**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an environment that was free of accident hazards for 1 of 43 residents (Resident #24) reviewed for accidents hazards. The facility failed to ensure safety measures were in place after Resident #24 received a second-degree burn (burns that involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful) from hot coffee that required treatment. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 9:33 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for diminished quality of life, injury, and burns. Findings included: Record review of Resident #24's face sheet, dated [DATE], indicated an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Syncope and collapse(a medical term for fainting or passing out), venous insufficiency (occurs when your leg veins don't allow blood to flow back up to your heart), Diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high ), and Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning). Record review of Resident #24's quarterly MDS assessment, dated [DATE], indicated Resident #24 was understood and understood by others. Resident #24's BIMS score was 12, which indicated he was cognitively moderately impaired. The MDS indicated Resident #24 required assistance with bathing, toileting bed mobility, dressing, transfers, and set up for personal hygiene and eating. Record review of Resident #24's comprehensive care plan dated [DATE] did not reveal a care plan for the risk of injury from hot liquids. Record review of Resident #24's Physician order dated [DATE] revealed Resident #24 had an order for a start date of [DATE] and a stop date of [DATE] to monitor for any new signs or symptoms to the top of the left foot every shift. Record review of Resident #24's Physicians order dated [DATE], revealed Resident #24 had an order with a start date of [DATE] and a stop date of [DATE] for Silvadene External Cream 1 % (Silver Sulfadiazine), Apply cream to his left top foot topically every day shift for redness. Record review of Resident #24's MAR dated [DATE] thru [DATE], revealed Resident #24 had an order with a start date of [DATE] and stop date of [DATE] for Silvadene External Cream 1 % (Silver Sulfadiazine), Apply cream to his left top foot topically every day shift for redness. Staff initialed they had applied the cream as ordered from [DATE] through [DATE]. Record review of incident report dated [DATE] at 3:50 p.m., indicated Resident #24 was sitting up in the dining room in his wheelchair. No distress was noted. Resident #24 spilled his coffee on his left leg and floor. Resident #24 said he was getting a cup of coffee and spilled it down his leg. LVN Q accessed Resident #24 left leg and noted redness. No open areas or blisters were noted. LVN Q notified the wound care nurse the responsible party the nurse practitioner the DON and the Administrator. No measurements were indicated on the incident report. Record review of Resident #24's SBAR dated [DATE] at 5:33 p.m., by LVN Q revealed Resident #24 spilled hot coffee on his left ankle and foot. No open areas or blisters were noted but the area was red and tender. Record review of Resident #24's skincare observation dated [DATE] at 5:59 p.m., revealed Resident #24 had redness to his left lower leg from the coffee spill but no blisters or open areas. The skin care observation failed to include the size of the redness on the left lower leg. Record review of Resident #24's incident report, pain assessment, skin assessment, and SBAR dated [DATE] was completed. Record review of Resident #24's progress note dated [DATE] at 2:56 a.m., by LVN R, revealed, Resident #24 complained of discomfort to the left foot after spilling the hot coffee on it earlier yesterday morning. The resident had several blisters/fluid-filled pockets located to the top of the left foot and to the top of the pinky toe on the left foot. The blisters were intact and not opened or draining. The left foot was red. Record review of Resident #24's progress note dated [DATE] at 9:26 a.m., by LVN Q Day 1/3 burn from coffee to Left foot. Redness and blisters noted. No drainage/bleeding at this time. Treatment was in place. Res able to voice all needs, no needs at this time. Call light in reach. Record review of Resident #24's progress note dated [DATE] at 2:49 a.m., by LVN R Day 2/3: Resident continues to have fluid-filled blisters noted to the top of the left foot and the pinky toe on the left foot. No opened areas noted. The redness had decreased some with daily wound care completed. Record review of Resident #24's progress note dated [DATE] at 5:30 p.m., by LVN Q Day 2/3 burn from coffee to Left foot. Blister noted to top of the foot. No drainage/bleeding at this time. Tx in place. Res able to voice all needs, no needs voiced. Call light in reach. Record review of Resident #24's progress note dated [DATE] at 1:10 a.m., by LVN R Day 3/3 for a burn from coffee to the left foot. There continue to be blisters/fluid-filled pockets intact to the top of the left foot and pinky toe. No drainage noted at this time. No signs or symptoms of infection were noted. Continued daily wound care in place. No c/o pain verbalized. Record review of Resident #24's Occupation therapy note dated [DATE] revealed: a new goal, Patient will improve the ability to safely and efficiently perform eating tasks with setup or clean up assistance with use of to ensure adequate nutrition and hydration and no spillage target date of [DATE]. Record review of Resident #24's progress note dated [DATE] By the facility NP revealed an [AGE] year-old male resides at [facility] as a long-term resident. The resident was a DNR with a history of Diabetes, Dementia, and multiple other chronic conditions for which he was being monitored. The resident can get around by wheelchair. The resident continues working with PT/OT during the week. The Resident recently spilled coffee on himself. The resident had a blister to the top of the left foot that shows no signs of infection. Record review of Resident #24's skincare observation dated [DATE] at 3:34 p.m., revealed Resident #24 had redness to his left toe and scabbed area to the left front lower leg with Silvadene applied. The skin care observation failed to include the size of the redness on the left lower leg. Record review of Resident #24's skincare observation dated [DATE] at 3:22 p.m., revealed Resident #24 had redness to his left pinky toe with Silvadene applied. The skin