Every finding on record at Lasalle Nursing Home

Based on observation, interview and record review, the facility failed to ensure that residents received medications in accordance with the manufacturer's guidelines and accepted standards of practice for 1 (Resident #2) of 4 residents receiving Fentanyl (a potent opioid) patches.Findings:Accepted standards of practice is defined as guidelines that define the competent level of basic nursing care and ethical behavior.According to Louisiana Administrative Code 46:XLCII.3405 (A), nurses must practice in accordance with the legal standards of nursing practice and must utilize appropriate judgment.Review of Fentanyl manufacturer's recommendations revealed in part.Each Fentanyl transdermal system may be worn continuously for 72 hours. The next patch should be applied to a different skin site after removal of the previous transdermal system. Do not wear more than one Fentanyl transdermal system at a time, unless your doctor tells you to do so.Review of Resident #2's medical record revealed an admit date of 03/30/2023 with diagnoses that included in part.Parkinson's Disease, Chronic Pain Syndrome, Thrombocytopenia Unspecified, Encounter for Palliative Care, Acute Kidney Failure, Myelodysplastic Syndrome and Heart Failure.Review of Resident #2's Quarterly MDS with an ARD of 07/23/2026 revealed Resident #2 had a BIMS score of 15 (which indicated intact cognition), had the ability to make self-understood and had the ability to understand others. The MDS revealed Resident #2 was coded as requiring set up or clean-up assistance with eating and bathing, independent with toileting, personal hygiene and transfers.Review of Resident #2's care plan with a target date of 11/09/2026 read in part ., Potential risk for continuous burning, throbbing or electric like pain related to diagnosis of Chronic Pain Syndrome with interventions that included to administer medication as ordered.During an interview on 08/17/2026 at 4:00 p.m. Resident #2's daughter stated on 08/10/2026 during a visit she noticed the resident wasn't himself, appeared more confused than normal, and was lethargic. She stated Resident #2 was sent to the ER for evaluation and it was discovered by ER staff that Resident #2 had two Fentanyl patches on. Resident #2's daughter stated a patch dated 08/06/2026 was removed by ER staff and Resident #2 was sent back to the facility.Review of Resident #2's 08/2026 Physician's Orders read in part , Fentanyl Transdermal Patch 72 Hours 25 mcg/hr apply 1 patch transdermally at bedtime every 3 day (s) related to Chronic Pain Syndrome, with a start date of 07/16/2026.Review of Resident #2's Medication Administration Record read in part , 08/09/2026 at 8:00 p.m. Fentanyl Transdermal Patch 72 Hours 25 mcg/hr apply 1 patch transdermally at bedtime every 3 day (s) related to Chronic Pain Syndrome. Medication initialed as administered by S3 LPN and site documented as 12 (Left Chest Wall). Entry for 08/03/2026 and 08/06/2026 had a line drawn and the letter H' (indicating Resident #2 was in the hospital).Review of a Nursing Progress noted dated 08/10/2026 at 8:20 a.m. read in part. Resident up in wheelchair in therapy department. Noted to be increasingly confused and lethargic. Also noted to be unable to focus with right eye. AM meds had to be crushed in order for resident to be able to take them. Required assistance x 3 staff members when transferring resident from bed to wheelchair. Resident was unable to assist staff with transfer earlier this AM and was noted with poor trunk control once in wheelchair. MD notified of all of the above. Phone order to send to hospital ER for further evaluation and treatment.Review of a hospital note dated 08/10/2026 at 1:14 p.m. read in part , Patient also had two Fentanyl 25 mcg/hr patches on (one dated 08/06/2026 which we removed) and one dated 08/09/2026. AMS most likely associated with wearing the extra patch. Resident #2 received CT of the head and spine, and a chest x-ray in the ER.Review of a hospital Medication Administration Record dated 08/06/2026 read in part.Given Fentanyl 25 mcg/hr Topical Right Arm Q3D (hospital staff name) 08/06/2026 13:15.During an interview on 08/18/2026 at 3:31 p.m. S2 DON stated on 08/10/2026 that Resident #2 had been sent to the ER due to weakness, increased confusion and low blood pressure. S2 DON stated she had been notified by the ER supervisor on 08/10/2026 that Resident #2 had on two Fentanyl 25 mcg/hr transdermal patches, one dated 08/06/2026 and one dated 08/09/2026. S2 DON stated Resident #2 had been recently hospitalized from [DATE] through 08/07/2026. S2 DON stated Resident #2 had returned to the facility on [DATE]. S2 DON stated she had interviewed S3 LPN who had applied the Fentanyl 25 mcg/hr Patch to Resident #2 on 08/09/2026, and S3 LPN confirmed she had not removed a Fentanyl Patch dated 08/06/2026. S2 DON stated S3 LPN had stated, I thought I had removed it. S2 DON confirmed a resident should not wear more than one Fentanyl patch at a time unless specifically instructed by the doctor.During an interview on 08/19/2026 at 9:33 a.m. S4 Medical Doctor confirmed on 08/10/2026 Resident #2 was seen in the ER and had on two Fentanyl 25 mcg/hr patches, one dated 08/06/2026 which was removed in the ED, and one dated 08/09/2026. S4 Medical Doctor confirmed the two patches were a contributing factor to Resident #2's Altered Mental Status.During an interview on 08/19/2026 at 10:00 a.m. S5 Consulting Pharmacist stated there was no way to know how much medication was still in the old patch dated 08/06/2026, which was left on Resident #2.During an interview on 08/19/2026 at 10:21 a.m. S3 LPN stated she was the nurse assigned to care for Resident #2 on 08/09/2026 for the 6:00 p.m. to 6:00 a.m. shift. S3 LPN confirmed she had not removed a Fentanyl patch from Resident #2 before applying a patch to Resident #2's left chest wall.

Based on observation and interview the facility failed to ensure nurse staffing data was displayed daily in a prominent location readily accessible to all residents, staff, and visitors for viewing. This deficient practice had the potential to affect all 64 residents who resided in the facility. Findings: Observation on 12/08/2025 at 8:35 a.m. of the facility entrance revealed no display of the nurse staffing posting. Observation on 12/09/2025 at 9:29 a.m. of the facility entrance revealed no display of the nurse staffing posting. Observation on 12/09/2025 at 9:27 a.m. revealed the facility nurse staffing posting was displayed at the end of Hall W and then turning right onto 1 (Hall Y) of 5 hallways, in the window of 1 (Nurse Station X) of 3 nurse stations. Observation revealed the location (Nurse Station X on Hall Y) of the nurse staffing posting was difficult for all visitors, residents, and staff to locate and access for viewing.In an interview on 12/09/2025 at 9:27 a.m., S6 [NAME] Clerk revealed she was responsible for completion and displaying of the nurse staffing form. S6 [NAME] Clerk confirmed the facility nurse staffing form is only displayed in one area, which was Nurse Station X.In an interview on 12/09/2025 at 9:37 a.m., S2 DON revealed the facility displayed the nurse staffing form only in Nurse Station X. In an interview on 12/09/2025 at 3:00 p.m., S2 DON revealed all guests/staff enter the facility through the front door at the entrance of the facility. S2 DON acknowledged that if an individual took a route through the facility that did not require them to walk down Hall Y, the individual would not come into contact with the nurse staffing form displayed and would not be able to view the required information. S2 DON confirmed that due to the placement of the nurse staffing form, all individuals would not have been able to easily access and view the nurse staffing information as required.

Based on observation, interview, and record review the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to store clean linen and hygiene products properly. This failed practice had the potential to affect all residents who received a whirlpool bath. Findings:Review of facility's policy on 12/10/2025 at 1:35 p.m. titled Linens with a revision date of 03/27/2023 revealed the following part.1. Personnel must handle, store, process and transport linens so as to prevent the spread of infection. Observation of Bath 1 on 12/10/2025 at 11:37 a.m. revealed 4 unidentified deodorants on a shelf and multiple folded towels on a bench. Observation of Whirlpool X, Whirlpool Z, Shower X, Shower Z, and Bath 2 on 12/10/2025 from 11:44 a.m. until 11:58 a.m. revealed all of these areas had more than one folded towel stored on benches and uncovered shelves. In an interview on 12/11/2025 at 1:12 p.m., S7 CNA revealed she uses the 4 different unidentified roll on deodorants in Bath W on different residents and she uses the folded linen on the bench in Bath W for the residents receiving whirlpools. S7 CNA stated she brings a stack of clean linen into Bath W and uses them throughout the day on residents that she is providing whirlpools to on that day.In an interview on 12/10/2025 at 1:23 p.m. S2 DON confirmed staff shouldn't be using multiple unidentified roll on deodorants on multiple residents and should not have had multiple linens in the showers, baths or whirlpools while bathing different residents.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #5 and Resident #16) of 19 sampled residents. The facility failed to ensure Resident #5's and Resident #16's care plan was developed to address advance directives and/or code status.Findings:Review of a facility policy on 12/09/2025 at 12:49 p.m. titled, Comprehensive Care Plan revised on 01/22/2018 revealed the following in part.Purpose: Ensure that each resident will have a person centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the residents' medical, physical, mental, and psychosocial needs.Resident #5Review of Resident #5's medical record revealed an admission date of 07/29/2021, with diagnoses that included in part .Cardiomyopathy, Unspecified; Encounter for Palliative Care; Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side; Unspecified Dementia. Review of Resident #5's current physician orders revealed in part.07/29/2021 (start date): DNR (Do Not Resuscitate)Review of Resident #5's care plan with a next review date of 12/08/2025 revealed no information addressing advanced directives and/or code status.Resident #16Review of Resident #16's medical record revealed an admission date of 04/17/2024, with diagnoses that included in part.Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Cognitive Communication Deficit, Abnormalities of Gait and Mobility, and Dry Eye Syndrome of Bilateral Lacrimal Glands.Review of Resident #16's current physician orders revealed in part.04/17/2024 (start date): Full CodeReview of Resident #16's care plan revealed no information addressing advanced directives and/or full code status.In an interview on 12/09/2025 at 11:08 a.m., S3 Care Plan Coordinator revealed she is responsible for completing and updated all resident's care plans. S3 Care Plan Coordinator and S4 MDS LPN each reviewed both Resident #5's and Resident #16's care plans and confirmed the above findings. S3 Care Plan Coordinator confirmed both Resident #5 and Resident #16 should have had a care plan that addressed advanced directive and/or code status but did not

