Health inspection·April 28, 2022

F 0550 respect, and personal hygiene for residents. (Copy of grievance form obtained) Level of Harm - Minimal harm or potential for actual harm In an interview on 04/28/22 at 5:30 PM, the Administrator confirmed that there had been incidents when staff had failed to show respect and were not compassionate. He added that there was an incident that was brought to his attention about staff who were unpleasant to each other during the survey. He added that there had been multiple in-services about customer service, and moving forward, staff who did not adhere facility policy would be terminated. Residents Affected - Few A review of the facility's policy and procedure titled Dignity (CD-17), created on 3/8/21, revealed that each resident shall be cared for in a manner that promotes and enhances quality of life and dignity, respect and individuality. The policy interpretation and implementation read: 1. Resident shall be treated with dignity and respect at all times. 2. Treated with Dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by promptly responding to the resident's request for toileting assistance. 2. On 04/26/22 at 1:16 PM, Resident #31 stated he had been sitting in his soiled brief since before lunch. He notified his assigned CNA (Employee H) at approximately 10:30 AM that he needed assistance with incontinence care. CNA H turned the call light off and did not return to change his brief. Registered Nurse (RN) I, standing at the medication cart outside of the resident's room, was notified at 1:20 PM that the resident stated he had been waiting for assistance with incontinence care since approximately 10:30 AM. RN I stated she was not aware that the resident needed incontinence care. She verified with the resident that he needed to be changed and then went and to find CNA H. At approximately 1:23 PM, CNA H was observed walking up the hallway stating the resident was telling a story. CNA H stated she went in the resident's room to change the resident in bed A, and she asked Resident #31 if he needed changing. He said no, he was dry. CNA H then went into the room to assist the resident with incontinence care. During a follow-up interview with Resident #31 on 04/28/22 at 11:37 AM, he stated CNA H became upset with him and told him that he lied on her and she wasn't speaking to him now. When asked how it made him feel, the resident stated, It hurt. I just want her to like me again. The resident stated he feared being discharged because he spoke up about what happened, and he didn't want to lose his home because he had nowhere else to go. The resident's Quarterly MDS assessment, dated 3/18/22, indicated he had a brief interview for mental status (BIMS) score of 12 out of a possible 15 points, indicating minimal cognitive impairment. A review of the facility's policy and procedure titled Dignity (CD-17), created on 3/8/21, revealed that each resident shall be cared for in a manner that promotes and enhances quality of life and dignity, respect and individuality. The policy interpretation and implementation read: 7. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105927 If continuation sheet Page 2 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105927 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains Rehabilitation at Mill Cove 9960 Atrium Way Jacksonville, FL 32225 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 diagnosis, or care needs. Level of Harm - Minimal harm or potential for actual harm 9. Staff shall maintain an environment in which confidential clinical information is protected, for example: Residents Affected - Few a. Verbal staff-to-staff communication (e.g. change of shift reports) shall be conducted outside the hearing range of residents and the public. 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: b. Promptly responding to the resident's request for toileting assistance. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105927 If continuation sheet Page 3 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105927 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains Rehabilitation at Mill Cove 9960 Atrium Way Jacksonville, FL 32225 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, by failing to ensure one (Resident #74) of four residents reviewed, from a total sample of 30 residents, received medication as ordered by the physician. Residents Affected - Few On 4/25/22 at 12:06 p.m., Resident #74 stated she took lithium daily and had not received the medication for the last five days. A review of Resident #74's medical record revealed that she was admitted on [DATE] with diagnoses including insomnia, anxiety disorder and bipolar disorder. A review of the admission Minimum Data Set (MDS) assessment, dated 4/13/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating intact cognition. She required limited assistance for bed mobility, transfers, eating and toilet use. She received hypnotic and anxiolytic medications. A nursing note dated 4/18/22, indicated that the resident appeared anxious throughout the shift. A review of the resident's active physician's orders revealed a 4/7/22 order for lithium carbonate ER (extended release) 300 mg (milligrams) daily at bedtime (9:00 p.m.) for bipolar disorder. A review of the current care plan revealed that Resident #74 received psychotropic and anticonvulsant medications, and herbal supplements related to diagnoses of anxiety, bipolar disorder, and insomnia. Interventions included the administration of medications as ordered by the physician. Staff were to monitor for side effects and effectiveness