care observation failed to include the size of the redness on the left pinky toe. Record review of Resident #24's skincare observation did not indicate a skin assessment for [DATE] and [DATE]. Record review of Resident #24's skincare observation dated [DATE] at 4:27 p.m., revealed Resident #24 had no skin concerns to his left lower leg or toe. The skin care observation failed to include the size of the redness on the left lower leg or toe. During an interview on [DATE] at 4:10 p.m., Resident #24 said he remembered spilling his coffee on his left leg sometime back. He said he remembered getting coffee from the coffee pot and then he went to his seat and somehow spilled his coffee on his leg. He said he was unaware at first, he had any skin problems related to the coffee spill until the unknown staff told him. He said he knew the unknown staff did treatments on his leg but could not remember how long. He said the area was healed. During an interview on [DATE] at 4:12 p.m., MA F said she thought they did an in-service after Resident #24 had a coffee spill but it had been so long ago, that she did not remember. She said the coffee remained in the dining room and the residents could get coffee at any time. During an interview on [DATE] at 4:15 p.m., CNA H said he was aware Resident #24 spilled coffee on his leg. He said he had some blisters and the nurses did treatment on them. He said Resident #24 got his own coffee and still did. He said they had cups sitting next to the coffee area. He said he could not remember if they have had an in-service or not on coffee spills. During an interview on [DATE] at 4:24 p.m., the treatment nurse said she was aware Resident #24 had spilled coffee on his left leg. She said she applied Silvadene cream until it healed. She said she could not remember what they looked like when she first started treating them but he did have blisters. She said she could not remember if they had an in-service on the coffee spill. She said she was unaware of any other coffee spills until today ([DATE]) when another resident spilled his coffee on his pants between lunch and supper. She said he was assessed and had no injuries. During an interview on [DATE] at 4:41 p.m., the DON said she had gone home on the day Resident #24 had spilled coffee on himself. She said the nurse at the facility called her and then she called her RNC. She said she explained what had happened and the RNC told her to have staff call the doctor and follow his directions. She said she asked the RNC if that incident needed to be reported to the State of Texas and was told no. She said the nurses called the doctor and obtained orders. She said they had OT to evaluate him to see if he had a dexterity problem and she did not remember them saying he did. The DON said she could not recall if she did an in-service related to the coffee spill. She said they had not had any more issues with coffee spills until today ([DATE]) when another resident spilled his coffee on his pants between lunch and supper. She said he was assessed and had no injuries. She said she thought they did everything they needed to do after Resident #24 obtained his coffee burn; she said they notified the RNC, and the doctor, obtained treatment orders, and had OT elevate him. She said she was not aware of any hot liquid assessment nor did she renotify the RNC after Resident #24 developed blisters on his foot. During an interview on [DATE] at 4:56 p.m., the rehab director- said she remembered when Resident #24 spilled coffee on himself. She said he had OT and they determined he did not need any special devices for his coffee. During an interview on [DATE] at 05:15 p.m., the Administrator said she was aware Resident #24 had spilled coffee on his leg. She said she was still in the facility at the time of the coffee spill. She said she went into the kitchen and looked at the temperature of the coffee. She said it was at 165 degrees. She said the DON called the RNC and explained what had happened and was given the directions to monitor Resident #24 because he was able to tell us what happened. She said to her knowledge the area on Resident #24's leg was just a reddened area. She said sometime later she became aware that Resident #24 had developed blister(s) and they treated them. She said after the blister(s) came up she did not renotify the RNC. She said she did not recall an in-service about the coffee spill but they discussed the coffee spill in the morning meeting and at-the risk meeting. She said they decided from the meeting that if any resident needed help with the coffee; then staff should assist them. She said they did not have any form of written communication with the at-risk residents. She said they communicated this process through word of mouth to the staff. She said she was unaware of any hot liquid assessments. She said she thought they did everything they needed to do after Resident #24 spilled his coffee and obtained a 2nd-degree burn. She said she checked the temperature of the coffee, had OT evaluate him, and the nurses did his treatment until the area resolved., She said they had not had any issues with coffee spills until today ([DATE]). She said another resident spilled his coffee on himself during lunch. She said they assessed him and he had no injuries. During an observation and interview on [DATE] at 4:26 p.m., a coffee pot and no lids were in the dining room unattended. MA F came into the dining room and verified the coffee pot was left unattended. She said as far as she knew the coffee stayed on all the time and residents were allowed to get coffee at any time. During an observation on [DATE] at 7:30 a.m., 12 residents were sitting in the dining room and 4 residents had coffee cups sitting in front of them with no staff in the dining area. Coffee pots and cups were available for any resident to obtain their own coffee. During an attempted phone interview on [DATE] at 07:48 a.m., the facility NP was unable to be reached; a message was left. During an attempted phone interview on [DATE] at 08:09 a.m., LVN R was unable to be reached; a message was left. During an interview on [DATE] at 8:25 a.m., the RNC said she was told Resident #24 had a coffee spill on his foot. She said the process was for the nurses to notify her, complete a head-to-toe skin assessment, notify the doctor, and if treatment was needed, complete an SBAR and incident report. The RNC said they should have completed an investigation