Every finding on record at Signature Healthcare of Fentress County

Based on facility policy review, observations, and interviews, the facility failed to ensure the kitchen equipment was maintained in a sanitary working condition.The findings include: Review of the facility's Nutritional Services policy titled, Equipment, dated 9/2017, revealed .All food service equipment will be clean, sanitary, and in proper working order .All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials .All food contact equipment will be cleaned and sanitized after every use .All non-food contact equipment will be clean and free of debris . During an observation and interview of the kitchen during the initial tour on 1/5/2026 at 9:55 AM, with the Certified Dietary Manager (CDM) revealed on inspection of the cook-top stove / oven, the splash plate behind the stove top burners was noted to have smeared, dried, dark brown food debris present.The food debris collection pans under the burners of the stove had no aluminum foil lining the pans, the pans had a moderate amount of partially burned food debris present representing multiple food groups. The oven doors of the unit had dried, brown/black food debris on the top of both oven doors. The double convection oven was observed with dried brown/black food debris present on the inside of both doors of the upper convection oven unit. The glass portion of the doors of the upper unit and lower unit were covered with brown food debris which completely blocked the view of food cooking in the convection oven unit. Review of dietary staff in-service/education material and competencies provided to the kitchen staff upon hire and as needed revealed the dietary staff had completed education upon hire and routinely on preventing foodborne illness, infection control, maintaining a sanitary kitchen, maintaining/operating kitchen equipment, and safety procedures in the kitchen. Review of the equipment cleaning logs for the previous 90 days prior to the survey revealed complete entries documented on the logs, no missing entries were noted. During an interview on 1/5/2026 at 10:35 AM, the CDM stated the kitchen's food service equipment was deep cleaned weekly and daily after use and confirmed the cook-top oven as well as the double convection oven unit needed a thorough cleaning and was not currently in a sanitary condition.

Based on facility policy review, medical record review, and interview, the facility failed to provide resident-centered interventions to prevent pressure injury development for one 1 resident (Resident #10) of 3 residents reviewed with pressure injuries.The findings include: Review of the facility policy titled, Skin Integrity, dated 1/31/2025, revealed .a resident receives care, consistent with standards of practice, to prevent avoidable skin integrity issues .the facility utilizes either a pressure reducing, pressure relieving, or pressure redistributing mattress on each resident bed . Review of the medical record revealed Resident #10 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses including Spinal Vertebrae Compression Fracture, Diabetes, Peripheral Vascular Disease, and Dementia. Review of Resident #10's Nursing Leader Wound assessment dated [DATE], revealed the resident had redness to the coccyx on admission to the facility. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 scored an 11 on the Brief Interview of Mental Status (BIMS) assessment which indicated the resident had mild cognitive impairment. Further review revealed Resident #10 required partial/moderate assistance with bed mobility and transfers, was not ambulatory, was frequently incontinent of bladder, and always incontinent of bowel. Review of the current comprehensive care plan for Resident #10 revealed standard interventions dated 6/20/2025, including .assist to turn and position frequently .weekly skin check .Braden assessment quarterly and prn .pressure relieving mattress .incontinence care . Review of a Braden risk assessment dated [DATE], revealed Resident #10 scored a 13, which stated, .13-14=MODERATE RISK-if other risk factors are present advance to next level of risk . Resident #10 had risk factors including advanced age, and multiple diagnoses that could contribute to risk for skin breakdown including Diabetes and Peripheral Vascular Disease. Review of a Braden risk assessment dated [DATE], revealed Resident #10 scored a 15 which stated, .15-18=MILD RISK-if other major risk factors are present .advance to next level of risk . Review of the medical record and Physician's Orders prior to 9/9/2025 revealed no orders or documentation of resident-specific measures to prevent skin impairment and injury from pressure. Review of a wound evaluation for Resident #10 dated 9/9/2025, revealed the resident was observed on 9/9/2025 with a new stage 3 pressure injury on the right heel, and a treatment order was initiated. Review of the Physician's Orders for Resident #10 revealed an order dated 9/9/2025 to float heels when lying in bed and an order for heel protectors when lying in bed or as resident allows. Review of a wound evaluation for Resident #10 dated 11/5/2025, revealed the resident was observed on 11/4/2025 with a new deep tissue injury on the left heel, and a treatment order was initiated. Review of the current comprehensive care plan for Resident #10 revealed a problem dated 11/11/2025, .demonstrates non-compliance .as evidenced by refusal to turn and reposition . Review of a Pressure Ulcer Letter of Unavoidability for Resident #10 dated 12/3/2025, revealed documentation .despite routine and appropriate prevention interventions such as turning and repositioning, use of pressure-reducing or relieving devices, good skin care, and maintenance of adequate nutrition and hydration .the ulcer is considered unavoidable. Review of a wound evaluation for Resident #10 dated 12/10/2025, revealed the resident was observed on 12/9/2025 with new unstageable pressure injuries clustered on right and left buttocks area and combined as 1 sacral area, and a treatment order was initiated. Review of the current comprehensive care plan for Resident #10 revealed interventions dated 12/10/2025, .implement pressure reducing device such as mattress, cushion to chair as indicated .assist with turning and positioning as allows . and an intervention dated 12/22/2025, .air mattress placed on bed . Review of the entire Medical Record revealed no evidence of preventive interventions to prevent a pressure ulcer to the heels until 9/9/2025 when the resident developed a new facility-acquired stage 3 pressure ulcer on the right heel. Further review revealed the resident experienced a steady deterioration in condition related to diagnoses and comorbidities, including other pressure ulcers deemed unavoidable, and the practitioner determined on 1/7/2026, .pressure wounds unavoidable, even with strict adherence to turning schedules, air mattress, offloading pressure, appetite stimulants, emotional support, and proper skin care .contributing comorbid conditions: poorly controlled Diabetes, Anemia, poor/unbalanced sodium, Chronic Kidney Disease, Heart Failure . Resident #10 was admitted to Hospice services on 1/6/2026. During an interview on 1/7/2026 at 10:00 AM, the Director of Nursing (DON) stated a pressure reduction mattress is standard on all beds at the facility and confirmed the standard of practice to avoid pressure ulcer development on the heels is to provide off-loading using pillows, wedges, or heel boots. The DON confirmed there was no documentation that off-loading was provided to Resident #10 until after the new facility acquired stage 3 pressure injury was found on the left heel on 9/9/2025.

Based on facility policy review, observation, and interview, the facility failed to meet safety requirements for personal refrigerator temperatures and foods in date for 1 resident (Resident #76) of 18 residents with personal refrigerators.The findings include: Review of the facility's policy titled, Foods Brought by Family/Visitors, revised 3/25/2024, revealed .If a resident has a refrigerator in their room temperatures will be maintained at an appropriate level . Resident #76 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Acute Kidney Failure, and Cirrhosis of the Liver. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #76 scored a 14 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. During an observation on 1/5/2026 at 10:50 AM, Resident #76's room revealed a personal refrigerator in use. Upon opening the refrigerator door, one pint sized milk carton unopened was located on the top shelf inside of the refrigerator. The expiration date on the container was 11/14/2025. Further observation revealed the thermometer reading of 51 degrees Fahrenheit. During an interview and observation on 1/5/2026, Licensed Practical Nurse (LPN) A confirmed the milk in Resident #76's personal refrigerator was expired and the temperature on the thermometer was out of the safe range for food temperature storage at 51 degrees Fahrenheit. LPN A discarded the expired milk after notifying the resident and notified maintenance about the refrigerator temperature. During an interview on 1/6/2026 at 11:45 AM, the Director of Nursing (DON) confirmed that it was the responsibility of the housekeeping staff to clean, maintain and perform daily temperature checks and record the information on a temperature log.

Based on review of the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for weight loss and weight gain for 1 resident (Resident #7) of 19 residents reviewed.The findings include: Review of the MDS 3.0 RAI Manual Version 19.1, dated 10/2024, revealed instructions, .For a New Admission-Ask the resident, family, or significant other about weight loss over the past 30 and 180 days .If the admission weight is less than the previous weight, calculate the percentage of weight loss .Complete the same process to determine and calculate weight loss comparing the admission weight to the weight 30 and 180 days ago . For a New Admission-Ask the resident, family, or significant other about weight gain over the past 30 and 180 days .If the admission weight is more than the previous weight, calculate the percentage of weight gain .Complete the same process to determine and calculate weight gain comparing the admission weight to the weight 30 and 180 days ago . Further review revealed the weight gain and/or weight loss must be at least 30% in 30 days, and/or 10% in 180 days. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Pulmonary Disease, Spinal Compression Fractures, and Protein-Calorie Malnutrition. Review of the medical record revealed Resident #7 was transferred to the hospital on [DATE]. There was no weight documented between initial admission of 10/31/2025 and 11/4/2025. Review of an admission MDS assessment dated [DATE], revealed Resident #7 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed weight loss of 5% or more in the last month or loss of 10% or more in last 6 months was coded .yes, not on prescribed weight-loss regimen . and weight gain of 5% or more in the last month or gain of 10% or more in last 6 months was coded .yes, on physician-prescribed weight-gain regimen . Review of the medical record revealed Resident #7 returned to the facility on [DATE] and the next weight documented was 11/17/2025 of 84 lbs (pounds), followed by 11/24/2025 of 86 lbs, and 12/1/2025 of 88.4 lbs. Review of the medical record revealed Resident #7 was transferred to the hospital on [DATE] and returned on 12/9/2025. Weights were documented on 12/10/2025 of 85 lbs, 12/12/2025 of 85 lbs, and 12/14/2025 of 85.6 lbs. Review of a 5-day MDS assessment dated [DATE], revealed Resident #7 scored an 11 on the BIMS assessment which indicated the resident had mild cognitive impairment. Further review revealed weight loss of 5% or more in the last month or loss of 10% or more in last 6 months was coded .yes, not on prescribed weight-loss regimen . Review of the medical record revealed no documentation Resident #7 had experienced a weight loss or gain of 5% in 1 month or 10% in the past 6 months. During an interview on 1/7/2026 at 12:30 PM, the MDS Nurse stated Resident #7's family said the resident had a weight gain followed by weight loss prior to admission. The MDS Nurse confirmed there were no actual weights provided by the family to determine accurate percentages and confirmed the MDS's dated 11/4/2025 and 12/15/2025 were coded incorrectly.

Based on facility policy review, facility investigation review, medical record review, and interview, the facility failed to ensure current advance directive preferences were reflected in the electronic medical record (EMR) for 1 (Resident #5) of 89 residents reviewed. The findings include: Review of the policy titled, Cardiopulmonary Resuscitation dated [DATE], revealed .Cardiopulmonary resuscitation (CPR) will be attempted for any resident who is found to have no palpable pulse and/or no discernible respirations, unless there is a written physician order to the contrary and/or written advance directives .Cardiopulmonary resuscitation is defined as artificial respiration accompanied by external cardiac compressions .Upon identifying a resident with change of condition which presents as a unresponsive condition .check the medical record for advance directive status . Review of the policy titled Resident Rights dated [DATE] revised [DATE], revealed .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility .When providing care and services, the stakeholders will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with and access to persons and services inside and outside the facility .participate in decisions and care planning .Residents are entitled to exercise his/her rights and privileges as a resident of the facility and as a citizen or resident of the United States, to the fullest extent possible .The facility will make every effort to support watch resident in exercising his/her right to assure that the resident is always treated with respect, kindness and dignity .The facility provides equal access to quality care regardless of diagnosis, severity of condition . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Chronic respiratory failure, Acute on chronic diastolic (congestive) heart failure (CHF) and Chronic obstructive pulmonary disease (COPD). Resident #5 was admitted to hospice care on [DATE] and expired on [DATE]. Review of the Physician Order for Lift Sustaining Treatment (POLST) form dated [DATE] revealed, .DNR [Do Not Resuscitate] . The POLST was signed and dated by the physician on [DATE]. The POLST form dated [DATE] was not added Resident #5's medical record. Review of the Physician Order Report date XXX[DATE] Code Status: Do Not Resuscitate (DNR) .Admit to Hospice: Quality Hospice . Review of Care Plan for Resident revealed XXX[DATE] has potential for difficulty breathing XXX[DATE] has been diagnosed with a terminal condition .at risk for unavoidable significant declines .has pulmonary condition/DX [diagnosis] . Review of the Quarterly MDS assessment dated [DATE] revealed, a BIMS score of 12 which indicated a moderate cognitive impairment. Continued review revealed he had been receiving oxygen therapy. Review of the Nurse Practitioner (NP) Progress Notes dated [DATE], .Respiratory Failure with Pneumonia . CHF (Congestive Heart Failure . Comfort measures-patient to be admitted under [Named Hospice agency], will assist with Hospice company in making patient comfortable .Code Status: DNR [Do not resuscitate] . Review of the facility investigation dated [DATE], revealed LPN #3 was doing med pass she discovered Resident #5 to be unresponsive. There was no response to name being called,no pulse and no respiration. The electronic medical record (EMR)was checked, the banner and order entered on [DATE] read DNR, but the latest POLST form dated [DATE] read CPR full treatment. The DON (former DON) was contacted via phone by LPN #2 and LPN #3. The DON advised LPN #2 and LPN #3 to code him. LPN #5 obtained the crash cart, LPN #4 called 911, LPN #4 and LPN #5 were responsible for compressions, the NP was contacted, and the local emergency medical service (EMS) arrived at 5:44 AM. Review of the Resident Progress Notes dated [DATE] at 5:59 AM, revealed, res [resident] found around 530 am [5:30 AM] w [with]no apparent pulse or respirations, latest polst form [Physician order which tells what life sustaining treatment should have been done in the event of death] uploaded stated res was of full code status at 532 [5:32 AM] first compression performed. CPR performed until local EMS arrival at 544 am [5:44 AM]. The local EMS took over compressions at that time. res [resident] transported to local HSP [hospital] emergency room [ER]. NP [Nurse Practitioner], DON and resident rep [representative] notified of status. Review of facility investigation contained an email sent by CNA #4. The email dated [DATE] at 3:03 PM, revealed CNA #4 wrote,when I walked into named resident's room (Resident #5) he had his O2 on however he was not breathing and had no pulse. I started CPR immediately at that point. At the time it was 0532 [5:32 AM]. I was accompanied by two other nurses and two CNAs, we were giving breaths by using an ambu bag and giving compressions until EMS arrived which was approximately 30 minutes later . Review of the signed written statement dated [DATE], revealed LPN #2 had participated in the code involving Resident #5. During an interview on [DATE] at 12:25 PM, LPN #2 recalled her participation in the CPR conducted on [DATE]. She was on speaker phone along with LPN #3 and was told by the former DON to start CPR. During an interview on [DATE] at 12:35, LPN #6 was asked where she would go to find the code status, she responded she could look at the banner or under the documents in the EMR for the POLST form. LPN #6 also stated if the code status has been changed, the order must be entered into the EMR, the physician must sign the POLST form, and the form should be uploaded to the chart. During a phone interview on [DATE] at 4:35 PM, the NP stated (Resident #5) should have been listed as a DNR. During an interview on [DATE] at 10:00 AM, the DON was asked what the expectation was if a resident experienced cardiac arrest. The DON stated, .to follow [physician] orders, know where to find the POLST and follow it. During an interview on [DATE] at 11:01 AM, the former DON stated she was called when Resident #5 was found unresponsive and was told the banner said DNR and the POLST form in the EMR said full code. She instructed the staff to do CPR.

Based on facility policy review, medical record review, and interview, the facility failed to follow the Advanced Directive as ordered by the physician for 1 (Residents #3) of 84 residents reviewed. The findings include: Review of the facility policy titled, Advanced Directives, dated [DATE] revised [DATE] revealed, .The facility will ensure each resident has the right to request, refuse, and/or discontinue treatment .formulate an advance directive .Advance care planning, the process of communication between individuals and their healthcare agent to understand, reflect on, discuss and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions .Advance directive: a written instruction .for healthcare .related to the provision of healthcare when the individual is incapacitated . Review of the policy titled, Cardiopulmonary Resuscitation dated [DATE] revealed .Cardiopulmonary resuscitation (CPR) will be attempted for any resident who is found to have no palpable pulse and/or no discernible respirations, unless there is a written physician order to the contrary and/or written advance directives .Cardiopulmonary resuscitation is defined as artificial respiration accompanied by external cardiac compressions .Upon identifying a resident with change of condition which presents as a unresponsive condition .check the medical record for advance directive status .If circumstances are such that CPR is initiated on a resident, then the code status is clarified to indicate there is a current order to not initiate CPR in the event of death. Review of medical records revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Chronic respiratory failure, Acute on chronic diastolic (congestive) heart failure (CHF) and Chronic obstructive pulmonary disease (COPD). Resident #5 expired [DATE]. Review of the Life Sustaining Treatment (POLST) form signed and dated by the physician on [DATE] revealed, .DNR [Do Not Resuscitate] . Review of Care Plan for Resident revealed [DATE] has potential for difficulty breathing XXX[DATE] has been diagnosed with a terminal condition .at risk for unavoidable significant declines .has pulmonary condition/DX [diagnosis] . Review of the Quarterly MDS assessment dated [DATE] revealed, a BIMS score of 12 which indicated no cognitive impairment. Continued review revealed he had received oxygen therapy. Review of the Physician Order Report dated XXX[DATE] Code Status: Do Not Resuscitate (DNR) XXX[DATE] Admit to Hospice: [named hospice agency] . Review of the Nurse Practitioner (NP) Progress Notes dated [DATE], revealed .Code Status: DNR [Do not resuscitate] . Review of the Resident Progress Notes dated [DATE] at 5:59 AM, revealed, res [resident] found around 530 am [5:30 AM] w [with] no apparent pulse or respirations, latest post form uploaded stated res was of full code status. at 532 [5:32 AM] first compression performed. CPR performed until [Named Emergency Medical Service [EMS] arrival at 544 [5:44] am [AM]. [Named EMS] took over compressions at that time. res [resident] transported to [Named Hospital]. Review of the signed employee statement dated [DATE] revealed LPN #3 discovered Resident #5 to be unresponsive. There was no response to name being called. During assessment, there was no pulse and no respiration. The electronic medical record was checked, the banner (header at the top of the electronic medical record face sheet) and physician order entered on [DATE] read DNR. The latest POLST form dated [DATE] stated CPR full treatment. LPN #5 obtained the crash cart, LPN #4 called 911, LPN #4 and LPN #5 were responsible for chest compressions, the NP was contacted, and local EMS arrived at 5:44 AM. Review of the signed written statement dated [DATE], revealed LPN #2 had participated in the code involving Resident #5. During an interview on [DATE] at 10:00 AM, LPN #2 stated she was on speaker phone with the former DON and was instructed that they should code the resident (Resident #5) because there was a discrepancy with the code status. During a phone interview on [DATE] at 4:35 PM, the NP stated the resident should have been listed as a DNR. During an interview on [DATE] at 11:01 AM, the former DON stated she was called by staff (LPN #2 and LPN #3) when Resident #5 was found unresponsive and was told the banner indicated the resident was a DNR. The POLST in the electronic record said full code. She instructed the staff to do CPR.

