Every finding on record at Aviata at Spring Hill

Based on interview and record review the facility failed to accurately document vital signs ordered for 1 (Resident #1) of 6 residents reviewed for medical management.Findings include:Review of Resident #1's physician order dated 5/22/2026 read, Vital Signs: Vital Signs Q [every] shift every shift.Review of Resident #1's Treatment Administration Record for the month of May 2026 for night shift vital signs documented on 5/23/2026 and on 5/24/2026 Temperature, Respirations, and Oxygen Saturation were documented as NA [not applicable], on 5/25/2026 Respirations were document as NA, on 5/26/2026 Temperature and Oxygen Saturation were documented as NA, on 5/28/2026 Temperature, Respirations, and Oxygen Saturation were documented as NA, on 5/29/2026 Temperature was documented as NA, on 5/30/2026 Temperature and Pulse was documented as NA, and on 5/31/2026 Blood pressure, Temperature, Pulse, Respirations, and Oxygen Saturation was documented as NA.During an interview on 6/23/2026 at 11:48 AM Staff A Licensed Practical Nurse (LPN) stated, I am not sure why there is NA in the vital section. It might not carry over from the vital summary tab. It might not have carried over to that section. Typically, I go by the MAR [Medication Administration Record] and TAR [Treatment Administration Record].During an interview on 6/23/2026 at 12:56 PM Staff B, LPN, stated, If there is an NA I probably did not have the supplies at hand. There is supplies I just might not have it there when I am taking the vitals and I will go get it later and might forget to go back and document the vitals.During an interview on 6/23/2026 at 1:54 PM the Director of Nursing stated, Staff are to document accurately.During an interview on 6/23/2026 at 4:26 PM the Administrator stated, We do not have a policy for documentation or charting of vitals. This is a standard of practice.During an interview on 6/23/2026 at 4:30 PM the Director of Nursing stated, For skilled patients vitals should be taken every shift. I want staff to follow physician orders and document accurately the care provided.

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 3 of 7 residents reviewed, Residents #28, #30, and #105. Findings include: 1) Review of Resident #105's progress note dated 1/30/2025 at 7:53 AM read, EMS [Emergency Medical Service] called for emergent transfer to local ER [emergency room ] for evaluation and treatment. Review of Discharge Return Anticipated MDS assessment dated [DATE] showed the resident was discharged to home/community under Section A- 2105: Discharge Status. During an interview on 4/23/2025 at 9:30 AM, Staff C, MDS Registered Nurse (RN), and Staff D, RN, stated, There is an MDS discrepancy since section A reads that resident is coded that resident discharged to home on 1/30/2025, however, the progress notes show that the APRN [Advanced Practice Registered Nurse] sent [Resident #105's name] to hospital on 1/30/2025. During an interview on 4/24/2025 at 9:16 AM, the Director of Nursing confirmed there was an MDS discrepancy on Section A- discharge status. 51447 2) Review of Resident #28's physician order dated 3/20/2025 read, Sertraline HCl Oral Tablet 25 MG (Sertraline HCl), Give 50 mg by mouth one time a day for depression. Review of Resident #28's quarterly MDS dated [DATE] showed the resident was not receiving antidepressant medications under Section N- Medications. During an interview on 4/24/2025 at 1:25 PM, Staff C, MDS RN, confirmed that Section N of Resident #28's MDS is incorrect. 3) Review of Resident #30's physician order dated 3/5/2025 read, Atenolol Oral Tablet 50 MG (Atenolol), Give 1 tablet by mouth every 12 hours for HTN hold, for sbp [systolic blood pressure] less than 100 or pulse less than 60. Review of Resident #30's quarterly MDS dated [DATE] did not show hypertension indicated as a diagnosis under Section I- Active Diagnoses. During an interview on 4/24/2025 at 1:25 PM, Staff C, MDS RN, confirmed that Section I of Resident #30's MDS is incorrect.

Based on record review and interview, the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASRR) was completed for 3 of 5 residents reviewed for mood and behavior, Residents #28, #30, and #256. Findings include: 1) Review of Resident #256's admission record showed the resident was admitted on [DATE] with the diagnoses including schizoaffective disorder and major depressive disorder with onset dates of 4/9/2025. Review of Resident #256's PASRR dated 3/25/2025 showed no mental illness documented. Review of Resident #256's physician order dated 4/10/2025 read, Sertraline HCl Oral Tablet 100 MG [milligrams] (Sertraline HCl), Give 1 tablet by mouth one time a day for depression. Review of Resident #256's physician order date 4/17/2025 read, Quetiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate), Give 50 mg by mouth at bedtime related to schizoaffective disorder, depressive type . home med [medication], patient declines GDR [gradual dose reduction]. Review of Resident #256's psych admission note dated 4/15/2025 read, Chief Complaint: I'm ready to go home. History of Present Illness: This patient is a [AGE] year-old female who was admitted to this facility on 4/9/2025 with a diagnosis of traumatic subdural hemorrhage without loss of consciousness. Today's visit: The patient has a history of depression, schizoaffective disorder (depressive type with disorganized thinking and hallucinations), and prior opioid and nicotine dependence. She reports no anxiety with her current drug regimen but admits to depression related to adjustment, due to being away from her family and home. During an interview on 4/24/2025 at 8:43 AM, the Director of Nursing (DON) stated, Admission will ask for the screening, but they do not review them. I review them after resident is admitted in about 7 days. [Resident #256's name] screening needs to be revised to include the schizoaffective and major depressive diagnosis. Review of the facility policy and procedure titled Preadmission Screening and Resident Review (PASSR) with the last review date of 1/20/2025 read, Policy: The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screening according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Procedure: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screening, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 51447 2) Review of Resident #28's admission record showed the resident was most recently admitted on [DATE] with diagnoses including major depressive disorder with onset date of 12/26/2024. Review of Resident #28's PASRR dated 11/27/2024 showed no mental illness documented. Review of Resident #28's physician order dated 3/20/2025 read, Sertraline HCl Oral Tablet 25 MG (Sertraline HCl), Give 50 mg by mouth one time a day for depression. Review of psychiatric progress note dated 3/20/2025 read, Medical Necessity/ Reason for Today's Visit . Follow up for Medication and Behavior management and lab review . Follow-up after recent medication change. During an interview on 4/24/2025 at 9:57 AM, the DON confirmed that the PASSR was not accurate for Resident #28. 3) Review of Resident #30's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including major depressive disorder and generalized anxiety disorder with onset dates of 1/30/2025. Review of Resident #30's PASRR dated 2/16/2025 showed no mental illness documented. Review of Resident #30's physician order dated 2/17/2025 read, Trazodone HCl Oral Tablet 50 MG (Trazodone HCl), Give 1 tablet by mouth at bedtime related to major depressive disorder. Review of Resident #30's physician order dated 3/14/2025 read, Paroxetine HCl Oral Tablet 20 MG (Paroxetine HCl), Give 1 tablet by mouth one time a day related to panic disorder (episodic paroxysmal anxiety), major depressive disorder. During an interview on 4/24/2025 at 9:57 AM, the DON confirmed that the PASSR was not accurate for Resident #30.

Based on record review and interview, the facility failed to develop and implement a comprehensive care plan for 1 of 4 residents reviewed for oxygen therapy, Resident #37. Findings include: Review of Resident #37's admission record showed the resident was initially admitted on [DATE] with the diagnoses including chronic obstructive pulmonary disease (COPD), heart failure, presence of cardiac pacemaker, syncope and collapse, anemia, atherosclerotic heart disease of native coronary artery, chest pain, and peripheral vascular disease. During an observation on 4/22/2025 at 8:11 AM, Resident #37 was sitting on the side of the bed with an oxygen concentrator set at 2 liters and the oxygen tubing was lying on the ground. During an interview on 4/22/2025 at 8:11 AM, Resident #37 stated, I removed the oxygen, and I put it on whenever I need to. Review of Resident #37's physician order dated 1/27/2025 read, Oxygen As Needed (PRN) 2 L [liters] via nasal cannula. Review of Resident #37's physician order dated 7/21/2024 read, May self-administer medications. Review of Resident #37's care plan dated 1/31/2025 showed no focus for oxygen administration and self-administration of medications. Review of Resident #37's weights and vitals summary from January 1, 2025 through April 22, 2025 showed the resident received oxygen via nasal cannula on 1/12/2025, 1/13/2025, 1/16/2025, 1/18/2025, 1/23/2025, 1/27/2025, 2/1/2025, 2/6/2025, 2/9/2025, 2/10/2025, 2/13/2025, 3/26/2025, 3/27/2025 and 4/1/2025. During an interview on 4/22/2025 at 3:22 PM, Staff C, Minimum Data Set (MDS) Registered Nurse (RN), confirmed that there was no care plan written for oxygen therapy. During an interview on 4/23/2025 at 9:46 AM, the Director of Nursing (DON) confirmed that Resident #37 did not have a care plan for oxygen or for self-administration of medications, and the resident should be care planned for both. Review of the facility policy and procedure titled Plans of Care with the last review date of 1/20/2025 read, Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements . Procedure . Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA [Omnibus Budget Reconciliation Act] MDS assessment (except discharge assessments, and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate wound care for 2 of 6 residents reviewed for skin and wound care, Residents #65 and #406. Findings include: 1) During an observation on 4/21/2025 at 9:16 AM, Resident #406 was lying in bed. There was a gauze island bordered dressing on the resident's left forearm, which was dated 4/20/2025 (Photographic evidence obtained). During an observation on 4/22/2025 at 9:30 AM, Resident #406 was lying supine in bed, wearing blue foam heal protectors. There was a gauze bordered dressing on the resident's left forearm, which was dated 4/20/2025. During an observation on 4/22/2025 at 12:50 PM, Resident #406 was sitting in his wheelchair in his room. There was a foam bordered dressing on the resident's left forearm, which was dated 4/22/2025 with no initials. Review of Resident #406's physician orders did not show an order for wound care for the resident's left forearm. During an interview on 4/23/2025 at 10:17 AM, Staff F, Licensed Practical Nurse (LPN), stated, [Resident 406's name] has orders for wound care to right lower extremity, but I don't see any for his left forearm. I don't see any change of condition notes. During an interview on 4/23/2025 at 10:47 AM, the Director of Nursing (DON) stated, [Resident #406's name] does not have orders for wound care to the left forearm. The staff are not supposed to do wound care without having a wound care order. They are supposed to initial and date all dressings. 2) During an observation on 4/21/2025 at 11:11 AM, Resident #65 was sitting in her wheelchair in her room. There was a white gauze wrapped dressing on the resident's right arm, which had no date or initials (Photographic evidence obtained). During an observation on 4/22/2025 at 8:35 AM, Resident #65 was lying in her bed. There was a white gauze wrapped dressing on the resident's right arm, which had no date or initials. During an observation on 4/23/2025 at 8:30 AM, Resident #65 was sitting in her wheelchair in her room. There was a white gauze wrapped dressing on the resident's right arm, which had no date or initials. Review of Resident #65's physician orders did not show an order for dressing changes for the resident's right arm. During an interview on 4/23/2025 at 10:37 AM, Staff G, Registered Nurse (RN), stated, Wound care dressings should be dated. There should be orders for wound care. During an interview on 4/23/2025 at 10:50 AM, the DON stated, Dressing should be dated. [Resident #65's name] has orders for skin prep, but I do not see wound care orders to wrap with a gauze. Review of the facility policy and procedures titled Dressing, Dry/Clean with the last review date of 1/20/2025 read, Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Preparation: 1. Verify that there is a physician's order for this procedure . Steps in the procedure . 17. Apply the ordered dressing and secure with tape or bordered dressing per order. (Note: Use non-allergenic tape as indicated.) Label with date and initials to top of dressing.