Based on interview and record review the facility failed to ensure that residents who received psychotropic medications were monitored for behaviors and side effects for 2 (#36 and #49) of 5 (#25, #36, #42, #49, and #50) residents reviewed for unnecessary medications. Findings: Resident # 36 Review of Resident #36's medical records revealed an admitted [DATE] with diagnoses that included; Unspecified Dementia, with behavioral disturbance, Psychotic disturbance, and Mood disturbance, Depression, and Anxiety Disorder. Review of Resident # 36's Quarterly MDS with ARD of 06/24/2024 revealed a BIMS of 03, which indicates severe cognition impairment. Review of Resident #36's 08/2024 Physician's Order read in part 05/08/2024: Alprazolam, Give 0.25mg by mouth, twice daily for Anxiety Disorder, Unspecified Dementia and Other Behavioral Disturbances. 05/07/2024: Seroquel, Give 24mg by mouth at bedtime for Anxiety Disorder, Unspecified Dementia and Other Behavioral Disturbances. 03/27/2024: Zoloft, Give 25mg by mouth at bedtime for Depression. Review of Resident #36's Care Plan with a review date of 10/11/2024 read in part Risk for crying, drowsiness related to a diagnosis of Depression Intervention: Observe and address signs and symptoms of Depression such as crying, drowsiness, social isolation, irritability, little interest in things once enjoyed. Document and report to Medical Director if persist. Observe for any change in mood, behavior, or cognitive status. Document and report to Medical Director. Risk for side effects of Psychotropic drugs related to antianxiety, antidepressant and antipsychotic use. Interventions: Observe and address side effects related to psychotropic drug use such as sedation, increase confusion, increase agitation, increase anxiety, orthostatic hypotension, rigidity, tremors, lip smacking, abnormal face or jaw movement, abnormal lip movement, abnormal leg/arm movement. Document & report to Medical Director. Review of Resident #36's Medication Administration Record revealed the Medication Behaviors Monitoring tool was blank for the month of 07/2024 and 08/2024. Review of Resident #36's Medication Side effects Monitoring tool for the month of 07/2024 and 08/2024 revealed monitoring was done on 07/03/2024, 08/5/2024, 08/06/2024, and 08/07/2024 and all other days of 07/2024 and 08/2024 were left blank. Interview on 08/14/2024 at 9:19 a.m. with S4 LPN revealed she documented behaviors for residents on the behavior and side effect tool if behaviors occur, otherwise she does not document on the behavior/side effect tool. Interview on 08/14/2024 at 9:26 a.m. with S1 DON revealed the nurses should be documenting any behaviors exhibited by resident regardless if they are new or normal behaviors. S1 DON revealed any new abnormal behaviors should also be documented in nursing notes and that the Physician rounds on residents every two weeks and staff are to communicates any behaviors residents may have. S1 DON confirmed that Medication Side effects and Behavior monitoring was not completed daily but should have been. 44844 Resident #49 Review of Resident 49's medical record revealed an admitted [DATE], with diagnoses that included: Chronic Kidney Disease Stage 4, Cognitive Communication Deficit, Heart Failure, Unspecified Dementia, and Insomnia. Review of Resident #49's Admission MDS with a Target date of 06/04/2024 revealed a BIMS score of 3, indicating severe cognitve impairment. Review of Resident #49's Care Plan with a Target date of 09/12/2024 revealed in part .Potential risk for difficulty falling asleep related to diagnosis of Insomnia. Potential risk for side effects related to psychotropic drug use related to Hypnotic use, with interventions that included: Observe for adverse side effects such as sedation, increase in Confusion, increased Anxiety, and Orthostatic Hypotension. Document and report to Medical Doctor. Review of Resident #49's 08/2024 Medication Administration Record revealed in part .Temazepam (Restoril) give 7.5 MG by mouth at bedtime related to Insomnia, Unspecified. The Medication Administration Record had no documented Behavior Monitoring for Temazepam. Review of Resident #49's Gradual Dose Reduction sheet dated 07/02/2024 revealed in part .Resident currently taking Temazepam 7.5 MG every night. Medical Doctor noted resident still exhibiting behavioral symptoms at the present dose and further decrease would only make symptoms worse. Interview on 08/13/2024 at 3:55 p.m. with S1 DON confirmed Resident #49 had no documented behaviors on his behavioral monitoring sheet. S1 DON revealed the floor nurses were responsible for documenting behaviors. S1 DON confirmed Resident #49's behavior monitoring sheet was blank and should not have been.

Based on observation, record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #40) of 1 sampled resident who was identified as a smoker. Findings: Review of a facility policy titled Comprehensive Care Plan dated 01/22/2018 revealed the following including: Policy: The facility will complete person centered, comprehensive plans of care for each resident that will identify specific resident problems (or potential for problem), and will include measurable goals and interventions for each problem identified. Observation on 08/12/2024 at 2:56 p.m. of Resident #40 revealed he was sitting in his room preparing a cup of coffee. He was alert and oriented to person, place, and time. He stated he was able to smoke whenever he wanted and he kept his cigarettes with him. Observation on 08/13/2024 at 8:49 a.m. revealed Resident #40 sitting outside in his wheelchair smoking. He was without supervision although the area he was sitting was surrounded by glass. Safe smoking was observed. Review of Resident #40's facility record revealed an admitted [DATE] with the following diagnoses including: Major Depressive Disorder; Weakness; and Parkinson's. Review of Resident #40's Quarterly MDS with an ARD of 08/12/2024 revealed a BIMS score of 15. Review of Resident #40's Care Plan revealed no information concerning smoking. Review of Resident #40's 05/15/2024 Smoking Safety Evaluation revealed the following including: Resident continues to smoke safely in designated smoking areas per facility protocol. Interview on 08/13/2024 at 9:35 a.m. with S1 DON and S2 MDS Nurse confirmed Resident #40 was not care planned for smoking and should have been.

Based on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (#28) out of a total of 18 sampled Residents, by failing to ensure she was free of facial hair. Findings: Review of Resident #28's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included: Cognitive Communication Deficit, Need for Assistance, Type 2 Diabetes Mellitus and Neuropathy. Review of Resident #28's Quarterly MDS with an ARD of 06/06/2024 revealed she had a BIMS score of 15 (indicating intact cognition). The MDS revealed Resident #28 was independent with personal hygiene and required partial/moderate assistance with shower/bath. Review of Resident #28's care plan with a target date of 09/25/2024 revealed in part .Requires limited assist with bath. Independent in all others. Can feed self with meal tray set-up. Wheelchair used for locomotion. Care plan goal to have a neat well-groomed appearance. Observation on 08/12/2024 at 10:10 a.m. revealed Resident #28 sitting in her room. Resident #28 noted to have facial hair to chin. Resident #28 revealed she usually received a shave with her shower, but had not been shaven recently. Observation and interview on 08/14/2024 at 8:43 a.m. revealed Resident #28 with facial hair to her chin. Resident #28 revealed she was still waiting to be shaved. Interview on 08/14/2024 at 9:05 a.m. with S1 DON revealed Resident #28 received a shower or a whirlpool on the 6:00 p.m. to 6:00 a.m. shift. S1 DON confirmed Resident #28's bath roster indicated she received a shower on 08/12/2024 and a bed bath on 08/13/2024. S1 DON revealed facial hair was to be removed during a resident's bath or when the beautician visited. Observation and interview on 08/14/2024 at 9:35 a.m. of Resident #28 with S10 RN Unit Manager in attendance confirmed Resident #28 had facial hair to chin and should not have.

Based on interview and record review, the facility failed to ensure staff followed a resident's person centered plan of care, by failing to use two person physical assistance when transferring a resident from wheelchair to bed for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled residents. This failed practice resulted in an actual harm situation for Resident #1 on 07/25/2023 at 7:25 p.m., when S5 CNA transferred the resident from a chair to bed without assistance of another staff, as indicated on her plan of care. S5 CNA did not review the plan of care for transfer instructions prior to the transfer. Resident #1 sustained a large laceration to her left lower extremity, and was transferred to the ER. ER Physical Exam revealed: Leg 6cmx3cm flap abrasion present over inferior-lateral aspect of left leg. Procedure: Flap into subcutaneous, repair wound closed with sutures #5 2-0 Ethilon sutures. Clinical impression: Abrasion/contusion. Flap injury into subcutaneous tissue layer. Findings: Review of the facility's Accidents and Incidents - Investigating and Reporting policy revealed in part . Policy Statement - All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation: The Nurse Supervisor/ Charge Nurse and /or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Review of the facility's Safe Lifting and Movement of Residents policy revealed in part . Policy Statement - In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation: 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Review of Resident #1's Medical Record revealed an admitted [DATE] with diagnoses that included Anxiety Disorder, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Generalized Muscle Weakness, Edema, Low Back Pain, COPD, Osteoarthritis, Lack of Coordination and Abnormalities of Gait and Mobility. Review of Resident #1's Fall Risk assessment dated [DATE] revealed a score 14 indicative of Resident #1 was at High Risk for falls. Review of Resident #1's Quarterly MDS with an ARD of 07/10/2023 revealed a BIMS score of 11, indicative of moderate cognitive impairment. Resident #1 required extensive 1 person physical assist for bed mobility, bathing, dressing and toileting; and required 2 person physical assist for transfers. Resident #1 had ROM impairment on one side for upper extremities. Resident #1 required wheelchair device for mobility. Review of Resident #1's Care Plan with a Target date of 10/30/2023 revealed in part . Resident #1 at risk for injury r/t Fall Potential secondary to history of falls with goal to remain free of fall r/t injury AEB no falls. Interventions included in part . to assist with transfers 2 person assist or use stand up lift. Review of Resident #1's Physician's Orders for 08/2023 revealed to cleanse area to LLE with NS, pat dry, apply small amount of TAO, cover with collagen a non-adherent pad and secure with tape daily until healed. Review of Incident Report for Resident #1 dated 07/26/2023 at 8:29 a.m. revealed in part . Incident occurred 07/25/2023 at 7:25 p.m. Location of incident: Resident #1's room. Type of Injury - Laceration. Protective Action - Resident #1 evaluated in ER, RP notified. Incident Description -S5 CNA was assisting resident to bed and resident left leg got bumped on 1/4 side rail that was in low position resulting in laceration to left lower leg. POC established Resident #1 was 2 person assist and S5 CNA failed to follow POC by transferring resident by herself. Review of Resident #1's Nurses Notes documented by S4 LPN dated 07/25/2023 at 10:29 p.m. read in part . At 7:25 p.m. called to Resident #1's room per S5 CNA, stated when S5 CNA was transferring Resident #1 to bed, Resident #1 would not let go of the bed and received a skin tear on her left lower leg. This nurse went to room and assessed area. Area noted to be a very large skin tear. Unable to approximate edges. Area bleeding moderate amount. Area cleansed with normal saline and Vaseline gauze applied and wrapped with Kerlex. ER notified of this and order noted to send to ER for evaluation and treatment. Daughter notified. B/P 138/72, P72, R18, T98. At 7:45 p.m. Resident #1 transferred to ER per stretcher accompanied by 2 CNAs. Review of ED Notes with an admitted [DATE] at 7:51 p.m. revealed in part . Chief Complaint: Skin Tear left lower leg. Onset: just prior to arrival from NH. Sustained a gash injury while transferring in her room. Minimal discomfort by patient. Physical Exam revealed no acute distress, left foot/ ankle slightly edematous normal inspection, Non-tender, Leg 6cmx3cm flap abrasion present over inferior-lateral aspect of left leg. Procedure: Flap into subcutaneous, repair wound closed with sutures #5 2-0 Ethilon sutures. X-ray of left leg without evidence of fracture. Clinical impression: Abrasion/contusion. Flap injury into subcutaneous tissue layer. Disposition to NH. Condition improved. Plan of Care: Tetanus toxoid, wound approximated. NH advised to double Lasix dosing and check with PCP. Telephone interview on 08/21/2023 at 4:15 p.m. with S4 LPN revealed she was called to Resident #1's room by S5 CNA when she assessed Resident #1 and noted a large laceration with moderate amount of bleeding to her left lower leg. S4 LPN revealed she cleansed the area with NS, applied Vaseline gauze and a Kerlex wrap. S4 LPN revealed she called report to ER, sent Resident #1 to ER for evaluation and treatment as ordered, notified Resident #1's RP of incident, and sent to ER. S4 LPN confirmed she was aware Resident #1 needed 2 person assist for transfers according to Resident #1's plan of care, and S5 CNA did not follow Resident #1's plan of care, and should not have transferred Resident #1 by herself. Telephone interview on 08/22/2023 at 9:18 p.m. with S5 CNA revealed she worked on 07/25/2023 on the 6 p.m. to 6 a.m. shift, and cared for Resident #1. S5 CNA revealed she did not check Resident #1's plan of care prior to the incident when she transferred Resident #1 by herself from her chair to bed. S5 CNA revealed Resident #1 was holding onto the bed side rail and did not move her leg to turn to get into bed, when her leg hit the side of the bed. S5 CNA revealed once she got Resident #1 into the bed, she noticed the cut to her left lower leg and called out to S4 LPN who was outside of resident's room on the hall. S5 CNA revealed S4 LPN came and assessed Resident #1 and sent Resident #1 to the ER. S5 CNA revealed Resident #1 needed 2 persons assist for transferring from her wheelchair to bed, and should not have transferred Resident #1 by herself. Interview on 08/23/2023 at 4:20 p.m. with S3 CNA Supervisor revealed according to Resident #1's plan of care, Resident #1 required 2 person assist for transfers. S3 CNA Supervisor confirmed S5 CNA said she did not check Resident #1's plan of care on the kiosk or Kardex before she transferred Resident #1 by herself, and should have. Interview on 08/23/2023 at 4:30 p.m. with S1 ADM revealed after completion of investigation of Resident #1's incident, it was deemed that S5 CNA had not followed the plan of care for Resident #1. S1 ADM revealed S5 CNA had just returned from a leave of absence. S1 ADM revealed Resident #1's plan of care was one person assist for transfers prior to S5 CNA's leave of absence. She stated S5 CNA admitted to not checking Resident #1's plan of care at the beginning of her shift, and before she transferred resident by herself, and should have. S1 ADM confirmed S5 CNA should have followed Resident #1's plan of care and transferred Resident #1 with 2 person physical assist and did not. Interview on 08/24/2023 at 10:30 a.m. with S2 DON revealed S5 CNA had confessed as to not checking Resident #1's plan of care at the beginning of her shift. S2 DON revealed S5 CNA was not aware that Resident #1 required 2 person assist since her return from leave of absence. S2 DON revealed Resident #1's MDS and care plan stated Resident #1 required 2 people for transfers. S2 DON confirmed S5 CNA transferred Resident #1 from her wheelchair to her bed without assistance and should not have.

