Every finding on record at Avoyelles Manor Nursing Home

Based on observation and interview the facility failed to provide a safe environment to help prevent the development and transmission of communicable diseases and infections by failing to screen all visitors entering the facility. This had the potential to affect all residents in the facility. Findings: Review of the facility policy titled Coronavirus Disease (COVID-19) - Visitors revealed the following including: Policy Statement For the safety of residents and staff, visitation policies during the COVID-19 public health emergency (PHE) are in compliance with current recommendations from the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services Policy Interpretation and Implementation 1. Residents are permitted to receive visitors of their choice as long as: a. Visitors will be asked to use the front entrance. b. Core Principles of COVID-19 prevention and best practices to reduce COVID-19 transmission are adhered to at all times Observation conducted on 05/08/2023 at 8:45 a.m. in Area 1 revealed a man enter the facility through a door from the outside at the end of the hall and go into Resident #2's room. S6 LPN followed him into the room and was asking questions about Resident #2. Interview on 05/08/2023 at 8:49 a.m. with S6 LPN confirmed the visitor entered the Facility without being screened. S6 LPN stated he was not supposed to do this. At this time another visitor entered the Facility through the same door and was stopped by S6 LPN and instructed to go through the front door. The visitor ask through the front door or through the front, front door by the office? S6 LPN instructed her to enter by the office so she could be screened. Interview on 05/08/2023 at 8:55 a.m. with S2 DON revealed all visitors to the facility should be screened prior to entering the building. She stated all doors in the Facility require codes to obtain entrance. She stated the codes have been changed, but visitors learn them and enter the building without being screened. She confirmed the visitor should have entered the facility through the entrance door by the offices so that screening could have been done.

Based on interview and record review, the facility failed to ensure a personal funds statement was provided quarterly for 1(Resident #55) of 2 Residents (Resident #30 and Resident #55) reviewed for personal funds out of a total sample of 19 Residents. Findings: Review of the Facility's Policy titled Accounting and Records of Resident Funds read in part: Policy statement-Our facility maintains accounting records of resident funds on deposit with the facility. 5. Individual accounting records are made available to the resident through quarterly statements and upon request. Review of Resident #55's Medical record revealed she was admitted to the facility on [DATE], with diagnoses that included in part . Cerebrovascular Accident, Hypertension, Type 2 Diabetes Mellitus, and Depression. Review of Resident #55's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/15/2023 revealed Resident #55 had a BIMS (Brief Interview for Mental Status) of 11 (moderately impaired cognition). Resident #55 answered all questions appropriately. Interview with Resident #55 on 05/07/2023 at 10:10 a.m. revealed the facility managed her money. Resident #55 stated she was admitted to the facility approximately 6 months ago and had not received an account statement. Observation on 05/08/2023 at 8:00 a.m. revealed Resident #55 awake, alert and oriented. Resident #55 stated she had no family and her husband (Resident #30) was not able to manage her money. Resident #55 stated the facility managed her money. Resident #55 stated she was able to get money from the office whenever she needed to purchase cigarettes. Resident #55 stated she had not received an account statement since she was admitted to the facility and would like to know how much money was in her account. Interview on 05/08/2023 at 9:07 a.m. with S3 Business Office Manager stated Resident #55's finances were managed by the facility. S3 Business Office Manager stated resident account statements were printed and mailed out quarterly to the resident(s) responsible party. She stated Resident #55 had no family and was her own responsible party. She stated Resident #55's quarterly statement was printed; placed in a folder; filed in the facility's business office; and not hand delivered to her. She stated she was not aware that she had to issue a quarterly statement to Resident #55 since the resident came and asked about her account balance. S3 Business Office Manager confirmed that Resident #55 was not provided with a quarterly financial statement and should have been.

Based on record review and interview, the facility failed to ensure a RN (Registered Nurse) was on duty for 8 consecutive hours per day for 7 days per week for 5 of 92 days reviewed for RN staffing hours. This deficient practice had the potential to affect all 60 Residents residing in the facility, according to the facility's Resident Census and Conditions Form. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 1 2023 (October 1 - December 31, revealed the submitted weekend staffing data was excessively low. Review of the Time Card Report for 10/01/2022 - 10/31/2023 revealed the following: On 10/08/2023 the RN time card revealed 8.05 hours, and according to interview with S1 ADM, the RN actually worked 7.55 hours; on 10/09/2023 the RN time card revealed 8.27 hours, and according to interview with S1 ADM, the RN actually worked 7.77 hours; on 10/16/2023 the RN time card revealed 7.5 hours, and according to interview with S1 ADM, the RN actually worked 7.0 hours; and on 10/30/2022 the RN time card revealed 8.18 hours, and according to interview with S1 ADM, the RN actually worked 7.68 hours. Review of the Time Card Report for 12/01/2022 - 12/31/2022 revealed the facility RN worked 7.38 hours on 12/25/2022, and according to interview with S1 ADM, S8 RN worked 2.38 hours and S2 DON worked 5.0 hours. Interview on 05/08/2023 at 10:34 a.m. with S1 ADM revealed the facility required the RN to provide coverage for 8.5 hours per day for 7 days per week, with the 0.5 hours indicating a required unpaid 30 minute lunch break. S1 ADM revealed he pays the nurses for the exact hours worked. S1 ADM stated that the Time Card Report for the 10/2022 and 12/2022 time frame does not include the 30 minutes of time that is deducted from the nurse's lunch break time. S1 ADM confirmed the facility did not have RN coverage for 8 consecutive hours per day for 7 days per week; and the weekend RN hours provided were less than required 8 hours on 10/08/2022, 10/09/2022, 10/16/2022, 10/30/2022 and 12/25/2022. S1 ADM stated the One Star Staffing will trigger on the PBJ when RN coverage of 8 hours is not provided for 2 days in a quarter. Interview on 05/08/2023 at 1:30 p.m. with S1 ADM confirmed the Facility had not provided the minimum required hours on 10/08/2022, 10/09/2022, 10/16/2022 and 10/30/2022 and 12/25/2022 and should have.

Based on observation and interview the facility failed to ensure garbage and refuse was properly contained as evidenced by one dumpster lid not closed. Findings: Observation upon arrival to the facility on [DATE] at 7:45 a.m. revealed the facility's dumpsters were clearly visible by the surveyor from the road as the surveyor drove up to the facility. One of the two dumpsters was not properly contained and was open at the time of observation. The surveyor asked the owner of the nursing facility on 05/07/2023 at 8:57 a.m. the best way to go to the dumpsters. S4 CNA Supervisor was in the office at the time of the conversation with the owner. Observation on 05/07/2023 at 9:00 a.m. revealed the surveyor observed S7 Dietary Manager pushing S5 Kitchen Staff through the dining room door that lead to the outside where the dumpsters were located. The surveyor exited the dining room door immediately behind S5 Kitchen Staff and witnessed S5 Kitchen Staff closing one of the two flaps on the dumpster. The Surveyor asked S5 Kitchen Staff what was he doing, and he stated he had just closed one of the flaps on the dumpster. S5 Kitchen Staff stated the dumpster was open prior to him closing the flap. Observation at that time revealed the other flap to the dumpster remained open. Interview with S7 Dietary Manager on 05/07/2023 at 10:00 a.m. confirmed she instructed S5 Kitchen Staff to go and close the dumpster. Interview with S5 Kitchen Staff on 05/07/2023 at 10:05 a.m. revealed S7 Dietary Manager instructed him to close the dumpster, and confirmed that one of the two dumpsters were not properly contained.

