Health inspection·August 23, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete care. In an interview with facility's DON on 08/22/2025 at 12:32 PM, she stated she was not aware of Resident #1's skin concerns around her genital area as it has not been documented or reported to her. She stated she expected any skin changes to be properly assessed by her staff, which would then triggered care plan interventions for her clinical leadership to review and add to the comprehensive care plan to ensure proper care for the resident. Record review of the facility policy Care Plans - Comprehensive, dated 09/2010 revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 1. Our facility's Care Planning/Interdisciplinary Team in coordination with the resident. develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 3. Each resident's comprehensive care plan is designed to: a. incorporate identified problem areas b. Incorporate risk factors associated with identified problems c. Build on the resident's strengths . g. Aid in preventing or reducing declines in the resident functional status an/or functional levels h. enhance optimal functioning of the resident by focusing on a rehabilitative program i. Reflect currently recognized standards of practice for problem areas and conditions. 8. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's conditions change. Event ID: Facility ID: 455832 If continuation sheet Page 2 of 8 Printed: 05/15/2026 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 455832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Gardens 2535 W Pleasant Run Lancaster, TX 75146 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 observation, interview and record review, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #1 and Resident #2) of seven residents reviewed for skin integrity. 1. The facility failed to ensure Resident #1 received accurate skin assessments that included change of condition around her genital area on 08/04/2025, 08/13/2025, and 08/20/20252. The facility failed to ensure Resident #1 received medication and treatment per provider orders related to her genital area on 08/16/2025, 08/17/2025, and 08/21/2025. 3. The facility failed to ensure Resident #2 received Skin Assessments per doctor's orders on 07/05/2025, 07/12/2025 07/19/2025Review of Resident #1's face sheet dated 08/21/2025 revealed was a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. Relevant diagnoses included dementia (brain dysfunction related to memory and mood,) subdural hemorrhage (bleeding in the brain,) status post craniotomy (brain surgery) resulting in osteomyelitis (infection) to her scalp.Review of Resident #1's Quarterly MDS dated [DATE] revealed she was severely cognitively impaired with a BIMS score of 05. She was dependent upon staff for toileting, lower body dressing, and putting on/taking off footwear. She was always incontinent of bowel and bladder. It was documented that she was re-admitted to the facility with surgical wounds that required applications of ointments/medications. No documentation of skin concerns of the genital area were documented.Record review of Resident #1's Skin Assessment after her re-admission on [DATE] revealed-Right lateral (side) temporal (scalp) area surgical wound was resolved-Front, upper scalp injury was resolved-Right, upper scalp surgical wound. scabbing present, and skin prep was used as dressingNo evidence of skin integrity issues associated with the genital area were observed.Record review of Resident #1's LVN B's progress note dated 08/04/2025 at 10:48 AM revealed she did incontinent care on the resident and noted areas of redness [to her genital area] and notified the provider. LVN B further documented she received an order to apply Zinc Oxide 10% cream to peri area (genitals) three times a day until healed.Record review of Resident #1's Skin Assessment on 08/11/2025 revealed-Right, upper scalp surgical wound. serous exudate (drainage) that was cleansed with normal saline, debrided (removal of damaged tissues,) and a dressing with Mupirocin 2% dressing applied. No evidence of skin integrity issues associated with the genital area were observed.Record review of Resident #1's Skin Assessment on 08/18/2025 revealed :-Right, upper scalp surgical wound. no exudate. cleansed with normal saline, debrided (tissue removed,) and dressed with a dry dressing.No evidence of skin integrity issues associated with the genital area were observed.Record review on 08/21/2025 at 10:00 AM of Resident #1's Physician Orders and TAR revealed Zinc Oxide External Cream 10% (topical) Apply to excoriated peri area/butt topically three times a day for areas with excoriation until healed with a start date of 08/05/2025 at 1:00 AM. Record review of Resident #1's TAR revealed no documented evidence Resident #1 received the Zinc Oxide External Cream 10% on:-08/16/2025 at 1:00 AM and 9:00 AM-08/17/2025 at 1:00 AM and 9:00 AM-08/21/2025 at 1:00 AM Record review on 08/21/2025 at 10:05 AM of Resident #1's Physician Orders and TAR revealed Nystatin Powder Apply to Peri area topically two times a day for yeast for 14 days with a start date of 08/16/2025 at 9:00 PM. Record review of Resident #1's TAR revealed Resident #1 received Nystatin Powder as ordered. Record review on 08/21/2025 at 10:15 AM of Resident #1's Physician Orders and TAR revealed Diflucan Oral 150 MG Give 1 tablet by mouth one time only for fungal infection with a start date of 08/17/2025 at 8:00 AM. Record review of Resident #1's TAR revealed no documented evidence Resident #1 received the medication as ordered. In an observation of Resident #1 on 08/21/2025 at 9:44 AM, revealed CNA G provided Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455832 If continuation sheet Page 3 of 8 Printed: 05/15/2026 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 