Based on interview and record review, the facility failed to ensure residents who use psychotropic drugs received gradual dose reductions for 2 (#46, #49) of 5 (#2, #15, #33, #46, #49) residents reviewed for unnecessary medications. Findings: Resident #46: A review of Resident #46's medical record revealed an admitted [DATE] with diagnoses that included: Dementia, Chronic Obstructive Pulmonary Disease, Dysphagia, and Insomnia. A review of Resident #46's Quarterly MDS with ARD of 06/26/2023 revealed a Brief Interview for Mental Status score of 99 (indicating the BIMS was unable to be completed). A review of Resident #46's Comprehensive Care Plan revealed the Resident was at risk for side effects of psychotropic drug use. Interventions included in part: Pharmacist to review current drug regime for contraindications and possible reduction per protocol and report to doctor. A review of Resident #46's 07/2023 Physician Orders read in part: Restoril 7.5mg give 1 capsule by mouth at bedtime related to Insomnia. An interview with S2 DON on 07/26/2023 at 11:10 a.m. confirmed that a Gradual Dose Reduction had not been completed and signed by a physician since starting the pyschotropic medication in June of 2022. 47004 Resident #49 A review of Resident #49's medical record revealed an admitted [DATE] with diagnoses that included in part: Parkinson's, Psychotic Disorder with Delusions, Dementia, Congestive Heart Failure, and Cognitive Communication Deficit. A review of Resident #49's Quarterly MDS with ARD of 05/12/2023 revealed a Brief Interview for Mental Status score of 03 (indicating severe cognitive impairment). Resident received antipsychotic, anticoagulant, and diuretic medications. A review of Resident #49's Comprehensive Care Plan revealed the Resident was at risk for side effects of psychotropic drug use. Interventions included in part: Pharmacist to review current drug regime for contraindications and possible reduction per protocol and report to doctor. A review of Resident #49's 07/2023 Physician Orders read in part: Nuplazid 34mg by mouth daily related to Parkinson's, and Psychotic Disorder with Delusions. Interview on 07/26/2023 at 11:45 a.m. with S2 DON revealed a Gradual Dose Reduction had not been completed for Resident #49's psychotropic medication. S2 DON confirmed a Gradual Dose Reduction should have been completed, but had not.

FACILITY Based on record review and interview the facility failed to electronically submit complete and accurate direct care staffing information, based on payroll, to CMS as required. Findings: Review of the PBJ (Payroll Based Journal) Report for FY (Fiscal Year) Quarter 2 2023 (January 1-March 31) revealed triggers for the following: 1. One star staffing rating, 2. No RN hours, and 3. Failed to have licensed nursing coverage 24 hours/day. Interview on 07/25/2023 at 2:55 p.m. with S1 Administrator revealed S3 Human Resources was responsible for submitting the facility's PBJ information. Interview on 07/25/2023 at 2:57 p.m. with S3 Human Resources revealed she was responsible for submitting PBJ information for nursing staff and therapy department. S3 Human Resources stated she submitted the PBJ information for FY Quarter 2 2023 in April of 2023. Review of PBJ Final File Validation report dated 04/06/2023 revealed Total Employee Records submitted was 5. Interview on 07/25/2023 at 3:00 p.m. with S3 Human Resources revealed she had mistakenly submitted the therapy department's PBJ information twice and had not submitted nursing staff PBJ information for FY Quarter 2 2023 and should have.

Based on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. The facility failed to evaluate the appropriateness for the continued use of a PRN [CONDITION(S)] medication beyond 14 days for 1 (#32) of 5 (#20, #29, #32, #42, and #54) resident's sampled for unnecessary medications. Findings: Review of the facility's policy titled: Drug Regimen Review Policy and Procedure revealed in part . Clinically significant medication issues may include, but are not limited to: 1. Medication dose, frequency, route or duration not consistent with resident's condition, manufacturer's instructions, or applicable standards of practice. Review of the clinical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Anxiety Disorder, [CONDITION(S)], and Anorexia. Review of Resident #32's Physician's Orders revealed in part [MEDICATION(S)] tablet 0.25mg give 1 tablet by mouth qHS prn for anxiety related to Anxiety Disorder, dated 11/24/2021. Review of Resident #32's MARs revealed she received [MEDICATION(S)] 0.25 mg at HS the following months and number of days: 01/2022 - 24 of 31 days. 02/2022 - 28 of 28 days. 03/2022 - 20 of 31 days. 04/2022 - 30 of 30 days. 05/2022 - 22 of 31 days. 06/2022 - 22 of 30 days. 07/2022 - 14 of 18 days. Interview on 07/19/2022 at 1:30 p.m. with S1 DON confirmed Resident #32 received the antianxiety medication, [MEDICATION(S)], routinely as above. She also confirmed the prn antianxiety medication, [MEDICATION(S)], had not been ordered and evaluated in 14-day cycles to ensure appropriate dosage and duration, and should have been.

Resident #6 Based on observations, interviews and record review, the facility failed to provide respiratory care consistent with professional standards and according to the resident's plan of care for 1 ( #6) of 32 sampled residents. The facility failed to ensure oxygen was administered as ordered for Resident #6 who required continuous oxygen therapy. Findings: Review of Resident #6's clinical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Care plan with target date of 8/02/2022 revealed a potential risk for [CONDITION(S)] exacerbation, wheezing and shortness of breath related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions with a focus of [CONDITION(S)] included to administer oxygen as ordered. Observation on 07/18/2022 at 11:52 a.m. revealed Resident #6 lying in bed awake with oxygen in progress at 3 liters/minute via nasal cannula per oxygen concentrator. Observation on 07/19/2022 at 08:38 a.m. revealed Resident #6 lying in bed with oxygen in progress at 3 liters/minute via nasal cannula. Interview on 07/19/22 at 03:00 p.m. with S2 LPN revealed Resident #6 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 07/19/22 at 03:05 p.m. accompanied by S1 DON and S2 LPN revealed Resident #6 lying in bed with oxygen in progress at 3 liters/minute via nasal cannula per oxygen concentrator. Interview with S1 DON and S2 LPN at the time of observation confirmed Resident #6's oxygen concentrator was set at 3 liters/minute and should have been set at 2 liters/minute instead.

