**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, Nurse Practitioners and staff interviews, the facility failed to change the dressing to Resident #76's Peripherally Inserted Central Catheter (PICC) line. This occurred for 1 of 1 resident (Resident #76) reviewed for intravenous (IV) antibiotic therapy. The findings included: Resident #76 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis (infection of the bone) and methicillin-resistant Staphylococcus aureus (MRSA). The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was cognitively intact and was coded with IV access and antibiotics. Review of the active nurse practitioner orders dated 7/8/25 revealed orders to change the PICC dressing every seven days and as needed using sterile technique. On 7/28/25 at 2:35 PM an observation of Resident #76's PICC line, in the left upper arm, revealed a transparent dressing with rolled edges covering the insertion site dated 7/2/25. There was no redness, drainage, or signs of infection at the entry site. The resident denied itching or discomfort. Review of the treatment administration record (TAR) revealed an incomplete order entry on 7/8/25 under the heading PICC dressing change every seven days. The TAR did not have staff initials, or a scheduled timeframe available, for staff to document a dressing change had been completed. The Clinical Coordinator was interviewed on 7/29/25 at 11:29 AM and stated the dressing should be changed every seven days for any resident with a PICC line, and that the floor nurse assigned to the resident was responsible for completing the change. She further stated the date on the PICC line dressing was correct for the last dressing change. The Clinical Coordinator then assessed the PICC line and confirmed it was dated 7/2/25. She stated Resident #76 was getting ready to leave for an appointment with the Infectious Disease clinic, but she would change his dressing upon return to the facility since she was serving as the unit's nurse that day. On 7/29/25 at 12:27 PM the Director of Nursing (DON) was interviewed. She stated Resident #76 had an order to change his PICC line dressing every seven days, but it was not entered in the computer correctly. She stated due to the order not being entered correctly it did not show up on the TAR for the resident, so the nursing staff did not see an order to change the PICC line dressing. She confirmed the date on the PICC line dressing, 7/2/25, was correct for the last time the dressing was changed. On 7/30/25 at 4:26 PM the Infectious Disease clinic Nurse Practitioner (NP #2) was interviewed by phone. She stated she saw Resident #76 in the clinic on 7/29/25 and noted his PICC line dressing had not been changed since 7/2/25. She stated she assessed the site, and it did not appear to be infected, no redness, drainage, or pain at the site. She stated she had the clinic nurse change the PICC line dressing, called the facility, and requested they educate the staff on PICC line care. She further stated the clinic's PICC line dressing protocol for weekly dressing changes was sent with the resident at discharge from the hospital. A follow-up interview with the DON on 7/30/25 at 9:03 AM was completed. She stated she had received a phone call from the Infectious Disease clinic on 7/29/25 and was informed Resident #76's PICC line dressing was changed during his appointment. She stated the clinic asked the facility to educate the staff regarding PICC line care. She further stated she had entered the order for the PICC line dressing changes in Resident #76's chart, and it was now showing on the TAR. The DON stated she and the Clinical Coordinator had reviewed the order entry completed by the Clinical Coordinator, and they were uncertain how the computer system had allowed the order to advance without being completed correctly. Nurse Practitioner #1 was interviewed on 7/29/25 at 12:56 PM who stated Resident #76's PICC line dressing should be changed every seven days and as needed to prevent infection. She stated she had been regularly reviewing the resident's labs, and he had not shown any complications or signs of a new infection. She stated she had not been informed Resident #76's PICC line dressing had not been changed since 7/2/25.

Based on staff interviews and record review, the facility failed to issue a Centers for Medicare and Medicaid Services (CMS), CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to 1 of 3 residents reviewed for SNF Beneficiary Protection Notification Review (Resident # 50). Findings included: Resident #50 was admitted to the facility under part A Medicare services on 5/22/24. A review of the medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter (NOMNC) was discussed by telephone with Resident #50's responsible party on 6/17/24. The notice indicated that Medicare coverage for skilled services was to end 6/19/24 and the resident would remain in the facility. A review of the medical record revealed a CMS-10055 SNF ABN (ABN) was not provided to the resident or responsible party. An interview was conducted with the Social Worker on 7/10/24 at 12:26 PM and he revealed that Residents # 50 planned to remain in the facility and the social worker made the resident and family aware that there would be a private pay cost. The social worker further revealed the SNF ABN form was not issued because the family had appealed the Notice of Medicare Non-Coverage (NOMNC) and he thought he had to wait to issue the SNF ABN notice until after the NOMNC appeal decision had been received. An interview was conducted with the Administrator on 7/11/24 at 9:56 AM revealed the social worker had not yet issued the SNF ABN to Resident #50 because he did not want to confuse the family member by issuing the SNF ABN notice before the NOMNC appeal decision had been finalized.

