Every finding on record at Bowling Green Health & Rehabilitation Center

Based on observation, interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide safety during incontinence care for one of 12 residents in the survey sample, Resident #10. The facility staff failed to utilize two staff members to change Resident #10's soiled brief on 5/28/25. Resident #10 fell out of bed and sustained a broken femur. The facility's failure resulted in harm to Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to utilize two staff members to change Resident #10 on 5/28/25. The resident fell out of bed and suffered a fractured femur. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 416/25, R10 was coded as being cognitively intact. She was coded as being completely dependent on staff for bed mobility. On 5/28/25 at 1:18 p.m., R10 was observed lying in bed. She was awake and alert. She stated only one CNA (certified nursing assistant) was in the room earlier that morning to provide incontinence care for her. She stated the CNA was standing on R10's left, pulled the draw sheet too far, and the resident fell out of bed on the right side, landing on her knees. She stated she was still in a great deal of pain in both of her knees. She stated sometimes there are two CNAs when they provide incontinence care, and sometimes there is only one. A review of R10's care plan dated 4/10/25 revealed, in part: The resident is at risk for falls related to muscle weakness, related to recent hospitalization .The resident requires assistance with ADLs (activities of daily living) related to .weakness, recent hospitalization .2 person assist for bed mobility. A review of R10's Kardex for caregivers revealed, in part: Bed Mobility .2 person assist for bed mobility .draw sheet for turning and repositioning while in bed .lift sheet for turning and repositioning while in bed. A review of R10's clinical record revealed the following: 5/28/2025 08:02 (8:02 a.m.) Fall Note Description of the fall/V/S (vital signs) /injuries if any: Per CNA (certified nursing assistant) during perineal care, Resident slipped down to the floor. After assessment on Resident, there was no physical injuries, but Resident c/o (complained of) lateral knee pains .What interventions were in place at the time of the fall?: bed rails up, call bell, and personal belongings within reach, and bed in the lowest position. What are the risk factors that could have contributed to the fall?: Resident needs wide air mattress for comfort, and bed mobility. What new interventions were implemented in response to the fall?: Turned, repositioned, pain med administered, wired air mattress for comfort, and bed mobility ASAP (as soon as possible. 5/28/2025 12:40 p.m. Medical Visit .patient seen per nursing request s/p (after) fall. Pt (patient) seen and examined at bedside and reports pain to bilat (bilateral) knees. Denies hitting her head or any pain/ injury elsewhere. Denies hip pain. no abnormal bruising or injury noted to bilateral knees .Assessment and plan .c/w (continue with) Percocet (opioid pain medication) for pain .stat (immediate) x-rays of bilateral knees. 5/28/2025 16:30 (4:30 p.m.) COMMUNICATION - with Resident .Per follow up investigation from resident's fall on 5/28/25, spoke with resident regarding x-ray results still pending and resident's pain management not effective despite receiving scheduled and breakthrough interventions nonpharmacological interventions were implemented and ineffective as well, resident was offered to be sent to ER (emergency room) for further evaluation and accepted. NP (nurse practitioner) .made aware of resident wanting to go out and order was given to be sent to ER. 5/28/2025 16:57 (4:57 p.m.) Health Status Note .Resident sent to [name of local hospital] per request via 911 (emergency services). A review of R10's May 2025 MAR (medication administration record) revealed she received Percocet 5-325 mg (milligrams) one tablet at 11:07 a.m. and 3:25 p.m. with no pain relief experienced by R10. A review of R10's left knee X-ray result dated 5/28/25 revealed, in part: A fracture of the distal femur is identified. On 5/29/25 at 9:03 a.m., LPN (licensed practical nurse) #3 was interviewed. He stated nurses and CNAs (certified nursing assistants) know how many staff members are required to provide care to a resident from the Kardex. After reviewing R10's Kardex, he stated the resident required two staff members at the bedside when incontinence care was being given because the resident was required to turn back in forth in bed for the care. On 5/29/25 at 10:10 a.m., CNA #2 was interviewed. She stated she provided incontinence care to R10 on 5/28/25 early in the morning. She stated she was in the process of changing the resident and grabbed the draw sheet. As she grabbed the draw sheet, R10 reached out to grab the grab bar. CNA #2 stated R10 let go of the grab bar and fell over the right side of the bed. She stated R10 should always have two staff members when she is being changed for safety. She stated all other staff members were busy with other things because it was almost time for shift change. She stated she was aware that the resident fell because there was not a second staff member on the resident's right side of the bed. On 5/28/25 at 10:32 a.m., ASM (administrative staff member) #1, the administrator, was informed of these concerns, and was informed of the concern for harm to R10. A review of the facility policy, Fall Prevention, revealed no information related to the circum-stances of R10's fall.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to follow infection control practices during ADL (activities of daily living) care for one of 12 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to follow enhanced barrier precautions when providing ADL care including incontinence care, dressing and linen change on 5/29/25. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/6/25, the resident was assessed as being dependent for toileting, dressing and transfers. The assessment documented one venous or arterial ulcer present with dressing applications completed. Observation of R4's room on 5/28/25 at 11:53 a.m. revealed a sign located outside of the door which documented in part, Stop Enhanced Barrier Precautions . Wear gown and gloves when entering room to provide the following high-contact resident care activities: *Dressing *Bathing/Showering *Transferring *Changing Linens *Providing Hygiene *Changing briefs or assisting with toileting . A plastic bin located outside of R4's doorway contained yellow isolation gowns and gloves. The comprehensive care plan for R4 documented in part, The resident has a venous/stasis ulcer of the Right inner Lateral leg r/t (related to) PVD (peripheral vascular disease). Created on: 08/26/2021. Revision on: 04/20/2023. On 5/29/25 at 11:30 a.m., an observation was made of CNA (certified nursing assistant) #6 providing ADL care to R4. CNA #6 was observed providing incontinence care, changing a soiled brief, dressing R4 and changing soiled bed linens. CNA #6 was observed to wear gloves but failed to wear a gown during the care provided. After performing ADL care, LPN (licensed practical nurse) #7 assisted CNA #6 to transfer R4 from the bed to the wheelchair. Neither staff member wore a gown during the care provided. On 5/29/25 at 11:43 a.m., an interview was conducted with LPN (licensed practical nurse) #8, infection preventionist. LPN #8 stated that the criteria for residents to be on enhanced barrier precautions (EBP) was for chronic wounds with drainage, PICC (peripherally inserted central catheters) or anything that could cause an infection were an indication for EBP. She stated that the criteria was basically driven from the facility policy. LPN #8 stated that when on EBP, the staff wore gown and gloves when providing care such as wound care, bed baths, and ADL care. On 5/29/25 at 1:21 p.m., an interview was conducted with CNA #8 who stated that when a resident was on EBP there was a sign on the door and a bin outside of the room that held the gowns and gloves for them. She stated that they wore the gowns and gloves when they were providing care such as baths and incontinence care. The facility policy Enhanced Barrier Precautions (EBPs) effective 3/26/24, documented in part, Employees providing high-contact patient care activities will follow Enhanced Barrier Precautions (EBPs) for patients who meet the criteria . EBPs require the use of gown and gloves by staff during high-contact patient care activities as defined below: a. Dressing, b. Bathing/showering, c. Transferring, d. Changing linens, e. Providing hygiene, f. Changing briefs or assisting with toileting . On 5/29/25 at 2:51 p.m., ASM (administrative staff member) #1, the administrator and ASM #5, regional director of clinical services were made aware of the concern. No further information was provided prior to exit.

