Every finding on record at Country Village Center, Genesis Healthcare

Based on interview and record review, the facility failed to ensure that residents were free of significant medication errors which resulted in a resident requiring hospitalization for multiple nights in 1 of 3 residents reviewed for unnecessary medications. (Resident identifier is #1.)Findings include:Review on 8/27/26 of Resident #1's progress note, dated 8/11/26, revealed Resident #1 was sent to the emergency room because a medication error had occurred and nursing staff were concerned about his electrolyte levels.Review on 8/27/26 of Resident #1's laboratory results, dated 8/11/26, revealed that Resident #1's Blood Urea Nitrogen (BUN) was 112 mg/dL (milligrams per deciliter) and creatinine was 6.80 mg/dL. The laboratory report designated both BUN and creatinine as above normal range and at critical levels.Review on 8/27/26 of Resident #1's Hospital Discharge summary, dated [DATE], revealed, Patient [Resident #1] will be admitted . Will hydrate [pronoun omitted] cautiously given [pronoun omitted] CHF [congestive heart failure] and follow renal function closely . The patient [Resident #1] was admitted for acute kidney injury on a background of chronic kidney disease following ingestion of an excessive doses of torsemide and metolazone. [Pronoun omitted] presentation was consistent with prerenal/volume depleted physiology due to excessive diuresis. [Pronoun omitted] ARB [angiotensin receptor blocker] and diuretics were all held here. Management was supportive with careful volume resuscitation utilizing IV [intravenous] fluids. We monitored [pronoun omitted] electrolytes closely and there were no derangement noted. Review on 8/27/26 of Resident #1's provider orders in the paper medical record, dated and signed by Staff D (Physician Assistant) on 7/31/26, revealed an order for Torsemide 40 mg in the morning and 20 mg in the evening (a total of 60 mg per day).Review on 8/27/26 of Resident #1's August 2026 Medication Administration Record revealed Resident #1 received the following Torsemide doses:On 8/1/26 to 8/7/26: at 6 a.m. - 40 mg, at 8 a.m. - 40mg, at 4 p.m. - 20 mg, at 7 p.m. - 20mg (a total of 120 mg).On 8/9/26: at 6 a.m. - 40 mg, at 4 p.m. - 40 mg (a total 80 mg).Interview on 8/27/26 at approximately 12:30 p.m. with Staff B (Registered Nurse) confirmed he/she had input Resident #1's order for Torsemide on 7/31/26. Staff B did not discontinue the active order already in place. Staff B revealed he/she second checked (confirmed) his/her order entry for the Torsemide on 7/31/26 rather than another nurse confirming. Review on 8/27/26 of facility policy titled Medication Reconciliation revised 12/16/24 revealed, .POLICY .Medication reconciliation is the process of comparing a patient's existing medication orders to all of the previous medications the resident has been taking. The process involves obtaining and maintaining a complete and accurate list of current medication use .PURPOSE To ensure a complete and accurate list of current medications .Review on 8/27/26 of the facility's corrective action plan revealed the following: an ad hoc Quality Assurance (QA) meeting was held on 8/11/26, a facility-wide audit of all Torsemide medications was completed on 8/11/26, a new process for entering orders was created on 8/12/26, education on medication order entry and reconciliation was provided to Staff B on 8/11/26, education on medication order entry and reconciliation was provided to all nurses on 8/11/26, and ongoing audits of orders will be conducted by the clinical team and reviewed during clinical morning meetings.Review on 8/27/26 of facility's policies, audits, QA meeting minutes, and education confirmed the above findings.

Based on observation, interview, and record review, the facility failed to initiate contact precautions for a resident with active symptoms of C.diff (Clostridioides difficile) for 1 of 3 residents reviewed for infection control in a final sample of 16 (Resident identifier is #5). Findings include:Review on 8/6/26 at approximately 8:00 a.m. of CDC's C. diff Facts For Clinicians, dated 4/13/26 revealed, If a patient has 3 or more loose stools in 24 hours isolate patient with possible C.diff immediately, even if you only suspect CDI .Wear gloves and a gown when treating patients with potential infectious diarrhea, including C. diff infection, even during short visits. Gloves are important because hand sanitizer doesn't kill C. diff. In addition, handwashing alone may not be sufficient to eliminate all C. diff spores.Review on 8/4/26 of Resident #5's SBAR (Situation, Background, Assessment, and Recommendation) dated 8/2/26 at 8:00 p.m. revealed, . Before calling MD (Medical Doctor), NP (Nurse Practitioner)/ PA (Physician Assistant) . Have relevant information available when reporting . resident had 3 large loose water BM's [bowel movements] and low-grade fever this shift.Temp [temperature] 100.4 .Review on 8/3/26 of Resident #5's progress note, dated 8/2/2026 at 11:02 p.m. revealed, Vitals: T (temperature) 100.4 .Resident had three instances of large loose watery BM's this shift. Provider notified. Observation on 8/3/26 at approximately 10:00 a.m. of Resident # 5's room revealed no signage outside the patient's room or PPE available near the entrance of the resident's room. Interview on 8/4/26 at approximately 2:00 p.m. with Staff C (Registered Nurse) revealed that he/she was the supervisor on 8/2/26 during the evening. Further interview confirmed Resident #5 was not put on contact precautions after the three watery loose stools on 8/2/26. Review on 8/4/26 of Resident #5's LNA (Licensed Nursing Assistant) task tab revealed that extensive assist incontinent care was provided to Resident #5 at 4:40 a.m. on 8/3/26. Review on 8/4/26 of Resident #5's laboratory results revealed that Resident #5's stool collected on 8/3/26 was positive for C-diff toxin A& B and Glutamate Dehydrogenase enzyme. Interview on 8/4/26 at approximately 2:15 p.m. with Staff B (Infection Preventionist) revealed it is the facility's policy to put residents who have had 3 or more loose watery stools on contact precautions. Review on 8/5/26 of facility policy titled Clostridioides Difficile Infection (CDI), revised 9/15/2025, revealed: Place patients with three or more liquid or watery stools in a 24-hour period in presumptive Contact Precautions. Patients suspected of recurrent CDI should be placed in Enteric Contact Precautions even sooner.Review on 8/5/26 of facility policy titled Transmission Based Precautions, review date 5/15/26, revealed, Nursing staff may place patients with suspected or confirmed infectious diarrhea, influenza, or symptoms consistent with a communicable disease on Transmission Based Precautions empirically while awaiting confirmation .Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside of the patient's room . The center will have PPE readily available near the entrance of the patient's room .

