Every finding on record at Lake Port Square Health Center

Based on observation, interview and record review the facility failed to ensure the oxygen delivery rate was specified for 1 resident, Resident #11, and failed to ensure nebulizer equipment was properly stored for 1 resident, Resident #85, of 3 residents reviewed for respiratory care. Findings include: During an observation on 6/9/2026 at 8:12 AM, Resident #11 was semi reclined in his bed in his room. Resident #11 was being administered oxygen from a concentrator via nasal cannula at 2 liters per minute. Review of Resident #11's care plan, initiated 1/2/2026, revealed Resident #11 was at risk for complications related to sleep apnea secondary to the need for continuous positive airway pressure with a history of refusing the continuous positive airway pressure. Resident #11's respiratory care plan interventions included oxygen as needed to Promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated, head at 45 degrees). Review of Resident #11's physician's orders showed Resident #11 had physician orders that included O2 [Oxygen]: Clean oxygen filters every night shift every 4 weeks on Mon [Monday] for Maintenance, O2 [Oxygen]: Change nebulizer mask and tubing every night shift every Mon [Monday] for Infection control, Respiratory Orders: Oxygen PRN [as needed] night (Resident uses O2 [Oxygen] at night for sleep apnea, he does not like MASK for CPAP) every night shift for Sleep Apnea Resident uses O2 [Oxygen] at night for sleep apnea, he does not like MASK for CPAP. Review of Resident #11's clinical records failed to reveal a physician's order that established an ordered delivery rate for Resident #11's oxygen. During an interview on 6/10/2026 at 8:58 AM, Staff A, Licensed Practical Nurse, confirmed Resident #11's clinical records failed to reveal a physician's order that established an ordered delivery rate for Resident #11's oxygen. Staff A reported Resident #11 used the oxygen overnight typically and sometimes during the day. She reported Resident #11's oxygen delivery rate was set by facility nurses and Resident #11 did not set the oxygen delivery rate. During an interview on 6/10/2026 at 9:52 AM, the Director of Nursing agreed residents' oxygen delivery rates should be included in the residents' clinical record as a physician's order. During an observation on 6/8/2026 at 9:41 AM, Resident #85 was sitting in her wheelchair. There was a nebulizer mask lying on top of the nightstand that was not bagged. [photographic evidence obtained] During an observation on 6/8/2026 at 12:06 PM Resident #85 was lying in bed with her eyes closed. There was a nebulizer mask lying on top of the nightstand that was not bagged. Review of Resident #85's physician orders dated 6/7/2026 read, Levalbuterol HCl 0.63 MG [milligram] /3ML [milliliter] Nebulization solution Give 1 vial by mouth every 8 hours for sob [shortness of breath]. Review of Resident #85's physician orders dated 6/7/2026 read, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally every 6 hours as needed for SOB. During an interview on 6/10/2026 at 10:34 AM, Staff J, Licensed Practical Nurse [LPN] stated, Nebulizer mask and oxygen tubing should be stored in a bag when not in use. During an interview on 6/10/2026 at 10:40 AM, the Director of Nursing stated, The nebulizer mask and tubing should be stored in a bag that is dated when not in used. Review of the facility policy and procedure titled Departmental (Respiratory Therapy)-Prevention of Infection with a last review date 1/22/2026 read, Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Steps in the Procedure. 8. Keep the oxygen cannula and tubing used PRN in a plastic bag, when not in use. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name between uses.

Based on interview and record review the facility failed to document therapy sessions for 1 (Resident #38) out of 2 residents reviewed for rehabilitation services.Finding includes:During an interview on 6/9/2026 at 8:24 AM Resident #38 stated , I want to know if I am going to have therapy today. The guy who does my physical therapy has been on vacation and I have not gotten therapy in weeks.Review of Resident #38 physician order dated 4/21/2026 read, PT [physical therapy] recertification order for PT TX [treatment] QD [everyday]1 X/WK [week] x 60 days for thera ex, thera activity, Gait training, PT. /CG ed. TX DX R53. 1 one time for 60 Days.Review of Resident #38 Service Log Matrix for the Month of May 2026 there is no documentation for 5/19/2026 visit.Review of Resident #38 Service Log Matrix for the Month of April 2026 there is no documentation for 4/14/2026 and 4/28/2026 visits.During an interview on 6/10/2026 at 10:18 AM with the Director of Therapy stated, He[Resident #38] did missed on April 14. There is no documentation. He is on the assignment board for functional maintenance. The therapist is in Thailand and cannot communicate with me to see what happen. For whatever reason if he [Resident #38] refused or not feeling well it is not documented. On April 28 he is on case load assignment board that the therapist gets daily. For whatever reason it is not documented why he did not receive the therapy session. It is Pro bono and been on it since last July 2024. On May 19 he is on the assignment board but no documentation of visit. He really doesn't like to get out of bed a lot that could be the reason. If we cannot do it on Tuesday we will move it a day. The therapist should have documented the reasons why therapy session was not completed that day.During an interview on 6/10/2026 at 11:25 AM with Staff B Licensed Practical Nurse (LPN) stated, He [Resident #38] is usually pretty go about going to therapy. He goes every Tuesday and he is pretty go about going. He has not verbalized that he has missed therapy. They are good at providing therapy to the residents.During an interview on 6/10/2026 at 2:44 PM with the Director of Therapy stated, I spoke to [Resident #38's name and he remembers being sick on those particular days that are missing.During an interview on 6/10/2026 at 2:47 PM Resident #38 stated he has missed therapy once or twice due to him not feeling well. Stated his therapist has been sick once and they send someone and then the other time he was sick and did not have therapy due to this.Review of the facility policy and procedure titled Documentation Requirements with a last review date of 1/22/2026 read, Policy: It is company policy that documentation of a resident's care will be maintained in a complete, timely and orderly fashion.

Based on observation and interview the facility failed to ensure garbage and refuse was disposed of properly.Findings include: On 6/8/2026 at 9:51 AM, there was a large dumpster with no lid that contained exposed filled household style plastic garbage bags. The plastic garbage bags were not secured from pests or wildlife. There was 1 small dumpster in the area. The left side top lid of the small dumpster was open exposing the contents of the dumpster to pests and wildlife.During an interview on 6/8/2026 beginning at 9:51 AM, the Kitchen Manager reported the large dumpster with no lid should not contain garbage. She acknowledged the left side top lid of the small dumpster was open exposing the contents of the dumpster to pests and wildlife.During interview on 6/9/2026 at 9:09 AM, the Interim Certified Dietary Manager reported the large dumpster was a construction dumpster and should not contain facility trash. Review of the facility policy titled Sanitization, last reviewed 1/22/2026, read, All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects.14. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered).15. Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests.

Based on observation, interview and record review the facility failed to ensure food was stored in a safe manner in the main kitchen and in 1 of 2 nourishment rooms. Findings include: During the initial tour of the main facility kitchen on 6/8/2026 at 9:38 AM, there was no thermometer in the walk-in freezer. During an interview on 6/8/2026 beginning at 9:38 AM, the Kitchen Manager agreed there was no stand-alone thermometer in the walk-in freezer. During an observations on 6/8/2026 beginning at 9:48 AM, the thermometer in the 300 Hall nourishment room freezer registered 30 Fahrenheit degrees. There were 7 thawed ice cream bars stored in the 300 Hall nourishment room freezer. During interview on 6/8/2026 beginning at 9:48 AM, the Kitchen Manager reported the thermometer in the 300 Hall nourishment room freezer registered 30 degrees Fahrenheit. She agreed the ice cream bars stored in the 300 Hall nourishment room freezer were thawed. Review of the policy titled Food & Beverage Standards of Excellence, last reviewed 1/22/2026, read 5. Food will be purchased, stored, prepared and served in a sanitary manner.Proper food temperature .

Based on observation, interview and record review the facility failed to follow standards of medication storage for 2 out of 6 halls reviewed for unattended medication.Findings include: During an observation on 6/8/2026 at 9:15 AM Resident #86 was lying in bed. Resident #86's wife was at bedside. There was a clear medication cup with cream inside. Medication cup was not labeled. There were two normal saline flush syringes on top on nightstand. During an interview on 6/8/2026 at 2:11 PM, Staff I Licensed Practical Nurse (LPN) stated, I am not aware of any cream or normal saline flushes. I have not done any of it. During an interview on 6/8/2026 at 2:13 PM, Resident #86's Representative stated, The staff came in and applied the cream when the changed him [Resident #86]. During an interview on 6/8/2026 at 2:16 PM, Staff G Certified Nursing Assistant (CNA) stated, The wound care nurse gave me the cream this morning; I left it in his [Resident #86] room and when I came back I applied it. During an observation on 6/8/2026 at 10:25 AM Resident #38 was lying in bed. There was a clear medication cup at bedside with a spoon and cream. [photographic evidence obtained] During an interview on 6/8/2026 at 10:25 AM, Resident #38 stated that staff will apply the cream to him when they change him. During an interview on 6/8/2026 at 2:20 PM, Staff H, CNA confirmed there was a clear medication cup with a spoon at Resident #38 bedside nightstand. Staff H reported it is cream to apply when he is changed but should not have been left at bedside. During an interview on 6/8/2026 at 2:21 PM, Staff B, LPN, stated, [ Resident #38's name] does not have an order to self-administer medication. During an interview on 6/11/2026 at 6:22 AM, the Director of Nursing stated, [Residents #86 and #38's name] did not have orders to self-administer medications. The medication should not be left unattended at bedside. Review of the facility policy and procedure titled Medication Labeling and Storage with a last review date of 1/22/2026 read, Policy Statement. The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.

Based on observation, interview and record review the facility failed to provide nutritional supplements as order for 1 (Resident #12) of 6 residents reviewed for nutritional services. Findings include:During an observation on 6/8/2026 at 12:03 PM, Resident #12 was having lunch in her room. The meal tray contained soup, iced tea, noodles, brussels sprouts, peaches, and chicken. There was no nutritional treat observed. [photographic evidence obtained]During an interview on 6/8/2026 at 12:03 PM, Resident #12 stated, I do not get any additional nutrition treat. Nothing that is frozen. During an observation on 6/9/2026 at 12:48 PM, Resident #12 eating in her room. The tray contained iced tea, dessert, rice, vegetables, and pork. There was no frozen nutritional treat on the meal tray. [photographic evidence obtained]Review of Resident #12's physician order dated 11/26/2025 read, Frozen nutritional treat with Lunch and dinner two times a day for at risk for malnutrition.Review of Resident #12's medical record shows documented weights on 5/23/2026 187.4 lbs [pounds], 4/13/2026 194.6 lbs, 2/22/2026 189.8 lbs, and on 11/30/2026 196.1 lbs. Review of Resident #12's Dietary/Nutrition Evaluation dated 6/4/2026, reads, Weight history. Wt [weight] stable. C. Nutritional Approaches current nutritional supplements. Yes. magic cup bid [twice a day].During an interview on 6/10/2026 at 11:25 AM, Staff B, Licensed Practical Nurse (LPN), stated, Normally the frozen nutritional treat comes on the tray form the kitchen. I was not aware she [Resident #12] did not get her nutritional treat for lunch.During an interview on 6/10/2026 at 11:32 AM, Staff E Certified Nursing Assistant (CNA), stated, I cannot recall if [Resident #12's name] gets a frozen nutritional treat. If she did it would come from the kitchen we do not have them in the refrigerator.During an interview on 6/10/2026 at 11:33AM, Staff F, CNA, stated, No, [Resident #12's name] did not have a frozen treat on her treat for lunch yesterday. That I know of she does not get them.During an interview on 6/10/2026 at 3:01 PM, the Registered Dietician (RD) stated, I came in this week. Normally the RD puts in the orders in the system and then will fill out a communication sheet that goes to the kitchen. [Resident #12's name] frozen nutritional treat was not communicated with the [kitchen program] and was not showing up in the meal ticket.During an interview on 6/10/2026 at 3:06 PM, the Kitchen Manager stated, Nursing will normally write a communication form from nursing. If I get that [new orders in the communication sheet] I make the change but if I don't get it, I cannot make the change. Some how this one got overlooked. Nursing directly give it to me. It will show up on the ticket. The frozen nutritional treats will aways come from the kitchen on the meal tray. No one came to me to ask me for a frozen treat these past few days that I can recall. During an interview on 6/11/2026 at 6:21 AM with the Director of Nursing stat, The CDM walked out on Friday and he is the one that typically pull the order in and make sure that everything is on the tray.Review of the facility policy and procedure titled, Supplemental Feeding with a last review date of 1/22/2026 read, Policy: It is the policy of the community to provide nutritive supplements as appropriate for residents with weight loss or when other nutrition risk factors are identified. Procedures: 1. Nutritive Supplements will be given when ordered by the physician.

Based on observation, interview and record review the facility failed to administer correct dosage amount of medication to 1 (Resident #9) of 6 residents reviewed for medication administration and failed to provide intravenous device care as per nursing standards for 1 (Resident#15) of 2 residents reviewed for intravenous infusions. Findings include: During an observation on 6/10/2026 at 8:10 AM Staff B, Licensed Practical Nurse (LPN) was pouring medication for Resident #9. Staff B, LPN, poured one tablet of Methotrexate Sodium 2.5 mg into the medication cup. When Staff B, LPN was finished pouring all medications, Staff B entered Resident 9's room and administered the medications. Staff B, LPN then exited Resident #9's room and signed off on all the medications. Review of Resident #9 physician order dated 2/09/2026 read, Methotrexate Sodium Oral Tablet 2.5 MG [milligram] (Methotrexate Sodium) give 6 tablet by mouth one time a day every Wed [Wednesday] for rheumatoid arthritis 6 X 2.5 mg=15mg. During an interview on 6/10/2026 at 12: 25 PM, Staff B, LPN, stated, I should have given him [Resident #9] 6 tablets to make 15mg not just one tablet. I will have to call the provider to let him know and let the DON [Director of Nursing] know. During an interview on 6/10/2026 at 1:10 PM, the Director of Nursing stated, The nurse came to me and told me what happen. I told her to call the provider and let the patient know. Providers order a one-time dose for the missing amount. The nurse was nervous. During an interview on 6/11/2026 at 9:50 AM, the Director of Nursing stated, Nurses are to review orders and compare the medication cards to the orders in the system. Pharmacy will come and do medication observations and have not had any concerns. The pharmacy has not verbalized any concerns with [Resident #9's Name] medication not being given when they review the medication carts or when refilling medication. Review of the facility policy and procedure titled Administering Medications with a last review date of 1/22/2026 read, Policy Statement. Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. During an observation on 06/08/2026 at 9:30 AM, Resident #15's Midline dressing was dated 5/30/2026 on upper inner right arm. Skins visibly purple at insertion site with dry blood on foam circle around line under clear dressing. (photographic evidence obtained). IV (Intravenous) pump with empty bag of ordered antibiotics in room. During observation on 06/09/2026 at 9:22AM, Resident #15 did not have a Midline in place or dressing located on the upper inner right arm. A purple colored mark was still present on skin The IV pump was not in the room. During interview on 06/11/2026 at 11:38 AM, the Medical Director stated, A line is to be removed immediately after the last dose of antibiotic has been given. It is a verbal order over the phone usually. During interview on 06/11/2026 at 12:03 PM, the DON stated, The dressings are to be changed weekly it is typically done on Thursday, so we have a second pair of eyes on it because wound care is done on Tuesday and Thursday. The process to remove the midline is at the end of the treatment we get an order for the midline to be removed or obtain labs if ordered then flush it and remove it. After a verbal order is obtained it is to be put into PCC (point click care) by the end of their shift. Review of Resident #15's Nursing Progress Note Dated 06/07/2026 by Staff K, LPN (licensed practical nurse) reads, Normal Saline Flush Solution 0.9 %- Use 10 ml intravenously every shift for Midline Flush Bandage dry/intact with no s/s of infection/infiltration. Flushed with no resistance. Review of Resident #15's Physician Order dated 06/08/2026 reads, Review of Late Entry Nursing Progress Note Verbal order per MD to pull IV line as tx was complete. IV line pulled with no issues, Review of Resident #15's Physician Orders dated 06/02/2026, Reads, Change catheter site dressing one time a day every Thur (sic) for dressing change catheter securement device AND every 8 hours as needed for Dressing change catheter securement device., Observe midline site with intermittent therapy or when not in use for s/sx of infiltration/extravasation, redness, swelling and pain. every shift for monitor IV site, Normal Saline Flush Solution 0.9 % (Sodium Chloride Flush) Use 10 ml(milliliters) intravenously every shift for Midline Flush, ceftriaxone Sodium Intravenous Solution Reconstituted 1 GM(gram) Use 1 Gram intravenously one time a day for UTI(Urinary tract infection) until 06/06/2026, Sodium Chloride Solution 0.9% Use 125ml/hr (milliliters/hour) intravenously every evening shift for run for 2 liters for 1 day 05/30/2026, midline to be placed per (Medical Doctor). Review of facility policy titled, Policy for Peripheral and Midline IV Dressing Changes, last updated 01/22/2026, reads, 4. Change dressing if it becomes damp, loosened, or visibly soiled and at least every 7 days for TSM (transparent semi-permeable membrane) Dressing.

