Every finding on record at Legacy Nursing and Rehabilitation of Plaquemine

Based on interviews and record reviews, the facility failed to ensure residents received specialized rehabilitative services as ordered for 1 (Resident #2) of 4 sampled residents reviewed for rehabilitation services. Findings:Review of Resident #2's record revealed, in part, an admission date of 06/22/2026. Further review revealed Resident #2 had diagnoses of, in part, hemiplegia (a complete loss of strength and movement on one side) and hemiparesis (partial weakness, allowing some movement but reduced strength and coordination) following a cerebral infarction (a stroke) which affected the right dominant side, aphasia (a language disorder affecting communication), and dysphagia (difficulty swallowing). Review of Resident #2's hospital discharge instructions for admission to the facility dated 06/22/2026 revealed, in part, for Resident #2 to continue the therapy program. Review of Resident #2's progress notes revealed, in part, Resident #2 had an encounter visit with Resident #2's Family Nurse Practitioner on 06/23/2026. Further review revealed Resident #2 was admitted to the facility for continued physical therapy, occupational therapy, and speech therapy. Review of Resident #2's admission therapy screening dated 06/22/2026 revealed, in part, therapy was not indicated at the time of screening. In an interview on 07/15/2026 at 9:50AM, S3Director of Rehabilitation indicated when a resident was admitted to the facility and needed therapy, nursing staff was to let the therapy department know. S3Director of Rehabilitation further indicated she was not aware Resident #2 had orders for therapy; therefore, S3Director of Rehabilitation marked Resident #2's screening for therapy as not indicated. S3Director of Rehabilitation further indicated Resident #2's daughter had emailed the therapy department that Resident #2 was supposed to receive therapy, but had not. In an interview on 07/15/2026 at 10:00AM, S2Director of Nursing indicated the hospital discharge orders for Resident #2 were reviewed upon admission, and Resident #2's order to continue therapy at the facility was missed. In an interview on 07/15/2026 at 1:00PM, S3Director of Rehab indicated Resident #2 was delayed starting therapy, because S3Director of Rehabilitation was unaware Resident #2 had an order to receive therapy upon admission.

Based on observations, interview, and record review, the facility failed to ensure a resident's call light was within reach for 1 (Resident #2) of 4 sampled residents observed for access to their call light. Findings:Review of Resident #2's care plan initiated 06/23/2026 with a next review date of 09/21/2026, revealed, in part, Resident #2 had a cerebrovascular accident and had right sided hemiplegia with an intervention to place Resident #2's call light within reach. Observation on 07/14/2026 at 2:00PM revealed Resident #2 was lying in bed, and Resident #2's call light was hanging over the light on the wall, out of Resident #2's reach. Observation on 07/15/2026 at 8:50AM revealed Resident #2 was lying in bed, and Resident #2's call light was hanging over the light on the wall, out of Resident #2's reach. Observation on 07/15/2026 at 1:25PM revealed Resident #2 was sitting on his bed, and Resident #2's call light was hanging over the light on the wall, out of Resident #2's reach. In an interview on 07/15/2026 at 3:45PM, S1Administrator indicated Resident #2's call light should have been within Resident #2's reach and was not, as required.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident who was dependent on staff to carry out activities of daily living received assistance to maintain personal hygiene for 1 (Resident #102) of 5 sampled residents investigated for activities of daily living. Findings:Review of the facility's undated Certified Nursing Assistant's Job Description, revealed, in part, the duties and responsibilities of the Certified Nursing Assistant were to provide assistance to residents with activities of daily living and to follow a resident's care plan when providing care. Review of Resident #102's face sheet revealed, in part, Resident #102 had an admission date of 09/06/2022 and diagnoses of traumatic brain injury and quadriplegia (partial to total loss of all limbs). Review of Resident #102's Quarterly Minimum Data Set with an Assessment Reference Date of 11/19/2025 revealed, in part, Resident #102 was not capable of being interviewed, had bilateral impairment to upper and lower extremities, and was dependent on staff for all activities of daily living including personal hygiene. Review of Resident #102's Care Plan with a target date of 03/03/2026 revealed, in part, Resident #102 was totally dependent on staff for all activities of daily living, and Resident #102's activities of daily living needs would be met by staff. Further review revealed Resident #102 required a bed bath and assistance with personal hygiene. During the review of Resident #102's electronic health record revealed there was no documentation to confirm Resident #102 was provided assistance with activities of daily living, including personal hygiene. Observation on 01/27/2026 at 10:31AM revealed Resident #102 was lying on his right side in his bed, and Resident #102's hair appeared oily with small, dried, white flakes throughout the left side of his head. Observation on 01/28/2026 at 10:15AM revealed Resident #102 was lying on his right side in his bed, and Resident #102's hair appeared oily with small, dried, white flakes throughout the left side of his head. Observation on 01/28/2026 at 2:55PM revealed Resident #102 was lying on his right side in his bed, and Resident #102's hair appeared oily with small, dried, white flakes throughout the left side of his head. In an interview on 01/28/2026 at 2:58PM, S5Certified Nursing Assistant indicated the last time she washed Resident #102's hair was on 01/22/2026. S5Certified Nursing Assistant further indicated activities of daily living included hair care, and Resident #102 should not have had small, dried, white flakes throughout the left side of his head. In an interview on 01/28/2025 at 3:01PM, S3Assistant Director of Nursing confirmed Resident #102 had small, dried, white flakes throughout the left side of his head, and should not have. In an interview on 01/28/2026 at 3:25PM, S2Director of Nursing indicated Resident #102 did not have a diagnosis related to skin conditions that would be the cause of Resident #102's hair to have small, dried, white flakes throughout the left side of his head. Observation on 01/28/2026 at 3:30PM, S1Director of Nursing used her hand to rub and scratch Resident #102's hair to his left side of his head. Further observation revealed Resident #102 had small, dried, white flakes throughout the left side of his head. In an interview on 01/28/2026 at 3:31PM, S1Director of Nursing confirmed Resident #102 had small, dried, white flakes throughout the left side of his head, and should not have.

Based on observation, interviews, and record reviews, the facility failed to provide privacy for a resident during incontinence care for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents observed during incontinence care. Findings: Review of the facility's undated Resident Rights and Quality of Life policy and procedure revealed, in part, a resident had the right to be treated with consideration, respect, and full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 03/18/2025 revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 06, which indicated Resident #1 had severe cognitive impairment. Further review revealed Resident #1 was dependent on staff assistance for toileting hygiene. Observation of Resident #1's incontinence care on 05/27/2025 at 1:45PM revealed S3CNA did not pull the privacy curtain between Resident #1 and her roommate before providing incontinence care, allowing Resident #1's roommate to observe Resident #1 exposed genitalia during incontinence care. In an interview on 05/27/2025 at 1:58PM, S3CNA indicated she did not pull Resident #1's privacy curtain to ensure Resident #1's privacy during incontinence care and should have. In an interview on 05/28/2025 at 1:15PM, S2Director of Nursing indicated S3CNA should have pulled the privacy curtain prior to providing incontinence care to Resident #1. In an interview on 05/29/2025 at 12:10PM, S1Administrator indicated S3CNA should have pulled the privacy curtain between Resident #1 and her roommate before providing incontinence care.

Based on observation, interviews, and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) completed hand hygiene during incontinence care for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents observed for incontinence care. Findings: Review of the facility's undated Incontinence Care Policy and Procedure revealed, in part, the purpose of the policy and procedure was to prevent infection. Further review revealed for staff to remove gloves prior to replacing incontinence pads or applying an adult diaper. Observation of Resident #1's incontinence care on 05/27/2025 at 1:45PM revealed the following: 1. S3CNA did not sanitize her hands and apply clean gloves after cleaning Resident #1's perineal area with disposable wipes and removing Resident #1's soiled brief; and, 2. S3CNA placed the package of disposable wipes on Resident #1's bed and used her soiled gloves to obtain more wipes from the package multiple times while providing incontinence care to Resident #1. In an interview on 05/27/2025 at 1:58PM, S3CNA indicated she should have removed the soiled gloves, sanitized her hands and put on clean gloves before putting a clean brief on Resident #1. S3CNA further indicated she should have not obtained personal wipes from a multi-use package with soiled gloves while providing incontinence care to Resident #1. In an interview on 05/29/2025 at 10:30AM, S2Director of Nursing (DON) stated S3CNA should have not obtained personal wipes from a multi-use package with soiled gloves, and S3CNA should have completed hand hygiene and changed her soiled gloves before applying a clean brief after providing incontinence care to Resident #1. In an interview on 05/29/2025 at 12:10PM, S1Administrator indicated S3CNA should have not obtained personal wipes from a multi-use package with soiled gloves, and S3CNA should have completed hand hygiene and changed her soiled gloves before applying a clean brief after providing incontinence care to Resident #1.

Based on observations, interviews, and record review, the facility failed to ensure: 1. Staff had all hair restrained when in the food preparation areas (S8Dietary Helper and S9Dietary Helper); 2. Food items were labeled with an open date and/or labeled with the contents of the container/bag; 3. Prepared food items was covered and refrigerated until time to serve; 4. Staff did not store their personal food items with residents' food items; and, 5. Expired foods were not available for use. This deficient practice was identified for the facility kitchen observed during the kitchen task. Findings: Review of the facility's undated policy titled, Dietary Cook, revealed, in part: Dietary staff were to ensure the kitchen was maintained as required by state and federal governing agencies' regulations and standards; food items were to be immediately labeled and stored after opening; and all staff entering the kitchen were to wear hairnets according to regulations and facility dress code. Observation on [DATE] at 8:49AM revealed, in part, S8Dietary Helper and S9Dietary Helper hair was not fully contained in a hairnet. Further observation revealed uncovered individual cups of vanilla pudding were sitting on the preparation table. Observation on [DATE] at 8:55AM of the facility's refrigerator revealed, in part, an unlabeled and undated 1.5 gallon zip lock bag three fourth full of cooked cubed chicken; an 8 ounce Styrofoam cup containing a pudding like substance with no label and undated; one-half cream cheese Danish which had no label and was undated; and a 1.5 gallon unlabeled zip lock bag of chopped cabbage dated [DATE], which had a grayish black unknown substance on the cabbage. Observation on [DATE] at 9:00AM of the facility's freezer revealed, in part, an undated 16 ounce half full bag frozen fries, and an unlabeled and undated opened package of [NAME] which had 4 [NAME] remaining in the package. In an interview on [DATE] at 9:05AM, S8Dietary Helper indicated the opened cream cheese Danish in the facility's refrigerator was her personal food item and should have not been stored in the facility's food storage refrigerator. In an interview on [DATE] at 9:10AM, S7Dietary Manager indicated hairnets should be worn by all kitchen staff and all hair should be fully contained in the hairnet, the individual pudding cups should have been covered and stored in the refrigerator, the above listed items with no labels or dates should have been labeled and dated when opened, and the cabbage should have been discarded [DATE] and should have not been available for use. S7Diretary Manager further indicated staff should not store their personal food in the facility's food storage refrigerator.

