Ignite Medical Resort Fort Worth, LLC

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy for three (Residents #1, #2 and #3) of seven residents reviewed for resident rights. The facility failed to ensure RN A did not leave Residents #1, #2 and #3's empty medication cards on top of her unattended medication cart that was viewable for anyone to see. The medication cart was in front of room [ROOM NUMBER] then RN A opened room [ROOM NUMBER]'s door and walked up to the medication cart. This failure could place residents at risk of having their medical information disclosed by residents and visitors which could cause embarrassment, frustration, and feelings of decreased privacy, resulting in a decline in their health and psycho-social well-being.

Inspectors wroteBased on interview and observation, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication carts (Medication Cart#1) reviewed for labeled drugs. The facility failed to ensure insulin stored on Medication Cart #1 was dated when opened. This failure could place residents at risk of taking expired medication.

Inspectors wroteBased on interview and observation, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 medication carts (Medication Cart#1) reviewed for drug storage. The facility failed to dispose of a Lantus SoloStar (insulin pen), which was dated 05/30/26, which had exceeded the 28 days the pen could be kept at room temperature. This failure could place residents at risk of being administered expired medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen in that: The facility failed to ensure food items, placed in the refrigerator, were sealed, dated, and labeled appropriately. The facility failed to ensure food items, placed in the dry storage area, were sealed and kept off the floor. These failures could place residents at risk for food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep garbage storage receptacles in a sanitary condition according to professional standards: 1. The facility failed to keep the outside garbage storage area clean.2. The facility failed to ensure garbage receptacles in the kitchen had lids on them, when trash was in the containers, not being used. These failures could place residents at risk of attracting rodents, insects, and contracting food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of four medication carts (Med Cart A), One of two treatment carts (Treatment cart B) and 1 of 7 residents (Resident #94) reviewed for medication storage. 1. The facility failed to ensure Nurses Treatment Cart B was not left unlocked and unattended in the corridor by room [ROOM NUMBER] on 02/10/26. 2. LVN G failed to ensure the medication cart (Med Cart B) was not left unlocked and did not have a cup of medication left on top of the cart while out of view. 3. LVN G failed to ensure medications were not left at Resident #94's bedside while she was out of the resident's room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received, and the facility provided food that was palatable and attractive, for five of twenty-four residents (Residents #81, #83, #88, #93, and #95) reviewed for food and nutrition services. The facility failed to provide attractive and palatable regular diet items for the main and alternate regular diet meals for lunch on 02/11/26. This failure could place residents at risk for not enjoying meals and experiencing weight loss.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options to choose the alternative or option he or she preferred for one of three residents (Resident #101) reviewed for consent to receive psychotropic medications. The facility failed to obtain a written consent form for Resident #101 before starting the medications alprazolam (for treating anxiety), bupropion (for treating depression), hydrocodone-acetaminophen (an opiate pain killer), and zolpidem tartrate (to aid in sleeping). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident received reasonable accommodation of needs and preferences, for 1 of 17 Residents (Resident #62) reviewed for accommodations of needs. The facility failed to ensure Resident #62 had a call light within her reach. This failure could place residents at risk of not getting their needs met and diminishing their quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of six residents (Residents #8 and #81) reviewed for infection control. 1. The facility failed to ensure LVN E wore a gown for EBP before accessing an indwelling catheter (foley) to collect urine from Resident #8 on 02/10/26. 2. The facility failed to ensure LVN D wore a gown for EBP before accessing Resident #81's Central Venous Catheter (this is a flexible tube inserted in the vein for intravenous medication therapy) IV to administer intravenous antibiotics on 02/11/26. These failures could place residents at risk of Multidrug-resistant Organisms infections.