**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident #8's medical record revealed an admission date of 1/21/2022, with diagnoses that included syncope and collapse, stiffness of the right shoulder, metabolic encephalopathy, difficulty walking, major depressive disorder, vascular dementia, anxiety disorders, and history of fall. A review of the Resident #8's admission MDS assessment dated [DATE] revealed a BIMS score of 10 out of a possible 15 points, indicating moderate cognitive impairment. Resident required supervision for bed mobility, transfer, and toileting. Resident had a history of fall in the last month prior to admission. During an initial tour of Resident #8's room on 3/28/2022 at 12:00 p.m., a broom, mop and area rug were observed near in the bathroom. (Photographic evidence obtained) On 3/28/2022 at 12:10 p.m., an interview was conducted with Resident #8. She stated the area rug was on the bathroom floor because the floor was very slippery during showers. She explained that she was not supervised and didn't want to fall. A review of the resident's care plan revealed a focus area for falls related to weakness, psychotropic medication use, impaired cognition, diagnoses osteoporosis, dementia, and depression. Interventions included keep environment safe, place call bell within easy reach, and assist for toileting and transfer as needed. On 3/30/2022 at 9:43 a.m., Resident #8 was observed in the bathroom unsupervised using a curling iron near the sink. During the observation, Resident #8 stated, she was getting ready for bible study and had to do her hair. When asked if she was allowed to use the curling iron. She stated, Staff have seen it and they have not said anything. On 3/30/2022 at 11:10 a.m., a tour of Resident #8's room was conducted with the DON. Upon entering the resident's bathroom, the DON, shook her head and stated, Wow. She confirmed that the rug, broom and mop should not be in the resident's bathroom. When asked if the resident had an assessment to use of the curling iron. She stated the resident was independent with ADLs per therapy assessment and therefore she could use the curling iron. When asked for the facility's policy, she stated that there was no policy on accidents. On 3/31/2022 at 10:45 a.m., another tour of Resident #8's room was conducted with Employee A, Licensed Practical Nurse (LPN). The resident was lying in bed. A visit to the bathroom revealed the area rug was still in the bathroom. (Photographic evidence obtained). When the resident was asked if she still had her curling iron, she replied, Yes, it's in my dresser. She went onto explain that she used it weekly. When she was informed of the hazard, she replied, The staff see me use it and no one has ever said anything. She once again confirmed that she took her showers independently and therefore needed the area rugs. During the observation, Employee A, LPN stated, she was not aware Resident #8 had a curling iron or area rug. She acknowledged that the items were a hazard and due to resident's comorbidities, she should be supervised while using them. Employee A, LPN stated that she would talk to the family to have the items removed. A review of the occupational therapy (OT) evaluation dated 3/3/2022 revealed the following: Resident #8 was referred to skilled occupational therapy from nursing due to right shoulder pain. Resident has pain that interferes /limits functional activity. Resident was discharged from occupation therapy due to meeting maximum potential. The discharge assistance revealed morning and evening assistance from caregiver. During an interview with Employee C, Occupational Therapist on 3/31/2022 at 10:53 a.m., she stated that the OT evaluation dated 3/3/2022 did not include the use of area rugs or curling iron. She explained that the evaluation assessed the resident's dependence with ADLs. She further explained that the nursing staff should supervise the resident during care and the rug was a fall hazard. . Based on record reviews, observations, and interviews, the facility failed to 1) ensure each resident received adequate supervision to prevent accidents, failed to implement appropriate interventions, and failed to monitor the effectiveness of interventions to prevent falls for one (Resident #4) of three residents reviewed for accidents and hazards, and 2) failed to provide an environment free of hazards for one resident (Resident #8) in a total sample of 19 residents. The findings include: 1) A review of Resident #4's medical record revealed an admission date of 7/6/2021, with a primary diagnosis of cerebral infarction. The secondary diagnoses included dementia and fracture of the right wrist and hand. A review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15 points, indicating