Based on observation, interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for one of 12 residents in the survey sample, Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to implement Resident #10's care plan on 5/28/25 during incontinence care. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 416/25, R10 was coded as being cognitively intact. She was coded as being completely dependent on staff for bed mobility. On 5/28/25 at 1:18 p.m., R10 was observed lying in bed. She was awake and alert. She stated only one CNA (certified nursing assistant) was in the room earlier that morning to provide incontinence care for her. She stated the CNA was standing on R10's left, pulled the draw sheet too far, and the resident fell out of bed on the right side, landing on her knees. She stated she was still in a great deal of pain in both of her knees. She stated sometimes there are two CNAs when they provide incontinence care, and sometimes there is only one. A review of R10's care plan dated 4/10/25 revealed, in part: The resident is at risk for falls related to muscle weakness, related to recent hospitalization .The resident requires assistance with ADLs (activities of daily living) related to .weakness, recent hospitalization .2 person assist for bed mobility. A review of R10's Kardex for caregivers revealed, in part: Bed Mobility .2 person assist for bed mobility .draw sheet for turning and repositioning while in bed .lift sheet for turning and repositioning while in bed. A review of R10's clinical record revealed the following: 5/28/2025 08:02 (8:02 a.m.) Fall Note Description of the fall/V/S (vital signs) /injuries if any: Per CNA (certified nursing assistant) during perineal care, Resident slipped down to the floor. After assessment on Resident, there was no physical injuries, but Resident c/o (complained of) lateral knee pains .What interventions were in place at the time of the fall?: bed rails up, call bell, and personal belongings within reach, and bed in the lowest position. What are the risk factors that could have contributed to the fall?: Resident needs wide air mattress for comfort, and bed mobility. What new interventions were implemented in response to the fall?: Turned, repositioned, pain med administered, wired air mattress for comfort, and bed mobility ASAP (as soon as possible). On 5/29/25 at 9:03 a.m., LPN (licensed practical nurse) #3 was interviewed. He stated nurses and CNAs (certified nursing assistants) know how many staff members are required to provide care to a resident from the Kardex. After reviewing R10's Kardex, he stated the resident's care plan required two staff members at the bedside when incontinence care was being given because the resident was required to turn back in forth in bed for the care. He stated a care plan is developed to meet each resident's individual needs. He stated the charge nurse is responsible to oversee the CNAs and floor nurses to make sure the care plan is followed. On 5/29/25 at 10:10 a.m., CNA #2 was interviewed. She stated she provided incontinence care to R10 on 5/28/25 early in the morning. She stated she was in the process of changing the resident and grabbed the draw sheet. As she grabbed the draw sheet, R10 reached out to grab the grab bar. CNA #2 stated R10 let go of the grab bar and fell over the right side of the bed. She stated R10 should always have two staff members when she is being changed for safety. She stated all other staff members were busy with other things because it was almost time for shift change. She stated she was aware that the resident fell because there was not a second staff member on the resident's right side of the bed. On 5/28/25 at 10:32 a.m., ASM (administrative staff member) #1, the administrator, was informed of these concerns. A review of the facility policy, Care Planning, revealed, in part: A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide nutritional care and services consistent with a resident's comprehensive plan of care for one of 12 residents in the survey sample, Resident #12. The findings include For Resident #12 (R12), the facility staff failed to accurately monitor and document the resident's breakfast meal intake on 5/29/25. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 3/4/25, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. R12's comprehensive care plan revised on 3/4/25 documented, Nutrition Risk r/t (related to) therapeutic diet orders, hx/o (history of) sepsis, copd (chronic obstructive pulmonary disease [lung disease]), gerd (gastroesophageal reflux disease), bipolar. Hx/o sig (significant) wt (weight) gain .Interventions: monitor intake and record each meal . R12's meal ticket for breakfast on 5/29/25 documented the tray contained scrambled egg substitute with vegetables, wheat toast, orange juice, and grits. On 5/29/25 at 9:16 a.m., R12's breakfast tray was observed. R12 had drank coffee and juice but did not eat any of the food (the eggs, grits, or toast). R12 stated he did not feel like eating. CNA (certified nursing assistant) #8 entered the room, removed R12's tray, and did not open the plate cover to observe how much food the resident had consumed. A review of R12's May 2025 ADL (activities of daily living) records revealed CNA #8 documented R12 consumed 51% to 75% of his breakfast. On 5/29/25 at 1:33 p.m., an interview was conducted with CNA #8. CNA #8 stated she monitors residents' meal intakes by watching what the residents eat and documenting accordingly. CNA #8 stated she picked up R12's tray that morning and the resident ate about 75% of his meal. On 5/29/25 at 1:37 p.m., in the presence of CNA #8, R12 stated he did not eat breakfast that morning. CNA #8 stated R12's wife eats food off the resident's tray. On 5/29/25 at 1:39 p.m., another interview was conducted with CNA #8 (not in the presence of R12). CNA #8 stated that although she knew R12's wife eats food off the resident's plate, she documented according to her observation of the resident's plate and did not ask R12 how much food he consumed. On 5/29/25 at 1:41 p.m., another interview was conducted with R12. R12 stated his wife did not eat any food off his plate that morning. On 5/29/25 at 2:05 p.m., an interview was conducted with OSM (other staff member) #8 (the registered dietician). OSM #8 stated he reviews residents' meal intakes when completing their nutritional assessments. On 5/29/25 at 2:50 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Meal Intake documented, Meal intake will be documented after each meal. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for one of 12 residents in the survey sample, Resident #9. The findings include: For Resident #9 (R9), the facility staff failed to hold the medication hydralazine (medication for high blood pressure) per the physician ordered parameter of a systolic blood pressure less than 140. A review of R9's clinical record revealed a physician's order dated 2/27/25 for hydralazine 50mg (milligrams)-one tablet by mouth two times a day for hypertension (high blood pressure). Hold for SBP (systolic blood pressure) less than 140. A review of R9's March 2025 MAR (medication administration record) revealed the resident was administered hydralazine on 3/4/25 at 9:00 a.m. although the resident's systolic blood pressure was 134, administered hydralazine on 3/4/25 at 10:00 p.m. although the resident's systolic blood pressure was 137, and administered hydralazine on 3/5/25 at 9:00 a.m. although the resident's systolic blood pressure was 138 (as evidenced by check marks on the MAR). A nurse's note dated 4/8/25 documented, NP (Nurse Practitioner), (name) and (name) and RP (Responsible Party), (name) aware on 3/4 at 2200 (10:00 p.m.) and on 3/5 at 0900 (9:00 a.m.), resident was given hydralazine outside of prescribed parameters, no adverse reactions or abnormalities noted at the time, BP (Blood Pressure) continued to be monitored. On 5/28/25 at 4:00 p.m., an interview was conducted with LPN (licensed practical nurse) #1 (the nurse who documented the above note). LPN #1 stated on certain days, she runs a report and looks to see if medications were administered out of physician ordered parameters. LPN #1 stated that on 3/4/25 and 3/5/25, the nurses gave R9 hydralazine without paying attention to the parameter. LPN #1 stated the parameter was to hold the medication if the resident's systolic blood pressure was less than 140. LPN #1 stated that on those dates the medication was administered and should not have been. On 5/29/25 at 2:50 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, General Guidelines for Medication Administration documented, II. Administration. 2. Medications are administered in accordance with written orders of the prescriber. No further information was presented prior to exit.

