**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to weigh, assess and monitor a resident with significant weight loss. This failure resulted in R137 losing 21 lbs. (pounds) in 14 days without being re-weighed or assessed. The facility also failed to provide physician ordered supplements for a resident (R118) with a history of significant weight loss. These failures apply to 2 of 7 residents (R137 & R118) reviewed for weight loss in the sample of 30. The findings include: 1. R137's face sheet lists her diagnoses to include: senile degeneration of brain, dementia, unspecified psychosis, major depressive disorder, cognitive communication deficit and hallucinations. R137's face sheet also shows she was admitted to the facility on [DATE]. She weighed 145.6 lbs. R137's initial admission dietary evaluation dated July 31, 2024 shows, [AGE] year old female admitted from the hospital with a dx (diagnosis) of psychosis. Past medical hx (history) includes dementia, depression, hyperlipidemia. Diet: regular with thin liquids. Appetite appears fair with intake of ~50-75% of meals since admission. Current BMI (body mass index) is 22.5 which reflects weight within normal range for height, but low for age. Reviewed meds. No current labs to review. No skin breakdown noted. Visited with patient in the room during breakfast. Observed feeding herself with a good appetite. Patient was confused stating Hi Ma, will you be here all day? Patient was unable to answer any interview questions. Spoke with the POA (Power of Attorney) who reports patient's height to be 5'7 1/2 and states patient used to be ~190.6# (lbs) x ~4-5 months ago- unable to specifically quantify. POA states patient was eating well at home and did receive [NAME] (meals on wheels) for lunch, however continued to lose weight despite eating well. Obtained preferences and left meal tickets and alternative menu to fill out. Per POA, patient prefers cold cereal at breakfast, likes cheeseburgers, chicken and fish and loves anything chocolate. MNA (mini nutritional assessment) score is 12 which is normal nutritional status. Goals: PO (by mouth) intake >/=75%, weight maintenance. Patient appears well nourished at this time but will monitor weight trend and intake d/t (due to) reported wt (weight) loss. R137's progress notes dated August 4, 2024 shows, The patient refused to eat. She's always saying that I don't want to eat, I don't like the food. Spoke with POA she said that a family member will come by today to bring her burger which likes to eat. R137's electronic medical record (EMR) shows no re-weight from admission. R137's order details dated August 5, 2024 shows, mirtazapine tablet was ordered for increase appetite. R137's EMR continues to shows no re-weight from admission. R137's nutrition- amount eaten sheet shows the following percentages of food eaten: 8/3/24- 0-25% for all 3 meals, 8/4/24- 51-75% for all 3 meals, 8/5/24 & 8/6/24- 26-50% for breakfast and lunch, 51-75% for dinner, 8/7/24- 0-25% for breakfast and lunch and refused dinner, 8/8/24- 26-50% for breakfast, 51-75% for lunch and dinner, 8/9/24- 0-25% for all 3 meals and 8/10/24- breakfast refused and 26-50% for lunch. R137's weights show, she was not weighed again until August 13, 2024 (14 days later). She weighed 124.5 lbs (21 lb loss). R137's EMR and progress notes show, she was not seen by the dietitian after her initial assessment until August 20, 2024 (7 days later). Reported that resident continues to have varies to mainly poor p.o. (by mouth) intake with meals despite of assist and encourage. Diet was downgraded to Mechanical Soft on 8/19 and to Puree on 8/20 (started for Lunch) d/t (due to) continues poor intake. Per nursing provided Puree for lunch today and ate 100% of the meal with ice cream. Nursing notified MD and families regarding p.o. intake, current wt with wt loss and diet changes. Current wt is 126.6# as of 8/20 which showed 5# or 3.7% loss from last week's wt of 131.6# 8/15. Initial wt of 145.6# on 7/30 and 124.6# on 8/13 were both questionable, resident was re-weighed on 8/15-131.6#. With current wt BMI is 19.5 which remains normal status but at the low-end side. Per wound nurse today, resident has unstageable to coccyx area as of 8/19. Per nursing resident tolerates supplements well. Will recommend increasing to 120ml (milliliters) QID (four times a day) and to provide (fortified shake) which will provide 960kcal (kilocalories) and 40g (grams) of protein if all consumed. Added ice cream with lunch and dinner, super cereal at breakfast. Interventions should help with the healing process and maintain or have wt (weight) gain. Will make Rd (Registered Dietitian) aware. Will continue to monitor wt, labs and intake. On November 19, 2024 at 1:24 PM, V14 (Dietitian) stated, she asked for a re-weigh when R137 was admitted because she didn't believe she weighed 145 lbs. She did not get re-weighed until August 13, 2024. She only saw her on July 31, 2024 and August 20, 2024. New admits should have weekly weights for 4 weeks to make sure the initial weight are correct and monitor for any fluctuations. R137's care plan initiated on July 31, 2024 shows, Nutrition-Dementia focused. R137 is at risk for compromised nutritional status, related to diagnosis of Alzheimer's disease or related dementia . 