Based on observations and interviews the facility failed to ensure a resident's call bell was within reach and available for use for 2 (Resident #2, Resident #95) of 2 (Resident #2, Resident #95) sampled residents investigated for call bells being within reach. Findings: Resident #2 In an interview on 01/27/2025 at 12:36PM, Resident #2 indicated he could not reach his call bell. Observation on 01/28/2025 at 9:50AM revealed Resident #2's call bell was tangled and located under Resident's #2's bed. Observation on 01/28/2025 at 1:22PM revealed, in part, Resident #2 was sitting in his room in a wheelchair next to the television. Further observation revealed Resident #2's call bell was tangled and located under Resident #2's bed. In an interview on 01/28/2025 at 1:22PM Resident #2 indicated he could not reach the call bell because it was under the bed. In an interview on 01/28/2025 at 1:25PM, S10Licensed Practical Nurse (S10LPN) indicated Resident #2 was capable of using a call bell and confirmed Resident #2's call bell was not in reach. Resident #95 Observation on 01/27/2025 at 9:50AM revealed, in part, Resident #95 was lying in bed. Resident #95's call bell was located on top of a dorm size refrigerator which was placed on a nightstand, and Resident #95 was unable to reach the call bell. Observation on 01/27/2025 at 10:10AM revealed, in part, Resident #95 was lying in bed. Resident #95's call bell was located on top of a dorm size refrigerator which was placed on a nightstand, and Resident #95 was not able to reach the call bell. Observation on 01/27/2025 at 1:15PM revealed, in part, Resident #95 was lying in bed. Resident #95's call bell was located on top of a dorm size refrigerator which was placed on a nightstand, and, Resident #95 was not able to reach the call bell. Observation on 01/28/2025 at 9:45AM revealed, in part, Resident #95 was lying in bed. Resident #95's call bell was located on top of a dorm size refrigerator which was placed on a nightstand, and Resident #95 was not able to reach the call bell. In an interview on 01/28/2025 at 9:45AM, Resident #95 indicated he wanted ice water but was not able to call the staff because Resident #95's call bell was not within reach. Observation on 01/28/2025 at 1:20PM revealed, in part, Resident #95 was lying in bed. Resident #95's call bell was located on top of a dorm size refrigerator which was placed on a nightstand, and Resident #95 was not able to reach the call bell. In an interview on 01/28/2025 at 1:20PM S10Licensed Practical Nurse (LPN) indicated Resident #95 was capable of using the call bell. S10LPN confirmed Resident #95's call bell was not within reach and should have been. In an interview on 01/28/2025 at 1:30PM, S1Administrator indicated call bells should be within reach for residents to use.

Based on observations, interviews, and record review the facility failed to maintain a resident's right to privacy while performing care for 1 (Resident #17) of 22 (Resident #14, Resident #15, Resident #17, Resident #23, Resident #32, Resident #35, Resident #36, Resident #42, Resident #48, Resident #51, Resident #52, Resident #55, Resident #64, Resident #73, Resident #76, Resident #82, Resident #84, Resident #89, Resident #93, Resident #105, Resident #106, Resident #357) sampled residents. Findings: Review of Resident #17's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/03/2024 revealed the following, in part, Resident #17 had a Brief Interview Mental Status score of 01 which indicated severe cognitive impairment. Further review revealed Resident #17 was dependent on staff for incontinence care, showering/bathing, upper body dressing, and lower body dressing. Observation on 01/28/2025 at 10:46AM revealed S14Certified Nursing Assistant (CNA) and S15CNA provided Resident #17 with a bed bath. Observation further revealed the privacy curtain to the room was not pulled and the blinds to the window, which faces a parking lot, was pulled halfway up, which exposed Resident #17's nude body to the outside. Observation on 01/28/2025 at 10:58AM revealed S14CNA and S15CNA changed Resident #17's bedsheets while he was in bed and his body nude. Observation further revealed the privacy curtain to the room was not pulled and the blinds to the window, which faces a parking lot, was pulled halfway up, which exposed Resident #17's nude body to the outside. In an interview on 01/28/2025 at 11:10AM, S6CNA Supervisor indicated the privacy curtain should have been pulled and the blinds pulled down to provide Resident #17 privacy during his bed bath. In an interview on 01/28/2025 at 11:24AM, S13Assistant Director of Nursing confirmed Resident #17's privacy should have been maintained during care. In an interview on 01/28/2025 at 11:50AM, S2Director of Nursing further indicated privacy should have been provided for Resident #17 during care.

Based on observations, interviews, and record reviews, the facility failed to ensure care plan interventions were implemented to decrease risk of falls for 1 (Resident #84) of 3 (Resident #36, Resident #84, Resident #93) sampled residents investigated for falls. Findings: Review of Resident #84's current care plan revealed, in part, a care plan was initiated for Resident #84 being at risk for falls related to having an unsteady gait due to hemiplegia. Further review revealed an intervention start date of 10/19/2024 which included, in part, for staff to apply a self-release lap tray while up in his wheelchair. Observation on 1/27/2025 at 9:30AM revealed, in part, Resident #84 sitting up in his wheelchair without a self-release lap tray. Observation on 01/27/2025 at 10:10AM revealed, in part, Resident #84 up in his wheelchair by the nurse's station without a self-release lap tray on his wheelchair. Observation on 01/28/2025 at 9:27AM revealed, in part, Resident #84 was sitting up in his wheelchair with no self-release lap tray. Observation on 01/28/2025 at 11:45AM revealed Resident #84 was sitting up in his wheelchair in the dining room without a self-release lap tray on his wheelchair. In an interview on 01/28/2025 at 11:48AM, S10Licensed Practical Nurse (LPN) indicated Resident #84 should have a self-release lap tray on while up in his wheelchair. In an interview on 01/28/2025 at 11:50AM, S13Assistant Director of Nursing (ADON) indicated Resident #84 was supposed to have a self-release lap tray while up in his wheelchair.

Based on observations, interviews, and record reviews the facility failed to ensure staff positioned a resident's urinary catheter bag below the level of the bladder for or 1 (Resident #64) of 4 (Resident #15, Resident #17, Resident #35, Resident #64) sampled residents investigated for urinary catheter and/or UTI. Findings: Review of the Centers for Disease Control's (CDC) Guideline for Prevention of Catheter-Associated Urinary Tract Infections, dated 2009 and revised on 06/06/2019, revealed, in part, to maintain unobstructed urine flow, the urine collection bag should be kept below the level of the bladder at all times. Review of Resident #64's clinical record revealed Resident #64 had a suprapubic catheter related to neuromuscular dysfunction of the bladder (a condition where the bladder does not empty properly). Review of Resident #64's care plan revealed, in part, Resident #64 had a suprapubic catheter and staff were to ensure the catheter bag was positioned below the bladder. Review of Resident #64's infection reports revealed, in part, Resident #64 was diagnosed with a UTI on 07/08/2024, 08/22/2024, and 12/31/2024. Further review revealed Resident #64 was diagnosed with cystitis (inflammation of the bladder) on 09/24/2024 and 11/13/2024. Observation on 01/28/2025 at 10:09AM revealed Resident #64 was lying flat in bed and Resident #64's catheter bag was positioned in her bed near her feet and not below the level of her bladder. Observation on 01/29/2025 at 9:38AM revealed Resident #64 was lying flat in bed and S5Certified Nursing Assistant (CNA) initiated catheter care for Resident #64. Further observation revealed S5CNA placed Resident #64's catheter bag in her bed and not below the level of her bladder. Further observation revealed the catheter bag remained in Resident #64's bed until catheter care was completed at 9:50AM. In an interview on 01/29/2025 at 9:55AM, S5CNA indicated Resident's #64's catheter bag should have been positioned below her bladder when she provided catheter care. In an interview on 01/29/2025 at 11:20AM, S4Licensed Practical Nurse (LPN) indicated Resident #64 had a history of UTI's. S4LPN further indicated Resident #64's catheter bag should have been maintained below the level of the bladder and should not have been placed in the bed with Resident #64. In an interview on 01/29/2025 at 3:59PM, S3Assistant Director of Nursing (ADON)/Infection Preventionist indicated Resident #64 was treated for UTI's and/or cystitis on 07/08/2024, 08/22/2024, 09/24/2024, 11/13/2024, and 12/31/2024. S3ADON/Infection Preventionist further indicated Resident #64's catheter bag should have been kept below the level of her bladder.

Based on observations, interview, and record review, the facility failed to follow their policy and procedure for maintaining respiratory care equipment for 1 (Resident #23) of 3 (Resident #23, Resident #36, Resident #51) sampled residents investigated for respiratory care. Findings: Review of the facility's undated Nebulizer Continuous positive airway pressure (CPAP) Machine Cleaning Policy and Procedure revealed, in part, store respiratory tubing, mouthpiece, and mask in a plastic bag when not in use. Observation on 01/27/2025 at 10:37AM revealed Resident #23's nasal cannula, nebulizer mask, and oxygen tubing was uncontained and lying on the floor. Observation on 1/28/2025 at 3:30PM revealed Resident #23's nebulizer mask was uncontained and lying on Resident #23's chest. Observation on 01/29/2025 at 10:00AM revealed Resident #23's nebulizer mask was uncontained and lying on the bedside table. In an interview on 01/29/25 at 10:09AM, S2Director of Nursing (DON) indicated Resident #23's nebulizer mask was uncontained and lying on his bedside table. She further indicated Resident #23's nebulizer mask should have been contained in a clean labeled plastic bag and was not

Based on observations and interviews, the facility failed to ensure resident rooms and equipment were cleanded and maintained in a sanitary manner for 2 (Resident #32, Resident #37) of 6 (Resident #2, Resident #14, Resident #32, Resident #37, Resident #55, Resident #95) sampled residents investigated for environment. Findings: Resident #32 Observation on 01/28/2025 at 10:08AM revealed a dried light brown unknown substance was present on Resident #32's enteral feeding (a method of providing nutrition through a tube inserted directly into the stomach) pump pole, and on Resident #32's floor. Observation on 01/28/2025 at 3:45PM revealed a dried light brown unknown substance was present on Resident #32's enteral feeding pump pole, and on Resident #32's floor. In an interview on 01/28/2025 at 3:45PM, S1Administrator confirmed there was a dried light brown unknown substance present on Resident #32's enteral feeding pump pole and on Resident #32's floor and it should have been cleaned by the staff. Resident #37 Observation on 01/27/2025 at 11:31AM revealed a dried light brown unknown substance was present on Resident #37's enteral feeding pump, enteral feeding pump pole, and on Resident #37's floor. Observation on 01/28/2025 at 10:06AM revealed a dried light brown unknown substance was present on Resident #37's enteral feeding pump, enteral feeding pump pole, and on Resident #37's floor. Observation on 01/28/2025 at 3:42PM revealed a dried light brown unknown substance was present on Resident #37's enteral feeding pump, enteral feeding pump pole, and on Resident #37's floor. In an interview on 01/28/2025 at 3:46PM, S1Administrator indicated Resident #37's enteral tube feeding pump, enteral feeding pump pole, and floor had large areas of dried tube feeding formula. S1Administrator stated, that is terrible, just terrible. S1Administrator indicated Resident #32 and Resident 37's enteral feeding equipment and floor should have been cleaned by staff, and had not been.

Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS) was completed accurately for 2 (Resident #42, Resident #51) of 22 (Resident #14, Resident #15, Resident #17, Resident #23, Resident #32, Resident #35, Resident #36, Resident #42, Resident #48, Resident #51, Resident #52, Resident #55, Resident #64, Resident #73, Resident #76, Resident #82, Resident #84, Resident #89, Resident #93, Resident #105, Resident #106, Resident #357) sampled residents reviewed for resident assessments. Findings: Resident #42 Review of Resident #42's record revealed, in part, Resident #42 was admitted to the facility on [DATE] with diagnoses, in part, of a right above the knee amputation (AKA) and a left AKA. Review of Resident #42's Quarterly MDS with an Assessment Reference Date (ARD) of 12/18/2024 revealed, in part, Section GG: Functional Abilities and Goals, he was dependent on staff for putting on or taking off footwear. Review of Resident #42's Quarterly MDS with an ARD of 09/25/2024 revealed, in part, Section GG: Functional Abilities and Goals, he was dependent on staff for putting on or taking off footwear. In an interview on 01/29/2025 at 2:54 PM, S11Director of Rehabilitation (DOR)/Physical Therapy Assistant (PTA) indicated she was responsible for completing Section GG of the MDS for residents. S11DOR/PTA indicated Resident #42 cannot put on or take off footwear due to him being a bilateral amputee. In an interview on 01/29/2025 at 3:38PM, S12MDS Nurse indicated Resident #42 could not be assessed for putting on or taking off footwear due to him being a bilateral amputee and him not having any feet. S12MDS Nurse further indicated Resident #42's MDS assessment dated [DATE] was incorrect. In an interview on 01/29/2025 at 3:48PM, S2Director of Nursing further indicated Resident #42's Section GG for his MDS was not completed accurately. Resident #51 Review of Resident #51's record revealed, in part, an admitted [DATE] with diagnoses which included Schizophrenia, Bipolar Disorder, and Post Traumatic Stress Disorder (serious mental illnesses that required medications). Review of a significant change Minimal Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 10/22/2024 revealed, in part, Section A1500 Preadmission Screening question which inquired if Resident #51 had a serious mental illness was answered as no. In an interview on 01/28/2025 at 2:30 PM, S16MDS nurse indicated the above mentioned MDS question was not marked correctly. 45877

Based on facility records reviewed and interviews, it was determined that the facility failed to ensure a licensed nurse was designated as a charge nurse for each shift. Findings: Review of the facility's Nursing Daily Work Schedules from 12/02/2024 through 12/11/2024 revealed there was not a designated charge nurse for the 6:00 AM to 6:00 PM shift and the 6:00 PM to 6:00 AM shift. Review of the facility's November 2024 and December 2024 Nurse Schedules revealed there was not a designated charge nurse for each shift. In an interview on 12/11/2024 at 4:00 AM, S4Licensed Practical Nurse (LPN) indicated there was not a designated charge nurse on the night shift in the facility. In an interview on 12/11/2024 at 4:30 AM, S9LPN indicated there was no designated charge nurse on the night shift in the facility. In an interview on 12/11/2024 at 4:45 AM, S6LPN indicated there was no designated charge nurse on her current shift in the facility. In an interview on 12/11/2024 at 1:37 PM, S2Director of Nursing (DON) indicated she did not designate a charge nurse on the nursing schedule for each shift. S2DON further indicated she should have designated a charge nurse for each shift according to nurse staff regulations. In an interview on 12/11/2024 at 1:45 PM, S1Administrator indicated there was no documented evidence and she could not provide documented evidence a licensed nurse was designated as the charge nurse for each shift.

