**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the Resident's right to be free from neglect when licensed nurses did not provide needed services to prevent the resident, who had difficulty breathing, from becoming unresponsive and die for one of one sampled resident (Resident 45). The facility failed to: 1. Ensure licensed nurses conducted timely assessments of Resident 45's physical condition when the resident developed breathing difficulty. 2. Ensure Licensed Vocational Nurse (LVN) 1 had Resident 45 vital signs (measurements of the body's basic functions including oxygen saturation [amount of oxygen in blood], blood pressure [force of blood pushing against the blood vessels walls in the heart], respiration [process of breathing in and out], heart rate ( pulse : number of times the heart beats per minute), and temperature (measure how well the body can make and get rid of heat) taken and monitored when Certified Nursing Assistant (CNA 1) notified LVN 1 on [DATE] at 11:10 p.m., that the resident was having difficulty breathing. 3. Ensure Registered Nurse (RN) 1 monitored Resident 45's condition when she noted Resident 45 was having out of range oxygen saturation level (measure of how much oxygen is in the blood cells. For residents with Chronic Obstructive Pulmonary [referencing to lungs] disease ([COPD] a progressive lung disease that causes difficulty breathing) the reference range is 88% to 92%) on room air and was weak. 4. Ensure RN 1 notified Resident 45's physician of the resident's weakness and refusal to wear a LifeVest (a wearable device that help treat heart failure by monitoring for abnormal heart rhythms and deliver a shock to restore normal rhythm) upon admission. 5. Ensure staff followed the facility's policy and procedures (P&P) titled, Abuse Prevention and Prohibition Program, dated February 9, 2024, which indicated residents would be protected from neglect. These deficient practices resulted in Resident 45 not being monitored by the licensed nurses when Resident 45 had difficulty breathing and weakness on [DATE] at 11:10 p.m. On [DATE] at 4:26 a.m., Resident 45 was found unresponsive and was pronounced dead at 5:07 a.m., by the Paramedics (emergency medical response staff). These deficient practices placed 48 residents in the facility at risk to be neglected by licensed nurses in case their condition was changed. On [DATE] at 6:55p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) and the Director of Nursing (DON). On [DATE] at 2:57 p.m., the ADM submitted an acceptable IJ removal plan ([IJRP], an intervention to immediately correct the deficient practices). After verification of the IJRP implementation through observation, interview, and record reviews, the IJ was removed on [DATE] at 5:50p.m. in the presence of the ADM and the DON. The IJRP included the following: 1. Resident 45 expired on [DATE]. 2. On [DATE], the DON provided RN 1 with a one-to-one in-service (education) regarding responsibilities of a licensed nurse when assessment findings are outside the normal range. The in-service emphasized the importance of monitoring and reassessing the resident to determine the effectiveness of interventions and the resident's response to the interventions. 3. On [DATE], at 8:34 p.m., LVN 1 was sent home on an administrative leave pending the results of the facility's investigation of the allegation. 4. The facility has 48 residents in-house. All residents have the potential to be affected by the same deficient practice. 5. On [DATE], the DON reviewed changes in condition that occurred in the last 24 hours to ensure that the residents were assessed timely and appropriately. There were four residents with changes in condition. Licensed nurses assessed the residents timely and appropriately. 6. On [DATE] and [DATE] the Administrator and Director of Staff Development (DSD) provided an in-service to 47 facility's employees (62.6% of the total staff) regarding the facility's policy on Abuse and Neglect Prohibition. The in-service emphasized the following: a. Different types of abuse, including neglect. b. The definition and examples of neglect. c. The responsibility of the staff to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 7. The facility staff were given a post-test at the end of the in-service to evaluate their knowledge of the information they received. Passing score is 6 out of 6. Staff who don't pass will be asked to attend the in-service and take the post-test again. Staff who are currently on vacation or on leave (three licensed nurses) will be provided the in-service and post-test upon their return to work. 8. All new hires will be provided with an in-service and post-test by the Director of Staff Development (DSD) regarding the facility's policy on Abuse and Neglect Prohibition. Staff who don't pass will be asked to attend the in-service and take the post-test again. The in-service will address the following: a)Different types of abuse, including neglect; b)The definition and examples of neglect; c)The responsibility of the staff to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 9. Starting [DATE], the Administrator or designee will provide Abuse and Neglect Prevention in-service to staff quarterly for 1 year and twice a year thereafter. 10. On [DATE], the DON and Nurse Consultant provided an in-service to three RNs (100% of facility RNs) and 10 LVNs (76.9% of facility LVNs) regarding managing changes of condition. The in-service emphasized the following points: a) Conducting timely assessments, including vital signs, of a resident who has a change in condition; b) Notifying the physician of changes in condition; c) Monitoring the resident's condition; d) Reassessing the resident to determine the resident's response and the effectiveness of the interventions. 11. The licensed nurses were given a post-test at the end of the in-service to evaluate their knowledge of the information they received. Passing score is 5 out of 5. Licensed nurses who don't pass will be asked to attend the in-service and take the post-test again. Staff who are currently on vacation or on leave (three licensed nurses) will be provided the in-service and post-test upon their return to work. 12. Starting [DATE], the DON will provide training on managing changes in condition for all newly hired licensed nurses. 