Based on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for Enhanced Barrier Precautions (EBP) for 1 of 1 resident reviewed for urinary catheter in a final sample of 18 residents. (Residents identifier are #78.)Findings include: Review on 9/10/25 of the facility's policy titled, Enhanced Barrier Precautions, revision date of 12/16/24, revealed .Implementation of EBP .Patient Status .Has a wound or indwelling medical device .Use EBP Yes, if they do not meet criteria for Contact Precautions .Observation on 9/9/25 at approximately 11:00 a.m. with Resident #78 revealed that Resident #78 has an indwelling urinary catheter. Further observation revealed no EBP signage posted and no Personal Protective Equipment (PPE) cart or supplies in Resident #78's room or outside of Resident #78's room. Interview on 9/9/25 at 11:36 a.m. with Staff I (Licensed Nursing Assistant) revealed that he/she was not aware if Resident #78 was on EBP. Interview on 9/9/25 at 11:48 a.m. with Staff H (Licensed Practical Nurse) confirmed that Resident #78 was not on EBP. Staff H revealed that residents on EBP would have an EBP sign posted outside of the resident's room and a PPE cart in the hallway outside of the resident's room.Review on 9/10/25 of Resident #78's medical record revealed a foley (indwelling) catheter care plan with an initiated date of 9/9/25 with an intervention for EBP. Observation on 9/10/25 at approximately 9:05 a.m. with Staff H revealed that there were no EBP signage and PPE cart outside of Resident #78's room. Interview on 9/11/25 at approximately 9.:02 a.m. with Staff B (Infection Preventionist) confirmed the above policy and that residents with indwelling catheter should be on EBP.

Based on interview and record review, it was determined that the facility failed to ensure that residents were offered the COVID-19 vaccine or provided education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine for 2 of 5 residents reviewed for immunizations and to implement policies and procedures on COVID-19 immunization for 1 of 1 staff reviewed for COVID-19 immunizations. (Resident Identifiers are #20 and #39 and Staff identifier is Staff A).Findings include:Review on 6/4/25 of the current CDC immunization guidelines retrieved from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html revealed People ages 65 years and older .are up to date when you have received: 2 doses of any 2024-2025 COVID-19 vaccine 6 months apart.Review on 9/11/25 of facility policy titled COVID-19 Vaccination revised on 2/7/24 revealed . Centers will provide the opportunity to receive COVID-19 vaccination following Centers for Disease Control and Prevention (CDC) recommendations subject to availability. 3. Based on the patient's COVID-19 vaccination history, offer the vaccination following the manufacturer's recommended schedule. 4. Employees are encouraged to obtain COVID-19 vaccination from their personal health provider, health department, or community health partners. Employees who consent to COVID-19 vaccination but cannot obtain COVID-19 vaccination through their personal health provider, health department, or community health providers should consult with their supervisor regarding alternate potential sources to obtain the COVID-19 vaccination .7.2. If an employee refuses COVID-19 vaccination, document declination on the COVID-19 Vaccine Informed Declination in the approved automated system.Resident #20Review on 9/10/25 of Resident #20's medical record revealed that Resident #20 was born in 1939 ([AGE] years old).Review on 9/10/25 of Resident #20's vaccination records revealed Resident #20 received the 2024-2025 Pfizer COVID-19 vaccine on 9/26/24. There was no documentation of Resident #20 being offered or educated about the next dose recommendations.Resident #39Review on 9/10/25 of Resident #39's medical record revealed that Resident #39 was born in 1950 ([AGE] year-old).Review on 9/10/25 of Resident #39's vaccination records revealed the 2024-2025 Pfizer COVID-19 vaccine was administered on 9/24/24. There was no documentation of Resident #39 being offered or educated about the next dose recommendations.Interview on 9/11/25 at approximately 8:18 a.m. with Staff B (Infection Preventionist) confirmed that there was no documentation that Resident #20 and Resident #39 were offered or educated about the next dose recommendations.Review on 9/10/25 of Staff A's (Licensed Nursing Assistant (LNA)) COVID-19 Vaccination Information revealed that Staff A's last COVID-19 vaccination was 6/1/22.Interview on 9/10/25 at 1:01 p.m. with Staff A revealed that they were not provided information that a COVID-19 vaccination was available for 2024/25 and that he/she had not been asked to sign a declination that they had been educated and/or refused the COVID-19 vaccination.Interview on 8/13/25 at 3:10 p.m. with Staff C (Administrator) revealed that the facility does not offer COVID-19 vaccinations to employees or track/obtain a declination.

Based on interview and record review, it was determined that the facility failed to inform a resident and/or the resident's representative of the risks and benefits of psychotropic medications for 1 of 5 resident reviewed for unnecessary medications in a final sample of 18 residents. (Resident identifier is #3.)Findings include:Review on 9/10/25 of Resident #3's active physician's orders revealed the following psychotropic medications and start date:Buspirone 5 mg (milligram) give 1 tablet by mouth three times a day for anxiety with a start date of 6/24/25.Lamotrigine 100 mg give 1 tablet by mouth one time day for bipolar disorder with a start date of 6/25/25.Ziprasidone 60 mg give 1 capsule by mouth twice a day with meal or snack for bipolar disorder with a start date of 6/24/25. Review on 9/11/25 of Resident #3's medical record revealed no documentation that Resident #3 or Resident #3's representative was informed of the risk and benefits of the above psychotropic medications. Interview on 9/11/25 at approximately 11:25 a.m. with Staff D (Director of Nursing) confirmed the above findings. Staff D was unable to provide documentation that Resident #3 or Resident #3's representative were inform of the risks and benefits of the above psychotropic medications.