Based on facility policy review, medical record review, and interviews, the facility failed to follow their discharge policies and procedures and failed to meet the requirements for an appropriate discharge for 1 of 3 (Resident #1) residents reviewed for discharge requirements. The findings include: Review of the facility's policy titled, Transfer/Discharge Notice, revised 11/1/2022 revealed, .The appropriate notice will be provided to the resident and/or resident representative if it is necessary to transfer or discharge a resident from a facility .'Facility-initiated transfer or discharge': A transfer or discharge which the resident objects to, did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences .1. The facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met by the facility. b. The transfer or discharge is appropriate because the resident's health has improved so the resident no longer needs the services provided by the facility. c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. d. The health of individuals in the facility would otherwise be endangered. e. The resident has failed, after reasonable and appropriate notice, to pay for (or have paid under Medicare or Medicaid) a stay at the facility. f. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay, For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge only allowable charges under Medicaid; or; g. The facility ceases to operate . Review of the medical record revealed Resident #1 was admitted to the facility on (1/26/2023) with diagnoses which included Paraplegia, Acute Disseminated Encephalomyelitis, and Muscle Weakness. Review of the insurance authorization revealed Resident #1 was approved for treatment at a skilled nursing facility from 1/26/2023 through 4/23/2023. Review of the Admission Minimum Data Set (MDS) assessment for Resident #1 dated 1/31/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Continued review revealed resident exhibited no behaviors during the assessment period. Continued review revealed the resident received Occupational Therapy (OT) and Physical Therapy (PT) 4-5 days a week. Review of the OT Treatment Encounter Note(s) for Resident #1 dated 2/3/2023 through 2/28/2023 revealed treatment centered around improving trunk balance, postural control, improved sitting/standing tolerance, gross motor coordination, forward and lateral reach, and picking up objects from the floor. The notes revealed Resident #1 actively participated in all sessions. Review of the PT Treatment Encounter Note(s) for resident #1 dated 2/2/2023 through 3/2/2023 revealed treatment centered around dynamic balance training, lateral reach, sitting unsupported, range of motion, improved mobility, facilitate proprioception, balance, stretching, and ankle pumps. The notes revealed Resident #1 actively participated in all sessions. Review of the Transition of Care/Discharge Summary dated 3/2/2023 revealed Resident #1's goals of stay were core strengthening. The recapitulation of the stay revealed the resident participated in therapy services PT and OT 5 days weekly. Review of the discharge planning document for Resident #1 revealed the resident was discharged home on 3/2/2023. During an interview on 4/3/2023 at 12:33 PM, Resident #1 stated on 3/2/2023 the Administrator questioned the resident about smoking marijuana in her room, stated there was a strong smell coming from the room and requested consent to search her room. Resident #1 refused having her room searched, stating she had prescription medications (Gabapentin) from home in her room and knew she was not supposed to have them. The Administrator then stated she would call the police and Resident #1 said, OK. Resident #1 stated the police then arrived and asked consent to search her room and again she denied access to her room. Resident #1 stated on that day (3/2/2023) after that encounter, she was called to the Administrator's office and was told she was being discharged home that day. When Resident #1 asked the Administrator why she was being discharged so suddenly, she was told it was an emergency discharge and had been in the works for a while. Resident #1 stated the facility discharge planner arranged outpatient therapy for her with a clinic that didn't even have parallel bars, which she was using with progress at the facility. The resident stated after she got home, she had to set up her own therapy. The resident stated she was having amazing progress and did not understand why she was so abruptly and unfairly discharged . During an interview on 4/3/2023 at 1:53 PM, the Administrator stated on 3/2/2023 there was a smell of marijuana coming from Resident #1's room. When the Administrator requested consent to search the resident's room, the resident denied consent. The Administrator stated the resident was admitted to the facility for therapy. The Administrator stated the resident performed most all activities of daily living independently and did not require 24/7 nursing care. The Administrator stated Resident #1 was therefore discharged that day. When this surveyor asked the Administrator how much notice was given Resident #1 prior to discharge, she stated, we notified her that day. The Administrator stated the Medical Director agreed Resident #1 did not need 24/7 nursing care and gave an order for Resident #1 be discharged home. During an interview on 4/3/2023 at 2:17 PM the Registered Occupational Therapist (OTR) stated Resident #1 made excellent effort during therapy. She stated Resident #1 wanted to regain functional use of her legs. She stated Resident #1 participated well every day. During an interview on 4/3/2023 at 2:37 PM the Physical Therapy Assistant (PTA) stated Resident #1 was admitted to the facility to get muscle function back to be ambulatory again. The PTA stated Resident #1 had some muscle tone returning and her core had strengthened. The PTA stated the only thing she was told by her manager is that Resident #1 was being discharged that day. The PTA stated, It was a shock. During an interview on 4/3/2023 at 2:36 PM the Social Service Director (SSD) stated the Director of Nursing (DON) told her to start the discharge process for Resident #1 that day (3/2/2023.) During an interview on 4/3/2023 at 2:43 PM the Medical Director stated on 3/2/2023 he was told Resident #1 was ready to be discharged home. He stated he does not remember anyone communicating with him Resident #1 was experiencing great benefit with her OT and PT sessions. He stated he depended on the nursing staff/administration to be his eyes and ears and tell him what he needed to do. During an interview on 4/3/2023 at 3:00 PM, the Insurance Case Manager stated Resident #1's record revealed she was discharged from the facility due to illicit drug use. During an interview on 4/3/2023 at 3:30 PM the Assistant Chief of Police stated he received a from the facility regarding a resident smoking marijuana in her room. He stated upon arrival he questioned Resident #1, who refused to give consent for a room search. He stated he did not smell any scent of marijuana or see any drug paraphernalia from the doorway. He stated he left the facility without suspicion of drug use.

Based on facility policy review, observation, and interview the facility failed to clean 1 of 2 ice machines, cover drinks in the walk-in refrigerator, separate staff food from the kitchen food in the reach-in refrigerator, label and date food in the reach-in refrigerator, have a thermometer in the reach-in refrigerator, and failed to serve food within the temperature safety zone for 1 of 10 trays. The findings include: Review of the facility's policy titled, Ice, revised 9/2017, revealed, .Ice Machines will be cleaned monthly and as needed . Review of the facility's policy titled, Food Storage Cold foods, revised 4/2018, revealed, .An accurate thermometer will be kept in each refrigerator and freezer .All foods will be stored wrapped or in covered containers, labeled and dated . Review of the undated facility policy titled, Meal Distribution: Infection Control Considerations, revealed, .All food items will be transported promptly for appropriate temperature maintenance . Observation in the kitchen on 6/13/2022 at 10:01 AM, the ice machine had a two pink spots on the flap inside of the ice machine. Observation and interview in the kitchen on 6/13/2022 at 10:07 AM, with the Dietary Manager, revealed the walk in refrigerator had 16 cups of water uncovered in the refrigerator. The Dietary Manager confirmed the cups of water should have been covered and she did not know why the cups were there uncovered. Observation and interview in the kitchen on 6/13/2022 at 10:11 AM, with the Dietary Manager, revealed the reach in refrigerator did not have a thermometer and a bottled juice drink was in the refrigerator. Continued observation revealed 2 wrapped sandwiches and a opened container of sour cream were undated. The Dietary Manager confirmed the reach in refrigerator was supposed to have a thermometer, staff food was not to be mixed with the kitchen food, and the 2 sandwiches and sour cream needed to be dated. Observation and interview in the kitchen on 6/13/2022 at 10:19 AM, the Dietary Manager confirmed the pink debris on the flap of the ice machine. Observation and interview in the kitchen on 6/13/2022 at 11:33 AM, revealed the Dietary Manager (DM) obtained a small carton of milk on ice from a plastic bin set aside for the trayline. Continued observation revealed the DM tested on e of the milk cartons from the plastic bin, and the temperature was 43 degrees Fahrenheit. Observation in the kitchen on 6/13/2022 at 11:36 AM, 11:39 AM, 11:40 AM, 11:43 AM, and 11:44 AM, revealed the dietary staff placed milk from the plastic bin on the meal trays for delivery to the residents. Observation and interview in the kitchen on 6/13/2022 at 11:46 AM, revealed the dietary staff removed and replaced milk from the meal trays when prompted by this surveyor. Observation in the kitchen on 6/13/2022 at 12:55 PM, revealed the dietary staff placed the test tray on cart #7. Observation and interview on the 400 Hall on 6/13/2022 at 1:20 PM, with the Dietary Manager, revealed the last tray was delivered. The test tray was removed and the food temperatures were obtained. The meatball's temperature was 133 degrees Fahrenheit, potatoes 127 degrees Fahrenheit, and a pint size carton of milk was 56 degrees Fahrenheit. The Dietary Manager confirmed the temperatures were not within the safety zone for consumption. During a telephone interview on 6/15/2022 at 4;18 PM, the District Certified Manager stated when delivering meals to the residents. the food temperatures should be within the danger zone (135 degrees Fahrenheit or higher for hot foods and 41 degrees Fahrenheit or lower for cold foods). During an interview on 6/15/2022 at 5:22 PM, the Maintenance Director stated the ice machine was cleaned every 6 months and he was responsible for cleaning it.

Based on facility policy review, medical record review, observation, and interview, the facility failed to post a Transmission Based Precaution (TBP) sign on 4 of 6 TBP rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) and failed to apply Personal Protective Equipment (PPE) prior to entering a TBP room, failed to properly label and store bedpans and urinals in shared bathrooms for 6 of 39 residents. The findings include: Review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions, dated October 2018, revealed, .Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents .When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution .a. The signage informs the staff of the type of CDC [Centers for Disease Control] precaution(s), instructions for use of PPE [Personal Protective Equipment], and/or instructions to see a nurse before entering the room .Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected .Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status Review of the medical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed Resident #78 was admitted to room [ROOM NUMBER]. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed Resident #84 was admitted to room [ROOM NUMBER]. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed Resident #27 was admitted to room [ROOM NUMBER]. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #386 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed Resident #386 was admitted to room [ROOM NUMBER]. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Nursing Staff provide education and support to resident and family regarding isolation precautions, reason for isolation, maintaining specified isolation precautions for duration of required isolation . Observation on the 500 Hall on 6/13/2022 at 10:15 AM, 12:25 PM, 12:50 PM, and 3:20 PM, revealed no TBP sign posted on room [ROOM NUMBER]'s door. Observation and interview on the 400 Hall on 6/13/2022 at 10:23 AM, revealed there was no isolation signage on the door of room [ROOM NUMBER]. Registered Nurse (RN) #1 confirmed the resident in room [ROOM NUMBER] was on TBP and there was no isolation signage on the door. Observation and interview on the 400 Hall on 6/13/2022 at 11:05 AM, revealed there was no isolation signage on the door of room [ROOM NUMBER]. RN #1 confirmed there was no signage on the door and the resident in room [ROOM NUMBER] was on TBP. Observation and interview on the 400 Hall on 6/13/2022 at 12:42 PM, revealed there was no isolation signage on the door of room [ROOM NUMBER]. RN #1 confirmed there was no signage on the door and the resident in room [ROOM NUMBER] was on TBP. Observation and interview on the 500 Hall on 6/13/2022 at 3:40 PM, revealed no TBP sign posted on room [ROOM NUMBER]'s door. Licensed Practical Nurse (LPN) #1 confirmed the resident in room [ROOM NUMBER] was on TBP and there was not a TBP sign posted on the door. During an interview on 6/15/2022 at 9:12 AM, the Director of Nursing (DON) stated a TBP sign was to be posted on the door of a TBP isolation room. Observation and interview on the 400 Hall on 6/13/2022 at 12:39 PM, revealed Certified Nursing Assistant (CNA) #2 entered room [ROOM NUMBER] without PPE in place. CNA #2 confirmed the resident in room [ROOM NUMBER] was on TBP and she did not don the PPE required to enter the room. During an interview on 6/13/2022 at 12:42 PM, RN #1 confirmed staff were required to don PPE before entering an TBP room. Observation and interview in room [ROOM NUMBER] on 6/13/2022 at 10:07 AM, revealed two unlabeled urinals on top of the commode and two unlabeled bed pans on the floor beside the commode. Registered Nurse (RN) #1 confirmed the urinals and bedpans were unlabeled in the shared bathroom. Observation and interview in room [ROOM NUMBER] on 6/13/2022 at 10:44 AM, revealed two unlabeled bed pans on the floor of the bathroom shared by room [ROOM NUMBER] and #408. CNA #2 confirmed the two bed pans were unlabeled and on the floor. Observation and interview in room [ROOM NUMBER] on 6/13/2022 at 11:23 AM, revealed an unlabeled bed ban in the bathroom shared with room [ROOM NUMBER]. CNA #3 confirmed the bed pan in the shared bathroom was unlabeled.

Based on facility policy review, medical record review and interview, the facility failed to report an injury of unknown origin for 1 of 5 sampled residents (Resident #38) reviewed for potential abuse. The findings include: Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, revised 4/14/2022, revealed, .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation .assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law .Injury of Unknown Source .means an injury that meets both of the following conditions .(1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and (2) the injury is suspicious because of the extent of the injury; the location of the injury (for instance, the injury is located in an area not generally vulnerable to trauma) .Such occurrences will be investigated by the Administrator, Director of Nursing, or designee . Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurse Progress Notes for Resident #38 revealed, .5/16/2022 10:39 .Resident's sister was updated and informed of new bruise on right lateral eye lid .5/15/2022 20:00 .[Recorded as Late Entry on 5/16/2022 06:45] .found res.[resident] sitting on side of bed, yelling to go to bathroom. Certified Nursing Assistants (CNAs) found that resident's rt. [right] eyelid was bruised. denies pain/discomfort. no change noted this shift . During an interview on 6/14/2022 at 5:20 PM, Licensed Practical Nurse (LPN) #4 stated she saw the bruise on Resident #38's right eye when she returned to work that week. She stated there wasn't an event note to follow up on related to the bruise. During a telephone interview on 6/14/2022 at 5:30 PM, family member #1 stated the facility notified her about the bruise on his right eye. She stated she had not heard anything else about the bruise from the staff. During an interview on 6/15/2022 at 9:00 AM, the Director of Nursing (DON) confirmed there was not an investigation/event note completed for the bruise over Resident #38's right eye. She confirmed the bruise was an injury of unknown origin and should have been investigated. During a telephone interview on 6/15/2022 at 10:30 AM, Registered Nurse (RN) #1 stated LPN #6 notified her of the bruise in shift report on 5/16/2022, and she notified the sister. She stated she assumed Resident #38 had bumped his eye on the side rail getting out of bed, but did not know for sure. She confirmed no event report had been completed and the bruise was not reported.

Based on facility policy review, observation, and interview, the facility failed to ensure the Residents and/or Residents' Representative were invited to care plan meetings for 2 of 39 sampled residents (Resident #2 and #19). The findings include: Review of the facility's policy titled, Comprehensive Care Plan, revised on 7/18/2018, revealed, .The resident and the resident representative will participate to the extent practicable . Review of the facility's policy titled, Resident's Rights, revised on 8/16/2018, revealed, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: Participate in decisions and care planning . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment on 3/16/2022 for Resident #2, revealed no Brief Interview for Mental Status (BIMS) scored was documented. Review of the medical record revealed a care plan meeting was held on 3/16/2022 for Resident #2. Continued review revealed no documentation was found noting whether the resident and/or resident's representative attended the care plan meeting on 3/16/2022. There was no sign in sheet found in the medical record for the care plan meeting held on 3/16/2022. During an interview on 6/15/2022 at 8:51 AM, the MDS Coordinator confirmed she didn't reach out to resident's representative the day of the care plan meeting on 3/16/2022. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant change in status MDS assessment completed on 3/25/2022 for Resident #19, revealed a BIMS score of 2 which indicated severe cognitive impairment. Review of the medical record revealed a care plan meeting was held on 3/30/2022 for Resident #19. Continued review revealed no documentation was found noting whether the resident and/or resident's representative attended the care plan meeting on 3/30/2022. There was no sign in sheet found in the medical record for the care plan meeting held on 3/30/2022. During an interview on 6/15/2022 at 8:47 AM, the Social Service Director stated she kept a copy of the mailed care plan meeting notifications in a binder. Upon review of the binder, she confirmed there were no care plan meeting notifications found for Residents' #2 and #19 representatives.

Based on medical record review, and interview the facility failed to follow-up on a pharmacy recommendation for 1 of 5 sampled residents (Resident #3) reviewed for unnecessary medications. The findings include: Review of the medical record revealed Resident #3 was readmitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease and [CONDITION(S)] with Behavioral Disturbances. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had a BIMS score of 0, which indicated severe cognitive impairment. Review of the care plan revised 6/6/2022 revealed .[CONDITION(S)] Drug Use. PROBLEM: Resident is at risk for drug related adverse effects related to antipsychotic and antidepressant medication use . Review of the Physician Order Report dated 6/13/2022 revealed .[MEDICATION(S)] [MEDICATION(S)] ([MEDICATION(S)]) [antidepressant, appetite stimulant] tablet, disintegrating; 15 mg [milligram]; amt [amount]: 15 mg; oral Once A Day . Review of the Note to Attending Physician/Prescriber dated 4/12/2022, revealed .This resident has been taking the antidepressant [MEDICATION(S)] 15 MG QD [everyday] since 12/20. Please evaluate the current dose and consider a dose reduction . Continued review revealed the note was signed by the Medical Director and the word .psych . was written on the note. The note was blank of a response. During an interview on 6/15/2022 at 10:44 AM, the Nurse Practitioner (NP) stated she did not review or sign off on the pharmacy recommendations. The Medical Director reviewed and signed off on the pharmacy recommendations. During a telephone interview on 6/15/2022 at 10:53 AM, the Psychiatric NP confirmed she had not followed up on the pharmacy recommendation to gradually reduce the [MEDICATION(S)] or give a reason as to why it would be contraindicated. Continued interview revealed the Psychiatric NP was not aware of the pharmacy recommendation and the facility did not always notify her of any pharmacy recommendations regarding his [CONDITION(S)] medications. During an interview on 6/15/2022 at 3:35 PM, the Director of Nursing (DON) confirmed no one followed up on the pharmacy recommendation for Resident #3. Continued interview revealed the Medical Director would look at the pharmacy recommendations. He would not make any changes if [CONDITION(S)] medications were involved and would have the DON, Assistant Director of Nursing (ADON), or Unit Manager pass it along to the Psychiatric NP. No one informed the pharmacy recommendation for Resident #3 to the Psychiatric NP.

Based on facility policy review, observations, and interview, the facility failed to ensure a homelike environment for 2 of 4 residents observed in the Main Dining Room. The findings include: Review of the facility's policy titled, Resident Rights, dated 8/16/2018, revealed, .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility . Observation in the Main Dining Room on 6/13/2022 at 12:29 PM, revealed the CNA did not take the plates, utensils and glasses off of the meal tray and place on the table for 2 of 4 residents. During an interview on 6/13/2022 at 12:50 PM, the Staff Development Coordinator confirmed the plates, utensils, and glasses were not removed from the serving tray and placed on the table.

Based on facility policy review, medical record review, and interview, the facility failed to report 2 resident to resident altercations for 4 of 39 sampled residents (Resident #36 and Resident #52; Resident #34 and Resident #49) and failed to report an injury of unknown origin for 1 of 39 sampled residents (Resident #38). Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, revised 4/14/2022, revealed, .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation .assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law .Injury of Unknown Source .means an injury that meets both of the following conditions .(1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and (2) the injury is suspicious because of the extent of the injury; the location of the injury (for instance, the injury is located in an area not generally vulnerable to trauma) .Such occurrences will be investigated by the Administrator, Director of Nursing, or designee . Review of medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Continued review revealed the resident required extensive to total assistance of one to two person physical assist with all Activities of Daily Living (ADL)s. Review of Resident #34's Event Report dated 4/2/2022 revealed .heard yelling coming from room, when entering elders room, elder yelling I will kill you S.O.B. and had legs in position and kicking roommate in the back, asking elder why he was kicking his roommate and he states I will kill him . Review of the Occurrence Investigation for Resident #34 dated 4/2/2022 revealed, .Resident was found lying in floor on mat next to roommate's bed lifting feet in the air kicking resident in back. Resident yelling/cursing at roommate . Review of medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #49 had a BIMS score of 8, which indicated moderate cognitive impairment. Continued review revealed the resident required extensive assistance of one to two person physical assist with all ADLs. Review of Resident #49's Event Report dated 4/2/2022 revealed, .resident roommate found lying on mat in floor next to bed lifting feet in the air kicking resident in back . During a telephone interview with LPN #6 (who completed event report) on 6/14/2022 at 5:51 PM, she stated, I heard yelling coming from the room, when I walked in the room [named Resident #34] had his foot up in the air and [named Resident #49] said he had been kicking him, [named Resident #34] was yelling and cursing at him. Review of medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #36 had a Staff Assessment for Mental Status which indicated poor memory recall. Continued review revealed the resident required extensive assistance to total assistance of one to two person physical assist with all ADLs. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #52 had a Staff Assessment for Mental Status which indicated poor memory recall. Continued review revealed the resident required extensive to total assistance of one to two person physical assist with all ADLs. Review of Resident #52's Event Report dated 5/28/2020 revealed, .Resident was in scoot-n-go chair [a self propelled mobility chair] ambulating in hallway, another resident [named Resident #36] was also ambulating in hallway when resident went by, [named Resident #36] grabbed her wrist attempting to stop her. This caused resident to scream and pull her arm away, hitting herself in the chin, and caused a small skin tear on her chin .Residents were separated for safety . During an interview on 6/14/2022 at 4:45 PM, the Administrator confirmed the 2 Resident to Resident altercations were not reported to the State Agency. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change in Status MDS assessment dated [DATE], revealed Resident #38 had a BIMS score of 5, which indicated severe cognitive impairment. Continued review revealed the resident required supervision to extensive assistance of one to two person physical assist with all ADLs. Review of the Nurse Progress Notes for Resident #38 revealed, .05/16/2022 10:39 .Resident's sister was updated and informed of new bruise on right lateral eye lid .05/15/2022 20:00 .[Recorded as Late Entry on 05/16/2022 06:45] .found res.[resident] sitting on side of bed, yelling to go to bathroom. Certified Nursing Assistants (CNAs) found that resident's rt. [right] eyelid was bruised. denies pain/discomfort. no change noted this shift . During an interview on 6/14/2022 at 5:20 PM, Licensed Practical Nurse (LPN) #4 stated she saw the bruise on Resident #38's right eye when she returned to work that week. She stated there wasn't an event note to follow up on related to the bruise. During a telephone interview on 6/14/2022 at 5:30 PM, family member #1 stated the facility notified her about the bruise on his right eye. She stated she had not heard anything else about the bruise from the staff. During an interview on 6/15/2022 at 9:00 AM, the Director of Nursing (DON) confirmed there was not an investigation/event note completed for the bruise over Resident #38's right eye. She confirmed the bruise was an injury of unknown origin and should have been reported. During a telephone interview on 6/15/2022 at 10:30 AM, Registered Nurse (RN) #1 stated LPN #6 notified her of the bruise in shift report on 5/16/2022, and she notified the sister. She stated she assumed Resident #38 had bumped his eye on the side rail getting out of bed, but did not know for sure. She confirmed no event report had been completed and the bruise was not reported. During an interview on 6/15/2022 at 5:30 PM, the Administrator confirmed an injury of unknown origin involving Resident #38 was not reported to the State Agency.

