**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) was free from accident smoking hazards by failing to: 1. Supervise and monitor Resident 1, who was non-compliant with the facility's smoking policy, titled Resident Smoking, when the resident went to the facility's outdoor patio to smoke a cigarette while on oxygen. 2. Implement Resident 1's care plan interventions of being non-compliant with the facility's smoking schedule and policy that indicates facility staff would supervise Resident 1 while smoking. 3. Ensure the facility nursing staff maintained Resident 1's smoking materials, in accordance with the facility's policy and procedures (P&P) titled, Resident Smoking. 4. Revise and update Resident 1's care plan of being non-compliant with smoking schedule and smoking policies dated 6/17/2024, when Resident 1 attempted to go outside and smoke while on oxygen [a colorless, odorless, reactive gas] on 7/20/2024. 5. Designate a facility staff responsible in supervising residents while residents smoke, in accordance with the facility's policy and procedure, titled, Resident Smoking. As a result, on 7/31/2024, at around 3pm, Resident 1 went to the facility's outdoor patio and lit his cigarette while on oxygen via nasal cannula (NC- a thin, flexible tube that wraps around the head for oxygen administration). The resident sustained second degree burns (partial thickness burn that affects the first and second layer of the skin causing blistering [painful swellings that contain liquid], skin discoloration, and pain) to both cheeks, lips, singed (burned surface) facial hairs, and both hands when a flash fire ignited the oxygen flow from the resident's NC. Resident 1 was transferred to the General Acute Care Hospital (GACH) 1 via 911 emergency services on 7/31/2024. Subsequently, Resident 1 was transferred to GACH 2 Burn Center (a hospital specializing in the treatment of burns) for additional treatment. On 8/1/2024 at 5:15 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility's failure to provide supervised smoking for a resident (Resident 1) who had continued non-compliance with the facility's smoking safety and policy. The survey team notified the Administrator (ADM) and the Director of Nursing (DON) of an IJ situation on 8/1/2024 at 5:15 PM, due to the facility's failure to prevent accident and provide Resident 1 with sufficient supervision during smoking while oxygen is in use. On 8/3/2024 at 11:08 AM, the Administrator (ADM) provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On 8/3/2024 at 2:08 PM, while onsite and after the surveyor verified/confirmed the facility's full implementation of the IJ Removal Plan through observation, interview, and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM and the DON. The IJ Removal Plan dated 8/3/2024, included the following: 1.Immediate action(s) taken for the resident found to have been affected include: -Complete body assessment and inventory of his personal belongings on readmission. -Interdisciplinary team (IDT) will provide education to Resident 1 on readmission regarding Resident Smoking policy, smoking information which includes the designated smoking area (across nurse's station), smoking paraphernalia (any other item designed for the consumption, use or preparation of tobacco products) will be stored by nursing in a lockbox, smoking schedule, use of ashtrays and contraindication (not recommended). -All delivery/packages will be opened by the Activity Director (AD) in front of the resident to check for smoking paraphernalia. On 8/3/2024, IDT educated and explained to resident that the package/ deliveries will be opened in his presence to ensure that there is no smoking paraphernalia for his own safety. -Daily room sweep by the assigned department manager (DM) on Monday through Friday schedule and Manager of the Day (MOD) on weekends. -Resident 1 will be on one-on-one monitoring starting 8/2/2024. When the assigned one-on-one staff is on break, a certified nurse assistant (CNA) will relieve until the staff assigned to do one-on-one returns from his/her break. 2.Identification of other residents having the potential to be affected was accomplished by: -On 8/1/2024, IDT conducted care conference with Residents 2 and 3 that are smokers. IDT discussed smoking safety, facility's smoking practices and plan of care. Copy of smoking policy and smoking information which includes the designated smoking area (across nurses' station), smoking paraphernalia will be stored by nursing in a lock box, smoking schedule, use of ashtrays and contraindication (such as oxygen use) was provided to Residents 2 and 3. -On 7/31/2024, smoking safety assessment and care plans for Residents 2 and 3 were reviewed and revised by the DON to address physical and cognitive (mental processes) factors affecting ability to smoke safely. Revisions were made to reflect all current supervision and safety interventions. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: -On 7/31/2024, staff conducted room sweep for all residents with resident's permission to ensure there is no smoking paraphernalia stored in the rooms. 