Based on interview and record review, the facility failed to ensure that alleged violations of staff to resident physical abuse were reported to the State Survey Agency within 2 hours for 2 (Resident #2 and Resident #5) of 6 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6). Findings: Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revealed in part . Policy Statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; . 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Resident #2 Review of Resident #2's clinical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly MDS with an ARD of 10/19/2022 revealed a BIMS score of 10, indicating moderate cognitive impairment. Resident #2 required one person physical assist with dressing, toilet use, personal hygiene, and bathing. Review of a document titled Continuous Quality Improvement Corrective Action Plan revealed in part . Date: 07/09/2022 1. Problems Identified: Resident #2 complained of a CNA grabbing her by the throat and pushing her on the bed. Review of Resident #2's Incident Witness Statement revealed in part Date/Time: 07/09/2022 10:42 a.m. Statement: Resident #2 I was getting up and she grabbed me by my throat and pushed me back down on the bed. Resident #2 states the CNA held her neck down for a little while. Review of a progress note for Resident #2 documented by S7 LPN on 7/09/2022 at 1:27 p.m. revealed in part . Late entry 9:30 a.m. - Resident reported to this nurse that she was getting up to go take her bath and S8 CNA grabbed her by the neck and pushed her on the bed. Interview on 10/31/2022 at 2:57 p.m. with S1 ADM revealed he was not at the facility when Resident #2 complained of S8 CNA grabbing her by the throat and pushing her on the bed. S1 ADM reported he was not notified of the allegation immediately. S1 ADM confirmed he did not report the allegation of abuse to the State Survey Agency, but should have. Resident #5 Review of Resident #5's clinical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Quarterly MDS with an ARD of 10/12/2022 revealed a BIMS score of 14, indicating intact cognition. Resident #5 required two plus persons physical assist with toilet use and one person physical assist with bed mobility, transfer, unit, dressing, personal hygiene and bathing. Review of an Incident Report for Resident #5 revealed in part . Date of Incident: 10/25/2022 Time of Incident: 8:30 p.m. If injury occurred, describe type of injury and body part involved: Noted small bruise to resident's left hand 0.2 cm x 0.3 cm light purple in color and between left middle and ring finger light green/yellow 0.3 cm x 0.2 cm. Description of the incident: Resident states that when nurse tried to take her medicine from her on 10/25/2022, the nurse tried to take the medicine out of her hand and that is what caused the bruise. Interview on 11/02/2022 at 11:20 a.m. with S1 ADM revealed he received a text message on 10/25/2022 from S6 PTA that Resident #5 wanted him to call, so he called to see what was going on. S1 ADM reported Resident #5 told him S3 LPN forcefully pried medication out of her hand. S1 ADM reported he called S2 DON to go to facility to do investigation since she lived closer. S1 ADM confirmed he did not report the allegation of abuse to the State Survey Agency, but he should have within 2 hours of the allegation.

Based on observation and interview the facility failed to maintain a clean, comfortable and homelike environment, by failing to provide clean bath linens that were in good condition for resident use in the facility and by failing to ensure 1 (Resident #49) of 23 sampled residents had space to store his personal belongings. Findings: Observation on 05/10/2022 at 6:54 a.m. revealed a facility CNA removing linen from a linen cart on a hall in the facility. Observation of the cart at that time revealed approximately 4 towels and 3 washcloths. The towels had dark stains on them, and were dingy, and the washcloths were threadbare and ragged. Interview on 05/10/2022 at 7:32 a.m. with S5 LPN confirmed the towels and washcloths on the above linen cart were stained and ragged. S5 LPN stated that the facility had recently bought new linens, but someone must have pulled these from the old batch of towels and washcloths. Interviews conducted on 05/10/2022 at 2:00 p.m. during the Resident Council meeting revealed Resident #48 stated that staff were using rags that had been cut from towels as washcloths, and that some of the linens were stained and were not washed well. She stated that some of the rags (washcloths) smelled like feces and the residents were expected to use these. Resident #44 agreed. Observation on 05/11/2022 at 9:15 a.m. of the clean linen closet in the hall near the nurses' station revealed 2 linen carts. Observation of the linen on one of the carts revealed 1 of 4 towels badly stained. Interview with S8 CNA revealed the linens on the cart were for residents use. S8 CNA confirmed the towel was badly stained, she pulled the towel from the cart and stated this should not be used on residents. Interview on 05/10/2022 at 9:00 a.m. with S6 Laundry Manager and S7 Laundry Worker revealed they pull stained and discolored towel/linens and discard them when doing laundry. S6 Laundry Manager confirmed items should not have been on the cart. Interview on 05/11/2022 at 9:30 a.m. with S1 Administrator confirmed there was a problem with the amount of linen in the facility. S1 Administrator confirmed that staff were having to cut washcloths from towels, so the facility had gone to local stores and purchased towels and washcloths. S1 Administrator stated that the facility had changed companies for purchase of linens and the order from the current company was on backorder, and has since arrived. Resident #49 Interview and observation on 05/09/2022 at 9:47 a.m. with Resident #49 revealed resident had one armoire filled with clothes and clothes folded and placed on the floor near the foot of his bed. Resident #49 stated his roommate had all the space in the room. Observation on 05/10/2022 at 8:50 a.m. revealed Resident #49's clothes were still on the floor near the foot of his bed. Interview and observation on 05/11/2022 at 8:50 a.m. with S9 CNA in Resident #49's room confirmed the clothes on the floor belonged to Resident #49. S9 CNA stated she did not know why his clothes were on the floor. Interview and observation on 05/11/2022 at 9:00 a.m. of Resident #49's room with S3 SSD in attendance revealed resident's clothes on the floor near the foot of his bed. S3 SSD stated Resident #49 had moved into that room last week and his dresser should have been moved too. SSD confirmed Resident #49's clothes should not have been on the floor.

Based on observation and interview the facility failed to maintain a clean, sanitary environment and ensure food was served in accordance with professional standards for food service safety. Findings: Observation on 05/09/2022 at 9:00 a.m. accompanied by S4 Dietary Manager revealed: 1. A box of hamburger patties open and undated in freezer #2 2. A pack of [NAME] open and undated in freezer #2. 3. A container of barbecue sauce open and undated on pantry shelf. 4. A container of creamy cole slaw dressing open and undated on pantry shelf. 5. Pantry shelf littered with wasted mashed potato flakes from a Ziploc bag with a hole in it. Interview at the time of observation with S4 Dietary Manager revealed the staff who opens a food item should label and date it. S4 Dietary Manager confirmed the above listed items were not dated and they should have been and the pantry shelf was littered with flakes of mashed potatoes and it should not have been.

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #46 and #69) of 23 sampled residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly changed, labeled and stored. Findings: Facility's Policy on Oxygen Administration reads in part .Essential points: Nasal cannula or mask and oxygen tubing must be dated and changed every seven days and PRN. The humidifier container will be refilled every 7 days or PRN with distilled water. The container must be dated when distilled water is changed or added. Resident #69 Record review of Resident #69's Medical Record revealed resident had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Give one vial by mouth per nebulizer three times a day. Interview and observation on 05/09/2022 at 1:51 p.m. revealed Resident #69's nebulizer mask was stored inside a Ziploc bag with a date of 04/29/2022 on it. Resident stated he used the nebulizer for his breathing treatments. Observation on 05/10/2022 at 8:46 a.m. revealed Resident #69's nebulizer mask was stored inside a Ziploc bag with a date of 04/29/2022 on it. Interview and observation on 05/10/2022 at 12:07 p.m. with S2 DON in attendance revealed Resident #69's nebulizer mask lying on his bedside table, stored in a Ziploc bag with a date of 04/29/2022 on it. S2 DON stated the date of 04/29/2022 was the date the respiratory equipment was last changed. S2 DON confirmed the nebulizer mask should be changed every 7 days and PRN and it had not been. Resident #46 Review of Resident #46's Care Plan dated 03/23/2022 revealed resident returned from the hospital with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview and observation on 05/09/2022 at 10:10 a.m. revealed Resident #46 in bed with oxygen per nasal cannula in nostrils. The oxygen tubing was running through a Ziploc bag lying on the floor with a date of 04/26/2022 on it. The humidifier bottle was not dated. Observation on 05/10/2022 at 11:15 a.m. revealed Resident #46 in bed with oxygen per nasal cannula in her nostrils. The oxygen tubing was running through a Ziploc bag lying on the floor with a date of 04/26/2022 on it. The humidifier bottle was not dated. Interview and observation on 05/10/2022 at 12:11 p.m. with S2 DON in attendance revealed Resident #46 in bed with oxygen per nasal cannula in her nostrils. The oxygen tubing was running through a Ziploc bag lying on the floor with a date of 04/26/2022 on it. The humidifier bottle was not dated. S2 DON stated the date of 04/26/2022 was the date the respiratory equipment was last changed. S2 DON confirmed the respiratory equipment should be changed every 7 days and PRN and it had not been.

