Every finding on record at Walter B Crook Nursing Facility

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to identify, accurately assess, document, and implement treatment for a pressure injury for one (1) of 55 residents. This failure resulted in an avoidable full-thickness tissue loss wound not being treated after identification for ten (10) days because the physician order was not implemented for Resident #5. Findings Include:Review of the facility policy titled Wound Care Policy and Protocol dated 1/24/25, revealed under, 2. Policy Statement: Proper name of the facility is committed to 1. Proactive wound prevention through comprehensive assessments. 2. Prompt identification and treatment of wounds. 3. Use of advanced wound care techniques. 4. Minimizing infection risks through proper dressing techniques. 5. Educating staff and residents on wound prevention and care. The documented practice did not reflect the policy requirements for proactive identification and timely intervention.An observation and interview with Resident #5 on 11/11/25 at 1:16PM revealed he was lying in bed and stated he had a sore on his bottom that he developed after coming to the facility.Record review of the Progress Notes dated 11/05/25 revealed Resident #5 had a sacral Stage 3 pressure ulcer measuring 2.4 centimeters in length x (by) 1.3 centimeters in width x (by) 0.2 cm in depth with 100% granulation tissue, confirming advanced tissue loss.An observation of wound care on 11/12/25 at 9:05 AM with the Wound Nurse revealed Resident #5 had the sacral wound for a while. She stated the resident was seen weekly by wound care and the wound had been debrided several times. The wound was circular over the sacral region, edges well-defined, and the wound bed contained 80% (percent) red granulation tissue and 20% yellow adherent slough.Record review of Resident #5's hospital Discharge Summary dated 3/18/25 revealed documentation that the Sacrum and bilateral buttocks were clear of wound on admission to the facility. Record review of Resident #5's Skin/Wound Note dated 4/04/25 revealed, Nurse called to room regarding resident's sacral area. Nurse noted a stage III pressure ulcer measuring 1.9 centimeters (CM) x 3.0 CM x 0.1 CM. 50% epithelial tissue, 25% slough, 25% eschar noted, confirming full-thickness skin breakdown on this date. Record review of Weekly Skin Audits dated 3/22/25 for Resident #5 revealed, No new skin issues noted.Record review of Weekly Skin Audits dated 3/29/25 revealed documentation of No new skin issues noted at this time per CNA (Certified Nurse Aide) indicating assessments were inaccurately completed or concerns were not correctly documented.Record review of the April 2025 Treatment Administration Record (TAR) revealed an order dated 10/08/24, Apply lantiseptic ointment to coccyx area every shift related to (R/T) excoriation until resolved, was initialed as completed on 4/1, 4/2, 4/3, with no accompanying documentation indicating a change in skin condition. No evidence was found to show the skin issue was identified or escalated prior to being staged as a Stage III on 4/4/25.An interview with the Wound Nurse on 11/12/25 at 2:20 PM revealed aides were required to complete body map forms for new skin concerns and submit them to the Director of Nursing (DON). The wound nurse stated weekly skin audits were to be completed by the medication cart nurses each week. She acknowledged the wound should have been identified earlier and confirmed the wound was avoidable.An interview with Staff Development Nurse on 11/13/25 at 9:12 AM with the DON present, revealed they had discovered that a night shift CNA found the open area to Resident #5's sacrum on 3/26/25, and she had completed a body audit form and notified the night shift nurse. The night shift nurse received treatment orders from the emergency room (ER) doctor, but she failed to carry out the order or enter it into the computer system. She explained the nurse left the information in a binder at the nurse's desk for the incoming Registered Nurse (RN) charge nurse, which then called in the following morning, resulting in the order not being completed or carried out. The DON and the Staff Development Nurse confirmed this failure allowed the wound to remain unrecognized and untreated until 4/4/25, when it had progressed to full-thickness tissue loss. The nurse that was responsible was an agency staff nurse and she was no longer allowed to work at the facility.The facility provided documentation for Resident #5 that was left in a binder at the nurse's station dated 3/26/25 and read, Small open area to coxy area. There was a written note attached that read, emergency room (ER) doctors said clean with wound cleanser (WC) and apply Duoderm. Stage 2. Turn every (Q) two (2) hours and notify wound care. I didn't put order in yet, confirming staff acknowledgment of a wound. There was no documentation in the Electronic Medical Record (EMR) regarding new skin concerns, and no orders were carried out. Wound was later re-identified on 4/4/25 as a Stage III. Record review of the admission Record revealed the facility admitted Resident #5 on 3/19/25 with a medical diagnosis including Multiple Sclerosis.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/22/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 14, indicating Resident #5 was cognitively intact.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to provide proper nail care for two (2) of sixteen 16 sampled residents. (Resident #8 and #46) Findings Include: Record review of the facility policy titled Activities of Daily Living, Supporting revised March 2018, revealed .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility policy titled Activities of Daily Living revealed under Fingernails/Toenails, Care of with a revision date of February 2018 states, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Resident #8 During an observation and interview with Resident #8 on 11/11/2025 at 11:46 AM and again on 11/12/25 at 10:15 AM, revealed the resident had approximately three-fourths (3/4) inch long, jagged fingernails with brown substance underneath and she stated she would like to have her nails cut shorter. During an observation and interview on 11/12/2025 at 10:21 AM, Certified Nursing Assistant (CNA) #1, she confirmed Resident #8 had long jagged fingernails. She stated nail care was the responsibility of the treatment nurse. She further stated that long, jagged fingernails could cause skin tears. During an observation and interview on 11/12/2025 at 10:28 AM, with the Treatment Nurse, she confirmed that Resident #8's fingernails were approximately 3/4 in length and had jagged edges. She stated that nail care could be provided by nurses and CNAs unless the resident was a diabetic, then only a nurse could cut their nails. She further stated that when a resident had long, jagged fingernails that puts them at risk for scratches, skin tears, and infections and that proper nail care was just part of hygiene. During an interview on 11/12/2025 at 10:30 AM, with the Administrator, she confirmed that nail care could be provided by all nursing staff, except for diabetic residents, and it should be performed at least weekly. During an interview on 11/12/2025 at 10:34 AM, with the Director of Nursing (DON), she confirmed that CNA's and nurses can perform nail care on residents unless they are diabetic, then it is to be done by nurses only. Record review of Resident #8's admission Record revealed that the resident was admitted to the facility on [DATE] with a medical diagnosis that included Cerebral Infarction, Unspecified. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/19/2025 revealed under Section C that Resident #8's Brief Interview for Mental Status (BIMS) score was 7, indicating that the resident was severely impaired. Resident #46 An observation on 11/11/25 at 11:35 AM and again on 11/12/25 at 10:00 AM of Resident #46 revealed the resident lying in bed with long nails, approximately one-fourth (1/4) inches in length on the left hand and approximately one-half (1/2) inches in length on the right hand with a brown substance underneath. The right hand was observed as contracted and in a clenched fist. An observation and interview on 11/12/25 at 10:24 AM at Resident #46's bedside with Registered Nurse (RN) #2 confirmed the resident's nails were long and dirty. She opened her hand and revealed that all the fingernails were long with a brown substance underneath. No broken skin was observed on either hand. She stated, If his nails are not kept trimmed and clean, he could easily get a break in his skin and develop an infection. On 11/12/25 at 11:41 AM the DON was interviewed regarding the facility's expectations for fingernail care. The DON stated, Staff are expected to keep residents' fingernails trimmed and clean. Long or dirty nails could cause a break in the skin and lead to infection. Record review of Resident #46 's admission Record revealed that the facility admitted resident on 7/19/2019 with a medical diagnosis that included Cerebral Infarction, Unspecified. Record review of the MDS with an ARD of 8/29/2025 revealed under Section C that Resident #46's BIMS was 6 and the cognitive skills for daily decision making were severely impaired.

Based on staff interviews, record review, and facility policy review, the facility failed to accurately code a quarterly Minimum Data Set (MDS) assessment for one (1) of 16 MDS assessments reviewed. (Resident #6) Findings Include: Review of the facility policy titled, Comprehensive Assessments and the Care Delivery Process with revised date 12/2016, revealed, Comprehensive assessments will be conducted to .Define current treatments and services . Record review of Resident #6's quarterly MDS assessment, with an Assessment Reference Date (ARD) date of 10/14/25, noted that Section N - Medications, N0350 revealed the resident had received insulin injections for one (1) day during the last seven (7) days. Record review of Resident #6's Medication Administration Record (MAR) dated 10/1/2025-10/31/2025, revealed Resident #6 did not have an order for insulin, nor did she receive an insulin injection. Record review of Resident #6's Immunizations revealed Resident #6 received an influenza vaccination on 10/8/25. An interview on 11/12/2025 at 12:53 PM, with MDS Coordinator, she confirmed that Resident #6 does not receive insulin injections. She confirmed that the MDS was coded incorrectly. She further confirmed that Resident #6 received her flu shot on 10/8/25 and that was the only injection that she received in October 2025. An interview on 11/12/2025 at 1:00 PM, the Administrator, she expressed her expectation that MDS assessments be completed timely and accurate when completed. Record review of the admission Record revealed that Resident #6 was admitted to the facility on [DATE]. Her medical diagnoses included Unspecified Dementia, Unspecified Severity, with Other Behavioral Disturbance. Record review of the quarterly MDS with an ARD of 10/14/25 revealed, under Section C, a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was unable to complete the interview.

Based on observations, staff interviews, record review and facility policy review, the facility failed to ensure infection control practices were maintained for two (1) of three (3) care opportunities. (Resident #13) Findings include:A review of the policy titled, ENHANCED BARRIER PRECAUTIONS (EBP) effective 4/1/24 revealed, For residents whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Device care of use: Central line, urinary catheter, feeding tube, etc.During an observation of medication administration on 11/12/2025 at 9:08 AM for Resident #13 with Licensed Practical Nurse (LPN) #3, it was observed that the nurse failed to use EBP while administering Percutaneous Endoscopic Gastrostomy (PEG) medications. During an interview on 11/12/25 at 9:25 AM with LPN #3, she confirmed that EBP should have been used during medication administration for residents with PEG tubes. She further stated that EBP was ordered to help prevent the spread of infection and she forgot to put the gown on herself prior to administering the medications.During an interview on 11/12/25 at 9:38 AM with the Director of Nursing (DON), she stated EBP should be used with any tubes or wounds to prevent possible cross contamination. She further stated that her expectations were for staff to follow EBP with all care provided for residents with a tube or wound. Record review of the admission Record that Resident #13 was admitted to the facility on [DATE] with medical diagnoses that included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/2025 revealed, under Section C, a Brief Interview for Mental Status (BIMS) score of 0 indicated that an interview should not be conducted because the resident was rarely/never understood.

Based on staff interview, record review, and facility policy review, the facility failed to monitor for side effects of psychotropic medications for two (2) of five (5) residents reviewed for unnecessary medications. Resident #2 and #7 Findings Include: Review of the facility policy titled Antipsychotic Medication Use revised 12/16, revealed under, Policy Statement: Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Also revealed under, Policy Interpretation and Implementation: . 17. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician . Record review of Resident #2's Medication Administration Record (MAR) revealed an order dated 9/11/25, Quetiapine Fumarate (antipsychotic) Tab (tablet) 25 milligrams (MG) give one (1) tablet orally three times a day related to Major Depressive Disorder. There was no indication on the MAR that side effects were being monitored. Record review of Resident #7's MAR revealed an order dated 8/12/25, Seroquel (antipsychotic) oral tablet 50 MG (Quetiapine Fumarate) give 1 tablet by mouth in the evening related to Major Depressive Disorder. There was no indication on the MAR that side effects were being monitored. An interview with Licensed Practical Nurse (LPN) #1 on 11/12/25 at 2:10 PM revealed side effects were supposed to be monitored on all residents that take psychotropic medication to ensure the residents can tolerate the medication. After reviewing the MAR, she confirmed side effects were not being monitored for Resident #2 and #7. An interview with LPN #2 on 11/12/25 at 3:59 PM revealed when the facility swapped over charting systems in July 2024, the side effects monitoring did not carry over into the new medical record charting system. She stated side effect monitoring needed to be done to ensure the residents side effects did not go unrecognized. Record review of the admission Record revealed the facility admitted Resident #2 on 11/03/17 with a medical diagnosis including Major Depressive Disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/15/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #2 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #7 on 8/05/25 with a medical diagnosis including Unspecified Dementia with Behavioral Disturbance. Record review of the MDS with an ARD of 8/15/25 revealed under section C, a BIMS summary score of 99, indicating Resident #7 was unable to complete the interview.