37 residents were assessed as of 7/31/2024. -Smoking schedule was revised by the IDT on 8/1/2024 to reflect assigned department who will oversee smoking schedule. Activity Director (AD) and Charge Nurse will assign a specific staff to oversee smokers on a daily basis. The assignment will be posted at the nurses' station. -Starting 7/3/2024, the Director of Staff and Development (DSD) will in-service staff with the following topics. -Smoking Safety with emphasis on Handling/ Storage of Smoking paraphernalia & Inventory Delivery of Items- All Staff -Smoking Assessment - Licensed Nurses -Smoking Schedule - All staff -Smoking Care Plan Initiation & Revision - Licensed Nurses & IDT -Medical Emergency Response (Burn Management) - All Staff -Change of Condition for Resident that Smokes - All Staff -Resident that smokes and on respiratory therapy (treatments provided for the lungs such as oxygen, or medication) - all staff -Smoking policy - all staff -On 81/2024, the DSD provided Inservice to Activity Department regarding resident's package delivery. Resident will open the package in the presence of a staff member to ensure there is no smoking paraphernalia. The IDT will obtain a written or verbal consent from the resident(s) that will not comply with this will be educated by IDT regarding the Residents Smoking policy. -New hire or staff who were not able to attend the in-service will be educated prior to start of their scheduled shift. -Tentative completion of in-services will be 8/4/2024. -On 8/2/2024, IDT created a preliminary Resident Smoking policy that reflects additional safety measure for non - compliance. This preliminary policy will be presented by the IDT on the scheduled Quality Assurance (QA) meeting. The revision to the policy is stated below: -If a resident or family does not abide by the smoking policy or care plan, the plan of care may be revised to include additional safety measures identified by the IDT team to include increased supervision (visual monitoring every hour or one on one monitoring) for non - compliant residents. -The IDT will obtain a written or verbal consent from the resident prior to the resident opening the package or delivery to ensure resident's rights are not violated. Written consent will be kept in the resident medical records. -The Nursing management team will oversee assigned caregivers and residents during designated smoking times to ensure appropriate supervision and interventions are implemented and that plans of care are followed. -Starting 8/1/2024, the IDT will review admission and readmission within 72 hours to verify if resident uses tobacco. The findings will be documented utilizing admission - readmission Log. Once the resident is identified as a smoker, necessary documentation and assessment will be completed by licensed nurse. The DON or designee will audit utilizing the Resident that smokes form. -Starting 8/1/2024, Activity Department or designee will deliver packages(s) to the resident and will open the package in front of the resident to ensure that no smoking paraphernalia is inside. All package/delivery will be documented utilizing Package Delivery Log. -Starting 8/1/2024, Department Managers or designee will conduct room rounds on a Monday through Friday schedule, and Manager for the Day (MOD) on weekends. The room rounds will be conducted to check smoking paraphernalia in resident's rooms and will be documented utilizing Guardian Angel Rounds' form. If any smoking paraphernalia are found, the staff will immediately remove it and will notify Administrator for appropriate action. Findings: During a review of Resident 1's admission Record indicated the facility initially admitted the resident on 8/27/2019 and readmitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD; long term inflammation of lungs that causes blockages or interference with airflow in the lungs) exacerbation(worsening of a disease), acute and chronic respiratory failure (the body's tissues does not have enough oxygen), epilepsy (seizures), and muscle weakness. During a review of a facility provided document titled Smoking Schedule updated 7/21/2023, indicated the facility's smoking scheduled times for residents who smoke listed as 9 AM, 11 AM, 1 PM, 3:30 PM, and 6:30 PM. The Smoking Schedule indicated, Smoking assessment is done upon admission for resident safety. Smoking aprons (made from a flame retardant material use for protection of smokers) are provided to residents for safety. Smoking supplies are kept by staff for safety. During a review of Resident 1's care plan titled [Resident 1] is non-compliant with oxygen, dated 10/10/2023, indicated Resident 1 was using oxygen 5 liters per minute for COPD. The care plan interventions included discussing the consequences of non-compliant behavior and accepting/supporting the resident's decision. During a review of Resident 1's Order Summary Report indicated a physician's order dated 3/13/2024, to administer oxygen via NC at 5 liters per minute, may titrate (the process of adjusting the oxygen flow) oxygen to maintain oxygen saturation (the amount of oxygen in the blood) greater or equal to 94 % (normal levels are between 95% to 100%). During a review of Resident 1's History and Physical Examination (HPE, a comprehensive physician's note regarding the assessment of the resident's health status) signed by the attending physician (Physician 1) dated 6/6/2024, indicated Resident 1 had the capacity to understand and make decisions. During a review of a facility record title Acknowledgement and Smoking