Based on observation, record review, and interview, the facility failed to ensure residents received appropriate oxygen therapy for 2 of 4 residents reviewed for respiratory services, Residents #406 and #407. Findings include: 1) During an observation on 4/21/2025 at 11:38 AM, Resident #406 was lying in bed, receiving oxygen via nasal cannula (NC) at 2 liters per minute (L/min). During an observation on 4/22/2025 at 9:30 AM, Resident #406 was lying in bed, wearing receiving oxygen via NC at 2L/min. Review of Resident #406's physician order dated 4/17/2025 read, Respiratory: Oxygen For comfort. During an interview on 4/23/2025 at 12:50 PM, the Director of Nursing (DON) stated, We should have added 2 liters on the order. The oxygen was ordered per patient request. He wanted to be on oxygen. During an interview on 4/23/2025 at 10:17 AM, Staff F, Licensed Practical Nurse (LPN), stated, I do expect oxygen orders to have a flow rate, especially if they have COPD [Chronic Obstructive Pulmonary Disease], so that we don't hyper oxygenate them. 2) During an observation on 4/21/2025 at 10:10 AM, Resident #407 was lying in bed, receiving oxygen via NC with tubing attached to an oxygen concentrator, which was set to 2 liters per minute. During an observation on 4/22/2025 at 10:30 AM, Resident #407 was lying in bed, receiving oxygen via nasal at 2 liters per minute. Review of Resident #407's physician orders showed no orders for administration of oxygen. During an interview on 4/22/2025 at 12:50 PM, the DON stated, I only see an order for O2 [oxygen] tubing changes. She [Resident #407] needs an order for O2. During an interview on 4/23/2025 at 10:40 AM, Staff G, Registered Nurse (RN), stated, There should be orders in the system when a patient is on oxygen. Usually for comfort care, we do 2 liters. Review of the facility policy and procedure titled Oxygen Therapy with the last review date of 1/20/2025 read, Policy: Oxygen therapy is the administration of a FiO2 [fraction of inspired oxygen] greater than 21% by means of various administration devices to: raise the resident's PaO2 [partial pressure of oxygen] to an acceptable baseline using the lowest FiO2, to treat hypoxemia, to decrease work of breathing, to reverse and prevent tissue hypoxia, and/or to decrease myocardial work. Procedure: Physician's order for oxygen therapy shall include: Administration modality, FiO2 or liter flow, continuous or PRN [as needed[, PRN orders must include specific guidelines as to when the resident is to use oxygen.

Based on record review and interview, the facility failed to ensure residents were assessed before and after dialysis treatments for 1 of 1 resident receiving dialysis services, Resident #39. Findings include: Review of Resident #39 Hemodialysis Communication Record dated 4/10/2025 showed no pre and post dialysis vital signs or observations documented. Review of Resident #39's Hemodialysis Communication Record dated 4/12/2025 showed no pre and post dialysis vital signs or observations documented. Review of Resident #39's Hemodialysis Communication Record dated 4/22/2025 showed no pre and post dialysis vital signs or observations documented. Review of Resident #39' records showed no hemodialysis communication documentation for 3/8/2025, 3/11/2025, 3/13/2025, 3/20/2025, 3/22/2025, 3/25/2025, 3/27/2025, 3/29/2025. Review of Resident #39's physician order dated 3/6/2025 read, Hemodialysis Tuesday, Thursday, Saturday, [name, address and phone number of local dialysis center and transportation company information] every day shift every Tue [Tuesday], Thu [Thursday], Sat [Saturday] for ESRD [End Stage Renal Disease]/Hemodialysis send a Lunch. During an interview on 4/23/2025 at 3:42 PM, the Director of Nursing (DON) stated, For [Resident #39's name], I don't have any other communication forms for dialysis. I do not know if the nurses know to do the pre and post dialysis form. I have not educated them on it. During an interview on 4/23/2025 at 3:44 PM, Staff H, Licensed Practical Nurse (LPN), stated, Residents that go to dialysis have a binder, and in the form, we have to record the vitals, medications and assessment. When the residents come back, we have to assess them again and fill out the bottom portion of the form. Review of the facility policy and procedure titled Coordination of Hemodialysis Services with the last review date of 1/20/2025 read, Policy: Residents requiring an outside ESRD facility will have services coordinated by the facility. There will be communication between the facility and the ESRD facility regarding the resident. The facility will establish a Dialysis Agreement/ Arrangement if there are any residents requiring Dialysis Services. The agreement shall include how the residents [Sic.] care is to be managed. Procedure: 1. The Dialysis Communication form will be initiated by the facility for any resident going to an ESRD center for hemodialysis . 5 Nursing will complete the post dialysis information on Dialysis Communication form and file the completed form in the Resident's Clinical Record.

Based on observation, interview, and record review, the facility failed to ensure medications were secured in one of two halls (400 Hall). Findings include: 1) During an observation on 4/21/2025 at 11:25 AM, there was one bottle of antifungal powder (Miconazole Nitrate 2%) on the bedside table in Resident #3's room (Photographic evidence obtained). During an interview on 4/21/2025 at 11:25 AM, Resident #3 stated, The CNA [Certified Nursing Assistant] will put the fungal powder on my arms and legs once a day. During an observation on 4/22/2025 at 8:05 AM, there was one bottle of antifungal powder (Miconazole Nitrate 2%) on the bedside table in Resident #3's room. 2) During an observation on 4/21/2025 at 10:00 AM, there was one bottle of Equate medicated body powder, active ingredient menthol 0.15%, on the bedside table in Resident #37's room (Photographic evidence obtained). During an observation on 4/22/2025 at 8:11 AM, there was one bottle of Equate medicated body powder, active ingredient menthol 0.15%, on the bedside table in Resident #37's room. During an interview on 4/22/2025 at 8:11 AM, Resident #37 stated, I put the powder on my groin at least daily and sometimes even more when I get sweaty. During an interview on 4/22/2025 at 8:45 AM, Staff A, CNA, confirmed the medication was unsecured at the bedside and stated, I would tell the nurse, but no medication can be at the bedside. I do not apply any medications to the residents. During an interview on 4/22/2025 at 8:57 AM, Staff B, Licensed practical Nurse (LPN), stated, Medication is not allowed at the bedside. If they have been evaluated for self-administration, the medication can remain at the bedside, but the medication still needs to be locked in the drawer to make sure that the medication is secured. During an interview on 4/22/2025 at 9:11 AM, the Assistant Director of Nursing stated, Medications are not allowed at the bedside unsecure. If they have been evaluated for self-administration, the medication can remain at the bedside, but the medication still needs to be locked in the drawer to make sure that they are secure. During an interview of 4/23/2025 at 9:46 AM, the Director of Nursing (DON) stated, The nystatin powders should not have been in the room. No medication is allowed to be stored in the room unless the resident is screened for self-administration and then the medications can be stored in the room but locked up. Review of the facility policy and procedure titled Medication Storage with the last review date of 1/20/2025 read, Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with FL Department of Health Guidelines. Procedure: A. With the exception of Emergency Drug Kits, all mediations will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy. 46523 3) During an observation on 4/21/2025 at 10:09 AM, Resident #407 was lying in bed, wearing a gown. There was a Dextrose 5% intravenous (IV) fluid bag running. Neither IV bag nor tubing was dated. During an observation on 4/22/2025 at 12:50 PM, Resident #407 was lying in bed, wearing a gown. There was a Dextrose 5% intravenous (IV) fluid bag running. Neither IV bag nor tubing was dated. During an interview on 4/23/2025 at 10:40 AM, Staff G, Registered Nurse (RN), stated, [Resident #407's name] fluid bag should be dated. I am not sure about dating the tubing because it gets discarded. During an interview on 4/23/2025 at 11:00 AM, the Director of Nursing (DON) stated, Normally IV bag and tubing should be dated, initialed and timed. Review of the facility policy and procedure titled Intravenous Administration of Fluids and Electrolytes with the last review date of 1/20/2025 read, Policy: Staff will be knowledgeable regarding safe and aseptic administration of intravenous fluids and electrolytes for hydration. Procedure . 8. When infusion is complete . For continuous therapy: a. [NAME] solution container with label that states when bag started and approximate time of completion. b. Never write directly on the bag with ink or marker; always use a label or tape.

