Every finding on record at Sardis Community NH

Based on record review, interview, and facility policy review, the facility failed to develop and implement a comprehensive, person-centered care plan to address a newly identified skin breakdown to the sacrum for one (1) of three (3) residents reviewed (Resident #1).Findings included:Record review of facility policy titled, Care Plan Process, revised 12/24 revealed .The Care Plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, on an ongoing basis to reflect the services provided or arranged and must be consistent with each resident's written plan of care .Record review of the Care Plan Report for Resident #1 revealed no care plan had been developed related to the excoriated area to the sacrum.Record review of Progress Notes dated 2/15/26 confirmed the presence of a new excoriated area to the sacrum requiring treatment and monitoring.Interview on 3/19/26 at 12:07 PM with Registered Nurse #1 (RN) revealed that the purpose of the care plan was to ensure staff were aware of how to care for the resident.Interview on 3/19/26 at 1:05 PM with the Minimum Data Set (MDS) Nurse confirmed that no care plan was developed for the newly identified skin breakdown area to the sacrum but acknowledged that one should have been implemented.Record review of the Face Sheet for Resident #1 revealed that the facility admitted the resident on 5/22/2019 with diagnoses of Diabetes Mellitus and Cerebral Infarction.

Based on record review, interview, and facility policy review, the facility failed to ensure that a resident who developed skin breakdown to the sacrum received ordered treatment services to promote healing and prevent further skin breakdown for one (1) of three (3) residents reviewed for pressure ulcers. (Resident #1).Findings included:Review of facility policy titled, Prevention and Treatment of Skin Issues, latest review date 09/25 revealed Policy: It is the policy to properly identify and assess resident whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care .Record review of Progress Notes for Resident #1, dated 2/15/26, revealed the resident was noted with an excoriated area to the sacrum that was slightly reddened with no drainage. The note indicated the Director of Nursing (DON), wound care nurse, and Responsible Party were notified and a new order was obtained to cleanse the area with wound cleanser, pat dry, and apply zinc oxide.Record review of the Order Summary Report for Resident #1 revealed an order dated 2/15/26, to cleanse the excoriated area to the sacrum with wound cleanser, pat dry, and apply zinc oxide every shift until healed.Record review of the February 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #1 revealed there was no documentation that the ordered treatment dated 02/15/26 to the sacrum was provided.Interview on 3/19/26 at 12:00 PM, with Registered Nurse #1 (RN) revealed that a Certified Nursing Assistant (CNA) notified her of the skin issue on 2/15/26. She stated she assessed the resident, identified a red excoriated area, and obtained treatment orders, which she entered into the system and expected to trigger on the MAR/TAR.Interview and concurrent record review on 3/19/26 at 12:03 PM, with RN #1 confirmed there was no documentation that the ordered treatment was provided. RN #1 stated she did not know why the treatment had not triggered and agreed that failure to perform the treatment could have caused worsening of the area.Interview on 3/19/26 at 12:30 PM, with the DON revealed that daily review of orders is conducted; however, the treatment order for Resident #1 was missed. The DON further stated the order did not trigger to the MAR/TAR because an incorrect order type was selected when the order was put into the system on 02/15/26.Record review revealed that Resident #1 was sent out to the Emergency Department on 02/18/26 for a change in level of consciousness and never returned to the facility and was discharged from the facility on 02/25/26. Record review of the Face Sheet for Resident #1 revealed that the facility admitted the resident on 5/22/2019 with diagnoses of Diabetes Mellitus and Cerebral Infarction.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident was free from abuse for one (1) of five (5) residents reviewed (Resident #1), when staff engaged in abusive conduct by pulling the resident from his seated position onto the floor, verbally berating him, and spraying him with an aerosol substance. This failure resulted in actual psychosocial harm, including fear, distress, and compromised dignity. Findings Include:Cross-Reference F610Review of the facility policy titled Incident Investigation & Reporting, revised 5/24, revealed, .1. Each resident in this facility has the right to be free from any type of abuse including verbal, sexual, mental, physical abuse, neglect, exploitation, misappropriation of resident property .An interview with the Administrator (ADM) on 12/23/25 at 8:58 AM revealed Resident #1 no longer resided at the facility and had been discharged home. She explained that the alleged perpetrator, Nurse Aide (NA) #1, no longer worked at the facility. The ADM stated that on the day of the incident involving Resident #1 and NA #1, the aide left the resident's room, went outside to her car, refused to talk, and never returned to work. She revealed NA #1 contacted the facility approximately two (2) weeks later, denied intentions to harm the resident, and requested her job back; however, the facility decided to terminate her employment since so much time had passed.An interview with the Staff Development Nurse on 12/23/25 at 9:19 AM revealed she was responsible for training nurse aide classes. She stated Nurse Aide (NA) #1 completed the two-week nurse aide training program in August and subsequently trained with a Certified Nurse Aide (CNA) on different shifts. The Staff Development Nurse revealed NA #1 completed all required hours and had 120 days to pass the certification exam, which she had not completed prior to the incident involving Resident #1 on 9/17/25.Record review of the Incident Description dated 9/17/25 revealed, Summoned to room per CNA and housekeeper. Upon entering room with charge nurse present, resident sitting on floor in front of wheelchair and Nurse Aide #1 sitting in chair in resident's room. Resident was alert and appeared frightened after altercation with employee. Assisted resident from floor to wheelchair per charge nurse, CNA, and this nurse. Asked resident what happened resident states, 'The CNA pulled the pillow from under me pulling me on the floor.' The record further revealed under Resident Description: The CNA (Nurse Aide #1) came in my room and stated, 'I am tired' and I told her that she can sit in the chair over there and take a break. The CNA sat in the chair for a few minutes, then she got up, walked over to me and stated, 'I'm tired of y'all playing me.' Then she pulled the pillow from under me, pulling me on the floor, and sprayed me with that disinfectant spray. I started hollering for help.A telephone interview with Resident #1 on 12/23/25 at 10:50 AM revealed he recalled the incident with Nurse Aide #1 and stated she had come into his room several times that morning but was not supposed to be caring for him that day. He stated he was sitting in his wheelchair and she came into his room and said she was tired, so he told her to sit down in the chair and rest. He stated, I don't know if she went crazy or what, but she got up and started taking off my socks and shoes and then pulled a pillow out from under me that I was sitting on and I hit the floor. He revealed that while he was on the floor, she began hollering at him to get up, you know you can get up. He explained he believed she lost control because she picked up an aerosol spray can he believed to be disinfectant and began spraying him over his lower body. He stated he screamed for help, and the housekeeper came to the door, observed him on the floor, and got help. Resident #1 stated that after he was returned to his wheelchair, NA #1 continued spraying his legs with the aerosol spray and began throwing his clothes and items from the bedside table into the garbage can. He explained that he was shaken up by the incident and taken by surprise and it scared him the way she was acting, and he started yelling for help.An interview with Housekeeping #1 on 12/23/25 at 11:06 AM revealed that on the day of the incident involving Resident #1, Nurse Aide #1 appeared quiet and was acting unusual. She stated she was cleaning across the hall from Resident #1's room when she heard him hollering and screaming for help. She stated she immediately went to the room and observed NA #1 placing the resident on the floor with her hands. Housekeeping #1 stated the aide was hollering at the resident saying, You can get up, while the resident continued screaming for help. She stated she went to the nurse's desk to get help.Record review of the witness statement dated 9/17/25 written by Housekeeping #1 revealed, I was cleaning 106 (room) when I heard Resident #1 screaming, 'Stop what you are doing, I'm going to slide on the floor.' I walked out of 106 to check on him and he was coming out of his chair to the floor and the girl (Nurse Aide #1) was laughing and hollering back at him.An interview with CNA #1 on 12/23/25 at 11:15 AM revealed she was assigned to care for Resident #1 on the day of the incident. She stated Nurse Aide #1 was assigned to a different hall but repeatedly entered Resident #1's room that morning. CNA #1 stated she was providing care in another room when she heard Resident #1 screaming Stop, stop, stop, followed by calls for help. She stated when she entered the room, Resident #1 was on the floor sitting on the wheelchair foot pedals, and NA #1 was hollering at him stating, You get up, you get up from there. CNA #1 stated NA #1 began spraying the resident's legs with an aerosol spray and then threw the resident's belongings into the garbage can when nursing staff entered the room. She stated, He told me he was afraid for his life.An interview with Registered Nurse (RN) #1 on 12/23/25 at 11:41 AM revealed she was notified during the morning meeting that something had occurred involving Resident #1. She stated upon entering the resident's room, she observed Resident #1 on the floor and Nurse Aide #1 sitting in a chair laughing. RN #1 stated the resident reported NA #1 had pulled him onto the floor.A telephone interview with Licensed Practical Nurse (LPN) #1 on 12/23/25 at 1:17 PM revealed she was Resident #1's nurse on the day of the incident. She stated CNA #1 and Housekeeping #1 came to the nurse's desk stating, Y'all need to get this girl she is doing some crazy stuff. She stated she and the supervisor entered Resident #1's room and observed NA #1 sitting in the resident's chair laughing while the resident was on the floor. She stated Resident #1 reported NA #1 pulled the pillow from under him causing him to fall to the floor. She further stated NA #1 sprayed the resident's legs with air freshener and continued spraying despite being told to leave the room, then threw items from the bedside table into the garbage can. LPN #1 stated the resident was frightened and he told her the girl went crazy. An interview with the Administrator (ADM) on 12/23/25 at 1:38 PM revealed she believed the incident involving Resident #1 and Nurse Aide #1 was accidental. She revealed she did a thorough investigation interviewing the staff and they thought NA #1 was fine and stated there were a lot of conflicting stories. She stated she had interviewed the resident twice and the second time he stated that the aide was spraying disinfectant spray in his room that morning, then started rubbing hand sanitizer on his bedside table and it got on one of his pictures. The ADM stated there were too many conflicting stories from staff, some said that NA #1 was spraying disinfectant in the garbage can. She revealed she went to his room and was unable to find any spray aerosol to confirm this. The ADM stated Resident #1 told her that the aide was not trying to intentionally hurt him. She confirmed she spoke with Housekeeping #1 and CNA #1 and still felt as though she could not substantiate the abuse because she could not prove NA #1 showed intent to abuse the resident. She acknowledged that her decision to not substantiate abuse was not supported by the totality of evidence obtained. Record review of the witness statements and the interviews obtained during the investigation revealed that abuse did occur and that the resident felt frightened and scared for his life.Record review of the admission Record revealed Resident #1 was admitted on [DATE] with diagnoses including urinary tract infection, hypertensive urgency, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side.Record review of the Evaluation Scoring Report revealed a Brief Interview for Mental Status (BIMS) score of 12 on 7/18/25, indicating moderate cognitive impairment.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated for one (1) of five (5) residents reviewed. (Resident #1) Findings Include:Cross-Reference F600Review of the facility policy titled Incident Investigation & Reporting, revised 5/24, revealed, .6 The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent occurrence and/or further potential abuse.Record review revealed an allegation of abuse involving Resident #1 was reported on 9/17/25 after staff responded to the resident screaming for help and observed the resident on the floor following an altercation with Nurse Aide #1.Record review of the Incident Description dated 9/17/25 revealed, Summoned to room per CNA (certified nurse aide) and housekeeper. Upon entering room with charge nurse present, resident sitting on floor in front of wheelchair and CNA (Nurse Aide #1) sitting in chair in resident's room. Resident was alert and appeared frightened after altercation with employee. Assisted resident from floor to wheelchair per charge nurse, CNA, and this nurse. Asked resident what happened resident states, 'The CNA pulled the pillow from under me pulling me on the floor.' The record further revealed under Resident Description, The CNA (Nurse Aide #1) came in my room and stated, 'I am tired' and I told her that she can sit in the chair over there and take a break. The CNA sat in the chair for a few minutes, then she got up, walked over to me and stated, 'I'm tired of y'all playing me.' Then she pulled the pillow from under me, pulling me on the floor, and sprayed me with that disinfectant spray. I started hollering for help.Record review of the witness statement dated 9/17/25 written by Housekeeping #1 revealed, I was cleaning 106 (room) when I heard Resident #1 screaming, 'Stop what you are doing, I'm going to slide on the floor.' I walked out of 106 to check on him and he was coming out of his chair to the floor and the girl (Nurse Aide #1) was laughing and hollering back at him.On 12/23/25 at 11:15 AM an interview with Certified Nurse Aide (CNA) #1 revealed she heard Resident #1 screaming Stop, stop, stop, and observed the resident on the floor with Nurse Aide #1 yelling at him to get up and spraying his legs with an aerosol substance. CNA #1 stated she wrote a witness statement regarding the incident and provided it to administration.On 12/23/25 at 11:41 AM an interview with Registered Nurse (RN) #1 revealed she observed Resident #1 on the floor with Nurse Aide #1 sitting in a chair laughing and stated she wrote a witness statement and submitted it to administration.On 12/23/25 at 1:17 PM a telephone interview with Licensed Practical Nurse (LPN) #1 revealed she observed Resident #1 on the floor while Nurse Aide #1 was sitting in a chair laughing. LPN #1 further stated, Nurse Aide #1 sprayed the resident's legs with air freshener and threw personal items from the bedside table into the garbage can. LPN #1 stated she wrote a witness statement and provided it to administration.Record review of the facility's abuse investigation dated 9/17/25 revealed the Administrator determined the allegation of abuse could not be substantiated due to an inability to prove intent. Further record review of the abuse investigation file revealed witness statements from CNA #1, RN #1, and LPN #1 were not included in the investigation documentation, demonstrating the witness statements were excluded from the investigation. On 12/23/25 at 1:38 PM an interview with the Administrator (ADM) revealed she believed the incident involving Resident #1 and Nurse Aide #1 was accidental and stated conflicting accounts prevented substantiation of abuse. She stated she could not prove Nurse Aide #1 showed intent to harm Resident #1. The Administrator acknowledged her determination was not supported by the totality of evidence obtained and that conflicting accounts were used to dismiss the allegation.Record review of the admission Record revealed Resident #1 was admitted on [DATE] with diagnoses including urinary tract infection, hypertensive urgency, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side.Record review of the Evaluation Scoring Report revealed a Brief Interview for Mental Status (BIMS) score of 12 on 7/18/25, indicating moderate cognitive impairment.

Based on staff and resident interviews, record reviews and facility policy review, the facility failed to develop a comprehensive care plan for a resident taking an anticoagulant (Resident #32) and failed to implement an Activities of Daily Living (ADL) care plan (Resident #257) for two (2) of 26 resident's care plans reviewed. The scope for F656 was increased to E to indicate a pattern of noncompliance due to a prior citation during the last recertification survey 7/23/24. Findings include: Review of the facility policy titled, Care Plan Process with review date 12/24, revealed, .the facility shall develop and implement .care plan .for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care . Resident #32 Record review of Resident #32's Physician's Orders revealed an order with a start date of 4/7/25 for Apixaban Oral Tablet 5 milligrams (mg); Give 1 tablet by mouth two times a day related to Acute Embolism and Thrombosis of Unspecified Femoral Vein. Record review of Resident #32's care plans revealed that a comprehensive care plan had not been developed for anticoagulant therapy. During an interview on 6/30/25 at 11:00 AM with the Minimum Data Set (MDS) Coordinator, she confirmed that a comprehensive care plan addressing the risk for bleeding associated with anticoagulant therapy was absent. She emphasized the critical nature of this oversight, stating that a care plan should have been initiated at the same time the anticoagulant order was entered to ensure proper monitoring. The MDS Coordinator expressed serious concerns, noting that the resident could die if active bleeding occurred and went unnoticed due to the lack of monitoring protocols. During an interview with the Director of Nursing (DON) on 7/01/25 at 12:04 PM, she reiterated her expectation that a comprehensive care plan must be developed whenever an anticoagulant is prescribed for a resident. She highlighted the potential consequences of failing to implement such a plan, indicating that a resident could experience a bleed that might go undetected, potentially leading to hospitalization or worse outcomes. Record review of the admission Record revealed that the facility admitted Resident #32 on 3/31/25 with medical diagnoses that included Acute Embolism and Thrombosis of Unspecified Femoral Vein. Record review of the quarterly MDS with an Assessment Reference Date (ARD) of 4/16/25 under Section C revealed, a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact. Resident #257 An observation and interview with Resident #257 on 6/29/25 at 4:58 PM, revealed that Resident #257 had a foul odor and stated he had not had a bath or shower since his admission. Record review of the Care Plan Report for Resident #257 revealed: The resident needs assistance with ADLs (Activities of Daily Living) Date initiated 6/27/25 .Interventions: . The resident needs partial/moderate assist to transfer with bathing/showering . During an interview with the MDS Coordinator, on 6/30/25 at 2:45 PM, she stated, The purpose of a care plan is to make sure that staff addresses and provides the care for each resident for their specific care needs. On 7/01/25 at 10:22 AM, the DON stated, The purpose of a care plan is to provide person-centered care. Record review of Resident #257's admission Record revealed the facility admitted the resident on 6/16/25 with medical diagnoses that included Parkinson's Disease with Dyskinesia, with fluctuations. Record review of Resident #257's MDS with an ARD of 6/23/25 under Section C, revealed a BIMS score of 15, indicating that Resident #257 was cognitively intact.

Based on observation, interviews, record review and facility policy review, the facility failed to ensure that assistance with Activities of Daily (ADL) was provided to a resident that required assistance with bathing for one (1) of 26 sampled residents. Resident #257 Findings Include: Review of the facility's policy titled, Activities of Daily Living with a revision date of 11/24, revealed under Policy: Activities of Daily Living will be documented on a daily basis by the CNA (Certified Nursing Assistant) to reflect actual care rendered to the resident. The ADL shall become a permanent part of the residents' chart . 2. ADLS shall include, but are not limited to .bathing . On 6/29/25 at 4:58 PM, an observation of Resident #257 revealed a foul odor. An interview with Resident #257, revealed that he had not received a bath or shower since his admission two weeks ago. During an observation and interview on 6/30/25 at 11:00 AM, the resident was observed wearing the same pants as the day before and continued to have a foul odor. Resident #257 stated that he had not gotten a bath or shower this morning. His brother, who is also his roommate, stated that he had not seen Resident #257 get a bath or go to the shower room since his admission. An interview with 6/30/25 at 2:00 PM with CNA #1, revealed that she helps on the hall, and that Resident #257 is scheduled to receive a bath on Mondays, Wednesdays, and Fridays. She stated, I can't remember when he had a bath or shower. She attempted to locate documentation but was unable to provide any dates. Record review of the Kardex Follow Up Question Report 6/16/25 through 6/30/25 revealed documentation of personal hygiene, but there were no notations of a bath or shower in the record. During an interview on 6/30/25 at 2:15 PM with Licensed Practical Nurse (LPN) #1, she stated, I don't recall when he received a bath or shower. She also stated, He has never refused care with me. On 7/01/205, an interview with the Director of Nursing (DON), confirmed that Resident #257 should have received a bath or shower on Mondays, Wednesdays, and Fridays. Record review of Resident #257 admission Record revealed the facility admitted Resident #257 on 6/16/2025 with diagnoses including Parkinson's Disease. Record review of Resident #257 Minimum Data Set (MDS), Section C, with an Assessment Reference Date (ARD) of 6/23/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #257 is cognitively intact.