to find the root cause, complete a hot liquid assessment, and update Resident #24's care plan. During an attempted phone interview on [DATE] at 08:37 a.m., LVN Q was unable to be reached; a message was left. During an interview on [DATE] at 09:35 a.m., Housekeeper U said she had been at the facility for 2 months and had seen residents coming up to get coffee by themselves. She said the coffee pot sat out all the time. During a phone interview on [DATE] at 10:55 a.m., the NP said she remembered Resident #24 having a coffee spill. She said she could not remember what it looked like. She said if he spilled coffee and then developed blisters then it would be classified as a 2nd-degree burn. Record review of facility policy titled, Incidents/Accidents, dated 01/24, indicated, The facility will assess residents for risk factors of potential accidents/ hazard. The facility will recognize signs of incidents and accidents and assist residents, as indicated. The facility will conduct thorough investigations as indicated to determine underlying causes and contributing factors to incidents and accidents; and would put interventions in place from the investigative findings and IDT input Charge nurse procedure: the resident's care plan will be updated to reflect the incident or accident with interventions to prevent further occurrence as indicated Special considerations: the facility administrator should determine incidents or accidents that require thorough investigation and ensure completion. Record review of the facility policy titled, Hot Liquids, dated 12/23 indicated, The facility will adhere to safe practice when preparing, handling, and serving hot liquids. The facility aims to prevent burns and injuries from hot liquids, ensuring the safety and well-being of residents and staff. #1 Procedure: preparation and handling hot liquids or prepared and served at a safe temperature to prevent scalding and burns. #2 Transportation: used insulated containers with secure lids for transporting hot liquids to prevent spills #3. Serving: if a resident is alert and able to follow commands, encourage them to exercise caution before consuming hot liquids, and do not overfill cups. #4 Safeguard: allow hot liquids to cool before serving. #5 Monitoring: the facility will routinely inspect the equipment used to prepare and serve hot liquids to ensure it is in good working order. #6 Residents at risk: provide appropriate assistance and supervision to residents consuming hot liquids considering risk factors such as cognition impairment, visual impairment, behavioral, tremors, and functional impairment. The resident care plan should reflect any assistive devices or interventions required to safely consume hot liquids. #7 Incident response: provider first aid cool the burn with running cold water do not use ice or greasy substances, conduct an investigation as needed, document the findings in the electronic medical records, and update the care plan with any interventions initiated to prevent reoccurring. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 9:33 a.m., the Administrator was notified. The Administer was provided with the IJ template on [DATE] at 9:34 a.m. and a POR was requested. The following Plan of Removal submitted by the facility was accepted on [DATE] at 6:20 p.m.: The facility failed to Implement measures to prevent other coffee spills with burns, monitor temperatures of hot liquids served to residents, identify at risk resident, and failed to assess Resident #24 for hot liquid safety. On [DATE], Resident #24 accidentally spilled hot coffee on his left foot/ankle, resulting in redness. The charge nurse completed SBAR, skin assessment, pain assessment, and an incident report on the same day. The MD was informed and ordered daily application of Sulfadiazine to the affected area. On [DATE]th, 2024, OT evaluated Resident #24 with a long-term goal of safely eating and drinking without injury, with a focus on handling hot beverages. Resident #24 was on caseload from [DATE]-[DATE] and met his goals. On [DATE], the Director of Nursing assessed Resident #24 regarding safely consuming hot liquids and noted that Resident #24 had no changes in prior assessments and could safely consume hot liquids. Resident # 24 was discharged from OT services on [DATE] being independent with feeding. Resident #24's care plan was reviewed and required no updates. The self-service coffee station in the dining room was promptly removed on [DATE], and all coffee distribution will be supervised. The Administrator notified the Medical Director of the Immediate Jeopardy on [DATE]. On [DATE], the Director of Nursing initiated education with all staff- topics included: safe practices for preparing, handling, and serving hot liquids, emphasizing no unsupervised pouring of hot liquids by residents. Completion Date [DATE]. On [DATE], the Director of Nursing initiated education with all licensed nurses- topics included: procedures to follow in the event of an adverse hot liquid incident, including providing first aid, notifying the physician and responsible party, implementing new orders, completing an incident report, documenting findings in the EHR, and updating the resident's care plan with interventions as needed to prevent recurrence. Licensed nurses will receive education before their next shift, with new hires receiving training during orientation. Completion Date [DATE]. The Dietitian initiated education with dietary staff on [DATE]- topics included: checking temperatures before serving hot liquids to residents and documenting them on a hot liquid temperature log. All dietary members will receive this education before their next shift, with new hires receiving training during orientation. Completion Date [DATE]. The Director of Nursing initiated education with CNAs and Licensed Nurses on [DATE]- topics included: providing adaptive equipment (for example: specialized cups/lids) if indicated by the resident's care plan and how to use the equipment. CNAs and Licensed Nurses will receive the education before working their next shift, with new hires receiving the education on orientation. Completion Date: [DATE]. The Charge Nurse will identify residents with changes in condition that may affect their ability to safely consume hot liquids, such as cognitive or functional impairments, and update their care plans accordingly. New admissions and readmissions undergo screening through a baseline care plan