Every finding on record at Pines of Dekalb, the

Based on observation, interview and record review, the facility failed to store and label leftover foods and maintain kitchen sanitation for 68 of 68 residents served food prepared in the kitchen.Findings include:During an observation, on 07/30/2025 9:28 AM, a 2 foot by 24 foot section of floor was missing tile and the surface was a rough textured cement. The missing tile spanned the majority of the length of the floor, was underneath a prep table, refrigerator and a flat top grill.During an interview, on 07/30/2025 at 9:29 AM , the Dietary Manager (DM) indicated the facility experienced a sewer problem about two months prior and the floor had been removed to repair a pipeline. She indicated she was not aware of any definite plan to replace the flooring.During an observation, on 07/30/25 at 9:30 AM, a clear plastic container holding a white lumpy substance was observed in the reach in refrigerator. The lid on the container had a crack about 1 inch long and 1/4 inch wide. No label or date was on the container. A clear plastic container containing applesauce had a lid with a crack about 1/2 inch long and 1/8 inch wide. A container of fruit cocktail had a lid with a crack about 1/2 inch long and 1/8 inch wide. A container of pears had a crack on the lid about 1/2 inch long and about 1/8 inch wide. All cracks allowed air into the containers.During an interview, on 07/30/25 at 9:31 AM, the dietary manager indicated the item in the unlabeled container was sausage gravy on the menu the previous day. She indicated the container should have been labeled and dated. She indicated cracked storage containers should be discarded and only intact, undamaged containers should be used to store food.During an interview, on 07/30/25 at 9:32 AM, the Director of Maintenance indicated he had exchanged some text messages regarding estimates for tile replacement, but no estimates had been conducted thus far.During an observation, on 07/30/2025 10:14 AM, the conference room refrigerator contained a cookie in a plastic bag dated 7/24. A styrofoam takeout container with a resident's name was not dated. A freezer bag containing 9 ice cream cups did not have a label or date. The individual cups did not have a printed expiration date. A large container of cookies and cream ice cream was not labeled and dated. During an interview, on 07/30/25 at 10:15 AM, Certified Nurse Aide (CNA) 2 indicated the cookie should have been discarded after 3 days and all items should have been labeled and dated. She indicated there was not a way to determine the expiration date of the ice cream cups because the items had been removed from their original box and no label or date was on the bag or individual cups. During an interview, on 07/30/2025 2:47 PM, the Administrator indicated floors should be intact and only undamaged storage containers should be used. She indicated all food items should be labeled and dated. A current policy titled Food Purchasing and Storage, dated 12/10/24, provided by the Administrator on 07/31/25 at 8:50 AM, indicated any porous surface should be sealed with paint or other substances to ensure accidental food leakage would not be absorbed. The policy indicated all leftovers should be covered, labeled and dated. The policy indicated all items in the refrigerator should be properly labeled, dated and sealed with tight fitting lids on containers. 3.1-21(i)(3)

Based on interview and record review the facility failed to ensure timely treatment of an infection for 1 of 1 resident reviewed. (Resident 6)Findings include:Resident 6's record was reviewed on 8/4/25 at 1:05 PM. Diagnoses included MDS indicated renal insufficiency, diabetes mellitus, and depression.A review of Resident 6's current quarterly MDS indicated their BIMS (Basic Interview for Mental Status) score was 14 (cognitively intact). The MDS indicated the resident had frequent stool incontinence and intermittent urinary catheterization,A review of physician orders, dated 7/28/25, indicated Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohydrous Macro) Give 100 mg by mouth two times a day for for a urinary tract infection until 08/04/2025 at 20:00.A review of the Medication Administration Record from July to August 2025 indicated Nitrofurantoin was started on July 28th at 8:00 PM to be given two times a day until August 4th at 8:00 AM.A review of the Microbiology Report Document dated and faxed to the facility on 7/29/25 at 11:42 AM, indicated Klebsiella pneumoniae and Escherichia coli were resistant to Nitrofurantoin (Macrobid). A review of Progress Notes on 7/31/2025 at 10:00 AM, indicated missing documentation about notifying the physician of antibiotic resistance or the need to commence a new form of treatment based on new laboratory results between 7/29 and 7/31/25.A review of 3 laboratory documents on 7/31/2025 at 10:05 AM, had a hand written note on page 1 of the urinalysis results, dated 7/25/25, indicated the physician was notified on 7/29/25 and no new orders were received. The documentation on page 1 failed to indicate if the microbiology report on page 3 was communicated to the physician. In an interview, on 8/4/25 at 12:52 PM, RN 3 indicated Solaris Diagnostics faxed laboratory results to the facility. A nurse should review the lab results and evaluate for abnormal labs or a need to report to the physician. The nurse was to document in the Progress Notes the physician was notified or document the notification on the faxed paper copy. A review of Progress Notes, created on 8/4/25 at 14:09 PM by the Director of Nursing, indicated the physician was notified of the antibiotic resistance and an appropriate antibiotic was ordered.In an interview, on 8/5/25 at 9:30 AM the Director of Nursing, indicated the physician was notified multiple times and a Nurse Phone message was sent with all three pages of urinalysis results on 7/29/25. Additionally, the urinalysis was printed out and placed in a communication folder for physician review. A current policy, dated 2/14/24, provided by the Director of Nursing, indicated the facility staff must consult with the resident's practitioner if there is a need to discontinue an existing form of treatment or to commence a new form of treatment. The licensed nurse would document in the electronic medical record Progress Notes including the notification and the information that was provided to the physician. 16.2-3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure physician orders were obtained and followed regarding dressing changes for 1 of 7 residents reviewed (Resident 74). Findings include: On 9/3/24 at 9:07 AM, Resident 74 was observed with a dressing on their left below the knee amputation site. The date on the dressing was observed to be 8/22/24. In an interview on 9/3/24 at 9:09AM, Certified Nurse Aide (CNA) 25 indicated they observed the date on the dressing as 8/22/24. CNA 25 indicated they did not normally work on Resident 74's hall and had not been made aware of the dressing. In an interview on 9/3/24 at 9:19 AM, the Director of Nursing (DON) indicated the foam dressing to Resident 74's left leg amputation was most likely applied as a preventative measure to avoid injury. The DON indicated the skin under the dressing would have been inspected during weekly skin assessments. The DON indicated although the weekly skin assessments did not address specific areas of the body, the entire body was assessed. The DON indicated they did not believe the same dressing, dated 8/22/24, would have been reapplied after the dressing was removed to inspect the skin underneath. Resident 74's record was reviewed on 9/3/24 at 9:39 AM. Diagnoses included diabetes, peripheral vascular disease (poor blood circulation) and left below the knee amputation. Resident 74's Admission Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) score was 15 (no cognitive impairment). The MDS indicated Resident 74 had a left below the knee amputation surgical incision. The MDS indicated the resident required orthopedic surgical wound care. The MDS indicated Resident 74 was participating in occupational and physical therapy 5 times a week. The MDS indicated Resident 74 was being administered insulin, a blood thinner and antibiotics. A physician order, dated 7/24/24, indicated the wound care practitioner was to evaluate and treat Resident 74 as indicated. A physician order, dated 7/26/24, indicated Resident 74 was to be administered doxycycline (antibiotic) 2 times a day for 14 doses for left below the knee amputation infection. A physician order, dated 7/26/24, indicated Resident 74 was to be administered cephalexin (antibiotic) every 6 hours for 28 doses for left below the knee amputation infection. A physician order, dated 7/26/24, indicated Resident 74's dressing to their left leg was to be left in place until their orthopedic appointment on 8/13/24. Resident 74's physician orders did not include a current or discontinued order for dressing changes of a baby soap cleanse, pat dry, silver infused foam and a tubular compression bandage every Monday, Wednesday and Friday. Resident 74's Care Plan, dated 7/27/24, indicated the resident had a risk for impaired skin integrity related to impaired mobility, diabetes, weakness, incontinence and the use of an indwelling urinary catheter. The target goal was to minimize risk through 11/16/24. Interventions included weekly head to toe skin assessments, observe dressing frequently and refer to actual impaired skin integrity (left below the knee amputation) plan of care. Resident 74's Care Plan, dated 7/27/24, indicated the resident had a risk for complications from their left below the knee amputation incision. The target goal was for the incision to heal without complications through 11/16/24. Interventions included observance of temperature elevation of the resident and observance of swelling, increased drainage, redness, warmth or odor of the incision. Resident 74's Care Plan did not include interventions for Steri-Strips or a prophylactic dressing to their left below the knee amputation incision. An Orthopedic Clinical Visit Summary, dated 8/14/24, indicated staples were removed from Resident 74's left below the knee amputation incision. A Skilled Care Note, dated 8/16/24, indicated Resident 74's left blow the knee amputation incision was open to air with Ster-Strips in place. Resident 74's physician orders did not include a current or discontinued order for Steri-Strips. A Wound Care Consult, dated 8/19/24, indicated Resident 74 had been evaluated for a non-healing wound of their left below the knee amputation after dehiscence (separation of edges) of their incision. The wound bed was debrided mechanically to remove a small scab. A Center for Wound Healing After Visit Summary, dated 8/19/24, indicated Resident 74's wound was to be cleansed with baby soap and water, patted dry, covered with a silver infused foam dressing and secured with an elastic tubular bandage every Monday, Wednesday and Friday. Resident 74 was to follow up with the facility wound care practitioner unless the wound became worse. In an interview on 9/4/24 at 9:40 AM, the DON provided a handwritten Wound and Skin Record for Resident 74. The DON indicated Wound and Skin records were kept in a book at the nurse station and scanned into the resident's electronic medical record later. Resident 74's Wound and Skin Record entries were as follows: On 7/27/24, Resident 74 had a surgical wound to their left below the knee amputation. The dressing was to remain in place until their follow up orthopedic appointment on 8/14/24. On 8/1/24, Resident 74's dressing was intact. On 8/8/24, Resident 74's dressing was intact. On 8/14/24, Resident 74's incision measured 14 centimeters (cm) long and 3.5 cm wide, the incision was pink, well approximated with scattered scabs and Steri-Strips (adhesive wound closure) were intact. On 8/15/24, Resident 74's incision measured 14 centimeters (cm) long and 3.5 cm wide, the incision was pink with scattered scabs and Steri-Strips (adhesive wound closure) were intact. On 8/22/24, Resident 74's incision measured 14 centimeters (cm) long and 1 cm wide, the incision was pink, well approximated with small scabs. On 8/29/24, indicated Resident 74's incision measured 12 centimeters (cm) long and 1 cm wide, the incision was pink, and a prophylactic dressing was applied. In an interview on 9/4/24 at 1:20 PM, the DON indicated the dressing to Resident 74's left leg incision should not have been in place for 12 days. The DON indicated the foam dressing should be changed every 3 to 5 days and as needed. The DON indicated they were not aware of why the dressing was applied. The DON indicated a physician order for the dressing should have been obtained and the dressing application should have been documented. A current facility policy, dated 8/14/24, provided on 9/3/24 at 10:38 AM by the DON indicated residents admitted to the facility with any skin impairment would be provided with the following: -A physician order for treatment -Documentation of the location, measurements and characteristics of the wound -Appropriate interventions to promote wound healing -Preventative treatments would be documented in the care plan The policy indicated a licensed nurse would document preventative measures on the care plan and Kardex (summary of care plan). The policy indicated a licensed nurse would evaluate and document the condition of the dressing, the condition of the surrounding skin and pain in the resident's medical record. A current facility policy, dated 10/20/23, provided on 9/3/24 at 10:51 AM by the DON indicated the facility would obtain physician orders to ensure concise direction for the care of residents. 3.1-37