Based on staff interviews and record review, the facility failed to provide bowel and bladder training services to reduce incontinence for one (1) of 16 sampled residents. (Resident #10)Findings include: Review of Facility Statement Regarding Bowel and Bladder Policy with no date revealed the facility did not have a policy for Bowel and Bladder. Record review of Resident #10's Bowel/Bladder Screenings dated 8/15/24 and 11/8/24 revealed Resident #10 was a good candidate for retraining. The Bowel/Bladder Screenings dated 2/3/25, 4/29/25, and 7/23/25, revealed Resident #10 was a candidate for schedule toileting. An interview on 11/12/2025 at 4:00 PM, with the Administrator and Director of Nursing (DON), revealed the facility did not currently have a bowel/bladder (B/B) toileting program. They stated that after the screenings are completed that a Registered Nurse (RN) reviews the screening and makes a decision or recommendation accordingly. Record review of Resident #10's plan of care, I sometimes have trouble getting to the bathroom in time. Staff are helping me retrain my bladder and bowel so I can stay dry and comfortable as much as possible developed 10/10/25, revealed the following goals, I will improve or maintain my bladder and bowel control by participating in my individualized toileting program . with the following interventions noted, Adjust schedule based on identified bladder pattern or resident feedback .Interdisciplinary team reviews during quarterly and significant change assessments to determine continued appropriateness of retraining program .Nurse reviews weekly for progress or modification needs . During an interview on 11/13/2025 at 8:27 AM, with the DON and the RN #1, Care Plan Coordinator, confirmed that Resident #10 has incontinent episodes and is not on a toileting program because they don't currently have a toileting program. Both nurses confirmed that there was no documentation following each B/B screening by a RN assessing the need for the program. RN #1, Care Plan Coordinator, stated, There is a note in for October only. The DON stated they do remind her to toilet every few hours but there is not documentation for that. She confirmed that Resident #10 should be on a toileting program to help maintain her current level of independence. Record review of progress note dated 10/10/2025 revealed, Care plan review and update performed regarding bowel and bladder program screener. Resident scored as a candidate for scheduled toileting or timed voiding. Staff are providing regular, scheduled toileting assistance with the goal of helping the resident stay dry and maintain skin integrity. Resident is cooperative with toileting efforts. Progress and response to the toileting schedule will be monitored and documented, and care plan will be updated as needed.Record review of Resident #10's admission Record revealed that the resident was admitted to the facility on [DATE] with a medical diagnosis that included Multiple Sclerosis and Epilepsy.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/17/2025 revealed under Section C that Resident #10's Brief Interview for Mental Status (BIMS) score was 15, indicating that the resident was cognitively intact.

Based on observations, resident and staff interviews, record reviews, and facility policy review, the facility failed to develop a plan of care that included nail care for Activities of Daily Living (ADLs) for two (2) of 16 sampled residents, (Resident #8 and #46); and failed to implement comprehensive care plans for two (2) of 16 sampled residents. (Resident #2 and #7) Findings Include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered with a revision date of December 2016, revealed under Policy Statement .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Resident #2 and Resident #7 Record review of Resident #2's Care Plans revealed under, Focus: I am at risk for adverse effects r/t (related to) use of psychotropic medications for a dx (diagnosis) of Major Depressive d/o (disorder) and anxiety d/o (disorder). Also revealed under, Interventions: Monitor for side effects and effectiveness Q (every)-SHIFT. Record review of Resident #7's Care Plans revealed under, Focus: I am prescribed antidepressant medication (Seroquel) for a diagnosis of Major Depressive Disorder. Also revealed under, Interventions: Monitor/document side effects and effectiveness Q (every)-SHIFT. Record review of the November 2025 Medication Administration Record for Resident #2 and #7 revealed no documentation of side effect monitoring for either resident. On 11/12/25 at 2:10 PM, an interview with Licensed Practical Nurse (LPN) #1 confirmed side effects were not being monitored for Resident #2 and #7 and should have been according to the care plan. During an interview on 11/13/25 at 8:40 AM, the Care Plan Coordinator confirmed the care plans for Residents #2 and #7 were not followed. Record review of the admission Record revealed the facility admitted Resident #2 on 11/03/17 with a medical diagnosis including Major Depressive Disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/15/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #2 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #7 on 8/05/25 with a medical diagnosis including Unspecified Dementia with Behavioral Disturbance. Record review of the MDS with an ARD of 8/15/25 revealed under section C, a BIMS summary score of 99, indicating Resident #7 was unable to complete the interview. Resident #8 Record review of care plans for Resident #8 revealed no care plans were developed for nail care. On 11/11/2025 at 11:46 AM and again on 11/12/25 at 10:15 AM, during an observation an interview with Resident #8 revealed the resident had approximately three-fourths (3/4) inch long, jagged fingernails with brown substance underneath. She stated she would like to have her nails cut shorter. On 11/12/2025 at 10:34 AM during an interview with the Director of Nursing (DON), she confirmed that a nail care plan was not developed to include nail care for Resident #8 and that the importance of a care plan is to ensure the resident receives person-centered care, specific to residents' wants and needs. Record review of Resident #8's admission Record revealed that the resident was admitted to the facility on [DATE] with a medical diagnosis that included Cerebral Infarction, Unspecified. Record review of the MDS with an ARD of 9/19/2025 revealed under Section C that Resident #8's BIMS score was 7, indicating that the resident was severely impaired. Resident #46 Record review of care plans for Resident #46 revealed no care plan was developed for nail care. On 11/11/25 at 11:35 AM and again on 11/12/25 at 10:00 AM an observation of Resident #46 revealed the resident lying in bed with long nails, approximately one-fourth (1/4) inch in length on to the left hand and approximately one-half (1/2) inch in length on the right hand with a brown substance underneath. The right hand was observed as contracted and in a clenched fist. An interview on 11/12/25 at 1:16 PM with LPN #1 revealed that a care plan was not developed to include nail care for Resident #46 and that the importance of a care plan for residents is to ensure a person-centered care specific to residents' wants and needs. Record review of Resident #46 's admission Record revealed that the facility admitted resident on 7/19/2019 with a medical diagnosis that included Cerebral Infarction, Unspecified. Record review of the MDS with an ARD of 8/29/2025 revealed under Section C that Resident #46's BIMS was 6 and the resident's cognitive skills for daily decision making were severely impaired.