Based on observation, interview, and record review, it was determined that the facility failed to properly dispose of medications for 1 of 4 residents observed for medication administration. (Resident identifier is #23.)Findings include:Observation on 9/10/25 between 8:25 a.m. to 8:35 a.m. with Staff F (Licensed Practical Nurse (LPN)) during Resident #23's medication administration revealed that Staff F poured two tablets of multivitamin in a medicine cup and discarded one tablet of multivitamin in the sharps container. Further observation revealed that an open bottle of Over The Counter (OTC) Aspirin Enteric-Coated (EC) 81 mg (milligram) had no visible expiration date on the bottle. Staff G (LPN) came over to ask a question to Staff F and Staff G took the above mentioned open bottle of Aspirin EC 81 mg then discarded the bottle in the open waste bin that had no label and was attached to the medication cart.Interview on 9/10/25 between 8:25 a.m. to 8:35 a.m. with Staff F confirmed the above observation. Review on 9/10/25 of the facility policy titled, Disposal of Medication Waste, revision date of 7/1/24, revealed .Medications that cannot be returned to the pharmacy .will be placed in medication disposal bins labeled: 4.1.1 Hazardous/Nonhazardous waste 4.1.2 Incompatible waste, 4.1.3 Acute waste, 4 1.4 Controlled Substance waste .Waste bins will be stored in the medication room or other secure medication storage area not accessible to patients .Solid dosage form medications (e.g., pills, capsules) are to be removed from their original containers before disposal .Medications are not to be disposed in common areas, resident trash cans, or sharps container .

Based on observation, interview, and policy review, it was determined that the facility failed to store food in accordance with professional standards for food safety to prevent foodborne illness for 1 of 1 kitchen and 2 of 3 kitchenettes observed. Findings include: Observation on 9/4/24 at approximately 9:55 a.m. with Staff B (Dietary Manager) of the main kitchen milk cooler revealed the following: 1 open container and 1 unopened container of Grave prune juice, both with a manufacturer's use by date of 8/10/24; 10 single serve containers of Dannon Light and Fit yogurts with a manufacturer's use by date of 4/2/24. Observation on 9/4/24 at approximately 10:00 a.m. with Staff B of the Cohass Unit kitchenette refrigerator revealed the following: 1 open container of Hormel thick and easy hydrolyte water with hint of lemon with a hand written open date of 6/19/24. Further observation of the Hormel container revealed manufacturer's instructions that read Discard if not used with in 10 days of opening.; 1 open container of Chick-fil-A sauce with a manufacturer's use by date of 12/18/23. Observation on 9/4/24 at approximately 10:10 a.m. with Staff B of the Notchway Unit kitchenette refrigerator revealed the following: 1 storage container of green beans labeled with a residents name and the dates 8/28/24-8/30/24. Interview on 9/4/24 at approximately 10:10 a.m. with Staff B confirmed the above findings. Staff B stated that the green beans in Notchway unit refrigerator should have been discarded on 8/30/24. Review on 9/4/24 of facility policy titled, Food Handling, revised on 6/15/18, revealed: .Foods that are marked with a manufacturer's 'use by' date what are properly stored can be used until that date as long as the product has not been combined with any other food or prepared in any way including portioning . Review on 9/4/24 of facility policy titled, Food: Safe Handling for Foods from Visitors, revised 7/2019 revealed: .5. Refrigerator/freezer for storage of foods brought in by visitors will be properly maintained .Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for over 7 days . Review on 9/4/24 of the Food Code U.S. Public Health Service 2017 U.S. Department of Health and Human Services, retrieved from https://www.fda.gov/food/fda-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines .Chapter 3 Food .Page 458 Manufacturer's use-by dates .It is not the intent of this provision to give a product an extended shelf life beyond that intended by the manufacturer. Manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe. Most, but not all, sell-by or use-by dates are voluntarily placed on food packages .The manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind .

Based on observation, interview, and record review it was determined that the facility failed to follow CDC guidelines for hand hygiene and the use of appropriate Personal Protective Equipment (PPE) to prevent the spread of infection for 32 residents on Transmission Based Precautions (TBP) and 3 residents on Enhanced Barrier Precautions (EBP). Findings include: Isolation Gowns Interview on 9/4/24 at 9:46 a.m. with Staff A (Administrator) revealed that the facility currently had 32 residents on Droplet Precautions for COVID-19 and they resided on all 3 units. Review on 9/4/24 of the facility Resident Matrix, dated 9/4/24, revealed that there were 32 residents on TBP and 3 additional residents who had indwelling devices; who were observed to be on EBP. Observation on 9/4/24 at approximately 1:15 p.m. of the facility isolation gowns being used on all 3 units for TBP and EBP rooms revealed that gowns being used in the facility were thin and of a light material. There were no other gowns observed on the units. Review on 9/4/24 at approximately 1:15 p.m. of the plastic packaging for the of the above gowns revealed that they were Cover Gowns .Appropriate for situations where exposure to blood and/or bodily fluids is not a risk. Interview on 9/4/24 at 1:30 p.m. with Staff E (Infection Preventions) revealed that the facility only had the above gowns in the facility and those gowns were being used for all residents who were on TBP and EBP regardless of the risk for exposure to blood and/or bodily fluids. Review on 9/4/24 of the product description of the gowns, provided by the facility, revealed: Gown, Cover . Lightweight gowns offer comfort and breathability for less critical areas . Interview on 9/4/24 at 3:35 p.m. with Staff A confirmed that the gowns being used in the facility were not recommended for use with any potential bodily fluids and therefore should not be used . 28881 PPE and Hand Hygiene Observation on 9/6/24 at approximately 9:30 a.m. revealed Staff D (Licensed Nurse Assistant) exited a COVID-19 positive resident room after providing care, and without discarding or disinfecting their face shield, entered another resident room containing residents without COVID-19. Interview on 9/6/24 at approximately 9:35 a.m. with Staff D confirmed they entered a non-COVID-19 room without having changed or disinfected their face shield. Interview on 9/6/24 at approximately 9:40 a.m. with Staff E confirmed that staff were to discard used PPE prior to exiting a precaution room. 43408 Observation on 9/4/24 at approximately 11:40 a.m. of the Cohass unit meal service revealed the following: Staff F (Licensed Nursing Assistant) entering a COVID-19 positive room wearing an N95 mask and no isolation gown, gloves or eye shield. After exiting the room, Staff F did not perform hand hygiene before going to a COVID-19 negative room to assist a resident. Staff F then left that room without performing hand hygiene and retrieved a meal tray from the meal tray cart and delivered it to a second COVID-19 positive room with an N95 mask on without an isolation gown, gloves or eye shield. Interview on 9/4/24 at approximately 11:40 a.m. with Staff F revealed they were not aware that they had to don gloves, eye shield or isolation gown when entering a COVID-19 positive room unless they were directly coming in contact with the resident. Staff F also stated that they were not aware they had to perform hand hygiene unless they were coming into direct contact with a resident. Interview on 9/4/24 at approximately 11:55 a.m. with Staff E revealed that during meal service, the COVID-19 negative rooms were to be passed their trays before the COVID-19 positive rooms. Staff E stated that staff are to don full PPE when entering a COVID-19 positive room, which includes an N95 mask, isolation gown, gloves and an eye shield. Staff E stated that staff were expected to perform hand hygiene in between patient interactions, before donning and after doffing any PPE, or when hands were visibly soiled. Review on 9/4/24 of the Special Contact and Droplet Precautions for Special Respiratory Circumstances signage outside COVID-19 positive rooms revealed: .Perform Hand Hygiene Before and After patient contact, contact with environment and after removal of PPE (Alcohol based hand rub). Wear an N95 Respirator, Gown, Face Shield and gloves upon entering this room . Review on 9/6/24 of the facility's policy titled Infection Prevention and Control Program Description, revised 7/1/24, revealed: .Implementation of Control Measures and Precautions includes basics such as hand hygiene, Standard and Transmission Based Precautions, cleaning/disinfecting equipment and measures to protect persons . from communicable diseases or infections . Review on 9/9/24 of the CDC guidance titled, Infection Control Guidance: SARS-CoV-2, dated June 24, 2004, revealed: .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection .HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) . Review on 9/9/24 of the CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, last update: July 2023, revealed: .Isolation gowns are used as specified by Standard and Transmission-Based Precautions, to protect the HCW's [Health Care Worker's] arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material . The need for and type of isolation gown selected is based on the nature of the patient interaction, including the anticipated degree of contact with infectious material and potential for blood and body fluid penetration of the barrier. The wearing of isolation gowns and other protective apparel is mandated by the OSHA Bloodborne Pathogens Standard .Isolation gowns are always worn in combination with gloves, and with other PPE when indicated . Review on 9/9/24 of the CDC Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug Resistant Organisms (MDRO's), updated July 12, 2022 revealed: . Effective implementation of EBP requires .the availability of PPE and hand hygiene supplies at the point of care .Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing .MDRO's may be indirectly transferred from resident-to-resident during these high-contact activities. Nursing home resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO's. The use of gown and gloves for high-contact resident care activities is indicated . Review on 9/6/24 of CDC guideline titled, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24, retrieved from: https://www.cdc.gov/infection-control/hcp/core-practices/index.html, revealed: .Hand Hygiene .Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations. Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient .After touching a patient or the patient's immediate environment .Immediately after glove removal . Ensure proper selection and use of personal protective equipment (PPE) based on the nature of the patient interaction and potential for exposure to blood, body fluids and/or infectious material: Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Wear a gown that is appropriate to the task to protect skin and prevent soiling of clothing during procedures and activities that could cause contact with blood, body fluids, secretions, or excretions. Use protective eyewear and a mask, or a face shield, to protect the mucous membranes of the eyes, nose and mouth during procedures and activities that could generate splashes or sprays of blood, body fluids, secretions and excretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed. Remove and discard PPE, other than respirators, upon completing a task before leaving the patient's room or care area. If a respirator is used, it should be removed and discarded (or reprocessed if reusable) after leaving the patient room or care area and closing the door. Do not use the same gown or pair of gloves for care of more than one patient. Remove and discard disposable gloves upon completion of a task or when soiled during the process of care .

Based on record review and interview, it was determined that the facility failed to accurately code Minimum Data Set (MDS) assessments for 2 residents reviewed for MDS in a final sample of 18 residents (Resident Identifiers are #25 and #75). Findings include: Resident #75 Review on 9/6/24 of Resident #75 Discharge MDS with an assessment reference date of 7/23/24 revealed under Section A, Discharge Status, that the Resident was coded as discharged to a Short-Term General Hospital. Review on 9/6/24 of Resident #75's Discharge Summary dated 7/23/24 revealed that the resident discharged home. Interview on 9/6/24 at approximately 12:45 p.m. with Staff C (MDS Coordinator) revealed the discharge disposition was incorrectly coded and should have been coded as Home/Community. 48515 Resident #25 Review on 9/5/24 of Resident #25's medical record revealed no order for restraints or a care plan regarding the use of restraints. Review on 9/5/24 of Resident #25's Quarterly MDS, dated [DATE], Section P, Restraints and Alarms, revealed that Resident #25 was coded for use of bed rails daily. Interview on 9/5/24 at approximately 9:30 a.m. with Staff C confirmed that Resident #25 does not utilize a restraint and further confirmed that Resident #25's MDS was coded incorrectly.

Based on observation, interview, and policy review it was determined that the facility failed to store food in accordance to professional standards in the main kitchen. Findings include: Review on 9/21/23 of the Food Code U.S. Public Health Service 2022 U.S. Department of Health and Human Services retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2022 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food .3-305.11 Food Storage .FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . Observation on 9/18/23 at approximately 9:45 a.m. with Staff D (Cook) of the dry food storage area and walk-in refrigerator revealed the following: One (1) box of bananas in the dry food storage area containing 8 bananas that were wilted and brown, peels split open in some areas covered with fruit flies, stored with fresh bananas. One (1) box of celery in the walk-in refrigerator containing 3 wilted celery stocks with brown discolored wilted leaves. Interview on 9/18/23 at 10:00 am with Staff D confirmed the above findings. Review on 9/19/23 of the facility's policy titled, Dry Storage, dated 5/1/23, revealed: Policy - Products stored in dry storage areas are maintained in a safe and sanitary manner .Purpose - To prevent damage, spoilage, contamination, and infestation of products. Review on 9/19/23 of the facility's policy titled, Refrigerated/Frozen Storage, dated 5/1/23, revealed: Policy - Products stored in dry storage areas are maintained in a safe and sanitary manner .Purpose -To prevent damage, spoilage, contamination, and infestation of products.