Based on observation, interview, and record review the facility failed to ensure a nasogastric (ng) tube was trreated according to physician orders for 1 of 1 resident reviewed (Resident 24). Findings include: During an observation and interview on 8/28/24 at 11:21 AM, Resident 24 indicated she had an ng tube placed for nutrition because she was unable to eat due to a worsening hiatal hernia. An ng tube was present in Resident 24's left nostril with tubing attached to a container of Jevity (a nutritional formula for tube feedings). Resident 24's record was reviewed on 9/3/24 at 10:24 AM. Diagnoses included dysphagia, pharyngeal phase, gastro-esophageal reflux disease without esophagitis, and pulmonary hypertension. Resident 24's current significant change Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). Resident 24's current care plan titled .unable to tolerate nutritionally adequate food or fluid .indicated the resident had a problem of a need for an ng tube for nutrition and hydration, with a goal date of 12/1/24. Interventions included tube dysfunction, or malfunction should be reported to the provider. Current physician orders did not include specific orders for managing blockages in the tubing. Progress notes dated 8/24/24 at 10:29 PM indicated staff were unable to administer Jevity due to a blockage of the tubing. The note indicated Nurse Practitioner (NP) 4 had given orders to send Resident 24 to the hospital. Progress notes dated 8/31/24 at 12:10 PM indicated the ng tube had become blocked after medication administration and Registered Nurse 2 had used Coke (a carbonated beverage) to unblock the tube. The note indicated lab reports were sent to the Nurse Practitioner. No other reports to the NP were recorded in this progress note. In an interview on 9/3/24 at 11:59 AM, the Director of Nursing (DON) indicated the facility did not have a policy for ng tube maintenance and care. She indicated when a policy was not available, staff should refer to [NAME] best practices. In an interview on 9/4/24 at 9:48 AM, the DON indicated the nurse should have contacted the NP for orders when she discovered the ng tube was blocked and should not have used Coke to unclog the ng tube. Lippincott Nursing Center best practice, Nursing 2024, Volume: 48 Number 6, page 66 indicated juices, or carbonated beverages can worsen an occlusion by causing proteins in the formula to precipitate within the tube. The recommended method was pulling back on a syringe plunger and then gently injecting warm water and moving the plunger back and forth to loosen the blockage and clamping the tube to allow the water to loosen the blockage. Additional methods required specific provider orders. 3.1-44(a)(2)

Based on observation, interview and record review the facility failed to ensure supervision of self-administration of medication for 1 of 6 residents reviewed. (Resident 18) Findings include: During an observation 8/21/23 at 10:28 AM Resident 18 was sitting in a wheelchair in their room while RN 4 administered medications to Resident 18's roommate. A medication bottle was viewed on Resident 18's bedside table. In an interview on 8/21/23 at 3:00 PM, Resident 18 indicated the medication bottle contained eye drops. Resident 18 indicated they had experienced redness and dryness to both eyes for approximately 1 week. Resident 18 indicated they had made staff aware of the eye discomfort. Resident 18's record was reviewed on 8/22/23 at 10:07 AM. Diagnoses included diabetes mellitus, heart problems, major depressive disorder and chronic pain related to osteoarthritis and spinal stenosis. Resident 18's current comprehensive Minimum Data Set (MDS)dated 8/2/23 indicated their Basic Interview for Mental Status (BIMS) was 15 (no cognitive deficit). The MDS indicated the resident had adequate vision and wore glasses. Resident 18's current care plan initiated on 8/4/23 indicated the resident was at risk for side effects and adverse reactions related to medications with a goal date of 11/16/23. Interventions included administration of medications as ordered, observance for side effects such as dry eyes and reporting abnormal findings to the physician. In an interview on 8/22/23 at 3:16 PM, Resident 18 indicated facility staff had instructed the resident to hide the eye drops due to the government being in the building. The resident removed the eye drops from a plastic storage box. Resident 18 indicated a staff member had stated the resident's eyes were red due bearing down to have a bowel movement. In an interview on 8/24/23 at 9:50 AM, Resident 18 indicated their eyes remained uncomfortable due to dryness and redness. Resident indicated they had made facility staff aware of their eye symptoms and had requested an appointment with their eye doctor. Resident 18 indicated the eye drops were put out of sight due to the facility staff's report of government investigators being in the facility. In an interview on 8/24/23 at 11:45 AM, the Director of Nursing (DON) indicated they had spoken with Resident 18 about the resident having had red and dry eyes. The DON could not recall when the conversation had occurred. The DON indicated Resident 18 had reported their eyes were red due to bearing down to have a bowel movement. The DON indicated they were unaware of Resident 18 having the eye drops at the bedside. The DON indicated Resident 18 was unable to pass a medication self-administration evaluation. A current policy dated 10/14/22 provided by the Administrator indicated residents may administer their own medications after a self-administration evaluation was completed and authorization was granted by the physician. 3.1-11

Based on observation, record review, and interview the facility failed to ensure a resident catheter drainage bag did not touch the floor for 1 of 2 residents reviewed for catheter care. (Resident 82). Findings include: During an observation on 08/21/23 at 2:37 pm Resident 82's catheter drainage bag was obersved laying on the floor. During an observation on 08/22/23 at 10:19 am Resident 82's catheter drainage bag was observed laying on the floor. Resident 82's record was reviewed on 08/24/23 at 12:18 pm. Diagnoses included malignant neoplasm of prostate, neuromuscular dysfunction of Bladder, and quadriplegia. A review of Resident 82's current significant change Minimum Data Set (MDS) assessment, dated 6/30/23, indicated his Basic Interview for Mental Status (BIMS) score was 10 (moderately impaired). The MDS indicated the resident had an indwelling catheter (including suprapubic catheter and nephrostomy tube) and was on hospice. A review of Resident 82's current Care plan indicated the resident was at risk for urinary tract infections, catheter-related trauma and had a foley catheter related to a neurogenic bladder, with a goal he would show no signs or symptoms of urinary infection. Intervention included to ensure the drainage bag was secured properly. A Medication Review Report, dated 8/13/23, indicated the physician ordered an 18 French foley catheter with a 10mm balloon for Resident 82'd diagnosis of neurogenic bladder. In an interview on 8/24/23 at 11:07 AM, CNA 2 indicated a catheter bag should not be on or touching the floor due to contamination. In an interview on 8/24/23 at 11:07 AM, RN 3 indicated a indicated the catheter bag should not be on the floor or touching the floor due to infection risk. In an interview on 8/24/23 at 11:07 AM, The Director of Nursing (DON) indicated a indicated the catheter bag should not be on the floor or touching the floor due to infection risk. A current procedure titled Indwelling urinary catheter (Foley) care and management Critical Notes!, reviewed 12/2/22, provided by the DON on 8/24/23 at 11:15 AM indicated the catheter drainage bag should not be on the floor to reduce the risk of contamination and subsequent catheter-associated urinary tract infections (CAUTI). 3.1-41(a)(1)