Based on observation, interview and record review, the facility failed to maintain complete and accurate medical records for 4 of 7 residents reviewed for medication administration, Residents #37, #39, #256, and #407. Findings include: 1) Review of Resident #256's physician order dated 4/14/2025 read, Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML [milliliter] (Insulin Lispro), Inject as per sliding scale: if 120-150=1; 151-200=2 units; 201-250= 4 units; 251-300= 6 units, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with hypoglycemia with coma. Review of Resident #256's Medication Administration Record (MAR) for April 2025 for administration of Insulin Lispro using a sliding scale showed blood sugar level of 123 and code 12 (Insulin not required) on 4/15/2025 at 9:00 PM, blood sugar level of 387 and code 1 [Held per parameters] on 4/18/2025 at 9:00 PM, blood sugar level of 90 and code 12 on 4/19/2025 at 4:00 PM, blood sugar level of 480 and code 11 on 4/21/2025 at 9:00 PM, and blood sugar level of 322 and code 11 on 4/22/2025 at 6:00 AM. Review of Resident #256's physician order dated 4/15/2025 read, Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro), Inject 5 unit subcutaneously with meals for DM [Diabetes Mellitus]. Review of Resident #256's MAR for April 2025 for administration of Insulin Lispro 5 units showed blood sugar level of 90 and code 12 on 4/19/2025 at 4:30 PM, blood sugar documented as NA (Not Applicable) on 4/20/2025 at 6:30 AM and at 4:30 PM, and on 4/22/2025 at 6:30 AM. During an interview on 4/22/2025 at 1:49 PM, the Director of Nursing (DON) stated, I spoke to [Staff I, Licensed Practical Nurse (LPN)'s name] and she stated she gave [Resident #256's name] insulin. She does not know why it was not documented accurately. During an interview on 4/23/2025 at 8:15 AM, the DON stated, I spoke to [Staff N, LPN's name] and he stated he documented NA [for Resident #256's blood sugar level] because he had documented the blood sugar previously. I expect the staff to document the blood sugar every time it is required on the medication administration record even if it is multiple times. During an interview on 4/23/2025 at 8:56 AM, Staff K, LPN, stated, [Resident #256's name] felt uncomfortable with her blood sugar and felt more comfortable without insulin coverage and I consulted with the physician. I did not document the conversation with the physician. During an interview on 4/23/2025 at 9:42 PM, Medical Doctor #1 stated, [Resident #256's name] has a sliding scale in addition to 5-unit standing order. The staff contact me and notify me if they will be holding the medication when it is out of parameters. 2) Review of Resident #407's physician order dated 4/9/2025 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine), Inject 40 unit subcutaneously two times a day for DM. Review of Resident #407's MAR for April 2025 for administration of Insulin Glargine 40 units showed no entry documented on 4/16/2025 at 6:00 AM, code 12 on 4/17/2025 at 6:00 AM, and code 11 on 4/20/2025 at 6:00 AM. Review of Resident #407's physician order dated 4/9/2025 read, Novolin R FlexPen Injection Solution Pen-Injector 100 unit/ML (Insulin Regular (Human)), Inject as per sliding scale: if 151-200=1; 201-250= 2 unit; 251-300= 3 unit, subcutaneously before meals and at bedtime for DM. Review of Resident #407's MAR for April 2025 for administration of Novolin R Flex Pen showed no entry documented on 4/16/2025 at 6:00 AM. Review of Resident #407's progress notes for April 2025 did not document notification to the provider regarding blood sugar or insulin coverage. During an interview on 4/23/2025 at 8:15 AM, the DON stated, I spoke to [Staff I, LPN's name] and she stated [Resident #407's name] blood sugar was low, and she held the long-acting insulin, but did not recall if she contacted the provider. She stated normally she will contact the provider regarding holding any medication. Staff are expected to call the provider and get new orders or document the communication to the provider. During an interview on 4/23/2025 at 10:05 AM, Staff J, LPN, stated, [Resident #407's name] Long acting was given, and the short acting was held due to parameters. I do not know why it did not show in the system. During an interview on 4/23/2025 at 9:42 PM, Medical Doctor #1 stated, We follow [Resident #407's name] very closely regarding her diabetes. Nurses normally contact me if it is not by phone, it is in person when I am in the facility. The staff will call me if they are holding her insulin. She [Resident #407] sometimes runs pretty low. 3) Review of Resident #39's physician order dated 3/5/2025 read, Insulin Aspart Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Aspart), Inject as per sliding scale: if 0-150=0; 151-200=2; 201-250=4; 251-300=6; 301-350=8; 351-400=10; 401 + =10 give 10 units and call MD [Medical Doctor] for further instructions, subcutaneously before meals for DM. Review of Resident #39's MAR for April 2025 for administration of Insulin Aspart showed blood sugar levels of 540 on 4/8/2025 at 4:30 PM, 545 on 4/15/2025 at 11:30 AM, 424 on 4/16/2025 at 11:30 AM and 431 at 4:30 PM, 497 on 4/19/2025 at 11:30 AM and 411 at 4:30 PM, and 437 on 4/20/2025 at 11:30 AM. Review of Resident #39's progress notes for April 2025 did not show notifications to the provider regarding blood sugar levels or insulin coverage. Review of Resident #39's physician order dated 3/5/2025 read, Insulin Aspart Flex Pen Subcutaneous Solution Pen Injector 100 UNIT/ML (Insulin Aspart), Inject 5 unit subcutaneously before meals for diabetes mellitus. Review of Resident #39's MAR for April 2025 for administration of Insulin Aspart 5 units showed code 12 on 4/11/2025 at 6:30 AM, code 11 on 4/20/2025 at 6:30 AM, and code 12 on 4/21/2025 at 6:30 AM. Review of Resident #39's physician order dated 3/10/2025 read, Insulin Glargine Subcutaneous Solution Pen Injector 100 unit/ML (Insulin Glargine), Inject 15 units subcutaneously two times a day for DM. Review of Resident #39's MAR for April 2025 for administration of Insulin Glargine 15 units showed code 12 on 4/11/2025 at 6:00 AM. During an interview on 4/22/2025 at 3:49 PM, the DON stated, I spoke to [Staff B, LPN's name], who stated that she contacted [Medical Doctor #2s's name] about [Resident #39's name] blood glucose being over 400 on 4/8/25, and [Medical Doctor #2's name] did not give any new orders at that time. [Staff B's name] stated that typically she would document the notification of the provider in the progress notes, and must have forgotten to document. During an interview on 4/22/2025 at 3:50 PM, the DON stated, I spoke to [Staff I, LPN's name], who stated that she spoke with [Medical Doctor #3' name] regarding [Resident #39's name] blood sugar being over 400 on 4/15, and 4/16 that he was notified, and there were no new orders. During an interview on 4/22/2025 at 3:51 PM, the DON stated, I spoke with [Staff L, LPN's name], who stated that a new order for insulin was added on 4/20 at 17:50 [5:50 PM] after reviewing 4/19 and 4/20 glucose results with MD. During an interview on 4/23/2025 at 9:00 AM, Medical Doctor #3 stated, The nurses call the concierge line and they have access to secured text line and frequently text any concerns to me. Communication from the staff has been good. I have thousands of patients and cannot remember if I was called about that specific patient on that day. Normally the staff call. I do expect nurses to call me if they are ever uncomfortable or have concerns about a patient. During an interview on 4/23/2025 at 9:14 AM, Staff M, LPN, stated, Saturday night we tried and sent a text message. I might have contacted the provider. I am not sure. Usually when I hold the insulin, I normally will call the doctor and let him know. 45576 4) Review of Resident #37's physician order dated 3/28/2025 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine), Inject 25 unit subcutaneously at bedtime for DM, HOLD if BGM [Blood Glucose Monitoring] Less than 120, AND Inject 15 unit subcutaneously in the morning for DM2 hold for BG less than 100. Review of Resident #37's MAR for April 2025 showed blood sugar level of 94 on 4/8/2025 with 15 units of Insulin Glargine administered. During an interview on 4/23/2025 at 9:40 AM, Staff E, Registered Nurse (RN), stated, I reviewed the chart, and I had documented the blood sugar of 94 twice in error. I documented that I gave the insulin. I did not give the insulin in the AM [morning time] on 4/8/25. During an interview on 4/23/2025 at 3:28 PM, the Assistant Director of Nursing stated, If a medication is not given, then an explanation should be placed on why the medication was held. Physician orders are to be followed and if an error occurs in the chart. The error needs to be corrected. Review of the facility policy and procedure titled Medication-Oral Administration of with the last review date of 1/20/2025 read, Procedure . Review physician order . Review the MAR or EMAR [electronic Medication Administration Record] should there be any uncertainties verify the MAR or EMAR with the Physician's Order Sheet (POS) and seek clarification as indicated . Document the administration and acceptance or decline of all medications administered. This may include . b. When documenting in the EMAR, the nurse will document immediately prior to administration and or immediately post administration based on preferred individual professional practice of the nurse. Should the resident decline or be unable to accept the medication this will need to be documented following standard protocol. Review of the facility policy and procedure titled Insulin Administration-Injection Pens with the last review date of 1/20/2025 read Procedure . Document in medical record.

