Every finding on record at Diversicare of Meridian

Based on interviews and record review, the facility failed to implement care plan interventions regarding a sling type and size used during a mechanical lift transfer which resulted in Resident #1 falling from the lift and sustaining a subarachnoid hemorrhage (bleeding around the brain) for one (1) of four (4) sampled residents. Findings include:A record review of the Care Plan Report revealed Resident #1 had a Focus of I have a physical functioning deficit with transfers and require assistance of transferring with a Interventions including Hoyer Total lift Small (RED) Sling, initiated on 1/7/25.A review of the facility's Investigation Template, dated 4/22/26, revealed, .Incident Date: 4/18/26.Time: 7:00 PM.Description of the Allegation: Resident experienced a witnessed fall during transfer. Laceration to back of head. Resident was transferred to the hospital and returned within 24 hours at the same baseline as prior to the fall.Investigation Summary.She was identified as needing a full lift with sling to accommodate her body weight of 103 and body type.The center staff conducted a root cause analysis of the event and determined the sling was not appropriate size for the resident.A record review of the admission Record revealed the facility admitted Resident #1 on 9/13/13 with diagnoses including Flaccid Hemiplegia Affecting Right Dominant Side, Atrial Fibrillation, and Acquired Absence of Right Leg Above Knee with an onset date of 1/7/25.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/30/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of (14), which indicated the resident was cognitively intact.A record review of the H&P (History and Physical), dated 4/19/26 at 1:57 AM from the acute hospital, revealed, .104 y.o. (year old).Presents as transfer from (local acute hospital) after falling out of a hoyer lift at her nursing home.she has a right occipital laceration which was repaired with staples at the outside hospital.Care Timeline 04/19(2026) discharged 0901 (9:01 AM). Clinical impressions subarachnoid hemorrhage.Disposition Discharge Condition Stable.During a telephone interview with the Power of Attorney (POA) and daughter of Resident #1 on 5/4/26 at 11:47 AM, she explained she had been notified that her that a sling had been left under Resident #1 while in the wheelchair, which was not one typically used by the facility. The POA explained staff informed her the sling may have originated from another facility or outside provider and was somehow placed into the facility's inventory. The POA reported that Resident #1 sustained a brain bleed as a result of the fall, was initially sent to a local hospital, and was later transferred to another hospital out of town for a second Computed Tomography (CT) scan.During an interview on 5/4/26 at 2:14 PM, Licensed Practical Nurse (LPN) #1 explained she was present at the time of the incident and assisted the CNA with transferring Resident #1 from the wheelchair to the bed. LPN #1 stated she could not recall the color of the sling used during the transfer. LPN #1 explained the incident occurred quickly during the evening hours and Resident #1 struck her head on the leg of the mechanical lift. Resident #1 sustained a head laceration with active bleeding and gauze was applied to control the bleeding until further medical assistance arrived.During an interview on 5/4/26 at 2:40 PM, the Director of Nursing (DON) explained she came to the facility after being notified of the incident and determined Resident #1 had been transferred using a black sling, which was not consistent with the facility's standard equipment. During an interview on 5/4/26 at 3:11 PM, CNA #8 stated during the transfer Resident #1 shifted in the sling and fell out of it. CNA #8 reported that Resident #1 had a black sling underneath her while sitting in the wheelchair on the day of the incident. CNA #8 stated it was unknown where the black sling originated and confirmed she had not previously used that sling for Resident #1 or any other resident. CNA #8 reported because the sling was already positioned underneath Resident #1 while in the wheelchair, she thought it was acceptable to use.During a follow-up interview with the DON on 5/5/26 at 10:00 AM, she explained that her expectation is for the nursing staff to ensure that proper slings are used during transfers per the Kardex and the care plan.During an interview on 05/05/2026 at 1:00 PM, Registered Nurse (RN) #3)/MDS Nurse stated that the MDS Nurse is involved in developing care plans and that care plans are updated daily based on resident needs and physician orders. She reported that physician orders are reviewed and incorporated into the care plan as appropriate. RN#3 stated that incidents, including falls, are reported and discussed during daily morning meetings held at 9:00 AM. She further stated that it is important for staff to follow the care plan to ensure residents receive appropriate care based on their individual needs.During an interview on 05/05/2026 at 1:09 PM, RN #1 who is the facility's MDS/Care Plan Nurse stated that care plans are updated daily and that physician orders are printed each day to ensure accuracy and continuity of care. RN#1 stated that staff are expected to follow the care plan and emphasized that adherence is necessary to ensure residents receive care that is accurate and safe, as each resident's care plan is individualized. She further stated that when there are changes in physician orders, those changes are reviewed and discussed during the morning daily meeting to ensure updates are incorporated into the care plan.A record review of the facility's plan of correction revealed Resident #1 was being transferred from the wheelchair to the bed when Resident #1 slid out of the sling. The Administrator (ADM) and Director of Nursing Services (DNS) initiated an investigation on 4/18/26. The Nurse Practitioner (NP), Responsible Party (RP), ADM, DNS, and Medical Director were notified on 4/18/26. Licensed Practical Nurse (LPN) staff received an order on 4/18/26 to transfer Resident #1 to the emergency room (ER) for evaluation. DNS reviewed and updated Resident #1's Kardex and plan of care on 4/18/26 as required and removed the lift and sling from use on 4/18/26. All residents requiring lift transfers were identified as potentially affected on 4/18/26. Maintenance staff were directed by DNS on 4/18/26 to check all lifts for proper functioning. Staff were directed on 4/19/26 to check all slings for fraying and worn areas and to remove damaged slings from use as required. All residents were to be reevaluated for lift and transfer needs, including ensuring the correct sling type and size were used on 4/19/26. DNS completed immediate in-service training with LPN and Certified Nurse Aide (CNA) staff on 4/18/26 with return demonstration regarding lift use. DNS initiated in-service training with all nursing staff on 4/18/26 regarding the correct lift, sling type, and sling size to use. DNS and Assistant Director of Nursing Services (ADNS) initiated abuse and neglect in-service training with all staff on 4/18/26. DNS, ADNS, and Unit Manager (UM) retrained all nurses and CNAs on 4/18/26 regarding lift and transfer procedures, ensuring the correct sling type and size were used, the location of the Kardex, and verbal knowledge of following the resident's plan of care. DNS and ADNS implemented ongoing audits to monitor corrective actions and ensure sustainability. Audits of one hundred percent (100%) of newly admitted , readmitted , and current residents completed quarterly, annually, and with significant change to ensure residents were assessed for the correct lift, sling size, and sling type, with corresponding care plan and Kardex updates. Any negative findings reported to the Quality Assurance Performance Improvement (QAPI) committee monthly for a minimum of three (3) months beginning April 2026 for review and revision as necessary.Due to the facility's corrective actions on 4/18/26 and 4/19/26, the deficient practice was determined to be past noncompliance.Validation:The SA validated on 5/5/26, through interview and record review that all corrective actions had been implemented as of 4/19/26, and the facility was in compliance as of 4/20/26 prior to the SA's entrance on 5/4/26.

Based on interviews, record review, and facility lift guidelines review, the facility failed to ensure the correct sling type and size were used during a mechanical lift transfer which resulted in Resident #1 falling from the lift and sustaining a subarachnoid hemorrhage (bleeding around the brain) for one (1) of four (4) sampled residents. Findings include:A review of the facility's Lift 4 Care - Safe 4 All Guidelines, dated 5/2024, revealed, Purpose: To provide team members guidance with assisting patients and residents to safely reposition or transfer. Guideline.7. In order to maintain patients' and residents' safety, patients and residents should be lifted or transferred by the lift and sling which is deemed appropriate after the lift evaluation is completed. There should be no interchanging of lifts and slings.A review of the facility's Investigation Template, dated 4/22/26, revealed, .Incident Date: 4/18/26.Time: 7:00 PM.Description of the Allegation: Resident experienced a witnessed fall during transfer. Laceration to back of head. Resident was transferred to the hospital and returned within 24 hours at the same baseline as prior to the fall.Investigation Summary.She was identified as needing a full lift with sling to accommodate her body weight of 103 and body type.The center staff conducted a root cause analysis of the event and determined the sling was not appropriate size for the resident.A record review of the admission Record revealed the facility admitted Resident #1 on 9/13/13 with diagnoses including Flaccid Hemiplegia Affecting Right Dominant Side and Acquired Absence of Right Leg Above Knee with an onset date of 1/7/25.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/30/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact.A record review of the Order Summary Report, with Active Orders As Of: 4/30/26, revealed Resident #1 had a Physician's Order, dated 9/25/26 for Eliquis (a type of blood thinner) 5 milligrams (mg) two times daily.A record review of the Medication Administration Record (MAR) for April 2025 revealed Resident #1 was administered Eliquis 5 mg two times daily for Atrial Fibrillation.A record review of the Kardex revealed Resident #1 required Hoyer (type of full body mechanical lift) Total Lift Small (RED) Sling, Provide Hoyer sling for right side amputation, and TRANSFER: The resident uses a total lift with small red sling.A record review of the H&P (History and Physical), dated 4/19/26 at 1:57 AM from the acute hospital, revealed, .104 y.o. (year old).Presents as transfer from (local acute hospital) after falling out of a hoyer lift at her nursing home.she has a right occipital laceration which was repaired with staples at the outside hospital.Care Timeline 04/19(2026) discharged 0901 (9:01 AM). Clinical impressions subarachnoid hemorrhage.Disposition Discharge Condition Stable.On 5/4/26 at 11:47 AM, during a telephone interview with the Power of Attorney (POA) and daughter of Resident #1, she explained facility staff informed her a sling had been left under Resident #1 while in the wheelchair and the sling used was too small and not one typically utilized by the facility. The POA explained staff informed her the sling may have originated from another facility or outside provider and was somehow placed into the facility's inventory. The POA explained Resident #1 sustained a brain bleed as a result of the fall, was initially sent to a local hospital, and was later transferred to another hospital out of town for a second Computed Tomography (CT) scan.On 5/4/26 at 1:58 PM, during an interview with Certified Nursing Assistant (CNA) #6, she explained staff determined the appropriate sling for each resident by reviewing the Kardex prior to transfers and staff typically check this information each time a transfer is performed. CNA #6 explained an amputee sling differs from a standard sling because it extends from the back to the knees and requires two (2) staff members to safely complete the transfer.On 5/4/26 at 2:14 PM, during an interview with Licensed Practical Nurse (LPN) #1 regarding the incident involving Resident #1 on 4/18/26, LPN #1 explained she was present at the time of the incident and assisted the CNA with transferring Resident #1 from the wheelchair to the bed. LPN #1 explained she could not recall the color of the sling used during the transfer. LPN #1 explained the incident occurred quickly during the evening hours and Resident #1 struck her head on the leg of the mechanical lift. LPN #1 explained she instructed the CNA to notify nursing staff and initiate a call to Emergency Medical Services (EMS). LPN #1 explained Resident #1 sustained a head laceration with active bleeding and gauze was applied to control the bleeding until further medical assistance arrived.On 5/4/26 at 2:40 PM, during an interview with the Director of Nursing (DON), she explained she came to the facility after being notified of the incident and observed Resident #1 had been transferred using a black sling, which was not consistent with the facility's standard equipment. The DON explained she removed the sling from Resident #1's room following the incident and discarded it. The DON explained a search of the facility was conducted to identify any additional slings without weight indicators or identification and no other similar slings were found.On 5/4/26 at 3:11 PM, during an interview with CNA #8 regarding the transfer incident involving Resident #1 on 4/18/26, CNA #8 stated during the transfer she requested assistance from nursing staff. CNA #8 stated during the transfer Resident #1 shifted in the sling and fell out of it. CNA #8 stated Resident #1 had a black sling underneath her while sitting in the wheelchair on the day of the incident. CNA #8 stated it was unknown where the black sling originated and confirmed she had not previously used that sling for Resident #1 or any other resident. CNA #8 stated because the sling was already positioned underneath Resident #1 while in the wheelchair, she thought it was acceptable to use.A record review of the facility's plan of correction revealed Resident #1 was being transferred from the wheelchair to the bed when Resident #1 slid out of the sling. The Administrator (ADM) and Director of Nursing Services (DNS) initiated an investigation on 4/18/26. The Nurse Practitioner (NP), Responsible Party (RP), ADM, DNS, and Medical Director were notified on 4/18/26. Licensed Practical Nurse (LPN) staff received an order on 4/18/26 to transfer Resident #1 to the emergency room (ER) for evaluation. DNS reviewed and updated Resident #1's Kardex and plan of care on 4/18/26 as required and removed the lift and sling from use on 4/18/26. All residents requiring lift transfers were identified as potentially affected on 4/18/26. Maintenance staff were directed by DNS on 4/18/26 to check all lifts for proper functioning. Staff were directed on 4/19/26 to check all slings for fraying and worn areas and to remove damaged slings from use as required. All residents were to be reevaluated for lift and transfer needs, including ensuring the correct sling type and size were used on 4/19/26. DNS completed immediate in-service training with LPN and Certified Nurse Aide (CNA) staff on 4/18/26 with return demonstration regarding lift use. DNS initiated in-service training with all nursing staff on 4/18/26 regarding the correct lift, sling type, and sling size to use. DNS and Assistant Director of Nursing Services (ADNS) initiated abuse and neglect in-service training with all staff on 4/18/26. DNS, ADNS, and Unit Manager (UM) retrained all nurses and CNAs on 4/18/26 regarding lift and transfer procedures, ensuring the correct sling type and size were used, the location of the Kardex, and verbal knowledge of following the resident's plan of care. DNS and ADNS implemented ongoing audits to monitor corrective actions and ensure sustainability. Audits of one hundred percent (100%) of newly admitted , readmitted , and current residents completed quarterly, annually, and with significant change to ensure residents were assessed for the correct lift, sling size, and sling type, with corresponding care plan and Kardex updates. Any negative findings reported to the Quality Assurance Performance Improvement (QAPI) committee monthly for a minimum of three (3) months beginning April 2026 for review and revision as necessary.Due to the facility's corrective actions on 4/18/26 and 4/19/26, the deficient practice was determined to be past noncompliance.Validation:The SA validated on 5/5/26, through interview and record review that all corrective actions had been implemented as of 4/19/26, and the facility was in compliance as of 4/20/26 prior to the SA's entrance on 5/4/26.

Based on interview, record review, and facility policy review, the facility failed to ensure the resident's right to be free from misappropriation of resident property for one (1) of three (3) residents sampled. Resident #1.Findings include:A review of the facility's Abuse, Neglect, Misappropriation, Exploitation Policy, dated [DATE] revealed, .Purpose: To prohibit and prevent.misappropriation of resident property.Definitions.Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings.without the residents consent.A record review of the facility's Investigation Template, dated [DATE], revealed that on [DATE], at approximately 7:57 AM, as the hospice nurse was providing postmortem care to Resident #1, Certified Nursing Assistants (CNAs) # 1, 2, 3, 4 and 5 entered the room and proceeded to take his personal belongings from his room. These items included drinks, toilet tissue, bed pads, a cup, and a blanket. A review of the Investigation Summary revealed, After investigation of incident, it was determined the intent was there for misappropriation. All items were returned. Five team members terminated and one contracted housekeeper will not be returning to center. Further review of the investigation revealed a statement from CNA #1 that revealed I got to work and clocked in at 6:10AM, I saw night shift at the door of (Proper Name for Resident #1) room, and I saw (Proper names for CNA #3 and #5) in the room. I noticed that stuff was missing from the room (Proper names for CNA #3 and #5) were taking stuff out of the room, I took garbage bags and towels out of the room and placed them at the nurse's station to get later because I don't have a car. (Proper name of staff) came into the room, the Hospice nurse was asking for pads, there were none in the room and there should have been pads. (Proper name for CNA #2) came and took tissue and mouthwash. (Proper name for CNA #4) took a large tumbler out of the room. I saw (proper name for CNA #5) take reading glasses, air fresheners and bed bags out of the room and she placed them behind the hamper in her mother's room.A record review of the admission Record revealed the facility admitted Resident #1 on [DATE] with current diagnoses including Heart Failure. A record review of the Death in Facility Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #1 died in the facility.A record review of the Progress Notes, dated [DATE] at 5:32 AM, revealed Resident #1 was found unresponsive and there was no respirations or pulse noted by the nurse.A record review of the Progressive Discipline Form for CNA #1 revealed the CNA was placed on Administrative Leave on [DATE] and the Summary of Incident included, .it as alleged that personal items of a deceased resident had been removed from his room . There was another Progressive Discipline Form for CNA #1 that revealed the CNA was terminated on [DATE] with the Summary of Incident of .Following an investigation it was determined that your actions demonstrated an intent for misappropriation.A record review of the Progressive Discipline Form for CNA #2 revealed the CNA was placed on Administrative Leave on [DATE] and the Summary of Incident included, .it as alleged that personal items of a deceased resident had been removed from his room . There was another Progressive Discipline Form for CNA #2 that revealed the CNA was terminated on [DATE] with the Summary of Incident of .Following an investigation it was determined that your actions demonstrated an intent for misappropriation.A record review of the Progressive Discipline Form for CNA #3 revealed the CNA was placed on Administrative Leave on [DATE] and the Summary of Incident included, .it as alleged that personal items of a deceased resident had been removed from his room . There was another Progressive Discipline Form for CNA #3 that revealed the CNA was terminated on [DATE] with the Summary of Incident of .Following an investigation it was determined that your actions demonstrated an intent for misappropriation.A record review of the Progressive Discipline Form for CNA #4 revealed the CNA was placed on Administrative Leave on [DATE] and the Summary of Incident included, .it as alleged that personal items of a deceased resident had been removed from his room . There was another Progressive Discipline Form for CNA #4 that revealed the CNA was terminated on [DATE] with the Summary of Incident of .Following an investigation it was determined that your actions demonstrated an intent for misappropriation.A record review of the Progressive Discipline Form for CNA #5 revealed the CNA was placed on Administrative Leave on [DATE] and the Summary of Incident included, .it as alleged that personal items of a deceased resident had been removed from his room . There was another Progressive Discipline Form for CNA #5 that revealed the CNA was terminated on [DATE] with the Summary of Incident of .Following an investigation it was determined that your actions demonstrated an intent for misappropriation.On [DATE] at 10:24 AM, during an interview with CNA #2 she disclosed that someone (name unknown by CNA #2) told her that Resident #1 had passed away. CNA #2 stated that she went into the resident's room and found several workers in the room. CNA #2 confirmed that she took a pack of toilet paper and put it in a bag and took it to her car. CNA #2 noted that another CNA (name unknown by CNA #2) told her that someone was going to tell, so she went back to get the tissue from the car. CNA #2 affirmed that the resident was still in the room at the time that she took the tissue. CNA #2 reported that she understood that the tissue belonged to the resident and that taking it was stealing. CNA #2 noted that everything could have been avoided because she didn't need the tissue. CNA #2 confirmed that she lost her job over a pack of toilet tissue. CNA #2 stated that if she had it to do again, she would not have gone into that room.On [DATE] at 10:33 AM during an interview with CNA #3 she stated that a CNA (name unknown by CNA #3) from that hall came to tell her that Resident #1 had expired. CNA #3 stated that while the resident was still in the room, having recently expired, she took 2 cases of citrus flavored punch and 2 jugs of fruit punch and placed it behind the nurse's station. CNA #3 stated she recognized that the punch belonged to Resident #1, but she took the resident's belongings because he was deceased and it would be thrown away. CNA #3 acknowledged that only the Resident Representative has the authority to remove or claim personal belongings from a resident's room. CNA #3 confirmed that she did not receive authorization from the Resident Representative, prior to removing things from his room. CNA #3 stated she has been a CNA for 44 years and if she had it to do again, she would not have anything to do with it. CNA #3 stated she knows she was wrong and that she feels regret over her choice to remove the resident's belongings from his room. CNA #3 stated she knows there are consequences behind bad choices.On [DATE] at 10:40 AM during an interview with CNA #4 she revealed that when Resident #1 passed away one of the CNA's (CNA #4 could not recall the name) walked in Resident #1's room and said Hey, we might as well get this stuff. CNA #4 stated she took a pack of drinks (sodas), a blanket and a cup. CNA #4 confirmed that the resident was still lying in the bed, having recently expired, as she took his personal belongings from his room. CNA #4 stated she returned the blanket and the cup when she was questioned by the Director of Nursing (DON). CNA #4 reported that she has been a CNA for 10 years. CNA #4 noted that she felt peer pressure to take the things. CNA #4 stated she feels remorse and that she knew better. On [DATE] at 11:00 AM, during an interview with CNA #5 she stated that the day before the resident passed away, he told her that she could have some protective bed pads that he had in his closet. CNA #5 stated that the resident was always giving away his bed pads to other residents. CNA #5 noted that she should have taken the pads the day before when they were offered, because it was wrong to wait until after he was deceased to take them.On [DATE] at 9:01 AM, during an interview with the Director of Nursing Services (DNS) she revealed that on [DATE] at 7:52 AM she received a call from the Admissions Coordinator, RN Registered Nurse (RN) #1, to relay a report from the Hospice Nurse regarding staff taking personal belongings from Resident #1, who had passed away that morning. The DNS stated that when she arrived, she spoke with two CNAs for witness statements. The DNS reported that she then interviewed the CNAs seen in the room. The DNS stated that as soon as the CNAs gave their statements, four were put on Administrative Leave immediately. The DNS stated that CNA #4 was sent home on administrative leave on [DATE] because she was not honest when initially questioned. The DNS noted that with additional information CNA #4 was called back in and put on leave on [DATE]. The DNS stated that the staff were in-serviced on misappropriation of personal property and staff were no allowed to work until they were in-serviced.On [DATE] at 9:10 AM, during an interview with RN #1 (Charge Nurse at the time of the incident) revealed that on the day of the incident she had arrived at work at approximately 6:45 AM. RN #1 stated the Hospice Nurse was bathing Resident #1 who had recently expired resident. RN #1 reported that while she was assisting the hospice nurse, the hospice nurse reported that multiple CNAs had entered the room as she was cleaning the resident and proceeded to take personal belongings from the resident's room. RN #1 stated that she reported this information to the DNS. On [DATE] at 9:23 AM, during an interview with the Administrator, she revealed that on the morning of the incident she received a group text from the Hospice company's Executive Director stating that the Hospice Nurse had reported that the facility's staff had taken belongings from a residents' room. The Administrator stated she contacted the DNS and was informed that she had interviewed the staff, called law enforcement and had placed four of the CNAs on administrative leave. The Administrator stated that additional information caused them to reinterview a CNA the next day and place a 5th CNA on administrative leave. The Administrator stated that all staff were in-serviced on misappropriation of personal property.A review of the facility's correction plan dated [DATE], revealed the DNS made an attempt to contact the Resident Representative (RR) for Resident #1, but was unsuccessful. The plan detailed that an investigation was conducted starting [DATE], resulting in CNAs #1, 2, 3, and 5 were interviewed and suspended on [DATE] as well as the contracted housekeeper not allowed to return to the facility. On [DATE] CNA #4 was interviewed and suspended. On [DATE], the facility contacted local police department to make a report of the incident. On [DATE] the facility made a report of the incident to the State Agency. On [DATE] the facility notified the Medical Director. The plan included the Social Services Director interviewing residents with a Brief Interview for Mental Status (BIMS) of 12 or higher and the Resident Representatives (RRs) for residents with a BIMS of 11 or lower regarding possible missing items. On [DATE] an in-service on Abuse/Neglect/Misappropriation, Elder Justice act and Customer Service Standards was conducted by the DNS, Assistant DNS, and Administrator with no staff allowed to work until in-service was completed. A Quality Assurance and Performance Improvement (QAPI) meeting was held on [DATE]. To ensure system compliance, the SSD will interview three (3) residents weekly for twelve (12) weeks to ensure residents' belongings are not missing. Based on the implementation of the facility's corrective actions that were completed on [DATE], the deficient practice was determined to be Past Non-Compliance (PNC), and the facility was in regulatory compliance effective [DATE].Validation:The SA validated on [DATE], through interview and record review, that all corrective actions had been implemented as of [DATE], and the facility was in regulatory compliance on [DATE], prior to the SA's entrance on [DATE].