Based on facility policy review, medical record review, observation, and interview, the facility failed to administer oxygen (O2) per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to date and properly store oxygen tubing and nebulizer mask with tubing when not in use for 4 of 26 sampled residents (Resident #21, Resident #22, Resident #38, and Resident #78). The findings include: Review of the facility's policy titled, Respiratory Oxygen Administration - Nasal Cannula Clinical Practice Guideline, reviewed 10/23/2020, revealed, .set the flow rate to the prescribed liter flow .Date and store in treatment bag when not in use . Review of the facility's policy titled, Medication Administration General Guidelines, dated 9/2018, .Medications are administered in accordance with written orders of the prescriber Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. Continued review revealed Resident #21 required O2 therapy. Review of Resident #21's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Oxygen therapy: Change tubing every week once a day on Thursday . Review of Resident #21's Care Plan dated 3/28/2022, revealed plan of care for impaired oxygen gas exchange in place with intervention oxygen as ordered. Review of the medical record revealed Resident #22 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual MDS assessment dated [DATE] revealed Resident #22 had a BIMS score of 5, which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #22 required extensive to total assistance of 1 for Activities of Daily Living (ADL). Review of Resident #22's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)]-[MEDICATION(S)] solution for nebulization .1 unit dose; inhalation .every 6 hours as needed for shortness of breath/wheezing . Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant change in status MDS assessment dated [DATE], revealed Resident #38 had a BIMS score of 5, which indicated severe cognitive impairment. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Give nebulizer treatments every six hour for sob [shortness of breath] and wheezing . Review of the Comprehensive Care Plan for Resident #38 revealed care plans which included resident has a Pulmonary condition/DX (diagnosis) and has potential for difficulty breathing. [CONDITION(S)] SOB at times CHF (Congestive Heart Failure). Review of the medical record revealed Resident #78 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #78 received respiratory treatments while in the facility. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .every 4 hours . Review of the Comprehensive Care Plan for Resident #78 revealed care plans which included Resident has a Pulmonary condition/DX (diagnosis). Observation in resident #21's room on 6/13/2022 at 10:31 AM and 10:45 AM, revealed Resident #21 lying in bed, call light in reach, O2 Per NC at 6 Liters per room O2 concentrator, humidified with bottle dated 6/9/2022, the O2 mask and tubing on top of personal refrigerator not dated and not in a bag, and portable O2 tank at foot of bed with NC tubing attached was not in bag and not dated. Observation and interview on 6/13/22 10:19 AM, revealed Resident #22 lying in bed. A nebulizer machine was sitting on her nightstand with a nebulizer mask laying uncovered open to air. Interview with Licensed Practical Nurse (LPN) #1, she stated the Respiratory Department performs the breathing treatments and confirmed the nebulizer mask should be kept in a bag when not in use. Observation and interview in Resident #38's room on 6/13/2022 at 10:56 AM, revealed a nebulizer mask and tubing on top of the bedside table uncovered. Registered Nurse (RN) #1 confirmed the nebulizer equipment was on the table uncovered. Observation and interview in Resident #78's room on 6/13/2022 at 10:23 AM, revealed an uncovered nebulizer mask and tubing on the window ledge. RN #1 confirmed the nebulizer mask and tubing was uncovered and lying on the window ledge. During an interview in Resident #21's room on 6/13/2022 at 10:50 AM, LPN #5 confirmed the mask attached to O2 tubing was not bagged or dated. She stated, The O2 tubing on the oxygen tank needs to be in a bagged and dated. She confirmed the O2 was set at 6 L/pm. She stated, The O2 should be set at 5 liters per doctor's orders. During an interview on 6/15/2022 at 9:27 AM, the Director of Nursing (DON) stated, The expectation is that medications including O2 are to be administered as ordered. I expect O2 tubing and masks to be labeled, dated, and stored in a bag. During an interview on 6/15/2022 at 3:48 PM, the DON stated, O2 tubing should be changed every 7 days.

Based on observation, and interview, the facility failed to post the daily staffing hours for 5 of 30 days reviewed. The findings include: Observation and interview on 100 Hall on 6/13/2022 at 4:30 PM, revealed the current posted staffing hours was dated 6/8/2022. The Administrator confirmed the posted staffing hours was dated 6/8/2022.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure the call light was within reach for 1 of 84 residents (Resident #38) observed. The facility failed to ensure staff knocked and announced themselves when entering 2 of 84 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]). The facility also failed to ensure dignity for 3 of 13 sampled residents (Resident #3, #18 and #61) who required assistance with meals, 1 of 2 residents sitting at the same table were served their meal at the same time, and 1 of 5 sampled residents (Resident #49) who required an indwelling urinary catheter. The findings include: Review of the facility's policy titled, Resident Rights, dated 8/16/2018, revealed, .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility . Review of the facility's policy titled, Catheter Care Procedure, dated 5/23/2018, revealed, .Routinely check to ensure: Drainage bag is covered with a privacy cover . Review of the facility's policy titled, Assistance with Meals, dated 6/27/2018, revealed, .Residents who cannot feed themselves will be fed with attention to safety, comfort and required assistance with meals, dignity, for example .Note standing over residents while assisting them with meals . Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. Observation and interview in Resident #38's room on 6/13/2022 at 10:56 AM, Registered Nurse (RN) #1 confirmed the call light was hanging on the light fixture above the bed out of the reach of the resident. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #25 had a BIMS score of 15, which indicated no cognitive impairment. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Observation Detail List Report dated 6/13/2022, revealed Resident #84 had a BIMS score of 13, which indicated no cognitive impairment. Observation and interview on the 400 Hall on 6/13/2022 at 12:31 PM, revealed Certified Nursing Assistant (CNA) #3 entered room [ROOM NUMBER] without knocking on the door to announce himself when he delivered a lunch tray. CNA #3 confirmed he did not knock and announce himself when he entered room [ROOM NUMBER]. Observation and interview on the 400 Hall on 6/13/2022 at 12:39 PM, revealed CNA #2 entered room [ROOM NUMBER] without knocking to announce herself when she delivered a lunch tray. CNA #2 confirmed she did not knock and announce herself before entering room [ROOM NUMBER]. During an interview on 6/13/2022 at 12:42 PM, RN #1 confirmed staff was required to knock and announce themselves when entering all resident rooms. Review of the medical record revealed Resident #3 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #3 had a BIMS score of 0 which indicated severe cognitive impairment. Continued review revealed Resident #3 required total assistance from 1 staff member for eating. Review of the care plan revised 6/6/2022, revealed .Resident has an Activities of Daily Living [ADL] self-care deficit and is at risk for complications related to Deficits . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview in Resident #3's room on 6/14/2022 at 8:11 AM, revealed the Restorative Nurse Aide was standing while feeding Resident #3 his pureed breakfast. The Restorative Nurse Aide said she preferred to stand while feeding Resident #3 because he was unpredictable and would try to hit the staff. The Restorative Nurse Aide confirmed she was supposed to sit in a chair while assisting Resident #3 with his meal. During an interview on 6/15/2022 at 3:41 PM, the Director of Nursing (DON) stated she expected staff to be seated while feeding a resident who required assistance. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed a staff assessment for cognition that revealed poor memory recall. Continued review revealed Resident #18 required total assistance of 1 person for eating. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #61 had a BIMS score of 3, which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #61 required extensive assistance of 1 person for eating. Observation and interview in Resident #18's room on 6/13/2022 at 12:09 PM, revealed CNA #6 standing over the resident while she assisted her with the lunch meal. CNA #6 stated, I couldn't find a chair, probably not supposed to stand. Observation and interview on the 600 hall at Resident #61's doorway on 6/13/2022 at 12:33 PM, revealed CNA #7 standing over the resident while she assisted her with the lunch meal. CNA #7 stated, Well I don't know why I wasn't sitting down but my knees hurt sometimes. During an interview on 6/13/2022 at 12:35 PM, Licensed Practical Nurse (LPN) #1 confirmed the two CNAs were standing and should be sitting while assisting residents with meals. Observation in the Main Dining Room on 6/13/2022 at 12:30 PM, revealed the CNA served 1 resident her lunch tray, and the 2nd resident sitting at the table was not served her meal tray until 12:47 PM. During an interview on 6/13/2022 at 12:50 PM, the Staff Development Coordinator (SDC) confirmed the residents seated at the same table were not served their meals at the same time and they should have been. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #49 had a BIMS score of 8, which indicated moderate cognitive impairment. Review of the Care Plan for Resident #49 revealed a problem, .Indwelling Catheter .resident requires an indwelling urinary catheter . Observation and interview in the 200 hall on 6/13/2022 at 2:33 PM, revealed Resident #49 was self propelling in his wheelchair with the urinary catheter drainage bag attached to the arm of the wheelchair. The urinary catheter bag was not covered with a privacy cover. During an interview on 6/13/2022 at 3:39 PM, the Social Service Director (SSD) confirmed there was no privacy cover on the urinary drainage bag for Resident #49. During an interview on 6/15/2022 at 9:12 AM, the DON confirmed a privacy cover was to be placed on the urinary drainage bag at all times.

Based on facility policy review, medical record review, observation, and interview the facility failed to honor 1 of 39 sampled residents (Resident #3) food preferences. The findings include: Review of the facility's policy titled, Assistance with Meals dated 6/27/2018, revealed .1. Residents will be encouraged to eat in the dining space of their choice. A. Facility staff will serve resident meals and will help residents who require assistance with eating. B. Employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. C. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity . Review of the medical record revealed Resident #3 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had a BIMS score of 0 which indicated severe cognitive impairment. Review of the care plan revised 6/6/2022 revealed .ADL Functional/Rehabilitation Potential: Resident has an ADL self-care deficit and is at risk for complications . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the meal ticket dated 6/15/2022 revealed, .Pureed BBQ Pork Loin . Review of the Dietary Interview dated 3/30/2021 revealed, .Dislikes/Intolerances: Pork, Pork Chop, Pork Roast . Observation in Resident #3's room on 6/15/2022 at 1:30 PM, revealed Resident #3 being assisted with his lunch meal which consisted of pureed BBQ pork loin. During an interview on 6/15/2022 at 3:01 PM, the Dietary Manager confirmed Resident #3's meal preferences had not been honored when he was served puree pork for lunch.

Based on facility policy review, observation, and interviews, the facility failed to maintain resident confidentiality. The findings include: Review of the facility's policy titled, Health Information Management, revised 2/3/2022, revealed, .facility will safeguard all resident records, whether medical .to protect the confidentiality of the information . Review of the facility's policy titled, Medication Administration General Guidelines, dated 09/2018, revealed, .Resident's health information needs to remain private .resident health information must remain closed or covered when not in direct use . Observation at the Medication Cart on 300 Hall on 6/14/2022 at 8:52 AM, revealed a laptop open on top of the Medication Cart with residents' personal information displayed. Continued observation revealed 4 staff members passed by the medication cart on the 300 Hall with the open resident information displayed on the laptop. Observation and interview at the Medication Cart on 300 Hall on 6/14/2022 at 8:54 AM, revealed, a laptop open on top of the Medication Cart with residents' personal information displayed. Licensed Practical Nurse (LPN) #3 stated, I normally minimize the screen for patient privacy, I totally forgot to do that when I walked away. Continued interview LPN #3 confirmed he left patient information displayed on the laptop. He stated, It is a HIPPA [Health Information Portability Privacy Act] violation. Observation at the Wound Care Cart on 400 Hall on 6/14/2022 at 9:52 AM, revealed a laptop open with several residents' identifiable information displayed. Continued observation revealed 2 staff members walked by the Wound Care Cart on 400 Hall with open resident information displayed on the laptop. Observation and interview at the Wound Care Cart on 400 Hall on 6/14/2022 at 9:55 AM, revealed laptop open with several residents' identifiable information displayed. Registered Nurse (RN) #2 (Wound Care Nurse) confirmed the laptop was open and unattended with residents' private information displayed. Continued interview RN #2 confirmed the laptop screen should have been closed for resident privacy. During an interview on 6/15/2022 at 9:27 AM, the Director of Nursing (DON) stated she expected the laptop screens containing resident information to be minimized, shut down, or where you cannot see it to protect the residents' information.

Based on facility policy review, medical record review, and interview the facility failed to provide a bed hold notification for 1 of 6 sampled residents (Resident #22). The findings include: Review of the facility's policy titled, Facility Bedhold, revised 11/12/2018 revealed, .The Facility will notify the resident/responsible party of the facility's bed hold .at admission and anytime a resident is transferred to the hospital .the facility will provide written notice of the bed hold .before a resident's transfer to the hospital . Review of the medical record for Resident #22 revealed she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the medical record revealed Resident #22's last hospital stay from the facility was 2/27/2022 through 3/8/2022. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed recent admission entry date as 3/8/2022. Continued review of the MDS revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. Review of the resident documents revealed no bed hold notification in the medical record. During an interview on 6/15/2022 at 2:15 PM, Medical Record staff stated, The nursing staff fill out the bed hold notification but I do not have a bed hold for Resident #22 for 2/27/2022. During an interview on 6/15/2022 at 6:15 PM, the Director of Nursing (DON) confirmed the facility does not have a bed hold notification for Resident #22 for 2/27/2022.

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to provide Cardiopulmonary Resuscitation (CPR) to 1 resident (Resident #6) of 6 resident deaths reviewed, of 13 sampled residents. The facility's failure to provide CPR in accordance with the resident's Advanced Directives, Physician Orders, and the Care Plan on [DATE] at 7:00 AM, resulted in the death of Resident #6 on [DATE] at 7:06 AM, placing Resident #6 in Immediate Jeopardy (a situation where the providers noncompliance with one or more requirements of participation, has caused, or is likely to cause, serious injury, harm, impairment or death). F-309 at scope and severity J constitutes Substandard Quality of Care. The Administrator, Director of Nursing (DON), and Corporate Nurse were informed of the Immediate Jeopardy on [DATE] at 3:25 PM, in the conference room. The IJ was effective [DATE] - [DATE]. The facility's corrective action plan which removed the IJ was received and corrective actions validated onsite by the surveyor on [DATE] - [DATE]. The IJ was cited as past noncompliance for F-309 and the facility iss not required to submit a plan of correction. The findings included: Review of the facility policy, Cardiopulmonary Resuscitation, (CPR, undated) revealed .Upon identifying a resident with a change of condition which presents as an unresponsive condition .check the medical record for advance directive status .if resident record indicates CPR is to be instituted, then initiate Basic Life Support if a pulse and/or respirations are undetectable .if a resident is found unresponsive and without respirations, a licensed staff member who is certified in CPR .shall promptly initiate CPR for residents .who have requested CPR in their advance directives .who do not have a valid Do Not Resuscitate DNR order . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Admission Consent Forms and the Tennessee Physicians Orders for Scope of Treatment (POST, or advanced directives form), executed on [DATE], revealed Resident #6, a [AGE] year old resident, was to receive CPR, Intubation (insertion of a breathing tube), advanced airway interventions, mechanical ventilation as indicated, transfer to a hospital or intensive care unit if indicated, and full treatment in an intensive care unit if indicated, in the event of a respiratory or [MEDICAL CONDITION]. Medical record review of the Physician Orders dated [DATE], at 4:21 PM, revealed .Advanced Directive .FULL CODE . Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 15 (indicating she was cognitively intact), was independent in decision making, dependent upon supplemental oxygen to breathe, and the resident required moderate assistance of one person for activities of daily living (ADLs). Review of the Daily Skilled Nursing Note dated [DATE] at 1:30 AM, revealed .Cardiovascular .Cardiovascular concerns yes .radial/apical (pulse) irregular .Respiratory Concerns .yes .Labored Breathing .Orthopnea (shortness of breath with movement) shallow respirations .SOB (short of breath) .on exertion .at rest .lying flat .Lung Sounds .Rales (a type of abnormal lung sound often associated with lung disease, fluid in the lungs or swelling in the lungs) .Wheezing .(a type of abnormal lung sound often associated with [MEDICAL CONDITION], decreased lung volume, inflammation or mucous in the airways of the lungs) . Review of the Nursing Progress Notes Report revealed on the morning of [DATE], during the conclusion of the [DATE] 7:00 PM to 7:00 AM shift, at approximately 6:00 AM, Resident #6 exhibited an onset of symptoms of increased anxiety and increased shortness of breath, and summoned her primary nurse that evening, Licensed Practical Nurse (LPN) #1, to her room. Continued review revealed LPN #1 entered the room and found the resident seated on the side of her bed complaining of severe shortness of breath. Continued review revealed LPN #1 assessed the resident's blood oxygen saturation levels (O2 SAT) which were at 95% (within normal limits) at the time, administered a scheduled breathing treatment ([MEDICATION NAME], a medication to improve breathing) and oral [MEDICATION NAME] (narcotic, for pain) from 6:00 AM to 6:15 AM, and informed her supervisor, Registered Nurse (RN) #1, of the resident's status. Continued review of the Nursing Progress Notes Report revealed, around 6:30 AM, Resident #6 activated the call light and RN #1 and LPN #1 returned to the resident's room. Continued review revealed LPN #1 and RN #1 found Resident #6 again seated on the side of the bed, and the resident informed them she remained short of breath and wished to be transferred to the hospital to be intubated. Continued review revealed the resident's vital signs were heart rate at 88 beats per minute (within normal limits, WNL) O2 Saturation as 95% (WNL) and Respiratory Rate was 36 breaths per minute (elevated). Further review revealed RN #1 adjusted the resident's position and elevated the head of the bed 90 degrees. The resident was not transported to the hospital. Continued review revealed RN #1 documented .her color did not look right . and the nurses attempted to contact family members. Medical record review of the Nursing Progress Notes Report dated [DATE] at 7:00 AM, revealed Resident #6 was found by Registered Nurse (RN) #1 slumped over in bed, gray in color, without a pulse or respirations (cardiac and respiratory arrest). Continued review revealed RN #1 did not attempt to perform CPR on Resident #6 in accordance with the Residents' Advance Directives, Physicians Orders, and Care Plan, and instead pronounced the resident deceased at 7:06 AM. Continued review revealed .Despite elder being full code I (RN #1) did not perform CPR on elder who was clearly passed and stated that to Dr (doctor) .DON and ADON (assistant director of nursing) .notified . Medical record review revealed no documentation or evidence evidence to indicate the resident had been monitored from 6:37 AM until 7:00 AM (23 minutes after she complained of increased shortness of breath and requested to be hospitalized ) while the nurses attempted to contact family members. Review of the Record of Death, signed by the Physician, dated [DATE], revealed .immediate cause of death .Respiratory Arrest .pronounced by .( (RN #1). Review of the facility investigation and witness statements revealed on [DATE] at 7:00 AM, when Resident #6 was found in cardiac and respiratory arrest, RN #1 was informed by Licensed Practical Nurse (LPN) #1, LPN #15 and Respiratory Therapist (RT) #4, Resident #6 had advance directives and Physician Orders which specified the resident was a full code and CPR was to be performed. Continued review of the facility investigation revealed RN #1 ignored the directives of the employees, prohibited them from performing CPR on Resident #6, stood between them and the resident's bed with her arms out stretched to prevent them from approaching Resident #6, and informed them no CPR would be performed. RN #1 pronounced Resident #6 deceased at 7:06 AM on [DATE]. Review of RN #1's investigative interview summary (the findings of the investigative interview conducted by the facility's attorney) dated [DATE], revealed .Entered resident's room to give drink .assisted resident with same .replaced resident O2 (oxygen) mask back on face .(LPN #1 giving meds) .Resident SATS (blood oxygen saturations) were 95% good .Later 2 CNAs (Certified Nurse Aide) approached, saying resident would like to go to hospital .I assessed resident .resident stated she wanted to be intubated .I found not needed and that resident was very tired .covered resident with blanket .put at 90 degrees in middle of the bed .relayed I would notify her family and doctor .skin color dusky color .cool to touch .room was very cool .with .(LPN #1) .started looking up family contact info (information) .then walked back to resident room to get more family names from resident .found resident slumped over with her head down to the end of bed .this was approximately 30 minutes after I had left resident .yelled for stethoscope .two other nurses nearby .one went to call resident's daughter .assessed resident .no pulse or respirations .skin dusky, eyes ½ open, lips and nails blue tinge .Nurse (LPN #1) said resident is full code .I responded resident has clearly passed, nothing to do .Spoke with Doctor, told him resident expired and I would not initiate code, would pronounce her at 7:06 AM . Telephone interview with Physician #3 (the attending Physician for Resident #6) on [DATE] at 10:57 AM, revealed when he was contacted by RN #1 on [DATE] between 7:00 and 7:15 am, he questioned RN #1 if CPR had been initiated or was in progress at the time of the telephone call, and was informed by RN #1 CPR had not been initiated. Continued interview revealed he advised RN #1 the resident was full code status and CPR was to have been attempted and RN #1 asked, you want me do CPR on a dead person? Continued interview revealed RN #1 informed him she had pronounced the resident deceased at 7:06 AM and he was led to believe the resident had been pulseless for an extended period. Continued interview revealed he believed .CPR should have been attempted on Resident #6 prior to declaration of death by RN #1 . Further interview revealed RN #1 stated to him on [DATE], .you can take my license all the way to the state if you want, I'm not doing CPR on a dead person . Interview with LPN #1 on [DATE] at 11:36 AM, in the conference room, revealed she observed Resident #6 in [MEDICAL CONDITION] with RN #1 present, and the resident's appearance was .slumped over on the side of the bed, upright with no breathing and no pulse . and she assisted RN #1 to position the resident in the bed for assessment. Continued interview revealed as she assisted RN #1 to reposition the resident, she told RN #1 .she (Resident #6) is a full code . Continued interview revealed as RN #1 assessed Resident #6, LPN #15 and Respiratory Therapist (RT) #4 entered the room, and LPN #15 and RT #4 asked RN #1 if CPR was to begin. Both staff members advised RN #1 of the resident's advanced directives. Further interview revealed .(LPN #3 and LPN #15) came in the room, asked 'Are we gonna (going to) code her?' and (RN #1) said 'No we aren't gonna do anything' .no one else questioned it .(RN #1) was guarding the body, standing between us and everyone else and the body, arms outstretched, and said to everybody, 'No, we aren't going to do a thing.' Continued interview revealed no CPR was performed on Resident #6 and RN #1 declared the resident deceased . Interview with the Director of Nursing (DON) on [DATE] at 2:45 PM, in the conference room, confirmed Resident #6 had valid Advance Directives to Perform CPR in the event of cardiac or respiratory arrest, had valid Physician orders in place for full code status, and confirmed RN #1 had willfully failed to provide CPR in accordance with the Physician Orders, Care Plan and the Resident's Advance Directives. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 3:45 PM, in the conference room, revealed on [DATE] around 7:30 AM, RN #1 informed the DON that she had not performed CPR on Resident #6 in spite of valid Physician Orders and Care Plan directives to do so. Continued interview revealed RN #1 alleged the resident was clearly deceased when found, and stated to her and the DON, I take full responsibility for this. Continued interview revealed the facility investigation of the incident determined RN #1 failed to provide CPR to Resident #6, who had valid Advance Directives and Physician Orders for full code status. Interview with Respiratory Therapist (RT) #4 on [DATE] at 1:40 PM, revealed on [DATE] around 7:00 AM, she had entered Resident #6's room and observed her to be slumped sideways in the bed with her head tilted backwards, mouth open, not breathing, and ashen in color. Continued interview revealed she informed RN #1 the resident was a full code. Continued interview revealed when she informed RN #1 Resident #6 was a full code and CPR was to begin at once, the RN stated to her, .absolutely not, we are not doing a code, she has been down too long . Interview with the Administrator on [DATE] at 12:41 PM, in the conference room, revealed on [DATE] around 7:45 AM, RN #1 had informed him she did not perform CPR on Resident #6 in accordance with the Care Plan and Physician Orders. Continued interview revealed RN #1 stated to him I take full responsibility for this situation. Further interview revealed when he questioned RN #1 about the Physician's reaction to her refusal to perform CPR, she replied, .not much, but I told him I'm not performing CPR and you can take my license to the state . Continued interview confirmed RN #1 willfully failed to provide CPR to Resident #6 in accordance with the Physician Orders, Advance Directives and Care Plan. Telephone interview with LPN #15 on [DATE] at 2:24 PM, revealed she was present on the unit as an oncoming day shift nurse on [DATE] and witnessed the incident. Continued interview revealed when Resident #6 was discovered without a pulse or respirations at 7:00 AM, she responded to the room to assist in resuscitation efforts and she also informed RN #1 the resident was a full code. Continued interview revealed .I told (RN #1) the resident was a full code, we needed to code, and (RN #1) said, 'No we are not going to code her' .I advised (RN #1) facility policy was to code the resident, and (RN #1) refused even after I advised of facility policy . Continued interview revealed RN #1 told LPN #15 to leave from the resident's room and call Physician #3, report to him the resident was deceased . Further interview revealed LPN #15 reported when she contacted the Physician and advised him of the situation, he asked to speak directly to RN #1. Further interview revealed she heard RN #1 say to the Physician, I refuse to do CPR on a dead person. Continued interview revealed .I was getting crash cart with (LPN #3), (RN #1) held up her hand, waved 'No' to me .after that we stopped, we were taught to never disobey a RN but taught to do codes, felt stuck . The facility's corrective action plan included the following: Telephone interview with LPN #15 on [DATE] at 2:24 PM, revealed she was present on the unit as an oncoming day shift nurse on [DATE] and witnessed the incident. Continued interview revealed when Resident #6 was discovered without a pulse or respirations at 7:00 AM, LPN #15 responded to the room to assist in resuscitation efforts and she also informed RN #1 Resident #6 was a full code. Continued interview revealed .I told (RN #1) the resident was a full code, we needed to code, and (RN #1) said 'No we are not going to code her' .I advised (RN #1) facility policy was to code the resident and (RN #1) refused, even after I advised of facility policy .