Based on interviews and record review it was determined that the facility failed to communicate appropriate resident information to a receiving facility for 1 (Resident #1) of 1 (Resident #1) sampled residents reviewed for transfer requirements. Findings: Review of the facility's document titled Checklist for 6P-6A Shift revealed, in part, th nurse was supposed to call report to the hospital Resident #1 was being transferred to. Review of Resident #1's record revealed, in part, Resident #1 was discharged to the emergency department on 11/16/2024. Review of Resident #1's record revealed no documented evidence and the facility did not provide documented evidence that the receiving facility was provided with all Resident #1's required information for the 11/16/2024 transfer. In an interview on 12/10/2024 at 4:44 PM, S3License Practical Nurse (LPN) indicated she was assigned to work Resident #1's hall on 11/15/2024 for the 6:00 PM to 6:00 AM shift. S3LPN further indicated at 12:00 AM on 11/16/2024, Resident #1 was transferred to the emergency department. S3LPN further indicated she did not call report to the receiving facility and she should have. In an interview on 12/11/2024 at 1:37 PM, S2Director of Nursing (DON) indicated S3LPN should have called report to the receiving facility when Resident #1 was sent to the emergency department on 11/16/2024. In an interview on 12/11/2024 at 12:30 PM, S1Administrator indicated there was no documented evidence and she could not provide documented evidence that a thorough report was given to the receiving emergency department when Resident #1 was transferred on 11/16/2024 and should have been.

Based on interviews and record reviews, the facility failed to test a resident with signs and symptoms of COVID-19 in a timely manner for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for infection control. Findings: Review of the facility's undated policy titled, COVID-19 testing Policy and Procedure, revealed, in part, any resident who had signs or symptoms of COVID-19 should be tested as soon as possible. Review of Resident #2's August 2024's physician's orders revealed, in part, an order dated 07/26/2022 for a rapid antigen (a marker that tells the immune system whether something in a body is harmful or not) test (a test that can quickly detect the presence or absence of an antigen) to be performed if resident displayed signs and symptoms of COVID-19. Review of Resident #2's nursing note dated 08/22/2024 at 11:20 a.m. reveled, in part, a late entry of Resident #2 requested his temperature be taken. Further review revealed Resident #2's temperature was 101.2, Resident #2 was given Tylenol ( a medication used to treat fever), and Resident #2's temperature was rechecked at 3:00 a.m. Further review revealed Resident #2 indicted he felt just like he did when he had COVID-19 ,and he would like to be tested . Review of Resident #2's nursing note dated 08/23/2024 at 2:16 p.m. reveled, in part, Resident #2 tested positive for COVID-19 on 08/23/2024. In an interview on 09/23/2024 at 12:04 p.m., Resident #2 indicated about a month ago, he remembered feeling like he had a fever and was lethargic, similar to how he felt when he had COVID-19 in the past. Resident #2 further indicated that the staff did not test him until more than a day later. In a telephone interview on 09/23/2024 at 2:22 p.m., S2Licensed Practical Nurse (LPN) indicated when Resident #1 had a fever, she gave him Tylenol and wrote a nurse's note so the staff would know to test him the next day.

Based on record review and interview the facility failed to ensure a resident remained free from resident to resident physical abuse when the facility failed to increase supervision when residents displayed an increase in behaviors for 2 (Resident #4 and Resident #5) of 4 (Resident #1, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for abuse. This deficient practice resulted in actual harm on 03/30/2024 at 8:20 a.m. when Resident #4 attacked Resident #5 with a belt and Resident #5 sustained scratches to the right side of his neck and his right thumb which required daily wound care. Resident #4 and Resident #5 were both identified by staff to have had increased behaviors of agitation prior to the altercation with no increase in supervision. Findings: Review of the facility's policy and procedure titled Abuse Prevention and Prohibition with a review date of 03/01/2024 revealed, in part, each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including but not limited to other residents. Further review revealed physical abuse may include an aggressive act, including inappropriate physical contact that is harmful or likely to cause injury or harm to a resident, and included examples of physical abuse included, in part, hitting, slapping, pinching, biting, shoving, and kicking. Resident #4 Review of Resident #4's record revealed he was admitted to the facility on [DATE] with diagnoses, in part, delusional disorder, anxiety disorder, and paranoid personality disorder. Review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 03/13/2024 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 (a score of 13-15 indicated the resident was cognitively intact). Further review revealed Resident #4 had diagnoses, in part, non-traumatic brain dysfunction, and paranoid schizophrenia. Review of Resident #4's undated Care Plan revealed Resident #4 had potential to be verbally aggressive due to mental and emotional illness of schizophrenia, delusional/paranoid personality disorder with approaches, in part, when Resident #4 becomes agitated, intervene before agitation escalates, and guide away from source of distress. Review of Resident #4's Nursing Note dated 08/15/2023 revealed Resident #4 was very delusional, and voiced his roommate (Resident #5) was trying to kill him and Resident #5 had a knife. Further review revealed Resident #5 was placed on a physician emergency certificate for psychiatric treatment. Review of Resident #4's Nursing Notes dated 03/26/2024 at 4:03 p.m. revealed Resident #4 was pacing up and down the hall yelling he would call the Central Intelligence Agency (CIA) and Federal Bureau of Investigations (FBI). Review of Resident #4's Nursing Note dated 03/30/2024 at 8:20 a.m. revealed Resident #4 was walking around the hall with a belt and a lock in his hand stating his roommate attacked him. Further review revealed Resident #4's roommate, Resident #5, voiced they were fighting. Review of Resident #4's Nursing Note dated 03/30/2024 at 12:43 p.m., revealed S3Licensed Practical Nurse (LPN) was summoned to Resident #4's room and Resident #4 voiced Resident #5 had tried to break his neck and put Fentanyl (narcotic medication) in his coffee. Further review revealed, per staff, Resident #4 had been in a manic phase for the last couple of days. Review of the facility's Investigation of Incident dated 03/30/2024 revealed S1Administrator received a call regarding an altercation between Resident #4 and Resident #5. S9Registered Nurse (RN)/Weekend Supervisor indicated it was reported to her that Resident #5 went into his room to use the bathroom and Resident #4 started yelling at him to get out of his room. Review revealed Resident #4 took his belt off, Resident #5 then grabbed Resident #4's arm and then wrestled Resident #4 to the bed. Further review of the Investigation of Incident revealed a predisposing situation factor was Resident #4 disliked the roommate. In an interview on 04/03/2024 at 2:19 p.m., S10Certified Nursing Assistant (CNA) indicated last week Resident #4 was more active, and he was repeatedly saying he was going to call the FBI, and when Resident #4 was pacing and was talking about calling the FBI we knew his mental status was worsening. In an interview on 04/03/2024 at 2:26 p.m., S11CNA indicated last week Resident #4 was having issues with his behaviors. Resident #4 was observed by staff to be walking around with a belt in his hand. S11CNA further indicated Resident #4 did not usually walk around with a belt in his hand, and appeared to be talking in codes. In an interview on 04/03/2024 at 2:34 p.m., S12CNA Supervisor indicated on 03/30/2024 Resident #4 had been pacing back and forth and was not easily redirected. S12CNA Supervisor indicated Resident #4 had appeared agitated during the day while walking around with the belt buckle in his hand. S12CNA Supervisor indicated with the change in Resident #4's behavior the staff was not informed to increase supervision or do anything differently other than redirect him. In an interview on 04/03/2024 at 2:53 p.m., S3Licensed Practical Nurse (LPN) indicated around 04/26/2024 Resident #4 was pacing and acting differently than usual. S3LPN indicated on Saturday, 03/30/2024, Resident #4 was yelling and then stated someone tried to break his neck. S3LPN indicated Resident #5 had stated he was going into their room and this was when he was attacked by Resident #4. S3LPN indicated she observed Resident #5 had scratches to his hand and neck. S3LPN indicated about 7 months ago she suggested to the previous Director of Nursing (DON) to separate Residents #4 and #5 related to another incident, however, there were no interventions such as increased supervision to prevent another occurrence. In an interview on 04/04/2024 at 11:28 a.m., S2DON indicated staff had notified her of an increase in Resident #4's behaviors the week of 04/25/2024. S2DON indicated Resident #4 was observed pacing with increased agitation and redirected. S2DON indicated the facility had not increased supervision until after the incident because to her knowledge Resident #4 had never had issues with other residents. S2DON indicated she was not aware of the incident that happened in August 2023. In an interview on 04/04/2024 at 12:39 p.m., S1Administrator indicated she was not made aware Resident #4 had an increase in behaviors and was pacing more frequently. S1Administrator indicated she was not aware of the issues Resident #4 and Resident #5 had in August 2023 and Resident #4 and Resident #5 should not have been roommates after August 2023. S1Administrator indicated the staff who witnessed Resident #4 pacing with the belt in his hands should have notified the supervisor to ensure something was done to monitor him. In an interview on 04/04/2024 at 2:23 p.m., Resident #4's psychiatric counselor indicated he was not aware of Resident #4's delusions in August 2023 of Resident #5 trying to harm him. Resident #4's psychiatric counselor further indicated if he would have been notified of these issues, he would have recommended that Resident #4 and #5 be separated to prevent Resident #4 being triggered by Resident #5. Resident #5 Review of Resident #5's record revealed he was admitted on [DATE] with diagnoses, in part, bipolar disorder, major depressive disorder, and paranoid personality disorder. Review of Resident #5's MDS with an ARD dated 02/14/2024 revealed Resident #5 had a BIMS of 15 which indicated Resident #5 was cognitively intact. Review of Resident #5's Care Plan revealed problem of, in part, Resident #5 display of aggressive behavior with a target date of 05/14/2024. Further review revealed a revision on 03/27/2024 related to Resident #5 observed on the patio yelling and making racial slurs to staff and others. Following this incident, the care plan was revised to include staff education on de-escalation techniques with documentation of Resident #5's behavior. Review of Resident #5's March 2024 and April 2024 Physician's Orders revealed, in part, cleanse the scratch to the right side of Resident #5's neck with wound cleanser, pat dry and apply topical antibiotic ointment every shift with start date of 03/30/2024; and cleanse the scratch to Resident #5's right thumb with wound cleanser, pat dry, apply topical antibiotic ointment and cover with a dry dressing with a start date of 03/30/2024. Review of Resident #5's March 2024 Medication Administration Record (MAR) revealed on 03/29/2024 Resident #5 had a 17 coded for behaviors which indicated aggression to residents. Review of Resident #5's Nurses Notes dated 03/23/2024 at 2:30 p.m. revealed Resident #5 was down hallway yelling he was going to knock a resident in the head, but was redirected. Review of Resident #5's Nurse's Notes dated 03/27/2024 at 4:00 p.m. revealed the nurse was called to the patio due to Resident #5 making racial slurs. In an interview on 04/02/2024 at 2:28 p.m., Resident #5 indicated on 03/30/2024 Resident #4 was really mad about something. Resident #5 indicated he was going to the restroom and all he could understand Resident #4 say was he, Resident #4, was going to whoop my a** and then he got on the bed and took off his belt and wrapped it around his hand. Resident #5 indicated Resident #4 jumped off the bed at him, and when Resident #4 swung his arm back like he was winding up to hit Resident #5, Resident #5 grabbed Resident #4's hand, and then we fell on the bed and wrestled for approximately 20 seconds. Resident #5 indicated the thing that worried him the most was he had no idea what set Resident #4 off that morning. Resident #5 indicated Resident #4 had been acting off for a while and another resident in the hall had even warned him not to go into the room. Resident #5 indicated he left the room after the fight and notified the nurse. Observation on 04/02/2024 at 2:28 p.m. revealed a brown linear scab like tissue to Resident #5's right thumb base. In an interview on 04/03/2024 at 2:53 p.m., S3LPN indicated even though no one saw the fight between Resident #4 and Resident #5, she had assessed Resident #5 to have a scratch to his neck and on his right hand. In an interview on 04/04/2024 at 1:21 p.m., S2DON indicated she was not aware of either issue on 03/23/2024 or 03/27/2024, and she would have implemented something new to his care due to his behaviors. In an interview on 04/04/2024 at 12:39 p.m., S1Administrator indicated she was not made aware of any behaviors for Resident #5 and therefore did not increase supervision for Resident #5.