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that a biological was labeled with an opened date and failed to ensure that controlled drugs were in a double locked secure compartment in 1 out of 1 medication room observed (Resident Identifier is #11). Findings include: Observation on 9/18/23 at approximately 10:15 a.m. with Staff A (Registered Nurse) of the only medication room revealed 1 opened multi-dose vial of Aplisol (Tuberculin Purified Protein Derivative, diluted) not labeled with an open expiration date. Interview on 9/18/23 at approximately 10:15 a.m. with Staff A confirmed the above findings. Review on 9/18/23 of the manufacturer's instructions for APLISOL revealed .Storage Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency . Review on 9/18/23 of the Storage and Expiration Dating of Medications, Biologicals policy, dated 8/7/23 revealed . 5.3 If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured ), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial . Observation on 9/18/23 at approximately 10:30 a.m. in the medication room revealed 1 narcotic box in the refrigerator that was not locked. Further observation revealed that the narcotic box contained two bottles of liquid Ativan for Resident #11. Interview on 9/18/23 at approximately 10:30 a.m. with Staff A confirmed the above findings. Review of Storage and Expiration Dating of Medications, Biologicals policy, dated 8/7/23 revealed: .3. General Storage Procedures . 12.4 Controlled Substances stored in the refrigerator must be in a separate container and double locked .

Based on record review and interview, it was determined that the facility failed to follow professional standards for clarifying medication orders for as-needed pain medication for 1 of 1 resident reviewed for pain management in a final sample of 19 residents (Resident Identifier is #37). Findings include: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders. The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 9/19/23 of Resident #37's physician's orders revealed the following orders: Acetaminophen Tablet 325 milligram (mg) give two tablets by mouth every 4 hours as needed for mild/mod[erate] pain, dated 9/1/23. Oxycodone-Acetaminophen Oral Tablet 5-325 mg (milligrams) Give 1 tablet by mouth every 24 hours as needed for pain management, dated 7/3/23. Review on 9/19/23 of the Medication Administration Record for September 2023 revealed that Resident #37 received 24 doses of as-needed Acetaminophen in September 2023 for pain levels ranging from #1-4. Review on 9/19/23 of the Medication Administration Record for September 2023 revealed that Resident #37 received 1 dose of as-needed OxyCodone for a pain level of 4. Interview on 9/19/23 at approximately 8:45 a.m. with Staff F (Director of Nurses) confirmed that there were no defined parameters for the administration of as-needed Oxycodone. Review on 9/20/23 of the Pain Management policy dated 10/24/22 revealed: . 6.2 Have defined parameters for use

Based on interview and record review, it was determined that the facility failed to ensure a resident was offered or provided education on the risks and benefits of the Pneumococcal vaccination for 2 of 5 residents reviewed for Pneumococcal immunizations (Resident identifiers are #1 and #2). Findings include: Resident #1 Review on 6/21/23 of Resident #1's medical record revealed that Resident #1 was [AGE] years old. Review of Resident #1's immunization record revealed the following: Pneumovax Dose 1, 7/3/2008. Further review of Resident #1's medical record revealed that there was no indication that further Pnemococcal vaccination was offered or that education was provided on the Pneumococcal vaccination. Resident #2 Review on 6/21/23 of Resident #2's medical record revealed that Resident #2 was [AGE] years old. Review of Resident #2's immunization record revealed the following: Pneumovax Dose 1, 10/1/2014. Further review of Resident #2's medical record revealed that there was no indication that further Pneumococcal vaccination was offered or that education was provided on the Pneumococcal vaccination. Interview on 6/21/23 at approximately 11:30 a.m. with Staff A (Infection Preventionist) confirmed the above findings. Review on 6/21/23 of the facility policy titled, IC601 Pneumococcal Vaccination, Revision Date 11/15/22 revealed: Centers will provide the opportunity to receive the appropriate pneumococcal vaccine to all patients/residents Review of the CDC website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, effective 02/13/23, indicated . CDC recommends pneumococcal vaccination for all adults [AGE] years or older . For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give 1 dose of PCV [Pneumococcal Conjugate Vaccine] 15 or PCV20 . If PCV15 is used, this should be followed by a dose of PPSV [Pneumococcal Polysaccharide Vaccine] 23 at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 is used, a dose of PPSV23 is NOT indicated . For adults [AGE] years or older who have only received a PPSV23, CDC recommends you . May give 1 dose of PCV15 or PCV20 . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults [AGE] years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended . For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete .

Based on interview and record review, it was determined that the facility failed to follow professional standards by moving a resident who had fallen for 1 of 3 residents reviewed for accidents/neglect (Resident identifier #3). Findings Include: Standard Journal of Nursing; AJN, November 2007 Vol. 107, No. 11. Retrieved from https://www.nursingcenter.com/pdfjournal?AID=751198&an=00000446-200711000-00030&Journal_ID=54030&Issue_ID=751137 on 10/30/20: When a Fall Occurs Step one: assessment. When a patient falls, don't assume that no injury has occurred-this can be a devastating mistake. Before moving the patient .Observe the leg rotation, and look for hip pain, shortening of the extremity, and pelvic or spinal pain. Review on 6/21/23 of Resident #3's progress note, dated 5/16/23 at 1:20 a.m. and signed by Staff C (Registered Nurse), revealed found lying on [pronoun omitted] left side, on the floor, between door to [Pronoun omitted] bathroom and the room door .c/o [complained of] left hip pain. Leg noted to be slightly shorter w/ [with] possible external rotation .Transferred to bed via [by way of] full lift and assist of two. Call placed to 911 for EMS [Emergency Medical Staff] transfer . Interview on 6/21/23 11:15 a.m. with Staff B (Director of Nursing) confirmed that Resident #3 was moved after identifying signs of potential injury and before notifying provider and EMS. Staff B stated that the expectation when finding possible injury is to not move the resident and notify provider for further instructions.