every shift. A review of the pharmacy delivery receipt revealed that a 7-day supply of lithium carbonate was delivered to the facility on 4/11/22 at 6:09 p.m. (Copy Obtained) In an interview on 4/26/22 at 3:45 p.m., Licensed Practical Nurse (LPN) D was asked if Resident #74 had lithium carbonate in the medication cart. LPN D opened the cart and obtained a blister pack for a 30-day supply with a refill date of 4/22/22. Only one dose was removed. (Photographic Evidence Obtained) LPN D stated the resident took the medication at night and therefore, she did not know if the resident had been receiving it. When asked for the pharmacy delivery manifest, LPN D stated she did not think the facility had a system for keeping the manifests. She added that she would ask the Assistant Director of Nursing (ADON). In an interview on 4/26/22 at 3:50 p.m., the ADON confirmed that there was no process for maintaining the pharmacy delivery manifests. When asked how she would identify how many refills were made for Resident #74's lithium carbonate, she stated she had contacted the pharmacy about the medication and was notified that it was delivered on 4/22/22. She added that she had contacted the pharmacy since the family had contacted the facility to ensure that the resident had enough medication before her discharge on [DATE]. The ADON stated she was not sure whether there was another delivery made before 4/22/22. During a telephone interview on 4/26/22 at 3:55 p.m., the pharmacy representative stated Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105927 If continuation sheet Page 4 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105927 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains Rehabilitation at Mill Cove 9960 Atrium Way Jacksonville, FL 32225 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 #74's lithium carbonate was dispensed as follows: Level of Harm - Minimal harm or potential for actual harm A 7-day supply was sent on 4/11/22, and a 30-day supply was sent on 4/22/22. Residents Affected - Few A review of the April 2022 Medication Administration Record (MAR), revealed that lithium carbonate was scheduled daily at 9:00 p.m. and was signed off by nursing as having been administered every night from 4/7/22 through 4/26/22, except on 4/8/22, 4/10/22, and 4/22/22. (A 7-day supply sent on 4/11/22 would have made the medication available to the resident from 4/11 through 4/17/22. There was no explanation for how the facility administered the medication prior to 4/11/22. A 30-day supply sent on 4/22/22 would have made the medication available to the resident from 4/22/22 through her discharge on [DATE]. There was no explanation for how the facility administered the medication from 4/18 through 4/21/22, and there was no explanation for why the 30-day supply delivered on 4/22/22 was only missing one pill as of 4/27/22 when the medication was ordered routinely every night.) In an interview on 4/27/22 at 3:11 p.m., the Director of Nursing (DON) stated he was not sure where the nurses obtained the lithium carbonate for Resident #74 from 4/7/22 through 4/10/22, and from 4/18/22 through 4/21/22, since the April MAR had been signed off as though the medication had been administered during that time. Review of the facility policy and procedure titled Medication Administration Created 6/2018 and reviewed on 1/2022 indicated that medications shall be administered in a safe and timely manner, and as prescribed. Procedure revealed that: 1. The director of nursing services will supervise and direct all nursing personnel who administer medications and /or have related functions. 2. Medications must be administered in accordance with the orders, including any required time frame. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105927 If continuation sheet Page 5 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105927 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains Rehabilitation at Mill Cove 9960 Atrium Way Jacksonville, FL 32225 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to adminster tube feedings as ordered by the physician for one (Resident #44) of one resident reviewed for compliance with enteral nutrition from a total of 30 sampled residents. The findings include: A review of Resident #44's medical record revealed an admission date of 3/22/2022. His primary medical diagnosis was hemiplegia following cerebrovascular disease affecting the right dominant side. Secondary diagnoses included oropharyngeal dysphagia, diabetes, and cognitive/communication deficit. A five-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09 out of a possible 15 points, indicating moderately impaired cognition. Resident #44 required extensive to total assistance with activities of daily living (ADLs) and received his nutrition via enteral feeding (liquid nutrition delivered through a feeding tube). On 4/25/2022 at 1:35 p.m., Resident #44 was observed lying in his bed. His tube feeding was not connected. On 4/26/2022 at 2:19 p.m., Resident #44 was observed sitting in his wheelchair at his bedside. His tube feeding was not connected. On 4/28/2022 at 2:05 p.m., Resident #44 was observed sitting up in his wheelchair at his bedside with a visitor. His tube feeding was not connected. A review of Resident #44's physician's orders revealed an order dated 4/1/2022 for enteral feeding to he connected at 12:00 p.m. and disconnected at 8:00 a.m. the following morning. (Photographic Evidence Obtained) A review of Resident #44's progress notes revealed an entry by the dietician dated 3/31/2022 at 1:32 p.m., which indicated the resident's tube