13. The DON will review changes in condition daily, from Monday through Friday, to ensure that prompt resident assessment was conducted in response to the change in condition. Changes in condition that occur on the weekend will be reviewed the following Monday. Findings will be corrected immediately. 14. The Medical Records Director will audit changes in condition daily, from Monday through Friday, to ensure that the medical provider was notified of changes in condition. Changes in condition that occur on the weekend will be audited the following Monday. Findings will be reported to the DON for follow-up. 15. The DSD will report the number of new hires for the month and if the abuse in-service training was provided for them to the Quality Assessment and Assurance ([QAA] process to identify how the facility is performing and maintain quality of care) Committee during the Quality Assurance Performance improvement ([QAPI] process to improve services and outcomes) meeting monthly for three months. 16. The DON will report findings and trends from the change in condition review to the QAA Committee during the QAPI meeting monthly for three months. 17. The Medical Records Director will report findings and trends from the change in condition audits to the QAA Committee during the QAPI meeting monthly for three months. Findings: During a review of Resident 45's admission record, the admission Record indicated Resident 45 was initially admitted to the facility on [DATE] and was readmitted from a general acute care hospital (GACH) on [DATE] with diagnoses including COPD, End Stage Renal Disease ([ESRD] irreversible kidney failure), Congestive Heart Failure ([CHF] a disorder which causes the heart not to pump blood efficiently, sometimes resulting in leg swelling), and Type II Diabetes Mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 45's History and Physical (H&P) dated [DATE], the H&P indicated Resident 45 had fluctuating (varied) capacity to understand and make decisions. The H&P indicated Resident 45 was a full code (resident chooses to receive all life saving measures in case of an emergency) status. During a review of Resident 45's Minimum Data Set ([MDS] a resident assessment tool), dated [DATE], the MDS indicated Resident 45's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were mildly impaired. The MDS indicated Resident 45 required moderate assistance for most of her activities of daily living (sit to stand, chair/bed to chair transfer, walking 10 feet, shower transfer, dressing, bathing, oral and toileting hygiene), required supervision (no physical assistance) for personal hygiene, and required set up for eating. The MDS indicated Resident 45 utilized a wheelchair and did not have any impairments on both upper (arms/shoulders) and lower extremities (hip/legs). During a review of Resident 45's Order Summary Report (Physician's orders), the Order Summary Report indicated an order dated [DATE] to monitor the resident's vital signs every shift for 72 hours (every shift for baseline vital signs for three days). During a review of the Nurses Progress Notes dated [DATE] and timed at 7:25 a.m., completed by LVN 1, the Nurses Progress Notes indicated that on [DATE] around 2:20 a.m., Resident 45 was resting and was responsive to verbal stimuli (sounds or words produced by a speaker to get attention) with no complications. The Nurses Progress Notes indicated at 4:25 a.m., Resident 45 was unresponsive even after a Sternal Rub (painful stimulus with the knuckles at the center of the chest) to the center of the chest, so Cardiopulmonary Resuscitation (CPR an emergency procedure to restart a person's heart [chest compressions] and breathing after one or both have stopped) was initiated, 911 was called, and the doctor was notified. The Nurses Progress Notes indicated at 4:41a.m., Paramedics arrived at the facility and took over Resident 45's CPR. The Nurses Progress Notes indicated at 5:07a.m., Paramedics pronounced Resident 45 deceased . During a review of the Nurses Progress Notes dated [DATE] at 8:49 p.m., documented by RN 1, the Nurses Progress Notes indicated Resident 45 was alert and oriented, her respirations were even and unlabored (easy, effortless breathing, without any signs of difficulty or struggle), her blood pressure was 146/88 millimeters of mercury ([mmHg] unit of measure. Reference range 120/80 mmHg), heart rate of 80 beats per minute (reference range 60 to 100), respiratory rate of 17 breath per minute (reference range 12 to 20 breaths per minute), and 94% oxygen saturation on 3.0 ([L]unit of measure) per minute (min) L/M through a nasal cannula ([NC] device that delivers oxygen through thin tube s placed into nostrils). RN 1 stated she was uncomfortable with the way Resident 45 presented as she (Resident 45) seemed being out of it. RN 1 stated Resident 45 was too weak to sign the admission documents and the Physician Orders for Life-Sustaining Treatment ([POLST]residents' preferences for medical treatment) and said she would do it tomorrow on [DATE]. RN 1 stated when a resident is newly admitted or readmitted , the nurse that admits the resident completes a head-to-toe assessment, reviews the residents' medications and notifies the admitting physician for admission orders. RN 1 stated Resident 45 came to the facility with her LifeVest but she was not wearing it. RN 1 stated the nurse, who gave report over the phone from the GACH, told her Resident 45 refused the LifeVest. RN 1 stated when Resident 45 was admitted she did not look right. RN 1 stated she relayed this information to LVN 1 to ensure LVN 1 would monitor Resident 45 closely. RN 1 stated she should have informed the doctor that Resident 45 was not doing well upon admission. RN 1 stated the interventions to implement when a resident found unresponsive and pulseless (no heartbeat) include the following: 1. Do an assessment. 