Every finding on record at Brandon Court

Based on record review, staff interviews, and facility policy review the facility failed to immediately notify the resident's physician and Resident Representative (RR) following a change in condition involving one (1) of three (3) residents reviewed for notification requirements. Resident #1 Findings Include: Record review of the facility policy, Accident/Incident Reports, reviewed 9/25 revealed 1. All accidents/incidents including residents, employees, or visitors, will be reported to the Charge Nurse and to the appropriate department head immediately upon knowledge of occurrence, so that it may be evaluated. Accident/Incident is defined as an unexpected happening which may or may not have caused loss or injury to a visitor, resident, and/or staff person (i.e., a resident fall; a staff person closing finger in door; resident hitting staff member; a resident choking in the dining room; or resident wandering out of the community . An interview on 5/28/26 at 12:16 PM, with Licensed Practical Nurse (LPN) #1 revealed that on the night of 3/15/26, she found Resident #1 with abrasions to both knees after Certified Nursing Assistant (CNA) #1 reported to her that she had found the resident on the floor earlier in the evening around 11:00 PM. She noted that she cleaned the resident's knees and notified the Nurse Practitioner (NP) of her findings who in turn ordered an x-ray. She stated she asked CNA #1 three times did the resident fall out of the bed. Each time CNA #1 denied it and stated instead that she had found the resident lying in an awkward position in the bed. She noted that on 3/19/26 after an interview with CNA #1, the Director of Nurses (DON) and the Administrator that CNA #1 revealed that the resident was found on her knees in on the floor and had returned her to bed without getting another staff member to witness or aid in transfer. An interview with Registered Nurse (RN) #1 at 12:20 PM on 5/28/26, revealed she was not present on the night when the Resident #1 was found to have abrasions to her knees, but was at work on 3/19/26 when the family members of Resident #1 came to the facility expressing concerns related to the resident's injuries. An interview at 1:23 PM on 5/28/26, with the Nurse Practitioner (NP) revealed the resident was seen by her on 3/17/26. She believed that her injuries were consistent with a fall which was not reported by the CNA. She noted that abrasions were visible on both knees and since then she has assessed the resident who has not exhibited any other issues.An interview with the DON at 2:00 PM on 5/28/26, revealed the facility investigation of the incident indicated the resident fell onto her knees on 3/15/26 and was picked up and put back into bed by CNA #1 who then failed to report a fall to the staff members present that night. CNA#1 eventually admitted on [DATE] after being further interviewed that that the resident experienced a fall on 3/15/26. She noted that it is her expectation that CNAs appropriately notify nursing staff of falls so proper care can be administered to residents per policy and that failure to do such can lead to undiagnosed or missed injuries. An interview with at 2:15 PM on 5/28/26 with CNA#1 who was present on the night of the incident stated that the resident was found by herself on the floor on her knees. She noticed her knees were red and had abrasions after she moved her by herself back into the bed. She stated she didn't know that was considered a fall, so she told LPN#1 but didn't tell her the resident fell. She stated LPN#1 took care of the resident's knees and notified the NP of the injuries. She stated after talking to the Administrator a few days later it was made evident to her the incident was a fall and should have been reported as such.An interview on 5/28/26 at 3:05 PM, with the facility Administrator revealed that it is his expectation that staff are expected to promptly report falls so appropriate notifications can be made and residents can receive timely evaluation and care. A record review of Resident #1's Face Sheet revealed the facility admitted the resident on 4/4/2023 with diagnoses that included Unspecified Dementia, unspecified severity, with other behavioral disturbance; Major Depressive Disorder; Anxiety Disorder; History of Falling. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/7/2026 revealed Resident #1 was unable to complete a Brief Interview for Mental Status (BIMS).

Based on observation, interviews, record review, and facility policy review, the facility failed to prevent the possible spread of infection during Percutaneous Endoscopic Gastrostomy (PEG) tube care for one (1) of three (3) residents with PEG tubes. (Resident #57) Findings included: A review of the facility's policy titled Hand Hygiene, revised 01/24, revealed, Purpose * To cleanse hands to prevent transmission of infection or other conditions * To provide clean, health environment for residents, staff and visitors . Indications for Hand Washing . 4. Before and after applying gloves . On 11/20/2024 at 9:30 AM, during an observation of PEG tube care performed by Registered Nurse (RN)/Wound Care Nurse #1, after beginning care, she removed the dressing from the PEG tube site, removed her gloves, and applied clean gloves without performing hand hygiene. She cleaned the wound, removed her gloves, and applied another set of clean gloves, again without performing hand hygiene. She dried the wound and removed her gloves. Hand hygiene was not completed during the entire procedure. On 11/20/2024 at 9:40 AM, during an interview, RN #1 confirmed that she forgot to perform hand hygiene between glove changes. She acknowledged contaminating clean gloves by not washing her hands between changes and stated this could potentially result in an infection for the resident. On 11/20/2024 at 11:22 AM, during an interview, the Director of Nurses (DON) stated that RN#1 should have performed hand hygiene after each glove change. She emphasized that the resident could develop an infection at the PEG site due to this oversight and stated her expectation that all staff perform hand hygiene consistently. On 11/20/2024 at 11:34 AM, during an interview, Licensed Practical Nurse (LPN) #1 /Infection Preventionist (IP) confirmed that the RN #1 should have performed hand hygiene between glove changes. She stated that failing to do so constitutes cross-contamination and increases the risk of infection for Resident #57. She noted that she conducts hand hygiene in-services quarterly and as needed. A record review of the Admission Record revealed Resident #57 was admitted by the facility on 11/02/22. The resident had diagnoses that included Dysphagia, Pharyngoesophageal Phase. A record review of Resident #57's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/23/2024, revealed a Brief Interview for Mental Status (BIMS) score of (99), indicating that the resident could not complete the interview. Further review of the MDS revealed staff assessment of mental status indicated that Resident #57 had severe cognitive impairment. Review of Section K revealed the resident had a PEG tube. A record review of the in-service dated 9/25/2024, revealed the signature of RN #1 on the sign-in sheet for training related to Infection Control.

Based on interviews, record reviews, and facility policy reviews, the facility failed to ensure grievances regarding rude staff were resolved in a timely manner for five (5) of the 19 sampled residents. (Residents #3, #8, #9, #45 and #55) Findings included: A review of the facility's policy titled Grievances-Residents, revised 05/24, revealed, All residents are to be encouraged and assisted (if necessary) in filing grievances to include those with respect to care and treatment, the behavior of staff and other residents, and other concerns regarding their facility stay, in the event that they have a need to make a concern known . The facility shall make prompt efforts to resolve the grievances . A review of the facility's policy titled Resident Rights, dated 12/23, revealed, Every resident in this facility has the right to . 12. Be treated courteously, fairly, and with the fullest measure of dignity . On 11/20/2024 at 2:00 PM, during an interview with Resident Council members, several residents (Residents #3, #8, #9, #45, and #55) expressed concerns about rudeness from staff working the 11:00 AM to 7:00 PM shift. Residents reported that Certified Nurse Aides (CNAs) consistently displayed rude and dismissive behavior, often entering rooms with negative attitudes and phrases such as, What do you want? or Didn't someone help you earlier? Residents noted instances where CNAs turned off call lights without assisting or providing explanations. The Resident Council concluded that the issue had not been adequately resolved despite multiple complaints. On 11/21/2024 at 10:23 AM, during a follow-up interview, Resident #8 recounted that CNAs working the 11:00 AM to 7:00 PM shift frequently displayed rude behavior. She described an incident where she requested assistance pulling up her brief due to hand pain and muscle weakness. The CNA responded rudely, questioning, Can't you do that yourself? before reluctantly assisting her. Resident #8 expressed disappointment over the recurring rudeness and stated this issue had persisted for some time. On 11/21/2024 at 10:46 AM, during an interview, Resident #45 shared negative experiences with CNAs on the 11:00 PM to 7:00 AM shift. She stated that CNAs assigned to her usually entered with short tempers, expressing irritation at having to assist her. On 11/21/2024 at 11:00 AM, during an interview, the Social Services Director confirmed conducting Resident Council meetings and acknowledged persistent complaints about rude CNAs on the overnight shift. She noted that residents reported CNAs entering rooms with negative attitudes, turning off call lights without helping, and being unwilling to assist. These grievances were forwarded to the Staff Development Nurse, and copies were sent to the Administrator. On 11/21/2024 at 11:14 AM, during an interview, the Staff Development Nurse confirmed receiving the grievances and acknowledged the issue of CNA rudeness on the night shift. She explained that staff in-service training is typically used to address such concerns and disapproved of the CNAs' behavior, stating it could make residents feel uncomfortable and disrespected. A record review of the in-service sign-in sheets provided by the Staff Development Nurse revealed that in-services were conducted on 03/28/24, 05/29/24, and 07/25/24. All of these in-service sign-in sheets revealed that the attitude and rude behavior that had been reported was addressed. However, review of the sign-in sheets did not have signatures of any of the CNAs that work the 11:00 PM to 7:00 AM shifts. On 11/21/2024 at 11:36 AM, during an interview, the Administrator confirmed that all grievances are discussed during morning meetings, with a goal of resolving them within forty-eight (48) hours. She acknowledged the recurring complaints regarding rude CNAs on the 11:00 AM to 7:00 PM shift, which had been raised in previous Resident Council meetings. A record review of the corrective action plan for grievances revealed that concerns regarding rude CNAs on the 11:00 PM to 7:00 AM shift were documented on 05/22/2024 and 07/16/2024. A record review of Resident #3's Admission Record revealed the facility admitted the resident on 06/17/2021. The resident had diagnoses that included Generalized Osteoarthritis and Hemiplegia and Hemiparesis affecting the left non-dominant side. A record review of Resident #3's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/03/2024, revealed a Brief Interview for Mental Status (BIMS) score of (15), which indicated the resident was cognitively intact. A record review of Resident #8's Admission Record revealed the facility admitted the resident on 02/0/2008. The resident had diagnoses that included Generalized Muscle Weakness and Unsteadiness of Feet. A record review of Resident #8's Quarterly MDS with an ARD of 09/09/2024, revealed a BIMS score of (14), which indicated the resident was cognitively intact. A record review of Resident #9's Admission Record revealed the facility admitted the resident on 06/20/2024. The resident had diagnoses that included Parkinson's Disease with Dyskinesia and Muscle Weakness. A record review of Resident #9's Quarterly MDS with an ARD of 09/23/2024, revealed a BIMS score of (14), which indicated the resident was cognitively intact. A record review of Resident #45's Admission Record revealed the facility admitted the resident on 03/16/2021. The resident had diagnoses that included Unspecified Osteoarthritis and Muscle Weakness. A record review of Resident #45's Quarterly MDS with an ARD of 08/29/2024, revealed a BIMS score of (14), which indicated the resident was cognitively intact. A record review of Resident #55's Admission Record revealed the facility admitted the resident on 07/26/2023. The resident had diagnoses that included Morbid Obesity and Gout. A record review of Resident #55's Quarterly MDS with an ARD of 09/06/2024, revealed a BIMS score of (14), which indicated the resident was cognitively intact.

Based on observations, interviews, and facility policy review, the facility failed to ensure residents were provided with sufficient bath linens to allow residents to bathe at a time that they preferred on one (1) of three (3) days of observation. Findings included: Record review of the facility policy titled Laundry Infection Control-Department Responsibilities, reviewed 08/21, revealed, . The Laundry Department will supply a sufficient quantity of linen for proper resident care and comfort . On 7/30/24 at 9:50 AM observation and an interview with Resident #2 revealed that she had not had any washcloths to use on the morning of 7/30/24. She said the Certified Nurse Aides (CNAs) told her there were no clean washcloths. She said that prevented her from being able to wash up and get into her wheelchair at her preferred time. Observation revealed there were no washcloths in the room or attached bathroom of Resident #2. On 7/30/24 at 10:00 AM observation revealed there were no clean washcloths or bath towels in the linen closets on the first or second floor and there were no clean washcloths or bath towels on the four (4) clean linen carts on the hall. On 7/30/23 at 10:08 AM observations and an interview with Resident #1 revealed she had just received AM care and assistance to transfer into her wheelchair because she had to wait for clean linens to be delivered from the laundry. She stated she preferred to get up earlier and the reason she was told she was not able to get up at the time of her choosing was because there were no clean washcloths or bath towels. She said she preferred to get washed up and then get dressed and then get up in her wheelchair with staff assistance, as that was her usual routine. She confirmed that she had not been able to get up when she preferred on 7/30/24 or wear the clothes she preferred on 7/30/24 because she said the staff told her there was not adequate clean washcloths or towels for a bed bath and the clothes she preferred had not been returned from the laundry. She confirmed that the clothes she preferred to wear had been sent to the laundry several days before. Observation revealed there were no washcloths or bath towels in the room or attached bathroom of Resident #1. On 7/30/24 during an interview at 10:20 AM, CNA #2 revealed that Resident #1 and Resident #2 had to wait past their preferred time to have AM care/bed bath and get up because there were no clean washcloths or bath towels available on the morning of 7/30/24. On 7/30/24 during an interview at 10:23 AM, CNA #3 revealed that Resident #1 and Resident #2 had to wait past their preferred time to have AM care/bed bath and get up because there were no clean washcloths or bath towels available on the morning of 7/30/24. On 7/30/24 at 2:00 PM an interview with the Housekeeping Supervisor revealed that the facility had adequate linens, and added, but we are behind today. She confirmed that the CNAs had to wait for linens to complete the laundering process to have clean linens on 7/30/34. On 7/31/24 at 1:00 PM an interview with the Administrator revealed that he confirmed that it was the responsibility of the facility to ensure that all residents had clean linens available for their care in accordance with their preferred routine for rising, showering/bathing, dressing and other activities of daily living. He confirmed that there were residents that did not have access to clean linens on the morning of 7/30/24. Record review of the Face Sheet for Resident #1 revealed that the facility admitted the resident on 5/06/22 and the resident had diagnoses of atrial fibrillation, congestive heart failure, chronic peripheral venous insufficiency. Record review of the Quarterly Minimum Data Set (MDS) with ARD 6/13/24 for Resident #1 revealed she had a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Record review of the Face Sheet for Resident #2 revealed the facility admitted the resident on 10/27/21 and the resident had diagnoses of end stage renal disease, hypertension and osteoarthritis. Record review of the Quarterly MDS with ARD 6/06/24 for Resident #2 revealed she had a BIMS score of 15, which indicated no cognitive impairment.

