Health inspection·February 1, 2024

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Abbreviations: Residents Affected - Few ADON - Assistant Director of Nursing AS-Agency Staff BIMS-Brief Interview for Mental Status CO2-Carbon Dioxide DORC - Director of Resident Care DON - Director of Nursing ED - Executive Director FM-Family Member LVN-Licensed Vocational Nurse R-Resident MAR-Medication Administration Record MDS-Minimum Data Set MT - Resident Medication Technician OMB - Ombudsman O2-Oxygen RA-Resident Assistant RN-Registered Nurse PA Private Aide Page 1 of 14 676111 676111 02/01/2024 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0690 PICC-Peripherally Inserted Central Catheter Level of Harm - Minimal harm or potential for actual harm SW-Social Worker TAR-Treatment Administration Record Residents Affected - Few RN-Registered Nurse IT-Immediate Threat Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for indwelling urinary catheter care, in that: Resident #1's transported out of the facility with an indwelling urinnary catheter drainage bag leaking. These failures could place the residents with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections. Findings Included: Resident #1's Face Sheet dated 1/11/24 revealed a [AGE] year-old, female who was admittance into the facility with a diagnosis of Acute Myeloblastic Leukemia (a type of cancer of the myeloid line blood cells), not having achieved remission, Neutropenia (abnormal low white blood cell count) (unspecified), Muscle weakness (Generalized), unsteadiness on feet. Resident #1's MDS assessment, dated 1/17/24 revealed a BIMS score of 14, indicating Resident#1 was cognitively intact. Resident #1's Care Plan (Category 6-Urinary Incontinence/Indwelling Catheter) dated 1/30/2024 revealed R#1 is at risk for alteration in Elimination of Bladder related to cancer of the bladder. Will remain clean, dry and free of breakdown related to Nephrostomy tubes (lets urine drain from the kidney through an opening in the skin on the back), F/C and abdominal drainage; FOLEY CATHETER CARE WITH SOAP AND WATER EVERY SHIFT; Apply dry dressing to nephrostomies site (left and right back and abdominal); once daily. Record Review of R #1's Physician Orders dated 1/11/2024 revealed the following -Start Date-1/12/24-Check CBC-Every Shift (Days Drawn) -Start Date-1/11/24-Assess Pain Every shift -Start Date-1/11/24-FOLEY Catheter care with soap and water every shift -Start Date-1/11/24-Incentive spirometry-Every shift -Start Date-1/12/24-Apply dry dressing to nephrostomies site (left and right back and 676111 Page 2 of 14 676111 02/01/2024 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0690 abdominal)-once daily (Days) Level of Harm - Minimal harm or potential for actual harm -Start Date-1/12/24-Record Urine Output every shift -Start Date-1/12/24-Record PO intake every shift-Every Shift Residents Affected - Few -Start Date-1/12/24-Record Nephrostomy Output (right) every shift -Start Date-1/12/24-Record Nephrostomy Output (left) every shift -Start Date-1/12/24-Flush Orders for non-valved catheter Intermittent Meds 10ml of Normal Saline before Med 10ml of Normal Saline after Med Flush each port of PICC Line with 10cc of NS Daily-Every shift -Start Date-1/12/24-Observe IV site every shift for s/s of infection, infiltration, or extravasation -Start Date-1/24/24-Flush IV line double lumen with 10cc NS every shift-Every Shift -Start Date-1/24/24-Left fore arm surgical site with 1 stitch: clean with NS, pat dry, apply TAO, cover with dry dressing-Once daily (days) -Start Date-1/22/24-KUB in a.m.-one time for follow up to small ilieus 1X -Start Date-1/21/24-Monitor through out th night-ONE TIME for For worsening condition-Call on Call MD/NP -Start Date-1/21/24-STAT KUB-Start Date-1/15/24-Suprapubic Dressing Change-Every 3 days as needed (PRN) Interview with Resident #1 on 01/31/24 at 9:36 a.m. revealed the facility nurses did not flush her PICC line on the left upper arm. She said she went to the hospital, and they tried to draw blood, but the line was clogged up. Hospital staff sent her to a lab where they had to unclog the PICC lines before the blood draw. Resident #1 said RN A had not flushed her PICC line and when she came back to the facility, after it was unclogged, the facility failed to flush the line until 01/24 /24. Resident #1 said one of her Foley bags was leaking and it was not changed but it was taped up and she went to her appointment with the leaking foley bag. In a telephone interview with OMB on 1/26/24 at 9:38am - it was