Waiver signed by Resident 1 on 6/6/2024, indicated the resident wishes to exercise the right to smoke cigarettes while residing at the facility .The facility record indicated that in order to try to protect the lives and safety of all residents and staff, the facility requires that any resident smoking be conducted with the supervision of staff because the facility does not allow smoking unsupervised. The facility record indicated that the facility had explained to Resident 1 that the facility's designated smoking area was the Patio. During a review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) dated 6/12/2024, indicated the resident was moderately impaired ( difficulty remembering things, thinking clearly) of cognition (thought process). The MDS indicated Resident 1 required moderate/partial assistance (helper does less than half the effort) with upper body dressing, oral hygiene, sit to stand, chair transfers, and personal hygiene while Resident 1 required substantial/maximal assistance (helper does more than half the effort) for lower body dressing, toileting hygiene, putting on/taking off footwear, and sit to lying position. During a review of Resident 1's care plan titled [Resident 1] is non-compliant with smoking protocols/schedule dated 12/20/2023 and revised on 6/17/2024, indicated goals that included the resident not having injuries from smoking and for the resident to inform nursing staff to remove oxygen tank prior to smoking. On 7/22/2024, an intervention was added for the resident to seek assistance and supervision from facility staff for when the resident wants to smoke. The care plan interventions included encouraging the resident to seek assistance/supervision and removing oxygen tank prior to smoking, encouraging the use of smoking apron, and respecting the resident's rights. During a review of Resident 1's care plan titled [Resident 1] is non-compliant with smoking schedule, smoking policies, and keeping his own cigarette dated 3/6/2024 and revised on 6/17/2024, indicated goals that included for the resident to not smoke without supervision, resident would participate in decisions relating to smoking schedules and policies, and the resident would not suffer injuries from unsafe smoking practices. The care plan interventions included instructing Resident 1 about smoking risks and hazards, notifying charge nurse immediately if it is suspected the resident had violated the facility's smoking policy, observing clothing and skin for signs of cigarette burns, and instructing Resident 1 about facility policy on smoking, and locations. During a review of Resident 1's care plan titled [Resident 1] is a smoker revised on 6/18/2024, indicated goals that Resident 1 would not smoke without supervision and would not suffer injury from unsafe smoking practices. The care plan interventions included information that Resident 1 required supervision while smoking, instructing Resident 1 about facility policy on smoking, locations, times, safety concerns, notifying charge nurse immediately if it was suspected that Resident 1 has violated the facility smoking policy. During a review of facility records titled Smoking Safety - initial assessment, dated 5/9/2023, 6/5/2024, and 6/22/2024, indicated Resident 1's risk factors included impaired gait (walking) and balance. The facility records indicated the same recommendations for 5/9/2023, 6/5/2024, and 6/22/2024 Smoking Safety- V2 initial assessments, that indicated discussion of smoking cessation plan and resident smoking with staff supervision. During a review of Resident 1's care plan titled Resident is at risk for injury due to non-compliance with smoking policy creating/making his own cigarette dated 7/22/2024, indicated goals that included the resident will not cause injury to himself or to others and the resident will ask staff when he needs to smoke. The care plan interventions included to continue teaching/reminding the resident with his risk factors, frequent monitoring of resident's behavior, encourage verbalization of feelings and concerns, and for the IDT to review the resident's behavior regarding smoking needs, and informing the resident of the consequences for non-compliant behavior. During a review of Resident 1's Progress Notes dated 7/23/2024 timed at 4:02 PM, indicated an incident that occurred on 7/20/2024 during the night shift (11 PM to 7 AM), when Licensed Vocational Nurse (LVN 3) would not allow Resident 1 to go outside the outdoor patio to smoke. During a review of LVN 3's written statement dated 7/25/2024 timed at 10:41 AM, indicated the incident that occurred on 7/20/2024, during the start of the night shift (11PM-7AM) when Resident 1 requested to smoke. LVN 3 informed Resident 1 that he cannot go outside because it was past the facility's Smoking Scheduled times and the resident got upset. The written statement indicated Resident 1 still went out the outdoor patio smoking area while the resident's oxygen tank was on and attached to the resident's wheelchair while the resident attempted to light a cigarette. The written statement further indicated LVN 3 was able to remove the oxygen tank before Resident 1 was able to light the cigarette. During a review of Resident 1's record titled Change of Condition [COC] dated 7/31/2024 timed at 3 PM, indicated another incident that occurred