Based on review of facility policy, medical record review, review of facility investigation, review of personnel files, and interview, the facility failed to ensure qualified staff implemented the resident's care plan for 1 resident (#6) of 6 resident deaths reviewed, of 13 sampled residents. The failure of qualified staff to provide Cardiopulmonary Resuscitation (CPR) in accordance with the Care Plan on [DATE] at 7:00 AM, for Resident #6, who was in cardiac and respiratory arrest, placed the resident in Immediate Jeopardy (a situation where the providers noncompliance with one or more requirements of participation, has caused, or is likely to cause, serious injury, harm, impairment or death). The Administrator, Director of Nursing (DON), and Corporate Nurse were informed of the Immediate Jeopardy (IJ) on [DATE] at 3:25 PM, in the conference room. The IJ was effective [DATE] - [DATE]. The facility's corrective action plan which removed the IJ was received and corrective actions validated onsite by the surveyor on ,[DATE] and [DATE]. The IJ was cited as past noncompliance for F-282 and the facility is not required to submit a plan of correction. The findings included: Review of the facility policy, Cardiopulmonary Resuscitation, (CPR, undated) revealed .Upon identifying a resident with a change of condition which presents as an unresponsive condition .check the medical record for advance directive status .if resident record indicates CPR is to be instituted, then initiate Basic Life Support if a pulse and/or respirations are undetectable .if a resident is found unresponsive and without respirations, a licensed staff member who is certified in CPR .shall promptly initiate CPR for residents .who have requested CPR in their advance directives .who do not have a valid Do Not Resuscitate DNR order . Review of the facility policy Care Plans- Comprehensive (undated) revealed .Care Plan interventions are implemented after consideration of the resident's problem areas and their causes . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Admission Consent Forms and the Tennessee Physicians Orders for Scope of Treatment (POST, or advanced directives form), executed on [DATE], revealed Resident #6, a [AGE] year old resident, was to receive CPR, Intubation (insertion of a breathing tube), advanced airway interventions, mechanical ventilation as indicated, transfer to a hospital or intensive care unit if indicated, and full treatment in an intensive care unit if indicated, in the event of a respiratory or [MEDICAL CONDITION]. Medical record review of the Interim Plan of Care dated [DATE], revealed .Will follow Advanced Directives . Medical record review of the Nursing Progress Notes Report dated [DATE] at 7:00 AM, revealed Resident #6 was found by Registered Nurse (RN) #1 slumped over in bed, gray in color, and without a pulse or respirations (cardiac and respiratory arrest). Continued review revealed RN #1 did not attempt to perform CPR on Resident #6 in accordance with the Residents' Advance Directives and Care Plan, and instead pronounced the resident deceased at 7:06 AM. Continued review revealed .Despite elder being full code I (RN #1) did not perform CPR on elder who was clearly passed and stated that to Dr (doctor) .DON and ADON (assistant director of nursing) .notified . Review of the Record of Death signed, by the Physician and dated [DATE], revealed .immediate cause of death .Respiratory Arrest .pronounced by .(RN #1). Review of RN #1's investigative interview (the findings of the investigative interview conducted by the facility's attorney) summary dated [DATE], revealed .walked back to resident room .found resident slumped over with her head down to the end of bed .this was approximately 30 minutes after I had left resident .yelled for stethoscope .two other nurses nearby .one went to call resident's daughter .assessed resident .no pulse or respirations .skin dusky, eyes ½ open, lips and nails blue tinge .Nurse (LPN #1) said resident is full code .I responded resident has clearly passed, nothing to do .Spoke with Doctor, told him resident expired and I would not initiate code, would pronounce her at 7:06 AM . Review of the personnel file for RN #1 revealed she had completed all training and passed competency tests related to the facility policies on Advance Directives, CPR, Changes in Resident Condition, Resident Rights, Abuse and Neglect Prohibition, Following Physician Orders, Care Plans and all other required training on hire, 3 months prior to the incident. Interview with LPN #1 on [DATE] at 11:36 AM, in the conference room, revealed on [DATE] around 7:00 AM, she observed Resident #6 in [MEDICAL CONDITION] with RN #1 present. Further interview revealed LPN #1 stated .the day shift nurses came in the room, asked 'Are we gonna (going to) code her?' and (RN #1) said 'No we aren't gonna do anything' .no one else questioned it .(RN #1) was guarding the body, standing between us and everyone else and the body, arms outstretched and said to everybody, 'No, we aren't going to do a thing' . Continued interview confirmed no CPR was performed on Resident #6 and RN #1 pronounced the resident deceased . Telephone interview with Physician #3 (the attending Physician for Resident #6) on [DATE], at 10:57 AM, revealed when he was contacted by RN #1 on [DATE] between 7:00 and 7:15 am, he questioned the nurse if CPR had been initiated or was in progress and was informed by RN #1 CPR had not been attempted at all. Continued interview revealed Physician #3 advised RN #1 the resident was full code status and CPR was to have been initiated. Continued interview revealed RN #1 stated .you can take my license all the way to the state if you want, I'm not doing CPR on a dead person . Continued interview revealed she had declared the resident deceased at 7:06 AM. Interview with the DON on [DATE] at 2:45 PM, in the conference room, confirmed Resident #6 had valid Advance Directives to Perform CPR in the event of cardiac or respiratory arrest and confirmed RN #1 had failed to provide CPR in accordance with the Care Plan. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 3:45 PM, in the conference room, confirmed RN #1 had informed the DON in the presence of the ADON she had not performed CPR on Resident #6. Interview with Respiratory Therapist (RT) #4 on [DATE] at 1:40 PM, in the conference room, revealed on [DATE] around 7:00 AM, she had entered Resident #6's room and observed her to be slumped sideways in the bed with her head tilted backwards, mouth open, not breathing, and ashen in color. Continued interview revealed RT #4 informed RN #1 the resident was a full code. Continued interview revealed when she informed RN #1 Resident #6 was a full code, and CPR was to begin at once, the RN stated to her .absolutely not, we are not doing a code, she has been down too long . Interview with the Administrator on [DATE] at 12:41 PM, in the conference room, confirmed on [DATE] around 7:45 AM, RN #1 informed him she did not perform CPR on Resident #6 in accordance with the Care Plan. Telephone interview with LPN #15 on [DATE] at 2:24 PM, revealed she was present on the unit as an oncoming day shift nurse on [DATE] and witnessed the incident. Continued interview revealed when Resident #6 was discovered without a pulse or respirations at 7:00 AM, LPN #15 responded to the room to assist in resuscitation efforts and she also informed RN #1 Resident #6 was a full code. Continued interview revealed .I told (RN #1) the resident was a full code, we needed to code, and (RN #1) said 'No we are not going to code her' .I advised (RN #1) facility policy was to code the resident and (RN #1) refused, even after I advised of facility policy . The facility's corrective action plan included the following: On [DATE] the facility did the following: A. Held an ad hoc Quality Assurance (QA) meeting during the daily stand up meeting and reviewed the incident. Incident was reported to the State Agency. Follow up QA meeting was scheduled for [DATE]. Responsible party was the Administrator. B. The regional nurse consultant reviewed with the DON and the Administrator the education to be provided to all staff on [DATE] to include Abuse, Resident Rights, Advance Directives, Where to Locate the Advance Directives in the Medical Record, Cardiopulmonary Resuscitation (CPR), Following Physician Orders, Change in Condition and Following Care Plans. Responsible party was the Director of Nursing (DON). C. Once the Administrator and DON were educated, they were assigned to educate the Nursing Administration team Assistant Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Nurses, and Staff Development Coordinator), who in turn were assigned to educate all the staff on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives in the Medical Record, CPR, Following Physician Orders, Change in Condition, and Following Care Plans. Responsible party was the DON). D. Began written competency testing of all staff educated on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives, CPR, Following Physician Orders, Change in Condition and following Care Plans. Responsible party was the Director of Nursing (DON). E. All staff educated, were required to submit written post-tests with scores of 100% before being permitted to work. All staff who failed to score 100% on the post-tests were immediately re-educated and re-tested until all staff scored 100% on the post tests. Responsible party was the Director of Nursing (DON). F. Initiated the first Mock Code Drill conducted by the DON, ADON, Unit Manager (UM) and the Staff Development Coordinator (SDC) to ensure staff understanding and compliance with the facility code blue policy (policy related to emergency resuscitation) and procedures. No irregularities noted. Mock codes were then planned to be completed for every shift (7 A-7P, 7P-7A) for 72 hours through [DATE], then twice weekly on rotating shifts for 4 weeks starting on [DATE] through [DATE] (scheduled to occur on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and on [DATE] on both shifts) to ensure staff understanding and compliance with the facility code blue policy. The first two Mock Codes were conducted by members of the Nursing Administration Team under observation of the DON, then Mock codes were conducted by nursing staff members under observation of members of the Nursing Administration team. Findings were to be reported to the QA committee weekly for 4 weeks to determine compliance and any further need of continued education or revision of the plan. Responsible party was the Director of Nursing (DON). G. Began ongoing monitoring of staff compliance with abuse, advanced directives, resident rights, CPR, location of advanced directives and Do Not Resuscitate (DNR) forms in the medical record, following physician orders, change in condition reporting and following Care Plans. Responsible party was the Administrator. On [DATE] the facility did the following: A. Resident #6's chart and care plan were reviewed by the Regional Nurse Consultant and Director of Clinical Operations. Registered Nurse (RN) #1 was to have been terminated concluding the investigation but resigned prior to termination. Licensed Practical Nurses (LPN) LPN #1 LPN #3, LPN #15 and Respiratory Therapist (RT) #4 received disciplinary action related to not following facility policy. Responsible party was the DON. B. Began audits of the medical records for all residents in the facility, by the Regional Nurse Consultant and Director of Clinical Operations, to ensure advance directives were in the medical record, were addressed on the care plan, and had current Physician orders related to each resident's code status. Responsible party was the DON. C. All residents were assessed for any possible resident rights violations. Those residents with Brief Interview of Mental Status (BIMS scores, a measure of cognitive function), greater or equal to 8 (cognitively intact) were interviewed by the DON, ADON, UM, Social Services Director (SSD), Social Services Assistant (SSA) for quality of life or resident rights violations. No issues were identified. Responsible party was the DON. D. All residents with BIMS scores less or equal to 7 (cognitively impaired) had skin assessments completed on [DATE] for any concerns by ADONs and UMs for any possible abuse or neglect issues. All residents with a BIMS greater or equal to 8 were interviewed for possible abuse or neglect violations. No issues were identified. Responsible party was the DON. E. Held a Resident Council Meeting (a group of residents who reside in the facility and meet regularly, discuss resident concerns, and discuss resident concerns with Administration) and the SSD and Activities Director reviewed the Resident Rights Statement and Policies for Prohibition of Abuse, Neglect and Misappropriation of Property and provided a copy to each resident. Responsible party was the DON. F. All deaths in the facility for the past 30 days were reviewed by the Regional Nurse to ensure advanced directives were honored with no irregularities noted. The DON reviewed all resident deaths in the facility for the prior 12 months with no irregularities noted. Results were discussed in the QA meeting. Responsible party was the Administrator. G. Held first formal QA meeting to address the incident. DON, ADON, UM, Nursing Supervisors or Medical Records staff were to review all new admissions/readmits and residents with DNR related changes, 24 hour shift reports, and incidents accidents daily for 2 weeks, then Monday through Friday ongoing, starting during morning clinical meeting, to ensure sustained compliance with physician notification, physician orders, interim care plan, advance directives, and resident rights. Corporate administrative oversight of the QA meeting was completed by the Regional Vice President or member of the regional staff weekly for 4 weeks beginning [DATE], then monthly for one quarter. The facility allegation of compliance (AOC) was reviewed by the committee. Responsible party was the Administrator. H. Continued staff education and post testing on Abuse and Neglect, Advanced Directives, Where to find Advanced Directives in the chart, CPR, Resident Rights, following Physician orders, Notification of Change in Condition, and Following Care plans. Responsible party was the DON. I. Grievance logs were reviewed by the Director of Clinical Operation with no irregularities noted. J. Continued Mock Code drills as outlined. Responsbile party was the DON. K. Corrective actions were reviewed by the Administrator, DON, Medical Director and Regional Consultants. Responsible party was the Administrator. On [DATE] the facility did the following: A. The DON, ADON, UM, Administrator and Department Heads continued advance directive/abuse post-tests with 10 random Nursing staff members daily on rotating shifts for 2 weeks through [DATE]. Then 5 random nursing staff members on rotating shifts daily for 2 weeks through [DATE], then 5 random Nursing staff members weekly for 3 weeks through [DATE], with all staff required to score 100% on the post tests. Staff members who failed to achieve 100% scores on the tests were immediately re-educated and required to re-test until 100% scores were achieved. Responsible party was the DON. B. Continued education of all staff members on the facility Abuse and Neglect Policy, Resident Rights, CPR, Advance Directives and Where to find them in the medical record, Notification of Change in Condition, Physician Orders, and Care plans. Responsible party was the DON. C. Continued Mock Code drills on every shift through [DATE] as outlined. Responsible party was the DON. On [DATE] the facility did the following: A. Completed review of all residents medical records by the Director of Clinical Operations and the Regional Nurse to ensure advance directives were in the medical records, addressed on the care plans, and had a current Physician Order regarding code status. No irregularities noted. Responsible party was the Director of Clinical Operations. B. Completed a 100% audit of licensed clinical staff CPR certifications by the Regional Vice President and Regional Nurse Consultant. C. Completed 100% audit of all licensed staff to verify valid Tennessee professional licensure completed by the Regional Vice President. No irregularities were noted. D. Completed 100% audit to ensure staff were not listed on the abuse registry by the Regional Vice President with no irregularities noted. E. Mailed certified letters to all employees who had not completed mandatory training and education and advised completion of training was required prior to any return to work at the facility. The letters included all employees on vacation or paid leave, part time or prn (as needed status). Responsible party was the DON. F. The Administrator began reviews of completed audits for new admissions, readmissions and residents with DNR to ensure sustained compliance with all advanced directives. G. DON, ADON, UM or Weekend Manager on duty began interviews with 5 residents with BIMS scores equal or greater than 8 and 5 family members of residents with BIMS scores less than 8 daily for 2 weeks ([DATE] to [DATE]) for any possible resident rights violations; then 3 residents and 3 family members daily for 2 weeks ([DATE] to [DATE]), then 2 residents and 2 family members daily for 4 weeks ([DATE] to [DATE]), then 1 resident and 1 family member daily for 4 weeks ([DATE] to [DATE]). Results of the interviews and assessments forwarded to the QA committee. Responsible party was the DON. H. All deaths in the facility were reviewed by the DON, ADON, UM or Administrator to ensure code status was implemented correctly as per the resident's wishes and documented on the advance directives daily for 2 weeks through [DATE]; then weekly for 4 weeks from [DATE] to [DATE], then continuing as part of the daily stand up meetings attended by the Administrator, DON, ADONs, UM, MDS Coordinator, Treatment Nurses, Chaplain, SDC, Quality of Life Department Head, SSD, Dietary Manager and Formulary Nurse (the nurse in charge of the central supply office) to ensure sustained compliance. Responsible party was the DON. I. Began Administrative oversight of the facility by a member of Senior Regional Team twice weekly for 2 weeks, beginning [DATE] to [DATE]; then weekly for 4 weeks beginning [DATE] through [DATE], then monthly for one quarter. Responsible party was the Director of Clinical Operations. J. Continued Mock Code drills as outlined above. Responsible party was the DON. K. The DON and SDC began tracking all licensed staff members for CPR certification monthly for 3 months; then every 6 months to ensure all licensed nurses maintained CPR certifications. Findings documented and forwarded to the QA committee monthly to determine any need for education or revision of the process. Responsible party was the DON. L. Established plans for daily contact between the facility and nurses from the regional team or corporate office for 2 weeks, then 2 times weekly for 4 weeks. Nurses from the regional team or home office reviewed compliance with the Plan of Correction and Policy and Procedures, compliance of any code blue to occur, and review of compliance with all new/readmissions. Responsible party was the DON. On [DATE] the facility did the following: A. Completed the twice daily mock code drills as outlined above with no irregularities noted. Initiated the plan for transition to twice weekly Mock Code drills to occur on rotating shifts for another 4 weeks. Responsible party was the DON. B. Continued staff education and competency testing on Abuse and Neglect, Resident Rights, Advance Directives and Where to find them in the Chart, CPR, Notification of Change in Condition, Physician Orders, and Care Plans. Responsible party was the DON. C. Held a follow up QA meeting to review findings from initial audits, scheduled weekly QA meetings for 4 weeks, then monthly, for recommendations and further follow up regarding the Corrective Action Plan. At that time, based upon evaluation, the QA committee would determine at what frequency any ongoing audits would be continued. Responsible party was the Administrator. On [DATE] the facility did the following: A. Completed education and competency testing of all staff, with the exception of those on Family Medical Leave (FMLA) or PRN status who had not worked, with 100% scores attained on all post-tests for facility Abuse and Neglect Policy, Resident Rights, CPR and Advance Directives, Where to Locate Advance Directives in the Medical Records, Physician Orders, Notification of Change in Condition, and Care Plans. Employees on FMLA or PRN status were not permitted to work until all education and competency testing completed. Responsible party was the DON. B. Continued all random audits, staff and resident interviews, and competency testing as outlined above. Responsible party was the DON. C. Continued daily stand up meeting reviews as outlined above, which included reports to Administration on the progress of the facility corrective action plans and changes in resident condition. Responsible party was the DON.