2. On November 17 & 18th, 2024 both at the noon meals, R118 was not provided a magic cup. R118's dietary evaluation dated October 24, 2024 shows, Resident is seen for significant weight loss of 10.5% x 6 months. Current weight is 129.8# which is down from 145# x 6 months ago. Resident continues under hospice care w/a dx (with a diagnosis) of senile degeneration of the brain. Continues on Pureed with thin liquids, pudding at breakfast, magic cup at lunch and dinner. R118's physician orders shows, Regular diet, Puree texture, Thin liquids consistency. Magic cup with lunch and dinner, pudding at breakfast and whole milk with meals. No Straws. On November 19, 2024 at 1:24 PM, V14 (Dietitian) stated, R118 has had some weight loss. One of the interventions added was a magic cup at lunch and dinner. If he doesn't receive his magic cup, he could lose more weight. R118's care plan initiated on September 10, 2024 shows, Focus: Unintended weight loss/gain: R118 has the following conditions and risk factors that put him at risk for unintended weigh loss/gain: Alzheimer's disease/dementia. Significant weight loss x 6 months. Interventions: Proved pureed diet to meet the nutritional needs of the resident by: 1. providing fortified foods- magic cup BID (twice a day), pudding (date initiated October 25, 2024). The facility did not provide a weight loss/prevention policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R459's admission Restorative assessment dated [DATE] showed R459 required maximum assistance from staff for transferring and toileting. On 10/23/23 at 9:15 AM, V5 Certified Nursing Assistant (CNA) transferred R459, from her bed to a wheelchair, by lifting R459 under her armpits and sliding her into the wheelchair. No gait belt was used. V5 CNA wheeled R459 in her wheelchair, into the bathroom. Again, V5 CNA transferred R459, from her wheelchair onto the toilet, by lifting R459 under her armpits. No gait belt was used. Once R459 was finished going the bathroom, V5 CNA lifted R459 off the toilet by her armpits and asked her to hold onto the bar on the wall by the toilet. R459 grasped the bar and began yelling Help me! Help me! as V5 CNA briefly let go of R459 to wipe her. Once V5 CNA had finished wiping R459, V5 placed his hands under R459's buttocks and guided her into the wheelchair. No gait belt was used. On 10/24/23 at 11;45 AM, V2 Director of Nursing stated gait belts are to be used to transfer any resident that requires staff assistance to ensure resident safety. The facility's Gait Belt policy dated 7/28/23 showed, The facility will use gait or transfer belts to assist residents needing limited to total assistance during transfers and walking. Based on observation, interview, and record review the facility failed to ensure fall interventions were in place for a resident who is a HIGH risk for falls and failed to ensure a resident was safely transferred. This failure resulted in R135 falling on the floor in the dining room sustaining a right femoral neck fracture and requiring surgical intervention. This applies to 1 of 2 residents (R135, R459) reviewed for safety in the sample of 31. The findings include: 1. R135's face sheet shows he is a [AGE] year old male with diagnosis including fracture of the right femur neck, unspecified dementia without behavioral disturbance, unsteadiness on feet, cognitive communication deficit, weakness, monoplegia of upper limb following cerebral infarction affecting right dominant side, hydronephrosis, urine retention and aphasia. R135's Final Incident Report dated 9/19/23 documents on 9/13/23, (R135) stood up from chair in the dining room and lost his balance and fell hitting the right side of his body on the floor. A staff member from a distance observed him fall. He was kept immobilized until the paramedics arrived. (R135) was transferred to the local hospital and admitted for right acute femoral neck fracture and required surgical intervention. R135's Minimum Data Set assessment dated [DATE] shows his cognition is impaired, requires extensive assist with bed mobility, transfers, tolieting. He is not steady and only able to stabilize with staff assistance when moving from seated to standing position, walking, moving on and off the toilet, and surface to surface transfers. R135's Fall Risk assessment dated [DATE] shows he is HIGH risk for falls. On 10/22/23 at 9:25 AM, R135 was observed in his room in a low bed near the nurses station. On 10/24/23 at 10:27 AM, V16 (RN) said she was R135's nurse on 9/13/23 when he fell. She was on break and was alerted by staff he was on the floor. Last time she observed R135 was about 6:30 PM, in the dining room he was