revealed she received a telephone call from FM complaining about the staff not changing or cleaning the resident's PICC line or changing her catheter as ordered. The OMB stated she spoke with the FM who told her that Resident #1 was in the facility for 15 days. FM was told by the facility that there was nothing they could do without doctor's orders. FM presented the nursing staff with aftercare doctor's order, from the releasing facility. FM was informed by nursing staff they had not received the orders at the Facility's MD (medical doctor). OMB stated she reached out to the SW and is still awaiting a response. She further stated there is a care plan that the facility, R #1 and FM created that revealed what assistance will be provided, how Resident #1 would be treated, transportation set-up, and other nursing accommodations Resident #1 would get while in the facility. 676111 Page 3 of 14 676111 02/01/2024 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with FM on 1/26/2024 at 11:34am - it was revealed the facility initially stated they could not clean Resident #1's PICC Line because there was no doctor's order from the facility. He stated he showed the orders from OH, and still nothing was done for days. FM stated Resident #1 was in the facility over 13 days without her foley bags or PICC Line being cleaned. It was cleaned on 1/24/24. On 1/26/24 FM was at OH for an appointment with R#1 because of a surgical procedure. The hospital staff had to change the PICC Line and provided him with 2 Foley bags. An Interview with DON on 01/31/24 at 10:37am - revealed R#1 was admitted on [DATE] and the order to flush the PICC line was put in the computer on 01/12/24. DON said one of the nurses told her that one of Resident #1's Nephrostomy (a tube that lets urine drain from the kidney through an opening in the skin on the back) bags was leaking, and she fixed it so that it would not leak, and she would change it when she comes back from her appointment. She said the nurse was an agency nurse (Not official facility staff member but contracted through a placement agency) and she did not know what she meant by fixed the bag. She said that they have supplies to change the bag, but the nurse told her after the resident had left the building. She said none of the nurses told her that the suprapubic catheter (a medical device that helps drain urine from your bladder) was leaking, or the stitch was coming apart or had finally come apart. The DON stated Resident #1's PICC line was not flushed on the 12th,14th,15th,16th or the 24th of January 2024. She said the PICC line should be flushed as ordered to keep the line patent and if it was not flushed the line could clog. She said it could create a negative outcome if the staff did not get an order to flush the line with heparin. Review of the DON's report from her nursing staff reported - 24-hour Change Report/change of condition report dated 1/23/2024, revealed Resident #1 went out on Dr.'s appointment and Bags been leaking-No Bags her to replace them. Review of the Facility's Nursing Services, Revised December 2012, Policy and Procedural Manual for Long Term Care, Administering Medications shall be administered in a safe and timely manner, and as prescribed. 676111 Page 4 of 14 676111 02/01/2024 The Buckingham 8580 Woodway Drive Houston, TX 77063

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** Abbreviations: ADON - Assistant Director of Nursing Residents Affected - Few AS-Agency Staff BIMS-Brief Interview for Mental Status CO2-Carbon Dioxide DORC - Director of Resident Care DON - Director of Nursing ED - Executive Director F/C-Foley Care FM-Family Member LVN-Licensed Vocational Nurse R-Resident MAR-Medication Administration Record MDS-Minimum Data Set MT - Resident Medication Technician OMB - Ombudsman O2-Oxygen RA-Resident Assistant PA Private Aide PICC-Peripherally Inserted Central Catheter SW-Social Worker TAR-Treatment Administration Record RN-Registered Nurse IT-Immediate Threat 676111 Page 5 of 14 676111 02/01/2024 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Based on interview, and record review the facility failed to administer parenteral fluids consistent with professional standards of practice for 1 of 3 residents (Resident #1) reviewed for parenteral intravenous (IV)/ peripherally inserted central catheter (PICC) therapy. The facility failed to flush Resident #1's PICC Line (delivers medications and other treatments directly to the large central veins near your heart) as ordered by the physician. This failure could place 