Based on record review and interview the facility failed to ensure an allegation of resident to resident abuse was reported to the State Survey Agency within 5 working days for 2 (Resident #4 and Resident #5) of 4 (Resident #1, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for abuse and neglect. Findings: Resident #4 Review of Resident #4's record revealed he was admitted to the facility on [DATE] with diagnoses, in part, delusional disorder, anxiety disorder, and paranoid personality disorder. Review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 03/13/2024 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 (a score of 13-15 indicated the resident was cognitively intact). Further review revealed Resident #4 had diagnoses of, in part, non-traumatic brain dysfunction, and paranoid schizophrenia. Review of Resident #4's undated Care Plan revealed Resident #4 had potential to be verbally aggressive due to mental and emotional illness of schizophrenia, delusional/paranoid personality disorder with approaches, in part, when Resident #4 becomes agitated, intervene before agitation escalates, and guide away from source of distress. Review of Resident #4's Nursing Note dated 03/30/2024 at 8:20 a.m. revealed Resident #4 was walking around the hall with a belt and a lock in his hand stating his roommate attacked him. Further review revealed Resident #4's roommate, Resident #5, voiced they were fighting. Review of Resident #4's Nursing Note dated 03/30/2024 at 12:43pm revealed the nurse was summoned to Resident #4's room and Resident #4 voiced Resident #5 had tried to break his neck and put fentanyl in his coffee. Review of the facility's Investigation of Incident dated 03/30/2024 revealed S1Administrator received a call regarding a possible altercation between Resident #4 and Resident #5. S9Registered Nurse (RN)/Weekend Supervisor indicated it was reported to her that Resident #5 went into his room to use the restroom and Resident #4 started yelling at him to get out of his room. Review revealed Resident #4 took his belt off, Resident #5 then grabbed Resident #4's arm and then wrestled Resident #4 to the bed. Resident #5 Review of Resident #5's record revealed he was admitted on [DATE] with diagnoses of, in part, bipolar disorder, major depressive disorder, and paranoid personality disorder. Review of Resident #5's MDS with an ARD dated 02/14/2024 revealed Resident #5 had a BIMS of 15. Review of Resident #5's Care Plan revealed problem of, in part, Resident #5 displayed aggressive behavior with revision on 03/27/2024 of Resident #5 was on the patio yelling and making racial slurs to staff and others with a target date of 05/14/2024. Further review revealed approaches of, in part, staff educated on de-escalation techniques, resident's behavior was to be documented. Review of Resident #5's March 2024 and April 2024 Physician Orders revealed, in part, cleanse the scratch to the right side of Resident #5's neck with wound cleanser, pat dry and apply topical antibiotic ointment every shift with start date of 03/30/2024; and cleanse the scratch to Resident #5's right thumb with wound cleanser, pat dry, apply topical antibiotic ointment and cover with a dry dressing with a start date of 03/30/2024. In an interview on 04/02/2024 at 2:28 p.m., Resident #5 indicated on 03/30/2024 Resident #4 was really mad about something. Resident #5 indicated he was going to the restroom and all he could understand Resident #4 say was he, Resident #4, was going to whoop my a** and then he got on the bed and took off his belt and wrapped it around his hand. Resident #5 indicated Resident #4 jumped off the bed at him, and when Resident #4 swung his arm back like he was winding up to hit Resident #5, Resident #5 grabbed Resident #4's hand, and then we fell on the bed and wrestled for approximately 20 seconds. Resident #5 indicated the thing that worries him the most was he had no idea what set Resident #4 off that morning. Resident #5 indicated Resident #4 had been acting up for a while and another resident in the hall had even warned him not to go into the room. Resident #5 indicated he left the room after the fight and notified the nurse. Observation on 04/02/2024 at 2:28 p.m. revealed a brown linear scab like tissue to Resident #5's right thumb base. In an interview on 04/03/2024 at 2:53 p.m., S3LPN indicated even thought the incident between Resident #4 and Resident #5 was unwitnessed, she had assessed Resident #5 to have a scratch to his neck and on his hand. In an interview on 04/04/2024 at 12:39 p.m., S1Administrator indicated the incident was not reported to the state agency and she should have notified the state agency of Resident #4 and Resident #5's physical altercation.

Based on record review and interview the facility failed to ensure a resident had a crisis intervention plan developed per the resident's pre-admission screening and resident review (PASRR) for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for care and services. Findings: Review of Resident #4's record revealed he was admitted to the facility on [DATE] with diagnoses, in part, delusional disorder, anxiety disorder, and paranoid personality disorder. Review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 03/13/2024 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 (a score of 13-15 indicated the resident was cognitively intact). Further review revealed Resident #4 had diagnoses, in part, non-traumatic brain dysfunction, and paranoid schizophrenia. Review of Resident #4's Office of Behavioral Health PASRR Level II Evaluation Summary and Determination Notice for period of 03/08/2023 through 03/06/2024 revealed the nursing home was to facilitate the development of a crisis intervention plan/safety plan. Review of Resident #4's Office of Behavioral Health PASRR Level II Evaluation Summary and Determination Notice for period of 03/19/2024 through 03/18/2025 revealed the nursing home was to facilitate the development of a crisis intervention plan/safety plan. Review of Resident #4's record revealed no documented evidence and the facility presented no documented evidence of a crisis intervention plan/safety plan had been developed for Resident #4. In an interview on 04/04/2024 at 2:23 p.m., Resident #4's psychiatric counselor indicated the contracted psychiatric services company he worked for had not developed and/or assisted in the development of a crisis intervention plan/safety plan for Resident #4. In an interview on 04/04/2024 at 3:11 p.m., S2Director of Nursing indicated the facility was unable to present the surveyor with evidence a crisis intervention plan/safety plan had been developed for Resident #4.

Based on observation, record review, and interview, the facility failed to address signs of pain in a nonverbal resident for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 ) reviewed for pain. Findings: Review of Resident #1's care plan revealed the problem of left should fracture which was initiated on 04/02/2024. Further review revealed a goal for Resident #1 was to have minimal to no discomfort. Further review revealed interventions included for Resident #1 to have medications as prescribed by the physician and report any pain not relieved by pain medication to the physician. Review of Resident #1's March 2024 and April 2024 Electronic Medication Administration Record (EMAR) revealed the following , in part: pain level of 4 on the am shift on 03/29/2024, pain level of 8 on the am shift on 03/30/2024, pain level of 7 on the pm shift on 03/30/2024, pain level of 8 on the am shift on 03/31/2024, a pain level of 8 on the am shift on 04/03/2024 (for the pain scale 0 indicated no pain and 10 indicated the worst pain). Further review of Resident #1's March 2024 and April 2024 EMARs revealed no documented evidence and the facility was unable to provide any documented evidence that Resident #1received any pain medication. Review of the facility's standing physician orders revealed, in part, an order for mild-moderate pain to administer 650 milligrams of acetaminophen (a medication for pain) by mouth or percutaneous endoscopic gastrostomy tube (a tube to give food or medications when a person is unable to swallow) every 6 hours as needed for 4 doses. Further review of Resident #1's March 2024 and April 2024 MARs revealed no documented evidence and the facility was unable to provide any documented evidence of Resident #1 had his pain addressed. Observation on 04/02/2024 at 11:50 a.m., revealed S7Certified Nursing Assistant (CNA) and S5CNA provided Resident #1 with incontinence care. Observation further revealed Resident #1 had facial grimacing when he was being turned. In an interview on 04/04/2024 at 11:48 a.m., S8Licensed Practical Nurse (LPN) stated she measured pain for nonverbal residents by looking for signs of pain such as facial grimacing. Observation on 04/04/2024 at 11:58 a.m., revealed S6CNA and S4CNA provided Resident #1 with incontinent care. Observation further revealed Resident #1 had facial grimacing while they turned him. In an interview on 04/04/2024 at 12:06 p.m., S4CNA confirmed Resident #1 had facial grimacing during incontinence care. In an interview on 04/04/2024 at 12:21 p.m., S3Licensed Practical Nurse (LPN) stated pain medication should have been ordered per standing orders and given for the pain ratings of 7 and 8. S3LPN confirmed Resident #1 had no documented evidence of pain medication administered in EMAR. In an interview on 04/04/2024 at 12:32 p.m., S2Director of Nursing (DON) confirmed Resident #1 had pain scale ratings of 7 and 8 documented in his March 2024 and April 2024 EMAR. S2DON indicated Resident #1 did not receive pain medication. In an interview on 04/04/2024 at 2:15 p.m., Resident #1's Nurse Practitioner indicated a fracture can be painful and Resident #1 had standing orders to give acetaminophen for pain.

Based on interviews and record reviews, the facility failed to ensure a resident's code status was carried out per the resident's wishes by failing to have a system in place to ensure staff knew how to confirm a resident's code status in an emergency for 1 (Resident #406) of 3 (Resident #101, Resident #103, and Resident #406) residents reviewed for death in the facility. The deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 4:20 p.m. for Resident #406 when she was found in distress by Emergency Medical Services (EMS) and Cardiopulmonary Resuscitation (CPR) was initiated after S30Licensed Practical Nurse (LPN) presented EMS with a Louisiana Physician Order for Scope of Treatment (LaPOST) (a document that notes a resident's wishes as it relates resuscitation status) unsigned by Resident #406's physician. S1Administrator was notified of the Immediate Jeopardy on [DATE] at 4:45 p.m. The Immediate Jeopardy was removed on [DATE] at 3:05 p.m., after it was verified through observations, interviews, and record review the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimum harm to the remaining 99 residents who reside in the facility and may need to receive emergency care. Findings: Review of the facility's Advanced Directive Policy and Procedure revealed, in part, advanced directives will be respected in accordance with state law and facility policy. Further review revealed the interdisciplinary team will review annually with the resident his or her advanced directives. Further review revealed the nurse supervisor will be required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance is needed. Review of the Resident #406's LaPOST dated [DATE] revealed, in part, in the event of a cardiopulmonary arrest, Resident #406 elected to be a DNR (Do Not Resuscitate). Review of Resident #406's LaPOST dated [DATE], which was provided to EMS upon arrival, revealed, in part, in the event of a cardiopulmonary arrest, Resident #406 elected to be a DNR (Do Not Resuscitate). Further review revealed Resident #406's LaPOST was not signed by a physician. Review of Resident #406's progress note (late entry) dated [DATE] at 7:27 p.m. revealed, in part, EMS arrived at facility at approximately 4:20 p.m., and when walking into Resident #406's room, found Resident #406 in distress. Further review revealed, S30LPN presented EMS with Resident #406's LaPOST, and EMS informed S30LPN CPR had to be initiated because Resident #406's LaPOST was not signed by a physician. Further review revealed Resident #406's CPR was stopped at 5:00 p.m. when administration was able to locate a signed LaPOST. In a phone interview on [DATE] at 10:07 a.m., Resident #406's responsible party stated Resident #406's code status was DNR, and Resident #406 would not have wanted to have CPR performed. In a phone interview on [DATE] at 10:53 a.m., S30LPN stated on [DATE], she presented Resident #406's LaPOST to EMS, but EMS stated since Resident #406's LaPOST was not signed by a physician, EMS had to initiate CPR. S30LPN confirmed CPR was performed by EMS on Resident #406. S30LPN further stated she thought it was a problem that the facility had an unsigned LaPOST with a DNR order in Resident #406's EMR. In an interview on [DATE] at 12:11 p.m., S1Administrator stated the code status of resident should be reviewed every quarter. S1Administrator further confirmed there was a discrepancy with the LaPOSTs uploaded into Resident #406's Electronic Medical Record (EMR) because the LaPOST dated [DATE] was not signed by a physician. S1Administrator further stated CPR should not have been initiated if Resident #406's wishes were to be a DNR.

Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure: 1. a resident who had a history of unsafe smoking used the required safety smoking device and was supervised while smoking for 1 (Resident #90) of the 3 (Resident #29, Resident #61, Resident #90) sampled residents reviewed for smoking; 2. an environment that was free from roaches for 1 (Hall D) of 5 (Hall A, Hall B, Hall C, Hall D, Hall E) halls observed for the presence of pests; and 3. a resident's code status was carried out per the resident's wishes by failing to have a system in place to ensure staff knew how to confirm a resident's code status in an emergency for 1 (Resident #406) of 3 (Resident #101, Resident #103, and Resident #406) residents reviewed for death in the facility. This lack of administrative oversight resulted in Immediate Jeopardy situations: 1. On [DATE] at 9:50 a.m. when Resident #90, a resident identified by the facility as an unsafe smoker with severe cognitive impairment, was observed smoking without the use of a smoking apron (a safety device which provides protection against burns to clothing and/or skin) and without staff supervision. Resident #90 was identified as an unsafe smoker on [DATE] when he dropped a lit cigarette into his lap setting his clothes on fire which required the need for staff to use water to extinguish the fire. Resident #90's care plan was updated on [DATE] which included the need for Resident #90 to wear a smoking apron and may require staff supervision while smoking; 2. On [DATE] at 9:48 a.m. when Resident #21was observed to have live roaches crawling in his room and stated he hated having roaches living in his personal space; On [DATE] at 11:00 a.m., Resident #80 stated he had live roaches in his room daily and he was worried a roach might crawl in his ear at night. On [DATE] at 11:42 a.m., Resident #51 was observed spitting out a dead roach after taking a sip from his coffee cup. Resident #51 stated having a roach in his mouth was gross and nasty. On [DATE] at 1:20 p.m., an observation in Resident #45's room revealed multiple live roaches crawling in the room. On [DATE] at 4:00 p.m., a live roach was observed entering the facility through a gap in Exit Door 7. On [DATE] at 5:29 p.m., a live roach was observed crawling on the meal tray cart located on Hall D. Residents #21, #51, and #80 resided on Hall D; and 3. On [DATE] at 4:20 p.m. when Resident #406 was found in distress by Emergency Medical Services (EMS) and Cardiopulmonary Resuscitation (CPR) was initiated after S30Licensed Practical Nurse (LPN) presented EMS with a Louisiana Physician Order for Scope of Treatment (LaPOST) (a document that notes a resident's wishes as it relates resuscitation status) dated [DATE] and unsigned by Resident #406's physician. S1Administrator was notified of the Immediate Jeopardy on [DATE] at 5:10 p.m. for Resident #90, Resident #21, Resident #45, Resident #51 and Resident #80, and on [DATE] at 4:45 p.m. for Resident #406. The Immediate Jeopardy was removed on [DATE] at 3:05 p.m., after it was verified through observations, interviews, and record review the facility implemented an acceptable Plan of Removal, prior to the survey exit. Findings: 1. Cross Reference F689 In an interview on [DATE] at 3:10 p.m., S1Administrator acknowledged the facility did not implement an effective process in place to ensure residents who had been identified as unsafe smokers received the safety measures and staff supervision required. S1Administrator confirmed Resident #90 required a smoking apron and supervision when smoking due to his history of unsafe smoking and residents should not share smoking materials with other residents identified as unsafe smokers. S1Administrator further confirmed Resident #90 should not have been allowed to smoke without a smoking apron or without staff supervision. 2. Cross Reference F925 In an interview on [DATE] at 3:50 p.m. S1Administrator confirmed she was aware of the facility's pest issues with roaches in resident's rooms. S1Administrator further stated roaches are usually attracted to food or excessive water and that could be the cause of the roach infestation on Hall D. S1Administrator stated she did not identify issues with the gaps around Exit Door 1, Exit Door 2, Exit Door 3, Exit Door 4, Exit Door 5, Exit Door 6, and Exit Door 7. Observation on [DATE] at 4:00 p.m. of Exit Door 1, Exit Door 2, Exit Door 3, Exit Door 4, Exit Door 5, and Exit Door 6 with S1Administrator revealed gaps between the door and doorframes of the above mentioned Exit Doors. Further observation of Exit Door 7 revealed gaps between the door and the doorframe which measured ,d+[DATE]th of an inch on the bottom, ,d+[DATE]th of an inch on the top, and ,d+[DATE]th of an inch along the interior. Further observation of Exit Door 7 revealed a live roach crawled from the exterior of the facility into the interior of the facility through a gap present in Exit Door 7. In an interview on [DATE] at 4:00 p.m. S1Administrator confirmed there were gaps present between the door and doorframes of Exit Door 1, Exit Door 2, Exit Door 3, Exit Door 4, Exit Door 5, and Exit Door 6. S1Administrator further confirmed she witnessed a live roach crawling into the building from a gap in Exit Door 7. She stated she was aware of the reported issues with roaches on Hall D. S1Administrator revealed she had not noticed or identified issues with gaps in the exterior doors prior to the tour with the surveyor. In an interview on [DATE] at 5:13 p.m., S1Administrator stated she was not aware Resident #51 was observed spitting a roach from his mouth after taking a sip from his coffee cup. S1Administrator further stated it was not sanitary or homelike to have residents residing were roaches were. 3. Cross Reference F678 In an interview on [DATE] at 3:00 p.m., S2Director of Nursing stated that the facility was not checking the resident's advance directives for signatures during the quarterly care plan meetings. In an interview on [DATE] at 12:11 p.m., S1Administrator confirmed there was a discrepancy with the LaPOSTs uploaded into Resident #406's Electronic Medical Record (EMR) because the LaPOST dated [DATE] was not signed by a physician. S1Administrator further stated CPR should not have been initiated if Resident #406's wishes were to be a DNR.

Based on record reviews, observations, and interviews, the facility failed to maintain an environment that was free from roaches for 1 (Hall D) of 5 (Hall A, Hall B, Hall C, Hall D, Hall E) halls observed for the presence of pests. The deficient practice resulted in an Immediate Jeopardy situation on 02/05/2024 at 09:40 a.m. when live roaches were observed in Resident #21's room on Hall D. Resident #21 stated he hated having roaches in his room and personal space. The Immediate Jeopardy situation continued on 02/05/2024 at 11:00 a.m. for Resident #80 who stated he had live roaches in his room daily. Resident #80 stated he was worried a roach might crawl in his ear at night. The Immediate Jeopardy situation continued on 02/05/2024 at 11:42 a.m. for Resident #51 when he was observed spitting out a dead roach after taking a sip from his coffee cup. Resident #51 stated having a roach in his mouth was gross and nasty. The Immediate Jeopardy situation continued on 02/06/2024 at 4:00 p.m. when a live roach was observed entering the facility through a gap in Exit Door 7. The Immediate Jeopardy continued on 02/06/2024 at 5:29 p.m. when a live roach was observed crawling on the meal tray cart located on Hall D. S1Administrator was notified of the Immediate Jeopardy on 02/06/2024 at 5:10 p.m. The Immediate Jeopardy was removed on 02/08/2024 at 3:05 p.m., after it was verified through observations, interviews, and record review the facility implemented an acceptable Plan of Removal, prior to the survey exit. Findings: Review of the facility's Pest Control Policy and Procedure revealed, in part, the facility must maintain an effective pest control program to ensure the facility is kept free of insects. Further review revealed maintenance services assist in providing pest control services. Review of the facility's Pest Control Logs revealed, in part, roaches were identified in resident rooms on the following dates: -In rooms f, g, i, k, and p on 09/19/2023; -In room i on 10/21/2023; -In rooms i, l, q, r, and t on 12/13/2023; -In rooms h, i, j, k, m, o, p, q, r, s, and t on 01/04/2024; and -In rooms g, h, and n on 02/02/2024. Observation on 02/06/2024 at 3:05 p.m. revealed gaps were present between the door and the door frame for Exit Door 1, Exit Door 2, Exit Door 3, Exit Door 4, Exit Door 5, Exit Door 6, and Exit Door 7. Observation on 02/06/2024 at 5:29 p.m., revealed a live roach was crawling across the surface of the meal tray cart on Hall D. Resident #21 Review of Resident #21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/2023 revealed, in part, Resident #21 had a Brief Interview for Mental Status (BIMS) core of 13, which indicated Resident #21 was cognitively intact. In an interview on 02/05/2024 at 9:40 a.m., Resident #21, who lived on Hall D, stated he was concerned with the amount of roaches in his room. Resident #21 further stated roaches were very bad at night, but could also be seen crawling in his room during the day. Resident #21 stated he had placed two roach traps/baits on the top of his bedside table 2 days ago due to the amount of roaches in his room. Observation on 02/05/2024 at 9:40 a.m., revealed two roach traps/baits on top of Resident #21's bedside table. Further observation revealed multiple roaches covering the sticky lining of the inside of Resident #21's two roach traps/baits. Observation also revealed two live roaches crawled across the surface of the second drawer of Resident #21's bedside table. In an interview and observation on 02/06/2024 at 10:25 a.m., Resident #21 was asked if he observed any live roaches in his room today and Resident #21 stated, yes there is one right there on the wall. Observation revealed a roach crawling along the ceiling and 2 roaches crawling on the floor of Resident #21's room. Resident #21 further stated he hated having roaches in his room and personal space. Resident #21 also stated, about 6 months ago, he was bitten by a roach and it left a little red bump/bite on his arm. Resident #21 stated he purchased 3 plugin pest lights and placed them in his room, but the roaches remained with no improvement. Resident #21 stated the facility has been aware of the roach problem. Resident #45 Observation on 02/05/2024 at 1:20 p.m. revealed in Resident #45's room on Hall D, multiple live roaches crawling across the surface of a cardboard box. Observation on 02/06/2024 at 11:10 a.m. revealed in Resident #45's room on Hall D, multiple live roaches crawling across the surface of a cardboard box. Resident #51 Review of Resident #51's MDS with an ARD of 11/15/2023 revealed, in part, Resident #51 had a BIMS score of 15, which indicated Resident #51 was cognitively intact Observation on 02/05/2024 at 11:42 a.m. revealed Resident #51 was visiting Resident #42's room located on Hall D. Further observation revealed, Resident #51 was drinking coffee from a cup and noticed something other than liquid in his mouth. Further observation revealed Resident #51 spit out a dead roach. In an interview on 02/06/2024 at 9:38 a.m., Resident #51 stated having a roach in his mouth was gross and nasty. Resident #51 further stated he observed roaches in his room and in Resident #42's room. Resident #80 Review of Resident #80's MDS with an ARD of 11/15/2023 revealed, in part, Resident #80 had a BIMS score of 9, which indicated Resident #80 had moderate cognitive impairment. In an interview on 02/05/2024 at 11:00 a.m., Resident #80, who lived on Hall D, stated he had problems with roaches in his room for the last year and saw live roaches in his room daily. In an interview on 02/06/2024 1:06 p.m., Resident #80 stated he was worried a roach would crawl into his ear while he was sleeping. Resident #80 further stated he got up often during the night to use the restroom and saw roaches crawling on the walls and/or the furniture. In an interview on 02/06/2024 at 3:50 p.m. S1Administrator confirmed she was aware of the facility's pest issues with roaches in resident's rooms. S1Administrator further stated roaches are usually attracted to food or excessive water and that could be the cause of the roach infestation on Hall D. S1Administrator stated she did not identify issues with the gaps around Exit Door 1, Exit Door 2, Exit Door 3, Exit Door 4, Exit Door 5, Exit Door 6, and Exit Door 7. Observation on 02/06/2024 at 4:00 p.m. of Exit Door 1, Exit Door 2, Exit Door 3, Exit Door 4, Exit Door 5, and Exit Door 6 with S1Administrator revealed gaps between the door and doorframes of the above mentioned Exit Doors. Further observation of Exit Door 7 revealed gaps between the door and the doorframe which measured 7/16th of an inch on the bottom, 7/8th of an inch on the top, and 3/8th of an inch along the interior. Further observation of Exit Door 7 revealed a live roach crawled from the exterior of the facility into the interior of the facility through a gap present in Exit Door 7. In an interview on 02/06/2024 at 4:00 p.m. S1Administrator confirmed there were gaps present between the door and doorframes of Exit Door 1, Exit Door 2, Exit Door 3, Exit Door 4, Exit Door 5, and Exit Door 6. S1Administrator further confirmed she witnessed a live roach crawling into the building from a gap in Exit Door 7. She stated she was aware of the reported issues with roaches on Hall D. S1Administrator revealed she had not noticed or identified issues with gaps in the exterior doors prior to the tour with the surveyor. In an interview on 02/06/2024 at 5:13 p.m., S1Administrator stated she was not aware Resident #51 was observed spitting a roach from his mouth after taking a sip from his coffee cup. S1Administrator further stated it was not sanitary or homelike to have residents residing were roaches were.