Based on observation, record review and interview the facility failed to provide a resident with scheduled activities according to her comprehensive assessment and preference of choice of activities and have those preferences addressed in her care plan for 1 (#73) of 1 stage 2 residents reviewed for activity out of a stage 2 sample of 24. The total Facility Census was 95 according to the Resident Census and conditions of Residents provider by the facility. Findings. Review of Resident #73's Progress notes revealed a readmission date of [DATE] with [DIAGNOSES REDACTED]. Observations on 5/15/17 at 2:10 p.m. revealed the resident was lying in bed with full side rails in the up position. The resident was awake and was not observed to be engaged in any activities. Further observation of the facility's dinning area revealed a group activity of Bingo was being conducted at that time. Observations on 5/16/17 at 11:00 a.m. and 1:00 p.m. revealed the resident was lying awake in her bed. The television was observed to be on; however, the resident was not watching it and it was observed not to be on the news channel. Further observations on 5/16/17 at 2:00 p.m. revealed a group activity of lady's in red hats was taking place, and the resident was not in the group to participate. Observations on 5/17/17 at 9:00 a.m. revealed the resident was lying in bed with full side rails in the up position. Further observations revealed there were no activities being conducted in the resident's room at that time. Interview on 5/17/17 at 9:04 a.m. with the resident revealed she liked to get up at times. Further interview with the resident revealed she liked attending church activities. Review of the Annual MDS dated [DATE] revealed the resident had a BIMS score of 10. The MDS revealed the resident was usually understood by others and usually understands others. Further review of the Annual MDS revealed the following activity preferences were listed as very important to the resident: To have books, newspaper and magazines to read; Listen to music she liked; Be around animals such as pets; Keep up with the news; Do things with groups of people; Go outside to get fresh air when the weather is good and participate in religious services or practices. Review of the Activity Care Plan with an initial start date of 10/5/16 and a goal date of 6/13/17 revealed Activity deficit like to watch TV, Likes to watch simulated fish in aquarium, Prefers for light to be off in room, Gets up 3 times weekly in geri chair. The Approaches included 1:1 visits, assist to group activity when up in geri chair, inform of and invite to activities daily, encourage participation in those choices, post monthly activities calendar in room, respect resident's right to refuse activities, turn lights off in room as request, turn TV onto favorite channel, lotion to hands and arms and Aroma therapy. Further review of the Activity Care Plan did not include the resident's preference of listen to music, keep up with the news, go outside to get fresh air when the weather was good, participate in religious services or practices, and have newspaper, magazines and books read to her. Interview on 5/17/17 at 9:45 a.m. with S1 Activity Director revealed she started working as the Activity Director in January 2017. She stated she provided room bound activity on Tuesdays and Thursdays to the resident. S1 Activity Director stated she provided lotion therapy, talking with the resident, and opening the resident's window so she could look outside at the birds that ate from the bird feeder out side of her room. Review of the Activity Forms of documented activities provided to Surveyor by the Activity Director revealed the following: Week of 2/6/2017 - 2/10/2017 revealed one entry of documentation that the Activity Director had talked with the resident. The documentation did not specified the length of the communication or how often it was done that week; Week of 2/13/17 - 2/17/ 2017 revealed one entry of documentation that the resident was checked on. No other documentation for any other weeks in February 2017 received. Review of the Progress Notes dated 3/17/17 at 1444 hours by S1 Activity Director revealed resident speaks to us when we go in her room. We put lotion on her hands and offer aromatherapy. She is very nice. We talk about her military days sometimes. Often hard to understand. Review of the Activity Forms and Progress Notes for March 2017 revealed no other documentation of Activities recorded. Review of the Activity Forms dated 4/10/2017 revealed resident was sleeping. Review of the Activity Forms for the week of 4/24/2017 - 4/28/2017 revealed S1 Activity Director went in the resident's room and told the resident about bunnies outside her window, and the resident was watching them. Review of the activity documentation for the week of 5/1/2017 -5/5/2017 revealed the resident was offered music, she refused the music but looked for bunny rabbits outside her window. Further review of the Activity Forms revealed no documentation that in room activities were provided every Tuesday or Thursday in the resident's room as stated previously by S1 Activity Director. Interview on 5/17/17 at 10:00 a.m. with S2 CNA revealed the resident was scheduled to get up three times a week Mondays, Wednesday and Fridays. Surveyor informed S2 CNA that she was on site from 8:00 a.m. - 3:00 p.m. Monday (5/16/17) and did not observe the resident up in her geri chair. When surveyor asked S2 CNA did resident get up on Monday ( 5/15/17), S2 CNA stated she would get the resident up today. S2 CNA stated they documented in the electronic charting system when they got the resident up. Interview on 5/17/17 at 10:30 a.m. with S3 RN/MDS revealed that she was not able to give the surveyor a copy of the CNA task documentation of getting the resident up. She stated the electronic charting system did not lead the CNAs to document when the resident was gotten up. However, it reminded them that the resident need to be gotten up three time a week. Further interview with S3 RN/MDS on 5/17/17 at 10:30 a.m. confirmed the resident's current Care Plan had not been revised to include her preferences concerning activities in accordance with her comprehensive MDS assessment. She further confirmed that more in room activities should have been documented or provided. S3 RN/MDS revealed the Activity Director was the person to assess the resident's preferences and document it on the MDS. She stated the previous Activity Director had completed the resident's last Annual MDS but was no longer working at the facility, and when the current care plan was updated on 10/5/16 she did know where to find the assessment for that care plan. S3 RN/MDS stated she did not know who completed the last Activity Care Plan for the resident. Interview on 5/17/17 at 1:35 p.m. with S4 MDS/LPN revealed she and the Activity Director revised the resident's care plan. S4 MDS/LPN stated she talked to the resident that day (5/17/17) and revised her Care Plan according to her activities preferences. S4 MDS/LPN provided a revised copy of the resident's Care Plan for activities of choice.

Based on observation, interview and record review, the facility failed to serve attractive and palatable food to 10 of 38 Stage 2 sampled residents (#27, #113, #58, #79, #25, #106, #32, #9, #46 and #111). The facility's total census was 95 residents according to the Resident Census and Conditions of Residents Form. Findings: 1. Interview on 5/11/15 at 10:38 a.m. with resident #27 revealed she didn't like the taste of the food. Observation on 5/13/15 at 11:30 a.m. revealed the resident smelled the food on her lunch tray and stated "it stinks." The resident cut a piece of the meat and started to chew it. She stated it was too "tough" and spit the meat into the garbage can next to the bed. 2. Interview on 5/11/15 at 10:51 a.m. with resident #113 revealed the food did not taste good. 3. Interview on 5/11/15 at 11:09 a.m. with resident #58 revealed the food did not taste good in general. Observation on 5/13/15 at 11:50 a.m. during the noon meal revealed resident #58 did not know what the meat was and she didn't want to taste it. 4. Interview on 5/11/15 at 11:14 a.m. with resident #79 revealed the food was 'terrible" at times. 5. Observation on 5/11/15 at 11:30 a.m. revealed resident #25 was in the dining room eating lunch. He stated the turkey was tough and dry, and he didn't like the food at the facility. Further observation on 5/13/15 at 11:20 a.m. revealed the resident barely touched his food. He stated the meat was tough and had no taste. 6. Interview on 5/11/15 at 1:30 p.m. with resident #106 revealed the food was only "so-so". 7. Interview on 5/11/15 at 1:47 p.m. with resident #32 revealed the food was not very good. He stated the residents had to use plenty of condiments in order to eat it. 8. Interview on 5/11/15 at 2:09 p.m. with resident #9 revealed the food was "flat" and had no seasoning. 9. Interview on 5/13/15 at 9:07 a.m. with resident #46 revealed the food had "gone down hill" during the past few months. She stated she didn't recognize what was being served at times. She stated beans were served hard and rice was not completely cooked. 10. Interview on 5/13/15 at 10:45 a.m. with resident #111 on 5/13/15 at 10:45 a.m. revealed he did not like the taste of the food. Observation on 5/13/15 at 11:30 a.m. during the noon meal revealed staff were serving lunch trays in the dining area. The lunch was greens with raw onion slices on top, cornbread, apples (looked dry), meat was not identifiable (looked dry and not attractive) and potatoes. Interview at that time with the nurse who was cutting up a resident's meat revealed that she was not sure what kind of meat was on the lunch tray. Observation on 5/13/15 at 11:45 a.m. of a noon meal tray requested from the kitchen revealed a grayish colored piece of meat, greens with raw onion slices on top, stewed potatoes and cornbread. The meat was dry and tasteless, and the remaining food did not taste like it had any salt added. The cornbread was also dry and tasteless with no salt. Review of the menu for the day reflected the meat was a breaded pork chop, but there was no breading on the meat that was served on the noon meal trays. Review of the Resident Council minutes dated 1/25/15 at 1:09 p.m. reflected documentation under the Dietary Section that the food had no seasoning and the residents had requested they be given something different and better. Review of the Resident Council minutes dated 2/6/15 at 1:12 p.m. reflected documentation under the Dietary Section that the food was bad, tough to take, too strong sometimes and they would like to help the staff cook. Review of the Resident Council minutes dated 3/6/15 at 1:05 p.m. reflected documentation under the Dietary Section that the food was terrible, and the lima beans was undercooked. Review of the Resident Council minutes dated 4/10/15 at 1:29 p.m. reflected documentation under the Dietary Section that the food was terrible, not sure what it was, the residents were tired of peaches, pears and apricots, and they requested no more sloppy joes. Interview on 5/12/15 at 2:30 p.m. with S3 RAD on 5/12/15 at 2:30 p.m. revealed dietary was notified of the residents' food complaints made during the Resident Council meetings. She stated the complaints were usually voiced towards the end of a menu cycle. Interview with S4 DM on 5/13/15 at 11:30 a.m. revealed she did not receive a copy of the Resident Council minutes, and was not aware of all the food complaints. She stated it was usually the same residents that complained about the food.

Based on observation and interview, the facility failed to ensure expired narcotics were not available for residents' use on 2 of 3 medication carts for 7 of 38 Stage 2 sampled residents (#43, #65, #96, #6, #103, #70 and #86). The facility's total census was 95 residents according to the Resident Census and Condition of Residents form. Findings: 1. Observation on [DATE] at 10:10 a.m. of the B hall medication cart with S5 LPN revealed the following: resident #43's Ultram 50 mg q 8 hours prn had an expiration date of [DATE]; resident #65's Hydrocodone-APAP ,[DATE] mg q 4 hours prn had an expiration date of [DATE]; resident #96's Hydrocodone-APAP 7XXX,[DATE] q 8 hours prn had an expiration date of ,[DATE]; resident #6's Hydrocodone-APAP ,[DATE] mg q 8 hours prn had an expiration date of [DATE]; resident # 103's Hydrocodone-APAP ,[DATE] mg q 6 hours prn had an expiration date of [DATE]; and resident #70's Hydrocodone-APAP ,[DATE] mg bid prn had an expiration date of ,[DATE]. Interview with S5 LPN at that time confirmed the expiration dates on the labels of the above medications. She stated most of the medications were not taken very often but they were available for the residents' use if needed. 2. Observation on [DATE] at 10:35 a.m. of the A hall medication cart revealed and interview with S6 LPN confirmed resident #86's Hydrocodone-APAP 7XXX,[DATE] mg q 6 hours prn had an expiration date of [DATE]. S6 LPN also confirmed the medication was available for the resident's use. Interview on [DATE] at 10:45 a.m. with S7 RN confirmed the facility's policy was to comply with the expiration dates on the medicine cards whether the dates were on the medicine card labels or on the back of the cards.