1 resident receiving medication through PICC line at risk for infection, air embolism, and injury Findings Included: Resident #1's Face Sheet dated 1/11/24 revealed a [AGE] year-old, female who was admittance into the facility with a diagnosis of Acute Myeloblastic Leukemia (a type of cancer of the myeloid line blood cells), not having achieved remission, Neutropenia (abnormal low white blood cell count) (unspecified), Muscle weakness (Generalized), unsteadiness on feet. Resident #1's MDS assessment, dated 1/17/24 revealed a BIMS score of 14, indicating Resident#1 was cognitively intact. Resident #1's Care Plan (Category 6-Urinary Incontinence/Indwelling Catheter) dated 1/30/2024 revealed R#1 is at risk for alteration in Elimination of Bladder related to cancer of the bladder. Will remain clean, dry and free of breakdown related to Nephrostomy tubes (lets urine drain from the kidney through an opening in the skin on the back), F/C and abdominal drainage; FOLEY CATHETER CARE WITH SOAP AND WATER EVERY SHIFT; Apply dry dressing to nephrostomies site (left and right back and abdominal); once daily. Record Review of R #1's Physician Orders dated 1/11/2024 revealed the following -Start Date-1/12/24-Check CBC-Every Shift (Days Drawn) -Start Date-1/11/24-Assess Pain Every shift -Start Date-1/11/24-FOLEY Catheter care with soap and water every shift -Start Date-1/11/24-Incentive spirometry-Every shift -Start Date-1/12/24-Apply dry dressing to nephrostomies site (left and right back and abdominal)-once daily (Days) -Start Date-1/12/24-Record Urine Output every shift -Start Date-1/12/24-Record PO intake every shift-Every Shift -Start Date-1/12/24-Record Nephrostomy Output (right) every shift -Start Date-1/12/24-Record Nephrostomy Output (left) every shift -Start Date-1/12/24-Flush Orders for non-valved catheter Intermittent Meds 10ml of Normal Saline 676111 Page 6 of 14 676111 02/01/2024 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0694 before Med 10ml of Normal Saline after Med Flush each port of PICC Line with 10cc of NS Daily-Every shift Level of Harm - Minimal harm or potential for actual harm -Start Date-1/12/24-Observe IV site every shift for s/s of infection, infiltration, or extravasation Residents Affected - Few -Start Date-1/24/24-Flush IV line double lumen with 10cc NS every shift-Every Shift -Start Date-1/24/24-Left fore arm surgical site with 1 stitch: clean with NS, pat dry, apply TAO, cover with dry dressing-Once daily (days) -Start Date-1/22/24-KUB in a.m.-one time for follow up to small ilieus 1X -Start Date-1/21/24-Monitor through out th night-ONE TIME for For worsening condition-Call on Call MD/NP -Start Date-1/21/24-STAT KUB-Start Date-1/15/24-Suprapubic Dressing Change-Every 3 days as needed (PRN) Interview with Resident #1 on 01/31/24 at 9:36 a.m. revealed the facility nurses did not flush her PICC line on the left upper arm. She said she went to the hospital, and they tried to draw blood, but the line was clogged up. Hospital staff sent her to a lab where they had to unclog the PICC lines before the blood draw. Resident #1 said RN A had not flushed her PICC line and when she came back to the facility, after it was unclogged, the facility failed to flush the line until 01/24 /24. Resident #1 said one of her Foley bags was leaking and it was not changed but it was taped up and she went to her appointment with the leaking foley bag. In a telephone interview with OMB on 1/26/24 at 9:38am - it was revealed she received a telephone call from FM complaining about the staff not changing or cleaning the resident's PICC line or changing her catheter as ordered. The OMB stated she spoke with the FM who told her that Resident #1 was in the facility for 15 days. FM was told by the facility that there was nothing they could do without doctor's orders. FM presented the nursing staff with aftercare doctor's order, from the releasing facility. FM was informed by nursing staff they had not received the orders at the Facility's MD (medical doctor). OMB stated she reached out to the SW and is still awaiting a response. She further stated there is a care plan that the facility, R #1 and FM created that revealed what assistance will be provided, how Resident #1 would be treated, transportation set-up, and other nursing accommodations Resident #1 would get while in the facility. In an interview with FM on 1/26/2024 at 11:34am - it was revealed the facility initially stated they could not clean Resident #1's PICC Line because there was no doctor's order from the facility. He stated