on 7/31/2024, when Resident 1 was heard calling for help from the facility's outdoor patio. The resident was discovered to have sustained second degree burns on the resident's nose, mouth, and hands. The COC indicated Resident 1 reported having severe pain, rating it at10 out of 10 pain [numerical pain rating scale with 10 being the highest level of pain and 0 for no pain). The COC indicated that emergency services (911) where contacted, and the resident was transferred to the acute hospital (GACH 1). During a review of Resident 1's GACH 1 record titled Trauma Surgery History & Physical dated 7/31/2024 timed at 4:55 PM, indicated Resident 1 had a primary medical history of status post (medical or clinical shorthand that refers to a state after an event or intervention) explosive accident in the facility. The GACH 1 record indicated [Resident 1] was sitting in a chair, smoking cigarette with his NC oxygen, (the resident) has second degree bilateral (both) burns of the hands, singed facial hairs, second degree burns of bilateral cheeks, carbonaceous sputum (upper airway injury), with 10/10 pain. The GACH 1 record indicated Resident 1 received treatments for the burns and bilateral dressings to both hands. The GACH 1 record indicated Resident 1 would be transferred for further treatment to GACH 2 Burn Center. During a review of Resident 1's GACH 2 Burn Center records titled Inpatient Progress Note dated 7/31/2024 timed 9:50 PM, indicated the resident had deep partial thickness burns with necrotic (dead body tissues) tissues on upper and lower lips. In addition, the resident had left hand with partial thickness burn to left [NAME] (the inside) hand involving the fourth (ring finger) to the fifth digits (little finger) and right hand with partial thickness burn to right [NAME] hand at base of second digit (forefinger) to the fifth digits. Treatment plan of Santyl (ointment that removes dead infected skin) and Vashe (skin and wound cleansing solution) to hands and Bactroban (antibiotic [stops growth of bacteria] ointment) topically (applied to the skin)to the resident's face. The GACH 2 records indicated an order to give the resident Tylenol (over the counter pain medication), Gabapentin (medication for nerve pain) and oxycodone (a strong narcotic medicine used to treat severe pain) for pain as needed. During a review of Resident 1's GACH 2 Burn Center records titled Patient Discharge Instructions dated 8/2/2024 timed at 5:40 PM, indicated the resident was discharged back to the facility on 8/2/2024 with discharge diagnoses including, second degree burns of back of the right hand, back of the left hand, head, face, and neck, and wound pain. During the facility's initial tour and observation, in the presence of the DON, on 8/1/2024 at 10:16 AM, there were warning signs observed posted at the facility's double door exit to the outdoor patio Smoking Area that indicated No oxygen is allowed beyond that point. During an interview with the DON on 8/1/2024 at 10:16 AM, the DON stated if a resident smoker was using oxygen, the facility staff would remove the resident's oxygen prior to going to the outdoor patio Smoking Area. The DON stated the warning signs had been posted on the double door exit to the outdoor patio prior to Resident 1's smoking accident on 7/31/2024. During an interview on 8/1/2024 at 10:20 AM with the DON, the DON stated the facility's process for smoking supervision was for residents who smoke to go to the Nursing Station during the Scheduled Smoking times and notify the nursing staff if they wish to smoke and then nursing staff would notify the Activity Department to supervise the residents in the outdoor smoking patio. The DON stated the facility did not have a system to monitor residents who exit the double doors to smoke in the patio outside the Smoking Schedule (9 AM, 11 AM, 1 PM, 3:30 PM, and 6:30 PM). During an interview on 8/1/2024 at 10:50 AM with the DON, the DON stated that according to her investigation, the facility staff (Nursing and Activity staff) did not know that Resident 1 went outside to smoke on 7/31/2024. The DON stated she was uncertain how Resident 1 obtained his cigarettes and lighter. The DON stated that during her investigation, she found out that Resident 1 hid the cigarettes and lighter in his room. During a concurrent interview on 8/1/2024 at 11 AM, and record review of Resident 1's Progress Notes dated 7/23/2024 timed at 4:02 PM, the Progress Notes indicated the incident that happened with Resident 1 on 7/20/2024, when LVN 3 would not allow Resident 1 to go outside the patio to smoke on 7/20/2024, during the night shift. The DON stated that on 7/20/2024, during the night shift, Resident 1 wanted to go outside, but LVN 3 blocked the outdoor patio exit to prevent Resident 1 from smoking when the resident was on oxygen. The DON stated LVN 3 did not report the incident (7/20/2023) to the DON until after a few days when Resident 1 notified her (DON) that LVN 3 blocked the outdoor patio. The DON stated LVN 3 did not complete a Change in Condition documentation or revise the resident's care plan that addressed the Resident 1 attempting to go to the patio while on oxygen. During an interview on 8/1/2024 at 12:03 PM with LVN 1, LVN 1 stated he heard Resident 1 yelling for help on 7/31/2024 at around 3 PM, which prompted him (LVN 