Based on interview and record review, the facility failed to follow up on grievances voiced during Resident Council meetings. The total facility census was 95 residents according to the Resident Census and Conditions of Residents Form. Findings: Review of the Resident Council minutes dated 12/4/14 at 2:06 p.m. reflected documentation that the CNAs did not come when called and/or were very slow. Further review reflected the ward clerks didn't always tell them, and needed to be louder. Review of the Resident Council minutes dated 1/25/15 at 1:09 p.m. reflected documentation under the Aid section that it was wrong for them to go in rooms to get on their cell phones, they needed to do their jobs, come when called and check on residents at night. Further review reflected documentation under the Dietary section that the food had no seasoning and the residents requested they be given something different and better. Review of the Resident Council minutes dated 2/6/15 at 1:12 p.m. reflected the residents complained they didn't see the aides in the hall anymore and there weren't enough aides. Further review reflected documentation under the Dietary Section that the food was bad, tough to take, too strong sometimes and they would like to help the staff cook. Review of the Resident Council minutes dated 3/6/15 at 1:05 p.m. reflected documentation under the AIDS section that the CNAs were lazy. Further review reflected documentation under the Dietary Section that the food was terrible, and the lima beans were undercooked. The STAFFING section reflected the night CNAs said they needed help. Review of the Resident Council minutes dated 4/10/15 at 1:29 p.m. reflected documentation under the AIDS section that the CNAs didn't answer when called and/or didn't come at times. The residents also complained that the CNAs didn't give them a chance to talk. Further review reflected documentation under the Dietary Section that the food was terrible, not sure what it was, the residents were tired of peaches, pears and apricots, and they requested no more sloppy joes. Review of the Resident Council minute forms reflected sections for documentation of old business and new business, but the staff was just documenting new business. There was no documentation to reflect the old business had been addressed. Interview on 5/12/15 at 2:30 p.m. with S3 RAD revealed the system was to give concerns addressed in the Resident Council to the appropriate department head, and that person would address the issue with the appropriate staff. S3 RAD stated S2 DON should have the information regarding the complaints of the CNAs slow response to the call bells. S3 RAD also stated that dietary was notified of residents' food complaints during the Resident Council meetings, and the complaints were usually voiced towards the end of a menu cycle. Further interview revealed the CNAs did respond when called. She stated there was really only one resident that complained about the CNAs, and that they should have documented the resident's frequent complaints. Interview on 5/12/15 at 3:00 p.m. with S2 DON on 5/12/15 revealed that S3 RAD did not provide her with a copy of the Resident Council meeting minutes. S2 DON stated S3 RAD verbally reported in the facility's daily morning meetings if any grievances were expressed by residents in the Council meetings. S2 DON stated she had just been informed of the specific resident grievances from the past Resident Council meetings. Further interview on 5/13/15 at 9:15 a.m. with S2 DON revealed she has had meetings with the CNAs about answering the call bells timely; however, she confirmed the meetings were routine daily information and not a result of the Resident Council meetings. Interview on 5/13/15 at 11:30 a.m. with S4 DM revealed she did not receive a copy of the Resident Council minutes, and was not aware of all the food complaints. She stated it was always the same people that complained.

Based on observation, record reviews, and staff interviews the facility failed to develop a plan of care to meet the needs for 4 (#15, #36, #41, & #70) of 14 (#11, #13, #15, #36, #41, #49, #53, #54, #55, #61, #70, #89, #99, & #107) residents reviewed for care planning out of a total sample of 25 Stage 2 residents. The facility failed to develop a plan of care for impaired vision (#36 & #70), a plan of care for Depression and Dementia (#15), and a plan of care for Depression (#41). The facility's total census according to the Resident Census and Conditions of Residents was 94. Findings: 1. Review of resident #36's Admission MDS dated [DATE] (5 day) reflected the resident's vision was adequate with the use of corrective lenses. Review of the resident's MDS assessment dated [DATE] (14 day) reflected the resident's vision was impaired without the use of corrective lenses. Review of the resident's Comprehensive Care Plan dated [DATE] failed to reflect a plan of care had been developed for the resident's problem of visual impairment and required the use of eye glasses. Interview on [DATE] at 11:00 a.m. with S2 MDS Nurse confirmed the resident had a pair of eye glasses, but did not wear them for the 14 day assessment of [DATE]. Further interview of S2 MDS Nurse confirmed the resident's care plan and CNA ADL Kardex Care Plan did not include a plan of care for the problem of visual impairment and use of glasses and should have. 2. Review of resident #70's closed record reflected an admitted [DATE] and documentation that she had expired on [DATE]. Review of the resident's MDS dated [DATE] reflected she was coded as 2 (Moderately impaired-limited vision and not able to see newspaper headlines, but can identify objects). The resident was also coded as 0 (no) corrective lenses. Interview on [DATE] at 11:20 a.m. with S2 MDS Nurse revealed the resident had decreased vision and did not have glasses while at the facility because she did not want glasses. She said the resident was very sick, received Hospice services, and was not interested in reading any magazines or books during her stay here. Interview on [DATE] at 1:25 p.m. with S1 DON revealed residents identified with impaired vision should have a care plan in place addressing this issue. She confirmed the resident had been identified with impaired vision, but the facility had failed to develop a care plan for her regarding impaired vision. 3. Review of resident #15's Accumulative [DIAGNOSES REDACTED]. Review of the [DATE] physician orders [REDACTED]. 1. [MEDICATION NAME] 200 mg one by mouth everyday for Depression 2. [MEDICATION NAME] XR 150 mg one in the evening for Dementia/Depression Review of the Comprehensive Care Plan with a goal date of [DATE] reflected no problems identified or interventions for Depression or Dementia or the use of his [MEDICATION NAME] and [MEDICATION NAME]. Interview with S1 DON on [DATE] at 11:15 a.m. confirmed there was no care plan specific to the resident's [DIAGNOSES REDACTED]. 4. Review of resident #41's Face Sheet reflected she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's [DATE] Physician order [REDACTED]. Review of the resident's Comprehensive Plan of Care with a goal date of [DATE] reflected: [DATE]- At risk for adverse effects of medications r/t polypharmacy with approaches to include observe for and address possible side effects and pharmacist to perform monthly drug review. Further review did not reflect a care plan for depression. Interview and observation of the resident on [DATE] at 1:45 p.m. revealed her alert and responsive sitting in her wheelchair in the hallway. The resident stated she had no problems with her medications. Interview on [DATE] at 10:40 a.m. with S1 DON revealed the care plan for depression was not included on the current POC. S1 DON stated the care plan nurse did not develop a care plan for depression because she over looked the order for [MEDICATION NAME]. S1 DON confirmed the resident should have a current plan of care for depression.

Based on interviews and record reviews the facility failed to ensure the resident received adequate monitoring of behavior and had documentation of attempted behavioral interventions prior to the administration of a prn anxiety medication (#49), and failed to identify which medications were being monitored (#15,#41, #99) for 4 of 5 residents (#15, #41, #49, #99, #53) sampled for unnecessary medication review in a Stage 2 Sample of 25. Review of the Resident Census and Conditions of Residents report dated 7/7/14 reflected a total of 75 residents received psychoactive medication. Findings: 1. Review of resident #49's June, 2014 MD Orders reflected the order for [MEDICATION NAME] 1 mg po bid prn [DIAGNOSES REDACTED]. Review of the June, 2014 PRN Medication Flow Sheet revealed the resident had required a dose of Lorazapam on 6/10/14, 6/11/14, 6/12/14, 6/16/14 and 6/20/14 due to anxiety. Further review reflected the interventions diversion and medication administration were effective for relief for the above doses. Review of the June, 2014 MAR indicated [REDACTED]. Review of the June, 2014 nurses' notes for the above dates failed to reflect documentation of the resident's behavior of anxiety, failed to reflect that non-pharmacologic measures had been attempted prior to the administration of the prn medication, and failed to document the effectiveness of the prn medication. Interview with S1 DON on 7/9/14 at 1:30 p.m. confirmed the nurses' had not documented that the resident's behavior had been monitored and should have. Further interview of the S1 DON confirmed all doses of prn Lorazapam should have been documented on the prn flow sheet. Further interview of S1 DON confirmed the nurses' should have included documentation of the non-pharmacologic measures that were attempted, and should have documented the assessment of the effectiveness of the medication. Further interview with S1 DON confirmed there should have been documentation in the nurses' notes that described the behavior exhibited by the resident when she complained of increased anxiety. 2. Review of resident #15's Accumulative [DIAGNOSES REDACTED]. Review of the July 2014 physician orders [REDACTED]. 1. [MEDICATION NAME] 200 mg one by mouth everyday for Depression 2. [MEDICATION NAME] XR 150 mg one in the evening for Dementia/Depression Review of the Behavior and Side Effect Monitoring Forms for May, June and July, 2014 reflected the staff were monitoring for side effects and mood and behaviors but there was no indication for what medication they were monitoring. Interview with S1 DON on 7/9/14 at 11:15 am confirmed the Behavior and Side Effect Monitoring Forms failed to reflect which medication the staff were monitoring. 3. Review of Resident #41's Face Sheet reflected she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's July 2014 Physician order [REDACTED]. Review of the Behavior and Side Effect Monitoring Forms for May, June and July, 2014 reflected the staff were monitoring for side effects and mood and behaviors but there was no indication for what medication they were monitoring. Interview with S1 DON on 7/9/14 at 11:15 am confirmed the Behavior and Side Effect Monitoring Forms failed to reflect which medication the staff were monitoring. 4. Review of Resident #99's Face Sheet reflected the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Interview with S1 DON on 7/9/14 at 11:15 am confirmed the Behavior and Side Effect Monitoring Forms failed to reflect which medication the staff were monitoring. Review of the resident's July 2014 Physician order [REDACTED]. Review of the Behavior and Side Effect Monitoring Forms for May, June and July, 2014 reflected the staff were monitoring for side effects and mood and behaviors but there was no indication for what medication they were monitoring.

Based on observation, record review, and staff interviews the facility failed to ensure the plan of care had been revised for 1 (# 41) ) of 5 (#9, #15,#41, #49, and #53) residents reviewed for unnecessary medication of a total sample of 25 Stage 2 residents. The facility failed to ensure a care plan had been revised for a [MEDICAL CONDITION] medication ([MEDICATION NAME]). Findings: Review of Resident #41's Face Sheet reflected she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's July 2014 Physician order [REDACTED]. Review of the resident's Comprehensive Plan of Care with a goal date of 8/7/14 reflected: 2/7/14- At risk for adverse effects of medications r/t polypharmacy with approaches to include observe for and address possible side effects and pharmacist to perform monthly drug review. Further review did not reflect a care plan for [MEDICAL CONDITION]. Interview and observation of the resident on 7/8/14 at 1:45 p.m. revealed her alert and responsive sitting in her wheelchair in the hallway. The resident stated she had no problems with her medications. Interview on 7/9/14 at 10:40 a.m. with S1 DON revealed the care plan for [MEDICAL CONDITION] was not included on the current POC. S1 DON stated the care plan nurse did not input the [MEDICAL CONDITION] care plan into the computer when she received the [MEDICATION NAME] order. S1 DON confirmed the resident should have a current plan of care for [MEDICAL CONDITION].