455832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Gardens 2535 W Pleasant Run Lancaster, TX 75146 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incontinent care. Resident #1 had significant redness and inflamed skin around her genital area. In an interview with CNA G on 08/21/2025 at 9:55 AM, CNA G stated Resident #1's skin had been like that for an extended period and that she had informed the nursing staff. She stated Resident #1 has cream for the redness. She stated it was her responsibility to inform the nursing staff if the resident had any new skin changes or refused activity of daily living (ADL's) or incontinent care. Interview with Resident #1 on 08/21/2025 at 9:44 AM was not successful due to her cognition. Record review of Resident #1's Wound Care Provider Visit Notes, dated 08/22/2025, revealed:-Back/Sacrum (tailbone). irritation to sacrum with rash and satellite lesion and serpiginous border (damage or changes to the tissues)-Buttock. irritated dermatitis (irritated skin,) fungal rash with satellite lesions and serpiginous border-Groin/Perineum] (genital area). irritated dermatitis, fungal rash with satellite lesions and serpiginous border. Resident #1 was diagnosed with Tinea Cruris (fungal infection) around her groin and Irritant dermatitis from incontinence around her diaper distribution. Record review on 08/21/2025 at 11:00 AM of Resident #1's Physician Orders and TAR revealed Diflucan Oral 150 MG Give 1 tablet by mouth one time only for fungal infection was re-ordered on 08/22/2025 at 8:00 PM and record review of Resident #1's TAR revealed Resident #1 received Diflucan Oral 150 MG as ordered. In interview with LVN B on 08/21/2025 at 11:45 AM she recalled Resident #1 having skin redness earlier in the month of August 2025 and it had persisted since then. She stated she received an order from the provider for topical Zinc Oxide for treatment earlier in the month. She stated she did not complete a skin re-assessment to reflect the change but stated she should have completed a re-assessment as that was a change in condition for the resident. She stated it was her responsibility to accurately assess the resident as the resident's nurse for resident safety. In interview with 08/23/2025 at 2:11 PM, LVN D stated he was working as the charge nurse on 08/17/2025 and was assigned Resident #1 for that day. He stated he did not recall giving Resident #1's Diflucan as ordered, and stated he did not see the order. He stated he should have provided the medication as ordered and could not state why he did not. He stated it was his responsibility to provide the resident with medications as ordered. Interview with the facility's Treatment Nurse on 08/21/2025 11:00 AM was not successful as she was currently out of the country and could not be accessed via phone. In an interview with the facility's ADON on 08/23/2025 at 9:49 AM he stated he expected his nurses to complete timely and accurate skin assessments. He stated he expected any changes in resident's skin to be captured on skin assessments to catch skin concerns as early as possible for resident care and safety. He stated he was aware of Resident #1's genital area redness, and they've been treating it for an extended period. He stated he expected that to have been documented ion her weekly skin assessments and did not know why it was not. He stated the facility had a treatment nurse but she was currently out of the country on leave. He stated he expected Resident #1 to have received medications and treatment as ordered because the skin is the first line of prevention of infection. He stated he was not sure why Resident #1 did not receive medications and treatments as ordered but stated it was his and the DON's responsibility to ensure these interventions were completed. In an interview with facility's DON on 08/23/2025 at 2:06 PM, she stated Resident #1 was seen by the facility's wound care provider, Physician E, yesterday and new orders were added to Resident #1's treatment regimen. She stated that if Resident #1 had any skin changes dating back to 08/04/2025, the nurse should have completed a new skin assessment. She stated she expected her nurses to assess and document any skin changes of their residents and she expected the assessments her nurses completed to be accurate. She stated the facility had a treatment nurse, but she was currently on leave. She stated her expectation was for her nurses to provide medications as ordered. She stated the missed Zinc Oxide treatments were not acceptable and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455832 If continuation sheet Page 4 of 8 Printed: 05/15/2026 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 455832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Gardens 2535 W Pleasant Run Lancaster, TX 75146 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should have been completed per providers orders. She stated she was not sure why the treatments were not provided and declined to state the importance of this for the resident. She further stated the missed dose of Diflucan was because the order was not activated. She stated she expected the charge nurse to have captured that. She stated it was the charge nurse's responsibility to ensure any new orders for residents were activated and administered as ordered. She stated it was the ADON's responsibility to ensure that was completed for resident care and safety reasons. In an interview with Resident #1's wound care provider, Physician E, on 08/23/2025 at 2:35 PM, she stated she saw Resident #1 yesterday for her genital area. She stated she was already treating Resident #1 for other skin issues on her head; but would not necessarily assess her genital area unless the resident's skin assessments directed her to do so. She stated her visits were focused and she relied on facility staff to tell her what is