Based on interviews, record reviews, and facility policy review, the facility failed to ensure consent was received from residents prior to changing private insurance plans to another insurance company for one (1) of nine (9) sampled residents. Resident #3 Findings included: Record review of the facility provided titled Resident Rights, reviewed 12/23, revealed, Every resident in this facility has the right to: . Manage their personal affairs . On 7/30/24 at 9:35 AM, in an interview with a family member of Resident #3, he said that Resident #3 was admitted by the facility on 11/16/23 for a short term stay to receive therapy services following a fall with fracture which occurred at her home. He stated that the resident was her own Responsible Party (RP) and made her own decisions. He explained that the resident was enrolled in managed care insurance at the time of admission which allowed twenty (20) days of therapy, of which, the resident and family were aware. He stated that the resident decided to transfer to a personal care facility and discharged from the facility on 12/09/23. The family member stated that after the resident's discharge from the facility, the resident had been notified by mail of her disenrollment from managed care. The family member said that the resident was without managed care coverage for two (2) months following discharge from the facility. He acknowledged that the resident did not experience injury or illness during the two months and did not suffer loss due to the disenrollment, however, it could have been detrimental to the resident's finances should she have suffered a major illness. Record review of the Notice of Medicare Non-Coverage dated 12/06/23 and signed by Resident revealed the resident was notified that The effective date coverage of your current skilled nursing facility services will end: 12/08/24. The document contained the resident's right to appeal against this decision and instructions on how to ask for an immediate appeal. On 7/31/24 at 4:00 PM, in an interview with the Business Office Manager (BOM), she confirmed that she had used on-line access to Resident #3's managed care and entered information for disenrollment. She confirmed that she had no evidence or signed permission for agreement by the resident for disenrollment from her managed care insurance. She confirmed that she was not aware of any appeal requested for Resident #3 as described in the Notice of Medicare Non-Coverage. The BOM confirmed that Resident #3 was alert and oriented and was her own Responsible Party. On 7/31/24 at 5:00 PM, during an interview with the Administrator he confirmed that the BOM had processed disenrollment for Resident #3 from her managed care insurance. He also confirmed that the facility had no written authorization by Resident #3 for disenrollment from her managed care insurance. On 8/02/24 at 12:45 PM Resident #3 returned telephone call to SA and stated that she had not authorized disenrollment form her managed care insurance plan. She stated that she was made aware of her disenrollment through a letter mailed to her home address following her discharge from the facility. Record review of the Face Sheet for Resident #3 revealed the facility admitted the resident on 11/16/24 and the resident had diagnoses that included Wedge Compression Fracture of Fourth Lumbar Vertebra, Atrial Fibrillation, Macular Degeneration and Hearing Loss. Record review of the Admission Minimum Data Set (MDS), with Assessment Referral Date (ARD) 11/22/23 for Resident #3, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment.

Based on observations, interviews, and facility policy review, the facility failed to ensure that two (2) of nine (9) sampled residents had the opportunity to exercise their autonomy regarding preferences related to choice of bathing schedules and clothing. Residents #1 and #2 Findings included: Record review of the facility's policy titled Resident's Rights Policy, reviewed 12/23, revealed Every resident in this facility has the right to: .Retire and rise in accordance with reasonable requests . On 7/30/24 at 9:50 AM, during an observation and interview with Resident #2, the resident stated that she did not have any washcloths to use on the morning of 7/30/24. She said the CNAs told her there were no clean washcloths. She said that prevented her from being able to wash up and get into her wheelchair at her preferred time. Observation revealed there were no washcloths in the room or attached bathroom of Resident #2. On 7/30/24 at 10:00 AM observation revealed there were no clean washcloths or bath towels in the linen closets on the first or second floor and there were no clean washcloths or bath towels on the four (4) clean linen carts on the hall. On 7/30/23 at 10:08 AM, during an observation and an interview with Resident #1, she complained she had just received AM care and assistance to transfer into her wheelchair because she had to wait for clean linens to be delivered from the laundry. She stated she preferred to get up earlier and the reason she was told she was not able to get up at the time of her choosing was because there were no clean washcloths or bath towels. She said she preferred to bathe and then get dressed before staff assisted her to get up in her wheelchair, as this was her usual routine. She confirmed that she had not been able to wear the clothes she preferred on 7/30/24 because the clothes she preferred had not been returned from the laundry. She said that there were dresses she preferred to wear but wanted a slip or undershirt to wear beneath them and that none of her slips or undershirts had been returned from the laundry. She confirmed that the clothes she preferred to wear had been sent to the laundry several days before. Observation revealed there were no washcloths or bath towels in the room or attached bathroom of Resident #1. On 7/30/24 during an interview at 10:20 AM, CNA #2 revealed that Resident #1 and Resident #2 had to wait past their preferred time to have AM care/bed bath and get up because there were no clean washcloths or bath towels available on the morning of 7/30/24. The CNA confirmed that Resident #1's personal clothes of choice were not in her room and had not been returned from the laundry. She explained that Resident #1 had multiple slips and undershirts but none in her room. On 7/30/24 during an interview at 10:23 AM, CNA #3 confirmed that Resident #1 and Resident #2 had to wait past their preferred time to have AM care/bed bath and get up because there were no clean washcloths or bath towels available on the morning of 7/30/24. She confirmed that she and CNA #2 had searched for a slip or undershirt for Resident #1 and were unable to find any for her to wear. On 7/30/24 at 2:00 PM an interview with the Housekeeping Supervisor revealed that the facility had adequate linens, and added, but we are behind today. She confirmed that the CNAs had to wait for linens to complete the laundering process to have clean linens on 7/30/34. She said she did not know why Resident #1 had not gotten her slips or undershirts back from the laundry in a timely manner. On 7/31/24 at 1:00 PM an interview with the Administrator revealed that he confirmed that it was the responsibility of the facility to ensure that all residents had clean linens available for their care in accordance with their preferred routine for rising, showering/bathing, dressing and other activities of daily living. He confirmed that there were residents that did not have access to clean linens on the morning of 7/30/24 which interfered with the residents' right to autonomy and choice of schedule for bathing and getting out of bed. The Administrator stated that he was unaware that Resident #1 had personal clothing items which had not been returned to her and that the items would have to be located and returned to her or replaced by the facility to ensure she could dress according to her preference. Record review of the Face Sheet for Resident #1 revealed that the facility admitted the resident on 5/06/22 and the resident had diagnoses of atrial fibrillation, congestive heart failure, chronic peripheral venous insufficiency. Record review of the Quarterly Minimum Data Set (MDS) with ARD 6/13/24 for Resident #1 revealed she had a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Record review of the Face Sheet for Resident #2 revealed the facility admitted the resident on 10/27/21 and the resident had diagnoses of end stage renal disease, hypertension and osteoarthritis. Record review of the Quarterly MDS with ARD 6/06/24 for Resident #2 revealed she had a BIMS score of 15, which indicated no cognitive impairment.

Based on observation, interview, record review, and Nursing Proceudre review, the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services for one (1) of five (5) residents reviewed for incontinent care. Resident #2. Findings Include: Record review of the facility document titled Perineal Care, with Revision Date 10/18, revealed, PURPOSE To cleanse the perineum, To eliminate odor, To prevent irritation or infection, To enhance the resident's dignity and self-esteem . Record review of the RESIDENT COUNCIL meeting notes dated 6/12/23 revealed, NEW BUSINESS (Grievances & Recommendations) Nursing: Residents stated that .appropriate care is not being provided by the Certified Nurse Assistants (CNAs) when the residents ask. On 6/22/23 at 3:00 PM, an interview with CNA #3 revealed the facility had provided monthly in-service training to CNAs that included instructions that CNAs were to make rounds every two (2) hours to assess needs and provide care for incontinent residents. On 6/22/23 at 3:10 PM, an interview with CNA #4, also revealed the facility had provided monthly in-service training to CNAs that included instructions that rounds were to be conducted every two (2) hours to assess and provide care for incontinent residents. On 6/23/23 at 11:20 AM, observation and interview with Resident #2 revealed the resident had thrown her bed covers off to the left against the wall and there was a dried tea-colored ring on her fitted sheet beneath the incontinence pad that the resident was lying on. The incontinence pad was colored yellow around the resident. The resident's incontinence brief was obviously wet. There was a strong smell of urine in the room which was strongest at the bedside of Resident #2. Record review of the Completed Care Details for Resident #2 dated 6/21/22 through 6/23/23 revealed there were no entries which documented toilet use for the 7:00 AM-3:00 PM shift on 6/23/23. The report also documented that Resident #2 required Extensive Assistance to Total Dependence for Toilet Use. On 6/23/23 at 11:25 AM, during an interview and observation with the Administrator at the bedside of Resident #2, the Administrator described the resident's fitted sheet as stained brown and said the resident smells loud. She also commented that it appeared to her that the resident hadn't been changed since sometime last night. The Administrator confirmed that incontinent residents required assessment and assistance every two (2) hours and that the facility had provided in-service training routinely to CNAs to ensure that they were aware of expectations and requirements for care. On 6/23/23 at 11:28 AM, during an interview and observation with the Director of Nurses (DON) at the bedside of Resident #2, the DON confirmed that the resident's incontinence brief was saturated and that the incontinence pad and fitted sheet showed signs of dried urine. She acknowledged that it would have taken an extended amount of time for the sheet, pad, and brief to have reached the condition noted. The DON confirmed that residents with incontinence required assessment and assistance every two (2) hours. On 6/23/23 at 11:30 AM, during an interview with CNA #1 at the bedside of Resident #2, the CNA confirmed that she had not provided incontinence care for Resident #2 on 6/23/23. Record review of the Face Sheet for Resident #2 revealed the resident was admitted by the facility on 10/21/20 and had diagnoses that included Heart Failure, Type 2 Diabetes, and Dementia. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/21/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated significant cognitive impairment. Further MDS review revealed Resident #2 required Extensive two-person physical assistance for bed mobility, dressing, toilet use and limited one person assistance for personal hygiene and was frequently incontinent of bowel and bladder.

Based on observation, interview, record review, and facility policy review, the facility failed to post cautionary and safety signs indicating the use of oxygen for three (3) of nine (9) residents reviewed for oxygen usage. Residents #21, #181, and #185 Findings include: A review of the facility's policy titled, Oxygen-Administration, Concentrator, Storage, Assemblage, with a revision date of 10/17 revealed, . ADMINISTRATION PROCEDURE . 13. Post the NO SMOKING-OXYGEN IN USE sign on the door of the resident's room . Resident #21 On 3/27/23 at 2:38 PM, Resident #21 was observed lying in bed. An oxygen concentrator was noted at the bedside and oxygen was flowing at two (2) liters per minute. There was no cautionary signage posted at the entrance to the resident's room that indicated oxygen was in use. A record review of the Physician Orders for March 2023 for Resident #21, revealed an order, dated 3/13/23 for, O2 (oxygen) @ (at) 2 L/M (2 liters per minute) via nasal canula. On 3/27/23 at 2:38 PM, an observation of the door of Resident #21, who had orders for oxygen, revealed there was no sign on the door indicating that oxygen was in use. A record review of the Face Sheet for Resident # 21 revealed, the facility admitted the resident on 2/23/23, with diagnoses that included Shortness of Breath and Emphysema. Resident #181 On 3/27/21 at 2:21 PM, Resident #181 was observed sitting in her wheelchair, with her spouse at her side. There was an oxygen concentrator noted at the bedside, however, there was no cautionary signage posted at the entrance to the resident's room that indicated oxygen was in use. A record review of the Physician Orders for March 2023 for Resident #181, revealed an order, dated 3/23/23 for, O2 (oxygen) @ (at) 2 L (2 liters) NC (nasal canula) Continuously. On 3/27/23 at 2:21 PM, observation of the door of Resident # 181, who had orders for oxygen, revealed there was no sign on the door or that indicated that oxygen was used. A record review of the Face Sheet for Resident # 181 revealed, the facility admitted the resident on 3/23/23, with diagnoses that included Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia. Resident #185 On 3/27/223 at 2:20 PM, an observation of Resident #185 revealed the resident was receiving oxygen at 2 liters per nasal canula. There was no cautionary signage posted at the entrance to the resident's room that indicated oxygen was in use. A record review of the Physician Orders for March 2023 for Resident #185 revealed an order dated 3/6/23 for, O2 (oxygen) @ 2 L liters) via NC (nasal canula) Continuous. On 3/27/23, at 2:20 PM, an observation of the door of Resident # 185, who had orders for oxygen revealed, there was no sign on the door stating that oxygen was in use. On 3/27/23 at 3:20 PM, during an observation and interview with the Director of Nursing (DON), she confirmed there was no sign on the door that oxygen was in use. The DON confirmed there should have been a sign to inform staff and visitors that oxygen was in use, to ensure resident and staff safety, as oxygen can be dangerous. A record review of the Face Sheet of Resident # 185 revealed, the facility admitted the resident 3/6/23, with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, and Dependence on Supplemental Oxygen.

Based on a test tray meal observation, interviews, and facility policy review, the facility failed to provide food that is palatable with an appetizing temperature for seven (7) of seven (7) residents reviewed for meal satisfaction. Residents #1, #11, #18, #20, #27, #31 and #50. Findings include: Review of the facility policy titled, Resident Tray Service and Delivery, revealed, Procedure: . 2. B. Hot foods are held at or over 135' F . g. The temperature of foods is taken with a calibrated thermometer and documented on the Temperature Monitoring Log . 3. A food service employee tastes food items, including modified foods, to confirm acceptability quality . An observation on 3/27/23 at 11:33 AM, revealed Resident #50's lunch meal was late. When dietary was notified that the resident didn't receive a tray, they delivered a late lunch tray of country fried steak with French fries. The resident refused to eat the food, as the meat was fried hard, and the French fries were cold. The daughter was in the room and asked for something else. Dietary bought a tray with hamburger steak and mashed potatoes. During an interview on 3/27/23 at 11:40 AM, with the Resident #1's daughter, revealed the resident's food is always cold and does not taste good. The resident's daughter stated she brings sandwiches and bananas for the resident to eat because the food is so horrible. The daughter revealed that she has scheduled a meeting with the Care Plan Team and the Dietary Manager and if things do not improve after that, she is going to move her mother to another facility. During an interview on 3/27/23 at 2:00 PM, with the six (6) Resident Council members present at the meeting, the members complained the food was cold and had no taste (Residents #1, #11, #18, #20, #27, and #31). The Council members revealed the Social Worker and the Activity Director attended their meetings and are aware of their complaints. The members also revealed they had tried to talk to the Administrator but had been told she was too busy. During an observation on 3/28/23 at 11:00 AM, the Cook was observed calibrating the thermometer, used for checking the temperature of the food to 40 degrees. The Cook revealed she thought that's what it should have been calibrated to prior to use. The thermometer was re-calibrated to the correct temperature and the temperature of all the food on the line was at or above the holding temperature. The Dietary staff started preparing the plates at 11:32 AM. The requested test tray left the kitchen area on an open food cart at 12:05 PM. The test tray was received at 12:15 PM On 3/28/23 at 12:15 PM, during an observation and interview, the Dietary Manager (DM) checked the food temperatures of the food on the test tray using the same calibrated thermometer and they were: turnip greens 80 degrees Fahrenheit (F), pinto beans 80 degrees F, and fried chicken 100 degrees F. The food was tasted with the Dietary Manager and was cold and bland. The DM confirmed the food was not warm or seasoned enough to be palatable. The DM said, the facility has to get better. The manager revealed she knew the residents were complaining about the food; however, she had only been the manager for three (3) weeks and had not had enough time to address the complaints. During an interview on 3/28/23 at 4:00 PM, with the Activity Director and Social Worker, they confirmed the residents complained the food tasted bad and was cold during the resident council meetings. The Activity Director revealed complaints are forwarded to the department director of which the complaints are about. he Activity Director and Social Worker confirmed they would follow-up with the Administrator regarding the resident complaints and the recent finding regarding the food being served. Resident #1 Record review of the Face Sheet for Resident #1, revealed the facility admitted the resident on 2/22/2022, with the diagnoses that included Heart Failure, Diabetes, and Hypertension. Record review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD)of 2/22/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Resident #11 Record review of the Face Sheet for Resident #11, revealed the facility admitted the resident on 5/6/2022, with the diagnoses that included Atrial Fibrillation, Kidney Disease, and Hypertension. Record review of the quarterly MDS, with an ARD of 1/10/23, revealed Resident #11 had BIMS score of 15, that indicated Resident #11 was cognitively intact. Resident #18 Record review of the Face Sheet, for Resident #18, revealed the facility admitted the resident on 2/23/2023, with the diagnoses that included Osteoarthritis, Diabetes Mellitus, and Hypertension. Record review of the quarterly MDS with an ARD of 2/22/23, revealed Resident #18 had a BIMS score of 15, that indicated Resident #18 was cognitively intact. Resident #20 Record review of the Face Sheet for Resident #20, revealed the facility admitted the resident on 10/22/2021, with the diagnoses that included Heart Failure, Anxiety, and Hypertension. Record review of the quarterly MDS with an ARD of 1/27/23, revealed Resident #20 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident #27 Record review of the Face Sheet, for Resident #27, revealed the facility admitted the resident on 10/3/13, with diagnoses that included Parkinson's Disease, Diabetes, and Hypertension. Record review of the quarterly MDS, with an ARD of 3/1/23, revealed Resident #27 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident #31 Record review of the Face Sheet, for Resident #31, revealed the facility admitted the resident on 2/22/2022, with diagnoses that included Renal Disease, Diabetes, and Hypertension. Record review of the quarterly MDS, with an ARD of 2/3/23 revealed Resident #31 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident #50 Record review of the Face Sheet, for Resident #50, revealed the facility admitted the resident on 10/31/2022, with the diagnoses that included Cerebrovascular Disease, Hypothyroidism, and Hypertension. Record review of the quarterly MDS, with an ARD of 2/6/23, revealed Resident #50 had a BIMS score of 12, which indicated the resident was cognitively intact.