Based on observation, record review and interview, the facility failed to provide services in accordance with each resident's written plan of care for 4 of 5 sampled residents (#1, #2, #3 and #4). The facility failed to provide the ordered amount of oxygen per nasal cannula and failed to accurately monitor intake and output according to the plan of care for resident #1. The facility also failed to accurately monitor intake and output for residents as per care plan for #2, #3 and #4. The facility's total census was 101 according to the Resident Census and Condition of Residents form. Findings: 1. Observation on 11/20/13 at 9:45 a.m. revealed that resident #1 was receiving oxygen per nasal cannula at 1 1/2 liters per minute per oxygen concentrator. He was not observed to be in any respiratory distress. Further observations on 11/20/13 at 11:44 a.m. and again at 2:15 p.m. revealed that he continued to receive oxygen per nasal cannula at 1 1/2 liters per minute and was not observed to be in any distress. Review of the physician's orders [REDACTED]. Interview and observation with S11 LPN on 11/20/13 at 2:15 p.m. confirmed the resident was receiving oxygen at 1 1/2 liters per minute per nasal cannula and that he should have been receiving 3 liters per minute as per the physician's orders [REDACTED]. 2. Observation on 11/20/13 at 10:00 a.m. revealed resident #1 was in bed with a Foley catheter contained on the side of the bed. Review of the resident's admission record from his hospitalization dated 10/26/13 - 11/8/13 reflected [DIAGNOSES REDACTED]. Review of the plan of care, with a goal date of 1/13/14, reflected an approach to monitor and record the resident's intake and output. Review of the November 2013 [DEVICE] Feeding Flow Sheet reflected the resident's total amount of fluids and total amount of output had not been documented on the following dates: 11/8/13, 11/9/13, 11/10/13, 11/11/13, 11/12/13 (there was no documentation of output on the 2-10 shift), 11/13/13, 11/14/13 (there was no documentation of output on the 6-2 or 2-10 shift), 11/15/13 (there was no documentation of intake or output on the 6-2 or 2-10 shift), 11/16/13 (there was no documentation of output on the 2-10 or the 10-6 shift and no intake recorded on the 10-6 shift), 11/17/13, 11/18/13 (there was no documentation of output on the 6-2 shift) and 11/19/13 (there was no documentation of output on the 6-2 shift). Interview with S5 RN on 11/21/13 at 9:30 a.m. revealed that she was responsible for monitoring the residents' intake and output totals. She confirmed that the intake and output monitoring from 11/8/13 - 11/19/13 was not complete and accurate. She confirmed that she had not monitored his intake and output since he had returned from the hospital on [DATE] with a [DIAGNOSES REDACTED]. 3. Observation on 11/20/13 at 10:20 a.m. revealed resident #2 was lying in bed with a GU bag contained on the side of the bed. Review of the Record of Admission form reflected the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Accumulative [DIAGNOSES REDACTED]. Further review of the record reflected the resident had recurrent hospitalization s due to UTIs. Review of the care plan with a goal date of 1/14/14 reflected a problem of at risk for UTI r/t Foley catheter. The interventions included monitoring and documenting the I & O. Review of the November 2013 [DEVICE] Feeding Flow Sheet reflected the resident's total amount of fluids and total amount of output had not been documented on the following dates: 11/3/13, 11/5/13 (there was no documentation of the intake or output on the 2-10 shift), 11/6/13, 11/10/13 (there was no documentation of the intake or output on the 2-10 shift), 11/14/13, 11/15/13, 11/18/13 and 11/19/13. Review of the October 2013 [DEVICE] Feeding Flow Sheet reflected the total amount of output for each shift was specific to the resident's [DEVICE] which was draining, so the urine output was being monitored on a separate form. Further review of the October 2013 [DEVICE] Feeding Flow Sheet reflected the resident's total amount of fluids had not been documented on the following dates: 10/11/13, 10/12/13 (there was no documentation of the intake on the 10-6 shift), 10/17/13, 10/21/13, 10/22/13, 10/27/13 and 10/30/13 (there was no documentation of the intake on the 10-6 shift). Review of the October 2013 Intake and Output Record reflected the resident's total amount of output had not been documented on the following dates: 10/11/13, 10/13/13 (there was not documentation of the output on the 6-2 shift), 10/17/13 (there was not documentation of the output on the 6-2 shift), 10/29/13 (there was not documentation of the output on the 6-2 shift), 10/30/13 (there was not documentation of the output on the 6-2 shift) and 10/31/13 (there was not documentation of the output on the 6-2 shift). 4. Observation on 11/20/13 at 9:55 a.m. revealed resident #4 was lying in bed with a GU bag contained on the side of the bed. Review of the Record of Admission reflected the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Accumulative [DIAGNOSES REDACTED]. Further review of the record reflected the resident had recurrent hospitalization s due to Dehydration. Review of the care plan with a goal date of 1/14/14 reflected a problem of at risk for UTI r/t Foley catheter. The interventions included monitoring and documenting the I & O. Review of the November 2013 [DEVICE] Feeding Flow Sheet reflected the resident's total amount of fluids and total amount of output had not been documented on the following dates: 11/6/13, 11/10/13 ((there was not documentation of the intake or output on the 2-10 shift), 11/14/13, 11/15/13, 11/18/13 and 11/19/13. Review of the October 2013 [DEVICE] Feeding Flow Sheet reflected the resident's total amount of fluids and total amount of output had not been documented on the following dates: 10/1/13 (there was no documentation of the intake or output on the 10-6 shift), 10/2/13, 10/3/13, 10/4/13, 10/5/13, 10/8/13 (there was no documentation of the intake or output on the 6-2 shift) 10/9/13, 10/17/13, 10/21/13, 10/22/13 and 10/25/13 (there was no documentation of the intake or output for the 6-2 or 10-6 shifts). Interview on 11/21/13 at 10:15 a.m. with S6 RN revealed the night shift nurses should monitor the residents' intake and output to ensure the amounts were totaled for the past 24 hours. She stated if the intake or output did not meet the recommended totals, the nurse should notify the RN assigned to that hall. 5. Observation of resident #3 on 11/20/13 at 10:05 a.m. revealed he was lying in bed. Further observation at that time revealed he was a double [MEDICAL CONDITION] and he had an indwelling Foley catheter. The tubing was visible but there was no urine in the tubing at the time. Review of the resident's current care plan with a goal date of 2/1/14 revealed a problem of at risk for UTI r/t Foley catheter and to assist with wound healing. Approaches included to monitor and document intake and output. Review of I & O records for the months of 10/13 and 11/13 for resident #3 revealed his I & O records had not been totaled 10/29/13 and there were missing shift totals on 10/30/13 for the day and evening shifts and on 10/31/13 there was no intake recorded for the evening shift. In an interview with S15 RN on 11/21/13 at 10:00 a.m., she stated the evening shift LPNs were responsible for totaling the resident's I & Os for the previous 24 hours and reporting major discrepancies to the physician