Based on observation, interview, and record review the facility failed to ensure nutritional risk factors were assessed and intervened upon for 1 of 24 residents reviewed (Resident 6). Findings include: During an observation on 8/21/23 at 10:24 AM Resident 6 was observed seated in her wheelchair in her room. She had about 2+ edema of both feet and her abdomen and extremities were consistent with being above ideal body weight. Resident 6's record was reviewed on 8/21/23 at 11:11 AM. Diagnoses included heart failure, type 2 diabetes mellitus without complications, and unspecified intellectual disabilities. A review of Resident 6's current Medicare 5-day Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 8 (cognitively impaired). The MDS indicated the resident had a significant weight gain. A review of Resident 6's current care plan titled Resident is at risk for nutritional decline indicated Resident 6 had a problem of risk for nutritional decline, with a goal, dated 10/19/23, of maintaining current weight. Interventions included notifying the Registered Dietician (RD), family and physician of significant weight changes, and observing and evaluating weight and weight changes. A review of a weight summary document indicated on 2/3/23 Resident 6 weighed 138 lbs. On 8/3/23, Resident 6 weighed 170.2 lbs. This is a 23.33 % gain in six months. A review of a height summary indicated on 7/13/23 Resident 6 was 60 inches tall. A progress note dated 3/13/23 indicated Resident 6 had a weight gain of 8% in 30 days, the Nurse Practitioner (NP) and Power of Attorney (POA) were aware. There was not an indication the Registered Dietician had been notified to review her nutritional status, A progress note dated 4/7/23 indicated Resident 6 had a weight gain of 12% in 3 months and 15% in 6 months. The note indicated the NP and POA were aware. There was not an indication the Registered Dietician had been notified to review her nutritional status, A progress note dated 5/11/23 indicated Resident 6 had a weight gain of 14% in 3 months and the NP and POA were aware. There was not an indication the Registered Dietician had been notified to review her nutritional status, A progress note dated 6/16/23 indicated Resident 6 had a weight gain of 17% in 6 months and the NP and POA were aware. There was not an indication the Registered Dietician had been notified to review her nutritional status, A progress note dated 8/11/23 indicated Resident 6 had a 32.2 lb. weight gain since February and the NP and POA were aware. There was not an indication the Registered Dietician had been notified to review her nutritional status, A review of RD weight reviews dated 11/30/22 indicated Resident 6 weighed 134 lbs. with a BMI of 26.2 indicative of overweight status. No Registered Dietician evaluations after 11/30/22 were available for review. No documentation of Registered Dietician notification of weight changes after 11/30/22 was available for review. In an interview on 8/24/23 at 2:05 PM, the Dietary Manager indicated the RD came in every other week and reviewed all weights, making recommendations as needed. In an interview on 8/23/23 at 1:35 PM the Director of Nursing indicated she was not aware of a policy for Registered Dietician notification of weight changes. 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to ensure maintained environment affecting 12 of 12 residents. Findings include: During an observation on 10/17/22 at 10:16 AM room 104 had several large chips in the windowsill, exposing a chipped, flaking particle board. The chips were about 3 inches by 2 inches and 2 inches by 6 inches in size. A large tear in the drywall on the wall near the window was about 4 inches by 4 inches in size with chalky drywall plaster chipped and exposed. An additional chipped area that was about 6 inches by 1/2 inch was observed on the side of the window. Two residents resided in the room. An observation conducted on 10/19/22 at 10:28 AM indicated the following In room 103, chipped paint and windowsill damage was about 1 inch by 1 inch. two people resided in this room. In room 104, chipped paint was observed on the windowsill. Two people resided in this room. In room 107, the windowsill was chipped in the wood. Two people resided in this room. In room 109, the windowsill was chipped into the wood. Two people resided in this room. In room 111, the windowsill was chipped down to the wood. Two people resided in this room. In room 113, the windowsill was chipped down to the wood. Two residents resided in this room. In an interview, Resident 46 on 10/19/22 at 10:29 AM indicated she disliked having to look at the unsightly wall and windowsill damage. During a record review conducted on 10/19/22 at 11:28 AM, a Minimum Data Set (MDS) dated [DATE] indicated Resident 46 had diagnoses including [CONDITION(S)], [CONDITION(S)], and weakness. The MDS indicated she was alert and oriented. In an interview on 10/20/22 at 11:05 AM, the Maintenance man indicated he noted any damage to doors, walls, or window areas during daily rounds. He indicated he was unable to see the wall damage in Resident 46's room because the privacy curtain in the middle of the room blocked his view. He indicated direct care staff should notify him of such damage. He indicated that he had not received any work orders pertaining to wall or windowsill damage. A policy titled Maintenance Department indicated the department will do on-going monitoring for facility areas needing repair and, if needed, will report to the supervisor for approval of the repairs needed. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure the resident choice was observed for 1 of 1 resident reviewed. (Resident 10). Findings include: During an interview on 10/17/22 at 1:20 PM, Resident 10 indicated he had not been out of bed for eight weeks and he wanted to get up in his broda chair. The resident indicated the facility would not get him up due to the wound on his left hip. During an observation on 10/20/22 at 11:15 AM, the resident was lying in bed asleep with heel protector on right foot, foot elevated on pillow and heel floating. During an interview on 10/21/22 at 9:53 AM, Resident 10 was lying in bed. The resident indicated he would prefer being up in his broda chair. On 10/20/22 at 9:11 AM, Resident 10's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 10's quarterly Minimum Data Set (MDS) assessment, dated 7/17/22, was reviewed. The MDS indicated the resident's Brief Interview for Mental Status (BIMS) score was 13; he was alert, oriented and interviewable. The MDS assessment indicated the resident required a two-person physical assist to transfer from his bed to broda chair. In an interview on 10/20/22 at 11:20 AM, LPN 10 and LPN 11 indicated the resident's physician recommended the resident remain in bed due to his wound and pressure ulcer issues. LPN 10 indicated the resident had been educated concerning the physician's recommendation for him to stay in bed. No orders could be located by LPN 11 indicating resident should remain in bed to prevent further skin complications and/or promote wound healing. A review of Resident 10's progress notes indicated CNP 12 did not recommend the resident stay in bed to prevent further skin complications/promote wound healing. In an interview on 10/20/22 at 1:26 PM, the Director of Nursing (DON) indicated she reviewed the physician notes and found no recommendation from the resident's physician the resident should stay in bed to prevent further skin complications/promote wound healing. She indicated she spoke to LPN 10 and LPN 11 that Resident 10 could get up in his broda chair. The DON indicated Resident 10 should be asked during morning care if he would like to get up in his broda chair every morning. On 10/20/22 at 1:48 AM, a current policy titled Routine Guest/Resident Care, revised 6/26/21, provided by the DON, was provided morning care. The policy did not address offering residents help who require physical assistance to get up during or after morning care. No further policies were provided concerning assisting residents up in the morning during or after morning care by the survey exit. 3.1-3(u)(1)

Based on observation, interview, and record review the facility failed to ensure the area surrounding the outdoor dumpsters was free from debris in 2 of 2 observations. Findings include: During a tour with the Assistant Dietary Manager on 10/17/22 at 9:35 am the ground surrounding the dumpster area was observed to be littered with a soiled adult brief. She indicated it was not the dietary department's responsibility to remove debris from the ground. She indicated she believed the responsibility belonged to Maintenance or Housekeeping. During an observation on 10/18/22 at 9:10 am the ground surrounding the outdoor dumpster was littered with a soiled adult brief. In an interview, the Director of Nursing (DON) on 10/18/22 at 9:50 am indicated she was unaware of which department was responsible for cleaning the outdoor dumpster area. In an interview, the Maintenance Director on 10/20/22 at 11:15 am indicated he was not aware of which department was responsible for cleaning the area surrounding the outdoor dumpster. He indicated he saw the soiled adult brief and removed it the next day. A current policy titled Regulated Medical Waste Management was provided by the Administrator on 10/20/22 at 2:07 pm. The policy indicated final disposal on non-regulated waste was to be disposed of according to local, state, and federal regulations. 3.1-21(i)(5)

Based on interview and record review, the facility failed to ensure acionts were taken to prevent foalls for 1 of 3 residents reviewed. (Resident D) Findings include: Resident D's record was reviewed 3-30-22 at 10:58 A.M. Diagnoses included, but were not limited to, dementia, cognitive deficit, unsteadiness, and repeated falls. A current care plan dated 3-30-22 indicated Resident D was at risk for repeated falls related to dementia and weakness. The care plan indicated the residnet needed assistance with safety reminders and rest. The care plan goal indicated the resident would be free from injury related to falls. Interventions included to observe for fatigue and unsteadiness. A review of progress notes dated 1-30-22 indicated Resident D had been tested positive for COVID, and was isolated in her room. On 2-1-22, the resident was moved to a COVID unit for closer observation. On 2-8-22 at 10:15 A.M. Resident D was assisted to the restroom. LPN 1 was in the restroom with Resident D when a physician called out needing help. LPN reminded Resident D to use the call light, and went to assist the physician. On return to the restroom, Resident D had fallen and was calling out for help. Resident D was complaining of pain and was sent to the hosiptal. In an interview on 3-30-22 at 10:52 A.M., LPN 3 indicated when a resident has a change, increased unsteadiness, a new infection, even if they had been independant in the restroom, a change would warrant increased supervision and the residnet should not be left alone in the restroom. This Federal Citation is related to Complaint IN 084. 3.1-45(a)(2)