Based on interview and record review the facility failed to ensure medications were available to be administered as ordered for 1 (#31) of 23 sampled residents. Findings: Review of the facility policy titled Medication Orders and Receipt Record revealed in part 4. Medications should be ordered in advance, based on the dispensing pharmacy's required lead time. Review of Resident #31's clinical record revealed an admitted [DATE], with diagnoses that included: [CONDITION(S)] and [CONDITION(S)] following cerebral infarct affecting left non-dominant side, [CONDITION(S)], [CONDITION(S)], Hypertension, GERD without Esophagitis,and Constipation. Interview on 05/09/2022 at 1:34 p.m. with Resident #31 revealed she was not receiving her medications the way she needed to. She stated the facility ran out of her medications often and just last week she was told the facility was out of her [MEDICATION(S)]. Review of the resident's May 2022 MAR revealed an order to give [MEDICATION(S)] 145mcg capsule one by mouth every day. The medication administration was noted documented as (N) on 05/07/2022 and 05/08/2022 by S10 LPN. Further review of the MAR documentation revealed [MEDICATION(S)] 145mcg capsule was documented as not available on 05/07/2022 and 05/08/2022 by S10 LPN. Telephone interview on 05/10/2022 at 11:12 a.m. with S10 LPN revealed she did not have Resident #31's [MEDICATION(S)] to administer on 05/07/2022 or 05/08/2022. She stated she did not call the DON nor did she reorder the medications herself. She stated S11 LPN told her that she would reorder the medication. Review of the facility's pharmacy reorder fax transmission log revealed Resident #31's [MEDICATION(S)] had not been reordered until 05/09/2022 at 12:22 p.m. by S11 LPN. Interview on 05/10/2022 with S2 DON revealed medications should be reordered when the resident has 1 week of medication remaining which is color coded in blue on the medication cards received from pharmacy. She stated nurses are supposed to call her if there is a medication needed that is not available on the weekend and they are then directed to call the on call pharmacy so the medication can be delivered the same day. Further interview revealed she was not notified that Resident #31's [MEDICATION(S)] was not available for administration on 05/07/2022 or 05/08/2022 and should have been. She confirmed the resident's [MEDICATION(S)] was not reordered until 05/09/2022 and was not available for administration on 05/07/2022 and 05/08/2022 and should have been.

Based on observation and interview the facility failed to ensure garbage was disposed of properly. Findings: Observation on 05/09/2022 at 9:30 a.m. of the facility's trash receptacles accompanied by S4 Dietary Manager revealed two large blue dumpsters. The lid to both dumpsters were open. The dumpster closest to the kitchen door was overflowing with trash. There was debris and dirty gloves on the ground in front of the dumpster. S4 Dietary Manager confirmed the dumpster was too full and the lids should be closed. S4 Dietary Manager further confirmed there was debris and dirty gloves on the ground in front of the dumpster closest to the kitchen and it should not have been. Interview on 05/11/2022 at 1:14 p.m. with S1 Administrator revealed trash is picked up once a week. He stated the lids being left open to the dumpsters had been an ongoing problem.

