**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with staff, resident, and the Physician the facility failed to change the dressing for the peripherally inserted central catheter (PICC) for intravenous antibiotic administration according to the order. This deficient practice affected 1 of 3 residents reviewed for intravenous access devices (Resident #63). The findings included: Resident #63's hospital Discharge summary dated [DATE] documented she had a PICC line placed on 7/14/25 into her right antecubital space (front of the elbow) and a clear dressing was placed. The resident was receiving antibiotics for endocarditis (infection of the heart tissue) and sepsis (infection of the blood) through the PICC line. Resident #63 was receiving Ceftriaxone (antibiotic) 2 grams every 12 hours intravenously to continue at the facility. There was no mention of the PICC line dressing change in the hospital discharge summary. Resident #63 was admitted to the facility on [DATE] with diagnoses including septicemia (infection of the blood) and endocarditis. Resident #63's admission nursing note dated 7/16/25 documented she was admitted from the hospital with a PICC line in the right arm. The resident was alert and oriented and able to make her needs known. The care plan for Resident #63 dated 7/16/25 included she was at risk for infection related to peripheral intravenous access. The intervention included monitoring the catheter site for any signs or symptoms of infection. Resident #63's PICC line dressing change order was initiated on 7/21/25 by Nurse #1. The order specified that the PICC line dressing change was to be changed each week on Sunday using aseptic technique. A review of Resident #63's July 2025 Medication Administration Record documented Nurse #1 signed her initials for the PICC line dressing change completion on 7/27/25. On 7/31/25 at 3:00 pm an interview was conducted with Nurse #1. Nurse #1 stated she input the PICC line management order on 7/21/25 for Resident #63 to have the dressing on the PICC line changed once a week on Sunday. The resident was admitted on [DATE] from the hospital with the PICC line in place and a clear dressing dated 7/14/25. Nurse #1 stated she signed for completion of the dressing change on Sunday 7/27/25 in error. The shift was very busy on 7/27/25 and the electronic medical record had been updated which caused problems and error. After the date calendar was reviewed, Nurse #1 stated when she input the PICC line order it was Monday (7/21/25) and the day before Sunday was a missed opportunity to change the dressing within a week from 7/14/25 because the order was not started on admission. On 7/28/25 at 11:10 am an observation and interview were completed with Resident #63. The resident was able to state why she had a PICC line and her antibiotic treatment. The PICC line was observed in the right antecubital space and had an intact clear dressing that was dated 7/14/25. The resident stated the site was without pain and the observation revealed no signs and symptoms of infection. The resident stated the PICC line and dressing was placed at the hospital and the dressing had not been changed at the nursing home. On 7/29/25 at 10:45 am an observation of Resident #63's PICC line was completed with the Administrator. The PICC line had a clear dressing and was dated 7/14/25 and appeared the same as the day before. The Administrator was interviewed on 7/29/25 at 10:50 am. The Administrator stated nursing should have changed the dressing. It was dated 7/14/25 and was required to be changed every week. On 7/30/25 at 11:10 am the Physician was interviewed and informed that Resident #63's PICC line dressing was the original dressing from the hospital dated 7/14/25 when it was placed and the dressing change due on 7/27/25 at the facility was missed. The physician stated it takes a village in response.

Based on observations and dietary staff interviews, the facility failed to ensure facial hair was covered during food preparation. This practice had the potential for cross-contamination of food served to residents. Findings included: During the initial tour of the kitchen on 5/6/24 at 10:00 a.m., the dietary staff were observed cleaning after the breakfast meal service and preparing food for the lunch meal. There were four dietary staff members preparing food in the preparation areas with exposed facial hair (ranging from approximately ½ inch to 3 inches in length). On 5/9/24 at 11:33 a.m. during the meal tray line service in the kitchen, seven dietary staff were observed with exposed/uncovered facial hair ranging from ½ inch to 3 inches in length. During this observation the staff were noted to perform various food service tasks including meal production and service without hair coverings over their facial hair. Three of these staff members were identified as the cook, Executive Chef, and the Kitchen Manager. During an interview on 5/9/24 at 11:40 a.m., the Executive Chef and the Kitchen Manager acknowledged the male dietary staff were required to cover all hair while in the food preparation areas of the kitchen. the Executive Chef and the Kitchen Manager supplied each of the male dietary staff with chin guards. The dietary staff were observed donning the chin guards.