Based on observation, interviews, and facility policy review, the facility failed to provide care in a manner that treated residents with dignity and respect by not providing meals at the same time to all residents who needed assistance and were seated at the same table for one (1) of two (2) residents that required assistance with eating. Resident #67 Findings include: A review of the facility's policy titled, Resident Rights, with a revision date of 11/17, revealed . All residents in a long term care facility have rights guaranteed to them . Residents at this facility will be guaranteed a dignified existence . These rights include: 30. To be treated with dignity and respect . On 3/27/23 at 11:55 AM, during an observation of residents eating lunch in the dining room, Resident #67 was observed sitting in a Geri chair at a table for residents that required assistance with eating. Resident #67 was observed watching Licensed Practical Nurse (LPN) #1 feed an unsampled resident. On 3/27/23 at 11:59 AM, in an interview with LPN #1, she revealed that she had asked another staff member to assist with feeding Resident #67. On 03/27/23 at 12:08 PM, during an observation and interview with Resident #67, she continued to watch the unsampled resident at the same table being fed by LPN #1. Resident #67 stated I'm hungry, and looked down at her plate. LPN #1 responded to Resident #67 and stated someone was coming to feed her. On 03/27/23 at 12:10 PM, Registered Nurse (RN) #1 was observed entering the dining room and began feeding Resident #67. At this time, it was noted that the unsampled resident sitting at the same table had consumed approximately 75% of her meal. On 03/29/23 at 10:08 AM, in an interview with the Director of Nursing (DON), she confirmed all residents at a table that need to be fed should be fed at the same time. She stated LPN #1 should have fed both residents and not fed one resident while another is only able to watch. On 03/29/23 11:12 AM, in an interview with RN #1/Charge Nurse, she revealed the residents are usually fed at the same time. She confirmed LPN #1 should not have allowed a resident to sit and watch another resident be fed while her plate sat in front of her. RN #1 confirmed that LPN #1 should have sat in the center of the table and fed both residents at the same time. A record review of the Face Sheet for Resident # 67 revealed, the facility admitted the resident to the facility on [DATE], with diagnoses that included Alzheimer's Disease, Muscle Weakness, and Unspecified Lack of Coordination. A record review of the Physician Orders for March 2023 revealed an order, dated 3/3/2 for, Mechanical soft diet finger foods and assistance for initiation and cues during meals. A record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/6/23 for Resident #67 revealed a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severe cognitive impairment and required one-person physical assistance with eating.

Based on interviews, record reviews, and facility policy review, the facility failed to obtain a Physician's Order and to document that wound care was provided for one (1) of two (2) residents reviewed for pressure ulcers. Resident #1 Findings Included: Record review of the facility's policy Admission, revised 10/17, Follow-Through 1. The licensed nurse will notify the physician (or medical provider) of pertinent assessment findings and if needed clarify orders/medications . Record review of the facility's policy, Dressing Change Policy and Procedure, with a revision date of 08/21, revealed, .Steps in the Procedure .2. Review topical treatment order . Record review of Resident #1's Wound Assessment Report with the Date of Assessment listed as 2/18/22 and the Assessment Occasion listed as Admission revealed a Stage 2 Pressure Ulcer to the sacrum. The Date wound identified was 2/18/22. The Treatments was indicated as Pending treatment orders and the Date electronically signed was on 02/18/2022 by Registered Nurse (RN) #1. Record review of Resident #1's Physician Orders for the month of February 2022, revealed a Physician Order dated 3/04/22 to Cleanse stage 2 pressure injury to sacrum with NS (Normal Saline), pat dry, apply hydrogel impregnated gauze and cover with bordered dressing. The interval code was MTH to indicate treatments on Monday and Thursday. The Physician's Order for wound care treatment was not received until 14 days after Resident #1 was admitted to the facility. Record review of the electronic Treatment Administration Record (eTAR) for the month of February 2022 revealed there was no documentation that Resident #1 received wound care for the pressure ulcer to the sacrum that had been identified upon admission on 2/18/22. Record review of the eTAR for March 2022 revealed there was no documentation that Resident #1 received wound care for the pressure ulcer to the sacrum that had been identified upon admission on 2/18/22 until 3/7/22. A record review of the Nurse's Notes for Resident #1 revealed there was no wound treatment documentation or physician orders for the Stage 2 pressure wound to the sacrum until 3/4/22. In an interview with the Director of Nursing (DON) on 7/29/22 at 11:00 AM, she confirmed there was no wound care orders received from the physician when Resident #1 was admitted to the facility and the treatment nurse should not do wound care without an order. In an interview with Registered Nurse (RN) #1 on 7/29/22 at 12:06 PM, she confirmed that she is the Treatment Nurse for the facility. She stated that she should have gotten a wound care order from the physician when Resident #1 was admitted on [DATE] with the sacrum pressure ulcer. She explained that although she was treating the pressure wound to the sacrum from 2/18/22 through 3/4/22, she did not have a Physician's Order and she was not documenting it on the eTAR. During an interview with the Administrator on 7/29/22 at 12:33 PM, she confirmed that there was not a wound care order for Resident #1 for the pressure ulcer to his sacrum. She also confirmed that if the nurse had completed wound care, she should have documented it on the eTAR. Record review of Resident #1's Face Sheet revealed the facility admitted him on 2/18/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interviews, record reviews, and facility policy review, the facility failed to provide shower/bath assistance as scheduled to one (1) of three (3) residents reviewed who were dependent on staff for Activities of Daily Living (ADL) Care. Resident #7 A review of the facility's policy titled Bathing, with a revision date of 10/17, revealed the purpose is to ensure resident comfort and dignity, to cleanse the body and promote skin health, and to observe for skin abnormalities (e.g., breakdown, redness, bruising) . On 7/27/22 at 3:35 PM, an observation of Resident #7 (Res #7) revealed the resident lying in bed wearing an off white, blue flowered print, short sleeve shirt. Resident's hair appeared unwashed and oily. On 7/28/22 at 4:04 PM, an observation and interview with Res #7 confirmed the shirt she was wearing (an off white, blue flowered print, short sleeve shirt) was the same shirt she had on the day before. Res #7 stated she had been wearing the shirt for a week because she had not had a bath in a week. The resident further stated her hair had not been washed in a month. Res #7 denied ever refusing to take a bath or receive care. A record review of the facility's Bath Schedule revealed Res #7's bath days were Mondays, Wednesdays, and Fridays. A record review of Completed Care Details for Res #7 revealed between the dates of 06/29/22 through 7/28/22 the resident received a complete bed bath on 7/18/22. There were no other dates for a complete bed bath or whirlpool bath, in the last 30 days. On 7/29/22 at 11:00 AM, an interview with the Director of Nursing (DON) confirmed that it is very important for a resident to get their bath. She stated the nurses should be verifying that the Certified Nurse Aides (CNA)s are completing resident baths as scheduled. The DON stated that if a resident refused a bath, it should be reported to the nurse. The DON stated having hair washed should be included in the resident's bath unless the resident or family requests otherwise. The CNAs should let the nurses know if the resident is combative, refuses care, or anything else and that information should be documented. A record review of the Nurses notes for Res #7 revealed no entries of Res #7 being combative or refusing care. On 7/29/22 at 12:33 PM, an interview with the Administrator revealed residents have their hair washed when they get their baths. She stated that all activities of daily living are documented in the computer. A record review of Resident #7 Face sheet revealed that the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/31/22, revealed Res #7 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident had no cognitive dysfunction and a review of Section G revealed she required the one person to physically assist with bathing.

Based on staff interview, record review and facility policy review, the facility failed to maintain an accurate medical record regarding wound care treatment for one (1) of two (2) residents reviewed for wounds. Resident #1 Findings Include: Record review of the facility's policy, Medical Records, with a revision date of 04/17, revealed, Policies and Procedures This facility maintains a separate resident record on each resident .that are complete, accurate . Record review of Resident #1's Wound Assessment Report with the Date of Assessment listed as 2/18/22 and the Assessment Occasion listed as Admission revealed a Stage 2 Pressure Ulcer to the sacrum. The Date wound identified was 2/18/22. The Treatments was indicated as Pending treatment orders and the Date electronically signed was on 02/18/2022 by Registered Nurse (RN) #1. Record review of the electronic Treatment Administration Record (eTAR) for the month of February 2022 revealed there was no documentation that Resident #1 received wound care for the pressure ulcer to the sacrum that had been identified upon admission on 2/18/22. Record review of the eTAR for March 2022 revealed there was no documentation that Resident #1 received wound care for the pressure ulcer to the sacrum that had been identified upon admission on 2/18/22 until 3/7/22. A record review of the Nurse's Notes revealed there was no documentation for Resident #1 that indicated wound care was provided. On 7/29/22 at 12:06 PM, in an interview with RN #1, she confirmed that the resident was admitted to the facility on [DATE] with a stage 2 pressure ulcer to his sacrum. She stated she treated the pressure wound without a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/29/22 at 12:33 PM, in an interview with the Administrator, she confirmed that if the nurse was treating the pressure ulcer, she should have documented on the eTAR.

Based on interviews, record reviews, and facility policy review, the facility failed to notify a physician to obtain an order to provide a treatment to a resident admitted with a pressure ulcer for one (1) of two (2) residents reviewed for pressure ulcers. Resident #1 Findings Include: Record review of the facility's Admission policy, revised 10/17 revealed, .Follow-Through 2. The licensed nurse will notify the physician (or medical provider) of pertinent assessment findings and if needed, clarify orders/medications . Record review of Resident #1's Face Sheet revealed the facility admitted him on 2/18/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Wound Assessment Report with the Date of Assessment listed as 2/18/22 and the Assessment Occasion listed as Admission revealed a Stage 2 Pressure Ulcer to the sacrum. The Date wound identified was 2/18/22. The Treatments was indicated as Pending treatment orders and the Date electronically signed was on 02/18/2022 by Registered Nurse (RN) #1. Record review of Resident #1's Physician Orders for the month of February 2022, revealed a Physician Order dated 3/04/22 to Cleanse stage 2 pressure injury to sacrum with NS (Normal Saline), pat dry, apply hydrogel impregnated gauze and cover with bordered dressing. The interval code was MTH to indicate treatments on Monday and Thursday. This was the first Physician's Order obtained for a treatment to Resident #1's pressure ulcer to the sacrum, which had been identified upon admission on 2/18/22. Resident #1 was at the facility for 14 days before a Physician's Order was obtained for a treatment to the sacrum. Record review of the electronic Treatment Administration Record (eTAR) for the month of February 2022 revealed there was no documentation that Resident #1 received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the eTAR for March 2022 revealed there was no documentation that Resident #1 received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #1's Nurses Notes revealed there was no documentation related to notifying the physician or obtaining a Physician's Order for a treatment to the Stage 2 pressure ulcer to the sacrum. On 7/29/22 at 11:00 AM, the State Agency (SA) conducted an interview with the Director of Nursing (DON). She confirmed that the wound care nurse should have gotten a Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that the treatment nurse should not do wound care without a physician's order. On 7/29/22 at 12:06 PM, the SA conducted an interview with RN #1, who is the Wound Care /Treatment Nurse. She confirmed that she should have gotten a Physician's Order on 2/18/22 for Resident #1 because he was admitted to the facility with a pressure ulcer to the sacrum. She confirmed that the eTAR did not have treatments documented for the sacrum wound until 3/7/22. She stated that although it is not documented on the eTAR, she treated the wound from 2/18/22 through 3/4/22 without a Physician Order until one was obtained on 3/4/22. On 7/29/22 at 12:33 PM, the SA conducted an interview with the Administrator. She confirmed that there was not a Physician Order to treat Resident #1's pressure ulcer to the sacrum when he was admitted on [DATE]. She stated that the nurse should not have treated a wound without a Physician Order and from what she gathered the nurse knew the wound was there but realized a little later that there was no Physician Order.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure the comprehensive care plan was revised for a resident admitted with a Stage 2 pressure ulcer for one (1) of seven (7) sampled residents. Resident #1. Findings include: Record review of the facility's policy, Care Plan Process, with a revision date of 08/17, revealed, . The Comprehensive care plan is an interdisciplinary communication tool . The care plan is driven not only by identified resident issues and /or conditions but also by a resident's unique characteristics, strengths, and needs .based on a thorough assessment . Record review of Resident #1's Face Sheet revealed the facility admitted him on 2/18/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Wound Assessment Report with the Date of Assessment indicated as 2/18/22 and the Assessment Occasion listed as Admission revealed a Stage 2 Pressure Ulcer to the sacrum. The Date wound identified was 2/18/22. The Treatments was indicated as Pending treatment orders and the Date electronically signed was on 2/18/22 by Registered Nurse (RN) #1. Record review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The interval code was MTH to indicate treatments on Monday and Thursday. The order was discontinued on 3/26/22 when Resident #1 discharged from the facility. Record review of Resident #1's Care Plan with the Problem Onset date of 2/18/22 and the Problem/Need of (Proper Name of Resident #1) is at risk for further skin breakdown r/t (related to) age, mobility impairment, incontinence of B/B (Bowel/Bladder); admitted with surgical wound and alterations in skin. The Stage 2 pressure ulcer to the sacrum identified on Resident #1's Admission Wound Assessment Report was not included in the Problem/Need section of the care plan. The Goal & Target Date revealed, Will promote wound healing through 5/18/22 and Will promote no further skin breakdown through 5/18/22. The Approaches of the care plan did not include the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed there were no other care plans for Resident #1 related to skin breakdown or wounds. On 7/27/22 at 4:30 PM, in an interview with Registered Nurse #1 (RN), she confirmed that she and other nurses use the care plan to give care to the residents. She stated that the care plan specified that Resident #1 is at risk for further skin break down but did not indicate that he had an actual pressure ulcer to the sacrum when he was admitted to the facility. She stated the care plan was incomplete. On 7/27/22 at 4:30 PM, in an interview with RN #2/Care plan nurse, she stated that the care plan is based on the resident's diagnosis. She confirmed that Resident #1's comprehensive care plan should have included the actual problems, goals, and approaches for the pressure wound. Nurses cannot give adequate care if they do not have an accurate care plan because the care plan is a guide for staff to complete the nursing process for the residents. On 7/29/22 at 11:00 AM, in an interview with the Director of Nursing (DON), she confirmed the comprehensive care plan was incomplete for Resident #1. She stated it should include the actual wounds that the resident had upon admission and that it should have been updated. She stated that the care plan is used as a guide to give care to a specific resident. Nurses and CNAs use the care plan, and they technically cannot give adequate care without an accurate care plan.

