rate was moving up and
down. She was informed the rate was at 1.5 LPM, the same as observed earlier. The UM
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105872
If continuation sheet
Page 3 of 4
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
105872
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/15/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Tuskawilla Nursing and Rehab Center
1024 Willa Springs Dr
Winter Springs, FL 32708
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 0695
acknowledged the resident did not receive oxygen as ordered a 2 LPM.
Level of Harm - Minimal harm
or potential for actual harm
On 7/13/21 at 2:43 PM, the resident's assigned nurse, RN A said he had checked resident #136's oxygen
flow rate earlier today while he was standing near the concentrator. He said it was between 3-4 LPM. LPN A
said he did not know the order was for 2 LPM.
Residents Affected - Few
On 7/13/21 at 2:43 PM, the East Wing UM said nurses should be looking at the oxygen concentrator
settings at eye level and not from standing position.
Review of the policy dated 5/22/18 and titled, Oxygen Administration read, The purpose of this procedure. A
resident will need oxygen therapy when hypoxemia (low oxygen in blood) occurs The resident's disease,
physical condition, and age will help determine the most appropriate method of administration. A licensed
nurse or a respiratory care practitioner performs this procedure Check physician's order
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105872
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
FAQ · About this visit
Common questions about this visit
What happened during the July 15, 2021 survey of TUSKAWILLA NURSING AND REHAB CENTER?
This was a inspection survey of TUSKAWILLA NURSING AND REHAB CENTER on July 15, 2021. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at TUSKAWILLA NURSING AND REHAB CENTER on July 15, 2021?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide for the safe, appropriate administration of IV fluids for a resident when needed."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.