Based on observation, staff and resident interviews, record review and facility policy review, the facility failed to provide a homelike environment for one (1) of 55 residents residing in the facility. Resident #40. Findings include: Review of the facility policy titled, Resident Environment, dated 9/15 with no revision date revealed, It is the policy of this facility to provide a safe, clean, comfortable and homelike environment . During an observation on 6/29/25 at 4:00 PM, it was noted that Resident #40's room had an approximate two feet by four feet area of paint missing from the wall across from the bathroom door. The resident expressed concern, stating, It's been that way since I moved in here. Sometimes my family comes to visit me. I wouldn't have my home looking like that. During an observation and interview with the Maintenance Director on 6/30/25 at 12:52 PM confirmed that he was aware of the missing paint and stated, I just haven't got around to it. He further remarked, I wouldn't want my house to look like that, and this is their home and that they are supposed to be provided with a homelike environment. During an interview with the Administrator on 6/30/25 at 12:54 PM, she acknowledged the facility's responsibility to maintain a homelike environment and admitted to failing to notice the issue during her rounds. Record review of the admission Record revealed that the facility admitted Resident #40 on 5/6/22. Record review of the quarterly MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 5/14/25 under Section C, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating that the resident had moderate cognitive impairment.

Based on observation, staff interviews, record reviews, and facility policy review, the facility failed to accurately code an admission Minimum Data Set (MDS) assessment for one (1) of 18 resident MDS assessments reviewed. Resident #52 Findings include: Review of facility policy titled, Resident Assessment, last revised on 9/19, revealed, .The completed assessment guide the staff in identifying key information about the resident and serves as a basis for identifying resident specific issues and objectives in order to develop a care plan .healthcare professional that completes a portion of the assessment must sign and certify the accuracy of the portion of the assessment that they have completed . Record review of Resident #52's admission MDS, section P, with an Assessment Reference Date (ARD) of 4/29/25, revealed that the bed rails were coded as a restraint. Record review of Resident #52's Care Plan titled, Resident's Current Safety Devices and Special Equipment dated 4/22/25 revealed, .Side Rails x (times) two (2) .for bed mobility . An observation of Resident #52's bed on 6/29/25 at 5:04 PM revealed that half side rails were attached. During an interview on 6/30/25 at 9:55 AM with the MDS Coordinator, she acknowledged that Resident #52's bedrails were incorrectly coded, stating the bed rails were used for positioning rather than as a restraint. During an interview with the Director of Nursing (DON) on 7/01/25 at 12:10 PM, she expressed her expectation that MDS assessments accurately reflect the resident's condition and concurred that the bed rails should not have been coded as restraints, emphasizing that they were intended to assist with positioning. She firmly stated, We do not have restraints in this building. Record review of the admission Record revealed that the facility admitted Resident #52 on 4/22/25 with medical diagnoses that included Traumatic Hemorrhage of Left Cerebrum with Loss of Consciousness Status Unknown. Record review of the admission MDS with an ARD of 4/29/25 under Section C, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating that the resident had severe cognitive impairment.

Based on staff interviews, record reviews, and facility policy review, the facility failed to monitor the adverse effects of an anticoagulant medication for one (1) of five (5) residents reviewed for unnecessary medications. Resident #32. Findings include: Review of facility policy titled, Drug Administration and Documentation with last review date 3/25, revealed, .Residents shall be observed for adverse effects such as side effects, interactions, and allergic reactions. The physician shall be notified of any adverse effects that occur . Record review of Resident #32's Physician's Orders revealed an order with a start date of 4/7/25 for Apixaban Oral Tablet 5 milligrams (mg); Give 1 tablet by mouth two times a day related to Acute Embolism and Thrombosis of Unspecified Femoral Vein. Record review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #32 for June 2025, it was noted that there was no monitoring protocol in place for the side effects associated with an anticoagulant therapy. During an interview with Licensed Practical Nurse (LPN) #2 on 6/30/25 at 10:12 AM, she revealed there were no specific orders in place for monitoring the risk for bleeding related to the anticoagulant medication. The LPN emphasized the need for monitoring to detect active bleeding and/or excessive bruising, highlighting the potential for severe complications, such as hospitalization due to bleeding or low hemoglobin (Hgb) and hematocrit (Hct) levels. During an interview on 6/30/25 at 11:00 AM with the Minimum Data Set (MDS) Coordinator, she confirmed that monitoring for the risk of bleeding associated with anticoagulant therapy was absent. She stressed the importance of implementing monitoring tasks concurrently with the initiation of the anticoagulant order to ensure effective oversight. The MDS Coordinator expressed serious concerns, stating that without proper monitoring, the resident could die if active bleeding occurred and went unnoticed due to the lack of established protocols. The Director of Nursing (DON) during an interview on 7/01/25 at 12:04 PM, revealed that monitoring for bleeding should commence whenever an anticoagulant is prescribed for a resident. She underscored the potential consequences of failing to implement such a monitoring plan, indicating that undetected bleeding could lead to significant health risks and possible hospitalization. Record review of the admission Record revealed the facility admitted Resident #32 on 3/31/25 with medical diagnoses that included Acute Embolism and Thrombosis of Unspecified Femoral Vein. Record review of the quarterly MDS with an Assessment Reference Date (ARD) of 4/16/25 under Section C, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact.

Based on staff interviews, record review, and facility policy review, the facility failed to document wound treatments for a resident with a Stage 3 pressure ulcer for one (1) of three (3) residents with wounds reviewed. Resident #36 Findings include: Record review of facility policy titled, Physician Orders with a revision date of 01/25, revealed, It is the policy of this facility that all physician's orders will be implemented timely and carried out in a professional manner. Licensed nurses are responsible for following physician orders. Record review of Electronic Treatment Administration Record (ETAR) for April 2025 and May 2025 revealed an order with a start date of 4/15/25 and a discontinue date (D/C) date of 5/9/25 to Clean pressure ulcer stage 2 to sacral with wound cleanser. Pat day. Apply mupirocin and collagen to wound and cover with foam dressing daily until healed. Treatments for 4/19/25, 4/21/25, 4/27/25, 5/2/25, and 5/9/25 were not documented as administered. Record review of ETAR for May 2025 revealed an order with a start date of 5/10/25 and a D/C date of 5/23/25 to Cleanse with wound cleanser and apply Dakins wet to dry x 2 weeks and then rephotograph one time a day for treatment. Treatments for 5/18/25, 5/21/25, and 5/22/25 were not documented as administered. Record review of ETAR for May 2025 and June 2025 revealed an order with a start date of 5/24/25 and a D/C date of 6/5/25 to Clean wound to sacral area with wound cleanser. Pat dry. Apply mupirocin and alginate to wound and cover with bordered dressing every day until healed. Treatments for 5/25/25, 5/29/25, 6/2/25, and 6/4/25 were not documented as administered. Record review of ETAR for June 2025 revealed an order with a start date of 6/6/25 and a D/C date of 6/10/25 to Clean wound to sacral area with normal saline, pat dry, apply mupirocin, hydrofera blue, calcium alginate and cover with foam dressing daily and PRN (as needed) when soiled until healed. Treatment for 6/8/25 was not documented as administered. Record review of ETAR for June 2025 revealed an order with a start date of 6/11/25 to Clean Stage 3 pressure injury to sacral area with normal saline, pat dry, apply mupirocin, hydrofera blue, calcium alginate and cover with foam dressing daily and PRN when soiled until healed. Treatments for 6/21/25 and 6/22/25 were not documented as administered. On 06/30/25 at 11:00 AM, wound treatment observation and interview with Registered Nurse (RN) #2 revealed wound management services visits weekly on Wednesdays. She revealed she started at the facility in April 2025 and Resident #36 had a little bit of breakdown and we were treating it then and now it is looking much better with pink granulation. This observation confirmed the wound had pink granulation. During an interview and record review on 6/30/25 at 12:20 PM, the Director of Nurses (DON) confirmed that after reviewing the ETAR for Resident #36's wound treatment, there were fifteen days with missing documentation for the months of April, May, and June. She revealed that it is our expectation that all treatments are documented in the system, and if another nurse goes in to render treatment and finds a bandage with an old date, they will report it to me. She revealed I just can't imagine that my nurses wouldn't do a treatment, I think they have gotten busy and failed to document in the ETAR. She revealed that documenting care is part of the continuity of care, and treatments should be done and documented accurately. During an interview on 6/30/25 at 4:35 PM, Licensed Practical Nurse (LPN) #3 revealed she used to be the wound treatment nurse and still helps with treatments at times. She revealed she has not seen where treatments haven't been done. She revealed that if she had noticed a wound bandage with an old date then she would have reported that to the DON. She revealed that she thinks the nurses failed to document the care that they did. She revealed that she has honestly forgot to document treatment a few times herself. In an interview on 6/30/25 at 4:59 PM, Registered Nurse (RN) #2 revealed that she is the treatment nurse and works Monday-Friday. She revealed she is new as the treatment nurse and tries to ensure she documents in the system when she provides care. She revealed that she was not sure about the weekend nurses' documentation. Record review of Resident #36's admission Record revealed the facility admitted the resident on 5/8/24 with diagnoses which included Chronic Kidney Disease, Stage 4, and Dementia. Record review of Minimum Data Set (MDS) Section C with Assessment Reference Date (ARD) of 5/27/25 revealed that Resident #36 was rarely or never understood.

Based on observations, staff interviews, record reviews, and facility policy review, the facility failed to prevent the potential spread of infection by not ensuring staff performed proper hand hygiene during three (3) of nine (9) direct care observations. Specifically, staff failed to perform hand hygiene before and after medication administration and during wound care procedures, which poses a risk of cross-contamination and infection transmission. Findings include: Review of the facility policy titled, Hand Hygiene with a revised date of 1/24 revealed the following: Purpose: To cleanse hands to prevent transmission of infection or other conditions . 2. Hand hygiene should be performed between all contact with residents or when entering and exiting a resident's room . Review of the facility policy titled, Dressing Change Policy and Procedure with a revised date of 3/14, revealed the following: .9. Put on disposable gloves. 11.Remove dressing. Pull gloves over dressing and discard them into appropriate plastic waste bag. 12. Perform hand hygiene. Put on disposable gloves. 13. Irrigate/cleanse the area as ordered . 16. Perform hand hygiene. Apply disposable gloves . 18. Dress the area with the prescribed dressing . An observation on 6/30/25 at 7:35 AM revealed that Licensed Practical Nurse (LPN) #1 failed to wash her hands prior to setting up the medications from the medication cart, entered resident room [ROOM NUMBER]A and administered the medications without washing her hands. LPN #1 exited the room and failed to wash her hands or use hand sanitizer before setting up the medication for resident room [ROOM NUMBER]B. LPN #1 entered resident room [ROOM NUMBER]B and administered medications without washing her hands. An interview on 6/30/25 at 7:50 AM, LPN #1 confirmed that she didn't wash or sanitize her hands before setting up or administering both residents' medications. She confirmed that she should have practiced hand hygiene to prevent cross-contamination and prevent infections. LPN #1 stated, I guess I need to go up front and get myself a bottle of hand sanitizer for my cart. On 6/30/25 at 11:00 AM, an observation of wound care provided by Registered Nurse (RN) #2 revealed that RN #2 gathered her supplies, entered Resident #36's room, washed her hands, and donned gloves. RN #2 removed the soiled bandages from the sacral wound, proceeded with the wound treatment and cleaned the sacral wound with normal saline. She then patted dry with a 4x4 gauze, applied mupirocin, covered with hydrofera blue and calcium alginate, and covered the sacral wound with a clean foam dressing. This observation revealed RN #2 did not change gloves or perform hand hygiene between the dirty and clean steps of the wound care procedure. On 6/30/25 at 11:15 AM, RN #2 confirmed that she removed Resident #36's dirty wound dressings, cleaned her wound, and then administered her wound treatment, which included a clean dressing without changing her soiled gloves, washing her hands, and applying clean gloves in between the dirty and clean wound treatment process. She revealed this could contaminate the wound and prevent healing. During an interview on 6/30/25 at 11:30 AM, the Director of Nurses (DON) revealed we have done multiple in-services regarding hand washing. Our expectation is that while administering medications, proper hand hygiene is utilized, which is a vital part of ensuring that we possibly prevent the spread of infections. During a subsequent interview on 6/30/25 at 12:10 PM, the DON stated, It is basic 101 nursing that when doing wound care treatment, you change out your gloves between removing your dirty dressings and cleaning and applying clean bandages. She revealed that not doing proper hand hygiene can aid in the possible spread of a wound infection, and there is no excuse for it. Record review of Resident #36's admission Record revealed the facility admitted the resident on 5/8/24 with diagnoses including Chronic Kidney Disease, Stage 4, and Dementia.

Based on record review, staff interview, and facility policy review, the facility failed to complete and submit a Discharge Tracking Minimum Data Set (MDS) resident assessment to the Centers for Medicare and Medicaid Services (CMS) for a resident who transferred to an acute care facility for one (1) of 16 MDS's reviewed. Resident # 38. Findings Include: Review of the facility policy titled MDS Process with a revision date of 12/20 revealed, The RAI (Resident Assessment Instrument) is the source document to be used for further MDS coding guidelines, time schedules and requirements. Record review of the Progress Notes revealed Resident #38's was transferred to a behavioral health center on 6/25/24 and returned to the facility on [DATE]. Record review of Resident #38's MDS Assessments revealed a discharge tracking assessment was not completed after Resident #38 was transferred to a behavior health center. An interview with the Director of Nursing (DON) on 7/23/2024 at 2:45 PM, confirmed the MDS discharge tracking assessment for Resident #38 was not completed, and it should have been done. An interview with the MDS Nurse on 7/23/2024 at 3:19 PM, confirmed Resident #38 did not have a discharge tracking assessment completed following the transfer to behavioral health. She revealed the facility was in the process of changing over charting systems at the time the assessment was due, and she missed it. She confirmed this should be done for tracking purposes. Record review of the Admission Record revealed the facility admitted Resident #38 on 11/23/2021 and has diagnoses that include Senile degeneration of the brain.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a care plan for nail and oral care (Resident #31) and failed to develop an individualized resident specific comprehensive care plan that identified potential fears, triggers, and/or behavioral expressions along with interventions for a resident with Post Traumatic Stress Disorder (PTSD) (Resident #37) for two (2) of 16 care plans reviewed. Findings Include: Record review of the facility policy, Care Plan Process with revision date of 08/17 revealed .Step 9 .The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs, including culturally competent and trauma-informed as well as, these items or services that would be required but are not due to the exercise of resident rights (refusal) .The facility staff shall follow the care plan . Record review of Resident #31's Care Plan, with no problem onset date, revealed Resident has a dx (diagnosis) of Hemiplegia/Hemiparesis to right side .Approaches .Assist resident with ADLS (Activities of Daily Living) as needed . On 07/22/24 10:00 AM, an observation of Resident #31 revealed he was lying in bed, alert, with his mouth open and his teeth had yellow substance covering all teeth. Observation also revealed brown substance under the fingernails of his left hand. On 07/23/24 at 9:45 AM, an observation with Licensed Practical Nurse (LPN) #1, revealed Resident #31 lying in bed with a yellow substance covering his teeth and a brown substance under the fingernails of his left hand. LPN #1 confirmed that Resident #31 had yellow buildup on his teeth and revealed this could cause tooth decay and other problems with his mouth. On 07/23/24 at 12:30 PM, an interview with DON, revealed that the purpose of the care plan was to show the care that each resident needed so the staff knew how to meet each resident's individual needs. She agreed that the staff did not follow the care plan when they failed to provide oral and nail care for Resident #31. 47874 Resident #37 Record review of Resident #37's Care Plan revealed, Problem Onset: Resident has a DX (diagnosis) of Post Traumatic Stress Disorder/Emotional Trauma. The approaches were not individualized and did not address potential triggers/fears related to her history of trauma. Record review of the facility Social Assessment for Resident #37, dated 5/1/2024 revealed, Resident #37 had not experienced a traumatic event in the past, trauma-related symptoms, nor any impact to her daily routine. An interview with Social Services (SS) #1 on 7/23/2024 at 10:45 AM, revealed Resident #37 did have inappropriate touching behaviors and would touch residents and staff. An interview with LPN #2 on 7/23/2024 at 2:40 PM, confirmed she was aware that Resident #37 had a diagnosis of PTSD, and revealed the resident did not like people to hug her. An interview with the Director of Nursing (DON) on 7/23/2024 at 2:53 PM, confirmed a comprehensive resident specific care plan was not developed to include Resident #37's fears and possible triggers for re-traumatization and behavior expressions staff should be aware of. She revealed the care plan was not developed because the trauma informed care assessment was not completed. An interview with the Minimum Data Set (MDS) Nurse on 7/23/2024 at 3:45 PM, revealed the purpose of the care plan was to know how to care for the resident. She confirmed the care plan for Resident #37 was not individualized and did not address possible triggers or resident specific approaches for PTSD.