process to screen for the safe consumption of hot liquids. On [DATE], the Director of Nursing and Assistant Director of Nursing reviewed all residents to ensure they could safely consume hot liquids, updating care plans as necessary for any special considerations. No adverse findings were noted. The Administrator reviewed the Hot Liquid Policy and Procedure on [DATE], with no adverse findings. The Administrator confirmed the availability of specialized cups/lids on [DATE] with no adverse findings. On [DATE] the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of in-services done on [DATE] by the DON given to all staff on hot liquids, revealed Residents could no longer self-serve when getting coffee. They must ask dietary staff for a cup of coffee when a resident requests a cup. Please review the attached policy and procedure on hot liquids. Record review of in-services done on [DATE] by the DON given to nursing and CNAs on lids for beverages, revealed 5 residents at risk of hot liquid spills. It instructed staff to look at the [NAME] card for resident care information. Record review of the in-service on burn (incident response) dated [DATE] given by the DON to the nurses revealed anytime a resident had a burn from hot liquids you must provide #1 provide first aid, #2. notify the doctor or NP, #3. implement any new orders, #4. complete risk management, #5. investigate if needed, #6. document findings in chart and #7 update the care plan. Record review of the facility QAPI meeting held on [DATE] in were they created a four-point plan to address issues to prevent coffee spills with fire the facility will continue to monitor training and will monitor residents for any issues or adverse effects. #1. Corrective action #2 Identification of others #3 Systematic changes and #4 Monitoring. Record review of the hot liquid assessments dated [DATE] revealed all 43 residents were assessed. Record review of hot liquid care plans dated [DATE] revealed that 5 of 43 residents were at risk for hot liquid spills. All 4 residents' care plans were reviewed and had an updated care plan with interventions related to hot liquids.1 resident expired today ([DATE]). Record review of Resident #24's care plan updated [DATE], revealed he was at risk for injury related to consuming hot liquid (not limited to coffee, tea, or soup) related to a history of spills with injury on [DATE]. His interventions were to encourage the resident not to carry hot liquids while self-propelling in the wheelchair, to keep coffee away from the edge of the table, and to exercise caution before consuming hot liquids. Observation of the coffee pot removed from the dining room on [DATE]. During Interviews on [DATE] from 9:00 a.m. until 12:20 p.m. with 1 RN 6 am-6 pm (RN B), 3 PRN RN (RN Z, RNAA,RN BB),1double weekend (RN Y) 6 am-6 pm 3 LVN (LVN G, LVN P, LVN A,), 1 PRN LVN (LVN X) 2 6p-6a (LVN O, LVN R,), 2MA (MA F, MA T)and 6 am-6 pm 4 CNAs (CNA S, CNA M, CNA DD), 2 CNAs 6 pm-6 am (CNA CC, CNA EE), 2 PRN CNA (CNA GG, ) 2 Hospitality aide(HA V, HA W) Dietary staff 4 Cooks (Cook HH, dietary D, dietary C, and dietary II), housekeeping department 2 housekeepers (Housekeeper V, Housekeeper FF), Therapy Department 1 therapist (JJ) and the Administrator, DON ADON, MDS, BOM, HR, SW, Dietary manager, Maintenance supervisor, Rehab Supervisor, and activity director all who indicated they received a written in-service regarding the process of hot liquids. They said the coffee could no longer be left out and they must ask dietary for the coffee. They said they could look at the [NAME] card for information. They were able to identify the 5 at-risk residents. Nurses said if a resident did get a burn, they were to apply a cool towel to the area, assess, notify the doctor, investigate what happened, complete an incident report, and document findings in the resident's chart. During a phone interview on [DATE] at 12:30 p.m., the facility Medical Director said he was aware of the IJ received and attended a QAPI meeting via phone over the hot liquid process. During an interview on [DATE] at 2:36 p.m. the DON said the failure was they did not immediately remove the source for the injury when Resident #27 spilled coffee on himself. She said the RNC reviewed the policy and procedure with her to ensure she had the correct understanding then she educated staff on their policy and procedure. She said the RNC said they could have done things differently but now she understood the process. During an interview on [DATE] at 12:14 p.m. the Administrator said they started the process by removing the coffee pot from the dining room . She said the nurses assessed all the residents and identified 5 residents who were at risk of hot liquid spills. She said those 5 residents' care plans were updated. She said they in-serviced staff on the correct hot liquid policy. She said the dietary staff had a list of the 5 at-risk residents. She said they also educated staff to report to the charge nurse if they saw any resident shaking or at risk of spilling coffee. She said the nurse would assess the resident and update the care plan if needed. She said she did feel assured that if an event such as a coffee burn occurred again, staff would know how to manage the situation. She said the RNC did say after Resident #27 developed blisters, she should have been renotified. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 12:28 p.m. The facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy and due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 16 of 16 residents (Resident #s 1, 7, 10, 13, 15, 19, 20, 22, 24, 26, 30, 32, 37, 38, 40, and 43) reviewed for quality of care. The facility did not obtain informed written consents or document verbal consents, including risks, benefits, and potential adverse reactions, prior to IV vitamin and hydration infusions. The facility did not monitor residents, including documenting assessments, for a full 72 - hours, following infusion for adverse reactions. The facility licensed nursing staff were not trained in IV therapy, including post-care assessments and monitoring, and resident plans of care were not initiated prior to IV infusion. An Immediate Jeopardy was identified on 06/13/23. The IJ template was provided to the facility on [DATE] at 5:09 p.m. While the IJ was removed on 06/14/23, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy because all staff had not been trained on obtaining informed written consents, monitoring residents for 72 hours following infusions, IV therapy post assessments or monitoring. These failures could place residents who receive any type of IV therapy at high risk for adverse effects, decline in health, or death. Findings included: 1. Record review of the face sheet dated 06/13/23 indicated Resident #1 was a 61-year- old female admitted on [DATE] with diagnoses of cerebral palsy (abnormal development of the brain). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 15 indicating she was cognitive intact. She received IV therapy while being a resident of this facility and within the last 14 days. Record review of the most recent care plan dated 03/28/23 for Resident #1 did not include IV therapy. There were no revisions to address the IV therapy and no approaches to monitor the site, adverse reaction, or the effectiveness of the IV therapy. Record review of the physician ' s orders dated April 2023 for Resident #1 included orders for Nutrition Infusion IV -ONE TIME- 250ml 0.9% NS normal saline @250ML/HR Vitamin C (water soluble vitamin) 5gm, B Complex-(water soluble vitamins) {Thiamine 200mg, Riboflavin 4mg, Niacin 200 mg, Pyridoxine 4mg} B5 250mg Methylcobalamin (B-12), Magnesium Chloride (mineral supplements) 1000mg, Calcium 200mg, Zinc 10mg, Glutamine 150 mg, Arginine 500 mg Ornithine 150mg, Lysine 250mg, Citrulline250mg-BCAA 2 mls. Record review of a MAR dated April 2023 indicated Resident #1 received the cognitive IV infusion on 04/05/23 at 9:09 a.m. by Contract IV RN. Record review of Nursing Note dated 04/05/23 at 12:00 pm for Resident #1 indicated the following: .VS 133/79 97.3 80 17 [redacted] INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22 g LH x2 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/t multiple comorbidities, promote skin/tissue health, and promote the immune system. Order: 0.9% Normal Saline 250 ml, [redacted] Nutrition Protocol Infusion started at 250 ml/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1300 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc ' d gauze and Coban to site. Report of infusion complete. Indicated as entered by Contract IV RN. Record review of a Post IV Infusion Evaluation dated 04/05/23 indicated Resident #1 had no adverse reactions noted during the nutrition infusion or 4 hours later. There were no other post evaluations documented by facility staff after the dates of the infusions for Resident #1. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 received IV therapy while being a resident of this facility and within the last 14 days. Record review of the physician ' s orders dated May 2023 for Resident #1 included orders for Nutrition Infusion IV -ONE TIME- 250ml 0.9% NS normal saline @250ML/HR Vitamin C (water soluble vitamin) 5gm, B Complex-(water soluble vitamins) {Thiamine 200mg, Riboflavin 4mg, Niacin 200 mg, Pyridoxine 4mg} B5 250mg Methylcobalamin (B-12), Magnesium Chloride (mineral supplements) 1000mg, Calcium 200mg, Zinc 10mg, Glutamine 150 mg, Arginine 500 mg Ornithine 150mg, Lysine 250mg, Citrulline250mg-BCAA 2 mls. Record review of a MAR dated May 2023 indicated Resident #1 received the cognitive infusion on 05/02/23 at 9:09 a.m. by Contract IV RN. Record review of Nursing Note dated 05/02/23 at 12:00 for Resident #1 indicated the following: .VS 131/95 97.4 96 18 [redacted] INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22 g LH x2 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/t multiple comorbidities, promote skin/tissue health, and promote the immune system. Order: 0.9% Normal Saline 250 ml, [redacted] Nutrition Protocol Infusion started at 250 ml/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1300 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc ' d gauze and Coban to site. Report of infusion complete. Indicated as entered by Contract IV RN. Record review of a Post IV Infusion Evaluation dated 05/02/23 indicated Resident #1 had no adverse reactions noted during the nutrition infusion or 4 hours later. There were no other post evaluations after the dates of the infusions for Resident #1. Record review of the nurses ' note dated 05/02/23 indicated no nurse ' s notes on the next shift addressing the IV after the infusion was completed on 05/02/23. There were no nurses' notes dated 05/03/23 to indicate monitoring for adverse reactions. The nurses note dated 05/04/23 for Resident #1 did not address the IV therapy or the site of the discontinued IV on 05/2/23 and the section for IVs was left blank. Record review of Resident #1 ' s electronic record from 03/1/23 to 06/13/23 did not reveal a consent for the nutrition IV infusion. During an interview on 06/13/23 at 12:09 p.m., Resident #1 said there was no education provided about the nutrition IV infusion. She denied being told about side effects and did not remember signing a consent for the IV infusion. 2. Record review of a face sheet dated 06/13/23 indicated Resident #7 was a [AGE] year-old-female admitted [DATE] with diagnoses including COPD (a disease that cause airflow blockage and breathing-related problems), dementia (a group of thinking and social symptoms that interfere with daily functioning), high blood pressure, protein-calorie malnutrition (the state of inadequate intake of food and nutrients) and vitamin D deficiency (not having enough vitamin D in your body). Record review of a quarterly MDS dated [DATE] indicated Resident #7 had a BIMS score of 15 indicating she was cognitively intact, she needed supervision for bed mobility, transfers, toileting, dressing and hygiene. This quarterly MDS indicated she received IV therapy while a resident in the facility during the past 14 days. Record review of Resident #7 ' s care plans updated 03/23/23 did not address IV therapy to include what adverse reactions were to be monitored, and there was no documentation regarding who would monitor the resident for adverse reactions from the cognitive infusion therapy or for how often. Record review of physician orders dated April 2023 indicated Resident #7 was prescribed a cognitive infusion IV one time dose 250 ml normal saline 0.9% at 250 ml/hr Vitamin C (water soluble vitamin) 5 gm, B Complex-(water soluble vitamins) B1- 200 mg, B2 4 mg, B3 200 mg, B5 4 mg, B6 4 mg,B5 250 mg, B7 Biotin 20 mg, B12 Methyl cobalamin 2000 mcg, Magnesium Chloride 1000 mg, Calcium Gluconate 200 mg, Zinc 10 mg, Amino Blend, Calcium Gluconate 200 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg, Taurine 