he showed the orders from OH, and still nothing was done for days. FM stated Resident #1 was in the facility over 13 days without her foley bags or PICC Line being cleaned. It was cleaned on 1/24/24. On 1/26/24 FM was at OH for an appointment with R#1 because of a surgical procedure. The hospital staff had to change the PICC Line and provided him with 2 Foley bags. 676111 Page 7 of 14 676111 02/01/2024 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An Interview with DON on 01/31/24 at 10:37am - revealed R#1 was admitted on [DATE] and the order to flush the PICC line was put in the computer on 01/12/24. DON said one of the nurses told her that one of Resident #1's Nephrostomy (a tube that lets urine drain from the kidney through an opening in the skin on the back) bags was leaking, and she fixed it so that it would not leak, and she would change it when she comes back from her appointment. She said the nurse was an agency nurse (Not official facility staff member but contracted through a placement agency) and she did not know what she meant by fixed the bag. She said that they have supplies to change the bag, but the nurse told her after the resident had left the building. She said none of the nurses told her that the suprapubic catheter (a medical device that helps drain urine from your bladder) was leaking, or the stitch was coming apart or had finally come apart. The DON stated Resident #1's PICC line was not flushed on the 12th,14th,15th,16th or the 24th of January 2024. She said the PICC line should be flushed as ordered to keep the line patent and if it was not flushed the line could clog. She said it could create a negative outcome if the staff did not get an order to flush the line with heparin. Review of the DON's report from her nursing staff reported - 24-hour Change Report/change of condition report dated 1/23/2024, revealed Resident #1 went out on Dr.'s appointment and Bags been leaking-No Bags her to replace them. Review of the Facility's Nursing Services, Revised December 2012, Policy and Procedural Manual for Long Term Care, Administering Medications shall be administered in a safe and timely manner, and as prescribed. 676111 Page 8 of 14 676111 02/01/2024 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0695 Provide safe and appropriate respiratory care 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** Abbreviations: ADON - Assistant Director of Nursing Residents Affected - Few AS-Agency Staff BIMS-Brief Interview for Mental Status CO2-Carbon Dioxide CNS-Central Nervous System COPD-chronic obstructive pulmonary disease DORC - Director of Resident Care DON - Director of Nursing ED - Executive Director F/C -Foley Catheter FM-Family Member LVN-Licensed Vocational Nurse R-Resident MAR-Medication Administration Record MDS-Minimum Data Set MT - Resident Medication Technician OMB - Ombudsman O2-Oxygen RA-Resident Assistant PA Private Aide PICC-Peripherally Inserted Central Catheter SW-Social Worker TAR-Treatment Administration Record 676111 Page 9 of 14 676111 02/01/2024 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0695 RN-Registered Nurse Level of Harm - Minimal harm or potential for actual harm IT-Immediate Threat Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services was provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #2) reviewed for respiratory therapy. Facility failed to administer oxygen according to physician's order Facility failed to ensure a filter was on the concentrator and the humidifier was not empty This failure placed residents who received oxygen at risk for respiratory complication. Findings Include Record review of Resident #2's undated Face Sheet reflected an [AGE] year old, male with a diagnosis of chronic respiratory failure with hypoxia (CNS depression, diseases of the respiratory muscles, and COPD), Dependence on supplemental oxygen, and other abnormalities of breathing. Record review of R #2's MDS assessment, dated 12/29/23 indicates moderately impaired for cognitive skills for daily decision making. No BIMS score, which suggest severe impairment. Record review of R #2's Care Plan dated 12/23/23 states R #2 has potential for complications from CHF and respiratory failure. Monitor Oxygen saturation and administer oxygen per physician orders. Record review of undated physician orders indicated staff to check oxygen saturation every shift - Three times daily. Oxygen at 2-4 lpm via nc to keep saturations above 90% - 2-4 lpm Nasal every shift as needed. 