Based on record review and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of a resident for 1 (#2) of 62 residents (#2, #4, #6 - #44, and #46 - #66) with no advanced directives and/or a "NO CPR" order in their clinical record. The facility had a total census of 100 residents according to the facility's Resident Census and Conditions of Residents form. The facility failed to: 1. Ensure LPN staff immediately initiated CPR for resident #2 who had no advance directive, and was found unresponsive, without pulse, blood pressure and respirations on [DATE] at 3:13 a.m. 2. Ensure licensed staff followed facility policy to check the resident's chart for the resident's code status, and provide immediate lifesaving measures to the resident with no advance directive documented on record for an emergency situation (#2). 3. Ensure all licensed staff were in-serviced regarding the facility's policies for Advanced Directives, DNR, and LaPost, and the black dot system (used in conjunction with the NO CPR policy). The immediate jeopardy began for resident #2 on [DATE] at 5:15 a.m. when he was found in bed, without a pulse and respirations by S2 LPN. S2 LPN was not aware of the resident's code status and did not initiate CPR as according to nurse practice standards. S2 LPN was not aware of the resident's code status and did not follow policy to check the medical record for an advance directive. S2 LPN also failed to follow the facility's CPR policy for a resident without a written advanced directive or specific physician's orders [REDACTED]. S2 LPN called the coroner who released the body at 5:45 a.m. on [DATE]. The immediate jeopardy for resident #2 ended when his death was pronounced by the coroner at 5:45 a.m. on [DATE]. A plan of removal was submitted on [DATE] at 1:05 p.m. and read: 1. The facility would complete the in-service education regarding Advance Directives/DNR and LaPOST policy to all licensed nursing staff. 2. The facility would complete the implementation of an adjunct "black dot system" to assist staff in identifying a resident's code status, and prompt staff to check the resident's record for specific directives. 3. Monitoring effectiveness of the in-service education would be achieved by random interviews with staff members to ensure their knowledge of the facility procedures on Advanced Directives and code status of residents, with results discussed weekly in QA meetings. 4. A subsequent staff re-inservice would be conducted on [DATE] regarding Advance Directives and DNR policy. 5. Social Service would be responsible for obtaining Advanced Directives/LaPost documents upon admission of each resident in the facility to ensure the "Black Dot" quick reference system for that resident was put in place. 6. Social Service would be responsible for the LaPost document to be sent for physician signature and a copy would be placed in the resident's medical record. 7. Social Service would keep a copy of the directive in order to track receipt of the original. 8. Each RN supervisor was charged with the responsibility of reviewing each resident's record upon admission and monthly, to ensure the resident's code status and necessary documents were in place for each resident's Advanced Directive information. The immediate jeopardy was lifted on [DATE] at 1:05 p.m. after the plan of removal was submitted and accepted. The deficient practice continues at a pattern of potential for more than minimal harm for residents with no advanced directives/LaPost documents, or a NO CPR order upon admission to the facility. Findings: Review of resident #2's clinical records revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's record reflected he had acknowledged upon admission on [DATE] that he understood that he was not required to have an Advanced Directive in order to receive Medical treatment at the facility. The record signed by the resident and dated [DATE] reflected the resident had not executed an advanced directive. Further review of the physician's orders [REDACTED]. The resident's chart binder did not have a black dot noted on the chart. Review of the resident's last Quarterly MDS assessment dated [DATE] reflected the resident had a BIMS score of 15, and was able to make his needs known. Review of the facility's policy for NO CPR reflected the ultimate responsibility for making decisions concerning orders not to attempt cardiac resuscitation shall belong to the attending physician. The attending physician must write a specific order not to administer cardiac resuscitation in an event of cardiac standstill. The policy further reflected in the absence of an order not to attempt cardiac resuscitation shall be interpreted by the nursing staff as requiring such efforts should the resident have a [MEDICAL CONDITION]. Review of nurses' notes dated [DATE] at 5:15 a.m. revealed S2 LPN entered resident #2's room and noted the resident was not breathing, body still warm, unresponsive, no blood pressure and no heart rate. S2 LPN documented she then called the coroner who came at 5:45 a.m. and pronounced the resident's death. Review of the facility's Online Tracking Incident Report dated [DATE] revealed S4 LPN (who worked the 6:00 a.m. to 2:00 p.m. shift on [DATE], called S1 DON at 6:15 a.m. to inform S1 DON that resident #2 had expired at 5:15 a.m. that morning. The report reflected S2 LPN (who was resident #2's nurse from 10:00 p.m. to 6:00 a.m. on [DATE]) informed S1 DON that S5 CNA had gone in the resident's room at 5:00 a.m. to give him his bath, and called her to the room because the resident was not breathing. The report reflected S2 LPN informed S1 DON that when she assessed the resident, he was not breathing and had no pulse. S2 LPN informed S1 DON that the resident had no problems during the night, and that she had spoken to the resident earlier on the shift and he was fine. Review of the facility's incident investigation dated [DATE] reflected S1 DON received another follow up call at 7:00 a.m. from S2 LPN who stated that another nurse (later identified as S6 LPN) reviewed resident #2's chart and found no documentation that the resident was a DNR. S2 LPN was then asked by S1 DON if she had checked the resident's chart to see what the resident's code status was, and S2 LPN stated she didn't. Further review of the incident report reflected S1 DON conducted an investigation and the results reflected that S2 LPN failed to check the code status of a resident, and failed to perform CPR on a resident who was found in cardiac/respiratory arrest, as there was no documentation to reflect the resident was a DNR. The report further reflected an immediate facility wide in-service was begun on [DATE] to reinforce to staff what was expected of them in the event a resident was found not breathing and without a pulse. The incident report reflected random interviews with staff about the contents of the inservice and follow up inservice would be done on [DATE]. Review of the in-service records dated [DATE] and [DATE] reflected not all licensed nursing staff employed by the facility had been in-serviced. Review of the facility's [DATE] nurses schedule reflected 5 part-time LPNs identified by the facility (#S16, #S17, #S18, #S19 and #S20) who worked and provided care to facility residents after the incident on [DATE], had not received in-service training. Interview with S7 RN/Social Worker on [DATE] at 12:33 p.m. revealed if a nurse found a resident with no respirations, and no pulse, she would do nothing if the resident had a black dot next to his name on the door plate, or on the outside of the chart. She stated this indicated the resident was a DNR. S7 revealed all but the "A hall" had their charts checked to ensure they had either a LaPost or an Advanced Directive on the chart. S7 revealed she was still in the process of checking all charts to ensure they had some form of Advance Directives on their records, however, she confirmed they had not implemented the system for "A hall" yet. Interview with S6 LPN on [DATE] at 2:00 p.m. revealed she was the Body Assessment Nurse. She stated she was informed that resident #2 had died when she reported for duty the morning of [DATE]. S6 stated around 6:45 a.m. that same morning, she questioned S2 LPN regarding his code status, and if he was a DNR. S6 LPN stated that S2 LPN realized she did not know the resident's code status and did not perform CPR. S6 LPN stated she went to check the chart at the nursing station and did not find documentation that the resident was a DNR. S6 LPN instructed S2 LPN to call S1 DON to report what happened. Interview with S2 LPN on [DATE] at 2:15 p.m. revealed that she worked on [DATE] from 10:00 p.m. to 6:00 a.m. S2 LPN stated on [DATE] at 5:15 a.m., S5 CNA called her to go to the resident's room, and she found the resident with no heartbeat and no blood pressure. S2 stated she failed to check the resident's chart to see if he was a DNR. S2 LPN confirmed she did not perform CPR. S2 LPN stated S1 DON had informed her about the "black dot procedure", but she did not remember it until later. She stated the CNA was in the resident's room, so she had her put a clean gown on the resident. S2 LPN stated she called the Charge nurse (S3 LPN) who came and agreed with her that the resident was dead. S2 LPN revealed S3 LPN did not take vital signs because she (S2) had already taken it and the resident had no vital signs. S2 LPN stated when S4 LPN arrived (the nurse scheduled to work 6:00 a.m. to 2:00 p.m. on [DATE]), she to call the family, then they called the Coroner. Interview with S1 DON on [DATE] at 2:20 p.m. revealed he went to the facility on [DATE] around 8:30 a.m. to begin the investigation after receiving a call from S2 LPN at 7:15 a.m. informing him of the incident. S1 DON stated he then called S2 LPN at her home around 9:30 a.m. to tell her that her employment was terminated. S1 DON revealed he had the S8 ADON start the in-service of staff on CPRs and LaPost the same morning. Review of a nursing in-service dated [DATE] reflected facility nurses were in-serviced on the black dot system. However, review of resident #1's clinical record who expired on [DATE], was a hospice patient and had an advanced directive for a DNR, reflected there was no black dot on the chart. Interviews on [DATE] of #S11 CNA at 12:05 p.m., #S12 CNA at 12:10 p.m., #S13 CNA at ,[DATE] p.m., and #S14 CNA at 12:15 p.m. revealed they would call the nurse immediately if they found a resident with no respiration or pulse, and the nurse would know to start CPR or not. Interview with S8 ADON on [DATE] at 2:25 p.m. revealed she began the in-service training around 10:30 a.m. on [DATE] to reinforce the facility's policy on NO CPR and their Black Dot System. S8 ADON stated she in-serviced each shift. Interview with S7 Social Worker on [DATE] at 2:50 p.m. revealed she started working on the facility's black dot system after the inservice on [DATE]. She revealed was responsible for ensuring the residents filled out the advance directives (LaPOST) form, had it signed by the physician and placed in the resident's chart, along with placing a black dot on the chart and a black dot on the nameplate of the resident's door identifying that resident as having an advanced directive. She revealed the black dot system had not been completed for A-Wing; however, she had been working on it and had just completed it. Interview with S3 LPN/Charge nurse on [DATE] at 3:00 p.m. revealed she worked the 10:00 p.m. to 6:00 a.m., shift on [DATE] - [DATE]. S3 LPN stated the ward clerk located her and informed her she was needed in resident #2's room. S3 LPN stated she was in the middle of performing a fingerstick on a resident and securing her medication cart. She stated it took her 5 minutes to get to the resident's room. S3 LPN stated she went in resident #2's room and the resident looked dead. She stated she asked S2 LPN if she had checked the resident out and S2 LPN told her she did, and that she did not need any help. S3 LPN stated she then went back to her work and left S2 LPN to take care of it. She stated she thought the resident was a DNR. S3 LPN further stated she expected S2 LPN who had been employed at the facility longer than herself, to know her residents' code status. Interview with S9 LPN on [DATE] at 3:15 p.m. revealed she was one of the 3 LPNs on duty from 10:00 p.m. on [DATE] to 6:00 a.m. on [DATE]. She stated she was busy working, had no clue that resident #2 had died , and only found out when a CNA had told her. Interview with S1 DON on [DATE] at 9:40 a.m. confirmed after review of the in-service records, that not all licensed nursing staff who worked and cared for resident after the [DATE] incident had been in-serviced on the facility's CPR policy, Advance Directives/LaPost and Black Dot system. There were 6 part time LPNs who had not signed the in-service record. However, it was determined one of the 6 LPNs had not started working with residents, and the remaining 5 LPNs failed to sign and follow facility in-service procedures. S1 DON stated on [DATE], the QA team met and discussed the incident.

Based on record review and interviews the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical and mental well being of its residents. The facility failed to ensure licensed nursing staff followed and implemented their policy/procedures to ensure that 1 (#2) of 62 residents (#2, #4, #6 - #44, and #46 - #66) identified as not having advanced directives, were provided life saving measures in an emergency situation. The facility had a total census of 100 according to the Resident Census and Conditions Report. The facility failed to: 1. Ensure LPN staff immediately initiated CPR for resident #2 who had no advance directive, and was found unresponsive, without pulse, blood pressure and respirations on [DATE] at 3:13 a.m.; 2. Ensure licensed staff followed facility policy to check the resident's chart for the resident's code status, and provide immediate lifesaving measures to the resident with no advance directive on record in an emergency situation (#2); 3. Ensure the facility's system to monitor residents who may have expressed a desire for an advanced directive, and were awaiting final decision and completion of paperwork required, was followed through timely by staff assigned the responsibility; and ensure the black dot process was completed and monitored; 4. Ensure all licensed staff were in-serviced regarding the facility's policy directives regarding Advanced Directives, DNR, and LaPost, and in-serviced regarding the black dot system (used in conjunction with the NO CPR policy). The immediate jeopardy began for resident #2 on [DATE] at 5:15 a.m. when he was found in bed, without a pulse and respirations by S2 LPN. S2 LPN was not aware of the resident's code status and did not initiate CPR as according to nurse practice standards. S2 LPN was not aware of the resident's code status and did not follow policy to check the medical record for an advance directive. S2 LPN also failed to follow the facility's CPR policy for a resident without a written advanced directive or specific physician's orders [REDACTED]. S2 LPN called the coroner who released the body at 5:45 a.m. on [DATE]. The immediate jeopardy for resident #2 ended when his death was pronounced by the coroner at 5:45 a.m. on [DATE]. The immediate jeopardy continued for 61 residents who had no advanced directives or No CPR orders on record. A plan of removal was submitted on [DATE] at 1:05 p.m. and read: 1. The facility would complete the in-service education regarding Advance Directives/DNR and LaPOST policy to all licensed nursing staff. 2. The facility would complete the implementation of an adjunct "black dot system" to assist staff in identifying a resident's code status, and prompt staff to check the resident's record for specific directives. 3. Monitoring effectiveness of the in-service education would be achieved by random interviews with staff members to ensure their knowledge of the facility procedures on Advanced Directives and code status of residents, with results discussed weekly in QA meetings. 4. A subsequent staff re-inservice would be conducted on [DATE] regarding Advance Directives and DNR policy. 5. Social Service would be responsible for obtaining Advanced Directives/LaPost documents upon admission of each resident in the facility to ensure the "Black Dot" quick reference system for that resident was put in place. 6. Social Service would be responsible for the LaPost document to be sent for physician signature and a copy would be placed in the resident's medical record. 7. Social Service would keep a copy of the directive in order to track receipt of the original. 8. Each RN supervisor was charged with the responsibility of reviewing each resident's record upon admission and monthly, to ensure the resident's code status and necessary documents were in place for each resident's Advanced Directive information. The immediate jeopardy was removed on [DATE] at 1:05 p.m. after the plan of removal was submitted and accepted. The deficient practice continues at a pattern of potential for more than minimal harm for residents with no advanced directives/LaPost documents, or a NO CPR order upon admission to the facility. Findings: 1. Cross reference to findings at tag F281. 2. Cross reference to findings at tag F309. Review of resident #2's clinical records revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's record reflected he had acknowledged upon admission on [DATE] that he understood that he was not required to have an Advanced Directive in order to receive Medical treatment at the facility. The record signed by the resident and dated [DATE] reflected the resident had not executed an advanced directive. Further review of the physician's orders [REDACTED]. The resident's chart binder did not have a black dot noted on the chart. Review of the facility's policy for NO CPR reflected the ultimate responsibility for making decisions concerning orders not to attempt cardiac resuscitation shall belong to the attending physician. The attending physician must write a specific order not to administer cardiac resuscitation in an event of cardiac standstill. The policy further reflected absence of an order not to attempt cardiac resuscitation shall be interpreted by the nursing staff as requiring such efforts should the resident have a [MEDICAL CONDITION]. Interview with S1 DON on [DATE] at 9:40 a.m. confirmed after review of the in-service records, that not all licensed nursing staff who worked and cared for resident after the [DATE] incident had been in-serviced on the facility's CPR policy, Advance Directives/LaPost and Black Dot system. There were 6 part time LPNs who had not signed the in-service record. However, it was determined one of the 6 LPNs had not started working with resident, and the remaining 5 LPNs failed to sign and follow facility in-service procedures. S1 DON stated on [DATE], the QA team met and discussed the incident. An intervention was to put in place for the week-end RN Supervisor to begin checking each resident's record to check the code status of each resident. However, the QA action was not documented, and there was no written routine monitoring system/plan to ensure the residents' code status was checked. There was also no monitoring to ensure that the systems put in place were completed and staff complied. Interview of S10 Administrator on [DATE] at 12:25 p.m. revealed she was informed about incident, and the S10 Administrator stated "I don't know what to say".