Based on review of facility policy, medical record review, review of the facility investigation, and interview, the facility failed to prevent neglect of 1 resident (Resident #6) of 6 residents reviewed for abuse and neglect, of 13 sampled residents. The facility's failure to initiate Cardiopulmonary Resuscitation (CPR) to Resident #6, who was found in cardiac and respiratory arrest on [DATE] at 7:00 AM, constituting neglect, placed Resident #6 in Immediate Jeopardy (a situation where the providers noncompliance with one or more requirements of participation, has caused, or is likely to cause, serious injury, harm, impairment or death). F-224 was cited at a scope and severity of J and is Substandard Quality of Care. The Administrator, Director of Nursing (DON), and Corporate Nurse were informed of the Immediate Jeopardy on [DATE] at 3:25 PM, in the conference room. The IJ was effective [DATE] - [DATE]. The facility's corrective action plan which removed the IJ was received and corrective actions were validated onsite by the surveyor on [DATE] - [DATE]. The IJ was cited as past noncompliance for F-224 and the facility iss not required to submit a plan of correction. The findings included: Review of the facility policy, Abuse, Neglect and Misappropriation or Property (undated), revealed .policy to prevent the occurrence of abuse, neglect .willful means non-accidental, or not reasonably related to the appropriate provision of ordered care and services depending on the context .Neglect means failure to provide goods and services necessary to avoid physical harm .every stakeholder, contractor .and volunteer must intervene immediately, to the extent feasible and consistent with personal safety and the persons training to prevent or interrupt an incident of abuse . Review of the facility policy, Cardiopulmonary Resuscitation, (CPR), undated, revealed .Upon identifying a resident with a change of condition which presents as an unresponsive condition .check the medical record for advance directive status .if resident record indicates CPR is to be instituted, then initiate Basic Life Support (maintenance of airway, breathing, circulation) if a pulse and/or respirations are undetectable .if a resident is found unresponsive and without respirations, a licensed staff member who is certified in CPR .shall promptly initiate CPR for residents .who have requested CPR in their advance directives . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Admission Consent Forms and the Tennessee Physicians Orders for Scope of Treatment (POST, or advanced directives form) executed on [DATE], revealed Resident #6, a [AGE] year old resident, was to receive CPR, Intubation (insertion of a breathing tube), advanced airway interventions, mechanical ventilation as indicated, transfer to a hospital or intensive care unit if indicated, and full treatment in an intensive care unit if indicated, in the event of a respiratory or [MEDICAL CONDITION]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 15 (indicating she was cognitively intact), was independent in decision making, dependent upon supplemental oxygen to breathe, and the resident required moderate assistance of one person for activities of daily living (ADLs). Medical record review of the Physician Orders dated [DATE] at 4:21 PM, revealed .Advanced Directive .FULL CODE (full code is a hospital designation that means to intercede if a patient's heart stops beating or if the patient stops breathing) . Medical record review of a Nursing Progress Notes Report revealed on [DATE] at 6:00 AM, Resident #6 was found seated on her bed by Licensed Practical Nurse (LPN) #1, and the resident reported to the LPN she had problems breathing. LPN #1 administered ordered breathing treatments ([MEDICATION NAME], a medication to improve breathing) and oral [MEDICATION NAME] (narcotic, for pain) to the resident and informed Registered Nurse (RN) #1 of the resident's status. Medical record review of a Nursing Progress Notes Report revealed on [DATE] at 6:37 AM, Resident #6 activated the call light, RN #1 and LPN #1 responded, and found Resident #6 on the side of the bed. Continued medical record review revealed the resident remained short of breath and requested to be transferred to the hospital to be intubated (insertion of a breathing tube), and the Resident's request was not honored. Medical record review of the Nursing Progress Notes Report dated [DATE] at 7:00 AM revealed Resident #6 was found by RN #1, slumped over in bed, gray in color, and without a pulse or respirations (cardiac and respiratory arrest). Continued review of the Nursing Progress Notes Report revealed RN #1 did not attempt to perform CPR on Resident #6 in accordance with the Residents' Advance Directives and Physician Orders, and instead pronounced the resident deceased at 7:06 AM. Review of the facility investigation dated [DATE] revealed at the time of Resident #6's [MEDICAL CONDITION], LPN #1, LPN #3, LPN #15, and Respiratory Therapist (RT) #4 advised RN #1 of Resident #6's Advance Directives status as a full code. Continued review of the facility investigation revealed LPN #1, LPN #3, LPN #15 and RT #4 questioned the RN #1's decision to not perform CPR on the resident. Continued review revealed RN #1 stood between the staff and the resident's body with her arms outstretched, as if to deny them access to the resident, and informed them no CPR would be performed. None of the staff present (LPN #1, LPN #3, LPN #15, RT #4) intervened to perform CPR. Continued review revealed RN #1 refused to perform CPR on the resident when advised by Resident #6's Physician of the resident's full code status. Review of RN #1's investigative interview summary (the findings of the investigative interview conducted by the facility's attorney) dated [DATE], revealed .Entered resident's room to give drink .assisted resident with same .replaced resident O2 (oxygen) mask back on face .(LPN #1 giving meds) .Resident SATS (blood oxygen saturation) were 95% good .Later 2 CNAs (Certified Nurse Aide) approached, saying resident would like to go to hospital .I assessed resident .resident stated she wanted to be intubated .I found not needed and that resident was very tired .covered resident with blanket .put at 90 degrees in middle of the bed .relayed I would notify her family and doctor .skin color dusky color .cool to touch .room was very cool .with .(LPN #1) .started looking up family contact info (information) .then walked back to resident room to get more family names from resident .found resident slumped over with her head down to the end of bed .this was approximately 30 minutes after I had left resident .yelled for stethoscope .two other nurses nearby .one went to call resident's daughter .assessed resident .no pulse or respirations .skin dusky, eyes ½ open, lips and nails blue tinge .Nurse (LPN #1) said resident is full code .I responded resident has clearly passed, nothing to do .Spoke with Doctor, told him resident expired and I would not initiate code, would pronounce her at 7:06 AM . Interview with CNA #1 on [DATE] at 6:55 PM, in the conference room, revealed she witnessed the incident on [DATE] around 7:00 AM. Continued interview revealed CNA #1 stated I was getting report from the night CNA when (RN #1) came out of the room and said .(Resident #6) had passed . Continued interview revealed she witnessed a telephone call between RN #1 and Physician #3 and heard the nurse inform the Physician the resident had expired. RN #1 said she .wouldn't do compressions on a dead person . Telephone interview with Physician #3 (the attending Physician for Resident #6) on [DATE], at 10:57 AM, revealed when he was contacted by RN #1 on [DATE] between 7:00 and 7:15 am, he questioned the nurse if CPR had been initiated or was in progress and was informed by RN #1 CPR had not been attempted at all. Continued interview revealed Physician #3 advised RN #1 the resident was full code status and CPR was to have been initiated, and RN #1 stated you want me do CPR on a dead person? Continued interview revealed RN #1 informed him she had declared the resident deceased at 7:06 AM. Continued interview revealed he believed CPR .should have been attempted . on Resident #6 prior to declaration of death by RN #1. Interview with LPN #1 on [DATE] at 11:36 AM, in the conference room, revealed on [DATE] around 7:00 AM she observed Resident #6 in [MEDICAL CONDITION] and RN #1 was present. Continued interview revealed the resident's appearance was .slumped over on the side of the bed, upright with no breathing and no pulse . and LPN #1 assisted RN #1 to position the resident in the bed for assessment. Continued interview revealed LPN #1 advised RN #1 .she (Resident #6) is a full code . Continued interview revealed RN #1 replied to her and stated we're not doing nothing to this poor woman, she's gone, she's been through enough . Continued interview revealed .(RN #1) knew (Resident #6) was a full code because we had discussed it earlier in the shift when talking about the morning shift report . Continued interview revealed as she and RN #1 assessed Resident #6, LPN #15 and RT #4 entered the room. Continued interview revealed LPN #1 heard LPN #15 and RT #4 ask RN #1 if CPR was to begin and both staff members advised RN #1 of the resident's advanced directives. Further interview revealed .the day shift nurses came in the room and asked, 'Are we gonna (going to) code her' .and (RN #1) said, 'No we aren't gonna do anything' .no one else questioned it .(RN #1) was guarding the body, standing between us and everyone else and the body .arms outstretched and said to everybody, 'No, we aren't going to do a thing' .I'm screaming to call the doctor and (LPN #15) went and called the doctor and I followed her to the nurse station to call the doctor .(LPN #15) called the doctor on the phone and I started to take the phone to talk to the doctor to speak to him .Then (RN #1) comes running up the hall, snatched the phone from (LPN #15)'s hand and started talking to the doctor . Continued interview revealed LPN #1 observed RN #1 yell into the telephone, .I heard (RN #1) yell something like try to take my license .then she slammed down the phone and stormed off the unit .after that I heard someone ask can' t we still do CPR .then someone else say, 'No, the RN pronounced her' . Interview with LPN #3 on [DATE] at 12:47 PM, in the conference room, revealed she witnessed the incident. Continued interview revealed she overheard RN #1's telephone call with Physician #3 shortly after 7:00 AM. Continued interview revealed .I heard (RN #1) say 'I am not doing CPR on a dead person, you can take my license' and at that point there was big confusion .I pulled the crash cart to the nurses station, asked (LPN #15), we were confused, it wasn't protocol, especially after the phone call .didn't know exactly what was going on .stayed out of night shift's way because they were dealing with it .I didn't learn what had happened until after shift change .I did ask (RN #1) what were we going to do, and heard someone else ask her are we going to do CPR .and I heard (RN #1) say 'I am not doing CPR on a dead person' or something like that . Continued interview confirmed LPN #3 did not perform CPR on the resident. Interview with CNA #3 on [DATE] at 1:48 PM, in the conference room, revealed she witnessed the incident on [DATE], which she stated had occurred around 7:00 AM, at shift change. Continued interview revealed CNA #3 observed RN #1, RT #4 and LPN #1 enter the resident's room around 6:55 AM and the trio emerged ,[DATE] minutes later, and both LPN #1 and RT #4 were crying at the time. Interview with the Director of Nursing (DON) on [DATE] at 2:45 PM in the conference room, confirmed RN #1 had willfully withheld CPR from Resident #6. Continued interview confirmed RN #1 had failed to follow facility policy and confirmed RN # 1's actions constituted neglect of Resident #6. Interview with the Administrator on [DATE] at 4:17 PM, in the conference room, confirmed RN #1's actions on [DATE] were willful and confirmed multiple staff members failed to perform CPR on Resident #6, which constituted neglect. Interview with Respiratory Therapist (RT) #4 on [DATE] at 1:40 PM, in the conference room, revealed on [DATE] around 7:00 AM, she entered Resident #6's room and observed the resident slumped sideways in the bed with her head tilted backwards, mouth open, not breathing, and ashen in color. Continued interview revealed she informed RN #1 the resident was a full code and CPR was to begin at once. Further interview revealed RN 1# stated, .absolutely not, we are not doing a code, she has been down too long . Continued interview confirmed neither RT #4 or the other staff members attempted to perform CPR on the resident. Telephone interview with LPN #15 on [DATE] at 2:24 PM, revealed she witnessed the incident. Continued interview revealed when Resident #6 was discovered without a pulse or respirations at 7:00 AM, she responded to the room to assist in resuscitation efforts and informed RN #1 the resident was a full code. Continued interview revealed .I told (RN #1) the resident was a full code, we needed to code and (RN #1) said, 'No we are not going to code her' .I advised (RN #1) facility policy was to code the resident and (RN #1) refused even after I advised of facility policy . Continued interview revealed other personnel advised RN #1 of the resident's code status and RN #1 continued to prevent staff from performing CPR on Resident #6. Continued interview revealed LPN #15 heard RN #1 refuse to perform CPR on Resident #6, and she heard RN #1 say, I refuse to do CPR on a dead person. Continued interview revealed .I was getting the crash cart with when she (RN #1) held up her hand, mouthed 'No' to me on getting crash cart .after that we stopped, we were taught to never disobey an RN but taught to do codes, felt stuck . The facility's corrective action plan included the following: On [DATE] the facility did the following: A. Held an ad hoc Quality Assurance (QA) meeting during the daily stand up meeting and reviewed the incident. Incident was reported to the State Agency. Follow up QA meeting was scheduled for [DATE]. Responsible party was the Administrator. B. The regional nurse consultant reviewed with the DON and the Administrator the education to be provided to all staff on [DATE] to include Abuse, Resident Rights, Advance Directives, Where to Locate the Advance Directives in the Medical Record, Cardiopulmonary Resuscitation (CPR), Following Physician Orders, Change in Condition and Following Care Plans. Responsible party was the Director of Nursing (DON). C. Once the Administrator and DON were educated, they were assigned to educate the Nursing Administration team Assistant Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Nurses, and Staff Development Coordinator), who in turn were assigned to educate all the staff on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives in the Medical Record, CPR, Following Physician Orders, Change in Condition, and Following Care Plans. Responsible party was the DON). D. Began written competency testing of all staff educated on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives, CPR, Following Physician Orders, Change in Condition and following Care Plans. Responsible party was the Director of Nursing (DON). E. All staff educated, were required to submit written post-tests with scores of 100% before being permitted to work. All staff who failed to score 100% on the post-tests were immediately re-educated and re-tested until all staff scored 100% on the post tests. Responsible party was the Director of Nursing (DON). F. Initiated the first Mock Code Drill conducted by the DON, ADON, Unit Manager (UM) and the Staff Development Coordinator (SDC) to ensure staff understanding and compliance with the facility code blue policy (policy related to emergency resuscitation) and procedures. No irregularities noted. Mock codes were then planned to be completed for every shift (7 A-7P, 7P-7A) for 72 hours through [DATE], then twice weekly on rotating shifts for 4 weeks starting on [DATE] through [DATE] (scheduled to occur on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and on [DATE] on both shifts) to ensure staff understanding and compliance with the facility code blue policy. The first two Mock Codes were conducted by members of the Nursing Administration Team under observation of the DON, then Mock codes were conducted by nursing staff members under observation of members of the Nursing Administration team. Findings were to be reported to the QA committee weekly for 4 weeks to determine compliance and any further need of continued education or revision of the plan. Responsible party was the Director of Nursing (DON). G. Began ongoing monitoring of staff compliance with abuse, advanced directives, resident rights, CPR, location of advanced directives and Do Not Resuscitate (DNR) forms in the medical record, following physician orders, change in condition reporting and following Care Plans. Responsible party was the Administrator. On [DATE] the facility did the following: A. Resident #6's chart and care plan were reviewed by the Regional Nurse Consultant and Director of Clinical Operations. Registered Nurse (RN) #1 was to have been terminated concluding the investigation but resigned prior to termination. Licensed Practical Nurses (LPN) LPN #1 LPN #3, LPN #15 and Respiratory Therapist (RT) #4 received disciplinary action related to not following facility policy. Responsible party was the DON. B. Began audits of the medical records for all residents in the facility, by the Regional Nurse Consultant and Director of Clinical Operations, to ensure advance directives were in the medical record, were addressed on the care plan, and had current Physician orders related to each resident's code status. Responsible party was the DON. C. All residents were assessed for any possible resident rights violations. Those residents with Brief Interview of Mental Status (BIMS scores, a measure of cognitive function), greater or equal to 8 (cognitively intact) were interviewed by the DON, ADON, UM, Social Services Director (SSD), Social Services Assistant (SSA) for quality of life or resident rights violations. No issues were identified. Responsible party was the DON. D. All residents with BIMS scores less or equal to 7 (cognitively impaired) had skin assessments completed on [DATE] for any concerns by ADONs and UMs for any possible abuse or neglect issues. All residents with a BIMS greater or equal to 8 were interviewed for possible abuse or neglect violations. No issues were identified. Responsible party was the DON. E. Held a Resident Council Meeting (a group of residents who reside in the facility and meet regularly, discuss resident concerns, and discuss resident concerns with Administration) and the SSD and Activities Director reviewed the Resident Rights Statement and Policies for Prohibition of Abuse, Neglect and Misappropriation of Property and provided a copy to each resident. Responsible party was the DON. F. All deaths in the facility for the past 30 days were reviewed by the Regional Nurse to ensure advanced directives were honored with no irregularities noted. The DON reviewed all resident deaths in the facility for the prior 12 months with no irregularities noted. Results were discussed in the QA meeting. Responsible party was the Administrator. G. Held first formal QA meeting to address the incident. DON, ADON, UM, Nursing Supervisors or Medical Records staff were to review all new admissions/readmits and residents with DNR related changes, 24 hour shift reports, and incidents accidents daily for 2 weeks, then Monday through Friday ongoing, starting during morning clinical meeting, to ensure sustained compliance with physician notification, physician orders, interim care plan, advance directives, and resident rights. Corporate administrative oversight of the QA meeting was completed by the Regional Vice President or member of the regional staff weekly for 4 weeks beginning [DATE], then monthly for one quarter. The facility allegation of compliance (AOC) was reviewed by the committee. Responsible party was the Administrator. H. Continued staff education and post testing on Abuse and Neglect, Advanced Directives, Where to find Advanced Directives in the chart, CPR, Resident Rights, following Physician orders, Notification of Change in Condition, and Following Care plans. Responsible party was the DON. I. Grievance logs were reviewed by the Director of Clinical Operation with no irregularities noted. J. Continued Mock Code drills as outlined. Responsbile party was the DON. K. Corrective actions were reviewed by the Administrator, DON, Medical Director and Regional Consultants. Responsible party was the Administrator. On [DATE] the facility did the following: A. The DON, ADON, UM, Administrator and Department Heads continued advance directive/abuse post-tests with 10 random Nursing staff members daily on rotating shifts for 2 weeks through [DATE]. Then 5 random nursing staff members on rotating shifts daily for 2 weeks through [DATE], then 5 random Nursing staff members weekly for 3 weeks through [DATE], with all staff required to score 100% on the post tests. Staff members who failed to achieve 100% scores on the tests were immediately re-educated and required to re-test until 100% scores were achieved. Responsible party was the DON. B. Continued education of all staff members on the facility Abuse and Neglect Policy, Resident Rights, CPR, Advance Directives and Where to find them in the medical record, Notification of Change in Condition, Physician Orders, and Care plans. Responsible party was the DON. C. Continued Mock Code drills on every shift through [DATE] as outlined. Responsible party was the DON. On [DATE] the facility did the following: A. Completed review of all residents medical records by the Director of Clinical Operations and the Regional Nurse to ensure advance directives were in the medical records, addressed on the care plans, and had a current Physician Order regarding code status. No irregularities noted. Responsible party was the Director of Clinical Operations. B. Completed a 100% audit of licensed clinical staff CPR certifications by the Regional Vice President and Regional Nurse Consultant. C. Completed 100% audit of all licensed staff to verify valid Tennessee professional licensure completed by the Regional Vice President. No irregularities were noted. D. Completed 100% audit to ensure staff were not listed on the abuse registry by the Regional Vice President with no irregularities noted. E. Mailed certified letters to all employees who had not completed mandatory training and education and advised completion of training was required prior to any return to work at the facility. The letters included all employees on vacation or paid leave, part time or prn (as needed status). Responsible party was the DON. F. The Administrator began reviews of completed audits for new admissions, readmissions and residents with DNR to ensure sustained compliance with all advanced directives. G. DON, ADON, UM or Weekend Manager on duty began interviews with 5 residents with BIMS scores equal or greater than 8 and 5 family members of residents with BIMS scores less than 8 daily for 2 weeks ([DATE] to [DATE]) for any possible resident rights violations; then 3 residents and 3 family members daily for 2 weeks ([DATE] to [DATE]), then 2 residents and 2 family members daily for 4 weeks ([DATE] to [DATE]), then 1 resident and 1 family member daily for 4 weeks ([DATE] to [DATE]). Results of the interviews and assessments forwarded to the QA committee. Responsible party was the DON. H. All deaths in the facility were reviewed by the DON, ADON, UM or Administrator to ensure code status was implemented correctly as per the resident's wishes and documented on the advance directives daily for 2 weeks through [DATE]; then weekly for 4 weeks from [DATE] to [DATE], then continuing as part of the daily stand up meetings attended by the Administrator, DON, ADONs, UM, MDS Coordinator, Treatment Nurses, Chaplain, SDC, Quality of Life Department Head, SSD, Dietary Manager and Formulary Nurse (the nurse in charge of the central supply office) to ensure sustained compliance. Responsible party was the DON. I. Began Administrative oversight of the facility by a member of Senior Regional Team twice weekly for 2 weeks, beginning [DATE] to [DATE]; then weekly for 4 weeks beginning [DATE] through [DATE], then monthly for one quarter. Responsible party was the Director of Clinical Operations. J. Continued Mock Code drills as outlined above. Responsible party was the DON. K. The DON and SDC began tracking all licensed staff members for CPR certification monthly for 3 months; then every 6 months to ensure all licensed nurses maintained CPR certifications. Findings documented and forwarded to the QA committee monthly to determine any need for education or revision of the process. Responsible party was the DON. L. Established plans for daily contact between the facility and nurses from the regional team or corporate office for 2 weeks, then 2 times weekly for 4 weeks. Nurses from the regional team or home office reviewed compliance with the Plan of Correction and Policy and Procedures, compliance of any code blue to occur, and review of compliance with all new/readmissions. Responsible party was the DON. On [DATE] the facility did the following: A. Completed the twice daily mock code drills as outlined above with no irregularities noted. Initiated the plan for transition to twice weekly Mock Code drills to occur on rotating shifts for another 4 weeks. Responsible party was the DON. B. Continued staff education and competency testing on Abuse and Neglect, Resident Rights, Advance Directives and Where to find them in the Chart, CPR, Notification of Change in Condition, Physician Orders, and Care Plans. Responsible party was the DON. C. Held a follow up QA meeting to review findings from initial audits, scheduled weekly QA meetings for 4 weeks, then monthly, for recommendations and further follow up regarding the Corrective Action Plan. At that time, based upon evaluation, the QA committee would determine at what frequency any ongoing audits would be continued. Responsible party was the Administrator. On [DATE] the facility did the following: A. Completed education and competency testing of all staff, with the exception of those on Family Medical Leave (FMLA) or PRN status who had not worked, with 100% scores attained on all post-tests for facility Abuse and Neglect Policy, Resident Rights, CPR and Advance Directives, Where to Locate Advance Directives in the Medical Records, Physician Orders, Notification of Change in Condition, and Care Plans. Employees on FMLA or PRN status were not permitted to work until all education and competency testing completed. Responsible party was the DON. B. Continued all random audits, staff and resident interviews, and competency testing as outlined above. Responsible party was the DON. C. Continued daily stand up meeting reviews as outlined above, which included reports to Administration on the progress of the facility corrective action plans and changes in resident condition. Responsible party was the DON.