2-4 lpm NASL SHIFT. Observation on 1/31/24 at 12:57pm of R#2's room revealed R #2 lying in bed sleeping with oxygen cannula in both nostrils. There was no water in the humidifier bottle and no filter on the back of the Concentrator tank. Observation and interview on 1/31/24 at 1:25pm with LVN B leaving out of the resident's room, with a humidifier in her hand, as investigator was approaching the door. When asked what she was doing with the container, the nurse stated she had just changed the humidifier. Observation revealed the changed humidifier and the concentrator level set at 5 (Five). During the Interview with LVN B, she told investigator that she set the concentrator on level 5 but admitted the physician order was for 3. She stated she has made rounds today and checked on the resident, but she failed to check the humidifier or the level on the oxygen. She stated a humidifier that is administered to a resident with no water could cause dry nostrils, which could cause bleeding and irritations. LVN B checked the humidifier in the back where the filter is located and found the filter was missing. She stated it was important to have a filter because it helps to filter dust. She stated without the filter, the dust may go into the residents' nose and lungs. She stated even though she made rounds, she did not check the concentration levels. After changing the humidifier container, she set the concentrated level on 5. She stated too much CO2 could alter the resident's mental status. 676111 Page 10 of 14 676111 02/01/2024 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an Interview with the DON on 1/31/2024 at 3:30pm - Revealed oxygen is administered if there is a doctor's order. She stated it could be changed (level) only in an emergency if the resident's O2 stats drop into the 80's. Nurses should make rounds to check on residents with oxygen and they should check the humidifier to ensure there is water. Check the concentrated is safe for the correct number of liters for the resident. Check the nasal cannula in place. Make sure tubing is dated. All the oxygen machines in the facility should have a filter. If there is no filter, the dirt/dust is not filtered and the harm it causes is the O2 stats may decrease because the resident is not getting the correct amount of oxygen, which can cause hyperoxygenation which affects the heart and blood sugar. Can become hypercapnic because of too much carbon dioxide in the blood stream. The ADON and DON monitors nurses to ensure they are checking the residents. In an Interview with the ADON on 1/31/2024 at 4:00pm -revealed oxygen is administered if there is a doctor's order. It should be administered above doctor's order if residents' O2 stats drop into the 80's and the doctor is to be notified immediately. Before increasing the level of oxygen, nurses are required to do a respiratory assessment and call the doctor immediately. Nurses should make rounds to check on residents who use oxygen, and check the humidifier to ensure there is water, check concentrated level is safe for the correct number of liters for the resident, check the nasal cannula is in place and make sure tubing is dated. The oxygen machine should have a filter because if the dirt is not filtered it can cause the O2 stats to decrease because they are not getting the correct amount of oxygen. The negative outcome if a resident is given more oxygen than ordered is called oxygen toxicity. It can affect the lungs, cause hyperoxygenation which affects the heart and blood sugar, and the resident can become hypercapnic. Review of the Facility's Nursing Services, Revised December 2012, Policy and Procedural Manual for Long Term Care, Administering Medications shall be administered in a safe and timely manner, and as prescribed. 676111 Page 11 of 14 676111 02/01/2024 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Abbreviations: ADON - Assistant Director of Nursing Residents Affected - Few AS-Agency Staff BIMS-Brief Interview for Mental Status CO2-Carbon Dioxide DORC - Director of Resident Care DON - Director of Nursing ED - Executive Director F/C-Foley Catheter FM-Family Member LVN-Licensed Vocational Nurse R-Resident MAR-Medication Administration Record MDS-Minimum Data Set MT - Resident Medication Technician OMB - Ombudsman O2-Oxygen RA-Resident Assistant PA Private Aide PICC-Peripherally Inserted Central Catheter SW-Social Worker TAR-Treatment Administration Record RN-Registered Nurse IT-Immediate Threat 676111 Page 12 of 14 676111 02/01/2024 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection for one (RN B) of 2 staff