Based on observation, staff interview, and facility policy review the facility failed to provide Activities of Daily Living as evidenced by failure to provide daily oral care and nail care for one (1) of 16 residents reviewed. (Resident #31) Findings Included: Record review of the facility policy, Oral Hygiene with revision date of 10/17 revealed Purpose: To clean the mouth, teeth, gums .To remove bacteria and odor . Procedure .1. Offer oral hygiene before breakfast, and at bedtime . Record review of the facility policy, Nail Care with review date of 01/24 revealed Purpose: To promote cleanliness, safety and a neat appearance . Procedure .7. Remove any debris from under the nails with the orangewood stick . On 07/22/24 at 10:00 AM, an observation of Resident #31 revealed he was lying in bed, alert with his mouth open and a yellow substance covering all of his teeth. An observation of his hands revealed a brown substance under the fingernails of his left hand. On 07/23/24 at 9:45 AM, an observation with Licensed Practical Nurse (LPN) #1, revealed Resident #31 lying in his bed with a yellow substance covering his teeth and a brown substance under the fingernails of his left hand. LPN #1 confirmed that he had yellow buildup on his teeth and revealed this could cause tooth decay and other problems with his mouth. She revealed that the Certified Nursing Assistants (CNA)s were supposed to do mouth care every day and usually did this during their morning rounds while they were doing their baths. LPN #1 revealed they used mouth swabs to clean Resident #31's teeth because they were afraid of aspiration if they tried to brush his teeth. She agreed that Resident #31's mouth care had not been done. LPN #1 also confirmed the brown substance under the fingernails of Resident #31's left hand and stated, I will find some clippers and do the nails now. She revealed that they scheduled fingernails to be clipped every Sunday, but nails should be looked at every day and checked for cleanliness. LPN #1 agreed dirty fingernails could cause infection if he scratched himself and the CNAs should have taken care of this. On 07/23/24 at 9:50 AM, an interview with Director of Nursing (DON), revealed mouth care was supposed to be completed at least once a day. She revealed the CNAs were responsible for completing mouth care and they used mouth swabs if the residents couldn't tolerate brushing their teeth. The DON confirmed personal hygiene included nail care and mouth care. She revealed that the CNAs were responsible for checking fingernails and this should be done every day. She also revealed that failure to provide nail care and oral care was unacceptable and could cause sores in the mouth, tooth decay and other problems. The DON stated, This makes me angry. Record review of Resident #31's Face Sheet revealed an admitted [DATE] and included diagnoses of Parkinson's Disease, Dysphagia following Cerebral Infarction, and Cognitive Communication Deficit.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to complete a Trauma Informed Care Assessment for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) for one (1) of 1 resident reviewed for Trauma Informed Care. Resident #37 Findings Include: Review of the facility policy titled Social Documentation - Progress Notes with a revision date of 10/23 revealed under, Policy: Social Progress Notes should be entered into the resident's Medical Record during the observation period of each MDS (Minimum Data Set) and whenever unusual circumstances occur, or for changes in resident condition or status. An observation and interview with Resident #37 on 7/22/2024 at 12:35 PM, revealed she was sitting in a wheelchair in her room. Resident was verbal with few words and stated, I'm fine. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/2/2024 revealed, under section I, Resident #37 has a medical diagnosis of PTSD. Also revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicates the resident is cognitively intact. An interview with Social Services #1 (SS) on 7/23/2024 at 10:45 AM, explained that social assessments were due quarterly, and Resident #37 was upcoming but had not been completed yet. SS #1 confirmed she was aware that Resident #37 had a history of traumatic events, and revealed she was notified upon starting the social services position. She revealed to her knowledge the resident was diagnosed with PTSD after she was sent for a behavioral health stay and confirmed the facility did not have a social assessment that identified she had a traumatic history. Record review of Resident #37's Psychiatric Evaluation from the behavior health stay, dated 8/20/2022, revealed (Traumatic event) as a teen. States has bad dreams about it a lot. Also revealed under, Plan: Add Zoloft (anti-depressant) .daily for questionable PTSD symptoms. Record review of the facility Social Assessment for Resident #37, dated 5/1/2024 revealed, Resident #37 had not experienced a traumatic event in the past nor experienced any trauma-related symptoms. An interview with Licensed Practical Nurse (LPN) #2 on 7/23/2024 at 2:40 PM, revealed she was the nurse caring for Resident #37 today. She confirmed she was aware that the resident had a diagnosis of PTSD and revealed the resident did not like people to hug her. An interview with the Director of Nursing (DON) on 7/23/2024 at 2:53 PM, confirmed Resident #37 did not have a trauma informed care assessment completed to address the resident's diagnosis of PTSD and revealed it should have been done to address any symptoms and possible triggers. Record review of the Admission Record revealed the facility admitted Resident #37 on 6/25/21 with medical diagnoses that included Personal history of traumatic brain injury and Unspecified convulsions. A medical diagnosis of Post-Traumatic Stress Disorder was added to the resident's diagnoses list on 8/26/2022.

Based on staff interview, record review and facility policy review, the facility failed to notify the physician of the failure to obtain a medication for one (1) of 16 medications reviewed. Resident #18. Findings include: Review of the facility policy titled Drug Administration and Documentation, latest revision date 04/21, revealed, .If a dose of regularly scheduled medication is refused, held or for some reason not given for more than 2 doses in a row, notify the physician . During medication administration observation for Resident #18 with Licensed Practical Nurse (LPN) #2 on 6/7/23 at 7:45 AM, she revealed she was unable to give Resident #18 the Clopidogrel 75 milligram (mg) as ordered, revealing the medication had not been delivered from the pharmacy. LPN #2 stated the Plavix was ordered on 6/2/23 after the resident returned from a physician visit. Record review of the Physician Consultation Report dated 6/2/23, revealed, Findings: Mixed disease in the RLE (right lower extremity). PAD (Peripheral Arterial Disease) and Chronic Venous Insufficiency with nonhealing ulcer of RT (right) foot . New Orders: Start Plavix Daily . A review of the Physician's Orders for Resident #18 revealed Clopidogrel 75 mg tablet give one tablet daily at 8:00 AM with an order date of 6/2/23. During an interview with the Director of Nursing (DON) on 6/07/23 at 8:00 AM, she revealed she was unaware Resident #18 did not have his Clopidogrel. The DON revealed the resident has poor circulation and confirmed by not receiving the Plavix as ordered placed Resident #18 at risk for further circulation concerns and possible blood clots. In an interview with the DON and LPN #2 on 6/07/23 at 8:20 AM, LPN #2 confirmed she had not notified anyone of needing the Clopidogrel. On 6/07/23 at 3:10 PM, during a phone interview with LPN #3 confirmed the Clopidogrel was not in the facility the 6/3/23 or 6/4/23 when she worked. She confirmed she did not notify the pharmacy or the physician. LPN #3 confirmed she should have contacted the resident's physician and the pharmacy of these concerns. An interview with Registered Nurse (RN) #1 on 6/08/23 at 8:15 AM, confirmed if a nurse is unable to get a medication the physician needs to be notified. During an interview with the Administrator on 6/08/23 at 8:28 AM, she revealed the nurses did not give the Clopidogrel as ordered and failed to notify the pharmacy of the medication order and did not notify the physician of not having the medication to be administered. Record review of the Admission Record revealed that the facility admitted Resident #18 to the facility on [DATE] with diagnoses of Atrial Fibrillation, Heart Failure, and Atherosclerotic Heart Disease of Coronary Arteries.

Based on observation, resident and family interview, staff interview, record review, and facility policy review the facility failed to ensure residents were free from restraints for one (1) of 59 residents reviewed. Resident #42 Findings Include: Record Review of the facility policy titled, Restraints and Safety Devices, with a revision date of 10/22, revealed, It is the philosophy of this facility that a resident has the right to be free from any physical or chemical restraints . An observation on 6/6/23 at 9:15 AM, revealed Resident #42 was in the bed laying on a winged mattress with full siderails in the upright position on both sides of the bed. During an interview with Resident #42 on 6/6/23 at 9:16 AM, she shook her head no when asked if she knew why she was on the winged mattress and had full siderails up on either side of the bed. A record review of Resident #42's Physician Orders , dated June 2023 revealed that she did not have an order for a winged mattress or full side rails. A record review of Resident #42's Nurse Data Collection and Screening, completed on 5/17/23, revealed that she did not have a bed rail or a restraint in use. A record review of Resident #42's medical record revealed she did not have a consent or assessment for the use of the winged mattress or full siderails. An observation of Resident #42 on 6/7/23 at 4:00 PM, revealed she was in bed laying on a winged mattress with full siderails in the upright position on both sides of the bed. During an interview on 6/7/23 at 4:02 PM, with Resident #42's Resident Representative (RR), she stated she did not know anything about the winged mattress or full side rails and stated that Resident #42 did not like the mattress. During an interview with Resident #42 on 6/7/23 at 4:04 PM, she shook her head no when asked if she liked the winged mattress. Resident #42 shook her head yes when asked if the mattress was uncomfortable. During an interview with Licensed Practical Nurse (LPN) #1 on 6/7/23 at 4:20 PM, she stated that winged mattresses are used to prevent residents from falling out of bed. She stated that they only used one-half (1/2) side rails in the facility for bed mobility. She stated that if a resident had a winged mattress or full side rails, then they would not have a Physician's order for them. The order would not show up on the electronic Medication Administration Record (eMAR). She stated she would know if a resident was supposed to have a winged mattress or full side rails because she would be told in report. LPN #1 stated that she was familiar with Resident #42 and the resident did not have a winged mattress or full side rails. During an interview with the Minimum Data Set (MDS) Nurse on 6/7/23 at 4:30 PM, she stated that if a resident had a winged mattress or full side rails, then they would have a physician's order, assessment, and care plan. She stated that Resident # 42 did not have a winged mattress, full side rails, physician's orders for a winged mattress and side rails, or a care plan for a winged mattress and side rails. She stated when she did the Admission MDS she would have seen it and questioned it. The MDS Nurse stated that Resident # 42 moved rooms and if she now has a winged mattress and full side rails it is likely because that was the bed in the room when she moved into it. During an interview on 6/7/23 at 4:42 PM, with the Director of Nursing (DON) she stated that if a resident had a winged mattress or full side rails they should have a physician's order, assessment, and care plan; and that it would show up on the eMAR for the staff to know that the resident was supposed to have it. During an observation and interview with the DON on 6/7/23 at 4:45 PM, she verified that Resident #42 did have a winged mattress and full side rails on her bed and that she should not have them. The DON stated that these items were a restraint and if the resident attempted to get out of bed with them in place she could fall and injure herself. During an interview with the Administrator on 6/8/23 at 8:15 AM, she verified that the side rails on Resident #42's bed were 54 inches long. Record review of the Face Sheet revealed that the facility admitted Resident #42 to the facility on [DATE] with a diagnosis of Cerebral Infarction. Record review of the MDS Section C with an Assessment Reference Date (ARD) date of 5/17/23, revealed that Resident #42 had a Brief Interview for Mental Status (BIMS) score of seven (7) which indicated that she was moderately cognitively impaired.

Based on observation, staff interview, record review, and facility policy review the facility failed to assure that services were being provided according to accepted standards of clinical practice as evidenced by Clopidogrel (Plavix) signed off as administered on the medication record for Resident #18 by staff on four (4) consecutive days when the medication had not been dispensed by a pharmacy for one (1) of 16 medications reviewed. Findings include: A review of the facility policy titled, Administration of Medications, revised 10/17, Purpose: To administer medications in accordance with best practice. During medication administration observation for Resident #18 with Licensed Practical Nurse (LPN) #2 on 6/7/23 at 7:45 AM, she revealed she was unable to give Resident #18 the Clopidogrel 75 milligram (mg) as ordered, revealing the medication had not been delivered from the pharmacy. LPN #2 stated the Plavix was ordered on 6/2/23 after returning from a physicians visit. A review of the Physician's Orders for Resident #18 revealed Clopidogrel 75 mg tablet give one tablet daily at 8:00 AM with an order date of 6/2/23. A review of the Physician Consultation Report dated 6/2/23, revealed under New Orders: Start Plavix Daily . A review of the Electronic Medication Administration Record (e-MAR) for June 2023, revealed Clopidogrel 75 mg tablet daily at 8:00 AM was signed off as administered by LPN #3 on June 3rd and 4th and by LPN #2 on June 5th and 6th. An interview with the Director of Nursing (DON) on 6/07/23 at 8:00 AM, she revealed she was unaware Resident #18 did not have his Clopidogrel and confirmed the Resident has poor circulation and not receiving the Clopidogrel as ordered placed Resident #18 at risk for further circulation concerns and possible blood clots. An interview with the DON and LPN #2 on 6/07/23 at 8:20 AM, the State Agency (SA) presented the e-MAR record to LPN #2 and asked if she administered the Clopidogrel to Resident #18 on June 5th and 6th as it was signed off as administered. LPN #2 revealed to the SA and DON she did not give the Clopidogrel stating I guess I was just clicking the e-MAR. LPN #2 confirmed she should not have signed the medication as given. A phone interview with LPN #3 on 6/07/23 at 3:10 PM, she revealed she did not administer the Clopidogrel 75 mg because she questioned where the order came from. SA questioned LPN #3 as to why the medication record had her initials as Plavix being administered. LPN #3 revealed she should not have signed the Clopidogrel as given stating I must have been clicking the computer screen to fast. LPN #3 confirmed the medication was not in the facility and she should not have signed the Clopidogrel off because it was not given. An interview with the Minimum Data Set Nurse (MDS) on 6/07/23 at 1:30 PM, she revealed she called and spoke with a pharmacist at the pharmacy and the pharmacist revealed there was no record of an order for Clopidogrel for Resident #18 until the DON called this morning on 6/7/23. An interview with the Administrator on 6/08/23 at 8:28 AM, she revealed the nurses did not give the Clopidogrel as ordered. The Administrator confirmed LPN #2 and LPN #3 did not follow the standards of practice for medication administration when they signed off medications as given when the medication was not delivered until 6/7/23. Record review of the Admission Record revealed that the facility admitted Resident #18 to the facility on [DATE] with diagnoses of Atrial Fibrillation, Heart Failure, and Atherosclerotic Heart Disease of Coronary Arteries. Record review of the MDS with an Assessment Reference Date (ARD) of 3/16/23 with a Brief Interview of Mental Status (BIMS) score of 15 which indicates Resident #18 is cognitively intact.

Based on observation, staff interview, record review, and facility policy review the facility failed to meet the pharmaceutical needs of a resident when staff failed to obtain and provide the medication Clopidogrel for Resident #18 for one (1) of 16 medications reviewed. Findings include: A review of the facility policy titled, Physician Orders, revised 1/23, revealed It is the policy of the facility that all physician's orders will be implemented timely and carried out in a professional manner . An order for medication or supplies shall be placed to the pharmacy or appropriate supplier. A medication administration observation for Resident #18 with Licensed Practical Nurse (LPN) #2 on 6/7/23 at 7:45 AM, revealed she was unable to give Resident #18 the Clopidogrel 75 milligram (mg) as ordered. She revealed the medication had not been delivered from the pharmacy. LPN #2 stated the Clopidogrel was ordered on 6/2/23 after the resident returned from an outside appointment. She confirmed she faxed the order to the pharmacy that day. LPN #2 also revealed when she came back to work on Monday 6/5/23 the medication was not in the facility, so she notified pharmacy again on 6/5/23 and 6/6/23 and the physician of not having the medication to administer. A review of the Physician's Orders for Resident #18, revealed Clopidogrel 75 mg tablet give one tablet daily at 8:00 AM with an order date of 6/2/23. A review of the Physician Consultation Report dated 6/2/23, revealed under New Orders: Start Plavix Daily . During an interview with the Director of Nursing (DON) on 6/07/23 at 8:00 AM, she revealed she was unaware Resident #18 did not have his Clopidogrel. A review of the emergency drug kit with the DON revealed there is no Clopidogrel on the formulary list. The DON placed a call to pharmacy to have the medication sent from back-up pharmacy. The DON revealed the resident has poor circulation and confirmed by not receiving the Plavix as ordered placed Resident #18 at risk for further circulation concerns and possible blood clots. In an interview with the DON and LPN #2 on 6/07/23 at 8:20 AM, revealed the DON asked LPN #2 Who did you report to that Resident #18 needed Clopidogrel and if you notified the pharmacy who did you speak with. LPN #2 confirmed she had not notified anyone of needing the Clopidogrel. Record review of the Electronic Medication Administration Record (EMAR) revealed an order dated 6/2/23 Clopidogrel 75 mg tablet, oral 8a (AM) daily. Give 1 tab (tablet) by mouth daily. Documentation on the EMAR revealed staff initials were listed on 6/3/23 through 6/6/23 indicating the medication had been administered. An interview with the Administrator on 6/07/23 at 1:20 PM, revealed LPN #2 failed to order the Clopidogrel when she obtained the order on 6/2/23. During an interview with the Minimum Data Set Nurse (MDS) on 6/07/23 at 1:30 PM, revealed she called and spoke with a pharmacist at the pharmacy and the pharmacist revealed there was no record of an order for Clopidogrel for Resident #18 until the DON called this morning 6/7/23 at 8:02 AM. During a phone interview with LPN #3 on 6/07/23 at 3:10 PM, confirmed the Clopidogrel was not in the facility the 6/3/23 or 6/4/23 when she worked. She confirmed she did not notify the pharmacy or the physician. LPN #3 confirmed she should have contacted the resident's provider and the pharmacy of these concerns. An interview with Registered Nurse (RN) #1on 6/08/23 at 8:15 AM, revealed all new medication orders are faxed to the Pharmacy to be filled and delivered. She went on to say if orders are received after hours, the pharmacy has an on-call pharmacist, and they would notify a local pharmacy that contracts to delivery any medications needed immediately. RN #1 confirmed if a nurse is unable to get a medication the physician needs to be notified. During an interview with the Administrator on 6/08/23 at 8:28 AM, she revealed the nurses did not give the Clopidogrel as ordered and failed to notify the pharmacy of the medication order and did not notify the physician of not having the medication to be administered. The Administrator confirmed the Clopidogrel was not delivered until 6/7/23 and confirmed LPN #2 and LPN #3 should have followed up with pharmacy and notified the DON they did not have the medication. Record review of the Admission Record revealed that the facility admitted Resident #18 to the facility on [DATE] with diagnoses of Atrial Fibrillation, Heart Failure, and Atherosclerotic Heart Disease of Coronary Arteries. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 3/16/23 revealed Resident #18 had a Brief Interview of Mental Status (BIMS) score of 15 which indicates Resident #18 is cognitively intact.

Based on record review, staff interview, and facility policy review the facility failed to establish and maintain an infection prevention and control program designed to help prevent transmission of communicable diseases and infections as evidenced by failure to administer a second step Tuberculin (TB) skin test to employees prior to working in the facility for one (1) of 10 employees reviewed. Findings include : Review of the facility policy titled, TB Testing MS, with a revision date of 7/19 revealed, II: Employee Testing for Tuberculosis .Baseline .Employees with a negative tuberculin skin test and a negative symptom assessment shall have the second step of the the two-step Mantoux tuberculin skin test, administered, read, and documented in the employee's personnel record within fourteen (14) days of employment. A record review of the Maintenance Supervisor's EmployeeTuberculin TB Test Record revealed he received a step-one (1) Tuberculin purified protein derivative (PPD) skin test on 4/12/23 with a reading of 00 millimeters (mm) on 4/14/23. There is no evidence that the Maintenance Supervisor was offered or received a second step TB skin test. During an interview with Licensed Practical Nurse (LPN) Assessment Nurse on 6/8/23 at 11:45 AM, she stated that the Maintenance Supervisor did not receive a second step TB skin test. She stated that she previously administered TB skin testing but was moved into a different position. She stated now the Director of Nursing (DON) is responsible for the TB skin testing and she tries to help her. During an interview with the Administrator on 6/8/23 at 11:50 AM, she stated that she thought the LPN Assessment Nurse was responsible for administering the TB skin testing. During an interview with the DON on 6/8/23 at 12:35 PM, stated that the Staff Development Coordinator (SDC) is responsible for TB skin testing. She stated that the LPN Assessment Nurse was moved out of the SDC role, so she and the LPN Assessment Nurse have both been doing the TB Skin tests. The DON confirmed that during the time the facility was looking for a SDC there was not a consistent plan in place to ensure a TB test was not missed. She stated not doing a TB skin test on a staff or resident could cause the spread TB in the facility.