Based on staff interviews, record review, and facility policy review, the facility failed to accurately code an Admission Minimum Data Sheet (MDS) assessment for one (1) of seven (7) residents sampled. Resident #1 Findings Include: Record review of the facility's policy, MDS Process, with a revision date of 12/20, revealed, .The RAI (Resident Assessment Instrument) manual is the source document to be used for further MDS coding guidelines, time schedules and requirements . Record review of Resident #1's Admission MDS Assessment with an Assessment Reference Date (ARD) of 2/24/22 revealed, A1900: admitted [DATE] .M0210: Resident has 1+ unhealed PU (Pressure Ulcer/injuries 0. No . The MDS assessment indicated that Resident #1 did not have pressure ulcers/injuries when he was admitted to the facility. Record review of Resident #1's Wound Assessment Report with the Date of Assessment listed as 2/18/22 and the Assessment Occasion listed as Admission revealed a Stage 2 Pressure Ulcer to the sacrum. The Date wound identified was 2/18/22. The Date electronically signed was on 02/18/2022 by Registered Nurse (RN) #1. The Wound Assessment Report indicated that Resident #1 had a pressure ulcer when he was admitted to the facility. On 7/27/22 at 02:16 PM, in an interview with Registered Nurse (RN) #1, she stated Resident #1 was admitted to the facility with a pressure ulcer to the sacrum. On 7/27/22 at 04:30 PM, in an interview with RN #2/MDS nurse, she confirmed the Admission MDS assessment with an ARD of 2/24/22 for Resident #1 was coded incorrectly and that Section M should have reflected the stage 2 pressure ulcer to the sacrum. On 7/29/22 at 11:00 AM, in an interview with the Director of Nursing (DON). She stated the MDS dated [DATE] was coded incorrectly and according to the 2/18/22 Wound Assessment, the pressure ulcer should have been documented on the Admission MDS. She stated that the accuracy of the MDS is very important because it determines payment for the facility. Record review of Resident #1's Face Sheet revealed the facility admitted him on 2/18/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to assist residents with Activities of Daily Living (ADL), related to grooming/shaving, for two (2) of 25 residents observed, Resident #278, and Resident #29. Findings include: Review of the Quality of Care policy, revised 4/2019, revealed: Each resident shall receive optimal care to attain and/or maintain the highest possible mental and physical functional status as determined by the comprehensive assessment and person-centered plan of care. Bathing: At the time of the bath, all residents shall also receive, if applicable, a shave. Review of the Shaving Policy, with a revision date of 11/2017, revealed all male residents will be shaved daily. Residents on [MEDICATION NAME] or other anti-coagulation meds will be shaved with an electric razor/shaver. Resident #29: On 11/04/19 at 11:00 AM, an observation and interview, revealed Resident #29 had hair on her chin. Resident #29 stated she does not like hair on her chin and stated her husband used to shave the hair on her chin. Observation on 11/05/19 at 10:12 AM, revealed Resident # 29 with hair on her chin. She stated she was just given her bath early this morning, and no one shaved her chin. On 11/05/19 at 3:09 PM, an Interview with Director of Nursing (DON), regarding Resident #29's grooming, revealed someone should assist the resident with her facial hair; she will make sure it gets done today. Review of the Minimum Data Sheet (MDS), with an Assessment Reference Date of 9/6/19, revealed Resident #29 required assistance of two (2) persons for ADLs. The resident's Brief Interview for Mental Status (BIMS) score was 10, which indicated moderate cognitive impairment. Resident #278 Observation on 11/04/2019 at 11:00 AM, revealed Resident #278 sitting in the therapy room, unshaved. Observation on 11/05/19 at 10:39 AM, revealed Resident #278 sitting in his room in a wheelchair, unshaved. During an interview, on 11/05/19 at 10:40 AM, Resident #278 stated he preferred to be shaved. The Resident stated that he shaved every two (2)-three (3) days when he was at home. Resident #278 could not recall if staff asked him about shaving. Review of Resident #278's most recent Brief Interview for Mental Status (BIMS) score was 11, which indicated moderate cognitive impairment. On 11/06/19 at 10:47 AM, observation revealed Resident #278 sitting in therapy, in pajamas, unshaved. During an interview on 11/06/2019 around 11:00 AM, Licensed Practical Nurse (LPN) #1 revealed residents are assisted with ADLs on a daily basis. LPN #1 stated Resident #278 was admitted to the facility for Rehabilitation and had muscle weakness. On 11/06/19 at 11:20 AM, an interview with the Director of Nursing (DON) revealed the resident gets a shower every other day and staff should offer shaving at that time. On 11/06/19 at 2:00 PM, an interview with the DON revealed the facility had purchased an electric razor, so Resident #278 could be shaved, since he was on anti-coagulation medicine and could not be shaved with disposable razors. She stated the resident's family had shaved him in the past. and she was waiting on family to come in to shave him. She stated they will shave him today.

Based on observation, staff interview, record review and facility policy review, the facility failed to revise the care plan, related to a Dementia Diagnosis, for one (1) of 25 Comprehensive Care Plans reviewed, for Resident #16. Findings include: Review of the facility's policy, Care Plan Process, revised 8/2017, revealed following the decision to address a triggered condition on the care plan, key staff or the Interdisciplinary Team should subsequently review and revise the current care plan, as needed. Review of Resident #16's current Comprehensive Care Plan, through the next review date of 11/20/19, revealed a Dementia/Alzheimer's [DIAGNOSES REDACTED]. Review of a Psychiatric Evaluation Report, dated 4/14/19, revealed a [DIAGNOSES REDACTED]. Review of Resident #16's diagnoses, in the current (MONTH) 2019 Physician Orders, revealed a [DIAGNOSES REDACTED]. Review of Resident #16's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/12/19, revealed an active [DIAGNOSES REDACTED]. Review of Resident #16's MDS, with ARD date of 5/17/19, revealed a Care Area Assessment (CAA) Summary of Cognitive Loss/dementia, which triggered and directed staff to continue to care plan. In an interview on 11/07/19 at 9:15 AM, Registered Nurse (RN) #1/MDS Nurse, confirmed Resident #16 was diagnosed with [REDACTED]. RN #1 stated it was the responsibility of the Social Services staff, who was no longer working at the facility, to complete the cognitive section of the MDS, and to complete the care plan after the assessment. RN #1 stated she did not know why the care plan wasn't developed for Dementia at the time of the MDS, with an ARD of 5/17/19, but since the updates in October, the nurses would now be responsible, and the care plan for Dementia would be addressed. RN #1 stated, per facility policy, Resident #16 should have a care plan for Dementia, according to the CAA summary on the MDS, to proceed to care plan.

Based on observation, staff interview, record review, and facility policy review, the facility failed to perform an accurate Minimum Data Set (MDS) Assessments on two (2) of 25 MDS Assessments reviewed, Resident #73 for discharge location, and Resident #19 for an indwelling Foley Catheter. Findings include: Review of the facility's Resident Minimum Data Set (MDS) Assessment policy, revised 09/19, revealed an assessment will be completed on each resident utilizing the MDS. The reason for assessment, schedule, and timeframes will be according to the guidance of the Resident Assessment Instrument (RAI) Manual. The Registered Nurse is responsible for verifying the completion of the assessment. Any Healthcare professional that completes a portion of the assessment must sign and certify the accuracy of the portion of the assessment they have completed. Resident #19 Review of the MDS, with an Assessment Reference Date (ARD) of 8/12/19, revealed the section, which applied to an indwelling catheter, was not checked for Resident #19. On 11/05/19 at 9:51 AM, an observation of Resident #19 revealed the resident had a Foley Catheter. Review of Resident #19's physician's orders [REDACTED]. During an interview on 11/05/19 at 10:00 AM, Resident #19 revealed he's had a Foley Catheter since (MONTH) 2019. During an interview on 11/05/19 at 3:57 PM, Registered Nurse #1/MDS Nurse, revealed the MDS for Resident #19 was coded incorrectly; the resident has a Foley catheter. Resident #73 Review of the MDS, with an ARD of 9/24/2019, revealed the MDS coded the resident was discharged to the hospital. Review of the face sheet and discharge summary, dated 09/24/19, revealed Resident #73 was discharged home. Review of the physician orders, dated 09/17/19, revealed Resident #73 was discharged home with medications, home health physical therapy, and occupational therapy, on 9/24/19. On 11/06/19 at 2:00 PM, an interview with RN #1/MDS Coordinator, revealed Resident #73 was discharged home. RN #1 stated the MDS was coded incorrectly, that the resident was hospitalized ; the MDS should have been coded the resident was discharged home.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to allow residents to have personal property for one (1) of four (4) residents reviewed, Resident #50, as evidenced by staff removing a urinary drainage system from the resident's room and did not replace the urinary drainage system or adequately compensate the resident for the system. Findings include: Review of the facility's policy, Theft and Loss, dated (MONTH) 2013, revealed: It is the policy of this facility to assure each resident's right to retain and use personal possessions as space permits, unless those possessions infringe on the rights, health or safety of other residents. The Social Service Designee, Nurse Supervisor or Administrator will follow up on all reported losses and thefts and document such actions. Review of a written report, received by the State Agency (SA) on 3/1/19, revealed Resident #1 wanted to file a complaint, which involved the facility removing his urinary drainage system and throwing it away. The resident reported the system was bought by his brother for the resident's personal use and the facility should not have taken and destroyed the system. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/11/19, revealed Resident #50's Brief Interview for Mental Status (BIM) score to be 15, which indicated no cognitive impairment. During an interview on 11/04/19 at 10:40 AM, Resident #50 stated the facility gave him two (2) urinals after they took his urine drainage system out of his room. Resident #50 stated they took it out of his room during a state visit. Resident #50 stated that his brother ordered the urine drainage system on line, and could not produce a receipt. Resident #50 stated that he is very happy the facility gave him two (2) urinals to use. During an interview on 11/04/19 at 11:08 AM, the Director of Nursing (DON) stated Resident #50 did not want to get up during the night to use the restroom, and he had a system, literally a funnel draining into a catheter bag, that his brother had bought for him to use. The DON stated Resident #50 would pour his tea and cokes in the system, as well as his urine from a urinal, into the bag. The DON stated the system was not ordered by the physician and they removed the urine drainage system because it had stuff growing in it. The DON stated they replaced the system with multiple urinals. The DON stated Resident #50 told her his reason for needing the urine drainage device was because when he urinated, he filled one (1) urinal up too soon. The DON stated the resident added that when he was lying in bed using the urinal, urine would spill out because it was so full. The DON stated they gave him multiple urinals and he hasn't complained since. The DON stated the previous Administrator at the facility handled the issue with Resident #50, and she wasn't sure where it ended. Record review of a facility document titled petty [MEDICAL CONDITION] 8/21/19, revealed Resident #50 was given a google play gift card for $20.00. The receipt, offered by the facility, was labeled for Resident #50's activity, but not defined as repayment for the urinal drainage system. During an interview on 11/05/19 at 9:31 AM, Resident #50 stated he did receive a Google play gift card in August, but at the time he guessed he did not realize that was to pay him back for the urinary drainage system. Resident #50 stated when the facility showed him the document on 11/4/19, he remembered the Google card was probably for repayment, but he wasn't sure. Resident #50 stated he just wanted the issue closed and done with. Resident #50 stated the Director of Nursing (DON) told him he couldn't have another urinal drainage system, so he figured he wasn't going to get the system replaced, so he just took the card. During an interview on 11/05/19 at 9:55 AM, the DON revealed she actually thought that a gift card had been bought earlier than August. The DON stated they had bought Resident #50 several gift cards in the past. The DON stated after they gave him two (2) urinals, Resident #50 said he seemed happy and that was right after the urinal system was taken from his room. The DON stated that she could not say for certain that the gift card, dated 8/21/19, was in replacement for the urinal system, since it wasn't designated especially for that on the receipt. The DON stated the reason they didn't replace the urine system, was that Resident #50 and his brother said it was ordered from Amazon, and it didn't actually come from a medical supply. The DON stated the urine drainage system was an infection control issue, because Resident #50 would place ice, tea and soda in the urinal drainage system as well as urine. During an interview on 11/05/19 at 10:32 AM, the facility Administrator revealed she had reviewed the grievance log from (MONTH) (YEAR) forward, and there was no grievance or investigation on the urinal drainage system noted during that time. A review of the grievance log dated 12/1/17 through 11/5/19, revealed no grievance recorded on the behalf of Resident #50, nor his roommate, regarding the removal of personal property (urine drainage system) from his room. A review of facility departmental notes, dated 7/11/18, documented a CNA entered Resident #50's room to find ice chips in the urinary drainage system. No further facility departmental notes were furnished by the facility, regarding issues with the urinal drainage system. During an interview on 11/05/19 at 10:37 AM, the facility Ombudsman revealed she reported to the DON, when Resident #50 made the complaint about the urinary system was removed from his room. The Ombudsman stated the DON reported they needed a receipt in order to replace the urinary drainage system. The Ombudsman stated Resident #50 reported his brother could not find a receipt. The Ombudsman stated she reported the complaint to the State Agency, since the issue was not resolved, because at the time, Resident #50 wanted the system replaced. During an interview on 11/5/19 at 2:11 PM, the Administrator stated she found a picture of a similar urine drainage system with a value of $44.58, and showed it to Resident #50, who agreed the item was similar to the urine drainage system taken from his room earlier in the year. The Administrator stated Resident #50 wanted the money for the item instead of the facility replacing the item, so they deposited $44.58 in his facility account. A receipt dated 11/5/19, was provided for the $44.58 deposit. During an interview on 11/05/19 at 2:50 PM, the DON revealed they never intended to replace the urine drainage system, once it was removed from the room, because it was an infection control issue, as well as a fall hazard, related to spillage of urine on the floor.