Based on observations, interviews and record reviews, the facility failed to properly prevent and/or contain COVID-19 related to Personal Protective Equipment (PPE) during 17 of 17 observations. This affected 8 randomly observed residents (Resident 1, Resident 3, Resident 4, Resident 5, Resident 8, Resident 9, Resident 10, Resident 11, Resident 13, and Resident 14). Findings include 1. During observation on 11/16/21 at 3:15 P.M., Certified Nursing Aide (CNA) 6 entered room [ROOM NUMBER] (Resident 8, Resident 9) to answer the call light. The 300 hall was designated as a yellow zone with contact precautions. CNA 6 stepped out into the hallway wearing gown, gloves, mask, face shield and holding some cash, so she could ask the nurse if she could accept money since Resident 9 was Covid-19 positive. The nurse instructed CNA 6 to not stand in hallway; CNA 6 continued to stand in the hallway just inside the door frame, holding the door open. During interview at the same time, CNA 6 indicated she was not sure if she should be in the hallway with her PPE on. She indicated they had just found out today that the resident was positive. During interview on 11/16/21 at 3:36 P.M., the Director of Nursing (DON) indicated staff should not be in the hallways wearing PPE, and the all of 300 hall was a yellow zone except for the red zone rooms at the end of the hall. 2. During observation on 11/16/21 at 1:10 P.M., Cook 1 was screening visitors. Cook 1 was not wearing eye protection. During observation on 11/16/21 at 1:25 P.M., CNA 1 entered room [ROOM NUMBER] (Resident 4, Resident 5) wearing a face shield which was open at the top above the eyes. During observation on 11/16/21 at 1:30 P.M., on 300 hall, Personal Care Assistant (PCA) 1 and Housekeeper 1 were both in the hallway wearing face shields which were open at the top above the eyes. During observation on 11/16/21 at 1:35 P.M., Licensed Practical Nurse (LPN) 1 exited room [ROOM NUMBER] (Resident 1, Resident 3) and returned to the nurses' station. LPN 1 was wearing a face shield which was open at the top above the eyes. During interview at the same time, LPN 1 indicated the facility had the foam top shields available. During observation on 11/16/21 at 1:37 P.M., Activities Personal 1 was on 400 hall with the activity cart, to check which residents might have wanted 1:1 activities in their rooms. Activities Personnel 1 was wearing a face shield open at the top above the eyes. During interview at the same time, Activities Personnel 1 indicated she was going into the rooms to provide 1:1 activities. During observation on 11/16/21 at 1:39 P.M., on 400 hall, Certified Occupational Therapy Assistant (COTA) 1, Registered Nurse (RN) 1, and LPN 2 were all in the hallway wearing face shields open at the top above the eyes. During observation on 11/16/21 at 1:40 P.M., on 100 hall, three CNA staff were sitting in the lobby area midway down the hall. CNA 2, CNA 3, and CNA 4 were all wearing face shields open at the top above the eyes. During interview at the same time, CNA 2 indicated they had the foam top shields available, but were told the open top ones were acceptable. During observation at the nurse's station on 100 hall, on 11/16/21 at 1: 42 P.M., LPN 3, LPN 4, and RN 2 were all wearing face shields open at the top above the eyes. During observation on 11/16/21 at 1:43 P.M. on the memory care unit, CNA 5 and CNA 6 were both wearing face shields open at the top above the eyes. During interview on 11/16/21 at 1:45 P.M., the DON indicated the State Infection Preventionist was there in September and did not address the open top face shields, so the facility thought they were okay to use them. 3. During observation on 300 hall at 3:13 P.M., as PCA 2 was passing ice water, he exited room [ROOM NUMBER] (Resident 13, Resident 14), removed his gloves, placed ice into a bag, then moved the ice cart to beside room [ROOM NUMBER] (Resident 10, Resident 11). PCA 2 then donned PPE and took the ice into the room. When PCA 2 exited the room, he removed his gloves, then moved the cart across the hall. PCA 2 did not use hand sanitizer or perform any hand hygiene in between rooms. During interview at the same time, PCA 2 indicated he should have used hand sanitizer or washed hands after exiting each room. The facility policy titled Hand Hygiene, number 118 and revised 07/2021 indicated Alcohol based hand sanitizer may be used before and after: touch a guest/resident, before performing an aseptic task . after glove removal, . and after contact with contaminated surfaces The facility policy titled Multi Route Transmission Based Precautions, number 719, revised 08/2021 indicated Contact Precautions: . Use PPE [personal protective equipment] appropriately, including gloves and gown for all interactions that may involve contact with the guest/resident or the guests/residents environment. Donning PPE prior to entering the room and Doffing and properly discarding before exiting the room The facility policy titled Coronavirus (COVID 19), number 766, revised 11/2021 indicated Mode of Transmission Person-to-person spread . Includes all things that will expel respiratory droplets such as coughing and sneezing. Droplets can land in the . eyes of people who are nearby . Personal Protective Equipment Transmission Based Precautions: Use PPE including: If a guest/resident is in isolation . use . a face shield or goggles. HCP [health care personnel] working in facilities located in areas with moderate to substantial community transmission are more likely to encounter symptomatic or pre-symptomatic guests/residents with [CONDITION(S)]-CoV-2 [severe acute respiratory syndrome Coronavirus 2] infection. If [CONDITION(S)]-CoV-2 is not suspected in a guest/resident . eye protection (face shield or goggles) should be worn during guest/resident encounters (to ensure the eyes are also protected from exposure to respiratory secretions) and at all times while in the facility 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to follow CDC guidance during a pandemic and implement an infection control program regarding allowing staff to work with signs and symptoms of COVID-19, and failing to monitor symptoms and ensuring proper isolation requirements and testing were initiated timely to prevent the potential spread of infection, for 11 of 125 staff reviewed for infection control prevention screening (Speech Therapist 3, CNA 5, CNA 6, CNA 7, Activity Staff 8, CNA 9, Housekeeping Staff 10, LPN 11, CNA 12, CNA 13 and CNA 14). On 8/7/20, Speech Therapist 3 had symptoms of COVID-19, and worked with Resident B, Resident D, Resident E, Resident F, Resident G, Resident H and Resident J. These residents later developed symptoms suggestive of COVID-19. Between the dates of 8/7/20 and 8/20/20, the facility had 29 symptomatic residents suggestive of COVID-19, 11 staff with symptoms, and 2 staff test positive for COVID-19. The facility also failed to ensure 2 of 7 residents were placed in droplet precautions in a timely manner (Resident F and Resident G). The immediate jeopardy began on 8/7/20 when Speech Therapist 3 continued to work despite having symptoms of COVID-19. Multiple staff continued to work in the facility while having COVID-19 symptoms, and residents began experiencing symptoms of COVID-19. The Executive Director, and Director of Nursing were notified of the immediate jeopardy on 8/19/20 at 4:52 P.M. The immediate jeopardy was removed on 8/24/20 at 2:13 P.M., but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy Findings include: 1. A review of COVID-19 Associate/Employee daily screening logs from 7/31/20 to 8/19/20, indicated staff continued to work with signs and symptoms of COVID-19 on the following days: On 8/3/20 CNA 6 reported cough and runny nose; On 8/6/20 CNA 7 reported vomiting; On 8/7/20 Speech Therapist (ST) 3 reporting having a sinus infection; On 8/10/20 CNA 9 reported having a sore throat and congestion; On 8/14/20 Housekeeper 10 reported having nasal congestion; On 8/16/20 LPN 11 reported having a cough, sore throat and headache; On 8/17/20 CNA 12 reporting having fatigue; On 8/17/20 CNA 13 reported having a cough, runny nose and chills; On 8/18/20 CNA 14 reported having cough and chills; On 8/18/20 CNA 7 reported having a sore throat; On 8/19/20 CNA 5 reported having body aches, runny nose and a headache; On 8/19/20 Activity Staff 8 reported having diarrhea. The facility's COVID-19 Associate/Employee daily screening log indicated to refer to CDC guidelines for signs and symptoms related to COVID-19. The signs and symptoms were posted as a flier for staff to observe while being screened. The flier indicated symptoms of COVID-19 included fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. COVID-19 Screener/CNA 15 was interviewed on 8/19/20 at 10:59 A.M. During the interview COVID-19 Screener/CNA 15 indicated if staff had signs or symptoms, she would write them down on the screening log. She would then tell a nurse so they could talk with the staff having symptoms. The nurse would let the staff know if they could work. The nurse would then initial the screening log by the sign and symptoms section. COVID-19 Screener/CNA 15 had been screening staff since May. No staff had been sent home after reporting signs or symptoms of COVID-19 when being screened at the door. COVID-19 Screener/CNA 15 indicated no one had a temperature, and that is why they had not been sent home. Speech Therapist (ST) 3 was interviewed on 8/19/20 at 10:50 A.M. During the interview, ST 3 indicated she came to work on 8/7/20 with sinus pain, sinus drainage and congestion. She indicated she had a sinus infection on the screening log. ST 3 did not know what the facility did with screening information, but no one asked her for more information after she was screened. She indicated she wore a mask during her shift, but pulled it down to talk with Resident B who needed to see her mouth. She did not observe 6 foot distance when she pulled her mask down. The facility had educated her on signs and symptoms of COVID-19, but she did not think she was expected to do anything unless she was running a fever. Later, on 8/7/20, she developed a fever, cough, nausea, diarrhea, and continued to have sinus pain, sinus drainage and congestion. A Questionnaire for Employees Positive for COVID-19, dated 8/13/20, indicated ST 3 was tested for COVID-19 on 8/7/20 and positive results were relayed to the facility on [DATE] at 11:00 A.M. In an interview on 8/19/20 at 10:50 A.M., ST 3 indicated she had contact on 8/7/20 with Resident B. Information provided on 8/19/20 by LPN 17, indicated on 8/14/20, Resident B developed a temperature of 100.4, oxygen saturation of 75% on room air, and wheezes. Resident B was suspected of having COVID-19 and the facility was awaiting the results. In an interview on 8/19/20 at 10:50 A.M., ST 3 indicated she had contact on 8/6/20 and 8/7/20 with Resident D. Information provided on 8/19/20 by LPN 17, indicated Resident D began having dry heaves on 8/8/20 and had a temperature of 100.2 on 8/18/20. This resident was tested for COVID-19 on 8/20/20 and the facility was awaiting the results. In an interview on 8/19/20 at 10:50 A.M., ST 3 indicated she had contact on 8/6/20 and 8/7/20 with Resident E. ST 3 indicated she pulled her mask down so Resident E could see her mouth while talking. They were not distanced 6 feet apart at the time. Information provided on 8/19/20 by LPN 17, indicated Resident E developed wheezes on 8/16/20. This resident was tested for COVID-19 on 8/14/20 and the facility was awaiting the results. In an interview on 8/19/20 at 10:50 A.M., ST 3 indicated she had contact on 8/7/20 with Resident F. Information provided on 8/19/20 by LPN 17, indicated Resident F developed a cough and vomiting on 8/14/20. He developed a temperature of 99.2 and an oxygen saturation of 90% on 3 liters of oxygen on 8/17/20. In an interview on 8/19/20 at 10:50 A.M., ST 3 indicated she had contact on 8/7/20 with Resident G. Information provided on 8/19/20 by LPN 17, indicated Resident G developed vomiting on 8/16/20 and a cough on 8/19/20. This resident was tested for COVID-19 on 8/20/20 and the facility was awaiting the results. In an interview on 8/19/20 at 10:50 A.M., ST 3 indicated she had contact on 8/7/20 with Resident H. Information provided on 8/19/20 by LPN 17, indicated Resident H developed a temperature of 99.3, body aches and a headache on 8/19/20. This resident was tested for COVID-19 on 8/20/20 and the facility was awaiting the results. In an interview on 8/19/20 at 10:50 A.M., ST 3 indicated she had contact on 8/7/20 with Resident J. Information provided on 8/19/20 by LPN 17, indicated Resident J developed expiratory rhonchi on 8/18/20. This resident was tested for COVID-19 on 8/20/20 and the facility was awaiting the results. On 8/19/20, CNA 5 had symptoms of COVID-19, including body aches, runny nose and headache, and was observed working in the facility during the day shift on the 400 hall. On 8/13/20, CNA 5 had contact and worked with CNA 4, who tested positive for COVID-19 on 8/17/20. The Director of Nursing (DON) was interviewed on 8/19/20 at 3:31 P.M. During the interview the DON indicated staff are screened at the beginning of their shift. Staff had their temperature taken and were asked if they have any signs or symptoms of COVID-19 according to the CDC list. If they had a temperature greater than 100.0 they were removed from duty. The facility took staff temperatures at the end of their shift as well. If staff had signs or symptoms of COVID-19 they may not be sent home, unless they were having a temperature. The facility followed up and asked staff if the sign or symptom was normal for them, and if it was they could continue to work. The DON indicated she reviewed the screening sheets every couple of days. A temperature would be the biggest thing the facility was looking for when deciding if staff could continue to work or not. 2. Resident F's record review on 8/20/20 at 1:10 P.M., indicated [DIAGNOSES REDACTED]. On 8/14/20, the progress notes indicated Resident F had rhonchi in his upper lobes with diminished breath sounds in his bases. He had been eating a cookie, began to cough, and threw up. On 8/15/20, progress notes indicated a chest x-ray showed possible pneumonia. On 8/16/20, progress notes indicated he was weak and didn't have much energy. On 8/17/20, progress notes indicated the resident was started on [MEDICATION NAME] for pneumonia. He was also flushed, skin was warm to touch, and lung sounds were diminished throughout the lungs. On 8/18/20, a progress not indicated the resident was declining, and he was struggling to breathe. On 8/19/20 a physician's orders [REDACTED]. On 8/19/20 Resident F respirations and heart rate ceased at 9:20 P.M. Resident F was not placed on isolation when he began having symptoms of COVID-19. 3. Resident G's record review on 8/20/20 at 1:30 P.M., indicated [DIAGNOSES REDACTED]. On 8/16/2020, the progress note at 7:58 P.M., indicated Resident G was weak, and threw up. She became unresponsive, but responded to interventions by the staff. Then at 8:48 P.M., the resident became unresponsive, oxygen saturation was 90% and the resident went to the hospital. On 8/17/20 at 5:04 A.M., the resident returned to the facility without being tested for COVID-19. Then at 2:51 P.M., the progress notes indicated Resident G had a cough, but did not have a temperature. After exposure to ST 3 on 8/7/20 and developing symptoms on 8/16/20, Resident G was not placed on precautions to prevent possible spread of COVID -19. On 8/19/20 at 5:50 P.M., a physician's orders [REDACTED]. On 8/22/20, a lab result indicated Resident G was positive for COVID -19. A policy, dated 5/2020, was provided by the DON on 8/19/20 at 9:30 A.M., titled Coronavirus (COVID 19). The policy indicated .Care Givers. The facility will make all attempts to have consistent staff caring for guests/residents on precautions. Care givers and all facility staff will be screened as directed by CDC and CMS guidance. CDC guidance, Preparing for COVID-19 in Nursing Homes, dated as last updated 6/25/2020, indicated the following: .Remind HCP (Healthcare Personnel) to stay home when they are ill. If HCP develop fever (T?100.0oF) or symptoms consistent with COVID-19 while at work they should inform their supervisor and leave the workplace. Have a plan for how to respond to HCP with COVID-19 who worked while ill (e.g., identifying and performing a risk assessment for exposed residents and co-workers) . HCP with suspected COVID-19 should be prioritized for testing . Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19 CDC Guidance, Symptoms of Coronavirus, dated as last updated 5/13/2020, indicated the following: People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea. This Federal citation is related to IN 286 3.1-18(a)

