Inspection·March 16, 2023

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, interview, and record review, the facility failed to ensure the dressing on a Peripherally Inserted Central Catheter (PICC) line was changed every 48 hours as per professional standards of care for 1 of 1 resident with a PICC Line, Resident #36. Residents Affected - Few Findings include: During an observation on 3/15/2023 at 2:30 PM, Resident #36 had a PICC line on left upper arm with gauze under transparent dressing. The dressing was dated 3/10/23 (photographic evidence obtained). Review of the admission record for Resident #36 revealed the resident was admitted to the facility on [DATE] with diagnoses including fusion of spine, spinal stenosis of lumbar region, and lower back pain. Review of Resident #36's Medication Administration Record (MAR) revealed the PICC line dressing change was completed on 3/14/2023. Review of the physician orders for Resident #36 reads, Order Summary: Change PICC site dressing on admission, then once weekly and PRN [as needed] every day shift every 7 day(s) for PICC care. Order Date: 03/06/2023 . Order Summary: Daptomycin Intravenous Solution Reconstituted (Daptomycin) Use 850 mg [milligram] intravenously in the evening for MRSA until 04/13/2023 23:59 [11:59 PM]. Order Date: 03/07/2023 . Order Summary: Meropenem Intravenous Solution Reconstituted 1 GM [gram] (Meropenem) Use 1 gram intravenously every 8 hours for MRSA until 04/17/2023 23:59. Order Date: 03/06/2023 During an interview on 3/15/2023 at 3:00 PM, Staff A, Licensed Practical Nurse (LPN), stated, Yes, the date on PICC dressing is 3/10/23. During an interview on 3/15/2023 at 3:07 PM, the Director of Nursing (DON) stated, That is wrong. I know that dressing change was done on admission. It is a documentation error. The dressing change on 3/10/23 was a PRN dressing change and not documented. My expectation for my nurses is for them to follow orders and document. I did not realize the batch orders from the pharmacy does not include to change the PICC line dressing every 48 hours when there is gauze. I was not familiar with this pharmacy batch PICC line orders. Review of facility policy and procedure titled Central Venous Catheter Dressing Changes dated April 2017 reads, Policy: Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter -related infections that are associated with contaminated, loosened, soiled, or wet dressings . General Guidelines . 6. Change gauze dressings or TSM [Transparent (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: 106068 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 106068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Terrace Rehab and Health Care Center 110 Lodge Terrace Dr Altoona, FL 32702 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)