Based on record review, policy/procedure review, and interviews, the facility failed to follow the Advance Directive of one (1) of eight (8) residents reviewed as evidenced by Resident #1 had an Advance Directive to provide Cardio-pulmonary Resuscitation (CPR) if medically necessary. Resident #1 was found unresponsive on [DATE] at approximately 8:30 PM, and CPR was not initiated. Resident #1 expired. The failure of the facility to honor Resident #1's Advance Directive to initiate CPR placed Resident #1 and other residents with an Advance Directive in a situation that was likely to cause serious injury, harm, impairment or death. The situation was identified to be an Immediate Jeopardy (IJ) that began on [DATE], when CPR was not provided to Resident #1 per Advance Directive and the resident expired. The State Agency (SA) notified the Administrator on [DATE] at 5:00 PM, of the IJ. The facility provided an acceptable Corrective Action Plan (CAP) on [DATE], in which the facility alleged removal of the IJ on [DATE]. The SA validated the CAP and determined the IJ was removed on [DATE], prior to Surveyor entrance on [DATE]. FINDINGS INCLUDE: Review of the facility's Advanced Directives policy and procedure, last revised on ,[DATE], revealed It is the policy of the facility to encourage residents and their family/caregivers to participate in decisions regarding care and treatment. Valid Advance Directives, such as Living wills, Durable Powers of Attorney for Health Care and DNR (Do not resuscitate) orders will be followed to the extent permitted and required by law. The facility will not determine the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an Advance Directive. Nothing contained in the facility's admission criteria shall be deemed to discriminate against an individual based upon his or her Advance Directive status. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE], and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review revealed a Patient self Determination Act of 1990 Advance Directive Acknowledgment Form, dated [DATE], and signed by Resident #1, the Physician, and the Responsible Party (RP) was present. The Resident/family consent for Cardiopulmonary Resuscitation, dated [DATE] and the most recent consent, dated [DATE], revealed that the resident's Responsible Party (RP) marked that Resident #1 should have CPR done in the case of extreme emergency. Review of a Directive to Physician/DNR Order form from Hospice, dated and signed by the RP on [DATE], revealed a check mark in the section I wish to be a full code. Review of Nurse's Notes, an Incident report, and the facility investigation, revealed on [DATE], at approximately 8:30 PM, Certified Nursing Assistant (CNA) #1 found Resident #1 unresponsive and not breathing in her bed. CNA #1 alerted Licensed Practical Nurse (LPN) #1, who assessed the resident and found no respiration or pulse. LPN #2 also assessed Resident #1 and observed no respiration or pulse. LPN #1 and LPN #2 discussed that Resident #1 was a new Hospice patient and LPN #1 called Hospice with Resident #1's condition. LPN #1 spoke with the Hospice Nurse on [DATE] at approximately 8:34 PM, reporting that Resident #1 appeared to have expired. Before 9:00 PM, LPN #1 reviewed Resident #1's record and discovered the Resident had an Advance Directive for a full code. At approximately 9:00 PM, the Hospice nurse called and confirmed Resident #1 was a full code. CPR was not initiated by LPN #1 or LPN #2. Both LPNs were terminated for not providing CPR to a full code resident. An interview with LPN #1 on [DATE] at 11:55 AM, revealed she last saw Resident #1 responsive was at 6:00 PM on [DATE], during a medication pass. LPN #1 stated at approximately 8:30 PM on [DATE], CNA #1 came and reported she found Resident #1 unresponsive. LPN #1 assessed the resident finding no pulses or respiration. She asked CNA #1 to get LPN #2. She stated that LPN #2 assessed Resident #1, confirming there were no pulses or respiration. LPN #1 stated she called Hospice and was told they would be at the facility in an hour. She then continued to pass medications. LPN #1 stated as she got to the nurse's station, CNA #3 and LPN #2 were talking about a code status; LPN #2 was saying she didn't think Resident #1 was a full code because she was on Hospice, and the chart documented Don't call 911, call Hospice. LPN #1 stated, she and LPN #2 checked the chart and saw where Resident #1 was a full code; probably around 8:50 PM to 8:55 PM. She stated LPN #2 said they may have to start this code, then said the resident's chart hadn't been updated since (YEAR),and she was just put on Hospice. LPN #1 stated LPN #2 instructed her to call Hospice back and ask the Hospice nurse about Resident #1's code status. LPN #1 stated Resident #1 was a full code and they had done nothing at that point about CPR. LPN #1 stated she called RN #2 and reported Resident #1 had expired, Hospice had been called, family had been notified, and time had passed before they saw the resident was a full code. LPN #1 stated that RN #2 informed her to call 911. LPN #1 stated she let LPN #2 know and LPN #2 said it would be disrespectful to have told the family she had expired, then to start a full code after all that time, and family was on the way. LPN #1 stated they waited for the Hospice Nurse and Coroner to arrive. She confirmed CPR was not initiated for Resident #1. Interview on [DATE] at 11:58 AM, with LPN #2, revealed she assessed Resident #1 on [DATE] when LPN #1 asked for her. She stated, You automatically think no code when it's a Hospice patient. I thought she'd already called Hospice. She stated, I asked her if Resident #1 was a no code or not. (LPN #1) said I would think she is a no code. She's on Hospice. I had not checked the code status. The chart, when I checked it, had a (YEAR) Advance Directives. It had not been updated since. I told LPN #1 to call Hospice Nurse again and ask her what to do. (RN #1) called me. (RN #1) didn't tell me what to do. No one told us to do a code on this lady. I saw the Advance Directives, yes. But she had just come back from the hospital. I was thinking there were some updated orders regarding code status. Resident #1 was cool to the touch, her face discolored. It was around 8:40 PM when I went in there. I though LPN #1 knew the lady's code status, I though LPN #1 knew she was a no code. She asked me to check her. I thought she just wanted confirmation she had expired. I did think if a patient is on Hospice, they are a Do Not Resuscitate (DNR). Interview with the RP of Resident #1, on [DATE] at 2:00 PM, revealed, I got there after she died . There wasn't anyone helping her. The RP stated that he signed the papers for Resident #1 to get help and CPR if she needed it. He stated, There wasn't even an ambulance there that night. I haven't looked at any paperwork, but I know if I did, I'd see no one helped her. Interview with RN #1 on [DATE] at 11:10 AM, revealed she talked to RN #2 about 9:15 PM on [DATE], who reported staff at the facility called about Resident #1's code status; they had checked the chart and she was a full code and she had expired and wanted to know since she was on Hospice, had the code status changed to a DNR. RN #1 stated she checked with Hospice and found that the resident was a full code on their paperwork. RN #1 stated she called LPN #2 and told her Resident #1 was still a full code and they needed to perform CPR and LPN #2 said it had been 30 minutes since they found her unresponsive. She stated, I told her to do CPR and get someone to call 911 since she was a full code. She stated that LPN #2 said she didn't feel comfortable calling 911, or starting CPR, because Hospice had called the son and told him Resident #1 had expired. Interview with the DON on [DATE] at 2:00 PM, revealed she was called at approximately 9:28 PM on [DATE] by the Assessment Nurse and told that Resident #1 was found unresponsive and no code was done and she was a full code. She stated she arrived at the facility about 10:06 PM. She stated she had LPN #1 and LPN #2 come into her office and explained to them the severity of what happened, they they did not do a code when they should have. She stated that LPN #2 said she didn't know a resident on Hospice could be a full code. The DON stated, Yes, we do cover Advance Directives, CPR and DNR on hire and annual in-services. (LPN #2) said because the family had been told the resident was deceased , she didn't want them to come and see them coding her. The DON stated that LPN #2 said, We decided to not do a code. The DON said that LPN #1 and LPN #2 were suspended and then terminated for failure to follow the Advance Directive for providing CPR on a full code resident, Resident #1. On [DATE] at 5:00 PM, the SA notified the facility's Administrator that the failure of the facility not following the Advanced Directive for providing CPR to Resident #1 was deemed an Immediate Jeopardy (IJ). The facility submitted the following Corrective Action Plan: 1. On (MONTH) 8, (YEAR), at approximately 7:40 PM, Certified Nursing Assistant (CNA) #2 entered the room of Resident #1 and Resident #1 appeared to be sleeping. Certified Nursing Assistant (CNA) #1, at approximately 8:30 PM, went to check on Resident #1 and found that Resident 1 was not breathing. CNA #1 stepped out into the hallway and called Licensed Practical Nurse (LPN) #1 and LPN #1 immediately went into Resident #1's room. Resident #1 was lying on the bed and noted to be unresponsive. LPN #1 checked for a radial and carotid pulses and found none. Resident #1 was observed for respirations and none were noted. LPN #1 sent Certified Nursing Assistant (CNA) to call Licensed Practical Nurse (LPN) #2 to come to Resident #1's room to assess resident. LPN #2 observed no respirations or pulse. It was discussed by LPN #1 and LPN #2 about patient being newly admitted to Hospice services. LPN #1 opened Resident #1's chart finding an instruction sheet stating, Don't Call 911, call Hospice First. LPN #1 called Hospice with Resident #1's condition. LPN #1 spoke with the Hospice Nurse on [DATE] at approximately 8:34 PM reporting that Resident #1 appeared to have expired. Hospice Nurse stated, OK, I will be at the facility in about 1 hour. Shortly after 8:34 PM and before 9:00 PM on [DATE], LPN #2, CNA #3, CNA #2, and CNA #1 were at the nurse's desk discussing if anything else needed to be done and the code status for Resident #1 was brought up by CNA #3. LPN #1 was made aware of conversation, pulled Resident #1's chart and found that Resident #1 was a full code. At approximately 9:00 PM on [DATE], Hospice Nurse called and spoke with LPN #1 and confirmed that Resident #1 was a full code. At this time, Cardiopulmonary Resuscitation was not initiated. LPN #2 accepted a phone call from Resident #1's Resident representative on [DATE], at approximately 9:00 PM, stating that he was called by Hospice Nurse informing him that his mother was deceased . 2. On [DATE], at approximately 9:40 PM, the Coroner arrived at the facility. Director of Nursing (DON) was notified of the events surrounding the expiration of Resident #1 on [DATE], at approximately 9:28 PM by Assessment Nurse. The Administrator was notified of the events surrounding the expiration of Resident #1 on [DATE], at 9:27 PM by Registered Nurse #1. The Medical Director/Physician was notified by the DON on [DATE], at 10:39 PM that Resident #1 was a full code, found unresponsive and Cardiopulmonary Resuscitation (CPR) was not initiated and resident expired. 3. The DON arrived at the facility at approximately 10:00 PM on (MONTH) 8, (YEAR), and began the investigation regarding the event with Resident #1. Interviews and statements were taken from LPN #1 & LPN #2 and CNA #1 and CNA #2 regarding their knowledge of the events surrounding the failure to initiate CPR on Resident #1. LPN #1 and LPN #2 were suspended on 9//,[DATE], at approximately 11:00 PM, pending the outcome of the investigation for failure to perform CPR. 4. The facility corrective actions were initiated on (MONTH) 8, (YEAR), at approximately 10:30 PM, by the DON with inservice training with three (3) Licensed Practical Nurses, seven (7) Certified Nursing Assistants and one (1) laundry personnel. The in-service included facility policies on Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR), Incident Investigation and Reporting, Resident Rights, following Care Plan related to Code Status/Full Code/DNR, Advance Directives related to residents' preferences of Code Status, Emergency Care of All Residents (knowing when to call 911), and Abuse and Neglect. 5. Facility Quality Assurance Committee Meeting was held at 10:00 AM, Sunday, (MONTH) 9, (YEAR), with the committee consisting of facility DON, Administrator, Medical Director, Health Information Services, Assessment Nurse and RN #1. The topics discussed were failure to initiate Cardiopulmonary Resuscitation on Resident #1, failure to follow Advance Directive Form, and continuing of inservices for staff that began on [DATE]. the DON continued inservices with scheduled staff on Cardiopulmonary Resuscitation Policy-Full Code, No Code (DNR), Incident Investigation and Reporting, Resident Rights, Care Plan Process, Advance Directives and Emergency Care of Residents. 6. On (MONTH) 9, (YEAR), all active residents' medical record charts were audited by Health Information Services and Assessment Nurse to ensure proper code status identification. The audit consisted of the care plans, the physician orders [REDACTED]. 7. On (MONTH) 9, (YEAR), an audit was completed by the Health Information Services and Assessment Nurse on any resident who had expired in facility since last annual survey, (MONTH) 26, (YEAR). The audit was to ensure the proper code status was followed and the completed audit showed no issues. 8. Registered Nurses and Licensed Practical Nurses will not be allowed to provide direct care until participation in the inservices addressing Cardiopulmonary Resuscitation Policy-Full Code, No Code (DNR), Incident Investigation and Reporting, Resident Rights, Care Plan Process, Advance Directives and Emergency Care of Residents. 9. On (MONTH) 10, (YEAR), Administrator and DON terminated LPN #2 for failure to implement policy and procedure related to Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR). 10. On (MONTH) 10, (YEAR), DON attempted to contact Licensed Practical Nurse #1 via telephone, without success. LPN #1 was terminated from employment for failure to implement policy and procedure related to Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR). 11. (MONTH) 10, (YEAR), Cardiopulmonary Resuscitation CPR Code Drills were initiated by the facility Registered Nurse #2 and the Director of Nursing to include two (2) Registered Nurses,six (6) Licensed Practical Nurses, 14 Certified Nursing Assistants, three (3) Nursing Assistant Trainees, five (5) Office Personnel, two (2) Dietary Staff, and four (4)Laundry/Housekeeping Staff. Registered Nurses and Licensed Practical Nurses will not be allowed to provide direct care until participation in CPR Code Drill has been conducted. 12. The Administrator reported the incident involving Resident #1 to The Mississippi State Department of Health on (MONTH) 9, (YEAR), at 11:05 AM. The Administrator reported the incident to Attorney General Office on (MONTH) 9, (YEAR), at 3:22 PM. The Administrator reported the incident to the Police Department on (MONTH) 9, (YEAR), at 10:25 AM. The Police Department responded at facility to fulfill requirements for Elder Justice Act on (MONTH) 9, (YEAR) at 10:35 AM. The Administrator reported to Mississippi Board of Nursing on (MONTH) 9, (YEAR), at 11:10 AM that CPR was not initiated on Full Code Resident #1. 13. On (MONTH) 10, (YEAR), the Administrator and DON notified the Resident Representative at his home, to discuss the events of (MONTH) 8, (YEAR), involving Resident #1. Resident Representative was informed of Resident #1's condition and that a Full Code was not performed. 14. On (MONTH) 9, (YEAR), monitoring systems were put in place to sustain compliance (a) The facility began conducting Cardiopulmonary Resuscitation Code Drills on all three (3) shifts weekly for four (4) weeks, then all three (3) shifts monthly for three (3) months, and then all three (3) shifts quarterly thereafter, by the Director of Nursing and/or Registered Nurse #2. (b) all active resident medical records and plans of care will be monitored for the correct code status identification weekly for one (1) month, then bi-weekly for three (3) months, and then monthly until resolved by Health Information Services. (c) The Cardiopulmonary Resuscitation Certification status of each licensed nurse will be checked for each nurse upon hire and then monthly by Director of Nursing. The facility alleges that all corrective actions were completed on (MONTH) 10, (YEAR). The facility believes the IJ was removed as of (MONTH) 11, (YEAR). The SA validate the Corrective Action Plan through record review, sign-in sheet review, interview with staff throughout all disciplines and interview with Administrative Staff. 1. The SA validated by interviews with the Nursing and Administrative Staff and record review that Resident #1 was found unresponsive and without pulse or respiration on [DATE] at approximately 7:40 PM. The SA validated that LPN #1 and LPN #2 did not initiate CPR on Resident #1. The SA validated that Hospice was contacted and the full code status was validated by the Hospice Nurse. The Full code status was also documented in the medical record as an order and Advance Directive. The SA validated an instruction sheet in Resident #1's chart that documented Don't Call 911, call Hospice First. The SA validated that LPN #2 accepted a phone call from Resident #1's Resident representative on [DATE], at approximately 9:00 PM, stating that he was called Hospice Nurse informing him that his mother was deceased . 2. The SA validated by record review and interviews that on [DATE], at approximately 9:40 PM, the Coroner arrived at the facility, the DON was notified of the events surrounding the expiration of Resident #1 on [DATE], the Administrator was notified of the events surrounding the expiration of Resident #1 on [DATE], and the Medical Director/Physician was notified by the DON on [DATE], at 10:39 PM that Resident #1 was a full code, found unresponsive and Cardiopulmonary Resuscitation (CPR) was not initiated and resident expired. 3. Through record review and interview, the SA validated that the DON began an investigation on (MONTH) 8, (YEAR), regarding the event with Resident #1, which included interviews and statements from LPN #1 & LPN #2 and CNA #1 and CNA #2 regarding their knowledge of the events surrounding the failure to initiate CPR on Resident #1. The SA validated that LPN #1 and LPN #2 were suspended on 9//,[DATE], pending the outcome of the investigation for failure to perform CPR. 4. The SA validated by record review, sign-in sheet review, and interview that in-service training was initiated [DATE], including review of facility policies on Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR), Incident Investigation and Reporting, Resident Rights, following Care Plan related to Code Status/Full Code/DNR, Advance Directives related to residents' preferences of Code Status, Emergency Care of All Residents (knowing when to call 911), and Abuse and Neglect. The in-service included three (3) Licensed Practical Nurses, seven (7) Certified Nursing Assistants, and one (1) laundry personnel. 5. The SA validated through interview and record review of a sign-in sheet, that the facility Quality Assurance Committee Meeting was held at 10:00 AM, Sunday, (MONTH) 9, (YEAR), with the committee consisting of facility DON. Administrator, Medical Director, Health Information Services, Assessment Nurse and RN #1. The topics discussed were failure to initiate Cardiopulmonary Resuscitation on Resident #1, failure to follow Advance Directive Form, and continuing of in-services for staff that began on [DATE]. the DON continued in-services with scheduled staff on Cardiopulmonary Resuscitation Policy-Full Code, No Code (DNR), Incident Investigation and Reporting, Resident Rights, Care Plan Process, Advance Directives and Emergency Care of Residents. 6. Through interview and record review, the SA validated that on (MONTH) 9, (YEAR), all active residents' medical record charts were audited by Health Information Services and Assessment Nurse to ensure proper code status identification. The audit consisted of the care plans, the physician orders [REDACTED]. 7. The SA validated through record review and interview that on (MONTH) 9, (YEAR), an audit was completed by the Health Information Services and Assessment Nurse on any resident who had expired in facility since last annual survey, (MONTH) 26, (YEAR). The audit was to ensure the proper code status was followed and the completed audit showed no issues. 8. Through record review, employee roster review, and interviews, the SA validated that Registered Nurses and Licensed Practical Nurses was not allowed to provide direct care until participation in the in-services addressing Cardiopulmonary Resuscitation Policy-Full Code, No Code (DNR), Incident Investigation and Reporting, Resident Rights, Care Plan Process, Advance Directives and Emergency Care of Residents. 9. The SA validated through record review and interviews that on (MONTH) 10, (YEAR), the Administrator and DON terminated LPN #2 for failure to implement policy and procedure related to Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR). 10. Through interviews and record reviews the SA validated that on (MONTH) 10, (YEAR), LPN #1 was terminated from employment for failure to implement policy and procedure related to Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR). 11. The SA validated through interviews and record review that on (MONTH) 10, (YEAR), Cardiopulmonary Resuscitation CPR Code Drills were initiated by the facility Registered Nurse #2 and the Director of Nursing to include two (2) Registered Nurses, six (6) Licenses Practical Nurses, 14 Certified Nursing Assistants, three (3) Nursing Assistant Trainees, five (5) Office Personnel, two (2) Dietary Staff, and four (4) Laundry/Housekeeping Staff. The SA validated that Registered Nurses and Licensed Practical Nurses were not allowed to provide direct care until participation in CPR Code Drills had been conducted. 12. Through record review and interview, the SA validated that the Administrator reported the incident involving Resident #1 to The Mississippi State Department of Health, Attorney General's Office, Police Department and Mississippi Board of Nursing on (MONTH) 9, (YEAR), that CPR was not initiated on Full Code Resident #1. 13. The SA validated through interview and record review that on (MONTH) 10, (YEAR), the Administrator and DON notified the Resident Representative at his home to discuss the events of (MONTH) 8, (YEAR), involving Resident #1, and that the Resident Representative was informed of Resident #1's condition and a Full Code was not performed. 14. Through record review and the interviews with two (2) Registered Nurses, three (3) Licensed Practical Nurses, 11 Certified Nurses Assistants, four (4) Therapy staff, five (5) Housekeeping/Laundry Staff, five (5) Dietary Staff, two (2) Office Support Staff, one (1) Activity Staff Employee; the SA validated that on (MONTH) 9, (YEAR), monitoring systems were put in place to sustain compliance: (a) The facility began conducting Cardiopulmonary Resuscitation Code Drills on all three (3) shifts weekly, and will continue for four (4) weeks, then all three (3) shifts monthly for three (3) months, and then all three (3) shifts quarterly thereafter, by the Director of Nursing and/or Registered Nurse #2. (b) The facility began monitoring all active resident medical records and plans of care for the correct code status identification weekly for one (1) month, then to continue bi-weekly for three (3) months, and then monthly until resolved by Health Information Services. (c) The Cardiopulmonary Resuscitation Certification status of each licensed nurse will be checked for each nurse upon hire and then monthly by Director of Nursing. Based on the facility's corrective actions, initiated on [DATE], and completed on [DATE], the IJ was determined to be removed as of [DATE], prior to the SA entrance on [DATE]. The SA determined the IJ to be Past Non-Compliance and the facility was deemed to be in substantial compliance with this regulatory requirement.