Based on observation, interview, and facility policy review, the facility failed to store food and maintain food quality in accordance with professional standards for food safety related to overly ripe produce and improperly stored foods and unlabeled items during one (1) of three (3) kitchen observations. Findings include: A review of the facility's policy, Food Storage: Cold Foods revised ,d+[DATE], revealed, .Procedures .2. All perishable foods will be maintained at a temperature of 41 degrees F or below . On [DATE] at 10:35 AM, during an observation and interview of the kitchen with the Dietary Manager (DM), refrigerator #3 revealed a plastic storage container containing 14 overly ripe cucumbers with white slimy rind, soft and pliable to the touch, and liquid formed at the bottom of the container. A further observation of the pantry revealed one (1) opened bottle of yellow mustard with the manufacturer's instructions Best if used by date of [DATE]; one (1) opened gallon-sized bottle of soy sauce with the manufacturer's instructions to Refrigerate after opening for quality; 19 overly ripe oranges with green and white bio-growth on the rind; and one (1) overly ripe apple containing a brown soft spot with the interior of the apple exposed. The Dietary Manager acknowledged the overly ripe produce and improperly stored pantry items and stated it is her responsibility to make sure the food is not expired and is stored properly. The DM stated she did not examine the produce that day as she had intended and confirmed the risks of having overly ripe food in the kitchen. The DM noted that going forward she will do a regular check of the produce and pantry items to assure freshness. The DM affirmed that the dietary staff are in-serviced once a month on food safety, which includes lectures and tests. On [DATE] at 02:30 PM, in an interview with the Administrator, she acknowledged the overly ripe produce and improperly stored foods. The Administrator stated it is the responsibility of the DM to monitor the food supplies for proper storage and spoilage and stated her expectation is that the DM will get a system of organization to stay on top of monitoring food safety.

Based on interviews and Certification and Survey Provider Enhanced Reports (CASPER) reporting data review, the provider failed to ensure their Payroll Based Journal (PBJ) (information of the staffing hours for the appropriate care of the residents) had been corrected before submitting to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) quarters reviewed. Findings include: Review of the provider's CASPER reporting data revealed the facility triggered for excessively low weekend staffing for one (1) of four (4) quarters: October 1, 2024 - December 31, 2024. Review of the facility's Monthly Schedule dated October, November, and December 2024 revealed the Director of Nursing (DON) worked as supervisor on October 26 and 27, November 3, and December 14 and 29, 2024. She worked on the floor as a nurse on November 5 and December 29, 2024. Review of the facility's Monthly Schedule dated October, November, and December 2025 revealed the Assistant Director of Nursing (ADON) worked as supervisor on October 6 and 19, November 3, 14, 16, and 17, and December 1 and 29, 2024. The ADON worked on the floor on October 5, 12, 13, and 29, November 22, and December 29, 2024. During an interview on 5/19/25 at 11:00 AM with the Director of Nursing (DON), she explained she did not know the facility triggered for low weekend staffing in the first quarter. The DON said she and the Assistant Director of Nursing (ADON) work when the nursing staff is low. The DON revealed that both are salaried employees and were not clocking in and out during the first quarter. The DON said they just started clocking in and out within the last two (2) weeks. The DON also said the only proof they have that they worked is the assignment sheets, where they wrote themselves in. This is not included in the daily Payroll Based Journal. During an interview on 5/19/25 at 11:15 AM with Certified Nursing Assistant (CNA) #2, she revealed she is responsible for the schedule for the nurses and CNAs. CNA #2 stated that if the staff members work a different shift or work beyond their routine shift, she goes into the system and corrects the information. If the staff works on the floor but normally performs other jobs, she changes the code to reflect the correct position the staff worked that day. The corporate office is responsible for sending in the PBJ. During an interview on 05/20/25 at 09:00 AM with the Administrator, she explained she was not aware the facility triggered in the first quarter of 2025 for excessively low weekend staff. The staffing coordinator corrects the staff punches daily. This goes directly to the corporate office. The Administrator confirmed the facility just started two (2) weeks ago a new process requiring all salaried employees to clock in and out when they work on the floor. During an interview with the Director of Payroll, he explained he has not received anything from CMS showing that the facility triggered for excessively low staff for the first quarter. The Director said the PBJ was accepted.

Based on record review of resident council minutes, facility policy review, and interviews conducted during the Resident Council meeting, the facility failed to promptly resolve grievances related to condiments and call light response times for 12 of 12 Resident Council members. This failure has the potential to affect 87 residents. Cross Reference F725 Findings Include: A review of the facility's Resident Rights and Protections Under State and Federal Law dated 2022 indicates, You have the right to voice grievances and recommend changes . to representatives . and The nursing home must try to resolve the issue promptly. A review of the facility's Customer Concern (Grievance) Policy, effective date July 2018, indicates, Support residents' right to voice concerns . and ensure after receiving a concern, the center actively seeks a resolution ., and Customer concerns will have a prompt response . A record review of the Resident Council meeting minutes dated October 16, 2024, and November 20, 2024, confirmed residents raised concerns about the lack of condiments. On 05/18/25 at 12:30 PM, an observation of the dining room revealed baked potatoes served to residents with no salt or pepper packets on the trays to season the potatoes. No salt and pepper shakers were observed on the tables. On 05/18/25 at 12:55 PM, the State Agent observed Resident #52 having lunch in Styrofoam to-go containers. The resident's lunch consisted of slices of roast beef, carrots, baked potatoes, and a cookie. No condiments were noted on the tray. On 05/18/25 at 01:00 PM, during an interview with a Certified Nursing Assistant (CNA), she confirmed that she assisted Resident #52 with lunch and noted the resident had no condiments on her tray, including butter, salt, or pepper. She explained that she went to the kitchen and was informed there was no butter or salt and pepper. She further explained that the dietary manager had announced over the intercom that all meals would be served in Styrofoam to-go containers due to only two kitchen staff working that day. On 05/19/25 at 1:30 PM, the Resident Council met with the State Agent to discuss concerns raised by residents regarding the quality of care, staff responsiveness, food service, and general facility practices. Resident #14 stated that they pay too much money not to receive basic condiments such as salt, pepper, and butter. Residents reported that no condiments were provided the previous week. Resident #14 stated they were told the absence of condiments was due to milk being wasted on condiment boxes during delivery, and others were told the dietary department was operating on a budget. Resident #32 and Resident #68 reported that call lights often take up to 20 minutes to be answered. Resident #62 stated that during the 11:00 PM to 7:00 AM shift, call lights can go unanswered for up to 30 minutes. Residents alleged that during this shift, staff are often on their personal phones when calls come in and do not respond promptly. Resident #39 shared that she has had to call the facility using her personal phone to be connected to the nurses' station to request assistance because CNAs either took an excessive amount of time to respond or did not respond at all. Resident #14 confirmed similar issues during the day shift, stating that it takes a long time for CNAs to respond to call lights. Resident #68 stated that CNAs sometimes answer a call light only to say they will return but never come back. Resident #72 reported that CNAs often turn off the call light, say they will come back, and by the time they return, she has forgotten what she needed. Resident #39 confirmed that her call light has remained unanswered for more than 30 minutes on multiple occasions. Resident #68 reported that last month, she called 911 for an ambulance because her call light had been ignored for an extended period. On 05/19/25 at 2:46 PM, during an interview, the Ombudsman reported that during her routine visits and rounds at the facility, Certified Nursing Assistants (CNAs) are frequently not present or visible on the units. She stated that when she visits to speak with residents or follow up on areas of potential noncompliance, nurse aides are consistently difficult to locate. On 05/20/25 at 9:27 AM, during an interview conducted with the Social Services Director, she explained that grievances can be submitted by residents through various channels. She shared that common grievances often involve food preferences, response times to call lights, and missing personal items. Once a grievance form is completed, it is forwarded to the appropriate department. For example, concerns related to call lights are directed to the Director of Nursing (DON), who may then coordinate with Human Resources if necessary. She acknowledged that call light response times tend to be slower during breakfast and lunch tray pass because CNAs are actively engaged in meal service. On 05/20/25 at 9:43 AM, during an interview with the Activities Director, she confirmed that call light responsiveness has been an ongoing issue within the facility. She reported that while the problem may be resolved for a period, typically about a month, it often recurs. She stated that she documented the issue as a grievance and submitted it to the nursing department. On 05/21/25 at 9:00 AM, during an interview with the District Manager of Dietary (DMD), she revealed that the truck comes on Wednesday of every week and that last week, she was told something had spilled over the condiments on the truck, and the condiments had to be rejected. The DMD stated that staff could have gone to get condiments from the store so residents could have condiments during meals. She also stated that salt and pepper shakers were on the carts for residents during tray pass. The State Agent did not observe salt and pepper shakers on the trays or in the dining hall during lunch tray pass. On 05/21/25 at 11:35 AM, during an interview with the Dietary Manager (DM), she revealed that the condiments on the week's delivery appeared to have spilled milk or ice cream on the box. Although the condiments were sealed inside the box, she rejected the items and sent them back to the provider. The DM admitted to having run out of condiments. The State Agent informed the DM that, according to Resident Council members, the lack of condiments had been documented as an ongoing issue since October and November 2024, and residents reported they also did not have condiments the prior week.

Based on record review, staff interviews, and facility policy review, the facility failed to assure accurate coding of the Minimum Data Set (MDS) related to discharge status (Resident #90) and an anticoagulant medication (Resident #14) for two (2) of 23 residents sampled. The scope/severity for F641 was increased to E because this tag was cited on the last annual recertification survey 1/25/24. This represents a pattern of deficiency. Findings Include: A review of the facility's policy, MDS and Care Plans, dated August 2019, revealed, .MDS will be developed and maintained per RAI (Resident Assessment Instrument) Guidelines. A record review of the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 Manual, dated October 2019, revealed, .Completion of the RAI . The RAI process has multiple regulatory requirements . (1) the assessment accurately reflects the resident's status . Resident #90: A record review of the Admission Record revealed the facility admitted Resident #90 on 03/06/25 with diagnoses including fractured femur. A record review of the clinical record revealed Resident #90 had an order with an end date of 03/22/25 to Discharge home . A record review of the Discharge Summary, dated 03/17/25, revealed Resident #90 would transfer home . A record review of the facility's Notice of Transfer or Discharge revealed that on 03/19/25 the resident was discharged from the facility to home. A record review of the Discharge MDS with an Assessment Reference Date (ARD) of 03/19/25 revealed Resident #90 was coded as discharged to a Short-Term General Hospital. On 05/19/25 at 3:41 PM, in an interview with the Social Services Director (SSD), she acknowledged making an incorrect entry regarding Resident #90's discharge status. The SSD noted it was a simple mistake and confirmed she is responsible for ensuring her sections of the MDS are coded correctly. She affirmed that the importance of having accurate information on the MDS is for proper billing and stated she will be more careful to verify the accuracy of information. On 05/19/25 at 3:43 PM, in an interview with Registered Nurse (RN) #1, she acknowledged the discrepancy in the MDS, which listed the resident's discharge status as Short-Term General Hospital. RN #1 confirmed it is the responsibility of the discipline that coded their section to assure accuracy before submitting the MDS. She stated the MDS is used for reimbursement, and it is important to include accurate information. On 05/19/25 at 3:47 PM, during an interview with the Director of Nursing (DON), she stated the MDS nurse is responsible for ensuring the MDS contains accurate information. The DON emphasized the importance of accurate MDS coding to ensure proper billing and stated she expects the MDS nurse to verify information before submission. Resident #14: A record review of the Admission Record revealed Resident #14 was admitted on [DATE] with diagnoses including seizure. A record review of the Quarterly MDS with an ARD of 02/11/25 Section N revealed Resident #14 was taking an anticoagulant. A record review of the physician's orders and the electronic Medication Administration Record (MAR) for the month of February 2025 revealed there were no anticoagulant medications ordered or administered to Resident #14 during the lookback period. On 05/21/25 at 12:00 PM, during an interview, RN #1 explained she was not working in February 2025 and the MDS nurse responsible at the time was no longer employed at the facility. After reviewing Resident #14's physician's orders and MAR, RN #1 confirmed there was no indication the resident was on an anticoagulant medication and that the MDS must have been coded in error. On 05/21/25 at 3:24 PM, in an interview with the Administrator, she acknowledged the discrepancies related to discharge status and medication administration on the MDS. She stated that the discipline completing each section of the MDS is responsible for assuring its accuracy. The Administrator explained that accurate MDS coding is necessary to reflect the true picture of the resident's needs and acuity of care. She stated she will provide training to staff on MDS coding expectations.

Based on observation, interviews, and facility policy review the facility failed to ensure sufficient nursing staff were available to meet the care needs of residents during a shift change on three (3) of six (6) resident halls, as evidenced by the facility having one (1) Certified Nurse Aide (CNA) available during the transition from day shift to evening shift, while three nurses remained at the nurse's station, and five (5) resident call lights were observed activated for approximately 30 minutes without response. Cross Reference F565 Findings include: A review of the facility's Staffing Policy revealed it is the practice of (Proper Name of Facility) to assure that adequate staffing is maintained to provide the necessary care and services for each resident. Staff expectations are based on resident acuity and needs and may fluctuate based on the center population as identified in the facility assessment. The center conducts workforce management meetings daily to discuss open positions and call-ins as related to patient needs. The facility continues to actively recruit staff, offering various incentives. On 5/20/25 at 2:30 PM, the State Agency observed several lights sounding on the North Wing. One light was on in North A Hall, two call lights were sounding in North B Hall, and two call lights were sounding in North C Hall. The State Agency also observed three nurses at the nurse's station-one sitting and two standing-reporting to the oncoming shift. No one answered the call lights. No CNAs were observed on the floor until 2:45 PM. At that time, CNA #8 arrived for the evening shift on the North Unit and began answering call lights. Resident #11 was heard saying, Will someone please help me? Upon entering the room, the resident stated her call light had been on for 30 or 40 minutes and that she needed help. On 5/20/25 at 4:10 PM, CNA #2 confirmed there were no CNAs on the floor at 2:55 PM. She also stated she answered the call lights in Rooms N12 and N19. CNA #2 said she did not know where the other CNAs were but confirmed that nurses were present at the nurse's station when call lights were sounding. CNA #2 added that CNAs should notify nurses before leaving the floor and that she had just been informed that CNA #9, scheduled for the North Hall, was sent home on administrative leave at 2:45 PM. On 5/20/25 at 4:30 PM, during an interview, the Assistant Director of Nursing (ADON) stated she did not know where the CNAs were and was unaware that the Administrator had sent CNA #9 home on administrative leave until the State Agency asked about the unanswered call lights on the North Hall around 3:00 PM. On 5/21/25 at 8:00 AM, Licensed Practical Nurse (LPN) #3 confirmed there were no CNAs on the floor at 2:30 PM on 5/20/25. She was unaware that CNAs had left the floor until the State Agency asked to speak with them. She also did not know how long they had been gone. LPN #3 stated CNAs are supposed to report off to the nurses before leaving or going home but often fail to do so. She said administrative staff are aware that CNAs often leave without notification. On 5/21/25 at 8:10 AM, LPN #1 confirmed she was one of the cart nurses on North Hall during the day shift. She stated she did not know CNA #9 had been sent home on administrative leave and that the CNAs had not informed her they were leaving. On 5/21/25 at 9:00 AM, CNA #4 confirmed she was assigned to North C Hall. She stated she went outside to dump her barrel before the shift change and did not inform nurses she was leaving the hall. On 5/21/25 at 9:15 AM, CNA #1 confirmed she was assigned to North A Hall and also did not inform the nurses she was leaving the hall. She explained she went to dump her barrel before the next shift. She did not think to notify the nurse and was unaware CNA #9 had been placed on administrative leave. CNA #1 said the hall is often short-staffed. She stated, We try to do the best we can with what we have. On 5/21/25 at 9:30 AM, CNA #6 stated CNAs do not perform walking rounds to explain care to the oncoming shift. She said dayshift CNAs are often gone before the evening shift arrives. CNA #6 confirmed only one evening shift CNA was on the floor when she arrived. On 5/21/25 at 11:00 AM, CNA #8 confirmed she clocked in at 2:25 PM on 5/20/25. When she arrived on North Hall, call lights were sounding, and no CNAs were on the hall. She observed three nurses at the nurse's station. CNA #8 stated she normally worked as the transportation aide on dayshift but had been working evenings due to staffing shortages. She also confirmed seeing CNAs #4 and #5 outside. On 5/21/25 at 11:30 AM, LPN #2 confirmed she was at the nurse's station at 2:30 PM on 5/20/25 receiving report from LPN #1. She stated that CNAs do not conduct walking rounds and that the dayshift CNAs were not on the hall when she arrived, which she did not know until asked by the State Agency. She said she would have helped with call lights if she had known and acknowledged that nurses struggle to assist due to CNA shortages. On 5/21/25 at 12:00 PM, the Administrator confirmed she informed CNA #2 around 2:50 PM that CNA #9 had been placed on administrative leave, which left the North Hall down one CNA. She stated she was unaware the other CNAs were not on the hall. The Administrator acknowledged the facility is actively working to increase staffing and confirmed that available shifts are posted for staff to pick up as needed.