Complaint investigation MS # Based on policy/procedure review, record review and staff interview; the facility failed to ensure that staff provided necessary services to attain or maintain resident highest level of well being for one (1) of seven (7) sampled and two (2) Unsampled residents, Resident #1, as evidenced by Resident #1 was found unresponsive and without a pulse and Licensed Practical Nurse (LPN) #1 and LPN #2 failed to perform Cardiopulmonary Resuscitation (CPR) on Resident #1 as ordered, requested and care planned. Resident #1 was a full code, with a full code physician's orders [REDACTED]. There was no initiation of CPR on [DATE] at approximately 7:39 AM, when the facility staff found Resident #1 unresponsive and without a pulse and Resident #1 expired at the facility. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was determined to exist when CPR was not initiated for Resident #1 with an Advance Directive for a full code status. Certified Occupational Therapy Assistant (COTA) #1 found the resident unresponsive on [DATE], at approximately 7:39 AM, and informed nursing staff. LPN #1 and LPN #2 went to Resident #1's room as COTA #1 went to retrieve the medical record of Resident #1. After reviewing the code status of Resident #1 in the medical record, LPN #1 and LPN #2 walked back to the nurse's station without initiating CPR. LPN #2 called the Resident's Medical Doctor (MD), Coroner, and Resident #1's Responsible Party (RP). Emergency Personnel were not notified. The Coroner arrived and pronounced the resident at approximately 8:05 AM on [DATE]. The facility's failure to ensure residents received CPR per their Advance Directive for full code status led to the death of Resident #1 and placed other residents in a situation that was likely to cause serious harm, injury, impairment, or death. Based on the facility's implementation of corrective actions as of [DATE]-[DATE], initiated prior to the State Agency (SA) facility entrance on [DATE], the SA determined the SQC and IJ to be Past Non-Compliance (PNC) and removed as of [DATE]. Findings Included: Review of the facility's Cardiac Resuscitation Policy, with a revision date of ,[DATE], revealed In the event of a cardiopulmonary arrest, basic CPR will be performed, unless, a Do Not Resuscitate (DNR) Order has been made by the resident's physician and the resident or resident's appropriate representative has made a valid written request in advance not to initiate basic CPR. In the event of any cardiopulmonary arrest, an ambulance will be summoned unless a DNR order is in effect. The facility's Advance Directives policy, with a revision date of ,[DATE], revealed it was the policy of the facility to encourage residents and their family/caregivers to participate in decisions regarding care and treatment. Valid Advance Directives and orders will be followed to the extent permitted and required by law. The facility will conform to state laws regarding implementation of an Advance Directive. Review of a written report, dated [DATE], revealed COTA #1 found Resident #1 unresponsive on [DATE],at approximately 7:39 AM. She then informed LPN #1 and LPN #2. LPN #1 and LPN#2 went to Resident #1's room as COTA #1 went to retrieve the medical record. After reviewing the code status of Resident #1 in the hallway, LPN #1 and LPN #2 went back to the nurse's station without initiating CPR. Neither LPN called a Code Blue for CPR. Review of a Resident Rights, Advance Directives, Resident/Family consent for CPR, dated [DATE] and [DATE], revealed Resident #1's RP signed a consent for the Advance Directive and indicated a full code directive. Review of Resident #1's physician's orders [REDACTED].>Interview on [DATE] at 11:45 AM, with Certified Occupational Therapist Assistant (COTA) #1, revealed she went to Resident #1's room between 7:,[DATE]:40 AM ([DATE]). She noted Resident #1 was in bed, pale in color, with Oxygen on, eyes closed, and in a supine position. Resident #1 did not respond to her name or being touched on her leg. She then noticed there was no chest movement. She ran out of the room to get assistance. She saw LPN #1 and a Certified nurses aide (CNA) and told them she needed them in Resident #1's room and that she didn't think the resident was breathing. She recalled hearing LPN #1 say I think she is a full code, would you grab her chart?. COTA #1 stated that she ran to the nurse's station and retrieved the medical record. When returning to Resident #1's room, she encountered LPN #1 and handed her the chart. I don't think she flipped through it. She looked up at me and said It's too late. She stated she only dealt with LPN #1. She then left the hall. She stated she has never been required to get a CPR certificate. There were two (2) phone attempts by the SA to contact LPN #1 and LPN #2 on [DATE], with no success. Written and signed statements, on the same day of the event, [DATE], by both LPNS were obtained from the facility's investigation. Review of a written and signed statement, dated [DATE], by LPN #1, revealed she spoke to Resident #1 during rounds at 6:56 AM, and Resident #1 waved at nurse with her right hand. She wrote that later a therapist came to the nurse's desk and said the resident wasn't looking well. Nurses went to resident room and noted resident unresponsive. Resident was full code and no CPR was performed. Per review of the facility's investigation, LPN #1 was interviewed by the Director of Nurses (DON) #1 on [DATE] at approximately 9:15 AM, and revealed she did know that Resident #1 was a full code and did not know why she did not begin CPR. LPN #1 was suspended at that time. Review of a written and signed statement, dated [DATE], by LPN #2, revealed that she and LPN #1 went to Resident #1's room after a therapist stated I need y'all to come see about (name of Resident #1). She stated Resident #1 had expired when they entered the room. LPN #2 called the coroner and the residents responsible party and helped with postmortem care. Per review of the facility's investigation, LPN #2 was interviewed by the DON #1 on [DATE] at approximately 10:15 AM, and revealed she went into the resident's room, realized she had expired then went to the nurses station and notified the Medical Doctor, RP and the Coroner. When asked why she didn't initiate CPR on Resident #1 she stated I don't know, but I realize now that I should have. LPN #2 was suspended at that time. Interview on [DATE] at 10:20 AM, with the DON #1, revealed When I questioned both LPN's and asked why they did not initiate CPR, both said, I don't know. No, they did not call an ambulance. Yes, Resident #1 was a full code and CPR should have been started and code blue called. Interview on [DATE] at 2:00 PM, with the Medical Director/Resident #1's Primary Medical Doctor, revealed he was notified when Resident #1 expired and was told the nurses did not do CPR. Yes, I did participate in the Quality Assurance meeting and knew the plan going forward to correct this. Record review revealed Resident #1 was admitted to the facility on [DATE], and then again on [DATE], with [DIAGNOSES REDACTED]. Review of the 5 day Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) of 15, indicating Resident #1 was cognitive and able to make her own decisions for activities of daily living. The facility implemented the following Corrective Action Plan, prior to the State Agency (SA) entrance on [DATE]: 1. On [DATE], while making rounds at 6:56 AM, Licensed Practical Nurse (LPN) #1 entered the room of Resident #1 and spoke to Resident #1. Resident #1 waved back with her right hand to LPN #1. On [DATE], at approximately 7:39 AM, LPN #1 on duty was informed by Certified Occupational Therapy Assistant (COTA) #1 that Resident #1 was non-responsive when she attempted to call Resident #1 by her name. It was at this time LPN #1 and LPN #2 went to the room to check on Resident #1. COTA #1 retrieved Resident #1's medical record. LPN #1 and LPN #2 exited Resident #1's room and reviewed Resident #1's medical record in the hallway. LPN #1 and LPN #2 walked back to the nurse's station without initiating CPR. Resident #1's medical record indicated she was a full code status. On [DATE], at approximately 8:15 AM, the facility Administrator #1 was notified of the failure to initiate CPR on Resident #1 and at approximately 8:30 AM, the facility Director of Nursing #1 was notified of the failure to initiate CPR on Resident #1, which was a full code status. 2. On [DATE], at approximately 9:15 AM, the facility Director of Nursing #1 and Staff Development Nurse #1 interviewed LPN #1. The interview conducted indicated LPN #1 was aware of the full code status and failed to initiate CPR. On [DATE], at approximately 10:25 AM, the facility Director of Nursing #1 and the facility Administrator #1 interviewed LPN #2. The interview conducted indicated LPN #2 was aware of Resident #1's full code status and failed to initiate CPR. On [DATE], at approximately 9:00 AM, the facility Director of Nursing #1 and the facility Administrator #1 interviewed the COTA #1. The interview conducted indicated the COTA #1 notified LPN #1 of the condition of Resident #1 and obtained the medical record of Resident #1 as requested of LPN #1. LPN #1 was suspended on [DATE] at 9:20 AM. LPN #2 was suspended on [DATE], at 10:20 AM. COTA #1 was not suspended because she was following her scope of practice. 3. On [DATE], the facility Administrator #1 and the facility Director of Nursing #1 terminated LPN #2 for failure to follow physician orders [REDACTED]. The facility Director of Nursing #1 attempted to contact LPN #1 on three (3) attempts via telephone to discuss the employment status to no avail. On [DATE], the facility Administrator #1 mailed a certified return receipt requested termination letter to LPN #1 as a result of the investigation. 4. On [DATE], at approximately 4:40 PM, facility Administrator #1 notified the Mississippi State Department of Health and the Mississippi State Attorney General's Office. On [DATE], at approximately 11:21 AM and 11:34 AM, the facility Director of Nursing #1 notified the Mississippi State Board of Nursing of the incident involving LPN #1 and LPN #2 respectively. 5. Facility Medical Director #1 was notified on [DATE], by the Regional Supervisor #1 of failure to initiate CPR on Resident #1, who was of full code status at the time of non-responsiveness. 6. A facility Quality Assurance Committee meeting was held on [DATE] at 11:30 AM, to include facility Quality Assurance Committee members which consisted of the facility Director of Nursing #1, the facility Administrator #1, Regional Supervisor #1, Quality Improvement Nurse #1, Medical Director #1, Infection Control/Prevention Officer #1, Social Services Director #1, and Maintenance Supervisor #1. Topics discussed included: (a) Failure to initiate cardiopulmonary resuscitation on a full code resident, (b) Failure to show proper documentation of completed cardiopulmonary certification, (c) Failure to follow the care plan for Advanced Directives/Full Code. The facility corrective actions were reviewed and initiated on [DATE], to include the following: in-service training, code drills, medical record audits, and monitoring systems ongoing. On [DATE], in-service training was initiated by Staff Development Nurse #1 and the facility Director of Nursing #1 to include all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, Dietary staff, Office personnel and contracted therapy department staff on the following: (a) Cardiopulmonary Resuscitation Policy, (b) Incident Investigation and Reporting, (c) Change in Resident Medical Status, (d) Emergency Care of Residents, (e) Care Plan Process, (f) Advance Directives, (g) Resident Rights, (h) Abuse/Neglect. The in-service conducted on [DATE] included five (5) Registered Nurses, nine (9) Licensed Practical Nurses, and two (2) Certified Nursing Assistants. Staff will not be allowed to work until the proper in-service training has been conducted. The facility does not currently use contracted agency staff employees for nursing direct care. In the event contracted agency staff is utilized for nursing direct care, no staff will be allowed to work until the proper in-service training has been conducted. 7. On [DATE], Cardiopulmonary Resuscitation (CPR) Code Drills were initiated by the facility Staff Development Nurse #1 and the facility Director of Nursing #1 for all Registered Nurses and Licensed Practical Nurses. Registered Nurses and Licensed Practical Nurses will not be allowed to provide direct patient care until participation in a code drill has been conducted. 8. On [DATE], all active resident's medical record charts were audited by the facility Medical Records Staff #1 and the facility Medical Records Staff #2 to ensure proper code status identification. The results of this audit showed no deficiencies. 9. On [DATE], all active residents plan of care were audited by the facility Assessment Nurse #1, the facility Assessment Nurse #2, and the facility Nurse Case Manager #1 to ensure proper code status identification. The [DATE], audit identified two (2) residents care plans which were noted to be out of compliance and were corrected as of [DATE]. 10. On [DATE], monitoring systems were put in place to sustain compliance (a) The facility began conducting CPR Code Drills on all three (3) shifts weekly for four (4) weeks, then all three (3) shifts monthly for three (3) months, and then all three (3) shifts quarterly thereafter by the Director of Nursing #1 and/or Staff Development Nurse #1. (b) All active resident medical records and plan of care will be monitored for the correct codes status identification weekly for one (1) month, then bi-weekly for three (3) months, and then monthly thereafter by Medical Records #1 and Medical Records #2. (c) The CPR certification status of each licensed nurse will be checked for each nurse upon hire and then monthly by Director of Nursing #1. 11. The facility Administrator #1 will report all results of the established monitoring to the Quality Assurance Committee meeting for an immediate corrective plan of action of any deficient practice. The facility corrective action plan was initiated on [DATE]. The facility believes the IJ was removed as of [DATE]. The State Agency (SA) validated the facility's corrective action plan on [DATE] and [DATE] and determined all actions to remove the IJ were complete as of [DATE] and the IJ to be removed as of [DATE]. 1. The SA verified the facility's investigation of Resident #1's incident on [DATE]. Resident #1 was found unresponsive, without a pulse and CPR was not performed per interviews, record review, written statements from staff and written reports to the SA. 2. The SA validated by interview with the DON #1 and review of documents that interviews with LPN #1 and LPN #2 were conducted and both stated they did not know why CPR was not done on Resident #1. Validation of written and signed statements by LPN #1 and LPN #2, suspension of LPN #1 and LPN #2 started on [DATE]. 3. The SA validated by record review and interview with the DON #1: termination of employment of LPN #1 by certified letter on [DATE], and termination of employment of LPN #2 on [DATE]. 4. The SA validated by record review and interview with the DON #1: notification of incident to the State Agency of Licensure and Certification and the Attorney General office of Medicare and Medicaid Fraud on [DATE], and the Mississippi State Board of Nursing on [DATE]. 5. The SA validated by interview with the Medical Director that he was notified of the failure to perform CPR on Resident #1 on [DATE]. 6. The SA validated by record review of the Quality Assurance sign-in sheet dated [DATE], and interview with the DON #1, Medical Director, Administrator #1 and Social Worker that the facility initiated a Quality Assessment and Assurance meeting on [DATE], with the Director Of Nurses, facility Administrator, Medical Director, Regional Supervisor, Quality Improvement Nurse, Infection Control/Prevention Officer, Social Service Director, and Maintenance Supervisor in attendance concerning the incident with Resident #1 with recommendations of In-services with no policy changes or updates needed. Validated that Care-Plan audits, resident medical record audits for proper code status identification, and CPR code drills to be conducted on all three (3) shifts. The SA validated by interview with the DON #1 that staff in-services began on [DATE]. Review of the in-service content, signature sheets and random interviews with nursing staff, therapy staff, social service, and housekeeping staff validated the facility in-serviced facility staff regarding the CPR policy, Incident investigation and reporting, change in resident medical status, emergency care of residents, care plan process, advance directives, resident rights, and abuse/neglect. Review of in-service records and facility staff rosters revealed 124 of 128 staff members had been in-serviced from [DATE]-[DATE]. The four (4) staff who had not been in-serviced had not worked since the incident occurred on [DATE]. Random staff interviews confirmed staff were not allowed to work until in-serviced. 7. The SA validated by record review and random nursing staff interview that CPR drills were initiated and conducted beginning [DATE]. Random nursing staff interviews confirmed staff were not allowed to work until participation in a CPR drill. 8. The SA validated through interview with the DON #1 and record review that on [DATE] all active resident medical records were audited to ensure proper code status identification and that this audit showed no deficiencies. 9. The SA validated through interview with the DON #1 and facility Quality Improvement Nurse #1 and record review that on [DATE] all active resident care plans were audited to ensure proper code status identification. That audit identified two (2) resident care plans out of compliance and were corrected. 10. The SA validated through interview with the DON #1 and record review that beginning [DATE], monitoring systems were put in place. The facility had documented and will do random CPR code drills on all three (3) shifts weekly for four (4) weeks, then monthly for three(3) months and then quarterly thereafter, and all active resident medical records and care plans will be reviewed for correct code status identification weekly for one (1) month, then bi-weekly for three (3) months and then every month there after, and the CPR certification status of each licensed nurse will be checked upon hire and then monthly. 11. The SA validated through interview with the Administrator #1 that he will report the results of all established monitoring to the QA committee for immediate corrective plan of action of any deficient practice. The SA identified the Immediate Jeopardy and Substandard Quality of Care as Past Non-Compliance beginning [DATE] through [DATE]. The facility provided sufficient evidence to show the facility corrected the non-compliance and was in substantial compliance with regulatory requirements as of [DATE], prior to the SA entering the facility on [DATE].