Based on record review, policy/procedure review, and interviews, the facility failed to implement the Advance Directive comprehensive care plan for one (1) of eight (8) residents reviewed, Resident #1. Resident #1 was found unresponsive on [DATE] at approximately 8:30 PM, and Cardiopulmonary Resuscitation (CPR) was not initiated as indicated in her Advance Directive Care Plan. Resident #1 expired in the facility. The failure of the facility to implement Resident #1's Advance Directive care plan, to initiate CPR, placed Resident #1 and other residents with an Advance Directive for CPR, in a situation that was likely to cause serious injury, harm, impairment or death. The situation was identified to be an Immediate Jeopardy (IJ) that began on [DATE], when CPR was not implemented, per Advance Directive care plan, to Resident #1, and the resident expired. The State Agency (SA) notified the Administrator on [DATE] at 5:00 PM, of the IJ. The facility provided an acceptable Corrective Action Plan (CAP) on [DATE], in which the facility alleged removal of the IJ on [DATE]. The SA validated the CAP and determined the IJ was removed on [DATE], prior to Surveyor entrance on [DATE]. FINDINGS INCLUDE: Review of the facility's Care Plan Process policy/procedure, with a revision date of ,[DATE], revealed: The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs, including culturally-competent and trauma-informed as well as, the items or services that would be required but are not due to the exercise of resident rights (refusal). Consider each resident as a whole, with unique characteristics and strengths that affect his or her capacity to function; Identify areas of concern that may warrant interventions; Develop, to the extent possible, interventions to help improve, stabilize, or prevent decline in physical, functional, and psychosocial well-being, in the context of the resident's condition, choices and preferences for interventions; and address the need and desire for other important considerations, such as advanced care planning and palliative care; e.g., symptom relief and pain management .The facility staff shall follow the care plan. Review of Resident #1's care plan, initiated [DATE], revealed: Resident and/or family request Advanced Directive of Full Code Status, with an intervention: Honor resident/family Advanced Directive request. (This included initiation of CPR) Record review of the Patient self Determination Act of 1990 Advance Directive Acknowledgment Form, dated [DATE], signed by Resident #1, the Responsible Party (RP), and the Physician, revealed the Advance Directive was acknowledged and the Resident/family consent for Cardiopulmonary Resuscitation was documented, by a check mark, that CPR should be done in the case of extreme emergency for Resident #1. Review of a Directive to Physician/DNR Order from Hospice, dated and signed by the RP on [DATE], revealed a check mark in the section I wish to be a full code. Record review revealed Resident #1 was admitted to Hospice services on [DATE], with the [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for a significant change in status assessment with an Assessment Reference Date of [DATE] revealed a Brief Interview for Mental status (BIMS) of 9, meaning the resident could make simple independent decisions. Review of Resident #1's most recent Medical Doctor (MD) orders for (MONTH) (YEAR), revealed that FULL CODE was included in the orders. Review of the medical records, incident report and facility investigation, revealed on [DATE] revealed that on [DATE], at approximately 8:30 PM, Certified Nurses Assistant (CNA) #1 found Resident #1 unresponsive and not breathing in her bed. CNA #1 alerted Licensed Practical Nurse (LPN) #1, who assessed the resident and found no respiration or pulse. LPN #2 came and assessed Resident #1 and observed no respiration or pulse. LPN #1 and LPN #2 discussed that Resident #1 was a new Hospice patient and LPN #1 called and spoke with the Hospice Nurse on [DATE] at approximately 8:34 PM, reporting that Resident #1 appeared to have expired. Before 9:00 PM, LPN #1 reviewed Resident #1's record and discovered she was a full code. At approximately 9:00 PM, the Hospice Nurse called the facility and confirmed that the resident was a full code. CPR was not initiated when Resident #1 was found without pulse and respiration, per the care plan intervention. Interview with the RP of Resident #1 on [DATE] at 2:00 PM, revealed he got there after Resident #1 died and no one was helping her. He stated he had told Hospice and the nursing home he wanted the resident cared for. He stated he signed the papers for her to get help and CPR if she needed it. He stated there wasn't even an ambulance there that night. He stated he had not reviewed the paperwork, but knew if he did, he would find that no one helped her. Interview with the facility Assessment Nurse on [DATE] at 1:55 PM, revealed that Care plans are in-serviced once a quarter, including where care plans are located on the chart, updating with changes in resident condition, and new orders from the Medical Doctor. She stated that Advance Directives were discussed during the care plan meetings, or if family Responsible Party is in the facility and wants to come by, they meet with them then. She acknowledged the care plans should be followed. Interview with the Director of Nursing (DON) on [DATE] at 2:00 PM, revealed they had done in-service on following the care plan. She acknowledged the care plan for CPR was not followed for Resident #1. On [DATE] at 5:00 PM, the SA notified the facility's Administrator that the failure of the facility not following the Advanced Directive for providing CPR to Resident #1 was deemed an Immediate Jeopardy (IJ). The facility submitted the following Corrective Action Plan: 1. On (MONTH) 8, (YEAR), at approximately 7:40 PM, Certified Nursing Assistant (CNA) #2 entered the room of Resident #1 and Resident #1 appeared to be sleeping. Certified Nursing Assistant (CNA) #1, at approximately 8:30 PM, went to check on Resident #1 and found that Resident 1 was not breathing. CNA #1 stepped out into the hallway and called Licensed Practical Nurse (LPN) #1 and LPN #1 immediately went into Resident #1's room. Resident #1 was lying on the bed and noted to be unresponsive. LPN #1 checked for a radial and carotid pulses and found none. Resident #1 was observed for respirations and none were noted. LPN #1 sent Certified Nursing Assistant (CNA) to call Licensed Practical Nurse (LPN) #2 to come to Resident #1's room to assess resident. LPN #2 observed no respirations or pulse. It was discussed by LPN #1 and LPN #2 about patient being newly admitted to Hospice services. LPN #1 opened Resident #1's chart finding an instruction sheet stating, Don't Call 911, call Hospice First. LPN #1 called Hospice with Resident #1's condition. LPN #1 spoke with the Hospice Nurse on [DATE] at approximately 8:34 PM reporting that Resident #1 appeared to have expired. Hospice Nurse stated, OK, I will be at the facility in about 1 hour. Shortly after 8:34 PM and before 9:00 PM on [DATE], LPN #2, CNA #3, CNA #2, and CNA #1 were at the nurse's desk discussing if anything else needed to be done and the code status for Resident #1 was brought up by CNA #3. LPN #1 was made aware of conversation, pulled Resident #1's chart and found that Resident #1 was a full code. At approximately 9:00 PM on [DATE], Hospice Nurse called and spoke with LPN #1 and confirmed that Resident #1 was a full code. At this time, Cardiopulmonary Resuscitation was not initiated. LPN #2 accepted a phone call from Resident #1's Resident representative on [DATE], at approximately 9:00 PM, stating that he was called by Hospice Nurse informing him that his mother was deceased . 2. On [DATE], at approximately 9:40 PM, the Coroner arrived at the facility. Director of Nursing (DON) was notified of the events surrounding the expiration of Resident #1 on [DATE], at approximately 9:28 PM by Assessment Nurse. The Administrator was notified of the events surrounding the expiration of Resident #1 on [DATE], at 9:27 PM by Registered Nurse #1. The Medical Director/Physician was notified by the DON on [DATE], at 10:39 PM that Resident #1 was a full code, found unresponsive and Cardiopulmonary Resuscitation (CPR) was not initiated and resident expired. 3. The DON arrived at the facility at approximately 10:00 PM on (MONTH) 8, (YEAR), and began the investigation regarding the event with Resident #1. Interviews and statements were taken from LPN #1 & LPN #2 and CNA #1 and CNA #2 regarding their knowledge of the events surrounding the failure to initiate CPR on Resident #1. LPN #1 and LPN #2 were suspended on 9//,[DATE], at approximately 11:00 PM, pending the outcome of the investigation for failure to perform CPR. 4. The facility corrective actions were initiated on (MONTH) 8, (YEAR), at approximately 10:30 PM, by the DON with inservice training with three (3) Licensed Practical Nurses, seven (7) Certified Nursing Assistants and one (1) laundry personnel. The in-service included facility policies on Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR), Incident Investigation and Reporting, Resident Rights, following Care Plan related to Code Status/Full Code/DNR, Advance Directives related to residents' preferences of Code Status, Emergency Care of All Residents (knowing when to call 911), and Abuse and Neglect. 5. Facility Quality Assurance Committee Meeting was held at 10:00 AM, Sunday, (MONTH) 9, (YEAR), with the committee consisting of facility DON, Administrator, Medical Director, Health Information Services, Assessment Nurse and RN #1. The topics discussed were failure to initiate Cardiopulmonary Resuscitation on Resident #1, failure to follow Advance Directive Form, and continuing of inservices for staff that began on [DATE]. the DON continued inservices with scheduled staff on Cardiopulmonary Resuscitation Policy-Full Code, No Code (DNR), Incident Investigation and Reporting, Resident Rights, Care Plan Process, Advance Directives and Emergency Care of Residents. 6. On (MONTH) 9, (YEAR), all active residents' medical record charts were audited by Health Information Services and Assessment Nurse to ensure proper code status identification. The audit consisted of the care plans, the physician orders [REDACTED]. 7. On (MONTH) 9, (YEAR), an audit was completed by the Health Information Services and Assessment Nurse on any resident who had expired in facility since last annual survey, (MONTH) 26, (YEAR). The audit was to ensure the proper code status was followed and the completed audit showed no issues. 8. Registered Nurses and Licensed Practical Nurses will not be allowed to provide direct care until participation in the inservices addressing Cardiopulmonary Resuscitation Policy-Full Code, No Code (DNR), Incident Investigation and Reporting, Resident Rights, Care Plan Process, Advance Directives and Emergency Care of Residents. 9. On (MONTH) 10, (YEAR), Administrator and DON terminated LPN #2 for failure to implement policy and procedure related to Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR). 10. On (MONTH) 10, (YEAR), DON attempted to contact Licensed Practical Nurse #1 via telephone, without success. LPN #1 was terminated from employment for failure to implement policy and procedure related to Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR). 11. (MONTH) 10, (YEAR), Cardiopulmonary Resuscitation CPR Code Drills were initiated by the facility Registered Nurse #2 and the Director of Nursing to include two (2) Registered Nurses,six (6) Licensed Practical Nurses, 14 Certified Nursing Assistants, three (3) Nursing Assistant Trainees, five (5) Office Personnel, two (2) Dietary Staff, and four (4)Laundry/Housekeeping Staff. Registered Nurses and Licensed Practical Nurses will not be allowed to provide direct care until participation in CPR Code Drill has been conducted. 12. The Administrator reported the incident involving Resident #1 to The Mississippi State Department of Health on (MONTH) 9, (YEAR), at 11:05 AM. The Administrator reported the incident to Attorney General Office on (MONTH) 9, (YEAR), at 3:22 PM. The Administrator reported the incident to the Police Department on (MONTH) 9, (YEAR), at 10:25 AM. The Police Department responded at facility to fulfill requirements for Elder Justice Act on (MONTH) 9, (YEAR) at 10:35 AM. The Administrator reported to Mississippi Board of Nursing on (MONTH) 9, (YEAR), at 11:10 AM that CPR was not initiated on Full Code Resident #1. 13. On (MONTH) 10, (YEAR), the Administrator and DON notified the Resident Representative at his home, to discuss the events of (MONTH) 8, (YEAR), involving Resident #1. Resident Representative was informed of Resident #1's condition and that a Full Code was not performed. 14. On (MONTH) 9, (YEAR), monitoring systems were put in place to sustain compliance (a) The facility began conducting Cardiopulmonary Resuscitation Code Drills on all three (3) shifts weekly for four (4) weeks, then all three (3) shifts monthly for three (3) months, and then all three (3) shifts quarterly thereafter, by the Director of Nursing and/or Registered Nurse #2. (b) all active resident medical records and plans of care will be monitored for the correct code status identification weekly for one (1) month, then bi-weekly for three (3) months, and then monthly until resolved by Health Information Services. (c) The Cardiopulmonary Resuscitation Certification status of each licensed nurse will be checked for each nurse upon hire and then monthly by Director of Nursing. The facility alleges that all corrective actions were completed on (MONTH) 10, (YEAR). The facility believes the IJ was removed as of (MONTH) 11, (YEAR). The SA validate the Corrective Action Plan through record review, sign-in sheet review, interview with staff throughout all disciplines and interview with Administrative Staff. 1. The SA validated by interviews with the Nursing and Administrative Staff and record review that Resident #1 was found unresponsive and without pulse or respiration on [DATE] at approximately 7:40 PM. The SA validated that LPN #1 and LPN #2 did not initiate CPR on Resident #1. The SA validated that Hospice was contacted and the full code status was validated by the Hospice Nurse. The Full code status was also documented in the medical record as an order and Advance Directive. The SA validated an instruction sheet in Resident #1's chart that documented Don't Call 911, call Hospice First. The SA validated that LPN #2 accepted a phone call from Resident #1's Resident representative on [DATE], at approximately 9:00 PM, stating that he was called Hospice Nurse informing him that his mother was deceased . 2. The SA validated by record review and interviews that on [DATE], at approximately 9:40 PM, the Coroner arrived at the facility, the DON was notified of the events surrounding the expiration of Resident #1 on [DATE], the Administrator was notified of the events surrounding the expiration of Resident #1 on [DATE], and the Medical Director/Physician was notified by the DON on [DATE], at 10:39 PM that Resident #1 was a full code, found unresponsive and Cardiopulmonary Resuscitation (CPR) was not initiated and resident expired. 3. Through record review and interview, the SA validated that the DON began an investigation on (MONTH) 8, (YEAR), regarding the event with Resident #1, which included interviews and statements from LPN #1 & LPN #2 and CNA #1 and CNA #2 regarding their knowledge of the events surrounding the failure to initiate CPR on Resident #1. The SA validated that LPN #1 and LPN #2 were suspended on 9//,[DATE], pending the outcome of the investigation for failure to perform CPR. 4. The SA validated by record review, sign-in sheet review, and interview that in-service training was initiated [DATE], including review of facility policies on Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR), Incident Investigation and Reporting, Resident Rights, following Care Plan related to Code Status/Full Code/DNR, Advance Directives related to residents' preferences of Code Status, Emergency Care of All Residents (knowing when to call 911), and Abuse and Neglect. The in-service included three (3) Licensed Practical Nurses, seven (7) Certified Nursing Assistants, and one (1) laundry personnel. 5. The SA validated through interview and record review of a sign-in sheet, that the facility Quality Assurance Committee Meeting was held at 10:00 AM, Sunday, (MONTH) 9, (YEAR), with the committee consisting of facility DON. Administrator, Medical Director, Health Information Services, Assessment Nurse and RN #1. The topics discussed were failure to initiate Cardiopulmonary Resuscitation on Resident #1, failure to follow Advance Directive Form, and continuing of in-services for staff that began on [DATE]. the DON continued in-services with scheduled staff on Cardiopulmonary Resuscitation Policy-Full Code, No Code (DNR), Incident Investigation and Reporting, Resident Rights, Care Plan Process, Advance Directives and Emergency Care of Residents. 6. Through interview and record review, the SA validated that on (MONTH) 9, (YEAR), all active residents' medical record charts were audited by Health Information Services and Assessment Nurse to ensure proper code status identification. The audit consisted of the care plans, the physician orders [REDACTED]. 7. The SA validated through record review and interview that on (MONTH) 9, (YEAR), an audit was completed by the Health Information Services and Assessment Nurse on any resident who had expired in facility since last annual survey, (MONTH) 26, (YEAR). The audit was to ensure the proper code status was followed and the completed audit showed no issues. 8. Through record review, employee roster review, and interviews, the SA validated that Registered Nurses and Licensed Practical Nurses was not allowed to provide direct care until participation in the in-services addressing Cardiopulmonary Resuscitation Policy-Full Code, No Code (DNR), Incident Investigation and Reporting, Resident Rights, Care Plan Process, Advance Directives and Emergency Care of Residents. 9. The SA validated through record review and interviews that on (MONTH) 10, (YEAR), the Administrator and DON terminated LPN #2 for failure to implement policy and procedure related to Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR). 10. Through interviews and record reviews the SA validated that on (MONTH) 10, (YEAR), LPN #1 was terminated from employment for failure to implement policy and procedure related to Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR). 11. The SA validated through interviews and record review that on (MONTH) 10, (YEAR), Cardiopulmonary Resuscitation CPR Code Drills were initiated by the facility Registered Nurse #2 and the Director of Nursing to include two (2) Registered Nurses, six (6) Licenses Practical Nurses, 14 Certified Nursing Assistants, three (3) Nursing Assistant Trainees, five (5) Office Personnel, two (2) Dietary Staff, and four (4) Laundry/Housekeeping Staff. The SA validated that Registered Nurses and Licensed Practical Nurses were not allowed to provide direct care until participation in CPR Code Drills had been conducted. 12. Through record review and interview, the SA validated that the Administrator reported the incident involving Resident #1 to The Mississippi State Department of Health, Attorney General's Office, Police Department and Mississippi Board of Nursing on (MONTH) 9, (YEAR), that CPR was not initiated on Full Code Resident #1. 13. The SA validated through interview and record review that on (MONTH) 10, (YEAR), the Administrator and DON notified the Resident Representative at his home to discuss the events of (MONTH) 8, (YEAR), involving Resident #1, and that the Resident Representative was informed of Resident #1's condition and a Full Code was not performed. 14. Through record review and the interviews with two (2) Registered Nurses, three (3) Licensed Practical Nurses, 11 Certified Nurses Assistants, four (4) Therapy staff, five (5) Housekeeping/Laundry Staff, five (5) Dietary Staff, two (2) Office Support Staff, one (1) Activity Staff Employee; the SA validated that on (MONTH) 9, (YEAR), monitoring systems were put in place to sustain compliance: (a) The facility began conducting Cardiopulmonary Resuscitation Code Drills on all three (3) shifts weekly, and will continue for four (4) weeks, then all three (3) shifts monthly for three (3) months, and then all three (3) shifts quarterly thereafter, by the Director of Nursing and/or Registered Nurse #2. (b) The facility began monitoring all active resident medical records and plans of care for the correct code status identification weekly for one (1) month, then to continue bi-weekly for three (3) months, and then monthly until resolved by Health Information Services. (c) The Cardiopulmonary Resuscitation Certification status of each licensed nurse will be checked for each nurse upon hire and then monthly by Director of Nursing. Based on the facility's corrective actions, initiated on [DATE], and completed on [DATE], the IJ was determined to be removed as of [DATE], prior to the SA entrance on [DATE]. The SA determined the IJ to be Past Non-Compliance and the facility was deemed to be in substantial compliance with this regulatory requirement.