100 mg, Glycine 100 mg. Record review of a MAR dated April 2023 indicated Resident #7 received the cognitive IV infusion on 04/05/23 at 12:25 p.m. by Contract IV RN. Record review of a Nurses ' Note dated 04/05/23 at 12:30 a.m., for Resident #7 indicated the following . VS 123/84 97.4 82 17 {redacted} INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility's Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22g LAC x 1 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/multiple comorbidities and promote the immune system r/t infectious process. Order: 0.9% Normal Saline 250ML, {redacted} INFECTION PROTOCOL Infusion started @ 250ML/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1330 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc'd gauze and Coban to site. Report of infusion completion, indicated as entered by Contract IV RN. Record review of a Post IV Infusion Evaluation dated 04/05/23 for Resident #7 indicated he received an IV for hydration/ wellness over 60 minutes with no adverse reaction noted post infusion. Record review of Resident #7 ' s electronic record from 04/01/23 though 06/13/23 did not reveal a consent for the cognitive IV infusion. During an observation and interview on 06/14/23 at 10:00 a.m., Resident #7 was alert and oriented sitting on her bed. Resident #7 said one of the facility nurses, (unsure who) told her about the IV for vitamins and hydration but did not mention the side effects, or cost. Resident #7 said she did not remember signing a consent, but she gave them permission and agreed to do it. 3. Record review of face sheet dated 06/13/23 indicated Resident #10 was an [AGE] year-old female admitted [DATE] with diagnoses including diabetes and gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints). Record review of a quarterly MDS dated [DATE] indicated Resident #10 had a BIMS score of 15 indicating she was cognitive intact, she needed supervision for transfers, toileting, and hygiene. This quarterly MDS for Resident #10 indicated she had received an IV infusion. Record review of Resident #10 ' s most recent care plan dated 03/23/23, with planned revision date of 06/21/23, gave no indication for the IV therapy to include what adverse reactions were to be monitored, how often the resident should be monitored, or who would monitor the resident for adverse reactions. Record review of physician orders dated April 2023 for Resident #10 included Derma Infusion IV (250ml). Ingredients included Vitamin C (5000 mg). B-Complex which consisted of B1 (200 mg), B4 (4 mg), B3 (200 mg), B5 (4 mg), B6 (4mg), and B7-Biotin (20mg). Also, Zinc (10 mg), Amino blend, Glutamine 150 mg, Arginine 500 mg, Ornithine 150 mg, Kysine 250 mg, and Citruline 250 mg. Record review of Nursing Note dated 04/05/23 at 12:00 p.m. for Resident #10 indicated the following: .VS 133/79 97.3 80 17 [redacted] INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22 g LH x2 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/t multiple comorbidities, promote skin/tissue health, and promote the immune system. Order: 0.9% Normal Saline 250 ml, [redacted] Derma Protocol Infusion started at 250 ml/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1300 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc ' d gauze and Coban to site. Report of infusion complete. Indicated as entered by Contract IV RN. Record review of Post IV Infusion Evaluation dated 04/05/23 indicated Resident #10 had no adverse reactions noted during the derma infusion. There were no other post evaluations documented by facility staff after the dates of the infusions for Resident #10. Record review of a quarterly MDS dated [DATE] indicated Resident #10 had a BIMS score of 14 indicating she was cognitively intact, she needed supervision for transfers, toileting, and hygiene, and she received IV therapy. Record review of physician orders dated May 2023 for Resident #10 included Derma Infusion IV (250ml). Ingredients included Vitamin C (5000 mg). B-Complex which consisted of B1 (200 mg), B4 (4 mg), B3 (200 mg), B5 (4 mg), B6 (4mg), and B7-Biotin (20mg). Also, Zinc (10 mg), Amino blend, Glutamine 150 mg, Arginine 500 mg, Ornithine 150 mg, Kysine 250 mg, and Citruline 250 mg. Record review of Nursing Note dated 05/02/23 at 11:00 a.m. for Resident #10 indicated the following: .VS 110/66 97.0 71 17 [redacted] INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22 g LAC x1 attempt. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/t multiple comorbidities, promote skin/tissue health, and promote the immune system. Order: 0.9% Normal Saline 250 ml, [redacted] Derma Protocol Infusion started at 250 ml/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1200 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc ' d gauze and Coban to site. Report of infusion complete. Indicated as entered by Contract IV RN. Record review of Post IV Infusion Evaluation dated 05/02/23 indicated Resident #10 had no adverse reactions noted during the derma IV infusion. There were no other post evaluations documented by facility staff after the dates of the infusions for Resident #10. Record review of Resident #10 ' s electronic record for 04/01/23 through 05/30/23, did not reveal a consent for the derma IV infusion. During an interview on 06/13/23 at 11:00 a.m., Resident #10 said a female, who did not work at the facility, came into her room and told her she was to receive a vitamin infusion. She said she did not know who this nurse was, and she had not seen her in the facility except for during infusions. She said she was not told why she was receiving or any possible adverse reactions. She was not offered a consent to sign, and she did not sign one for either infusion. She said the infusion took about 20-25 minutes and all the residents who received the vitamin infusions were gathered in the sitting area behind the therapy gym so the nurse could watch all at one time. 4. Record review of a face sheet dated 06/13/23 indicated Resident #13 was a [AGE] year-old-male admitted [DATE] with diagnoses including stroke and malnutrition. Record review of a quarterly MDS dated [DATE] indicated Resident #13 had a BIMS score of 14 indicating he was cognitive intact, needed supervision for transfers, toileting, and hygiene, and received IV therapy during last 14 days while being a resident. Record review of Resident #13 ' s most recent care plan dated 03/23/23 did not address the IV therapy to include