MS Complaint Investigation # Based on policy/procedure review, record review and staff interview; the facility failed to ensure an Advance Directive care plan was followed for a full code for Resident #1 when facility staff failed to provide Cardiopulmonary Resuscitation (CPR) for one (1) of seven (7) sampled and two (2) Unsampled residents as evidenced by Resident #1 was found unresponsive with no pulse on [DATE], and Licensed Practical Nurse (LPN) #1 and LPN #2 failed to perform CPR as per her Advance Directive Care Plan. Immediate Jeopardy (IJ) was determined to exist when CPR was not initiated for Resident #1 with an Advance Directive for a full code status. Certified Occupational Therapy Assistant (COTA) #1 found the resident unresponsive on [DATE], at approximately 7:39 AM, and informed Licensed Practical Nurse #1. LPN #1 and LPN #2 went to Resident #1's room as COTA #1 went to retrieve the medical record of Resident #1. As COTA #1 was returning to Resident #1's room, LPN #1 and LPN #2 met her in the hallway out side of the resident's room. After reviewing the code status of Resident #1 in the medical record, LPN #1 and LPN #2 walked back to the nurse's station without initiating CPR. LPN #2 called the Resident's Medical Doctor (MD), Coroner, and Resident #1's Responsible Party (RP). Emergency Personnel were not notified. The coroner arrived to the facility at approximately 8:05 AM on [DATE]. The facility's failure to ensure residents received CPR per their Advance Directive for full code status care plan led to the death of Resident #1 and placed other residents in a situation that was likely to cause serious harm, injury, impairment, or death. Based on the facility's implementation of corrective actions as of [DATE]-[DATE], initiated prior to the SA facility entrance on [DATE], the SA determined the IJ to be Past Non-Compliance and removed as of [DATE]. Findings Included: Review of the facility's policy for Care Plan Process with a revision date ,[DATE], revealed, The Care Plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility staff shall follow the care plan. Review of Resident #1's care plan revealed a care plan for a full code dated [DATE]. The care plan interventions noted the Nursing staff's role to Ensure that advanced directive is followed. Record review revealed a written report from the facility dated [DATE]. The report revealed COTA #1 found Resident #1 unresponsive at approximately 7:39 AM on [DATE]. She then informed LPN #1 and LPN #2. LPN #1 and LPN #2 went to Resident #1's room as COTA #1 went to retrieve the medical record of Resident #1. As COTA #1 returned to Resident #1's room, LPN #1 and LPN #2 met her in the hallway outside the resident's room. After reviewing the code status of Resident #1 in the medical record, LPN #1 and LPN #2 walked back to the nurse's station without initiating CPR. Neither LPN called a Code Blue. LPN #2 called the Resident's Medical Doctor (MD), Coroner and Resident #1's RP. The coroner arrived to the facility at approximately 8:05 AM. Review of a Resident Rights, Advance Directives, Resident/Family consent for Cardiopulmonary Resuscitation dated [DATE] and [DATE], revealed Resident #1's Responsible Party (RP) signed a consent for the Advance Directive and indicated a full code directive. Interview on [DATE] at 2:45 PM, with the facility Social Worker, revealed that she verified the doctor's order for code status and verified with the family/resident the desired code status. The Social Worker stated that she wrote the code status care plan and verified that Resident #1 had a full code status care plan. An interview with Registered Nurse #2 on [DATE] at 2:20 PM, revealed the code status care plan and advance directives is located on the resident medical record. This medical record is located at the nurse's station. RN #2 confirmed the care plan for Resident #1 was not followed for the Advanced Directive of CPR. There were two (2) attempts to contact LPN #1 and LPN #2 on [DATE], with no success. Written and signed statements, on the same day of the event ([DATE]), by both LPNS were obtained. Review of a written and signed statement, dated [DATE], by LPN #1, revealed Resident #1 was full code and no CPR was performed. Review of the facility's investigation revealed that LPN #2 was interviewed by the DON #1 on [DATE] at approximately 10:15 AM, and when asked why she didn't initiate CPR on Resident #1 she stated I don't know, but I realize now that I should have. Record review revealed the facility admitted Resident #1 on [DATE], and again on [DATE], with [DIAGNOSES REDACTED]. Review of the 5 day Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) of 15 indicating Resident #1 was cognitively intact. The facility implemented the following Corrective Action Plan prior to the State Agency (SA) entrance on [DATE]: 1. On [DATE], while making rounds at 6:56 AM, Licensed Practical Nurse (LPN) #1 entered the room of Resident #1 and spoke to Resident #1. Resident #1 waved back with her right hand to LPN #1. On [DATE], at approximately 7:39 AM, LPN #1 on duty was informed by Certified Occupational Therapy Assistant (COTA) #1 that Resident #1 was non-responsive when she attempted to call Resident #1 by her name. It was at this time LPN #1 and LPN #2 went to the room to check on Resident #1. COTA #1 retrieved Resident #1's medical record. LPN #1 and LPN #2 exited Resident #1's room and reviewed Resident #1's medical record in the hallway. LPN #1 and LPN #2 walked back to the nurse's station without initiating CPR. Resident #1's medical record indicated she was a full code status. On [DATE], at approximately 8:15 AM, the facility Administrator #1 was notified of the failure to initiate CPR on Resident #1 and at approximately 8:30 AM, the facility Director of Nursing #1 was notified of the failure to initiate CPR on Resident #1, which was a full code status. 2. On [DATE], at approximately 9:15 AM, the facility Director of Nursing #1 and Staff Development Nurse #1 interviewed LPN #1. The interview conducted indicated LPN #1 was aware of the full code status and failed to initiate CPR. On [DATE], at approximately 10:25 AM, the facility Director of Nursing #1 and the facility Administrator #1 interviewed LPN #2. The interview conducted indicated LPN #2 was aware of Resident #1's full code status and failed to initiate CPR. On [DATE], at approximately 9:00 AM, the facility Director of Nursing #1 and the facility Administrator #1 interviewed the COTA #1. The interview conducted indicated the COTA #1 notified LPN #1 of the condition of Resident #1 and obtained the medical record of Resident #1 as requested of LPN #1. LPN #1 was suspended on [DATE] at 9:20 AM. LPN #2 was suspended on [DATE], at 10:20 AM. COTA #1 was not suspended because she was following her scope of practice. 3. On [DATE], the facility Administrator #1 and the facility Director of Nursing #1 terminated LPN #2 for failure to follow physician orders [REDACTED]. The facility Director of Nursing #1 attempted to contact LPN #1 on three (3) attempts via telephone to discuss the employment status to no avail. On [DATE], the facility Administrator #1 mailed a certified return receipt requested termination letter to LPN #1 as a result of the investigation. 4. On [DATE], at approximately 4:40 PM, facility Administrator #1 notified the Mississippi State Department of Health and the Mississippi State Attorney General's Office. On [DATE], at approximately 11:21 AM and 11:34 AM, the facility Director of Nursing #1 notified the Mississippi State Board of Nursing of the incident involving LPN #1 and LPN #2 respectively. 5. Facility Medical Director #1 was notified on [DATE], by the Regional Supervisor #1 of failure to initiate CPR on Resident #1, who was of full code status at the time of non-responsiveness. 6. A facility Quality Assurance Committee meeting was held on [DATE] at 11:30 AM, to include facility Quality Assurance Committee members which consisted of the facility Director of Nursing #1, the facility Administrator #1, Regional Supervisor #1, Quality Improvement Nurse #1, Medical Director #1, Infection Control/Prevention Officer #1, Social Services Director #1, and Maintenance Supervisor #1. Topics discussed included: (a) Failure to initiate cardiopulmonary resuscitation on a full code resident, (b) Failure to show proper documentation of completed cardiopulmonary certification, (c) Failure to follow the care plan for Advanced Directives/Full Code. The facility corrective actions were reviewed and initiated on [DATE], to include the following: in-service training, code drills, medical record audits, and monitoring systems ongoing. On [DATE], in-service training was initiated by Staff Development Nurse #1 and the facility Director of Nursing #1 to include all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, Dietary staff, Office personnel and contracted therapy department staff on the following: (a) Cardiopulmonary Resuscitation Policy, (b) Incident Investigation and Reporting, (c) Change in Resident Medical Status, (d) Emergency Care of Residents, (e) Care Plan Process, (f) Advance Directives, (g) Resident Rights, (h) Abuse/Neglect. The in-service conducted on [DATE] included five (5) Registered Nurses, nine (9) Licensed Practical Nurses, and two (2) Certified Nursing Assistants. Staff will not be allowed to work until the proper in-service training has been conducted. The facility does not currently use contracted agency staff employees for nursing direct care. In the event contracted agency staff is utilized for nursing direct care, no staff will be allowed to work until the proper in-service training has been conducted. 7. On [DATE], Cardiopulmonary Resuscitation (CPR) Code Drills were initiated by the facility Staff Development Nurse #1 and the facility Director of Nursing #1 for all Registered Nurses and Licensed Practical Nurses. Registered Nurses and Licensed Practical Nurses will not be allowed to provide direct patient care until participation in a code drill has been conducted. 8. On [DATE], all active resident's medical record charts were audited by the facility Medical Records Staff #1 and the facility Medical Records Staff #2 to ensure proper code status identification. The results of this audit showed no deficiencies. 9. On [DATE], all active residents plan of care were audited by the facility Assessment Nurse #1, the facility Assessment Nurse #2, and the facility Nurse Case Manager #1 to ensure proper code status identification. The [DATE], audit identified two (2) residents care plans which were noted to be out of compliance and were corrected as of [DATE]. 10. On [DATE], monitoring systems were put in place to sustain compliance (a) The facility began conducting CPR Code Drills on all three (3) shifts weekly for four (4) weeks, then all three (3) shifts monthly for three (3) months, and then all three (3) shifts quarterly thereafter by the Director of Nursing #1 and/or Staff Development Nurse #1. (b) All active resident medical records and plan of care will be monitored for the correct codes status identification weekly for one (1) month, then bi-weekly for three (3) months, and then monthly thereafter by Medical Records #1 and Medical Records #2. (c) The CPR certification status of each licensed nurse will be checked for each nurse upon hire and then monthly by Director of Nursing #1. 11. The facility Administrator #1 will report all results of the established monitoring to the Quality Assurance Committee meeting for an immediate corrective plan of action of any deficient practice. The facility corrective action plan was initiated on [DATE]. The facility believes the IJ was removed as of [DATE]. The State Agency (SA) validated the facility's corrective action plan on [DATE] and [DATE] and determined all actions to remove the IJ were complete as of [DATE] and the IJ to be removed as of [DATE]. 1. The SA verified the facility's investigation of Resident #1's incident on [DATE]. Resident #1 was found unresponsive, without a pulse and CPR was not performed per interviews, record review, written statements from staff and written reports to the SA. 2. The SA validated by interview with the DON #1 and review of documents that interviews with LPN #1 and LPN #2 were conducted and both stated they did not know why CPR was not done on Resident #1. Validation of written and signed statements by LPN #1 and LPN #2, suspension of LPN #1 and LPN #2 started on [DATE]. 3. The SA validated by record review and interview with the DON #1: termination of employment of LPN #1 by certified letter on [DATE], and termination of employment of LPN #2 on [DATE]. 4. The SA validated by record review and interview with the DON #1: notification of incident to the State Agency of Licensure and Certification and the Attorney General office of Medicare and Medicaid Fraud on [DATE], and the Mississippi State Board of Nursing on [DATE]. 5. The SA validated by interview with the Medical Director that he was notified of the failure to perform CPR on Resident #1 on [DATE]. 6. The SA validated by record review of the Quality Assurance sign-in sheet dated [DATE], and interview with the DON #1, Medical Director, Administrator #1 and Social Worker that the facility initiated a Quality Assessment and Assurance meeting on [DATE], with the Director Of Nurses, facility Administrator, Medical Director, Regional Supervisor, Quality Improvement Nurse, Infection Control/Prevention Officer, Social Service Director, and Maintenance Supervisor in attendance concerning the incident with Resident #1 with recommendations of In-services with no policy changes or updates needed. Validated that Care-Plan audits, resident medical record audits for proper code status identification, and CPR code drills to be conducted on all three (3) shifts. The SA validated by interview with the DON #1 that staff in-services began on [DATE]. Review of the in-service content, signature sheets and random interviews with nursing staff, therapy staff, social service, and housekeeping staff validated the facility in-serviced facility staff regarding the CPR policy, Incident investigation and reporting, change in resident medical status, emergency care of residents, care plan process, advance directives, resident rights, and abuse/neglect. Review of in-service records and facility staff rosters revealed 124 of 128 staff members had been in-serviced from [DATE]-[DATE]. The four (4) staff who had not been in-serviced had not worked since the incident occurred on [DATE]. Random staff interviews confirmed staff were not allowed to work until in-serviced. 7. The SA validated by record review and random nursing staff interview that CPR drills were initiated and conducted beginning [DATE]. Random nursing staff interviews confirmed staff were not allowed to work until participation in a CPR drill. 8. The SA validated through interview with the DON #1 and record review that on [DATE] all active resident medical records were audited to ensure proper code status identification and that this audit showed no deficiencies. 9. The SA validated through interview with the DON #1 and facility Quality Improvement Nurse #1 and record review that on [DATE] all active resident care plans were audited to ensure proper code status identification. That audit identified two (2) resident care plans out of compliance and were corrected. 10. The SA validated through interview with the DON #1 and record review that beginning [DATE], monitoring systems were put in place. The facility had documented and will do random CPR code drills on all three (3) shifts weekly for four (4) weeks, then monthly for three(3) months and then quarterly thereafter, and all active resident medical records and care plans will be reviewed for correct code status identification weekly for one (1) month, then bi-weekly for three (3) months and then every month there after, and the CPR certification status of each licensed nurse will be checked upon hire and then monthly. 11. The SA validated through interview with the Administrator #1 that he will report the results of all established monitoring to the QA committee for immediate corrective plan of action of any deficient practice. The SA identified the Immediate Jeopardy as Past Non-Compliance beginning [DATE] through [DATE]. The facility provided sufficient evidence to show the facility corrected the non-compliance and was in substantial compliance with regulatory requirements as of [DATE], prior to the SA entering the facility on [DATE].