Based on interview and record review, the facility failed to ensure assessments were updated following documentation of a new diagnosis for 2 Residents (Resident #4 and #9) out of 5 residents sampled for preadmission screening and resident reviews (PASARR). Findings include:Review of Resident #9's admission record shows resident was admitted on [DATE] and readmitted on [DATE] with diagnosis including but not limited to Brief psychotic disorder [onset date 11/14/2025] and major depressive disorder [onset date 3/17/2026].Review of Resident #9's State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASSR) dated 11/11/2025 did not document mental illness.Review of Resident #9's physician orders dated 11/18/2026 read, Quetiapine Fumarate Oral Tablet 25 MG [milligram] give 1 tablet by mouth at bedtime for Brief Psychosis for agitation and sedation.Review of Resident #9's [Name of Psychology Provider] admission Note dated 11/26/2026 reads, History of Present Illness: He was referred for psychotherapy services due to concerns of adjustment difficulties. [Resident #9's name] reported periods of mild anxiety related to current situation and being away from home. Sx [signs] have been present since health decline. Problem List Brief Psychotic Disorder active 11/18/2025, adjustment disorder active 12/02/2025.Review of Resident #9's physician orders dated 12/10/2025 read, Trazadone HCI Oral Tablet give 25 mg [milligram] by mouth at bedtime for insomnia related to depression.Review of Resident #9's [Name of Psychology Provider] Progress note dated 3/17/2026 read, Problem List: Adjustment Disorder active 12/2/2025. Major Depressive Disorder, recurrent, mild active 3/17/2026. Delusional disorders active 3/17/2026.During an interview on 6/11/2026 at 9:20 AM, the Director of Nursing stated, In March we were monitoring him [Resident #9], he was having a hard time because he found out his cancer had come back.Review of Resident #4's admission record shows resident was admitted on [DATE] and readmitted on [DATE] with diagnosis including but not limited to major depressive disorder [onset date 11/7/2025] and anxiety disorder [onset date 11/7/2025].Review of Resident #4's State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) dated 10/24/2025 did not document any mental illness.Review of Resident #4's [Name of Behavioral Science Provider] progress note dated 11/18/2025 read, The patient is a [age of Resident #4] year old female with a past psychiatric hx [history] of depression. Assessment/Plan: Major Depressive Disorder, Recurrent, Unspecified.Review of Resident #4's [Name of Behavioral Science Provider] progress note dated 1/7/2026 read, Treatment Plan: Encounter was requested by staff due to concerns in condition, overall decline and limiting behaviors.Review of Resident #4's physician order dated 2/18/2026 read, Escitalopram Oxalate Oral Tablet 5 MG give 1 tablet by mouth one time a day for Depression monitor for s/s of isolation and sadness. During an interview on 6/10/2026 at 10:57 AM, Social Services Assistant stated, Both PASSRs [Resident #4 and Resident #9] need to be updated.During an interview on 6/10/2026 at 11:43 AM, the Director of Nursing stated, Psych gives Social Services a list of all patients that were seen and they also sit in the meetings where we discuss changes and the residents.Review of the facility policy and procedure titled Psychotropic Medication Use with a last review date of 1/22/2026 read, Policy Interpretation and Implementation. Assessment and Evaluation of the Resident. 1. When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident. The evaluation includes the resident's: f. the state PASSAR evaluation.

Based on observation, interview and record review the facility failed to ensure resident assessments were completed accurately to reflect the resident's status for 4 (Resident #4, #6, #8 and, #15) of 9 residents reviewed. Based on observation, interview and record review the facility failed to ensure resident assessments were completed accurately to reflect the resident's status for 4 (Resident #4, #6, #8 and #15) of 9 residents reviewed. Findings include: During an observation on 6/8/2026 at 10:28 AM, Resident #8 was sitting in her wheelchair self-propelling in her room. There were no observations of restraints. During an interview on 6/8/2026 at 10:28 AM, Resident #8 stated, I have no concerns with my care and do not use any restraints. During an observation on 6/9/2026 at 2:14 PM, Resident #8 was sitting in activity room participating in activities in a wheelchair. No restraints observed at this time. Review of Resident #8's physician orders did not document orders for restraints. Review of Resident #8's Minimum Data Set (MDS) titled Quarterly dated 5/8/2026 read, Section P Restraints and Alarms: chair prevents rising. 1. Used less than daily. During an interview on 6/10/2026 at 8:42 AM, Staff B Licensed Practical Nurse (LPN) stated, [Resident #8's name] does not have any restraints. There is no seat belt or anything that would prevent her from getting out of her wheelchair. During an interview on 6/10/2026 at 9:35 AM, the MDS Coordinator stated, [Resident #8's name] does not use any restraints. No restraints in the building are used. I will update that section. During an interview on 6/10/2026 at 11:43AM, the Director of Nursing stated, We do not use any kind of restraints. Review of Resident #4's Minimum Data Set titled Quarterly dated 5/23/2026 read, Section N Medications: Antibiotics. No. Review of Resident #4's physician order dated 5/15/2026 read, Mupirocin External Ointment 2% (Mupirocin) apply to L [left] pointer and L mid [middle]. Fing [finger] topically two times a day for fungal rash for 7 Days left pointer and left middle finger. Review of Resident #4's Medication Administration Record for the month of May 2026 documented Mupirocin External Ointment 2% administered from 5/16/2026 through 5/22/2026. During an interview on 6/10/2026 at 9:29 AM, the MDS Coordinator stated, [Resident #4's name] assessment does say no for antibiotic use in the section. Mupirocin is considered an antibiotic. I will correct it. During an interview on 6/11/2026 at 8:13 AM with the Director of Nursing stated, The facility follows the RAI [Resident Assessment Instrument]. During observation on 06/09/2026 at 3:00PM, Resident #15 and her daughter were seated outside on front patio of facility. Resident was wearing a black sling on left arm. During interview on 06/10/2026 at 8:05AM, Resident #15 stated that she had hernia surgery in 2010 and has been dealing with the surgical site since then. During interview on 06/10/2026 at 8:51 AM, the MDS Coordinator stated, Section GG No impairment of upper and lower extremity is wrong, as she came in with a diagnosis of Left arm fracture. Yes, it is incorrect and I will have to change it. Section I does not have a diagnosis of Schizophrenia listed, and it is on her diagnosis. Section M Skin Issues with none listed is because she came in and the staging was still to be determined as of 05/21/2026 as to what it was to classified as. The hernia I have listed; she is getting wound care for. I see she is able to have ointments and dressings. It was that the etiology was not available for me at that time. I would have to go to the Resident and look at it myself to see how to classify it. During interview on 06/10/2026 at 11:47 AM, Wound Care Nurse stated, [Resident #15's Name]'s wound is an old hernia operation draining from her abdomen. I put an ABD and dry dressing on it. Review of Resident #15's admission record dated 05/20/2026, reads, Diagnosis: Primary Admitting 05/20/2026 Unspecified Fracture of Shaft of Humerus Left Arm, Ventral Hernia, and Schizophrenia. Review of Resident #15's MDS dated [DATE] reads, Section GG Functional Limitation in Range of Motion- Upper extremity and Lower Extremity Coded 0 No Impairment, Section I Active Diagnosis: Renal Insufficiency, Thyroid Disorder, Osteoporosis, Non-Alzheimer's Dementia, Seizure Disorder, Bipolar Disorder, Chronic Obstructive Pulmonary Disease, Unspecified Fracture of Shaft of Humerus, Left Arm, Repeated Falls, Cognitive Communication Deficit, Age Related Debility, Enterococcus as the Cause of Disease, Ventral Hernia, Section M Skin Conditions Unhealed Pressure Ulcers/ Injuries Code 0 No. Review of Resident #15's Physician Order dated 05/22/2026 reads, Wound care: Abdomen - Cleanse with NS (normal saline), Pat Dry, apply calcium alginate, skin prep surrounding tissue, apply ABD (Abdominal) pad, and silicone bordered dressing. every day and evening shift for wound Care AND every 8 hours as needed for If wet, soiled, dissolved. Review of Skin and Wound Progress Note dated 05/21/2026 from [Name of Wound Care Providers], Staff L, NP (nurse Practitioner) read, She has a closed fracture of the left humerus. Wound care consulted for evaluation and treatment of wounds. [Resident #15's Name] has a large weeping hernia on her abdomen that wound care will be following. Etiology to be determined and will collaborate with PCP (Primary Care Physician) regarding management moving forward. Review of Resident #6's admission record reads, Diagnosis: Onset Date 05/11/2026 Personal history of Transient Ischemic Attack (Tia), and Cerebral Infarction Without Residual. Review of Resident #6's Medical Doctor Progress Note, dated 05/12/2026 reads, Hemorrhagic stroke on 4/14 presented expressive aphasia during dialysis, CT (Computed tomography) head showed attenuation of left parietal region with focal hemorrhage +lytic lesion on right parietal calvarium. Review of Resident #6's MDS dated [DATE] Section I Active diagnoses does not include TIA or Cerebral Infarction. During interview on 06/10/2026 at 8:44 AM, the MDS coordinator stated, [Resident #6's Name] has a diagnosis of TIA (transient ischemic attack) and a history of stroke with no residual from his hospital paperwork. I will need to add it on to Section I.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to help prevent the spread and transmission of communicable diseases and follow infection control standards of practice for hand hygiene during 1 of 5 medication administration observations, 2 (Resident #265 and #266) of 10 residents reviewed for respiratory care equipment, 2 (Resident #20 and #167) of 4 residents reviewed for enhanced barrier precautions and 1(Resident #15) of 1 resident reviewed for transmission based precautions. Findings include: 1) During an observation on 2/10/2025 at 10:14 AM Resident #167's room had an enhanced barrier sign posted on the right side of the door entrance and personal protective equipment was observed upon entering the room. Staff G Certified Nursing Assistant (CNA) entered Resident #167's room with a towel and gown in her hand. Staff G donned a pair of gloves and began to assist Resident #167 to undress without donning personal protective equipment of a gown. Review of Resident #167's physician order dated 2/9/2025 read, Utilize Contact Precautions (esbl in Urine) [Extended-Spectrum Beta-Lactamase] every shift. During an interview on 2/12/2025 at 1:40 PM, Staff G, Certified Nursing Assistant (CNA), stated, I was not wearing a gown. I was helping her [Resident #167] remove her gown because she had vomited orange juice on her gown. I only need to wear a gown if the resident has an illness, and it is contagious. During an interview on 2/12/2025 at 3:00 PM, the Director of Nursing (DON) stated, Nurses will wear gloves and a gown when providing high contact care for residents on enhanced barrier precautions such a gastric tube medication administration or assisting a resident to change clothing. During an interview on 2/13/2025 at 8:37 AM, the DON stated, [Resident #167's name] is on contact precautions not enhance barrier precautions. Staff should don and doff the personal protective equipment before entering the room and when exiting the room. 2) During an observation on 2/12/2025 at 5:48 AM with Staff I, Licensed Practical Nurse (LPN), Staff I entered Resident #20's room. There was a sign on the door reading enhanced barrier precautions and personal protective equipment. Staff I washed her hand and placed medication on top of the bedside table. Staff I donned gloves but did not don a gown. Staff I placed feeding on hold and check Resident #20 for placement and residual. Staff I administered the medications via gastric tube. During an interview on 2/12/2025 at 5:48 AM, Staff I, LPN, stated, I should have worn a gown, I forgot. When administering medication via the gastric tube you should follow enhanced barrier precautions. Review of Resident #20's physician order dated 12/6/2024 read, EBP-Enhanced Barrier Precautions due to Specify G-tube every shift for Infection Prevention. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 12/2/2024 read, Policy statement: Enhanced barrier precautions (EBPs)are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation: 1. Enhanced barrier precautions (EBPs) are used an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident activity (as opposed to before entering the room). 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing .g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc ). 49777 3) During an observation on 2/10/2025 at 9:10 AM, Resident #265 was sitting on left side of the bed dressed in gown. CPAP [Continuous Positive Airway Pressure] nose piece was attached to tubing and was resting on top of the bedside table. During an interview on 2/10/2025 at 9:10 AM, Resident #265 stated, I use the CPAP to breath better at night. During an observation on 2/11/2025 at 9:30 AM, Resident #265 was walking in her room. Resident #265's CPAP nose piece was attached to tubing and was resting on top of bedside table. The CPAP was not in a bag. During an observation on 2/12/2025 at 8:25 AM, Resident #265 was sitting on side of bed. Resident #265's CPAP nose piece was attached to tubing and was resting on top of bedside table, it was not bagged. During an interview on 2/12/2025 at 8:28 AM, Staff B, Licensed Practical Nurse (LPN), stated, I am not sure, but I believe the CPAP nose piece should be placed in bag that is dated like another patient who is receiving inhalation treatment. I had her as a patient yesterday and should have noticed that. During an interview on 2/12/2025 at 10:30 AM, the DON stated, [Resident #265's name] CPAP nose piece should be placed in a labeled bag to store equipment between use. Review of the facility policy and procedure titled Prevention of Infection with the last review date of 12/2/2024 read, Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff 7. Store the circuit in plastic in plastic bag, marked with date and resident's name, between uses. 4) During an observation on 2/10/2025 at 9:25 AM, Resident #266's bedside table's top drawer was open with an unbagged inhalation mask lying inside the open drawer. During an interview on 2/10/2025 at 9:25 AM, Resident #266 stated, I am here because I had a stroke. I came in over the weekend. I do receive breathing treatments. During an observation on 2/11/2025 at 8:57 AM, Resident #266's inhalation mask was attached to the inhalation machine and not placed in a bag. During an interview on 2/12/2025 at 8:59 AM, Staff C, LPN, Unit Manager, stated, The inhalation mask for [Resident #266's name] should have been placed in bag after the treatment was completed and it should not have been left attached to the machine. Review of Resident #266's admission record documented an admitted [DATE] with diagnoses including sepsis (body's extreme response to infection), pneumonitis (swelling and irritation of lung tissue) due to inhalation of food and vomit, acute respiratory failure, hemiplegia (total or partial paralysis of one side of the body from injury or disease) and hemiparesis (muscle weakness) following unspecified cerebrovascular disease (stroke) affecting left dominant side, obstructive sleep apnea (collapse of upper airway during sleep blocking airflow), and emphysema (damage to air sacs in the lungs). Review of Resident #266's physician order dated 2/6/2025 read, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML [milligrams per 3 milliliters] (Ipratropium-Albuterol) 3 ml inhale orally every 4 hours for Shortness of breath. 45576 5) Review of Resident#15's clinical record documented admission 1/16/2025 with diagnosis that included sepsis unspecified organism, campylobacter enteritis. Review of Resident #15's physician order dated 2/7/2025 read, Contact isolation for C. diff [Clostridium difficile]. During an observation on 2/12/2025 at 1:24 PM, contact isolation signage noted on side of Resident #15 door. Signage read, Contact Precautions everyone must: clean their hands, including before entering and when leaving the room. Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. (Photographic evidence obtained). During an observation on 2/12/2025 at 1:24 PM, observation of door to Resident # 15's room open and Staff E, CNA, observed assisting Resident #15 from bedside chair back to the bed. Staff E adjusted Resident #15's bed-covers, bedside table and water. Staff E did not have a gown or gloves on while assisting Resident #15. During an interview on 2/12/2025 at 1:24 PM, Staff E, CNA, stated, I just ran down to this wing because the call light was going off and I was helping. I did not pay attention to the signage. I should have put on a gown and gloves prior to assisting [Resident #15's name] because she is on contact isolation. During an interview on 2/12/2025 at 3:45 PM, the DON stated, I expect any staff member to don a gown and gloves prior to entering any room that is on contact precautions. Review of the facility policy and procedure titled Isolation-Categories of Transmission-Based Precautions with the last review date of 12/2/2024 read, Policy Statement. Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents . 1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. 8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.