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to notify the physician of a change in condition for 1 resident (Resident #6) of 6 resident deaths sampled, of 13 residents reviewed for Notification of Change in Condition. The facility's failure to notify the Physician of a change in respiratory status for Resident #6 resulted in failure to implement appropriate interventions to prevent Resident #6's death on [DATE], placing Resident #6 in Immediate Jeopardy (a situation where the providers noncompliance with one or more requirements of participation, has caused, or is likely to cause, serious injury, harm, impairment or death). The Administrator, Director of Nursing (DON), and Corporate Nurse were informed of the Immediate Jeopardy on [DATE] at 3:25 PM, in the conference room. The IJ was effective [DATE] - [DATE]. The facility's corrective action plan which removed the IJ was received and corrective actions validated onsite by the surveyor on [DATE] - [DATE]. The IJ was cited as past noncompliance for F-157 and the facility is not required to submit a plan of correction. The findings included: Review of the Facility Policy, Change of Condition (undated) revealed .The facility will assess and document changes in the resident's condition .to relay assessment information to physician .to document actions to include but not limited to .significant change in the resident's physical, mental or psychosocial status . Medical record review of hospital Admission Summary and Discharge Summaries revealed Resident #6 was briefly admitted to the hospital from [DATE] to [DATE], with [DIAGNOSES REDACTED]. Resident #6 was stabilized and transferred to the nursing home on [DATE]. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Admission Consent Forms and the Tennessee Physicians Orders for Scope of Treatment (POST or advanced directives form) executed on [DATE], revealed Resident #6, a [AGE] year old resident, was to receive CPR (cardiopulmonary resuscitation), Intubation (insertion of a breathing tube), advanced airway interventions, mechanical ventilation as indicated, transfer to a hospital or intensive care unit if indicated, and full treatment in an intensive care unit if indicated, in the event of respiratory or [MEDICAL CONDITION]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 15 (indicating she was cognitively intact), was independent in decision making, dependent upon supplemental oxygen to breathe, and the resident required moderate assistance of one person for activities of daily living (ADLs). Review of the Daily Skilled Nursing Note dated [DATE] at 1:30 AM, revealed .Cardiovascular .Cardiovascular concerns yes .radial/apical (pulse) irregular .Respiratory Concerns .yes .Labored Breathing .Orthopnea (shortness of breath with movement) shallow respirations .SOB (short of breath) .on exertion .at rest .lying flat .Lung Sounds .Rales (a type of abnormal lung sound often associated with lung disease, fluid in the lungs or swelling in the lungs) .Wheezing .(a type of abnormal lung sound often associated with [MEDICAL CONDITION], decreased lung volume, inflammation or mucous in the airways of the lungs) . Review of the Nursing Progress Notes Report revealed on the morning of [DATE], during the conclusion of the [DATE] 7:00 PM to 7:00 AM shift, at approximately 6:00 AM, Resident #6 exhibited an onset of symptoms of increased anxiety and increased shortness of breath, and summoned her primary nurse that evening, Licensed Practical Nurse (LPN) #1, to her room. Continued review revealed LPN #1 entered the room and found the resident seated on the side of her bed complaining of severe shortness of breath. Continued review revealed LPN #1 assessed the resident's blood oxygen saturation levels (O2 SAT) which were at 95% (within normal limits) at the time, administered a scheduled breathing treatment ([MEDICATION NAME], a medication to improve breathing) and oral [MEDICATION NAME] (narcotic, for pain) from 6:00 AM to 6:15 AM, and informed her supervisor, Registered Nurse (RN) #1, of the resident's status. Continued medical record review revealed no documentation in the medical record LPN #1 reported the changes in Resident #6's respiratory condition to the Physician. Continued review of the Nursing Progress Notes Report revealed, around 6:30 AM, Resident #6 activated the call light and RN #1 and LPN #1 returned to the resident's room. Continued review revealed LPN #1 and RN #1 found Resident #6 again seated on the side of the bed, and the resident informed them she remained short of breath and wished to be transferred to the hospital to be intubated. Continued review revealed the resident's vital signs were heart rate at 88 beats per minute (within normal limits, WNL) O2 Saturation as 95% (WNL) and Respiratory Rate was 36 breaths per minute (elevated). Further review revealed RN #1 adjusted the resident's position and elevated the head of the bed 90 degrees. The resident was not transported to the hospital. Continued review revealed RN #1 documented .her color did not look right .the LPN and I pulled the chart and looked up to see the next of kin .and attempted to call .next call was made to .went to voice mail . Medical record review revealed no documentation either LPN #1 or RN #1 had attempted to call the resident's attending Physician to inform him of the deterioration in the resident's condition at 6:00 AM or at 6:30 AM. Continued review revealed on [DATE] at 7:00 AM, RN #1 entered the resident's room and found Resident #6 slumped over in the bed, gray in color, without respirations or a heart rate, and after assessing for heart and lung sounds and performing a check for a pulse, RN #1 determined Resident #6 was deceased . No CPR was initiated and RN #1 pronounced Resident #6 dead at 7:06 AM. Continued medical record review revealed RN #1 contacted the attending Physician for Resident #6 shortly after 7:06 AM and advised the Physician she had pronounced Resident #6 dead. Review of RN #1's investigative interview summary (the findings of the investigative interview conducted by the facility's attorney) dated [DATE], revealed .Entered resident's room to give drink .assisted resident with same .replaced resident O2 (oxygen) mask back on face .(LPN #1 giving meds) .Resident SATS (blood oxygen saturation) were 95% good .Later 2 CNAs (Certified Nurse Aide) approached, saying resident would like to go to hospital .I assessed resident .resident stated she wanted to be intubated .I found not needed and that resident was very tired .covered resident with blanket .put at 90 degrees in middle of the bed .relayed I would notify her family and doctor .skin color dusky color .cool to touch .room was very cool .with .(LPN #1) .started looking up family contact info (information) .then walked back to resident room to get more family names from resident .found resident slumped over with her head down to the end of bed .this was approximately 30 minutes after I had left resident .yelled for stethoscope .two other nurses nearby .one went to call resident's daughter .assessed resident .no pulse or respirations .skin dusky, eyes ½ open, lips and nails blue tinge .Nurse (LPN #1) said resident is full code .I responded resident has clearly passed, nothing to do .Spoke with Doctor, told him resident expired and I would not initiate code, would pronounce her at 7:06 AM . Telephone interview with Physician #3 (Resident #6's Physician) on [DATE] at 10:57 AM, revealed the Physician reported he was called sometime between 7:00 and 7:15 AM on [DATE] and was informed by RN #1, Resident #6 had expired. Continued interview revealed at no time during the overnight shift was he contacted by the facility and informed of the deterioration in the resident's respiratory condition prior to her [MEDICAL CONDITION]. The Physician stated had he known he would have given an order to transfer Resident #6 to the hospital immediately. Interview with LPN #1 on [DATE] at 11:36 AM, in the conference room, revealed on [DATE] at 6:30 AM, after discussions with RN #1, LPN #1 attempted to contact family members to notify them of the change in the resident's condition, but LPN #1 had not called the Physician. LPN #1 confirmed to her knowledge RN #1 had not attempted to contact the Physician to report changes in Resident #6's condition. Interview with the DON on [DATE] at 2:45 PM, in the conference room, confirmed RN #1 had failed to follow the facility policy and notify the physician of significant changes in Resident #6's respiratory status. The facility's corrective action plan included the following: On [DATE] the facility did the following: A. Held an ad hoc Quality Assurance (QA) meeting during the daily stand up meeting and reviewed the incident. Incident was reported to the State Agency. Follow up QA meeting was scheduled for [DATE]. Responsible party was the Administrator. B. The regional nurse consultant reviewed with the DON and the Administrator the education to be provided to all staff on [DATE] to include Abuse, Resident Rights, Advance Directives, Where to Locate the Advance Directives in the Medical Record, Cardiopulmonary Resuscitation (CPR), Following Physician Orders, Change in Condition and Following Care Plans. Responsible party was the Director of Nursing (DON). C. Once the Administrator and DON were educated, they were assigned to educate the Nursing Administration team Assistant Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Nurses, and Staff Development Coordinator), who in turn were assigned to educate all the staff on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives in the Medical Record, CPR, Following Physician Orders, Change in Condition, and Following Care Plans. Responsible party was the DON). D. Began written competency testing of all staff educated on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives, CPR, Following Physician Orders, Change in Condition and following Care Plans. Responsible party was the Director of Nursing (DON). E. All staff educated, were required to submit written post-tests with scores of 100% before being permitted to work. All staff who failed to score 100% on the post-tests were immediately re-educated and re-tested until all staff scored 100% on the post tests. Responsible party was the Director of Nursing (DON). F. Initiated the first Mock Code Drill conducted by the DON, ADON, Unit Manager (UM) and the Staff Development Coordinator (SDC) to ensure staff understanding and compliance with the facility code blue policy (policy related to emergency resuscitation) and procedures. No irregularities noted. Mock codes were then planned to be completed for every shift (7 A-7P, 7P-7A) for 72 hours through [DATE], then twice weekly on rotating shifts for 4 weeks starting on [DATE] through [DATE] (scheduled to occur on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and on [DATE] on both shifts) to ensure staff understanding and compliance with the facility code blue policy. The first two Mock Codes were conducted by members of the Nursing Administration Team under observation of the DON, then Mock codes were conducted by nursing staff members under observation of members of the Nursing Administration team. Findings were to be reported to the QA committee weekly for 4 weeks to determine compliance and any further need of continued education or revision of the plan. Responsible party was the Director of Nursing (DON). G. Began ongoing monitoring of staff compliance with abuse, advanced directives, resident rights, CPR, location of advanced directives and Do Not Resuscitate (DNR) forms in the medical record, following physician orders, change in condition reporting and following Care Plans. Responsible party was the Administrator. On [DATE] the facility did the following: A. Resident #6's chart and care plan were reviewed by the Regional Nurse Consultant and Director of Clinical Operations. Registered Nurse (RN) #1 was to have been terminated concluding the investigation but resigned prior to termination. Licensed Practical Nurses (LPN) LPN #1 LPN #3, LPN #15 and Respiratory Therapist (RT) #4 received disciplinary action related to not following facility policy. Responsible party was the DON. B. Began audits of the medical records for all residents in the facility, by the Regional Nurse Consultant and Director of Clinical Operations, to ensure advance directives were in the medical record, were addressed on the care plan, and had current Physician orders related to each resident's code status. Responsible party was the DON. C. All residents were assessed for any possible resident rights violations. Those residents with Brief Interview of Mental Status (BIMS scores, a measure of cognitive function), greater or equal to 8 (cognitively intact) were interviewed by the DON, ADON, UM, Social Services Director (SSD), Social Services Assistant (SSA) for quality of life or resident rights violations. No issues were identified. Responsible party was the DON. D. All residents with BIMS scores less or equal to 7 (cognitively impaired) had skin assessments completed on [DATE] for any concerns by ADONs and UMs for any possible abuse or neglect issues. All residents with a BIMS greater or equal to 8 were interviewed for possible abuse or neglect violations. No issues were identified. Responsible party was the DON. E. Held a Resident Council Meeting (a group of residents who reside in the facility and meet regularly, discuss resident concerns, and discuss resident concerns with Administration) and the SSD and Activities Director reviewed the Resident Rights Statement and Policies for Prohibition of Abuse, Neglect and Misappropriation of Property and provided a copy to each resident. Responsible party was the DON. F. All deaths in the facility for the past 30 days were reviewed by the Regional Nurse to ensure advanced directives were honored with no irregularities noted. The DON reviewed all resident deaths in the facility for the prior 12 months with no irregularities noted. Results were discussed in the QA meeting. Responsible party was the Administrator. G. Held first formal QA meeting to address the incident. DON, ADON, UM, Nursing Supervisors or Medical Records staff were to review all new admissions/readmits and residents with DNR related changes, 24 hour shift reports, and incidents accidents daily for 2 weeks, then Monday through Friday ongoing, starting during morning clinical meeting, to ensure sustained compliance with physician notification, physician orders, interim care plan, advance directives, and resident rights. Corporate administrative oversight of the QA meeting was completed by the Regional Vice President or member of the regional staff weekly for 4 weeks beginning [DATE], then monthly for one quarter. The facility allegation of compliance (AOC) was reviewed by the committee. Responsible party was the Administrator. H. Continued staff education and post testing on Abuse and Neglect, Advanced Directives, Where to find Advanced Directives in the chart, CPR, Resident Rights, following Physician orders, Notification of Change in Condition, and Following Care plans. Responsible party was the DON. I. Grievance logs were reviewed by the Director of Clinical Operation with no irregularities noted. J. Continued Mock Code drills as outlined. Responsbile party was the DON. K. Corrective actions were reviewed by the Administrator, DON, Medical Director and Regional Consultants. Responsible party was the Administrator. On [DATE] the facility did the following: A. The DON, ADON, UM, Administrator and Department Heads continued advance directive/abuse post-tests with 10 random Nursing staff members daily on rotating shifts for 2 weeks through [DATE]. Then 5 random nursing staff members on rotating shifts daily for 2 weeks through [DATE], then 5 random Nursing staff members weekly for 3 weeks through [DATE], with all staff required to score 100% on the post tests. Staff members who failed to achieve 100% scores on the tests were immediately re-educated and required to re-test until 100% scores were achieved. Responsible party was the DON. B. Continued education of all staff members on the facility Abuse and Neglect Policy, Resident Rights, CPR, Advance Directives and Where to find them in the medical record, Notification of Change in Condition, Physician Orders, and Care plans. Responsible party was the DON. C. Continued Mock Code drills on every shift through [DATE] as outlined. Responsible party was the DON. On [DATE] the facility did the following: A. Completed review of all residents medical records by the Director of Clinical Operations and the Regional Nurse to ensure advance directives were in the medical records, addressed on the care plans, and had a current Physician Order regarding code status. No irregularities noted. Responsible party was the Director of Clinical Operations. B. Completed a 100% audit of licensed clinical staff CPR certifications by the Regional Vice President and Regional Nurse Consultant. C. Completed 100% audit of all licensed staff to verify valid Tennessee professional licensure completed by the Regional Vice President. No irregularities were noted. D. Completed 100% audit to ensure staff were not listed on the abuse registry by the Regional Vice President with no irregularities noted. E. Mailed certified letters to all employees who had not completed mandatory training and education and advised completion of training was required prior to any return to work at the facility. The letters included all employees on vacation or paid leave, part time or prn (as needed status). Responsible party was the DON. F. The Administrator began reviews of completed audits for new admissions, readmissions and residents with DNR to ensure sustained compliance with all advanced directives. G. DON, ADON, UM or Weekend Manager on duty began interviews with 5 residents with BIMS scores equal or greater than 8 and 5 family members of residents with BIMS scores less than 8 daily for 2 weeks ([DATE] to [DATE]) for any possible resident rights violations; then 3 residents and 3 family members daily for 2 weeks ([DATE] to [DATE]), then 2 residents and 2 family members daily for 4 weeks ([DATE] to [DATE]), then 1 resident and 1 family member daily for 4 weeks ([DATE] to [DATE]). Results of the interviews and assessments forwarded to the QA committee. Responsible party was the DON. H. All deaths in the facility were reviewed by the DON, ADON, UM or Administrator to ensure code status was implemented correctly as per the resident's wishes and documented on the advance directives daily for 2 weeks through [DATE]; then weekly for 4 weeks from [DATE] to [DATE], then continuing as part of the daily stand up meetings attended by the Administrator, DON, ADONs, UM, MDS Coordinator, Treatment Nurses, Chaplain, SDC, Quality of Life Department Head, SSD, Dietary Manager and Formulary Nurse (the nurse in charge of the central supply office) to ensure sustained compliance. Responsible party was the DON. I. Began Administrative oversight of the facility by a member of Senior Regional Team twice weekly for 2 weeks, beginning [DATE] to [DATE]; then weekly for 4 weeks beginning [DATE] through [DATE], then monthly for one quarter. Responsible party was the Director of Clinical Operations. J. Continued Mock Code drills as outlined above. Responsible party was the DON. K. The DON and SDC began tracking all licensed staff members for CPR certification monthly for 3 months; then every 6 months to ensure all licensed nurses maintained CPR certifications. Findings documented and forwarded to the QA committee monthly to determine any need for education or revision of the process. Responsible party was the DON. L. Established plans for daily contact between the facility and nurses from the regional team or corporate office for 2 weeks, then 2 times weekly for 4 weeks. Nurses from the regional team or home office reviewed compliance with the Plan of Correction and Policy and Procedures, compliance of any code blue to occur, and review of compliance with all new/readmissions. Responsible party was the DON. On [DATE] the facility did the following: A. Completed the twice daily mock code drills as outlined above with no irregularities noted. Initiated the plan for transition to twice weekly Mock Code drills to occur on rotating shifts for another 4 weeks. Responsible party was the DON. B. Continued staff education and competency testing on Abuse and Neglect, Resident Rights, Advance Directives and Where to find them in the Chart, CPR, Notification of Change in Condition, Physician Orders, and Care Plans. Responsible party was the DON. C. Held a follow up QA meeting to review findings from initial audits, scheduled weekly QA meetings for 4 weeks, then monthly, for recommendations and further follow up regarding the Corrective Action Plan. At that time, based upon evaluation, the QA committee would determine at what frequency any ongoing audits would be continued. Responsible party was the Administrator. On [DATE] the facility did the following: A. Completed education and competency testing of all staff, with the exception of those on Family Medical Leave (FMLA) or PRN status who had not worked, with 100% scores attained on all post-tests for facility Abuse and Neglect Policy, Resident Rights, CPR and Advance Directives, Where to Locate Advance Directives in the Medical Records, Physician Orders, Notification of Change in Condition, and Care Plans. Employees on FMLA or PRN status were not permitted to work until all education and competency testing completed. Responsible party was the DON. B. Continued all random audits, staff and resident interviews, and competency testing as outlined above. Responsible party was the DON. C. Continued daily stand up meeting reviews as outlined above, which included reports to Administration on the progress of the facility corrective action plans and changes in resident condition. Responsible party was the DON.