self propelling in his wheelchair. R135 is alert to self, sometimes he can verbalize his needs and is unable to follow direction. He had a fall a week prior getting up without assistance. V17 (CNA) was the only staff in the dining room. He told me there were so many residents in the dining room at that time who were at high risk for falls and could not watch them all. When she entered the dining room he was laying on the floor on his right side complaining of pain. She called the ambulance and did not move him, he was admitted with femur fracture. V16 said V18 was his assigned CNA (Certified Nursing Assistant) that day and was in another residents room. There's supposed be two staff supervising the dining room for safety. On 10/24/23 at 1:08 PM, V18 (CNA) said R135 is alert to person, does not follow direction. He was R135's CNA on 9/13/23 when he fell. He's supposed to be toileted every two hours, that day he toileted him about 3:30 PM and did not take him to the bathroom after dinner. At the time of the fall he was in another residents room. Residents should be toileted before and after meals, when awake, and before bed to prevent them from getting up on their own. There should be two staff in the dining room to help supervise the residents for safety reasons. On 10/25/23 at 9:59 AM, V2 (DON) said V17 is no longer an employee at the facility. She said R135 has dementia and poor safety awareness. He got up from the chair and fell and fractured his femur. She confirmed R135 was not assisted to the toilet after the dinner meal and that was an intervention they put in place after his fall on 9/8/23. It doesn't matter if there was only one CNA in the dining room that's considered supervision. We in-serviced the staff to offer tolieting to residents every two hours and frequent monitoring. On 10/25/23 at 2:21 PM, V22 (R135's Nurse Practitioner) said R135 has dementia and is alert to himself, he has poor safety awareness, and is at high risk for fall. Staff should be monitoring him closely. and he needs staff assistance for his activities of daily living. She confirmed he fell and sustained a femur fracture. R135's Post Fall Investigation Report dated 9/9/23 shows on 9/8/23 he had a fall in his room, he was attempting to stand without staff assistance. The interventions included to re-educate staff to offer toileting to the resident upon rising in the morning, before and after each meals and at bedtime. The facility's Falls Policy revised 8/20 states, The Fall Prevention Program is designed to ensue a safe environment for all residents. Each resident will be evaluated upon admission, quarterly and as needed .to assess his/her individual fall risk .implementing an individualized Plan of Care designated to meet the resident's needs. To ensure the consistency in the implementation of preventive measures to assist with the reduction of falls .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure intravenous therapy to central venous catheters was performed in accordance with standards or practice; failed to ensure staff were qualified and trained to provide care for central venous catheters (long, flexible tubes inserted by providers that lead directly to vena cava, near the heart); and failed to implement policies for the administration of medications and maintenance of the central venous catheter site for 2 of 3 residents (R1, R2) reviewed for intravenous access in the sample of 7. These failures resulted in R1's implanted port (central line) becoming infected, requiring hospitalization and surgical removal of the infected port. R1 developed bacteremia (infection of the blood stream). The findings include: 1. On 5/5/23 at 7:38 AM, V22 (R1's Power of Attorney) said [R1] had the implanted port in place since 2018 and never had any issues with it prior to it becoming infected. The port was placed because [R1] needed frequent lab draws and medications and she was a hard stick. The port was implanted, under her skin in her upper chest. V22 stated, I don't think it was ever flushed at the facility. In December 2022, [R1] started getting weird and hallucinating. She would see dogs in her bed at night. The doctor said she probably was dehydrated and ordered IV fluids. The nurse called me to report that they were attempting to access [R1's] port and gook came out. The nurse said she called the doctor back right away and [R1] was sent to the emergency room. [R1's] port was infected and had to be removed. She was in the hospital for several days for a very aggressive infection. The doctor toil me there wasn't much more we could do, so [R1] went back to the facility in early January 2023. A PICC (Peripherally Inserted Central Catheter) was inserted for IV antibiotics, fluids, and blood draws. R1 never got better, and she was placed on hospice care. [R1] passed away on 2/24/23 at the facility. I had a care meeting with the facility staff when it was obvious that [R1] wasn't improving. They discussed her decline, due to a