feeding was adjusted to promote participation in therapy. Resident is more alert and oriented in the AM and fatigued by lunch time per therapy. (Photographic Evidence Obtained) On 4/28/2022 at 2:15 p.m., an interview was conducted with Licensed Practical Nurse (LPN) A. He confirmed he was familiar with Resident #44 and that he was assigned to care for Resident #44 today. When asked what time Resident #44's tube feeding was due to be connected, LPN A stated, I think it is supposed to be connected at 3 o'clock. LPN A was asked to review Resident #44's physician's orders for enteral feeding and confirm the time the feeding was supposed to be connected. After reviewing the physician's orders for approximately five minutes, LPN A was unable to find the time. On 4/28/2022 at 2:26 p.m., LPN A returned and explained that the enteral feeding should be connected at 12:00 p.m. He stated he thought the order had changed. LPN A stated he was going to connect the enteral feeding immediately. A review of Resident #44's comprehensive care plan revealed a focus area for nutritional risk. Interventions included administration of tube feedings as ordered. (Photographic Evidence Obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105927 If continuation sheet Page 6 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105927 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains Rehabilitation at Mill Cove 9960 Atrium Way Jacksonville, FL 32225 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105927 If continuation sheet Page 7 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105927 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains Rehabilitation at Mill Cove 9960 Atrium Way Jacksonville, FL 32225 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews, the facility failed to provide oxygen at the prescribed flow rate for one (Resident #31) of 19 residents receiving respiratory treatments from a total of 30 residents in the sample. Residents Affected - Few The findings include: A review of Resident #31's medical record revealed his most recent admission date was 12/28/2021. His diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea (OSA). An active physician's order revealed oxygen was to be provided at 3 liters per nasal cannula continuous, Check oxygen saturation, respirations and temperature qshift (every shift). A review of the care plans revealed a focus area for COPD with an intervention that read, Give oxygen therapy as ordered by the physician. Resident #31 was observed on 4/26/2022 at approximately 11:11 AM. He was wearing his oxygen cannula and the concentrator was dispensing oxygen at a flow rate of 4 liters per minute (LPM). On 4/27/2022 at 1:16 PM, the flow rate for Resident #31's oxygen was set between 3.5 and 4 LPM. (Photographic Evidence Obtained) On 4/28/2022 at 11:37 AM, the oxygen concentrator's flow rate was set between 3.5 and 4 LPM. (Photographic Evidence Obtained) Registered Nurse (RN) F was interviewed at 11:45 AM on 4/28/2022. When asked about the resident's oxygen order, RN F confirmed that the resident was to receive oxygen at 3 LPM. When asked about the protocol for checking residents' oxygen concentrators, the nurse stated they were to be checked once per shift and documented on the Medication Administration Record (MAR). RN F checked Resident #31's oxygen concentrator flow rate and verified it was set at 4 LPM. An interview was conducted with the Assistant Director of Nursing (ADON) on 4/28/22 at 12:26 PM. The ADON stated all orders were checked on admission. The nurses assigned to the unit were expected to check residents' flow rates every shift and sign off on the Treatment Administration Record (TAR), verifying the oxygen flow rate settings. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105927 If continuation sheet Page 8 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105927 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains Rehabilitation at Mill Cove 9960 Atrium Way Jacksonville, FL 32225 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less, based on four errors out of 30 opportunities for error, resulting in a facility error rate of 13.33%, and involving Residents #59, #6, #23, and #228. Residents Affected - Few The findings include: 1. During medication administration on 4/26/22 at 11:30 a.m., Licensed Practical Nurse (LPN) A reviewed the Medication Administration Record (MAR) for Resident #59. He obtained the equipment necessary for blood sugar monitoring. He explained the process to the resident and obtained a blood glucose reading of 194 milligrams per deciliter (mg/dl). He then obtained the resident's Novolog flex pen (insulin) and administered 5 units in the resident's left upper arm. He performed hand hygiene and documented in the MAR. (Copy obtained) In an interview on 4/26/22 at 11:40 a.m., LPN A confirmed that he had administered 5 units of Novolog insulin. He added that the resident had a standard order for 5 units before meals. When asked to review the physician's orders, LPN A revealed orders for Novolog 100 units/ml (units per milliliter), inject 5 units subcutaneously before meals, and another order for Novolog 100 units/ml, inject per sliding scale. If blood sugar is 181-220, give 2 units. LPN A confirmed that he should have given 7 units in total instead of 5 units. He added that he was not sure if he should give the other 2 units since the resident had a low blood sugar of 60 earlier this morning. After pausing momentarily, LPN A proceeded to the resident's room and administered the remaining 2 units of insulin. He initially checked off both orders