1) to rush to the facility's outdoor patio. LVN 1 stated when he went out to the patio, he observed Resident 1 with black discoloration around the lower part of the face, nostrils, and both hands. LVN 1 stated he did not know where Resident 1 got his cigarettes and lighter or how the resident was able to go out to the facility's patio without staff supervising resident while smoking. During an interview on 8/1/2024 at 12:30 PM with LVN 2, LVN 2 stated in the afternoon of 7/31/2024, he observed Resident 1 go out to the facility's outdoor patio (Smoking Area). Shortly thereafter, LVN 2 stated he heard Resident 1 yelling for help outside the facility's outdoor patio smoking area. LVN 2 stated he went outside and removed the resident's oxygen tank. LVN 2 stated he observed black and red discoloration on Resident 1's nose, lips and both hands. LVN 2 stated he did not know how Resident 1 obtained cigarettes and lighter. Resident 1 was not allowed to keep smoking materials in his room or maintain in his possession. During an interview on 8/1/2024 at 12:46 PM with Resident 2, Resident 2 stated he was outside in the facility's outdoor smoking area patio on 7/31/2024, around 3 PM, when he observed Resident 1 removed a cigarette and a lighter from beneath his gown. Resident 2 stated when Resident 1 attempted to light the cigarette, he witnessed flames igniting and coming from the lower part of Resident 1's face. Resident 2 stated Resident 1 tried to put out the fire with his own hands. During a concurrent interview and record review of Resident 1's care plan titled [Resident 1] is non-compliant with smoking schedule, smoking policies, and keeping his own cigarette revised on 6/17/2024, on 8/1/2024 at 1 PM, Registered Nurse (RN) 1 stated the care plan indicated Resident 1 was non-compliant with smoking protocols and schedule. RN 1 stated Resident 1 was instructed to inform nursing staff to remove his oxygen tank prior to smoking in the facility's outdoor patio and seek supervision. RN 1 stated, Resident 1 was known to be non-compliant with the facility's smoking policy and keeps his cigarettes on his own. RN 1 stated that even if Resident 1's care plan indicated education was provided to Resident 1 about the Smoking Policy, the facility staff should have done more interventions, that included one-to-one supervision every shift, to ensure Resident 1's safety since he continued to be non-compliant with the smoking policy. During an interview on 8/1/2024 at 3:59 PM with Treatment Nurse [TX] 1, TX1 stated LVN 1 had called for assistance for Resident 1 on 7/31/2024 around 3 PM, TX 1 stated on 7/31/2024 upon responding to Resident 1's call for help resident 1 refused to have facial burns cleansed with saline solution (a mixture of water and salt) and requested A&D ointment (first aid salve used on burns) be applied on 7/31/2024 at the facility's outdoor smoking patio. TX 1 stated Resident 1 had a history of being non-compliant with the facility's smoking policy to seek staff supervision prior to smoking during the designated smoking times, despite being provided with education. During an interview on 8/2/2024 at 12:31 PM with the Activity Director [AD], the AD stated there had been a lack of communication between the Activity Department and Nursing Department on who is assigned to supervise the resident smokers during smoking times. The AD stated that residents are supervised during smoking by anyone who is available. The AD stated that Resident 1 sometimes hide from facility staff when he goes outside the patio to smoke. The AD stated that on 7/31/2024, during the afternoon shift [3 PM to 11 PM] she did not verbally notify the nursing staff that there was no available Activity Assistants to help supervise smoking. During an interview on 8/2/2024 at 12:45 PM, the DON stated the facility's Activity Department and overseen by the AD who had two Activity Assistants (AA) was in charge of supervising and monitoring resident smokers during smoking schedule for 9 AM, 11 AM, 1 PM, and 3:30 PM. The DON stated that the 6:30 PM smoking schedule was the last time for residents to smoke for the day. The DON stated that the Nursing Department should be assigned to supervise resident smokers at 6:30 PM. The DON stated that there was no specified facility staff from the Activity Department and Nursing Department assigned for each schedule indicated in the facility's Smoking Schedule and staffing assignments and/or the resident's care plans, as a means to communicate to all facility staff. The DON stated the staff assignments was based on verbal communication by the AD to either of the two AAs or the charge nurses to any of the nursing staff available during the morning [7 AM to 3 PM] and [3 PM to 11 PM] evening shifts. The DON stated that Nursing staff was to cover the Activity Staff (AD and AAs) in supervising resident smokers if the AD and the AAs were not available to supervise residents during the smoking schedule or outside the smoking scheduled times. During a concurrent interview and review of the facility's undated policy and procedures (P&P) titled, Resident Smoking, on 8/2/2024 at 2:18 PM, the DON stated that the P&P did not indicate what the facility's actions for residents who continued to be non-compliant with the facility's smoking policy, that included additional safety