2. Get the crash cart (trays and drawers on wheels that contains emergency medication and equipment for life threatening emergencies). 3. Put the back board under the resident. 4. Announce a Code Blue (an announcement that signifies a medical emergency where a patient is experiencing a life-threatening situation) through the overhead paging system. 5. Take vital signs. 6. Put a nonrebreather mask (oxygen mask that delivers high concentrations of oxygen) on the resident. 7. Initiate chest compressions immediately. RN 1 stated the chest compressions should continue until the paramedics arrive at the room and take over. During an interview on [DATE] at 3:55p.m., LVN 1 stated he worked on [DATE] during the night shift (11 p.m. to 7 a.m.). LVN 1 stated when he came to work, he made rounds and visual checks on all residents to see if the residents were breathing. LVN 1 stated he received report from the outgoing RN 1, read Resident 45's H&P, and continued to provide care to other residents after he observed Resident 45 was doing okay at 2:20 a.m., on [DATE]. LVN 1 stated he normally makes rounds every one to two hours. LVN 1 stated facility residents' vital signs are taken at the beginning of the shift. LVN 1 stated around 4:00 a.m., he noticed Resident 45 was not communicating and unresponsive. LVN 1 stated Resident 45 was lying in bed and was warm to the touch. LVN 1 stated assessing a resident included to check vital signs and to document in the progress notes. LVN 1 stated vital signs are taken to identify the actual state of the resident since he would not know what is going on with the resident otherwise. During an interview on [DATE], at 9:15 a.m., CNA 1, stated on [DATE] at 11:10 p.m., she notified LVN 1 that Resident 45 was gasping for air and did not look well. CNA 1 stated she went to Resident 45's room with LVN 1. CNA 1 stated she did not witness LVN 1 assessing the resident or taking Resident 45 vital signs. CNA 1 stated LVN 1 told her he would go and look in Resident 45's chart. CNA 1 stated she went to check on Resident 45 again between 4:00 a.m. and 4:05 a.m., and she was still breathing. CNA 1 stated she went back to Resident 45's room around 4:26 a.m., when she heard LVN 1 in Resident 45's room calling Resident 45's name out loud four times. CNA 1 stated LVN 1 told her that Resident 45 was unresponsive, and they did not need to do anything. CNA 1 stated LVN 1 told her we do not need to check Resident 45's vitals. CNA 1 stated she still went to get the vital signs machine and asked CNA 2, who was in the hallway, to join her to assist. CNA 1 stated when CNA 2 and her went back into Resident 45's room with the vitals machine, LVN 1 instructed CNA 2 and her (CNA 1) to start CPR. CNA 1 stated when they started CPR Resident 45 was cold to the touch on her face, hands, and legs. CNA 1 stated LVN 1 brought in the crash cart, did not provide oxygen rescue breaths to Resident 45 during CPR, did not take the vital signs, and did not place the Back Board under Resident 45. CNA 1 stated she did not witness LVN 1 perform CPR on Resident 45 at any time. CNA 1 stated LVN 1 stated he was going to call the Paramedics and did not return to Resident 45's room after that. CNA 1 stated she and CNA 2 took turns to do Resident 45's chest compressions, but they did not provide any rescue breaths as they did not have an Ambu-Bag (handheld device to provide respiratory support to patients who are not breathing). CNA 1 stated while CNA 2 was doing chest compressions, she heard the Paramedics entering the facility and she instructed CNA 2 to stop doing chest compressions since the Paramedics were in the building. During an interview on [DATE], at 10:07 a.m., CNA 2 stated when he was going to take the trash out after changing a resident, he saw CNA 1 walking towards him. CNA 2 stated he did not know what was going on as he did not hear any Code Blue called. CNA 2 stated he walked with CNA 1 to Resident 45's room per CNA 1's request and observed Resident 45 laying in bed with the head of bed elevated. CNA 2 stated CNA 1 asked LVN 1 if he wanted to take vitals and he said, no it is fine and instructed him and CNA 1 to begin CPR, as he (LVN 1) left the room to call Paramedics. CNA 2 stated CNA 1 was looking out in the hallway and heard the Paramedics were coming so she told him (CNA 2) to stop doing chest compressions. CNA 2 stated Paramedics came in and took over the situation. CNA 2 stated at the beginning of the shift (11:00 p.m. to 7:00 a.m.), CNA 1 notified him (CNA 2) that Resident 45 did not look well so CNA 1 and him went to observe Resident 45 together. CNA 2 stated upon observation, Resident 45 had the oxygen via nasal cannula on, but seemed weak as she was not able to move her arms or change positions in her bed and appeared to have issues with breathing. During a concurrent interview and record review on [DATE] at 1:47 p.m., with RN 1, Resident 45's Medication Administration Record ([MAR] document that tracks medications given to residents) dated [DATE] - [DATE] was reviewed. RN 1 stated there were no vital signs documented but considering Resident 45's history of COPD, the oxygen saturation should have been checked and documented. RN 1 stated a review of the doctor's order indicated to monitor vital signs every shift for 72 hours (every shift for baseline vital signs for three days) on [DATE]. RN1 stated since Resident 45's vital signs were not taken; the doctors' orders were not followed. RN 1 stated if it was not documented it was not done. RN 1 stated doctors' orders have to be followed, not following the orders can compromise the residents' health. During an interview on [DATE] at 2:32 p.m., the DSD stated if a Code Blue is called, someone gets supplies, check oxygen saturation, have someone documenting the vital signs, get the crash cart, and call 911. The DSD stated the blood pressure cuff will not be taken off and the vital signs will be continuously checked. The DSD stated every resident's vital signs should be checked at the beginning of the shift. The DSD stated there is a nonrebreather (a manual device used to deliver