Based on record review, policy/procedure review, and interviews, the facility failed to provide basic life support, including Cardiopulmonary Resuscitation (CPR), per physician's orders [REDACTED].#1. Resident #1 was found unresponsive on [DATE] at approximately 8:30 PM, by facility staff, and CPR was not performed as requested by Resident's signed Advance Directive, Medical Doctor orders and Care Plan. Resident #1 expired in the facility. The facility's failure to provide CPR, per physician's orders [REDACTED]. The situation was identified to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), that began on [DATE], when CPR was not provided to Resident #1 per order and Advance Directive, and the resident expired. The State Agency (SA) notified the Administrator on [DATE] at 5:00 PM, of the IJ and SQC. The facility provided an acceptable Corrective Action Plan (CAP) on [DATE], in which the facility alleged removal of the IJ on [DATE]. The SA validated the CAP and determined the IJ was removed on [DATE], prior to Surveyor entrance on [DATE]. FINDINGS INCLUDE: Review of the Facility's Cardiopulmonary Resuscitation-CPR policy/procedure, last revised ,[DATE], revealed PURPOSE to prevent death in a resident that requires such care consistent with Advance Directives and Physician orders, To restore normal breathing and heart actions and to ensure proper and appropriate utilization of the Ambu-bag for emergency resuscitation. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE], and readmitted on [DATE]. Her current [DIAGNOSES REDACTED]. Review of the Patient self Determination Act of 1990 Advance Directive Acknowledgment Form, revealed it was dated and signed by the Resident, Responsible Party (RP) and the Physician on [DATE], for Resident #1. The most recent Resident/family consent for Cardiopulmonary Resuscitation dated [DATE], revealed that the resident's Responsible Party (RP) marked the form, indicating that Resident #1 should have CPR done in the case of extreme emergency. Record review revealed that Resident #1 was admitted to Hospice services on [DATE], with the [DIAGNOSES REDACTED]. Review of the Hospice records, noted on the facility's medical record, revealed that on [DATE], Resident #1's RP signed a Directive to Physician/DNR Order, which indicated: I wish to be a full code. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of Resident 1's Nurse's Notes, facility incident report, and facility investigation, revealed on [DATE], at approximately 8:30 PM, Certified Nursing Assistant (CNA) #1 found Resident #1 in her bed, unresponsive and not breathing. CNA #1 alerted Licensed Practical Nurse #1 (LPN) and LPN #1 assessed the resident and found no respiration or pulse. LPN #2 came and assessed Resident #1 and observed no respiration or pulse. LPN #1 and LPN #2 reviewed that Resident #1 was a new Hospice patient and LPN #1 called Hospice and reported that Resident #1 appeared to have expired. Before 9:00 PM, LPN #1 reviewed Resident #1's record and discovered she was a full code. At approximately 9:00 PM, the Hospice nurse returned a call and confirmed that the resident was a full code. CPR was not initiated for Resident #1. An interview with LPN #1 on [DATE] at 11:55 AM, revealed she last saw Resident #1 responsive was at 6:00 PM on [DATE], during a medication pass. At approximately 8:30 PM on [DATE], CNA #1 came and said that she found Resident #1 unresponsive. LPN #1 assessed the resident finding no pulses or respiration. She asked CNA #1 to go and get LPN #2. LPN #2 came and assessed Resident #1 confirming there were no pulses or respiration. LPN #1 stated she called Hospice and resumed passing medications. She stated later, as she got to the nurse's station, CNA #3 and LPN #2 were talking about a code status and LPN #2 was saying she didn't think Resident #1 was a full code because she's on Hospice and the chart says don't call 911, call Hospice. LPN #1 stated that she and LPN #2 checked the record and discovered Resident #1 was a full code; probably 8:50 to 8:55 PM. LPN #1 stated that LPN #2 said We may have to start this code. LPN #1 stated she called Hospice back to inform them of the code status and to see what their status indicated and during that time LPN #2 answered a phone call from Resident #1's RP, that he had been notified by Hospice that his mother had expired. LPN #1 stated that LPN #2 told her to call Registered Nurse (RN) #1 to find out about this because Resident #1 was a full code and we had not done anything at this point. LPN #1 stated she could reach RN #1, so she called RN #2, told her that Resident #1 had expired, we called Hospice, family had been notified, and time had passed before they saw where the resident was a full code. LPN #1 stated that RN #2 said to call 911. She stated she let LPN #2 know, and LPN #2 said it would be disrespectful to have told the family she had expired then to start a full code after all that time and family was on the way. LPN #1 said she then waited for the Hospice nurse and Coroner to arrive and CPR was never initiated for Resident #1. LPN #1 stated when you open Resident #1's chart, documentation says don't call 911, call Hospice. Interview on [DATE] at 11:58 AM, with LPN #2 revealed she went and assessed Resident #1 on [DATE], when LPN #1 asked for her. She stated, You automatically think no code when it's a Hospice patient. I thought she'd already called Hospice. She stated, she asked LPN #1 if Resident #1 was a no code or not and LPN #1 said, I would think she is a no code. She's on Hospice. LPN #2 stated she had not checked the code status and when she checked the chart it had a (YEAR) Advance Directives. She stated she told LPN #1 to call Hospice again and ask what to do. She stated RN #1 called her, but didn't tell her what to do, No one told us to do a code on this lady. I saw the Advance Directives, yes, but she had just come back from the hospital. I was thinking there were some updated orders regarding code status. LPN #2 stated Resident #1 was cool to the touch, her face discolored, and it was around 8:40 PM when she went in the room. She stated she thought LPN #1 knew the resident's code status; knew she was a no code. She stated when LPN #1 asked her to check, she just wanted confirmation she had expired. LPN #2 confirmed that CPR was not initiated on Resident #1. She stated she thought if a resident was on Hospice, there were a NO Code. Interview with CNA #1 on [DATE] at 11:40 AM, revealed it was approximately 8:30 PM when she found Resident #1 unresponsive. She stated, I had last seen her about 7:00 PM. We did incontinent care on her. Interview with CNA #2 on [DATE] at 11:50 AM revealed, I saw the two (2) nurses looking at her chart, talking about her being Hospice. Interview with the RP of Resident #1 on [DATE] at 2:00 PM, revealed, I got there after she died . There wasn't anyone helping her. I told Hospice and the nursing home I wanted her cared for. I was told that if we put her on Hospice, she'd get better care. The Hospice Nurse is the person that called me and told me she was gone. The Administrator said he understood I was upset the Hospice nurse is the one that called me. The boss and black nurse came to our house to see us. I signed the papers for her to get help and CPR if she needed it. There wasn't even an ambulance there that night. I haven't looked at any paperwork, but I know if I did, I'd see no one helped her. Interview with RN #1 on [DATE] at 11:10 AM, revealed It was [DATE]. I was not on call, RN #2 was. RN #2 called me the first time at 9:13 PM. I missed that call. I called her back at 9:15 PM. She said staff at the facility called about Resident #1's code status and they had checked the chart and she was a full code and she had expired. They wanted to know since she was on Hospice had the code status changed to a DNR. I told her that I didn't know of it changing, but I would check with Hospice. RN #1 stated she checked with Hospice and found that the resident was a full code on their paperwork. She stated, I called LPN #2 on her personal cell. I told her Resident #1 was still a full code and they needed to perform CPR. LPN #2 said it had been 30 minutes since they found her unresponsive. She said the Hospice Nurse had called the family and told the family that Resident #1 had expired. I told her to do CPR and get someone to call 911 since she was a full code. LPN #2 said she didn't feel comfortable calling 911 or starting CPR, because Hospice had called the son and told him Resident #1 had expired. Interview with RN #2 on [DATE] at 11:30 AM, revealed she got a phone call from LPN #1 on [DATE] at approximately 9:15 PM, She said Resident #1 had passed away, it had been about 30 minutes and she just saw that she was a full code. I told her I thought they should call 911. No, I did not tell her to start CPR because it had been 30 minutes. I spoke with (RN #2), and she said she'd call the facility. Since she was going to call the facility, I never called back up here. Interview with the DON on [DATE] at 2:00 PM, revealed, I was called at approximately 9:28 PM on [DATE], by the Assessment Nurse. She said I needed to get to the facility because apparently (Resident #1) was found unresponsive and no code was done and she was a full code. I got to the facility at about 10:06 PM. I talked to the funeral director, came and talked with (LPN #1) and (LPN #2). She stated she went to the nurse's station and told LPN #1 and LPN #2 to write statements and had LPN #1 and LPN #2 come into my office and explained to them the severity of what happened; they they did not do a code when they should have. LPN #2 said she didn't know a resident on Hospice could be a full code. The DON stated, Yes, we do cover Advance Directives, CPR and DNR on hire and annual in-services. The DON stated that LPN #2 said because the family had been told the resident was deceased , she didn't want them to come and see them coding her. The DON stated LPN said, We decided to not do a code. (We being LPN #1 and LPN #2). The DON said that LPN #1 and LPN #2 were suspended and then terminated for failure to follow the Advance Directive and do a full code on Resident #1. Review of the Minimum Data Set (MDS) for a significant change in status assessment with an Assessment Reference Date of [DATE], revealed a Brief Interview for Mental status (BIMS) of 9, meaning the resident could make simple independent decisions. On [DATE] at 5:00 PM, the SA notified the facility's Administrator that the failure of the facility not following the Advanced Directive for providing CPR to Resident #1 was deemed an Immediate Jeopardy (IJ). The facility submitted the following Corrective Action Plan: 1. On (MONTH) 8, (YEAR), at approximately 7:40 PM, Certified Nursing Assistant (CNA) #2 entered the room of Resident #1 and Resident #1 appeared to be sleeping. Certified Nursing Assistant (CNA) #1, at approximately 8:30 PM, went to check on Resident #1 and found that Resident 1 was not breathing. CNA #1 stepped out into the hallway and called Licensed Practical Nurse (LPN) #1 and LPN #1 immediately went into Resident #1's room. Resident #1 was lying on the bed and noted to be unresponsive. LPN #1 checked for a radial and carotid pulses and found none. Resident #1 was observed for respirations and none were noted. LPN #1 sent Certified Nursing Assistant (CNA) to call Licensed Practical Nurse (LPN) #2 to come to Resident #1's room to assess resident. LPN #2 observed no respirations or pulse. It was discussed by LPN #1 and LPN #2 about patient being newly admitted to Hospice services. LPN #1 opened Resident #1's chart finding an instruction sheet stating, Don't Call 911, call Hospice First. LPN #1 called Hospice with Resident #1's condition. LPN #1 spoke with the Hospice Nurse on [DATE] at approximately 8:34 PM reporting that Resident #1 appeared to have expired. Hospice Nurse stated, OK, I will be at the facility in about 1 hour. Shortly after 8:34 PM and before 9:00 PM on [DATE], LPN #2, CNA #3, CNA #2, and CNA #1 were at the nurse's desk discussing if anything else needed to be done and the code status for Resident #1 was brought up by CNA #3. LPN #1 was made aware of conversation, pulled Resident #1's chart and found that Resident #1 was a full code. At approximately 9:00 PM on [DATE], Hospice Nurse called and spoke with LPN #1 and confirmed that Resident #1 was a full code. At this time, Cardiopulmonary Resuscitation was not initiated. LPN #2 accepted a phone call from Resident #1's Resident representative on [DATE], at approximately 9:00 PM, stating that he was called by Hospice Nurse informing him that his mother was deceased . 2. On [DATE], at approximately 9:40 PM, the Coroner arrived at the facility. Director of Nursing (DON) was notified of the events surrounding the expiration of Resident #1 on [DATE], at approximately 9:28 PM by Assessment Nurse. The Administrator was notified of the events surrounding the expiration of Resident #1 on [DATE], at 9:27 PM by Registered Nurse #1. The Medical Director/Physician was notified by the DON on [DATE], at 10:39 PM that Resident #1 was a full code, found unresponsive and Cardiopulmonary Resuscitation (CPR) was not initiated and resident expired. 3. The DON arrived at the facility at approximately 10:00 PM on (MONTH) 8, (YEAR), and began the investigation regarding the event with Resident #1. Interviews and statements were taken from LPN #1 & LPN #2 and CNA #1 and CNA #2 regarding their knowledge of the events surrounding the failure to initiate CPR on Resident #1. LPN #1 and LPN #2 were suspended on 9//,[DATE], at approximately 11:00 PM, pending the outcome of the investigation for failure to perform CPR. 4. The facility corrective actions were initiated on (MONTH) 8, (YEAR), at approximately 10:30 PM, by the DON with inservice training with three (3) Licensed Practical Nurses, seven (7) Certified Nursing Assistants and one (1) laundry personnel. The in-service included facility policies on Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR), Incident Investigation and Reporting, Resident Rights, following Care Plan related to Code Status/Full Code/DNR, Advance Directives related to residents' preferences of Code Status, Emergency Care of All Residents (knowing when to call 911), and Abuse and Neglect. 5. Facility Quality Assurance Committee Meeting was held at 10:00 AM, Sunday, (MONTH) 9, (YEAR), with the committee consisting of facility DON, Administrator, Medical Director, Health Information Services, Assessment Nurse and RN #1. The topics discussed were failure to initiate Cardiopulmonary Resuscitation on Resident #1, failure to follow Advance Directive Form, and continuing of inservices for staff that began on [DATE]. the DON continued inservices with scheduled staff on Cardiopulmonary Resuscitation Policy-Full Code, No Code (DNR), Incident Investigation and Reporting, Resident Rights, Care Plan Process, Advance Directives and Emergency Care of Residents. 6. On (MONTH) 9, (YEAR), all active residents' medical record charts were audited by Health Information Services and Assessment Nurse to ensure proper code status identification. The audit consisted of the care plans, the physician orders [REDACTED]. 7. On (MONTH) 9, (YEAR), an audit was completed by the Health Information Services and Assessment Nurse on any resident who had expired in facility since last annual survey, (MONTH) 26, (YEAR). The audit was to ensure the proper code status was followed and the completed audit showed no issues. 8. Registered Nurses and Licensed Practical Nurses will not be allowed to provide direct care until participation in the inservices addressing Cardiopulmonary Resuscitation Policy-Full Code, No Code (DNR), Incident Investigation and Reporting, Resident Rights, Care Plan Process, Advance Directives and Emergency Care of Residents. 9. On (MONTH) 10, (YEAR), Administrator and DON terminated LPN #2 for failure to implement policy and procedure related to Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR). 10. On (MONTH) 10, (YEAR), DON attempted to contact Licensed Practical Nurse #1 via telephone, without success. LPN #1 was terminated from employment for failure to implement policy and procedure related to Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR). 11. (MONTH) 10, (YEAR), Cardiopulmonary Resuscitation CPR Code Drills were initiated by the facility Registered Nurse #2 and the Director of Nursing to include two (2) Registered Nurses,six (6) Licensed Practical Nurses, 14 Certified Nursing Assistants, three (3) Nursing Assistant Trainees, five (5) Office Personnel, two (2) Dietary Staff, and four (4)Laundry/Housekeeping Staff. Registered Nurses and Licensed Practical Nurses will not be allowed to provide direct care until participation in CPR Code Drill has been conducted. 12. The Administrator reported the incident involving Resident #1 to The Mississippi State Department of Health on (MONTH) 9, (YEAR), at 11:05 AM. The Administrator reported the incident to Attorney General Office on (MONTH) 9, (YEAR), at 3:22 PM. The Administrator reported the incident to the Police Department on (MONTH) 9, (YEAR), at 10:25 AM. The Police Department responded at facility to fulfill requirements for Elder Justice Act on (MONTH) 9, (YEAR) at 10:35 AM. The Administrator reported to Mississippi Board of Nursing on (MONTH) 9, (YEAR), at 11:10 AM that CPR was not initiated on Full Code Resident #1. 13. On (MONTH) 10, (YEAR), the Administrator and DON notified the Resident Representative at his home, to discuss the events of (MONTH) 8, (YEAR), involving Resident #1. Resident Representative was informed of Resident #1's condition and that a Full Code was not performed. 14. On (MONTH) 9, (YEAR), monitoring systems were put in place to sustain compliance (a) The facility began conducting Cardiopulmonary Resuscitation Code Drills on all three (3) shifts weekly for four (4) weeks, then all three (3) shifts monthly for three (3) months, and then all three (3) shifts quarterly thereafter, by the Director of Nursing and/or Registered Nurse #2. (b) all active resident medical records and plans of care will be monitored for the correct code status identification weekly for one (1) month, then bi-weekly for three (3) months, and then monthly until resolved by Health Information Services. (c) The Cardiopulmonary Resuscitation Certification status of each licensed nurse will be checked for each nurse upon hire and then monthly by Director of Nursing. The facility alleges that all corrective actions were completed on (MONTH) 10, (YEAR). The facility believes the IJ was removed as of (MONTH) 11, (YEAR). The SA validate the Corrective Action Plan through record review, sign-in sheet review, interview with staff throughout all disciplines and interview with Administrative Staff. 1. The SA validated by interviews with the Nursing and Administrative Staff and record review that Resident #1 was found unresponsive and without pulse or respiration on [DATE] at approximately 7:40 PM. The SA validated that LPN #1 and LPN #2 did not initiate CPR on Resident #1. The SA validated that Hospice was contacted and the full code status was validated by the Hospice Nurse. The Full code status was also documented in the medical record as an order and Advance Directive. The SA validated an instruction sheet in Resident #1's chart that documented Don't Call 911, call Hospice First. The SA validated that LPN #2 accepted a phone call from Resident #1's Resident representative on [DATE], at approximately 9:00 PM, stating that he was called Hospice Nurse informing him that his mother was deceased . 2. The SA validated by record review and interviews that on [DATE], at approximately 9:40 PM, the Coroner arrived at the facility, the DON was notified of the events surrounding the expiration of Resident #1 on [DATE], the Administrator was notified of the events surrounding the expiration of Resident #1 on [DATE], and the Medical Director/Physician was notified by the DON on [DATE], at 10:39 PM that Resident #1 was a full code, found unresponsive and Cardiopulmonary Resuscitation (CPR) was not initiated and resident expired. 3. Through record review and interview, the SA validated that the DON began an investigation on (MONTH) 8, (YEAR), regarding the event with Resident #1, which included interviews and statements from LPN #1 & LPN #2 and CNA #1 and CNA #2 regarding their knowledge of the events surrounding the failure to initiate CPR on Resident #1. The SA validated that LPN #1 and LPN #2 were suspended on 9//,[DATE], pending the outcome of the investigation for failure to perform CPR. 4. The SA validated by record review, sign-in sheet review, and interview that in-service training was initiated [DATE], including review of facility policies on Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR), Incident Investigation and Reporting, Resident Rights, following Care Plan related to Code Status/Full Code/DNR, Advance Directives related to residents' preferences of Code Status, Emergency Care of All Residents (knowing when to call 911), and Abuse and Neglect. The in-service included three (3) Licensed Practical Nurses, seven (7) Certified Nursing Assistants, and one (1) laundry personnel. 5. The SA validated through interview and record review of a sign-in sheet, that the facility Quality Assurance Committee Meeting was held at 10:00 AM, Sunday, (MONTH) 9, (YEAR), with the committee consisting of facility DON. Administrator, Medical Director, Health Information Services, Assessment Nurse and RN #1. The topics discussed were failure to initiate Cardiopulmonary Resuscitation on Resident #1, failure to follow Advance Directive Form, and continuing of in-services for staff that began on [DATE]. the DON continued in-services with scheduled staff on Cardiopulmonary Resuscitation Policy-Full Code, No Code (DNR), Incident Investigation and Reporting, Resident Rights, Care Plan Process, Advance Directives and Emergency Care of Residents. 6. Through interview and record review, the SA validated that on (MONTH) 9, (YEAR), all active residents' medical record charts were audited by Health Information Services and Assessment Nurse to ensure proper code status identification. The audit consisted of the care plans, the physician orders [REDACTED]. 7. The SA validated through record review and interview that on (MONTH) 9, (YEAR), an audit was completed by the Health Information Services and Assessment Nurse on any resident who had expired in facility since last annual survey, (MONTH) 26, (YEAR). The audit was to ensure the proper code status was followed and the completed audit showed no issues. 8. Through record review, employee roster review, and interviews, the SA validated that Registered Nurses and Licensed Practical Nurses was not allowed to provide direct care until participation in the in-services addressing Cardiopulmonary Resuscitation Policy-Full Code, No Code (DNR), Incident Investigation and Reporting, Resident Rights, Care Plan Process, Advance Directives and Emergency Care of Residents. 9. The SA validated through record review and interviews that on (MONTH) 10, (YEAR), the Administrator and DON terminated LPN #2 for failure to implement policy and procedure related to Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR). 10. Through interviews and record reviews the SA validated that on (MONTH) 10, (YEAR), LPN #1 was terminated from employment for failure to implement policy and procedure related to Cardiopulmonary Resuscitation Policy-Full Code: No Code (DNR). 11. The SA validated through interviews and record review that on (MONTH) 10, (YEAR), Cardiopulmonary Resuscitation CPR Code Drills were initiated by the facility Registered Nurse #2 and the Director of Nursing to include two (2) Registered Nurses, six (6) Licenses Practical Nurses, 14 Certified Nursing Assistants, three (3) Nursing Assistant Trainees, five (5) Office Personnel, two (2) Dietary Staff, and four (4) Laundry/Housekeeping Staff. The SA validated that Registered Nurses and Licensed Practical Nurses were not allowed to provide direct care until participation in CPR Code Drills had been conducted. 12. Through record review and interview, the SA validated that the Administrator reported the incident involving Resident #1 to The Mississippi State Department of Health, Attorney General's Office, Police Department and Mississippi Board of Nursing on (MONTH) 9, (YEAR), that CPR was not initiated on Full Code Resident #1. 13. The SA validated through interview and record review that on (MONTH) 10, (YEAR), the Administrator and DON notified the Resident Representative at his home to discuss the events of (MONTH) 8, (YEAR), involving Resident #1, and that the Resident Representative was informed of Resident #1's condition and a Full Code was not performed. 14. Through record review and the interviews with two (2) Registered Nurses, three (3) Licensed Practical Nurses, 11 Certified Nurses Assistants, four (4) Therapy staff, five (5) Housekeeping/Laundry Staff, five (5) Dietary Staff, two (2) Office Support Staff, one (1) Activity Staff Employee; the SA validated that on (MONTH) 9, (YEAR), monitoring systems were put in place to sustain compliance: (a) The facility began conducting Cardiopulmonary Resuscitation Code Drills on all three (3) shifts weekly, and will continue for four (4) weeks, then all three (3) shifts monthly for three (3) months, and then all three (3) shifts quarterly thereafter, by the Director of Nursing and/or Registered Nurse #2. (b) The facility began monitoring all active resident medical records and plans of care for the correct code status identification weekly for one (1) month, then to continue bi-weekly for three (3) months, and then monthly until resolved by Health Information Services. (c) The Cardiopulmonary Resuscitation Certification status of each licensed nurse will be checked for each nurse upon hire and then monthly by Director of Nursing. Based on the facility's corrective actions, initiated on [DATE], and completed on [DATE], the IJ was determined to be removed as of [DATE], prior to the SA entrance on [DATE]. The SA determined the IJ to be Past Non-Compliance and the facility was deemed to be in substantial compliance with this regulatory requirement.