Based on interview and record review, it was determined that the facility failed to ensure surveillance testing for COVID-19 was performed for staff who were not up to date with COVID-19 vaccination based on level of community transmission for 1 of 3 staff reviewed for COVID-19 vaccination. Findings include: Review on 9/28/22 at approximately 11:00 a.m. of Staff K (Licensed Nursing Assistant (LNA)) COVID-19 vaccination status revealed that they were fully vaccinated but not up-to-date with COVID-19 vaccinations. Review on 9/28/22 at approximately 11:00 a.m. of the facility's community transmission risk and testing guidance for the time period of 8/26/22 through 9/23/22 revealed the following levels of transmission: 8/26/22-9/2/22- Community Transmission Risk : High- Minimum testing frequency: Twice Weekly; 9/2/22-9/9/22- Community Transmission Risk : Moderate- Minimum testing frequency: Weekly; 9/8/22-9/15/22- Community Transmission Risk : Substantial- Minimum testing frequency: Twice Weekly; 9/16/22-9/23/22- Community Transmission Risk : High- minimum testing frequency: Twice Weekly. Review on 9/28/22 at approximately 11:00 a.m. of Staff K's testing log for the time period 8/26/22 through 9/23/22 revealed the following COVID-19 tests were conducted: 8/26/22-9/2/22 a COVID-19 test was performed on 8/30/22 and 9/2/22; 9/2/22-9/9/22 a COVID-19 test was performed on 9/2/22, which was used for the previous weekly testing; 9/8/22-9/15/22 a COVID-19 test was performed on 9/13/22; 9/16/22-9/23/22 No COVID-19 tests were performed. Interview on 9/28/22 at approximately 1:00 p.m. with Staff J (Infection Preventionist) confirmed that Staff K did not have appropriate COVID-19 surveillance testing per the CMS (Centers for Medicare and Medicaid Services) guidelines. Staff J stated that it was very likely others were missed as well. Review on 9/28/22 of the CMS memo QSO-20-38-NH titled, Interim Final Rule (IFR), CMS-340-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID-19 Focused Survey Tool, revision date of 3/10/22 revealed: .Routine testing of staff, who are not up-to-date, should be based on the extent of the virus in the community . When the level of COVID-19 community transmission is HIGH then testing of staff who are not up to date with COVID-19 vaccionation should be conducted at a minimum of twice a week.

Based on observation, interview, and record review, it was determined that the facility failed to follow professional standards for labeling and storage of food items for 2 of 3 kitchenettes reviewed. Findings include: Review on 9/27/22 at approximately 10:27 a.m. of the Cohass Unit Kitchenette refrigerator revealed 1 fruit bowl, from outside the facility, with a handwritten label identifying a resident name and a date of 9/19/22. Interview on 9/27/22 at approximately 10:27 a.m. with Staff H (Licensed Nursing Assistant) confirmed the above findings. Staff H stated the fruit should have been thrown out after 3 days. Review on 9/27/22 at approximately 10:35 a.m. of the Notch Way Unit Kitchenette refrigerator revealed an opened bag of cooked shrimp with a store sticker which read packed on 9/23/22, sell by 9/24/22. Further review revealed the outside of the bag to be visibly moist along with other food items in the drawer. Interview on 9/27/22 at approximately 10:35 a.m. with Staff G (Registered Nurse) confirmed the above findings. Review on 9/27/22 at approximately 11:00 a.m. of the facility policy titled Safe Handling for Foods from Visitors, revised on 7/2019, revealed .4. When food items are intended for later consumption, the responsible facility staff member will: Ensure that the food is stored separate or easily distinguishable from the facility food. Ensure that foods are in a sealed container to prevent cross-contamination. Label foods with the resident name and the current date. Determine if food items are shelf stable and whether they can be stored in the resident's room or stored under refrigeration. 5. Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and .daily monitoring for refrigerated storage duration and discard of any food items that have been stored for >7 days . Review on 9/28/22 of the Food and Drug Administration (FDA) article titled Selecting and Serving Fresh and Frozen Seafood Safely; found at https://www.fda.gov/food/buy-store-serve-safe-food/selecting-and-serving-fresh-and-frozen-seafood-safely, updated on 2/17/22, revealed the following .As with any type of food it is important to handle seafood safely to reduce the risk of foodborne illness, often called food poisoning.If seafood will be used within 2 days after purchase, store it in a clean refrigerator at a temperature of 40 F or below .

Based on interview, observation, and record review, it was determined that the facility failed to ensure that medications were labeled with resident identifiers, open or use by dates, and failed to separate expired medications from unexpired medications for 1 out of 3 medication carts observed. Resident Identifier #73. Findings include: Observation on 9/27/22 at 9:35 a.m. of the Upper Notch Medication Cart revealed the following: One opened insulin pen without an opened date or a use by date. The delivery date noted to be on 9/18/22. [MEDICATION(S)] (Insulin) Pen 100 unit/milliliter (ml) for Resident #73. Interview with Staff F (Licensed Practical Nurse (LPN)), on 9/27/22 at approximately 9:37 a.m. confirmed the above findings for the Upper Notch Medication Cart. Staff F stated that the pen is used for Resident #73. Review of Resident #73's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 9/27/22 of the facility policy titled Storage and Expiration Dating of Medications, Biologicals revised on 7/21/22 revealed .5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the opened date on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened.

Based on interview, record review, and policy review it was determined that the facility failed to determine what may have contributed to the fall or properly assess the resident after the fall for 1 of 1 resident reviewed for abuse in a final sample of 18 residents. (Resident identifier is #28). Findings include: Interview on 9/27/22 at approximately 11:15 a.m. with Resident #28 revealed that Resident #28 fell while walking in the aisle to get off the facility bus after a scheduled activities trip on 9/26/22. Review on 9/27/22 of Resident #28's progress notes revealed no documentation of the description of the fall and no documented assessment of Resident #28 on 9/26/22. Interview on 9/28/22 at approximately 11:00 a.m. with Staff D (Recreation Aide) revealed that Resident #28 lost her balance while ambulating in the aisle of the bus as resident #28 was exiting the bus after a bus ride on 9/26/22. Staff D stated she was able to assist Resident #28 with the assistance of Staff C (Licensed Nursing Assistant) before Resident #28 fell to the floor. Further interview revealed Staff D reported the incident to the evening charge nurse. Interview on 9/28/22 at approximately 11:20 a.m. with Staff C confirmed the above findings. Interview on 9/28/22 at approximately 11:30 a.m. with Staff A (Director of Nursing) revealed the facility was not aware of the fall for Resident # 28 that occurred on 9/26/22. Review on 9/29/22 of the facility policy titled Accident/Incidents, revised 5/1/22, revealed .POLICY Center staff will report, review and investigate all accidents/incidents which occurred, or allegedly occurred, on or off center property and involving, or alleged involving, a patient who is receiving services PURPOSE To provide standards for review and investigation of accident/incidents. To determine root cause and contributing factors, identify measures to reduce further occurrences and adverse outcomes as part of the Quality Assurance Performance Improvement (QAPI) process. To meet regulatory requirements for analyzing and reporting accidents/incidents PROCESS .Evaluation: 2.1 Patients: 2.1.1 The nurse will evaluate the patient. 2.1.2 First Aid will be provided .2.1.3 The nurse will notify the Physician/APP of the accident/incident, report physical findings .2.5.1 The patient's representative will be notified of the accident/incident .2.1.6 The nurse will: .2.1.6.2 Document the accident the accident/incident in the patients chart; Documentation will include all pertinent information, date, time, place, notifications, post accident/incident evaluation, and ongoing evaluations Reporting: 3.1 All accidents/incidents, witnessed or unwitnessed, will be reported to the supervisor 3.2 The supervisor will notify the Administrator and DON of accident/incident.