Based on observation, record review, and interview the facility failed to maintain an infection prevention and control program to prevent the spread of Covid-19 by failing to: 1. ensure monitoring all staff and visitors to ensure compliance with screening and source control prior to entering the facility; 2. ensure CNA used appropriate PPE when caring for COVID positive and COVID negative residents; 3. ensure the plastic screen used to separate the COVID positive unit from non-positive residents remained closed; and 4. ensure the dishwasher temperature and sanitizer levels were tested prior to washing dishes/eating utensils that were used by all residents whether COVID positive or non-positive. Findings: 1. Review of the facility's Indoor Visitation, Infection Control During COVID 19 policy revealed in part: 2. Visitation will require screening of all who come to the facility for signs and symptoms of COVID-19 (e.g. temperature checks, questions or observations about signs and symptoms' and denial of entry for those with signs and symptoms. 9. Visitors must follow instruction from the appropriate personnel on duty regarding facility infection control practices and visitation restrictions. Observation upon arrival at the facility on 01/24/2022 at 8:15 a.m. revealed signage on entry doors regarding screening and COVID restrictions. An unidentified female was noted inside completing screening on her own. Upon entrance, staff informed surveyor to self- screen with temperature check and questionnaire. The staff member (S3HR) stated that each person self-screened and the DON checked during the day to ensure screening was completed. Interview on 01/24/2022 at 8:23 a.m. with S3HR revealed she never screened staff or visitors. S3HR stated everyone entering the building self-screened by taking their own temperature and answering the screening questions. S3HR stated the DON was responsible for checking to ensure all screening was completed. Interview on 01/26/2022 at 8:50 a.m. with S1Adm. revealed the facility did not have a designated person to ensure screening was conducted for visitors entering the facility. S1 Adm. stated all the administrative staff were responsible for screening of visitors. S1 Adm. confirmed there was no system in place to ensure everyone entering the facility was screened for COVID. Interview on 01/26/2022 at 9:35 a.m. with Confidential Interview #1revealed she visited the facility almost on a daily basis. She stated she sometimes screened herself and sometimes the staff screened her. Telephone interview on 01/26/2022 at 9:45 a.m. with Confidential Interview #2 revealed that he visited his mother at the facility about 5-6 times a week. He stated that he had a code to the front door and he often screened himself upon entering the facility. Interview on 01/26/2022 at 9:35 a.m. with S1Adm. revealed some visitors did have the code to the facility, and that the administrative staff was responsible for ensuring they were screened before entering the facility. S1 Adm. stated that if the administrative staff were out of the office or the office door was closed, they would not be aware the visitor was in the building. S1 Adm. stated that there was not one staff member designated to ensure everyone entering the building was screened. S1 Adm. stated, We don't' have enough staff to place someone at the screening desk, and it doesn't make sense since visitors are allowed to come it freely anyway without limitations. S1 Adm. confirmed a visitor could not be honest about having a temperature when checking in, but stated that was no different from them not being truthful about having symptoms of COVID-19. Observation on 01/26/2022 at 10:59 a.m. 01/26/2022 at 10:59 a.m. revealed a Hospice Aide entered the facility, place the thermometer to her forehead, then proceeded to the resident area. Interview at this time with the Hospice Aide revealed she had forgotten to sign in, and she returned to the screening table to sign in. The Hospice Aide stated she was at the facility three times a week, and was last at the facility on Monday, 01/24/2021. Review of the visitor log did not reveal her screening for that day. She stated, I was sure I signed in. Interview on 01/26/2022 at 1:45 p.m. with S2DON revealed all the facility's administrative staff and regular staff were responsible for self-screening and screening of visitors. S2 DON stated there was not a designated staff member to ensure the accuracy of visitor screening. S2 DON stated there was not any way to ensure anyone was telling the truth when answering the screening questions, and there was not enough staff to designate one person to the screening table. 2. Review of the facility's Infection Control Guidelines for All Nursing Procedures policy revealed in part: 6. Staff will wear KN95 mask on non-Covid unit. Staff will wear KN95 mask and face shield with isolation gown in Covid unit and observation rooms. Face shields will be disinfected at the end of each shift or on an as needed basis if soiled during shift. Observation on 01/24/2022 at 11:25 a.m. revealed S5CNA donned gloves and gown, sanitized hands, and placed gloves on, then entered a Droplet Precaution Room and set up the dinner tray. S5 CNA exited the room, doffed the PPE, donned gloves and gown, sanitized hands and placed gloves on, and re- entered the same Droplet Precaution Room and set up another dinner tray. She was not noted to don a face shield before entering another non-isolation resident's room. Interview on 01/25/2022 at 10:30 a.m. with S5CNA confirmed she did not don a face shield and change her N95 mask before entering Droplet Precaution Room and setting up the dinner trays. S5 CNA further stated she did not change out her mask before entering another resident's room as observed at 11:25 a.m. on 01/24/2021. Observation on 01/26/2022 at 10:30 a.m. revealed S12CNA exited a resident's room, walked down the resident hallway, entered the courtyard, and re-entered the building. S12 CNA was noted wearing a surgical mask. Interview at this time with S12CNA stated, The staff are allowed to wear either an N95 mask or a surgical mask. Interview on 01/26/2022 at 10:31 a.m. with S2DON revealed due to the facility's current COVID - 19 status all staff were required to wear N95 mask. S2 DON confirmed at this time that S12CNA had on a surgical mask and she then proceeded to provide S12CNA with an N95 mask to wear. Interview on 01/26/2022 at 10:33 a.m. with S13LPN revealed she was responsible for monitoring to ensure the staff on her hall wore the proper PPE. S13 LPN stated she did not notice that S12CNA was wearing a surgical mask instead of an N95 mask. S13 LPN stated she thought she had an N95 mask under the surgical mask. 3. Review of the facility's Isolation-Initiating Transmission-Based Precautions policy reveled in part: 3. h. In the event of COVID, a plastic barrier will be placed within the room from ceiling to floor to create a clean area when entering the room. 3. i. In the event that a COVID Unit is made two plastic barriers will be made from ceiling to floor creating a clean area before entering the COVID Unit. Observation on 01/26/2022 at 8:30 a.m. of the special unit at this time revealed the two plastic coverings separating the CV-19 unit and the PPE supply area outside the unit were both unzipped and the unit could be observed through the opening. Interview with S8LPN on the above date and time confirmed both plastic coverings were unzipped and should have been zipped. Interview on the above date and time with S9LPN, revealed she entered the unit and zipped the first plastic covering closed, then entered the other area and zipped the plastic. She stated the two CNAs on the unit must have unzipped the plastic. Interview on the above date and time with S10CNA confirmed she entered the second layer of plastic into the COVID positive unit, and neglected to re-zip it. Interview on the above date and time with S11CNA confirmed she unzipped the first layer of plastic and neglected to re-zip upon exit of the CV-19 positive unit. 4. Review of the facility's Isolation Sanitization policy revealed in part: 8. Dishwashing machines must be operated using the following specifications: Low-Temperature Dishwasher (Chemical Sanitization) a. Wash temperature (120 degrees F); b. Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds. Further review of the policy did not reveal any designation for dishwashing of COVID-19 positive resident's dishware. Review of the facility's Daily Temperature Logs for the Dish Machine from 01/10/2022 to 01/25/2022 revealed that there was missing documentation for the following: Dinner on 01/10/2022, Dinner on 01/12/2022, Dinner on 01/15/2022, Dinner on 01/16/2022, and no documentation for Breakfast, Lunch, and Dinner on 01/24/2022 and 01/26/2022. Interview on 01/24/2022 at 9:50 a.m. with S4Dietary revealed there were no disposable plates used on any residents in the facility. S4 Dietary stated both the COVID-19 positive and non-positive residents ate on dinner plates. S4 dietary stated the dishwasher sanitized the dishes at 129 degrees. Interview on 01/25/2022 at 8:55 a.m. with S6Dishwasher, revealed he had been washing dishes at the facility since 4:50 a.m. that morning. S6 Dishwasher stated he had not checked the dishwasher sanitizer levels or hot water temperature because no one had ever showed him how to test. Observation on 01/25/2022 at 8:55 a.m. revealed S1Adm. training S6Dishwasher on the technique for checking sanitizer levels and water temperatures on the dishwasher. S1Adm. stated he did not know where the temperature logs were since the dietary manager had left one week ago. Interview on 01/25/2022 at 9:00 a.m. with S7Cook, revealed she had just returned to work that morning after an extended leave. S7 cook confirmed she had not checked the dishwasher temperature or the sanitizer levels that morning. Interview on 01/25/2022 at 9:30 a.m. with S1Adm. revealed he found the logbooks and the staff had been checking the PPM and temperatures. Review of the logbooks at this time revealed the temperature and sanitizer levels had not been checked that morning prior to the start of the dishwashing. S1 Adm. stated the dishwasher was a Low-Temperature Chemical Sanitation Dishwasher and the water temperature was to be maintained at 120 degrees Fahrenheit and the final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds. S1 Adm. provided the Isolation Sanitization Policy that indicated the above information. Interview on 01/26/2022 at 12:45 p.m. with S14Dietary confirmed there was no documentation of PPM and water temperatures for today. S14 Dietary confirmed she had not checked the sanitizer levels and temperatures prior to washing the breakfast, snack, and lunch dishes this day. Interview on 01/26/2022 at 12:45 p.m. with S1Adm. confirmed after review of the Daily Temperature Logs from 01/10/2022 to 01/25/2022, that there was missing documentation for the following: Dinner on 01/10/2022, Dinner on 01/12/2022, Dinner on 01/15/2022, Dinner on 01/16/2022, no documentation for 01/24/2022 and 01/26/2022. S1 Adm. further confirmed there was no specific policy for washing dishes of the COVID-19 positive residents, and he did not have a source for the policy that allowed the dishes of non-COVID-19 positive and COVID-19 positive residents to be disinfected in the same manner.

Based on record review and interview the facility failed to ensure nursing assessments were conducted timely when changes were identified in a resident's vital signs after the resident experienced a fall with the potential for head injury (#2) for 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled residents. The total facility census was 65 residents according to the Resident Census and Condition Report dated 6/17/19. Findings: Review of Resident #2's (MONTH) 2019 Physician order [REDACTED]. Further review of the Physician order [REDACTED]. Review of the Quarterly MDS Assessment (ARD Date 6/5/19) revealed the resident had a BIMS of 5 (severe cognitive impairment), and required limited assistance of 1 person for bed mobility and transfer; required set up help and supervision for locomotion on the unit; and extensive assist of one person for personal hygiene. Further review of the MDS revealed the resident's balance was not steady for turning around and for surface to surface transfer, and he was only able to stabilize with staff assistance. Review of the Nurses' Progress Note documented by S3 LPN dated 6/6/19 at 7:00 p.m. revealed the resident got up out of his wheelchair, started to walk, lost his balance, fell and hit the back of his head on the wall. Review of the Neurological Assessment Flowsheet dated 6/6/19 revealed neuro checks were initiated at 7:00 p.m. by S3 LPN, and the findings were BP - 99/56, P - 100, RR - 22, T - 98.2. Neuro checks and vital signs were documented every 15 minutes until 8:00 p.m. and then every 30 minutes until 9:00 p.m. The resident's BP at 9:00 p.m. was 118/66. Review of the Nurses' Progress Note on 6/6/19 at 9:30 p.m. documented by S3 LPN revealed the resident sustained [REDACTED]. S3 LPN documented the resident's vital signs were BP - 130/71, P - 95, RR - 20, T - 98.2 after the incident. Review of the Nurses' Progress Note on 6/6/19 at 11:00 p.m. documented by S4 LPN revealed the resident's vital signs were BP - 153/82, P - 88, RR - 20, T - 97.1, and O2 Sat 91%. Review of the Nurses' Progress Note revealed the next assessment of the resident's vital signs was not completed until 6/7/19 at 1:15 a.m. (documented by S4 LPN), and the vital signs were 155/77, P - 93, RR - 20, T - 99.7, and O2 Sat 91%. Review of the Nurses' Progress Note dated 6/7/19 at 2:15 a.m. by S4 LPN revealed the resident's vital signs were BP - 153/80, P - 116, RR - 23, T - 101.0, and O2 Sat - 84%. Telephone interview on 6/19/19 at 8:50 a.m. with S4 LPN revealed she worked the night shift on 6/6/19 from 10:00 p.m. to 6:00 a.m. and was informed the resident had fallen on the previous shift. S4 LPN stated the vital sign assessments conducted on the night shift were documented in the Nurses' Progress Notes. S4 LPN confirmed the vital signs were monitored as documented in the NN at 11:00 p.m., 1:15 a.m. and 2:15 a.m. S4 LPN stated the resident had a change in the level of consciousness at 2:15 a.m., and staff could not wake him up. S4 LPN stated the NP was notified and ordered transfer to the hospital. Interview on 6/18/19 at 10:13 a.m. with S1 NP revealed the resident experienced a fall on 6/6/19. S1 NP reviewed the Nurses' Progress Notes and Neurological Assessments documented by the nurses on 6/6/19 and 6/7/19. S1 NP confirmed the nurses had documentation of the resident's vital signs at 7:00 p.m. on 6/6/19 of BP - 99/56 and T - 98.2; at 9:00 p.m. of BP - 118/66 and T - 97; and at 11:00 p.m. of BP - 153/82 and T - 97.1. S1 NP noted the next assessment of vital signs was at 1:15 a.m. and the BP was 155/77, and T - 99.7. S1 NP noted the next assessment was documented at 2:15 a.m. and the findings were BP - 153/80, T - 101.0, and O2 Sat - 84%. Further interview with S1 NP at the above date and time revealed staff should have increased the frequency of vital sign assessments after the resident's BP was elevated on 6/6/19 at 11:00 p.m., and the vital signs and neuro check frequency should have been increased to every 15 minutes. Further interview with S1 NP confirmed the resident's medication regimen included the medications [MEDICATION NAME] and ASA which contributed to the risk factors associated with falling. S1 NP confirmed there were changes in the resident's BP at 11:00 p.m. and that warranted an increase in the frequency of monitoring. Interview on 6/19/19 at 9:30 a.m. with S2 DON confirmed the vital signs documented in the Nurses' Progress Notes and Neurological Assessment Flowsheets on 6/6/19 and 6/7/19 completed the documentation of vital signs for the resident after his falls.