Based on observation, staff interview and facility document review, it was determined the facility staff failed to store and serve food in a sanitary manner in one of one kitchen and on one of two units. The findings include: Observation was made of the kitchen on 3/5/25 at 11:39 a.m. The freezer was observed with an open bag of frozen rolls, that was not labeled or dated. A box of southern style biscuit dough was open and the bag inside was open to air. No label or date noted on the box. An interview was conducted with OSM (other staff member) #1, the cook, who stated she doesn't remember labeling and dating a box in the freezer. On 3/5/25 at 12:07 a.m. OSM #2, a dietary aide, was preparing for the tray line to start. She had on her gloves and was resting her chin on her gloved hands. At 12:08 p.m. OSM #2 was observed washing her hands and donning new gloves. She proceeded to the tray line where she stood with gloved hands folded across her chest with her hands resting on her elbows. On 3/5/25 at 1:15 p.m. observation was made of the day room on the A side, during mealtime. CNA (certified nursing assistant) #1 was observed grabbing a bottle of soda off the top shelf of the bookcase and taking a drink from it and then returning the bottle to the top shelf next to a fast-food services drink cup. CNA #2 was sitting next to the bookcase, feeding a resident in a recliner chair. An interview was conducted with OSM #3, the dietary manager, on 3/5/25 at 4:00 p.m. The above observations were shared with OSM #3.OSM #3 stated the bag of rolls should have been labeled and dated. The box with the biscuit dough should not be open to air and should have been labeled and dated. OSM #3 stated the staff member, once the don gloves, should not be touching anywhere on their personal body. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 3/5/25 at 5:23 p.m. When asked where the staff is to keep their personal drinks, ASM #2 stated in the unit manager's office. ASM #2 stated, the drinks should not be stored in a resident area and not consumed during care. The facility policy, Food: Preparation documented in part, 1. The Dining Services Director ensures that all staff practice proper hand washing technique and practice proper glove use. The facility policy, Food Storage: Cold, documented in part, 5. The Ding Services Director/Cook(s) ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. ASM #1, the administrator, ASM #2, and ASM #3, regional director of operations, were made aware of the above concerns on 3/5/25 at 5:40 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow physician orders for two of five residents in the survey sample, Residents #1 and #4. The findings include: 1a. For Resident #1 (R1), the facility staff failed to administer antibiotics as ordered. The physician order dated, 10/17/24 at 3:26 p.m. documented, Amoxicillin Oral Tablet (1) 500 MG (milligrams); Give 1 tablet by mouth every morning and at bedtime for dental abscess for 10 days. The MAR (medication administration record) for October 2024, documented the above order. For 10/17/24, the 9:00 p.m. dose documented a 5. A 5 indicates Hold/See Progress notes. Review of the progress notes for 10/17/24, failed to evidence any documentation as to the reason the medication was not administered. The physician order dated, 7/26/24 at 2:13 p.m. documented, Amoxicillin Oral Tablet 500 MG; Give 1 capsule by mouth two times a day for abscess for 14 days. The resident completed, as ordered, the Amoxicillin up to 11 1/2 days. The last dose was administered on 8/7/24 at 9:00 a.m. The physician order dated 8/7/24 at 2:01 p.m. documented, Clindamycin HCL (hydrochloride) Capsule (2) 300 MG; Give 1 capsule by mouth every 12 hours for dental abscess for 7 days, no improvement with Amox (amoxicillin) for 14 days. The MAR for August 2024 documented the order for the Clindamycin. It was not scheduled to start until 8/8/24 at 9:00 p.m. The resident went for 36 hours without any antibiotic therapy, thus a delay in treatment. Review of the contents of the Omnicell (backup medication storage system) documented, Amoxicillin 250 MG capsule - PAR level of 10. Clindamycin 150 MG capsule - PAR level of 6. An interview was conducted with LPN (licensed practical nurse) #2, on 3/6/25 at 12:28 p.m. LPN #1 stated that antibiotics should be given as soon as ordered. If the medication is not in the Omnicell, then the nurse should call the pharmacy and get it sent over STAT, which is usually between 2-4 hours. If the medication is still not available for when it is prescribed, the nurse should call the nurse practitioner and let her know. Any actions taken should be documented in a progress note. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 3/6/25 at 2:52 p.m. The above information was reviewed with ASM #2. ASM #2 returned at 4:02 p.m. and stated that it is what you see documented. Her expectation is that antibiotics should be started at the time of the order. If the antibiotic is not available in the Omnicell, then the nurse should call the nurse practitioner as to why the medication was not started. ASM #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional director of operations, were made aware of the above concern on 3/6/25 at 4:06 p.m. References: (1) Amoxicillin is used to treat certain infections caused by bacteria, such as pneumonia; bronchitis (infection of the airway tubes leading to the lungs); and infections of the ears, nose, throat, urinary tract, and skin. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a685001.html. (2) Clindamycin is used to treat certain types of bacterial infections, including infections of the lungs, skin, blood, female reproductive organs, and internal organs. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682399.html. 1b. The facility staff failed to follow the physician orders for the administration of Midodrine (3). The physician order dated, 10/23/24, documented, Midodrine HCL Oral Tablet 10 MG; Give 10 MG by mouth three times a day for hypotension (low blood pressure), give while sitting up; hold if SBP (systolic blood pressure) > (greater than) 115. The September 2024 MAR documented the above order. On 9/1/24 for the 12:00 p.m. dose the documented blood pressure was 119/76. The medication was documented as being administered. The October 2024 MAR documented the above order. On 10/27/24 at 2:00 p.m. dose, the documented blood pressure was 116/71. The medication was documented as being administered. Both readings greater than 115. An interview was conducted with LPN #2 on 3/6/25 at 12:28 p.m. LPN #2 reviewed the above order. She stated the nurse should take the blood pressure and hold the medication if the blood pressure is out of the prescribed parameters. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional director of operations, were made aware of the above concern on 3/6/25 at 4:06 p.m. References: (3) Midodrine is used to treat orthostatic hypotension (sudden fall in blood pressure that occurs when a person assumes a standing position). This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a616030.html. 2. For Resident #4 (R4), the facility staff failed follow the physician orders to notify the nephrologist when the resident's blood pressure was above the set parameters. The physician order dated, 4/19/24, documented, Daily BP (blood pressure) monitoring and call Nephrology (kidney specialist) for SBP >140 or DBP (diastolic blood pressure) > 90. (phone number); every day shift for monitoring. The February 2025 MAR documented the above order. On the following dates the blood pressures were documented: 2/2/25 - 147/52 2/7/25 - 144/76 2/22/25 - 148/76 Review of the progress notes failed to evidence notification to the nephrologist of the blood pressure greater than 140. A physician order dated, 11/10/24, documented, Hydralazine HCL Tablet (4) 25 MG; Give 1 tablet by mouth every 8 hours as needed for SBP > 160. The January 2025 MAR documented the above order. On the following dates the medication was administered for the documented blood pressure: 1/5/25 - 12:21 p.m. - 160/58 1/6/25 - 2:14 p.m. - 166/73 1/18/25 - 2:16 p.m. - 173/62 1/19/25 - 6:45 p.m. - 170/85 These blood pressure readings happened on the day shift Review of the progress notes failed to evidence notification to the physician of the blood pressure greater than 140. An interview was conducted with LPN #2 on 3/6/25 at 12:28 p.m. LPN #2 stated for the Midodrine, the nurse should hold the medication if the blood pressure is out of the parameters and notify the nurse practitioner and responsible party. The nurse should attempt to notify the nephrologist, if they cannot contact the nephrologist, then they should contact the nurse practitioner. All nurses should be aware of the order for the nephrologist notification. It should be flagged for every shift. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional director of operations, were made aware of the above concern on 3/6/25 at 4:06 p.m. References: (4) Hydralazine is used to treat high blood pressure. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682246.html.

Based on observation, staff interview and facility document review, it was determined the facility staff failed to serve food at a palatable temperature on one of two units, Unit A. The findings include: The facility staff failed to serve food that was at a palatable temperature on one of two units, Unit A. Observation was made of the kitchen on 3/5/25 at 11:53 a.m. The food temperatures were taken and were as followed: Chicken - 197 degrees Peas - 198 degrees Puree Squash - 177.8 (thrown away) degrees Puree bread - 171 degrees Mashed potatoes - 171 degrees Puree chicken - 140.5 degrees Gravy - 166 degrees Puree peas - 147 degrees Minced moist chicken - 133 - returned to steamed - 12:12 p.m. - 180 degrees. Sweet potato fries at 12:12 p.m. - 165 degrees The chicken was put into rolls, topped with cheese and put in the oven to melt the cheese. A test tray of all foods served was prepared. The last cart was taken to Unit A at 1:04 p.m. The last resident was served and started eating at 1:30 p.m. The food was served on white styrofoam trays for this meal due to anticipated construction in the kitchen that afternoon. The food temperatures were taken of the test tray at 1:31 p.m. accompanied by OSM #6, a cook, and were as followed: Pureed bread - 100 - a drop of 71 degrees Mashed potatoes - 116 - a drop of 55 degrees - not warm to eat. Puree peas - 103 - a drop of 44 degrees - cold to eat. Pureed chicken - 106 - a drop of 34.5 degrees - tasted cold and the texture was very thick and sticky. Mince moist chicken - 93 - a drop of 87 degrees - cold to eat. Chicken steak sandwich - 97 - a drop of 83 degrees - lukewarm