Health inspection·February 21, 2025

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 policy review, interview, and record review, the facility failed to ensure timely provision of medications for 2 of 3 sampled residents, as evidenced by the failure to provide insulin and an antibiotic timely upon Resident #1's admission to the facility, and failure to provide insulin timely upon Resident #2's admission to the facility. Residents Affected - Few The findings included: 1) Review of the record revealed Resident #1 was admitted to the facility from the hospital on [DATE] at 6:00 PM, with diagnoses to include Type 1 Diabetes. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating he was cognitively intact. This MDS also documented the resident received both insulin and an antibiotic during the look-back period of 01/28/25 through 02/01/25. Review of the hospital discharge paperwork documented Resident #1 was to receive insulin, one short-acting and one long-acting, but the paperwork lacked any specific dose or frequency. Further review of the discharge paperwork revealed documentation the resident was to receive Zosyn (an antibiotic), intravenously, every 8 hours. During an interview on 02/21/25 at 11:21 AM, Resident #1 stated it took a long time to get his insulin, upon admission to the facility. The resident stated he thought it was because he was admitted to the facility late in the evening, and they had to get the insulin from an outside pharmacy. Review of the January 2025 Medication Administration Record (MAR) for Resident #1 revealed the following: a) Lantus insulin (long-acting) was ordered to start on 01/29/25 at 6 AM, but was discontinued and not provided. b) A sliding scale insulin regimen with Novolog (short-acting) was ordered to start on 01/29/25 at 7:30 AM with blood sugar checks ordered before each meal and at bedtime but was discontinued and not provided. This order was then initiated on 01/29/25 at 4:30 PM, missing three opportunities for coverage on 01/28/25 at bedtime, 01/29/25 before breakfast, and on 01/29/25 before lunch. This order was initiated nearly 24 hours after admission to the facility. The resident's blood sugar was high at 335 at that time, with a desired blood sugar of less than 200. c) Glargine insulin (long-acting) was not started or provided until 01/29/25 at 4:30 PM, nearly 24 (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: 106075 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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)