MS Complaint Investigation # Based on policy/procedure review, record review and staff interview; the facility failed to ensure the residents were free of neglect for one (1) of seven (7) sampled and two (2) Unsampled residents, Resident #1, as evidenced by Resident #1 had an advance directive and physician order [REDACTED].#1 expired. Immediate Jeopardy (IJ) and substandard Quality of Care (SQC) was determined to exist when Cardio-Pulmonary Resuscitation (CPR) was not initiated for Resident #1 with an Advance Directive for a full code status. Certified Occupational Therapy Assistant (COTA) #1 found the resident unresponsive on [DATE] at approximately 7:39 AM, and informed LPN #1. LPN #1 and LPN #2 went to Resident #1's room while COTA #1 went to retrieve the medical record of Resident #1. As COTA #1 returned to Resident #1's room, LPN #1 and LPN #2 met her in the hall outside of the resident's room. After reviewing the code status of Resident #1 in the medical record, LPN #1 and LPN #2 walked back to the nurses station without initiating CPR. Emergency Personnel were not notified. The coroner arrived to the facility at approximately 8:05 AM, on [DATE]. The facility's failure to ensure residents received CPR, per their Advance Directive for full code status, lead to the death of Resident #1 and placed other residents in a situation that was likely to cause serious harm, injury, impairment, or death. Based on the facility's implementation of corrective actions as of [DATE]-[DATE], initiated prior to the SA facility entrance on [DATE], the SA determined the Immediate Jeopardy to be Past Non-Compliance and removed as of [DATE]. Findings include: Review of the facility's policy/procedure for Abuse/neglect Elder Justice Act with a revision date ,[DATE], revealed the definition of neglect being the failure of a caregiver or fiduciary to provide the goods or services that are necessary to maintain the health or safety of an elder. Record review of a written report from the facility dated [DATE], revealed COTA #1 found Resident #1 unresponsive ([DATE]) at approximately 7:39 AM. She then informed LPN #1 and LPN #2. LPN #1 and LPN #2 went to Resident #1's room as COTA #1 went to retrieve Resident #1's medical record. As COTA #1 was returning to Resident #1's room, LPN #1 and LPN #2 met her in the hall. After reviewing the code status of Resident #1 in the medical record, LPN #1 and LPN #2 walked back to the nurse's station without initiating CPR or calling a code. LPN #2 called the Resident's Medical Doctor (MD), Coroner, and Resident #1's Responsible Party (RP). The coroner arrived to the facility on [DATE] at approximately 8:05 AM. Review of a Resident Rights, Advance Directives, Resident/Family consent for Cardiopulmonary Resuscitation, dated [DATE] and [DATE], revealed Resident #1's RP signed a consent for the Advance Directive and indicated a full code directive. Review of Resident #1's [DATE] physician orders [REDACTED]. Interview with DON #1 on [DATE] at 10:20 AM, revealed neglect is when you fail to provide a service to a resident. The DON stated, When I questioned both LPN #1 and LPN #2 to ask why they did not initiate CPR, both said I don't know. The DON said both LPNs admitted they knew Resident #1 was a full code and CPR should have been started. Observation on [DATE] at 11:35 AM revealed a stocked crash cart located on each floor of the facility accessible to staff. The surveyor made two (2) attempts to contact LPN #1 and LPN #2 on [DATE] by telephone, with no success. Review of a written and signed statement, dated [DATE], by LPN #1, revealed at 6:56 AM she spoke to Resident #1 during rounds and Resident #1 waved at nurse with her right hand. She wrote that later a therapist came to the nurse's desk and said the a resident wasn't looking well. Nurses went to resident room and noted resident unresponsive. Resident was full code and no CPR was performed. Review of the facility's investigation revealed that LPN #1 was interviewed by the Director of Nurses (DON) #1 on [DATE], at approximately 9:15 AM, and revealed she did know that Resident #1 was a full code and did not know why she did not begin CPR. LPN #1 was suspended at that time. Review of a written and signed statement, dated [DATE], by LPN #2, revealed that she and LPN #1 went to Resident #1's room after a therapist stated I need y'all to come see about (name of Resident #1). She stated Resident #1 was expired when they entered the room. LPN #2 called the coroner and the residents responsible party and helped with postmortem care. Review of the facility's investigation revealed that LPN #2 was interviewed by the DON #1 on [DATE], at approximately 10:15 AM, and revealed she went into the residents room, realized she had expired then went to the nurse's station and notified the Medical Doctor, RP and the Coroner. When asked why she didn't initiate CPR on Resident #1 she stated I don't know, but I realize now that I should have. LPN #2 was suspended at that time. Record review revealed that on [DATE], the DON #1 terminated the employment of LPN #2 for failure to follow physician orders [REDACTED]. After failed attempts to contact LPN #1 by phone, a certified termination letter was mailed. Record review revealed the facility admitted Resident #1 on [DATE], and again on [DATE], with the [DIAGNOSES REDACTED]. Review of the 5 day Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) of 15, indicating Resident #1 had no cognitive impairment. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on [DATE]: 1. On [DATE], while making rounds at 6:56 AM, Licensed Practical Nurse (LPN) #1 entered the room of Resident #1 and spoke to Resident #1. Resident #1 waved back with her right hand to LPN #1. On [DATE], at approximately 7:39 AM, LPN #1 on duty was informed by Certified Occupational Therapy Assistant (COTA) #1 that Resident #1 was non-responsive when she attempted to call Resident #1 by her name. It was at this time LPN #1 and LPN #2 went to the room to check on Resident #1. COTA #1 retrieved Resident #1's medical record. LPN #1 and LPN #2 exited Resident #1's room and reviewed Resident #1's medical record in the hallway. LPN #1 and LPN #2 walked back to the nurse's station without initiating CPR. Resident #1's medical record indicated she was a full code status. On [DATE], at approximately 8:15 AM, the facility Administrator #1 was notified of the failure to initiate CPR on Resident #1 and at approximately 8:30 AM, the facility Director of Nursing #1 was notified of the failure to initiate CPR on Resident #1, which was a full code status. 2. On [DATE], at approximately 9:15 AM, the facility Director of Nursing #1 and Staff Development Nurse #1 interviewed LPN #1. The interview conducted indicated LPN #1 was aware of the full code status and failed to initiate CPR. On [DATE], at approximately 10:25 AM, the facility Director of Nursing #1 and the facility Administrator #1 interviewed LPN #2. The interview conducted indicated LPN #2 was aware of Resident #1's full code status and failed to initiate CPR. On [DATE], at approximately 9:00 AM, the facility Director of Nursing #1 and the facility Administrator #1 interviewed the COTA #1. The interview conducted indicated the COTA #1 notified LPN #1 of the condition of Resident #1 and obtained the medical record of Resident #1 as requested of LPN #1. LPN #1 was suspended on [DATE] at 9:20 AM. LPN #2 was suspended on [DATE], at 10:20 AM. COTA #1 was not suspended because she was following her scope of practice. 3. On [DATE], the facility Administrator #1 and the facility Director of Nursing #1 terminated LPN #2 for failure to follow physician orders [REDACTED]. The facility Director of Nursing #1 attempted to contact LPN #1 on three (3) attempts via telephone to discuss the employment status to no avail. On [DATE], the facility Administrator #1 mailed a certified return receipt requested termination letter to LPN #1 as a result of the investigation. 4. On [DATE], at approximately 4:40 PM, facility Administrator #1 notified the Mississippi State Department of Health and the Mississippi State Attorney General's Office. On [DATE], at approximately 11:21 AM and 11:34 AM, the facility Director of Nursing #1 notified the Mississippi State Board of Nursing of the incident involving LPN #1 and LPN #2 respectively. 5. Facility Medical Director #1 was notified on [DATE], by the Regional Supervisor #1 of failure to initiate CPR on Resident #1, who was of full code status at the time of non-responsiveness. 6. A facility Quality Assurance Committee meeting was held on [DATE] at 11:30 AM, to include facility Quality Assurance Committee members which consisted of the facility Director of Nursing #1, the facility Administrator #1, Regional Supervisor #1, Quality Improvement Nurse #1, Medical Director #1, Infection Control/Prevention Officer #1, Social Services Director #1, and Maintenance Supervisor #1. Topics discussed included: (a) Failure to initiate cardiopulmonary resuscitation on a full code resident, (b) Failure to show proper documentation of completed cardiopulmonary certification, (c) Failure to follow the care plan for Advanced Directives/Full Code. The facility corrective actions were reviewed and initiated on [DATE], to include the following: in-service training, code drills, medical record audits, and monitoring systems ongoing. On [DATE], in-service training was initiated by Staff Development Nurse #1 and the facility Director of Nursing #1 to include all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, Dietary staff, Office personnel and contracted therapy department staff on the following: (a) Cardiopulmonary Resuscitation Policy, (b) Incident Investigation and Reporting, (c) Change in Resident Medical Status, (d) Emergency Care of Residents, (e) Care Plan Process, (f) Advance Directives, (g) Resident Rights, (h) Abuse/Neglect. The in-service conducted on [DATE] included five (5) Registered Nurses, nine (9) Licensed Practical Nurses, and two (2) Certified Nursing Assistants. Staff will not be allowed to work until the proper in-service training has been conducted. The facility does not currently use contracted agency staff employees for nursing direct care. In the event contracted agency staff is utilized for nursing direct care, no staff will be allowed to work until the proper in-service training has been conducted. 7. On [DATE], Cardiopulmonary Resuscitation (CPR) Code Drills were initiated by the facility Staff Development Nurse #1 and the facility Director of Nursing #1 for all Registered Nurses and Licensed Practical Nurses. Registered Nurses and Licensed Practical Nurses will not be allowed to provide direct patient care until participation in a code drill has been conducted. 8. On [DATE], all active resident's medical record charts were audited by the facility Medical Records Staff #1 and the facility Medical Records Staff #2 to ensure proper code status identification. The results of this audit showed no deficiencies. 9. On [DATE], all active residents plan of care were audited by the facility Assessment Nurse #1, the facility Assessment Nurse #2, and the facility Nurse Case Manager #1 to ensure proper code status identification. The [DATE], audit identified two (2) residents care plans which were noted to be out of compliance and were corrected as of [DATE]. 10. On [DATE], monitoring systems were put in place to sustain compliance (a) The facility began conducting CPR Code Drills on all three (3) shifts weekly for four (4) weeks, then all three (3) shifts monthly for three (3) months, and then all three (3) shifts quarterly thereafter by the Director of Nursing #1 and/or Staff Development Nurse #1. (b) All active resident medical records and plan of care will be monitored for the correct codes status identification weekly for one (1) month, then bi-weekly for three (3) months, and then monthly thereafter by Medical Records #1 and Medical Records #2. (c) The CPR certification status of each licensed nurse will be checked for each nurse upon hire and then monthly by Director of Nursing #1. 11. The facility Administrator #1 will report all results of the established monitoring to the Quality Assurance Committee meeting for an immediate corrective plan of action of any deficient practice. The facility corrective action plan was initiated on [DATE]. The facility believes the IJ was removed as of [DATE]. The State Agency (SA) validated the facility's corrective action plan on [DATE] and [DATE] and determined all actions to remove the IJ were complete as of [DATE] and the IJ to be removed as of [DATE]. 1. The SA verified the facility's investigation of Resident #1's incident on [DATE]. Resident #1 was found unresponsive, without a pulse and CPR was not performed per interviews, record review, written statements from staff and written reports to the SA. 2. The SA validated by interview with the DON #1 and review of documents that interviews with LPN #1 and LPN #2 were conducted and both stated they did not know why CPR was not done on Resident #1. Validation of written and signed statements by LPN #1 and LPN #2, suspension of LPN #1 and LPN #2 started on [DATE]. 3. The SA validated by record review and interview with the DON #1: termination of employment of LPN #1 by certified letter on [DATE], and termination of employment of LPN #2 on [DATE]. 4. The SA validated by record review and interview with the DON #1: notification of incident to the State Agency of Licensure and Certification and the Attorney General office of Medicare and Medicaid Fraud on [DATE], and the Mississippi State Board of Nursing on [DATE]. 5. The SA validated by interview with the Medical Director that he was notified of the failure to perform CPR on Resident #1 on [DATE]. 6. The SA validated by record review of the Quality Assurance sign-in sheet dated [DATE], and interview with the DON #1, Medical Director, Administrator #1 and Social Worker that the facility initiated a Quality Assessment and Assurance meeting on [DATE], with the Director Of Nurses, facility Administrator, Medical Director, Regional Supervisor, Quality Improvement Nurse, Infection Control/Prevention Officer, Social Service Director, and Maintenance Supervisor in attendance concerning the incident with Resident #1 with recommendations of In-services with no policy changes or updates needed. Validated that Care-Plan audits, resident medical record audits for proper code status identification, and CPR code drills to be conducted on all three (3) shifts. The SA validated by interview with the DON #1 that staff in-services began on [DATE]. Review of the in-service content, signature sheets and random interviews with nursing staff, therapy staff, social service, and housekeeping staff validated the facility in-serviced facility staff regarding the CPR policy, Incident investigation and reporting, change in resident medical status, emergency care of residents, care plan process, advance directives, resident rights, and abuse/neglect. Review of in-service records and facility staff rosters revealed 124 of 128 staff members had been in-serviced from [DATE]-[DATE]. The four (4) staff who had not been in-serviced had not worked since the incident occurred on [DATE]. Random staff interviews confirmed staff were not allowed to work until in-serviced. 7. The SA validated by record review and random nursing staff interview that CPR drills were initiated and conducted beginning [DATE]. Random nursing staff interviews confirmed staff were not allowed to work until participation in a CPR drill. 8. The SA validated through interview with the DON #1 and record review that on [DATE] all active resident medical records were audited to ensure proper code status identification and that this audit showed no deficiencies. 9. The SA validated through interview with the DON #1 and facility Quality Improvement Nurse #1 and record review that on [DATE] all active resident care plans were audited to ensure proper code status identification. That audit identified two (2) resident care plans out of compliance and were corrected. 10. The SA validated through interview with the DON #1 and record review that beginning [DATE], monitoring systems were put in place. The facility had documented and will do random CPR code drills on all three (3) shifts weekly for four (4) weeks, then monthly for three(3) months and then quarterly thereafter, and all active resident medical records and care plans will be reviewed for correct code status identification weekly for one (1) month, then bi-weekly for three (3) months and then every month there after, and the CPR certification status of each licensed nurse will be checked upon hire and then monthly. 11. The SA validated through interview with the Administrator #1 that he will report the results of all established monitoring to the QA committee for immediate corrective plan of action of any deficient practice. The SA identified the Immediate Jeopardy and Substandard Quality of Care as Past Non-Compliance beginning [DATE] through [DATE]. The facility provided sufficient evidence to show the facility corrected the non-compliance and was in substantial compliance with regulatory requirements as of [DATE], prior to the SA entering the facility on [DATE].