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to administer Cardiopulmonary Resuscitation (CPR) in accordance with the resident's advanced directives for 1 resident (Resident #6) of 6 resident deaths sampled, of 13 residents reviewed for advanced directives. The facility's failure to honor Resident #6's Advance Directives status resulted in Resident #6 not receiving CPR on [DATE] and dying, placing Resident #6 in Immediate Jeopardy (a situation where the providers noncompliance with one or more requirements of participation, has caused, or is likely to cause, serious injury, harm, impairment or death). The Administrator, Director of Nursing (DON), and Corporate Nurse were informed of the Immediate Jeopardy on [DATE] at 3:25 PM, in the conference room. The IJ was effective [DATE] - [DATE]. The facility's corrective action plan which removed the IJ was received and corrective actions were validated onsite by the surveyor on [DATE] - [DATE]. The IJ was cited as past noncompliance for F-155, the facility is not required to submit a plan of correction. The findings included: Review of the facility policy, Cardiopulmonary Resuscitation, (CPR), undated, revealed .Upon identifying a resident with a change of condition which presents as an unresponsive condition .check the medical record for advance directive status .if resident record indicates CPR is to be instituted, then initiate Basic Life Support (maintenance of airway, breathing, circulation) if a pulse and/or respirations are undetectable .if a resident is found unresponsive and without respirations, a licensed staff member who is certified in CPR .shall promptly initiate CPR for residents .who have requested CPR in their advance directives . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Admission Consent Forms and the Tennessee Physicians Orders for Scope of Treatment (POST or advanced directives form) executed on [DATE], revealed Resident #6, a [AGE] year old resident, was to receive CPR, Intubation (insertion of a breathing tube), advanced airway interventions, mechanical ventilation as indicated, transfer to a hospital or intensive care unit if indicated, and full treatment in an intensive care unit if indicated, in the event of a respiratory or [MEDICAL CONDITION]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE], revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 15 (cognitively intact), was independent in decision making, dependent upon supplemental oxygen to breathe, and the resident required moderate assistance of one person for activities of daily living (ADLs). Medical record review of a Nursing Progress Notes Report dated [DATE] at 6:00 AM, revealed Resident #6 was found seated on her bedside by Licensed Practical Nurse (LPN) #1, and the resident reported to the LPN she had problems breathing. Continued review revealed LPN #1 administered ordered breathing treatments ([MEDICATION NAME], a medication to open airways in the lungs) and oral medications ([MEDICATION NAME], narcotic for pain relief) to the resident. Review of the facility investigation dated [DATE] revealed after LPN #1 administered medications to Resident #6, she informed her supervisor, Registered Nurse (RN) #1 of the resident's status. Continued review revealed at 6:37 AM, Resident #6 activated the call light and RN #1 and LPN #1 responded to the resident's call. Medical record review of the Nursing Progress Notes Report dated [DATE], revealed RN #1 and LPN #1 found Resident #6 again seated on the side of the bed, and the resident informed them she remained short of breath and requested to be transferred to the hospital for intubation. Continued review of the Nursing Progress Note Report revealed the resident's vital signs were heart rate at 88 beats per minute (within normal limits, WNL) Oxygen (O2) Saturation (a measure of blood oxygen levels) 95% (WNL) and Respiratory Rate 36 breaths per minute (abnormally elevated). Further review revealed Resident #6 asked for assistance back into bed and RN #1 placed the resident in her bed, with head of the bed elevated 90 degrees. Continued review revealed no documentation either nurse attempted to arrange transport for Resident #6 to the hospital as requested. Continued review of the Nursing Progress Notes Report revealed . elder did not look right .pulled .the .elder .chart and looked up to see the next of kin .and attempted to call the ex-husband work number x4 (4 times) .next call was made to .son in law .went to voice mail . Continued review revealed at around 7:00 AM (23 minutes after the resident exhibited respiratory distress and requested to be transported to the hospital), RN #1 re-entered the resident's room and discovered Resident #6 slumped over, without a pulse or respirations, and gray in color. Continued review of the Nursing Progress Notes Report revealed .I (RN #1) entered the room and there were no breath sounds .elder gray in color .no palpable pulse was felt .Despite elder being full code .I did not perform CPR on elder . Continued review of the Nursing Progress Notes revealed RN #1 declared Resident #6 deceased at 7:06 AM (6 minutes after she was discovered in cardiac and respiratory arrest) and no attempts to resuscitate the resident were documented. Review of RN #1's investigative interview summary (the findings of the investigative interview conducted by the facility's attorney) dated [DATE], revealed .Entered resident's room to give drink .assisted resident with same .replaced resident O2 mask back on face .(LPN #1) giving meds .Resident SATS (blood oxygen saturation) were 95% good .Later 2 CNAs (Certifiied Nurse Aide) approached, saying resident would like to go to hospital .I assessed resident .resident stated she wanted to be intubated .I found not needed and that resident was very tired .covered resident with blanket .put at 90 degrees . relayed I would notify her family and doctor .skin color dusky color .cool to touch .room was very cool .with .(LPN #1) .started looking up family contact info (information) .called ex-husband and son in law both went to VM (voice mail) with no ability to leave message .tried calling son in law again .no connect .then walked back to resident room to get more family names from resident .found resident slumped over with her head down to the end of bed .this was approximately 30 minutes after I had left resident .yelled for stethoscope .two other nurses nearby .one went to call resident's daughter .assessed resident .no pulse or respirations .skin dusky, eyes ½ open, lips and nails blue tinge .Nurse (LPN #1) said resident is full code .I responded resident has clearly passed, nothing to do .Spoke with Doctor, told him resident expired and I would not initiate code, would pronounce her at 7:06 AM .Doctor adamant about doing compressions, I refused, relayed he could speak to administration about it .I then told my administrator and DON (Director of Nursing) what happened, wanted them to know from me . Interview with CNA #1 on [DATE] at 6:55 PM, in the conference room, revealed she was present on the unit when Resident #6 was declared deceased by RN #1, and confirmed no CPR was attempted on the resident. Further interview revealed CNA #1 overheard RN #1 advise the resident's physician .I will not do chest compressions on a dead person . Interview with Physician #3 on [DATE] at 10:57 AM, by telephone, revealed the physician reported he was called sometime between 7:00 and 7:15 AM on [DATE], and was informed by RN #1 Resident #6 had expired and no CPR was attempted. Continued interview revealed the Physician questioned RN #1 if CPR was in progress or had been attempted on Resident #6, prior to her being declared deceased . Continued interview revealed Physician #3 informed RN #1 the resident was a full code and CPR was to have been attempted. Physician #3 reported RN #1 questioned him initially and asked him you want me do compressions on a dead person? Continued interview revealed Physician #3 stated RN #1 failed to honor the resident's wishes and he did not order CPR to begin after his conversation with RN #1, as he was given the impression by the nurse Resident #6 had been pulseless for an extended period of time when the telephone call to him was made. Interview with LPN #1 on [DATE] at 11:36 AM, in the conference room, revealed on [DATE] at 7:00 AM, when Resident #6 was discovered in cardiac and respiratory arrest, LPN #1 entered the resident's room behind RN #1, and LPN #1 informed RN #1 the resident was a full code and the resident's desire was to have CPR. Continued interview revealed RN #1 stated to the LPN .we're not doing nothing to this poor woman, she's gone, she has been through enough . Continued interview revealed LPN #1 reported Respiratory Therapist (RT) #4, LPN #3 and LPN #15 had also been prohibited from performing CPR on Resident #6 by RN #1. LPN #1 reported RN #1 stood between the staff and the resident's body, with her arms outstretched laterally, as if to block them from approaching Resident #6, as she told the staff no CPR would be performed. Interview with LPN #3 on [DATE] at 12:47 PM, in the conference room, confirmed RN #1 refused to perform CPR on Resident #6. Interview with the DON on [DATE] at 2:45 PM, in the conference room, revealed the facility investigation concluded RN #1 was fully aware of Resident #6's Advance Directives status at the time she elected not to perform CPR on Resident #6. The DON confirmed the nurse failed to perform CPR in accordance with the resident's advance directives and failed to follow facility policy. Interview with Respiratory Therapist (RT) #4 on [DATE] at 1:40 PM, in the conference room, revealed on [DATE] around 7:00 AM, she entered Resident #6's room and observed her slumped sideways in the bed with her head tilted backwards, mouth open, not breathing, and ashen in color. Continued interview revealed RT #4 informed RN #1 the resident was a full code. Continued interview revealed RN #1 stated to her, .absolutely not, we are not doing a code, she has been down too long . Further interview revealed RN #1 repeatedly prohibited attempts by other staff members to perform CPR. Telephone Interview with LPN #15 on [DATE] at 2:24 PM, revealed she was present on the unit as an oncoming day shift nurse on [DATE] and witnessed the incident. Continued interview revealed when Resident #6 was discovered without a pulse or respirations at 7:00 AM, she responded to the room to assist in resuscitation efforts and she informed RN #1 the resident was a full code. Continued interview revealed RN #1 refused to permit CPR to be performed and ordered her from the resident's room. Further interview revealed RN #1 told LPN #15 to go to the nursing station and call Physician #3 and advise him the resident was deceased . Further interview revealed LPN #15 called Physician #3 sometime after 7:06 AM, and as she spoke to the Physician, RN #1 took the phone from her hands and took over the phone call at that point. Further interview revealed as LPN #15 and LPN #3 moved the crash cart toward the resident's room, RN #1 waved her hands, pointed at the two LPNs and mouthed NO. The facility's corrective action plan included the following: On [DATE] the facility did the following: A. Held an ad hoc Quality Assurance (QA) meeting during the daily stand up meeting and reviewed the incident. Incident was reported to the State Agency. Follow up QA meeting was scheduled for [DATE]. Responsible party was the Administrator. B. The regional nurse consultant reviewed with the DON and the Administrator the education to be provided to all staff on [DATE] to include Abuse, Resident Rights, Advance Directives, Where to Locate the Advance Directives in the Medical Record, Cardiopulmonary Resuscitation (CPR), Following Physician Orders, Change in Condition and Following Care Plans. Responsible party was the Director of Nursing (DON). C. Once the Administrator and DON were educated, they were assigned to educate the Nursing Administration team Assistant Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Nurses, and Staff Development Coordinator), who in turn were assigned to educate all the staff on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives in the Medical Record, CPR, Following Physician Orders, Change in Condition, and Following Care Plans. Responsible party was the DON). D. Began written competency testing of all staff educated on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives, CPR, Following Physician Orders, Change in Condition and following Care Plans. Responsible party was the Director of Nursing (DON). E. All staff educated, were required to submit written post-tests with scores of 100% before being permitted to work. All staff who failed to score 100% on the post-tests were immediately re-educated and re-tested until all staff scored 100% on the post tests. Responsible party was the Director of Nursing (DON). F. Initiated the first Mock Code Drill conducted by the DON, ADON, Unit Manager (UM) and the Staff Development Coordinator (SDC) to ensure staff understanding and compliance with the facility code blue policy (policy related to emergency resuscitation) and procedures. No irregularities noted. Mock codes were then planned to be completed for every shift (7 A-7P, 7P-7A) for 72 hours through [DATE], then twice weekly on rotating shifts for 4 weeks starting on [DATE] through [DATE] (scheduled to occur on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and on [DATE] on both shifts) to ensure staff understanding and compliance with the facility code blue policy. The first two Mock Codes were conducted by members of the Nursing Administration Team under observation of the DON, then Mock codes were conducted by nursing staff members under observation of members of the Nursing Administration team. Findings were to be reported to the QA committee weekly for 4 weeks to determine compliance and any further need of continued education or revision of the plan. Responsible party was the Director of Nursing (DON). G. Began ongoing monitoring of staff compliance with abuse, advanced directives, resident rights, CPR, location of advanced directives and Do Not Resuscitate (DNR) forms in the medical record, following physician orders, change in condition reporting and following Care Plans. Responsible party was the Administrator. On [DATE] the facility did the following: A. Resident #6's chart and care plan were reviewed by the Regional Nurse Consultant and Director of Clinical Operations. Registered Nurse (RN) #1 was to have been terminated concluding the investigation but resigned prior to termination. Licensed Practical Nurses (LPN) LPN #1 LPN #3, LPN #15 and Respiratory Therapist (RT) #4 received disciplinary action related to not following facility policy. Responsible party was the DON. B. Began audits of the medical records for all residents in the facility, by the Regional Nurse Consultant and Director of Clinical Operations, to ensure advance directives were in the medical record, were addressed on the care plan, and had current Physician orders related to each resident's code status. Responsible party was the DON. C. All residents were assessed for any possible resident rights violations. Those residents with Brief Interview of Mental Status (BIMS scores, a measure of cognitive function), greater or equal to 8 (cognitively intact) were interviewed by the DON, ADON, UM, Social Services Director (SSD), Social Services Assistant (SSA) for quality of life or resident rights violations. No issues were identified. Responsible party was the DON. D. All residents with BIMS scores less or equal to 7 (cognitively impaired) had skin assessments completed on [DATE] for any concerns by ADONs and UMs for any possible abuse or neglect issues. All residents with a BIMS greater or equal to 8 were interviewed for possible abuse or neglect violations. No issues were identified. Responsible party was the DON. E. Held a Resident Council Meeting (a group of residents who reside in the facility and meet regularly, discuss resident concerns, and discuss resident concerns with Administration) and the SSD and Activities Director reviewed the Resident Rights Statement and Policies for Prohibition of Abuse, Neglect and Misappropriation of Property and provided a copy to each resident. Responsible party was the DON. F. All deaths in the facility for the past 30 days were reviewed by the Regional Nurse to ensure advanced directives were honored with no irregularities noted. The DON reviewed all resident deaths in the facility for the prior 12 months with no irregularities noted. Results were discussed in the QA meeting. Responsible party was the Administrator. G. Held first formal QA meeting to address the incident. DON, ADON, UM, Nursing Supervisors or Medical Records staff were to review all new admissions/readmits and residents with DNR related changes, 24 hour shift reports, and incidents accidents daily for 2 weeks, then Monday through Friday ongoing, starting during morning clinical meeting, to ensure sustained compliance with physician notification, physician orders, interim care plan, advance directives, and resident rights. Corporate administrative oversight of the QA meeting was completed by the Regional Vice President or member of the regional staff weekly for 4 weeks beginning [DATE], then monthly for one quarter. The facility allegation of compliance (AOC) was reviewed by the committee. Responsible party was the Administrator. H. Continued staff education and post testing on Abuse and Neglect, Advanced Directives, Where to find Advanced Directives in the chart, CPR, Resident Rights, following Physician orders, Notification of Change in Condition, and Following Care plans. Responsible party was the DON. I. Grievance logs were reviewed by the Director of Clinical Operation with no irregularities noted. J. Continued Mock Code drills as outlined. Responsbile party was the DON. K. Corrective actions were reviewed by the Administrator, DON, Medical Director and Regional Consultants. Responsible party was the Administrator. On [DATE] the facility did the following: A. The DON, ADON, UM, Administrator and Department Heads continued advance directive/abuse post-tests with 10 random Nursing staff members daily on rotating shifts for 2 weeks through [DATE]. Then 5 random nursing staff members on rotating shifts daily for 2 weeks through [DATE], then 5 random Nursing staff members weekly for 3 weeks through [DATE], with all staff required to score 100% on the post tests. Staff members who failed to achieve 100% scores on the tests were immediately re-educated and required to re-test until 100% scores were achieved. Responsible party was the DON. B. Continued education of all staff members on the facility Abuse and Neglect Policy, Resident Rights, CPR, Advance Directives and Where to find them in the medical record, Notification of Change in Condition, Physician Orders, and Care plans. Responsible party was the DON. C. Continued Mock Code drills on every shift through [DATE] as outlined. Responsible party was the DON. On [DATE] the facility did the following: A. Completed review of all residents medical records by the Director of Clinical Operations and the Regional Nurse to ensure advance directives were in the medical records, addressed on the care plans, and had a current Physician Order regarding code status. No irregularities noted. Responsible party was the Director of Clinical Operations. B. Completed a 100% audit of licensed clinical staff CPR certifications by the Regional Vice President and Regional Nurse Consultant. C. Completed 100% audit of all licensed staff to verify valid Tennessee professional licensure completed by the Regional Vice President. No irregularities were noted. D. Completed 100% audit to ensure staff were not listed on the abuse registry by the Regional Vice President with no irregularities noted. E. Mailed certified letters to all employees who had not completed mandatory training and education and advised completion of training was required prior to any return to work at the facility. The letters included all employees on vacation or paid leave, part time or prn (as needed status). Responsible party was the DON. F. The Administrator began reviews of completed audits for new admissions, readmissions and residents with DNR to ensure sustained compliance with all advanced directives. G. DON, ADON, UM or Weekend Manager on duty began interviews with 5 residents with BIMS scores equal or greater than 8 and 5 family members of residents with BIMS scores less than 8 daily for 2 weeks ([DATE] to [DATE]) for any possible resident rights violations; then 3 residents and 3 family members daily for 2 weeks ([DATE] to [DATE]), then 2 residents and 2 family members daily for 4 weeks ([DATE] to [DATE]), then 1 resident and 1 family member daily for 4 weeks ([DATE] to [DATE]). Results of the interviews and assessments forwarded to the QA committee. Responsible party was the DON. H. All deaths in the facility were reviewed by the DON, ADON, UM or Administrator to ensure code status was implemented correctly as per the resident's wishes and documented on the advance directives daily for 2 weeks through [DATE]; then weekly for 4 weeks from [DATE] to [DATE], then continuing as part of the daily stand up meetings attended by the Administrator, DON, ADONs, UM, MDS Coordinator, Treatment Nurses, Chaplain, SDC, Quality of Life Department Head, SSD, Dietary Manager and Formulary Nurse (the nurse in charge of the central supply office) to ensure sustained compliance. Responsible party was the DON. I. Began Administrative oversight of the facility by a member of Senior Regional Team twice weekly for 2 weeks, beginning [DATE] to [DATE]; then weekly for 4 weeks beginning [DATE] through [DATE], then monthly for one quarter. Responsible party was the Director of Clinical Operations. J. Continued Mock Code drills as outlined above. Responsible party was the DON. K. The DON and SDC began tracking all licensed staff members for CPR certification monthly for 3 months; then every 6 months to ensure all licensed nurses maintained CPR certifications. Findings documented and forwarded to the QA committee monthly to determine any need for education or revision of the process. Responsible party was the DON. L. Established plans for daily contact between the facility and nurses from the regional team or corporate office for 2 weeks, then 2 times weekly for 4 weeks. Nurses from the regional team or home office reviewed compliance with the Plan of Correction and Policy and Procedures, compliance of any code blue to occur, and review of compliance with all new/readmissions. Responsible party was the DON. On [DATE] the facility did the following: A. Completed the twice daily mock code drills as outlined above with no irregularities noted. Initiated the plan for transition to twice weekly Mock Code drills to occur on rotating shifts for another 4 weeks. Responsible party was the DON. B. Continued staff education and competency testing on Abuse and Neglect, Resident Rights, Advance Directives and Where to find them in the Chart, CPR, Notification of Change in Condition, Physician Orders, and Care Plans. Responsible party was the DON. C. Held a follow up QA meeting to review findings from initial audits, scheduled weekly QA meetings for 4 weeks, then monthly, for recommendations and further follow up regarding the Corrective Action Plan. At that time, based upon evaluation, the QA committee would determine at what frequency any ongoing audits would be continued. Responsible party was the Administrator. On [DATE] the facility did the following: A. Completed education and competency testing of all staff, with the exception of those on Family Medical Leave (FMLA) or PRN status who had not worked, with 100% scores attained on all post-tests for facility Abuse and Neglect Policy, Resident Rights, CPR and Advance Directives, Where to Locate Advance Directives in the Medical Records, Physician Orders, Notification of Change in Condition, and Care Plans. Employees on FMLA or PRN status were not permitted to work until all education and competency testing completed. Responsible party was the DON. B. Continued all random audits, staff and resident interviews, and competency testing as outlined above. Responsible party was the DON. C. Continued daily stand up meeting reviews as outlined above, which included reports to Administration on the progress of the facility corrective action plans and changes in resident condition. Responsible party was the DON.