Based on observations, staff interview, record review, and facility policy review, the facility failed to provide a comfortable, homelike environment in the resident rooms for three (3) of 32 rooms on the North Unit. Findings include: A review of the facility's Resident Rights & Quality of Life Policy, Policy#CC-20, effective March 13,2020 indicated: The patient or resident has the right to . receive services in a center environment that is safe, clean, and comfortable . On 05/19/25 at 10:43 AM, the State Agent (SA) observed exposed sheetrock surrounding the air conditioner in room N2. On 05/21/25 at 10:05 AM, during a room tour and interview with the Maintenance Supervisor, rooms N2, N4, and N8 were observed to have exposed wall areas near the door and air conditioner, chipped paint, and exposed metal on the bottom corner of walls. The Maintenance Supervisor stated that the damage in room N8 occurred while moving a bed and confirmed that all identified areas were in need of repair. Also, on 05/21/25, during an interview with the Maintenance Supervisor, the SA reviewed maintenance work orders from April to May 2025. The review revealed no documented requests for repairs in room N2 room N4, or room N8. The Maintenance Supervisor admitted that more repair requests are communicated to him verbally during rounds than are formally documented.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to revise a care plan for a resident no longer requiring the use of a lift for transfers for one (1) of 23 resident care plans reviewed (Resident #14). Findings include: A review of the facility's policy, MDS and Care Plans, dated August 2019, revealed, .MDS will be developed and maintained per RAI (Resident Assessment Instrument) Guidelines. A review of the RAI 3.0 Operations Manual dated October 2019 revealed, .Planning for Care: Individualized care plans should address strengths and weakness .Individualized care plans should be based on an accurate assessment of the resident's self-performance and the amount and type of support being provided to the resident . A record review of Resident #14's Comprehensive Care Plan revealed a care plan with a revision date of 05/15/25 stated, .I have a physical functioning deficit with transfers and require assistance of 1 to two (2) staff as needed . with interventions listed as Hoyer Total Lift Large (Green) Sling and Invacare Total Lift Large (Green) . During an observation and interview on 05/18/25 at 11:41 AM, the State Agency (SA) observed Resident #14 sitting up in his wheelchair in the hallway. Resident #14 complained that the staff would not let him use the large bathroom in the hallway. He stated he could not get in and out of the bathroom in his room and had difficulty getting on the toilet. He reported he could transfer himself but did need assistance, although it took staff a long time to come and help. On 05/19/25 at 12:10 PM, during an interview with Certified Nurse Aide (CNA) #3, she explained Resident #14 is very independent and will do everything for himself. He is to be assisted with transfers but will not wait or even ask for assistance. She stated he requires assistance from one (1) staff member with transfers. On 05/19/25 at 12:25 PM, the SA observed Resident #14 returning to his room with two (2) staff members. During an interview with the Therapy Director, she explained the resident was recently discharged from therapy but was referred back due to his complaint about not being able to use his bathroom. Resident #14 was discharged from therapy with no problems using the bathroom in his room and was walking 10-15 feet with assistance. Resident #14 wheeled himself into the bathroom without concerns, stood, and used the assist bar on the wall. No concerns were noted with the transfer with therapy staff providing contact guard assist. On 05/19/25 at 2:00 PM, during an interview with Registered Nurse (RN) #2, she explained Resident #14 requires assistance from one (1) staff member, but the resident will not call for assistance. On 05/19/25 at 2:30 PM, during an interview with the Therapy Director and record review, she confirmed Resident #14 was discharged from therapy back in February 2025 with stand-by guard assistance. Prior to therapy, the resident could not walk or transfer. She confirmed through a record review of Resident #14's PT (Physical Therapy) Discharge Summary that the resident was contact guard assist with transfers. On 05/21/25 at 12:00 PM, during an interview with RN #1, she explained the facility uses ongoing care plans and updates them daily by reviewing physician orders. She stated she uses physician orders and assessments to complete the Minimum Data Sets (MDS) and care plans. She reviewed Resident #14's care plan and confirmed the resident had a care plan for a lift. She uses the lift evaluation to complete the care plan, and the last lift evaluation completed for the resident was from 11/24, which indicated the resident required a lift. She confirmed she was unaware that the resident was no longer using a lift but acknowledged there were no current orders for a lift. The care plan had not been revised accurately to reflect the individual's current needs. On 05/21/25 at 12:45 PM, during an interview with the Assistant Director of Nursing (ADON), she confirmed Resident #14 does not require a mechanical lift. She stated she expects all care plans to be updated according to current resident assessments. On 05/21/25 at 12:55 PM, during an interview with the Administrator, she confirmed she expects all care plans to reflect an accurate assessment of each resident and be revised according to the RAI guidelines. A record review of Resident #14's Admission Record revealed the facility admitted the resident on 02/23/24 with the diagnoses of Other Seizures, Anxiety Disorder, Unspecified, Delusional Disorders, and Personal History of Traumatic Brain Injury. A record review of Resident #14's Order Summary Report with active orders as of 05/20/25 revealed orders for OT clarification: OT to treat patient three (3) times a week times 2 weeks with therapeutic exercise, therapeutic activity, self-care training, and group to increase safety and independence with functional tasks active on 05/19/25. No orders were noted for a mechanical lift. A record review of Resident #14's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/13/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Section GG revealed the resident required partial/moderate assistance with toilet transfers. A record review of Resident #14's PT Discharge Summary revealed dates of service from 01/23/25 through 02/26/25, with discharge at CGA (contact guard assist) for transfers on 02/26/25.

Based on interviews, record review, and facility policy review, the facility failed to ensure effective and timely pain management for one (1) of three (3) sampled residents (Resident #5) with multiple cancer diagnoses, including lung, pancreatic, rectal, and glottic cancer and was admitted with physician orders for scheduled and as-needed (PRN) opioid analgesics but did not receive PRN pain medication for approximately twelve (12) hours following his admission, which resulted in unmanaged pain. Findings include: A review of the facility policy titled Pain Management, dated January 2021, revealed, .To provide guidelines for consistent evaluation, management and documentation of pain in order to provide maximum comfort and enhanced quality of life .Upon admission pain is evaluated .Findings are recorded in the EMR (Electronic Medical Record) .Physician notification occurs as indicated for communication of findings and review of need for pharmacological options . A record review of the Admission Record, revealed the facility admitted Resident #5 on 2/14/25 and he had diagnoses including Malignant Neoplasm of Rectum, Pancreas, Glottis, and Bronchus or Lung. A record review of the After Visit Summary from the acute hospital, dated 2/14/25, revealed Instructions included to start fentaNYL Start taking on: February 15, 2025 and HYDROmorphone (Dilaudid). The medication list included fentaNYL 50 mcg (last time patch was given was on 2/12/25) and HYDROmorphone 4 mg every four (4) hours as needed. These orders were received by the facility on 2/14/25 at 2:40 PM. A record review of Resident pain level documented on 2/15/25 at 4:52 AM was three (3). A record review of the Nurse Practioner (NP) note, dated 2/15/25, signed at 10:17 AM revealed, Chief Complaint/Reason for this Visit was new patient needs pain medication .New patient; admitted last night complaints of pain all over. History of cancer; lung. Has a prescription for dilaudid but it is not available at this time. Resident has a fentanyl patch in use with no relief of pain .Nurse reports that his medications should be arrive tomorrow but resident needs relief now .Orders for this visit Norco 10-325 mg (milligrams) take one tablet by PEG (Percutaneous Endoscopic Gastrostomy) every 12 hours x (times) 2 doses. A record review of the Transactions by Patient report revealed LPN #1 removed Hydrocodone 10 mg for Resident #5 on 2/15/25 at 10:46 AM. A record review of the acute care hospital admission records, dated 2/15/25, revealed Resident #5 was, .significant for .lung cancer, rectal cancer, and pancreatic cancer. He has chronic back pain and the right lower extremity pain for which he is on analgesic. He returned because of worsening pain back and right hip. Pain medications were not controlling his pain enough .Patient ultimately succumbed to his illness on 02/20/2025 . On 3/11/25 at 11:15 AM, during a phone interview with one of Resident #5's family members revealed the resident was admitted to the facility late on 2/14/25 at approximately 10:30 PM, and the facility did not have his pain medication available until the next day on 2/15/25 at around 11:00 AM. She revealed her brother had cancer throughout his body and complained of pain frequently. During a phone interview on 3/13/25 at 10:14 AM, with License Practical Nurse (LPN) #1 confirmed that the facility did not have the written prescription of hydromorphone in their emergency medications. She reported to work on 2/15/25 at 7:00 AM, the resident's family member informed her of Resident #5's pain, after realizing the facility did not have the medication. She notified the Nurse Practioner (NP) on call, who returned her call to request a pain medication for the resident. The NP ordered Hydrocodone-Apap 10-325 MG for the resident. On 2/15/25 at 10:46 AM, LPN #1 removed the medication from the emergency medication and administered to the resident. He was later transferred to the hospital for evaluation and treatment due to his pulse oximetry was dropping. On 3/13/25 at 10:21 AM, during an interview with the Director of Nurses (DON), she confirmed that she was aware of Resident #5 being admitted to the facility on [DATE] with a hard copy (written) prescription for hydromorphone (Dilaudid). The facility expected for him to arrive at the facility earlier so that the medication would have been delivered by their pharmacy. The DON revealed there was a delay in the resident receiving his pain medication due to their emergency medication did not have his prescribed medication of Dilaudid. The staff contacted the NP on 2/15/25 to obtain an order for pain medication that they kept at the facility. On 3/13/25 at 3:00 PM, an interview with the Administrator confirmed that the facility policy is to administer pain medication as requested, that the facility failed to give the medication at the requested time, which caused a delay in treatment. On 3/17/25 at 1:00 PM, during a post exit phone interview with Resident #5's other family member, she stated she was at the facility on 2/15/25, at approximately 7:30 AM and the resident stated that he was in pain all night and he was calling out in pain. She stated that his face was red, agitated, and he was coughing. She went to the nurses' station and the night nurse reported that they did not have his medication in the facility, but that they were in the process of contacting the NP to obtain another prescription for a pain medication. The family member reported that she was walking up and down the hall, waiting for the nurse to obtain the resident's pain medication. The family member also reported they brought it to him around 11:00 AM, and Resident #5 kept asking her to take him to the hospital because of his pain. On 3/17/25 at 2:00 PM, during a post exit phone interview, LPN #2, confirmed that on 2/14/25 she worked the night shift and Resident #5 entered the facility around 8:30 PM, with a hard copy prescription for Dilaudid. She reported that she observed Resident #5 sleeping frequently during the night and he did not complain of pain or use his call light. She revealed that she was not aware that she could have contacted the on-call NP during the night for a pain prescription for medication kept in the emergency kit. LPN #2 stated that a family member came to the facility on [DATE] and reported that Resident #5 was in pain.

Based on observation, staff and resident interview, and facility policy review the facility failed to ensure residents' rights were respected as evidenced by staff members using their cell phones in the resident's rooms for two (2) of 34 sampled residents. Residents #30, 32, 35 and 61. Findings Include: Review of the facility's policy, Resident's Rights and Quality of Life, with an effective date of 5/1/2012, revealed Policy Statement .It is the policy .that all residents have the right to a dignified existence, self-determination, and communication with an access to people and services inside and outside the facility . Review of the facility's policy, Personal Cell Phone and Portable Electronic Device Usage Policy, with an effective date of 7/1/2014, revealed Purpose .we require that our employee follow the guidelines listed below for the safety of the residents, patients, our associates, and others . Policy .Usage in Work Areas During Work Time .Personal cell phones and/or portable electronic devices may not be used in resident care areas or other work areas during work time. Usage may only take place during regular break and meal periods in non-work areas . An observation and interview on 1/23/24 at 3:30 PM, revealed Certified Nurse Aide (CNA) #1 standing in the corner of Resident #39's room talking on a cell phone with the resident lying in bed. When the State Agency (SA)entered the resident's room, the staff member stated, Ok I've got to get off here. CNA #1 stated he should not have been in the resident's room talking on the phone. During a resident council meeting on 1/24/24 at 10:00 AM, there were four (4) residents (Residents #30, 32, 35 and 61) that complained the staff talked on their cell phone or those ear things while they were in resident rooms. Resident #30 stated that staff came into his room and went behind the curtain to his roommate's side and talked on their phones for personal conversations. He stated that his roommate was bed bound and did not talk much, but they both could hear. Resident #32 revealed he agreed with Resident #30, and he had also had staff come into his room talking on the phone and at times has thought they were talking to him, but they were talking to someone on those ear things. Resident #35 agreed with Resident #30 and #32 and stated that she had complained about staff doing that to her and that several had come into her room and had about a 20-minute conversation. Resident #61 agreed with the other residents and admitted that staff had done that to her in her room on their cell phones. All four residents stated they had complained about this to other staff members but could not remember anyone's name. Resident #35 stated she had told the head nurse on her hall, but nothing had changed. Resident #30 stated they did not need to be coming in our rooms and talking on their phone because that is our home. An observation and interview on 1/24/24 at 10:55 AM, revealed CNA #2 standing in an unsampled resident's room, with the door closed and the resident not present in the room. This observation revealed she was looking at her cell phone and stated in the interview that she was on her cell phone checking messages. She admits that she should not have been in the resident's room doing that and the facility policy was that staff are not to use their cell phones in front of the residents and that they are supposed to use them in a break area. She revealed the reason they should not use their cell phones in resident areas is because it is disrespectful. An interview on 1/24/24 at 11:22 AM, with the Director of Nursing (DON) confirmed that staff should not use their cell phones or earpiece phones while in the resident areas. She stated they are supposed to use those in break areas if needed. She revealed the reason they should not use them was because they would not be able to provide care. She confirmed the facility policy was that cell phone usage was not permitted in the resident care areas. Resident #30 Record review of Resident #30's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Anxiety disorder. Record review of Resident #30's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/23 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact. Resident #32 Record review of Resident #32's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Heart Failure and Major Depressive Disorder. Record review of Resident #32's MDS with an ARD of 12/22/23 revealed under Section C a BIMS score of 15, which indicates the resident is cognitively intact. Resident #35 Record review of Resident #35's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Generalized Anxiety Disorder Record review of Resident #35's MDS with an ARD of 10/31/23 revealed under Section C a BIMS score of 15, which indicates the resident is cognitively intact. Resident #61 Record review of Resident #61's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Chronic Kidney Disease. Record review of Resident #61's MDS with an ARD of 11/7/23 revealed under Section C a BIMS score of 15, which indicates the resident is cognitively intact.

Based on staff interview, record review, and facility policy review, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was accurately coded for ordered medication for one (1) of 21 MDS assessments reviewed. Resident #63 Findings Include: Record review of facility policy titled, RAI (Resident Assessment Instrument) Process Guideline , dated September 2020, revealed, Guideline Statement: The purpose of this guideline is to provide guidance and instruction on how to complete the RAI process. The RAI process consists of three components: The Minimum Data Set (MDS) Version 3.0, The Care Area Assessment (CAA) process, and the RAI utilization guideline .Process .The center will determine how the process is completed ensuring that the process includes direct observation and communication with the residents and direct care staff . Record review of Resident #63's Admission Record revealed she was admitted to the facility on [DATE]. She had a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia with an onset date of 10/30/23. Record review of the Order Summary Report, with active orders as of 1/25/2024, revealed Resident #63 had a Physician's Order, dated 10/30/23, for Ozempic .Inject 0.25 milligrams (mg) subcutaneously weekly .for Diabetes related to Type 2 Diabetes Mellitus. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/11/24, Section N revealed Resident #63 received one (1) Insulin injection during the seven day look back period. Review of the medical record revealed there were no Physician's Orders or documentation recorded that Resident #63 received insulin in January of 2024. During an interview on 1/23/24 at 4:03 PM, the MDS Assistant Coordinator Registered Nurse (RN) revealed she was responsible for entering the information for the MDS, dated [DATE], for Resident #63. She stated she was new to the position and thought that since Ozempic was an injectable medication that lowered the blood sugar for diabetic residents and that it was categorized as Insulin. She stated the MDS assessment provides health information on each resident and confirmed she failed to accurately enter Resident #63's medication information. An interview with the Director of Nursing (DON) on 1/25/24 at 8:45 AM, revealed she thought Ozempic was classified as an insulin. She confirmed after researching this, she determined that it was not an insulin and coding it as an insulin was an MDS discrepancy.

Based on observation, staff interview, record review and facility policy review the facility failed to implement a care plan related to resident activities for one (1) of 21 resident care plans reviewed. Resident #39 Findings include: Review of the facility policy, Comprehensive Care Plan, with an effective date of May 1, 2012, revealed .Practice Guidelines . 1. The interdisciplinary care plan is implemented to guide health care center staff in the provision of necessary care and services to obtain and maintain the highest practicable physical, mental, and psychosocial well-being of the resident and promotion of the resident and family in planning care . A record review of the Comprehensive Care Plan revealed Focus (Proper Name) is (dependent on staff .) for meeting emotional, intellectual, physical, and social needs r/t (related to ) CVA (Cerebral Vascular Accident) affected left dominant side or vision deficits . revised 6/2/2023 .Interventions/Tasks .Invite the resident to scheduled activities. The resident needs assistance/escort to activity functions. An interview and observation on 01/22/24 at 03:01 PM, revealed Resident #39 stated he does not usually go out of the room for activities, but would like to, and revealed that he cannot see. He stated he does not know when the activities are, and the staff had not asked or told him. An observation and interview on 1/23/24 at 10:40 AM, revealed a group activity of Devotion was taking place in the room while Resident #39 was sitting up in bed in his room. Resident #39 said that he was not asked if he wanted to attend the activity. During an interview on 1/23/23 at 11:00 AM, with Certified Nurse Aide (CNA) #3, she stated that Resident #39 had to be taken to Activities, because he could not get himself out of bed or self-propel his wheelchair. During an interview on 1/23/24 at 11:15 AM, the Activities Director confirmed that Resident #39 did not attend the group activity of Devotion this morning. She revealed that she does not document who all comes to her group activities and she depends on the staff to help her know when residents are not coming to activities so she can put them on in room activities. She stated that the resident was not documented as having received in room activities for the month of January. During an observation on 1/23/24 at 1:45 PM, a facility staff member was going down the hallway where Resident #39 resides and asking residents if they wanted to go to activities. The staff member did not ask Resident #39 if he wanted to attend the activity. On interview on 1/23/24 at 2:15 PM, with the Director of Nurses (DON) and the Administrator, revealed that Resident #39 should be having one-on-one activities at a minimum. The DON revealed that the purpose of residents going to activities is for socialization and livelihood. During an interview on 1/23/24 at 3:04 PM, the Activities Director confirmed that activities are for residents to socialize with others. She revealed that if Resident #39 had a care plan that indicated the staff should be assisting the resident with his activities, then his care plan was not implemented. An interview with CNA #3 and record review of the Comprehensive Care Plan, on 1/24/24 at 8:30 AM, confirmed Resident #39 had a care plan intervention to invite the resident to scheduled activities #3 confirmed that by not inviting or taking Resident #39 to activities means the care plan was not implemented.

Based on observation, resident, staff and family interview, record review, and facility policy review, the facility failed to shave a resident who required staff assistance for Activities of Daily Living (ADLs) for one (1) of 21 sampled residents. Resident # 52 Findings Include: A review of the facility policy, ADL's, with an effective date of August 2021, revealed Policy: Ensure ADL's are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences . An observation and interview on 01/22/24 at 2:30 PM, with Resident #52 revealed he had facial hair that was approximately a quarter of an inch in length. The resident's mother was at the bedside and stated, He needs to be shaved and I have told them that I can't do it anymore. The resident confirmed that he wanted to be shaved. An observation and interview on 01/23/24 at 1:30 PM, with the Director of Nursing (DON) confirmed that Resident #52 needed to be shaved. She stated that the resident should have been shaved when he received a bath or shower, and that if a resident refused, the Certified Nurse Aide (CNA) should have reported it to the nurse. She revealed that there was no documentation that Resident #52 refused to be shaved. An interview on 01/23/24 at 01:45 PM, with CNA #4 confirmed that she was responsible for caring for Resident #52 today and she had him every day. She revealed the resident received baths, which included shaving, on Mondays, Wednesdays, and Fridays. CNA #4 revealed that Resident #52 was not shaved on Monday (1/22/24) because she did not think that he needed to be shaved and commented, His facial hair may be long to you, but it is not to him. An observation and interview on 01/23/24 at 2:10 PM, with Resident #52 and the DON confirmed that the resident wanted to be shaved. Record review of Resident #52's Admission Record revealed he was initially admitted to the facility on [DATE] with a medical diagnoses that included Type Two Diabetes Mellitus with Diabetic Neuropathy. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/23 revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated his cognition was moderately impaired. A review of Section GG revealed he required assistance with bathing.

Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to invite and assist a dependent resident to group activities for one (1) of 21 sampled residents. Resident #39 Findings Include: Review of the facility policy titled, Activities, with an effective date of April 2022, revealed, Policy .It is the policy of this center to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Center-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction with the community .Policy Explanation and Compliance Guidelines .10. All staff will assist residents to and from activities when necessary . During an interview and observation on 01/22/24 at 03:01 PM, revealed Resident #39 sitting in bed in his room, staring out of the window. He stated he does not usually go out of the room for activities, but would like to, and revealed that he cannot see. He stated he does not know when the activities are, and the staff had not asked or told him. An interview on 1/22/24 at 3:12 PM, with Licensed Practical Nurse (LPN) #2, revealed most of the residents on the hall were at activities because they were having devotion. During an observation and interview on 1/23/24 at 10:40 AM, revealed that Resident #39 was sitting up in bed in his room and there was a group activity of Devotion in process in the dining room. An interview with the resident revealed he was not asked to go to Activities and that he had not done anything but sit there where he was. In an interview on 1/23/23 at 11:00 AM, with Certified Nurse Aide (CNA) #3, she stated that Resident #39 had to be taken to Activities, because he could not get himself out of bed or self-propel his wheelchair. An interview on 1/23/24 at 11:15 AM, with the Activities Director confirmed that Resident #39 did not attend the group activity of Devotion this morning. She revealed that she does not document who all comes to her group activities and she depends on the staff to help her know when residents are not coming to activities so she can put them on in room activities. She stated that the resident was not documented as having received in room activities for the month of January. An observation on 1/23/24 at 1:45 PM revealed a staff member going down the hallway where Resident #39 lives asking residents if they wanted to go to activities, but the staff member did not stop and ask Resident #39. An interview and observation on 1/23/24 at 1:50 PM, with CNA #3 revealed Resident #39 was sitting in bed with his eyes closed. She stated that the resident had diarrhea this morning, so she did not even ask him if he wanted to go to activities. She asked the resident at this time if he would like to go to activities and the resident stated, Yes. On interview on 1/23/24 at 2:15 PM, with the Director of Nurses (DON) and the Administrator, revealed that Resident #39 should be having one-on-one activities at a minimum. The DON revealed that the purpose of residents going to activities is for socialization. An interview on 1/23/24 at 3:04 PM, with the Activities Director confirmed that activities are for residents to have some socialization with other residents. An interview 1/24/24 at 8:30 AM, with CNA #3 confirmed that activities are important for the residents to have something to do and get out of their rooms. Record review of Resident #39's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side. Record review of Resident #39's Minimum Data Set with an Assessment Reference Date of 11/16/23 revealed under Section C a Brief Interview for Mental Status score of 12, which indicates the resident's cognition is moderately impaired.