Based on observation, staff interview, record review and facility policy review the facility failed to promote the healing of existing pressure injuries as evidenced by failure to perform hand hygiene during wound care. Resident #34 currently has a foul odor and purulent discharge to facility acquired pressure wounds of the right lower leg and right heel with a history of recent multiple pressure ulcer infections. Resident #42 has two (2) facility acquired pressure ulcers with a history of pressure ulcer infection. This is for two (2) of five (5) residents reviewed for pressure ulcers. (Resident #34 and Resident #42). Findings include: Review of the facility policy titled, Wound Care, revised October 2010, revealed, Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in procedure: 2.) Wash and dry hands thoroughly.4.) Put on exam gloves, loosen tape, and remove dressing.5.) Pull gloves over dressing and discard. Wash and dry hands thoroughly .6.) Put on gloves.23.) Wash and dry hands thoroughly. Review of the facility policy titled, Handwashing/Hand Hygiene, revised August 2019, revealed, Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infections.Policy Interpretation and Implementation: 7.) Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following.) Before handling clean or soiled dressings, gauze pads, etc.h.) Before moving from a contaminated body site to a clean body site during resident care.i.) After contact with a resident's skin. j.) after contact with blood or bodily fluids.k.) After handling used dressings, contaminated objects. m.) After removing gloves. An observation and interview during the initial tour on 2/26/24 at 4:00 PM revealed a foul odor was coming from the room of Resident #34. An interview with the Registered Nurse (RN)-Wound Care Nurse that was in the resident's room revealed Resident #34 has pressure ulcers, some of them are having some malodorous drainage and she obtained an order to culture the wounds. Review of the physician's orders for Resident #34, revealed Right Lateral lower leg pressure ulcer stage 3: clean with NS (normal saline), apply Santyl to wound bed, cover with boarder dressing daily and prn (as needed).Right heel unstageable: cleanse with spray wound cleanser pat dry, apply Santyl ointment to wound bed then calcium alginate to slough, wrap with kerlix, and secure with paper tape daily and prn Unstageable wound to Dorsalis Pedis Right, cleanse with wound cleanser, pat dry with 4 x 4, apply Santyl ointment to wound bed, cover with ABD (abdominal gauze pad) then wrap with kerlix qd (every day) and prn. During an interview and record review of the treatment record for Resident #34 on 2/27/24 at 9:55 AM with the Registered Nurse (RN)- Wound Care Nurse, revealed that the wound to the right dorsalis pedis should read DTI (Deep Tissue Injury) not unstageable and she would do a clarification order. She stated that the right heel is now presenting as a stage 4 and would clarify that as well. An observation and interview during wound care for Resident #34 with the RN-Wound Care Nurse and Licensed Practical Nurse (LPN) #1 on 2/27/24 at 10:00 AM, revealed the RN-Wound Care Nurse sanitized hands applied gloves and verbalized during wound care she always cleans the peg (percutaneous endoscopic gastrostomy) site, the Foley catheter site first and then takes care of the wounds. She then cleaned around the stoma of the peg tube site and applied a clean dressing around the site with the same gloves used to clean the peg stoma site . The RN-Wound Care Nurse then pulled down Resident #34s brief and cleaned around the Foley catheter with a wet washcloth with the same gloves used to perform peg site care with no hand hygiene before or after the catheter care. The RN-Wound Care Nurse then removed the glove off her right hand and applied a clean glove, left the dirty glove on her left hand, began to cut, and date tape with no hand hygiene performed. LPN #1 performed hand hygiene, removed dressings off the resident's right heel, right dorsalis pedis area (top of right foot), and right lateral leg then discarded them in a red bag. She then grabbed moistened gauze and patted the leg wound once and discarded the gauze, then patted the right heel wound bed once and discarded the gauze, and patted the right dorsalis pedis wound bed with a gauze pad and discarded it with no hand hygiene performed between wounds. LPN #1 then applied an ointment to the wound bed of each wound with the same gloves used to remove the soiled dressings and clean the wound beds, the RN- Wound Care nurse then handed LPN #1 clean dressings and dated tape to cover the wounds with the same contaminated gloves worn during catheter care. LPN #1 applied clean dressings and dated tape, removed her gloves, and performed hand hygiene. Record review of the Wound Assessment Details from the local hospital for the right lateral leg lower pressure ulcer assessments revealed initial onset 11/27/23. Further review of the Wound Assessment Report revealed last assessment dated [DATE] now a stage 3 measuring 5.50 cm (centimeters) length x (times) 1.30 cm width x 0.50 cm depth. This wound was facility acquired. Record review of the Wound Assessment Report for the right heel pressure ulcer assessments revealed initial 9/21/23 DTI (deep tissue injury) measuring 1.60 cm length x 1.00 cm width. Further review revealed last assessment dated [DATE] now worsened to a stage 4, measuring 7.00 cm length x 6.00 cm width x 0.20 cm depth. This wound was facility acquired. Record review of an Infection Report-Basic for Resident #34 dated 12/3/23, revealed a culture of the right heel pressure ulcer with growth of Proteus mirabilis- Intervention: Ceftriaxone 1 (one) gram IV (intravenous) daily times 10 days ordered related to right heel wound infection. Infection source: It is likely infection developed in the facility. Review of an Infection Report-Basic for Resident #34 dated 12/22/23 culture of right heel pressure ulcer related to purulent/malodorous drainage with growth of multiple organisms Bacteroides fragilis, Staphylococcus aureus, Enterococcus faecalis, Finegoldia [NAME], [NAME] morganii, and Proteus mirabilis. Treated with Invanz 1-gram IV daily times 10 days and Tygacil 50 mg (milligrams) IV every 12 hours times 10 days. Record review of the Wound Assessment Report for the right dorsalis pedis revealed initial onset of 2/14/24 as a DTI measuring 4.50 cm length x 4.50 cm width x 0.25 cm depth. Further review of the Wound Assessment Report dated 2/21/24 revealed the DTI measuring 5.00 cm length x 5.00 cm width x 0.25 cm depth. This revealed an increase in size of the wound and this wound was facility acquired. A review of a physician's order for Resident #34 dated 2/25/24 revealed an order to obtain wound culture on 2/26/24 related to foul odor and purulent discharge to wounds right lower leg and right heel. An interview with the RN-Wound Care Nurse on 2/27/24 at 2:30 PM, confirmed she had noticed an increase in the number of wound infections that Resident #34 has had and confirmed there was worsening to all her wounds. She then confirmed she did not perform hand hygiene between any of the treatments for Resident #34 and stated it did not occur to her to wash her hands after cleaning the peg tube, catheter care, and wound care revealing she normally sanitizes her hands before she starts the treatments of a resident and when she finishes doing all the treatments for the resident. She revealed that not performing hand hygiene between the treatments could lead to cross contamination and could have resulted in increased risk for infections and may cause wounds to worsen or cause a systemic infection. An interview with the Infection Control (IC) nurse on 2/27/24 at 3:00 PM, revealed she has watched the RN-Wound Care Nurse do treatments in the past and she did break infection control barriers and was educated. She revealed she had noticed the increase in the number of wound infections and had done three one on one check offs with the RN-Wound Care Nurse related to wound care but did not document the check offs. She revealed she had reported to the Administrator and the Director of Nurses (DON) on Friday 2/23/24 of her concerns with the RN-Wound Care Nurse but was unaware of the finding of what they did. She verbalized that these residents are vulnerable and more susceptible to infection and confirmed failing to perform hand hygiene during treatments and between different treatments increased the risk for infections and could have been a factor in the increase in wound infections. An interview with the Administrator and the DON on 2/27/24 at 4:00 PM, revealed that they were aware that the RN-Wound Care Nurse was having problems with time management but was unaware of her having any infection control issues. The Administrator also revealed they have met with the RN-Wound Care Nurse on several occasions about her understanding of her role and time management and had reached out to HR (Human Resource) on Monday 2/26/24 about beginning a 30-day performance program of action to see improvement. The DON confirmed that failing to perform hand hygiene between treatments and during wound care places the residents at risk for increased infection and worsening wounds. An interview with LPN #1 on 2/28/24 at 8:49 AM, confirmed she did not perform hand hygiene while doing wound care to Resident #34's wounds. She revealed that she was unaware that she should have performed one treatment at a time and performed hand hygiene in between cleaning the wounds and applying the clean wound supplies but confirmed that she can see where that would be cross contamination and lead to increased risk for infection. A phone interview with the Medical Director on 2/28/24 at 9:34 AM, confirmed that poor infection control practices could lead to wound infections and worsening of wounds. Record review of Resident #34's Face Sheet revealed that the resident was admitted to the facility on [DATE] with medical diagnoses that included Atherosclerotic heart disease of native coronary artery. Record review of Resident #34's Minimum Data Set (MDS) Section M with an Assessment Reference Date (ARD) of 12/04/23 revealed M0210 was coded as yes resident has one or more unhealed pressure ulcers/injuries. Resident #42 Record review of Resident #42's Wound Assessment Report revealed the resident currently has three pressure wounds revealing the following: -Wound to the Sacrum -Stage 3-Identified on 11/18/19 after readmission from the hospital with measurements of 9.00 centimeters (cm) (length) x 11.00 cm (width) x 0.20 cm (depth) and a current measurement on 2/22/24 of 7.50 cm x 7.90 cm x 0.40 cm with a wound status of Improved. -Wound to the Right Buttock; lower-Stage 2-Identified on 2/9/23-facility acquired-with measurements of 1.50 cm x 2.00 cm x 0.10 cm and a current measurement on 2/22/24 of 1.90 cm x 1.30 cm x 0.30 cm Stage 3 with a wound status of Improved. -Wound to the Right Lateral Shin; right medial leg lower-Stage 3-Identified on 1/30/24-facility acquired-with measurements of 2.20 cm x 1.20 cm x 0.20 m and a current measurement on 2/22/24 of 1.70 cm x 0.60 cm x 0.01 cm with a wound status of Improved. An observation on 2/27/24 at 1:26 PM revealed RN-Wound Care Nurse, LPN #2 and Certified Nurse Assistant (CNA) #1 with Resident #42 for wound care. RN-Wound Care Nurse washed her hands, applied gloves, and cleaned the supra pubic catheter. She removed those gloves, did not perform hand hygiene, applied new gloves, pulled the residents draw sheet that revealed bowel movement on the bed pad draw sheet and up the residents back above the brief and on the legs below the brief. She removed the residents brief which revealed the resident's buttocks were covered in bowel movement, removed the coccyx wound dressing and the lower buttock wound dressing which revealed there was bowel movement under the dressings and in the wounds. She cleaned the bowel movement up with a washcloth and warm water, no soap, removed gloves, did not perform hand hygiene, applied new gloves, and cleaned the coccyx wound with normal saline. She then removed her gloves, did not perform hand hygiene, applied new gloves, applied silver cell to the coccyx wound, covered it with a 4x4 pad, and covered that with an ABD pad. She then rolled the dirty brief under the wound and held the pad in place while LPN #2 took her gloves off, washed her hands and handed RN-Wound Care Nurse the tape for the dressing. She then taped down the dressing, removed the dirty brief and put it in a biohazard bag, applied two more pieces of tape to the coccyx wound dressing, removed gloves, picked up new gloves then laid them back inside the box with multiple clean gloves. She washed her hands then applied those same gloves that she had picked up and laid down. She cleaned the lower left buttock wound removed gloves, did not perform hand hygiene, put on new gloves, and helped apply a new brief. An interview on 2/27/24 at 2:50 PM with LPN #2 confirmed that RN-Wound Care Nurse did not wash her hands when she changed her gloves and should have. She confirmed that was a break in infection control and could lead to the spread of infections. An interview with RN-Wound Care Nurse on 2/27/24 at 3:40 PM confirmed that she broke infection control when she was doing wound care on Resident #42 by not washing her hands after changing gloves from a dirty procedure, which could cause a spread of infection or cross contamination leading to a wound infection. Record review of Resident #42's Final Report for the residents wound culture from the Coccyx wound with a final result date of 11/17/23. This culture revealed a result of Acinetobacter baumannli, Bacteroides fragilis, Escherichia coli, Morganella morganii, Proteus mirabilli, Pseudomonas aeruginosa, Clostridium perfringens, Enterococcus faecalis with an order to start Levaquin 500 milligram (mg) 1 tab via PEG tube daily for 14 days (Start 11/27-Stop 12/10) Record review of Resident #42's Infection Report-Basic dated 11/27/23 revealed the resident had a wound infection that indicated Infection Source: It is likely infection developed in the facility. Record review of Resident #42's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Sequelae of Cerebral Infarction. Record review of Resident #42's MDS with an ARD of 1/22/24 revealed in Section C a Brief Interview for Mental Status (BIMS) with no score, which indicates the resident is severely cognitively impaired and in Section M that the resident had one or more unhealed pressure ulcers at Stage 1 or higher. 47157

Based on observation, staff interview, record review and facility policy review the facility failed to perform hand hygiene during wound care, Foley and suprapubic catheter care, and Percutaneous Endoscopic Gastrostomy (PEG) tube care (Resident's #34 and #42) Resident #34 currently has a foul odor and purulent discharge from facility acquired pressure wounds of the right lower leg and right heel with a history of recent multiple pressure ulcer infections. Resident #42 has two (2) facility acquired pressure ulcers with a history of pressure ulcer infection. This is for two (2) of 10 residents observed during direct patient care. Resident's #34 and 42 Cross reference F686 Findings include: Review of the facility policy titled, Standard Precautions, effective 01/01/2020, revealed, Policy: Standard Precautions are designed for care of all patients in facilities, regardless of diagnosis or presumed infection status, to reduce the risk of transmission from both recognized and unrecognized sources of infection.Standard Precautions include Gloves: To be worn when touching blood, body fluids, secretions, mucous membranes, non-intact skin, and other contaminated items .Gloves do not take the place of hand hygiene .Hands are to be washed after removing gloves .Gloves should be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Review of the facility policy titled, Handwashing/Hand Hygiene, revised August 2019, revealed, Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infections .Policy Interpretation and Implementation: 7.) Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following. Before handling clean or soiled dressings, gauze pads, etc.h.) Before moving from a contaminated body site to a clean body site during resident care.i.) After contact with a resident's skin. j.) after contact with blood or bodily fluids.k.) After handling used dressings, contaminated objects. m.) After removing gloves . Review of the facility policy titled, Catheter Care, revised September 2014, revealed, Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections .Infection Control: 1.) Use standard precautions when handling or manipulating the drainage system . Review of the facility policy titled, Gastrostomy/Jejunostomy Site Care, revised October 2011, revealed, Purpose: The purpose of this procedure is to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection Steps in the procedure: 2.) Wash hands and dry thoroughly.2.) Wear clean gloves.14. Remove gloves and discard. 15.) Wash your hands . Review of the facility policy titled, Wound Care, revised October 2010, revealed, Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Steps in procedure: 2.) Wash and dry hands thoroughly .4.) Put on exam gloves, loosen tape, and remove dressing .5.) Pull gloves over dressing and discard. Wash and dry hands thoroughly .6.) Put on gloves.23.) Wash and dry hands thoroughly . Observation of wound care for Resident #34's wound care with the (Registered Nurse) RN-Wound Care Nurse and Licensed Practical Nurse (LPN) #1 on 2/27/24 at 10:00 AM revealed, the RN-Wound Care Nurse sanitized hands applied gloves and verbalized during wound care she always cleans the PEG tube site, and the Foley catheter site first and then takes care of the wounds. She then cleaned around the stoma of the PEG tube site and applied a clean dressing around the stoma site with the same gloves used to clean the PEG stoma site. The RN-Wound Care Nurse then pulled down Resident #34's brief and performed catheter with the same contaminated gloves used to perform PEG site care. There was no observation of hand hygiene before or after the Foley catheter care. The RN-Wound Care Nurse then removed the glove off of her right hand and applied a clean glove, began to cut, and date tape, with no observation of hand hygiene and no observation of removing the soiled glove from the left hand. LPN #1 performed hand hygiene, removed dressings off of the residents right heel, right dorsalis pedis area (top of right foot), and right lateral leg and discarded them in a red bag. She then grabbed moistened gauze and patted the leg wound once and discarded the gauze, then patted the right heel wound bed once and discarded the gauze ,and patted the right dorsalis pedis wound bed with a gauze pad and discarded it with no observation of hand hygiene between cleaning each wound. LPN #1 then applied an ointment to the wound bed of each wound with the same gloves used to remove the soiled dressings and clean the wound beds. The RN-Wound Care Nurse then handed LPN #1 clean dressings and dated tape to cover the wounds with the same contaminated gloves worn during PEG site and catheter care. LPN #1 applied clean dressings and dated tape, removed her gloves she applied at the beginning of wound care, and performed hand hygiene. Record review of an Infection Report - Basic for Resident #34 dated 12/3/23, revealed an order for a culture of right heel pressure ulcer for foul and purulent drainage with growth of Proteus mirabilis- Ceftriaxone 1(one) gram IV (intravenous) daily times 10 days ordered related to right heel wound infection. Record review of an Infection Report - Basic for Resident #34 dated 12/22/23 culture of right heel pressure ulcer related to purulent/malodorous drainage with growth of Bacteroides fragilis, Staphylococcus aureus, Enterococcus faecalis, Finegoldia [NAME], [NAME] morganii, and Proteus mirabilis. Treated with Invanz 1-gram IV daily times 10 days and Tygacil 50 mg (milligrams) IV every 12 hours times 10 days. A record review of a physician's order for Resident #34 dated 2/25/24 revealed an order to obtain wound culture on 2/26/24 related to foul odor and purulent discharge to wounds. Record review of the facility infection log for dates 9/27/23-2/27/24, revealed there were 11 wound infections. During an interview with the RN-Wound Care Nurse on 2/27/24 at 2:30 PM confirmed she had noticed an increase in the number of wound infections that Resident #34 has had and confirmed there was worsening to all her wounds. She then confirmed she did not perform hand hygiene between any of the treatments for Resident #34 and stated it did not occur to her to wash her hands after cleaning the PEG tube, catheter care, and wound care revealing she normally sanitizes her hands before she starts the treatments of a resident and when she finishes doing all the treatments for the resident. She then confirmed that not performing hand hygiene between the treatments could lead to cross contamination and could have resulted in increased risk for infections and may cause wounds to worsen or cause a systemic infection. During an interview with the Infection Control (IC) nurse on 2/27/24 at 3:00 PM, revealed she has watched the RN treatment nurse do treatments in the past and she did break infection control barriers and was educated. She revealed she had noticed the increase in the number of wound infections and had done three one on one check offs with the treatment nurse related to wound care but did not have documentation and revealed she had reported to the Administrator and DON on Friday of her concerns with the treatment nurse but was unaware of the finding of what they did. She verbalized that these residents are vulnerable and more susceptible to infection and confirmed failing to perform hand hygiene during treatments and between different treatments increased the risk for infections and could have been a factor in the increase in wound infections. On 2/27/24 at 4:00 PM an interview with the Administrator and Director of Nurse (DON) revealed that they were aware that the treatment nurse was having problems with time management but was unaware of her having any infection control issues. The Administrator also revealed they have met with the RN treatment nurse on several occasions about her understanding of her role and time management and had reached out to HR (Human Resource) on Monday 2/26/24 about beginning a 30-day performance program of action to see improvement. The DON confirmed that failing to perform hand hygiene between treatments and during wound care places the residents at risk for increased infection. During an interview with LPN #1 on 2/28/24 at 8:49 AM, revealed that she was unaware that she should have performed one treatment at a time and performed hand hygiene in between cleaning the wounds and applying the clean wound supplies but confirmed she can see where that would be cross contamination and lead to increased risk for infection. She confirmed she did not perform hand hygiene while doing wound care to Resident #34's wounds. During a phone interview with the Medical Director on 2/28/24 at 9:34 AM confirmed that poor infection control practices could lead to wound infections. Record review of the Face Sheet revealed that the facility admitted Resident #34 to the facility on [DATE] with a diagnosis of Atherosclerotic heart disease of native coronary artery. Resident #42 During an observation on 2/27/24 at 1:26 PM revealed Registered Nurse (RN)-Wound Care Nurse, LPN) #2 and Certified Nurse Assistant (CNA) #1 with Resident #42 for wound care. The RN-Wound Care Nurse removed the Percutaneous Endoscopic Gastrostomy (PEG) tube dressing that revealed a yellow drainage around the site. She then cleaned the area, removed her gloves, and did not perform hand hygiene. She applied a new PEG dressing and did not perform hand hygiene before or after applying the new dressing. She then applied new gloves and cleaned the supra pubic catheter. RN-Wound Care Nurse then pulled the residents draw sheet back that revealed bowel movement (BM) on the bed pad, draw sheet, and up the residents back and legs. She removed the residents brief which revealed the resident's buttocks were covered in BM. The RN -Wound Care Nurse removed the coccyx wound dressing and the lower buttock wound dressing which revealed there was BM under the dressings and in the wounds. She cleaned the BM with a washcloth and warm water. She did not use any soap to clean the BM. She removed her gloves but did not perform hand hygiene. After applying new gloves, she cleaned the coccyx wound and changed her gloves did not perform hand hygiene and proceeded to apply the dressing to the coccyx wound. She then rolled the BM soiled brief under the wound and held the pad in place while LPN #2 handed RN-Wound Care Nurse the tape for the dressing. She then taped down the dressing, removed the soiled brief and put it in a biohazard bag, and applied two more pieces of tape to the coccyx wound dressing all while wearing the same gloves. She removed her gloves and did not perform hand hygiene. She then picked up new gloves then laid them back inside the box with multiple clean gloves. She washed her hands then applied those same gloves that she had previously picked up and laid down prior to washing her hands. She cleaned the lower left buttock wound and removed her gloves but did not perform hand hygiene and helped apply a new brief. She then applied new gloves and cleaned the right shin pressure wound. She removed her gloves, washed her hands, picked up a 4x4 off the top of the protected barrier table with wound treatment supplies and dried her hands with it. During an interview on 2/27/24 at 2:50 PM with LPN #2 confirmed that RN-Wound Care Nurse did not wash her hands when she changed her gloves and should have. She confirmed that was a break in infection control and could have led to the spread of infections. During an interview with RN-Wound Care Nurse on 2/27/24 at 3:40 PM confirmed that she did not follow infection control when she was providing wound care for Resident #42 because she did not wash her hands after changing gloves from a dirty procedure, which could cause a spread of infection or cross contamination leading to a wound infection. Record review of Resident #42's Final Report for the residents wound culture from the Coccyx wound with a final result date of 11/17/23. This culture revealed a result of Acinetobacter baumannli, Bacteroides fragilis, Escherichia coli, Morganella morganii, Proteus mirabilli, Pseudomonas aeruginosa, Clostridium perfringens, Enterococcus faecalis with an order to start Levaquin 500 mg 1 tab via PEG tube daily for 14 days (Start 11/27-Stop 12/10) Record review of Resident #42's Infection Report-Basic dated 11/27/23 revealed the resident had a wound infection that indicated Infection Source: It is likely infection developed in the facility. Record review of Resident #42's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Sequelae of Cerebral Infarction. Record review of Resident #42's Minimum Data Set with an Assessment Reference Date of 1/22/24 revealed in Section C a Brief Interview for Mental Status with no score, which indicates the resident is severely cognitively impaired and in Section M that the resident had one or more unhealed pressure ulcers at Stage 1 or higher. 47157