Based on record reviews and interviews, the facility failed to accurately document notifications of medication parameters for 3 (Resident #26, #27, and #163) of 6 residents reviewed for medication administration. Findings include: 1) Review of Resident #27's physician order dated 1/30/2025 read, Amlodipine Besylate Oral Tablet 2.5 MG (milligram) (Amlodipine Besylate) Give 1 tablet by mouth at bedtime for htn (hypertension). Review of Resident #27's physician order dated 1/30/2025 read, Metoprolol Succinate ER (extended release) Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 1 tablet by mouth at bedtime for htn. Review of Resident #27's physician order 1/31/2025 read, Metoprolol Tartrate Tablet Give 12.5 mg by mouth one time a day for HTN Review of Resident #27's Medication Administrator Record (MAR) for the month of February 2025 documented Amlodipine Besylate 2.5mg was coded a 4 [vital sign outside of parameter] on 2/4 at 2100 [9:00 PM] no blood pressure or pulse documented and on 2/10/2025 no blood pressure or pulse documented. Review of Resident #27's MAR for the month of February 2025 documented Metoprolol Succinate ER 25mg was coded a 4 [vital sign outside of parameter] on 2/4/2025 at 2100 [9:00 PM] no blood pressure or pulse documented. and on 2/10/2025 no blood pressure or pulse documented. Review of Resident #27's MAR for the month of February 2025 documented Metoprolol Tartrate 12.5mg was coded a 4 [vital sign outside of parameter] on 2/9/2025 at 0900 [9:00 AM] for blood pressure 102/60 and pulse 82 and on 2/10/2025 no blood pressure or pulse documented. During an interview on 2/11/2025 at 1:14 PM, Staff H, Licensed Practical Nurse (LPN), stated, Normally I hold systolic blood pressure that is under 110. I will not give the medication and I will let the provider know. I recheck and if the blood pressure is still low I don't give them blood pressure medication. There are times with low readings they take blood pressure medications and they also have fluid pills ordered and those too can lower blood pressure. I have contacted the provider before holding the medication. I know I'm suppose to always document but I don't always document the contact to the provider in the patient record. During an interview on 2/11/2025 at 1:17 PM, Staff D, LPN, stated, Normally we have parameters for medications especially hypertension medications. I hold medication if the systolic blood pressure is 110 or the heart rate is 60. I will notify the doctor and let them know she [Resident #27's name] is running low and documented. We do a progress note the system will generate the box where you able to document the blood pressure and the notification. During an interview on 2/11/2025 at 1:37 PM, the Director of Nursing (DON) stated, The nurses are able to use their nursing judgment when they are administering a blood pressure medication. They should recheck the blood pressure and if it is still too low the physician should be notified. They should document the communication in a progress or skill note. During an interview on 2/11/2025 at 2:18 PM, Medical Doctor #1 stated, The nursing staff call me or text me when they are going to hold the blood pressure medication for [Resident #27's name]. I could add parameters but this way I am able to be aware of the residents vitals. I am able to determine if the patient is having constant low blood pressure and determine if I should make changes to the medication or discontinue the medication instead of waiting to do a medication review for the resident. 2) Review of Resident #163's physician order dated 2/10/2025 read, Insulin Glargine Subcutaneous Solution 100 unit/ml (Insulin Glargine) inject 15 units subcutaneously at bedtime for DM [Diabetes Mellitus]. Review of Resident #163's physician order dated 2/10/2024 read, Novolog Flexpen subcutaneous Solution Pen-injector 100 unit/ml (Insulin Aspart) inject 5 unit subcutaneously before meals and at bedtime for DM. Review of Resident #163's MAR for the month of February 2025 for Insulin Glargine documented on 2/10/2025 at 2100 (9:00 PM) a 4 [vital sign outside of parameter]. Review of Resident #163's MAR for the month of February 2025 for Novolog Flexpen documented on 2/10/2024 at 0630[6:30AM] coded 5 [Hold/see nurse notes], at 1130 [11:30 AM] coded 5, oat 1630 (4:30 PM) coded 4, and at 2100 (9:00 PM) coded 4. Review of Resident #163's progress notes did not document physician notification of holding medication. Review of Resident #163's admission record resident was first admitted on [DATE] with diagnosis including but not limited to type 2 diabetes mellitus with unspecified complications, morbid obesity and hyperlipidemia. During an interview on 2/11/2025 at 1:14 PM, Staff H, LPN, stated, I should have put a note in the system but I did not. I check blood sugar levels and don't want them to bottom out in the middle of the night so will I notify the provider that I am holding the insulin and see if he agrees. First time having him [Resident #163] was last night we were busy with admission and didn't get to document it. I know some providers say to give the long term acting they don't want them to get out of scale too much if we were to hold it. I spoke to the provider and they said it was ok to hold. During an interview on 2/11/2025 at 1:20 PM, Staff D, LPN, stated, I spoke to him [Resident #163] and he told me he had never been a diabetic. I contacted Medical Doctor #2 to notify him but I did not document it. During an interview on 2/11/2024 at 1:44 PM, the DON stated, If a nurse does not feel comfortable administering a medication she can contact the provider and get clarification. The staff should document the interaction in the system and code the correct information in the MAR if the resident refused. Review of the facility policy and procedure titled Charting and Documentation with the last review date of 12/2/2024 read, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physicals, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation: .3. Documentation in the medical record will be objective (not opinionated or speculative) complete, and accurate. 45576 3) Record review of Resident # 26's clinical record documented admission to the facility 1/17/2025 with diagnosis to include type 2 diabetes mellitus. Review of Resident #26's physician order read, Basaglar Kwik-Pen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine). Inject 14 unit subcutaneously at bedtime for Diabetes Mellitus (DM). Review of Resident #26's MAR documented code (5) for insulin for 2/10/2025 at 2100. Chart code (5) = hold/see nurses note. Review of Resident #26's nurses note dated 2/10/2025 22:31 (10:31 PM) read, Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML Inject 14 unit subcutaneously at bedtime for DM sugar too low. During an interview on 2/11/2025 at 10:37 AM, Staff A, LPN, stated, [Resident #26's name] refused her insulin last night. I did not call the doctor and should have. In error I coded a 5 which means medication are held and not given, but I should have coded a 4 which means the resident refused. The resident and her daughter refused. I will make sure that I document correctly in the future. This is a documentation error and I will correct it and make sure I chart appropriately in the future. During an interview on 2/11/2025 at 10:41 AM, the DON stated, It is my expectation if the nurse holds the insulin it is documented why the insulin is not given and the physician is to be notified. This is a documentation error and the insulin should have been documented as refused not held because of parameters. There are no parameters to hold long lasting insulin. If the nurse uses her nurses judgement to hold, she would need to call the physician. Review of the facility policy and procedure titled Documentation of Medication Administration with the last review date of 12/2/2024 read, Policy Statement: A medication administration record is used to document all medications administered .3. f. reason(s) why a mediation was withheld, not administered, or refused (as applicable).

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were properly stored. Findings include: 1) During an observation on 2/10/2025 at 9:30 AM, there was one tube of menthol pain relieving gel lying on the bedside table in Resident #24's room (Photographic evidence obtained). During an interview on 2/10/2025 at 9:30 AM, Resident #24 stated, I use the gel for my shoulder. It really helps. I just rub it on whenever I hurt. Maybe a couple of times a week. During an observation on 2/11/2025 at 9:16 AM, there was one tube of menthol pain relieving gel lying in opened container on the bedside table in Resident #24's room. 2) During an observation on 2/10/2025 at 10:22 AM, there was one bottle of Antifungal powder with Miconazole Nitrate 2% on the bedside table in Resident #59's room. During an interview on 2/10/2025 at 10:23 AM, Resident #59 stated, I use the powder under my breast. During an interview on 2/11/2025 at 1:55 PM, Staff D, Licensed Practical Nurse (LPN), stated, Medication cannot be at the bedside unless a physician has written an order for self-administration and then the medication has to be locked in the bedside table. During an interview on 2/11/2025 at 2:05 PM, the Director of Nursing (DON) stated, All medications must be secured. Medications cannot be at the bedside unsecured. If the resident self-administers their medication, the medication has to be secured in the bedside table in their room and the physician has to place orders for self-administration. 46523 2) During an observation on 2/10/2025 at 9:18 AM, Resident #43 was sitting in his room in a chair. There was one bottle of Latanoprost 0.005% eye drops on top of the bedside table (Photographic evidence obtained). During an interview on 2/10/2025 at 9:18 AM, Resident #43 stated, Someone brought it [eye drops] one night and left it behind. I think it needs to be thrown out. During an interview on 2/13/2025 at 9:10 AM, the Director of Nursing stated, [Resident #43's name] is not able to self-administer medications and medication should not be left unattended in the residents room. Review of the facility policy and procedures titled Medication Labeling and Storage with the last review date of 12/2/2024 showed it read, Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation . 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards of practice for 1 (Resident #265) of 4 residents reviewed for respiratory services. Findings include: During an observation on 2/10/2025 at 9:10 AM, Resident #265 was sitting on left side of the bed dressed in gown. CPAP [Continuous Positive Airway Pressure] nose piece was attached to tubing and was resting on top of the bedside table. During an interview on 2/10/2025 at 9:10 AM, Resident #265 stated, I use the CPAP to breath better at night. During an observation on 2/10/2025 at 9:30 AM, Resident #265 was walking with walker in her room. CPAP nose piece was attached to tubing and was resting on top of the bedside table. During an observation on 2/12/2025 at 8:25 AM, Resident #265's CPAP nose piece was attached to tubing and was resting on top of the bedside table. Review of Resident #265's admission record showed the resident was admitted on [DATE] with diagnoses to include unilateral primary osteoarthritis of left hip, morbid (severe) obesity due to excess calories, sleep apnea, weakness, pain in left knee, type 2 diabetes mellitus without complications, atherosclerotic heart disease of native coronary, personal history of transient ischemic attack (TIA) and cerebral infarction. Review of Resident #265's physician orders on 2/12/2025 at 9:32 AM showed no order for CPAP. During an interview on 2/12/2025 at 10:30 AM, the Director of Nursing (DON) stated, [Resident #265's name] should have an order in place for her to receive CPAP at the facility. Review of the facility policy and procedure titled CPAP/BiPAP [Bilevel Positive Airway Pressure] Support with the last review date of 12/2/2024 showed it read, Purpose: 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease . Preparation . 3. Review the physician's order to determine the oxygen concentration and flow, and the PEEP [Positive End Expiratory Pressure] pressure (CPAP, IPAP [Inspiratory Positive Airway Pressure], and EPAP [Expiratory Positive Airway Pressure] for the machine.

Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for 1 (Resident #26) of 5 residents reviewed for medication administration, and 2 (Resident #265 and Resident #266) of 4 residents reviewed for respiratory services. Findings include: 1) Review of Resident #26's admission record showed the resident was admitted on [DATE] with diagnoses to include atherosclerotic heart disease, cardiac pacemaker, prosthetic heart valve and atrial fibrillation (abnormal heartbeat). Review of Resident #26's physician order dated 1/18/2025 showed it read, Eliquis Oral Tablet 5 mg [milligrams] (Apixaban), Give 1 tablet by mouth two times a day for afib [atrial fibrillation]. Review of Resident #26's Medication Administration Record (MAR) for January and February 2025 showed the resident received Eliquis oral tablet 5 mg (Apixaban) as ordered. Review of Residents #26's care plan did not show a focus area or interventions for anticoagulant medication or a-fib. During an interview on 2/11/2025 at 9:26 AM, the Director of Nursing (DON) stated, [Resident #26's name] was not care-planned for monitoring of anticoagulant complications and the care plans are initiated by MDS [Minimum Data Set] Coordinator on admission. During an interview on 2/12/2025 at 9:21 AM, the MDS Coordinator stated, I do not see a care plan initiated for monitoring for complications of anticoagulants and there should be a care plan completed initially and with the comprehensive care plan. 49777 2) During an observation on 2/10/2025 at 9:10 AM, Resident #265 was sitting on the left side of the bed dressed in gown. CPAP [Continuous Positive Airway Pressure] nose piece was attached to tubing and was resting on top of the bedside table. During an interview on 2/10/2025 at 9:10 AM, Resident #265 stated, I use the CPAP to breath better at night. Review of Resident #265's admission record showed the resident was most recently admitted on [DATE] with diagnoses to include unilateral primary osteoarthritis of left hip, morbid (severe) obesity due to excess calories, sleep apnea, weakness, pain in left knee, type 2 diabetes mellitus without complications, atherosclerotic heart disease of native coronary, personal history of transient ischemic attack (TIA) and cerebral infarction. During an interview on 2/12/2025 at 10:30 AM, the DON stated, I do not see a care plan for respiratory services. The care plan is to be developed within 72 hours from admission and then MDS reviews the care plan. Review of Resident #265's comprehensive care plan on 2/12/2025 at 9:33 AM showed no focus for respiratory services. 3) During an observation on 2/10/2025 at 9:25 AM, there was an inhalation mask inside the drawer of Resident #266's bedside table. During an interview on 2/10/2025 at 9:25 AM, Resident #266 stated, I am here because I had a stroke. I do receive breathing treatments. Review of Resident #266's admission record showed the resident was most recently admitted on [DATE] with diagnoses to include sepsis, pneumonitis (swelling and irritation of lung tissue) due to inhalation of food and vomit, acute respiratory failure, obstructive sleep apnea, and emphysema (damage to air sacs in the lungs). Review of Resident #266's physician order dated 2/6/2025 showed it read, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML [milligrams per 3 milliliters] (Ipratropium-Albuterol) 3 ml [milliliters] inhale orally every 4 hours for shortness of breath. Review of Resident #266's physician order dated 2/7/2025 showed it read, Oxygen 2 lpm [liters per minute] via nasal cannula PRN [as needed], may titrate to maintain SPO2 [oxygen saturation] greater than 90% as needed for Shortness of Breath. Review of Resident #266's comprehensive care plan on 2/12/2025 at 10:00 AM showed no focus for respiratory services. During an interview on 2/12/2025 at 10:30 AM, the DON stated, [Resident #266's name] should have care plan for respiratory services. I do not see a care plan for respiratory services. The care plan is to be developed within 72 hours from admission and then MDS reviews the care plan. Review of the facility policy and procedure titled Care planning- Interdisciplinary Team with the last review date of 12/2/2024 showed it read, Policy Statement. The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation . 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). Review of the facility policy and procedure titled Care Plans, Comprehensive Person-Centered with the last review date of 12/2/2024 showed it read, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission . 7. The comprehensive, person-centered care plan . e. reflects currently recognized standards of practice for problem areas and conditions. Review of the facility policy and procedure titled Resident Assessment Instruments (RAI) with the last review date of 12/2/2024 showed it read, Policy: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's MDS to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by Department of Health and Human Services Center for Medicare and Medicaid Services. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development.

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 1(Resident #20) of 3 residents reviewed for nutrition. Findings include: During an observation on 2/12/2025 at 5:48 AM, Staff I, Licensed Practical Nurse (LPN), entered Resident #20's room and administered medications to Resident #20 via gastric tube. Review of Resident #20's quarterly MDS dated [DATE] showed the resident did not have a feeding tube while a resident in the facility under Section K- Swallowing/Nutritional Status. Review of Resident #20's physician order dated 12/6/2024 showed it read, G-tube [gastric tube] Enteral feedings- Monitor for adverse reactions check residuals with Bolus feedings every shift for Dysphagia. Review of Resident #20's physician order dated 12/6/2024 showed it read, Jevity 1.2 55 ml/hr x 20 hours= 1100 ML [55 milliliters per hour times 20 hours equals 1100 milliliters] total up at 4 pm (afternoon) & down at 12P [PM] or until volume is delivered in the afternoon for daily nutrition. During an interview on 2/12/2025 at 9:44 AM, the MDS Coordinator stated, [Resident #20's name] section K was coded in error. She does have a feeding tube. Review of the facility policy and procedure titled Resident Assessments with the last review date of 12/2/2024 showed it read, Policy Interpretation and Implementation . 6. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments.