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident who required dialysis received such services, consistent with professional standards of practice for 1 (Resident #1) of 1 resident reviewed peritoneal dialysis. The facility failed to ensure nursing staff received training to administer, monitor and intervene for Resident #1 who required PD (During peritoneal dialysis, a cleansing fluid flows through a tube into part of the stomach area, also called the abdomen. The inner lining of the abdomen, known as the peritoneum, acts as a filter and removes wastes from blood. After a set amount of time, the fluid with the filtered waste flows out of the abdomen and is thrown away). Resident #1 was admitted to the hospital with peritonitis (bacteria into the peritoneum). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with state and federal laws in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 Residents reviewed for medication storage. LVN-C failed to ensure Resident #1's PICC line medication was secured in a locked compartment. This failure could place residents at risk for consuming or tampering with medications that could result in adverse medication reactions. Record review of Resident #1's face sheet dated 10/23/2025, reflected he was an [AGE] year-old male that was admitted on [DATE] with diagnosis including: infection and inflammatory reaction due to internal left knee prothesis, subsequent encounter (infection of other causes). [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 3 (Resident #1, Resident #9, and Resident #22) of 4 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1, Resident #9, and Resident #22 MDS were coded for BiPAP/CPAP treatments. The facility staff failed to ensure that Resident #9 was coded for a PICC line per MD orders. This failure could place residents at risk of receiving the incorrect care and treatments. During an observation and interview with Resident # 1 on 10/23/2025 at 1:15 PM his BIPAP/CPAP mask was on the floor on the left side of his bag. Resident #1 stated that he used the mask at night. Resident#1 said while he was s patient at the facility, he has not observed staff cleaning or bagging his CPAP mask. He does receive treatments from the machine at night. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 4 of 10 (Resident #1, Resident #9, Resident #14, and Resident #22) residents reviewed for respiratory care. The facility failed to ensure:Resident #1's, Resident #9's, and Resident #22's BiPAP/CPAP mask were stored properly when it was not in use, per facility protocol for sanitation. Resident #14's NC (a medical device that delivers supplemental oxygen through a flexible tube with two prongs that rest in the nostrils.) was discarded properly when changed, and dating the new NC tubing was installed. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Residents #1 and #2) of five residents reviewed for infection control. 1. The facility failed to ensure the WCN performed hand hygiene and used a clean technique to apply Triad paste (Triad is a for light-to-moderate wound exudate that helps maintain a moist wound healing environment) to the resident's buttocks during incontinence care for Resident #1. 2. The facility failed to ensure RN A changed gloves and performed hand hygiene during incontinence care for Resident #1. This failure could place residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for pressure ulcers, in that: 1. The facility failed to provide preventive care, consistent with professional standards of practice, to Resident#1 who was at risk for pressure injury development. On 04/24/25, Resident #1's admission progress note revealed skin integrity concerns that included, Resident #1 had redness to bilateral heels, Eschar (a hardened, dry, black, or brown dead tissue that forms a scab-like covering over deep wounds) to the left big toe, redness to the groin area, and redness to the buttock and coccyx (tailbone) area. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of quality of life for 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 9 reviewed for dignity. 1. The facility failed to ensure that Resident #1's gown was properly closed, which exposed her shoulder and upper chest areas. 2. The facility failed to provide Resident #2, Resident #3, and Resident #4 a privacy cover for the indwelling urinary catheter drainage bags on 05/30/25. These failures could place the residents at risk of psychosocial harm feeling uncomfortable, disrespected and could decrease residents' self-esteem and/or diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain proper grooming, hygiene (personal and oral hygiene) and proper feeding for 1 (Resident#1) of 6 residents reviewed for activities of daily living care. 1. The facility failed to provide bed baths, grooming and hygiene for Resident #1 on a consistent basis according to the facility's ADL Schedule. 2. LVN B used an incorrect feeding technique to feed Resident #1. LVN B was observed standing up while assisting Resident #1 with feeding on 04/28/25. These failures could place the residents at risk of psychosocial harm feeling uncomfortable, disrespected and could decrease residents' self-esteem and/or diminished quality of life.