on the MAR indicating he had administered 7 units when he had only administered 5 units, prior to administering the final 2 units per sliding scale. (Photographic Evidence Obtained) 2. On 4/26/22 at 12:06 p.m., Registered Nurse (RN) B was observed preparing to perform blood sugar monitoring for Resident #6. RN B performed hand hygiene with hand sanitizer donned clean gloves and obtained the glucometer, lancet, alcohol wipe and test strip. She entered Resident #6's room, cleansed the resident's right index finger with the alcohol wipe, pricked the resident's finger with the lancet, and obtained the blood sample. She obtained a blood sugar reading of 178 mg/dl. She cleansed the residents' finger used to obtain the blood sample with an alcohol wipe, collected the supplies and exited the resident's room. After appropriately discarding the lancet and test strip, she placed the glucometer on the medication cart, doffed her gloves and donned new gloves. She cleaned the glucometer with disinfecting wipes and placed it back on the medication cart. She doffed her gloves, performed hand hygiene, donned new gloves, obtained Resident #6's Novolog insulin pen, and set it to 2.5 units. She proceeded to the resident's room and cleansed the resident's left upper arm. Just prior to administration of the insulin, RN B was asked to show the setting for the Novolog pen and it revealed 2.5 units. She then adjusted the dosage to 2 units and administered the insulin. In an interview on 4/26/22 at 12:10 p.m., RN B confirmed that the insulin pen was at the wrong setting until she was prompted to adjust it. 3. On 4/27/22 at 10:19 a.m. LPN C was observed preparing medications for Resident #23. After performing hand hygiene, she obtained FiberCon tablet (Calcium Polycarbophil), 625 miligrams (mg), metoprolol tartrate 75 mg and probiotics (a lactobacillus capsule). The nurse crushed the medications separately and poured them into separate medication cups. She entered the resident's room, obtained water from the resident's bathroom sink and donned gloves. After donning gloves, the nurse proceeded to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105927 If continuation sheet Page 9 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105927 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains Rehabilitation at Mill Cove 9960 Atrium Way Jacksonville, FL 32225 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident's bedside table, opened the probiotic capsule and poured the contents into a separate cup. She obtained a disposable spoon, stirred the medication and began administering the medications one-at-a-time via the resident's Percutaneous Endoscopic Gastrostomy (PEG) tube (feeding tube). Medication was observed in the medication cups as the nurse completed administration of the medication. Before she could dispose of the cups, she was asked to look in the medication cups, which revealed approximately 50 % of the medications was not administered. (Photographic Evidence Obtained) In an interview on 4/27/22 at 10: 25 a.m., she confirmed that the medication was not completely dissolved and therefore not completely administered. She asked,Would you want to completely administer them? 4. On 4/27/22 at 10:30 a.m., the Assistant Director of Nursing (ADON) was observed preparing intravenous (IV) antibiotic medication for Resident #228. She obtained Daptomycin, 500 mg vial (Antibiotic) and reconstituted the powdered medication in a vial with 100 ml (milliliters) of normal saline. She primed the medication administration set, hung the medication on the IV pole, and connected the IV pump. There were visible bubbles still in the line. After cleaning the central line hub, she flushed it with 100 milliliters of normal saline, and connected the end of the IV medication administration set to the central line hub. As she was about to start the medication administration pump, she was stopped and notified of the air bubbles in the IV line. (Photographic evidence obtained). She disconnected the IV and started priming the line on a paper towel placed on the resident's bedside table. The paper towel did not absorb all of the medication; excess medication was running down the table. After she was finished reconnecting the IV, she dried the bedside table with a paper towel, doffed her gloves, performed hand hygiene and exited the resident's room. According to National library of medicine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665124/ (accessed on 4/28/22 at 1:17 p.m.), Air embolism is a rare but potentially fatal occurrence and may result from a variety of procedures and clinical scenarios. It can occur in either the venous or arterial system depending on where the air enters the systemic circulation. The effects will vary according to the vessels affected but cardiovascular, pulmonary, and neurological effects predominate the clinical picture. Occlusions of the cerebral and cardiac circulation are usually more clinically significant as these systems are highly vulnerable to hypoxia. A review of the facility's policy and procedure titled Medication Administration (created 6/2018 and reviewed on 1/2022), revealed that Medications shall be administered in a safe and timely manner, and as prescribed. Procedure revealed that: 1. The director of nursing services will supervise and direct all nursing personnel who administer medications and /or have related functions. 2. Medications must be administered in accordance with the orders, including any required time frame. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105927 If continuation sheet Page 10 of 10