Based on observations and dietary staff interviews, the facility failed to ensure waste was contained in 1 of 1 trash compactor and had no opened areas with exposed trash, debris, and accessibility to animals. These practices had the potential to affect all residents. Findings included: On 5/6/24 at 10:54 a.m., during the observation of the facility's trash compactor accompanied by the Executive Chef and the Clinical Nutritionist, the opened chute area of the compactor consisted of multiple large white bags of trash and a live opossum. The Executive Chef immediately notified the Maintenance Director to remove the opossum. A follow-up observation of the trash compactor was conducted with the Executive Chef, Kitchen Manager, and the Clinical Nutritionist on 5/9/24 at 11:54 a.m. There were multiple large bags of trash observed in the opened chute area of the compactor. During an interview on 5/9/24 at 11:57 a.m., the Executive Chef stated the trash compactor's provider emptied the compactor two times each month. He also stated he routinely checked the trash compactor twice each day (upon his arrival in the morning and at 4:00 p.m.). He revealed the dietary department only used black colored trash bags and the white/clear bags in the compactor were the type used by the facility's housekeeping department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #10 was admitted to the facility on [DATE] with diagnoses that included a functional intestinal disorder with ileostomy. A review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #10 was cognitively intact and always incontinent of bowel and bladder. The diagnoses section identified the Resident had an ileostomy. A review of the most recent care plan dated 11/14/2022 did not include a care plan focused area for ileostomy care. An observation was conducted on 1/24/2023 at 9:28 a.m. of Resident #10 and she had a bowel elimination bag attached to her abdomen with a red moist stoma (an artificial opening made into a hollow organ, especially one on the surface of the body leading to the gut or trachea). The elimination bag had a small amount of brown stool. There were no lingering odors. An interview was conducted with Resident #10 on 1/24/2023 at 9:28 a.m. and she stated staff assist her with changing of the ileostomy bag and emptying the bag. She revealed some staff had been hesitant or did not assist quickly, as if they were not aware she had the bag or did not know how to provide the care. She added they always return with someone to assist them. An interview was conducted with the MDS Nurse Coordinator on 1/26/2023 at 12:28 p.m. and revealed she was responsible for updating the care plan for a resident. She reviewed the most recent MDS for Resident #10 and the diagnoses list. She then reviewed the most recent care plan dated 11/14/2022 and reported she did not see a focused area for ileostomy/bowel elimination. She added this was a care area that she would place on the care plan and would be added immediately. An interview was conducted with the Administrator on 1/26/2022 at 12:42 p.m. and she revealed she expected a resident to have a care plan focused area for any diagnoses that required specialized care such as an ileostomy. Based on observations, staff interviews and record review, the facility failed to 1) follow the care plan to place floor mats next to the bedside for fall prevention for 1 of 4 residents (Resident #14) reviewed for falls, and 2) failed to implement a care plan for ileostomy care for 1 of 1 resident (Resident #10) reviewed for ileostomy bowel care. Findings included: 1) Resident #14 was admitted to the facility on [DATE] with diagnoses that included, in part, dementia, osteoporosis and repeated falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had severe cognitive impairment. She required extensive assistance with transfers and bed mobility. She was coded on the MDS as having one fall with no injury. The care plan, updated 11/24/22, included a focus area of risk for falls. A care plan intervention stated, Fall mats next to bedside while in bed. On 1/23/23 at 10:10 AM, Resident #14 was observed in bed. The bed was in the low position. A fall mat was observed on the floor to the right of the bed. There was no fall mat on the left side of the bed; however, a fall mat was leaned up against the dresser. Nurse #1 was interviewed on 1/24/23 at 1:49 PM. She reported Resident #14 needed one person to assist her when she got out of bed. She acknowledged the resident was unable to use her call light due to confusion and was at risk for falls. She said fall prevention interventions used for Resident #14 included the use of a low bed and staff placed two floor mats on either side of the bed when the resident was in bed. During an observation on 1/24/23 at 1:53 PM, Resident #14 was asleep in bed. A fall mat was on the floor to the right of the resident's bed. There was no fall mat on the floor to the left of the resident's bed. A second fall mat was leaned up against the clothes closet. Interviews were completed with Nurse Aide (NA) #1 on 1/25/23 at 2:15 PM and 1/26/23 at 10:53 AM. She shared Resident #14 required assistance with transfers. NA #1 said the resident had at times tried to get up unassisted and fell. She specified staff looked on the computer and accessed the care plan which revealed to them what fall prevention interventions were to be used when staff cared for a resident. She explained current fall prevention interventions for Resident #14 included a fall mat on both sides of the bed, frequent rounds by staff and the bed placed in the low position. NA #1 verified she worked with Resident #14 on 1/23/23 during the day. When asked why there was only one fall mat observed on the floor next to the resident's bed, NA #1 said she forgot to put the second mat down after she fed the resident breakfast. An attempt to interview NA #2 (who worked with Resident #14 on 1/24/23) was unsuccessful. The Director of Nursing was interviewed on 1/25/23 at 9:37 AM and 1/26/23 at 1:23 PM. She stated Resident #14 was at risk for falls and had a history of attempting to get out of bed unassisted. She shared fall prevention interventions included fall mats at bedside times two, frequent rounding and positioning checks. She added when a new fall prevention intervention was added, the staff were educated to review the care plan and point of care charting system on their tablets and she expected staff to adhere to the interventions listed on the care plan.