Health inspection·February 19, 2026

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 interview and record review, the facility failed to properly care for one of three residents' (Resident 1) Peripherally Inserted Central Catheter (PICC line, a long, thin, flexible tube inserted into a peripheral vein and threaded into a large central vein near the heart to provide long-term access for administering medications, fluids, or blood products, and for drawing blood, reducing the need for repeated needle sticks) during several shifts by failing to follow flushing and monitoring protocols.This finding could have led to inability to maintain PICC line patency, the formation of blood clots which could have caused a stroke or heart attack, and a potentially life-threatening infection for Resident 1.A review of Resident 1's admission Record (Facility demographic) indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses which included metabolic encephalopathy (a reversible, acute, or chronic brain dysfunction caused by systemic illness, toxins, or chemical imbalances) and bacteremia (the presence of bacteria in the bloodstream).A review of a nursing progress note dated 2/03/26 at 2:57 a.m., stated, resident [Resident 1] on alert charting for S/P [status post] IV [Intravenous, through the vein] ABO [antibiotics] for bacteremia.A review of a physician order for Resident 1 dated 1/03/26 indicated, CEN (central)-PICC: Monitor every shift for s/s (signs or symptoms) of infection every day shift.A review of Resident 1's Medication Administration Record (MAR) for February 2026 indicated that the above order was not carried out during the day shift (as scheduled) on 2/03, 2/04, 2/09, and 2/10/26, as no staff documented completing it.A review of a physician order for Resident 1 dated 1/30/26 indicated, Heparin (A medication to prevent blood clots) Lock Flush Solution 100 UNIT/ML (milliliters, a unit of measure) Use 500 unit intravenously in the afternoon for PICC line.A review of Resident 1's MAR for February 2026 indicated that the above order was not carried out at 12 pm on 2/01, 2/02, 2/03, 2/04, 2/09, and 2/10/26, as no staff documented completing it. Additionally, the order was not carried out at 2:30 pm on 2/13 and 2/16/26 based on the MAR documentation.During a phone interview with Licensed Staff A on 3/02/26 at 8:05 a.m., who worked with Resident 1 on 2/01, 2/02, 2/03, 2/04, 2/09, 2/10 and 2/13/26 according to Resident 1's MAR, Licensed Staff A confirmed the documentation for Resident 1's PICC line care was missing in the February 2026 MAR. Licensed Staff A explained that, as he was not a Registered Nurse (RN), he could not flush the line himself. Licensed Staff A stated that instead of flushing the line himself, he reminded the RNs on duty to do it, but without documentation, he could not confirm it was done. Licensed Staff A also mentioned that since some RNs worked evening shifts when he was not present, he could not verify their actions. Licensed Staff A stated he monitored Resident 1's PICC line site daily. A review of the MAR indicated this was not documented consistently. Licensed Staff A stated that if a task was not documented, he could not confirm it was completed.During a phone interview on 3/02/26 at 11:30 a.m., Resident 1 stated that staff were flushing and monitoring his PICC line less than half the required times, and definitely not daily. Resident 1 stated he reminded staff repeatedly, but they did not comply. Residents Affected - Some Page 1 of 2 555490 555490 02/19/2026 Meadowood Nursing Center 3805 Dexter Lane Clearlake, CA 95422

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 1 stated he felt neglected and feared acquiring an infection.During a phone interview on 3/02/26 at 12:40 p.m., the Director of Nursing (DON) stated a PICC line that was not flushed consistently could get clogged. The DON also stated that not monitoring a PICC line site could miss a reaction or infection. The DON acknowledged the missing documentation on Resident 1's February MAR and stated that if a task was not documented, it meant it was not completed.A review of the facility policy titled, PICC and Midline Catheter Care, dated December of 2025, indicated, The purposes of this procedure are to maintain patency of midline and PICC line. Flush catheters at regular intervals to maintain patency.Monitor resident for any signs and symptoms of IV complications.The following information should be recorded in the resident's medical record: 1. The date and time the medication was administered.Notify the supervisor, physician, and oncoming shift of any complications. Report other information in accordance with facility policy and professional standards of practice. 555490 Page 2 of 2