what adverse reactions were to be monitored nor was there documentation regarding who would monitor the resident for adverse reactions from the cognitive infusion therapy or for how often. Record review of physician orders dated April 2023 indicated Resident #13 had orders and included Cognition Infusion IV (250ml) one time dose 250 ml normal saline 0.9% at 250 ml/hr Vitamin C (water soluble vitamin) 5 gm, B Complex-(water soluble vitamins) B1- 200 mg, B2 4 mg, B3 200 mg, B5 4 mg, B6 4 mg,B5 250 mg, B7 Biotin 20 mg, B12 Methyl cobalamin 2000 mcg, Magnesium Chloride 1000 mg, Calcium Gluconate 200 mg, Zinc 10 mg, Amino Blend, Calcium Gluconate 200 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg, Taurine 100 mg, Glycine 100 mg. Record review of MAR dated April 2023 indicated Resident #13 received the cognitive IV infusion on 04/05/23 at 9:09 a.m. by Contract IV RN. Record review of the nurse ' s notes for Resident #13 indicated he received the cognitive IV infusion on 04/05/23 with no follow up noted after the infusion dates. Record review of Post IV Infusion Evaluation dated 04/05/23 indicated Resident #13 had no adverse reactions were noted during the nutrition infusion or 4 hours later. There were no other post evaluations made after the dates of the infusions for Resident #13 until May 2023 when he received the infusion again. Record review of a quarterly MDS dated [DATE] indicated Resident #13 had a BIMS score of 15 indicating he was cognitive intact, needed supervision for transfer, toileting, and hygiene, and he received IV therapy during last 14 days while being a resident. Record review of physician orders dated May 2023 indicated Resident #13 had orders and included Cognition Infusion IV (250ml) one time dose 250 ml normal saline 0.9% at 250 ml/hr Vitamin C (water soluble vitamin) 5 gm, B Complex-(water soluble vitamins) B1- 200 mg, B2 4 mg, B3 200 mg, B5 4 mg, B6 4 mg,B5 250 mg, B7 Biotin 20 mg, B12 Methyl cobalamin 2000 mcg, Magnesium Chloride 1000 mg, Calcium Gluconate 200 mg, Zinc 10 mg, Amino Blend, Calcium Gluconate 200 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg, Taurine 100 mg, Glycine 100 mg. Record review of MAR dated May 2023 indicated Resident #13 received the cognitive IV infusion on 05/02/23 at 9:09 a.m. by Contract IV RN. Record review of the nurse ' s notes for Resident #13 indicated he received the cognitive infusion on 05/02/23 at 10:11 a.m., for Resident #13 indicated the following . VS . INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility's Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22g LH x 1 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/multiple comorbidities and promote the immune system r/t infectious process. Order: 0.9% Normal Saline 250ML, {redacted} Cognitive PROTOCOL Infusion started @ 250ML/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1111 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc'd gauze and Coban to site. Report of infusion completion, indicated as entered by Contract IV RN and with no follow up noted after the infusion date. Record review of Post IV Infusion Evaluation dated 05/02/23 indicated Resident #13 had no adverse reactions noted during the nutrition infusion or 4 hours later. There were no other post evaluations made by facility staff after the dates of the infusions for Resident #13. Record review of Resident #13 ' s electronic record did not reveal a consent for the cognitive IV infusion from 03/1/23 to 06/13/23. During an interview on 06/13/23 at 11:35 a.m., Resident #13 said, They said I was on a list to get IV vitamins; that ' s all that was told so I took the IV vitamins. He said the lady was the one who started the IV and administered the vitamins and he had never seen her in the facility before. Resident #13 said the IV fluids went in within 20 minutes. Resident #13 said there were several residents in the back area with IVs running. He said the nurses just said it was vitamins and did not explain the side effects. Resident #13 said he could not name the nurses or the lady who did the IV. 5. Record review of a face sheet dated 06/13/23 indicated Resident #15 was a [AGE] year-old-female admitted [DATE] with diagnoses including Alzheimer's ' disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest task) chronic kidney disease (your kidneys are damaged and can't filter blood the way they should) and hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys that can occur in people with chronic kidney disease when the arteries servicing the kidneys become narrow and hardened). Record review of physician orders dated January 2023 indicated Resident #15 was prescribed a cognitive infusion IV one time dose of 250 ml normal saline 0.9% at 250 ml/hr Vitamin C (water soluble vitamin) 5 gm, B Complex-(water soluble vitamins) B1- 200 mg, B2 4 mg, B3 200 mg, B5 4 mg, B6 4 mg,B5 250 mg, B7 Biotin 20 mg, B12 Methyl cobalamin 2000 mcg, Magnesium Chloride 1000 mg, Calcium Gluconate 200 mg, Zinc 10 mg, Amino Blend, Calcium Gluconate 200 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg, Taurine 100 mg and Glycine 100 mg. Record review of a MAR dated January 2023 indicated Resident #15 received the cognitive IV infusion on 01/03/23 at 3:43 p.m. by Contract IV RN. Record review of a Nurses ' Note dated 01/03/23 at 10:11 a.m., for Resident #15 indicated the following . VS 119/67 73 97.2 18 {redacted} INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility's Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22g LH x 2 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/multiple comorbidities and promote the immune system r/t infectious process. Order: 0.9% Normal Saline 250ML, {redacted} INFECTION PROTOCOL Infusion started @ 250ML/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1351 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc'd gauze and Coban to site. Report of infusion completion, indicated as entered by Contract IV RN. Record review of a Post IV Infusion Evaluation dated 01/03/23 for Resident #15 indicated she received an IV for hydration/ wellness over 60 minutes with no adverse reaction noted post infusion by Contract IV RN. Record review of a quarterly MDS dated [DATE] indicated Resident #15 had a BIMS score of 3 indicating she had severely impaired cognition, she needed extensive assistance for bed mobility, transfers, toileting, and hygiene. This quarterly MDS indicated Resident #15 received IV therapy while a resident in