CI MS #23089 Based on observations, interviews, record review, and facility policy review, the facility failed to immediately honor and resolve the food/meal grievances, requests, and concerns of the residents. Five (5) of seven (7) sampled residents voiced unresolved food grievances, food/meal requests, and concerns, Residents #1, #2, #3, #5, and #6 and three (3) of (3) unsampled residents voiced food/meal grievances, concerns, and requests that were unresolved. Findings Include: Review of the facility's policy, Customer Concern (Grievance) Policy dated July 2018, revealed, Purpose: Support each customer's (patient's/resident's) right to voice concerns (grievances) and to ensure after receiving a concern, the center actively seeks a resolution and keeps the customer appropriately apprised of its progress toward resolution .The Administrator shall follow up on the correction of the problem . During a pre-entrance phone interview on 11/28/23 at 2:38 PM, with the Ombudsman, she stated that she visited the facility regularly due to complaints that she received from residents concerning cold food served at breakfast and no meat served with breakfast per residents' request. She stated that she had taken the specific complaints to the facility Administrator (ADM) and to the Social Services Director (SSD). The Ombudsman stated that on 10/18/23 she met with the ADM and SSD and they assured her that they would begin a 90-day improvement plan and that all of the residents' concerns would be resolved in 90 days. The Ombudsman followed up with several residents to see if efforts were being made and the residents reported no changes in the poor quality of food and breakfast was served ice cold. The Ombudsman stated that she had witnessed cold breakfast foods served to the residents well after 9:45 AM and that a resident had made repeated requests to have bacon served to him for breakfast and that he had not received his preferences/requests. Resident #5 During an observation and interviews on 11/29/23 at 8:10 AM, revealed Resident (Res) #5 was in her room with her breakfast tray. Res #5 identified her breakfast food as: [NAME] gravy poured over a hard as a rock biscuit and uncooked hashbrowns, cold grits that you can't eat and no meat of any kind and no eggs. Res #5 stated that she had issued numerous complaints about her breakfast but it never does any good. Res #5 stated that nothing on her tray was served warm enough to enjoy. Res #5 stated that breakfast was typically her favorite meal of the day, but she had not been served breakfasts the way that she preferred, and she could not eat cold food or food that was not cooked enough. Record review of the Admission Record revealed the facility admitted Res #5 on 10/13/23 with a diagnosis of Myocardial Infarction. Record review of the Comprehensive Minimum Data Set (MDS), with an Assessment reference Date (ARD) of 9/25/23, revealed Res #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Unsampled A During an observation an interview on 11/29/23 at 8:15 AM, with unsampled Res A, revealed that she had not been served bacon with her breakfast tray per her requests. She stated that she had requested to be served bacon with her breakfast each morning. She stated that her breakfasts were usually served to her cold and that she had complained about could breakfast foods. Unsampled B During an interview and observation on 11/29/23 at 8:25 AM, unsampled Res B revealed that her breakfast was cold, and she was not served any meat. She stated that she would love to have bacon or ham or sausage each morning, but rarely received meat at breakfast. Res stated that the brown gravy she was served contained no sausage. Res stated that no one had recently assessed her food preferences or concerns and to her knowledge no one from the dietary department had talked to her about her concerns with meals/food served at the facility. Res stated that most days her breakfast arrived cold. Unsampled C During an interview and observation on 11/29/23 at 8:30 AM, with unsampled Res C, she stated that her breakfast was served cold. She stated that most mornings the breakfast was served cold, and she had issued complaints but that she continued to receive cold food. Unsampled Res C confirmed that she had not been served any meat with her breakfast tray. Observation of breakfast tray revealed that there was no bacon, no sausage, and no meat served to unsampled Res C. An observation of the North Unit from 8:35 AM through 9:10 AM on 11/29/23, revealed that the breakfast trays had not been delivered from the kitchen. The breakfast trays arrived at the North Unit at 8:50 AM. The last tray was served at 9:10 AM on the North Unit. Resident #1 During an observation and interview on 11/29/23 at 8:55 AM, Res #1 revealed that he had received his breakfast at 8:55 AM on 11/29/23 and his food was cold. Res #1 stated that he had issued numerous complaints on a regular basis, and he had not been able to get his food preferences served per his request. Res #1 stated that he had requested bacon to be served to him every morning with breakfast and he had not yet received his bacon. Res #1 voiced that he had issued concerns about poor quality food/meals, and he had talked to the Ombudsman several times and he was glad to see the surveyor in hopes that he could get a good hot breakfast served to him in a timelier manner. He stated that he would like to have a hot breakfast served to him daily between 7:00-7:45 AM. Record review of the Admission Record revealed the facility admitted Res #1 on 9/16/2015 with a diagnosis of Type 2 Diabetes Mellitus. Record review of the Comprehensive MDS, with an ARD of 11/10/2023, revealed Resident #1 had a BIMS score of 15, which indicated he was cognitively intact. Resident #2 During an observation and interview on 11/29/23 at 8:55 AM, with Res #2, he stated that he received his breakfast on 11/29/23 at approximately 8:55 AM, and his breakfast was cold. He reported that most mornings he and his roommate (Res #1) received cold food and did not receive their breakfasts until approximately 9:00 AM. He stated that he had issued grievances about the breakfast meals being cold and not having meat served with breakfast. Record review of the Admission Record revealed the facility admitted Res #2 on 6/3/2020 with a diagnosis of Multiple Myeloma. Record review of the Comprehensive MDS with an ARD of 10/5/23, revealed Res #2 had a BIMS score of 15, which indicated he was cognitively intact. Resident #3 During an observation and Interview on 11/29/23 at 9:00 AM, with Res #3, revealed that he voiced that he was served cold foods for breakfast. On 11/29/23, Res #3 was not served any eggs or meat. Res #3 reported that he had issued food complaints to the facility staff and to the Ombudsman that were not resolved to date. Record review of the Admission Record revealed the facility admitted Res #3 on 10/19/23 and he had a diagnosis of Heart Failure. Record review of the Comprehensive MDS with an ARD of 11/13/23, revealed Res #3 had BIMS score of 15, which indicated he was cognitively intact. An interview on 11/29/23 at 10:00 AM, with the Activities Director (AD), revealed that she does not hear the resident council members complain about the food when she meets with them each month. The AD provided the Resident Council Meeting minutes and none of the sampled or unsampled residents were in attendance of the Resident Council Meetings since January 2023. The AD confirmed that the seven (7) or eight (8) members/attendees of the Resident Council were not the sampled or unsampled residents. The AD explained that once per week the residents are encouraged to attend the food committee meeting to issue their concerns directly to the food committee. The AD stated that she did not attend the weekly food committee meeting. During an interview and record review of grievance logs, on 11/29/23 at 11:00 AM, with the SSD, she confirmed that she had received several grievances that residents had issued concerning poor-quality food, cold food/meals, and meals not served in a timely manner. The SSD stated that the Ombudsman had met with her and the ADM back in October of 2023, and that they had planned to correct the residents' food concerns within 90 days from 10/18/23. The SSD confirmed that to date the food concerns of the residents had not been resolved. The SSD provided copies of the grievance logs for the past 10 months dating January 2023 through October 2023. There were 10 documented grievances that various residents had issued concerning dietary and foods. The SSD provided the grievances that were documented as: 2/23/23 Food not the same as on the meal tray menu (ticket); 3/6/23 concerns with the food ticket ; 3/14/23 food always cold; 4/26/23 Resident Council issued group grievance that there was no salt and no pepper and butter on the meal trays; 5/11/23 resident filed a grievance that the food was cold; 8/28/23 Resident #1 voiced a grievance that the food was burnt and glasses were broken; 9/13/23 Resident #1 filed a grievance that his food was cold; 9/18/23 a resident filed a grievance that her food was cold; 10/09/23 a resident filed a grievance that the food was not healthy; 10/11/23 multiple residents on the North Unit filed a grievance of cold food. The Disconfirmed that the grievance log was kept by her and that she handled most all grievances. The SSD confirmed that to date the residents have unresolved food/meal concerns. Resident #6 An interview on 11/29/23 at 2:18 PM, with the Resident Representative (RR) for Res #6 revealed that she and her siblings had several meetings with the facility concerning the diet and foods that were served and not served to Res #6. The RR stated that the facility food was not served timely and that her mother goes to dialysis three (3) times per week from approximately 12:20 PM-5:00 PM and that she or one of her siblings come to the facility each day at approximately 5:00 PM with supper food/meals to serve to Res #6. The RR explained that her mother was hungry by 5:00 PM and could not wait until 6:00 PM-6:30 PM to be served the facility meals/food and that the supper/dinner meal was not served to the residents until 6:00 PM or after and that was too late for Res #6 to wait for meal service. The RR reported the quality of the facility food/meals was poor and that her mother refused to eat much of the food/meals because her preferences were not honored. The RR expressed that the family's concerns with poor quality of foods/meals and the serving not being timely had not been resolved after concerns have been issued on several occasions and felt that the staff just does not care enough about the residents to do the right thing. Record review of the Admission Record revealed the facility admitted Res #6 on 3/29/23 with a diagnosis of Heart Failure. Record review of the Quarterly MDS, with an ARD of 9/26/23, revealed Res #6 had a BIMS score of 11, which indicated her cognition was moderately impaired. An interview on 11/29/23 at 3:30 PM, the ADM confirmed that the facility had work to do in the dietary department to provide dietary services that better met the needs of the residents' requests.

MS CI #23089 Based on observation, interviews, record review, and facility policy review, the facility failed to provide and serve foods/meals to residents in a manner that honored their voiced requests and preferences. Five (5) of seven (7) sampled residents #1, #2, #3, #5 and #6 and three (3) of (3) unsampled residents A, B, and C had made requests for better quality foods/meals to be delivered and served in a more timely and palatable manner. Review of the facility's policy, Meal Distribution, revised 9/2017, revealed .Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely manner . Review of the facility's policy, Dining and Food Preferences, revised 9/2017, revealed, .Individual dining, food, and beverage preferences are identified for all residents/patients .Procedures .2 .The purpose of identifying individual preferences for dining location, mealtimes, including times outside of the routine schedule, food, and beverage preferences . Findings Include: During an observation and interview on 11/29/23 at 7:45 AM, with the facility's Administrator (ADM) and the Dietary Manager (DM), revealed there were two (2) dietary employees working on the tray line and one (1) cook who was cooking and helping serve on the tray line during the breakfast meal. There were no residents in the dining room area eating or being served breakfast in the dining room on 11/29/23. The ADM stated that since COVID-19, the residents prefer to eat in their rooms and do not come to breakfast in the dining room. The menus for the three (3) meals of the day were not posted in the facility for Wednesday November 29, 2023. The ADM stated that he would have the correct menus posted for Wednesday and he confirmed that the correct daily menus for Wednesday, 11/29/23 were not posted. The ADM also confirmed that the meal service times were not posted in the facility. During the breakfast observation, there were no scheduled times for meals posted in the facility. The DM stated that the South Unit residents had been served their breakfast at 7:45 AM. There were no tray line temperatures recorded and the ADM confirmed that the breakfast temperatures were not obtained by the dietary department prior to the delivery of the meal trays to the South Unit of the facility. The dietary manager (DM) stated that they forgot to take the breakfast temperatures prior to delivering the breakfast trays to the South Unit residents. The staff were observed preparing the trays for the North unit and loading them on to the tray transporter/cart. Resident #5 On 11/29/23 at 8:10 AM, during an observation, interview, and record review of the breakfast trays on the South Unit revealed that all trays had been delivered to the residents in their rooms. Res #5 identified her breakfast food to the surveyor as: [NAME] gravy poured over a hard as a rock biscuit and uncooked hashbrowns, cold grits that you can't eat and no meat of any kind and no eggs. Observation revealed that Res #5 was correct in her observation of her breakfast food tray. Her tray contained no protein of any type and no meat, and no eggs. There was brown gravy with no meat poured over an open-faced biscuit. Res #5 stated that the breakfasts that she received were always cold and she never was served bacon or sausage per her requests. Resident gave the surveyor her breakfast tray menu slip to compare with what she was served. Record review of the menu slip did not contain eggs or meat. The slip did list sausage gravy 4 oz. (ounces) but there was no sausage in the brown gravy served over the biscuit on the breakfast tray. Res #5 had taken the hashbrowns off of her plate and had discarded them to the side of her plate on her meal tray. Observations revealed that the hashbrowns were white and had no gold or brown visible, the hashbrowns presented as uncooked. Res #5 stated these hashbrowns ain't even cooked and they are cold. Res #5 invited the surveyor to touch her bowl that contained grits and the bowl was not warm to the touch. The resident placed her spoon in the grits, and they were stuck together in a large lump indicating that the grits were no longer warm/hot. Resident stated that nothing on her tray was served warm enough to enjoy. Res #5 stated that breakfast was typically her favorite meal of the day, but she had not been served breakfasts the way that she preferred, and she could not eat cold food or food that was not cooked enough. Record review of the Admission Record revealed the facility admitted Res #5 on 10/13/23 with a diagnosis of Myocardial Infarction. Record review of the Comprehensive Minimum Data Set (MDS), with an Assessment reference Date (ARD) of 9/25/23, revealed Res #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Unsampled A During an interview and observation on 11/29/23 at 8:15 AM, with unsampled Res A revealed that she had not been served bacon with her breakfast tray per her requests. She stated that she had requested to be served bacon with her breakfast each morning. She stated that her breakfasts were usually served to her cold and that she had complained about could breakfast foods. Observation of unsampled Res A breakfast tray revealed that she had brown gravy poured over an open-faced biscuit and there was no sausage visible in the brown gravy and the hashbrowns were white and presented as uncooked and/or undercooked. Unsampled Res A stated that her breakfast was cold and the hashbrowns were not cooked. Unsampled B During an interview and observation on 11/29/23 at 8:25 AM, unsampled Res B revealed that her breakfast was cold, and she was not served any meat. She stated that she would love to have bacon or ham or sausage each morning but rarely received meat at breakfast. Res stated that the brown gravy she was served contained no sausage. Resident stated that no one had recently assessed her food preferences or concerns and to her knowledge no one from the dietary department had talked to her about her concerns with meals/food served at the facility. Res stated that most days her breakfast arrived cold. There was no bacon and no sausage served to unsampled Res B on 11/29/23. Unsampled C At 8:30 AM on 11/29/23, in an interview and observation with unsampled Res C, she stated that her breakfast was served cold. Unsampled Res C stated that most mornings the breakfast was served cold and she had issued complaints but that she continued to receive cold food. Unsampled Res C confirmed that she had not been served any meat with her breakfast tray as per her request. Observation of breakfast tray revealed that there was no bacon, no sausage, and no meat served to unsampled Res C. Observation of the North Unit from 8:35 AM through 9:10 AM revealed that the breakfast trays had not been delivered from the kitchen. The breakfast trays arrived at the North Unit at 8:50 AM. The food transportation/cart rolled up and down the North halls with the door to the cart open and the food trays were placed inside the open cart with uncovered liquids and foods. The juices and hot cereals (oatmeal and grits) were served in open bowls/cups/glasses that were uncovered. The uncovered hot cereals were cold when served to residents and juices were not cold when they were served to the residents on 11/29/23 at 9:10 AM. The last tray was served at 9:10 AM on the North Unit. All residents observed and interviewed on the North Unit confirmed that their breakfasts were not served warm enough most mornings and that most mornings they were not served breakfast until after 9:00 AM. None of the residents interviewed knew what time meals were to be served. There were no meal service times posted in the facility on 11/29/23. Staff observed walking through the halls serving breakfast trays with uncovered food and drink items on the tray. Resident #1 On 11/29/23 at 8:55 AM, Res #1 revealed that he had received his breakfast at 8:55 AM on 11/29/23 and his food was cold. He received a small glass of uncovered orange juice that was not cold, and he did not receive his cranberry juice per the menu slip on his tray. He was served oatmeal that was uncovered and was not warm enough per Res #1. Res #1 stated that he had issued numerous complaints on a regular basis, and he had not been able to get his food preferences served per his request. Res #1 stated that he had requested bacon to be served to him every morning with breakfast and he had not yet received his bacon. He stated that he would like to have his hot breakfast served to him daily between 7:00 AM to 7:45 AM. Interview on 11/29/23 at 8:56 AM, with Certified Nursing Assistant, (CNA #1) on the North Unit revealed that the trays contained uncovered foods and juices. CNA #1 confirmed that the North Unit usually did not receive breakfast trays until after 8:30 AM on most mornings Record review of the Admission Record revealed the facility admitted Res #1 on 9/16/2015 with a diagnosis of Type 2 Diabetes Mellitus. Record review of the Comprehensive MDS, with an ARD of 11/10/2023, revealed Resident #1 had a BIMS score of 15, which indicated he was cognitively intact. Resident #2 On 11/29/23 at 8:55 AM, during an observation and interview on 11/29/23 at 8:55 AM, with Res #2, who was the roommate of Res #1, he stated that he did not receive his breakfast on 11/29/23 until 8:55 AM and his breakfast was cold. He stated that most mornings he and his roommate received cold food and did not receive their breakfasts until approximately 9:00 AM. Observation on 11/29/23 at 8:55 AM revealed that Res #2 did not receive cranberry juice as documented on his tray menu slip and he did not receive hashbrowns as documented on his tray menu slip. Res #2 did not receive any meat, did not receive beacon as listed on his tray menu slip and was served corn flakes in an uncovered bowl. Res #2 received a small glass of orange juice in an uncovered glass. Res #2's breakfast tray did not match his tray menu slip. Record review of the Admission Record revealed the facility admitted Res #2 on 6/3/2020 with a diagnosis of Multiple Myeloma. Record review of the Comprehensive MDS with an ARD of 10/5/23, revealed Res #2 had a BIMS score of 15, which indicated he was cognitively intact. Resident #3 On 11/29/23 at 9:00 AM, in an observation and interview, Res #3 revealed that he voiced that he was served cold foods for breakfast, and he usually was served cold breakfast on most mornings. On 11/29/23 resident #3 was not served any eggs, meat, bacon, or sausage. Res #3's breakfast tray was observed to contain no oatmeal as listed on his tray menu slip. Resident #3's tray menu slip did not contain protein. Resident #3's tray menu slip did not match what was served on his breakfast tray. Res #3 stated that he had issued food complaints to the facility staff and to the Ombudsman that were not resolved. Record review of the Admission Record revealed the facility admitted Res #3 on 10/19/23 and he had a diagnosis of Heart Failure. Record review of the Comprehensive MDS with an ARD of 11/13/23, revealed Res #3 had BIMS score of 15, which indicated he was cognitively intact. An observation on 11/29/23 at 9:15 AM, of the meal test tray provided to the surveyor revealed that there was no salt and pepper on the tray, no jelly, no eating utensils, and no napkin. The test tray contained an open-faced biscuit with brown gravy poured over the biscuits. There were scrambled eggs with no salt and pepper and there was approximately one (1) tablespoon of uncooked hashbrowns on the plate with brown gravy running into the hashbrowns and scrambled eggs. The eggs were slightly warm and were not palatable due to no taste and no seasoning and no salt and pepper provided. The hashbrowns were cold and uncooked and white in color. The brown gravy contained no meat, the biscuit was not warm and was not moist. The biscuit was dry and there was no tray menu slip provided with the test tray. On 11/29/23 at 11:00 AM, in an interview with the Director of Social Services (SSD), she confirmed that the Ombudsman had met with her and the ADM back in October 2023 and that they had made a plan to correct the residents' food concerns within 90 days from 10/18/23. SSD stated that to date the food concerns of the residents have not been resolved. Resident #6 On 11/29/23 at 2:18 PM, in an interview with the Resident Representative (RR) for Res #6 revealed that she and her sisters had several meetings with the facility concerning the diet and foods that were served and not served to Res #6. RR stated that the facility food was not served timely and that her mother goes to dialysis three (3) times per week from approximately 12:20 PM-5:00 PM and that she or one of her siblings come to the facility each day at approximately 5:00 PM with supper food/meals to serve to Res #6. RR stated that her mother was hungry by 5:00 PM and could not wait until 6:00 PM-6:30 PM to be served the facility meals/food. RR stated that the quality of the facility food/meals was poor and that her mother refused to eat much of the food/meals because her preferences were not honored. The RR stated that the family's concerns with poor quality of foods/meals and the serving not being timely had not been resolved after concerns have been issued on several occasions. The RR stated that she felt that the staff just does not care enough about the residents to do the right thing. Record review of the Admission Record revealed the facility admitted Res #6 on 3/29/23 with a diagnosis of Heart Failure. Record review of the Quarterly MDS, with an ARD of 9/26/23, revealed Res #6 had a BIMS score of 11, which indicated her cognition was moderately impaired. On 11/29/23 at 3:30 PM, during an interview with the facility's ADM revealed that he was aware that there needed to be improvements with the meal service, and he confirmed that he had not posted the meal service times throughout the facility. The ADM stated that he would make sure that the service times were posted and that all residents and staff knew what time meals should be served. The ADM confirmed that the facility had work to do in dietary to provide dietary services that better met the needs of the residents' requests. The ADM stated that they had not served meat with each meal but that he had talked to the corporate office and they had agreed to allow meat at each meal. The ADM stated that the bowls of hot cereals and the side dishes and liquids/juices were not to leave the kitchen uncovered and he had instructed the Dietary Manager to order lids for the bowels and glasses. He stated that they usually had all food items covered but they had run out of covers and had to order more. The ADM provided the surveyor with the meal service times and he confirmed that Breakfast was to be served to all residents in the following manner: Breakfast: Dining room [ROOM NUMBER]:30 AM-7:00 AM; North Unit 7:15 AM-7:30 AM; South Unit 7:20 AM - 7:45 AM; Lunch: Dining room [ROOM NUMBER]:30 AM - 12:00 PM; North Unit 11:45 AM - 12:15 PM; South Unit 12:00 PM - 12:30 PM; Dinner: Dining room [ROOM NUMBER]:30 PM - 4:45 PM; North Unit 4:45 PM - 5:00 PM; South Unit 5:00 PM - 5:15 PM.

