Health inspection·March 27, 2025

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, observation, record review, and facility policy review, the facility failed to provide care for a peripherally inserted central catheter (PICC) consistent with standards of practice when they did have physician orders for the dressing change of the PICC line, did not flush the catheter per order, and did not change the PICC line dressings weekly. This affected one, (Resident #59) of three residents reviewed for intravenous lines. The facility census was 92. Residents Affected - Few Finding include: Record review for Resident #59 revealed an admission date of 04/13/22 with pertinent diagnoses of cerebral infarction due to thrombosis, dependence on respirator, tracheostomy status, gastrostomy status, persistent vegetative state, chronic respiratory failure with hypoxia, thrombocytopenia, pulmonary embolism, anemia, hypertension, retention of urine, and hirsutism. Review of the 01/10/25 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was in a persistent vegetative state and was dependent for all activities of daily living. The Resident used a ventilator for breathing. Review of Physician Orders dated 02/28/25 revealed Sodium Chloride Solution 0.9 % use 10 milliliters (ml)intravenously every shift for flush. Review of the Physician Orders on 03/26/25 at 11:30 A.M. revealed no order for changing PICC line dressings for Resident #59. Interview with Licensed Practical Nurse (LPN) #22 on 03/26/25 at 11:40 A.M. revealed there were two residents on her hallway with intravenous (IV) lines. She stated she was an LPN but was not IV certified. Observation of Resident #59's PICC line on 03/26/25 at 11:50 A.M. revealed the dressing was dated as changed 03/07/25. Interview with the Director of Nursing (DON) on 03/26/25 at 11:50 A.M. verified the PICC line dressing was dated 03/07/25 and the dressing was suppose to be changed every seven days. Review of the medication administration record for Resident #59 on 03/26/25 at 12:10 P.M. revealed there were nine times the PICC line flush was not signed off as completed during the month of March 2025. Page 1 of 2 365469 365469 03/27/2025 Batavia Nursing Care Center 4000 Golden Age Drive Batavia, OH 45103

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the DON on 03/26/25 at 12:55 P.M. verified there was no Physician Order for PICC line dressing change and there were nine spots on the medication administration record for March 2025 where the every shift PICC lines flushes were not sign off as completed when Licensed Practical Nurse #22 worked as Resident #59's nurse. Review of the facility 10/01/10 midline dressing changes policy revealed change midline catheter dressing 24 hours after catheter insertion, every five to seven days, or if it is wet, dirty, not intact, or compromised in any way. This deficiency represents non-compliance investigated under Complaint Number OH00163050. 365469 Page 2 of 2