Complaint investigation # Based on staff interview, record review, and policy/procedure review, the facility failed to ensure Resident #1's rights and wishes were honored related to Advance Directives for one (1) of seven (7) Sampled and two (2) Unsampled residents. Immediate Jeopardy (IJ) was determined to exist when Cardio-Pulmonary Resuscitation (CPR) was not initiated for Resident #1, with an Advance Directive for a full code status. Certified Occupational Therapy Assistant (COTA) #1 found the resident unresponsive on [DATE], at approximately 7:39 AM, and informed Licensed Practical Nurse (LPN) #1. LPN #1 and LPN #2 went to Resident #1's room and COTA #1 returned to Resident #1's room with the medical record. LPN #1 and LPN #2 met her in the hall outside of the resident's room. After reviewing the code status of Resident #1 in the medical record, LPN #1 and LPN #2 walked back to the nurse's station without initiating CPR on Resident #1, per Advanced Directive. LPN #2 called the Resident's Medical Doctor (MD), Coroner, and Resident #1's Responsible Party (RP). Emergency Personnel were not notified. The coroner arrived to the facility at approximately 8:05 AM on [DATE]. The facility's failure to ensure residents received CPR, per their Advance Directive for full code status, led to the death of Resident #1 and placed other residents in a situation that was likely to cause serious harm, injury, impairment, or death. Based on the facility's implementation of corrective actions, as of [DATE]-[DATE], initiated prior to the SA entrance on [DATE], the SA determined the IJ to be Past Non-Compliance (PNC) and removed as of [DATE]. Findings include: The facility's Resident Rights policy, with a revision date of ,[DATE], revealed All residents in a long term care facility have rights guaranteed to them under Federal and State law. 18. To request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research. The facility's Advance Directives policy, with a revision date of ,[DATE], revealed It is the policy of the facility to encourage residents and their family/caregivers to participate in decisions regarding care and treatment. The policy also documented that valid Advance Directives will be followed to the extent permitted and required by law. Review of the facility's Cardiac Resuscitation Policy, with a revision date of ,[DATE], revealed, In the event of a cardiopulmonary arrest, basic CPR will be performed, unless, a Do Not Resuscitate (DNR) Order has been made by the resident's physician and the resident or resident's appropriate representative has made a valid written request in advance not to initiate basic CPR. Review of a Resident Rights, Advance Directives, Resident/Family consent for Cardiopulmonary Resuscitation form, dated [DATE] and [DATE], revealed Resident #1's RP signed a consent for the Advance Directive, which indicated a full code directive. Review of Resident #1's [DATE] physician's orders [REDACTED].>Review of a written report from the facility, dated [DATE], revealed at approximately 7:39 AM on [DATE], COTA #1 found Resident #1 unresponsive and informed LPN #1 and LPN #2. The report indicated that after reviewing the code status of Resident #1 in the medical record, LPN #1 and LPN #2 failed to initiate CPR. Interview with COTA #1 on [DATE] at 11:45 AM, revealed she went to Resident #1's room between 7:,[DATE]:40 AM on [DATE] and Resident #1 was in bed, pale in color, oxygen on, eyes closed, and did not respond to her name or being touched on her leg. She stated she noticed there was no chest movement and ran out of the room to get assistance. COTA #1 stated that she told LPN #1 and a Certified Nurse Aide (CNA) that she didn't think Resident #1 was breathing. She recalled hearing LPN #1 say, I think she is a full code, would you grab her chart?, so she ran to the nurse's station and retrieved the medical record. When returning to Resident #1's room, COTA #1 stated that she handed LPN #1 the chart. and LPN #1 stated, It's too late. COTA #1 stated that Resident #1 was able to follow commands and was planning to return home after therapy completion. Review of the facility's investigation revealed documentation that LPN #1 was interviewed by the Director of Nurses (DON) #1 on [DATE] at approximately 9:15 AM, and revealed she was aware that Resident #1 was a full code and did not know why she did not begin CPR. LPN #1 was suspended at that time. DON #1 interviewed LPN #2 on [DATE] at approximately 10:15 AM, LPN #2 stated she went into the resident's room, realized she had expired, then went to the nurse's station and notified the Medical Doctor, RP, and the Coroner. When asked why she didn't initiate CPR on Resident #1, she stated I don't know, but I realize now that I should have. LPN #2 was suspended at that time. On [DATE], phone attempts to contact LPN #1 and LPN #2 were not successful. Interview with DON #1 on [DATE] at 10:20 AM, revealed When I questioned both LPN's and asked why they did not initiate CPR, both said I don't know. The DON stated both LPNs admitted they knew Resident #1 had chosen to be a full code and CPR should have been started. Record review revealed the facility admitted Resident #1 on [DATE], and again on [DATE], with [DIAGNOSES REDACTED]. Review of the 5 day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) of 15, indicating Resident #1 had no cognitive impairment. The facility implemented the following Corrective Action Plan prior to the SA entrance on [DATE]: 1. On [DATE], while making rounds at 6:56 AM, Licensed Practical Nurse (LPN) #1 entered the room of Resident #1 and spoke to Resident #1. Resident #1 waved back with her right hand to LPN #1. On [DATE], at approximately 7:39 AM, LPN #1 on duty was informed by Certified Occupational Therapy Assistant (COTA) #1 that Resident #1 was non-responsive when she attempted to call Resident #1 by her name. It was at this time LPN #1 and LPN #2 went to the room to check on Resident #1. COTA #1 retrieved Resident #1's medical record. LPN #1 and LPN #2 exited Resident #1's room and reviewed Resident #1's medical record in the hallway. LPN #1 and LPN #2 walked back to the nurse's station without initiating CPR. Resident #1's medical record indicated she was a full code status. On [DATE], at approximately 8:15 AM, the facility Administrator #1 was notified of the failure to initiate CPR on Resident #1 and at approximately 8:30 AM, the facility Director of Nursing #1 was notified of the failure to initiate CPR on Resident #1, which was a full code status. 2. On [DATE], at approximately 9:15 AM, the facility Director of Nursing #1 and Staff Development Nurse #1 interviewed LPN #1. The interview conducted indicated LPN #1 was aware of the full code status and failed to initiate CPR. On [DATE], at approximately 10:25 AM, the facility Director of Nursing #1 and the facility Administrator #1 interviewed LPN #2. The interview conducted indicated LPN #2 was aware of Resident #1's full code status and failed to initiate CPR. On [DATE], at approximately 9:00 AM, the facility Director of Nursing #1 and the facility Administrator #1 interviewed the COTA #1. The interview conducted indicated the COTA #1 notified LPN #1 of the condition of Resident #1 and obtained the medical record of Resident #1 as requested of LPN #1. LPN #1 was suspended on [DATE] at 9:20 AM. LPN #2 was suspended on [DATE], at 10:20 AM. COTA #1 was not suspended because she was following her scope of practice. 3. On [DATE], the facility Administrator #1 and the facility Director of Nursing #1 terminated LPN #2 for failure to follow physician orders [REDACTED]. The facility Director of Nursing #1 attempted to contact LPN #1 on three (3) attempts via telephone to discuss the employment status to no avail. On [DATE], the facility Administrator #1 mailed a certified return receipt requested termination letter to LPN #1 as a result of the investigation. 4. On [DATE], at approximately 4:40 PM, facility Administrator #1 notified the Mississippi State Department of Health and the Mississippi State Attorney General's Office. On [DATE], at approximately 11:21 AM and 11:34 AM, the facility Director of Nursing #1 notified the Mississippi State Board of Nursing of the incident involving LPN #1 and LPN #2 respectively. 5. Facility Medical Director #1 was notified on [DATE], by the Regional Supervisor #1 of failure to initiate CPR on Resident #1, who was of full code status at the time of non-responsiveness. 6. A facility Quality Assurance Committee meeting was held on [DATE] at 11:30 AM, to include facility Quality Assurance Committee members which consisted of the facility Director of Nursing #1, the facility Administrator #1, Regional Supervisor #1, Quality Improvement Nurse #1, Medical Director #1, Infection Control/Prevention Officer #1, Social Services Director #1, and Maintenance Supervisor #1. Topics discussed included: (a) Failure to initiate cardiopulmonary resuscitation on a full code resident, (b) Failure to show proper documentation of completed cardiopulmonary certification, (c) Failure to follow the care plan for Advanced Directives/Full Code. The facility corrective actions were reviewed and initiated on [DATE], to include the following: in-service training, code drills, medical record audits, and monitoring systems ongoing. On [DATE], in-service training was initiated by Staff Development Nurse #1 and the facility Director of Nursing #1 to include all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, Dietary staff, Office personnel and contracted therapy department staff on the following: (a) Cardiopulmonary Resuscitation Policy, (b) Incident Investigation and Reporting, (c) Change in Resident Medical Status, (d) Emergency Care of Residents, (e) Care Plan Process, (f) Advance Directives, (g) Resident Rights, (h) Abuse/Neglect. The in-service conducted on [DATE] included five (5) Registered Nurses, nine (9) Licensed Practical Nurses, and two (2) Certified Nursing Assistants. Staff will not be allowed to work until the proper in-service training has been conducted. The facility does not currently use contracted agency staff employees for nursing direct care. In the event contracted agency staff is utilized for nursing direct care, no staff will be allowed to work until the proper in-service training has been conducted. 7. On [DATE], Cardiopulmonary Resuscitation (CPR) Code Drills were initiated by the facility Staff Development Nurse #1 and the facility Director of Nursing #1 for all Registered Nurses and Licensed Practical Nurses. Registered Nurses and Licensed Practical Nurses will not be allowed to provide direct patient care until participation in a code drill has been conducted. 8. On [DATE], all active resident's medical record charts were audited by the facility Medical Records Staff #1 and the facility Medical Records Staff #2 to ensure proper code status identification. The results of this audit showed no deficiencies. 9. On [DATE], all active residents plan of care were audited by the facility Assessment Nurse #1, the facility Assessment Nurse #2, and the facility Nurse Case Manager #1 to ensure proper code status identification. The [DATE], audit identified two (2) residents care plans which were noted to be out of compliance and were corrected as of [DATE]. 10. On [DATE], monitoring systems were put in place to sustain compliance (a) The facility began conducting CPR Code Drills on all three (3) shifts weekly for four (4) weeks, then all three (3) shifts monthly for three (3) months, and then all three (3) shifts quarterly thereafter by the Director of Nursing #1 and/or Staff Development Nurse #1. (b) All active resident medical records and plan of care will be monitored for the correct codes status identification weekly for one (1) month, then bi-weekly for three (3) months, and then monthly thereafter by Medical Records #1 and Medical Records #2. (c) The CPR certification status of each licensed nurse will be checked for each nurse upon hire and then monthly by Director of Nursing #1. 11. The facility Administrator #1 will report all results of the established monitoring to the Quality Assurance Committee meeting for an immediate corrective plan of action of any deficient practice. The facility corrective action plan was initiated on [DATE]. The facility believes the IJ was removed as of [DATE]. The State Agency (SA) validated the facility's corrective action plan on [DATE] and [DATE] and determined all actions to remove the IJ were complete as of [DATE] and the IJ to be removed as of [DATE]. 1. The SA verified the facility's investigation of Resident #1's incident on [DATE]. Resident #1 was found unresponsive, without a pulse and CPR was not performed per interviews, record review, written statements from staff and written reports to the SA. 2. The SA validated by interview with the DON #1 and review of documents that interviews with LPN #1 and LPN #2 were conducted and both stated they did not know why CPR was not done on Resident #1. Validation of written and signed statements by LPN #1 and LPN #2, suspension of LPN #1 and LPN #2 started on [DATE]. 3. The SA validated by record review and interview with the DON #1: termination of employment of LPN #1 by certified letter on [DATE], and termination of employment of LPN #2 on [DATE]. 4. The SA validated by record review and interview with the DON #1: notification of incident to the State Agency of Licensure and Certification and the Attorney General office of Medicare and Medicaid Fraud on [DATE], and the Mississippi State Board of Nursing on [DATE]. 5. The SA validated by interview with the Medical Director that he was notified of the failure to perform CPR on Resident #1 on [DATE]. 6. The SA validated by record review of the Quality Assurance sign-in sheet dated [DATE], and interview with the DON #1, Medical Director, Administrator #1 and Social Worker that the facility initiated a Quality Assessment and Assurance meeting on [DATE], with the Director Of Nurses, facility Administrator, Medical Director, Regional Supervisor, Quality Improvement Nurse, Infection Control/Prevention Officer, Social Service Director, and Maintenance Supervisor in attendance concerning the incident with Resident #1 with recommendations of In-services with no policy changes or updates needed. Validated that Care-Plan audits, resident medical record audits for proper code status identification, and CPR code drills to be conducted on all three (3) shifts. The SA validated by interview with the DON #1 that staff in-services began on [DATE]. Review of the in-service content, signature sheets and random interviews with nursing staff, therapy staff, social service, and housekeeping staff validated the facility in-serviced facility staff regarding the CPR policy, Incident investigation and reporting, change in resident medical status, emergency care of residents, care plan process, advance directives, resident rights, and abuse/neglect. Review of in-service records and facility staff rosters revealed 124 of 128 staff members had been in-serviced from [DATE]-[DATE]. The four (4) staff who had not been in-serviced, had not worked since the incident occurred on [DATE]. Random staff interviews confirmed staff were not allowed to work until in-serviced. 7. The SA validated by record review and random nursing staff interview that CPR drills were initiated and conducted beginning [DATE]. Random nursing staff interviews confirmed staff were not allowed to work until participation in a CPR drill. 8. The SA validated through interview with the DON #1 and record review that on [DATE] all active resident medical records were audited to ensure proper code status identification and that this audit showed no deficiencies. 9. The SA validated through interview with the DON #1 and facility Quality Improvement Nurse #1 and record review that on [DATE] all active resident care plans were audited to ensure proper code status identification. That audit identified two (2) resident care plans out of compliance and were corrected. 10. The SA validated through interview with the DON #1 and record review that beginning [DATE], monitoring systems were put in place. The facility had documented and will do random CPR code drills on all three (3) shifts weekly for four (4) weeks, then monthly for three(3) months and then quarterly thereafter, and all active resident medical records and care plans will be reviewed for correct code status identification weekly for one (1) month, then bi-weekly for three (3) months and then every month there after, and the CPR certification status of each licensed nurse will be checked upon hire and then monthly. 11. The SA validated through interview with the Administrator #1 that he will report the results of all established monitoring to the QA committee for immediate corrective plan of action of any deficient practice. The SA identified the Immediate Jeopardy as Past Non-Compliance beginning [DATE] through [DATE]. The facility provided sufficient evidence to show the facility corrected the non-compliance and was in substantial compliance with regulatory requirements as of [DATE], prior to the SA entering the facility on [DATE].