Based on interview, and record review, the facility failed to report an allegation of abuse to the Indiana State Department of Health (ISDH) within 24 hours of the occurrence, for 1 of 1 residents. (Resident M) Findings include The clinical record of Resident M was reviewed on 8/20/2020. [DIAGNOSES REDACTED]. Assessment of the resident on admission to the facility included coughing or choking during meals or when swallowing medications, but no loss of liquids/solids from mouth when eating or drinking. The record failed to indicate an assessment of the resident after an alleged incident on 7/24/2020. During an interview on 8/20/2020 at 2:00 P.M., Employee 19 indicated she reported what she felt was inappropriate treatment. The report was made 3 or 4 weeks ago regarding a nurse's treatment of [REDACTED]. She indicated Resident M was having a hard time swallowing breakfast, and looked like she had milk running down her face; as if having trouble swallowing. LPN 22 (Licensed Practical Nurse) went to give medications crushed in applesauce. Resident M couldn't get it down, started coughing, had a gurgly cough, and was making vomiting noises. LPN 22 then placed tissues over her mouth and held it there, aggressively, and also berated the resident saying what, do you have to be a 2 year old to be on my hall? Resident M tried to back away and the wheelchair started to tip so Employee 19 caught it. After taking Resident M to the physical therapy room, she continued to cough and sounded like she had gurgling in her throat. Employee 19 indicated she just did what she could to be able to get her therapy done. She indicated she told the Occupational Therapist in the room with her and reported it to her supervisor and they both reported it to the Administrator. Nobody ever asked her anything more about it. She indicated she did not document anything about her observations. During an interview on 8/20/2020 at 2:46 P.M., the Administrator indicated she recalled Employee 19 came in and reported the incident. The Administrator indicated she would have documentation about the interviews, but had not reported it to ISDH. On 8/20/2020 at 3:28 P.M., the Administrator provided a typed up statement dated 7/24/2020. She indicated the statement was from her notes. In response to being asked why it was not on an incident report, and reported to ISDH, Administrator indicated because there was no injury. The facility policy titled Abuse Prohibitions, Investigation, and Reporting, revised 08/16, stated Policy: . Allegations of abuse/misappropriation and the investigative conclusion will be reported to the appropriate State regulatory agency, Law Enforcement agency, licensing, and/or certification board as required by State and Federal law. This Federal citation is related to Complaint IN 476 3.1-28(c)