Based on observations, staff interviews, record review and facility procedural guidelines, the facility failed to ensure that residents were treated with respect and dignity while providing personal care for one (1) of six (6) residents reviewed for incontinent/catheter care observations. Resident #1. Findings Include: Record review of the facility's Performance Checklist Procedural Guideline: Perineal Care revealed, .3. Assembled supplies . 5. Performed perineal care for a female: . c. Draped patient appropriately with bath blanket. d. Folded outer corners of blanket around patient's thighs, lifted lower tip of blanket to expose perineum . Record review of the facility's policy titled Residents' Rights Summary dated May 1, 2012 revealed, 1. Exercise of Rights: The resident has the right to exercise his/her rights as a resident of the facility . and to be free from interference, coercion, discrimination . Examples of Violations: . 4. Allowing a resident's body to be exposed. Resident #1 On 11/30/21 at 11:10 AM, the State Survey Agency (SSA) observed Resident #1 being cleaned, washed, and receiving perineal care. The SSA observed Certified Nursing Assistant (CNA) #2 as she removed the resident's gown, washed the resident, and performed incontinent care for Resident #1. Throughout the procedure, CNA #2 did not drape the resident with a blanket to provide privacy. During the procedure, CNA #2 left the room to get supplies and continued to leave the resident uncovered and exposed, wearing only a brief. CNA #3 assisted CNA #2 with the procedure and stayed with the resident. Although the resident complained of being cold, CNA #3 did not cover the resident for comfort or dignity. CNA #2 returned and completed the care. The resident was left exposed for the duration of the procedure which lasted twenty minutes. At 11:30 AM on 11/30/21, during an interview with CNA #2, she stated she was nervous and couldn't remember. The SSA asked CNA #2 about the resident's dignity, she said she did not cover the resident while providing care and left the resident with just her brief on for an extended amount of time. She confirmed she left the room during care to gather supplies and had left the resident uncovered. On 11/30/21 at 11:55 AM, during an interview with CNA #3, she confirmed CNA #2 did leave the resident uncovered for a long period of time and the resident complained of being cold. CNA #3 stated she could have covered the resident but she just forgot. On 12/01/21 at 04:05 PM, during an interview with Registered Nurse (RN) #1, she reported CNA #2 and CNA #3 should have covered the resident and by not covering her up, this was a dignity issue. She explained she completed orientation with CNA #2 upon hire and the CNA completed a performance checklist procedure for perineal care. She reported she also completed an in-service training months ago with all CNA's regarding providing care and dignity to residents. On 12/01/21 at 04:53 PM, during an interview with the Director of Nursing (DON), she stated CNA #2 should have had all supplies available, covered the resident when providing care, and CNA #3 could have covered Resident #1. She explained not covering while providing care is an issue of dignity for Resident #1. Record review of the facility's Performance Checklist Procedural Guideline: Perineal Care revealed CNA #2 completed the check off on 10/26/21 successfully with instructor RN #1, which indicated CNA #2 received training related to perineal care. Record review of an in-service training completed on 09/15/21 and presented by RN #1 revealed the Program Content of the training as perineal care which included, Resident dignity always comes first. CNA #3's signature was on the sign-in sheet which indicated she was present for the training. Record review of Resident #1's Admission Record revealed the facility admitted Resident #1 on 5/18/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/24/21, revealed Section C, staff assessment for Mental Status resident had Brief Interview for Mental Status (BIMS) of 99, which indicated Resident #1 could not complete the assessment and resident had short and long-term memory problems, did not know the current season, location of room, or staff names and faces but did understand she was in a nursing home but rarely understands others. Resident #1 had no behaviors noted in the seven days look back. Section G revealed that Resident #1 required total assistance for eating and toilet use and extensive assistance for dressing, bed mobility, and personal hygiene and was always incontinent of bowel and bladder.

Based on observation, interviews, record review, and facility policy review the facility failed to follow the comprehensive care plan for two (2) of (19) care plans reviewed. Resident #1 and Resident #87. Findings Include: Review of the facility's policy Care Plans with an effective date of October 2021, revealed Policy .Care plans are developed by the interdisciplinary team and revised as needed according to resident and status or change. Resident #1 On 11/30/21 at 11:00 AM, SA observed incontinent care provided by Certified Nurse Assistant (CNA) #2. The State Agency (SA) noted Resident #1 had an incontinent episode and had a small bowel movement. During the procedure, the resident was lying on her left side and had her back toward the CNA. CNA #2 wiped the resident from behind and continued wiping from front to back until no more bowel movement was noted on the resident. She then placed a clean brief on the resident. CNA #2 did not reposition Resident #1 onto her back so that care could be provided to the groin and perineal areas. CNA #3 was assisting CNA #2 during care. On 11/30/21 at 11:30 AM, during an interview with CNA #2 confirmed she did not clean the groin and perineal area. On 11/30/21 at 11:55 AM, during an interview with CNA #3 confirmed CNA #2 only cleaned Resident #1 from the back and didn't clean the groin or front perineal area. On 12/01/21 at 04:53 PM during an interview with Director of Nursing (DON), she confirmed that CNA #2 provided improper incontinent care and did not follow the plan of care for cleaning the perineal area. Record review of Admission Record revealed the facility admitted Resident #1 on 05/18/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/24/21, revealed Section C, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 99, which indicated Resident #1 could not complete the assessment and the staff assessment for mental status revealed Resident #1 had short- and long-term memory problems. Section G revealed Resident #1 required total assistance for eating and toilet use and extensive assistance for dressing, bed mobility, and personal hygiene. Section H revealed Resident #1 was always incontinent of bowel and bladder. Record review of the Comprehensive Care Plan revealed a care plan initiated on 08/05/21 for Resident #1 with focus area (Formal Name) has bowel and bladder incontinence, diarrhea r/t (related to) Dementia, history of Urinary Tract Infection ([CONDITION(S)]), and Impaired Mobility .Interventions .Clean peri-area with each incontinence episode .INCONTINENT: Check every two (2) hours and as required for incontinence. Wash, rinse, and dry perineum . Resident #87 On 11/30/21 at 01:35 PM, the SA observed RN #4 performing an in/out catheter procedure for Resident #87. During the observation, RN #4 used one (1) of the three (3) [MEDICATION(S)] swabs to clean the perineal area. She used only the one swab to clean the meatus, and then inserted the catheter. RN #4 failed to use the other two (2) swabs to clean each side of the labia before inserting the catheter. At 1:38 PM on 11/30/21, during an interview with RN #4, she explained she just got nervous and should have used all three (3) [MEDICATION(S)] swabs and cleaned the labia and meatus. On 12/01/21 at 4:30 PM, during an interview with the DON, she confirmed the catheter insertion was not completed properly and RN #4 did not follow the plan of care. Record review of Admission Record revealed the facility admitted Resident #87 on 05/31/2017 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Comprehensive Care Plan revealed a person centered care plan for Resident #87 initiated 2/26/14, Focus: (Formal Name) has potential for Urinary Tract Infections related to in and out Foley catheterization secondary to Neuromuscular Dysfunction of Bladder, unspecified ., with goal will be free from signs and symptoms of urinary tract infection, .Interventions: Intermittent cath (catheter) (in and out cath) TID (three times a day) every shift . Record review of Order Summary Report for Resident #87 revealed an order dated 11/22/21 orders for intermittent catheter (in and out) three times a day, in and out catheter every eight (8) hours as needed. Record review of Quarterly MDS with an ARD of 11/23/21, revealed Resident #87 had a BIMS score of 15, which indicated cognitively intact. On 12/01/21 at 3:50 PM ,during an interview with Minimum Data Set (MDS) nurse Registered Nurse (RN) #3, she explained she completes the MDS and care plan for the residents. She explained when a care plan is initiated, she expects staff to follow the care plan.

Based on Record Review, Facility Policy Review, Resident's Responsible Party (RP) Interview, and Staff Interview, the facility failed to accurately develop a Baseline Care Plan regarding an Advance Directive for a full code for one (1) of five (5) resident records reviewed, Resident #1. Resident #1's Baseline Care Plan summary listed Do Not Resuscitate (DNR) and the Advanced Directive was documented for a full code status (provide CPR for the Resident), signed by Resident #1's responsible party (RP). Resident #1 was found unresponsive and with no pulse at 10:30 PM on [DATE], by Certified Nursing Assistant (CNA) #1. Licensed Practical Nurse (LPN) #1 was notified by CNA #1 that Resident #1 was unresponsive. CNA#1 states that she began CPR, but stopped. LPN #1 stated that she did not find the resident's code status in the medical record and began CPR, but stopped. The facility failed to develop an accurate Baseline Care Plan to alert staff to the resident's code status and failed to continuously provide CPR to Resident #1 until Emergency Medical Services (EMS) arrived or physician ordered CPR to cease. Resident #1 expired. The facility's failure to develop an accurate Baseline Care Plan for a full code status, as noted in the Advanced Directive, and signed by Resident #1's RP, resulted in staff failure to continue CPR. The noncompliance with the Full Code Resuscitation order of the Advance Directive, resulted in the resident's death and placed other residents with a full code status in a situation that was likely to cause serious injury, harm, impairment, or death. The facility's Administrator was notified of the IJ on [DATE]. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged all corrective actions to remove the IJ were completed on [DATE], and the IJ removed on [DATE]. The SA validated the facility's Removal Plan on [DATE], and determined the IJ was removed on [DATE]. Therefore, the scope and severity for: 42 CFR(s):483.21(a) (1)-Base Line Care Plan, (F655) was lowered from a J to a scope and severity of a D level, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy document titled, Care Plans, dated (MONTH) (YEAR), revealed that it is the policy of this facility that Care plans will be developed for all patients and residents based upon the Resident Assessment Instrument (RAI) manual guidelines. The facility policy states that Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. Review of the facility policy titled, Advance Directives, dated (MONTH) 1, (YEAR), revealed that the facility recognizes the dignity and value of each Resident's right to make health care decisions. The policy noted that the facility recognizes the right of each Resident to issue Advanced Directives regarding his or her health care; and that under an Advance Directive, a Resident may appoint an individual who is familiar with the Resident or whom the Resident trusts to make health care decisions on his or her behalf should the Resident lose capacity. The facility policy states that such healthcare decisions may include decisions regarding whether or not to receive or continue life support. The guidelines state that the facility will document in the Resident's medical record whether or not the Resident has executed an Advance Directive. Review of Resident #1's medical records document titled, Baseline Care Plan - V 3, with Resident #1's name and an admission date of [DATE], revealed that the summary of the Baseline Care Plan documented: Fall Risk DNR. Review of Resident #1's medical records document titled, Resuscitation Orders, dated [DATE], revealed that Resident #1's Responsible Party (RP), her daughter, signed the form, indicating that in the event of a cardiopulmonary arrest, cardio-pulmonary resuscitation will be performed. The Resuscitation Order was also marked by Resident #1's RP, to indicate that in the event of a [MEDICAL CONDITION] and/or respiratory arrest, to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR). Review of Resident #1's (MONTH) 2019 Physician's Orders revealed no orders for a Do Not Resuscitate. Review of a written report from Resident #1's family member, dated [DATE], revealed a complaint that facility staff started CPR on Resident #1 and didn't continue until EMS arrived. The report documented that when the family member walked into Resident #1's room, the nurse was standing there, and when asked why wasn't she doing anything, the nurse replied, She's a DNR right?. The family member documented that she informed the nurse that Resident #1 was a full code. The report documented the family member stated there was clearly no Code (CPR) performed on Resident #1. Review of the facility's investigative report, dated [DATE], revealed there was an allegation from Resident #1's Responsible Party and her daughter that CPR was initiated and then stopped too soon on Resident #1. The investigative report concluded that LPN #1 initiated CPR on the resident and then stopped when the family came into the room. The report documented that LPN #1 was suspended, reported to the Board of Nursing, and terminated related to not continuing CPR on Resident #1. During an interview, on [DATE] at 10:45 AM, with the Director of Nursing (DON), it was revealed that she had been made aware of the incident that occurred on [DATE], concerning Resident #1. The DON confirmed that she had reviewed Resident #1's Baseline Care Plan that had been developed upon admission, and it in the summary it did indeed state, Fall Risk/DNR. The DON stated, The Advance Directive that was signed said Resident #1 was a full code, so I don't know why there is a DNR on the summary, and I don't know who would have put it on there either. The DON confirmed the care plan should have reflected the Advanced Directive for CPR for Resident #1. During an interview, on [DATE] at 11:41 AM, the facility's Provider Liaison for Admissions (PLA) revealed that she completed the admission packet with the daughter and Responsible Party (RP) of Resident #1. The PLA stated that the Advanced Directives form was read out to loud to Resident #1's RP. The PLA stated that Resident #1's RP verbally stated that her mother, Resident #1, was to be a Full Code. The PLA stated Resident #1's RP signed the Advance Directive form, and dated it for [DATE]. During an interview, on [DATE] at 2:44 PM, Resident #1's RP revealed that she was the person who signed the Admission Agreement on behalf of Resident #1 on [DATE]. The RP stated that during this meeting she conveyed that the family wanted CPR to be performed. Further interview with the DON on [DATE] at 3:05 PM, revealed LPN #1 was responsible for not continuing CPR on Resident #1 until EMS arrived or a physician's order to discontinue CPR, and had been terminated on [DATE]. Review of Resident #1's face sheet, revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the 5 Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed that Resident #1 had not been assessed for a Brief Interview of Mental Status (BIMS) score, but had been identified as having modified independent decision-making skills. The facility submitted a Removal Plan for the I[NAME] Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. After a conversation with Resident's #1's granddaughter on (MONTH) 16, 2019, the Director of Nursing Services (DNS) initiated an investigation. 2. Licensed Practical Nurse (LPN) #1 was suspended pending an investigation on (MONTH) 16, 2019, by the DNS for failure to continue CPR until Emergency Medical Services (EMS) arrived. 3. A 100 percent (%) audit of resident's charts was completed to verify all advanced directives and code status orders were in place on (MONTH) 16, 2019, by the DNS. Results revealed every resident had correct code status in the computer. 4. A 100% audit of resident's charts for designated code status form on the front of the chart was conducted by the DNS on (MONTH) 16, 2019. Results revealed two (2) residents did not have code status on the chart and code status was placed in the front of the chart; corrected immediately. 5. Eleven (11) Registered Nurses (RNs), 18 LPNs and one (1) Social Service Coordinator (SSC) were educated beginning (MONTH) 16, 2019, and ending (MONTH) 19, 2019, on CPR to include correctly responding, performing CPR, and continuing CPR until EMS arrives and begins care or a physician in attendance and orders to cease CPR. 6. Eleven (11) RNs, 18 LPNs, and one (1) SSC were educated on the Advance Directive Policy by the DNS beginning on (MONTH) 16, 2019, and ending on (MONTH) 19, 2019. 7. Beginning (MONTH) 16, 2019 and ending (MONTH) 22, 2019, one (1) code drill was conducted daily on various shifts by the DNS and /or RN Unit Manager (UM) to include correctly responding to Code Blue being called, including all Licensed Nurses to be in room, performing CPR, and continuing CPR until EMS arrives and begins care, or a physician in attendance and orders are given to cease CPR. 8. The Nurse Consultant #1 and the Administrator conducted 100% audit of all Baseline Care Plans and Comprehensive Care Plan to include Code Status on (MONTH) 27, 2019. The Baseline Care Plan audit revealed five (5) baseline care plans that did not reflect the code status in the chart. The Comprehensive Care Plan was correct for the five (5) residents. A care plan note was written in the medical records. The Comprehensive Care Plan audit revealed one (1) comprehensive care plan that did not reflect the code status in the chart and was updated to reflect code status. 9. The Director of Clinical Education (DCE) educated 11 LPNs, five (5) RNs and one (1) SSC on Baseline Care Plans to include correctly developing Baseline Care Plans on (MONTH) 27, 2019. 10. The Mississippi State Board of Nursing was notified on (MONTH) 27, 2019, related to the LPN #1's failure to provide CPR by professional standards and of her suspension. 11. LPN #1 was terminated on (MONTH) 27, 2019, by the DNS for failure to continue CPR until EMS arrived for Resident #1. 12. The Quality Assurance Performance Improvement (QAPI) meeting was held on (MONTH) 27, 2019 at 5:30 PM. Systemic changes and monitoring have been developed, presented and approved by Administrator, Director of Nursing Services, Nurse Consultant, Clinical Education Nurse, and Medical Director. Systemic changes include code status and baseline care plan review at the next day Daily Clinical Start Up meeting. Post CPR reviews will be conducted on any charts of residents who may have required CPR. Findings from CPR order audits and baseline care plan audits were discussed at the QAPI meeting. 13. The Administrator reported the Immediate Jeopardy to the Attorney General's office on (MONTH) 27, 2019 at 8:30 PM. 14. RNs, LPNs, and CNAs will not be allowed to work until education has been completed on CPR and Baseline Care Plans. The facility alleges all corrective actions were completed on (MONTH) 27, 2019, and removal of the immediate jeopardy on (MONTH) 28, 2019. On [DATE], The SA survey validated through staff interviews, record reviews, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy: 1. The SA verified the facility's investigation of Resident #1's death on [DATE]. Resident #1 was found unresponsive, without vital signs, with CPR initiated but not continuously provided per interviews, records reviews, and reviews of written statements from facility staff, and written reports to the S[NAME] 2. The SA validated through record review, time card review, and interview with the DNS, that LPN #1 was suspended prior to her shift on [DATE], and terminated on [DATE]. 3. The SA validated through document review and interview with the DNS that an audit was completed on [DATE], of all resident charts to ensure that all Advance Directives, Code orders, and the Code Status on the chart was accurate according to the facility's computer and was easily accessible. 4. The SA validated through record review and interview with the DNS that the Administrator conducted a 100 % Audit of all resident's Base Line Care Plans to ensure the code status of all residents in the facility on [DATE], were correct. 5. The SA validated through record reviews and through staff interviews of Registered Nurse (RN)s, Licensed Practical Nurse (LPN)s, Certified Nursing Assistants (CNAs), and Social Service Coordinator (SSC), that in-service training was conducted, starting on [DATE], regarding responding correctly, providing CPR and continuing until EMS arrived or a physician gave an order to stop. 6. The SA validated through record reviews and through staff interviews of Registered Nurse (RN)s, Licensed Practical Nurse (LPN)s, Certified Nursing Assistants (CNAs), and Social Service Coordinator (SSC), that in-service training was conducted, starting on [DATE], regarding Advance Directives. 7. The SA validated through record reviews and through staff interviews of Registered Nurse (RN)s, Licensed Practical Nurse (LPN)s, Certified Nursing Assistants (CNAs), that drills were conducted related to correctly responding to Code Blue and continuing until EMS arrived or a physician's order to discontinue. 8. The SA validated through interview and record review that the Nurse Consultant #1 and the Administrator conducted a 100% audit of all Baseline Care Plans and Comprehensive Care Plan to include Code Status on (MONTH) 27, 2019, and corrected any negative findings. 9. The SA validated through interview and in-service record review that the Director of Clinical Education (DCE) educated 11 LPNs, five (5) RNs and one (1) SSC on Baseline Care Plans to include correctly developing Baseline Care Plans on (MONTH) 27, 2019. 10. The SA validated through document review with the Mississippi Board of Nursing Investigator on [DATE], that the office had received an online complaint on [DATE], from the facility regarding LPN #1's failure to continue CPR to Resident #1 on [DATE]. 11. The SA validated through record review, time card review, and interview with the DNS, that LPN #1 was suspended prior to her shift on [DATE], and terminated on [DATE], for failure to continue CPR on Resident #1. 12. The SA validated through record review of the Quality Assurance (QA) Committee sign it sheet, dated [DATE], and interviews with the Administrator, the DNS, the Medical Director, and Registered Nurse (RN) #1/Unit Manager, that the facility initiated a QA Committee meeting on [DATE], with the facility's Administrator, the DNS, Registered Nurse (RN) #1 Unit Manager, and Nursing Practitioner in attendance concerning the failure of LPN #1 to follow the Advance Directive for Code Status of Resident #1, Policy and Procedures pertaining to Code Status, CPR, and Advance Directives were reviewed. Systemic changes to resident's code status and Base Line Care plans were reviewed, and that follow-up will continue at the next day daily clinical start-up meeting. 13. The SA validated through record review and Administrator confirmation, that the Immediate Jeopardy status was reported to the Attorney General (AG)'s office on [DATE]. 14. The SA validated through interviews and schedule review, that the Nursing staff was not allowed to return to work until in-serviced. The SA validated that all corrective actions to remove the IJ were completed on [DATE], and the IJ removed on [DATE].