measures to protect residents who uses oxygen and who consistently do not adhere to the policy. During the same interview on 8/2/2024 at 2:18 PM, the DON stated that all resident smokers' care plans about smoking, including Resident 1 did not have the specific smoking measures designed for each resident's concerns, including communication of these safety measures to all facility staff, especially those who will be the staff responsible in supervising the residents while smoking. The DON stated that nursing staff should have added and implemented additional safety measures especially when Resident 1 was on oxygen and continued to be noncompliant of smoking safety such as removing oxygen tank before smoking. The DON stated the additional safety measure should had been a one-to-one staff supervision when the resident continued to show non-compliance to safety while smoking. The DON stated that Resident 1 had an interdisciplinary team (IDT) discussion about his care and including smoking compliance on 3/14/2024, 6/6/2024, and 7/24/2024, indicating the same information such as reeducation of facility smoking, and oxygen policies and procedures and that resident will not smoke without supervision. The DON stated Resident 1's smoking care plans were not specific to increase observation/supervision. The DON stated the facility staff should have been more attentive to Resident 1's issues and concerns and could have added a one-to one sitter, increase monitoring, remove the oxygen tank prior to resident going to the outdoor smoking area patio. The DON stated Resident 1's care plans was not specific to Resident 1's main issues and concerns. During a concurrent observation and interview on 8/3/2024 at 11:05 AM, in Resident 1's room, Resident 1 was lying in bed, with oxygen delivering 5 liters/min humidified via NC. Resident 1's bilateral hands were wrapped with gauze [a very thin, light cloth, used to cover cuts] dressing. During the observation, Resident 1 was observed with second degree burns on the lower part of the face, from the tip of the nose to both lower cheeks, down to the chin. Resident 1's lips were dark in color. Resident 1 complained of 10/10 (severe) pain. Resident 1 stated that on 7/31/2024, he lit a cigarette while on NC with oxygen flowing at 5 liters/min and the cigarette blew up in his face. During the same interview, on 8/3/2024 at 11:05 AM, Resident 1 stated Normally, [facility] staff catches me before I go outside. Normally they see me coming before going outside, and normally they [facility staff] say wait, let me take off your oxygen. Resident 1 stated that on 7/31/2024, during that time (3 PM) the facility staff did not remind him. Resident 1 stated Resident 1 forgot that he had his oxygen on when he lit up his cigarette. Resident 1 stated when he put the cigarette in his mouth and lit it with his lighter, the cigarette exploded. Resident 1 stated that the plastic part of the NC and his face caught on fire and burnt his mustache. Resident 1 stated he tried to put the fire out by using his hands. Resident 1 stated he yelled for help and it took forever for nurses to come. Resident 1 stated he did not remember how long it took for staff to come help him. Resident 1 stated he puts his cigarettes and lighter inside his drawer in his room. Resident 1 stated he orders his smoking materials online (an activity or service available on or performed using the internet or other computer network) and stores them in his drawer. During a review of the facility's undated policy and procedures (P&P) titled, Resident Smoking, the P&P indicated the following: 1. The facility was to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. 2. Safety measures included the prohibition of oxygen use in the smoking area. 3. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. 4. Any resident who was deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan. 5. All smoking measures will be documented in each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible supervising residents while smoking. 6. If a resident or family does not abide by the smoking policy or care plan, the plan of care may be revised to include additional

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 41) was immediately provided CPR (cardiopulmonary resuscitation a lifesaving emergency procedure for a victim who has signs of cardiac arrest [a situation when a victim becomes unresponsive, no normal breathing, and no pulse] consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [a device used to help someone breathe]) prior to the arrival of emergency medical personnel in accordance with the standard of practice and the facility's policy and procedure titled Medical Emergency Response and Cardiopulmonary Resuscitation (CPR) by failing to: 1. Ensure Licensed Vocational Nurse (LVN 1) immediately initiated CPR to Resident 41 when found unresponsive, without pulse and not breathing rather than checking the code status (a resident's record that describes the type of life saving procedures (if any) the resident or their representative would the health care team to conduct if your heart stopped beating and/or stopped breathing to keep him/her alive) of Resident 41 and calling for assistance. 