Based on record review and interview the facility failed to ensure that staff provided services that met professional standards of quality according to a licensed nurse's accepted clinical nursing practice standards for 1 (#2) of 62 residents (#2, #4, #6 - #44, and #46 - #66) with no advanced directives and/or a "NO CPR" order in their clinical record. The facility had a total census of 100 residents according to the facility's Resident Census and Conditions of Residents form. The facility failed to: 1. Ensure the LPN staff checked the medical record for code status when a resident (#2) was found unresponsive, with no blood pressure and not breathing; 2. Ensure LPN staff initiated CPR for resident #2 who had no advance directive in his record, and was found unresponsive, and without a pulse, blood pressure and respirations on [DATE] at 5:15 a.m.; 3. Ensure licensed nursing staff followed the facility's CPR policy that reflected "in the absence of an attending physician's specific order not to attempt cardiac resuscitation, it shall be interpreted by the nursing staff as requiring CPR efforts should the resident have a [MEDICAL CONDITION]." The immediate jeopardy began for resident #2 on [DATE] at 5:15 a.m. when he was found in bed, without a pulse and respirations by S2 LPN. S2 LPN was not aware of the resident's code status and did not initiate CPR as according to nurse practice standards. S2 LPN was not aware of the resident's code status and did not follow policy to check the medical record for an advance directive. S2 LPN also failed to follow the facility's CPR policy for a resident without a written advanced directive or specific physician's orders [REDACTED]. S2 LPN called the coroner who released the body at 5:45 a.m. on [DATE]. The immediate jeopardy for resident #2 ended when his death was pronounced by the coroner at 5:45 a.m. on [DATE]. The immediate jeopardy continued for 61 residents who had no advanced directives or No CPR orders on record. A plan of removal was submitted on [DATE] at 1:05 p.m. and read: 1. The facility would complete the in-service education regarding Advance Directives/DNR and LaPOST policy to all licensed nursing staff. 2. The facility would complete the implementation of an adjunct "black dot system" to assist staff in identifying a resident's code status, and prompt staff to check the resident's record for specific directives. 3. Monitoring effectiveness of the in-service education would be achieved by random interviews with staff members to ensure their knowledge of the facility procedures on Advanced Directives and code status of residents, with results discussed weekly in QA meetings. 4. A subsequent staff re-inservice would be conducted on [DATE] regarding Advance Directives and DNR policy. 5. Social Service would be responsible for obtaining Advanced Directives/LaPost documents upon admission of each resident in the facility to ensure the "Black Dot" quick reference system for that resident was put in place. 6. Social Service would be responsible for the LaPost document to be sent for physician signature and a copy would be placed in the resident's medical record. 7. Social Service would keep a copy of the directive in order to track receipt of the original. 8. Each RN supervisor was charged with the responsibility of reviewing each resident's record upon admission and monthly, to ensure the resident's code status and necessary documents were in place for each resident's Advanced Directive information. The immediate jeopardy was removed on [DATE] at 1:05 p.m. after the plan of removal was submitted and accepted. The deficient practice continues at a pattern of potential for more than minimal harm for residents with no advanced directives/LaPost documents, or a NO CPR order upon admission to the facility. Findings: Review of resident #2's clinical records revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's record reflected he had acknowledged upon admission on [DATE] that he understood that he was not required to have an Advanced Directive in order to receive Medical treatment at the facility. The record signed by the resident and dated [DATE] reflected the resident had not executed an advanced directive. Further review of the physician's orders [REDACTED]. The resident's chart binder did not have a black dot noted on the chart. Review of the resident's last Quarterly MDS assessment dated [DATE] reflected the resident had a BIMS score of 15, and was able to make his needs known. Review of the facility's policy for NO CPR reflected the ultimate responsibility for making decisions concerning orders not to attempt cardiac resuscitation shall belong to the attending physician. The attending physician must write a specific order not to administer cardiac resuscitation in an event of cardiac standstill. The policy further reflected absence of an order not to attempt cardiac resuscitation shall be interpreted by the nursing staff as requiring such efforts should the resident have a [MEDICAL CONDITION]. Review of nurses' notes dated [DATE] at 5:15 a.m. revealed S2 LPN entered resident #2's room and noted the resident was not breathing, body still warm, unresponsive, no blood pressure and no heart rate. S2 LPN documented she then called the coroner who came at 5:45 a.m. and pronounced the resident's death. Review of the facility's Online Tracking Incident Report dated [DATE] revealed S4 LPN (who worked the 6:00 a.m. to 2:00 p.m. shift on [DATE], called S1 DON at 6:15 a.m. to inform S1 DON that resident #2 had expired at 5:15 a.m. that morning. The report reflected S2 LPN (who was resident #2's nurse from 10:00 p.m. to 6:00 a.m. on [DATE]) informed S1 DON that S5 CNA had gone in the resident's room at 5:00 a.m. to give him his bath, and called her to the room because the resident was not breathing. The report reflected S2 LPN informed S1 DON that when she assessed the resident, he was not breathing and had no pulse. S2 LPN informed S1 DON that the resident had no problems during the night, and that she had spoken to the resident earlier on the shift and he was fine. Review of the facility's investigation dated [DATE] reflected S1 DON received another follow up call at 7:00 a.m. from S2 LPN who stated that another nurse (later identified as S6 LPN) reviewed resident #2's chart and found no documentation that the resident was a DNR. S2 LPN was then asked by S1 DON if she had checked the resident's chart to see what the resident's code status was, and S2 LPN stated she didn't. Further review of the incident report reflected S1 DON conducted an investigation and the results reflected that S2 LPN failed to check the code status of a resident, and failed to perform CPR on a resident who was found in cardiac/respiratory arrest, as there was no documentation to reflect the resident was a DNR. The report further reflected an immediate facility wide in-service was begun on [DATE] to reinforce to staff what was expected of them in the event a resident was found not breathing and without a pulse. The incident report reflected random interviews with staff about the contents of the inservice and follow up inservice would be done on [DATE]. Review of the in-service records dated [DATE] and [DATE] reflected not all licensed nursing staff employed by the facility had been in-serviced. Review of the facility's [DATE] nurses schedule reflected 5 part-time LPNs identified by the facility (#S16, #S17, #S18, #S19 and #S20) who worked and provided care to facility residents after the incident on [DATE], had not received in-service training. Interview with S7 RN/Social Worker on [DATE] at 12:33 p.m. revealed if a nurse found a resident with no respirations, and no pulse, she would do nothing if the resident had a black dot next to his name on the door plate, or on the outside of the chart. She stated this indicated the resident was a DNR. S7 revealed all but the "A hall" had their charts checked to ensure they had either a LaPost or an Advanced Directive on the chart. S7 revealed she was still in the process of checking all charts to ensure they had some form of Advance Directives on their records, however, she confirmed they had not implemented the system for "A hall" yet. Interview with S6 LPN on [DATE] at 2:00 p.m. revealed she was the Body Assessment Nurse. She stated she was informed that resident #2 had died when she reported for duty the morning of [DATE]. S6 stated around 6:45 a.m. that same morning, she questioned S2 LPN regarding his code status, and if he was a DNR. S6 LPN stated that S2 LPN realized she did not know the resident's code status and did not perform CPR. S6 LPN stated she went to check the chart at the nursing station and did not find documentation that the resident was a DNR. S6 LPN instructed S2 LPN to call S1 DON to report what happened. Interview with S2 LPN on [DATE] at 2:15 p.m. revealed that she worked on [DATE] from 10:00 p.m. to 6:00 a.m. S2 LPN stated on [DATE] at 5:15 a.m., S5 CNA called her to go to the resident's room, and she found the resident with no heartbeat and no blood pressure. S2 stated she failed to check the resident's chart to see if he was a DNR. S2 LPN confirmed she did not perform CPR. S2 LPN stated S1 DON had informed her about the "black dot procedure" but she did not remember it until later. She stated the CNA was in the resident's room, so she had her put a clean gown on the resident. S2 LPN stated she called the Charge nurse (S3 LPN) who came and agreed with her that the resident was dead. S2 LPN revealed S3 LPN did not take vital signs because she (S2) had already taken it and the resident had no vital signs. S2 LPN stated S4 LPN (the nurse scheduled to work 6:00 a.m. to 2:00 p.m. on [DATE]), arrived and helped to call the family, then they called the Coroner. Interview with S1 DON on [DATE] at 2:20 p.m. revealed he went to the facility on [DATE] around 8:30 a.m. to begin the investigation after receiving a call from S2 LPN at 7:15 a.m. informing him of the incident. S1 DON stated he then called S2 LPN at her home around 9:30 a.m. to tell her that her employment was terminated. He further stated S2 LPN had not worked at the facility since. S1 DON revealed he had the S8 ADON start the in-service of staff on CPRs and LaPost the same morning. A subsequent interview with S1 DON at 2:30 p.m. revealed facility staff were in-serviced on the black dot system on [DATE], to include S2 LPN. The S1 DON stated that although it was not in their policy and procedure, it was to be used in conjunction with their policy. Interview with S8 ADON on [DATE] at 2:25 p.m. revealed she began the in-service training at 10:30 a.m. on [DATE] to reinforce the facility's policy on NO CPR and their Black Dot System. S8 ADON stated she in-serviced each shift. Interview with S7 Social Worker on [DATE] at 2:50 p.m. revealed she started working on the facility's black dot system after the inservice on [DATE]. She revealed was responsible for ensuring the residents filled out the advance directives (LaPOST) form, had it signed by the physician and placed in the resident's chart, along with placing a black dot on the chart and a black dot on the nameplate of the resident's door identifying that resident as having an advanced directive. She revealed the black dot system had not been completed for A-Wing; however, she had been working on it and had just completed it. Interview with S3 LPN/Charge nurse on [DATE] at 3:00 p.m. revealed she worked the 10:00 p.m. to 6:00 a.m., shift on [DATE] - [DATE]. S3 LPN stated the ward clerk located her and informed her she was needed in resident #2's room. S3 LPN stated she was in the middle of performing a fingerstick on a resident and securing her medication cart. She stated it took her 5 minutes to get to the resident's room. S3 LPN stated she went in resident #2's room and the resident looked dead. She stated she asked S2 LPN if she had checked the resident out and S2 LPN told her she did, and that she did not need any help. S3 LPN stated she then went back to her work and left S2 LPN to take care of it. She stated she thought the resident was a DNR. S3 LPN further stated she expected S2 LPN who had been employed at the facility longer than herself, to know her residents' code status. Interview with S9 LPN on [DATE] at 3:15 p.m. revealed she was one of the 3 LPNs on duty on the 10:00 p.m. to 6:00 a.m., shift on [DATE] - [DATE]. She stated she was busy working, had no clue that resident #2 had died , and only found out when a CNA had told her. Interview with S1 DON on [DATE] at 9:40 a.m. confirmed after review of the in-service records, that not all licensed nursing staff who worked and cared for residents after the [DATE] incident had been in-serviced on the facility's CPR policy, Advance Directives/LaPost and Black Dot system. There were 6 part time LPNs who had not signed the in-service record. However, it was determined one of the 6 LPNs had not started working with residents, and the remaining 5 LPNs failed to sign and follow facility in-service procedures.