Based on observation, interview, and record review it was determined that the facility failed to provide necessary treatment to prevent the development/progression of a pressure ulcer and failed to monitor a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers in a final survey sample of 18 residents. (Resident identifier is #40.) Findings include: Professional Reference: Per National Pressure Ulcer Advisory Panel (March 2014) The NPUAP Selected 'Quality of Care Regulations made easy . (See http://www.npuap.org/wp-content/uploads/2014/03/NPUAP-F-tag-final-March-2014.pdf accessed 1/29/2018) .Pressure Ulcers: With each dressing change or at least weekly .an evaluation of the pressure ulcer wound should be documented. At a minimum, documentation should include the date observed and: -Location and staging -Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth; and the presence, location, and extent of any undermining or tunneling/sinus tract; -Exudate, if present: type (such as purulent/serous), color, odor, and approximate amount; -Pain, if present: nature and frequency (e.g., whether episodic or continuous); -Wound bed: Color and type of tissue/character including evidence of healing (e.g., granulation tissue), or necrosis (slough or eschar); and -Description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) as appropriate . Review on 9/28/22 of Resident #40's August 2022 and September 2022's TAR (Treatment Administration Record) revealed the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 9/29/22 at approximately 8:00 a.m. with Staff L (Unit Manager) and Staff A (Unit Manager) revealed that they were unaware of Resident #40 having had any pressure ulcers recently and they had not been monitored weekly. Review on 9/28/22 of Resident #40's skin checks for September 2022 revealed that on 9/14/22 there were no longer areas of concern. Interview on 9/29/22 at approximately 8:15 a.m. with Staff A revealed that when a pressure ulcer develops, the resident is followed by the facility wound team. Staff A confirmed that Resident #40 was not being followed the wound team and there was no documented monitoring or measuring of the 2 pressure ulcers between 8/2/22 and 9/14/22. Observation on 9/29/22 at approximately 9:00 a.m of Resident #40's 4th and 5th toes with Staff L revealed the 2 areas were closed with 2 areas noted on the 4th toe that appeared darker pink in color than the rest of the toes. Review on 9/29/22 of the facility policy titled, Skin Integrity Care Delivery Process, dated 6/1/2016 revealed: . Evaluation . 3. Daily Skin Observation . Check for pressure related to positioning, shoes, Skin Wound Management 1. Skin Integrity Report . Wound Documentation Guidelines . Weekly Routine evaluations will be provided to monitor the patient and his/her wound's response to treatments and interventions

Based on interview and record review, it was determined that the facility failed to follow physicians orders for 1 out of 4 residents reviewed for nutrition in a final sample of 18 residents. (Resident identifier is #61.) Findings include: Standards: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 9/28/22 of Resident #61's September 2022 MAR (Medication Administration Record) revealed the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Daily weight x7 days, order date 9/24/22. Further review of September 2022's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 9/25/22 no weight entered 9/26/22 no weight entered Interview on 9/28/22 at approximately 1:00 p.m. with Staff A (Unit Manager) confirmed Resident #61's weights were not obtained on 9/25/22 and 9/26/22.