2. Ensure Resident 41's Advance Directives (document signed by the resident or representative indicating the care treatments that the resident wished in an event of emergency) and or POLST (a Portable Orders for Life Sustaining Treatment- is a record singed by the resident/representative and the physician that indicates the resident's medical treatment wishes so that emergency personnel know what treatments the resident wants during medical emergency) and/or code status was known to the facility staffs and available to the staffs for review in an event of a code. 3. Ensure the Emergency Cart (EC, a storage cart that contains equipment necessary to perform life-saving procedures on residents experiencing a medical emergency) is maintained containing contents, devices/equipment that are accessible and used during CPR such as Ambu-bag (a type of device known as a bag valve mask, which is commonly used to provide respiratory support to patients who are not breathing or not breathing adequately),Glucometer (device used to check blood sugar levels), pulse oximeter (device used to check oxygen saturation levels in the blood), 20 gauge (inner size) Intravenous Catheter (IV catheter is a thin plastic tube that is inserted into the vein for the purpose of giving medications, blood, etc.), kerlix (a type of gauze), nebulizer kit (device used to provide treatment to the lungs), First Aid kit (a kit used for emergency). As a result of these deficient practices, the initiation of CPR was not initiated immediately, for Resident 41 with a full code status (resident wishes to be revived when breathing and/or heart stopped). Resident 41 was transferred to the General Acute Care Hospital (GACH) 1 Emergency Department (ED) on [DATE], after being found unresponsive, without pulse and not breathing. The GACH 1 ED Report indicated 911 (an emergency call system) and paramedics were called by the facility at approximately 5:52 AM. Resident 1 expired at the GACH 1 on [DATE] at 6:50 AM with the diagnosis of cardiac arrest. On [DATE] at 11:47 AM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the failure to ensure CPR was immediately performed on Resident 41. The survey team notified the Director of Nursing (DON), the Administrator (ADM) and the Regional Consultant (RC) of the IJ situation. On [DATE] at 6:03 PM, the IJ was removed in the presence of the ADM, and the DON after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified/confirmed onsite the facility's implementation of the IJ Removal Plan and the IJ situation was no longer present. The IJ Removal Plan dated [DATE] at 6:03 PM, included the following: 1. On [DATE], (DON) had a 1:1 (one on one) in-service with the licensed nurse assigned to Resident 41 regarding Medical Emergency Response. Disciplinary action was taken with licensed nurse who delayed the CPR on the full code resident and was suspended pending investigation. 2. On [DATE], the Medical Records Director (MRD) or designee completed a chart audit on every resident and compared the Advance Directive/Physician Orders for Life Sustaining Treatment (POLST) to the physician order for accuracy. 3. On [DATE] the facility emergency cart checklist was revised by the DON. The glucometer, glucose strips, lancets, nebulizer, and nebulizer kit were added on [DATE]. The updated form will be utilized by licensed nurses starting [DATE]. The emergency cart was checked by the DON on [DATE] for appropriate supplies and equipment. No issues were identified. 4. On [DATE], the Resource Nurse Consultant (RNC) and Respiratory Therapy Consultant designee educated licensed nurses and certified nurse assistance (CNAs) on the facility's policy and procedure for Medical Emergency Response and location of code status for each resident. Licensed nurses and CNAs were not permitted to work a shift until education was completed. Nurses on leave will receive education prior to their next scheduled shift. 5. On [DATE], the RNC and Respiratory Therapy Consultant initiated Code Blue (a code called out by the facility to alert other staffs about residents that needed emergency care) drill to be completed on all shifts randomly by using the facility landline's paging system located at the nurse's station, hallway outside room [ROOM NUMBER], between rooms [ROOM NUMBERS], activity room, rehabilitation room and office rooms (Administrator, DON, Dietary, SSD office), and announcing Code Blue to room. Licensed nurses and CNAs were in-serviced by the RNC regarding the paging system on [DATE]. The licensed nursing and CNAs staffs who were not scheduled to work on [DATE] will participate in the Code Blue drill during their scheduled shift. 6. On [DATE] the RNC, (Director of Nursing) DON and (Director of Staff Development) DSD conducted an audit of licensed nurses and certified nurse assistants (CNAs) CPR certification. No issues were identified. 7. Starting [DATE], newly hired licensed nurses and CNAs will have their CPR certification card on file and have competency prior to their scheduled shift. 8. Starting [DATE], DON or designee will audit new admissions chart to compare the resident's Advance Directives/ POLST to the physician orders for accuracy. This audit will continue for three months. Findings will be reviewed at the monthly QA (Quality Assurance) Committee meeting for discussion and recommendations. 