oxygen) mask on the crash cart, and a Back Board that is needed to provide effective chest compressions. The DSD stated during a Code Blue, while one staff is performing chest compressions another staff member gives rescue breaths with the Ambu-Bag. The DSD stated someone calls the code blue on the overhead paging system to ensure everyone in the facility is aware of the emergency and can respond immediately. The DSD stated CPR needs to be continuous until there is a pulse or until Paramedics arrive and take over the CPR. During an interview on [DATE] at 3:21p.m., the DON stated if a resident is nonresponsive the most important body systems to assess are airways (a passage where air reaches a person's lungs), breathing, and blood circulation. The DON stated if it is appropriate, to start chest compressions, have someone call 911, bring the crash cart, use the Ambu-Bag for rescue breaths. The DON stated chest compressions will be continuously provided until the Paramedics will arrive and take over. During an interview on [DATE] at 4:22 p.m., the DON, stated when a new admission or readmission arrives at the facility, the licensed nurse should accompany the resident to the room to observe the resident's condition and ensure the resident is stable. The DON stated when a resident has a change in condition (COC) the licensed staff are expected to check the resident's blood sugar level and vital signs to see if they are within normal reference range. The DON stated when a resident is having shortness of breath, the licensed nurse cannot leave the resident unmonitored until the resident's condition is stable. During a concurrent interview and record review on [DATE] at 4:42 p.m., LVN 1's Progress Notes were reviewed. The DON stated Resident 45 was admitted back to the facility on [DATE] and passed at the facility on [DATE]. The DON stated the vital signs should have been taken within the shift 11 p.m. to 7 a.m. The DON stated the vital signs were not recorded and if it was not documented it was not done The DON stated LVN 1 and/or RN 1 did not check Resident 45's blood sugar level since Resident 45 was a diabetic and was unresponsive. The DON stated the licensed nurses did not check Resident 45's vital signs during 11:00 p.m. to 7:00 a.m. shift and the last vital signs were taken on [DATE] at 8:49 p.m. during the resident's admission. The DON stated there were no documentations to indicate whether LVN 1 checked Resident 45's pulse prior to instructing CNA 1 and CNA 2 to start CPR. The DON stated when CNA 1 reported to LVN 1 that Resident 45 was not doing well, LVN 1 should have assessed Resident 45 immediately when he went to the resident's room and to check vital signs. During a concurrent interview and record review on [DATE] at 4:53 p.m., with the DON, Resident 45's the Cardiology (a department responsible for concerns with diagnosis and treatment of heart-related diseases and disorders) Note and Supportive Care and Palliative (care focused on improving quality of life for individuals with serious illness without curing the condition) Visit Notes from the GACH were reviewed. The DON stated the Cardiology Note dated [DATE], indicated Resident 45 had a risk for sudden cardiac arrest (an unexpected condition where the heart stops breathing). The DON stated since Resident 45 refused the LifeVest and further implantable cardioverter defibrillator ([ICD] small device that monitors and responds to abnormal heart rhythm), Resident 45 was a high risk for cardiac arrest without interventions from the LifeVest or the ICD. The DON stated the Supportive Care and Palliative Visit Note from the GACH indicated Resident 45 wanted CPR. The DON stated when a resident has a Full Code status, the CPR is expected to be initiated when a resident unresponsive. During a concurrent interview and record review on [DATE] at 5:13 p.m., with the Emergency Medical Services Captain (EMSC), the Paramedic Run Sheet dated [DATE] was reviewed. The EMSC stated when the Paramedics arrived on scene, Resident 45 was found lying on her back in bed pulseless and apneic (involuntarily and temporarily stoped breathing). The EMSC stated the facility's staff were not doing CPR when they arrived. The EMSC stated initiating CPR may increase the chances of a resident survival. During an interview on [DATE] at 6:28 p.m., the DON stated neglect constitutes when staff does not provide needed care and staff is not doing their job in such instances if a resident needs medication and it is not given, that would be considered negligence. During a review of the facility's P&P titled, Abuse Prevention and Prohibition Program, dated February 9, 2024, the P&P indicated each resident has the right to be free from neglect, and mistreatment. The facility has zero-tolerance for neglect, staff must not permit anyone to engage in neglect, and mistreatment. The facility maintains adequate staffing on all shifts to ensure that the needs of each resident are met. Neglect: inadequate provision of care, caregiver indifference to resident's personal care and needs. During a review of the facility's P&P, titled, Change of Condition Notification, dated February 9, 2024, the P&P indicated an acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavior, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. The Licensed Nurse will assess the resident's change of condition and document the observations and symptoms. A Licensed Nurse will document the following: Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received. A Licensed Nurse will document each shift for at least seventy-two (72) hours. During a review of the facility's P&P, titled, admission Assessment, dated February 9, 2024, the P&P indicated the assessment process must include direct and indirect observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. Assessment findings may necessitate communication with attending physician for treatment or care orders. The assessment will be documented and will be communicated with licensed and nonlicensed direct care staff members on all shifts. During a review of the facility's P&P, titled, Cardiopulmonary Resuscitation, dated February 21, 2024, the P&P indicated to sustain or support a resident's cardiac and/or pulmonary function(s) until medical emergency personnel are available to take over the resuscitation efforts. Cardiopulmonary resuscitation is instituted on all residents except those designated as No Code or No CPR. In the absence of a DNR order, CPR will be performed. The facility will perform CPR in accordance with the guideline set forth by the American Heart Association. Establish unresponsiveness, verify code status prior to the initiation of CPR, alert the emergency response team (call 911), check for pulse, CPR will be initiated using the standards outline in the American Heart Association's most current CPR guidance, continue CPR until paramedics arrive and take over.