Based on record review and interview the facility failed to ensure the Physician / NP was notified when a change was identified in a resident's vital signs, after the resident experienced a fall with a potential head injury (#2) for 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled residents. The total facility census was 65 residents according to the Resident Census and Condition Report dated 6/17/19. Findings: Review of Resident #2's (MONTH) 2019 Physician order [REDACTED]. Further review of the Physician order [REDACTED]. Review of the Quarterly MDS Assessment (ARD Date 6/5/19) revealed the resident had a BIMS of 5 (severe cognitive impairment), and required limited assistance of 1 person for bed mobility and transfer; required set up help and supervision for locomotion on the unit; and extensive assist of one person for personal hygiene. Further review of the MDS revealed the resident's balance was not steady for turning around and for surface to surface transfer, and he was only able to stabilize with staff assistance. Review of the Nurses' Progress Note documented by S3 LPN dated 6/6/19 at 7:00 p.m. revealed the resident got up out of his wheelchair, started to walk, lost his balance, fell and hit the back of his head on the wall. Review of the Neurological Assessment Flowsheet dated 6/6/19 revealed neuro checks were initiated at 7:00 p.m. by S3 LPN, and the findings were BP - 99/56, P - 100, RR - 22, T - 98.2. Neuro checks and vital signs were documented every 15 minutes until 8:00 p.m. and then every 30 minutes until 9:00 p.m. The resident's BP at 9:00 p.m. was 118/66. Review of the Nurses' Progress Note on 6/6/19 at 9:30 p.m. documented by S3 LPN revealed the resident sustained [REDACTED]. S3 LPN documented the resident's vital signs were BP - 130/71, P - 95, RR - 20, T - 98.2 after the incident. Review of the Nurses' Progress Note on 6/6/19 at 11:00 p.m. documented by S4 LPN revealed the resident's vital signs were BP - 153/82, P - 88, RR - 20, T - 97.1 and O2 Sat 91%. Review of the Nurses' Progress Note dated 6/7/19 at 2:15 a.m. by S4 LPN revealed the resident's vital signs were BP - 153/80, P - 116, RR - 23, T - 101.0 and O2 Sat - 84%. Further review of the nurse's note revealed the NP was notified and the resident was sent to the hospital. Telephone interview on 6/19/19 at 8:50 a.m. with S4 LPN confirmed she worked the night shift on 6/6/19 from 10:00 p.m. to 6:00 a.m. and was informed of the resident's falls that occurred on the previous shift. S4 LPN confirmed the resident's BP was 153/82 when she checked it at 11:00 p.m. and she stated she did not report the change in the BP to the MD / NP at that time. Interview on 6/18/19 at 10:13 a.m. with S1 NP revealed the resident experienced a fall on 6/6/19. Further interview with S1 NP revealed the resident was at higher risk for complications after falling related to the medications of [MEDICATION NAME] and ASA. S1 NP confirmed there was a change in the resident's BP at 11:00 p.m. on 6/6/19 with findings of 153/82, and she stated staff should have notified the NP / MD of the change in the resident's BP, and did not.

Based on record review and interviews the facility failed to submit mandatory documents to the Louisiana Stated Board of Practical Nurse Examiners to obtain approval for other RN's in the facility to supervise a probated nurse routinely in the absence of the approved on-site supervisor for 1 of 1 probated nurses in the facility. According to the Resident Census and Conditions of Residents Form, the total facility census was 68. Findings: Review of S2 LPN's License Verification Report dated 1/30/19 provided by S1 DON revealed the status of the nurse's license was Probation. Further review revealed the nurse's license had been suspended and was reinstated Conditional. The Expiration Date of the nurse's license was 1/31/2020. Review of the LOUISIANA STATE BOARD OF PRACTICAL NURSE EXAMINERS EMPLOYER'S AGREEMENT dated 12/14/18 revealed the individual must be directly supervised by an on-site RN / LPN (higher ranking) / Physician, and the employer was to notify the board if there was a change in the on-site supervisor. Further review revealed S1 DON was the on-site supervisor for S2 LPN, and S2 LPN had been ordered or agreed to work with restrictions in the healthcare setting with monitoring requirements. The monitoring requirements for S2 LPN revealed the nurse must have on-site supervision during the entire term of the program agreement or until completion of probation; and the on-site supervisor must see the nurse regularly during the scheduled shift. Interview on 5/21/19 at 11:45 a.m. with S1 DON confirmed the facility had a nurse employed that was on probation and required on-site monitoring. S2 DON stated she was the on-site supervisor assigned to monitor S2 LPN. Further interview revealed S2 LPN was scheduled to work every other weekend, and when she worked weekend shifts she may be supervised by one of the RN Supervisors (if S1 DON was not on duty). Telephone interview on 5/22/19 at 2:30 p.m. with S5 LSBPNE Compliance Investigator revealed the facility had entered into an agreement to employ and to directly supervise S2 LPN. S5 LSBPNE Compliance Investigator stated S1 DON was the designated on-site supervisor for S2 LPN, and S1 DON must be present when the probated nurse was on duty (at all hours). Further interview with S5 LSBPNE Compliance Investigator revealed any changes in the personnel assigned to provide the on-site supervision must be reported to them in writing, and S1 DON was the only staff member assigned to provide the on-site supervision for S2 LPN. Review of the Nurse's Schedule revealed S2 LPN was scheduled to work the day shift on 3/30/19, 3/31/19, 4/14/19, 4/27/19 and 4/28/19. Further review revealed S1 DON was not scheduled to work on the dates of 3/30/19, 3/31/19, 4/14/19, 4/27/19 and 4/28/19. Interview on 5/22/19 at 3:00 p.m. with S1 DON confirmed S2 LPN had worked the above dates and was supervised on 3/30/19, 3/31/19, 4/14/19, 4/27/19 by the weekend supervisor S3 RN, and on 4/28/19 by the weekend supervisor S4 RN. Further interview with S1 DON confirmed she was not on duty the dates of 3/30/19, 3/31/19, 4/14/19, 4/27/19 and 4/28/19, and had not conducted the required on-site supervision for the probated nurse.