the facility during the past 14 days. Record review of Resident #15 ' s care plans updated 05/08/23 did not address the IV therapy to include what adverse reactions were to be monitored nor was there documentation regarding who would monitor the resident for adverse reactions from the cognitive infusion therapy or for how often. Record review of physician orders dated May 2023 indicated Resident #15 was prescribed a cognitive infusion IV one time dose of 250 ml normal saline 0.9% at 250 ml/hr Vitamin C (water soluble vitamin) 5 gm, B Complex-(water soluble vitamins) B1- 200 mg, B2 4 mg, B3 200 mg, B5 4 mg, B6 4 mg,B5 250 mg, B7 Biotin 20 mg, B12 Methyl cobalamin 2000 mcg, Magnesium Chloride 1000 mg, Calcium Gluconate 200 mg, Zinc 10 mg, Amino Blend, Calcium Gluconate 200 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg, Taurine 100 mg and Glycine 100 mg. Record review of a MAR dated May 2023 indicated Resident #15 received the cognitive IV infusion on 05/02/23 at 09:19 a.m. by Contract IV RN. Record review of a Nurses ' Note dated 05/02/23 at 10:11 a.m., for Resident #15 indicated the following . VS 88/55 97.0 85 18 {redacted} INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility's Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22g LH x 1 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/multiple comorbidities and promote the immune system r/t infectious process. Order: 0.9% Normal Saline 250ML, {redacted} INFECTION PROTOCOL Infusion started @ 250ML/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1111 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc'd gauze and Coban to site. Report of infusion completion, indicated as entered by Contract IV RN. Record review of Resident #15 nurse's note dated 05/02/23 indicated Resident #15 received the cognitive infusion, had no complications or redness at injection site and no adverse reaction by LVN D (facility staff). There was no follow up noted after the infusion date. Record review of a Post IV Infusion Evaluation dated 05/02/23 for Resident #15 indicated she received an IV for hydration/ wellness over 60 minutes with no adverse reaction noted post infusion by Contract IV RN. Record review of Resident #15 ' s electronic record from 04/01/23 though 06/13/23 did not reveal a consent for the cognitive IV infusion. During an observation and interview on 06/13/23 at 11:28 a.m., Resident #15 was alert and sitting in her wheelchair. Resident #15 said she remembered getting an IV last month, but she did not remember anything about it or anyone telling her anything about it. During a family interview on 06/13/23 at 12:00 p.m., Resident #15 ' s daughter said the facility did not call her and ask her about the IV nutrients. She said she was not aware her mother received IV nutrients. She said she did not sign a consent for the IV. 6. Record review of a face sheet dated 06/13/23 indicated Resident #19 was a [AGE] year-old-female admitted [DATE] and readmitted [DATE] with diagnoses including hemiplegia of the left side (paralysis of one side of the body), stroke, diabetes mellitus (disease of inadequate control of blood levels of glucose) and morbid obesity. Record review of a quarterly MDS dated [DATE] indicated Resident #19 had a BIMS score of 15 indicating she was cognitively intact, and she needed extensive assistance for bed mobility, transfers, toileting, dressing, and hygiene. This quarterly MDS indicated Resident #19 received IV therapy while a resident in the facility during the past 14 days. Record review of Resident #19 ' s care plans updated 03/28/23 did not address the IV infusion therapy to include what adverse reactions were to be monitored nor was there documentation regarding who would monitor the resident for adverse reactions from the cognitive infusion therapy or for how often. Record review of physician orders dated April 2023 indicated Resident #19 was prescribed an infection infusion IV one time dose of 250 ml normal saline 0.9% at 250 ml/hr Vitamin C (water soluble vitamin) 5 gm, B Complex-(water soluble vitamins) B1- 200 mg, B2 4 mg, B3 200 mg, B5 4 mg, B6 4 mg,B5 250 mg, Zinc 10 mg, Amino Blend, Glutamine 150 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg and Glutathione 600 mg. Record review of a MAR dated April 2023 indicated Resident #19 received the infection infusion on 04/05/23 at 12:47 p.m. by Contract IV RN. Record review of a Nurses ' Note dated 04/05/23 at 12:43 p.m., for Resident #19 indicated the following . VS 88/55 97.0 85 18 {redacted} INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility's Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22gRAC x 1 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/multiple comorbidities and promote the immune system r/t infectious process. Order: 0.9% Normal Saline 250ML, {redacted} INFECTION PROTOCOL Infusion started @ 250ML/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1120 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc'd gauze and Coban to site. Report of infusion completion, indicated as entered by Contract IV RN. There was no follow up noted after the infusion date. Record review of a Post IV Infusion Evaluation dated 04/05/23 for Resident #19 indicated she received an IV for infection/viral and hydration over 60 minutes with no adverse reaction noted post infusion by Contract IV RN. Record review of physician orders dated May 2023 indicated Resident #19 was prescribed an infection infusion IV one time dose of 250 ml normal saline 0.9% at 250 ml/hr Vitamin C (water soluble vitamin) 5 gm, B Complex-(water soluble vitamins) B1- 200 mg, B2 4 mg, B3 200 mg, B5 4 mg, B6 4 mg,B5 250 mg, Zinc 10 mg, Amino Blend, Glutamine 150 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg and Glutathione 600 mg. Record review of a MAR dated May 2023 indicated Resident #19 received the infection IV infusion on 05/02/23 at 9:19 a.m. by Contract IV RN. Record review of Resident #19 ' s nurse's note dated 05/02/23 indicated Resident #19 received the infection/viral and hydration IV infusion and she tolerated it without difficulty or complications by Contract IV RN. Record review of a Nurses ' Note dated 05/02/23 at 10:20 a.m., for Resident #19 indicated the following . VS 88/55 97.0 85 18 {redacted} INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility's Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22gRAC x 1 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/multiple comorbi[TRUNCATED]