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident, who had a Full Code (resident wants all life saving measures in case of emergencies) status and was in distress received Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart (chest compressions) to increase the chances of a resident's survival for one of 39 residents who had a Full Code status (Resident 45). The facility failed to: 1. Ensure facility staff were knowledgeable what actions to take when responding to a resident in distress. 2. Ensure Licensed Vocational Nurse (LVN )1 announced a Code Blue (an announcement that signifies a medical emergency where a patient is experiencing a life-threatening situation) when he found Resident 45 unresponsive. 3. Ensure LVN 1 provided resuscitation (action or process of reviving someone from unconsciousness or apparent death) and basic life support ([BLS], basic care healthcare professionals provide to anyone who's heart stops beating suddenly) such as CPR, immediately without loss of critical time to Resident 45 when the resident was found unresponsive (a person is unable to respond to their surrounding and do not react to stimulation like touch, sound, or pain) on [DATE] at 4:30 p.m. 4. Ensure Certified Nursing Assistant (CNA) 1 and CNA 2 did not stop delivering chest compressions (involves giving strong, rapid pushes to the chest to keep blood moving through the body) to Resident 45's before the Paramedics were able to take Resident 45's CPR over. 5. Ensure staff implemented the facility's policy and procedure (P&P) titled, Cardiopulmonary Resuscitation dated February 21, 2024, which indicated to sustain or support a resident's cardiac (related to heart) and/or pulmonary (related to lungs) function(s) until medical emergency personnel are available to take over the resuscitation efforts and the American Heart Association ([AHA] the leader in resuscitation science, education, and training, and publisher of the official Guidelines for CPR) guidelines that indicated First responder would call for help, send available staff to call a Code Blue and retrieve emergency medical equipment, assess the residents' level of consciousness, circulation, airway, and breathing and begin CPR, call 911, CPR will continue until the paramedics arrive and assume responsibility. These deficient practices resulted in the delay of life saving measures such as CPR for Resident 45 when she was found unresponsive on [DATE] at 4:30 p.m., and pronounced dead on [DATE] at 5:07 a.m. These deficient practices placed 38 residents, who had a Full Code status at risk not to receive CPR. On [DATE] at 6:55 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure the facility staff provided basic life support to Resident 45, including CPR immediately upon discovering the resident had difficulty breathing and became unresponsive. On [DATE] at 2:57 p.m., the Facility submitted an acceptable IJ removal plan ([IJRP], an intervention to immediately correct the deficient practices). After verification the IJRP was implemented through observation, interview, and record reviews, the IJ was removed while onsite on [DATE] at 5:50 p.m., in the presence of the ADM and the DON. The IJRP included the following: 1. Thirty eight of the 48 residents in the facility were Full Code. All 38 residents have the potential to be affected by the same deficient practice. There were no medical emergencies that occurred in the last 24 hours. 2. On [DATE], a BLS certified instructor provided BLS training to 11 licensed nurses (91.6% of total licensed staff) and 18 CNAs (64.2%). The training consisted of in person instructions on when to initiate CPR and how to perform the CPR correctly according to the American Heart Association guidelines, and skills demonstration of the proper CPR procedure. 3. On [DATE], the DON and the Nurse Consultant conducted a Code Blue drill for nursing staff to simulate a medical emergency. The drill emphasized the staff's responsibility to respond to a medical emergencies, the various roles and responsibilities of the staff when responding to a medical emergency, how to operate emergency equipment found in the crash cart (cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate a patient experiencing cardiac arrest), including the Ambu-bag (a medical device that helps patients breathe by forcing air into their lungs) and cardiac board (a rigid board used to provide a firm surface for chest compressions during CPR). There were 12 licensed nurses (92.3% of total number of licensed nurses) and 18 CNAs (64.2%) who participated in the drill. Nursing staff who were currently on vacation or on leave will be provided the in-service and post-test upon their return to work. 4. Starting [DATE], the DON and Nurse Consultant will conduct a Code Blue drill for nursing staff quarterly for one year and then annually thereafter. 