Based on observation and record review, the facility failed to provide at least eighty square feet per resident in bedrooms with three and four beds in each room for 7 of 7 rooms (Rooms 29, 30, 33, 35, 36, 38, and 40). Findings: Room measurements were as follows: 1. room [ROOM NUMBER] - 15' x 19.8' = 297.0' (4 bed capacity) or 74.25'/resident. 2. room [ROOM NUMBER] - 11.0' x 21.25' = 233.75' (3 bed capacity) or 77.9'/resident. 3. room [ROOM NUMBER] - 15.0' x 21.5' = 318.75' (4 bed capacity) or 79.68'/resident. 4. room [ROOM NUMBER] - 15.0' x 20.25' = 311.25' (4 bed capacity) or 77.81'/resident. 5. room [ROOM NUMBER] - 14.75' x 20.25' = 298.7' (4 bed capacity) or 74.67'/resident. 6. room [ROOM NUMBER] - 14.75' x 21.25' = 313.43' (4 bed capacity) or 78.35'/resident. 7. room [ROOM NUMBER] - 14.75' x 20.25' = 298.7' (4 bed capacity) or 74.67'/resident. Review of a waiver approval dated 5/10/18 revealed that the facility had a waiver for the sizes of the above rooms. Interview with S1 Assistant Administrator on 4/1/19 at 10:00 a.m. confirmed there had been no changes to the above rooms.

Based on observation and record review, the facility failed to provide at least eighty square feet per resident in bedrooms with three and four beds in each room for 7 of 7 rooms (Rooms 29, 30, 33, 35, 36, 38, and 40). Findings: Room measurements were as follows: 1. room [ROOM NUMBER] - 15' x 19.8' = 297.0' (4 bed capacity) or 74.25'/resident. 2. room [ROOM NUMBER] - 11.0' x 21.25' = 233.75' (3 bed capacity) or 77.9'/resident. 3. room [ROOM NUMBER] - 15.0' x 21.5' = 318.75' (4 bed capacity) or 79.68'/resident. 4. room [ROOM NUMBER] - 15.0' x 20.25' = 311.25' (4 bed capacity) or 77.81'/resident. 5. room [ROOM NUMBER] - 14.75' x 20.25' = 298.7' (4 bed capacity) or 74.67'/resident. 6. room [ROOM NUMBER] - 14.75' x 21.25' = 313.43' (4 bed capacity) or 78.35'/resident. 7. room [ROOM NUMBER] - 14.75' x 20.25' = 298.7' (4 bed capacity) or 74.67'/resident. Review of a waiver approval dated 5/7/18 revealed that the facility had a waiver for the sizes of the above rooms. Interview with S1 Assistant Administrator on 5/7/18 at 2:00 p.m. confirmed there had been no changes to the above rooms.

.Based on observation and interview the facility failed to ensure all components of the call system were working by failure to ensure the call lights for the bathrooms that adjoined resident rooms a and b, and resident rooms c and d were functional. Findings: Observation on 5/8/17 at 10:25 a.m. of the bathroom for the residents in rooms a and b revealed there was a push button emergency call light available on the wall beside the toilet. Further observation revealed the bathroom call light did not come on in the hallway in front of the 2 adjoining resident rooms (a and b) when the button was pushed. Interview on 5/8/17 at 10:30 a.m. with S4 CNA confirmed the call light in the residents' bathroom did not light up in the hallway for room a and room b when pushed and should have. S4 CNA confirmed the red light on the ceiling outside the residents' room did not come on when it was pushed in the bathroom, and the residents in room b were ambulatory and used the bathroom as needed. Observation on 5/10/17 at 12:00 p.m. of the bathroom for the residents in room c and d revealed there was a push button emergency call light available on the wall beside the toilet. Further observation revealed the button did not click and hold, and the light outside the doors came on but did not stay on when the call light button was pushed. Interview on 5/10/17 at 12:04 p.m. with S3 LPN confirmed the bathroom call light did not click and stay on when pushed and the call light outside the doors for room c and d did not stay on when the call light button was pushed, and should have. Interview on 5/10/17 at 12:10 p.m. with S2 DON confirmed the call lights above the doors in front of the residents' rooms should have come on and stayed on when pushed, until a staff member answered the call light, and turned the light off.

Based on observation and record review, the facility failed to provide at least eighty square feet per resident in bedrooms with three and four beds in each room for 7 of 7 rooms (Rooms 29, 30, 33, 35, 36, 38, and 40). Findings: Room measurements were as follows: 1. Room 29 - 15' x 19.8' = 297.0' (4 bed capacity) or 74.25'/resident. 2. Room 30 - 11.0' x 21.25' = 233.75' (3 bed capacity) or 77.9'/resident. 3. Room 33 - 15.0' x 21.5' = 318.75' (4 bed capacity) or 79.68'/resident. 4. Room 35 - 15.0' x 20.25' = 311.25' (4 bed capacity) or 77.81'/resident. 5. Room 36 - 14.75' x 20.25' = 298.7' (4 bed capacity) or 74.67'/resident. 6. Room 38 - 14.75' x 21.25' = 313.43' (4 bed capacity) or 78.35'/resident. 7. Room 40 - 14.75' x 20.25' = 298.7' (4 bed capacity) or 74.67'/resident. Review of a waiver approval dated 7/7/16 revealed that the facility had a waiver for the sizes of the above rooms, approved as of 6/9/16.

Based observation and interview the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior by failing to ensure residents' rooms and personal property were free of dust, debris and spills (#9, #10, #67); failing to ensure furniture in use by residents (#9, #10) was not rusted and was functional; and failing to ensure the air conditioning vent/grates were also clean (#9, #46). The facility's total resident census was 66, according to the Resident Census and Conditions of Residents form provided by the facility. Findings: Observation on Tour on 6/6/2016 at 10:16 a.m. of resident #9 and #46's room revealed resident #9's bed frame was covered with rust, and the head of the bed and feet did not adjust to allow the resident to elevate his head while in bed. Interview with the resident at that time confirmed the head and feet of his bed would not adjust. Observation of the resident #10 and #67's room on 6/6/16 at 10:58 a.m. at this time revealed multiple surfaces in the room to be dirty with dust and debris. The blinds and window seals were heavily soiled with dust. Observation of resident #10's area revealed his personal items (television, radio and other items) located on the overbed table and shelves were soiled with dust and debris. The resident's overbed table was soiled with dust, dried spills and was rusted. Observation of #67's personal area revealed the resident's personal items (television and other items) located on the nightstand were soiled with dust and debris. The air conditioning vent/grate was also observed to be soiled with debris and dust. Observation and interview on 6/8/16 at 10:40 a.m. with the S5 Administrator confirmed the above findings.

Based on observation and interview the facility failed to properly store food items under sanitary conditions by failing to date and/or label frozen food items located in the facility's freezer areas. According to the Resident Census and Conditions of Residents form the total census was 66. Findings: Observation and interview on 6/6/16 at 9:45 a.m. during the initial tour of the kitchen revealed the person in charge was S4 Acting Dietary Manager, who stated she was the Housekeeping/Laundry Supervisor filling in for the Dietary Manager position temporarily for the past 3 months. Observation on 6/6/16 at 10:00 a.m. of the facility's kitchen storage area with S4 Acting DM revealed 2 large upright freezers which contained the following frozen food items that had not been labeled with the name and/or the date that the item was opened and/or stored in the freezer: 1. Large bag of frozen biscuits 2. Large ziplock bag of frozen chicken spaghetti 3. Large bag of frozen fish filets 4. Large bag of frozen chicken breasts Interview on 6/6/16 at 10:00 a.m. with S4 Acting DM confirmed the above findings and that the staff should have dated and labeled the items when they were opened and stored.