Based on staff interview, record review, and facility policy review the facility failed ensure the Minimum Data Set (MDS) accurately reflects the resident's status when the Discharge MDS was inaccurately coded for (1) one of 18 MDS assessments reviewed. (Resident #62) Findings include: Record review of the facility policy Resident Assessments, revised November 2019, revealed Policy Interpretation and Implementation, 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments . A review of the Departmental notes for Resident #62 dated 12/21/23 revealed the resident was discharged home at her request. Review of Resident #62's Discharge MDS with an Assessment Reference Date (ARD) date of 12/21/23 revealed Section A Item A2105 Discharge status was coded as the resident was discharged to a short term general hospital. An interview with Registered Nurse (RN) MDS Nurse on 02/28/24 at 11:14 AM, she revealed that Resident #62 was discharged home not to the hospital and confirmed the Discharge MDS was inaccurately coded and stated the purpose of the accurate coding is to identify where the resident is and for billing purposes. Review of Resident #62's Face sheet revealed the facility admitted the resident on 8/02/24 with medical diagnoses that included Cerebral Infarction and discharged the resident on 12/21/23.

Based on staff interview, record review and facility policy review the facility failed to complete and submit a Discharge Minimum Data Set (MDS) assessment timely in accordance with the current federal and state submission timeframes for one (1) of 18 resident's MDS assessments reviewed. Resident #28 Findings include: Record review of the facility policy Resident Assessments, revised [DATE], revealed, Policy Interpretation and Implementation, 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessment and reviews according to the following requirements . (5) Discharge Assessment-Conducted when a resident is discharged from the facility. Record review of Resident # 28's Face Sheet revealed the facility admitted the resident on [DATE], with a diagnosis of Benign prostatic hyperplasia. Resident #28 was discharged on [DATE] due to death in the facility. During an interview with the MDS nurse on [DATE] at 8:40 AM, she revealed that she is responsible for scheduling all assessments. She verified that she was aware that Resident #28 died in the facility on [DATE] and his assessment was on her schedule. She verified that no discharge tracking MDS was completed for Resident #28 and did not know why she missed it. The MDS Nurse agreed the importance of completing the discharge tracking assessment was to report residents' status. In an interview with Administrator on [DATE] at 8:47 AM, she verified that it was her expectation that the discharge tracking MDS would be completed in a timely manner.

Based on record review, staff interviews, and facility policy review, the facility failed to complete a Quarterly Minimum Data Set (MDS) Assessment, within 120 days, for 1 of 20 residents reviewed in the sample for MDS Assessments. Resident #38 FACILITY Resident Assessment Review of the facility policy titled, Resident Assessments, revised November 2019, revealed Policy Statement, A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements. 2. Quarterly Assessment - Conducted not less frequently than three (3) months following the most recent OBRA assessment of any type. An interview on 12/07/22 at 01:30 PM with the Minimum Data Set (MDS) Nurse revealed she neglected to open the Quarterly MDS Assessment for the Assessment Reference Date (ARD) 10/18/22 for Resident #38. She revealed she had Resident #38's name written in on the MDS calendar, on 10/18/22, to remind her to open the Quarterly MDS Assessment for completion. She also revealed there was documentation entered in the Departmental Notes in the electronic health record (EHR), by facility staff members, for the Quarterly MDS Assessment for 10/18/22, and it was discussed in the care plan meeting. She noted it was her fault the Quarterly MDS Assessment for Resident #38 was not submitted, in the 120 day time frame, and the Quarterly MDS Assessment should have been completed. She revealed no other staff had knowledge of how to open a MDS Assessment. An interview on 12/7/22 at 01:40 PM with the Administrator confirmed the Quarterly MDS Assessment should have been completed for Resident #38, that it was missed by the MDS Nurse, and other staff did not report they had not completed their section, of the Quarterly MDS Assessment, because it was not opened. He revealed the Quarterly MDS Assessment should have been completed and submitted, for Resident #38, to ensure monitoring was being done of care indicators, to assist in monitoring for possible status changes, and to report the care being provided to Resident #38 at the nursing facility. He also revealed the Quarterly Assessment not being completed indicated the nursing facility was not following the Omnibus Budget Reconciliation Act of 1987 (OBRA) Assessment Schedule. An interview on 12/7/22 at 02:05 PM with the Social Worker revealed he was not aware that the Quarterly MDS Assessment, with an ARD of 10/18/22, had not been opened by the MDS Nurse. He confirmed he had documented in the Departmental Notes on 10/19/22, but could not recall that he had not completed his sections of the Quarterly MDS Assessment for the ARD of 10/18/22. An interview on 12/7/22 at 02:15 PM with MDS Nurse revealed she did not look for the MDS Quarterly Assessments, with an ARD of 10/18/22, to conduct her care plan meeting, but she did confirm she had the care plan meeting, on 10/21/22, for the quarterly review relevant to the Quarterly MDS Assessment ARD of 10/18/22. Record review of the MDS Calendar revealed Resident #38's name written in on 10/18/22 to indicate her ARD, and a Q was written behind her name to indicate the assessment due was a quarterly assessment. Record review of the care plan Quarterly Review Dates sign-in sheet revealed a care plan meeting was conducted relevant to the Quarterly MDS Assessment with an ARD of 10/18/22, for Resident #38.

Based on observations, staff and resident interviews, facility policy review and record review, the facility failed to keep residents free from physical restraints for one (1) of 20 residents reviewed during the survey. Resident #2 Findings include: Review of the facility policy titled, Restraints - Definitions, dated 12/1/14, revealed: 1. Physical restraints Any manual method or physical or mechanical device material or equipment attached or adjacent to the resident's body that the resident cannot remove easily which restricts freedom of movement for normal access to one's body. 2. Side Rails a. Side rail use is addressed in the same manner as any other restraint. b. side rails used as an enabler must be supported by documentation. c. The use of side rails as restraints is prohibited unless they are necessary to treat a resident's medical symptoms. d. Residents who attempt to exit a bed through between over or around side rails are at risk of injury or death. e. The potential for serious injury is more likely from a fall from a bed with raised side rails than from a fall from a bed where side rails are not used. f. If the resident is immobile and cannot voluntarily get out of bed due to a physical limitation, the bed rails do not meet the definition of a restraint. g. The same device may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances. For example, partial rails may assist one resident to enter and exit the bed independently while acting as a restraint for another. h. Full side rails may be one or more rails along both sides of the residence bed that block 3/4 to the whole length of the mattress from top to bottom including: beds with one side placed against the wall (prohibiting the resident from entering and exiting on that side) and the other side blocked by a full rail (one or more rails) j. Side Rails Used a Positioning Devices - if the side rail has the effect of restraining the resident and makes the definition of a physical restraint for that individual, the facility is responsible to assess the appropriateness of that restraint. k. Side Rails Used with Residents Who Are Immobile i. if the resident is immobile and cannot voluntarily get out of bed due to physical limitation and not due to a restraining device or because proper assistive devices were not present, the bed rails do not make the definition of a restraint. ii. For residents who have no voluntary movement, the staff needs to determine if there is any appropriate use of bed rail. An observation, on 12/05/22 at 03:42 PM and 12/07/22 at 10:15 AM revealed Resident #2 in bed with two (2) full length rails up on each side of the bed. An observation and interview, on 12/07/22 on 12:20 PM with the Director of Nursing (DON) concerning Resident #2, revealed that the 2 full length side rails should be considered a restraint. An interview on 12/8/22 at 11:20 AM, with Resident #2 revealed that she was glad the rails were off (the side rails were removed after the surveyor brought the side rails to the attention of the administration). She stated they took up all her room in the bed and she would bump her legs on them sometimes. Resident #2 stated that now she could sit up by herself. Review of the physician orders dated 1/20/22 revealed Resident #2 may use side rails for mobility and to aid in turning and repositioning. The order did not give instructions to how many side rails, or if they should be full length or half length. Record review of the side rail assessment dated [DATE] revealed the reason side rails are being utilized is to increase bed mobility and allow Resident #2 to shift his/her weight. The number of rails indicated for use is 2. The length of side rails did not indicate if the side rails should be full length or half and they were not documented as a restraint. Record review of Resident #2's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses that include Chronic Congestive Heart Failure, Rheumatoid Arthritis, Type 2 Diabetes Mellitus. Record review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/22 revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated Resident #2 was moderately impaired. An interview, on 12/7/22 at 3:00 PM with the Director of Nurse (DON) revealed she did not realize they had so many beds with full rails up. She stated that they are working now on getting rails changed throughout the facility. An interview with the Administrator on 12/8/22 at 9:15 AM revealed that he understands the regulation but, in his mind they had considered the side rails as safety for the residents. He stated there had been no injuries related to side rail use. An interview, on 12/8/22 at 10:50 AM with the Care Plan Coordinator revealed she does side rail assessments on residents and did not document the side rails as restraint. She stated that she goes to the room and does a complete assessment. She stated that she did not feel like she had seen a resident who did not not need their side rail, full or otherwise.