5. On [DATE], the DON and Nurse Consultant provided an in-service to three Registered Nurses (RNs) (100%) and 10 LVNs (76.9%) regarding managing changes of condition. The in-service emphasized the following points: a. Conducting timely assessments, including vital signs, of a resident who has a change in condition. b. Notifying the physician of changes in condition. c. Monitoring the resident's condition. d. Reassessing the resident to determine the resident's response and the effectiveness of the interventions. e. Initiating CPR promptly when the resident is not breathing and/or does not have a pulse. f. The licensed nurses were given a post-test at the end of the in-service to evaluate their knowledge of the information they received. Passing score was 5 out of 5. Licensed nurses who don't pass will be asked to attend the in-service and take the post-test again. Staff who are currently on vacation or on leave (three licensed nurses) will be provided the in-service and post-test upon their return to work. g. The DON will review changes in condition daily, from Monday through Friday, to ensure that prompt resident assessment was conducted in response to the change in condition. Changes in condition that occur on the weekend will be reviewed the following Monday. Findings will be corrected immediately. h. The DON will report findings and trends from the change in condition review to the Quality Assessment and Assurance ([QAA ] process to identify how the facility is performing and maintain quality of care) Committee during the Quality Assurance Performance improvement ([QAPI] process to improve services and outcomes) meeting monthly for three months. i. The Medical Records Director will report findings and trends from the change in condition audits to the QAA Committee during the QAPI meeting monthly for 3 months. Findings: During a review of Resident 45's admission record, the admission Record indicated Resident 45 was initially admitted to the facility on [DATE] and was readmitted from a general acute hospital (GACH) on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease (COPD: progressive lung disease causing difficulty in breathing), End Stage Renal Disease (ESRD: irreversible kidney failure), Congestive Heart Failure (CHF: a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and Type II Diabetes Mellitus (DM: a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 45's History and Physical (H&P) dated [DATE], the H&P indicated Resident 45 had fluctuating (varied) capacity to understand and make decisions. The H&P indicated Resident 45 was a Full Code (FC) status. During a review of Resident 45's Minimum Data Set ([MDS] a resident assessment tool), dated [DATE], the MDS indicated Resident 45's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were mildly impaired. The MDS indicated Resident 45 required moderate assistance for most of her activities of daily living (sit to stand, chair/bed to chair transfer, walking 10 feet, shower transfer, dressing, bathing, oral and toileting hygiene), required supervision (no physical assistance) for personal hygiene, and required set up for eating. The MDS indicated Resident 45 utilized a wheelchair and did not have any impairments on both the upper (arms/shoulders) and lower extremities (hip/legs). During a review of Resident 45's Order Summary Report (physician's orders), the Order Summary Report indicated an order dated [DATE] to monitor the resident's vital signs (measurements of the body's basic functions including oxygen saturation [amount of oxygen in blood], blood pressure [force of blood pushing against the blood vessels walls in the heart], respiration [process of breathing in and out], heart rate (pulse : number of times the heart beats per minute), and temperature (measure how well the body can make and get rid of heat) every shift for 72 hours (every shift for baseline vital signs for three days). During a review of the Paramedics (emergency medical responders) report dated [DATE] at 4:45 a.m., the Paramedics report indicated when the Paramedics arrived to Resident 45's room, Resident 45 was lying on her back, pulseless (no heart beat), apneic (involuntarily and temporarily stops breathing), had an oxygen saturation (amount of oxygen in blood) of 79 percent (%) (COPD resident reference rate 88% to 92%), and a blood glucose (amount of sugar in blood) level of 45 (reference range 70 milligrams per deciliter (mg/dL: unit of measure used to report concentration of a substance in a fluid) to 100mg/dL). The Paramedics report indicated the staff did not conduct CPR prior to the Paramedics arrival. The report indicated the Paramedics initiated CPR at 4:45a.m., and after 20 minutes of performing CPR with no change, Resident 45 was pronounced dead at 5:07 a.m. During a review of the Nursing admission assessment dated [DATE] at 8:43 p.m., the Nursing admission Assessment indicated Resident 45 was admitted on [DATE] at 6:55p.m. Resident 45 was alert, oriented to person, had weakness in both upper and lower extremities. During a review of the Nurses Progress Notes dated [DATE] at 7:25 a.m., documented by LVN 1, the Nurses Progress Notes indicated around 2:20 a.m., Resident 45 was resting and responsive to verbal stimuli (sounds or words produced by a speaker to get attention) with no complications. The Nurses Progress Notes indicated at 4:25a.m., Resident 45 was unresponsive to sternal rub (painful stimulus with the knuckles at the center of the chest), CPR was initiated, 911 was called, and the doctor was notified. The Nurses Progress Notes indicated at 4:41 a.m., Paramedics arrived at the facility and took over Resident 45's CPR. The Nurses Progress Notes indicated at 5:07a.m., Paramedics pronounced Resident 45 deceased . During an interview on [DATE] at 2:32p.m., RN 1 stated when Resident 45 arrived at the facility on [DATE], she appeared unkempt, speech was clear and seemed tired. RN 1 stated during Resident 45's admission assessment, Resident 45 was able to state her name, her oxygen saturation (measure of how much oxygen is in the blood cells [COPD resident reference rate 88% to 92%] was in the low 90s. so she gave the resident oxygen at 3.0 liters ([L] unit of measure) per minute (min) via nasal canula ([NC] device that delivers oxygen through a very small thin tubes placed into each nostril ). RN 1 stated she was uncomfortable with the way Resident 45 presented because she seemed out of it. RN 1 stated Resident 45 was too weak to sign admission documents or the Physician Orders for Life-Sustaining Treatment ([POLST] residents' preferences for medical treatment) and indicated she would do it tomorrow. RN 1 stated at the end of her shift she gave report to LVN 1 (the incoming nurse) to monitor Resident 45. RN 1 stated Resident 45 came to the facility with her LifeVest (a wearable device to monitor for abnormal heart rhythms and deliver a shock to restore normal rhythm) but she was not wearing it. RN 1 stated 1. RN 1 stated when Resident 45 was admitted , she did not look right. During an interview on [DATE] at 3:55p.m., LVN 1 stated he worked on [DATE] during the night shift (11p.m. to 7 a.m.). LVN 1 stated when he came to work, he made rounds and visually checked on all the residents, to see if the residents were breathing. LVN 1 stated he received report from the outgoing RN 1 read Resident 45's H&P and continued to provide care to other residents after he observed Resident 45 at 2:20 a.m. was doing okay. LVN 1 stated he normally makes rounds every one to two hours. LVN 1 stated around 4:00 a.m., he noticed Resident 45 was not communicating and unresponsive. LVN 1 stated Resident 45 was laying down and was warm to the touch. LVN 1 stated he initiated CPR, went to call 911, and had to go back to continue CPR. LVN 1 stated CNA 1 and CNA 2 were in Resident 45's room to help with CPR while he called 911. LVN 1 stated CNA 1 and CNA 2 took turns to do CPR. LVN 1 stated Resident 45 was wearing her nasal canula and he placed the flat board (provide a firm surface when chest compressions are performed to provide adequate and effective compressions) underneath the resident. During an interview on [DATE], at 9:15 a.m., CNA 1, stated she went to check on Resident 45 between 4:00 a.m. and 4:05 a.m., and the resident was breathing. CNA 1 stated she went back to Resident 45's room around 4:26 a.m., when she heard LVN 1 calling Resident 45's name out loud four times. CNA 1 stated LVN 1 told her that Resident 45 was unresponsive. CNA 1 stated LVN 1 to her nothing needed to be done, and she did not need to check Resident 45's vital signs. CNA 1 stated she still went to get the vital signs machine and asked CNA 2, who was in the hallway, to join her to assist. CNA 1 stated when CNA 2 and her went back into Resident 45's room with the vitals machine, LVN 1 instructed CNA 2 and her (CNA 1) to start CPR. CNA 1 stated when they started CPR, Resident 45 was cold to the touch on her face, hands, and legs. CNA 1 stated LVN 1 brought in the crash cart. CNA 1 stated no one provided rescue breaths to Resident 45 during CPR, no one took her vital signs and no one placed a Back Board under Resident 45. CNA 1 stated she did not witness LVN 1 perform CPR on Resident 45 at any time. CNA 1 stated LVN 1 stated he was going to call the Paramedics and never came back to Resident 45's room after that. CNA 1 stated she and CNA 2 took turns doing compressions, but they did not provide any rescue breaths as they did not have an Ambu-bag. CNA 1 stated while CNA 2 was doing compressions, she heard the Paramedics entering the facility and she instructed CNA 2 to stop doing compressions since the Paramedics were in the building. During an interview on [DATE], at 10:07 a.m., CNA 2 stated at the on [DATE] at the beginning of the shift (11:00 p.m. to 7:00 a.m.), CNA 1 notified LVN 1 that Resident 45 did not look-well and they together went to observe Resident 45. CNA 2 stated upon observation Resident 45 had oxygen via nasal cannula, but seemed weak as she was not able to move her arms and could not change positions in bed and appeared to have issues breathing. CNA 2 stated on [DATE], when he was going to take the trash out after changing one of the residents, he saw CNA 1 walking towards him and asked for his help with Resident 45, who was in distress. CNA 2 stated he did not know there was a Code Blue because he did not hear the code to be announced overhead . During an interview on [DATE] at 2:32 p.m., with the Director of Staff Development (DSD), the DSD stated during any shift, if a resident is in respiratory distress, licensed staff must assess the resident, call the doctor, check vital signs, and to give oxygen if the resident is desaturating (blood oxygen level is dropping). The DSD stated someone will call a Code Blue on the overhead to ensure everyone in the facility is aware and can respond immediately. The DSD stated staff must work together to gather supplies such as the crash cart, check and document the vital signs, and call 911. The DSD stated if a resident has a change of condition staff should take vital signs. The DSD stated an Ambu-bag is on the Crash Cart to provide breaths during compressions. The DSD stated staff should use a Back Board from the Crash Cart to provide effective compressions, if there is no Back Board, then staff need to put the resident on the floor for effective compressions. The DSD stated CPR needs to be continuous until there is a pulse or until the Paramedics arrive and take over. During an interview on [DATE] at 1:56 p.m., CNA 3 stated she worked the 11 p.m. to 7 p.m. shift on [DATE]. CNA 3 stated she did not hear any Code Blues called on [DATE] during the 11:00p.m. to 7:00a.m. During an interview on [DATE] at 3:21 p.m., the DON stated if a resident is nonresponsive the licensed nurses should assess the resident's breathing, heartbeat, and if indicated start chest compressions while another staff member calls 911, bring the Crash Cart, use the Ambu-bag. The DON stated chest compressions should be continuous until the Paramedics come and take CPR over. During a concurrent interview and record review on [DATE] at 4:42 p.m., with the DON, Resident 45's Nurses Progress Notes dated [DATE] were reviewed. The DON stated Resident 45 was admitted back to the facility on [DATE] and passed at the facility on [DATE]. The DON stated the resident's vital signs were not recorded during the 11 p.m. to 7 a.m. shift. The DON stated if it was not documented, it was not done. The DON stated during a life-threatening emergency someone will call a Code Blue on the overhead speaker to ensure everyone in the facility is aware and can respond