Based on record review and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being when they failed to perform CPR (Cardiopulmonary Resuscitation) on a resident(#66) that was found pulseless and not breathing. The facility had a total of 37 residents ( #2, #5, #6, #7, #8, #9, #14, #15, #17, #18, #19, #20, #21, #24, #27, #28, #30, #31, #32, #33, #36, #39, #40, #42, #45 ,#47, #48, #56, #57, #58 ,#59, #60, #61, #63, #65, #66, #67) out of a total census of 56 residents that wanted life saving measures done in an emergency situation. The Facility failed to: 1. Ensure staff honored the resident's (#66) CPR Directive signed and dated [DATE] that indicated he wanted all possible measures taken to revive him if his heart stopped beating; 2. Ensure staff immediately initiated CPR on a resident (#66) who was found pulseless and not breathing on [DATE]; 3. Immediately call 911 emergency services when a resident (#66) was found pulseless and not breathing on [DATE]; 4. Contact the Physician to notify him that CPR had not been started on a resident (#66) who was found pulseless and not breathing; 5. Have procedures in place for residents found pulseless and not breathing who wanted life saving measures performed in an emergency situation; 6. Ensure staff were aware of procedure for providing life saving measures in an emergency situation. Resident #66 was in Immediate Jeopardy on [DATE] at 3:50 a.m. when he was found in bed, pulseless, and not breathing by S6 LPN and CPR was not initiated and 911 was not called. S6 LPN called the coroner who released the body and then S6 LPN notified the resident's MD to tell him the resident was dead, but did not inform the MD that CPR was not attempted to try and revive the resident. The Immediate Jeopardy ended on [DATE] for Resident # 66 when he died . The Immediate Jeopardy continued for 32 residents identified by the facility as wanting life saving measures in an emergency situation on [DATE] when CPR was not initiated on a resident who wanted life saving measures in an emergency situation. The plan of removal was submitted by the facility on [DATE] at 3:30 p.m. which stated: Problem Identified:Code status not honored on one resident Plan of action: 1. Immediate in-service on code protocol. 2. DNR status [REDACTED]. 3. Upon new admit SSD will discuss with family and resident code status wishes. 4. Code status will be reviewed quarterly or with any significant change in status. 5. Charts flagged with Red paper for DNR and Green paper for full code status. 6. Care plan will reflect resident's rights on code status and will be honored. 7. Nurses will be in-serviced on code status and crash cart. 8. CNAs will be in-serviced on assisting during code-ex. getting chart, calling 911. 9. DON/designee will check documentation on residents who have expired in the building or resident's that CPR was started on. Follow up date: Will be reviewed [DATE] due to circumstances and charts will be checked weekly x 4 weeks and then quarterly for DNR status. Policy: Code Status Procedure: 1. When resident found unresponsive, immediately obtain crash cart and chart to check for code status. 2. If resident is a full code proceed with CPR and notify 911 immediately. 3. Notify MD. 4. If resident is a Do Not Resuscitate, do not initiate CPR. 5. Notify the MD of cessation of VS and resident code status of DNR 6. Follow the doctor's orders following notification. 7. Notify family and responsible party of event. The Immediate Jeopardy ended on [DATE] for the remaining 32 residents when the facility implemented the policy/procedure for immediately providing CPR for a resident with no vital signs and ensured that staff was in-serviced regarding the initiation of CPR if resident is found pulseless and not breathing. The deficient practice remains at a potential for more than minimal harm "E" for all 36 residents identified by the facility as having a directive to have all possible measures taken to revive them if their heart stops beating. Findings: Review of resident #66's Face Sheet reflected he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the Accumulative [DIAGNOSES REDACTED]. Review of the resident's CPR Directive dated [DATE] reflected that he did want all possible measures taken to revive him if his heart stopped beating. Review of the resident's Nurses' Progress Notes dated [DATE] reflected the following: 3:50 a.m. the nurse was summoned to the room by the CNA and found resident lying in bed with eyes opened, pupils fixed and dilated, and absence of vital signs. 3:57 a.m. S2 DON arrived at the facility and noted the resident had expired, all vital signs ceased, and no signs of life. The Sheriff's department was notified at 4:10 a.m. to contact the coroner. 4:20 a.m. the coroner returned the call and released the resident's body to the funeral home. 4:30 a.m. the doctor was notified of the resident's death. 4:35 am. the family was notified of the resident's death. Further review of the Nurses' Progress Notes did not reflect CPR being initiated or EMS activated for the resident. Interview on [DATE] at 9:20 a.m. with S2 DON revealed she arrived to the facility 7 minutes after being notified that the resident had expired. She revealed she did not start CPR because she assumed the doctor had been notified. She further revealed she did not think S6 LPN had initiated CPR. Further interview with S2 DON revealed the facility did not have a policy for care of an unresponsive resident. She confirmed the procedure should have been to initiate CPR on a resident found unresponsive. S2 DON could not provide an explanation as to why CPR was not initiated on this resident. Interview on [DATE] at 10:30 a.m. with S4 LPN and S5 LPN revealed when a resident was found unresponsive, the correct procedure was to immediately check the resident's chart to determine if the resident was a DNR. If the resident was not a DNR then assess the resident's vital signs and initiate CPR. They further confirmed in-services instructing nurses on the correct procedure for caring for unresponsive residents were provided to the nursing staff yearly. Telephone interview with S6 LPN on [DATE] at 11:05 a.m. revealed he was summoned to the resident's room on [DATE] at approximately 3:50 a.m. and found the resident unresponsive with pupils fixed and dilated. He reported he did not call the doctor or 911 because, " He was too far gone, I did what I could for him, he had no vital signs, I moved him around." He confirmed he should have called the doctor, but did not. When asked if he should have called 911, he reported, "No I should have called the doctor first." He further revealed he did not know the resident was not a DNR. Telephone interview on [DATE] at 12:20 p.m. with S16 CNA revealed on [DATE] at approximately 3:50 a.m. she was making her every two hour rounds and discovered resident #66 unresponsive. She reported she immediately went to the dayroom and used the telephone to notify the nurse working in the facility. She reported the nurse checked to see if the resident was breathing and when he discovered the resident was not breathing he called the DON. She further reported he made more phone calls, but she could not recall who else was notified. She confirmed she made rounds on the resident every 2 hours and the resident was fine on her last round. Telephone interview on [DATE] at 12:35 p.m. with S8 MD revealed he was notified early on the morning of [DATE] and informed by the nurse that resident #66 had expired. He further reported there was never any mention of CPR being performed or withheld and he never inquired about CPR being performed. An interview was held on [DATE] at 2: 20 p.m. with S17 LPN. When asked what would she have done if she had found a resident who did not have a pulse or was not breathing, she revealed that she would have checked the resident's vital signs, have the CNA check the chart for DNR status, start CPR, and call 911 if the resident's wishes were to be resuscitated. An interview was held on [DATE] at 2:30 p.m. with S18 LPN. When asked what would she have done if she had found a resident who did not have a pulse or was not breathing, she stated that she would have sent the CNA to get the crash cart and the chart, check the advance directives, and have the CNA call 911 while she started CPR. An interview was held on [DATE] at 2:35 p.m. with S2 LPN. When asked what would she have done if she had found a resident who did not have a pulse or was not breathing, she stated as a nurse her first impulse would be to initiate CPR, have the CNA get the crash cart, and chart to obtain DNR or full code status. She reported if the resident was a DNR she would stop CPR and if he was a full code she would have the CNA call 911 while she continued CPR. An interview was held on [DATE] at 2:35 p.m. with S3 ADON. When asked how would she have identified if a resident was DNR or a Full Code she stated Social Services was responsible for obtaining the resident's wishes and placing them in the chart. She reported that prior to [DATE] a resident either had a sticker or a red sheet indicating DNR status, but now the chart had a red sheet to indicate DNR and a green sheet to indicate Full code status. When asked if she was aware of resident #66's Full code status she reported she was not, but would have checked the chart and initiated CPR. Interview on [DATE] at 2:53 p.m. with S2 DON revealed on the morning of [DATE] she arrived to the facility after being summoned by S6 LPN. She reported she was told by S6 LPN that resident #66 had expired. She stated she assumed S6 LPN had checked the chart and the resident was a DNR, therefore she did not question why CPR was not done for the resident. She further reported the only in-services she had conducted prior to [DATE] related to the use of the crash cart, but since then she had in-serviced the staff and created a policy on honoring the code status of the residents. Interview on [DATE] at 3:16 p.m. with S1 Adm. revealed he was not aware until [DATE] that resident #66 had not received CPR as per the resident's wishes. He revealed he was not aware the facility did not have a policy for DNR or CPR prior to [DATE]. S1 Adm. revealed that he was not a nurse, nor was he CPR certified, but he would have assumed as a nurse S6 LPN would have initiated CPR and called 911 for resident #66.