Based on observations, interviews, and record reviews the facility failed to ensure a resident, who had a history of unsafe smoking used a safety smoking device and was supervised while smoking for 1 (Resident #90) of the 3 (Resident #29, Resident #61, and Resident #90) sampled residents reviewed for smoking. This deficient practice resulted in an Immediate Jeopardy situation on 02/05/2024 at 9:50 a.m. when Resident #90, a resident identified by the facility as an unsafe smoker with severe cognitive impairment, was observed smoking without the use of a smoking apron (a safety device which provides protection against burns to clothing and/or skin) and without staff supervision. Resident #90 was identified as an unsafe smoker on 09/16/2023 when he dropped a lit cigarette into his lap setting his clothes on fire which required the need for staff to use water to extinguish the fire. Resident #90's care plan was updated on 09/18/2023 which included the need for Resident #90 to wear a smoking apron and may require staff supervision while smoking. S1Administrator was notified of the Immediate Jeopardy situation on 02/06/2024 at 5:10 p.m. The Immediate Jeopardy was removed on 02/08/2024 at 3:05 p.m., after it was verified through observations, interviews, and record review, the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimum harm to all 3 residents (Resident #29, Resident#61, and Resident #90) identified by the facility as unsafe smokers who required safety smoking devices and/or supervision while smoking. Findings: Review of the facility's Resident Smoking Policy and Procedure revealed, in part, the facility's staff shall consult with the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on a Safe Smoking Evaluation. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the resident's care plan, and all personnel caring for the resident shall be alerted to these issues. Further review revealed, any resident with restricted smoking privileges requiring monitoring shall have direct supervision at all times while smoking, and sharing smoking articles among residents was prohibited. A review of the facility's smoking list revealed, in part, Resident #90 was identified by the facility as being an unsafe smoker. A review of Resident #90's medical record revealed, in part, Resident #90 was admitted to the facility on [DATE]. Review of Resident #90's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/03/2024 revealed, in part, Resident #90 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #90 was severely cognitively impaired. Further review revealed Resident #90 had active medical diagnoses of hemiplegia (weakness and/or paralysis to one side of the body), and aphasia (a comprehensive and/or communication disorder). Review of Resident #90's nursing progress note dated 09/16/2023 at 6:25 p.m. revealed, in part, Resident #90 was discovered to have a lit cigarette in his lap, burning his clothing. Further review revealed staff poured water into Resident #90's lap to extinguish the fire. A review of Resident #90's Comprehensive Care Plan, with an initiation date of 09/19/2023 and a target date of 04/02/2024 revealed, in part, that a plan of care was developed addressing Resident #90 had a potential for injury related to being an unsafe smoker with interventions for Resident #90 to wear a smoking apron and may require staff supervision while smoking. A review of Resident #90's Smoking Safety screening completed on 10/04/2023 revealed, in part, Resident #90 had short-term memory loss, weak grasp-drops items, could not light his cigarette, had holes and/or burn marks in his clothing, was an unsafe smoker, and required supervision and a smoker's apron when smoking. A review of Resident #90's Smoking Safety screening completed on 01/03/2024 revealed, in part, Resident #90 had short-term memory loss, visual deficits, limitations with range of motion, and weak hand grasp. Further review revealed, Resident #90 was assessed as an unsafe smoker and required a smoking apron when smoking. Observation on 02/05/2024 at 9:35 a.m. revealed Resident #90 was wearing a navy blue t-shirt with two cigarette burn holes present. Observation on 02/05/2024 at 9:50 a.m. revealed Resident #90 was smoking without wearing a smoking apron and without staff supervision. Observation on 02/05/2024 at 11:45 a.m. revealed Resident #90 was getting his cigarette lit by another resident's cigarette. Observation further revealed Resident #90 was not wearing a smoking apron and without staff supervision. Observation on 02/06/2024 at 9:26 a.m. revealed Resident #90 smoking without wearing a smoking apron and without staff supervision. Observation on 02/06/2024 at 9:48 a.m. revealed Resident #90 was wearing a long-sleeved faded blue hoodie with three cigarette burn holes present. In an interview on 02/06/2024 at 10:32 a.m., S8Certified Nursing Assistant (CNA) stated Resident #90 did not require a smoking apron or supervision while smoking. S8CNA further stated she has never seen Resident #90 use a smoking apron. In an interview on 02/06/2024 at 10:40 a.m., S13Licensed Practical Nurse (LPN) stated Resident #90 was a safe smoker and did not require a smoking apron or supervision when smoking. In an interview on 02/06/2024 at 11:28 a.m., S6Recreational Therapist stated Resident #90 was an unsafe smoker and required a smoking apron and supervision when smoking. S6Recreational Therapist stated Resident #90 should never be allowed to smoke without a smoking apron due to his history of unsafe smoking. S6Recreational Therapist further stated residents should not share smoking materials with unsafe smokers due to safety issues. In an interview on 02/06/2024 at 12:30 p.m., S9Minimum Data Set (MDS)/Care Plan Coordinator stated Resident #90 was listed as an unsafe smoker on the facility's smoking list. S9MDS/Care Plan Coordinator further stated Resident #90 required a smoking apron and supervision of staff while smoking due to his history of unsafe smoking. S9MDS/Care Plan Coordinator stated the nursing staff was responsible for supervising unsafe smokers and making sure each unsafe smoker used the appropriate safety measures required. In an interview on 02/06/2024 at 3:10 p.m., S2Director of Nursing (DON) stated she was not aware who was responsible for making sure each unsafe smoker used the appropriate safety devices while smoking. S2DON further stated she was unaware of the process for making sure unsafe smokers smoked safely without causing harm or injury to themselves or others. In an interview on 02/06/2024 at 3:10 p.m., S1Administrator stated the nursing department was responsible for making sure unsafe smokers used the appropriate safety devices and were supervised while smoking. S1Adminstrator further stated Resident #90 was identified as an unsafe smoker. S1Administrator acknowledged the facility did not have an effective process in place to ensure residents who were identified as unsafe smokers received the safety measures and staff supervision required. S1Administrator confirmed Resident #90 required a smoking apron and/or staff supervision while smoking due to his history of unsafe smoking, and residents should not share smoking materials with residents identified unsafe smokers. S1Administrator further confirmed Resident #90 should not have not been allowed to smoke without a smoking apron or staff supervision.