Based on observation, record review, and interview, the facility failed to establish antibiotic stewardship program to monitor antibiotic use for 1 of 3 residents reviewed for antibiotic use, Resident #406. Findings include: Review of Resident #406's physician order dated 4/17/2025 read, Erythromycin Ophthalmic Ointment 5 MG (milligram)/GM (gram), Instill 1 application in left eye three times a day for eye infection . Order Status: Active. Start Date: 04/17/2025. End date: [Blank]. During an observation on 4/23/2025 at 8:13 AM, Resident #406 was sitting up in bed, eating breakfast. Resident #406's left eye was not red or drooping, and no drainage was visible. During an interview on 4/23/2025 at 10:17 AM, Staff F, Licensed Practical Nurse (LPN), stated, I think the Erythromycin antibiotic ointment is ordered continuously for him and was something he was using at home for drooping, draining left eye. It has an indefinite end date. During an interview on 4/23/2025 at 10:47 AM, the DON (Director of Nursing) stated, Antibiotics normally have a stop date. We are waiting for the provider to see [Resident #406's name] before we put in a stop date for his erythromycin ointment. When I saw his left eye on Monday, it still had a lot of drainage. During an interview on 4/23/2025 at 3:05 PM, the Infection Preventionist stated, Usually antibiotic orders have an end date. Everything should have an end date. When [Resident #406's name] came in his eye showed signs of an eye infection and now he [Resident #406] started to clear up and is doing better. [Resident #406's name] came in with that order. Review of the facility policy and procedure titled Antibiotic Stewardship -Orders for Antibiotics with the last review date of 01/20/2025 read, Policy Statement: Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program and in conjunction with the facility's general policy for Medication Utilization and Prescribing. Policy Interpretation and Implementation . 2. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements . d. duration of treatment: (1) start and stop date or (2) number of days of therapy.

Based on record review and interview, the facility failed to ensure resident assessment was accurate for 1 of 3 residents reviewed for discharge, Resident #114. Finding include: Review of Resident #114's summary of discharge date d 12/4/2023 at 6:00 PM showed the resident was discharged to home with spouse/family. Review of Resident #114's Minimum Data Set (MDS) Discharge Return Not Anticipated Assessment, dated 1/4/2024, showed the resident was discharged to an acute hospital on 12/4/2023. During an interview on 2/7/2024 at 12:37 PM, the Minimum Data Set Coordinator confirmed Resident #114 discharged home and the MDS dated [DATE] was inaccurate. Review of the facility policy and procedures titled MDS last reviewed on 1/24/2024 showed the policy read, Policy: The center conducts initial and periodical standardized, comprehensive and reproducible assessments no less than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weaknesses and preferences using the federal and/or state required RAI. Procedure . Each person completing a section or portion of a section of the MDS signs the Attestation Statement indicating its accuracy.

Based on observation, interview, and record review, the facility failed to ensure the medications and biologicals were stored and labeled properly in 4 of 7 medication carts reviewed (Photographic evidence obtained). Findings include: During an observation of Magnolia Medication Cart on 2/5/2024 at 8:57 AM with Staff B, Licensed Practical Nurse (LPN), there were one opened Humalog insulin pen with no opened or expiration dates, one opened bottle of pro-stat with no opened or expiration dates, one opened Fluticasone Furoate/Vilanterol Ellipta Inhaler with no opened or expiration dates, and one medication cup containing gold color gel capsules with no identifier. During an interview on 2/5/2024 at 9:02 AM, Staff B, LPN, stated, The insulin pen belongs to a resident that was discharged last week. The pen should have been removed from the medication cart. The medication should be labeled with the opened date when opened. The capsules are fish oil. I got them from the other medication cart. I was waiting on central supply to get a bottle. Medication should be stored in original packaging. During an observation of Split Medication Cart on 2/5/2024 at 9:07 AM with Staff D, LPN, there were one opened bottle of pro-stat with no opened or expiration dates, one opened Humulin vial with no opened or expiration dates, one opened vial of insulin Glargine-yfgn with no opened or expiration dates, one opened vial of insulin Lispro with no opened or expiration date and not stored in original packaging, and one medication cup containing two gold clear gel capsules with no identifier. During an interview on 2/5/2024 at 9:10 AM, Staff D, LPN, stated, Medication should be stored in the original packing from pharmacy. Medication should be labeled with opened and expiration dates. The capsules are fish oil. During an observation of Elm Medication Cart on 2/5/2024 at 9:15 AM with Staff E, LPN, there were one opened bottle of Latanoprost eye drop with no opened or expiration dates, one opened bottle of Ciprofloxacin eye drops with no opened or expiration dates, two opened Advair Diskus inhaler with no opened or expiration dates, one opened Breo Ellipta inhaler with no opened or expiration dates, one opened Trelegy Ellipta inhaler with no opened or expiration dates, and one opened bottle of pro-stat with no opened or expiration dates. During an interview on 2/5/2024 at 9:20 AM, Staff E, LPN, stated, All opened medications should be dated when opened. During an observation of Lake Street Medication Cart on 2/5/2024 at 9:25 AM with Staff C, LPN, there were one opened Fiasp flex insulin pen with no opened or expiration dates, one expired Basaglar kwikpen with an opened date of 12/20/2023, one opened Humalog insulin pen with no opened or expiration dates, one opened Latanoprost eye drops with no opened or expiration dates, and one expired Novolog insulin pen with an opened date of 1/1/2024. During an interview on 2/5/2024 at 9:35 AM, Staff C, LPN, stated, Expired medications should be removed from medication cart. When we open a medication, the medication should be labeled with opened and expiration date. During an interview on 2/7/2024 at 10:20 AM, Staff A, LPN, Unit Manager, stated, Medication should be labeled with opened and expiration date. Medication should be stored in the original pharmacy packing and expired medication should be removed from medication cart. Review of the facility policy and procedures titled Medication Storage with the last review date of 1/24/2024 showed the policy read, Procedure . E. Medications will be stored in the original, labeled containers received from the pharmacy. Review of the facility policy and procedures titled Insulin Pen Labeling & Packaging with the last review date of 1/24/2024 showed the policy read, Procedure: A. Labeling and packaging of individual Insulin Pens . 2. Insulin Pens are placed in a resealable bag with the following labels/stickers . d. A yellow Date/Expiration sticker.

Based on observation, interview, and record review, the facility failed to ensure food items were dated and/or labeled, and covered, and the kitchen equipment was maintained in a clean condition. Findings include: During an observation while conducting an initial tour of the kitchen on 2/5/2024 at 9:05 AM with the District Dietary Manager (DDM) and the Kitchen Manager, there were two pitchers containing juice in the reach-in cooler without an identifying label or date, and one medium-sized stainless steel bowl with a partial clear plastic cover with no date or identifying label that had use for puree written on the clear plastic cover. The catch tray on the gas stove had a large buildup of burnt food particles and debris spills. There was rust and food on the can opener blade and holder. There were 54 glasses of assorted drinks without an identifying label in the reach-in cooler. During an interview on 2/5/2024 at 9:12 AM, the DDM stated that all foods should have identifying labels and dates. The DDM stated that the stainless steel bowl with use for puree written on the cover should have been labeled as chicken salad and dated. The DDM also stated that the catch tray on the stove should have been cleaned weekly and it had a lot of buildup and had not been cleaned. During the follow-up visit to the kitchen on 2/6/2024 at 6:25 AM with the DDM, there were six vanilla health shakes with no pulled or use-by dates, one opened gallon container of milk with no opened date, and nine swirl bowls of a fruit type dessert leftover with no identifying label or date. During an observation on 2/6/2024 at 6:57 AM, a robot coupe machine used to prepare ground, pureed, and chopped foods was stored with water in the base and not stored to allow the equipment to air dry. During an interview on 2/6/2024 at 6:57 AM, the Morning Cook stated the robot coupe was clean and ready to use. During an interview on 2/6/2024 at 7:00 AM, the DDM stated all products should be labeled and dated when opened including leftover foods, and the equipment should be cleaned and stored properly. The DDM stated the supplements should have a pulled to thaw date and a use by date. During an observation while conducting a tour of the nourishment rooms with the Dietary Supervisor (DS) on 2/7/2024 at 6:47 AM, there were seven assorted sandwiches with no identifying label in Unit One Nourishment Room and eleven sandwiches with no identifying label in Unit Two Nourishment Room. The microwave oven in Unit Two Nourishment Room had a large amount of food spatter on the inner top of the microwave oven. During an interview on 2/7/2024 at 6:55 AM, the DS stated that all food items should be identified, and refrigerators and microwave ovens should be cleaned according to the cleaning of equipment policy. Review of the facility policy and procedures titled Food Storage: Cold Foods last reviewed on 1/24/2024 showed the policy read, Procedures . 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility policy and procedure titled Manual Warewashing last reviewed on 1/24/2024 showed the policy read, Procedure . 3. All serviceware and cookware will be air dried prior to storage. Review of the facility policy and procedures titled Equipment last reviewed on 1/24/2024 showed the policy read, Procedures: 1. All equipment will be routinely cleaned and maintained in accordance with the manufacturer's directions and training materials.