Based on record review and interviews the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical and mental well being of its residents. The facility failed to have a system in place to ensure that residents' directives were honored for 1 (#66) of 37 residents ( #2, #5, #6, #7, #8, #9, #14, #15, #17, #18, #19, #20, #21, #24, #27, #28, #30, #31, #32, #33, #36, #39, #40, #42, #45 ,#47, #48, #56, #57, #58 ,#59, #60, #61, #63, #65, #66, #67) wanting life saving measures done in the case of an emergent situation out of a facility census of 56. The facility failed to: 1. Have a policy and procedure in place for residents who wished to have CPR (Cardiopulmonary Resuscitation) performed. 2. Ensure staff honored the client's CPR Directive for resident (#66) on [DATE]. 3. Ensure staff initiated CPR on a resident (#66) found pulseless and not breathing on [DATE]. 4. Immediately call 911 emergency services when a resident was found pulseless and not breathing on [DATE]. 5. Have a system in place to ensure staff honored resident's directives for provision of CPR in the event of no pulse or not breathing. Resident #66 was in Immediate Jeopardy on [DATE] at 3:50 a.m. when he was found in bed, pulseless and not breathing by S6 LPN and CPR was not initiated and 911 was not called. S6 LPN called the coroner who released the body then S6 LPN notified the resident's MD to tell him the resident was dead, but did not inform the MD that no CPR was attempted to try to revive the resident. The Immediate Jeopardy ended on [DATE] for Resident # 66 when he died . The Immediate Jeopardy continued for 32 residents identified by the facility as wanting life saving measures in an emergency situation [DATE] when CPR was not initiated on a resident who wanted life saving measures in an emergency situation. The plan of removal was submitted by the facility on [DATE] at 3:30 p.m. which stated: Problem Identified:Code status not honored on one resident Plan of action: 1. Immediate in-service on code protocol. 2. DNR status [REDACTED]. 3. Upon new admit SSD will discuss with family and resident code status wishes. 4. Code status will be reviewed quarterly or with any significant change in status. 5. Charts flagged with Red paper for DNR and Green for full code status. 6. Care plan will reflect resident's rights on code status and will be honored. 7. Nurses will be in-serviced on code status and crash cart. 8. CNA's will be in-serviced on assisting during code-ex. getting chart, calling 911. 9. DON/designee will check documentation on residents who have expired in the building or CPR was started on. Follow up date: Will be reviewed [DATE] due to circumstances and charts will be checked weekly x 4 weeks and then quarterly for DNR status. Policy: Code Status Procedure: 1. When resident found unresponsive, immediately obtain crash cart and chart to check for code status. 2. If resident is a full code proceed with CPR and notify 911 immediately. 3. Notify MD. 4. If resident is a Do Not Resuscitate, do not initiate CPR. 5. Notify the MD of cessation of VS and resident code status of DNR. 6. Follow the doctor's orders following notification. 7. Notify family and responsible party of event. The Immediate Jeopardy ended on [DATE] for the remaining 32 residents when the facility implemented the policy/procedure for immediately providing CPR for a resident with no vital signs and ensured that staff was in-serviced regarding the initiation of CPR if resident is found pulseless and not breathing. The Immediate Jeopardy was lowered to actual harm for Resident # 66 on [DATE] when he expired. The deficient practice remains at a potential for more than minimal harm "E" for all 32 residents identified by the facility as having a directive to have all possible measures taken to revive them if their heart stops beating. Findings: Review of resident #66's Face Sheet reflected he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the Accumulative [DIAGNOSES REDACTED]. Review of the resident's CPR Direction dated [DATE] reflected that he did want all possible measures taken to revive him if his heart stopped beating. Review of the resident's Nurses' Progress Notes dated [DATE] reflected the following: 3:50 a.m. the nurse was summoned to the room by the CNA and found resident lying in bed with eyes opened, pupils fixed and dilated, and absence of vital signs. 3:57 a.m. S2 DON arrived at the facility and noted the resident had expired, all vital signs ceased, and no signs of life. 4:10 a.m. The Sheriff's department was notified and the coroner was contact. 4:20 a.m. the coroner returned the call and released the resident's body to the funeral home. 4:30 a.m. the doctor was notified at of the resident's death. 4:35 am. the family was notified of resident's death. Further review of the Nurses' Progress Notes did not reflect CPR being initiated or EMS activated for the resident. Interview on [DATE] at 9:20 a.m. with S2 DON revealed she arrived to the facility 7 minutes after being notified that the resident had expired. She revealed she did not start CPR because she assumed the doctor had been notified. She further revealed she did not think S6 LPN had initiated CPR. Further interview with S2 DON revealed the facility did not have a policy for care of an unresponsive resident. She confirmed the procedure should have been to initiate CPR on a resident found unresponsive. She could not provide a explanation as to why CPR was not initiated on this resident. Interview on [DATE] at 10:30 a.m. with S4 LPN and S5 LPN revealed when a resident is found unresponsive the correct procedure is to immediately check the resident's chart to determine if the resident is a DNR. If the resident is not a DNR then assess vital signs, and initiate CPR . They further confirmed in-services instructing nurses on the correct procedure for caring for unresponsive residents are provided to the nursing staff yearly. Telephone interview with S6 LPN on [DATE] at 11:05 a.m. (after 3 unsuccessful attempts on [DATE]) revealed he was summoned to the resident's room on [DATE] at approximately 3:50 a.m. and found the resident unresponsive with pupils fixed and dilated. He reported he did not call the doctor or 911 because, " He was too far gone, I did what I could for him, he had no vital signs, I moved him around". He confirmed he should have called the doctor, but did not. When asked if he should have called 911 he reported, "No I should have called the doctor first." He further revealed he did not know the resident was not a DNR. Telephone interview on [DATE] at 12:20 p.m. with S16 CNA revealed on [DATE] at approximately 3:50 a.m. she was making her every two hour rounds and discovered resident # 66 unresponsive. She reported she immediately went to the dayroom and used the telephone to notify the nurse working in the facility. She reported the nurse checked to see if the resident was breathing and when he discovered the resident was not breathing he called the DON. She further reported he made more phone calls, but she could not recall who else was notified. She confirmed she made rounds on the resident every 2 hours and the resident was fine on her last round. Telephone interview on [DATE] at 12:35 p.m. with S8 MD revealed he was notified early on the morning of [DATE] and informed by the nurse that resident #66 had expired. He further reported there was never any mention of CPR being performed or withheld and he never inquired about CPR being performed. An interview was held on [DATE] at 2:35 p.m. with S3 ADON. When asked how would she have identified if a resident was DNR or a Full Code she stated Social Services was responsible for obtaining the resident's wishes and placing them in the chart. She reported that prior to [DATE] a resident either had a sticker or a red sheet indicating DNR status, but now the chart had a red sheet to indicate DNR and a green sheet to indicate Full code status. When asked if she was aware of resident #66's Full code status she reported she was not, but would have checked the chart and initiated CPR. Interview on [DATE] at 2:53 p.m. with S2 DON revealed on the morning of [DATE] she arrived to the facility after being summoned by S6 LPN. She reported she was told by S6 LPN that resident #66 had expired. She stated she assumed S6 LPN had checked the chart and the resident was a DNR, therefore she did not question why CPR was not done for the resident. She further reported the only in-services she had conducted prior to [DATE] related to the use of the crash cart, but since then she had in-serviced the staff and created a policy on honoring the code status of the residents. Interview on [DATE] at 3:16 p.m. with S1 Administrator revealed he was not aware until [DATE] that resident # 66 had not received CPR as per the resident's wishes. He revealed he was not aware the facility did not have a policy for DNR or CPR prior to [DATE]. S1 Administrator revealed that he was not a nurse, nor was he CPR certified, but he would have assumed as a nurse S6 LPN would have initiated CPR and called 911 for resident #66.