Based on Record Review, Facility Policy Review, Responsible Party (RP) Interview, and Staff Interview, the facility failed to continuously deliver care within the scope of professional standards of practice for Cardio-Pulmonary Resuscitation (CPR) for one (1) of five (5) resident's reviewed, Resident #1. Resident #1 was found unresponsive and with no pulse at 10:30 PM, on [DATE], by Certified Nursing Assistant (CNA) #1. Licensed Practical Nurse (LPN) #1 was notified that Resident #1 was unresponsive. CNA#1 stated that she began CPR, but stopped. LPN #1 stated that she began CPR, but did not continue until Emergency Medical Services (EMS) arrived. Resident #1's Responsible Party (RP) and the EMS staff reported that CPR was not in process when they arrived to the resident's room. The failure to continuously deliver care within the scope of professional standards of practice for CPR, until the arrival of the EMS, despite Resident #1's Full Code status Advance Directive, resulted in the resident's death and placed other residents with a full code status in a situation with the likelihood to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on [DATE], when the facility failed to continue CPR on Resident #1, who had an Advanced Directive of Full Code Status, resulting in the death of Resident #1. The facility's Administrator was notified of the IJ and SQC on [DATE]. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged all corrective actions to remove the IJ were completed on [DATE], and the IJ removed on [DATE]. The SA validated the facility's Action Plan on [DATE], and determined the IJ was removed on [DATE]. Therefore, the scope and severity for: 42 CFR(s): 483.24(b) (3) (i)-Services Provided Meet Professional Standards, (F658) was lowered from J to a scope and severity of a D, while the facility developed a plan of correction to monitor the effectiveness of the systematic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy titled, Cardio [MEDICAL CONDITION] Resuscitation Policy, dated (MONTH) (YEAR), revealed that it is the policy of this facility that basic life support, including initiation of Cardio-Pulmonary Resuscitation (CPR), is provided to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) who do not show obvious clinical signs of irreversible death, (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition) and in accordance with the resident's Advance Directive and any related physician order such as code status, or in the absence of advance directives or a Do Not Resuscitate (DNR) order. The facility policy's procedural guidelines noted that CPR will be initiated when [MEDICAL CONDITION] (CA) occurs for residents who have requested CPR in their Advance Directives. Review of the facility policy titled, Advance Directives, dated (MONTH) 1, (YEAR), revealed that it is the policy of this facility that the facility recognizes the dignity and value of each Resident's right to make health care decisions and to be fully informed of his or her health status. The facility policy noted the facility recognized the right of each Resident to issue Advanced Directives regarding his or her health care. The facility policy noted Advanced Directives that comply with state law and that are consistent with the level of care the facility is licensed to provide, will be honored. The policy noted that for the purpose of this policy, Advance Directive means a living will or durable power of attorney for health care, recognized under State law relating to the provisions of health care when a Resident is incapacitated. The policy also noted that under an Advance Directive, a Resident may appoint an individual who is familiar with the Resident, or whom the Resident trusts, to make health care decisions on his or her behalf should the Resident lose capacity. The facility policy states that such healthcare decisions may include decisions regarding whether or not to receive or continue life support. The procedural guidelines also noted that the facility will provide education and training to its staff regarding policies and procedures related to Advance Directives. Review of Resident #1's medical records document titled, Resuscitation Orders, dated [DATE], revealed that Resident #1's Responsible Party (RP), her daughter, signed the form indicating that in the event of a cardiopulmonary arrest, cardio-pulmonary resuscitation will be performed. The Resuscitation Order was also marked by Resident #1's RP, to indicate that in the event of a [MEDICAL CONDITION] and/or respiratory arrest, to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR). Review of Resident #'1's medical records revealed a Progress Note, dated [DATE], which noted that Licensed Practical Nurse (LPN) #1 entered a General Note at 11:34 PM. The note read documented that a CNA stated Resident #1 was put to bed around 7:30 PM. At approximately 8:30 PM, LPN #1 went to give the resident medication. At approximately 8:55 PM, CNA rounded and stated Resident was fine. CNA rounded at approximately 10:30 PM, came to the nurses' station, and stated the resident was not responding. LPN #1 electronically documented that a Code was called and CPR performed. LPN #1 documented that vital signs were not registering and the Coroner was called by ambulance services. During an interview, on [DATE] at 10:45 AM, the Director of Nursing (DON) revealed that she had been made aware of the incident that occurred on [DATE], concerning Resident #1's code status. The DON stated that she had begun to educate the nursing staff on the American Heart Association (AHA) recommendations for performing CPR until the Emergency Medical Technicians (EMTs) arrive and take over. The DON also stated that she had begun to in-service the nursing staff on Resident's Advance Directives, Code Status, and Base Line Care Plans. The DON stated that until in-serviced, the Nursing Staff would not be able to return to work. During a telephone interview, on [DATE] at 3:35 PM, Licensed Practical Nurse (LPN) #1 confirmed that she was notified by CNA #1, about 10:30 PM, that Resident #1 was not responding. LPN #1 stated that she immediately went to the Resident #1's room and CNA #1 followed her. LPN #1 stated that she assessed Resident #1 at that time, noting that the resident was not responding to verbal or tactile stimulus. LPN #1 stated that she told CNA #1 to start CPR, while she went to the nurse's station to check the resident's chart. LPN #1 stated that while she was at the station, she called the resident's daughter to tell her that the resident was not responding. LPN #1 stated that she called the telephone number on the chart, but it was not the daughter, who was Resident #1's emergency contact. LPN #1 stated that she went back to the resident's room and told CNA #1 that she couldn't find a code status, and so she (LPN #1) would take over the CPR. LPN #1 stated that she continued chest compressions, while CNA #1 was counting. LPN #1 stated that she only stopped performing CPR, when she heard Resident #1's ribs crack. LPN #1 stated that she called out to the nurse's station and told LPN #2 to bring the crash cart to Resident #1's room. LPN #1 stated that LPN #2 placed the crash cart at the foot of the Resident #1's bed, when he brought it into the room. LPN #1 stated, I did not have an opportunity to use anything from the cart, I didn't even use the Ambu bag. LPN #1 stated that she was the only person in the room for some time. LPN #1 stated that the daughter walked into the room and said, She's gone! She's gone! LPN #1 stated that she took that statement to mean that the daughter did not want her to continue CPR. LPN #1 stated the Emergency Medical Technicians (EMTs) came in right behind the daughter. LPN #1 stated that after the EMTs checked Resident #1 for vital signs, and found none, they left. During an interview on [DATE] at 3:55 PM, Licensed Practical Nurse (LPN) #2 revealed that he arrived on [DATE], for the 11:00 PM to 7:00 shift, he passed Resident #1's room and noticed three (3) to four (4) staff members in the room. LPN #2 stated that as he continued towards the nurse's station, LPN #1 called out to him and told him to bring her the crash cart. LPN #2 stated that while he was getting the crash cart, he also told LPN #3 to call 911, because he was unsure if anyone had called them yet. LPN #2 stated that he took the crash cart to the doorway of Resident #1's room. LPN #2 stated no one was doing chest compressions or CPR, so he left to go assist with another resident who had fallen. LPN #2 also stated that LPN #1 never asked him to help her perform CPR. LPN #2 stated that he never heard anyone call a Code Blue. During an interview on [DATE] at 4:15 PM, CNA #1 revealed that she had been working the night of [DATE], and was assigned to Resident #1. CNA #1 stated that she went into Resident #1's room while doing her end-of-shift rounds at about 10:30 PM, and noticed that Resident #1 was unresponsive. CNA #1 stated that she had been in the room twice, earlier in the evening, and the resident was just fine. CNA #1 stated that when she touched Resident #1's arm, she still felt warm. CNA #1 stated when she saw that Resident #1 wasn't breathing, she immediately started doing chest compressions and only did about four (4) to five (5) pushes on Resident #1's chest, then stopped to get a nurse. CNA #1 stated she reported that Resident #1 was gone to LPN #1 at the nurse's station. CNA #1 stated LPN #1 got up from the nurse's station, got the vital sign machine, and went to Resident #1's room. CNA #1 stated she accompanied LPN #1 back to Resident #1's room, where LPN #1 instructed her to try to get Resident #1's vital signs and to start CPR, while she (LPN #1) went back to the nurse's station to check Resident #1's chart for her code status. CNA #1 stated when LPN #1 returned from the nurse's station, LPN #1 informed her that Resident #1 was a full code. CNA #1 states that LPN #1 took over CPR. CNA #1 stated that she was present inside Resident #1's room, when LPN #2 pushed the crash cart from the doorway. CNA #1 stated that it was at this time that she left, because she realized that she still needed to finish her rounds, so that she could clock out and go home. CNA #1 stated that she wasn't in the room when Resident #1's daughter arrived, but she did hear the daughter say, She's gone. CNA #1 stated that after her rounds, she clocked out. CNA #1 stated that as she was clocking out, she saw the EMTs arrive and go into Resident #1's room. During a telephone interview, on [DATE] at 11:10 AM, an Ambulance Service Representative (ASR) revealed a report was filed with the billing department of the facility's Ambulance Service. The ASR stated that in the report, it noted the following: Emergency Medical Technicians (EMTs) responded to a call from the facility that came in at 22:57 (10:57 PM). Caller stated that a resident is unresponsive, unconscious, and not breathing. EMTs arrived at the facility at 23:04 (11:04 PM). Nurse in charge (No Name) reported that the resident was okay 45 minutes earlier, prior to EMTs arrival. Nurse (no name) reported that CPR had stopped per the daughter's request. Departed Facility at 23:20 (11:20 PM). Resident was: Dead on Arrival (DOA). The ASR stated that this was all the information she could provide me at this time. During an interview, on [DATE] at 2:44 PM, Resident #1's Responsible Party (RP)/ Daughter revealed that she was the person who signed the Admission Agreement on behalf of Resident #1, on [DATE]. The RP stated during this meeting she conveyed that the family wanted CPR to be performed. The RP stated that she was Contact #1 for Resident #1. The RP stated that on the night of [DATE] at 10:44 PM, her sister, who was Contact #3, received a call from the facility. The RP stated that her sister didn't answer this call, but LPN #1 did leave a voice mail. The RP stated the facility called again at 10:45 PM, and a nurse from the facility told her sister that their mother was unresponsive. The RP stated that her sister called her and while she was on her way to the facility, she contacted her daughter. The RP stated that on the night of [DATE] at 11:04 PM, she arrived at the facility. The RP stated that as she approached her mom's room, she noticed that the door to her mom's room was wide open. The RP stated that she saw her mother from the doorway. The RP stated that her mother was turned slightly toward the left and the head of the bed was elevated. The RP stated that no one was in the room with her mother. The RP stated that she didn't see any staff until she turned and saw LPN #1 coming up the hall toward her. The RP stated that LPN #1 was shaking her head in an empathetic way, as to indicate to her that her mom had passed away. The RP stated that she remembers saying in an inquisitive manner to LPN #1, She's gone? She's gone? The RP stated that LPN #1 called out for someone to get her a chair, and then LPN #1 proceeded into the room. The RP stated that at no time did she see anyone doing CPR. The RP stated, If I'd a seen somebody doing CPR, I'd a never told them to stop. The RP stated she followed LPN #1 into the room. The RP stated that her mom was already dressed. The RP stated her daughter, Resident #1's granddaughter, came into the room almost right behind her and asked, What was going on? The RP stated that the EMTs came in right behind her daughter and started talking to LPN #1, asking them what was going on. The RP stated that the EMTs checked for her mom's vital signs, stayed for a few minutes, and left. During a telephone interview, on [DATE] at 10:33 AM, Resident #1's Medical Doctor (MD) revealed if CPR was initiated, then it should continue. During a telephone interview, on [DATE] at 2:19 PM, LPN #3 confirmed that she was sitting at the nurse's station documenting before the shift changed, when a CNA, whose name she doesn't know, walked up to LPN #1 and said that Resident #1 was dead. LPN #3 stated, LPN#1 left the station, and returned approximately ,[DATE] minutes later, and told me that Resident #1 was dead. LPN #3 stated she asked LPN #1 if she had checked the resident's chart for her code status, and she said No, I didn't. LPN #3 stated that she looked at Resident #1's chart and couldn't find a DNR. LPN #3 stated that she told LPN#1 that it would have to be treated as a full code. LPN #3 stated she told LPN #1 to grab the crash cart, and that she would call the ambulance. LPN #3 stated that she also told LPN #1 that she would get the transfer paperwork filled out. LPN #3 stated that by the time she called 911, finished writing the paperwork, and she arrived at the room, the daughter, granddaughter, and the EMTs were all present in the room. LPN #3 stated that she gave the paperwork to the EMTs and then returned to the nurse's station. LPN #3 stated that at no time did she see or hear of anyone starting or stopping CPR. LPN #3 stated that she never heard anyone call for someone to go to Resident #1's room over the intercom. LPN #3 stated she was never told to call, nor did she ever hear, a Code Blue called over the intercom that night. LPN #3 stated when a Code Blue is called, all staff are supposed to report to that location, because that means there is a full code in progress, due to a [MEDICAL CONDITION] or [MEDICAL CONDITION]. LPN #3 stated when CPR is initiated, it should always continue until the emergency team arrives, or unless a doctor is present to say stop. During an interview, on [DATE] at 3:05 PM, the Director of Nursing (DON) revealed that she suspended LPN #1 on [DATE], pending the conclusion of the investigation. The DON stated that she terminated LPN #1 on [DATE], for not continuing CPR once initiated. Review of Resident #1's face sheet, revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed that Resident # 1 had not been assessed for a Brief Interview of Mental Status (BIMS) score, but had been identified as having modified independent decision-making skills. The facility submitted a Removal Plan for the I[NAME] Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. After a conversation with Resident's #1's granddaughter on (MONTH) 16, 2019, the Director of Nursing Services (DNS) initiated an investigation. 2. Licensed Practical Nurse (LPN) #1 was suspended pending an investigation on (MONTH) 16, 2019, by the DNS for failure to continue CPR until Emergency Medical Services (EMS) arrived. 3. A 100 percent (%) audit of resident's charts was completed to verify all advanced directives and code status orders were in place on (MONTH) 16, 2019, by the DNS. Results revealed every resident had correct code status in the computer. 4. A 100% audit of resident's charts for designated code status form on the front of the chart was conducted by the DNS on (MONTH) 16, 2019. Results revealed two (2) residents did not have code status on the chart and code status was placed in the front of the chart; corrected immediately. 5. Eleven (11) Registered Nurses (RNs), 18 LPNs and one (1) Social Service Coordinator (SSC) were educated beginning (MONTH) 16, 2019, and ending (MONTH) 19, 2019, on CPR to include correctly responding, performing CPR, and continuing CPR until EMS arrives and begins care or a physician in attendance and orders to cease CPR. 6. Eleven (11) RNs, 18 LPNs, and one (1) SSC were educated on the Advance Directive Policy by the DNS beginning on (MONTH) 16, 2019, and ending on (MONTH) 19, 2019. 7. Beginning (MONTH) 16, 2019 and ending (MONTH) 22, 2019, one (1) code drill was conducted daily on various shifts by the DNS and /or RN Unit Manager (UM) to include correctly responding to Code Blue being called, including all Licensed Nurses to be in room, performing CPR, and continuing CPR until EMS arrives and begins care, or a physician in attendance and orders are given to cease CPR. 8. The Nurse Consultant #1 and the Administrator conducted 100% audit of all Baseline Care Plans and Comprehensive Care Plan to include Code Status on (MONTH) 27, 2019. The Baseline Care Plan audit revealed five (5) baseline care plans that did not reflect the code status in the chart. The Comprehensive Care Plan was correct for the five (5) residents. A care plan note was written in the medical records. The Comprehensive Care Plan audit revealed one (1) comprehensive care plan that did not reflect the code status in the chart and was updated to reflect code status. 9. The Director of Clinical Education (DCE) educated 11 LPNs, five (5) RNs and one (1) SSC on Baseline Care Plans to include correctly developing Baseline Care Plans on (MONTH) 27, 2019. 10. The Mississippi State Board of Nursing was notified on (MONTH) 27, 2019, related to the LPN #1's failure to provide CPR by professional standards and of her suspension. 11. LPN #1 was terminated on (MONTH) 27, 2019, by the DNS for failure to continue CPR until EMS arrived for Resident #1. 12. The Quality Assurance Performance Improvement (QAPI) meeting was held on (MONTH) 27, 2019 at 5:30 PM. Systemic changes and monitoring have been developed, presented and approved by Administrator, Director of Nursing Services, Nurse Consultant, Clinical Education Nurse, and Medical Director. Systemic changes include code status and baseline care plan review at the next day Daily Clinical Start Up meeting. Post CPR reviews will be conducted on any charts of residents who may have required CPR. Findings from CPR order audits and baseline care plan audits were discussed at the QAPI meeting. 13. The Administrator reported the Immediate Jeopardy to the Attorney General's office on (MONTH) 27, 2019 at 8:30 PM. 14. RNs, LPNs, and CNAs will not be allowed to work until education has been completed on CPR and Baseline Care Plans. The facility alleges all corrective actions were completed on (MONTH) 27, 2019, and removal of the immediate jeopardy on (MONTH) 28, 2019. On [DATE], The SA survey validated through staff interviews, record reviews, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy: 1. The SA verified the facility's investigation of Resident #1's death on [DATE]. Resident #1 was found unresponsive, without vital signs, with CPR initiated but not continuously provided per interviews, records reviews, and reviews of written statements from facility staff, and written reports to the S[NAME] 2. The SA validated through record review, time card review, and interview with the DNS, that LPN #1 was suspended prior to her shift on [DATE], and terminated on [DATE]. 3. The SA validated through document review and interview with the DNS that an audit was completed on [DATE], of all resident charts to ensure that all Advance Directives, Code orders, and the Code Status on the chart was accurate according to the facility's computer and was easily accessible. 4. The SA validated through record review and interview with the DNS that the Administrator conducted a 100 % Audit of all resident's Base Line Care Plans to ensure the code status of all residents in the facility on [DATE], were correct. 5. The SA validated through record reviews and through staff interviews of Registered Nurse (RN)s, Licensed Practical Nurse (LPN)s, Certified Nursing Assistants (CNAs), and Social Service Coordinator (SSC), that in-service training was conducted, starting on [DATE], regarding responding correctly, providing CPR and continuing until EMS arrived or a physician gave an order to stop. 6. The SA validated through record reviews and through staff interviews of Registered Nurse (RN)s, Licensed Practical Nurse (LPN)s, Certified Nursing Assistants (CNAs), and Social Service Coordinator (SSC), that in-service training was conducted, starting on [DATE], regarding Advance Directives. 7. The SA validated through record reviews and through staff interviews of Registered Nurse (RN)s, Licensed Practical Nurse (LPN)s, Certified Nursing Assistants (CNAs), that drills were conducted related to correctly responding to Code Blue and continuing until EMS arrived or a physician's order to discontinue. 8. The SA validated through interview and record review that the Nurse Consultant #1 and the Administrator conducted a 100% audit of all Baseline Care Plans and Comprehensive Care Plan to include Code Status on (MONTH) 27, 2019, and corrected any negative findings. 9. The SA validated through interview and in-service record review that the Director of Clinical Education (DCE) educated 11 LPNs, five (5) RNs and one (1) SSC on Baseline Care Plans to include correctly developing Baseline Care Plans on (MONTH) 27, 2019. 10. The SA validated through document review with the Mississippi Board of Nursing Investigator on [DATE], that the office had received an online complaint on [DATE], from the facility regarding LPN #1's failure to continue CPR to Resident #1 on [DATE]. 11. The SA validated through record review, time card review, and interview with the DNS, that LPN #1 was suspended prior to her shift on [DATE], and terminated on [DATE], for failure to continue CPR on Resident #1. 12. The SA validated through record review of the Quality Assurance (QA) Committee sign it sheet, dated [DATE], and interviews with the Administrator, the DNS, the Medical Director, and Registered Nurse (RN) #1/Unit Manager, that the facility initiated a QA Committee meeting on [DATE], with the facility's Administrator, the DNS, Registered Nurse (RN) #1 Unit Manager, and Nursing Practitioner in attendance concerning the failure of LPN #1 to follow the Advance Directive for Code Status of Resident #1, Policy and Procedures pertaining to Code Status, CPR, and Advance Directives were reviewed. Systemic changes to resident's code status and Base Line Care plans were reviewed, and that follow-up will continue at the next day daily clinical start-up meeting. 13. The SA validated through record review and Administrator confirmation, that the Immediate Jeopardy status was reported to the Attorney General (AG)'s office on [DATE]. 14. The SA validated through interviews and schedule review, that the Nursing staff was not allowed to return to work until in-serviced. The SA validated that all corrective actions to remove the IJ were completed on [DATE], and the IJ removed on [DATE].