Based on staff interview, record review, and facility policy review, the facility failed to implement care plans for the use of side rails for one (1) of six (6) residents reviewed for side rails. Resident #17 Findings include: Review of the facility care plan policy with a revision date of December 2016, titled, Care Plans, Comprehensive Person-Centered revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan will reflect currently recognized standards of practice for problem areas and conditions. An observation, on 12/05/22 at 02:47 PM revealed Resident #17 in bed with all four side rails up. An observation, on 12/06/22 at 02:30 PM revealed Resident #17 in bed with all four side rails up. An observation, on 12/07/22 at 8:06 AM revealed Resident #17 in bed with all four (4) rails up. An interview, on 12/7/22 at 11:35 AM with Certified Nursing Assistant (CNA) #1 revealed to her knowledge Resident #17 has always had four rails up. CNA #1 stated that they have care plans for the residents in a binder at the nurses desk and thinks Resident #17's plan is for four side rails. Record review of the comprehansive care plan for Resident #17 revealed a problem with an onset date of 4/25/17 related to the total assistance with all of the activities of daily living (ADL) due to severe impaired cognition as evidenced by a low brief interview for mental satus score and impaired mobility due to diagnosis of Left sided Hemiplegia following a Cerebrovascular Accident. Approaches that include: padded siderails x two (2) for secure self injury precautions and may have side rails to define perimeters per responsible party. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/7/22 revealed a Brief Interview for Mental Status (BIMS) score of 00 which indicated Resident #17 had severe cognitive impairment. Review of the Face Sheet revealed Resident #17 was admitted to the facility on [DATE] with diagnoses which include Hemiplegia following unspecified cerebrovascular disease, Aphasia, Major depressive disorder, Type 2 Diabetes Mellitus, and Generalized Anxiety Disorder. An interview, with the Administrator (ADM) on 12/8/22 at 10:00 AM revealed if the care plan called for two side rails and four side rails where up, obviously they were not following the care plan. On 12/08/22 at 10:15 AM, an interview with the Director of Nursing (DON) confirmed care plans were not being followed for residents with four side rails up . On 12/8/22 at 10:50 AM an interview with the Care Plan Coordinator revealed she does side rail assessments on all residents. The care plan is developed based on the physician orders and every resident has an order for side rails. She stated that she did not feel like she had seen a resident who did not not need their side rail, full or otherwise.

Based on observation, staff interview, facility policy review, and record review, the facility failed to implement the care plan related to providing a gauze roll into the resident's hand to help prevent contractures for one (1) of 18 resident care plans reviewed, Resident #20. Findings include: Review of the facility's Comprehensive Care Plan policy, dated 9/2/15, revealed: Care, treatment and services shall be planned to ensure that they are individualized to the resident's needs. Record review of Resident #20's comprehensive care plan with a problem dated 1/19/17, revealed a risk for further skin breakdown, due to history of pressure ulcers to right hip, left hip, coccyx, and to right hand. An intervention listed for nursing treatment revealed to apply rolled guaze to the right hand daily for preventative measures. On 06/17/19 at 10:56 AM, an observation of Resident #20, sitting in his wheelchair in his room, revealed the resident with bilateral hand contractures with no hand rolls. On 06/17/19 at 02:45 PM, an observation of Resident #20, sitting in his wheelchair at the nurses station, revealed no hand rolls in either hand. On 06/18/19 at 10:33 AM, an observation of Resident #20, up in his wheelchair at the nurses station, revealed no hand rolls in the right or left hand. On 06/18/19 at 04:06 PM, an observation of Resident #20, in his room in his bed, revealed no hand roll in the right or left hand. On 06/18/19 at 04:04 PM, an interview with the Occupational Therapist (OT) revealed she understood that nursing was placing a gauze roll in the hands of Resident #20 bilateral to prevent further contractures. On 06/18/19 at 04:12 PM, an interview with Certified Nursing Assistant (CNA) #1 revealed she was assigned to Resident #20 and she had not seen anything in Resident #20's hand on that day. CNA #1 revealed she thinks Therapy may be working with Resident #20. On 06/18/19 at 04:25 PM, an interview with Licensed Practical Nurse (LPN) #1 revealed she was the medication nurse for Resident #20 and had worked in this position for eight (8) months. LPN #1 stated I can't say that I have ever seen a gauze roll in (Resident #20's) hand. On 06/18/19 at 04:35 PM, an interview with the Director of Nursing (DON) revealed an order for [REDACTED].#20's right hand. On 06/19/19 at 11:45 PM, an interview with Licensed Practical Nurse (LPN) #2 revealed she is the Treatment Nurse and responsible for placing the gauze in Resident #20's right hand. LPN #2 revealed she did not know why the gauze roll was not in Resident #20's hand unless it just fell out. LPN #2 revealed she does not check during the day to see if the gauze has fallen out. On 06/19/19 at 01:45 PM, an interview with Licensed Practical Nurse (LPN)/Minimum Data Set Nurse revealed she was responsible for developing the comprehensive care plans related to nursing problems and their interventions. The MDS/LPN confirmed the care plan for Resident #20 included an intervention to apply rolled gauze to right hand daily for preventative measures and should have been followed by nursing.

Based on observation, staff interview, facility policy, and record review, the facility failed to provide services and care of splinting, with a hand roll, to maintain or prevent the resident's decline in range of motion for one (1) of two (2) residents investigated for range of motion, Resident #2. Findings include: Review of the facility's policy titled, Splinting, not dated, revealed splinting is used to protect joints and surrounding soft tissues. This can be accomplished by maintaining joints at position of rest, preventing positions that contribute to contracture and/or deformity, protecting the system of arches within the hands and feet and increasing or maintaining range of motion (ROM) in the joint. Review of Resident #20's (MONTH) 2019 orders revealed an order dated 12/17/18, to apply rolled gauze to the right hand daily for preventive measures. Observations on 06/17/19 at 10:56 AM and 2:45 PM, 6/18/19 at 10:33 AM and 4:06 PM revealed Resident #20 without any type of hand roll in his hands, which had bilateral contractures. During an interview on 06/18/19 at 4:04 PM, the Occupational Therapist (OT) revealed she understood nursing was placing a gauze roll in the hands of Resident #20 bilateral to prevent further contractures. An interview on 06/18/19 at 04:12 PM, with Certified Nursing Assistant (CNA) #1 revealed she was assigned to Resident #20 and gauze had not been in his hands. CNA #1 stated she thinks Therapy may be working with Resident #20. An interview on 06/18/19 at 4:25 PM, with Licensed Practical Nurse (LPN) #1 revealed she was the Medication Nurse for Resident #20 and had worked in this position for eight (8) months. LPN #1 stated she couldn't say she'd ever seen a gauze roll in Resident #20's hand. An interview and observation on 06/18/19 at 4:35 PM, with the Director of Nursing (DON) revealed an order for [REDACTED].#20's right hand. An interview on 06/19/19 at 11:45 PM, with Licensed Practical Nurse (LPN) #2 revealed she is the Treatment Nurse and responsible for placing the gauze in Resident #20's right hand. LPN #2 revealed she did not know why the gauze was not in Resident #20's hand on 6/17/19 and 6/18/19 unless it fell out. LPN #2 revealed she does not check during the day to see if the gauze has fallen out. Record review of Occupational Therapy quarterly screen notes, dated 4/4/19, revealed, under section of equipment comments, that nursing is providing the patient with rolled gauze in bilateral hands to decrease risk of further contracture and skin breakdown.