moderate cognitive impairment. Resident #4 required supervision with most activities of daily living (ADLs). She was continent of bowel and bladder and had a history of falls in the facility. On 3/28/2022 at 11:45 a.m., Resident #4 was observed lying in bed with her eyes closed. A splinting device was observed to her right forearm and wrist. On 3/31/2022 at 9:58 a.m., an interview was conducted with Resident #4 in her room. She was sitting in her wheelchair. She was alert and oriented to person and was a poor historian. She was wearing a splinting device to the right wrist. She was not wearing her glasses. Resident #4 was initially unable to recall whether she had fallen in the facility. However, when asked about the splinting device on her right wrist, Resident #4 stated, Well, I fell and broke it. Resident #4 was unable to expand on the circumstances of the fall. When asked if she was able to move her fingers, Resident #4 stated, They are so stiff. The whole hand is stiff. The resident's call light was observed clipped to the left side of her bed. When asked what the call light button was for, the resident stated, Oh, it's a night light. When asked how she called for staff assistance, the resident stated she did not know. Resident #4 was unable to recall whether facility staff had spoken to her about her fall risk factors and interventions. During the interview, an observation of the room was made. There was no bedside commode or reaching device observed in the resident's room. A review of the nursing progress notes revealed an entry date 2/11/2022 at 8:35 a.m. which indicated Resident #4 had sustained a recent fall. The nurse noted Resident #4's right wrist was swollen purple and hard to move. The nurse described Resident #4 as guarding her right wrist and indicated Resident #4 was unable to hold cup of water for morning medications. Resident #4 requested pain medication for pain which she rated an 8/10. The Nurse Practitioner was notified, and an x-ray of the right wrist was ordered. (Photographic evidence obtained) An x-ray of Resident #4's right wrist was reviewed which identified an acute, mildly displaced, impacted transverse distal radial fracture. (Photographic evidence obtained) A provider progress notes by the Nurse Practitioner dated 2/11/2022 indicated the fall occurred on 2/10/2022 at approximately 7 p.m. in the resident's room. She was sitting in her wheelchair and toppled out using her right arm to break the fall. An x-ray was ordered by the Nurse Practitioner which revealed an acute, mild displaced, impacted transverse distal radial fracture. The Nurse Practitioner ordered an orthopedic consult Monday morning. (Photographic evidence obtained) A nursing progress note dated 2/11/2022 at 5:59 p.m. indicated the results of the x-ray were shared with Resident #4's daughter and that the daughter was made aware that the resident did not want to be transferred to the emergency room. (Photographic evidence obtained) A nursing progress note dated 2/12/2022 at 1:16 a.m. indicated the resident was up throughout the night and was non-compliant with assistive devices. The note indicated that a sling was in place, but the resident continued to use her right hand. Resident #4's right wrist and hand presented with significant swelling and bruising, and the resident complained of 10/10 pain. The note did not indicate that supervision was increased to limit worsening of the injury. (Photographic evidence obtained) A nursing progress note dated 2/13/2022 at 1:08 a.m. indicated Resident #4's daughter came to visit and insisted that the resident be sent to the emergency room for evaluation of the right wrist. The resident returned from the hospital with a splint on right wrist to just below right elbow. The resident was ordered to follow up with orthopedics at a previously scheduled appointment. (Photographic evidence obtained) A therapy Discharge summary dated [DATE] indicated discharge recommendations for resident to use a wheelchair for mobility and therapy to assess the resident at a new facility. The note read, Pt [patient] initially was making progress towards goals however patient had fall midway through assessment period and fractured right wrist. POC [plan of care] transitioned to training patient on functional mobility without use of R UE [right upper extremity] which has made tasks more challenging. Pt also experienced increased dementia symptoms and agitation further complicating recent progress. POC had transitioned to mobility training without use of UE [upper extremity] however therapist notified patient will be transferring to another LTC [long term care] facility for increased supervision. (Photographic evidence obtained) On 3/31/2022 at 1:35 p.m., an interview was conducted with the Physical