members reviewed for infection control. Facility staff failed to follow effective hygiene procedures when providing care for resident (Resident #1), by not washing hands appropriately and not utilizing sterilized equipment. This failure placed resident at risk for the development and /or spread of infection. Findings included: Resident #1's Face Sheet dated 1/11/24 revealed a [AGE] year-old, female who was admittance into the facility with a diagnosis of Acute Myeloblastic Leukemia (a type of cancer of the myeloid line blood cells), not having achieved remission, Neutropenia (abnormal low white blood cell count) (unspecified), Muscle weakness (Generalized), unsteadiness on feet. Resident #1's MDS assessment, dated 1/17/24 revealed a BIMS score of 14, indicating Resident#1 was cognitively intact. Resident #1's Care Plan (Category 6-Urinary Incontinence/Indwelling Catheter) dated 1/30/2024 revealed R#1 is at risk for alteration in Elimination of Bladder related to cancer of the bladder. Will remain clean, dry and free of breakdown related to Nephrostomy tubes (lets urine drain from the kidney through an opening in the skin on the back), F/C and abdominal drainage; FOLEY CATHETER CARE WITH SOAP AND WATER EVERY SHIFT; Apply dry dressing to nephrostomies site (left and right back and abdominal); once daily. Record Review of R #1's Physician Orders dated 1/11/2024 revealed the following -Start Date-1/12/24-Check CBC-Every Shift (Days Drawn) -Start Date-1/11/24-Assess Pain Every shift -Start Date-1/11/24-FOLEY Catheter care with soap and water every shift -Start Date-1/11/24-Incentive spirometry-Every shift -Start Date-1/12/24-Apply dry dressing to nephrostomies site (left and right back and abdominal)-once daily (Days) -Start Date-1/12/24-Record Urine Output every shift -Start Date-1/12/24-Record PO intake every shift-Every Shift -Start Date-1/12/24-Record Nephrostomy Output (right) every shift -Start Date-1/12/24-Record Nephrostomy Output (left) every shift -Start Date-1/12/24-Flush Orders for non-valved catheter Intermittent Meds 10ml of Normal Saline before Med 10ml of Normal Saline after Med Flush each port of PICC Line with 10cc of NS Daily-Every 676111 Page 13 of 14 676111 02/01/2024 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0880 shift Level of Harm - Minimal harm or potential for actual harm -Start Date-1/12/24-Observe IV site every shift for s/s of infection, infiltration, or extravasation -Start Date-1/24/24-Flush IV line double lumen with 10cc NS every shift-Every Shift Residents Affected - Few -Start Date-1/24/24-Left fore arm surgical site with 1 stitch: clean with NS, pat dry, apply TAO, cover with dry dressing-Once daily (days) -Start Date-1/22/24-KUB in a.m.-one time for follow up to small ilieus 1X -Start Date-1/21/24-Monitor through out th night-ONE TIME for For worsening condition-Call on Call MD/NP -Start Date-1/21/24-STAT KUB-Start Date-1/15/24-Suprapubic Dressing Change-Every 3 days as needed (PRN) In an Interview on 1/26/2024 at 11:34am FM stated on 1/24/24 around between 5p-6p, RN#1 came into the room to clean the PICC line and dropped the syringe on the floor, then picked it up and used it. FM and and Resident #1were shocked. Both stated it happened so quickly they were unable to question. Observation on 01/31/24 at 9:46 a.m. reflected LVN A (agency nurse) walked into the room and she did not sanitize her hands before she donned her gloves and touched the PICC line dressing. In an Interview on 01/31/24 at 10:03 a.m., LVN A she said that she forgot to wash her hand before she donned the gloves and touched the resident PICC line. She said she could have transferred the germs from her hands to the resident PICC line and it could cause the resident to be sick. She said she was in serviced with her agency and today (1/31/24) was her second day working with residents. In an Interview with the DON on 1/31/2024 at 3:30pm - revealed ALL nursing staff should practice safe sanitation and infection control. She states failure to adhere to the Infection Control policy would cause the transfer of bacteria to residents, which could cause infection. In an Interview with the ADON on 1/31/2024 at 4:00pm-revealed there is handwashing and personal protective Equipment to prevent the spread of infection, and wound contamination. Record Review of the Handwashing/Hand Hygiene Policy revised August 2015 revealed, facility considers hand hygiene the primary means to prevent the spread of infections. Perform hand hygiene before applying non-sterile gloves. 676111 Page 14 of 14