Based on interview, and record review, the facility failed to investigate an allegation of abuse to 1 of 1 residents. (Resident M) Findings include The clinical record of Resident M was reviewed on 8/20/2020. [DIAGNOSES REDACTED]. Assessment of the resident on admission to the facility included coughing or choking during meals or when swallowing medications, but no loss of liquids/solids from mouth when eating or drinking. The record failed to indicate an assessment of the resident after an alleged incident on 7/24/2020. Facility incident reports were reviewed from 7/1 through 8/20/20. These reports failed to indicate any alleged abuse or incidents toward Resident M. During an interview on 8/20/2020 at 2:00 P.M., Employee 19 indicated she reported what she felt was inappropriate treatment. The report was made 3 or 4 weeks ago regarding a nurse's treatment of [REDACTED]. She indicated Resident M was having a hard time swallowing breakfast, and looked like she had milk running down her face; as if having trouble swallowing. LPN 22 (Licensed Practical Nurse) went to give medications crushed in applesauce. Resident M couldn't get it down, started coughing, had a gurgly cough, and was making vomiting noises. LPN 22 then placed tissues over her mouth and held it there, aggressively, and also berated the resident saying what, do you have to be a 2 year old to be on my hall? Resident M tried to back away and the wheelchair started to tip so Employee 19 caught it. After taking Resident M to the physical therapy room, she continued to cough and sounded like she had gurgling in her throat. Employee 19 indicated she just did what she could to be able to get her therapy done. She indicated she told the Occupational Therapist in the room with her and reported it to her supervisor and they both reported it to the Administrator. Nobody ever asked her anything more about it. She indicated she did not document anything about her observations. During a follow up interview on 8/21/2020 at 10:18 A.M., Employee 19 indicated her interpretation of the nurse being aggressive was the nurse, in a forceful way was putting her fingers in the resident's mouth when the resident was trying to back away from her. The medication was in applesauce and the nurse placed it in her mouth. Employee 19 was next to the resident to the left and then got behind the resident's wheelchair when the chair started to tip back. she tried to dab some of the food off the residnet's chin, but the nurse just went ahead and gave the meds. Employee 19 indicated she was pretty much able to see what the nurse was doing the entire time. Employee 19 was standing about 2 feet from the nurse and the resident. She indicated she could see everything until she moved behind the resident. The wheelchair was locked. She felt it was a violation of dignity for sure, but the nurse did not stop when the resident started to back away. Nobody ever followed up with her. A couple days later she talked to one of the nurses about Resident M complaining of new pain in her hip or leg- and the nurse said I can't really give her any medication if she can't swallow now, can I? During an interview on 8/20/2020 at 2:25 P.M., the therapy supervisor indicated whenever an allegation of abuse is reported, her role is to go straight to the Administrator, and they are to do the investigation together . She indicated that she remembered Employee 19 came to her and told her what happened, that the nurse administered medications in a not so kind manner, and Employee 19 had explained it in detail. Both she and Employee 19 went to the Administrator and reported it. The therapy supervisor indicated that the Administrator and Director of Nursing (DON) said they would handle it from there. The therapy supervisor indicated she was not aware that anyone else witnessed it. During an interview on 8/20/2020 at 2:46 P.M., the Administrator indicated that she recalled Employee 19 came in and spoke of LPN 22 being loud while talking and that Resident M was having difficulty eating her meal and food was coming from her mouth. She indicated she went straight to the LPN and asked about it. The LPN indicated she was wiping the resident's mouth off with the tissues, and the resident was pushing back. The LPN told the Administrator, Employee 19 was behind holding the wheelchair so it didn't tip back. Employee 19 was behind the resident and could not see her face. The Administrator indicated she would have documentation about the interviews. On 8/20/2020 at 3:28 P.M., the Administrator provided a typed up statement and indicated this was from her notes. In response to being asked why it was not on an incident report, the Administrator indicated because there was no injury.The Administrator indicated she did not interview other staff or residents in the immediate area, or to see if anyone had any concerns about rough treatment. A blank form titled Incident Report, #ADMIN005, was requested and received on 8/20/2020 and stated Type of Occurrence: . Type of Injury . H. None Identified The facility policy titled Abuse Prohibitions, Investigation, and Reporting, revised 08/16, stated Policy: . Reports of alleged abuse and/or misappropriation will be immediately reported to the Administrator and thoroughly investigated. III. Investigation: A. When an incident of guest abuse is alleged, the incident must be reported to the charge nurse . B. Upon receiving a report of abuse, the charge nurse will immediately examine the guest. The findings of the examination will be recorded in the medical record. (The physician is to be notified timely even if no injuries are observed.) C. Facility employees who have been accused of guest abuse will be suspended until the results of the investigation have been reviewed by the Administrator. D. The Administrator will appoint a representative to investigate the incident. The Administrator will initiate the Investigation of Alleged Abuse, Mistreatment, or Misappropriation (Laurel form #ADMIN009) and make the appropriate notifications as outlined on the form. E. The Administrator or designee will coordinate an immediate investigation in accordance with the investigation guidelines in this policy. A copy of the findings will be provided to the Administrator within five (5) working days of the occurrence of the incident. The investigation may consist of but is not limited to: 1. An interview with the person(s) reporting the incident 2. Interviews with any witnesses to the incident 3. An interview with the guest 4. A review of the guest's medical cal record 5. An interview with staff members (on all shifts) who had contact with the guest during the period of the alleged incident. 6. Interviews with the guest's roommate, family members, and visitors 7. Physical assessment of other potentially affected guests. 8. A review of all circumstances surrounding the incident. F. The charge nurse will complete the Incident Report (Laurel form #ADMIN005). H. Upon receiving information concerning an allegation of abuse, . the Director of Nursing or Administrator will request that a representative of the Social Services Department or designee monitor the guest's feelings concerning the incident, as well as the guest's reactions to his or her involvement in the investigation. This Federal citation is related to IN 476 3.1-28(d)

Based on observation, interview and record review the facility failed to ensure windows were maintained to prevent drafts for 28 rooms affecting 49 residents. Findings include: In an interview on 01/08/2020 at 11:10 [NAME]M., CNA 1 indicated some windows were cold and drafty. In a confidential interview on 01/08/2020 at 12:06 P.M., a family member indicated windows were drafty. On 01/08/20 at 12:07 PM, in a confidential interview, a family member indicated the windows were drafty, cold, and the resident had to wrap up to keep warm. The resident occupied the bed next to the window. On 01/08/2020 at 12:12 P.M., in an interview with a resident identified as interviewable by facility staff, he indicated the window in his room was draftyand he had been complaining for 2 years. An ambient temperature taken during the conversation indicated the room was 72 degrees. In an interview on 01/08/2020 at 12:22 P.M., LPN 2 indicated there were some windows drafty in some rooms. In an interview on 01/08/2020 at 2:15 P.M., the Administrator indicated the facility had noticed the drafty windows,and brought it to the attantion of the corporation, but there had not been action taken on the windows yet. In an observation on 01/08/2020 at 12:16 P.M. windows in room [ROOM NUMBER] were noted to be cold and drafty. In an observation on 01/08/2020 at 12:27 P.M., the windows were noted to be drafty in room [ROOM NUMBER]. Black duct tape was observed around the window 1/2 way up left side of window and 1/2 way on the base where the window track met the sill to the right side of the window. In an observation on 01/08/2020 at 12:32 P.M., the window in room [ROOM NUMBER] was observed to have towels along the window sill, where the window track met the sill. The window was drafty along the sides. An ambient room temperature was obtained, and was 74 degrees. Further observation and record review indicated the following windows were cold and drafty: room [ROOM NUMBER], 1 resident resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 1 resident resided in the room room [ROOM NUMBER], 1 resident resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 1 resident resided in the room room [ROOM NUMBER], 1 resident resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 1 resident resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 1 resident resided in the room room [ROOM NUMBER], 2 residents resided in the room room [ROOM NUMBER], 2 residents resided in the room Review of (MONTH) and (MONTH) work orders and preventative maintenance logs indicated drafty windows had not been tracked. 3.1-19 (e)

Based on observation, interview, and record review the facility failed to ensure refusals were addressed for 1 of 3 residents reviewed with pressure ulcer (Resident 13). Findings include: The clinical record for Resident 13 was reviewed on 1/6/20 at 10:34 [NAME]M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment from 10/16/19, indicated Resident 13 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). A physician's orders [REDACTED]. A care plan problem initiated on 10/22/19 indicated Resident 13 was at risk for impaired skin integrity/pressure ulcer injury related to impaired mobility, current pressure areas to left heel and right heel, diabetes, weakness and occasional incontinence of urine. Interventions included, but were not limited to, if Resident 13 chooses not to follow recommended treatment, confer with resident, interdisciplinary team and family to determine why and try alternative methods to gain compliance. Document alternative methods and preferences. During an observation on 1/7/20 at 9:22 [NAME]M., Resident 13 was not wearing soft boots while sitting in his wheelchair. The soft boots were observed sitting in a chair in the room. During an observation on 1/9/20 at 1:23 P.M., Resident 13 was not wearing soft boots while sitting in his wheelchair. The soft boots were observed sitting in a chair in the room. During an observation on 1/10/20 at 9:51 [NAME]M., Resident 13 was not wearing soft boots while sitting in his wheelchair. The soft boots were observed sitting in a chair in the room. During an observation on 1/10/20 at 11:33 [NAME]M., Resident 13 was observed in bed with his heels floating on pillow. During an observation on 1/10/20 at 3:37 P.M., Resident 13 was not wearing soft blue boots while sitting in his wheelchair. The soft boots were observed in the room. During an observation with the Director of Nursing Services (DNS) on 1/13/20 at 10:36 [NAME]M., Resident 13 was not wearing soft boots while sitting up in his chair. The soft boots were observed sitting in a chair in the room. A Medication Administration Record [REDACTED]. The Wound Nurse was interviewed on 1/10/20 at 11:20 [NAME]M. During the interview the Wound Nurse indicated Resident 13 had a pressure ulcer on his right heel and he had been wearing soft boots when he was sitting in his wheelchair to help prevent further breakdown to his right heel. Resident 13 was interviewed on 1/10/20 at 3:37 P.M. During the interview Resident 13 indicated he had not been wearing the soft boots when he was up in a wheelchair for two weeks. He indicated he did not like the boots because they were too big and the velcro on them got tangled when he wore them. Staff had stopped putting them on him a while ago. The DNS was interviewed on 01/13/20 at 11:22 [NAME]M. During the interview the DNS indicated Resident 13 should have been wearing the soft boots while up in the chair as ordered. She also indicated staff was not aware Resident 13 had not been wearing the soft boots and did not want to wear the soft boots while up in the chair. The DNS indicated if Resident 13 had been refusing to wear the soft boots while up in the wheelchair the facility should have addressed it when the refusals started. The DNS was interviewed on 1/13/20 at 2:24 P.M. During the interview the DNS indicated there was no documentation indicating Resident 13 had been refusing to wear soft boots while in the chair, or that the facility had addressed the residents refusals. A policy, dated 10/2017, was provided by the DNS on 1/13/20 at 11:42 [NAME]M., titled Skin Management and she indicated it was the policy currently used by the facility. The policy indicated Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes .6. The interdisciplinary team considers whether the guest/resident exhibits conditions or is receiving treatments that may place the guest/resident at higher risk of developing pressure ulcer injury or complicate their treatment. Such conditions may include: .Guest/resident refusal of some aspect of care and treatment. 3.1-40