Based on observation, interview, and record review, the facility failed to ensure food was safely and properly stored, labeled, or discarded in the areas of the kitchen walk-in cooler, and failed to ensure all areas were cleaned and free of debris. Findings include: A walk-through tour of the kitchen was conducted on 2/10/2025 at 9:12 AM with the Certified Dietary Manager (CDM)/Assistant Dining Manager. An observation was made of several containers of open food condiments [salad dressing, mustard, and sauces] in the reach-in cooler without an open date. An observation was made of numerous trash paper items and debris on the freezer floor and open box flaps exposing food items. An observation was made of a male staff member [Staff F, Dietary Aide] with no hair covering or beard guard. During an interview on 2/10/2025 at 9:28 AM, Staff F, Dietary Aide, confirmed he had not put on a hair net or beard guard when starting his job assignment. During an interview on 2/10/2025 at 9:19 AM, the CDM stated he was unaware of condiment containers in the reach-in cooler needing an open date. The CDM agreed that the freezer floor should be cleaned according to the cleaning schedule and lids should be closed. The CDM confirmed that all staff should be using hair restraints in the kitchen. During an observation on 2/11/2025 at 6:15 AM with the Food Service Director (FSD) for the campus, an observation was made of breakfast food items already placed on the tray line at 6:25 AM. An observation was made of a large buildup of food bits and dried debris on the floor mixer. An observation was made of the two convection ovens with excessive buildup of dirt and debris on the walls, door, and bottom of the ovens. An observation was made of the food/grease trap drawer on the regular stove (range) to have excessive food particles and black burnt on debris. During an interview on 2/11/2025 at 6:30 AM, the FSD confirmed that the cook at 6:15 AM had placed the food on the tray line early and should not be there until 20 minutes prior to tray service at 7:00 AM according to the facility policy. The FSD confirmed that the covered mixer was supposed to be clean before a cover was placed and was not. During an interview on 2/11/2025 at 6:42 AM, the CDM stated it was his expectation that all policies and training were followed whether he was personally in the department or not. The CDM stated that all dietary staff were required to wear hair coverings while working in the department. Review of the facility policy and procedures titled Equipment and Utensil Cleanliness with the last review date of 12/2/2024 read, 4. Deep fat fryers, ovens, slicers, ranges, mixers, and similar equipment cleaned daily. Review of the facility policy and procedure titled Food Storage Areas with the last review date of 12/12/2024 read, 2. Floors should be free of .other debris. 7. Refrigerator and freezer should be cleaned regularly and free from food debris or spillage. Review of the facility policy and procedure titled Oven Cleaning with the last review date of 12/2/2024 read, Standard: The Food & Beverage Department will have a cleaning schedule for all equipment and work areas, to be completed in a timely manner as directed by the Food & Beverage Director. Purpose: Proper cleaning and maintaining ovens in order to comply with sanitation and safety standards and preserve condition. Review of the facility policy and procedure titled Employees-Personal Cleanliness with the last review date of 12/2/2024 read, The Food & Beverage Department will have a comprehensive Sanitation program to prevent the spread of infection and foodborne illness throughout all areas of the operation. 3. All staff will wear hair restraints at all times. Review of the facility policy and procedure titled Perishable Storage with the last review date of 12/2/2024 read, 5. Items such as ketchup, mustard, salad dressings, bottled sauces, etc. are dated when opened and will have a used-by date of two months if kept in the original container.

Based on observation, interview, and record review, the facility failed to ensure central venous catheter dressing was changed in accordance with professional standards of practice for 2 of 2 residents with central venous catheters, Residents #3 and #4. Findings include: 1. Review of Resident #3's admission record showed the resident was admitted to the facility with the diagnoses including unspecified fracture of left forearm, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, arthritis due to other bacteria left elbow, atrial fibrillation, and pneumonia. During an observation on 4/11/2024 at 9:10 AM, Resident #3 was in bed with a right upper extremity peripherally inserted central catheter (PICC) line with a net stocking over the insertion site. The resident rolled down the netting. There was a gauze under a transparent dressing that was covering the insertion site. The transparent dressing was dated 4/1/2024. The dressing was curling up at the edges and the insertion site remained covered. During an interview on 4/11/2024 at 9:12 AM, Resident #3 stated, I'm in here for antibiotics because I have an infection after I broke my arm. It is an MRSA [Methicillin Resistant Staphylococcus Aureus] infection, so I needed a PICC line and antibiotics for a long time, another 6 weeks. They changed this about 10 days ago I guess. Review of Resident #3's physician order dated 3/26/2024 read, Change PICC line dressing q [every] week every day shift every Sat [Saturday] for PICC line. Review of Resident #3's Physician Orders dated 3/26/2024 reads, Monitor PICC line Q shift, inform MD ( Medical Doctor) of any abnormal findings every shift for PICC line. Review of Resident #3's Treatment Administration Record (TAR) for April 2024 showed dressing change on 4/6/2024 by Staff A, Registered Nurse (RN). Review of Resident #3's TAR for April 2024 showed that Staff B, Licensed Practical Nurse (LPN), monitored the PICC line on 4/11/2024 at 9:00 AM. 2. Review of Resident #4's admission record showed the resident was admitted to the facility with the diagnoses including discitis (an infection of the discs between the bones of the spine) in lumbosacral area, low back pain, type 2 diabetes mellitus with diabetic neuropathy unspecified, essential primary hypertension, and chronic obstructive pulmonary disease. During an observation on 4/11/2024 at 11:15 AM, Resident #4 was resting in bed with a left upper arm single lumen PICC line with transparent dressing over a gauze dressing. The transparent dressing was dated 4/6/2024. During an interview on 4/11/2024 at 11:15 AM, Resident #4 stated, Oh, they changed that a few days ago now, maybe a week. I am getting antibiotics every day. I am going to be on antibiotics for about another month. Review of Resident #4's physician order dated 4/5/2024 read, Change PICC dressing and measure external catheter length and document every seven days and PRN [as needed]. Note any complications. Every day shift every Saturday for IV [Intravenous] abt [antibiotic] tx [treatment]. Change PICC dressing and measure external catheter length and document every seven days and PRN. Note any complications. If any discrepancy in length from any previous measure, stop using line and notify provider immediately. Obtain f/u [follow up] instructions. During an interview on 4/11/2024 at 12:07 PM, Staff A, RN, stated, I did observe the PICC lines for [Resident #3 and #4's names] and didn't realize that they had gauze under them. I should have changed it when I saw that. We should only have gauze in the initial dressings. After that, it should be a transparent dressing. We should assess the sites every shift and when we give an IV meds [medications]. During an interview on 4/11/2024 at 12:37, Staff B, LPN, stated, I did administer both patients [Resident #3 and #4's] normal saline flush this morning and I should observe the dressing and the site when I do that. I didn't notice they had the gauze under the transparent dressing. I just didn't realize it. We should assess the insertion site when we administer the medication. I should have looked at the date of the dressing and the insertion site when I gave the normal saline. It is outdated. The dressing was dated 4/1/2024 for [Resident #3's name]. [Resident #4's name] dressing is in date it was done on 4/6, but it does have gauze under it, so it should have been changed on 4/8. During an interview on 4/11/2024 at 1:30 PM, the Director of Nursing stated, I can't say why the staff put gauze under the dressings for the PICC lines. The dressings should have been changed after 2 days because of the gauze under them. It is our policy to do that. Review of the facility policy and procedure titled Central Venous Catheter Dressing Changes read, Policy: Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. General Guidelines . 2. Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (when wet, soiled, or not intact). 3. If gauze is used, it must be changed every 2 days.

Based on record review and interview, the facility failed to ensure the consulting pharmacist reported any irregularities to the attending physician and director of nursing, and these reports were acted upon for 3 of 5 residents reviewed for unnecessary medications (Residents #1, #36 and #59). Findings include: 1. Review of Resident #1's admission record showed the resident was admitted initially on 11/27/2014 and most recently on 10/14/2023 with diagnoses including unstable angina, anxiety disorder, type II diabetes mellitus, dementia, bipolar disorder, and muscle weakness. Review of the consulting pharmacist's recommendations for Resident #1 dated 7/13/2023 showed the recommendation for adding Sitagliptin 100 mg daily for diabetes was accepted by the physician. Review of Resident #1's medical records revealed no record for addition of Sitagliptin 100 mg daily for diabetes. 2. Review of Resident #36's admission record showed the resident was admitted initially on 9/30/2016 and most recently on 3/19/2023 with diagnoses including displaced intertrochanteric fracture of right femur, atherosclerotic heart disease, abdominal aortic aneurysm, spinal stenosis, dementia, psychosis, dysphagia, protein calorie malnutrition, dementia, behavioral disturbance, adult failure to thrive. Review of the consulting pharmacist's recommendations for Resident #36 dated 3/20/23 showed the recommendation for evaluating and considering changing Baclofen 10 mg (milligrams) routinely in the morning and at bedtime to as needed in the morning and at bedtime was accepted by the physician on 4/11/2023. Review of Resident #36's Medication Administration Record (MAR) for October 2023 showed the resident received Baclofen Oral Tablet 10 mg by mouth at bedtime for muscle spasms on 10/1/2023 through 10/23/2023 at 9:00 PM and received Baclofen Oral Tablet 10 mg by mouth in the morning for muscle spasms on 10/1/2023 through 10/23/2023 at 6:00 AM. 3. Review of Resident #59's admission record showed the resident was readmitted on [DATE] with diagnoses including fracture of left femur with onset date of 9/10/2023, peripheral vascular disease, age related osteoporosis, anxiety disorder, cognitive communication deficit, major depressive disorder, unspecified disorder of adult personality and behavior, muscle weakness and difficulty walking. Review of the consulting pharmacist's recommendations for Resident #59 dated 9/11/2023 reads, #2) Falls (F757): Resident has a history of falls. The following medications are commonly linked to falls. Please review and deprescribe to lowest effective regimen. Amlodipine 10 mg, Coreg 6.25 mg, Hydralazine 50 mg, sertraline 100 mg, Tamsulosin 0.4mg. #3. Excessive dose, change order to (F757): Aspirin 325 mg po [by mouth] BID [twice daily]. There is a risk of major bleeding from aspirin increases markedly in older age (sic). Increased risk of GI [gastrointestinal] bleeding or peptic ulcer disease in high-risk groups, including those greater than [AGE] years old or taking oral corticosteroids or antiplatelet agents; use of proton pump inhibitor or misoprostol reduces but does not eliminate risk. Also, it can increase blood pressure and induce kidney injury . Consider a dose reduction. (75-100 mg/ daily). The physician agreed to reduce Aspirin dosage, decrease hydralazine to 25 mg, and added monitor BP (blood pressure) on 9/19/2023. Review of Resident #59's physician orders showed active orders for Aspirin EC (enteric coated) tablet 325 mg delayed release, 1 tablet by mouth two times a day for TIA (Transient Ischemic Attack) prevention with a start date of 9/11/2023 and Hydralazine HCl (Hydrochloride) oral tablet 50 mg, 1 tablet by mouth every 12 hours for HTN (hypertension), Hold for SBP (Systolic Blood Pressure) less than 110 with a start date of 9/10/2023. Review of Resident #59's MAR for October 2023 showed the resident received Aspirin EC tablet delayed release 325 mg at 9:00 AM on 10/1/20123 through 10/24/2023 and at 5:00 PM on 10/1/2023 through 10/23/2024 and received Hydralazine HCl (Hydrochloride) oral tablet 50 mg at 9:00 AM on 10/1/2023 through 10/24/2023 and at 5:00 PM from 10/1/2023 through 10/23/2023. During an interview on 10/25/2023 at 11:30 AM, the Interim Director of Nursing verified that Residents #1, #36 and #59's physician-agreed changes as proposed by the consulting pharmacist had not been put into effect until 10/24/2023. Review of the facility policy and procedure titled Medication Regimen Reviews last reviewed on 1/27/2023 reads, Policy Statement: The consultant pharmacist reviews the medication regimen of each resident at least monthly. Policy Interpretation and Implementation: 1. The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medications . 11. If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator. 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it.

Based on observation, interview, and record review, the facility failed to ensure oxygen was administered as prescribed by the physician for 2 of 4 residents reviewed for oxygen administration (Residents #20 and #64). Findings include: 1. Review of Resident #20's physician order dated 10/9/2023 showed oxygen to be administered at 2 liters per minute via nasal cannula for shortness of breath every shift. During an observation on 10/22/2023 at 9:33 AM, Resident #20 was lying in her bed, with oxygen being administered via nasal cannula at 3.5 liters per minute. During an observation on 10/23/2023 at 8:17 AM, Resident #20 was lying in her bed, with oxygen being administered via nasal cannula at 2.5 liters per minute. During an observation on 10/24/2023 at 8:23 AM accompanied with the Weekend Supervisor Registered Nurse, Resident #20 was being administered oxygen via nasal cannula at 2.5 liters per minute. During an interview on 10/24/2023 at 8:23 AM, the Weekend Supervisor Registered Nurse confirmed Resident #20 was being administered oxygen at 2.5 liters per minute. He stated he was not aware of Resident #20 changing the rate of her oxygen. 2. Review of Resident #64's physician order dated 8/27/2023 showed oxygen to be administered at 2 liters per minute via nasal cannula every shift. During an observation on 10/22/2023 at 10:43 AM, Resident #64 was lying in her bed, with oxygen being administered via nasal cannula at 2.5 liters per minute. During an observation on 10/23/2023 at 8:19 AM, Resident #64 was lying in her bed, with oxygen being administered via nasal cannula at 2.5 liters per minute. During an observation on 10/24/2023 at 8:25 AM accompanied with the Weekend Supervisor Registered Nurse, Resident #64 was being administered oxygen via nasal cannula at 3 liters per minute. During an interview on 10/24/2023 at 8:25 AM, the Weekend Supervisor Registered Nurse confirmed Resident #64 was being administered oxygen at 3 liters per minute. He stated Resident #64 was not able to reach and adjust her oxygen administration level.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for 1 of 3 residents reviewed for communication/sensory services (Resident #23), 1 of 1 resident reviewed for hospice services (Resident #15), 2 of 6 residents reviewed for nutrition (Residents #6 and #21), and 1 of 4 residents reviewed for respiratory care (Resident #35). Findings include: 1. Review of Resident #23's inventory of personal effects downloaded on 7/28/2023 revealed the resident was admitted to the facility with right and left side hearing aids. Review of Resident #23's Admission Medicare 5-Day MDS assessment dated [DATE] showed Section B. Hearing, Speech and Vision, B0300. Hearing Aid had been documented as No to indicate Resident #23 did not use a hearing aid or other hearing appliance. During an interview on 10/24/2023 at 10:34 AM, the MDS Coordinator stated Resident #23's admission 5-day MDS had been coded incorrectly related to use of hearing aids. 40559 2. Review of Resident #15's physician order dated 3/15/2023 reads, [Hospice's name] hospice services DX [diagnosis]: Alzheimer's disease. Order Status: Active. Review of Resident #15's care plan dated 2/27/2023 reads, [Resident #15's name] has a terminal prognosis/end stage condition, Alzheimer's disease. Active with [Hospice's name] as of 2/24/23. Review of Resident #15's MDS assessments for significant change dated 3/2/2023 and quarterly assessments dated 4/10/23 and 7/11/23 showed Section O. Special Treatments, Procedures, and Programs had been documented as No for being on hospice. During an interview on 10/24/2023 at 10:41 AM, the MDS Coordinator verified that the MDS assessments on 3/2/2023, 4/10/2023 and 7/11/2023 were inaccurate due to Resident #15 having been on hospice since February of 2023 and the assessments were checked no for hospice. 46523 3. Review of Resident #6's physician order dated 8/21/2023 reads, Pureed diet. Refer to diet type for texture texture [Sic.], Regular /Thin liquids consistency, Staff to position patient upright in bed during meals; standard aspiration precautions. Order Status: Active. Review of Resident's #6's quarterly MDS dated [DATE] revealed no nutritional approaches identified for the resident under Section K-Swallowing/Nutritional Status. The box for mechanically altered diet was unchecked. During an interview on 10/24/2023 at 10:34 AM, the MDS Coordinator stated, Yes, I see [Resident #6] has orders for a pureed diet. The MDS needs to be corrected. 4. Review of Resident #21's physician order dated 9/8/2023 reads, CCHO [Controlled Carbohydrate] diet. Refer to diet type for texture texture [Sic.], Regular /Thin liquids consistency. Order Status: Active. Review of Resident's #21's Admission/Medicare 5-day MDS dated [DATE] revealed no nutritional approaches identified for the resident under Section K-Swallowing/Nutritional Status. During an interview on 10/24/2023 at 12:42 PM, the MDS Coordinator stated, The diet was coded incorrectly. It needs to be corrected since the resident has an order for CCHO diet. 5. Review of Resident #35's physician order dated 6/22/2023 reads, Oxygen administration 4 LPM [liters per minute] PRN [as needed] for sats [oxygen saturation] below 90% as needed for low oxygen level. Order Status: Active. Review of Resident #35's quarterly MDS dated [DATE] revealed no information for oxygen therapy under Section O- Special Treatments, Procedures, and Programs. Review of Resident #35's Weights and Vitals Summary for September 2023 showed oxygen saturation of 96% (Oxygen via Nasal Cannula) on 9/27/2023 at 5:51 PM, and 93% (Oxygen via Nasal Cannula) on 9/25/2023 at 12:55 AM. During an interview on 10/24/2023 at 10:35 AM, the MDS Coordinator stated, I do see where [Resident #35's name] used oxygen during the look back period. It was not coded accurately. Review of the facility policy and procedures titled Comprehensive Assessments last reviewed on 1/4/2023 reads, Policy Statement: Comprehensive assessments are conducted to assist in developing person-centered care plans. Policy Interpretation and Implementation . 6. Chapter 2 of the Resident Assessment Instrument (RAI) User Manual provides detailed Guidelines for Determining a Significant Change in a Resident's Status.