UTI (Urinary Tract Infection). That frustrated me because the issue was her port became infected and caused an infection in her blood. I asked when [R1's] port had been flushed and none of them could answer me. I requested to see the documentation and it was never provided to me. R1 was doing poorly, so my focus was on her, and I wasn't the best at following-up. The staff never provided in the information about the port care and when I remembered to ask them, they would say, I'll ask, but no one got back to me. I can't remember names, but I know how they made me feel. R1 was alert and oriented prior to this infection, but at the end she didn't seem to know who I was. R1's Face sheet dated 5/9/23 showed diagnoses to include, but not limited to: CKD (Chronic Kidney Disease - Stage 4); dysphagia; reduced mobility; need for assistance with personal care; severe protein-calorie malnutrition; MRSA (Methicillin Resistant Staphylococcus Aureus) infection; local infection due to central venous catheter; hyperparathyroidism; hypokalemia; noninfective gastroenteritis and colitis; real tubulo-interstitial disease; sleep apnea; bullous pemphigoid; diabetes; chronic respiratory failure; adult failure to thrive; hypothyroidism; anxiety; anemia; COPD (Chronic Obstructive Pulmonary Disease); major depressive disorder; and Crohn's Disease. R1's facility assessment dated [DATE] showed R1 was cognitively intact; required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene; and had limited ROM (Range of Motion) to one upper extremity. R1's November 2022 TAR (Treatment Administration Records) showed, If the port has not been accessed: Access the port monthly and flush with 5 ml normal saline followed by 5 ml Heparin (100 Units/ml) every night shift starting on the 15th of every month. This entry was signed out as completed by V18 (LPN - Licensed Practical Nurse). (The care and use of port (central venous catheter) is beyond the scope of practice for LPNs). This document showed, Implanted port (lumen is used for blood draws). For blood draws: flush before, draw 10 ml blood then waste; draw 10 ml for blood draw. For patency: flush with 10 ml NS daily every day shift. This was signed out as completed on 19 of the 30 days in November. (During this investigation, the facility and staff interview were unable to prove when R1's port was accessed with a needle and dressing in place and unable to report how long the needle was left in place. They were unable to explain the conflicting orders for the care of the port.) This document showed, Only if in use, change dressing and the non-coring needle on day shift on Saturday for right chest mediport. This was signed out on 11/5 (by V12, RN - Registered Nurse), 11/12, and 11/26. (This entry was left blank on 11/19. R1's December 2022 TAR showed on 12/15/22 the port was not accessed by V19 (LPN). The document showed the initials NN, which means there should be a nurses' note explaining why the port was not accessed and flushed, as ordered. There was no nurse note entry by V19 on 12/15/22. The document showed the facility nurses documented the blood draw flushes and flushes were performed 21 of 30 days. The document showed, Only if in use, change dressing and non-coring needle on day shift every Saturday for right chest mediport. This was signed out on 12/3 (by V12, RN) and 12/17 by V20 (Agency LPN). During interviews, V12 (RN) reported she was uncomfortable providing care for implanted ports. A dressing change and needle chart of a mediport requires sterile procedure to prevent the risk of infection and should only be performed by qualified, competent staff. V20 is an LPN and care of an implanted port is beyond the scope of practice. R1's Progress Notes dated 12/27/22 showed, Patient appeared lethargic and had loose stools. V17 (R1's PCP - Primary Care Physician) was notified. V17 ordered labs, IV fluids, and antifungal medication. R1's Medical Professional Progress Note dated 12/27/22 showed R1 was seen for a change in condition. CNA (Certified Nursing Aide) felt R1 had an altered mental status. V17 (R1's PCP) saw R1 and found her to be complaining of loose stools, nausea, and no appetite. R1's diaper was filled with loose, mucoid, liquid, foul-smelling bowel movement. There were orders placed for immediate labs and IV fluids for an acute flare up of her Crohn's disease. R1 had an implanted port in place due to difficult IV access. R1's Change of Condition (SBAR) report dated 12/27/22 at 4:16 PM showed R1 had purulent (infectious) drainage from the implanted port and diarrhea. R1 had a low-grade temperature and was lethargic. V17 was notified at 2:45 PM and orders were given to send R1 to the emergency room. R1's admission summary dated [DATE] at 7:41 PM, showed R1 was readmitted to the facility from the local hospital. R1 was placed on contact isolation for MRSA in her blood. Per the hospital nurse, the right chest (chemo) port was infected, and the port was removed. R1 is on IV