Based on observation, record review and interview the facility failed to ensure 1 of 1 resident reviewed for smoking safety was assessed for safety. (Resident 21) Findings include: The Clinical Record of Resident 21 was reviewed on 1/10/20 at 10:35 [NAME]M., indicated the resident's [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was interviewable. A list titled Residents that choose to smoke was received from the Assistant Director of Nursing Service (ADNS) on 1/6/20 at 9:30 [NAME]M., included on the list was Resident 21.There were 10 other resident names on the list. A list of supervised smoking times was received from the ADNS on 1/6/20 at 9:40 [NAME]M. The list indicated and included, but were not limited to, the department of the staff member who were scheduled to supervise the residents while they smoked and the location of where the residents could smoke. Resident 21's Smoking Evaluation dated 10/19/19 at 8:39 P.M., indicated the following questions, in regard to the resident's mental status, decision making ability and manual dexterity. Also included in the section titled direct observation were questions in regard to if the resident could hold the smoking materials safely, respond quickly to fallen ashes and if the resident could follow the smoking guidelines of the facility policy . The only section that had been completed was the comments section smoking assessment not completed at this time resident is on contact isolation and had no personal cigarettes at (sic) (the) facility to consume. The resident's Smoking Evaluation dated 1/10/20 at 6:00 [NAME]M., indicated the following: Resident 21 had been assessed as alert, had consistent decision ability, responded quickly to fallen ashes, followed the smoking guidelines of the facility policy. The summary of the resident's evaluation indicated the resident would be supervised and smoked safely. The most current policy titled GUEST SMOKING revised on 6/17 was received from the Administrator on 1/10/20 at 12:05 P.M. The Policy indicated the following: It is the policy of this facility to utilize the Smoking Data Collection and Assessment for guests who wish to smoke in the designated guest smoking area The purpose of this policy is to provide and maintain guest smoking practices to ensure the safety and comfort of all guests, staff, and visitors. On 1/10/20 at 10:43 [NAME]M., an interview was conducted with Resident 21 who indicated he had just finished smoking a cigarette outside of the facility and had been supervised by the facility staff. On 1/10/20 at 1:15 P.M., an interview was conducted the Director of Nursing Service (DNS) indicated the nurse who had done the smoking evaluation on 10/19/19 had not completed the resident's of the evaluation completely and the nurse had only filled out the comments section of the smoking evaluation. The DNS indicated Resident 21 had not started to smoke until 10/21/19 when the isolation precautions ended and the resident's daughter had brought in the resident's cigarettes on 10/21/19. The DNS indicated the resident had been supervised by staff when he smoked outside the facility and the resident should had been assessed for safe smoking on 10/21/19 before the resident went outside to smoke. The ADN indicated the smoking evaluations are done when a resident is admitted to the facility and every 3 months. On 10/20/19 at 2:14 P.M., an interview was conducted with Licensed Practical Nurse 1 indicated all of the staff takes turns supervising the resident who smoke and Resident 21 had been smoking outside since the resident had been taken off of isolation precautions. On 1/10/20 at 2:24 P.M., an observation was made of Resident 21 was outside of the facility in an enclosed area, with a staff member present, smoking a cigarette. 3.1-45(a)

Based on observation, interview and record review the facility failed to ensure interventions were in place to prevent weight loss for 1 of 3 residents reviewed. (Resident 19) Findings include: The clinical record of Resident 19 was reviewed on 01/10/20 at 09:20 [NAME]M., and [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a severe cognitive impairment, required limited assistance of 1 with eating, started speech therapy on 10/15/19, had no wounds or pressure ulcers and was not on hospice services. The Hospital Discharge Summary dated 10/14/19 indicated the resident weighed 151 pounds (lbs). Resident 19's Weights and Vitals Summary form indicated the following weights: 10/14/19; 138 lbs (pounds)- facility weight 10/19/19; 131 lbs 10/26/19; 134.4 lbs 11/2/19; 136 lbs 11/9/19; 137.2 lbs 11/11/19; 136 lbs 11/16/19; 137.2 lbs 11/23/19; 132.2 lbs 12/2/19; 129.6 lbs 12/10/19; 129.6 lbs (a 4.9% loss from 11/2) A Nursing Assistant Admission Checklist dated 10/14/19, indicated the resident's height was 5 foot 2 inches, and weight was 135.8 pounds. The Diet History/Food Preference form dated 10/18/19 at 1:39 P.M., documented by the Dietary Manager (DM), indicated the resident's appetite was fair. The Nutritional Risk Form dated 10/18/19 at 1:41 P.M., signed by the DM, indicated the resident's usual weight history basic metabolic index (BMI) was 19-27. The Nutritional Evaluation dated 10/18/19 at 1:44 P.M., indicated an initial assessment was done by the DM and indicated the most recent weight was 138.0 pounds. The note indicated on 10/14/19 at 7:30 P.M., the resident's BMI was 25, weights were acceptable, intakes were 50-100% of meals, and the resident was on a controlled carbohydrate diet (CCD) mechanical soft, with nectar thick liquids. The resident exhibited swallowing difficulties and was in speech therapy to improve functioning of swallowing ability. The Nurse Practitioner's (NP) progress notes indicated the NP had addressed Resident 19's weights at 241 pounds (lbs) on the following dates: 10/16, 10/18, 10/23, 10/30, 11/4, 11/8, 11/11, 12/2, 12/6, 12/11, and 12/13/19. There was no documentation the facility informed the NP the weight of 241 was incorrect, or that the resident was trending a loss. The NP's progress notes indicated the following: Dated 11/21/19 documented as a late entry Resident 19's weighed 137.2 lbs. There were no new interventions recommended or put into place. The resident care plans indicated the following: Resident 19 was identified as at risk for weight changes due to [MEDICAL CONDITION], difficulty swallowing, and variable appetite, and mechanically altered therapeutic diet. Goal was to maintain weight with no significant weight changes through the next review. Interventions included but were not limited to, and initiated on 10/17/19 to monitor fluid and food intake at meals, weigh per facility policy; and then to use supplements as ordered on [DATE]. The intervention initiated on 10/24/19 indicated to report significant weight changes of 5% in 1 month, 7.5% in 3 months or 10% in 6 months to the physician and dietician. The Care Conference Minutes dated 10/21/19 at 2:19 P.M., documented by the Social Services Worker indicated Resident 19 had received physical, occupational and speech therapy, started on 10/15/19 due to a [MEDICAL CONDITION]. The resident had severe cognitive deficits, moderate swallowing difficulties and received a mechanical soft diet with nectar liquids,. Resident 19's mobility required moderate to minimum assist, intakes were variable from 0-100%, currently weighed 131 lbs., and indicated a weight loss of 7 pounds, or 5 % in the past 30 days. There were no recommendations made regarding the resident's weight loss. The Nutritional At Risk Monitoring Record dated 10/31/19 at 4:23 P.M., indicated he resident's current weight on 10/26/19 was 134.4 pounds and the prior weight from 10/19/19 was 131 pounds. She continued to receive the CCD diet with mechanical soft and nectar thick liquids, consumption was 25-100% of meals and continued to receive speech therapy. The intervention was: will continue to monitor for four weeks. A physician order [REDACTED].M., indicated the resident was upgraded from nectar consistency to regular consistency of liquids and to provide a Magic cup with each meal. A progress note dated 11/20/19 at 11:08 [NAME]M., the Registered Dietitian (RD) indicated the resident's nutritional assessment and care plan were reviewed, weight was stable and diet was appropriate at this time, and that resident was not at high risk. The policy titled Weight Management revised on 10/2019 was received from the Director of Nursing Service (DNS) on 1/13/20 at 1:30 P.M. The policy indicated, but were not limited to, the following: ' .re-weights ate initiated for a five- pound variance .a re-weight will be done for a weight loss .of 3% or consult with the Dietary Manager or RD/designee. Re-weights will be done within 48-72 hours Guests/residents determined to be at risk or have significant weight changes will be weighed on a weekly basis. Guests/residents at risk are: .resident with insidious weight loss and ; 5% in one month. 7.5% in three months. 10% in six months .Dietary Manager, Unit Manager and/or RD are to communicate weight changes to the IDT (Interdisciplinary Team), attending physician .This is documented in the medical record. Once an insidious weight loss is identified, the RD further assesses the guest/resident and makes recommendations as indicated to prevent /treat unintended weight loss .The Dietary Manager and /or Dietician will calculate the Monthly and Weekly Significant Weight Changes . On 1/06/20 at 3:45 P.M., an interview, conducted with the DNS, indicated there were no current residents who had been identified as having an excessive unplanned weight loss. On 1/13/20 at 10:33 [NAME]M., an interview, conducted with Unit Manager (UM) 5, indicated the RD had thought Resident 19's admission weight of 139 lbs was incorrect and the resident was reweighted on 10/19/19 at 131 lbs. The resident had trace left ankle [MEDICAL CONDITION], was not taking diuretics, and was unsure why the resident's weight had been obtained on 12/31/19, because the weights are due on the 5 th of every month. On 1/13/20 at 12:21 P.M.,an interview, conducted with CNA 3, indicated Resident 19 had ate 40% of her lunch On 1/13/20 at 12:25 P.M., an interview, conducted with the Assistant DM, indicated Resident 19 had milk and a magic cup which was considered the resident's supplement On 1/13/20 at 12:27 P.M., an interview, conducted with UM 5, indicated the NP was not notified until 1/6/20 of the resident's weight loss. On 1/13/20 at 2:29 P.M., an interview, conducted with DNS, indicated an alternate was offered when the resident ate less 50%, but was not sure what alternate was offered or how much the resident had consumed. On 1/13/20 at 2:32 P.M., a phone interview was conducted with Speech Language Pathologist (SLP) 1. She indicated the resident, on admission had some swallowing issues. On 1/13/20 at 3:00 P.M., an interview, conducted with the DNS indicated after Resident 19 had been re-weighed and the weight loss was identified the Physician should had been notified immediately . On 1/13/20 at 3:11 P.M., a phone interview was conducted with the Registered Dietician (RD). She indicated the following: The RD comes to the facility on ce a month and is unable to remote access the resident's chart. The DM assesses the residents unless the residents are at high risk for weight loss. The DM does not recommend any supplements for the residents. The RD saw Resident 19 on 11/20/19, had no new recommendations and would have only reviewed if the resident had a significant weight loss. The RD had not seen the resident in the month of (MONTH) and was not aware of the resident's weight loss. On 1/13/20 at 3:37 P.M., a phone interview was conducted with the DM. She indicated when Resident 19 ate less than 50 % of her meals she wass offered a house shake, ice cream or whatever the resident would eat. On 1/10/20 at 11:54 [NAME]M., an observation was conducted Resident 19. She was in the assist dining room sitting in a wheelchair at a table. The resident had no difficulties chewing or swallowing. difficulty. A staff member had attempted to assist the resident, but she turned her head away. The staff member offered the resident a bite of food and the resident accepted the bite of food. The tray included 4 oz of milk, 8 oz of water, a magic cup, beef and noodles, buttered bread and and cooked carrot and potatoes. Resident 19 appeared to be thin in size. She ate 25% of her meal. On 1/13/20 at 11:39 [NAME]M., an observation, conducted with UM 5, weighed the resident in her wheel chair at 120 lbs. On 1/13/20 at 12:21 P.M., an observation, conducted with CNA 3, of Resident 19's lunch tray included 8 oz of water, 4 oz of milk, vegetable blend, baked potato, and ground meat. Resident 19 had consumed 25% 3.1-46