Based on record review and interview, the facility failed to complete the quarterly assessment in a timely manner for 1 of 3 residents reviewed for minimum data set assessments, Resident #59. Findings include: Review of Resident #59's Minimum Data Set (MDS) records showed the next quarterly assessment with assessment reference date of 12/29/2023 was overdue for 26 days. During an interview on 2/7/2024 at 9:40 AM, the MDS Coordinator stated, [Resident #59's name] quarterly assessment is overdue 26 days. Review of the facility policy and procedures titled MDS last reviewed on 1/24/2024 showed the policy read, Policy: The center conducts initial and periodical standardized, comprehensive and reproducible assessments no less than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weaknesses and preferences using the federal and/or state required RAI. Procedure: Maintain all resident assessments completed within the previous 15 months in the resident's active clinical record or in a centralized location that is easily and readily accessible.

Based on record review and interview, the facility failed to develop a comprehensive care plan for 1 of 6 residents reviewed, Resident #74. Findings include: 1. Review of Resident #74's admission record revealed the resident was admitted on [DATE] with a diagnosis of malignant neoplasm of brain. Review of Resident #74's palliative medicine consult note dated 6/29/2022 revealed the resident was referred for palliative care services related to diagnoses that included malignant neoplasm of brain, dysphagia, aphasia, and physical deconditioning. Review of Resident #74's palliative care note dated 1/24/2024 revealed the resident continued in receiving palliative care services for the active diagnoses that included adult failure to thrive syndrome, with the medical interventions that included comfort interventions only. Review of Resident #74's care plan with the start date of 12/21/2023 revealed no focus area with goals and interventions related to palliative care. During an interview on 2/7/2024 at 10:28 AM, the Minimum Data Set Coordinator confirmed that palliative care services had not been included in Resident #74's care plan. She confirmed palliative care services should have been included in Resident #74's comprehensive care plan.

Based on observation, record review, and interview, the facility failed to ensure that residents received care and services consistent with professional standards of practice for 1 of 5 residents receiving intravenous medication, Resident #216. Findings include: During an observation on 2/7/2024 at 8:11 AM, Staff B, License Practical Nurse (LPN), entered Resident #216's room and performed hand hygiene. Staff B primed Resident #216's intravenous (IV) tubing and sanitized the needleless connector. Staff B did not prime the normal saline flush syringe or check blood return before flushing the peripherally inserted central catheter (PICC) line. During an interview on 2/7/2024 at 8:27 AM, Staff A, LPN, Unit Manager, stated, The nurse should have primed the normal saline syringe before administering it. During an interview on 2/7/2024 at 8:35 AM, Staff B, LPN, stated, I just took the IV refresher course and I don't remember them saying we needed to do that. I always stop short of administering the whole syringe definitely. The class was very detailed but don't remember them mentioning that. Review of Resident #216's physician order dated 2/6/2024 showed the order read, Cefepime HCl [Hydrochloride] Intravenous Solution 2 GM [gram]/100 ML [milliliter]. Use 2 grams intravenously every 12 hours for wound infection until 2/11/2024. Review of Resident #216's physician order dated 2/2/2024 showed the order read, IVs: Flush PICC Line with10 ml of normal saline every shift and as needed. Review of the facility policy and procedures titled Medication Administration with the last review date of 1/24/2024 showed the policy read, Procedure . 8. Prime administration set, if not pre-primed by pharmacy . 10. Maintaining asepsis, attach flush syringe to needleless connector. Aspirate the catheter to obtain positive blood return to verify vascular access patency. Flush with prescribed flushing agent. Remove syringe.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards of practice for 1 of 3 residents reviewed for oxygen therapy, Resident #319. Findings include: During an observation on 2/5/2024 at 12:50 PM, Resident #319 was lying in bed with oxygen running at 4 liters per minute via nasal cannula. During an observation on 2/6/2024 at 8:15 AM, Resident #319 was lying in bed with oxygen running at 4 liters per minute via nasal cannula. Review of Resident #319's physician order dated 2/4/2024 showed the order read, Oxygen As Needed PRN 3l [as needed 3 liters] via nasal cannula for shortness of breath as needed. Review of Resident #319's care plan initiated on 1/24/2024 showed the care plan read, Focus: The resident has oxygen therapy r/t [related to] COPD [Chronic Obstructive Pulmonary Disease] . Interventions . Oxygen Setting: O2 [Oxygen] via nasal prongs @ 3L [at 3 liters] as ordered. Humidified (as ordered). During an observation on 2/7/2024 at 8:35 AM with Staff A, Unit Manager, Resident #319 was lying in bed with oxygen running at 4 liters per minute via nasal cannula. During an interview on 2/7/2024 at 8:35 AM, Staff A, Unit Manager, stated, [Resident #319's name] oxygen orders are for 3 liters per minute. I will go back in and correct the flow rate. Review of the facility policy and procedures titled Oxygen Therapy with the last review date of 1/24/2024 showed the policy read, Policy: In the event that a resident requires the use of oxygen to manage a medical condition, The Company will offer assistance as ordered by the resident's physician. Only enrichers, concentrators, and liquid oxygen will be used. Oxygen therapy must be reviewed by the nurse on a regular basis and all staff members offering assistance with oxygen must be properly trained. Procedure: 1. The nurse will organize the oxygen therapy as ordered by the resident's physician.

Based on record review and interview, the facility failed to ensure orders for psychotropic drugs were limited to 14 days for 1 of 6 residents reviewed for unnecessary medications, Resident #74. Findings include: Review of Resident #74's physician order dated 1/19/2024 showed the order read, Alprazolam Oral Tablet 0.5 MG [milligrams] (Alprazolam) *Controlled Drug* Give 1 tablet by mouth every 3 hours as needed for restlessness agitation Under the care of [NAME] Program Palliative Care. Review of Resident #74's Medication Administration Record for January 2024 revealed the resident received Alprazolam Oral Tablet 0.5 MG on 1/19/2024. Review of Resident #74's Medication Administration Record for February 2024 revealed the resident received Alprazolam Oral Tablet 0.5 MG on 2/1/2024, 2/2/2024 (two doses), 2/4/2024, and 2/6/2024 (two doses). Review of Resident #74's psychiatric progress notes dated 1/19/2024 and 1/30/2024 revealed no documentation indicating the attending physician or prescribing practitioner had specified the duration of Resident #74's PRN [as needed] anti-anxiety medication. Review of Resident #74's most recent psychiatric progress notes, dated 1/30/2024 and 1/19/2024, failed to reveal documentation attending physician or prescribing practitioner had specified the duration of Resident #74's PRN antianxiety medication. During an interview on 2/7/2024 at 9:55 AM, Staff A, Licensed Practical Nurse, confirmed that Resident #74 had been prescribed with an antianxiety medication on 1/19/2024, and the resident's antianxiety medication prescription had exceeded 14 days. Review of the facility policy and procedures titled Medication Management- Psychotropic Medications last reviewed on 1/24/2024, showed the policy read, Procedure . 7. PRN physician order(s) for psychotropic medications are limited to 14 days. Except, if the physician or prescribing practitioner believes that it is appropriate to extend beyond 14 days and documents the rationale in the medical record and indicates the duration of the PRN order.

Based on observation, record review, and interview, the facility failed to ensure staff performed hand hygiene during tracheostomy care for 1 of 1 resident reviewed for tracheostomy care, Resident #32, and during medication administration for 2 of 6 residents reviewed for medication administration, Residents #74 and #69, to prevent possible spread of infection and communicable diseases. Findings include: 1. Review of Resident #32's physician order dated 10/13/2022 read, Change trach [Tracheostomy] q [every] 30 days. Review of Resident #32's physician order dated 9/18/2019 read, Tracheostomy- Access skin around stoma site and under ties during trach care. During an observation on 2/7/2024 at 11:40 AM, Staff F, License Practical Nurse (LPN), removed Resident #32's oxygen mask, inner cannula, and gauze from the tracheostomy site. Staff F removed her surgical gloves and without performing hand hygiene proceeded to open the sterile tracheostomy kit. Staff F donned new sterile gloves and started to clean the tracheostomy plate and surrounding areas. Without changing gloves or performing hand hygiene, Staff F proceeded to open a new inner cannula and placed the inner cannula into the outer cannula with the same gloves she used to clean the tracheostomy site. Staff F touched the inner cannula portion that would be inserted into the stoma. Review of the facility policy and procedure tilted Tracheostomy Care with the last review date of 1/24/2024 showed the policy read, For tracheostomy with disposable inner canula . Remove your gloves and discard into a waster container . Perform Hand Hygiene. Review of the facility policy and procedures tilted Hand Hygiene with the last review date of 1/24/2024 showed the policy read, Process: Hand hygiene should be performed . When hands are moved from a contaminated-body site to a clean body site during patient care. Review of the facility's skills competency assessment for tracheostomy care dated 10/2021 showed the assessment read, The employee demonstrates skills and competence in the following . Wash hands and apply gloves (soap and water or hand sanitizer). Clean work surface and cover with non-permeable barrier. Remove gloves, discard. Perform hand hygiene. During an interview on 2/7/2024 at 12:30 PM, Staff A, LPN, Unit Manager, stated, [Staff F's name] did not practice sterile techniques and should have washed her hands when changing gloves during the tracheostomy care. 2. During an observation on 2/7/2024 at 8:46 AM, Staff F, LPN, started preparing medications for Resident #74 at the medication cart without performing hand hygiene. Staff F entered the resident's room and washed her hands and took Resident #74's blood pressure with a small wrist blood pressure cuff. Staff F exited the room and returned to the medication cart. Staff F did not perform hand hygiene. Staff F retrieved blood pressure medication and entered Resident #74's room and handed a cup and water to the resident. Resident #74 spit out the medication and refused to take medications. Staff F returned to the medication cart and started preparing medications for Resident #69 without performing hand hygiene. Staff F grabbed the blood pressure cuff without sanitizing it in between residents and entered Resident #69's room. Staff F washed her hands after entering the resident's room. Staff F took the resident's blood pressure and exited the room. Staff F returned to the medication cart and retrieved blood pressure medication without performing hand hygiene. Staff F entered Resident #69's room and administered all medications to Resident #69. Staff F exited the resident's room and returned to the medication cart and opened a new resident record without performing hand hygiene. During an interview on 2/7/2024 at 9:17 AM, Staff F, LPN, stated, I should have washed my hands more in between residents. I know you sanitize the blood sugar machine, but I did not know we had to sanitize the blood pressure machine. During an interview on 2/7/2024 at 9:20 AM, Staff A, LPN, Unit Manager, stated, The nurse should have washed her hands in between resident interaction and sanitized her blood pressure cuff between resident use. During an interview on 2/7/2024 at 1:10 PM, the Infection Preventionist stated, The nurse should have sanitized the blood cuff in between resident use. It is considered a reusable item. Review of the facility policy and procedures titled Handwashing with the last review date of 1/24/2024 showed the policy read, Policy: An essential component of infection control is hand washing. All staff members must wash their hands. Review of the facility policy and procedures titled Cleaning and Disinfection of Resident-Care Items and Equipment with the last review date of 1/24/2024 showed the policy read, Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standards. Policy Interpretation and Implementation . d. Reusable items are cleaned and disinfected or sterilized between residents.