antibiotics every 48 hours for 10 days, for the infected port. R1's port removal incision area was seen by the wound nurse. R1 had a PICC line with 2 lumens to the left upper arm. R1's Progress Notes showed R1 continued to decline, upon return to the facility. R1 was refusing to eat, drink, and take some medications. A Palliative Care Consult was performed on 1/20/23. R1 continued to refuse to eat/drink and take medications. R1 was placed on hospice on 1/26/23 and passed away on 2/24/23. R1's EMR (Electronic Medical Record) did not contain a Care Plan for the implanted port prior to R1 being re-admitted to the facility, after her port became infected. R1's Care Plan was updated on 1/6/23 and showed, Resident requires Contact Precautions related to MRSA in the blood. and resident has potential for infection related to chemo port removal incision; and resident is on antibiotic therapy. R1's hospital records faxed on 5/8/23 showed R1 was admitted to the hospital from [DATE] - 1/6/23 for an infected right chest port. The port was scabbed over with puss noted. R1's wound culture and blood cultures were both positive for the same organism, MRSA. MRSA is a drug-resistant bacteria. R1 was placed on isolation and an Infectious Disease Consult was in place. R1's medi-port was removed on 12/29/23. R1 had a PICC placed on 1/5/23 and returned to the nursing home on 1/6/23. R1's emergency room Record dated 12/27/23 showed R1 reported to the emergency room for a possible port infection. R1 stated that a nurse at the nursing home accessed the port, and she thinks she did it wrong. Since then, she has had pain, redness, and discharge from the area. R1's chest assessment showed port with overlying redness and crusted lesion. R1 was alert and oriented to person, place, and time. R1 was diagnosed with cellulites over the port and concerns of bacteremia (systemic infection of the blood stream). On 5/9/23 at 12:09 PM, V4 (RN) she usually works second shift, on second floor. She said she had taken care of R1. R1's port was used for medications, IV fluids, and blood draws. If the RN is activating (accessing) the port, then they should be performing flushes according to facility protocol. The nurses should be following the correct orders for flushing and care of a central venous line (port or PICC). V4 stated, There are special nurses that have been trained to access the ports. I've never done it. The managers usually do it. I went on leave for a couple months. When I left R1 was fine and when I came back, she was declining and on hospice. R1 had a poor appetite and often refused to eat/drink or take medications. On 5/9/23 at 12:59 PM, V12 (RN) said she was not comfortable with implanted ports. V12 stated, I was working the day R1 started to be lethargic and have increased diarrhea. V17 (R1's PCP) went to see R1 and ordered labs and IV fluids. I had never accessed a port before, so I had V13 (RN/Nursing Supervisor) come with me. I gathered the supplies, and we went in the room. R1 had teeny scab over the port area. V13 picked at it and purulent drainage came out. We didn't continue with accessing the port. I called V17 (R1's PCP) and got orders to send R1 to the emergency room. R1 had been having severe diarrhea so V17 wanted us to try IV fluids and obtain labs at the facility. R1 refused the medications. She was lethargic and her hands were twitchy. I was glad V17 sent R1 out. I think R1's port was infected and had to be removed. I saw her a couple times after she came back. She seemed depressed and was refusing to eat/drink and take medications. On 5/9/23 at 1:19 PM, V14 (ADON - Assistant Director of Nursing/Unit Manager) said central venous catheters should only be cared for by RNs. LPNs are not allowed to provide care for central venous access. R1 had a port. The nurses should follow facility protocol for flushes and blood draws. There is a set of orders in the EMR that the nurse can chose. The RN should make sure the proper orders are entered for the proper use of the central venous catheter. The RN should be checking the site daily to assess for any changes and ensure they are not developing an infection. The proper maintenance of a port depends on if the site is accessed (needle in place) or not. The RNs should be following facility protocol for flushing and maintaining the port. The port should only be accessed by an RN that is trained. Most of the supervisors can access the port and have received training. I'm not sure who provided the training or when it was done. There should be records of the RNs training. The surveyor requested to see the specialized training. On 5/9/23 at 2:17 PM, V17 (R1's PCP) said R1 had several chronic illnesses that required close monitoring and treatment. R1 had a port because she was a difficult stick, and required frequent infusions and blood draws. R1 did not have an implanted port for the typical reason most residents do. R1's port was not used for chemo or dialysis. R1 had [NAME] syndrome, a