Based on record review and staff interviews, the facility failed to report allegations of abuse to Adult Protective Services (APS). This deficient practice was for 4 of 4 residents reviewed for abuse. (Resident # 41, Resident #324, Resident #72 and Resident #223). Finding included: 1. A review of the Initial Allegation Report for an allegation of misappropriation of property submitted on 6/18/24 at 3:47 PM indicated the facility became aware of the alleged incident on 6/18/24 at 1:00 PM for Resident #41. The allegation details revealed Resident #41 alleged that someone stole $100 from her pocketbook. The initial report indicated local law enforcement was notified on 6/18/24 at 2:30 PM. The initial report did not indicate APS was notified. The Investigation Report completed on 6/24/24 for the 6/18/24 incident concerning Resident #41 indicated APS was not notified of the allegation of misappropriation of resident property. During an interview with the Director of Clinical Services 7/11/24 9:52 AM he indicated that he did not contact APS and that he was not aware APS needed to be notified an allegation of misappropriation of resident property During an interview with the Administrator on 7/11/24 at 10:08 AM he indicated that he did not know APS needed to be notified of an allegation of misappropriation of resident property. 2. A review of the Initial Allegation Report for an allegation of misappropriation of property submitted on 6/18/24 at 3:47 PM indicated the facility became aware of the alleged incident on 6/18/24 at 1:00 PM for Resident #72. The allegation details revealed Resident #41 alleged that someone stole $20 from her pocketbook. The initial report indicated local law enforcement was notified on 6/18/24 at 2:30 PM. The initial report did not indicate APS was notified. The Investigation Report completed on 6/24/24 for the 6/18/24 incident concerning Resident #72 indicated APS was not notified of the allegation of misappropriation of resident property. During an interview with the Director of Clinical Services 7/11/24 9:52 AM he indicated that he did not contact APS and that he was not aware APS needed to be notified of the allegation of misappropriation of resident property During an interview with the Administrator on 7/11/24 at 10:08 AM he indicated that he did not know APS needed to be notified of the allegation of misappropriation of resident property. 3. A review of the Initial Allegation Report for an allegation of resident abuse submitted on 7/2/24 at 3:57 PM indicated the facility became aware of the alleged incident on 7/2/24 at 12:00 AM for Resident #324. The allegation details revealed Resident # 324 alleged the accused pushed resident #324 into the shower, shut the door to the shower and did not come back when Resident #324 yelled for help. Resident #324 also alledged the accused told Resident #324 to shut up, and to go to bed. The initial report indicated no injuries occurred and local law enforcement was notified on 7/2/24 at 2:06 AM. The initial report did not indicate whether APS was notified. The Investigation Report completed on 7/9/24 for the 7/2/24 incident concerning Resident #324 indicated the allegation was not substantiated and APS was not notified of the allegation of resident abuse. During an interview with the Director of Clinical Services 7/11/24 9:52 AM he indicated that he did not contact APS and that he was not aware APS needed to be notified of the allegation of resident abuse. During an interview with the Administrator on 7/11/24 at 10:08 AM he indicated that he did not know APS needed to be notified of the allegation of resident abuse. 4) A review of the Initial Allegation Report for an allegation of abuse with no serious bodily injury was submitted on 6/7/24. The report indicated the facility became aware of the incident on 6/7/24 at 10:00 AM for Resident #223. The allegation details read Resident #223 alleged that another resident hit her in the hip. The initial report indicated law enforcement was notified on 6/7/24 at 11:06 AM. The initial report did not indicate that APS was notified. The Investigation Report completed on 6/14/24 for the 6/7/24 incident concerning Resident #223 revealed that APS was not notified for an allegation of abuse. On 7/11/24 at 9:43 AM, an interview occurred with the Administrator and the Director of Clinical Services. They stated they were not aware that APS had to be notified regarding an allegation of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews the facility failed to treat a resident with dignity and respect by not removing food debris from a resident's clothing and bed after meal trays were removed for 1 of 4 residents reviewed for dignity (Resident #28). The reasonable person concept was applied to this deficiency as individuals have the expectation of being treated with dignity while in their home environment. The findings included: Resident #28 was admitted to the facility on [DATE] with multiple diagnoses which included Parkinson's Disease and Alzheimer's Disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 had a severe cognitive impairment and required supervision with eating with 1 staff member. Resident #28 was observed on 04/03/23 at 9:40 AM to be lying asleep in her bed. She had large pieces of brown food debris on her face, clothing, and clothing protector, an article worn around a resident's neck and drapes over the resident's torose to prevent food from soiling the resident's clothing. There was no meal tray located in the room. Resident #28 was observed on 04/04/23 at 11:00 AM to be lying awake in her bed. She was wearing a clothing protector around her chest with large pieces of brown food debris on her right side of her chest and a large brown piece of food debris on her bed sheet. There was no meal tray located in the room. Resident #28 was observed on 04/04/23 at 11:26 AM to be lying asleep in her bed with a clothing protector around her chest with what appeared to be the same large brown pieces of food debris on her face and in her bed. There was no meal tray located in her room. Resident #28 was observed on 04/05/23 at 1:05 PM. She was lying awake in her bed. She was wearing a clothing protector with large brown pieces of food debris on it. There was no meal tray located in her room. An observation and interview with Nurse Aide #3 occurred on 04/05/23 at 1:12 PM. She stated she was familiar with Resident #28's care needs and was assigned to work with Resident #28 on this day and stated she had not worked with Resident #28 the other two days. She stated Resident #28 required assistance with feeding but was able to feed herself. She stated Resident #28 often dropped food on her clothing. She stated she did not remove the clothing protector or the food from Resident #28's clothing when she removed her lunch tray because she was busy assisting other residents A joint interview with the Director of Nursing and Administrator on 04/05/23 at 2:49 PM revealed it was their expectation for the staff to come back after removing trays and clean residents after meals to promote dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to trim and clean a dependent resident's nails (Resident #35) for 1 of 3 residents reviewed for Activities of Daily Living (ADLs). The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, lack of coordination and muscle weakness. Resident #35's active care plan, with an effective date of 12/30/22, included a problem area for self-care deficit associated with the need for assistance with ADLs related to weakness, decreased mobility and range of motion secondary to a fall with fracture to the left femur (hip). One of the interventions included to provide assistance to complete ADL tasks. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #35 had severely impaired cognition and displayed no behaviors or rejection of care. She required extensive assistance for personal hygiene and was dependent on staff for bathing tasks. A review of Resident #35's nursing progress notes from 12/30/22 through 4/4/23 revealed no refusals of nail care documented. On 4/3/23 at 9:50 AM, an observation of Resident #35 occurred while she was lying in bed with her hands resting on top of the covers. Her left thumb and fourth finger had a dark substance under them, and the third fingernail was broken and jagged. Her right first finger had a dark substance under it and the fifth fingernail was broken and jagged. Resident #35 was observed on 4/4/23 at 2:24 PM while sitting in her recliner. Her fingernails were unchanged from the prior observation. An interview occurred with Nurse Aide (NA) #1 on 4/5/23 at 9:57 AM and explained that nail care should occur during showers and personal care tasks. She was not assigned to Resident #35. Resident #35 was observed on 4/5/23 at 10:03 AM while sitting up in her recliner. Her hands rested in her lap and revealed her nails remained the same from prior observations. An interview occurred with NA #2 on 4/5/23 at 10:41 AM. She was the NA assigned to care for Resident #35. She stated nail care was completed when there was a need during a shower or personal care. An observation occurred with NA #2 of Resident #35's nails. NA #2 confirmed there was a dark substance under the left thumb and fourth finger and the right first finger as well as broken and jagged nails to the left third and right fifth fingernails. NA #2 stated she had not observed Resident #35's nails during personal care that morning and care would be rendered to them. The Director of Nursing was interviewed on 4/5/23 at 2:45 PM and stated she was not aware of any refusals of nail care from Resident #35 or that nail care was needed. She added that she would expect fingernails to be observed on shower days and during personal care daily with nail care rendered as needed.