Based on medical record review, facility investigation review, and interview, the facility failed to supervise to prevent falls for one (#2) of five residents reviewed for falls, which resulted in harm to resident #2. The findings included: Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], after a stay in a geri-psych unit, with [DIAGNOSES REDACTED]. The resident was deceased [DATE]. Medical record review of the care plan initiated on [DATE], revealed the resident was at risk for falls. Further review revealed approaches included place the resident in a low bed; place call light within reach; provide and monitor use of adaptive devices; remind resident to lock brakes on wheelchair; remind resident to request assistance prior to ambulation or transfers; staff to assist with transfers; and staff to assist with ambulation. Medical record review of a communication form and progress note dated [DATE], revealed the resident had a fall and was transferred to the hospital. Further review revealed, "...This nurse was standing behind St II (station 2) desk, saw CNA (certified nurse aide)...walking toward resident then heard resident fall...Has egg size hematoma to (left) forehead. Res (resident) was using rolling walker et (and) was lying beside resident on floor..." Review of a facility fall investigation dated [DATE], revealed the resident's unwitnessed fall occurred at 11:15 p.m., in a hallway. Further review revealed, "...cna was walking toward resident when resident was losing balance and fell . Resident landed on left side. Has egg size hematoma to left forehead. Has small discolored area to left shoulder. c/o (complaint of) left hip pain, no redness or bruising noted to hip at this time...Were there any interventions in place at the time of the fall? Yes List interventions in place at the time of the fall: egg size hematoma to left forehead (interventions which were in place was not indicated on the investigation)...Were any new nursing interventions implemented? Yes Document the implemented interventions: resident would ask for help to lay down, once resident was in bed, would then get right back up. Resident voiced several times that she did not like that air mattress. Air mattress exchanged for a regular mattress..." Continued review of the facility's investigation revealed the resident was sent to the hospital and x-rays and CT of the head were all normal. Medical record review of a communication form and progress note dated [DATE], revealed the resident had a fall, "CNA...informed this nurse that Res was lying on floor. Res noted to be lying on (right) side (with right) arm under her...O2 sat (oxygen saturation) 78% (normal ,[DATE]). This nurse checked O2 concentrator noted that O2 bottle was not connected properly, fixed this O2 sat came up to 98% within a few seconds..." Review of a falls investigation dated [DATE], revealed the resident's unwitnessed fall occurred at 5:15 a.m., in the doorway to room. Further review revealed, "...cna informed this nurse that resident was in floor. Resident noted to be lying on floor in doorway to room on right side with right are (arm) under her. Denies pain or discomfort, moves extremities as usual. No new areas noted...Were there any interventions in place at the time of the fall? Yes List interventions in place at the time of the fall: (no interventions or any comments were documented in this section)...Were any new nursing interventions implemented? Yes Document the implemented interventions: Monitor O2 sats (oxygen saturation) to keep sats within normal limits...Describe any identified precipitating factors: O2 bottle not connected properly...What actions were implemented for the resident involved...O2 bottle connected properly, and monitor O2 sat to maintain within normal limits..." Medical record review of a physician's progress note dated [DATE], revealed, "Patient is back from the hospital now after having a short stay in the geri-psych unit. She seems to be a bit less agitated..." Medical record review of a Daily Skilled Nurse's Note dated [DATE], revealed, "...one on one while awake trying to keep res (resident) free from falls..." Medical record review of the fourteen day Minimum Data Set (MDS) dated [DATE], revealed the resident scored a 0 on the Brief Interview for Mental Status (BIMS), indicating the resident was severely cognitively impaired; was confused and disoriented; unable to make needs and wants known most of the time; required extensive assistance of two people for transfers, ambulation, dressing, eating, grooming, and bathing; and was continent of bowel and occasionally incontinent of bladder. Medical record review of a Daily Skilled Nurse's Note dated [DATE], at 3:00 p.m., revealed, "...Resident is constantly trying to get out of chair. Confused, restless..." Medical record review of a Daily Skilled Nurse's Note dated [DATE], not timed, revealed, "Resident continues to get out of chair - is off balance, very unsteady - requires continuous one on one care." Medical record review of a Daily Skilled Nurse's Note dated [DATE], revealed, "Gait unsteady - hx (history) of falls. Barely ambulatory (with) weakness not physically able to ambulate safely @ (at) this time staff continues one on one care..." Medical record review of a communication form and progress note dated [DATE], revealed, "...Climbing out of chair won't sit still unsteady balance...Fall...UA (urinalysis) lab negative...Resident found sitting in floor. Nurse heard a crash say walker turned over & (and) resident sitting in floor..." Medical record review of nurse's notes dated [DATE], revealed "...Resident was sitting in Broda (special chair which reclines) chair with alarm. Alarm did not go off. Loud crash heard and resident found sitting in floor approx. (approximately) 5 foot from Broda chair. Walker was turned on its side..." Review of a facility falls investigation dated [DATE], revealed the resident's unwitnessed fall occurred at 9:15 a.m., in a hallway. Further review revealed, "...Resident was sitting in Brodi chair with alarm. Alarm did not go off. Loud crash heard and resident found sitting in floor approx. 5 foot from Brodi chair. Walker was turned on its side...Describe the behavioral issues: Confused, disoriented, unable to orient resident...Were there any interventions in place at the time of the fall? Yes. List interventions in place at the time of the fall: (area had no documentation as to what interventions were in place)...Were any new nursing interventions implemented? Yes. Document the implemented interventions: Check labs frequently to check for possible UTI (urinary tract infection) walk resident frequently...Was any equipment involved? No..." Further review revealed the section of the investigation for "Investigative Summary" was not completed and there were no actions regarding the alarm not sounding. Medical record review of a left hip x-ray, dated [DATE], revealed "...There is a displaced fracture of the greater trochanter (hip) without dislocation..." Medical record review of a Daily Skilled Nurse's Note dated [DATE], revealed, "9:15 Resident fell in hallway near nurse's station (unwitnessed)..XXX[DATE] 3:07 AM Resident continues to have periods of restlessness and rejects care from staff continues to be crawling out of chair. Continues to c/o pain from Lt (left) hip fx (fracture) and Rt (right) hip dislocation..." Medical record review of a physician's progress note dated [DATE], revealed "...Patient has recently fallen and suffered a hip fracture. Long discussion with family member...concluded with (resident) will likely be a best candidate for Hospice type care...Assessment/Plan: Fracture hip- will likely do conservative and comfort care at this point. She is not a candidate for surgical repair and her multiple medical problems would likely lead to her demise during surgery. This is being conveyed to the family and they are in agreement at this point..." Medical record review of a physician's progress note dated [DATE], revealed, "Patient continues to decline. She has had a head injury recently requiring medical treatment. At this point in her care process and comfort of care we will transitional her to a Morphine Pump..." Medical record review of a communication form and progress note dated [DATE], revealed, "...flailing, fearful, climbing OOB (out of bed)...found lying on floor bleeding from head..." Medical record review of nursing notes dated [DATE], revealed "...Resident was found on the floor in room by nurse. Resident was lying in a pool of clotted blood. Resident was semi-conscious initially but within a few minutes became fully conscious. Resident was initially laying on right side with right arm underneath. Pressure was applied to wound discovered on head. Resident slowly regained consciousness..." Continued review of nursing notes revealed the resident had an injury to the posterior head, right side. Review of a facility falls investigation dated [DATE], revealed the resident's unwitnessed fall occurred at 11:20 a.m., in the resident's room. Further review revealed, "...Resident was found on the floor in her room by nurse...Resident was laying in a pool of clotted blood. She was semi conscious initially but within a few minutes became fully conscious...pressure applied to the wound discovered on her head, which at this time is bleeding very little...transport resident to the...ER (emergency room )...Were there any interventions in place at the time of the fall? Yes. List interventions in place at the time of the fall: Posterior head right side (the injury site, and no interventions which were in place were documented)...Were any new nursing interventions implemented? No...Investigative summary...Describe any identified precipitating factors: Recent decline in cognitive functioning...Summary of findings from staff member interviews: Resident continued decreased LOF (level of functioning) and LOC (level of consciousness) and Disregard for staff teaching and instruction along with her disregard for her own personal safety were major contributing unavoidable factors to this event...Overall summary of investigative findings and conclusions: Fall was unavoidable d/t (due to) resident ongoing and increased and continuous anxiety restlessness and complete disregard for her own safety needs...What education/competencies were provided to staff to address any issues? Ensure bed alarm in place and functioning properly..." Medical record review of nurse's notes dated [DATE], at 3:15 p.m., revealed, "...Back from (hospital)...staples x 2 (times two) to RS (right side) of head...remains restless-fearful-one on one as before..." Medical record review of nursing notes and a falls investigation revealed the resident had a fall on [DATE], at 6:10 a.m., from the bed. Further review revealed the resident rolled from the low bed to the floor mat and suffered a scratch or abrasion to the nose. Further review revealed the facility implemented the use of a mattress with high edges to prevent rolling out of the bed. Medical record review and review of falls investigations revealed the resident was restless and had multiple attempts at ambulating and transferring independently. The resident had severe cognitive deficits and could not retain staff teaching, was unaware of personal safety, and could not remember to call staff for assistance. The nursing notes indicated the resident needed one on one care on [DATE], [DATE], [DATE], and [DATE], but had unwitnessed falls on [DATE], [DATE], and [DATE]. The resident had an alarm which was not sounding during the fall on [DATE], and the fall resulted in a fractured hip. After the fall on [DATE], in which the resident required two staples, no new interventions were put in place, and the resident had another fall on [DATE]. Interview with the Director of Nursing (DON) on [DATE], at 12:45 p.m., in the conference room, revealed the alarm on the bed was not working on [DATE], when the resident fell . Continued interview with the DON revealed the resident had a bed and chair alarm at all times and the staff had access to alarms at any time. Continued interview with the DON confirmed the DON thought the resident's bed alarm was in place and functioning on [DATE] and 6, 2014, even though the facility investigation did not specify they were in place. c/o # , #

Based on medical record review and interview, the facility failed to ensure the accuracy of the admission Minimum Data Set (MDS) for one resident (#96) resulting in Harm of twenty-nine sampled residents of forty-one residents reviewed in stage two. The findings included: Resident #96 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Nursing Admission Skin Evaluation dated April 10, 2012, revealed "...dark discolored area on coccyx 3 cm (centimeters) x (times) 3 cm...T=Tissue Damage Y (yes)...Pressure Ulcer N (no)..." Medical record review of the Weekly Skin Rounds dated April 14, 2012, revealed "...Has open abrasion coccyx and left lower buttocks..." Medical record review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident was at risk for developing pressure ulcers, required extensive assistance for bed mobility, transfers, bathing, toliet use and no skin problems. Medical record review of the Weekly Skin Rounds dated April 21, 2012, revealed "...Has open area to coccyx and left lower buttocks..." Interview with the MDS Coordinator #1 on August 16, 2012, at 10:00 a.m., in the MDS office, confirmed resident #96 had a stage two pressure ulcer on the coccyx and left lower buttocks and the MDS was not accurate.

Based on medical record review, and interview, the facility failed to develop a comprehensive care plan for two residents (#96, #77) of twenty-nine sampled residents of forty-one residents reviewed in stage two resulted in Harm for resident #96. The findings included: Resident #96 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Nursing Admission Skin Evaluation dated April 10, 2012, revealed "...dark discolored area on coccyx 3 cm (centimeters) x (times) 3 cm...T=Tissue Damage Y (yes)...Pressure Ulcer N (no)..." Medical record review of the Interim Care Plan dated April 10, 2012, revealed "...Alteration in skin integrity: Potential..." Medical record review of the Weekly Skin Rounds dated April 14, 2012, revealed "...Has open abrasion coccyx and left lower buttocks..." Medical record review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident was at risk for developing pressure ulcers, required extensive assistance for bed mobility, transfers, bathing, toilet use and no skin problems. Medical record review of the Weekly Skin Rounds dated April 21, 2012, revealed " ...Has open area to coccyx and left lower buttocks ..." Medical record review of the April 2012 Physician Recapitulation Orders revealed no order for treatment to the pressure ulcer. Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of the Care Plan dated April 18, 2012, revealed "...Resident at risk for developing skin breakdown...report changes in skin status...new areas...to physician...assist as needed to reposition/shift weight to relieve pressure..." Interview with the MDS Coordinator #1 on August 16, 2012, at 10:00 a.m., in the MDS office, confirmed the facility failed to develop a comprehensive care plan to include a stage two pressure ulcer identified on April 10, 2012. Resident #77 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation on August 14, 2012, at 4:05 p.m., revealed the resident lying on the bed with a bed alarm in place, watching television. Medical record review of the current Comprehensive Care Plan dated July 24, 2012, revealed no documentation of interventions or measureable goals to address the resident's rehabilitative needs. Interview on August 14, 2012, at 4:20 p.m., with Assistant Director of Nursing #1, in the conference room, confirmed the Comprehensive Care Plan dated July 24, 2012, did not address measurable goals or interventions to address the resident's rehabilitative needs.

Based on medical record review, facility policy review, and interview, the facility failed to prevent pressure sore development for one resident (#96) resulting in harm to the resident of three sampled residents of forty-one residents reviewed in stage two. The findings included: Resident #96 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Nursing Admission Skin Evaluation dated April 10, 2012, revealed "...dark discolored area on coccyx 3 cm (centimeters) x (times) 3 cm...T=Tissue Damage Y (yes)...Pressure Ulcer N (no)..." Medical record review of the Interim Care Plan dated April 10, 2012, revealed "...Alteration in skin integrity: Potential..." Medical record review of the Weekly Skin Rounds dated April 14, 2012, revealed "...Has open abrasion coccyx and left lower buttocks..." Medical record review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident was at risk for developing pressure ulcers, required extensive assistance for bed mobility, transfers, bathing, toilet use and no skin problems. Medical record review of the Weekly Skin Rounds dated April 21, 2012, revealed "...Has open area to coccyx and left lower buttocks..." Medical record review of the April 2012 physician's orders [REDACTED]. Medical record review of the Medication/Treatment Administration Record dated April 2012, revealed no documentation of treatments to the pressure ulcer were provided. Medical record review of the Care Plan dated April 18, 2012, revealed "...Resident at risk for developing skin breakdown...report changes in skin status...new areas...to physician...assist as needed to reposition/shift weight to relieve pressure..." Review of facility policy, Skin Care and Wound Management Program, dated 2011 revealed "...Treatment Protocol: Stage II Pressure Ulcer: choose the treatment most appropriate...obtain physician order..." Interview with the MDS Coordinator #1 on August 16, 2012, at 10:00 a.m., in the MDS office, confirmed the stage two pressure ulcer had not been assessed and no plan of care had been developed for a stage two pressure ulcer. Interview with the Wound Care Nurse on August 16, 2012, at 10:15 a.m., in the conference room, confirmed no order had been obtained for wound care. Interview with the Assistant Director of Nursing (ADON) #1 on August 16, 2012, at 10:30 a.m., in the Conference Room, confirmed the resident was admitted on [DATE], from the hospital with a dark, discolored area on the sacral area approximately 3 x 3 in size. Further interview with the ADON on August 16, 2012, confirmed the resident was at high risk for developing pressure ulcers; and a Stage II pressure ulcer to the buttock was identified on April 14, 2012. Continued interview confirmed the staff was to notify the physician and obtain an order for [REDACTED].

Based on medical record review, facility investigation, observation, and interview, the facility failed to ensure an intervention was in place for falls for one resident (#29) resulting in harm, of four sampled residents of forty-one residents reviewed in stage two. The findings included: Resident #29 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Data Set (MDS) dated [DATE], and the quarterly MDS dated [DATE], revealed the resident was cognitively intact for daily decision making, required extensive assist with all activities of daily living (ADL)'s, and had no behaviors. Medical record review of a Monthly Summary dated March 11, 2012, revealed "...lethargic...memory problems..." Medical record review of a Fall Risk Evaluation dated March 12, 2012, revealed "...periods of lethargy...scores of ten or higher at risk...total score 16..." Review of a facility investigation dated March 21, 2011, (1st fall) revealed "...res (resident) found lying in the floor...sent to ER (emergency room ) for eval (evaluation) and tx (treatment)...resident states went to sleep in wheelchair fell out..." Medical record review of a Nurse's Note dated March 22, 2011, revealed "...returned from...with no new orders..." Medical record review of the Care Plan dated March 25, 2011, and approach dated April 18, 2011, revealed "...will apply lap buddy to W/C (wheelchair) at all times when up..." Review of a facility investigation dated April 15, 2011, (2nd fall) revealed "...went to sleep fell out of wheelchair...returned from...on April 15, 2012...sling L (left) arm for L clavicle FX (fracture)...please have PCP (primary care physician) eval meds in AM...Intervention: Place lap buddy in wheelchair...will assist if resident falls asleep..." Medical record review of a Fall Risk Evaluation dated April 18, 2012, revealed "...periods of lethargy...scores of ten or higher is at risk...total score 20..." Medical record review of a resident Care Plan/Communication Form dated May 11, 2011, revealed "...do not leave on toilet..." Medical record review of the Care Plan dated March 21, 2012, revealed no intervention to prevent the resident from falling out of the wheelchair. Medical record review of a Nurse's Note dated May 31, 2012, at 8:00 a.m., revealed "...episodes of confusion..." Review of facility documentation dated May 31, 2012, at 4:42 p.m., revealed (3rd fall) "...fell asleep and fell out of chair..." Medical record review of a Physician's Telephone Order dated May 31, 2012, at 7:30 p.m., revealed "...admitted to...Dx: Fracture to L Hip..." Medical record review of a hospital History and Physical dated May 31, 2012, revealed "...fell ...left hip fracture..." Medical record review of a progress note dated June 11, 2012, revealed "...we do feel that...was over-medicated with her previous pain medicine regimen..." Observation on August 14, 2012, at 1:45 p.m., in the resident's room, revealed the resident on the bedside commode (BSC) with no staff present. Observation on August 15, 2012, at 1:00 p.m., in the resident's room revealed the resident sitting in the wheelchair with no lap buddy in place. Interview with Certified Nurse Aide (CNA) #2 on August 14, 2012, at 1:51 p.m., on the 600 hall, confirmed the resident had been left alone on the BSC, and in the wheelchair. Further interview at this time revealed no interventions to prevent a fall or injury are in place. Interview with the Director of Physical Therapy (PT) on August 16, 2012, at 10:30 a.m., in the PT office, confirmed the resident had an intervention for a lap buddy in the wheelchair to be implemented on April 18, 2012, and therapy was to reassess the resident's wheelchair in order to implement the lap buddy. Further interview at this time revealed the lap buddy did not fit the wheelchair and the facility failed to assess the resident for a different wheelchair the lap buddy would fit. Interview on August 16, 2012, at 11:00 a.m., with Assistant Director of Nursing (ADON) #1 in the conference room, confirmed the lap buddy did not fit the wheelchair and another intervention had not been put in place. The ADON confirmed at this time the facility failed to put an intervention in place to prevent falls with injury and the resident fell from the wheelchair resulting in a fracture tothe left hip requiring hospitalization and surgery. C/O #

Based on medical record review, review of facility policy, observation, and interview, the facility failed to notify the physician of the development of a stage two pressure ulcer for one resident (#96) and change in condition for one resident (#191) of forty-one residents reviewed in stage two. The facility's failure resulted in harm to resident #96. The findings included: Resident #96 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Nursing Admission Skin Evaluation dated April 10, 2012, revealed "...dark discolored area on coccyx 3 cm (centimeters) x (times) 3 cm...T=Tissue Damage Y (yes)...Pressure Ulcer N (no)..." Medical record review of the Weekly Skin Rounds dated April 14, 2012, revealed "...Has open abrasion coccyx and left lower buttocks..." Medical record review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident was at risk for developing pressure ulcers, required extensive assistance for bed mobility, transfers, bathing, toilet use and no skin problems. Medical record review of the Weekly Skin Rounds dated April 21, 2012, revealed "...Has open area to coccyx and left lower buttocks..." Medical record review of the physician's admission orders [REDACTED]. Review of facility policy, Skin Care and Wound Management Program, dated 2011 revealed "...Treatment Protocol: Stage II Pressure Ulcer: choose the treatment most appropriate...obtain physician order..." Interview with the Assistant Director of Nursing (ADON) #1 on August 16, 2012, at 10:30 a.m., in the Conference Room, confirmed the resident was admitted on [DATE], without a pressure ulcer to the coccyx. Further interview with the ADON on August 16, 2012, confirmed the resident was at high risk for developing pressure ulcers; the pressure ulcer was identified on April 21, 2012. Continued interview confirmed the physician had not been notified of the development of the pressure ulcer and no order or intervention had been implemented or obtained. Resident #191 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated August 1, 2012 through August 31, 2012, revealed "...Resident to attend [MEDICAL TREATMENT]...on (Monday/Wednesday/Firday)..." Medical record review of a Nutritional Progress Note dated July 19, 2012, revealed "...Significant wt (weight) (increase) of 11.36% (percent) x 3 months r/t (related to) fluid. Resident refuses [MEDICAL TREATMENT] (at) times..." Interview on August 16, 2012, at 10:40 a.m., with the ADON #1, in the conference room, confirmed the physician had not been notified of the significant weight increase or the resident refusing [MEDICAL TREATMENT].