Therapist. He was asked whether any therapy services had been provided for Resident #4 after her wrist fracture. He explained that the resident was planning to be discharged from therapy anyway because of her advancing dementia. She didn't seem like she was making much progress. When asked to clarify whether the resident would benefit from therapy services related to the wrist fracture, he stated, We were waiting for the splint to come off. On 3/31/2022 at 1:41 p.m., an interview was conducted with Occupational Therapist. She explained that Resident #4's ability to follow directions was about 25%. She stated, We have repeatedly educated the resident for some sort of carryover. It's difficult to redirect her. She doesn't believe she has deficiencies. She has very poor safety awareness. A review of an orthopedic consult dated 3/15/2022 indicated recommendations for a wrist brace at all times, Occupational Therapy and Physical Therapy for fingers range of motion, weight-bearing as tolerated to right hand with brace on and follow up in three weeks. (Photographic evidence obtained) Further review of Resident #4's medical record revealed approximately 19 other falls. A nursing progress note dated 7/7/2021 at 1:38 p.m. indicated Resident #4 was found on the bathroom floor with her brief off and stool on the ground. Resident #4 reported that she had to go and forgot how to press the call light. Resident #4 reported hitting the back side of her head. The nurse had the resident practice using the call light to ensure she knew how to use it. Resident #4 voiced that she might forget but will use the call light if she needs help. (Photographic evidence obtained) During an interview with the Director of Nursing (DON) on 3/31/2022 at 11:25 a.m., she explained that the cause of the fall was tiredness, and that the resident's dementia medication was changed from day shift to night shift. A nursing progress note dated 7/8/2021 at 1:25 a.m. indicated Resident #4 was observed on floor in her bathroom during care rounds. Resident #4 stated, I had to go to the bathroom. She had taken off her brief and used her rollator (a walking frame that has wheels on the bottom) to ambulate to the restroom. The nurse educated the resident on the use of her call light. Review of the comprehensive care plan revealed an intervention dated 7/8/2021 to place a bedside commode in the resident's room. (Photographic evidence obtained) On 3/31/2022 at 11:00 a.m., an observation of Resident #4's room was conducted with the Director of Nursing. She confirmed that there was no bedside commode in the room. During an interview with the DON on 3/31/2022 at 11:25 a.m., she stated she was not sure of the cause of the fall but confirmed that a bedside commode should have been placed in the resident's room. During observations of Resident #4's room on 3/28/2022 at 11:35 a.m., 3/29/2022 at 12:45 p.m., 3/30/2022 at 5:20 p.m., and 3/31/2022 at 9:58 a.m., a bedside commode was not noted in the resident's room or restroom. A nursing progress note dated 7/10/2021 at 4:01 a.m. indicated Resident #4 was on the floor in her bathroom. The resident stated she just had to go to the bathroom. Resident #4 stated she sat on the ground given her gown was under her feet. Resident #4 was provided with non-skid socks and a shorter robe. The note indicated the resident was and is continually advised to use her call light for assistance for ambulation. A review of the comprehensive care plan revealed an intervention dated 7/10/2021 which directed staff to encourage proper footwear. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., she was asked whether the facility had considered establishing a bowel and bladder pattern for Resident #4 and proactively assisting her to the restroom to avoid unassisted trips to the restroom. The DON stated she was unsure and would look into it. A nursing progress note dated 7/27/2021 at 5:39 p.m. indicated Resident #4 was trying to push her room door closed and fell to the floor. The note indicated the fall was witnessed by staff. The physician was notified, and the resident was transferred to the hospital for evaluation. A review of the comprehensive care plan revealed an intervention dated 7/28/2021 which directed staff to remind the resident to call for assistance. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., the DON explained she was not sure of the cause of the fall and confirmed that the intervention was to remind the resident to call for assistance with transfers. A nursing progress note dated 7/31/2021 at 1:41 p.m. indicated Resident #4 was standing in the doorway and tripped over her feet and fell. The note indicated the fall was witnessed. A review of the comprehensive care plan revealed no updated interventions for this fall. (Photographic evidence obtained) During interview with the DON on 3/31/2022 at 11:25 a.m., she explained that the resident was provided with her grandpad which she explained was an electronic tablet. The DON was unsure of what the resident was doing at the time of the fall or how the facility determined this intervention was suitable for Resident #4. A nursing progress note dated 8/14/2021 at 6:27 p.m. indicated Resident #4 was noted on the floor between the bed and air conditioning unit. The resident stated she was trying to get up to go vomit and felt dizzy and slid off the bed. The note indicated neuro checks were initiated but the resident refused after having two sets of vital signs assessed. Review of the comprehensive care plans revealed an intervention dated 8/14/2021 which directed staff to obtain orthostatic blood pressures for three days. (Photographic evidence obtained) Review of the medical record revealed no documented orthostatic blood pressures. During interview with the DON on 3/31/2022 at 11:25 a.m., the DON explained that the cause of the fall was likely hypotension and confirmed that orthostatic blood pressures were to be obtained and documented. She was not able to locate the orthostatic blood pressures in the medical record. A nursing progress note dated 9/27/2021 at 7:48 a.m. indicated Resident #4 was observed kneeling on the side of the bed closest to the window. The resident stated she rolled out of bed. The note indicated neurological checks were initiated and a new order was obtained to monitor for skin and mental status changes over the next 72 hours. A review of the comprehensive care plan revealed no updated interventions for this fall. (Photographic evidence obtained) During interview with the DON on 3/31/2022 at 11:25 a.m., the DON explained that the Nurse Practitioner had been notified of the fall and ordered a cardiology consult. She added that cardiology recommended a [NAME] Monitor and stated the procedure had been completed. She was unable to locate the [NAME] Monitor findings in the medical record and stated she would look for them. The facility was unable to produce the findings of the [NAME] Monitor as of the time of survey exit. On 4/5/2022 at 12:26 p.m., email correspondence was received from the facility Administrator which read, I just wanted to follow up with you in regard to the [NAME] monitor. The resident at the time of the order was Covid positive, which at that time cardiology did not find was necessary to complete the [NAME] monitor due to causing inaccuracy. Review of a provider progress note by the Nurse Practitioner dated 9/28/2021 indicated the resident was seen after report of a fall. The assessment and plan indicated gait instability with a plan to continue working with therapy for spatial awareness and strength training. A second diagnosis was noted for tachycardia with a plan to consult in-house cardiology. (Photographic evidence obtained) A nursing progress note dated 10/16/2021 at 4:45 p.m. indicated Resident #4 fell to the ground on her right side hitting the right area of her head above her eye. The resident indicated she was feeling pain in her right hip. An order was obtained to transfer the resident to the hospital. Review of the comprehensive care plan revealed an intervention dated 10/16/2021 which directed staff to remind resident to use her walker. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., she explained that the cause of the fall was the resident's impulsiveness, and that staff reminded the resident to use her walker for ambulation. A nursing progress note dated 10/17/2021 at 4:23 a.m. indicated Resident #4 returned from the hospital with a diagnosis of facial and hip contusion. (Photographic evidence obtained) A nursing progress note dated 10/23/2021 at 10:14 p.m. indicated Resident #4 was found sitting in her bathroom on the floor. The resident stated she lost her balance while trying to get to the toilet. A skin tear was observed to the left knee. A review of the comprehensive care plans revealed an intervention dated 10/23/2021 which directed staff to draw labs. (Photographic evidence obtained) Review of the medical record revealed no lab results from 10/23/2021. During an interview with the Director of Nursing (DON) on 3/31/2022 at 11:25 a.m., the DON confirmed that the fall response intervention was to obtain labs. She explained that the labs had been drawn and that she would need to look for them. When asked whether the facility had increased supervision or implemented any other immediate safety interventions as a response to this fall, the DON again stated, We ordered labs. The facility had not been able to produce the lab results as of the time of survey exit on 3/31/2022. On 3/31/2022 at 9:21 p.m., email correspondence was received from the Administrator which contained an attachment of Resident #4's lab results. There were no labs results for 10/23/2022. A nursing progress note dated 11/20/2021 at 4:17 a.m. indicated Resident #4 was observed sliding off the bed down to the floor and onto her buttocks. Her walker was noted to be in front of the bed. The resident was assisted to toilet and then was assisted back to bed where she was then resting comfortably. A review of the comprehensive care plan revealed no updated interventions related to this fall. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., she explained that the intervention for the fall was to adjust the Resident's thyroid medication and provide melatonin for sleep. Review of the physician orders revealed the medications were adjusted on 11/15/2021 and 11/29/2021. A nursing progress note dated 11/25/2021 at 6:01 a.m. indicated Resident #4 sustained an unwitnessed fall with head injury. The resident was observed lying on the floor next to the bed with a significant amount of blood noted at right side of head. The resident was transferred to the hospital for evaluation and treatment. A nursing progress note dated 11/30/2021 5:56 p.m. indicated the resident was readmitted to the facility with a diagnosis of pneumonia. A review of the comprehensive care plan revealed no updated interventions related to this fall. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., she confirmed that no new safety interventions had been implemented. A nursing progress note dated 12/11/2021 at 5:13 a.m. indicated Resident #4 was noted lying on the floor with a skin tear to the right brow which presented with significant bleeding. The resident was transferred to the emergency room for evaluation and treatment. She was placed on continuous supervision until transfer. A review of the comprehensive care plan revealed an intervention dated 12/11/2021 which directed staff to reiterate the importance of using a walker to ambulate. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., she confirmed that no immediate safety interventions had been implemented. A nursing progress note dated 1/15/2022 at 2:57 a.m. indicated Resident #4 was observed sitting on the floor in the bathroom in front of the shower chair. The resident stated she lost her balance. A review of the comprehensive care plan revealed no updated interventions for this fall. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., she confirmed that there were no new safety interventions implemented on the resident's care plan. She stated, The nurse provided education on safety measures and educated staff to remind the resident to use her walker. A nursing progress note dated 1/26/2022 at 5:11 a.m. indicated Resident #4 alerted nursing staff by calling out. She was observed in seated position on the floor in doorway to room with the door closed. Her walker was near her bedside and was out of reach of the resident. A round raised area was noted to right side of the resident's head with purple discoloration. Resident #4 stated she was leaning forward to get something and lost her balance. Resident #4 requested to go to the hospital for evaluation and treatment. A review of the comprehensive care plan revealed an intervention dated 1/26/2022 which directed staff to provide with reacher. During observations of Resident #4's room on 3/28/2022 at 11:35 a.m., 3/29/2022 at 12:45 p.m., 3/30/2022 at 5:20 p.m., and 3/31/2022 at 9:58 a.m., a reaching device was not observed in Resident #4's room, restroom, or closet. During an interview with the DON on 3/31/2022 at 11:25 a.m., the DON confirmed that the intervention the facility implemented was to provide the resident with a reaching device. A nursing progress note dated 1/27/2022 at 2:26 a.m. indicated that at approximately 1:20 a.m., the nurse heard a thud and observed resident on the floor in the doorway of her room. She was not using her walker. The resident stated she hit her left knee. The knee was noted to have immediate signs of swelling and bruising. Frequent gentle reminders provided. Staff continues to make frequent rounds. A review of the comprehensive care plan revealed an intervention dated 1/27/2022 which directed staff to consult psychiatry for insomnia but did not reflect any immediate safety interventions. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., the DON confirmed that the facility recommended a psychiatry referral but did not implement any immediate safety interventions. A nursing progress note dated 2/1/2022 at 1:23 a.m. indicated that Resident #4 was heard calling for help. The resident was observed lying face down with walker in front of her. Resident #4 was advised to reapply nonskid socks back to feet and she refused. Discoloration was noted to the left side of the resident's forehead. A review of the comprehensive care plan revealed an intervention dated 2/1/2022 which read, educated family on importance of having rollator and asked to return it to facility. There were no immediate safety interventions noted. (Photographic evidence obtained) A nursing progress note dated 2/10/2022 at 3:27 p.m. read, Resident discussed in risk meeting, continues to be on fall protocol, resident has an unsteady gait, has behaviors of aggressions and yelling out, resident is able to be redirected. Family aware of resident's behavior. Resident reminded to use her walker. On 3/30/2022 at 1:10 p.m., an interview was conducted with the Director of Nursing (DON). She described Resident #4 as impulsive with fluctuating levels of cognitive impairment. The DON confirmed that Resident #4 had sustained a fall resulting in a fracture of her right wrist. When asked for evidence of investigations for each fall, the DON explained that the facility had initiated a performance improvement project for the management of falls on or around 2/18/2022. She stated, there probably isn't much information before that, I just recently took over being the Risk Manager. According to the Agency for Healthcare Research and Quality (AHRQ) (Accessed on 3/30/2022 at 2:30 p.m.), an immediate response should help to reduce fall risk until more comprehensive care planning occurs. Therefore, an immediate intervention should be put in place by the nurse during the same shift that the fall occurred. When investigation of the fall circumstances is thorough, it is usually clear what immediate action is necessary. For example, if the resident falls on the way to the bathroom because of urgency and poor balance, interventions related to toileting and staff assistance would be appropriate.

Based on observation, record review, staff interviews, and facility policy and procedure, the facility failed to ensure a peripherally inserted central catheter (PICC) used for the administration of intravenous fluids was maintained in accordance with professional standards of practice, failed to develop a comprehensive person-centered care plan regarding the use of intravenous (IV) antibiotic, and failed to obtain physician's order for a PICC line for one (Resident #48) of one resident receiving intravenous antibiotic, from a total sample of 19 residents. The findings include: A review of Resident #48's medical record revealed an admission date of 3/9/2022, with a primary diagnosis (dx) of cellulitis (a serious bacterial infection of the skin) of the right lower limb. The secondary diagnoses included lymphedema, cellulitis of the left lower limb, cellulitis of other sites, and need for assistance with personal care. A review of the physician's order dated 3/9/2022 revealed, Piperacillin - tazobactam recon solution 3.375-gram, 50 ml intravenous [DX: Cellulitis of other sites] every 6 hours; 05:00, 11:00, 17:00, 23:00 with end date of 3/24/2022. A second physician's order revealed May d/c PICC (peripherally inserted central catheter line) [Dx: Cellulitis of right lover limb] on 3/29/2022. (Copies obtained) A review of the resident's care plan with start date of 3/21/2022 revealed a problem category of Health Related Complications. Resident #48 has a Peripherally Inserted Midline. Approaches included check site every 8 hours for signs and symptoms of inflammation/infection, dressing changes as ordered, ensure site is lean and protected with sterile dressing, label infusion lines with dates of renewal, and observe for signs of bleeding at site entry. The care plan did not include any documentation concerning orders for the IV-line initiation or maintenance. (Copies obtained) During a tour of the facility on 3/28/2022 at 11:28 AM, Resident #48 was observed in his room lying in the bed. There was an empty IV bag hanging on the pump at the bedside. An observation of the resident's IV site dressing was dated 3/8/2022. The site area was soiled with blood and the insertion site was not visible. (Photographic evidence obtained) An interview was conducted with Employee A, Licensed Practical Nurse (LPN) on 3/31/2022 at 1:40 PM. When asked about the facility's policy regarding IV line changes. She stated, she was not sure but the IV dressing should be changed at least every 72 hours. An interview was conducted with Employee B, Registered Nurse (RN)/Infection Control Specialist (ICS) on 3/31/2022 at 1:40 PM. When asked about the facility's policy regarding IV line changes. She stated, she was not sure what the facility's protocol was for the IV-line dressing. She explained that she did not do the antibiotic stewardship but that the IV dressing change should be conducted every 72 hours and as needed. During an