kidney disorder that causes imbalances of potassium and magnesium. R1 had Crohn's and would have flare ups and become dehydrated, required IV fluids administration. Generally, the RN would access the port for the chemo or blood draw, administer the flushes, and remove the needle. The fluctuations in R1's labs and IV fluids resulted in R1's needle needing to be left in for a short time. The RN would usually change the needle every 4-5 days, but the maximum a needle could be left in place is 7 days. R1 was seen at least monthly by myself and my NP. I remember seeing R1 with the port accessed, needle in place and dressing covering it. R1 was in and out of the hospital for flare ups, from chronic Crohn's and bullous pemphigoid (autoimmune pruritic skin disease). In December, the nurse called me to report that R1 was lethargic and was having severe diarrhea. I ordered STAT (immediate) labs, IV fluids, and some medications. A little while later I received a call from the nurse that R1's port may be infected. There was pus noted at the port site and R1 was complaining of pain when the area was touched. I went to assess R1 and decided to send her to the emergency room. When I sent her to the emergency room, I was more concerned about the diarrhea and need for treatment. The next day I rounded on R1 at the hospital and found out R1's port culture and blood culture were positive for the same organism (MRSA). That was concerning. When the cultures grow same organism, then it is likely the port was the source of R1's blood infection. Then the focus shifted to the infected port. R1 was placed on isolation and followed by several specialties at the hospital. R1's port was removed at the hospital due to infection. The facility should be following protocol for the care central venous catheters. I would expect they were following the standards of practice. If they were not, then it is possible the port could become clogged or infected. The nurses should call me if there are any issues with the central venous access. The nurses should be documenting the care and maintenance of the port, as well as any assessments or changes in assessments. If it's not charted, then how do we know what is going on. On 5/9/23 at 3:11 PM, V13 (RN/Nursing Supervisor) said she has 30 years of experience at the facility. The nurses will call me if they are uncomfortable with something. They usually call me to access an implanted port. There are order sets in the EMR for the proper care of the central venous lines and the nurse must enter the orders. The orders will then populate on the MAR or TAR for the RN to chart the assessments, dressings, and flushes. A port should only be accessed by an RN. Not everyone is comfortable, so they usually call the supervisors or managers. There isn't any proper training, for the central lines, but there had been in-services in the past. There was a change in ownership a couple years ago. That was the last time I remember having training on central venous catheters. I accessed R1's port. I'm not sure how long R1's needle would remain in place. Normally we access the port to draw blood and de-access it after flushing. The day R1 was sent to the hospital (12/27/23) I was asked to assist with accessing R1's port because the nurse was uncomfortable. When we looked at the port site, we noticed there was a white dot with pus over the port. We called the doctor because it looked infected. The skin over the port was red and R1 had facial grimacing and complained of pain when we touched it. The port was not accessed. R1 was sent to the emergency room. V13 reviewed R1's November and December 2022 MARs and TARs. V13 said the port site should be assessed daily. I'm not sure if R1's port was access on the 15th? This charting is confusing. If there is any abnormal finding or I can't access the port, then I enter a progress note. On 5/9/23 at 3:39 PM, V2 (DON) said LPNs are not allowed to access or care for central lines, only peripheral lines. The RNs are the only ones that should be taking care of R1's port. I'm not sure if there has been any specialized training for central lines at the facility. The RN is certified for central lines access as part of their licensure, but they may not see them often and be uncomfortable. If they are uncomfortable, they can call someone for help. I'm not sure if there has been an formalized in-services or training for central venous lines at the facility. I'd have to look. The EMR has order bundles for the proper care of the central lines. The nurse must enter the appropriate orders and follow the facility protocol. There should be clear orders in the Physician's Order Sheet and the care should be documented on the MAR or TAR, and possible the progress notes. On 5/10/23 at 3:13 PM, V2 (DON) was asked to review R1's November and December 2022 MAR and TAR with the surveyor. V2 said a checkmark with initials means the care was provided. On 11/15/22 the care was provided and signed out by