Based on record review, facility policy review, and staff interview, the facility failed to develop and implement an Advance Directive Care Plan for full code status for one (1) of nine (9) sampled and three (3) unsampled resident care plans reviewed for Advance Directives, Resident #1, as evidenced by no Care Plan for an Advance Directive full code status in the resident's medical record. On [DATE], a facility Certified Nurse Aide (CNA) found Resident #1 unresponsive and paged for a nurse twice. The facility nurse checked for Resident #1's vital signs with no results and failed to initiate Cardiopulmonary Resuscitation (CPR) for Resident #1, who elected an Advance Directive for a full code status. Resident #1's care plan did not reflect the full code status. The facility's failure to develop and implement a Care Plan, for an Advance Directive for full code status, placed this resident and and other residents, who have elected full code status, in a situation that was likely to cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ), which began on [DATE], when CPR was not initiated for Resident #1. The facility Administrator was notified of the IJ on [DATE]. The State Agency (SA) received an acceptable credible Allegation of Compliance (A[NAME]) on [DATE], in which the facility alleged removal of the IJ on [DATE]. The SA determined the IJ to be removed as of [DATE], prior to exit. The scope and severity for IJ at 42 CFR 483.21 (b) (1) F656 Comprehensive Person-Centered Care Plan was lowered to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Comprehensive Care Plan policy, with a reviewed date of [DATE], revealed: Care, treatment and services shall be planned to ensure that they are individualized to the resident's needs. Facility shall provide an individualized, interdisciplinary plan of care for all residents that shall be appropriate to the resident's needs, strengths, results of diagnostic testing, limitations and goals. The plan of care shall be individualized, based on the diagnoses, resident assessment, and personal goals of the resident and his/her family. Resident #1 Review of Resident #1's Comprehensive Care Plan revealed no Advance Directive Care Plan or implementation of CPR if the resident was found with no pulse and unresponsive. Review of Code Status consent form, dated [DATE], revealed a signed consent, by Resident #1's daughter, for a full code directive for Resident #1. Review of Resident #1's (MONTH) (YEAR) physician's orders [REDACTED]. Interview with LPN #2, Minimum Data Set (MDS) Coordinator, on [DATE] at 12:28 PM, revealed the care plan meetings were quarterly and they look at just the DNRs (Do Not Resuscitate) and those are the only care plans the MDS developed for code status. She stated I think Medical Records looks at the Full Code status. LPN #2 stated, If a resident takes a turn for the worse, the Social Worker then talks with the family. LPN #2 confirmed that Resident #1 had no care plan with the directive for CPR and full code status. Interview with the Director of Nursing (DON) on [DATE] at 12:40 PM, revealed that in the quarterly care plan meetings, DNRs are discussed. She stated there is no set time frame for when residents with a full code status are reviewed. The DON stated that when a resident had a decline, she and the Administrator met with the family to discuss the situation. She stated nursing is responsible for the Advance Directive care plan, and that Advance Directives are a part of the plan of care. The DON confirmed Resident #1's care plan did not include a full code status. Interview with the Social Worker on [DATE] at 1:05 PM, revealed that annually he asks families if they wish for their resident to remain a DNR. He stated if a full code resident had a decline, he asked the family if they wish to change to a DNR, or the family comes to him wishing to change. Review of the facility's face sheet revealed Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #1 had moderately severe cognitive impairment. The facility provided an acceptable A[NAME] on [DATE] for the IJ. Review of the facility's A[NAME] revealed the facility took the following actions to remove the IJ: 1. On (MONTH) 7, (YEAR), at 5:40 PM, Licensed Practical Nurse (LPN) #1 was called to the room of Resident #1, by Certified Nursing Assistant (CNA) #1, and found Resident #1 to be unresponsive with no vital signs at 5:44 PM, which LPN #1 documented in the Nurses Notes. CNA #1 was not certified in Cardiopulmonary Resuscitation (CPR), therefore did not initiate CPR. At 5:45 PM, LPN #1 and CNA #1 exited Resident #1's room and transported Resident #1 in her hospital bed to the ER. The Responsible Party (RP) of Resident #1 was notified on (MONTH) 7, (YEAR) at 5:59 PM, of Resident #1 being sent to the ER. CPR was not performed as ordered by the Physician. Resident #1 had a code status of resuscitate. LPN #1 failed to follow Physician orders [REDACTED].#1 on (MONTH) 7, (YEAR) at 5:44 PM. Based on ER records Resident #1 was received in the ER and chest compressions were initiated at 5:50 PM. Resident #1 was found unresponsive at 5:40 PM, and chest compressions were not initiated until 5:50 PM, in the ER. On (MONTH) 7, (YEAR) at approximately 9:30 PM, the Medical Director, who is also the Primary Physician for Resident #1, was informed of the failure of LPN #1 to follow Doctor's orders (for resuscitation) for Resident #1. 2. The Administrator and Director of Nursing reviewed the chart of Resident #1 on (MONTH) 11, (YEAR) at approximately 7:30 AM. A list of all residents who had died in the facility from (MONTH) 1, (YEAR) to (MONTH) 7, (YEAR) was reviewed on (MONTH) 11, (YEAR) at approximately 7:30 AM by the Administrator and Director of Nursing. Of the nine (9) deaths in the facility, only one (1) resident had a code status of resuscitate which was Resident #1. There were no circumstances to indicate any of the other eight (8) residents who died in the facility were the result of failure to follow physician orders [REDACTED]. 3. The Administrator, Director of Nursing and Director of Medical Records reviewed the code status of all residents at 8:00 AM on (MONTH) 11, (YEAR). It was determined that 28 residents out of 59 had a code status of resuscitate. 4. The Administrator notified the Attorney General's Office on (MONTH) 12, (YEAR) at 10:51 AM of the failure of LPN #1 to follow physician orders [REDACTED]. 5. The Board of Nursing was notified on (MONTH) 12, (YEAR) at 9:54 AM, by the Administrator, of the failure of LPN #1 to follow physician orders [REDACTED]. 6. On (MONTH) 12, (YEAR), the Director of Medical Records, Director of Nursing, and Minimum Data Set (MDS) Nurse reviewed all 59 charts to ensure that the code status, (Red) for Do Not Resuscitate and (Green) for Resuscitate and (Yellow) for Partial Code was on the physician orders [REDACTED]. It was noted at this time that all records were correct and reflected proper code status. 7. An in-service was initiated on (MONTH) 8, (YEAR) at 7:00 AM, by the Staff Development Coordinator, for all Licensed Practical Nurses and Registered Nurses regarding following physician orders [REDACTED]. There were a total of 15 nurses in-serviced. Twelve (12) LPNs and three (3) RNs were in-serviced. No LPN or RN will be allowed to work until in-serviced. 8. The Administrator suspended LPN #1 on (MONTH) 7, (YEAR) pending termination for failure to follow physician orders [REDACTED].#1. 9. The Quality Assurance Committee met on (MONTH) 15, (YEAR) at 5:00 PM, with the following members present: Licensed Social Worker, Licensed Activity Director, Administrator, Certified Food Service Manager, Medical Director, Minimum Data Set Coordinator, and Director of Nursing. Committee members were made aware of the allegation of noncompliance of the failure of LPN #1 to follow Doctor's orders for code status of Resident #1. Members were told that all licensed staff would be in-serviced regarding following physician orders [REDACTED]. They were also informed that the residents' code status would be visible on all doors. 10. An official report was made to the Mississippi State Department of Health by the Administrator on [DATE] at 8:46 AM, of the incident of the failure of LPN #1 to follow physician orders [REDACTED].#1. The Facility alleges the immediacy was removed effective [DATE]. On [DATE], the State Agency (SA) survey validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable credible Allegation of Compliance (A[NAME]) was verified by staff interviews and record reviews of in-services on [DATE] across all disciplines. 1. The SA verified the facility's investigation of Resident #1's incident on [DATE]. Resident #1 was found unresponsive, without vital signs, and CPR was not performed per interviews, record review and review of written statements from staff and written reports to the SA. 2. The SA validated through interview with the DON and record review that all residents who had expired in the facility since [DATE], were reviewed to ensure code status was followed. 3. The SA validated through interview with the Administrator and DON and record review that the code status of all residents was reviewed by the facility on [DATE]. 4. The SA validated through document review and interview with the Attorney General Office Chief Investigator on [DATE], that the office had received an online report on [DATE], from the facility regarding the incident. 5. The SA validated through document review and interview with the Mississippi Board of Nursing Investigator on [DATE], that the office had received an online complaint on [DATE], from the facility regarding the incident. 6. The SA validated through document review and interviews with the DON, MDS Nurse, and the Director of Medical Records that an audit was completed on [DATE], of all residents' charts to ensure code status was on physician orders [REDACTED]. 7. The SA validated through record review and through interviews of RNs and LPNs that in-service training was conducted starting [DATE], regarding CPR, abuse/neglect, resident rights, following physician orders [REDACTED]. The SA validated through interview that staff were not allowed to work until in-serviced. 8. The SA validated through record review, time card review, and interview with the DON and Administrator that LPN #1 was suspended on [DATE] at the completion of her shift. 9. The SA validated by record review of the Quality Assurance (QA) Committee sign in sheet dated [DATE], and interview with the Administrator, DON, Medical Director, MDS Coordinator, Certified Food Service Manager, and Licensed Social Worker that the facility initiated a QA Committee meeting on [DATE], with the Facility Administrator, DON, Medical Director, MDS Coordinator, Certified Food Service Manager, Licensed Social Worker, and Licensed Activity Director in attendance concerning the failure of LPN #1 to follow Doctor's orders for code status of Resident #1. Policy and Procedure pertaining to code status, CPR, Abuse/Neglect, Resident Rights and Advance Directives were reviewed. 10. The SA validated through document review and interview with the DON and Administrator that notification of the facility's failure to initiate CPR to Resident #1 was made to the State Agency of Licensure and Certification on [DATE].

Based on policy/procedure review, record review, and staff interview, the facility failed to ensure the residents were free from neglect for one (1) of nine (9) residents reviewed, Resident #1, as evidenced by: On [DATE], a facility Certified Nurse Aide (CNA) found Resident #1 unresponsive and paged for a nurse twice. The facility nurse checked for Resident #1's vital signs with no results and failed to initiate Cardiopulmonary Resuscitation (CPR) for Resident #1, who had elected a full code status. More than 10 minutes elapsed between the time Resident #1 was found unresponsive and when CPR began in the emergency room (ER). Resident #1 expired in theER on [DATE] at 6:11 PM. The facility's failure to ensure a resident's right to be free from neglect placed this resident and other residents, who chose to be full code status, in a situation that was likely to cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ), which began on [DATE], when the facility failed to initiate CPR for Resident #1. The Facility Administrator was notified of the IJ on [DATE]. The State Agency (SA) received an acceptable credible Allegation of Compliance (A[NAME]) on [DATE], in which the Facility alleged removal of the IJ on [DATE]. The SA determined the IJ to be removed as of [DATE], prior to exit. The scope and severity for IJ at 42 CFR 483.12 (a) (1) F600 Freedom from Abuse, Neglect, and Exploitation was lowered to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Abuse, Neglect, or Exploitation policy, with a review date of [DATE], revealed the definition of neglect as: The failure of a caretaker to supply for the vulnerable adult the food, clothing, supervision, or other services which are necessary to maintain his/her mental or physical health. Resident #1 Review of a written report from the facility, dated [DATE], revealed CNA #1 found Resident #1 unresponsive at approximately 5:40 PM on [DATE]. CNA #1 called to the desk for a nurse to the resident's room. Licensed Practical Nurse (LPN) #1 entered Resident #1's room at approximately 5:44 PM, and found the resident sitting up in bed unresponsive and without vital signs. At 5:45 PM, LPN #1 and CNA #1 exited the room pushing the resident in her bed, headed to the emergency room (ER), which the facility is attached to via a hallway. CPR was initiated in the ER at 5:50 PM, approximately 10 minutes after the resident was found unresponsive. Resident #1 expired at 6:11 PM on [DATE]. Review of Code Status consent form, dated [DATE], revealed Resident #1's daughter signed consent for a full code directive. Review of Resident #1's (MONTH) (YEAR) physician orders, under the Advanced Directives, revealed an order for [REDACTED].>A telephone interview with CNA #1 on [DATE] at 2:00 PM, revealed she went into Resident #1's room to pick up the resident's supper tray on [DATE], and found Resident #1 unresponsive. CNA #1 stated I didn't know what her code status was. She stated when the nurse arrived, the nurse didn't say anything about CPR, Just that we had to get her to the ER. CNA #1 confirmed she was not CPR certified. CNA #1 stated CPR wasn't initiated until the resident was in the ER, and ER staff started CPR. During an interview on [DATE] at 6:45 PM, the Administrator stated CPR should have been started by LPN #1, because the resident was a full code. The Administrator stated, It's considered neglect. During an interview on [DATE] at 6:00 PM, the DON stated Resident #1's code status should have been honored and LPN #1 failed to initiate CPR. She stated it was neglect not to provide CPR on a full code resident. Interview with the facility Medical Director on [DATE] at 4:40 PM, revealed CPR should have been initiated on Resident #1, as that was the resident's or her family's wish for her to be a full code. Interview with LPN #1 on [DATE] at 10:30 AM, revealed LPN #1 did not know Resident #1 was a full code until she was leaving the room with the resident and saw the green dot on Resident #1's door, which meant she was a full code. LPN #1 stated, It didn't dawn on me to start CPR. I was just trying to get her to help. I should have started CPR. Review of the facility's face sheet revealed Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed staff assessed Resident #1 with moderately impaired cognition. The facility provided an acceptable A[NAME] on [DATE] for the IJ. Review of the facility's A[NAME] revealed the facility took the following actions to remove the IJ: 1. On (MONTH) 7, (YEAR), at 5:40 PM, Licensed Practical Nurse (LPN) #1 was called to the room of Resident #1, by Certified Nursing Assistant (CNA) #1, and found Resident #1 to be unresponsive with no vital signs at 5:44 PM, which LPN #1 documented in the Nurses Notes. CNA #1 was not certified in Cardiopulmonary Resuscitation (CPR), therefore did not initiate CPR. At 5:45 PM, LPN #1 and CNA #1 exited Resident #1's room and transported Resident #1 in her hospital bed to the ER. The Responsible Party (RP) of Resident #1 was notified on (MONTH) 7, (YEAR) at 5:59 PM, of Resident #1 being sent to the ER. CPR was not performed as ordered by the Physician. Resident #1 had a code status of resuscitate. LPN #1 failed to follow Physician orders [REDACTED].#1 on (MONTH) 7, (YEAR) at 5:44 PM. Based on ER records Resident #1 was received in the ER and chest compressions were initiated at 5:50 PM. Resident #1 was found unresponsive at 5:40 PM, and chest compressions were not initiated until 5:50 PM, in the ER. On (MONTH) 7, (YEAR) at approximately 9:30 PM, the Medical Director, who is also the Primary Physician for Resident #1, was informed of the failure of LPN #1 to follow Doctor's orders (for resuscitation) for Resident #1. 2. The Administrator and Director of Nursing reviewed the chart of Resident #1 on (MONTH) 11, (YEAR) at approximately 7:30 AM. A list of all residents who had died in the facility from (MONTH) 1, (YEAR) to (MONTH) 7, (YEAR) was reviewed on (MONTH) 11, (YEAR) at approximately 7:30 AM by the Administrator and Director of Nursing. Of the nine (9) deaths in the facility, only one (1) resident had a code status of resuscitate which was Resident #1. There were no circumstances to indicate any of the other eight (8) residents who died in the facility were the result of failure to follow physician orders [REDACTED]. 3. The Administrator, Director of Nursing and Director of Medical Records reviewed the code status of all residents at 8:00 AM on (MONTH) 11, (YEAR). It was determined that 28 residents out of 59 had a code status of resuscitate. 4. The Administrator notified the Attorney General's Office on (MONTH) 12, (YEAR) at 10:51 AM of the failure of LPN #1 to follow physician orders [REDACTED]. 5. The Board of Nursing was notified on (MONTH) 12, (YEAR) at 9:54 AM, by the Administrator, of the failure of LPN #1 to follow physician orders [REDACTED]. 6. On (MONTH) 12, (YEAR), the Director of Medical Records, Director of Nursing, and Minimum Data Set (MDS) Nurse reviewed all 59 charts to ensure that the code status, (Red) for Do Not Resuscitate and (Green) for Resuscitate and (Yellow) for Partial Code was on the physician orders [REDACTED]. It was noted at this time that all records were correct and reflected proper code status. 7. An in-service was initiated on (MONTH) 8, (YEAR) at 7:00 AM, by the Staff Development Coordinator, for all Licensed Practical Nurses and Registered Nurses regarding following physician orders [REDACTED]. There were a total of 15 nurses in-serviced. Twelve (12) LPNs and three (3) RNs were in-serviced. No LPN or RN will be allowed to work until in-serviced. 8. The Administrator suspended LPN #1 on (MONTH) 7, (YEAR) pending termination for failure to follow physician orders [REDACTED].#1. 9. The Quality Assurance Committee met on (MONTH) 15, (YEAR) at 5:00 PM, with the following members present: Licensed Social Worker, Licensed Activity Director, Administrator, Certified Food Service Manager, Medical Director, Minimum Data Set Coordinator, and Director of Nursing. Committee members were made aware of the allegation of noncompliance of the failure of LPN #1 to follow Doctor's orders for code status of Resident #1. Members were told that all licensed staff would be in-serviced regarding following physician orders [REDACTED]. They were also informed that the residents' code status would be visible on all doors. 10. An official report was made to the Mississippi State Department of Health by the Administrator on [DATE] at 8:46 AM, of the incident of the failure of LPN #1 to follow physician orders [REDACTED].#1. The Facility alleges the immediacy was removed effective [DATE]. On [DATE], the State Agency (SA) survey validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable credible Allegation of Compliance (A[NAME]) was verified by staff interviews and record reviews of in-services on [DATE] across all disciplines. 1. The SA verified the facility's investigation of Resident #1's incident on [DATE]. Resident #1 was found unresponsive, without vital signs, and CPR was not performed per interviews, record review and review of written statements from staff and written reports to the SA. 2. The SA validated through interview with the DON and record review that all residents who had expired in the facility since [DATE], were reviewed to ensure code status was followed. 3. The SA validated through interview with the Administrator and DON and record review that the code status of all residents was reviewed by the facility on [DATE]. 4. The SA validated through document review and interview with the Attorney General Office Chief Investigator on [DATE], that the office had received an online report on [DATE], from the facility regarding the incident. 5. The SA validated through document review and interview with the Mississippi Board of Nursing Investigator on [DATE], that the office had received an online complaint on [DATE], from the facility regarding the incident. 6. The SA validated through document review and interviews with the DON, MDS Nurse, and the Director of Medical Records that an audit was completed on [DATE], of all residents' charts to ensure code status was on physician orders [REDACTED]. 7. The SA validated through record review and through interviews of RNs and LPNs that in-service training was conducted starting [DATE], regarding CPR, abuse/neglect, resident rights, following physician orders [REDACTED]. The SA validated through interview that staff were not allowed to work until in-serviced. 8. The SA validated through record review, time card review, and interview with the DON and Administrator that LPN #1 was suspended on [DATE] at the completion of her shift. 9. The SA validated by record review of the Quality Assurance (QA) Committee sign in sheet dated [DATE], and interview with the Administrator, DON, Medical Director, MDS Coordinator, Certified Food Service Manager, and Licensed Social Worker that the facility initiated a QA Committee meeting on [DATE], with the Facility Administrator, DON, Medical Director, MDS Coordinator, Certified Food Service Manager, Licensed Social Worker, and Licensed Activity Director in attendance concerning the failure of LPN #1 to follow Doctor's orders for code status of Resident #1. Policy and Procedure pertaining to code status, CPR, Abuse/Neglect, Resident Rights and Advance Directives were reviewed. 10. The SA validated through document review and interview with the DON and Administrator that notification of the facility's failure to initiate CPR to Resident #1 was made to the State Agency of Licensure and Certification on [DATE].