Based on observation, interview, and record review, the facility failed to ensure residents were free from medical neglect by allowing unqualified agency and/or facility staff to work outside of their scope of practice, administering IV (intravenous) medications via midline catheters for 4 of 4 residents, Residents #2, #56, #138, and #237, without certification of education, training and validation of competency for IV medication infusion to residents who are administered IV medications. 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. Findings include: 1. Review of the medical record for Resident #56 documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation for IV medication administration for Resident #56 on 5/4/2022 at 7:37 AM, Staff E, Licensed Practical Nurse (LPN), stated, The medication is due at 9 AM. I will not be able to administer it until 8 AM. Staff E entered Resident #56's room. The resident had a right double lumen peripherally inserted central catheter (PICC, a thin flexible tube that is inserted into a vein in the upper arm and guided, threaded, into a large vein above the right side of the heart called the superior vena cava, it is used to give intravenous fluids, antibiotics, blood [CONDITION(S)] and other drugs). The PICC line had no needleless connector on the left port, only a green cap and two needleless connectors on the right port of the PICC line. An empty [MEDICATION(S)] 1000 mg bag of antibiotics was connected to the right port of the PICC line. Staff E removed the empty bag of [MEDICATION(S)], did not perform hand hygiene, did not don gloves, did not clean the IV insertion site, and flushed the right port of the PICC line that had two needleless connectors with ten milliliters of normal saline. Staff E did not aspirate to check for line patency (this ensures the line is open and in the correct placement). After exiting Resident #56's room, Staff E was observed speaking to other staff members. During an interview on 5/4/2022 at 7:47 AM, Staff E, LPN, stated, You will have to have another nurse hang the antibiotic. I am not IV certified. I did not take the 30-hour IV course. I cannot administer the medication. I am not certified to take care of the PICC line. I did not clean the hub or check that the line was patent by aspirating before I pushed the normal saline. I didn't think I needed to. I was just doing a flush. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record (MAR) for Resident #56 documented Staff O, LPN, administered IV [MEDICATION(S)] HCL on 3/22/22 at 10:59, on 3/23/22 at 8:31 AM, on 3/24/22 at 10:31 AM, on 3/25/22 at 12:31 PM, on 3/29/22 at 9:34 AM, on 3/30/22 at 9:35 AM, on 3/31/22 at 9:24 AM, on 4/1/22 at 9:16 AM, on 4/2/22 at 9:59 AM, on 4/3/22 at 9:44 AM, 4/3/22 at 9:21 PM, on 4/5/22 at 9:29 AM, 4/6/22 at 9:43 AM, on 4/7/22 at 10:01 AM, 4/8/22 at 9:53 AM, 4/12/22 at 9:49 AM, on 4/13/22 at 9:00 AM, on 4/16/22 at 10:11 AM, on 4/17/22 at 9:39 AM, 4/19/22 at 9:48 AM, on 4/20/22 at 10:14 AM, 4/21/22 at 10:17 AM, and on 4/22/22 at 10:34 AM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV [MEDICATION(S)] HCL solution on 4/3/22 at 5:50 PM, on 4/4/22 at 5:08 AM, 4/12/22 at 5:01 PM, on 4/13/22 at 5:58 AM, and on 5/1/22 at 9:36 PM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV [MEDICATION(S)] HCL solution on 4/12/22 at 9:15 PM, on 5/1/22 at 5:50 PM, and on 5/2/22 at 5:43 AM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV [MEDICATION(S)] HCL solution on 4/6/22 at 6:30 PM, and on 5/3/22 at 9:33 PM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV [MEDICATION(S)] HCL solution on 5/3/22 at 4:40 PM. Review of the MAR for Resident #56 documented Staff A, LPN, administered IV [MEDICATION(S)] HCL solution on 4/6/22 at 9:14 PM. Review of the MAR for Resident #56 documented Staff L, LPN, administration of IV [MEDICATION(S)] HCL solution on 4/18/22 at 10:54 PM, on 4/19/22 at 7:15 AM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV [MEDICATION(S)] HCL solution on 4/20/22 at 6:58 PM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV [MEDICATION(S)] HCL solution on 4/20/22 at 9:21 PM. 2. Review of the medical record for Resident #2 documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Use 50 ml Intravenously every 12 hours for bacteremia [bacteria in the circulating blood] until 5/22/22. Review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for Resident #2 documented Staff F, LPN, administered IV [MEDICATION(S)]-Dextrose on 4/20/22 at 9:00 PM, IV normal saline flush solution 0.9% sodium chloride (NS) on 4/20/22 at 9:35 PM, IV NS flush on 4/29/22 at 6:28 PM, and IV [MEDICATION(S)]-Dextrose solution and IV NS flush on 4/29/22 at 9:45 PM. Review of the MAR for Resident #2 documented Staff I, LPN, administered IV [MEDICATION(S)]-Dextrose solution on 4/21/22 at 9:25 PM, IV NS flush on 4/23/22 at 4:31 PM, and IV NS flush on 4/23/22 at 9:25 PM. Review of the MAR for Resident #2 documented Staff A, LPN, administered IV NS flush on 4/23/22 at 7:44 PM, IV NS flush on 4/24/22 at 10:09 AM, IV [MEDICATION(S)]-Dextrose solution on 4/24/22 at 10:11 AM, and IV NS flush on 4/24/22 at 9:21 PM. Review of the MAR for Resident #2 documented Staff H, LPN, administered IV NS flush on 4/27/22 at 12:46 AM Review of the MAR for Resident #2 documented Staff E, LPN, administered IV NS flush on 4/27/22 at 3:47 PM, IV [MEDICATION(S)]-Dextrose solution and a NS flush on 4/27/22 at 8:58 PM, IV NS flush on 5/3/22 at 3:51 PM, IV [MEDICATION(S)]-Dextrose solution and IV NS flush on 5/3/22 at 9:00 PM, and IV NS flush on 5/4/22 at 11:03 AM. Review of the MAR for Resident #2 documented Staff J, LPN, administered IV NS flush on 4/30/22 at 6:24 PM, IV [MEDICATION(S)]-Dextrose solution and IV NS flush on 4/30/22 at 9:51 PM, and IV NS flush on 5/1/22 at 4:29 AM. Review of the MAR for Resident #2 documented Staff G, LPN, administered IV [MEDICATION(S)]-Dextrose solution and IV NS flush on 5/1/22 at 9:37 PM. 3. Review of the medical record for Resident #138 documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #138's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #138's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for Resident #138 documented Staff F, LPN, administered IV [MEDICATION(S)] on 4/10/22 at 8:00 PM, on 4/11/22 at 8:58 PM, on 4/13/22 at 9:26 PM, on 4/14/22 at 10:03 PM, on 4/22/22 at 9:32 AM, on 4/23/22 at 10:37 PM, on 4/24/22 at 8:53 PM, on 4/25/22 at 8:26 PM, on 4/27/22 at 9:19 PM, and on 4/28/22 at 8:17 PM. Review of the MAR for Resident #138 documented Staff A, LPN, administered IV [MEDICATION(S)] on 4/16/22 at 10:20 AM, on 4/20/22 at 9:06 AM, on 4/20/22 at 9:36 PM, on 4/22/22 at 10:35 AM, on 4/27/22 at 11:13 AM, and on 4/29/22 at 8:23 AM. 4. Review of the medical record for Resident #237 documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Use 75 ml/hr [hour] IV every shift for dehydration for 1 day. IV fluids for 2 liters then stop fluids. Review of the MAR for Resident #237 documented Staff E, LPN, administered IV NS flush on 5/3/22 at 6:20 PM. During an interview on 5/4/2022 at 8:17 AM, the Acting Director of Nursing (DON) stated, I am responsible for all the care delivered in the facility. I spoke to the LPN, [Staff E's name] and he was saying he did an IV course, but it might not be the 30-hour course that he needs. We are checking with the agency and with human resources to determine what is true. I'm not sure who actually takes care of knowing an agency staff qualification if they are an LPN. I will check into this. A request was made for Staff E's 30-hour IV certification documentation. During an interview on 5/4/2022 at 8:25 AM, the Quality Improvement Nurse Manager stated, It is a nursing standard of practice that the LPN must be certified with an IV course to administer IV medications in a central line. I am not responsible for the onboarding of staff and what their certifications and abilities are. I was not aware that there were LPNs who are not certified administering IV medications. We have a registered nurse or IV certified LPN available at all times and they are on call also for off hours. During an interview on 5/4/2022 at 8:30 AM, the Administrator was informed Staff E administered IV NS and Staff E then stated he did not have IV certification. When asked how the facility received information from the agencies related to IV certification, the Administrator stated, I don't know. During an interview on 5/4/2022 at 8:38 AM, the Acting DON stated, He [Staff E] only has 16 hours. A request was made for all IV certifications for all nurses on staff and all agency staff. During an interview on 5/4/2022 at 8:40 AM, the Education Coordinator stated, I am not responsible for maintaining staff competency. I am responsible for onboarding and education of brand-new staff. I work out of HR [Human Resources] and do orientation, Relias training, fire and life safety and HIPPA [Health Insurance Portability and Accountability Act] compliance. I do not deal with maintaining competency of agency staff that is the responsibility of the DON. During an interview on 5/4/2022 at 9:45 AM, Staff A, Agency LPN, stated, I am not IV certified and I would get a staff member who was if I had any to administer. I did administer medications if I signed that I did. If my initials are in the box, I must have administered them. I should not administer any IV medications or flush a PICC, midline or IV. I did administer IV medications to [Resident #138's name] on 4/16, 4/20, 4/22, 4/27 and 4/29. Those are my initials that I administered them. During an interview on 5/4/2022 at 3:20 PM, Staff F, Agency LPN, stated she was not IV certified. She was not aware that she needed to be IV certified in the state of Florida. She stated no one at this facility asked her for IV certification before giving IV medications. She has been administering IVs in the facility, hanging IVs and administering IV pushes. During an interview on 5/5/2022 at 9:02 AM, the Administrator stated the agency provided staff with baseline requirements and IV certification was not one of them. He stated he could not verify if any of the agency staff had IV certifications because that information was not requested. His expectation was that agency staff that were not IV certified should not administer IV medications. The facility posted staff openings on an application called on shift. The agency staff signed up for the shifts they wanted. The posting for the needed shift did not indicate if IV certification was required. Review of the Supplemental Staffing Agreement for Healthcare Professionals entered into August 22, 2021 between [Staffing Agency's name] and Lake Port Square, LLC, read, II. Temporary Placement. b. Candidate Qualifications. Except where prohibited by law, [Staffing Agency's name] will provide Client with qualifications of Candidates as reasonably necessary to establish competency, which may include completed employment application, clinical skills checklist(s), medication competency exam professional references, and verification of license. [Staffing Agency's name] will verify that each Candidate has the minimum experience requested by Client within the area of assignment. Furthermore, [Staffing Agency's name] will maintain compliance documentation on file for each Candidate referred to Client. Client agrees to maintain such compliance documentation in a trustworthy manner in a secure and confidential location and to protect such documentation from any unauthorized disclosure consistent with state and federal law. The required compliance documentation will be specified in writing by Client prior to Candidate's start date (the required documentation). Client may request additional compliance documentation; provided, however, [Staffing Agency's name] shall not be obligated to produce documentation in addition to the Required Documentation. If [Staffing Agency's name] does not produce additional documentation, Client may cancel the order. All Clients request for additional documentation requests must be made in writing. During an interview on 5/5/2022 at 9:05 AM, the Acting Director of Nursing (DON) stated, We use agency staff every day. Each staff from agency that we use should be aware of the need for the IV certification 30-hour course and not administer any medications they are not qualified to administer. There is a nurse on call 24 hours a day, an RN [Registered Nurse], so even if we did not have someone in the building who was certified they could call at any time and we would need to come administer the medication. I expect that our nurses would not sign for something that they have not administered. I would expect the nurses who administered the medication to follow the five rights of administration and would complete their own documentation. I can't give you