and not palatable. Sweet potato fries - 96 degrees - very cold to taste Peas - 113 - a drop of 85 degrees - tasted okay. The food was tested by both OSM #6 and the surveyor. Both agreed on the above answers related to the food palatability. An interview was conducted with CNA (certified nursing assistant) #2 on 3/6/25 at 12:21 p.m. CNA #2 stated the food is usually on time. The last cart served if for the residents that require assistance. She stated there are 8-10 residents that required feeding assistance on the unit. CNA #2 stated on 3/5/25, they fed at a rate of one to one, but usually feed to residents at a time. The facility policy, Food: Quality and Palatability, documented in part, It is the center policy that, food is prepared by methods that conserve nutritive value, flavor and appearance. Food is palatable, attractive and served at a safe and appetizing temperature. ASM #1, the administrator, ASM #2, and ASM #3, regional director of operations, were made aware of the above concerns on 3/5/25 at 5:40 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for one of five residents in the survey sample, Resident #4. The findings include: The comprehensive care plan dated, 5/17/23 and revised on 4/24/24, documented in part, Focus: Cardiac: the resident is at risk for cardiac complications secondary to chronic kidney disease, hyperlipidemia, hypertension, CAD (coronary artery disease) and PVD (peripheral vascular disease). Interventions: administer medications as ordered. Cardiology referral as indicated. Diagnostics as ordered. Labs (laboratory tests) as ordered. The physician order dated, 4/19/24, documented, Daily BP (blood pressure) monitoring and call Nephrology (kidney specialist) for SBP >140 or DBP (diastolic blood pressure) > 90. (phone number); every day shift for monitoring. The February 2025 MAR documented the above order. On the following dates the blood pressures were documented: 2/2/25 - 147/52 2/7/25 - 144/76 2/22/25 - 148/76 Review of the progress notes failed to evidence notification to the nephrologist of the blood pressure greater than 140. A physician order dated, 11/10/24, documented, Hydralazine HCL Tablet (1) 25 MG; Give 1 tablet by mouth every 8 hours as needed for SBP > 160. The January 2025 MAR documented the above order. On the following dates the medication was administered for the documented blood pressure: 1/5/25 - 12:21 p.m. - 160/58 1/6/25 - 2:14 p.m. - 166/73 1/18/25 - 2:16 p.m. - 173/62 1/19/25 - 6:45 p.m. - 170/85 These blood pressure readings happened on the day shift Review of the progress notes failed to evidence notification to the physician of the blood pressure greater than 140. An interview was conducted with LPN (licensed practical nurse) #1 on 3/6/25 at 12:01 p.m. LPN #1 stated the purpose of the care plan is to guide how to take care of specific residents and should be followed. The facility policy, Care Planning, documented in part, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional director of operations, were made aware of the above concern on 3/6/25 at 4:06 p.m. References: (1) Hydralazine is used to treat high blood pressure. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682246.html.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the care plan for one of five residents in the survey sample, Resident #3. The findings include: For Resident #3(R3), the facility staff failed to review and revise the care plan to include the use of a wander guard (1). On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date 1/7/25, the resident scored a three of of 15, indicating the resident was severely impaired for making cognitive daily decisions. The physician order dated, 4/24/24, documented, Check function and placement of wander guard daily. Left ankle assess skin for breakdown every shift for placement & functioning. The comprehensive care plan dated, 6/1/23 and revised on 2/15/25, documented, Focus: The resident is at risk for elopement related to confusion and disorientation, exit seeking, severe cognitive impairment. Interventions: elopement risk assessment as needed. Further review of the care plan failed to evidence documentation related to the use of a wander guard. An interview was conducted with RN (registered nurse) #1 on 3/6/25 at 2:14 p.m. RN #1 stated if a resident has a wander guard, it should be addressed on the care plan. The above care plan was reviewed with RN #1. At 2:36 p.m. RN #1 returned and stated unfortunately, the part of the care plan with the wander guard was resolved. It accidentally got dropped off the care plan. The facility policy, Care Planning, documented in part, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient .5. Care plans will be updated on an ongoing basis as changes in the patient occur and reviewed quarterly with the quarterly assessment. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional director of operations, were made aware of the above concern on 3/6/25 at 4:06 p.m. References: (1) Wander Guard is a technology made solely for the purpose of keeping elderly people or people with dementia from wandering. Wander Guard's devices alert the caregiver whenever his or her ward breaches a perimeter or strays too far. This technology is used in eldercare communities or nursing homes or even at homes where people live independently. Wander/elopement alarm includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn/attached to the resident that alert the staff when the resident nears or exits an area or building. Standard wander management systems sound alarms and/or send alerts when an at-risk wanderer approaches a monitored door. This information was obtained from the following website: https://themedichannel.com/[NAME]-wanderguard-bracelets-review/.

Based on observation, staff interview, and facility document review, the facility staff failed to store food in a sanitary manner in one of one kitchen. The findings include: 1. The facility staff failed to store a scoop used for dry pureed bread mix in a sanitary manner. On 3/26/24 at 11:30 a.m., 3/26/24 at 4:30 p.m., and 3/27/24 at 10:20 a.m., a scoop was observed sitting inside of a container of dry pureed bread mix. The handle of the scoop was touching the inside of the container. On 3/27/24 at 1:11 p.m., an interview was conducted with OSM (other staff member) #5 (the dietary manager). OSM #5 stated sometimes the cook uses the scoop inside the dry pureed bread mix throughout the day and at the end of the day, he washes the scoop and hangs it up. OSM #5 stated most of the time, the cook removes the scoop from the container as soon as he uses it. OSM #5 stated the scoop should not be stored in the container because you want to make sure it isn't cross contaminated and someone else hasn't used it for other purposes. On 3/27/24 at 4:14 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing were made aware of the above concern. The facility policy titled, Food Storage-Dry Goods documented, It is the Center policy to insure all dry goods will be appropriate stored in accordance with guidelines of the FDA Food Code. 2. The facility staff failed to ensure a vendor wore a hair restraint while in the kitchen. On 3/26/24 at 11:24 a.m., a vendor delivering boxes of food was observed walking through the kitchen twice without a hair restraint. No staff was observed asking the vendor to use a hair restraint. On 3/27/24 at 1:11 p.m., an interview was conducted with OSM (other staff member) #5 (the dietary manager). OSM #5 stated vendors are supposed to wear hair restraints in the kitchen and normally she monitors to ensure this is done. OSM #5 stated the regular vendor knows to wear a hair restraint, but he was off on 3/27/24 and a different vendor made the delivery. On 3/27/24 at 4:14 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing were made aware of the above concern. The facility policy titled, Staff Attire documented, 1. The Dining Services Director insures that all staff members have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide notification to the responsible party of a change in resident treatment for one of 33 residents in the survey sample, Resident #309. The findings include: For Resident #309 (R309), the facility staff failed to notify the responsible party of the Losartan (1) medication being held due to low blood pressure. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/29/2023, the resident scored 5 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The comprehensive care plan for R309 documented in part, Cardiac: the resident is at risk for cardiac complications secondary to hypertension r/t (related to) bilateral lower edema. Created on: 12/05/2023. Revision on: 12/18/2023. Review of R309's progress notes revealed the following: - 11/27/2023 0821 (8:21 a.m.) Note Text : Losartan Potassium Oral Tablet 100 MG, med withheld due to low BP, BP-92/57. - 11/27/2023 1300 (1:00 p.m.) Medical Progress Note . VS (vital signs) show hypotension today and currently on supplemental O2 (oxygen) and labs show AKI (acute kidney injury), hypocapnia, hyperglycemia and leukocytosis. CXR (chest x-ray) shows mild pneumonia in left base . Assessment and Plan: .AKI/hypocapnia, Hold Losartan, Start BMP (basic metabolic profile) in a few days. Hypotension, Hold BP (blood pressure) meds (medications), Check BP in 1 hr, HTN (hypertension) hold Losartan 2/2 (secondary to) AKI and hypotension . The progress notes failed to evidence notification of the responsible party for the holding the Losartan secondary to the acute kidney injury and hypotension. The physician orders documented in part, Losartan Potassium Oral Tablet 100 MG (milligram) (Losartan Potassium) Give 1 tablet by mouth one time a day for HTN. On hold starting 11/27/2023 16:09 (4:09 p.m.). Order Date: 11/22/2023 . The eMAR (electronic medication administration record) for R309 documented the Losartan tablet administered from 11/23/2023 through 11/26/2023 and held on 11/27/2023. Review of R309's medical record documented a medical power of attorney dated 12/29/2020 granting power of attorney to a family member. On 3/27/2024 at 1:46 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that if a medication was held due to low blood pressure they alerted the physician or nurse practitioner to get orders to hold the medication or to give the medication at a later time. She stated that after the physician or nurse practitioner were notified, staff also informed the responsible party and documented the notification in the medical record. On 3/27/2024 at 2:27 p.m., an interview was conducted with LPN #4. LPN #4 stated that if a medication was held they called the nurse practitioner and notified the responsible party. She stated that they wrote a progress note when holding a medication and documented in the note about the physician or nurse practitioner and responsible party notification. A request was made to LPN #4 for evidence of responsible party notification of the Losartan being held on 11/27/2023. On 3/27/2024 at approximately 3:00 p.m., LPN #3 stated that they were unable to find evidence of the responsible party being notified of the Losartan being held due to hypotension on 11/27/2023. The facility policy Significant Change of Condition dated 11/1/2019 documented in part, . Responsible party will also be notified of a change in condition . Notification of the responsible party shall be documented in the progress notes including time and name of person notified . On 3/28/2024 at 8:49 a.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: (1) Losartan is used alone or in combination with other medications to treat high blood pressure. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a695008.html