Based on staff interview, record review, and facility policy review, the facility failed to ensure a resident's rights and wishes were honored per Advance Directive for one (1) of nine (9) sampled residents, as evidenced by: On [DATE], a facility Certified Nurse Aide (CNA) found Resident #1 unresponsive and paged for a nurse twice. The facility nurse checked for Resident #1's vital signs with no results and failed to initiate Cardiopulmonary Resuscitation (CPR) for Resident #1, who elected an Advance Directive for a full code status. Resident #1 was taken to the emergency room (ER) where CPR was initiated at least 10 minutes after the resident was found unresponsive. Resident #1 expired in the ER. The facility's failure to ensure a resident's right for the Advance Directive for full code status was honored, placed this resident and other residents in a situation that was likely to cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ), that began on [DATE], when CPR was not initiated for Resident #1. The facility Administrator was notified of the IJ on [DATE]. The State Agency (SA) received an acceptable credible Allegation of Compliance (A[NAME]) on [DATE], in which the Facility alleged removal of the IJ on [DATE]. The SA determined the IJ to be removed as of [DATE], prior to exit. The scope and severity for IJ at 42 CFR 483.10 (c)(6)(8)(g)(12)(i)-(v)-F578 Resident Rights-(Advanced Directive) was lowered to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Resident's Rights policy, undated, revealed: Each resident has the right to formulate an advanced directive if they so desire. Review of the facility's Advance Directives policy, with a revision date of (MONTH) (YEAR), revealed: Advance directives will be respected in accordance with state law and facility policy. Resident #1 Review of a Code Status consent form, dated [DATE], revealed Resident #1's daughter signed the consent for a full code directive. Review of Resident #1's (MONTH) (YEAR) physician orders [REDACTED].>Review of a facility reported incident, dated [DATE], revealed CNA #1 entered Resident #1's room on [DATE], and found her unresponsive at approximately 5:39 PM. CNA #1 called to the desk for a nurse to the resident's room. Licensed Practical Nurse (LPN) #1 entered Resident #1's room at approximately 5:44 PM, and found the resident sitting up in bed unresponsive and without vital signs. At 5:45 PM, LPN #1 and CNA #1 exited the room, pushing the resident in her bed, headed to the emergency room (ER) attached to the facility via a hallway. CPR was initiated in the ER at 5:50 PM, and Resident #1 expired in the ER at 6:11 PM. This was an elapsed time of approximately 10 minutes from the time the resident was found unresponsive until CPR was initiated. A telephone interview with CNA #1 on [DATE] at 2:00 PM, revealed she went into Resident #1's room to pick up the resident's supper tray on [DATE], and found Resident #1 unresponsive. CNA #1 stated I didn't know what her code status was and the nurse didn't say anything about CPR. CNA #1 stated that she and another CNA pushed Resident #1 to the ER and when the ER nurse asked if the resident was a full code, we told her that we didn't know, so the ER nurse began CPR. CNA #1 confirmed she was not CPR certified. Interview with the facility Administrator on [DATE] at 6:45 PM, revealed the Administrator stated CPR should have been started by the LPN because the resident had an advanced directive for a full code. Interview with the Director of Nursing (DON) on [DATE] at 6:00 PM, revealed the DON stated Resident #1's code status/advanced directive, should have been honored, and LPN #1 failed to initiate CPR as required. During an interview on [DATE] at 4:40 PM, the facility Medical Director stated that CPR should have been initiated as that was the resident's or her family's wish as an Advanced Directive, for her to be a full code. Interview with LPN #1 on [DATE] at 10:30 AM, revealed LPN #1 did not know that Resident #1 was a full code until she was leaving the room with the resident (on [DATE]) and saw the green dot on Resident #1's door, which meant she was a full code. LPN #1 stated, It didn't dawn on me to start CPR. I was just trying to get her to help. LPN #1 stated, Yes, I should have started CPR. LPN #1 confirmed she was CPR certified. Review of the facility's face sheet revealed Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed staff assessed Resident #1 with moderately severe cognitive impairment. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE] for the IJ. Review of the facility's A[NAME] revealed the facility took the following actions to remove the IJ: 1. On (MONTH) 7, (YEAR), at 5:40 PM, Licensed Practical Nurse (LPN) #1 was called to the room of Resident #1, by Certified Nursing Assistant (CNA) #1, and found Resident #1 to be unresponsive with no vital signs at 5:44 PM, which LPN #1 documented in the Nurses Notes. CNA #1 was not certified in Cardiopulmonary Resuscitation (CPR), therefore did not initiate CPR. At 5:45 PM, LPN #1 and CNA #1 exited Resident #1's room and transported Resident #1 in her hospital bed to the ER. The Responsible Party (RP) of Resident #1 was notified on (MONTH) 7, (YEAR) at 5:59 PM, of Resident #1 being sent to the ER. CPR was not performed as ordered by the Physician. Resident #1 had a code status of resuscitate. LPN #1 failed to follow Physician orders [REDACTED].#1 on (MONTH) 7, (YEAR) at 5:44 PM. Based on ER records Resident #1 was received in the ER and chest compressions were initiated at 5:50 PM. Resident #1 was found unresponsive at 5:40 PM, and chest compressions were not initiated until 5:50 PM, in the ER. On (MONTH) 7, (YEAR) at approximately 9:30 PM, the Medical Director, who is also the Primary Physician for Resident #1, was informed of the failure of LPN #1 to follow Doctor's orders (for resuscitation) for Resident #1. 2. The Administrator and Director of Nursing reviewed the chart of Resident #1 on (MONTH) 11, (YEAR) at approximately 7:30 AM. A list of all residents who had died in the facility from (MONTH) 1, (YEAR) to (MONTH) 7, (YEAR) was reviewed on (MONTH) 11, (YEAR) at approximately 7:30 AM by the Administrator and Director of Nursing. Of the nine (9) deaths in the facility, only one (1) resident had a code status of resuscitate which was Resident #1. There were no circumstances to indicate any of the other eight (8) residents who died in the facility were the result of failure to follow physician orders [REDACTED]. 3. The Administrator, Director of Nursing and Director of Medical Records reviewed the code status of all residents at 8:00 AM on (MONTH) 11, (YEAR). It was determined that 28 residents out of 59 had a code status of resuscitate. 4. The Administrator notified the Attorney General's Office on (MONTH) 12, (YEAR) at 10:51 AM of the failure of LPN #1 to follow physician orders [REDACTED]. 5. The Board of Nursing was notified on (MONTH) 12, (YEAR) at 9:54 AM, by the Administrator, of the failure of LPN #1 to follow physician orders [REDACTED]. 6. On (MONTH) 12, (YEAR), the Director of Medical Records, Director of Nursing, and Minimum Data Set (MDS) Nurse reviewed all 59 charts to ensure that the code status, (Red) for Do Not Resuscitate and (Green) for Resuscitate and (Yellow) for Partial Code was on the physician orders [REDACTED]. It was noted at this time that all records were correct and reflected proper code status. 7. An in-service was initiated on (MONTH) 8, (YEAR) at 7:00 AM, by the Staff Development Coordinator, for all Licensed Practical Nurses and Registered Nurses regarding following physician orders [REDACTED]. There were a total of 15 nurses in-serviced. Twelve (12) LPNs and three (3) RNs were in-serviced. No LPN or RN will be allowed to work until in-serviced. 8. The Administrator suspended LPN #1 on (MONTH) 7, (YEAR) pending termination for failure to follow physician orders [REDACTED].#1. 9. The Quality Assurance Committee met on (MONTH) 15, (YEAR) at 5:00 PM, with the following members present: Licensed Social Worker, Licensed Activity Director, Administrator, Certified Food Service Manager, Medical Director, Minimum Data Set Coordinator, and Director of Nursing. Committee members were made aware of the allegation of noncompliance of the failure of LPN #1 to follow Doctor's orders for code status of Resident #1. Members were told that all licensed staff would be in-serviced regarding following physician orders [REDACTED]. They were also informed that the residents' code status would be visible on all doors. 10. An official report was made to the Mississippi State Department of Health by the Administrator on [DATE] at 8:46 AM, of the incident of the failure of LPN #1 to follow physician orders [REDACTED].#1. The Facility alleges the immediacy was removed effective [DATE]. On [DATE], the State Agency (SA) survey validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable credible Allegation of Compliance (A[NAME]) was verified by staff interviews and record reviews of in-services on [DATE] across all disciplines. 1. The SA verified the facility's investigation of Resident #1's incident on [DATE]. Resident #1 was found unresponsive, without vital signs, and CPR was not performed per interviews, record review and review of written statements from staff and written reports to the SA. 2. The SA validated through interview with the DON and record review that all residents who had expired in the facility since [DATE], were reviewed to ensure code status was followed. 3. The SA validated through interview with the Administrator and DON and record review that the code status of all residents was reviewed by the facility on [DATE]. 4. The SA validated through document review and interview with the Attorney General Office Chief Investigator on [DATE], that the office had received an online report on [DATE], from the facility regarding the incident. 5. The SA validated through document review and interview with the Mississippi Board of Nursing Investigator on [DATE], that the office had received an online complaint on [DATE], from the facility regarding the incident. 6. The SA validated through document review and interviews with the DON, MDS Nurse, and the Director of Medical Records that an audit was completed on [DATE], of all residents' charts to ensure code status was on physician orders [REDACTED]. 7. The SA validated through record review and through interviews of RNs and LPNs that in-service training was conducted starting [DATE], regarding CPR, abuse/neglect, resident rights, following physician orders [REDACTED]. The SA validated through interview that staff were not allowed to work until in-serviced. 8. The SA validated through record review, time card review, and interview with the DON and Administrator that LPN #1 was suspended on [DATE] at the completion of her shift. 9. The SA validated by record review of the Quality Assurance (QA) Committee sign in sheet dated [DATE], and interview with the Administrator, DON, Medical Director, MDS Coordinator, Certified Food Service Manager, and Licensed Social Worker that the facility initiated a QA Committee meeting on [DATE], with the facility Administrator, DON, Medical Director, MDS Coordinator, Certified Food Service Manager, Licensed Social Worker, and Licensed Activity Director in attendance concerning the failure of LPN #1 to follow Doctor's orders for code status of Resident #1. Policy and Procedure pertaining to code status, CPR, Abuse/Neglect, Resident Rights and Advance Directives were reviewed. 10. The SA validated through document review and interview with the DON and Administrator that notification of the facility's failure to initiate CPR to Resident #1 was made to the State Agency of Licensure and Certification on [DATE].