Based on record review, staff interview and facility policy review, the facility failed to revise the care plan was follow to prevent the development of pressure area in one (1) of nine (9) residents identified at high risk for development of pressure areas (Resident #7). Findings include: Cross refer to F-314 for failure of the facility to ensure that the care plan addressed care for the pressure area on Resident #7's left foot. Review of the "Treatments" record noted, "5/19 (2013), Order clarification, clean stage 2 (two) to Left outer foot (symbol for with) wound cleanser, pat dry, apply [MEDICATION NAME] cover (symbol for with) 4x4's, and Kerlix ...Start date 5/24/13, Clean Wounds To Rt (right) Foot With Wound Cleanser And Apply Normal Gel And Border Dressing Daily... The form had a handwritten line through RT (right) and Lt (left) was handwritten above the line. The Treatments record was observed to have handwritten initials from May 25, 2013 through May 30, 2013. Review of the care plan, noted, "Problem Onset: 5/24/13 At risk for skin breakdown r/t (related to) decreased bed mobility, decreased transfer ability, bowel incontinence, bladder incontinence ...skin impairment blister to Rt (right) foot ... Approaches: Pressure red (reducing) matt (mattress), turn Q (every) 2 hr (hours) (symbol for and) prn (as needed) Wd (wound) care as ordered." The care plan did not identify any areas on the left foot. Interview with Registered Nurse (RN) #3 at 12:00 p.m. on 06/02/13, RN #3 was asked what area he had been doing wound care for Resident #7. RN #3 stated "on the left foot." RN #3 was asked what the doctor's orders documented and RN #3 stated, "Right foot." Review of the facility's "Resident at Risk of Pressure Ulcers" policy, revised 06/94, documented, "To identify those residents who are at risk for developing pressure ulcers. To implement appropriate nursing intervention to prevent the development of pressure ulcers ...5. The potential to develop pressure ulcers will be identified on the resident's comprehensive plan of care. Interventions may include use of pressure relieving devices on the bed and in a chair, turning and repositioning schedules, ambulation programs, toileting schedules for incontinent resident. 6. The licensed nurse will document the resident's responses and reactions to the interventions used to prevent pressure ulcers. 7. All pressure ulcers which develop will be documented in the resident's medical record."

Based on observation, record review, staff interview and policy review, the facility failed to provide care and services in a manner to prevent the development of pressure areas in residents identified to be at high risk as evidenced by the failure to provide evidence of assessing and implementing wound care for three (3) of nine (9) residents according to the physician's orders, including identifying the right area and the right treatment for [REDACTED]. Resident #9 was identified to be at high risk for developing pressure ulcers and totally dependent on staff for care, and failure to assess and implement preventative measure for Resident #10. Resident #10 was identified to be at high risk for developing pressure ulcers and developed three pressure areas after admission to the facility on [DATE]. Findings include: Review of the facility's "Resident at Risk of Pressure Ulcers" policy, revised 06/94, documented, "To identify those residents who are at risk for developing pressure ulcers. To implement appropriate nursing intervention to prevent the development of pressure ulcers ...5. The potential to develop pressure ulcers will be identified on the resident's comprehensive plan of care. Interventions may include use of pressure relieving devices on the bed and in a chair, turning and repositioning schedules, ambulation programs, toileting schedules for incontinent resident. 6. The licensed nurse will document the resident's responses and reactions to the interventions used to prevent pressure ulcers. 7. All pressure ulcers which develop will be documented in the resident's medical record." Review of the facility's "Skin Care Policy & (and) Procedure, policy, revised 05/11, noted, "It is the policy of this facility that skin problems will be minimized to the greatest extent possible through an aggressive approach consisting of four components ...I. Prevention, Evaluation and Screening. Each resident will be evaluated for risk factors at the time of admission using Skin At risk Screening Form ...Every effort will be made to prevent skin breakdown ...The Nursing Department's procedure will be such that the staff is alerted immediately if the resident either has the problem of skin breakdown or is at risk for the development of skin breakdown. The Nursing Department will maintain the capability to respond to patient needs (in the area of skin integrity) by the following means: ...With an array of preventive measures practiced on the resident's behalf when the resident has been identified as being at risk ...Ongoing Surveillance: A weekly evaluation of pressure sores/or (and/or) surgical wounds will be made addressing at least the following: 1. site, 2. Stage (1, 2, 3, 4) as applicable. 3. Size, diameter and depth. 4. Presence or absence of drainage. 5. Presence or absence of odor. 6. Color ... Definition of a Pressure Ulcer: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear/and or friction ...Staging Of Pressure Ulcers..Stage 2 (two) Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister... III. Treatment Orders. A. After observation/evaluation of the affected skin area, notify physician for the treatment order ...C. After completion of each treatment, date and initial each dressing. Document on the TAR (Treatment Administration Record) as per procedure. D. Accurate treatment orders will ensure that each licensed nurse administer the treatments per the physician's order ..." Resident #7 Record review revealed Resident #7 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 99, which indicated that Resident #7 was not able to complete the interview. Resident #7 was identified the resident with memory problems and severely impaired cognitive skills for daily decision making. The resident has no speech, rarely/never understood and rarely/never understands. Resident #7 was totally dependent on staff for all activities of daily living (ADLs). Resident #7 was incontinent of bowel and bladder and received all of nutrition by a feeding tube. Review of the May 2013 physician's orders revealed an order, dated 05/19/13, for "Order Clarification: Clean Stage 2 (two) To Left Outer Foot With Wound Cleanser, Pat Dry, Apply [MEDICATION NAME], Cover With 4X4's AND Kerlix." Review of the admission physician's orders, dated May 24, 2013, noted, "Clean Wounds To Rt (right) Foot With Wound Cleanser And Apply Normal Gel And Border Dressing Daily." Review of "Telephone Orders/Physician Verbal Orders", dated 6/1/13 at 6:30 p.m., noted, "Clean unstageable wound to left lateral foot distal to 5th toe with wound cleanser pat dry apply [MEDICATION NAME] and cover with border dressing ...Clean Stage 2 decubitus to left lateral foot proximal to 5th toe with wound cleanser pat dry apply normogel and cover with border gauze daily ...6/1/13 9:22 PM clean unstageable wound to rt (right) foot with wound cleanser pat dry apply [MEDICATION NAME] and cover with border dressing daily." Review of the "Treatments" record noted, "5/19 (2013), Order clarification, clean stage 2 (two) to Left outer foot (symbol for with) wound cleanser, pat dry, apply [MEDICATION NAME] cover (symbol for with) 4x4's, and Kerlix ...Start date 5/24/13, Clean Wounds To Rt (right) Foot With Wound Cleanser And Apply Normal Gel And Border Dressing Daily... The form had a handwritten line through RT (right) and Lt (left) was handwritten above the line. The Treatments record was observed to have handwritten initials from May 25, 2013 through May 30, 2013. Review of the ETAR (Electronic Treatment Administration Record) for May 2013, noted, "Clean Wounds To Rt (right) Foot With Wound Cleanser And Apply Normal Gel And Border Dressing Daily. Start date 5/24/13. Discontinue 5/31/13. The ETAR was electronically signed on 05/30/13 by Registered Nurse (RN) #2 and on 05/31/13 by RN #3. Review of the "Administration Record" for the "E-MAR (Electronic Medication Administration Record) noted, "5/30/13. Follow up ...clean wound to Rt (right) foot ...scheduled for 05/30/13 ...No expressed pain ...5/31/13. Follow up ...Clean wound to Rt foot ... Medication was effective." Review of the "Wound/Skin Management Documentation Record," revealed there were spaces on the form to identify the date, stage, length, width and surface area, exudate, and tissue type of wounds. The form also included a space for identifying the site. Review of the Wound/Skin Management Documentation Record, noted, "Date 5/8 (2013) Length 2 cm (centimeters) X (by) 2 cm (centimeters) {symbol for equals} 4 cm Surface Area. Surface area category 6 (six) (3.1 - 4.0 cm), 0 (none) exudate, tissue type 0 (closed) ...Date 5/16 (2013) 1cm X .5 cm (symbol for equals) .5 cm. Surface area category 2 (0.3 - 0.6). This form identified the site as "Rt (right) ft (foot)." Review of a second Wound/Skin Management Documentation Record, noted, "Date 5/24 (2013) Stage 2 (two) 1 cm (centimeters) x 1 cm (symbol for equals) surface area 1 cm. Surface Area Category 3 (0.7 -1.0) 0 (none) exudate, Tissue type 3 (slough)." This form identified the site as "Rt ft (right foot)." "Date 5/28. Stage 2 (two) 1 cm x 1 cm (symbol for equals) Surface Area 1 cm. Surface Area Category 3 (0.7 -1.0) 0 (none) exudate, Tissue type 3 (slough)." The form identified the site as "Rt ft." Observation revealed there was no "Wound/Skin Management Documentation Record " was provided by the facility for identifying or measuring wounds on the Left foot. Review of the care plan, noted, "Problem Onset: 5/24/13 At risk for skin breakdown r/t (related to) decreased bed mobility, decreased transfer ability, bowel incontinence, bladder incontinence ...skin impairment blister to (symbol for right) foot ... Approaches: Pressure red (reducing) matt (mattress), turn Q (every) 2 hr (hours) (symbol for and) prn (as needed) Wd (wound) care as ordered." The care plan did not identify any areas on the left foot. Review of the "Weekly Body Audit Roster" from 5/24/13 through 6/2/13" documented "No new skin issue noted." Review of the nurse's notes revealed the following: " 05/07/13 ...Small 2 cm X 2 cm Blister noted on outer RT (right) foot, TX (treatment) in progress ..." "05/19/13 Received clarification order for treatment from MD (Medical Doctor). Order received to clean stage 2 (two) to left outer foot with wound cleanser, pat dry, apply [MEDICATION NAME], cover with 4X4's, and Kerlix ..." "05/29/13 ...Tx (treatment) in progress to lt (left) foot ..." "05/31/13 Late Entry: 5/30/2013. 08:00 Wound Care to Rt (right) and Lt (left) Foot Done As Ordered Due To Computer Changes Order Was Not In Computer Correctly. The entry was electronically signed by Registered Nurse #2. Review of the SNF (Skilled Nursing Facility) Documentation Record for 05/24/13, noted, "Wound care to left foot being performed daily." The entry was electronically signed by Registered Nurse #2. Review of the "Skin At Risk Screening," dated 05/24/13, identified Resident #7 with a score of 26 ...Notes Greater than 12 High Risk." Observation of wound care on 05/31/13 at 3:40 p.m. provided by RN (Registered Nurse) #3 revealed RN #3 identified the area as a Stage 2 pressure ulcer on the resident's left lateral foot. RN #2 stated the wound measured 2.4 cm (centimeters) by 3.3 cm. Observation revealed there was no treatment provided for the right foot. Review of the "Departmental Notes", dated 06/01/13, and electronically signed by Registered Nurse #3, noted, "1) Stage 2 Decubitus to left lateral foot proximal to fifth toe ... 2) Unstageable wound to left lateral foot distal to fifth toe. 3) Unstageable wound to right inner foot proximal to great toe ...care plan to be adjusted to reflect wound care orders." Review of the care plan, dated 6/1/13, noted provided 06/02/13, "Low air loss mattress to bed." This care plan still did not address an area on the left foot. Interview and observation on 06/02/13 at 12:10 p.m. with Registered Nurse (RN) #2 revealed RN #2 reviewed the copy of the Wound Management record and the documentation of 5/24/13 and 5/28/13. RN #2 affirmed the documentation addressed the site as the right foot. Interview with Registered Nurse (RN) #3 on 06/02/13 at 10:05 a.m. revealed RN #3 stated a complete body audit was completed on everyone on 06/01/13 and Resident #7 had an "area come up on right foot" and a low air loss mattress was put on Resident #7's bed. RN #3 was asked the advantage of an air flow mattress, and RN #3 stated the flow could be adjusted, "be more conforming and would help alleviate pressure points." Interview with Registered Nurse (RN) #3 at 12:00 p.m. on 06/02/13, RN #3 was asked what area he had been doing wound care for Resident #7. RN #3 stated "on the left foot." RN #3 was asked what the doctor's orders documented and RN #3 stated, "Right foot." Interview with the Director of Nursing (DON) on 06/02/13 at 2:25 p.m., revealed she was asked to review notes on Resident #7, including physician's orders and Wound Documentation record and identify that treatments were completed as ordered to the correct site. The DON stated, "I can't by what I'm looking at." Interview on 06/02/13 at 2:45 p.m. with two (2) Certified Nurse Aides (CNAs), assigned to Resident #7 (CNA #1 and CNA #3), were asked about their observations of a dressing on Resident #7's feet. CNA #1 and CNA #3 stated the dressing had been seen on the left foot. Record review revealed Resident #7 was readmitted to the facility on [DATE], with physician's orders for treatment to the right foot and documentation on the Wound Documentation record and electronic ETAR identified an area on the resident's right foot. Wound care was observed on 05/31/13 to be provided to the left foot. Although nurse's notes revealed treatment had been provided for the left foot, the facility did not provide any documentation of identifying the area, including measurements or obtaining physician's orders until 06/01/13. Nurse's notes for late entry on 05/30/13 documented treatments were done for both right and left foot; however, there was no treatment identified on the Treatment Record for both the right and the left foot or an assessment identified until 06/01/13. The physician's orders did not include any order for treatment of [REDACTED]. The medical record did not include any measurements of an area on the left foot from 05/24/13 until 06/01/13. Although the facility was asked to provide any additional information regarding assessment or treatment, no additional information was provided during the survey. Resident #9 Record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of blank, which indicated that Resident #9's cognitive status was severely impaired. Review of the funbctional status section of this MDS coded that Resident #9 was totally dependent on staff for all activities of daily living. Resident #9 was not identified as having a pressure ulcer; however, was coded as incontinent of both bowel and bladder. Observation on 05/31/13 at 11:30 a.m. revealed Resident #9 was in her bed awake. Resident #9 had repetitive movements and was being fed by a Gastrostomy tube. Observation on 06/01/2013 at 7:30 a.m. revealed Resident #9 was seated in a wheelchair in the front lobby with her tube feeding infusing. Resident #9 had a lap tray across her lap and was moving repetitively in the wheelchair. At 7:45 a.m. Resident #9 was still in the same place in the front lobby. Observation on 06/01/13 at 8:05 a.m., 8:45 a.m., 9:56 a.m. and 10:23 a.m. she remained in the front lobby in the same place she had been since 7:30 a.m. (3 hours) and had not been observed to be checked or changed. Observation on 06/01/2013 at 10:50 a.m. revealed the Director of Nursing (DON), Registered Nurse (RN) # 1 and RN #4 were observed to take Resident #9 to her room and change the tube feeding. Observation, at this time, revealed that no incontinence care was provided for Resident #9 and Resident #9 was returned to the front lobby area. Observation on 06/01/2013 at 11:15 a.m. revealed two (2) Certified Nurse Aides (CNA) #2 and CNA #3 took Resident #9 to her room and transferred Resident #9 into the bed with a lift. CNA #2 and CNA #3 stated that the resident had not been changed on the 7 (a.m.) - 3 (p.m.) shift and that 11 (p.m.) to 7 (a.m.) shift had got the resident out of bed. CNA #2 and CNA #3 removed Resident #9's pants and untapped the resident's brief. The brief was wet and bowel movement was observed. CNA #2 and CNA #3 were asked to describe the resident's pants and brief. CNA #3 stated Resident #9's pants were wet and the disposable brief was soaked with urine and soiled with bowel movement. CNA #3 stated Resident #9 was not able to do anything for herself. CNA #2 and CNA #3 acknowledged that Resident #9 had been up in the wheelchair since the 11 to 7 shift got Resident #9 out of bed, and no incontinence care had been provided until 11:15 a.m. (more than four (4) hours.) Record review revealed Resident #9 was assessed for Skin at Risk on 04/04/2013. Resident #9's score was "26", greater than 12 being at high risk. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the care plan, dated 01/13/12, noted, "Excoriation with potential for further skin breakdown due to incontinent of bowel. History of Decubitus for positioning due to Right [MEDICAL CONDITION] ... Approaches: Check for incontinence Q (every) H (hour) and provide incontinent care PRN (as needed). High Risk Skin. Apply skin protectant to redness to buttocks Q (every) shift." Review of the care plan, dated 06/06/2012, noted, "Dependent on staff for bed mobility, Transfers, Locomotion, toileting, dressing, bathing, hygiene and eating... Approaches: Turn and reposition Q (every) 2 h (hours) and PRN (as needed)." Resident #10 Record review revealed Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #10's pressure ulcer/skin care plan on admission, dated 05/24/13, identified that Resident #10 had no care plan in place with regard to skin and/or pressure ulcer prevention. Interview on 06/02/13 at 10:30 a.m. with Registered Nurse #2, who admitted Resident #10, revealed she failed to address the pressure ulcer prevention in the care plan. Review of Resident #10's Skin at Risk Assessment, dated 05/24/2013, identified Resident #10 scored a "15" with greater than 12 being high risk for pressure ulcer development. Review of the May 2013 physician's orders identified Resident #10 was being treated for [REDACTED]. On the June 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 06/01/2013 at 4:13 p.m. a Registered Nurse (RN) documented in the nurses notes, "Called to room by family member. Noted Stage II Ulcer to left lower lateral leg, Measuring 7.2 cm (centimeters) x (by) 1.8 cm, no drainage no odor wound bed beefy red with granulation tissue noted. Wound care done as ordered. Res. (resident) tolerated well. Interview on 06/02/13 at 10:30 a.m. revealed RN #1 was asked if the area to the left lower leg she treated the day before was open and what was the stage of the wound. RN #1 replied, "Yes, Stage II." RN #1 was asked since Resident #10's admission did anyone assess the skin beneath the leg brace weekly or daily? RN #1 replied she came in clean (no wounds) developed an excoriation to bottom and a Stage II. RN #1 was asked what prevention measure were implemented when the brace was identified by therapy as a potential problem. RN #1 replied, "Requested sheep skin." RN #1 was asked if it had been utilized and she replied she had not gotten it. RN #1 was asked what caused the breakdown to the buttocks. RN #1 replied the resident had problems with mobility (non weight bearing). RN #1 was asked what was changed to aid in healing. RN #1 replied she requested a fracture bed pan after the area developed. Observation of wound care to Resident #10's left lower leg provided by Registered Nurse (RN) #2 on 06/02/13 at 3:40 p.m. revealed RN #2 stated wound care had already been done to the area on Resident #10's coccyx area this morning. RN #2 stated the area on the coccyx was a Stage II pressure. RN #2 was asked what caused the area on the resident's coccyx and the RN #2 stated "I think from the bedpan. It was big and hard to get on bedpan. We had to get a fracture pan." Resident #10 was observed to have a brace with Velcro closures on the left lower leg. RN #2 stated the brace/splint was an "Immobility Brace." RN #2 released the Velcro closures on the brace and provided wound care. RN #2 described the area on the left leg as a "Stage II with some granulation, surrounding tissue bruised from ankle to mid calf, almost to the knee and measured 7.5 centimeters (cm) by 1.5 centimeters wide with red drainage." RN #2 stated the area was a "Stage II pressure from the splint and area is directly in line with clasp on the brace." RN #2 stated Resident #10 also had a new area near the knee. RN #10 identified the area as a Stage 1, measuring 1.6 cm by 2 cm." RN #2 stated she had asked for sheepskin to put inside the splint but had not received the sheepskin.