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for a pressure injury for one of 33 residents in the survey sample, Resident #97. The findings include: For Resident #97 (R97), the facility staff failed to clean a pair of scissors immediately before pressure injury wound care was provided. R97 was admitted to the facility with a stage four pressure injury (1) on the left buttock. R97's comprehensive care plan dated 1/18/24 failed to document information regarding sanitation during wound care. A review of R97's clinical record revealed a physician's order dated 3/12/24 to cleanse the left buttock with normal saline, pack with collagen particles, cover with moist gauze, and cover with bordered foam. On 3/27/24 at 1:55 p.m., during an observation of R97's pressure injury wound care, LPN (licensed practical nurse) #2 removed a pair of scissors from her pocket, placed the scissors on a clean field, picked up the scissors, cut a piece of collagen with the scissors, then placed the collagen into R97's wound. LPN #2 did not clean the scissors in between removing them from her pocket and cutting the collagen that was placed into R97's wound. On 3/27/24 at 2:15 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated she cleaned the scissors while setting up in the hall but did not clean the scissors in between removing the scissors from her pocket and cutting the collagen. LPN #2 stated she should have cleaned the scissors after removing them from her pocket for sanitation. On 3/27/24 at 4:14 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing were made aware of the above concern. The facility policy titled, General Wound Care/Dressing Changes failed to document specific information regarding cleaning scissors for wound care. Reference: (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf

Based on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence bed inspections for three of 33 residents in the survey sample, Residents #15, #38 and #54. The findings include: 1.The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for Resident #15. Resident #15 was observed in bed with bilateral grab bars on 3/26/24 at 3:10 PM and 3/27/24 at 3:45 PM. Resident #15 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), ESRD (end stage renal disease) and dementia. Resident #15's most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/7/24, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as maximal assist for bed mobility, transfer, eating and hygiene. A review of Resident #15's comprehensive care plan dated 5/22/20 revealed, FOCUS: The resident has Activity Intolerance and Fatigue. INTERVENTIONS: DEVICES: Assist bars/ Grab bars/ Bed rails aid in turning and positioning. A review of the physician orders dated 2/3/23 revealed, Grab bars for bed mobility. On 3/26/24 at approximately 2:30 PM the bed audit book 2024 was provided. A review of the bed safety audit form identified beds were inspected 3/26/24. The inspections included space less than four inches between mattress rails or footboard. On 3/27/24 at 9:40 AM ASM (administrative staff member) #1, the administrator stated, yes, the bed inspections were done yesterday. We have a new maintenance director. I will see if he can find the ones from 2023. On 3/27/24 at 1:10 PM an interview was conducted with OSM (other staff member) #2, the maintenance technician. When asked about the bed inspections, OSM #2 stated, we did them yesterday. We could not find any documents for 2023, but I will check with the director. 3/27/24 at 1:20 PM an interview was conducted with OSM #3, the maintenance director. When asked about the bed inspections, OSM #3 stated, it has been 10 days since I have been onsite here. I have been doing audits and realized that the prior 2023 bed inspections did not meet all the criteria. When asked what criteria is evaluated, OSM #3 stated, we look for the space between mattress/rails and footboard to make sure there is no entrapment concerns. We check for bed functionality and if all the bed parts are in good repair. The other form from 2023, did not identify any of those items. On 3/27/24 at 4:30 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the Director of Nursing, were made aware of the findings. A review of the facility's Bed System Audits policy revealed Maintenance will maintain an inventory of all beds in order to conduct annual and intermittent bed system audits to identify and mitigate areas of risk for possible entrapment and bed safety. No further information was provided prior to exit. 2.The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for Resident #38. Resident #38 was observed in bed with bilateral grab bars on 3/26/24 at 3:00 PM and 3/27/24 at 8:23 AM. Resident #38 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), cerebrovascular accident and hemiparesis/hemiplegia. Resident #38's most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/7/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as maximal assist for bed mobility, transfer, eating and hygiene. A review of Resident #38's comprehensive care plan dated 4/28/21 revealed, FOCUS: The resident has ADL (activities of daily living) self-care performance deficit related to Amputation bilateral BKA (below the knee amputation), Impaired balance and Limited Mobility. INTERVENTIONS: DEVICES: assist bar to aid in bed mobility in turning and positioning. A review of the physician orders dated 2/3/23 revealed, Grab bars for bed mobility. On 3/26/24 at approximately 2:30 PM the bed audit book 2024 was provided. A review of the bed safety audit form identified beds were inspected 3/26/24. The inspections included space less than four inches between mattress rails or footboard. On 3/27/24 at 9:40 AM ASM (administrative staff member) #1, the administrator stated, yes, the bed inspections were done yesterday. We have a new maintenance director. I will see if he can find the ones from 2023. On 3/27/24 at 1:10 PM an interview was conducted with OSM (other staff member) #2, the maintenance technician. When asked about the bed inspections, OSM #2 stated, we did them yesterday. We could not find any documents for 2023, but I will check with the director. 3/27/24 at 1:20 PM an interview was conducted with OSM #3, the maintenance director. When asked about the bed inspections, OSM #3 stated, it has been 10 days since I have been onsite here. I have been doing audits and realized that the prior 2023 bed inspections did not meet all the criteria. When asked what criteria is evaluated, OSM #3 stated, we look for the space between mattress/rails and footboard to make sure there is no entrapment concerns. We check for bed functionality and if all the bed parts are in good repair. The other form from 2023, did not identify any of those items. On 3/27/24 at 4:30 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided prior to exit. 3.The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for Resident #54. Resident #54 was observed in bed with bilateral grab bars on 3/26/24 at 2:45 PM and 3/27/24 at 8:55 AM. Resident #54 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: obstructive and reflux uropathy, chronic hepatitis and quadriplegia. Resident #54's most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/7/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as maximal assist for bed mobility, transfer, eating and hygiene. A review of Resident #54's comprehensive care plan dated 1/16/23 revealed, FOCUS: The resident requires assistance with ADL (activities of daily living) relate to chronic health conditions, inability to perform ADLs, weakness; Diagnoses of Quadriplegia. INTERVENTIONS: DEVICES: Assist bars/ Grab bars/ Bed rails aid in turning and positioning. A review of the physician orders dated 2/3/23 revealed, Grab bars for bed mobility. On 3/26/24 at approximately 2:30 PM the bed audit book 2024 was provided. A review of the bed safety audit form identified beds were inspected 3/26/24. The inspections included space less than four inches between mattress rails or footboard. On 3/27/24 at 9:40 AM ASM (administrative staff member) #1, the administrator stated, yes, the bed inspections were done yesterday. We have a new maintenance director. I will see if he can find the ones from 2023. On 3/27/24 at 1:10 PM an interview was conducted with OSM (other staff member) #2, the maintenance technician. When asked about the bed inspections, OSM #2 stated, we did them yesterday. We could not find any documents for 2023, but I will check with the director. 3/27/24 at 1:20 PM an interview was conducted with OSM #3, the maintenance director. When asked about the bed inspections, OSM #3 stated, it has been 10 days since I have been onsite here. I have been doing audits and realized that the prior 2023 bed inspections did not meet all the criteria. When asked what criteria is evaluated, OSM #3 stated, we look for the space between mattress/rails and footboard to make sure there is no entrapment concerns. We check for bed functionality and if all the bed parts are in good repair. The other form from 2023, did not identify any of those items. On 3/27/24 at 4:30 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the required notification, to the Ombudsman, for a facility-initiated transfer for one of 33 residents in the survey sample, Residents #92 (R92). The findings include: For R92, the facility staff failed to have evidence that written notification was provided to the ombudsman for a facility-initiated transfer on 12/04/2023. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 02/24/2024, R92 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R92 was cognitively intact for making daily decisions. The facility's progress noted for R92 dated 12/04/2023 documented, Resident transferred out to (Name of Hospital) ER (emergency room) r/t (related to) fluctuations in blood pressure readings @ (at) 2100 (9:00 p.m.) 12/4/23. This nurse called hospital and spoke with (Name of Registered Nurse) in ER who states resident is being admitted for UTI (urinary tract infection), low blood pressure and possible sepsis (1). NP (nurse practitioner) notified. Review of the EHR (electronic health record) for R92 failed to include evidence that written notification of the transfer was provided to the ombudsman for the facility-initiated transfer on 12/04/2023. On 03/27/24 at approximately 1:06 p.m., an interview was conducted with OSM (other staff member) #6, director discharge planning. OSM #6 stated she did not have evidence that the ombudsman was notified of R92's transfer to the hospital on [DATE]. When asked to describe the procedure for notifying the ombudsman of a resident's discharge or transfer she stated the facility's notice of transfer form is faxed to the ombudsman the same day the resident is transferred. The facility's policy Notice of Transfer/Discharge documented in part, Procedure: 7. Provide designated copies of the completed (Name of Corporation) Notice of Transfer/Discharge form to each of those specified on the form, which includes the Ombudsman. 9. Once the document has been scanned into PCC (point click care - electronic health record), complete a Social Work and Discharge Planning Progress Note confirming the following: b. Date the notice was sent to the Ombudsman and the method by which it was sent (The Ombudsman should be notified as close as possible to the actual time of a facility-initiated transfer or discharge. On 03/27/2024 at approximately 4:15 p.m., ASM (administrative staff member) # 1, administrator, and ASM # 2, director of nursing were made aware of the above findings. No further information was provided prior to exit. Reference: (1) An illness in which the body has a severe, inflammatory response to bacteria or other germs. This information was obtained from the website: https://medlineplus.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide medically related social services to maintain the highest practicable physical, mental and psychosocial well-being for two of 33 residents in the survey sample, Residents #86 and #62. The findings include: For Resident #86 (R86) and Resident #62 (R62), the facility staff failed to evidence comprehensive medically related social service assessments for continued ability to consent to intimate relations. R86 and R62 shared a semi-private room in the facility, planned to be married and were currently sexually active. R86 most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/25/2024 assessed the resident as scoring 6 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were severely impaired for making daily decisions. The 8/25/2023 MDS assessment documented R62 scoring 13 out of 15 on the BIMS assessment, indicating they were cognitively intact at that time and the 11/25/2023 MDS assessment documented R62 scoring 9 out of 15 on the BIMS assessment, indicating they were moderately impaired for making daily decisions at that time. R62 most recent MDS assessment, an annual assessment with an ARD of 3/3/2024 assessed the resident as scoring 13 out of 15 on the BIMS assessment, indicating they were cognitively intact for making daily decisions. The previous assessment, a quarterly MDS with an ARD of 9/1/2023 assessed R62 as scoring 15 out of 15 on the BIMS assessment, indicating they were cognitively intact for making daily decisions. On 3/26/2024 at 12:10 p.m., an observation was made of R86 and R62's room. R86 was not in the room at the time. R62 was observed dressed lying on the bed. When asked about their roommate, R62 stated that he shared the room with his fiance and they were getting married soon. He stated that his girlfriend was in the dining room at that time. On 3/26/2024 at 3:59 p.m., an observation was made of R86 and R62 in their shared room. At this time an interview was conducted. R86 was observed to be oriented to person, place and month/year at that time. When asked about the shared room, R86 stated that she shared the room with her boyfriend and she loved him. R62 stated that the wedding was planned in June of this year at the facility and R86 was observed smiling. When asked about intimate relations, R86 and R62 both stated that they had relations and that staff allowed them privacy in the room when they were intimate. Both residents stated that they got along well and were happy with their living situation. The nursing progress notes for R86 documented in part, - 6/20/2023 15:45 (3:45 p.m.) This nurse spoke with resident's daughter/RP (responsible party) [Name of RP] about resident wanting to have sexual relations with another resident in the facility. Just to make RP aware that this is what resident is asking to do with another resident. RP stated that she understands and is fine with what [the resident] wants to do. - 10/4/2023 12:33 (12:33 p.m.) Resident RP [Name of RP] called and is fine with resident moving into a room with male resident. RP says she does not have any issues with it as long as it is allowed. A Room Change Notification for R86 dated 10/5/2023 documented R86 moving to the room with R62 at the request of R86. The psychiatric evaluations for R86 documented in part, - 6/21/2023 .She denies any anxiety or depression and states she really enjoys spending time with her boyfriend at the facility. She states he is very good to her . - 10/25/2023 .Pt (patient) has moved in the same room with her boyfriend who is also a patient at the faility [sic]. She states they get along well and she is happy about the move . Additional psychiatric evaluations dated 11/20/2023, 1/5/2024, and 2/23/2024 failed to evidence documentation of evaluation of R86's ability to continue to consent to be involved in an intimate relationship with another resident at the facility. The Discharge Planning Admission Assessment for R86 dated 4/30/2023 and 11/9/2023 documented the resident planning to stay at the facility for long term care. The assessments failed to evidence continuing assessment for R86's cognitive abilities to engage in the relationship and ability to consent. The Discharge Planning Reassessment for R86 dated 7/31/2023 and 11/24/2023 failed to evidence documentation regarding the intimate relationship between R62 and R86. The assessments failed to evidence continuing assessment for R86's cognitive abilities to engage in the relationship and ability to consent. On 3/26/2024 at 4:27 p.m., a request was made to ASM (administrative staff member) #1, the administrator, for evidence of continued assessments for the ability to continue to consent for the sexual relationship between R86 and R62. On 3/27/2024 at approximately 8:00 a.m., ASM #1 provided the psychiatric nurse practitioner notes dated 6/21/2023, 8/30/2023 and 10/25/2023 and the nursing progress notes dated 6/20/2023 and 10/4/2023. The notes provided failed to evidence continued assessment for R86's cognitive abilities to engage in the relationship and ability to consent. On 3/27/2024 at 9:43 a.m., an interview was conducted with ASM #3, psychiatric nurse practitioner. ASM #3 stated that she followed R86 at the facility. She stated that R86 had requested to move into the room with R62 and she had evaluated both residents separately at that time to ensure that it was a mutual decision and that R86 was not coerced in any way to make the decision. She stated that the residents had been together for awhile and had plans to get married soon. She stated that she felt that R86 understood the decision that she was making but could not say that she was cognitively intact because that would mean that she was 100% able to make all decisions. She stated that R86 did make some decisions that were not the best but they were health related which were her main concern and what she followed R86 for. She stated that as far as intimate relations, R86 understood enough to make the decision to be involved and she did not have any concerns about her being involved in anything that she did not want to be in. She stated that R86's cognition waxed and waned and she had never come across as being coerced in the relationship. On 3/27/2024 at 10:29 a.m., an interview was conducted with OSM (other staff member) #6, the director of social services/discharge planner. OSM #6 stated that R86 did have a low BIMS score which indicated she was cognitively impaired but her cognition varied from day to day. She stated that the nurse had spoken with R86's responsible party because R86 and R62 were adamant about moving in together and getting married. She stated that the nurse had gotten permission from the RP for R86 to move in with R62 and they had also notified the RP that R86 wanted to have intimate relations with R62. She stated that when residents in the facility wanted to have intimate sexual relationships they had conversations with the residents to make sure that they were getting along and if things were happening quarterly and annually. She stated that she documented these in the discharge planning assessments. She stated that the former social service assistant did the last assessment for R86. She reviewed the assessment dated [DATE] and stated that she did not see anything regarding an assessment for cognitive ability to continue to consent for intimate relationships but would expect to see it documented. She stated that she thought that because the staff saw R86 everyday and were always observing for any changes that they did not always document it. The facility policy Medically Related Social Services dated 2022 documented in part, .In conjunction with medical and clinical staff, Social Work and Discharge Planning Staff will identify and provide assistance in meeting patients' psychosocial and medically related social service needs. Procedure: 1. Conduct initial and ongoing reviews of patients to assess needs. 2. Advocate for reasonable accommodation of individual patient needs or preferences except when the health or safety of other patients would be endangered; . 5. Provide emotional support and guidance in decision making. 6. Document interventions in patient medical record . The facility policy Standards of Documentation dated 2022 documented in part, Social Work and Discharge planning staff will provide timely and ongoing documentation in the patient's medical record to provide evidence of assessment of patient needs, for establishment of an individualized and appropriate interdisciplinary care plan, and to keep all interdisciplinary team members informed of psychosocial events impacting patient care/treatment . On 3/27/2024 at approximately 4:45 p.m., ASM #1, the administrator, and ASM #2, the director of nursing were made aware of the concern. On 3/28/2024 at 8:45 a.m., ASM #2 stated that R86's psychosocial needs were being assessed on an ongoing basis and any changes would be reported and reassessed as needed. He stated that the psychiatric nurse practitioner was following R86 and they had a counselor who was scheduled to see both residents. No additional documentation or written evidence or assessment was provided at that time. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide urostomy care and services for one of 33 residents in the survey sample, Resident #259. The findings include: For Resident #259 (R259), the facility staff failed to obtain physician's orders for the type of urostomy wafer/pouch to use, and for how often the urostomy wafer/pouch should be changed. R259's comprehensive care plan dated 2/27/24 documented, The resident has a Urostomy. Change wafer and provide site care as ordered . A review of R259's clinical record revealed physician's orders to monitor urostomy output every shift and monitor for signs and symptoms of infection every shift. Further review of the clinical record failed to reveal physician's orders for the type of urostomy wafer/pouch to use, and for how often the urostomy wafer/pouch should be changed. On 3/27/24 at 2:34 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated residents with urostomies should have physician's orders to monitor for output and to monitor the site. LPN #3 stated residents with urostomies should also have physician's orders for the type of device and how often to change it to ensure nurses are using the right device and the device is being changed. On 3/27/24 at 3:24 p.m., LPN #3 stated she read the manufacturer's instructions for the urostomy wafer/pouch being used for R259 and the instructions did not document how often to change the device. LPN #3 stated she spoke to R259 and one nurse who stated the resident's urostomy wafer/pouch is changed every three to four days. LPN #3 stated she also talked to another nurse who didn't specify she changes R259's urostomy pouch/wafer every three to four days but stated she changes it when she notices sediment. On 3/27/24 at 4:14 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing were made aware of the above concern. The facility did not provide a policy regarding urostomies. The manufacturer's instructions for the urostomy pouch used for R259 failed to document specific directions for when to change the pouch. Urostomy pouches are special bags that are used to collect urine after some types of bladder surgery. Instead of going to your bladder, urine will go outside of your abdomen into the urostomy pouch. The surgery to do this is called a urostomy. Part of the intestine is used to create a channel for the urine to drain. It will stick outside your abdomen and is called the stoma. The urostomy pouch is attached to the skin around your stoma. It will collect the urine that drains out of your urostomy. The pouch is also called a bag or appliance. The pouch will help: Prevent urine leaks Keep the skin around your stoma healthy Contain odor Types of Urostomy Pouches Most urostomy pouches come as either a 1-piece pouch or 2-piece pouch system. Different pouching systems are made to last different lengths of time. Depending on the type of pouch you use, it may need to be changed every day, every 3 days, or once a week. A 1-piece system is made up of a pouch that has an adhesive or sticky layer on it. This adhesive layer has a hole that fits over the stoma. A 2-piece pouch system has a skin barrier called a flange. The flange fits over the stoma and sticks to the skin around it. The pouch then fits onto the flange. Both kinds of pouches have a tap or spout to drain the urine. A clip or another device will keep the tap closed when urine is not being drained .Buying and Storing Supplies: Your provider will write a prescription for your supplies . This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000480.htm Changing the pouch Different pouching systems are made to last different lengths of time. Some are changed every day, some every 3 days or so, and some just once a week. It depends on type of pouch you use. This information was obtained from the website: https://www.cancer.org/cancer/managing-cancer/treatment-types/surgery/ostomies/urostomy/management.html

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide urinary catheter care and services for one of 33 residents in the survey sample, Resident #97. The findings include: For Resident #97 (R97), the facility staff failed to maintain the resident's urinary catheter (1) drainage bag in a sanitary manner. R97's comprehensive care plan dated 1/19/24 failed to document information regarding the placement of the resident's urinary catheter drainage bag. A review of R97's clinical record revealed a physician's order dated 2/21/24 that documented an order for a Foley (urinary) catheter related to a neurogenic bladder. On 3/27/24 at 8:26 a.m., R97 was observed lying in a low bed. The resident's urinary catheter drainage bag was attached to the bed frame and the bag was sitting on the floor. On 3/27/24 at 2:34 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated a urinary catheter drainage bag should not touch the floor for infection control reasons and also because someone's feet or a wheelchair could, yank on it. On 3/27/24 at 4:14 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing were made aware of the above concern. The facility policy titled, Indwelling Urinary Foley Cath. & Drain Bag Changes failed to document specific information regarding the placement of the drainage bag. Reference: (1) A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide complete and accurate documentation for one of 33 residents, Resident #15. The findings include: The facility staff failed to evidence complete and accurate documentation for incontinence care for Resident #15. Resident #15 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), ESRD (end stage renal disease) and dementia. Resident #15's most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/7/24, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as maximal assist for bed mobility, transfer, eating and hygiene. A review of Resident #15's comprehensive care plan dated 6/29/23 revealed, FOCUS: The resident is at increased risk for complications secondary to requiring hemodialysis secondary to ESRD. INTERVENTIONS: hemodialysis on M-W-F. Observe for signs and symptoms of complications related to ESRD including but not limited to fluid overload, hemorrhage, infection to the access site, hypotension, respiratory and/ or cardiac distress and notify physician as indicated. A review of the physician's order 2/2/23 revealed, 1500ml (milliliters) Fluid Restriction every shift for ESRD on HD (hemodialysis) 1500cc Fluid Restriction 1380ml 7a-7p and 120ml 7p-7a. A review of the February 2024 MAR (medication administration record) reveals documentation on 7pm-7am shift on 2/13 and 2/27 as 1380 ml. A review of the March 2024 MAR reveals documentation on 7pm-7am shift on 3/25 and 3/26 as 1500 ml. An interview was conducted on 3/27/24 at 3:40 PM with LPN (licensed practical nurse) #5. When asked if she remembered Resident #15's fluid restriction, LPN #5 stated, yes. She is usually asleep most of the night and then she is up early for dialysis. She takes a little water with her medication. When asked did she consume 1380 ml of fluid on night shift, LPN #5 stated, oh no, if that was documented then it was mis documented. I must have been in the middle of my documentation and was interrupted and documented that in error. When asked if Resident #15's medical record was complete and accurate, LPN #5 stated, no, it is not. On 3/27/24 at 4:30 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the Director of Nursing, were made aware of the findings. A review of the facility's Documentation Summary policy revealed Licensed nurses and CNAs (certified nursing assistant) will document all pertinent nursing assessments, care interventions and all follow up actions in the medical record. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow physician's orders for three of 37 residents in the survey sample, Resident # 93 (R93), Resident #15 (R15) and Resident #75 (R75). The facility staff failed to monitor a fluid restriction for R93; and failed to provide care and services for a central venous access (central line) for R15 and R75. The findings include: 1. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/31/2022, R93 scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs, the resident was coded as receiving [CONDITION(S)]. The physician order dated 4/11/2022, documented, Fluid Restriction (1200 ml [milliliters]) Give the following fluid volume with medication administration: 7-3 [7:00 a.m. to 3:00 p.m.] meds: (120 ml with morning meds and 120 ml afternoon meds) 3-11 [3:00 p.m. to 11:00 p.m.] meds: 120 ml (evening meds) 11-7 [11:00 p.m. to 7:00 a.m.] meds: 40 ml (night meds). Remainder 600 ml with daily meals (120 ml breakfast, 240 ml lunch, 240 ml dinner) every shift for Fluid Restriction. The MAR (medication administration record) documented the above order. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/15/2022 the days documented 1340 ml, the nights documented 550 ml consumed, for a total of 1890 ml in a 24 hour period. On 4/19/2022, the days documented 960 ml and the nights documented 960 ml consumed, for a total of 1920 ml in a 24 hour period. Review of the nurse's notes dated 4/11/2022 through 4/19/2022, failed to evidence documentation regarding the fluid restriction. The comprehensive care plan dated, 7/2/2020 and revised on 4/19/2022, documented in part, Focus: Nutrition Risk r/t (related to) [CONDITION(S)] ([CONDITION(S)]) on HD (hemodialysis) .+1200 ml fluid restriction. LPN (licensed practical nurse) #3 was interviewed on 4/20/2022 at 4:16 p.m. When asked who is responsible for monitoring the physician ordered fluid restriction for a resident, LPN #3 stated she looks at the meal trays as they are handed out and then the CNA (certified nursing assistants) usually provides information on how much they are drinking. LPN #3 stated the residents have a certain amount of cups. When asked where the amount of fluids a resident consumes is documented, LPN #3 stated it is documented in the MAR. When asked who monitors the fluid restriction, LPN #3 stated each nurse on each shift monitors the amount for the shift. LPN #3 stated she monitors and records it for 3-11 shift. When asked if anyone is responsible for monitoring the totals for the day, LPN #3 stated, no, the nurse monitors it when she puts it in for her shift. When asked the purpose of a fluid restriction for R93, LPN #3 stated the resident is a [CONDITION(S)] patient and his kidneys are not working properly. Again asked who is monitoring the exact amount the resident is taking, LPN #3 stated that was a good question. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/20/2022 at 4:43 p.m., RN (registered nurse) #2, and RN #1, both unit managers, were interviewed. When asked the purpose of a fluid restriction for a resident on [CONDITION(S)], RN #2 stated so the resident will not go into fluid overload between [CONDITION(S)] as they can't rid themselves of the fluid. When asked who monitors the fluid restriction, RN #2 stated the nursing staff. When asked who looks at it to see if the resident is over or under the physician ordered fluid restriction, RN #2 stated it should have a total for the day and the nurses should look at it at the end of their shift. Each nurse is responsible on their shift to monitor it. RN #1 stated, typically we, the nurses, go around to the residents on fluid restrictions and make sure there are no extra cups in the room, everything they drink is recorded. RN #1 stated the physician orders specify what the resident are supposed to get each shift. RN #1 stated each nurse is documenting what they gave. The above orders were reviewed with RN #1, when asked about documentation, RN #1 stated, the nurse signing off at 3:00 p.m. should tell the oncoming nurse how much they gave the resident and then the next nurse will document the total until 7:00 p.m. When asked what are the potential consequences for R93 to go over their fluid restriction, RN #2 stated, a lot could arise, [CONDITION(S)], fluid overload or [CONDITION(S)]. The facility policy, Fluid Management/Fluid Restriction documented in part, Policy: The nursing staff will assess and monitor adherence to fluid management for patients placed on fluid restriction .Procedure: 7. Document fluid intake. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and RN (registered nurse) #1, the unit manager, were made aware of the above findings on 4/20/2022 at approximately 5:15 p.m. No further information was provided prior to exit. 2. On the most recent MDS, (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/18/22, R15 scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately cognitively impaired for making daily decisions. On 4/19/22 at 4:05 p.m., R15 was sitting up in a wheelchair. During the interview, R15 stated concern about the central line used to administer IV antibiotics. R15 stated the antibiotic was complete, but the central line had remained. The resident was worried about getting an infection from the central line. The central line access was located on R15's right upper arm. The dressing was dated 4/4/22. On 4/20/22 at 12:38 p.m., R15 was sitting up in bed, awake and alert. The dressing on R15's central line access on the right upper arm was unchanged from the previous day, and dated 4/4/22. A review of R15's physician orders revealed the following: Mid-line (type of central venous access) dressing change Q (every) Sunday and prn (as needed) every day shift every Sun (Sunday) for infection prevention .Midline flush - 10 ml (milliliters) NS (normal saline) infuse medication, then 10 ml NS flush and follow with 5 ml 10 units/mlv [MEDICATION(S)] (2) one time a day. Both orders were dated 3/2/22 and were discontinued 4/12/22. A review of R15's MARs (medication administration records) and TARs (Treatment Administration Records) for April 2022 revealed no evidence R15's central line dressing was changed after 4/4/22. R15's MARs revealed the normal saline and [MEDICATION(S)] flushes were administered as ordered between 3/2/22 and 4/12/22. The clinical record contained no evidence R15's central line access was assessed or flushed between 4/12/22 and 4/20/22. A review of R15's comprehensive care plan dated 5/25/20 and updated 3/2/22 revealed, in part: (Central line) catheter .change dressing with a transparent dressing weekly or as needed .flush as ordered. On 4/20/22 at 12:54 p.m., LPN (licensed practical nurse) #2 was interviewed. When asked about specific interventions to care for a central line, she stated there should be orders in place to have the dressing changed weekly. She stated if a resident has completed treatment requiring use of the central line, the nurses should still be assessing the site and flushing it regularly to make sure no blood clots form within or around the line. On 4/20/22 at 1:08 p.m., LPN #1 was interviewed. She stated the nursing staff should have orders to change the central line dressing once a week, and as needed. She stated sometimes a provider will want to leave a central line in place beyond completion of a round of IV medications in case additional laboratory tests reveal the necessity for additional IV medications. She stated a nurse needs an order to do anything with a central line, including flushing and dressing changes. She stated flushes should continue as part of routine central line care, whether or not the line is being used for medication administration. She stated it is important to change the central line dressing in order to prevent infection, and to allow a nurse to see the access site more clearly. On 4/20/22 at 1:54 p.m., ASM (administrative staff member) #3, a nurse practitioner, was interviewed. She stated central line care should include flushes every shift to check for blood return and to clear the line, as well as dressing changes each week. She stated if the line is not flushed regularly, even if it is not in use, it could develop blood clots. She stated central line care should include dressing changes each week. She stated if a dressing is not changed regularly, there is a higher risk of bacteria getting into the central line and causing an infection. When asked if she knew why R15's central line was still in place, she stated R15 was cleared from isolation on 4/19/22, and should have the central line removed today. On 4/20/22 at 5:09 p.m., ASM #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. 3. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/18/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. On 4/19/2022 at approximately 11:20 a.m. R75 was observed resting in bed. A PICC line was observed on the resident's right arm just above the elbow. The dressing on the PICC line was dated 4/8/2022. On 4/20/2022 at 8:30 a.m., a second observation was made of R75's PICC line dressing. The same dressing was in place dated 4/8/2022. R75 was asked if the staff has changed the dressing on the PICC line since they returned to the facility on [DATE]. R75 stated the dressing had not been changed since before they left the hospital. When asked if the nurses look at the dressing and measure it, R75 stated, not really. R75 stated they just do the flush before and after the antibiotic and infuse the antibiotic. The physician order dated 4/12/2022 documented, PICC line dressing change on admission, then Q (every) week on Sunday and PRN (as needed) every day shift every Sunday for infection Prevention. A physician order dated 4/17/2022 documented, PICC line - measure external portion of PICC line catheter weekly with dressing changes every night shift every Sunday. There were no orders to flush the PICC line. The MAR (medication administration record) for April 2022 documented the above order for the PICC line dressing. The order of 4/17/2022 did not appear on the MAR. On 4/17/2022 a 9 was documented. The Chart Codes documented a 9 equal Other/See Progress Note. The nurse's note dated 4/17/2022 at 12:45 p.m. documented, PICC line dressing change on admission, then Q week on Sunday and PRN every day shift every Sun for Infection Prevention - Being done on 3-11 p.m. There was no documentation that the dressing was completed on 3-11 p.m. shift on 4/17/2022. The comprehensive care plan dated, 4/19/2022 documented in part, PICC/Midline catheter Medication administration for [CONDITION(S)] to right foot. The Interventions documented in part, Change dressing with a transparent dressing weekly or as need. Flush as ordered. Monitor insertion site for redness, drainage and pain. An interview was conducted with LPN (licensed practical nurse) #1 on 4/20/2022 at 1:08 p.m. When asked how a nurse cares for a resident with a PICC line, LPN #1 stated there should be orders for the dressing changes, the resident may come with orders for laboratory tests and the SASH (Saline, antibiotic, saline, [MEDICATION(S)]) protocol. LPN #1 stated the dressing should be changed at least weekly and as needed. When asked if there should be orders for the flushes, LPN #1 stated yes. When asked where the flushes are documented, LPN #1 stated on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if she had observed R75's PICC line this morning, LPN #1 stated she observed it once on rounds this morning. When asked if she noticed anything, LPN #1 stated it looked like it needed to be changed. When asked if she checked the date, LPN #1 stated she did not. When asked why the dressing is changed weekly, LPN #1 stated because of infection control; the nurse needs to observe the site, and when the dressing is changed, the nurse has to measure the amount of tubing is hanging out from the insertion site. When asked where this measurement is documented, LPN #1 stated it should be with the order for the dressing change. An interview was conducted with ASM (administrative staff member) # 3, the nurse practitioner, on 4/20/2022 at 1:53 p.m. When asked what kind of care should central lines, PICC, Midline catheters receive from the staff, ASM #3 stated they should be flushed every shift, to make sure it's flushing and maintaining the integrity of the line. ASM #3 stated she was not sure of the facility protocol. When asked if the nurses need orders for the flushes and dressing changes, ASM #3 stated there is a plan of care in the electronic medical record system that should populate, but yes the nurses need orders for daily PICC care. When asked why should there be orders to flush the line, ASM #3 stated the PICC line can clot and that's why there should be orders for [MEDICATION(S)] flush or regular flush. When asked why there should be orders for a dressing change, ASM #3 stated if the dressing is loose then bacteria can get in and cause an infection. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and RN (registered nurse) #1, the unit manager, were made aware of the above findings on 4/20/2022 at approximately 5:15 p.m. Policies regarding central line care were requested. On 4/21/22 at 8:40 a.m., ASM #1 stated the facility did not have a policy related to central line care. No further information was provided prior to exit.