Based on record review and interview, the facility failed to: 1. Ensure a cognitively impaired resident, who exhibited exit-seeking behaviors was adequately supervised to prevent an elopement for 1 (#3) of 5 (#1, #2, #3, #4, and #5) residents reviewed; and 2. Ensure residents were assessed for wandering and elopement risk supervised for 3 (#3, #5, #19) out of a sample of 16 residents (#2, #3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17 and #18) reviewed for wander/elopement risk. This deficient practice resulted in an Immediate Jeopardy situation on 12/08/2021 at 10:30am, for Resident #3 when a code pink (code used by the facility to notify staff of a missing resident) was announced when Resident #3 was unable to be located in the facility and on facility grounds. A facility staff found Resident #3 naked, wet, shivering, and covered with mud sitting in a sugar cane field, 75-100 yards from the facility on 12/8/2021 at 12:00pm. On 12/08/2021 at 12:30pm Resident #3 was transferred to a local hospital where he was treated for hypothermia with a temperature of 93.8 Fahrenheit. S1Administrator was notified of the Immediate Jeopardy on 12/15/2021 at 2:40pm, The Immediate Jeopardy was removed on 12/08/2021 at 12:30pm for Resident #3 when he was transferred to a local hospital. The likelihood of injury, harm, and/or death continued for 15 other residents (#2, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17 and #18) who were identified by the facility staff as moderate or at high risk for wandering and eloping. The Immediate Jeopardy was removed on 12/15/2021 at 5:40pm, after it was determined through observation, interview, and record review, the facility implemented an acceptable Plan of Removal prior to the survey exit, which included: 1. The facility have identified risk assessments that were not completed on all residents in the building. a. Census printed on 12/15/2021 b. All residents risk assessments updated on 12/15/2021 c. MDS (Minimum Data Set) will be responsible for ensuring that all risk assessments are completed upon admit, readmit, quarterly and as needed. This will be verified in the weekly high risk meeting. 2. The facility identified that some of the staff were not in-service on the elopement policies and procedures of notification. Staff that were not in-serviced on 12/08/2021 through 12/14/2021 were contacted to come in and sign the in-service form or were called and in-serviced over the phone on 12/15/2021. The staff that were in-serviced over the phone will come into the office on their next scheduled work day to sign Wander/Elopement sign in sheet. 3. We identified that the elopement binder was not current. All risk assessment scores were verified for entire building and list dated and updated. All face sheets in facility binders were updated based on the 12/15/2021 list. MDS will be responsible for continuously updating the elopement list, binder. S7LPN (Licensed Practical Nurse) and/or designee will be responsible for training staff upon hire, yearly, and as needed. Risk assessments will be audited during the weekly high risk meeting. ADON (Assistant Director of Nursing) will be responsible for ensuring wander/elopement binders are up to date and correct. 4. When a resident is identified at risk for wandering and elopement, the floor nurses will implement the physician order to be placed on the MAR (Medication Administration Record) for every two hour monitoring. When an elopement has been attempted, monitoring will be increased by floor nurses to every one hour. Floor nurse will implement one on one monitoring with a facility staff member. Floor nurse will notify Nurse Practitioner and/or Doctor for guidance regarding behavior and any recommendations. Floor nurse will contact family, responsible party, DON (Director of Nursing), ADON (Assistant Director of Nursing) and Administrator. ADON/DON will assure that the MAR has been updated and increased monitoring implemented. Every two hour batch was implemented on 12/10/2021. Every one hour batch order implemented on 12/15/2021. Rounding will be monitored during the day by the Nurse Managers, ADON's and/or DON. During the nights (weekdays and weekends) the 100 hall and/or 400 hall nurses (will be indicated on the monthly nursing schedule) will monitor the rounding. On the weekend days, the RN charge nurses will supervise the rounding. 5. The key pads' codes will be changed weekly by maintenance. Once the codes are changed, maintenance will sign off on the weekly log and report the new code to the administrator. The administrator will ensure that the codes have been changed and also sign off on the weekly log to be kept in binder in the administrator's office. To ensure that the residents do not have the code, the Activity Director will randomly pick 5 residents to ask them if they have the code and document their response. If the resident responds yes the Activity Director will report it to the Maintenance staff and the Administrator. The code will be immediately changed by the Maintenance staff. The new code will be documented in the log in the Administrators office. If the residents are seen entering the code, staff will notify Maintenance, Nursing, DON and Administrator and the code will be changed immediately. Findings: 1. Review of the facility's policy and procedure for Wandering/Elopement Behavior, Guidelines for Potential Assessment revealed, in part: a resident exhibiting wandering or potential for wandering/elopement behavior will be assessed with interventions implemented as applicable to provide safety. Review of Wandering Risk Reporting revealed, in part: Staff are to report any resident verbalizing their desire to leave the facility to go home or elsewhere and if the resident is behaving in a manner that suggest they are attempting to leaving the facility immediately notify the Resident's nurse, Social Worker, Administrator and/or the DON. Further review revealed no documented evidence of protocol to prevent elopement for a resident with exit seeking and/or elopement behaviors. Review of Resident #3's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/06/2021 revealed Resident #3 had a BIMS (Brief Interview Mental Status) score of 11 (Moderately impaired cognition). Review of Resident #3's Wandering/Risk assessment dated [DATE] revealed risk assessment completed with a score of 7 (0-7 = low risk) and was identified as not a wander/elopement risk. Review of Resident #3's care plan dated 12/06/2021 revealed, in part, he was at risk for elopement related to wandering, impaired cognition, and impaired decision making. Further review of Resident #3's care plan revealed, in part interventions were to: identify pattern of exit-seeking wandering and intervene as appropriate, report changes to physician, monitor whereabouts frequently, and wander risk assessment as needed. Review of Resident #3's clinical records revealed, in part no re-assessment of wander risk or implementation of elopement interventions on 12/06/2021 when Resident #3 was readmitted from an acute hospital stay that required 24-hour sitter supervision, 4 point restraints, and a PEC (Physician Emergency Certificate). Review of clinical record revealed, in part Resident #3 did not have a Wandering/Risk Assessment completed on 12/06/2021, when the resident returned from a hospital stay with a change in condition. Further review revealed, in part staff did not provide increase supervision when Resident #3 had exit seeking behaviors. Review of Resident #3's Nursing Admission Progress Note dated 12/06/2021 revealed, in part Resident #3 returned from a hospital stay and was verbalizing he wants to go home. Resident #3 was walking the halls looking for a way to get out the facility to go home. Review of Resident #3's Nursing Progress Note dated 12/07/2021 revealed, in part: 5:40am - Resident #3 wandered the halls most of the shift as he was lost in the facility. 6:11am - Resident #3 was also going in and out of resident's rooms and shaking the doors as if he was trying to get out. Review of Resident #3's Nursing Progress Note dated 12/08/2021 revealed, in part: 9:02am - S5LPN could not locate the resident to administer his medications. 10:37am - S5LPN called Resident #3's daughter and asked if she came pick up the resident and Resident #3's daughter replied no. S5LPN informed Resident #3's daughter that the resident wandered from his room and would call Resident #3's daughter when the resident gets back. Review of the facility's incident report dated 12/08/2021 revealed, in part, Resident #3 eloped on 12/08/2021. Resident #3 was noted missing from his room during medication pass at approximately 9:15am. S5LPN searched the hall and then made rounds through the building to locate the resident. S5LPN was unable to locate the resident and notified S2DON and a code Pink was called. Resident #3 was located in the sugar cane field at approximately 11:15am, the resident was confused, naked, covered in mud. The facility did not identify any environmental factors during their investigation contributing to the elopement. Review of the weather history for the local area revealed the temperature during the time of elopement ranged from 51 degrees Fahrenheit to 53 degrees Fahrenheit. Between the hours of 5:28am and 6:53am there were episodes of light and heavy rain. Review of the facility's time line of events for 12/08/2021 revealed: 9:15am - Resident #3's daughter notified 9:30am - Notification of resident elopement 9:30am - 10:00am - Search of building and grounds 10:30am - Nurse Practitioner notified 11:28am - Police notified 11:34am - Police arrive at the facility 11:40am - 911 notified 11:42am - Emergency medical service called 11:44am - First responders notified 11:50am - First responders arrived 12:10pm - Emergency medical service arrived Review of Resident #3's Medical Record from local Emergency Department (ED) revealed, in part on 12/08/2021 at 12:40pm Resident #3 presented to the ED awake, alert, disheveled, and covered with mud and a rectal temperature of 93.8 degrees Fahrenheit. Resident #3 was diagnosed with Hypothermia. In an interview on 12/14/2021 at 11:33am, S4ADON stated the wandering assessments are done on admit and when a resident verbally says they want to leave and shows exit seeking behavior. S4ADON stated Resident #3 should have had a wander/elopement assessment done when he returned from the hospital on 12/06/2021. S4ADON stated when wandering behaviors occur the nurse will notify the DON and the Administrator and increase supervision should be put in place. S4ADON stated on 12/07/2021 when Resident #3 exhibited behavior such as wandering in and out of rooms, shaking and pushing on the doors and stating he wanted leave; increase supervision such as rounding 1-2 hours, keeping the resident in eyes view or one on one. In an interview on 12/15/2021 at 11:30am, S3Corporate Nurse stated wandering risk assessments should be done on residents that are new admits, re-admissions, and for changes in the residents condition, especially if the resident starts to wander or exit seeks. In an interview on 12/14/2021 at 10:16am, S5LPN confirmed she was the nurse who worked on 12/08/2021 day shift, and was Resident #3's assigned nurse. S5LPN stated her shift started on 12/08/2021 at 6:00am. After receiving report form the outgoing shift, S5LPN started to make her rounds starting with Resident #3 because the outgoing nurse reported Resident #3 returned back from the hospital on 12/06/2021 and was acting differently, going in other resident's room, shaking and pulling on the doors. S5LPN stated Resident #3 was not in his room and S5LPN stated she asked the CNA about the resident's whereabouts and the CNA replied the resident was probably in the dining room. S5LPN stated around 8:30am - 9:00am she asked again if anyone saw the resident and someone stated they didn't see him but he may be outside smoking. S5LPN stated she went looking for him at approximately 9:00am in the courtyard and proceeded to look on Hall A. She then spoke to the housekeeping Supervisor and told her she could not find Resident #3 so they looked several times in different places in the facility. S5LPN stated she did not report Resident #3 missing until between 10:00am and 10:30am when she reported to S2DON and S1Administrator that she could not locate Resident #3. S5LPN stated she did not see Resident #3 on 12/08/2021 from the time she clocked in at 6:07am until he was found in the cane field at 12:00pm. In a telephone interview on 12/14/2021 at 10:43am, S6LPN stated she was the night nurse on 12/08/2021 for Resident #3. S6LPN confirmed the last time she saw Resident #3 was at 4:30am peaking his head out of the door to his room. S6LPN stated prior to Resident #3 eloping, Resident #3 made comments on leaving and asked her for assistance to help him leave. S6LPN stated Resident #3 was observed wandering in and out of resident rooms and pushing on doors to get out. S6LPN stated Resident #3 would verbalize he wanted to leave and make attempts to leave and Resident #3 was not identified as an elopement risk and should have been. S6LPN stated she did not notify the physician or the administration of Resident #3's behaviors. S6 LPN stated she re-directed Resident #3 back to his room about every 10 minutes. In an interview on 12/14/2021 at 11:33am, S4ADON stated she found Resident #3 when she discovered footprints in the mud outside Hall B foyer door. S4ADON stated when Resident #3 indicated he wanted to leave and had exit seeking behaviors Resident #3 should have been re-assessed and supervision should have been increased. In an interview on 12/15/2021 at 11:01am, S1Administrator stated she was made aware of Resident #3 being missing at 10:30am by S8Business Office Manager. S1Administrator confirmed staff did not know Resident #3's whereabouts from 4:30am until he was found in the cane field. S1Administrator stated there was no video surveillance at the time of the resident's elopement to identify where the resident eloped or what time the resident eloped. S1Administrator stated footprints were found by S4ADON on the outside of Hall B that led to where Resident #3 was found. S1Administrator stated there was no conclusion of how the resident got out the door, it is believed another resident used the code to let the resident out. 2. Review of facility's At Risk for Elopement/Wandering list revealed 3 residents (#3, #5, and #19) of the 18 residents (#2, #3, #5, #6, #7, #8, #9, #10, #11, #13, #14, #15, #16, #17, #18, #19, #20, and #21) listed as moderate to high risk for Wandering/Elopement had missing assessments and Resident #21 was discharged from the facility on 12/06/2021. In an interview on 12/15/2021 at 11:01am, with S1Administrator, review of the At Risk For Elopement/Wandering List, S1Administrator agreed the list was not current. Review of the wander list revealed there were 18 residents identified as wanderers. In reviewing the list with S1Administrator, she confirmed the list of wanderers was not up to date. Confirmed Resident #3 did not have an assessment when readmitted on [DATE] or when wandering behaviors displayed. Resident #19 was admitted on [DATE] and did not have any wander assessment completed. Resident #20 was discharged on [DATE] and should have not been on the list. S1Administrator stated the At Risk For Elopement/Wandering List was at each nurses station for staff to identify those residents at risk to provide the necessary supervision. In an interview on 12/13/2021 at 3:00pm, S1Administrator stated the facility's investigation and plan of correction was in the binder and handed this surveyor the binder. During the interview with S1Administrator, review of the facility's binder for Resident #3's elopement revealed, in part an alphabetical signature page for all employees. Review of the signature page for the in-services revealed the page had incomplete documentation and did not include the subject matter or date or what information was covered, nor did the binder contain any evidence of what the in-service was about. S1Administrator stated the policy and procedure on wanders and elopements that was in a clear sleeve before the signature page should have been attached. S1Administrator stated not all staff had the in-service at this time. S1Administrator stated she did not have any statements from staff and/or residents related to Resident #3's elopement.