interview with the Director of Nursing (DON) on 3/31/2022 at 2:25 PM, she stated that she was training the ICS on antibiotic stewardship as she was new to the role. She explained that residents admitted with antibiotic orders or have new antibiotic orders are reviewed during the next day's clinical meeting to ensure the antibiotics had a diagnosis and stop date. She was asked how often the PICC line dressing was supposed to be changed, she said, Every 7 days. She confirmed that Resident #48 did not have a physician order for PICC line insertion and the resident's IV dressing had not been changed from 3/8/22 to 3/28/22. She stated that an in-service for nurses was initiated. A review of the facility's Vascular Access Devices and Infusion Therapy Procedures and Dressing Change for Vascular Access Devices with effective date of 08/21, included the following: Purpose: To prevent local and systemic related to the IV catheter. Policy: 1. Short peripheral catheter dressing are changed every 7 days or when the integrity of the dressing is compromised. Change the dressing if moisture, draining, or blood is present of for further assessment if infection is suspected. 2, Central venous devices and midline dressing changes will be done at established intervals and immediately if the integrity of the dressing is compromised, if moisture, drainage, or blood is present, or for further assessment of infection is suspected. 4. Initial dressings after catheter placement will be changed PRN if saturated, and 24-48 hours post insertion of midlines, PICCs, or other central venous access devices if gauze is present under the dressing and/or there is blood/drainage under the dressing. Initial dressing with BioPatch at the site may be left in place for 7 days unless the Biopatch is saturated, or the dressing is otherwise compromised. 18. Suggested charting included: site assessment, prep used, type of dressing, Catheter securement (integrity of sutures, other devices), and resident response to procedure. (Copy obtained) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure all professional staff was licensed in accordance with applicable State laws for one (Employee A) of ten employee records reviewed. The employee was listed on the employee roster and working as a licensed practical nurse (LPN), the employee's license status was listed as application in process. This practice has the potential to affect all 50 residents present in the facility at the time of the survey. The findings include: Record review of the list of staff with position and hire dates documented Employee A was listed as an LPN and the date of hire was [DATE]. Review of the Florida Department of Health license verification website https://mqainternet.doh.state.fl.us/MQASearchServices/HealthCareProviders revealed Employee A's LPN license was null and void and expired on [DATE]. (Copy obtained) Review of the Agency for Health Care Administration (AHCA) background screening form on [DATE] revealed Employee A's hire date was [DATE] and her current LPN license stated was listed as APPLICATION IN PROCESS. Employee A's previous LPN license revealed an original date of [DATE], with an expiration date of [DATE]. Her license status read, NULL AND VOID. During an interview with the Administrator on [DATE] at approximately 3:30 PM, she stated that a licensure check was completed for Employee A, and she had a valid license in Ohio. She explained that Employee A was hired as a Patient Care Attendant (PCA) and then moved into the LPN position once her application for licensure was submitted. At that time, the Administrator, and the Director of Nursing (DON) were told that the licensure application had not been approved by the State of Florida. Therefore, Employee A was not currently licensed as an LPN in the State of Florida. A review of timesheets provided by the Staffing Coordinator, revealed Employee A started working in the facility as an LPN on [DATE]. During an interview with Employee A on [DATE] at 4:38 PM, she stated, she had previously lived in Florida and had a valid license in Florida. When she moved to Ohio, she did not renew her license in Florida. She returned to Florida in August of 2021 and applied for her nursing license in September of 2021. She messed up the application by selecting the wrong option. She received an e-mail that told her that there was an issue with her application. She had applied for a multi-state license but did not fill in the information for multi-state. She explained that she intended to apply for just the Florida license, but the paperwork was on her desk at home, and it had not been submitted yet. When asked what her duties included, Employee A replied, I do medication administration, answer call lights, and provide patient care. .