Based on record review, staff interview and facility policy review, the facility failed to ensure the medical record accurately document the area of care to be provided one (1) of nine (9) residents identified at high risk for development of pressure areas (Resident #7). Findings include: Cross refer to F-314 for failure of the facility to ensure that the care plan in the record addressed care for the pressure area on Resident #7's left foot. Review of the "Treatments" record noted, "5/19 (2013), Order clarification, clean stage 2 (two) to Left outer foot (symbol for with) wound cleanser, pat dry, apply [MEDICATION NAME] cover (symbol for with) 4x4's, and Kerlix ...Start date 5/24/13, Clean Wounds To Rt (right) Foot With Wound Cleanser And Apply Normal Gel And Border Dressing Daily... The form had a handwritten line through RT (right) and Lt (left) was handwritten above the line. The Treatments record was observed to have handwritten initials from May 25, 2013 through May 30, 2013. Review of the care plan, noted, "Problem Onset: 5/24/13 At risk for skin breakdown r/t (related to) decreased bed mobility, decreased transfer ability, bowel incontinence, bladder incontinence ...skin impairment blister to (symbol for right) foot ... Approaches: Pressure red (reducing) matt (mattress), turn Q (every) 2 hr (hours) (symbol for and) prn (as needed) Wd (wound) care as ordered." The care plan did not identify any areas on the left foot. Interview with Registered Nurse (RN) #3 at 12:00 p.m. on 06/02/13, RN #3 was asked what area he had been doing wound care for Resident #7. RN #3 stated "on the left foot." RN #3 was asked what the doctor's orders documented and RN #3 stated, "Right foot." Review of the facility's "Resident at Risk of Pressure Ulcers" policy, revised 06/94, documented, "To identify those residents who are at risk for developing pressure ulcers. To implement appropriate nursing intervention to prevent the development of pressure ulcers ...5. The potential to develop pressure ulcers will be identified on the resident's comprehensive plan of care. Interventions may include use of pressure relieving devices on the bed and in a chair, turning and repositioning schedules, ambulation programs, toileting schedules for incontinent resident. 6. The licensed nurse will document the resident's responses and reactions to the interventions used to prevent pressure ulcers. 7. All pressure ulcers which develop will be documented in the resident's medical record."

Based on record review, resident interview and staff interview, the facility failed to ensure that one (1) four (4) residents reviewed, Resident # 1, was not a victim of neglect. This was evidenced by Resident #1 experiencing a fractured shoulder when facility staff failed to use the lift for transfer. Findings Include: Cross refer findings to F-323 for the facility's failure to ensure that an injury did not occur for Resident #1. Resident #1 was transferred without the use of a lift and experienced a fractured shoulder.

Based on record review, resident interview, staff interview and policy review, the facility failed to ensure that an injury did not occur for one (1) of four (4) residents reviewed, Resident #1. Resident #1 was transferred without the use of a lift and experienced a fractured shoulder. Findings Include: Resident #1 Record Review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/27/11 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated that the Resident #1 was cognitively intact. Section GO110 Activities of Daily Living (ADL) revealed that he required the assistance of two plus (2+) persons for transfer with extensive assistance. Review of his "Lift Transfer Assistance Screening" document dated 06/14/11 revealed that the use of the "Green-Stand-n-lift" with two persons was required for the transfer of Resident #1. Review of Resident # 1's "Care Plan" revealed: Page six (6) of 24, with a date of 06/18/11 the use of a Stand up lift with large sling x 2 person which was discontinued on 07/06/11. This was changed to "Requires total lift c (with) large sling x 2 (times two) assist. Keep left arm in sling for support & (and) help c pain". Page five (5) of 24 with an onset date of 06/09/11 for "POTENTIAL FOR PAIN DUE TO DJD (DEGENERATIVE JOINT DISEASE) & LT (LEFT) HUMERUS FX (FRACTURE)". The approach was to "Keep left arm in sling for support & help c (with) pain". Page eight (8) of 24 with an onset date of 06/18 11 for "POTENTIAL FOR FALLS DUE TO HISTORY OF FALLS". The approach was "TRANSFER USING STANDUP LIFT X 2 PERSON ASSIST WITH LARGE VEST (GREEN)". That approach was changed on 07/06/11 to "(triangle indicating change) Lift to Total Lift c ii (2) Person Assist". Review of Resident #1's ADL dated 6/11 revealed a Start Date of 12/17/10 for "STAND UP LIFT WITH LARGE SLING (GREEN) TRANSPORT SLING c 1 or more assist". Resident #1 was transferred to the hospital emergency roiagnom on [DATE] at 01:35 p.m. with "c/o (complaints of) pain to left shoulder due to fracture from fall". Review of the Physician Orders for Resident #1 revealed: "06/21/11 (triangle indicating change) Lortab 7.5 mg (milligrams) q (every) 6 (hours) PRN (as needed) to Lortab 7.5 i (one) po (by mouth) q 4 hrs (hours) PRN -Pain". "6/21/11 May have LOA (leave of absence) to Dr. (name) today @ 330 pm for eval (evaluation) of (L) shoulder". Review of an "Incident Report" dated 06/17/11 revealed that Resident #1 told a Certified Nursing Assistant (CNA) that he had fallen early that morning when he was being transferred from the bed to the chair and hurt his arm. He stated that the CNA's got him up and put him in the chair. He told the nurse of left arm and shoulder pain. An xray of the left shoulder was ordered and obtained on 06/18/11. The xray report, dated 06/18/11, revealed that Resident #1 had a "HUMERAL HEAD/NECK JUNCTION FRACTURE". The xray exam was for "LT (left) SHOULDER, LT HUMERUS" with the reason for the xray "PAIN DUE TO FALL". Further review of the Incident Report documentation for Resident #1 revealed: "(name of CNA #1) reported to (Licensed Practical Nurse {LPN} #1) on 3-11 shift (6/1/11) that (Resident #1) was complaining of shoulder pain when she was preparing him for bed, the LPN went to (the) room and ask him what was going on and he told her that he was dropped when they getting me up this morning. LPN ordered an x-ray of the shoulder. Radiographics came 6-18-11 and performed an x-ray. At 12:47 x ray report received, (name of attending physician) notified of results and ordered he (Resident #1) be sent to (name of hospital) for evaluation and possible admit. Resident returned to facility at 9:30 p.m. with an order or (for) Lori tab (Lortab) 7.5. Nurses notes indicated he complained very little with pain during the remainder of the 3-11 or 11-7 shift. An immobilizer was placed on him at the hospital." "(Registered Nurse {RN} #1) attempted to call NA (Nursing Assistant {#1})and (name of CNA #2) regarding what (Resident #1) had said. (NA #1) was assigned to (Resident #1) and she was notified not to return to work until the investigation was complete. She was actually off Saturday and Sunday." "On Monday 6-20-2011 I arrived at the facility at 7:50 and (NA #1) and (CNA #2) were waiting on me. I ask each of them what happened Friday morning regarding (Resident #1). (NA #1) began by saying that she had the stand up lift and was getting him up and his legs buckled like noodles and she eased him back on the bed, she then got his legs back on the bed and pulled the side rails up and when (went) to get (CNA #2) to help her get him up, (CNA #2 and NA #1) both said they used the lift to get him up. (NA #1) said while she was undressing him in the bed he complained of arm pain. After both of the aides left, I had a meeting with the DON (Director of Nursing) and told her what they had said to me and she said well we are getting a different story from (Resident #1) And he said no lift was used on him, so I called (NA #1) back and she admitted she did have another C.N.A. with her when using the lift I then told her that it was against our policy and that this was ground for termination, she said tell me now if I am fired because I can not come back in I don't have a car. I said to her that her not using a lift is ground for termination and she was terminated." "I came to my office and looked at the camera to see if the lift was even carried into the room, I started watching the camera around 5:30 and around 5:45 (NA #1) went into (Resident #1) room by her self, no lift. Around 6:01 she came out (no lift) went down the hall got the lift and pushed it into (Resident #1's) room and came back out and went toward the nurses station. When she returned to his room she had (CNA #2) with her the lift was pushed out of room and both went back in. (CNA #2) was in there just a few minutes and she came out. (NA #1) remained in the room until about 6:13. The lift was never used by either aid at any point and time. (CNA #2) was called back in to ask again if the lift was used , she said yes when she come and got me to help him get up we used the lift, I said well lets go look at what the camera say it was at this time when we watched that she admitted not using the lift but did say that at no time during the time she was in the room did (Resident #1) fall or slip or anything. I told her as I did (NA #1) not using a lift is what is going to cost you your job. I terminated her for not using the lift and not being honest in the beginning. I believe that when (NA #1) went in at around 5:45 she attempted to get (Resident #1) up by herself. When his legs buckled she set him fall back on the bed and he fell on the bed on his arm. She then lifted his legs on to the bed and went to get (CNA #2) to help get him out of bed. She put the lift in the room to make it appear that she used the lift." "I interviewed (Resident #1) and he said it all happen so fast I don't really know what happened. I don't know if I went on the floor or the bed I do know that I heard my shoulder pot (pop). I ask did you say anything to the aid and he said no I thought she heard it. He said she left and went to get someone to help her get me up. I ask did anyone use a lift on you during this time and he said no." "I have interviewed the 7-3 nurse(name of LPN #2), who had (Resident #1) on 6-17-2011. She said he never said a word to her on her shift about any of the above nor did he complain of any pain. She said I did finger sticks on him and say (saw) him numerous times thorough out the shift and (he) never said a word about pain. She said the 11-7 nurse (name) said that (NA #1) told her he complained of arm pain and when she went in to give his meds he was sitting in wheel chair with lap buddy in place. She ask him about the pain in his arm/shoulder he told her it will be fine, and shook his head no. She said maybe you slept on it wrong, he nodded and smiled at the nurse. (name of CNA #3) was the C.N.A. that had (Resident #1) on the 7-3 shift. She said toward the end of her shift on her last rounds when she lifted his arms to take the lap tray off he hollered ouch. As she was leaving her shift she told the LPN (LPN #2) , but she was giving report. When I spoke to (LPN #2) she said she does not remember (CNA #3) telling her about him complaining of pain, but if it was during change of shift I may not have actually heard it. When I ask (CNA #3) again she said well maybe she did not hear me." "When I spoke to (Resident #1) this morning he did not appear to be in any pain and he said he was not in pain." "Both C.N.A.'s were terminated related to this incident and not using the lift. C.N.A. failed to report to nurse that his legs buckled and he went back on the bed. I do not think he went to the floor because there is no way 1 aide or 2 could get him up out of the floor with out a lift. As the camera showed the lift was never in the room long enough to be used." "In-services started on using lifts and going by the resident's ADL, not to lift resident with out lifts and to follow policy." This typed document was signed by the Administrator and dated 06/20/11. Interview with CNA #1 on 07/13/11 at 03:25 p.m. revealed that Resident #1 had reported to her that two CNA's had dropped him that morning. He stated that he did not know their names. Interview with Resident #1 on 07/13/11 at 04:15 p.m. revealed that he did not recall what happened the day his shoulder got hurt because everything happened so quickly but it "was about 2 weeks ago". Interview with NA #1 on 07/13/11 at 11:21 a.m. revealed that she had used a lift when transferring Resident #1. She stated he did not fall, that he had his hand on the wheelchair and his legs got weak and he slipped. She stated that CNA #1 was not in the room when Resident #1 slipped on 06/17/11. Attempts to contact CNA #1 were unsuccessful during the survey. Review of the facility policy "Lifting Policy" dated Latest Revision 3/11 revealed "This facility will strive to provide a safe work environment for resident care areas by providing and requiring the use of safety materials, equipment and training designed to help prevent personnel and patient injury." "It is crucial that health care professionals practice safe lifting, transporting and proper back care at all times. Mechanical lifts are a key component in this effort. Failure to utilize a mechanical lift when the use of this equipment is indicated in resident's plan of care, unless exception is met, could result in disciplinary action up to and including termination of employment. When any mechanical lift is used, one (1) or more staff members must be in attendance." "Procedures 2. Staff will follow the documented lifting protocol deemed appropriate for each resident. Plan of Care for lifting will be developed for each resident in need of a mechanical lift and followed per all staff."