Based on Record Review, Facility Policy Review, Resident's Responsible Party (RP) Interview, and Staff Interview, the facility failed to continuously provide Cardio-Pulmonary Resuscitation (CPR), per American Heart Association guidelines, on Resident #1, who had an Advance Directive for a full code status, for one (1) of five (5) resident records reviewed. Resident #1 was found unresponsive, with no pulse at 10:30 PM on [DATE], by Certified Nursing Assistant (CNA) #1. CNA#1 began CPR on Resident #1, but stopped. Licensed Practical Nurse (LPN) #1 began CPR, but didn't continue until Medical Services (EMS) arrived. Resident #1 expired prior to Emergency arrival to EMS the facility, and without a physician's order. Resident #1's Responsible Party (RP) and the Emergency Medical Technicians (EMTs) reported that no one was performing CPR when they arrived. The failure to continuously provide CPR until the arrival of the Emergency Medical Technicians (EMTs), despite Resident #1's Full Code status Advance Directive, resulted in the resident's death and placed other residents with a full code status in a situation, which was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on [DATE], when the facility failed to continue CPR on Resident #1, who had an Advanced Directive of Full Code Status, resulting in the death of Resident #1. The facility's Administrator was notified of the IJ and SQC on [DATE]. The facility submitted an acceptable Removal Plan on [DATE] at 4:29 PM, in which the facility alleged all corrective actions to remove the IJ were completed on [DATE], and the IJ removed on [DATE]. The SA validated the facility's Removal Plan on [DATE], and determined the IJ to be removed on [DATE], prior to exit. Therefore, the scope and severity for: 42 CFR(s): 483.24(a) (3)-Cardio-Pulmonary Resuscitation (CPR), (F678) was lowered from a scope and severity of J to a scope and severity of a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy titled, Cardio [MEDICAL CONDITION] Resuscitation Policy, dated (MONTH) (YEAR), revealed that it is the policy of this facility that basic life support, including initiation of Cardio-Pulmonary Resuscitation (CPR), is provided to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) who do not show obvious clinical signs of irreversible death, (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition) and in accordance with the resident's Advance Directive, any related physician order, such as code status, or in the absence of advance directives, or a Do Not Resuscitate (DNR) order. The policy's procedural guidelines documented that CPR will be initiated when CA ([MEDICAL CONDITION]) occurs for residents who have requested CPR in their Advance Directives. The guidelines documented that the Resident's code status will be designated prominently in the front of the resident's chart. Review of the facility policy titled, Advance Directives, dated (MONTH) 1, (YEAR), revealed the facility recognizes the right of each Resident to issue Advanced Directives regarding his or her health care. The policy documented that Advanced Directives that comply with state law, and are consistent with the level of care the facility is licensed to provide, will be honored. The facility policy states that for the purpose of this policy, Advance Directive means a living will or durable power of attorney for health care, recognized under State law relating to the provisions of health care when a Resident is incapacitated. The facility policy's procedural guidelines documented that the facility will document in the Resident's medical record whether or not the Resident has executed an Advance Directive. Review of the facility's employee training document titled, Emergency Operations Plan Training Guide, no date, revealed that the facility's Nursing department has designated the following Code words to notify team members of certain types of emergencies over the public address system. The training document noted that all other types of emergencies will be announced using plain language. The training document listed Code Blue as the [MEDICAL CONDITION]/Medical Emergency code. Review of the American Heart Association Guidelines, (YEAR), revealed CPR is initiated unless a valid DNR order is in place; obvious signs of irreversible death (rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer. The guidelines note that staff must provide and continue CPR, prior to the arrival of Emergency Medical Services (EMS). Review of a facility document titled, Progress Notes, dated [DATE], revealed that Licensed Practical Nurse (LPN) #1 entered a General Note at 11:34 PM. The note documented that a CNA (not named) stated Resident #1 was put to bed around 7:30 PM, at approximately 8:30 PM, LPN #1 went in to give the resident medication. The note documented the following: At approximately 8:55 PM, CNA rounded and stated the Resident was fine. CNA did rounds at approximately 10:30 PM, came back to nurses' station and stated the resident was not responding. A Code (Blue) was called. CPR performed. Vital signs not registering. Coroner called by ambulance services, funeral home notified. The progress note was electronically signed by LPN #1. Review of a written report from Resident #1's family member, dated [DATE], revealed a concern that facility staff started CPR on Resident #1 and didn't continue until EMS arrived. The family member documented that when she walked into Resident #1's room, the nurse was standing there, and when asked why wasn't she doing anything, the nurse replied, She's a DNR right?. The family member documented that she informed the nurse that Resident #1 was a full code. The family member documented there was clearly no Code (CPR) performed on Resident #1. Review of the facility's investigative report, dated [DATE], revealed an allegation from Resident #1's Responsible Party and her daughter. The investigative report documented a concern that CPR was stopped too soon on Resident #1. The investigative report concluded that LPN #1 initiated CPR on the resident and then stopped when the family came into the room. The report documented that LPN #1 was suspended, reported to the Board of Nursing, and terminated. Review of the facility's report to the Board of Nursing, dated [DATE], revealed LPN #1 was suspended, pending investigation, on [DATE]. The report noted: Nurse acted outside her scope and discontinued CPR without a physician order. The decision was made to terminate LPN #1, effective [DATE]. Review of Resident #1's medical records revealed a document titled, Resuscitation Orders, dated [DATE]. The orders revealed that Resident #1's Responsible Party (RP), her daughter, signed the form indicating that in the event of a cardiopulmonary arrest, cardio-pulmonary resuscitation will be performed. The Resuscitation Order was also marked by Resident #1's RP, to indicate that in the event of a [MEDICAL CONDITION] and/or respiratory arrest, to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR). Review of Resident #1's (MONTH) 2019's Physician's Orders revealed there were no orders for a Do Not Resuscitate (DNR). During an interview, on [DATE] at 10:45 AM, the Director of Nursing (DON) revealed that she had been made aware of the incident that occurred on [DATE], concerning Resident #1 (not having continued CPR). The DON stated Resident #1's Advance Directive documented the Resident was a full code. She stated she didn't know why there was a DNR on the summary in the Baseline Care Plan, and didn't know who would have put it on the summary. The DON stated that she had begun to educate the nursing staff on the American Heart Association (AHA) recommendations for performing CPR until the Emergency Medical Technicians (EMTs) arrive and take over. The DON also stated that she had begun to in-service the nursing staff on Resident's Advance Directives, Code Statuses, and Base Line Care Plans. The DON stated that until in-serviced, the Nursing Staff would not be able to return to work. The DON stated that a Resident's Advance Directive would be placed in a sleeve and would be the very first document in a resident's active medical record chart. During a telephone interview, on [DATE] at 3:35 PM, Licensed Practical Nurse (LPN) #1 confirmed that CNA #1 came to at the nurse's station about 10:30 PM ([DATE]), and reported that Resident #1 was not responding. LPN #1 stated that she immediately went to the Resident #1's room and CNA #1 followed her. LPN #1 stated that she assessed Resident #1 at that time, noting that the resident was not responding to verbal or tactile stimulus. LPN #1 stated that she told CNA #1 to start CPR, while she went to the nurse's station to check the resident's chart. LPN #1 stated that while she was at the station, she called the resident's daughter to tell her that the resident was not responding. LPN #1 stated that she went back to the resident's room and told CNA #1 that she couldn't find a code status, so they would have to consider the resident a full code. LPN #1 stated she took over the CPR. LPN #1 stated that she continued chest compressions, while CNA #1 was counting. LPN #1 stated that she only stopped performing CPR, when she heard Resident #1's ribs crack. LPN #1 stated that she called out to the nurse's station and told LPN #2 to bring the crash cart to Resident #1's room. LPN #1 stated that LPN #2 placed the crash cart at the foot of Resident #1's bed. LPN #1 stated, I did not have an opportunity to use anything from the cart, I didn't even use the Ambu bag. LPN #1 stated that she was the only person in the room for some time. LPN #1 stated that the daughter walked into the room and said, She's gone! She's gone! LPN #1 stated that she took that statement to mean that the daughter did not want her to continue CPR. LPN #1 stated the Emergency Medical Technicians (EMTs) came in right behind the daughter. LPN #1 stated that after the EMTs checked Resident #1 for vital signs, and found none, they left. LPN #1 confirmed she was certified in CPR. Review of the Basic Life Support (CPR Certification) card for LPN #1, revealed a training date of [DATE], with the American Heart Association guidelines. Review of a written statement, as part of the facility's investigation, signed by LPN #1, undated, revealed that she initiated CPR on Resident #1 and when the daughter came into the room, she stopped CPR after the daughter made the statement, she's gone. During an interview on [DATE] at 3:55 PM, Licensed Practical Nurse (LPN) #2 stated that upon his arrival to the facility on [DATE], for the 11:00 PM-7:00 AM shift, he passed Resident #1's room and noticed three (3) to four (4) staff members in the room. LPN #2 stated as he continued towards the nurse's station, LPN #1 called out to him and told him to bring her the crash cart. LPN #2 stated that while he was getting the crash cart, he also told LPN #3 to call 911, because he was unsure if anyone had called them yet. LPN #2 stated that he took the crash cart to the doorway of Resident #1's room. LPN #2 stated no one was doing chest compressions or CPR, so he left to assist another resident. LPN #2 also stated that LPN #1 never asked him to help her perform CPR. LPN #2 stated that he never heard anyone call a Code Blue. During an interview on [DATE] at 4:15 PM, Certified Nursing Assistant (CNA) #1 stated that she had been working the night of [DATE], and was assigned to Resident #1. CNA #1 stated that she went to Resident #1's room while doing her end-of-shift rounds at about 10:30 PM, and noticed that Resident #1 was unresponsive. CNA #1 stated that she had been in the room twice, earlier in the evening, and the resident was fine. CNA #1 stated that when she touched Resident #1's arm, it still felt warm. CNA #1 stated when she saw that Resident #1 wasn't breathing, she immediately started doing chest compressions. CNA #1 stated that she only did about four (4) to five (5) pushes on Resident #1's chest, stopped, and went to go get a nurse. CNA#1 stated she reported that Resident #1 was gone/dead to LPN #1 at the nurse's station. CNA #1 stated LPN #1 got up from the nurse's station, got the vital sign machine, and went to Resident #1's room. CNA #1 stated that she accompanied LPN #1 back to Resident #1's room and LPN #1 instructed her to try to get Resident #1's vital signs and to start CPR, while she (LPN #1) went back to the nurse's station to check Resident #1's chart for her code status. CNA #1 stated when LPN #1 returned from the nurse's station, LPN #1 informed her that Resident #1 was a full code. CNA #1 stated LPN #1 then took over CPR. CNA #1 stated that she was present inside Resident #1's room, when LPN #2 pushed the crash cart from the doorway. CNA #1 stated that it was at this time that she left, because she realized that she still needed to finish her rounds, so she could clock out and go home. CNA #1 stated that she wasn't in the room when Resident #1's daughter arrived, but she did hear the daughter say, She's gone. CNA #1 stated she finished rounds, and as she clocked out, she saw the EMTs arrive at the facility and go into Resident #1's room. During a telephone interview, on [DATE] at 11:10 AM, an Ambulance Service Representative (ASR) revealed that a report was filed, which stated the following: Emergency Medical Technicians (EMTs) responded to a call from the facility that came in at 22:57. Caller stated that a resident is unresponsive, unconscious, and not breathing. EMTs arrived at the facility at 23:04. Nurse in charge (No Name) reported that the resident was okay 45 minutes earlier prior to EMTs arrival. Nurse (no name) reported that CPR had stopped per the daughter's request. Departed Facility at 23:20. Resident was: Dead on Arrival (DOA). The ASR stated that this was all the information she could provide at this time. During an interview, on [DATE] at 11:41 AM, the facility's Provider Liaison for Admissions (PLA) revealed that she was the facility staff member who initiated the admission process. The PLA stated that she completed the admission packet with the daughter of Resident #1. The PLA stated that Resident #1's daughter, the Responsible Party (RP). The PLA stated that the Advanced Directives form was read out to loud to Resident #1's RP and the RP verbally stated that her mother, Resident #1, was to be a Full Code. The PLA stated Resident #1's RP signed the Advance Directive form, and dated it [DATE]. During an interview, on [DATE] at 2:44 PM, Resident #1's RP/ Daughter stated that she signed the Admission Agreement on behalf of Resident #1, on [DATE]. The RP stated during this meeting she conveyed that the family wanted CPR to be performed. The RP stated that she was Emergency Contact Number #1 for Resident #1. The RP stated that on the night of [DATE] at 10:44 PM, her sister, who was Emergency Contact Number #3, received a call and voicemail from the facility. The RP stated that the facility called again at 10:45 PM, and a nurse from the facility told her sister that their mother was unresponsive. The RP stated her sister notified her at 10:46 PM. The RP stated that on the night of [DATE] at 11:04 PM, she arrived at the facility and as she approached her mom's room, she noticed that the door to her mom's room was wide open. The RP stated that she saw her mother from the doorway and her mother was turned slightly toward the left and the head of the bed was elevated. The RP stated that no one was in the room with her mother. The RP stated that she didn't see any staff until she turned and saw LPN #1 coming up the hall toward her. The RP stated that LPN #1 was shaking her head in an empathetic way, as to indicate to her that her mom had passed away. The RP stated that she remembered saying in an inquisitive manner to LPN #1, She's gone? She's gone? The RP stated that at no time did she see anyone doing CPR. The RP stated, If I'd seen somebody doing CPR, I'd never told them to stop. The RP stated she followed LPN #1 into the room and her mom was already dressed. The RP stated her daughter, Resident #1's granddaughter, came into the room almost right behind her and asked, What was going on? The RP stated that the EMTs came in right behind her daughter and started talking to LPN #1. The RP stated that the EMTs checked for her mom's vital signs, stayed for a few minutes, and left. During a telephone interview, on [DATE] at 10:33 AM, Resident #1's Medical Doctor (MD) revealed that he had not been notified on the night of the incident that occurred on [DATE], concerning Resident #1's death. The MD stated he was not on-call, so perhaps the call was forwarded to the on-call partner, but it was reported to him several days later. The MD replied you're probably right, when questioned if CPR should continue once started. During a telephone interview, on [DATE] at 2:19 PM, Licensed Practical Nurse (LPN) #3 confirmed that she was working on the 3:00 PM-11:00 PM shift on [DATE]. LPN #3 stated that she was sitting at the nurse's station documenting, when a CNA, walked up to LPN #1 and said that Resident #1 was dead. LPN #3 stated, LPN #1 left the station, and returned approximately two (2) to three (3) minutes later, and told me that Resident #1 was dead. LPN #3 stated she asked LPN #1 if she had checked the resident's chart for her code status, and she said No, I didn't. LPN #3 stated that she looked at Resident #1's chart and couldn't find a DNR or code status. LPN #3 stated that she told LPN #1 that it would have to be treated as a full code. LPN #3 stated she told LPN #1 to grab the crash cart, and that she would call the ambulance. LPN #3 stated that she also told LPN #1 that she would get the transfer paperwork filled out. LPN #3 stated that by the time she called 911, finished writing the paperwork, and she arrived at the room, the daughter, granddaughter, and the EMTs were all present in the room. LPN #3 stated that she gave the paperwork to the EMTs and then returned to the nurse's station. LPN #3 stated that at no time did she see or hear of anyone starting or stopping CPR. LPN #3 stated that she never heard anyone call a code over the intercom for someone to go to Resident #1's room. LPN #3 also stated that she was never told to call or ever heard a Code Blue called over the intercom that night. LPN #3 stated that when a Code Blue is called all staff are supposed to report to that location, because that means there is a full code in progress, due to a [MEDICAL CONDITION] or [MEDICAL CONDITION]. LPN #3 stated that when CPR is initiated, it should always continue until the emergency team arrives or unless a doctor is present to say stop. During an interview, on [DATE] at 3:05 PM, the Director of Nursing (DON) confirmed LPN #1 did not continue CPR for Resident #1 once started, and suspended/terminated the LPN related to the investigation. The DON stated that an audit had been conducted on all of the resident charts in the facility to ensure that the Code Status in the computer matched the Code status on the chart and that the code status matched the care plans. The DON also stated an audit of residents that had expired in the facility over the last six (6) months was conducted to ensure the Code Status had been followed correctly. The DON stated that she suspended LPN #1 on [DATE], pending the conclusion of the investigation and terminated the LPN on [DATE], for failure to continue CPR, once started, on a full code resident. Review of Resident #1's face sheet, revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the 5-Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed that Resident #1 had not been assessed for a Brief Interview of Mental Status (BIMS) score, but had been identified as having modified independent decision-making skills. The facility submitted a Removal Plan for the I[NAME] Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. After a conversation with Resident's #1's granddaughter on (MONTH) 16, 2019, the Director of Nursing Services (DNS) initiated an investigation. 2. Licensed Practical Nurse (LPN) #1 was suspended pending an investigation on (MONTH) 16, 2019, by the DNS for failure to continue CPR until Emergency Medical Services (EMS) arrived. 3. A 100 percent (%) audit of resident's charts was completed to verify all advanced directives and code status orders were in place on (MONTH) 16, 2019, by the DNS. Results revealed every resident had correct code status in the computer. 4. A 100% audit of resident's charts for designated code status form on the front of the chart was conducted by the DNS on (MONTH) 16, 2019. Results revealed two (2) residents did not have code status on the chart and code status was placed in the front of the chart; corrected immediately. 5. Eleven (11) Registered Nurses (RNs), 18 LPNs and one (1) Social Service Coordinator (SSC) were educated beginning (MONTH) 16, 2019, and ending (MONTH) 19, 2019, on CPR to include correctly responding, performing CPR, and continuing CPR until EMS arrives and begins care or a physician in attendance and orders to cease CPR. 6. Eleven (11) RNs, 18 LPNs, and one (1) SSC were educated on the Advance Directive Policy by the DNS beginning on (MONTH) 16, 2019, and ending on (MONTH) 19, 2019. 7. Beginning (MONTH) 16, 2019 and ending (MONTH) 22, 2019, one (1) code drill was conducted daily on various shifts by the DNS and /or RN Unit Manager (UM) to include correctly responding to Code Blue being called, including all Licensed Nurses to be in room, performing CPR, and continuing CPR until EMS arrives and begins care, or a physician in attendance and orders are given to cease CPR. 8. The Nurse Consultant #1 and the Administrator conducted 100% audit of all Baseline Care Plans and Comprehensive Care Plan to include Code Status on (MONTH) 27, 2019. The Baseline Care Plan audit revealed five (5) baseline care plans that did not reflect the code status in the chart. The Comprehensive Care Plan was correct for the five (5) residents. A care plan note was written in the medical records. The Comprehensive Care Plan audit revealed one (1) comprehensive care plan that did not reflect the code status in the chart and was updated to reflect code status. 9. The Director of Clinical Education (DCE) educated 11 LPNs, five (5) RNs and one (1) SSC on Baseline Care Plans to include correctly developing Baseline Care Plans on (MONTH) 27, 2019. 10. The Mississippi State Board of Nursing was notified on (MONTH) 27, 2019, related to the LPN #1's failure to provide CPR by professional standards and of her suspension. 11. LPN #1 was terminated on (MONTH) 27, 2019, by the DNS for failure to continue CPR until EMS arrived for Resident #1. 12. The Quality Assurance Performance Improvement (QAPI) meeting was held on (MONTH) 27, 2019 at 5:30 PM. Systemic changes and monitoring have been developed, presented and approved by Administrator, Director of Nursing Services, Nurse Consultant, Clinical Education Nurse, and Medical Director. Systemic changes include code status and baseline care plan review at the next day Daily Clinical Start Up meeting. Post CPR reviews will be conducted on any charts of residents who may have required CPR. Findings from CPR order audits and baseline care plan audits were discussed at the QAPI meeting. 13. The Administrator reported the Immediate Jeopardy to the Attorney General's office on (MONTH) 27, 2019 at 8:30 PM. 14. RNs, LPNs, and CNAs will not be allowed to work until education has been completed on CPR and Baseline Care Plans. The facility alleges all corrective actions were completed on (MONTH) 27, 2019, and removal of the immediate jeopardy on (MONTH) 28, 2019. On [DATE], The SA survey validated through staff interviews, record reviews, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy: 1. The SA verified the facility's investigation of Resident #1's death on [DATE]. Resident #1 was found unresponsive, without vital signs, with CPR initiated but not continuously provided per interviews, records reviews, and reviews of written statements from facility staff, and written reports to the S[NAME] 2. The SA validated through record review, time card review, and interview with the DNS, that LPN #1 was suspended prior to her shift on [DATE], and terminated on [DATE]. 3. The SA validated through document review and interview with the DNS that an audit was completed on [DATE], of all resident charts to ensure that all Advance Directives, Code orders, and the Code Status on the chart was accurate according to the facility's computer and was easily accessible. 4. The SA validated through record review and interview with the DNS that the Administrator conducted a 100 % Audit of all resident's Base Line Care Plans to ensure the code status of all residents in the facility on [DATE], were correct. 5. The SA validated through record reviews and through staff interviews of Registered Nurse (RN)s, Licensed Practical Nurse (LPN)s, Certified Nursing Assistants (CNAs), and Social Service Coordinator (SSC), that in-service training was conducted, starting on [DATE], regarding responding correctly, providing CPR and continuing until EMS arrived or a physician gave an order to stop. 6. The SA validated through record reviews and through staff interviews of Registered Nurse (RN)s, Licensed Practical Nurse (LPN)s, Certified Nursing Assistants (CNAs), and Social Service Coordinator (SSC), that in-service training was conducted, starting on [DATE], regarding Advance Directives. 7. The SA validated through record reviews and through staff interviews of Registered Nurse (RN)s, Licensed Practical Nurse (LPN)s, Certified Nursing Assistants (CNAs), that drills were conducted related to correctly responding to Code Blue and continuing until EMS arrived or a physician's order to discontinue. 8. The SA validated through interview and record review that the Nurse Consultant #1 and the Administrator conducted a 100% audit of all Baseline Care Plans and Comprehensive Care Plan to include Code Status on (MONTH) 27, 2019, and corrected any negative findings. 9. The SA validated through interview and in-service record review that the Director of Clinical Education (DCE) educated 11 LPNs, five (5) RNs and one (1) SSC on Baseline Care Plans to include correctly developing Baseline Care Plans on (MONTH) 27, 2019. 10. The SA validated through document review with the Mississippi Board of Nursing Investigator on [DATE], that the office had received an online complaint on [DATE], from the facility regarding LPN #1's failure to continue CPR to Resident #1 on [DATE]. 11. The SA validated through record review, time card review, and interview with the DNS, that LPN #1 was suspended prior to her shift on [DATE], and terminated on [DATE], for failure to continue CPR on Resident #1. 12. The SA validated through record review of the Quality Assurance (QA) Committee sign it sheet, dated [DATE], and interviews with the Administrator, the DNS, the Medical Director, and Registered Nurse (RN) #1/Unit Manager, that the facility initiated a QA Committee meeting on [DATE], with the facility's Administrator, the DNS, Registered Nurse (RN) #1 Unit Manager, and Nursing Practitioner in attendance concerning the failure of LPN #1 to follow the Advance Directive for Code Status of Resident #1, Policy and Procedures pertaining to Code Status, CPR, and Advance Directives were reviewed. Systemic changes to resident's code status and Base Line Care plans were reviewed, and that follow-up will continue at the next day daily clinical start-up meeting. 13. The SA validated through record review and Administrator confirmation, that the Immediate Jeopardy status was reported to the Attorney General (AG)'s office on [DATE]. 14. The SA validated through interviews and schedule review, that the Nursing staff was not allowed to return to work until in-serviced. The SA validated that all corrective actions to remove the IJ were completed on [DATE], and the IJ removed on [DATE].