going on. She stated her expectations were for facility nurses to complete accurate assessments to then guide her skin assessments. Furthermore, she expected facility staff to provide medications and treatments as ordered for the wellbeing of the resident.Record review of Resident #2's face sheet dated 08/22/2025 reflected a [AGE] year old male who admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease with late onset,(brain disorder that causes memory loss, confusion, and other cognitive decline), hemiplegia(condition characterized by paralysis or weakness on side of the body), and atherosclerotic heart disease of native coronary artery without angina pectoris(buildup of fats, cholesterol and other substances in and on the artery walls). Record review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected he had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. The resident was considered at risk for developing pressure ulcers/injuries but did not have any unhealed pressure ulcers/injuries.Record review of Resident #2's Comprehensive Care Plan date 07/03/2025 reflected pressure ulcer prevention-barrier cream-turn and reposition every 2 hours and as needed. Keep body in good alignment-encourage to float heels as tolerated-Pressure ulcer redistributions mattress-Use suspension devices, pillows, and/or wedges to reduce pressure on heels and bony prominences Record review of Resident #2's TAR dated 07/1/2025-07/31/2025, revealed orders for weekly head to toe skin assessments every day shift every Saturday. Further review revealed there were no entries for weekly head to toe skin assessments on 07/05/2025, 07/12/2025, and 07/19/2025.Record review of the facility's Census dated 08/20/2025 revealed Resident #2 was discharged to the hospital] on August 8, 2025. In an interview with the DON on 08/22/2025 at 10:40am she stated it was the charge nurse's responsibility to complete weekly skin assessments. She stated staff was expected to follow the physician's orders and complete weekly skin assessments. She stated weekly skin assessments were documented on the TAR. She stated skin assessments were completed to identify any new skin breakdowns or issues. She stated not completing skin assessments was failure to identify a new issue. She stated Resident #2 did not have any pressure ulcers. She stated she could not say why the weekly skin assessments for Resident #2 were not completed and it was the ADON's and DON's responsibility to ensure weekly skin assessments were completed. She revealed Resident #2 was currently in the hospital due to a change in condition.In an interview with the RP for Resident #2 on 8/22/2025 at 3:51pm revealed Resident #2 was currently in the hospital and Resident #2 admitted to the facility 2 years ago. She stated in the past, Resident #2 had skin issues, but he did not have any current skin issues. In an interview with the ADON on 8/23/2025 at 10:01am he stated nurses were responsible for completing skin assessments. He stated skin assessments were supposed to be completed weekly because it gave staff a chance to look at the resident entire head to toe. He stated there should be no reason skin assessments were not completed. He stated skin assessments are documented in the TAR. He stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455832 If continuation sheet Page 5 of 8 Printed: 05/15/2026 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 455832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Gardens 2535 W Pleasant Run Lancaster, TX 75146 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete failure to complete weekly skin assessments can affect the residents tremendously and could lead to sepsis and death. He stated the last in service on wounds took place approximately two weeks ago. In an interview with the ADM on 8/23/2025 at 11:03am she stated it was the charge nurse's and wound care nurse's responsibility to complete weekly skin assessments. She stated there were several systems in place to ensure skin assessments were being completed. She stated she would assume she would assume someone missed the documentation on weekly skin assessments for Resident #2 because nothing was there. She stated failure to document completed skin assessments and follow protocol could cause staff to miss any new skin issues. She stated in-services on skin assessments are completed every quarter and as needed. In an interview with LVN D on 8/23/2025 at 12:26pm he stated it was the charge nurse's or wound care nurse's responsibility to completed skin assessments as ordered. He stated aides should also share any skin issues with the nurse when aides performed incontinent care or showered to residents. He stated skin assessments were documented in the TAR. He stated he could not recall not completing weekly skin assessments on Resident #2 or any other resident. He stated failure to complete skin assessments could cause a big issue such as skin breakdowns that could become worse. He stated staff was in serviced on skin assessments continuously and as needed. He stated he could not recall the last in service on skin assessments. Record review of the facility's Patient Care Management System 1 dated July 2022 revealed 1. The Treatment Nurse or Nurse Manager designee will complete a head-to-toe assessment and document in the EMR to validate the findings of the initial skin assessment. Head to toe assessments must be completed weekly and prior to discharge/transfer of a Patient. 19. The Director of Nursing or designee will audit and verify system compliance weekly including prevention focused rounding and education as appropriate. Record review of facility policy Skin, dated 07/2022, revealed . 2. Head-to-toe assessments must be completed weekly. 