immediately. The DON stated on [DATE] at 11:10 p.m. when CNA 1 reported to LVN 1 that Resident 45 was having difficulty breathing, LVN 1 should have assessed Resident 45 immediately, including taking vital signs and checking oxygen saturation. The DON stated since Resident 45 was a Full Code, the life saving measures such as CPR should have been initiated immediately when the resident was found unresponsive. During a concurrent interview and record review on [DATE] at 4:53 p.m., with the DON Resident 45's GACH records were reviewed. The DON stated on the Cardiology Note dated [DATE], Resident 45 had a risk for sudden cardiac arrest as she had refused the LifeVest and further implantable cardioverter defibrillator ([ICD] small device that monitors and responds to abnormal heart rhythm) workup. During a concurrent interview and record review on [DATE] at 5:13 p.m., the Paramedic Run Sheet dated [DATE] was reviewed with the Emergency Medical Services Captain (EMSC).The EMSC stated when the Paramedics arrived on scene (Resident 45's bedside), Resident 45 was found pulseless and apneic lying on her back in bed. The EMSC stated staff did not start CPR prior to the Paramedics arrival. The EMSC stated initiating CPR timely may increase the chances of survival of the resident and the facility was not doing CPR when they arrived. During a review of the facility's P&P titled, Cardiopulmonary Resuscitation dated February 21, 2024, the P&P indicated to sustain or support a resident's cardiac and/or pulmonary function(s) until medical emergency personnel are available to take over the resuscitation efforts. Cardiopulmonary resuscitation is instituted on all residents except those designated as No Code or No CPR. In the absence of a Do Not Resuscitate ([DNR] medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) order, CPR will be performed. The facility will perform CPR in accordance with the guideline set forth by the American Heart Association. Establish unresponsiveness, verify code status prior to the initiation of CPR, alert the emergency response team (call 911), check for pulse, CPR will be initiated using the standards outline in the American Heart Association's most current CPR guidance, continue CPR until paramedics arrive and take over, Documentation: Whether the incident was witnessed: A. Date and time event was recognized. B. When you found the resident and started CPR. C. Condition of the resident when ventilation (respiration status), chest compressions or defibrillation needed. D. How long the resident received CPR. E. The resident's response to CPR. F. Any interventions taken to correct complications. During a review of the facility's P&P titled, Change of Condition Notification, dated February 9, 2024, the P&P indicated an acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavior, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. The Licensed Nurse will assess the resident's change of condition and document the observations and symptoms. A Licensed Nurse will document the following: Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received. A Licensed Nurse will document each shift for at least seventy-two (72) hours. During a review of the facility's P&P titled, Medical Emergencies-Code Blue dated February 9, 2024, the P&P indicated to ensure the prompt and effective response by Facility personnel during medical emergencies through the use of the Code Blue procedure. A medical emergency is defined as one of the following conditions requiring immediate medical intervention and the initiation of the Code Blue procedure: Respiratory or cardiac arrest (when the heart suddenly and unexpectedly stops beating). Once CPR is initiated, it will continue until Paramedics arrive. I. First Responder A. The first of Facility personnel to arrive and find a resident with any of the above conditions will: 1. Call for help. 2. Send available staff to call a Code Blue and retrieve emergency medical equipment. 3. Assess the resident's level of consciousness, circulation, airway, and breathing; begin CPR according to the current practice. Note: The first responder should not leave the victim to call for help unless absolutely necessary according to the situation. 4. When the second responder arrives, have the second responder place the cardiac arrest board under the resident and assist with two-rescuer CPR. II. Subsequent Responder(s): A. Active the Emergency Response System-Call 911. B. Direct all needed personnel to the Code Blue site. C. Send a Staff member to the entrance door to wait where the ambulance is expected to arrive. D. The first RN to respond will lead the code unless responsibility is transferred to another licensed staff member (RN or Medical Doctor). E. If no other RN or MD is available, the RN will follow the procedure as given in the Unit Nurse or Designee section below. F. Note: One person CPR will be maintained until there is a second responder available to begin two person CPR. G. CPR will continue until the paramedics arrive and assume responsibility. III. Roles During the Code: Any available Nursing Staff will complete the tasks as directed in the First Responder and Subsequent Responder sections of this procedure. IV. Licensed Nurse: A. In the absence of an Attending Physician, it will be the responsibility of the first licensed staff member responding to the code to lead, and coordinate the resuscitation efforts until paramedics arrive. B. The nurse will assure that the following tasks have been completed and/or assigned: 1. CPR has been initiated. 2. 911 has been called. 3. Code Blue or STAT (immediately) has been paged overhead. 4. Emergency Cart is on the scene. 5. Staff have been assigned to monitor other residents and move them to a safe area during the code blue. 6. Attending MD and/or MD on-can has been notified Director of Nursing/Nurse Manager has been notified. 7. Document the event in the resident record. 8. Charting of time and condition of the resident at the time of discovery, CPR initiated, when Code Blue called, when physician and family notified, and when nursing staff responded.