a good answer as to why this wasn't happening. I was not aware that this wasn't happening. We do not have a specific competency for agency staff. I don't think we would need to post for a specifically IV certified LPN because we have someone available twenty-four hours a day, someone on call in case of emergencies and they should just call me if they have questions. The on-call schedule is posted at each nurse's station and the fulltime staff would always know they can call me. During an interview on 5/5/2022 at 9:23 AM, the Medical Director stated he was made aware of the fact that unqualified LPNs were administering IV medications to the residents in the facility, in which two of the residents [Residents #138 and #237's names] were directly under his care. He stated he received a call from the administrator from the facility on 5/4/2022. He stated he was not aware of the fact that the situation prior to the call/notification on 5/4/2022. During a telephone interview on 5/5/2022 at 2:17 PM, Staff H, LPN, stated, I have completed IV flushes and administered antibiotics when I have worked at [Facility's name]. I wasn't aware that I was not able to administer premixed medications. I thought that I could. I knew that I could not administer anything that needed to be mixed or start an IV, but I did think I could do flushes and hang antibiotics that were already mixed. I never asked anyone to do those for me. I am not IV certified and I haven't changed a PICC line dressing, I can't do that. I didn't know that I was supposed to get an IV certified nurse to give my antibiotics. During an interview on 5/5/2022 at 2:35 PM, the Staffing Coordinator stated, I do the scheduling for the health center. We do not have enough staff to cover all the shifts, so we use agency. I put any open shifts in 'On shift'. I can not specify whether they are IV certified. I can only request a CNA, LPN, or RN positions. I schedule five to six nurses during the day, five to six nurses on the second shift and four for overnight. I do not staff specifically for IV administration of medications due to the fact that we always have an RN on site or one on call. I do not have access to whether they are IV certified or not. If they are agency staff, I cannot see if they are IV certified either. During a telephone interview on 5/5/2022 at 2:35 PM, Staff M, LPN, stated, I did not administer any IV medications. A flush is not a medication. I do not consider a flush to be an IV medication. My initials are on the MAR and that means that I administered the medication. I have not administered any other IV medications. During an interview on 5/5/2022 at 2:45 PM, the Staffing Scheduler was requested to provide the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 2:56 PM, Staff J, LPN, stated, I have not administered IV medication for anyone. On Saturday, I think it was Saturday, I told them I was not IV certified and the nurse said don't worry about it someone else will do it. I just signed it off and I don't know if it was administered but I did not administer it. I did sign the MAR, thinking about this I guess I shouldn't have done that at all. I don't remember what nurse I told that to. During an interview on 5/5/2022 at 2:57 PM, the Staffing Coordinator stated, The facility has two agency contracts, [Staffing Agencies' names]. From these agencies, we get staff that work a permanent shift, for example 40 hours a week, every week. The required documents are documents that are needed for our facility like TB [[CONDITION(S)]], and background checks. IV certification documentation is not one of the required documents. During an interview on 5/5/2022 at 3:05 PM, the Staffing Scheduler entered the conference room. The requested documentation was not provided. A second request was made for the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 3:13 PM, Staff O, LPN, stated, I am not certified to do IV administration of medications. I always get someone else to do my IVs for me. I will get everything ready, get the medication, the tubing, and the flushes. We will go into the room together and they administer the IV medication when I give the other medications. We do those at the same time. We both go into the room at the same time. I didn't realize that I shouldn't sign for the medication unless I actually administer it. I was provided training in my orientation about medication administration. I guess I should have known not to do that, not to sign if I didn't administer it, but I thought it was okay because I saw it being hung. A request was made for names of nurses who hung the medications signed as administered by Staff O. No names were provided. Review of the MARs and nursing progress notes for Resident #56 for the period of 3/22/2022 through 5/1/2022 did not provide documentation for nurses who may have hung and/or provided NS flushes for Resident #56 other than Staff O. During a telephone interview on 5/5/2022 at 5:30 PM, the Medical Doctor (MD) (attending physician for Residents #2 and #56) stated that he was not made aware that unqualified LPNs were administering IV medications to the residents in the facility. He stated, I would have thought the facility would have a system in place to either get their nurses certified or not allow them to give IV medications. That was not too smart of them. I will inform the rest of my staff of the situation so the residents can be assessed for injury. During an interview on 5/6/2022 at 2:10 PM, when discussed the IV 30-hour certifications were not provided for Staff O, LPN, Staff G, LPN, Staff E, LPN, Staff A, LPN, Staff F, LPN, Staff L, LPN, Staff I, LPN, Staff H, LPN, and Staff J, LPN, the DON stated, I do not have IV certifications for any nurses that had not already been provided. Review of the policy and procedure titled. Abuse, Neglect and Exploitation with an approval date of 2/23/2022 read, Abuse, neglect and exploitation is a complex and often hidden problem. Everyone has the responsibility to make a report when abuse, neglect or exploitation is suspected. Neglect: The failure or omission on the part of the caregiver to provide care, supervision, and services necessary to maintain the physical and mental health of a vulnerable adult. The failure of the caregiver to make a reasonable effort to protect a vulnerable adult from abuse neglect and exploitation by others. Review of the policy and procedure titled, Abuse Prevention Program with an approval date of 2/23/2022 read, It is the policy of this community to provide each resident with an environment that is free from verbal, sexual physical and mental abuse, corporal punishment, and involuntary seclusion. We have established policies and procedures that will provide personnel (including consultants, contractors, volunteers, and other caregivers who provide care and services to residents) with the knowledge to further ensure each resident is treated with individual respect and dignity. II. Orientation and Training of Employees: To assist in identification of abuse, the following definitions of abuse are provided during training: a. Abuse is defined as the willful infliction of injury, unreasonable confinement: intimidation: punishment with resulting physical harm, pain or mental anguish; or deprivation by an individual, including a caretaker, of goods and services that are necessary to attain and maintain physical, mental and psychosocial well-being; g. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. III, Preventing Resident Abuse- Establishing a Resident Sensitive Environment: This community desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach including the following: Staff supervision: On a regular basis, supervisors will monitor the ability of the staff to meet the needs of residents, staff understanding of individual resident care needs, and situations such as inappropriate language, incentive handling or impersonal care will be corrected as they occur. Incidents short of willful abuse will be handled through counseling, training, and if necessary or repeated, the community's progressive discipline policy. Review of the policy and procedure titled, Midline Catheter Flushing and Locking with a revision date of July 1, 2012, and an approval date of 2/23/2022 read, 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. Review of the policy and procedure titled, Guidelines for Preventing Intravenous Catheter-Related Infections with a revision date of August 2014, and an approval date of 2/23/2022 read, Purpose: The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters. General Guidelines: 1. Facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy, including: b. proper procedures for the insertion and maintenance of IV catheters; and c. appropriate infection control measures to prevent IV catheter-related infections. Nurse Practice Guidelines to Prevent Catheter-Related Infections: Surveillance: 6. Any time that dressing is not intact or end caps are missing, the catheter has the potential for contamination. Catheter Site Dressing regimens: 1. Change the initial dressing after catheter placement within 24 hours. 4. Change TSM dressings on CVADs every 5-7 days or PRN (as needed) if damp, loosened, or visibly soiled. This does not require a doctor's order. Cleaning Needleless Connection devices: 2. Disinfect the needleless connector prior to each access using alcohol, tincture of iodine, or chlorohexidine [MEDICATION(S)]/alcohol combination. Review of the policy and procedure titled, Administering Medications with an approval date of 2/23/2022 read, Policy statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only licensed persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Review of Florida Administrative Code under 64B9-12.005, Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy, read, (1) Contents. The board endorses the Intravenous Therapy Course Guidelines issued by the Education Department of the National Federation of Licensed Practical Nurses, November, 1983. The intravenous therapy education must contain the following components: (a) Policies and procedures of both the Nurse Practice Act and the employing agency in regard to intravenous therapy. This includes legalities of both the Licensed Practical Nurse role and the administration of safe care. Principles of charting are also included. (b) Psychological preparation and support for the patient receiving IV therapy as well as the appropriate family members/ significant others. (c) Site and function of the peripheral veins used for veinpuncture. (d) Procedure for veinpuncture, including physical and psychological preparation, site selection, skin preparation, palpation of veins, and collection of equipment. (e) Relationship between intravenous therapy and the body's homeostatic and regulatory functions, with attention to the clinical manifestations of fluid and electrolyte imbalance. (f) Signs and symptoms of local and systemic complications in the delivery of fluids and medications and the preventive and treatment measures for these complications. (g) Identification of various types of equipment used in administering intravenous therapy with content related to criteria for use of each and means of troubleshooting for malfunction. (h) Formulas used to calculate fluid and drug administration rate. (i) Methods of administering drugs intravenously and advantages and disadvantages of each. (j) Principles of compatibility and incompatibility of drugs and solutions. (k) Nursing management of the patient receiving drug therapy, including principles of [CONDITION(S)], protocols, actions, and side effects. (l) Nursing management of the patient receiving blood and blood components, following institutional protocol. Include indications and contraindications for use; identification of adverse reactions. (m) Nursing management of the patient receiving [MEDICATION(S)] nutrition, including principles of metabolism, potential complications, and physical and psychological measures to ensure the desired therapeutic effect. (n) Principles of infection control in IV therapy, including aseptic technique and prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (p) Glossary of common terminology pertinent to IV fluid therapy. (q) Performance check list by which to evaluate clinical application of knowledge and skills. (2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C. Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training required in this subsection shall include, at a minimum, didactic and clinical practicum instruction in the following areas: (a) Central venous anatomy and physiology; (b) CVL site assessment; (c) CVL dressing and cap changes; (d) CVL flushing; (e) CVL medication and fluid administration; (f) CVL blood drawing; and (g) CVL com [TRUNCATED]