7. Non-Pressure Injury Plan of Care will be completed by the Treatment Nurse or Charge Nurse upon identification. and updated with any changes to interventions and upon resolution. Event ID: Facility ID: 455832 If continuation sheet Page 6 of 8 Printed: 05/15/2026 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 455832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Gardens 2535 W Pleasant Run Lancaster, TX 75146 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received parenteral fluids consistent with professional standards of practice in accordance to physician's orders, the comprehensive person-centered care plan, and the resident's goals and preferences for (Resident #1) of five residents reviewed for parenteral fluids. The facility failed to ensure Resident #1 who had intravenous access present upon observation on 08/21/2025 at 9:44 AM had physician's orders for assessment, care, monitoring, and treatment. This failure could place residents at risk of injury, infection, and a decreased quality of life.Findings included: Review of Resident #1's face sheet dated 08/21/2025 revealed was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted from an acute care hospital 07/30/2025. Relevant diagnoses included dementia (brain dysfunction affecting memory and mood,) subdural hemorrhage (brain bleed,) status post craniotomy (brain surgery) resulting in osteomyelitis (infection) to her scalp. Review of Resident #1's Quarterly MDS dated [DATE] revealed she was severely cognitively impaired with a BIMS score of 05. She was dependent upon staff for toileting, lower body dressing, and putting on/taking off footwear. She was always incontinent of bowel and bladder. She was admitted with surgical wounds that required applications of ointments/medications. Review of Resident #1's Comprehensive Care Plan dated 08/21/2025 revealed she had:-Impaired cognitive function and thought processes related to dementia with intervention that included that she required assistance for mobility, dressing, and repositioning in bed. -Had an infection [to her scalp] with intervention that included to administer antibiotics as ordered, maintain universal precautions, and monitor, document, and report to provider and signs or symptoms of delirium.-Had intravenous access for the purposes of receiving [antibiotics] with intervention that included to administer intravenous fluids as prescribed, change tubing site dressing every 72 hours, check IV site every 2 hours, observe signs of infection, infiltration (catheter coming out of the vein and into the surrounding tissues.)In observation and interview of Resident #1 on 08/21/2025 9:44 AM revealed her in bed resting with a single lumen intravenous access (one line) present on her on her right upper arm. The dressing appeared clean, dry, and intact and was dated 08/19/2025. The resident stated she received the intravenous access in the hospital but was not able to provide any further detail due to her cognitive status. Review of Resident #1's Physician's Orders on 08/21/2025 at 9:00 AM revealed orders for two intravenous antibiotics with a start and end date of 08/13/2025 - 08/22/2025 respectively. -Cefepime HCL Solution 2 GM/100 ML every 8 hours-Vancomycin HCL Solution 750 MG/150 ML every 24 hoursNo evidence of orders related to the assessment, care, monitoring, and treatment of Resident #1's intravenous access.In an interview with LVN A on 08/21/2025 at 12:38 PM, he stated he had been Resident #1's nurse for a couple of days and today. He stated he was aware that Resident #1 had a PICC line. He stated Resident #1 should have physician's orders for assessment, care, monitoring, and treatment and was not aware of the reason she did not. He stated it was the nurse's responsibility to ensure those orders were in the resident's MAR. He stated it was the ADON's responsibility to catch it if it was missed. He stated it's important for residents with PICC lines (intravenous access) to have provider orders for the safety of the resident and so the care could be documented every shift. In an interview with DON on 08/22/2025 12:32 PM, she stated Resident #1 did have intravenous access and she was re-admitted with it. She stated Resident #1 should have physician orders in the MAR for the nurses to document the assessment, care, monitoring, and treatment of her PICC line. She stated her specific expectations for the assessment, care, monitoring, and treatment of Resident #1's PICC line would be per physician orders. She stated it was the nurse's responsibility to ensure Resident #1 had Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455832 If continuation sheet Page 7 of 8 Printed: 05/15/2026 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 455832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Gardens 2535 W Pleasant Run Lancaster, TX 75146 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete physician orders for her PICC line and it was the ADON's responsibility to ensure it was completed. She stated she was not aware of why it was missed but it was important for infection control purposes. Record review of facility policy, Care of Peripherally Inserted Central Catheter dated 01/2013, revealed Purpose. To provide standards for the safe maintenance of a PICC line in order to reduce the risk of infection or dislodging. catheter is to remain in place for the duration of treatment unless signs of complications occur.when catheter is not in use flush at least 12-24 hours with 10 ml sodium chloride 0.9% . Procedure. Assess catheter site. Observe for the following: Skin breakdown, drainage site, leaking connections, catheter integrity, any change in catheter position, broken or loose suture. Record review of facility policy, Intravenous Administration of Fluids and Electrolytes, dated 04/2016 revealed 1. A physician order is necessary to give intravenous fluids and electrolytes. Event ID: Facility ID: 455832 If continuation sheet Page 8 of 8