Based on observation, interview and record review, the facility failed to maintain adequate hot water temperatures for dishwashing procedures on 2 of 2 observations affecting 88 of 88 residents residing in the facility. Findings include: During an observation in the kitchen on 4/23/14 at 9:15 A.M., the High Temperature Dishwashing Machine, during the wash cycle, reached a high of 130 degrees for two attempts. During an observation in the kitchen on 4/23/14 at 11:10 A.M., the High Temperature Dishwashing Machine, during the wash cycle, reached a high of 140 degrees. On a subsequent attempt, the temperature reached 150 degrees during the wash cycle. On 4/23/14, at 11:15 A.M., the Dietary Manager (DM) provided the "Dishmachine Temperature/Sanitizer Logs" for March and April, 2014. The logs indicated the acceptable temperatures for the High Temperature wash cycle was 150 degrees. The temperatures were to be recorded at all three meals for the month. In March 2014, 24 temperatures for the wash cycle were recorded as less than 150 degrees out of 71 recorded temperatures. There were 19 blank spaces for the wash cycles. For March 2014 (from March 1-22), 14 temperatures for the wash cycle were recorded as less that 150 degrees out of 63 recorded temperatures and there were 2 blank spaces for the wash cycles. During an interview 4/24/14 at 11:20 A.M., the DM indicated the Dish Machine temperatures for the wash cycle were supposed to be at least 150 degrees. The DM indicated if the temperatures for the wash cycle did not reach at least 150 degrees staff were to wash dishes in a three sink cycle. The DM indicated the rinse cycle being at least 180 degrees was the sanitizing aspect of the dishwashing cycle. The DM noted the rinse cycle temperatures for March and April 2014 were all documented at 180 degrees or above. At 11:25 A.M., the DM provided a copy of the Dish Machine Temperature/Sanitizer Records dated 4/2010. The procedure section, under number 3 indicated for a a High Temperature Dish Machine, the wash cycle was to be 150-165 degrees. Under number 8 in the procedure section indicated if there is a concern about the sanitizing quality due to inadequate wash or rinse temperature, the dishware washing should be stopped and reported to the supervisor immediately. 3.1-21(i)(1)

Based on interview and record review, the facility failed to monitor the amount of fluids provided to, and consumed by, 1 resident (Resident #70) reviewed for [MEDICAL TREATMENT] of 3 residents who met the criteria for [MEDICAL TREATMENT]. This deficient practice resulted in an emergency hospitalization with [MEDICAL CONDITION] secondary to volume overload and [MEDICAL CONDITION]. Findings include: Review of the clinical record for Resident #70 on 4/24/13 at 2:57 p.m., indicated the following: [DIAGNOSES REDACTED]. A Cumulative [DIAGNOSES REDACTED]. Resident #70 was re-admitted to the facility on [DATE] following a stay in the hospital for an amputation of her left leg below the knee. An admission physician's orders [REDACTED]. A Nutritional Assessment for Resident #70, dated 4/4/13, indicated a Pureed NAS NCS Diet with 1500 cc fluid restriction daily. A Fluid Restriction Distribution Plan for Resident #70, dated 4/4/13, indicated 1500 cc fluid restriction per 24 hour period - 960 cc per dietary with 480 cc's at breakfast, 240 cc's at lunch, and 240 cc's at dinner and 540 cc's per nursing department. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] LPN #1, was interviewed on 4/25/13 at 11:19 a.m. During the interview she indicated Resident #70 took her medications orally and during each medication pass a 6 ounce glass of water was provided, or a total of 720 cc fluid per nursing service in a 24 hour period. A physician's orders [REDACTED]. A Progress Note for Resident #70, dated 4/8/13 and written by the Registered Dietitian, indicated a Pureed NCS NAS Diet with 1500 ml fluid restriction. The note also indicated she received Nephro 120 ml BID. The note recommended Prostat 30 ml (milliliter) TID (three times a day) for extra protein. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. LPN #1, was interviewed on 4/25/13 at 11:19 a.m. During the interview she indicated Resident #70 was on the Frazier Water Protocol. When queried, she could not identify the amount of water consumed, stating it depended on her level of thirst. Resident #70 had a BIMS (brief inventory of mental status) score of 15 out of 15 which indicated the resident was alert and oriented. The Speech Language Pathologist was interviewed on 4/25/13 at 12:39 p.m. During the interview she indicated she had not recommended any specific amount of water for Resident #70 for the Frazier Water Protocol and did not know how much water she consumed. She also indicated the amount of water used was determined by nursing. She further indicated once oral care was completed a resident could follow the Frazier Water Protocol as many times during the day as desired and as much water could be consumed as wanted. Review of the MAR for Resident #70 for the month of April 2013 indicated she received 180 cc water with medication pass QID, Nephro 120 ml BID, beginning 4/6/13, Prostat 30 ml TID, beginning 4/9/13, and [MEDICATION NAME] 17 grams in 8 ounces of fluid q HS, beginning 4/18/13, as ordered. Calculations for the fluids provided by nursing services for Resident #70, indicated she received 1290 cc in a 24 hour period from nursing staff. The resident also received an additional 960 cc of fluids from dietary, as well as additional fluids given through the Frazier Water Protocol. A physician's orders [REDACTED]. A hospital History and Physical for Resident #70, dated 4/24/13, indicated she received [MEDICAL TREATMENT] on Monday-Wednesday-Friday and came to the hospital with shortness of breath and altered sensorium. A chest x-ray was consistent with [MEDICAL CONDITION]. The hospital report also indicated she had a history of [REDACTED]. The hospital report indicated the impression of [MEDICAL CONDITION] secondary to volume overload. The report further indicated Resident #70 was emergently dialyzed in the ICU. The report also indicated the resident was "quite short of breath and unable to provide a reliable review of symptoms...her condition was critical and prognosis was guarded." The Director of Nursing was interviewed on 4/25/13 at 2:35 p.m. During the interview she indicated nursing services had provided more than the allowed fluid level of 540 cc to Resident #70. The Certified Dietary Manager (CDM) was interviewed on 4/25/13 at 2:45 p.m. During the interview she indicated she developed a fluid distribution plan based on a resident's previous intake schedule. The plan was then reviewed by the Registered Dietitian for approval. She also indicated the Registered Dietitian reviewed the orders for residents on a fluid restriction and documented the information in her progress notes. The meal slip for Resident #70, provided by the CDM, indicated dietary provided her with 480 cc's of fluid at breakfast, 240 cc's of fluid at lunch, and 240 cc's of dinner. The Registered Dietitian was interviewed on 4/26/13 at 10:20 a.m. During the interview she indicated the CDM completed a Fluid Restriction Distribution Plan for residents on a fluid restricted diet. The plan, which described the breakdown of fluids between dietary and nursing services, was provided to nursing. She also indicated nursing were to notify dietary if they were giving more fluids than allowed so dietary could adjust the fluids provided at mealtime. The Director of Nursing was interviewed on 4/26/13 at 10:30 a.m. During the interview she indicated the Cumulative [DIAGNOSES REDACTED]. A facility care plan for Resident #70, dated 1/24/13, indicated the problem area of alteration in nutrition related to end stage [MEDICAL CONDITION] and [MEDICAL TREATMENT]. Approaches to the problem included, but were not limited to, serve diet as ordered, send lunch to [MEDICAL TREATMENT] 3 x weekly, Nephro as ordered, and Frazier Water Protocol. A facility care plan for Resident #70, dated 4/11/13, indicated the problem area of end stage [MEDICAL CONDITION]. Approaches to the problem included, but were not limited to, diet as ordered and fluid restrictions as ordered. Additional facility care plans for Resident #70 included the areas of: impaired vision, ADL's (activities of daily living), falls, surgical wound, admitted with pressure ulcers, potential for impaired skin integrity, pain, diabetes mellitus, hypertension, [MEDICAL CONDITION], end stage [MEDICAL CONDITIONS] reflux disease, [MEDICAL CONDITION],and alteration in mood. There was no care plan for [MEDICAL CONDITION]. A current facility policy "Fluid Restriction", dated April 2010 and provided by the Administrator on 4/25/13 at 11:30 a.m., indicated "...All guests with a nutrition prescription for a fluid restriction shall receive only the amount of fluids as prescribed by the physician...." 3.1-37(a)