Based on record review, facility policy review, and staff interview, the facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) on Resident #1, who had an Advance Directive for full code status, for one (1) of nine (9) resident records reviewed, as evidenced by Resident #1 was found unresponsive and without vital signs and CPR was not initiated by facility staff. Resident #1 expired in the emergency room . On [DATE], a facility Certified Nurse Aide (CNA) found Resident #1 unresponsive in bed and paged for a nurse. The facility nurse checked for Resident #1's vital signs with no results and failed to initiate CPR for Resident #1, who had a documented Advance Directive for a full code status. The facility's failure to initiate CPR on a resident with an Advance Directive for full code status, who was found to be unresponsive and without vital signs, placed this resident and other residents, with an advanced directive for full code status, in a situation that was likely to cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ), which began on [DATE], when Resident #1 did not receive CPR as required. The facility Administrator was notified of the IJ on [DATE]. The State Agency (SA) received an acceptable credible Allegation of Compliance (A[NAME]) on [DATE], in which the facility alleged removal of the IJ on [DATE]. The SA determined the IJ to be removed as of [DATE], prior to exit. The scope and severity for IJ at 42 CFR 483.24 (a) (3) F678 Cardio-Pulmonary Resuscitation (CPR), was lowered to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Emergency Procedure - Cardiopulmonary Resuscitation (CPR) policy, with a revision date of (MONTH) (YEAR), revealed General Guidelines 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall initiate CPR unless: a. it is known that a DNR order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis). 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [REDACTED]. Emergency Procedure - Cardiopulmonary Resuscitation 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911. B. Instruct a staff member to retrieve the automatic external defibrillator. C. Verify or instruct a staff member to verify the DNR or code status of the individual. D. Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, and breathing). 7. Continue with CPR/BLS until emergency medical personnel arrive. Review of Resident #1's medical record revealed a Code Status consent form, dated [DATE], signed by the resident's daughter, for a full code directive. Review of Resident #1's (MONTH) (YEAR) physician orders [REDACTED].>Review of a written report from the facility, dated [DATE], revealed CNA #1 found Resident #1 unresponsive on [DATE], at approximately 5:40 PM, and without vital signs. CNA #1 called for a nurse to the resident's room. Licensed Practical Nurse (LPN) #1 entered Resident #1's room at approximately 5:44 PM, and found the resident in bed, unresponsive, and without vital signs. The LPN did not initiate CPR. The report documented at 5:45 PM, LPN #1 and CNA #1 exited the resident's room, headed to the emergency room (ER), with the resident in bed. The ER is attached to the facility via a hallway. CPR was initiated in the ER at 5:50 PM, approximately 10 minutes after the resident was found unresponsive. Resident #1 expired at 6:11 PM. A telephone interview with CNA #1, on [DATE] at 2:00 PM, revealed she went into Resident #1's room to pick up the resident's supper tray on [DATE], and found Resident #1 unresponsive. She stated she pulled the call light and reported that she needed the nurse in the room now. CNA #1 stated she waited and finally went to find the nurse herself. She stated, I told the nurse (LPN #1) I needed her in Resident #1's room and she told me she'd be there in a minute. I told her I needed her in the room now because the resident was unresponsive. She stated that LPN #1 said, Let's go. CNA #1 stated they entered Resident #1's room and LPN #1 rubbed Resident #1's chest and checked for a pulse and then said, Let's take her to the ER. CNA #1 stated, We headed down the hall to the ER, pushing the resident in her bed. I didn't know what her code status was and the nurse didn't say anything about CPR, just that we had to get her to the ER. CNA #1 confirmed she was not certified in CPR. Interview with LPN #1 on [DATE] at 10:30 AM, revealed that she was in another resident's room giving medications when she heard the page and finished the medication pass for that resident. LPN #1 stated she hit the call light and the ward clerk told her that Resident #1 wasn't looking good. She stated as she came out of that resident's room CNA #1 was coming around the corner, and said Resident #1 was unresponsive. LPN #1 stated that she locked her cart and went straight to Resident #1's room, where the resident was sitting up in bed with her eyes closed. I went up to her and touched her hands and she was cool to touch. LPN #1 stated that she rubbed the resident's chest, felt for a pulse in her wrist and couldn't feel anything, and the resident didn't respond at all. She stated that they unplugged the bed and started wheeling Resident #1 to the ER. LPN stated that she saw the green dot on the door as they were leaving the room, which meant the resident was a full code. LPN #1 stated, It didn't dawn on me to start CPR. I was just trying to get her to help. LPN #1 stated, Yes, I should have started CPR. Interview with the Director of Nursing (DON) on [DATE] at 6:00 PM, revealed that on [DATE], LPN #1 failed to initiate CPR on Resident #1, who had an Advance Directive for Full code status, and should have. Review of the Facility's face sheet revealed Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed staff assessed Resident #1 with moderately severe cognitive impairment. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], for the IJ. Review of the facility's A[NAME] revealed the facility took the following actions to remove the IJ: 1. On (MONTH) 7, (YEAR), at 5:40 PM, Licensed Practical Nurse (LPN) #1 was called to the room of Resident #1, by Certified Nursing Assistant (CNA) #1, and found Resident #1 to be unresponsive with no vital signs at 5:44 PM, which LPN #1 documented in the Nurses Notes. CNA #1 was not certified in Cardiopulmonary Resuscitation (CPR), therefore did not initiate CPR. At 5:45 PM, LPN #1 and CNA #1 exited Resident #1's room and transported Resident #1 in her hospital bed to the ER. The Responsible Party (RP) of Resident #1 was notified on (MONTH) 7, (YEAR) at 5:59 PM, of Resident #1 being sent to the ER. CPR was not performed as ordered by the Physician. Resident #1 had a code status of resuscitate. LPN #1 failed to follow Physician orders [REDACTED].#1 on (MONTH) 7, (YEAR) at 5:44 PM. Based on ER records Resident #1 was received in the ER and chest compressions were initiated at 5:50 PM. Resident #1 was found unresponsive at 5:40 PM, and chest compressions were not initiated until 5:50 PM, in the ER. On (MONTH) 7, (YEAR) at approximately 9:30 PM, the Medical Director, who is also the Primary Physician for Resident #1, was informed of the failure of LPN #1 to follow Doctor's orders (for resuscitation) for Resident #1. 2. The Administrator and Director of Nursing reviewed the chart of Resident #1 on (MONTH) 11, (YEAR) at approximately 7:30 AM. A list of all residents who had died in the facility from (MONTH) 1, (YEAR) to (MONTH) 7, (YEAR) was reviewed on (MONTH) 11, (YEAR) at approximately 7:30 AM by the Administrator and Director of Nursing. Of the nine (9) deaths in the facility, only one (1) resident had a code status of resuscitate which was Resident #1. There were no circumstances to indicate any of the other eight (8) residents who died in the facility were the result of failure to follow physician orders [REDACTED]. 3. The Administrator, Director of Nursing and Director of Medical Records reviewed the code status of all residents at 8:00 AM on (MONTH) 11, (YEAR). It was determined that 28 residents out of 59 had a code status of resuscitate. 4. The Administrator notified the Attorney General's Office on (MONTH) 12, (YEAR) at 10:51 AM of the failure of LPN #1 to follow physician orders [REDACTED]. 5. The Board of Nursing was notified on (MONTH) 12, (YEAR) at 9:54 AM, by the Administrator, of the failure of LPN #1 to follow physician orders [REDACTED]. 6. On (MONTH) 12, (YEAR), the Director of Medical Records, Director of Nursing, and Minimum Data Set (MDS) Nurse reviewed all 59 charts to ensure that the code status, (Red) for Do Not Resuscitate and (Green) for Resuscitate and (Yellow) for Partial Code was on the physician orders [REDACTED]. It was noted at this time that all records were correct and reflected proper code status. 7. An in-service was initiated on (MONTH) 8, (YEAR) at 7:00 AM, by the Staff Development Coordinator, for all Licensed Practical Nurses and Registered Nurses regarding following physician orders [REDACTED]. There were a total of 15 nurses in-serviced. Twelve (12) LPNs and three (3) RNs were in-serviced. No LPN or RN will be allowed to work until in-serviced. 8. The Administrator suspended LPN #1 on (MONTH) 7, (YEAR) pending termination for failure to follow physician orders [REDACTED].#1. 9. The Quality Assurance Committee met on (MONTH) 15, (YEAR) at 5:00 PM, with the following members present: Licensed Social Worker, Licensed Activity Director, Administrator, Certified Food Service Manager, Medical Director, Minimum Data Set Coordinator, and Director of Nursing. Committee members were made aware of the allegation of noncompliance of the failure of LPN #1 to follow Doctor's orders for code status of Resident #1. Members were told that all licensed staff would be in-serviced regarding following physician orders [REDACTED]. They were also informed that the residents' code status would be visible on all doors. 10. An official report was made to the Mississippi State Department of Health by the Administrator on [DATE] at 8:46 AM, of the incident of the failure of LPN #1 to follow physician orders [REDACTED].#1. The Facility alleges the immediacy was removed effective [DATE]. On [DATE], the State Agency (SA) survey validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable credible Allegation of Compliance (A[NAME]) was verified by staff interviews and record reviews of in-services on [DATE] across all disciplines. 1. The SA verified the facility's investigation of Resident #1's incident on [DATE]. Resident #1 was found unresponsive, without vital signs, and CPR was not performed per interviews, record review and review of written statements from staff and written reports to the SA. 2. The SA validated through interview with the DON and record review that all residents who had expired in the facility since [DATE], were reviewed to ensure code status was followed. 3. The SA validated through interview with the Administrator and DON and record review that the code status of all residents was reviewed by the facility on [DATE]. 4. The SA validated through document review and interview with the Attorney General Office Chief Investigator on [DATE], that the office had received an online report on [DATE], from the facility regarding the incident. 5. The SA validated through document review and interview with the Mississippi Board of Nursing Investigator on [DATE], that the office had received an online complaint on [DATE], from the facility regarding the incident. 6. The SA validated through document review and interviews with the DON, MDS Nurse, and the Director of Medical Records that an audit was completed on [DATE], of all residents' charts to ensure code status was on physician orders [REDACTED]. 7. The SA validated through record review and through interviews of RNs and LPNs that in-service training was conducted starting [DATE], regarding CPR, abuse/neglect, resident rights, following physician orders [REDACTED]. The SA validated through interview that staff were not allowed to work until in-serviced. 8. The SA validated through record review, time card review, and interview with the DON and Administrator that LPN #1 was suspended on [DATE] at the completion of her shift. 9. The SA validated by record review of the Quality Assurance (QA) Committee sign in sheet dated [DATE], and interview with the Administrator, DON, Medical Director, MDS Coordinator, Certified Food Service Manager, and Licensed Social Worker that the facility initiated a QA Committee meeting on [DATE], with the Facility Administrator, DON, Medical Director, MDS Coordinator, Certified Food Service Manager, Licensed Social Worker, and Licensed Activity Director in attendance concerning the failure of LPN #1 to follow Doctor's orders for code status of Resident #1. Policy and Procedure pertaining to code status, CPR, Abuse/Neglect, Resident Rights and Advance Directives were reviewed. 10. The SA validated through document review and interview with the DON and Administrator that notification of the facility's failure to initiate CPR to Resident #1 was made to the State Agency of Licensure and Certification on [DATE].