V18 (LPN). The surveyor asked if LPNs were allowed to provide care to R1's port. V2 stated, No, and I'm not sure he's the only LPN that accessed that. He's not supposed to do that. The surveyor read the order for the blood draw flushes to V2 and asked how often the flush was performed, as the order has conflicting information. V2 stated, if it was signed as completed, then I would think the flushes were done. That order should be separated, so it's not confusing. V2 said R1's port was not accessed on 12/15/22 but is unsure why. V2 stated, I can't find any information in the nurses notes. NN, means there should be more information in a nurses' note. On 12/17/22 R1's TAR showed V20 (Agency LPN) completed R1's port access, flushes and dressing changed. V2 was asked how often the port was accessed. V2 had difficulty providing information about when R1's port was accessed for blood draws, medication infusions, and IV fluids. The facility's undated Order Set Screenshot showed the type of port and the picklist of orders for the nurse to add. The nurse must check the orders to enter them into the MAR and TAR. The facility's Competency Skills Forms for Central Line Dressing Change Skilled were dated 2021 and only provided for 3 RNs. 2. On 5/5/23 at 1:34 PM, V3 (RN) gathered R2's IV antibiotic and NS flushes. R2's room had a sign for Enhanced Barrier Precautions on the door and an isolation cart, stocked with gowns and gloves outside the door. V3 donned a gown and gloves before entering R2's room. V3 used the add-a-vial set to mix the antibiotic medication. R2 was sitting up in the recliner with a dual lumen PICC inserted in his right upper arm. The dressing was dry and intact and both lumens were capped. V3 primed the tubing for the antibiotic and set up the infusion pump. V3 cleansed both ports with alcohol swabs and flushed each port with 10 ml NS, after obtaining blood return. V3 said the facility has a lot of IV lines and she is familiar with PICC lines. The PICC lines are flushed before and after use with 10 ml NS. The NS flushes should be entered in the R2's orders because it's considered a medication. After completing the NS flushes, the nurse will sign them off on the MAR or TAR. If the flushes are not documented, then there is no way of knowing when it was done. The RNs are responsible for care and management of the central lines, including Port-a-caths, midline catheters, and PICCs. R2's Face-sheet dated 5/9/23 showed R2 was admitted to the facility on [DATE]. R2 had diagnoses to include, but not limited to abdominal wall abscess, pleural effusion, other bacterial infections, candidiasis, iron deficiency anemia, mild protein-calorie malnutrition, esophageal varices, peritoneal abscess, alcoholic cirrhosis of the liver, hepatic encephalopathy, weakness, fatigue, reduced mobility, and presence of other specified devices for long-term use of antibiotics. R2's Physician's Order Sheet dated 5/9/23 did not show any orders for NS flushes to R2's PICC line. There were no documented PICC line flushes on R2's April or May 2023 MARs (Medication Administration Records). R2's Care Plan dated 4/14/23 showed, Resident has potential for infection at IV site (on IV ABT (antibiotics) due to abdominal abscess. Interventions: Initiate proper precaution per facility protocol. On 5/5/23 at 1:19 PM, V14 (ADON/2nd floor manager) said only RNs can completed IV infusions and dressing changes for PICC lines. The NS flushes should be done before and after each use. There should be an order for the flushes, so the nurse is aware it is due. I don't see any orders for NS flushes to R2's PICC line. I only see dressing change orders and the measurements. There should be an order because NS is a medication. It's important to perform the flushes as order to keep the line open, prevent clotting issues, and reduce the risk of infection. The facility's Intravenous Therapy revised 7/28/22 showed, It is the facility's policy to ensure that intravenous policy and procedures are complaint to federal standards of care. Procedures: All IV access will be assessed by the nurse to ensure that no signs and symptoms of infection and infiltration are left unaddressed. 2. Dressing Change: b. All Central line dressing (PICC lines, single and multi-lumen central catheters inserted in subclavian, Juglar, or inguinal area) will be changed every 7 days and PRN (as needed). c. Implanted ports such as Portacath (PAC) dressing will be changed every 7 days and PRN during Huber needle change. 3. Flushing: B: Central line including PICC lines are flushed with 5 to 10 ml NSS. c. Implanted ports including Portacath will be flushed with 5 to 10 ml of NSS before and after infusion. If implanted port is not accessed, flush with 5 ml NSS followed by 5 ml of Heparin (100 Units/ml) every month.