Based on observation, interview, and record review, the facility failed to ensure residents were free from medical neglect by allowing unqualified facility staff to work outside of their scope of practice, administering intravenous (IV) medications via a peripherally inserted central catheter (PICC) line for 1 of 2 residents, Resident #84, without certification of education, training, and validation of competency for IV medication administration. IV infusion without IV certification and validation of competency could result in the likelihood of serious harm and/or death for residents who are administered IV medication infusions. This can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots, which can occur from a poorly administered IV infusion. Phlebitis can cause blood clots, which can block important blood vessels, causing tissue damage or even be life-threatening. Lack of proper training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into the patient's vein) can increase the spread of infection. Lack of training and verified competency to assess the insertion site for signs and symptoms of phlebitis or infection, fluid leaking (resulting in the treatment not being administered as ordered), redness, pain, tenderness, and swelling can result in the likelihood of increased risk of serious harm and/or death. Proper placement of the PICC through X-ray or ultrasound is required prior to the administration of medication; this knowledge is provided through training and education as part of the certification process. Findings include: Review of Resident #84's records revealed the resident was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . IV [intravenous] NS [normal saline] to run continuously until IV ABT [antibiotic] completed. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Pharmacy to dose. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the IV company report dated 8/22/2022 for Resident #84 reads, Reason for Consultation: PICC (non-valved) . Reason for Insertion: Drugs . Post-Insertion Data. Line Insertion: 3 CG PICC. Comments: 4 FR [French] PICC inserted into R [Right] basilic vein successfully . Instructed to order CXR [chest x-ray] for verification of PICC line tip placement prior to use. Review of the radiology report dated 8/22/2022 at 3:12 PM for Resident #84 reads, Conclusion: No acute cardiopulmonary process. Right PICC line tip in the right jugular venous system, recommend repositioning. Review of the IV company report dated 8/23/2022 for Resident #84 reads, Reason for Consultation: PICC (non-valved) . Reason for Insertion: Drugs . Post-Insertion Data. Line Insertion: 3 CG PICC. Reinsertion: Yes. Reinsertion Due To: Malpositioned PICC. Comments: 4 FR PICC inserted into L [left] basilic vein successfully . Instructed to order CXR for verification of PICC line tip placement prior to use. Review of Resident #84's medical record indicated that no chest X-ray was ordered to confirm and verify proper placement prior to administering the medications. Review of Resident #84's medical record indicated that no [NAME] 3CG tip confirmation report (magnetic tracking of the tip of the PICC line that uses ECG (electrocardiogram) was present in the medical report. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #84. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #84. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #84. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #84. Review of the employee file for Staff J, LPN, showed no IV competency or PICC line competency training within the file. Review of the employee file for Staff I, LPN, showed no IV competency or PICC line competency training within the file. Review of the employee file for Staff H, LPN, no IV competency or PICC line competency training within the file. During an interview on 8/31/2022 at 8:40 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not aware that we did not do an X-ray to confirm line placement prior to administering medications. There are possible complications related to infusing medications into any line that is not confirmed. During an interview on 8/31/2022 at 9:15 AM, the Attending Physician stated, I was made aware yesterday we did not complete an X-ray of the PICC line. Since then, we have obtained an X-ray showing the catheter is in place so there is no harm to the patient. I can't speak to harm to the patient as it is properly positioned at this time. I do expect for IV fluids to be administered per my orders and if they don't, they need to call me. During an interview on 8/31/2022 at 12:00 PM, Staff H, LPN, stated, I was the nurse on the day that [Resident #84's name] PICC line was reinserted. The nurse from the IV company came in and inserted it. I helped him with [Resident #84's name] arm. I held it, so he could get the dressing on. He told me that he thought it was in the right place. He did give me the paper that explained that I needed to get an X-ray. It is my signature on the sheet. I didn't know that I needed to get an X-ray. The nurse, he told me he didn't think he would need to come back. I just didn't know. I thought it was okay to use. I just attached it to his PICC line after the IV nurse left. I didn't know that I needed to get a chest X-ray. I should not have hung the IV. I really didn't think I was hanging it. I just connected it to the IV. I am not IV certified. I did not take the IV certification. I know that I can't hang antibiotics. I just didn't think that the normal saline was a problem. I have flushed PICC lines after antibiotics, but I haven't hung them. I just wanted him to get his fluids, so I did hang it. I did hang a new bag to the peripheral IV that the resident had before the PICC line was put in. Once they came to do the PICC, the IV was out and I just connected the normal saline to the PICC line as soon as the IV nurse left. During an interview on 8/31/2022 at 1:45 PM, the Director of Nursing (DON) stated, I was shocked that [Staff H, LPN's name] had done anything related to [Resident #84's name] PICC line. I heard her say that she did not have the IV certification and I was shocked. She was practicing outside her scope as an LPN. I was not aware that this was happening. I do not really know the process for verifying if an LPN is competent to do IVs. I just got here. I literally started the day you arrived for survey. We should have a copy of their 30-hour course when they are hired. We should not allow LPNs to administer IV medications unless we know that they have had the course. During a telephone interview on 8/31/2022 at 2:59 PM Staff I, LPN, stated, I took an 8-hour course many years ago. I guess I did not do the 30-hour IV course, so I guess I am not IV certified. I thought I was okay to do the IVs with what I had done. No one ever asked me for my certification to do IV med administration. I did administer the [MEDICATION(S)], flush the PICC line and do the normal saline that was ordered to run continuously to [Resident #84's name]. I wasn't aware that it would be a problem. I wish I had known. I did not do a competency specific to the care of the PICC line dressing when I was hired. During a telephone interview on 8/31/2022 at 3:10 PM, Staff J, LPN, stated, I did administer [Resident #84's name] IV and I hung the normal saline. I have been doing IV medications. I was told that as long as there is an RN [Registered Nurse] in the building that I could do it. I was told that by [Staff C, LPN's name] the unit manager. I am in school to be an RN and I was told that I could do it, so I have. I am aware that as an LPN without IV certification I cannot administer any IV medications because it's against the nurse practice act. But I was told it was okay because I was in nursing school. During an interview on 8/31/2022 at 3:20 PM, the Assistant Director of Nursing (ADON) stated, I was not aware that any LPNs who were not IV certified would be administering IV medications. I would not tell any staff that they could practice outside of the nurse practice act. I am not aware of anyone telling an LPN that it was acceptable to administer meds through a PICC or change dressings if they had not taken the course. During an interview on 8/31/2022 at 3:30 PM, Staff C, LPN, stated, I have not told anyone that they could administer IV medications if they are not IV certified as an LPN. I have not said that it is okay for any LPN to administer IV medications if there is an RN in the building. I know that we as LPNs have to follow our scope of practice and that if we have not had the additional training, we can't administer medications IV. During an interview on 9/1/2022 at 7:35 AM, the Human Resources Director stated, The process of hiring staff starts with the application. We do verify licenses for licensed staff, and we will ask LPNs who tell us they are IV certified. The process used to be for human resources to get all certification nurses have and the DON would know and keep record of any staff competencies for nurse. During a telephone interview on 9/1/2022 at 8:10 AM, the Medical Director stated, I came by yesterday and found out about this problem. I did not know we had LPNs who weren't IV certified, administering IV medications. I would expect nurses to practice within their scope of practice. We plan to implement a solution. I would expect that all nurses practice within their scope of practice. Review of the policy and procedure titled Abuse, Neglect, Exploitation & Misappropriation with an approval date of 8/8/2022 reads, Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. Definitions . Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Examples include but are not limited to . Failure to take precautionary measures to protect the health and safety of the resident . Procedure: Acts of abuse directed against residents are absolutely prohibited. Such acts are cause for disciplinary action, including dismissal and possible criminal prosecution. Questions may arise as to what actions constitute abuse of a resident. Any action that may cause or causes actual physical, psychological or emotional harm, which is not caused by simple negligence, constitutes abuse. Review of the policy and procedure titled Administration of Intermittent Infusion with an approval date of 8/8/2022 reads, Guidance . 2. Documentation of central vascular access device (CVAD) tip location must be included in the medical record prior to administration of medications. Maintain catheter patency per flushing/locking protocol while awaiting confirmation. Documentation may include: 2.1. Copy of chest X-ray results reporting location of tip, or fluoroscopy report. Review of the policy and procedure titled Continuous infusion of Medications and Solutions with an approval date of 8/8/2022 reads, To be Performed by: Licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation is documented in accordance with organizational policy . Guidance . 2. Documentation of central vascular access tip location must be included in the medical record prior to administration of medications. Maintain catheter patency per flushing/locking protocol while awaiting tip confirmation. Documentation may include: 2.1. Copy of chest x-ray or fluoroscopy report; 2.2. Telephone order from radiologist stating location of tip (e.g. cavoatrial junction, IVC); 2.3. Copy of ECG technology insertion report.