Based on medical record review and interview, it was determined that the facility failed to ensure that a facility staff provided the intervention of CPR (Cardiopulmonary Resuscitation) to a full code resident at the time of their death resulting in neglect at a past non-compliance immediate jeopardy level for 1 resident out of a survey sample of 9 residents. (Resident identifier is #1.) Findings include: Review on [DATE] of Resident #1's medical record revealed a physician order [REDACTED]. Review of Resident #1's care plan for advance directives with a revision date of [DATE] revealed that Resident #1 wished to be a full code. In addition, Resident #1 had been full code prior to the revision date of [DATE]. Review on [DATE] of the facility's Description of incident or concerns; revealed, (Resident #1) was found by licensed nursing assistant (Staff E) and (Staff F , LNA) on [DATE] (death occurred on [DATE]; [DATE] was the day that the shift began) at 01:30 in bed and did not appear to be breathing, LNA (Staff E) immediately went to nurse (Staff C, Licensed Practical Nurse) who was caring for resident (Resident #1), and informed .(Staff C), while LNA (Staff F) grabbed vital sign pole (pole/cart to be used to check blood pressure, respirations, temperature, etc.), LPN (Staff C) stated .(Staff C) administered CPR, however, all evidence supports that CPR was not provided, code cart was undisturbed, employee statements support no CPR given, LPN (Staff C) admitted .(Staff C) did not check for conclusive signs of death, did not get code cart, did not notify physician, and did not intervene when .(Staff C) saw the resident (Resident #1) one hour before in distress. Review on [DATE] of facility interview on [DATE] at 3:15 p.m. with Staff E revealed, .About 01:15 .(Staff E) got .(Staff F) to help .(Staff E) with rounds and we went into .(Resident #1's) room we saw .(Resident #1) was pale and didn't think .(Resident #1) was breathing. (Staff E) went to get the nurse .(Staff C) who came down and locked (sic) at .(Resident #1) and asked .(Staff E) to get .(Staff G, Licensed Practical Nurse) the other nurse. (Staff E) walked to the nurse's station to get .(Staff G), and .(Staff F) got the vital sign pole and took it in the room. (Staff E) told .(Staff G) that .(Staff C) wanted .(Staff G) in .(Resident #1's) room and .(Staff G) went down there. (Staff E) did not see anything else .(Staff E) was not in the room. (Staff C) the nurse came out of the room about 2 minutes later and told us that .(Resident #1) passed and to go in and do post mortem care. During interview on [DATE] in the afternoon with Staff E, Staff E's interview dated [DATE] at 3:15 p.m. was reviewed. Staff E confirmed that what was documented was accurate to what Staff E had told the facility. Review on [DATE] of facility interview on [DATE] at 11:15 a.m. with Staff F revealed, On [DATE] .(Staff F) was helping .(Staff E) with rounds it was about 1:30 .(Staff F) think, we went into .(Resident #1's) room and .(Resident #1) looked dead, .(Resident #1) was cold on .(Resident #1's) hands and face, and pale .(Resident #1's) eyes were closed we told the nurse .(Staff C) and .(Staff C) went in and looked at .(Resident #1) then .(Staff C) called for .(Staff G) the other nurse and .(Staff C) went in the room, .(Staff F) went to get the vital sign pole because .(Staff F) thought they would need it. (Staff F) left to finish helping with rounds. Review on [DATE] of Staff G's written statement dated [DATE] revealed, On (MONTH) 10,2018 at 01:30 a.m.- .(Staff G) was at the nurses' station doing paperwork when .(Staff E) came up to .(Staff G) and said .(Staff C) needs you in .(Resident #1's) Rm (room). On arrival to Rm (room number omitted), .(Resident #1's) Rm .(Staff G) found .(Staff C) standing beside the bed, the nurse on the shift (Staff C) was there- .(Resident #1) was lying prone in bed, no respirations, color ashen, skin cool to touch eyes + mouth open slightly- .(Staff C) states, 'she's passed.' (Staff C) then walks out with (Staff G) to the nurse's station, .(Staff G) said .(Staff C) will have to call a RN in to pronounce. During interview on [DATE] in the afternoon with Staff G, Staff G's written statement dated [DATE] was reviewed and Staff G confirmed that it was accurate to what Staff G remembered happening. Review on [DATE] of Staff D's (Registered Nurse) written statement dated [DATE] revealed, (Staff D) was called at 0134 a.m. [DATE] by .(Staff C). (Staff C) stated, '(Resident #1) passed and .(Staff C) need someone to pronounce (Resident #1) as neither .(Staff G) nor (Staff C) can do that.' (Staff D) arrived at (facility) at 0200 and found .(Resident #1) in .(Resident #1's) bed lying flat, no audible respirations, no chest rise noted. (Staff D) listened to chest for 1 minute with stethoscope and no heart beats were noted. Resident was pronounced at 0200. During interview on [DATE] in the afternoon with Staff D, Staff D's written statement dated [DATE] was reviewed and Staff D confirmed that it was accurate to what Staff D remembered happening. Review on [DATE] of Staff C's written statement dated [DATE] revealed, (Staff C) was informed by LNA (Staff E) @ 0130 something was wrong c (with) .(Resident#1). (Staff C) had get to .(Resident #1's) room attempted v/s (vital signs) started to do CPR. looked around saw LNA told .(Staff E) to get .(Staff G). (Staff G) came in looked @ .(Resident #1) and said yes .(Resident #1) is passed-said a quick word to .(Resident #1)-looked @ .(Staff C) said .(Resident #1) is gone we need to call someone to pronounce .(Resident #1). During interview on [DATE] in the morning with Staff C, Staff C's written statement was reviewed and Staff C confirmed that it was accurate to what Staff C remembered happening. Review on [DATE] of facility interview notes dated [DATE] at 1:30 p.m. with Staff C, Staff H (Licensed Practical Nurse) and Staff B (Director of Nurses) present, revealed, (Staff B) read .(Staff C's) written statement back to .(Staff C) and .(Staff C) stated it was correct; (Staff B) then read (Staff C's) nurse's note and asked the following questions: 1.) Did .(Staff C) shake .(Resident #1) call .(Resident #1's) name or do a sternal rub? Answer No 2.) Did .(Staff C) check .(Resident #1's) pupils for a response? Answer No 3.) Did .(Staff C) look for .(Resident #1's) chest to rise and fall? Answer No 4.) Did .(Staff C) check .(Resident #1's) neck pulse (carotid pulse) or listen to .(Resident #1's) heart for ,[DATE] seconds? Answer No 5.) Did .(Staff C) attempt to obtain a blood pressure or temperature? Answer No 6.) Did .(Staff C) get the code cart? Answer No 7/) Did .(Staff C) call or ask anyone to call 911? Answer No 8.) When was the last time .(Staff C) saw this .(Resident #1) and what .(Resident #1) doing? Answer about one hour before What was .(Resident #1) doing? Answer .(Resident #1) was stoking (breathing characterized by rhythmic waxing and waning of depth of respiration) 9.) What did .(Staff C) do? Answer Nothing it was expected 10.) Did .(Staff C) you know .(Resident #1's) code status? Answer No unto until I saw the chart on the counter 11.) Did .(Staff C) call the provider? Answer No Review on [DATE] of Staff C's employee record revealed the following: Staff C had worked for the facility as an agency nurse for approximately a year prior to changing to a full time employee of the facility on [DATE]. Staff C was trained on the facility's policy regarding abuse and neglect prevention on [DATE]. Staff C was trained on conclusive signs of irreversible death on [DATE] when Staff C was working for the facility as an agency nurse. Staff C's nurse license was current and she had been trained in BLS (Basic Life Support) on [DATE]. Interview on [DATE] at 10:30 a.m. with Staff B (Director of Nurses) reviewed the above findings and confirmed that Staff C should have known Resident #1's code status as this information is available on the E-MAR (Electronic Medication Administration Record), on a red sticker for DNR (Do Not Resuscitate) on the paper chart if the resident had been a DNR and on the shift change sheet for each nurse's assignment. During interview on [DATE] at 1:45 p.m. with Staff A (Administrator) and Staff B the above findings were review. Staff A and Staff B confirmed that Staff C was negligent in her duties by not providing CPR for Resident #1 at the time of their death when Resident #1 wanted to be full code and had a physician's orders [REDACTED].#1 was a full code.