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1. “Cheat Sheets” used by nursing staff to access resident’s DNR/code status – Minnesota Department of Health investigators found neglect on the part of a Pioneer Care facility located in Fergus Falls, MN in an incident involving a resident who died without being given CPR. The state investigation finding of neglect was based partly on the facility’s informal system or “cheat sheet” maintained by the nursing staff to access each resident’s advance directive choice or “code status”.