Based on interview and record review, the facility failed to ensure adequate pain management was provided for 1 of 5 residents (R2) reviewed for pain control in the sample of 5. This failure resulted in R2 experiencing unrelieved pain after a fracture. The findings include: On 4/24/23 at 9:52 AM, V2, Director of Nursing (DON), said R2 has a lot of pain due to advanced cancer. R2 had increasing pain on Saturday (4/15/23). On 4/24/23 at 12:21 PM, V9, Licensed Practical Nurse (LPN), said she was R2's nurse on the day shift (7 AM to 3:30 PM) on 4/15/23. V9 said R2 requested pain medication around 8:00 AM and she administered it. V9 said R2 has bone cancer and they have to be very careful with R2's care due to his cancer and chronic pain. V9 said around lunch, R2 still had pain. V9 said R2 had a BM and they were unable to clean his backside due to his pain. V9 said she told the evening shift nurse they were unable to change R2 due to his pain not being relieved by the narcotics she gave around 8:00 AM and again around lunch. V9 said she called R2's doctor for an X-ray. V9 said the following day (4/16/23), the night shift nurse told her R2 had been in too much pain during the night to wait for the in house x-ray results, so they sent him to the hospital. On 4/24/23 at 2:55 PM, V16, LPN, said she was R2's nurse on the evening shift (3 PM to 11:30 PM) on 4/15/23. V16 said R2 complained of pain in the left knee. V16 said she spoke with R2's daughter and was told not to change R2 because he was in too much pain. V16 said she did not contact R2's doctor during her shift. V16 then said R2 told her he was not in pain. On 4/15/23 at 6:54 PM, V16 documented an eMAR note which rated R2's pain a 0. However, V16 said she gave R2 pain medication around 9 something. V16 said when she gives pain medication, she documents it on the Medication Administration Record (MAR). R2's MAR provided by the facility for 4/1/23-4/30/23 (printed 4/24/23) does not show any documentation of R2 receiving PRN (as needed) Oxycodone (narcotic pain medication) after 3:30 PM on 4/15/23. There is no correlating documentation in R2's Progress Notes to explain why or when R2 may have received pain medication while V16 was his nurse on 4/15/23 nor was there documentation regarding R2's doctor being contacted during that time. On 4/24/23 at 2:41 PM, V15, Registered Nurse (RN), said she was R2's nurse during the night shift on 4/15/23 going into 4/16/23. V15 said she went to check on R2 and R2 told her he was in pain and did not want to be touched. V15 said R2 complained of pain when they tried to change him or give him care. V15 said she believes R2 had been rating his pain a 7 or 8 on a 0-10 scale. V15 said R2 was not comfortable. V15 said she did not administer any pain medications to R2. V15 said when pain medication is given, it is documented on the MAR. V15 said she contacted R2's doctor and was told to send him to the hospital because they could not control his pain. R2's Progress Notes written by V15 on 4/15/23 at 11:15 PM show V15 attempted to call R2's doctor and was waiting for a return call and R2 was refusing care due to pain of his left knee and left hip. V15 noted swelling to R2's left knee. V15's documentation on 4/16/23 at 2:15 AM in R2's General Progress Note shows V15 spoke to R2's doctor and received an order to send R2 to the hospital for further evaluation. R2 was sent to the hospital at 3:20 AM and at 2:16 AM R2 continued to complain of pain to his left leg. No other pain interventions were documented as being attempted. On 4/24/23 at 1:30 PM, V18, Emergency Medical Personnel (EMS), said he went to the facility on a 911 call and the nurse said R2 could not be moved due to being in so much pain. V18 said R2 was in a lot of pain and no one called EMS until 3 AM. V18 said they gave R2 pain medication in the ambulance. R2's admission Record dated 4/24/23 shows R2's diagnoses include, but are not limited to, pathological fracture of the left femur, weakness, fatigue, reduced mobility, malignant neoplasm of the lung, pain in left hip, and malignant neoplasm of unspecified bones. R2's MAR shows he received Oxydocone on 4/15/23 at 8:20 AM and a last documented dose at 3:30 PM. On 4/15/23 at 3:52 PM, V9 documented that R2's pain medication was ineffective and rated R2's pain a 5. R2's Physician's Order Sheets (POS) dated 4/24/23 does not show any new medication ordered in April of 2023. The facility's Pain Policy (Revised 7/28/22) shows, After the administration of PRN pain medication, the resident will be assessed for the effectiveness of the pain medication. If the resident is still unrelieved of pain despite pharmacologic and nursing measures, the resident's physician will be called to refer to the lack of relief. It is important that pain medication will be administered to residents prior to repositioning. If despite the administration of pain medication. The resident still complains or shows signs of pain. The staff will stop the procedure and allow more time. If the resident continues to exhibit signs of pain afterwards, the nurse will call the physician and obtain additional pain relieving interventions.