Based on interview, observation and record review, the facility failed to maintain an effective pest control program resulting in maggots discovered during routine care for 2 (Resident #4 & #5) of 5 records reviewed. This deficient practice had the potential to affect any of the 96 residents who resided in the facility as documented on the facility's Resident Census and Conditions of Residents Form CMS-672. This deficient practice resulted in an Immediate Jeopardy for Resident #5 on 08/21/2020 when during scheduled [MEDICAL CONDITION] care S2 Respiratory Therapist (RT) observed maggots coming from inside of the resident's trachea area and around the neck area. On 08/05/2020, maggots had been observed by S1 Licensed Practical Nurse (LPN)/Treatment Nurse in the wound of another resident (Resident #4) who resided in the facility on the same hall as resident #5. S1 LPN notified the DON of the observation of the maggots in resident #4's foot wound, but no further actions were taken in regards to finding the source of the maggots. On 8/21/2020, Resident #5 was transferred to a local hospital where she remained hospitalized until 08/25/2020. The facility implemented corrective actions which were completed prior to the State Agency's investigation thus it was determined to be a past non-compliance. Findings: Review of Resident #5's clinical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of Resident #5's record revealed she was hospitalized from [DATE] through 08/25/2020. Review of Resident #5's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/2020 revealed, in part, a severe impairment in cognition; total dependence for Activities of Daily Living (ADLs) and received suctioning and [MEDICAL CONDITION] care. Review of Resident #5's Care Plan initiated on 02/17/2020 and revised on 03/09/2020 revealed, in part, resident had a [MEDICAL CONDITION] related to [MEDICAL CONDITION]. Documented interventions included, in part, suction as necessary. Further review of Resident #5's Care Plan revealed, in part, monitor residents respiratory rate, quality of respiration pattern, and breath sounds every 2 hours. Review of Resident #5's Progress Notes dated 08/21/2020 at 7:24am revealed, in part, at 0600 while [MEDICAL CONDITION] on resident observed maggots coming from inside of trachea area and around neck area. Nurse notified and wound care notified. Further review revealed, in part, no respiratory distress noted, Nurse Practitioner notified and an order to send Resident #5 to the hospital for evaluation was received. Review of Resident #5's Hospital Records 08/21/2020 revealed, in part, right eye [MEDICAL CONDITION] and in bed not in any acute distress. Review of the Otolaryngology consult note dated 08/22/2020 revealed, in part, no acute distress, no maggots seen in ears, oral cavity, and no signs of maggots or necrotic tissue intra orally. Further review revealed, in part, laryngoscopy through nasal passages with no signs of necrotic tissue and no maggots seen in bilateral nasal cavity. Further review revealed no maggots or necrotic tissue were seen in Resident #5's trachea, nasal cavities ears or mouth. Resident #5 returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observation on 08/31/2020 at 9:00am revealed S3 Respiratory Therapist (RT) provided [MEDICAL CONDITION] site care for Resident #5. Observation revealed no breaks in infection control practices and there were no maggots present on the resident. No flies were observed in Resident #5's room. Observation on 09/01/2020 at 10:45am revealed S1 Treatment Nurse provided wound care for Resident #3. Observation revealed no maggots noted to Resident #3's sacral area. Wound care completed as ordered with no breaks in infection control. No flies were observed in Resident #3's room. In a telephone interview on 09/01/2020 at 11:44am, Resident #5's Nurse Practitioner stated he is in the facility at least 2 to 3 times per week and had seen flies on occasion. The Nurse Practitioner stated on the morning of 08/21/2020 he was called by Resident #5's nurse who reported the discovery of maggots. The Nurse Practitioner stated Resident #5 was not in distress but he felt it was best to send her to the Emergency Department for an assessment. The Nurse Practitioner stated upon Resident #5's return to the facility the only [DIAGNOSES REDACTED]. In an interview on 08/31/2020 at 9:49am, S3Respiratory Therapist stated he worked the night shift on 08/20/2020 along with S2RT. S3RT stated all residents who had tracheostomies and/or ventilator residents were assessed every 2 hours throughout the shift and there were no issues. S3RT stated he and S2RT made final rounds before the end of their shift on 08/21/2020 and S2RT asked him to go to Resident #5's room with her. S3RT stated he saw small white maggots come out of Resident #5's [MEDICAL CONDITION] stoma site. S3RT stated he and S2RT cleaned the area with normal saline and suctioned the [MEDICAL CONDITION]. S3RT stated the nurse was notified and the nurse was asked to notify the physician or nurse practitioner. S3RT stated at no time was Resident #5 in respiratory distress. In an interview on 08/31/2020 at 9:49am, S3RT was asked by the surveyor if he had ever seen maggots in the facility prior to 08/21/2020 and he stated yes. S3RT stated a couple of weeks ago S1Treatment Nurse asked him and S2RT to go to Resident #4's room because she thought there were maggots on his wound. S3RT stated he went to Resident #4's room and confirmed the presence of maggots on Resident #4's foot wound. In a telephone interview on 08/31/2020 at 10:20am, S2RT stated on 08/20/2020 she worked the night shift on the Respiratory Unit at the facility. S2RT stated she assessed Resident #5 every 2 hours and had no issues until her last round when she removed Resident #5's [MEDICAL CONDITION] collar and observed maggots coming out of Resident #5's stoma. S2RT stated she asked S3RT to come to Resident #5's room and together they cleaned the area with normal saline and suctioned the [MEDICAL CONDITION]. S2RT was asked by the surveyor if she had ever seen maggots in the facility prior to 08/21/2020 and she stated yes. S2RT stated on 08/05/2020 S1Treatment Nurse asked her to go to Resident #4's room to look at maggots on Resident #4's foot wound. S2RT confirmed she observed maggots on Resident #4's foot wound. In an interview on 08/31/2020 at 10:30am, S1Treatment Nurse stated on 08/05/2020 she performed wound care on Resident #4's foot wound as ordered. S1Treatment Nurse stated she undressed the wound and there were maggots present on the wound. S1 Treatment Nurse stated she asked S2RT and S3RT to come to Resident #4's room to see the maggots. S1Treatment Nurse stated she removed the maggots, cleaned the wound per treatment orders, called Resident #4's physician and notified S4Former Director of Nurses (DON). S1 Treatment Nurse stated at that time the facility was having issues with flies entering into the facility at the door near the 200 hall. S1 Treatment Nurse stated she had never seen maggots in the facility prior to 08/05/2020. Resident #4 and Resident #5 resided on the 200 hall. In a telephone interview on 08/31/2020 at 12:04pm, S4 Former DON stated on 08/05/2020 she was informed of maggots on Resident #4's foot wound by S1Treatment Nurse and stated she did not report it to the Administrator or take any additional action in attempting to determine the source of the maggots. In an interview on 08/28/2020 at 10:33am, S7 RT stated prior to 08/21/2020 there were times she had seen flies on the 200 hall. In an interview on 08/31/2020 at 9:02am, S6 LPN stated that prior to the incident on 08/21/2020 she had seen flies on the 200 hall. S6 LPN further stated at this time she has not seen flies in the facility. In an interview on 08/31/2020 at 10:55am, S6Acting DON/Quality Assurance (QA) Nurse stated a corrective action plan was initiated due to the incident which involved maggots on Resident #5 on 08/21/2020. S6Acting DON/QA stated the facility would continue to monitor daily through 11/21/2020 and had current monitoring in place to prevent the re-occurrence of maggots. The surveyor asked S6 Acting DON/QA if she had knowledge of the 08/05/2020 incident with maggots on Resident #4 and she stated she had no knowledge of the incident. In an interview on 08/31/2020 at 12:26pm, S5Assistant Administrator stated she was not aware of maggots on Resident #4's wound on 08/05/2020; therefore, a corrective plan had not been implemented at that time. Observations made by the surveyors on 08/28/2020, 08/31/2020, 09/01/2020 and 09/02/2020 revealed no flies or maggots in the facility and revealed trash was not stored on the ground near the 200 hall entrance. Interviews with multiple staff members revealed no reports of observations of flies or maggots in the facility. The facility has implemented the following Quality Assurance activities to correct the deficient practice: 1. The facility determined the root cause of the flies on the 200 hall, which progressed to maggots, to be garbage bags near the 200 hall entrance. The garbage bags had been kept on the outside of the facility on the ground near the door located behind the 200 hall nurses station. The facility educated the staff not to leave garbage bags on the ground beside the door. The facility placed bins away from the facility entrance door and educated and assigned designated staff to dispose of the garbage in the bins three times per day. The facility has implemented monitoring to ensure garbage is no longer kept on the ground near the entrance door; 2. Maintenance staff along with Housekeeping staff make rounds daily for environmental issues including flies and pest; 3. Respiratory therapy staff continue with every 2 hours rounds as well as a designee round daily to ensure tracheostomies are clean; and 4. Increase in pest control services, education of staff to use the pest control log, installation of Halo fly light glue boards at all entrances of building, increase in fly bait as well as the placement of sticky traps has been implemented in the facility. Completion date of 08/25/2020; however, the facility will continue to provide daily monitoring and review until 11/21/2020 as part of the corrective action.

Based on record review and interview the facility failed to provide the necessary care when residents had no pulse or respirations by not performing CPR for these residents who did not have a physician order [REDACTED]. This deficient practice was identified for 2 of 3 stage II sample residents reviewed (#31 & #112) and 23 other random residents at the facility (#46, #11, #19, #75, #57, #13, #113, #56, #101, #21, #17, #109, #26, #88, #44, #98, #8, #83, #73, #7, #12, #90, & #110) in a total of 86 Residents on the Stage II Sample Resident List. The facility's census was 91 as documented on the facility's Resident Census and Conditions of Residents. Per the facility policy, the facility's will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order (DNRO) in effect. A DNRO must be signed by the resident's attending physician on the physicians order sheet maintained in the resident's medical record. Resident #112 and #31 did not have a signed physician's orders [REDACTED]. Resident #31 was in Immediate Jeopardy on [DATE] when the facility staff found the resident with no respirations and no pulse and did not initiate CPR. The Immediate Jeopardy ended for Resident #112 on [DATE] when the resident died and ended for Resident #31 on [DATE] when the resident died . The 23 residents (#46, #11, #19, #75, #57, #13, #113, #56, #101, #21, #17, #109, #26, #88, #44, #98, #8, #83, #73, #7, #12, #90, & #110) currently residing in the facility were in Immediate Jeopardy. These Residents did not have a signed DNR order by their physicians but were named on a red sheet of paper as DNR. The Administrator was informed of the Immediate Jeopardy situation on [DATE] at 12:10 pm. The facility provided a written plan to remove the Immediate Jeopardy. The Immediate Jeopardy was removed on [DATE] at 3:35 pm when Surveyors determined that the facility removed chart information which would have identified that a resident had a DNR status and residents who were Do Not Resuscitate had a physician's DNR order. The nursing staff and respiratory staff were inserviced that the current system is ineffective and were instructed to view each resident's record for DNR status per facility policy. The staff at work were in-serviced and all new staff and other staff would be in-serviced prior to working there next scheduled. The deficient practice remains at a level II for all residents in the facility as the facility has not put a system in place with quality assurance to ensure the deficient practice does not reoccur. Findings: Review of the facility's policy on Do Not Resuscitate Order revealed the facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order (DNRO) in effect. A DNRO must be signed by the resident's attending physician on the physicians order sheet maintained in the resident's medical record. Resident #31: Review of Resident #31's Admission Record face Sheet revealed she was admitted on [DATE] with S26/Physician listed as her primary physician. Review of her [DATE] Physician order [REDACTED]. Review of Resident # 31 Nurses Notes dated [DATE] revealed: 6:45am the resident was asked why she was crying. The Resident said I'm not crying, I'm laughing, I'm happy, and I'm sad. The resident denied any pain or distress; respirations were even and unlabored, 7:20am revealed the nurse was called to resident's room by CNA per page, and resident had a bluish color on face with no respirations and had no pulse. Resident code status DNR, and no CPR was performed. Record review revealed no order for DNR. In an interview on [DATE] at 2:40pm S2/DON indicated she could not find an actual order for DNR, she would go check with another staff member to check if it is filled out somewhere else. In an interview on [DATE] at 3:15am, S3/LPN/ADON indicated for a DNR you need 2 physician signatures. She further indicated the Advance Directive was not signed by the patient but by the responsible party. S3/LPN/ADON took the chart to see if she could find a DNR order. In an interview on [DATE] at 3:30pm S4/Social Worker presented a transcript order from a hospital with a dictation dated [DATE]. Review of this dictation revealed, in part, the patient was a DNR per documentation but S27/Physician was not the resident's attending doctor, it was the resident's hospital doctor and there was no doctor's signature documented. Resident #112: Record review revealed the resident was admitted on [DATE]. Record review revealed a red sheet with bold black labeled letters DNR written with the resident ' s name and an advance directive to do not resuscitate and no noted doctor order for DNR. Review of the nurses notes dated [DATE] revealed the following: 6:00am the resident had no complaints, 6:45am the nurse was called to the resident's room and she had no pulse, ambulance service was contacted and doctor. Further review revealed CPR was not performed. In an interview on [DATE] at 11:40am S3/LPN/ADON indicated the resident died and no signed physician order [REDACTED]. She further indicated it appears to be the same situation as the other resident (Resident #31) who did not have an order for [REDACTED]. In an interview on [DATE] at 11:45am S2/DON indicated after reviewing the resident's record CPR was not performed and the resident did not have a DNR order on the chart. Residents #46, #11, #19, #75, #57, #13, #113, #56, #101, #21, #17, #109, #26, #88, #44, #98, #8, #83, #73, #7, #12, #90, & #110: The S6/LPN/Unit Manager and S4/Social worker gave surveyor a facility list of residents who had, in their individual clinical records, their names written on red sheets labeled DNR in bold black letters but no signed DNR order. Reveiw revealed there were 23 residents (#46, #11, #19, #75, #57, #13, #113, #56, #101, #21, #17, #109, #26, #88, #44, #98, #8, #83, #73, #7, #12, #90, & #110) on the list. In an interview on [DATE] at 9:40am, S4/Social Worker indicated none of the above identified residents with red sheets labeled DNR in their charts had a physician order [REDACTED]. On [DATE] surveyor randomly chose an active resident's chart that had a red sheet with DNR written with the resident's name on it and no doctors signature and no doctors order for DNR. The surveyor ased several nurses if this resident was found with no respirations or pulse what would they do: In an interview at 3:35pm, S19/LPN Wound Care indicated, she would not do anything. In an interview at 3:36pm, S15/LPN indicated he would not perform CPR. In an interview at 3:40pm, S7/LPN indicated she would look beyond the red DNR page and look at the Advance directives to see what to do. In an interview at 3:41pm, S16/LPN indicated she would not do CPR.