Based on observation, interview, and record review, the facility failed to ensure licensed nurses had appropriate competencies and skills sets to provide nursing and related services to residents by allowing unqualified facility staff to work outside of their scope of practice, administering intravenous (IV) medications via a peripherally inserted central catheter (PICC) line for 1 of 2 residents, Resident #84, without certification of education, training, and validation of competency for IV medication administration. IV infusion without IV certification and validation of competency could result in the likelihood of serious harm and/or death for residents who are administered IV medication infusions. This can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots, which can occur from a poorly administered IV infusion. Phlebitis can cause blood clots, which can block important blood vessels, causing tissue damage or even be life-threatening. Lack of proper training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into the patient's vein) can increase the spread of infection. Lack of training and verified competency to assess the insertion site for signs and symptoms of phlebitis or infection, fluid leaking (resulting in the treatment not being administered as ordered), redness, pain, tenderness, and swelling can result in the likelihood of increased risk of serious harm and/or death. Proper placement of the PICC through X-ray or ultrasound is required prior to the administration of medication; this knowledge is provided through training and education as part of the certification process. Findings include: Review of Resident #84's records revealed the resident was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . IV [intravenous] NS [normal saline] to run continuously until IV ABT [antibiotic] completed. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Pharmacy to dose. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the IV company report dated 8/22/2022 for Resident #84 reads, Reason for Consultation: PICC (non-valved) . Reason for Insertion: Drugs . Post-Insertion Data. Line Insertion: 3 CG PICC. Comments: 4 FR [French] PICC inserted into R [Right] basilic vein successfully . Instructed to order CXR [chest x-ray] for verification of PICC line tip placement prior to use. Review of the radiology report dated 8/22/2022 at 3:12 PM for Resident #84 reads, Conclusion: No acute cardiopulmonary process. Right PICC line tip in the right jugular venous system, recommend repositioning. Review of the IV company report dated 8/23/2022 for Resident #84 reads, Reason for Consultation: PICC (non-valved) . Reason for Insertion: Drugs . Post-Insertion Data. Line Insertion: 3 CG PICC. Reinsertion: Yes. Reinsertion Due To: Malpositioned PICC. Comments: 4 FR PICC inserted into L [left] basilic vein successfully . Instructed to order CXR for verification of PICC line tip placement prior to use. Review of Resident #84's medical record indicated that no chest X-ray was ordered to confirm and verify proper placement prior to administering the medications. Review of Resident #84's medical record indicated that no [NAME] 3CG tip confirmation report (magnetic tracking of the tip of the PICC line that uses ECG (electrocardiogram) was present in the medical report. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #84. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #84. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #84. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #84. Review of the employee file for Staff J, LPN, showed no IV competency or PICC line competency training within the file. Review of the employee file for Staff I, LPN, showed no IV competency or PICC line competency training within the file. Review of the employee file for Staff H, LPN, no IV competency or PICC line competency training within the file. During an interview on 8/31/2022 at 8:40 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not aware that we did not do an X-ray to confirm line placement prior to administering medications. There are possible complications related to infusing medications into any line that is not confirmed. During an interview on 8/31/2022 at 9:15 AM, the Attending Physician stated, I was made aware yesterday we did not complete an X-ray of the PICC line. Since then, we have obtained an X-ray showing the catheter is in place so there is no harm to the patient. I can't speak to harm to the patient as it is properly positioned at this time. I do expect for IV fluids to be administered per my orders and if they don't, they need to call me. During an interview on 8/31/2022 at 12:00 PM, Staff H, LPN, stated, I was the nurse on the day that [Resident #84's name] PICC line was reinserted. The nurse from the IV company came in and inserted it. I helped him with [Resident #84's name] arm. I held it, so he could get the dressing on. He told me that he thought it was in the right place. He did give me the paper that explained that I needed to get an X-ray. It is my signature on the sheet. I didn't know that I needed to get an X-ray. The nurse, he told me he didn't think he would need to come back. I just didn't know. I thought it was okay to use. I just attached it to his PICC line after the IV nurse left. I didn't know that I needed to get a chest X-ray. I should not have hung the IV. I really didn't think I was hanging it. I just connected it to the IV. I am not IV certified. I did not take the IV certification. I know that I can't hang antibiotics. I just didn't think that the normal saline was a problem. I have flushed PICC lines after antibiotics, but I haven't hung them. I just wanted him to get his fluids, so I did hang it. I did hang a new bag to the peripheral IV that the resident had before the PICC line was put in. Once they came to do the PICC, the IV was out and I just connected the normal saline to the PICC line as soon as the IV nurse left. During an interview on 8/31/2022 at 1:45 PM, the Director of Nursing (DON) stated, I was shocked that [Staff H, LPN's name] had done anything related to [Resident #84's name] PICC line. I heard her say that she did not have the IV certification and I was shocked. She was practicing outside her scope as an LPN. I was not aware that this was happening. I do not really know the process for verifying if an LPN is competent to do IVs. I just got here. I literally started the day you arrived for survey. We should have a copy of their 30-hour course when they are hired. We should not allow LPNs to administer IV medications unless we know that they have had the course. During a telephone interview on 8/31/2022 at 2:59 PM Staff I, LPN, stated, I took an 8-hour course many years ago. I guess I did not do the 30-hour IV course, so I guess I am not IV certified. I thought I was okay to do the IVs with what I had done. No one ever asked me for my certification to do IV med administration. I did administer the [MEDICATION(S)], flush the PICC line and do the normal saline that was ordered to run continuously to [Resident #84's name]. I wasn't aware that it would be a problem. I wish I had known. I did not do a competency specific to the care of the PICC line dressing when I was hired. During a telephone interview on 8/31/2022 at 3:10 PM, Staff J, LPN, stated, I did administer [Resident #84's name] IV and I hung the normal saline. I have been doing IV medications. I was told that as long as there is an RN [Registered Nurse] in the building that I could do it. I was told that by [Staff C, LPN's name] the unit manager. I am in school to be an RN and I was told that I could do it, so I have. I am aware that as an LPN without IV certification I cannot administer any IV medications because it's against the nurse practice act. But I was told it was okay because I was in nursing school. During an interview on 8/31/2022 at 3:20 PM, the Assistant Director of Nursing (ADON) stated, I was not aware that any LPNs who were not IV certified would be administering IV medications. I would not tell any staff that they could practice outside of the nurse practice act. I am not aware of anyone telling an LPN that it was acceptable to administer meds through a PICC or change dressings if they had not taken the course. During an interview on 8/31/2022 at 3:30 PM, Staff C, LPN, stated, I have not told anyone that they could administer IV medications if they are not IV certified as an LPN. I have not said that it is okay for any LPN to administer IV medications if there is an RN in the building. I know that we as LPNs have to follow our scope of practice and that if we have not had the additional training, we can't administer medications IV. During an interview on 9/1/2022 at 7:35 AM, the Human Resources Director stated, The process of hiring staff starts with the application. We do verify licenses for licensed staff, and we will ask LPNs who tell us they are IV certified. The process used to be for human resources to get all certification nurses have and the DON would know and keep record of any staff competencies for nurse. During a telephone interview on 9/1/2022 at 8:10 AM, the Medical Director stated, I came by yesterday and found out about this problem. I did not know we had LPNs who weren't IV certified, administering IV medications. I would expect nurses to practice within their scope of practice. We plan to implement a solution. I would expect that all nurses practice within their scope of practice. Review of the policy and procedure titled Administration of Intermittent Infusion with an approval date of 8/8/2022 reads, Guidance . 2. Documentation of central vascular access device (CVAD) tip location must be included in the medical record prior to administration of medications. Maintain catheter patency per flushing/locking protocol while awaiting confirmation. Documentation may include: 2.1. Copy of chest X-ray results reporting location of tip, or fluoroscopy report. Review of the policy and procedure titled Continuous infusion of Medications and Solutions with an approval date of 8/8/2022 reads, To be Performed by: Licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation is documented in accordance with organizational policy . Guidance . 2. Documentation of central vascular access tip location must be included in the medical record prior to administration of medications. Maintain catheter patency per flushing/locking protocol while awaiting tip confirmation. Documentation may include: 2.1. Copy of chest x-ray or fluoroscopy report; 2.2. Telephone order from radiologist stating location of tip (e.g. cavoatrial junction, IVC); 2.3. Copy of ECG technology insertion report.