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 agency and/or facility staff to work outside of their scope of practice, administering IV (intravenous) medications via midline catheters for 4 of 4 residents, Residents #2, #56, #138, and #237, without certification of education, training and validation of competency for IV medication infusion to residents who are administered IV medications. 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. Findings include: 1. Review of the medical record for Resident #56 documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation for IV medication administration for Resident #56 on 5/4/2022 at 7:37 AM, Staff E, Licensed Practical Nurse (LPN), stated, The medication is due at 9 AM. I will not be able to administer it until 8 AM. Staff E entered Resident #56's room. The resident had a right double lumen peripherally inserted central catheter (PICC, a thin flexible tube that is inserted into a vein in the upper arm and guided, threaded, into a large vein above the right side of the heart called the superior vena cava, it is used to give intravenous fluids, antibiotics, blood [CONDITION(S)] and other drugs). The PICC line had no needleless connector on the left port, only a green cap and two needleless connectors on the right port of the PICC line. An empty [MEDICATION(S)] 1000 mg bag of antibiotics was connected to the right port of the PICC line. Staff E removed the empty bag of [MEDICATION(S)], did not perform hand hygiene, did not don gloves, did not clean the IV insertion site, and flushed the right port of the PICC line that had two needleless connectors with ten milliliters of normal saline. Staff E did not aspirate to check for line patency (this ensures the line is open and in the correct placement). After exiting Resident #56's room, Staff E was observed speaking to other staff members. During an interview on 5/4/2022 at 7:47 AM, Staff E, LPN, stated, You will have to have another nurse hang the antibiotic. I am not IV certified. I did not take the 30-hour IV course. I cannot administer the medication. I am not certified to take care of the PICC line. I did not clean the hub or check that the line was patent by aspirating before I pushed the normal saline. I didn't think I needed to. I was just doing a flush. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record (MAR) for Resident #56 documented Staff O, LPN, administered IV [MEDICATION(S)] HCL on 3/22/22 at 10:59, on 3/23/22 at 8:31 AM, on 3/24/22 at 10:31 AM, on 3/25/22 at 12:31 PM, on 3/29/22 at 9:34 AM, on 3/30/22 at 9:35 AM, on 3/31/22 at 9:24 AM, on 4/1/22 at 9:16 AM, on 4/2/22 at 9:59 AM, on 4/3/22 at 9:44 AM, 4/3/22 at 9:21 PM, on 4/5/22 at 9:29 AM, 4/6/22 at 9:43 AM, on 4/7/22 at 10:01 AM, 4/8/22 at 9:53 AM, 4/12/22 at 9:49 AM, on 4/13/22 at 9:00 AM, on 4/16/22 at 10:11 AM, on 4/17/22 at 9:39 AM, 4/19/22 at 9:48 AM, on 4/20/22 at 10:14 AM, 4/21/22 at 10:17 AM, and on 4/22/22 at 10:34 AM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV [MEDICATION(S)] HCL solution on 4/3/22 at 5:50 PM, on 4/4/22 at 5:08 AM, 4/12/22 at 5:01 PM, on 4/13/22 at 5:58 AM, and on 5/1/22 at 9:36 PM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV [MEDICATION(S)] HCL solution on 4/12/22 at 9:15 PM, on 5/1/22 at 5:50 PM, and on 5/2/22 at 5:43 AM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV [MEDICATION(S)] HCL solution on 4/6/22 at 6:30 PM, and on 5/3/22 at 9:33 PM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV [MEDICATION(S)] HCL solution on 5/3/22 at 4:40 PM. Review of the MAR for Resident #56 documented Staff A, LPN, administered IV [MEDICATION(S)] HCL solution on 4/6/22 at 9:14 PM. Review of the MAR for Resident #56 documented Staff L, LPN, administration of IV [MEDICATION(S)] HCL solution on 4/18/22 at 10:54 PM, on 4/19/22 at 7:15 AM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV [MEDICATION(S)] HCL solution on 4/20/22 at 6:58 PM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV [MEDICATION(S)] HCL solution on 4/20/22 at 9:21 PM. 2. Review of the medical record for Resident #2 documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Use 50 ml Intravenously every 12 hours for bacteremia [bacteria in the circulating blood] until 5/22/22. Review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for Resident #2 documented Staff F, LPN, administered IV [MEDICATION(S)]-Dextrose on 4/20/22 at 9:00 PM, IV normal saline flush solution 0.9% sodium chloride (NS) on 4/20/22 at 9:35 PM, IV NS flush on 4/29/22 at 6:28 PM, and IV [MEDICATION(S)]-Dextrose solution and IV NS flush on 4/29/22 at 9:45 PM. Review of the MAR for Resident #2 documented Staff I, LPN, administered IV [MEDICATION(S)]-Dextrose solution on 4/21/22 at 9:25 PM, IV NS flush on 4/23/22 at 4:31 PM, and IV NS flush on 4/23/22 at 9:25 PM. Review of the MAR for Resident #2 documented Staff A, LPN, administered IV NS flush on 4/23/22 at 7:44 PM, IV NS flush on 4/24/22 at 10:09 AM, IV [MEDICATION(S)]-Dextrose solution on 4/24/22 at 10:11 AM, and IV NS flush on 4/24/22 at 9:21 PM. Review of the MAR for Resident #2 documented Staff H, LPN, administered IV NS flush on 4/27/22 at 12:46 AM Review of the MAR for Resident #2 documented Staff E, LPN, administered IV NS flush on 4/27/22 at 3:47 PM, IV [MEDICATION(S)]-Dextrose solution and a NS flush on 4/27/22 at 8:58 PM, IV NS flush on 5/3/22 at 3:51 PM, IV [MEDICATION(S)]-Dextrose solution and IV NS flush on 5/3/22 at 9:00 PM, and IV NS flush on 5/4/22 at 11:03 AM. Review of the MAR for Resident #2 documented Staff J, LPN, administered IV NS flush on 4/30/22 at 6:24 PM, IV [MEDICATION(S)]-Dextrose solution and IV NS flush on 4/30/22 at 9:51 PM, and IV NS flush on 5/1/22 at 4:29 AM. Review of the MAR for Resident #2 documented Staff G, LPN, administered IV [MEDICATION(S)]-Dextrose solution and IV NS flush on 5/1/22 at 9:37 PM. 3. Review of the medical record for Resident #138 documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #138's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #138's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for Resident #138 documented Staff F, LPN, administered IV [MEDICATION(S)] on 4/10/22 at 8:00 PM, on 4/11/22 at 8:58 PM, on 4/13/22 at 9:26 PM, on 4/14/22 at 10:03 PM, on 4/22/22 at 9:32 AM, on 4/23/22 at 10:37 PM, on 4/24/22 at 8:53 PM, on 4/25/22 at 8:26 PM, on 4/27/22 at 9:19 PM, and on 4/28/22 at 8:17 PM. Review of the MAR for Resident #138 documented Staff A, LPN, administered IV [MEDICATION(S)] on 4/16/22 at 10:20 AM, on 4/20/22 at 9:06 AM, on 4/20/22 at 9:36 PM, on 4/22/22 at 10:35 AM, on 4/27/22 at 11:13 AM, and on 4/29/22 at 8:23 AM. 4. Review of the medical record for Resident #237 documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Use 75 ml/hr [hour] IV every shift for dehydration for 1 day. IV fluids for 2 liters then stop fluids. Review of the MAR for Resident #237 documented Staff E, LPN, administered IV NS flush on 5/3/22 at 6:20 PM. During an interview on 5/4/2022 at 8:17 AM, the Acting Director of Nursing (DON) stated, I am responsible for all the care delivered in the facility. I spoke to the LPN, [Staff E's name] and he was saying he did an IV course, but it might not be the 30-hour course that he needs. We are checking with the agency and with human resources to determine what is true. I'm not sure who actually takes care of knowing an agency staff qualification if they are an LPN. I will check into this. A request was made for Staff E's 30-hour IV certification documentation. During an interview on 5/4/2022 at 8:25 AM, the Quality Improvement Nurse Manager stated, It is a nursing standard of practice that the LPN must be certified with an IV course to administer IV medications in a central line. I am not responsible for the onboarding of staff and what their certifications and abilities are. I was not aware that there were LPNs who are not certified administering IV medications. We have a registered nurse or IV certified LPN available at all times and they are on call also for off hours. During an interview on 5/4/2022 at 8:30 AM, the Administrator was informed Staff E administered IV NS and Staff E then stated he did not have IV certification. When asked how the facility received information from the agencies related to IV certification, the Administrator stated, I don't know. During an interview on 5/4/2022 at 8:38 AM, the Acting DON stated, He [Staff E] only has 16 hours. A request was made for all IV certifications for all nurses on staff and all agency staff. During an interview on 5/4/2022 at 8:40 AM, the Education Coordinator stated, I am not responsible for maintaining staff competency. I am responsible for onboarding and education of brand-new staff. I work out of HR [Human Resources] and do orientation, Relias training, fire and life safety and HIPPA [Health Insurance Portability and Accountability Act] compliance. I do not deal with maintaining competency of agency staff that is the responsibility of the DON. During an interview on 5/4/2022 at 9:45 AM, Staff A, Agency LPN, stated, I am not IV certified and I would get a staff member who was if I had any to administer. I did administer medications if I signed that I did. If my initials are in the box, I must have administered them. I should not administer any IV medications or flush a PICC, midline or IV. I did administer IV medications to [Resident #138's name] on 4/16, 4/20, 4/22, 4/27 and 4/29. Those are my initials that I administered them. During an interview on 5/4/2022 at 3:20 PM, Staff F, Agency LPN, stated she was not IV certified. She was not aware that she needed to be IV certified in the state of Florida. She stated no one at this facility asked her for IV certification before giving IV medications. She has been administering IVs in the facility, hanging IVs and administering IV pushes. During an interview on 5/5/2022 at 9:02 AM, the Administrator stated the agency provided staff with baseline requirements and IV certification was not one of them. He stated he could not verify if any of the agency staff had IV certifications because that information was not requested. His expectation was that agency staff that were not IV certified should not administer IV medications. The facility posted staff openings on an application called on shift. The agency staff signed up for the shifts they wanted. The posting for the needed shift did not indicate if IV certification was required. Review of the Supplemental Staffing Agreement for Healthcare Professionals entered into August 22, 2021 between [Staffing Agency's name] and Lake Port Square, LLC, read, II. Temporary Placement. b. Candidate Qualifications. Except where prohibited by law, [Staffing Agency's name] will provide Client with qualifications of Candidates as reasonably necessary to establish competency, which may include completed employment application, clinical skills checklist(s), medication competency exam professional references, and verification of license. [Staffing Agency's name] will verify that each Candidate has the minimum experience requested by Client within the area of assignment. Furthermore, [Staffing Agency's name] will maintain compliance documentation on file for each Candidate referred to Client. Client agrees to maintain such compliance documentation in a trustworthy manner in a secure and confidential location and to protect such documentation from any unauthorized disclosure consistent with state and federal law. The required compliance documentation will be specified in writing by Client prior to Candidate's start date (the required documentation). Client may request additional compliance documentation; provided, however, [Staffing Agency's name] shall not be obligated to produce documentation in addition to the Required Documentation. If [Staffing Agency's name] does not produce additional documentation, Client may cancel the order. All Clients request for additional documentation requests must be made in writing. During an interview on 5/5/2022 at 9:05 AM, the Acting Director of Nursing (DON) stated, We use agency staff every day. Each staff from agency that we use should be aware of the need for the IV certification 30-hour course and not administer any medications they are not qualified to administer. There is a nurse on call 24 hours a day, an RN [Registered Nurse], so even if we did not have someone in the building who was certified they could call at any time and we would need to come administer the medication. I expect that our nurses would not sign for something that they have not administered. I would expect the nurses who administered the medication to follow the five rights of administration and would complete their own documentation. I can't give you a good answer as to why this wasn't happening. I was not aware that this wasn't happening. We do not have a specific competency for agency staff. I don't think we would need to post for a specifically IV certified LPN because we have someone available twenty-four hours a day, someone on call in case of emergencies and they should just call me if they have questions. The on-call schedule is posted at each nurse's station and the fulltime staff would always know they can call me. During an interview on 5/5/2022 at 9:23 AM, the Medical Director stated he was made aware of the fact that unqualified LPNs were administering IV medications to the residents in the facility, in which two of the residents [Residents #138 and #237's names] were directly under his care. He stated he received a call from the administrator from the facility on 5/4/2022. He stated he was not aware of the fact that the situation prior to the call/notification on 5/4/2022. During a telephone interview on 5/5/2022 at 2:17 PM, Staff H, LPN, stated, I have completed IV flushes and administered antibiotics when I have worked at [Facility's name]. I wasn't aware that I was not able to administer premixed medications. I thought that I could. I knew that I could not administer anything that needed to be mixed or start an IV, but I did think I could do flushes and hang antibiotics that were already mixed. I never asked anyone to do those for me. I am not IV certified and I haven't changed a PICC line dressing, I can't do that. I didn't know that I was supposed to get an IV certified nurse to give my antibiotics. During an interview on 5/5/2022 at 2:35 PM, the Staffing Coordinator stated, I do the scheduling for the health center. We do not have enough staff to cover all the shifts, so we use agency. I put any open shifts in 'On shift'. I can not specify whether they are IV certified. I can only request a CNA, LPN, or RN positions. I schedule five to six nurses during the day, five to six nurses on the second shift and four for overnight. I do not staff specifically for IV administration of medications due to the fact that we always have an RN on site or one on call. I do not have access to whether they are IV certified or not. If they are agency staff, I cannot see if they are IV certified either. During a telephone interview on 5/5/2022 at 2:35 PM, Staff M, LPN, stated, I did not administer any IV medications. A flush is not a medication. I do not consider a flush to be an IV medication. My initials are on the MAR and that means that I administered the medication. I have not administered any other IV medications. During an interview on 5/5/2022 at 2:45 PM, the Staffing Scheduler was requested to provide the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 2:56 PM, Staff J, LPN, stated, I have not administered IV medication for anyone. On Saturday, I think it was Saturday, I told them I was not IV certified and the nurse said don't worry about it someone else will do it. I just signed it off and I don't know if it was administered but I did not administer it. I did sign the MAR, thinking about this I guess I shouldn't have done that at all. I don't remember what nurse I told that to. During an interview on 5/5/2022 at 2:57 PM, the Staffing Coordinator stated, The facility has two agency contracts, [Staffing Agencies' names]. From these agencies, we get staff that work a permanent shift, for example 40 hours a week, every week. The required documents are documents that are needed for our facility like TB [[CONDITION(S)]], and background checks. IV certification documentation is not one of the required documents. During an interview on 5/5/2022 at 3:05 PM, the Staffing Scheduler entered the conference room. The requested documentation was not provided. A second request was made for the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 3:13 PM, Staff O, LPN, stated, I am not certified to do IV administration of medications. I always get someone else to do my IVs for me. I will get everything ready, get the medication, the tubing, and the flushes. We will go into the room together and they administer the IV medication when I give the other medications. We do those at the same time. We both go into the room at the same time. I didn't realize that I shouldn't sign for the medication unless I actually administer it. I was provided training in my orientation about medication administration. I guess I should have known not to do that, not to sign if I didn't administer it, but I thought it was okay because I saw it being hung. A request was made for names of nurses who hung the medications signed as administered by Staff O. No names were provided. Review of the MARs and nursing progress notes for Resident #56 for the period of 3/22/2022 through 5/1/2022 did not provide documentation for nurses who may have hung and/or provided NS flushes for Resident #56 other than Staff O. During a telephone interview on 5/5/2022 at 5:30 PM, the Medical Doctor (MD) (attending physician for Residents #2 and #56) stated that he was not made aware that unqualified LPNs were administering IV medications to the residents in the facility. He stated, I would have thought the facility would have a system in place to either get their nurses certified or not allow them to give IV medications. That was not too smart of them. I will inform the rest of my staff of the situation so the residents can be assessed for injury. During an interview on 5/6/2022 at 2:10 PM, when discussed the IV 30-hour certifications were not provided for Staff O, LPN, Staff G, LPN, Staff E, LPN, Staff A, LPN, Staff F, LPN, Staff L, LPN, Staff I, LPN, Staff H, LPN, and Staff J, LPN, the DON stated, I do not have IV certifications for any nurses that had not already been provided. Review of the policy and procedure titled, Midline Catheter Flushing and Locking with a revision date of July 1, 2012, and an approval date of 2/23/2022 read, 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. Review of the policy and procedure titled, Guidelines for Preventing Intravenous Catheter-Related Infections with a revision date of August 2014, and an approval date of 2/23/2022 read, Purpose: The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters. General Guidelines: 1. Facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy, including: b. proper procedures for the insertion and maintenance of IV catheters; and c. appropriate infection control measures to prevent IV catheter-related infections. Nurse Practice Guidelines to Prevent Catheter-Related Infections: Surveillance: 6. Any time that dressing is not intact or end caps are missing, the catheter has the potential for contamination. Catheter Site Dressing regimens: 1. Change the initial dressing after catheter placement within 24 hours. 4. Change TSM dressings on CVADs every 5-7 days or PRN (as needed) if damp, loosened, or visibly soiled. This does not require a doctor's order. Cleaning Needleless Connection devices: 2. Disinfect the needleless connector prior to each access using alcohol, tincture of iodine, or chlorohexidine [MEDICATION(S)]/alcohol combination. Review of the policy and procedure titled, Administering Medications with an approval date of 2/23/2022 read, Policy statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only licensed persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Review of Florida Administrative Code under 64B9-12.005, Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy, read, (1) Contents. The board endorses the Intravenous Therapy Course Guidelines issued by the Education Department of the National Federation of Licensed Practical Nurses, November, 1983. The intravenous therapy education must contain the following components: (a) Policies and procedures of both the Nurse Practice Act and the employing agency in regard to intravenous therapy. This includes legalities of both the Licensed Practical Nurse role and the administration of safe care. Principles of charting are also included. (b) Psychological preparation and support for the patient receiving IV therapy as well as the appropriate family members/ significant others. (c) Site and function of the peripheral veins used for veinpuncture. (d) Procedure for veinpuncture, including physical and psychological preparation, site selection, skin preparation, palpation of veins, and collection of equipment. (e) Relationship between intravenous therapy and the body's homeostatic and regulatory functions, with attention to the clinical manifestations of fluid and electrolyte imbalance. (f) Signs and symptoms of local and systemic complications in the delivery of fluids and medications and the preventive and treatment measures for these complications. (g) Identification of various types of equipment used in administering intravenous therapy with content related to criteria for use of each and means of troubleshooting for malfunction. (h) Formulas used to calculate fluid and drug administration rate. (i) Methods of administering drugs intravenously and advantages and disadvantages of each. (j) Principles of compatibility and incompatibility of drugs and solutions. (k) Nursing management of the patient receiving drug therapy, including principles of [CONDITION(S)], protocols, actions, and side effects. (l) Nursing management of the patient receiving blood and blood components, following institutional protocol. Include indications and contraindications for use; identification of adverse reactions. (m) Nursing management of the patient receiving [MEDICATION(S)] nutrition, including principles of metabolism, potential complications, and physical and psychological measures to ensure the desired therapeutic effect. (n) Principles of infection control in IV therapy, including aseptic technique and prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (p) Glossary of common terminology pertinent to IV fluid therapy. (q) Performance check list by which to evaluate clinical application of knowledge and skills. (2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C. Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training required in this subsection shall include, at a minimum, didactic and clinical practicum instruction in the following areas: (a) Central venous anatomy and physiology; (b) CVL site assessment; (c) CVL dressing and cap changes; (d) CVL flushing; (e) CVL medication and fluid administration; (f) CVL blood drawing; and (g) CVL complications and remedial measures. Upon completion of the intravenous therapy training via central lines, the Licensed Practical Nurse shall be assessed on both theoretical knowledge and practice, as well as clinical practice and competence. The clinical practice assessment must be witnesses by a Registered Nurse who shall file a proficiency statement regarding the Licensed Practical Nurse's ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurse's personnel file. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death as evidenced by review of Abuse and Neglect training provided by the Education Coordinator completed on 5/4/2022; review of Abuse and Neglect training provided by the Administrator completed on 5/4/2022 to include all leadership staff; review of daily audits dated 5/4/2022, 5/5/2022 and 5/6/2022 on current IV residents; review of the on-call schedule for May 2022 documenting an RN scheduled on call for each day of May; review of the posted list of the approved IV certified agency nurses posted at both nursing stations; review of the Ad Hoc Quality Assurance Meeting dated 5/4/2022 to discuss LPN staff qualifications to administer IV medications; interviews conducted on 5/6/2022 PM with six agency LPNs and three facility LPNs, five facility registered nurses who verified the provided training related to IV certification requirement to administer IV medications, and abuse and neglect; interviews with the Administrator, the Acting DON, the MDS Nurse, and the Quality Improvement Nurse Manager on 5/6/2022, who verified receiving training on scope of practice of LPNs, IV certifications, and abuse and neglect.