Based on staff interview, record review and facility policy review, the facility failed to develop a comprehensive care plan for one (1) of 20 residents reviewed (Resident #19) as evidenced by the lack of a "Full Code" care plan which resulted in the likelihood of a resident with a full code status being at risk of serious injury, impairment, or death during an emergency situation. Resident #19 expired at the facility on [DATE] without Cardiopulmonary Resuscitation (CPR) being performed. The facility had no knowledge of the failure to perform CPR for Resident #19 until they were informed by the survey team on [DATE]. The failure of the facility to initiate CPR on a Full Code resident on [DATE] at 5:45 a.m. was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE]. Findings include: Resident #19 Review of Resident #19's care plan revealed that there was no care plan developed for Resident #19's code status at any point during her stay at the facility. Record review of "Resuscitation Orders", dated [DATE], for Resident #19 revealed that Resident #19's Responsible Party (RP) elected for Cardiopulmonary Resuscitation (CPR) to be initiated in the event of a cardiac and/or respiratory arrest. This form was signed by the RP and Resident #19's physician. Record review of printed and noted physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on [DATE] at 10:10 a.m. revealed the DON stated she did not know why the code status was not on the care plan. The DON stated, "I don't handle that". Review of Resident #19's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date of [DATE] , revealed Resident #19 had a Brief Interview Mental Status (BIMS) score of three (3), which indicated Resident #19 was severely cognitively impaired. Review of the facility's policy entitled "Care Plans" (undated) noted: "The care plan describes the care and treatment provided to the resident. The care plan ensures that the resident attains or maintains the highest practicable physical, mental and psychosocial well being. The care plan includes any care or treatment that would otherwise be required for the provision of quality care." The facility submitted a credible allegation of compliance related to the Immediate Jeopardy on [DATE]. Credible Allegation of Compliance 1. "Documented nurses' notes on [DATE] reflected at approximately 5:45 am CNA #1 entered Resident #19 room and noted Resident #19 was not responding. CNA #1 immediately notified RN #1 that Resident #19 was not responding. RN #1 assessed Resident #19 and noted Resident #19 not breathing with vital signs unobtainable and an axillary temperature of 96.0. RN #1 was not able to get a response from Resident #19. RN #1 then notified Resident #19 Physician, Resident #19 RP, the coroner and the funeral home. RN #1 did not perform CPR, however Resident #19 was a full code. 2. On [DATE] at 5:00 pm Director of Clinical Education initiated training for Licensed nursing staff on full code status process to include Code Blue status-resident is in [MEDICAL CONDITION] or has no pulse and respirations. Staff informed when a resident is found under these conditions and is a full code; staff is to page over the intercom "Code Blue" along with the station and room number. A CPR certified licensed nurse should begin CPR (unless a DO Not Resusitate (Resuscitate) (DNR) order is in place) and continue until Emergency Medical Services ( EMS) arrives. 3. On [DATE] at 5:00 pm Assistant Director of Nursing Services, Licensed Practical Nurse # 1 and Social Worker conducted a 100% code status audit on current residents, with a census of 100, to ensure each resident had a Physician order [REDACTED]. 4. On [DATE] at 5:15 pm Business Office Manager conducted a CPR certification audit on all current twenty-eight licensed direct care nursing staff to ensure a valid CPR certification is on file. 5. On [DATE] at 5:20 pm Director of Nursing Services contacted Resident # 19 Attending Physician and informed that CPR was not initiated by RN #1 on [DATE] at 5:45 am. 6. On [DATE] at 6:45 pm a special Quality Assurance Meeting took place with: Director of nursing Services, Director of Rehab, Licensed Practical Nurse #1, Activity Director, Social Worker, Medical Records and Director of Clinical Education to analyze and identify opportunities for quality improvement related to code status procedures to ensure compliance, beginning with investigation, followed by training of licensed nursing staff on code status process, code blue procedure, and chart audits surrounding code status. 7. On [DATE] at 8:00 pm, Assistant Director of Nursing Services, Registered Nurse #3, Registered Nurse #4 and Director of Nursing Services conducted a care plan audit related to code status on all current residents with a census of 100. Care plans, Physician orders [REDACTED]. No revisions were necessary. All current 100 resident orders were found to be correct. 8. On [DATE] at 10:00 pm, the Director of Nursing Services, Assistant Director of Nursing Services, Registered Nurse #4 and Licensed Practical Nurse #1 conducted an audit on the medical record chart code status identification system on all current residents with a census of 100. Forty-four resident's identified as a DNR have a red dot on the spine of the chart to signify a no code status. Chart spines without a colored dot signify the fifty-five full code residents. Chart spines with a green dot signifies one resident with a CPR/do not intubate code status. 9. All residents have the potential to be affected by code status. The Director of Clinical Education initiated training on [DATE] at 5:00 pm for Licensed nursing staff on procedures and processes of full code status, which includes the definition of CODE BLUE: resident is in [MEDICAL CONDITION] or has no pulse and respiration. Nurses will not be allowed to work until this training has been completed. On [DATE], Director of Clinical Education began training on the signs and symptoms of clinical death to include cessation of respirations, cessation of heartbeat, cyanosis, no pupilary response and no obtainable blood pressure. Training to the definition of an advanced directive: a document that allows you to outline health care decisions of your choosing in the event you are unexpectedly disabled and not able to make these decisions for yourself. A DO NOT RESUSCITATE order instructs medical personnel, including emergency medical personnel, not to perform cardiopulmonary resuscitation if you heart stops or if you stop breathing. A Full Code is performing all measures to revive and sustain life. 10. The Director of Nursing Services suspended Registered Nurse #1 pending an investigation on [DATE] at 1:20 pm. Beginning [DATE] at 4:45 pm numerous attempts were made per phone to reach Registered Nurse #1. On [DATE] at 10:39 am Registered Nurse #1 contacted Director of Nursing Services via phone stating that her phone was not in working order for the past three days. Registered Nurse #1 stated she purchased a new phone on [DATE] and then noted multiple missed calls and voice messages from Director of Nursing Services. 11. On [DATE] at 1:30 pm The Mississippi Board of Nursing was notified per voice mail by the Director of Nursing Services regarding the pending investigation of Registered Nurse #1 for failure to perform CPR on a Resident with a full code order. 12. The Director of Nursing Services notified the Attorney Generals Office at 3:00 pm on [DATE] regarding the pending investigation of Registered Nurse #1 for failure to perform CPR on a Resident with a full code order. 13. Social Worker to review desired code status with Responsible Party and/or Resident in quarterly care plan meeting. Social Worker will provide updates during monthly Quality Assurance (QA) meeting. The Director of Nursing Services or Assistant Director of Nursing Services will review all admissions for accuracy of Physician cod status order, medical record chart code status identification system, appropriate code status care plan, and face sheet for status weekly; all findings will be reviewed and discussed at QA meeting monthly. Director of Clinical Education will conduct ongoing code status training with all licensed nurses quarterly and report to QA monthly. Medical records will audit expired/closed resident records code status for procedural compliance for the past three months; any negative findings will be addressed and results to be reviewed during monthly QA meeting. The facility feels the Immediate Jeopardy was abated on [DATE] at 3:15 pm." On [DATE], the survey team validated the corrected measures taken by the facility as follows: 1. The in-service on [DATE] for licensed nursing staff was validated by review of the sign in sheets and interviews with staff members. The content of the meeting was validated which included the meaning of Full Code Status that CPR must be initiated until EMS arrives; code status can only be changed with a physician's orders [REDACTED]. 2. The survey team validated by review of a signed statement from the Assistant Director of Nursing (ADON) which confirmed the chart audit was performed on [DATE] of all 100 residents to ensure that each resident had a physician's orders [REDACTED]. 3. The survey team also validated by review of copies of staff CPR cards provided by the facility, the CPR certification of all 28 licensed direct care nursing staff. 4. The survey team reviewed a signed statement by the DON validating that she informed Resident #19's Attending Physician on [DATE] at 5:50 p.m. that CPR was not initiated by Registered Nurse (RN) #1 on Resident # 19 on [DATE] at 5:43 a.m. 5. The survey team validated a QA meeting sign in sheet dated [DATE] which included the Administrator, the DON, the Assistant DON, the Director of Education, and the Medical Director. The facility Administrator and the DON validated the content of the QA meeting by indicating that the following was discussed: Code Status; Full Code definition; signs/symptoms of clinical death, and measures to prevent the reoccurrence. 6. The survey team validated by interview with RN #4 and review of the resident list sheets the audit done on [DATE] by the DON and the ADON on all 100 current residents to ensure care plans, physician orders, and resident face sheets were accurate. 7. The survey team also validated by interview with the ADON the audit done on [DATE] on the medical record chart code status identification system (Red Dot) of all 100 current residents. 8. The survey team validated by review of the sign in sheets and interviews with RNs and Licensed Practical Nurses (LPN) that an in-service was again initiated on [DATE] which included a focus on the clinical signs and symptoms of death, along with a review of the definition of Advanced Directives including Full Code and DNR. 9. The survey team validated suspension of RN #1 by reviewing facility documentation signed by RN #1, the DON, and the ADON which indicated "These offenses are considered gross misconduct and are subject to immediate suspension, pending investigation for termination." 10. Review of a signed statement by the DON noted that the Mississippi Board of Nursing was notified per voice mail of the pending investigation of RN #1 on [DATE] at 1:30 p.m. 11. Review of an additional signed statement by the DON confirmed the Attorney General's Office was notified of the pending investigation of RN #1 on [DATE] at 3:00 p.m.

Based on staff and family interviews, resident's closed record review, and professional reference material, the facility failed to ensure that a resident received care to maintain their highest well-being by failure to initiate Cardio-Pulmonary Resuscitation (CPR) on Resident #19 who was designated as a "Full Code" and failure to contact Emergency Medical Services (EMS) when Resident #19 was found to be unresponsive with an axillary temperature of 96.0 degrees Fahrenheit and no other vital signs. This resulted in the likelihood of full code status residents being at risk of serious injury, impairment, or death. The facility had no knowledge of the failure to perform CPR for Resident #19 until they were informed by the survey team on [DATE]. The failure of the facility to initiate CPR on a Full Code resident on [DATE] at 5:45 a.m. was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE]. Findings include: Record review of Resident #19's Nurses Notes dated [DATE] at 8:25 a.m., revealed documentation by Registered Nurse (RN) #1 which stated that on [DATE] at 5:45 a.m. a CNA went in Resident #19's room to do an incontinent brief change and found Resident #19 not responding. The RN documented that she went to the resident's room where she found the resident not breathing with unobtainable vital signs. RN#1 documented that Resident #19's axillary temperature at the time of assessment was 96.0 degrees Fahrenheit and she was not able to get a response from the resident. RN #1 then documented "I then notified resident's father who asked me to please call the coroner and the funeral home for arrangements". RN #1 then documented she notified Resident #19's attending physician, the coroner, and funeral home. RN #1 documented the resident's body left for the funeral home at 6:00 a.m. Upon review of professional standards the Handbook of Clinical Skills revealed the normal adult range for oral temperature was from 97 degrees Fahrenheit (F) to 99.5 degrees F temperature with an axillary temperature reading being one degree lower than the oral temperature. Review of the Certificate of Death signed by the county medical examiner on [DATE] revealed that Resident #19 was pronounced dead on [DATE] at 7:25 a.m. which does not correlate with RN #1's documentation in the Nurses Notes. Interview with CNA #1 on [DATE] at 6:00 p.m., by telephone, revealed that she (CNA #1) recalled finding Resident #19 unresponsive on [DATE]. CNA #1 stated, "Between 5:00 and 6:30, when I went in Resident #19's room, that's when I found her. I can't pinpoint a time. When I went in and called her name, she didn't respond. I was touching her and she didn't feel right. She wasn't ice cold, but she was cold. So, I turned her over; she was lying on her stomach, which she always did, and I realized she wasn't breathing. That's when I went and got the nurse (RN #1). The nurse came down and checked her vital signs. I did hear her say that she needed to call the doctor before I left the room. I'm thinking at some point she (RN#1) must have told me she was a No Code because I realized she wasn't doing CPR". Interview by telephone with RN #1 on [DATE] at 1:45 p.m., revealed that RN #1 recalled events of Resident #19's condition on [DATE]. RN #1 stated that Resident #19 was alive between the hours of 2:00 a.m. and 3:00 a.m. when rounds were made by herself and CNA #1. RN #1 stated that after 5:00 a.m. the CNA came out of the resident's room and was repeatedly stating Resident #19's name. RN #1 stated in the interview that Resident #19 was unresponsive and that she was unable to obtain vital signs. She stated in the interview that Resident #19 was purple and lips were blue. This was not documented in the Nurses Notes. When asked about RN #1's documentation of the resident's temperature of 96.0 axillary, RN #1 stated that the documentation "was a mistake". RN #1 continued to state that she had "a lot of dead people with temperatures of 96.0 or 97.0. That's not uncommon from what I've seen." During the same interview on [DATE] with RN #1, she stated that she contacted the physician and then called Resident #19's responsible party (step-father) to inform him that Resident #19 was dead. RN #1 stated that she told Resident #19's step-father (Responsible Party) that "we could try CPR or call the ambulance" and he said to go ahead and call the coroner and the funeral home to make the arrangements. RN #1 stated after speaking with the step-father, she went back in the room to reassess, and the resident was dead so she called the coroner. RN #1 stated the coroner arrived at the facility about twenty-five or thirty minutes later and stated that she (Resident #19) was dead. RN #1 stated she then called the funeral home. RN #1 stated that she believed Resident #19 was dead and did not perform CPR or call emergency personnel. RN #1's Nurses Note documented that the family member was contacted before the physician. Record review of Resident #19's admission form entitled "Resuscitation Orders", dated [DATE], revealed that Resident # 19's Responsible Party (RP) elected the statement "In the event of a cardiac and/or respiratory arrest, initiate CPR". This form was signed by the RP and Resident #19's physician. Review of printed physician's orders [REDACTED]. This order was noted by an RN on [DATE]. During a telephone interview with Resident # 19's Attending Physician on [DATE] at 9:30 a.m., the physician stated "I got a call from the nurse, (RN # 1), and she said 'we found (Resident #19) unresponsive so we went by protocol, and you know she's a full code' and I said 'Yes, I know' and she said they (facility) called the family member to let them know." When Resident #19's Attending Physician was informed that there was no documentation of CPR being given to Resident #19, she stated "That's not the understanding I got. She (RN#1) said she had found her unresponsive and that she went by protocol, which means CPR if they're a full code". Resident #19's Attending Physician confirmed that Resident #19 was a full code and stated, "We had talked to her family since her admission about changing her code status and they would not do it. They wanted to keep her full code." Resident # 19's Attending Physician was also asked, during the [DATE] interview, if she was aware that Resident #19's temperature on [DATE] at 5:45 a.m. was documented as 96 degrees (axillary), she responded "She was warm? Umm. Now if she was warm she should have done CPR. Not that much time had passed. That means if her temp was 96, she should have done CPR. I assumed when she said she went by protocol that meant she had done CPR. That means she was still warm." Interview, by telephone, with Resident #19's step-father on [DATE] at 9:20 a.m., revealed that he received a phone call from RN #1 on [DATE] and he stated "The nurse said she hated to tell me this but that (Resident #19) had passed away". When asked if anything else was said, he replied "No, that was all she said, as I remember". When Resident #19's step-father was asked about deciding Resident #19's code status on admission, he replied "I don't remember anything about that". Interview with the Administrator and the Director of Nursing (DON) on [DATE] at 4:00 p.m. when asked why CPR was not initiated on Resident #19 who had a Full Code status documented, the Administrator stated "I'm not clinical so I don't know how that works". The DON stated "I wasn't here, but I believe that's the way it went. From what I understand, she (Resident #19) was cold and stiff. She (RN #1) said she did call the step-father and he said 'Okay' ". The facility denied having a policy for code status or advance directives. The survey team was given a statement on facility letterhead on [DATE] which stated "There is no specific CPR Policy, family and/or resident is given information during the referral and admission process on Advance Directives and family and/or resident make their decision." Review of Resident #19's medical record revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #19's date of birth was [DATE]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date of [DATE], revealed that Resident #19 had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated Resident #19 was severely cognitively impaired. The facility submitted a credible allegation of compliance related to the Immediate Jeopardy on [DATE]. Credible Allegation of Compliance 1. "Documented nurses' notes on [DATE] reflected at approximately 5:45 am CNA #1 entered Resident #19 room and noted Resident #19 was not responding. CNA #1 immediately notified RN #1 that Resident # 19 was not responding. RN #1 assessed Resident #19 and noted Resident # 19 not breathing with vital signs unobtainable and an axillary temperature of 96.0. RN #1 was not able to get a response from Resident # 19. RN #1 then notified Resident # 19 Physician, Resident # 19 RP, the coroner and the funeral home. RN #1 did not perform CPR, however Resident # 19 was a full code. 2. On [DATE] at 5:00 pm Director of Clinical Education initiated training for Licensed nursing staff on full code status process to include Code Blue status-resident is in [MEDICAL CONDITION] or has no pulse and respirations. Staff informed when a resident is found under these conditions and is a full code; staff is to page over the intercom "Code Blue" along with the station and room number. A CPR certified licensed nurse should begin CPR (unless a DO Not Resusitate (Resuscitate) (DNR) order is in place) and continue until Emergency Medical Services (EMS) arrives. 3. On [DATE] at 5:00 pm Assistant Director of Nursing Services, Licensed Practical Nurse # 1 and Social Worker conducted a 100% code status audit on current residents, with a census of 100, to ensure each resident had a Physician order [REDACTED]. 4. On [DATE] at 5:15 pm Business Office Manager conducted a CPR certification audit on all current twenty-eight licensed direct care nursing staff to ensure a valid CPR certification is on file. 5. On [DATE] at 5:20 pm Director of Nursing Services contacted Resident # 19 Attending Physician and informed that CPR was not initiated by RN #1 on [DATE] at 5:45 am. 6. On [DATE] at 6:45 pm a special Quality Assurance Meeting took place with: Director of nursing Services, Director of Rehab, Licensed Practical Nurse # 1, Activity Director, Social Worker, Medical Records and Director of Clinical Education to analyze and identify opportunities for quality improvement related to code status procedures to ensure compliance, beginning with investigation, followed by training of licensed nursing staff on code status process, code blue procedure, and chart audits surrounding code status. 7. On [DATE] at 8:00 pm, Assistant Director of Nursing Services, Registered Nurse # 3, Registered Nurse # 4 and Director of Nursing Services conducted a care plan audit related to code status on all current residents with a census of 100. Care plans, Physician orders [REDACTED]. No revisions were necessary. All current 100 resident orders were found to be correct. 8. On [DATE] at 10:00 pm, the Director of Nursing Services, Assistant Director of Nursing Services, Registered Nurse # 4 and Licensed Practical Nurse # 1 conducted an audit on the medical record chart code status identification system on all current residents with a census of 100. Forty-four resident's identified as a DNR have a red dot on the spine of the chart to signify a no code status. Chart spines without a colored dot signify the fifty-five full code residents. Chart spines with a green dot signifies one resident with a CPR/do not intubate code status. 9. All residents have the potential to be affected by code status. The Director of Clinical Education initiated training on [DATE] at 5:00 pm for Licensed nursing staff on procedures and processes of full code status, which includes the definition of CODE BLUE: resident is in [MEDICAL CONDITION] or has no pulse and respiration. Nurses will not be allowed to work until this training has been completed. On [DATE], Director of Clinical Education began training on the signs and symptoms of clinical death to include cessation of respirations, cessation of heartbeat, cyanosis, no pupilary response and no obtainable blood pressure. Training to the definition of an advanced directive: a document that allows you to outline health care decisions of your choosing in the event you are unexpectedly disabled and not able to make these decisions for yourself. A DO NOT RESUSCITATE order instructs medical personnel, including emergency medical personnel, not to perform cardiopulmonary resuscitation if you heart stops or if you stop breathing. A Full Code is performing all measures to revive and sustain life. 10. The Director of Nursing Services suspended Registered Nurse # 1 pending an investigation on [DATE] at 1:20 pm. Beginning [DATE] at 4:45 pm numerous attempts were made per phone to reach Registered Nurse # 1. On [DATE] at 10:39 am Registered Nurse # 1 contacted Director of Nursing Services via phone stating that her phone was not in working order for the past three days. Registered Nurse # 1 stated she purchased a new phone on [DATE] and then noted multiple missed calls and voice messages from Director of Nursing Services. 11. On [DATE] at 1:30 pm The Mississippi Board of Nursing was notified per voice mail by the Director of Nursing Services regarding the pending investigation of Registered Nurse # 1 for failure to perform CPR on a Resident with a full code order. 12. The Director of Nursing Services notified the Attorney Generals Office at 3:00 pm on [DATE] regarding the pending investigation of Registered Nurse # 1 for failure to perform CPR on a Resident with a full code order. 13. Social Worker to review desired code status with Responsible Party and/or Resident in quarterly care plan meeting. Social Worker will provide updates during monthly Quality Assurance (QA) meeting. The Director of Nursing Services or Assistant Director of Nursing Services will review all admissions for accuracy of Physician cod status order, medical record chart code status identification system, appropriate code status care plan, and face sheet for status weekly; all findings will be reviewed and discussed at QA meeting monthly. Director of Clinical Education will conduct ongoing code status training with all licensed nurses quarterly and report to QA monthly. Medical records will audit expired/closed resident records code status for procedural compliance for the past three months; any negative findings will be addressed and results to be reviewed during monthly QA meeting. The facility feels the Immediate Jeopardy was abated on [DATE] at 3:15 pm." On [DATE], the survey team validated the corrected measures taken by the facility as follows: The in-service on [DATE] for licensed nursing staff was validated by review of the sign in sheets and interviews with staff members. The content of the meeting was validated which included the meaning of Full Code Status that CPR must be initiated until EMS arrives; code status can only be changed with a physician's orders [REDACTED]. The survey team validated by review of a signed statement from the Assistant Director of Nursing (ADON) which confirmed the chart audit was performed on [DATE] of all 100 residents to ensure that each resident had a physician's orders [REDACTED]. The survey team also validated by review of copies of staff CPR cards provided by the facility, the CPR certification of all 28 licensed direct care nursing staff. The survey team reviewed a signed statement by the DON validating that she informed Resident # 19's Attending Physician on [DATE] at 5:50 p.m. that CPR was not initiated by Registered Nurse (RN) #1 on Resident # 19 on [DATE] at 5:43 a.m. The survey team validated a QA meeting sign in sheet dated [DATE] which included the Administrator, the DON, the Assistant DON, the Director of Education, and the Medical Director. The facility Administrator and the DON validated the content of the QA meeting by indicating that the following was discussed: Code Status; Full Code definition; signs/symptoms of clinical death, and measures to prevent the reoccurrence. The survey team validated by interview with RN #4 and review of the resident list sheets the audit done on [DATE] by the DON and the ADON on all 100 current residents to ensure care plans, physician orders, and resident face sheets were accurate. The survey team also validated by interview with the ADON the audit done on [DATE] on the medical record chart code status identification system (Red Dot) of all 100 current residents. The survey team validated by review of the sign in sheets and interviews with RNs and Licensed Practical Nurses (LPN) that an in-service was again initiated on [DATE] which included a focus on the clinical signs and symptoms of death, along with a review of the definition of Advanced Directives including Full Code and DNR. The survey team validated suspension of RN #1 by reviewing facility documentation signed by RN #1, the DON, and the ADON which indicated " These offenses are considered gross misconduct and are subject to immediate suspension, pending investigation for termination." Review of a signed statement by the DON noted that the Mississippi Board of Nursing was notified per voice mail of the pending investigation of RN #1 on [DATE] at 1:30 p.m. Review of an additional signed statement by the DON noted the Attorney General's Office was notified of the pending investigation of RN #1 on [DATE] at 3:00 p.m.