Based on observation, interview, and record review, the facility administration failed to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by not assuming full responsibility for the day to day operations of the facility by allowing unqualified facility staff to work outside of their scope of practice, administering intravenous (IV) medications via a peripherally inserted central catheter (PICC) line for 1 of 2 residents, Resident #84, without certification of education, training, and validation of competency for IV medication administration. IV infusion without IV certification and validation of competency could result in the likelihood of serious harm and/or death for residents who are administered IV medication infusions. This can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots, which can occur from a poorly administered IV infusion. Phlebitis can cause blood clots, which can block important blood vessels, causing tissue damage or even be life-threatening. Lack of proper training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into the patient's vein) can increase the spread of infection. Lack of training and verified competency to assess the insertion site for signs and symptoms of phlebitis or infection, fluid leaking (resulting in the treatment not being administered as ordered), redness, pain, tenderness, and swelling can result in the likelihood of increased risk of serious harm and/or death. Proper placement of the PICC through X-ray or ultrasound is required prior to the administration of medication; this knowledge is provided through training and education as part of the certification process. Findings include: Review of the job description for the Executive Director 1, with an effective date of 8/8/2022, reads, Purpose of Your Job Position: The Executive Director 1 is responsible for management of the facility in a manner which exemplifies Consulate Health Care's standard of operational excellence, to include but not limited to creating an environment in which employees demonstrate Compassion, Honesty, Integrity and Respect for one another and everyone they come into contact with, and business practices are conducted with [MEDICATION(S)]. The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. Review of the job description for Director of Clinical Services I, with an effective date of 8/22/2022, reads, Purpose of Your Job Position: As a Consulate Health Care Director of Clinical Services, you are entrusted with the responsibility of caring for our residents, families, co-workers, visitors, and all others; as well as demonstrating in all interactions, Consulate Health Care's five core values of Compassion, Honesty, Integrity, Respect, and [MEDICATION(S)]. The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Executive Director to ensure that the highest degree of quality care is maintained at all times. You are entrusted to provide innovative, responsible healthcare with creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results . Duties and Responsibilities . 5. Set and monitor achievement of goals and objectives for the nursing department consistent with established philosophy and standard of practice. 6. Recruit and hire a sufficient number of qualified nursing staff to deliver efficient resident care in accordance with the established staffing plan. 7. Establish, implement, and continually update competency/ skills checklists for nursing staff . 9. Maintain and guide the implementation of current policies and procedures, which reflect adherence to corporate and external regulatory guidelines . 11. Establish and monitor compliance with an effective medical record documentation system . 14. Actively participate in the quality improvement process for the facility . 15. Participate in and/or provide in-service education sessions. Review of Resident #84's records revealed the resident was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . IV [intravenous] NS [normal saline] to run continuously until IV ABT [antibiotic] completed. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Pharmacy to dose. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the IV company report dated 8/22/2022 for Resident #84 reads, Reason for Consultation: PICC (non-valved) . Reason for Insertion: Drugs . Post-Insertion Data. Line Insertion: 3 CG PICC. Comments: 4 FR [French] PICC inserted into R [Right] basilic vein successfully . Instructed to order CXR [chest x-ray] for verification of PICC line tip placement prior to use. Review of the radiology report dated 8/22/2022 at 3:12 PM for Resident #84 reads, Conclusion: No acute cardiopulmonary process. Right PICC line tip in the right jugular venous system, recommend repositioning. Review of the IV company report dated 8/23/2022 for Resident #84 reads, Reason for Consultation: PICC (non-valved) . Reason for Insertion: Drugs . Post-Insertion Data. Line Insertion: 3 CG PICC. Reinsertion: Yes. Reinsertion Due To: Malpositioned PICC. Comments: 4 FR PICC inserted into L [left] basilic vein successfully . Instructed to order CXR for verification of PICC line tip placement prior to use. Review of the medical record indicated that no Chest X ray was ordered to confirm and verify proper placement prior to administering medications. Review of the medical record indicated that no [NAME] 3CG tip confirmation report (magnetic tracking of the tip of the PICC line that uses ECG (electrocardiogram) was present in the medical report. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #84. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #84. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #84. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #84. Review of the employee file for Staff J, LPN, showed no IV competency or PICC line competency training within the file. Review of the employee file for Staff I, LPN, showed no IV competency or PICC line competency training within the file. Review of the employee file for Staff H, LPN, no IV competency or PICC line competency training within the file. During an interview on 8/31/2022 at 8:40 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not aware that we did not do an X ray to confirm line placement prior to administering medications. There are possible complications related to infusing medications into any line that is not confirmed. During an interview on 8/31/2022 at 9:15 AM, the Attending Physician stated, I was made aware yesterday we did not complete an x-ray of the PICC line. Since then, we have obtained an x-ray showing the catheter is in place so there is no harm to the patient. I can't speak to harm to the patient as it is properly positioned at this time. I do expect for IV fluids to be administered per my orders and if they don't, they need to call me. During an interview on 8/31/2022 at 12:00 PM, Staff H, LPN, stated, I was the nurse on the day that [Resident #84's name] PICC line was reinserted. The nurse from the IV company came in and inserted it. I helped him with [Resident #84's name] arm. I held it, so he could get the dressing on. He told me that he thought it was in the right place. He did give me the paper that explained that I needed to get an X-ray. It is my signature on the sheet. I didn't know that I needed to get an X-ray. The nurse, he told me he didn't think he would need to come back. I just didn't know. I thought it was okay to use. I just attached it to his PICC line after the IV nurse left. I didn't know that I needed to get a chest X-ray. I should not have hung the IV. I really didn't think I was hanging it. I just connected it to the IV. I am not IV certified. I did not take the IV certification. I know that I can't hang antibiotics. I just didn't think that the normal saline was a problem. I have flushed PICC lines after antibiotics, but I haven't hung them. I just wanted him to get his fluids, so I did hang it. I did hang a new bag to the peripheral IV that the resident had before the PICC line was put in. Once they came to do the PICC, the IV was out and I just connected the normal saline to the PICC line as soon as the IV nurse left. During an interview on 8/31/2022 at 1:45 PM, the Director of Nursing (DON) stated, I was shocked that [Staff H, LPN's name] had done anything related to [Resident #84's name] PICC line. I heard her say that she did not have the IV certification and I was shocked. She was practicing outside her scope as an LPN. I was not aware that this was happening. I do not really know the process for verifying if an LPN is competent to do IVs. I just got here. I literally started the day you arrived for survey. We should have a copy of their 30-hour course when they are hired. We should not allow LPNs to administer IV medications unless we know that they have had the course. During a telephone interview on 8/31/2022 at 2:59 PM, Staff I, LPN, stated, I took an 8-hour course many years ago. I guess I did not do the 30-hour IV course, so I guess I am not IV certified. I thought I was okay to do the IVs with what I had done. No one ever asked me for my certification to do IV med administration. I did administer the [MEDICATION(S)], flush the PICC line and do the normal saline that was ordered to run continuously to [Resident #84's name]. I wasn't aware that it would be a problem. I wish I had known. I did not do a competency specific to the care of the PICC line dressing when I was hired. During a telephone interview on 8/31/2022 at 3:10 PM, Staff J, LPN, stated, I did administer [Resident #84's name] IV and I hung the normal saline. I have been doing IV medications. I was told that as long as there is an RN [Registered Nurse] in the building that I could do it. I was told that by [Staff C, LPN's name] the unit manager. I am in school to be an RN and I was told that I could do it, so I have. I am aware that as an LPN without IV certification I cannot administer any IV medications because it's against the nurse practice act. But I was told it was okay because I was in nursing school. During an interview on 8/31/2022 at 3:20 PM, the Assistant Director of Nursing (ADON) stated, I was not aware that any LPNs who were not IV certified would be administering IV medications. I would not tell any staff that they could practice outside of the nurse practice act. I am not aware of anyone telling an LPN that it was acceptable to administer meds through a PICC or change dressings if they had not taken the course. During an interview on 8/31/2022 at 3:30 PM, Staff C, LPN, stated, I have not told anyone that they could administer IV medications if they are not IV certified as an LPN. I have not said that it is okay for any LPN to administer IV medications if there is an RN in the building. I know that we as LPNs have to follow our scope of practice and that if we have not had the additional training, we can't administer medications IV. During an interview on 9/1/2022 at 7:15 AM, the Administrator stated, I am ultimately responsible for all that occurs in the building, and I had asked about whether all the LPNs were IV certified and knew that there were several LPNs needing the course. We had not arranged the course yet because I was waiting for the new director of nursing to get here. During the onboarding process, we should be verifying whether LPNs are IV certified and keeping record of this within their employee files. This should have been done and I can't tell you why it has not been. During an interview on 9/1/2022 at 7:35 AM, the Human Resources Director stated, The process of hiring staff starts with the application. We do verify licenses for licensed staff, and we will ask LPNs who tell us they are IV certified. The process used to be for human resources to get all certification nurses have and the DON would know and keep record of any staff competencies for nurse. During a telephone interview on 9/1/2022 at 8:10 AM, the Medical Director stated, I came by yesterday and found out about this problem. I did not know we had LPNs who weren't IV certified, administering IV medications. I would expect nurses to practice within their scope of practice. We plan to implement a solution. I would expect that all nurses practice within their scope of practice. Review of the policy and procedure titled Administration of Intermittent Infusion with an approval date of 8/8/2022 reads, Guidance . 2. Documentation of central vascular access device (CVAD) tip location must be included in the medical record prior to administration of medications. Maintain catheter patency per flushing/locking protocol while awaiting confirmation. Documentation may include: 2.1. Copy of chest X-ray results reporting location of tip, or fluoroscopy report. Review of the policy and procedure titled Continuous infusion of Medications and Solutions with an approval date of 8/8/2022 reads, To be Performed by: Licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation is documented in accordance with organizational policy . Guidance . 2. Documentation of central vascular access tip location must be included in the medical record prior to administration of medications. Maintain catheter patency per flushing/locking protocol while awaiting tip confirmation. Documentation may include: 2.1. Copy of chest x-ray or fluoroscopy report; 2.2. Telephone order from radiologist stating location of tip (e.g. cavoatrial junction, IVC); 2.3. Copy of ECG technology insertion report.