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 agency and/or facility staff to work outside of their scope of practice, administering IV (intravenous) medications via midline catheters for 4 of 4 residents, Residents #2, #56, #138, and #237, without certification of education, training and validation of competency for IV medication infusion to residents who are administered IV medications. 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. Findings include: Review of the job description for the Administrator (effective date August 3, 2021) read, General summary/major function: The administrator is responsible for assisting the Chief Administrative Officer/Executive Director in the overall administration of the Community. S/he supervises the operation of the service departments as directed by the Executive Director, with primary emphasis on the health center. Essential duties and responsibilities: Supervise assigned department directors, attend and participate in department director meetings Monitor in-service education for employees, oversee/conduct in-service education for employees. Review of the job description for the Director of Clinical Services (Director of Nursing) (effective date 02/2020) read, The Director of Clinical Services is responsible for the overall supervision, provision, and quality of nursing care in the Health center and residential apartments. He/She is responsible for the selection, training, discipline, and supervision for all nursing related Health center personnel. Principle Duties: Essential job duties . 7. Develops and participates in a new staff orientation program for his/her employees, including private duty and agency staff. Review of the job description for the Quality Improvement Nurse (effective date 02/2020) read, General Summary: Monitors and manages the quality measures and indicators of the community through planning, developing, directing and evaluating educational and clinical training programs. Evaluates and develops policies for the community's risk management systems in accordance with regulations to protect residents, staff and facility from loss. Principle duties: 2, documents and reviews medication and treatment sheets for accuracy and compliance with physician orders, professional standards, federal and state regulations and company policies. 5. Directs and coordinates all in-service educational programs of the facility in accordance with regulations. Develops, maintains and directs orientation programs for skilled nursing personnel. 1. Review of the medical record for Resident #56 documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 5/4/2022 at 7:37 AM, when the surveyor requested Staff E, Licensed Practical Nurse (LPN), to observe IV medications administration for Resident #56, Staff E stated, The medication is due at 9 AM. I will not be able to administer it until 8 AM. Staff E entered Resident #56's room. The resident had a right double lumen peripherally inserted central catheter (PICC, a thin flexible tube that is inserted into a vein in the upper arm and guided, threaded, into a large vein above the right side of the heart called the superior vena cava, it is used to give intravenous fluids, antibiotics, blood [CONDITION(S)] and other drugs). The PICC line had no needleless connector on the left port, only a green cap and two needleless connectors on the right port of the PICC line. An empty [MEDICATION(S)] 1000 mg bag of antibiotics was connected to the right port of the PICC line. Staff E removed the empty bag of [MEDICATION(S)], did not perform hand hygiene, did not don gloves, did not clean the IV insertion site, and flushed the right port of the PICC line that had two needleless connectors with ten milliliters of normal saline. Staff E did not aspirate to check for line patency (this ensures the line is open and in the correct placement). After exiting Resident #56's room, Staff E was observed speaking to other staff members. During an interview on 5/4/2022 at 7:47 AM, Staff E, LPN, stated, You will have to have another nurse hang the antibiotic. I am not IV certified. I did not take the 30-hour IV course. I cannot administer the medication. I am not certified to take care of the PICC line. I did not clean the hub or check that the line was patent by aspirating before I pushed the normal saline. I didn't think I needed to. I was just doing a flush. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record (MAR) for Resident #56 documented Staff O, LPN, administered IV [MEDICATION(S)] HCL on 3/22/22 at 10:59, on 3/23/22 at 8:31 AM, on 3/24/22 at 10:31 AM, on 3/25/22 at 12:31 PM, on 3/29/22 at 9:34 AM, on 3/30/22 at 9:35 AM, on 3/31/22 at 9:24 AM, on 4/1/22 at 9:16 AM, on 4/2/22 at 9:59 AM, on 4/3/22 at 9:44 AM, 4/3/22 at 9:21 PM, on 4/5/22 at 9:29 AM, 4/6/22 at 9:43 AM, on 4/7/22 at 10:01 AM, 4/8/22 at 9:53 AM, 4/12/22 at 9:49 AM, on 4/13/22 at 9:00 AM, on 4/16/22 at 10:11 AM, on 4/17/22 at 9:39 AM, 4/19/22 at 9:48 AM, on 4/20/22 at 10:14 AM, 4/21/22 at 10:17 AM, and on 4/22/22 at 10:34 AM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV [MEDICATION(S)] HCL solution on 4/3/22 at 5:50 PM, on 4/4/22 at 5:08 AM, 4/12/22 at 5:01 PM, on 4/13/22 at 5:58 AM, and on 5/1/22 at 9:36 PM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV [MEDICATION(S)] HCL solution on 4/12/22 at 9:15 PM, on 5/1/22 at 5:50 PM, and on 5/2/22 at 5:43 AM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV [MEDICATION(S)] HCL solution on 4/6/22 at 6:30 PM, and on 5/3/22 at 9:33 PM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV [MEDICATION(S)] HCL solution on 5/3/22 at 4:40 PM. Review of the MAR for Resident #56 documented Staff A, LPN, administered IV [MEDICATION(S)] HCL solution on 4/6/22 at 9:14 PM. Review of the MAR for Resident #56 documented Staff L, LPN, administration of IV [MEDICATION(S)] HCL solution on 4/18/22 at 10:54 PM, on 4/19/22 at 7:15 AM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV [MEDICATION(S)] HCL solution on 4/20/22 at 6:58 PM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV [MEDICATION(S)] HCL solution on 4/20/22 at 9:21 PM. 2. Review of the medical record for Resident #2 documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Use 50 ml Intravenously every 12 hours for bacteremia [bacteria in the circulating blood] until 5/22/22. Review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for Resident #2 documented Staff F, LPN, administered IV [MEDICATION(S)]-Dextrose on 4/20/22 at 9:00 PM, IV normal saline flush solution 0.9% sodium chloride (NS) on 4/20/22 at 9:35 PM, IV NS flush on 4/29/22 at 6:28 PM, and IV [MEDICATION(S)]-Dextrose solution and IV NS flush on 4/29/22 at 9:45 PM. Review of the MAR for Resident #2 documented Staff I, LPN, administered IV [MEDICATION(S)]-Dextrose solution on 4/21/22 at 9:25 PM, IV NS flush on 4/23/22 at 4:31 PM, and IV NS flush on 4/23/22 at 9:25 PM. Review of the MAR for Resident #2 documented Staff A, LPN, administered IV NS flush on 4/23/22 at 7:44 PM, IV NS flush on 4/24/22 at 10:09 AM, IV [MEDICATION(S)]-Dextrose solution on 4/24/22 at 10:11 AM, and IV NS flush on 4/24/22 at 9:21 PM. Review of the MAR for Resident #2 documented Staff H, LPN, administered IV NS flush on 4/27/22 at 12:46 AM Review of the MAR for Resident #2 documented Staff E, LPN, administered IV NS flush on 4/27/22 at 3:47 PM, IV [MEDICATION(S)]-Dextrose solution and a NS flush on 4/27/22 at 8:58 PM, IV NS flush on 5/3/22 at 3:51 PM, IV [MEDICATION(S)]-Dextrose solution and IV NS flush on 5/3/22 at 9:00 PM, and IV NS flush on 5/4/22 at 11:03 AM. Review of the MAR for Resident #2 documented Staff J, LPN, administered IV NS flush on 4/30/22 at 6:24 PM, IV [MEDICATION(S)]-Dextrose solution and IV NS flush on 4/30/22 at 9:51 PM, and IV NS flush on 5/1/22 at 4:29 AM. Review of the MAR for Resident #2 documented Staff G, LPN, administered IV [MEDICATION(S)]-Dextrose solution and IV NS flush on 5/1/22 at 9:37 PM. 3. Review of the medical record for Resident #138 documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #138's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #138's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for Resident #138 documented Staff F, LPN, administered IV [MEDICATION(S)] on 4/10/22 at 8:00 PM, on 4/11/22 at 8:58 PM, on 4/13/22 at 9:26 PM, on 4/14/22 at 10:03 PM, on 4/22/22 at 9:32 AM, on 4/23/22 at 10:37 PM, on 4/24/22 at 8:53 PM, on 4/25/22 at 8:26 PM, on 4/27/22 at 9:19 PM, and on 4/28/22 at 8:17 PM. Review of the MAR for Resident #138 documented Staff A, LPN, administered IV [MEDICATION(S)] on 4/16/22 at 10:20 AM, on 4/20/22 at 9:06 AM, on 4/20/22 at 9:36 PM, on 4/22/22 at 10:35 AM, on 4/27/22 at 11:13 AM, and on 4/29/22 at 8:23 AM. 4. Review of the medical record for Resident #237 documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Use 75 ml/hr [hour] IV every shift for dehydration for 1 day. IV fluids for 2 liters then stop fluids. Review of the MAR for Resident #237 documented Staff E, LPN, administered IV NS flush on 5/3/22 at 6:20 PM. During an interview on 5/4/2022 at 8:17 AM, the Acting Director of Nursing (DON) stated, I am responsible for all the care delivered in the facility. I spoke to the LPN, [Staff E's name] and he was saying he did an IV course, but it might not be the 30-hour course that he needs. We are checking with the agency and with human resources to determine what is true. I'm not sure who actually takes care of knowing an agency staff qualification if they are an LPN. I will check into this. A request was made for Staff E's 30-hour IV certification documentation. During an interview on 5/4/2022 at 8:25 AM, the Quality Improvement Nurse Manager stated, It is a nursing standard of practice that the LPN must be certified with an IV course to administer IV medications in a central line. I am not responsible for the onboarding of staff and what their certifications and abilities are. I was not aware that there were LPNs who are not certified administering IV medications. We have a registered nurse or IV certified LPN available at all times and they are on call also for off hours. During an interview on 5/4/2022 at 8:30 AM, the Administrator was informed Staff E administered IV NS and Staff E then stated he did not have IV certification. When asked how the facility received information from the agencies related to IV certification, the Administrator stated, I don't know. During an interview on 5/4/2022 at 8:38 AM, the Acting DON stated, He [Staff E] only has 16 hours. A request was made for all IV certifications for all nurses on staff and all agency staff. During an interview on 5/4/2022 at 8:40 AM, the Education Coordinator stated, I am not responsible for maintaining staff competency. I am responsible for onboarding and education of brand-new staff. I work out of HR [Human Resources] and do orientation, Relias training, fire and life safety and HIPPA [Health Insurance Portability and Accountability Act] compliance. I do not deal with maintaining competency of agency staff that is the responsibility of the DON. During an interview on 5/4/2022 at 9:45 AM, Staff A, Agency LPN, stated, I am not IV certified and I would get a staff member who was if I had any to administer. I did administer medications if I signed that I did. If my initials are in the box, I must have administered them. I should not administer any IV medications or flush a PICC, midline or IV. I did administer IV medications to [Resident #138's name] on 4/16, 4/20, 4/22, 4/27 and 4/29. Those are my initials that I administered them. During an interview on 5/4/2022 at 3:20 PM, Staff F, Agency LPN, stated she was not IV certified. She was not aware that she needed to be IV certified in the state of Florida. She stated no one at this facility asked her for IV certification before giving IV medications. She has been administering IVs in the facility, hanging IVs and administering IV pushes. During an interview on 5/5/2022 at 9:02 AM, the Administrator stated the agency provided staff with baseline requirements and IV certification was not one of them. He stated he could not verify if any of the agency staff had IV certifications because that information was not requested. His expectation was that agency staff that were not IV certified should not administer IV medications. The facility posted staff openings on an application called on shift. The agency staff signed up for the shifts they wanted. The posting for the needed shift did not indicate if IV certification was required. Review of the Supplemental Staffing Agreement for Healthcare Professionals entered into August 22, 2021 between [Staffing Agency's name] and Lake Port Square, LLC, read, II. Temporary Placement. b. Candidate Qualifications. Except where prohibited by law, [Staffing Agency's name] will provide Client with qualifications of Candidates as reasonably necessary to establish competency, which may include completed employment application, clinical skills checklist(s), medication competency exam professional references, and verification of license. [Staffing Agency's name] will verify that each Candidate has the minimum experience requested by Client within the area of assignment. Furthermore, [Staffing Agency's name] will maintain compliance documentation on file for each Candidate referred to Client. Client agrees to maintain such compliance documentation in a trustworthy manner in a secure and confidential location and to protect such documentation from any unauthorized disclosure consistent with state and federal law. The required compliance documentation will be specified in writing by Client prior to Candidate's start date (the required documentation). Client may request additional compliance documentation; provided, however, [Staffing Agency's name] shall not be obligated to produce documentation in addition to the Required Documentation. If [Staffing Agency's name] does not produce additional documentation, Client may cancel the order. All Clients request for additional documentation requests must be made in writing. During an interview on 5/5/2022 at 9:05 AM, the Acting Director of Nursing (DON) stated, We use agency staff every day. Each staff from agency that we use should be aware of the need for the IV certification 30-hour course and not administer any medications they are not qualified to administer. There is a nurse on call 24 hours a day, an RN [Registered Nurse], so even if we did not have someone in the building who was certified they could call at any time and we would need to come administer the medication. I expect that our nurses would not sign for something that they have not administered. I would expect the nurses who administered the medication to follow the five rights of administration and would complete their own documentation. I can't give you a good answer as to why this wasn't happening. I was not aware that this wasn't happening. We do not have a specific competency for agency staff. I don't think we would need to post for a specifically IV certified LPN because we have someone available twenty-four hours a day, someone on call in case of emergencies and they should just call me if they have questions. The on-call schedule is posted at each nurse's station and the fulltime staff would always know they can call me. During an interview on 5/5/2022 at 9:23 AM, the Medical Director stated he was made aware of the fact that unqualified LPNs were administering IV medications to the residents in the facility, in which two of the residents [Residents #138 and #237's names] were directly under his care. He stated he received a call from the administrator from the facility on 5/4/2022. He stated he was not aware of the fact that the situation prior to the call/notification on 5/4/2022. During a telephone interview on 5/5/2022 at 2:17 PM, Staff H, LPN, stated, I have completed IV flushes and administered antibiotics when I have worked at [Facility's name]. I wasn't aware that I was not able to administer premixed medications. I thought that I could. I knew that I could not administer anything that needed to be mixed or start an IV, but I did think I could do flushes and hang antibiotics that were already mixed. I never asked anyone to do those for me. I am not IV certified and I haven't changed a PICC line dressing, I can't do that. I didn't know that I was supposed to get an IV certified nurse to give my antibiotics. During an interview on 5/5/2022 at 2:35 PM, the Staffing Coordinator stated, I do the scheduling for the health center. We do not have enough staff to cover all the shifts, so we use agency. I put any open shifts in 'On shift'. I can not specify whether they are IV certified. I can only request a CNA, LPN, or RN positions. I schedule five to six nurses during the day, five to six nurses on the second shift and four for overnight. I do not staff specifically for IV administration of medications due to the fact that we always have an RN on site or one on call. I do not have access to whether they are IV certified or not. If they are agency staff, I cannot see if they are IV certified either. During a telephone interview on 5/5/2022 at 2:35 PM, Staff M, LPN, stated, I did not administer any IV medications. A flush is not a medication. I do not consider a flush to be an IV medication. My initials are on the MAR and that means that I administered the medication. I have not administered any other IV medications. During an interview on 5/5/2022 at 2:45 PM, the Staffing Scheduler was requested to provide the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 2:56 PM, Staff J, LPN, stated, I have not administered IV medication for anyone. On Saturday, I think it was Saturday, I told them I was not IV certified and the nurse said don't worry about it someone else will do it. I just signed it off and I don't know if it was administered but I did not administer it. I did sign the MAR, thinking about this I guess I shouldn't have done that at all. I don't remember what nurse I told that to. During an interview on 5/5/2022 at 2:57 PM, the Staffing Coordinator stated, The facility has two agency contracts, [Staffing Agencies' names]. From these agencies, we get staff that work a permanent shift, for example 40 hours a week, every week. The required documents are documents that are needed for our facility like TB [[CONDITION(S)]], and background checks. IV certification documentation is not one of the required documents. During an interview on 5/5/2022 at 3:05 PM, the Staffing Scheduler entered the conference room. The requested documentation was not provided. A second request was made for the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 3:13 PM, Staff O, LPN, stated, I am not certified to do IV administration of medications. I always get someone else to do my IVs for me. I will get everything ready, get the medication, the tubing, and the flushes. We will go into the room together and they administer the IV medication when I give the other medications. We do those at the same time. We both go into the room at the same time. I didn't realize that I shouldn't sign for the medication unless I actually administer it. I was provided training in my orientation about medication administration. I guess I should have known not to do that, not to sign if I didn't administer it, but I thought it was okay because I saw it being hung. A request was made for names of nurses who hung the medications signed as administered by Staff O. No names were provided. Review of the MARs and nursing progress notes for Resident #56 for the period of 3/22/2022 through 5/1/2022 did not provide documentation for nurses who may have hung and/or provided NS flushes for Resident #56 other than Staff O. During a telephone interview on 5/5/2022 at 5:30 PM, the Medical Doctor (MD) (attending physician for Residents #2 and #56) stated that he was not made aware that unqualified LPNs were administering IV medications to the residents in the facility. He stated, I would have thought the facility would have a system in place to either get their nurses certified or not allow them to give IV medications. That was not too smart of them. I will inform the rest of my staff of the situation so the residents can be assessed for injury. During an interview on 5/6/2022 at 2:10 PM, when discussed the IV 30-hour certifications were not provided for Staff O, LPN, Staff G, LPN, Staff E, LPN, Staff A, LPN, Staff F, LPN, Staff L, LPN, Staff I, LPN, Staff H, LPN, and Staff J, LPN, the DON stated, I do not have IV certifications for any nurses that had not already been provided. Review of the policy and procedure titled, Midline Catheter Flushing and Locking with a revision date of July 1, 2012, and an approval date of 2/23/2022 read, 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. Review of the policy and procedure titled, Guidelines for Preventing Intravenous Catheter-Related Infections with a revision date of August 2014, and an approval date of 2/23/2022 read, Purpose: The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters. General Guidelines: 1. Facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy, including: b. proper procedures for the insertion and maintenance of IV catheters; and c. appropriate infection control measures to prevent IV catheter-related infections. Nurse Practice Guidelines to Prevent Catheter-Related Infections: Surveillance: 6. Any time that dressing is not intact or end caps are missing, the catheter has the potential for contamination. Catheter Site Dressing regimens: 1. Change the initial dressing after catheter placement within 24 hours. 4. Change TSM dressings on CVADs every 5-7 days or PRN (as needed) if damp, loosened, or visibly soiled. This does not require a doctor's order. Cleaning Needleless Connection devices: 2. Disinfect the needleless connector prior to each access using alcohol, tincture of iodine, or chlorohexidine [MEDICATION(S)]/alcohol combination. Review of the policy and procedure titled, Administering Medications with an approval date of 2/23/2022 read, Policy statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only licensed persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Review of Florida Administrative Code under 64B9-12.005, Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy, read, (1) Contents. The board endorses the Intravenous Therapy Course Guidelines issued by the Education Department of the National Federation of Licensed Practical Nurses, November, 1983. The intravenous therapy education must contain the following components: (a) Policies and procedures of both the Nurse Practice Act and the employing agency in regard to intravenous therapy. This includes legalities of both the Licensed Practical Nurse role and the administration of safe care. Principles of charting are also included. (b) Psychological preparation and support for the patient receiving IV therapy as well as the appropriate family members/ significant others. (c) Site and function of the peripheral veins used for veinpuncture. (d) Procedure for veinpuncture, including physical and psychological preparation, site selection, skin preparation, palpation of veins, and collection of equipment. (e) Relationship between intravenous therapy and the body's homeostatic and regulatory functions, with attention to the clinical manifestations of fluid and electrolyte imbalance. (f) Signs and symptoms of local and systemic complications in the delivery of fluids and medications and the preventive and treatment measures for these complications. (g) Identification of various types of equipment used in administering intravenous therapy with content related to criteria for use of each and means of troubleshooting for malfunction. (h) Formulas used to calculate fluid and drug administration rate. (i) Methods of administering drugs intravenously and advantages and disadvantages of each. (j) Principles of compatibility and incompatibility of drugs and solutions. (k) Nursing management of the patient receiving drug therapy, including principles of [CONDITION(S)], protocols, actions, and side effects. (l) Nursing management of the patient receiving blood and blood components, following institutional protocol. Include indications and contraindications for use; identification of adverse reactions. (m) Nursing management of the patient receiving [MEDICATION(S)] nutrition, including principles of metabolism, potential complications, and physical and psychological measures to ensure the desired therapeutic effect. (n) Principles of infection control in IV therapy, including aseptic technique and prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (p) Glossary of common terminology pertinent to IV fluid therapy. (q) Performance check list by which to evaluate clinical application of knowledge and skills. (2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C. Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training required in this subsection shall include, at a minimum, didactic and clinical practicum instruction in the following areas: (a) Central venous anatomy and physiology; (b) CVL site assessment; (c) CVL dressing and cap changes; (d) CVL flushing; (e) CVL medication and fluid administration; (f) CVL blood drawing; and (g) CVL complications and remedial measures. Upon completion of the intravenous therapy training via central lines, the Licensed Practical Nurse shall be assessed on both theoretical knowledge and practice, as well as clinical practice and competence. The clinical practice assess [TRUNCATED]