Inspection·March 21, 2024

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 ensure nurses administered Intravenous (IV) medications according to physician's orders for 1 of 4 residents reviewed for Quality of Care and Treatment, of a total sample of 10 residents, (#1). Residents Affected - Few Findings: A review of the medical record revealed resident #1, a [AGE] year old female was admitted to the facility on [DATE] from an acute care hospital with diagnoses of fractures of the right arm and shoulder, severe aortic (main heart artery) valve stenosis (narrowing), severe malnutrition, need for assistance with personal care, and osteoporosis. On 2/09/24, she was diagnosed with a stage four pressure wound to her sacrum (tailbone), sacral osteomyelitis (infection of bone), deep tissue pressure wounds to her left and right heels and ankles, and a non-pressure wound to her right elbow. The Minimum Data Set (MDS) Modified admission assessment with Assessment Reference Date (ARD) 1/19/24 noted resident #1 scored 15 out of 15 for the Brief Interview for Mental Status (BIMS) which indicated she was cognitively intact, and did not reject evaluations or care. The assessment showed the resident required staff assistance to complete Activities of Daily Living (ADLs), was incontinent, and she had one stage three pressure ulcer documented as present upon admission during the look-back period. The MDS Discharge Return Anticipated assessment with ARD 2/18/24 showed the resident had one stage four, and four deep tissue pressure ulcers that were not present upon admission during the look-back period. The Comprehensive Care Plan included focuses for osteomyelitis infection with interventions to administer physician ordered IV medications and treatments, pressure wounds to sacrum, both heels and ankles, and right elbow with interventions to administer physician ordered medications and a wound vacuum (negative-pressure therapy). The Order Summary Report noted physicians' orders for antibiotic (infection) medications included Doxycycline 100 Milligrams (MG) every 12 hours for osteomyelitis on 2/02/24, Cefdinir 300 MG every 12 hours on 2/09/24 for infection, Peripherally Inserted Central Catheter (PICC) line insertion for IV medications, Vancomycin HCI 750 MG IV solution every morning for osteomyelitis on 2/09/24, and Levaquin 500 MG once daily for osteomyelitis on 2/16/24. On 3/20/24 at 11:19 AM, Licensed Practical Nurse (LPN) A explained nurses had 24/7 access to certain medications that included IV solutions and supplies from the Pyxis(automated dispenser). She showed the surveyor where the machine was located and demonstrated how nurses accessed it with written laminated administration instructions secured to the machine. (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 3 Event ID: 105904 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 105904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Shores Nursing and Rehab Center 4251 Stack Blvd Melbourne, FL 32901 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)