Inspectors wroteBased on observations, interviews, and records review the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services for 3 of 3 residents (Resident #2, Resident #3, and Resident #4) reviewed for quality of care. 1. The facility failed to ensure Resident #2 and Resident #4 had an indwelling urinary catheter strap in place to prevent pulling or tugging on 05/30/25. These failures could place residents at risk for discomfort, urethral trauma, loss of dignity and urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 2 of 6 residents (Resident #1, and Resident #4) reviewed for quality of care. 1. The facility failed to ensure Resident #1's ointment and betadine application, and wound dressing change was completed per physician orders. 2. The facility failed to ensure Resident #4's wound dressing change was competed per physician orders. These failures could place residents at risk of not receiving treatments and medications, worsening of wounds and a decline in health.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infections for 1 of 6 (Resident #3) residents reviewed for quality of care. The facility failed to ensure Resident #3's wound dressing change was competed per physician orders. This failure could place residents at risk of not receiving treatment, worsening of wounds and a decline in health.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 6 residents (Resident #2) reviewed for respiratory care. The facility failed to ensure Resident #2's albuterol inhaler was given per physician orders. This failure could place residents at risk of not receiving medications, an exacerbation of their condition and a decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for nutrition services. 1. The facility failed to ensure food in the refrigerators and freezer was properly stored, labeled and dated. 2. The facility failed to ensure temperatures were taken and recorded for reach in refrigerators. 3. The facility failed to ensure all items on the steam table were temped for the correct holding temperature 4. The facility failed to ensure the thermometer on the dishwasher was functioning. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents goals and preferences for 1 of 5 residents (Resident #26) reviewed for respiratory care. The facility failed to ensure Resident #26's oxygen tubing was replaced every week on Sunday, according to physician's orders. This failure could place residents at risk for respiratory compromise and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment leading to potential entrapment hazards for 1 (Resident #202) of 14 residents reviewed for safety in rooms. The facility failed to conduct regular inspections of resident bed frames and mattresses to identify risks and problems and to ensure Resident #202's twin sized bed did not have an oversized bariatric mattress. These failures could place residents at risk of injury resultant from equipment malfunction, entrapment, or falls.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of six residents (Resident #1) reviewed for pain management. The facility failed to administer Resident #1's pain medication Acetaminophen 1000 mg and/or Tramadol 100 mg for pain before wound care. This failure could place residents at risk for increased pain due to not having their pain medication when it was available.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (Resident #1) of six residents reviewed for ileostomy care. The facility failed to follow proper ileostomy care which led to Resident #1's skin being excoriated around the site area and caused stool to seep out of the ileostomy. This failure could place residents with an ostomy at risk of infection, ostomy occlusion, or decreasing feelings of self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who received nutrition by enteral means received the appropriate treatment and services according to professional standards of maintenance for one (Resident #2) of one resident reviewed for enteral feeding The facility failed to ensure Resident #2's eternal tube water flush was set at 200 ML/every 4 hrs. as per order. This failure could place residents at risk of infection due to not following appropriate procedures.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one of two hallways (A hallway) medications carts in hallways that were reviewed for security and storage of drugs and biologicals. The facility failed to ensure LVN C locked and secured medication cart when unattended and out of view on A hallway. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for two of seven residents (Resident #1) reviewed for resident records. The facility failed to ensure Resident #1 had physician orders for PICC line dressing and care. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for one of five (Resident #1), residents reviewed for infection control. The facility failed to ensure RN H sanitized her hands and changed soiled gloves during ileostomy bag change for Resident #1 . Facility failed to ensure RN H did not take supplies from Resident #1's room who was on isolation and placed them on the treatment cart in the hallway. These failures placed residents at risk for contamination, spread of infection, and can cause infections to get worse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 9 residents (Resident #1, #2, and #3) reviewed for pain management. 1. The facility failed to provide medication oxycodone Oral tablet 10 MG per doctor's order for Resident #1 on 6-5-2024 after Resident #1 complained of continued pain and requested medication. Resident #1 admitted to the facility on [DATE] at 3:30 PM and only received Acetaminophen Capsule 500 MG for pain at 11:55 PM. Resident #1 did not receive oxycodone oral tablet 10 MG until 6-6-2024 at 1:20 AM, at which time Resident #1's pain level was at an 8. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assured accurate administering of all drugs to meet the needs of the residents, for 1 resident (Residents #1) of 5 residents reviewed for medication regimen in that: LVN A and MA B failed to follow physician orders when they administered Resident #1's Bidil (heart medication) on [DATE] and [DATE] and the resident's blood pressure was not within the physician-ordered parameters. This failure could place residents at risk for not receiving the therapeutic benefits of the prescribed medications, which could lead to harm or a decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse and neglect for 2 of 5 residents reviewed (Resident # 7's and Resident # 26) for abuse and neglect. The facility failed to: 1. Respond and assist Resident #7 after a fall and constantly yelling out for help on 10/27/23. The resident was found by EMT, lying in feces and with partially dried blood to laceration on her head requiring 10 sutures. LVN F ignored the pleas for help according to the EMT. Resident #26 had to call 911 and guided the EMTs to Resident #7's room. 2. (Non IJ in IJ) Provide Resident #26 ostomy care during shift on 10/31/23 leaving the bag soiled that was connected due to him emptying independently. According to the EMT, on 10/27/23, they observed Resident #26 with a heavily soiled ostomy bag that was leaking. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect establish policies and procedures to investigate any such allegations for 2 (Resident 7 and Resident #26) of 5 residents reviewed for abuse and neglect in that: The facility failed to implement their abuse and neglect policy because Resident #7 and #26 were not free from abuse/neglect and failed to: 1. Respond and assist Resident #7 after a fall and constantly yelling out for help. on 10/27/23. The resident was found by EMT, lying in feces and with partially dried blood to laceration on her head requiring 10 sutures. LVN F ignored the pleas for help according to the EMT. Resident #26 had to call 911 and guided the EMTs to Resident #7's room. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse and neglect, including injuries of unknown source, were reported immediately to the facility and to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #7) of 5 residents reviewed for abuse and neglect. The facility failed to report an injury of neglect when Resident #7 fell on the floor and remained for some time yelling out for help. Resident sustained injury to head requiring 10 sutures. Resident #26 said Resident #7 yelled out for help for over 3 hours, so he called 911. This failure could place residents at risk for unreported abuse and/or neglect.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who needed colostomy care were provided such care, consistent with professional standards of practice for 1 of 5 residents (Resident #26) reviewed for ostomies (surgical opening (stoma) from an area inside the body to the outside). The facility failed to: Provide Resident #26 ostomy care during shift on 10/31/23 leaving the bag soiled that was connected due to him emptying independently. This failure could place residents with an ostomy at risk of risk of infection, ostomy occlusion, or decreasing feelings of self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 (Residents #1, #2, #3, #4,) of 7 residents observed for infection control. The facility failed to ensure phlebotomist A wore proper personal protective equipment (PPE) when drawing blood on resident #1 and resident #2. The facility failed to ensure phlebotomist A disinfected handheld phlebotomy case between Residents #1 and #2 in communicable diseases isolation rooms, and Residents #3 and #4. The facility failed to ensure phlebotomist A performed hand hygiene after encounter with Residents #1, #3, and #4. [...]

Inspectors wroteBased on interview, and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was an accident involving the resident which results in injury and has the potential for requiring physician intervention for one of 16 residents (Resident #50) reviewed for physician notification. 1. The facility failed to notify the physician of Resident #50's fall with acute hip fracture. The failure could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, 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 one of 16 residents (Resident #50) reviewed for quality of care. The facility failed to notify the physician of Resident #50's fall with acute hip fracture and failed to follow-up on x-ray results which would require physician intervention or timely transport to the hospital. The failure could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for one of 16 residents (Resident ##50) reviewed for x-ray results. The facility failed to follow-up on x-ray results for Resident #50 which indicated an acute hip fracture, preventing the resident from being sent out timely to the hospital. The failure could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen for three (Dietary Aide J, [NAME] H, and [NAME] I ) of three kitchen staff reviewed for dietary services. The facility failed to ensure kitchen staff wore appropriate hair and beard restraints while preparing food. This failure could affect residents by placing them at risk for a decreased quality of life and risk of food contamination.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 2 of 16 residents (Resident #47 and #49) reviewed for accidents and supervision. The facility failed to ensure resident rooms were free of tripping hazards for Resident #47 and Resident #49. The failure could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to review the risks and benefits of bed rails and enabler grab bars with the resident or resident representative and obtain informed consent prior to installation for five (Residents #266, #16, #26, #35, and #42) of 30 residents reviewed for bed rails in that: The facility failed to have consents signed for the quarter bed rails for Residents #266, #16, #26, #35, and #42 . This failure could affect residents who used bed rails at risk of the resident/responsible party not being aware of the risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, for 1 of 15 residents (Resident #7) reviewed for parenteral IV (intravenous) fluids. 1. The facility failed to ensure the dressing covering for Resident #7 peripherally inserted central catheter (PICC) site to the right arm was not changed for 14 days but was checked off in the EMAR that it was changed on 8/17/23. 2. The facility failed to apply an end cap, to prevent contamination to the intravenous tubing line when not in use. 3. The facility failed to follow physician's orders and left Resident #50's IV's up for too long. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed nurses have the appropriate competencies and skills sets to provide nursing services to assure resident safety and attain or maintain the highest practicable well-being for 1 of 3 Licensed Nurse (LVN B) reviewed for PICC line care in that: 1. Resident #7 PICC line dressing hadn't been changed for 14 days, the cap on the PICC line to maintain sterility was not handled correctly, and Resident #7's antibiotic IV was running longer than what was in the physician orders. 2. The facility failed to ensure training was provided for LVN B to handle IVs (intravenous), PICC lines, or dressing changes. This failure could place residents at risk of the intravenous site becoming infected and the line becoming unusable.