9. Starting [DATE], 11-7 licensed nurse will print the daily code status from PCC orders and will place it in the binder labeled Code Status located at the nurse's station. The SSD will oversee that the code status is available and updated daily. In the absence of SSD, the license nurse working will verify that the code status is updated. 10. Starting [DATE], the POLST will be reviewed and verified by the DON and SSD immediately after admission of the resident to the facility. The RN Sup will oversee the POLST in the A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented on [DATE]. DON or designee to complete weekly mock (fake) code drills on all shifts and monitor code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. Any trends will be discussed during monthly Quality Assurance meeting which will be held scheduled monthly. The DON will conduct compliance audits weekly for three months. Findings will be reported at monthly QA Committee meeting for discussion and recommendations. 11. Starting [DATE], the DON will randomly audit the emergency cart on a weekly basis in addition to the daily checks from 11-7 licensed nurse to ensure that the equipment and supplies are stocked as indicated on the emergency cart checklist. This audit will continue for three months. Findings will be reviewed at the monthly QAA (Quality Assurance) Committee meeting for discussion and recommendations. Cross reference to F695 and F726 Findings: 1. A review of Resident 41's admission Record indicated the facility originally admitted the resident on [DATE], and was readmitted on [DATE], with diagnoses that included congestive heart failure (failure of the heart to meet the body's demand), acute respiratory failure with hypoxia (a condition where a person do not have enough oxygen in the tissues of the body), chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 41's Clinical admission record, dated [DATE] timed at 3:18 PM, indicated Resident 41 was receiving oxygen at 3 liters per minute. The Clinical admission indicated Resident 41's pulse oximetry (pulse oximetry is a painless, noninvasive method of measuring the saturation of oxygen in a person's blood) reading during admission to the facility was at 95% (a resting oxygen saturation level between 95% and 100% is regarded as normal for a healthy person) using oxygen administered via nasal cannula (a long plastic hose used to deliver oxygen into the nares). The Clinical admission indicated Resident 41's discharge goal was to return home. A review of Resident 41's History and Physical (H&P) dated [DATE], indicated the resident had the capacity to understand and make decisions. The H&P indicated one of Resident 1's diagnosis included Pneumonia (severe lung infection) treated. A review of Resident 41's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) with assessment reference date of [DATE], indicated the resident had moderate cognitive (thought process) impairment. The MDS indicated Resident 41 required partial/moderate assistance (helper does less than half the effort) in walking up to 10 feet and was not attempted to be assessed if she could walk 50 feet or more. The MDS indicated Resident 41 required supervision (helper provides verbal cues) on task such as oral hygiene, upper body dressing, sit to stand and bed mobility. The MDS indicated Resident 41 required partial/moderate assistance with toileting, shower and lower body dressing. A review of Resident 41's POLST signed by Resident 41 on [DATE], and signed and dated by Physician 1 on [DATE], indicated to attempt CPR to Resident 41 to restore breathing and heart circulation and beat. During the review of Resident 41's Progress Notes dated [DATE] timed at 5:30 AM, authored by Licensed Vocational Nurse (LVN) 1 indicated Resident 41 approached LVN 1 at the Nursing Station asking for another oxygen tank (a container with oxygen inside it, used for helping people to breathe). The Progress Notes indicated LVN 1 advised Resident 41 that Resident 41 still had half a tank left and will change (the oxygen tank) when it is lower. The Progress Notes indicated Resident 41 understood and just waited outside Nursing Station until staff finished with rounds. During the same review of Resident 41's Progress Notes dated [DATE] timed at 5:30 AM, the Notes indicated Noted Resident 41's oxygen tank outside Nursing Station. The Progress Notes indicated LVN 1 went inside Resident 41's room to ask if the resident still wanted her oxygen tank. The Progress Notes indicated Resident 41 was found unresponsive in bed with eyes slightly open, no pulse, no rise of chest (an indication that the resident was not breathing). [Resident 41] was still warm, blood sugar 301, unable to get blood pressure. The Progress Notes indicated 911 [paramedics] was called while staff (unknown) did CPR The Progress Notes indicated Resident 41 was transferred to the GACH on [DATE] at 6:25 AM, and family and Physician 1 was notified. A review of Resident 41's Change of Condition (COC) note dated [DATE] timed at 6:23 AM, indicated Found [Resident 41] unresponsive lying in bed with eyes slightly open. Called code blue and started CPR. 911 was called and noted patient (Resident 41) was full code, did CPR for 10 minutes before paramedics arrived and took over patient care. No pulse, after 25 minutes of CPR patient was transferred to GACH. The COC indicated Physician 1 was notified on [DATE] at 6:42 AM and the vital signs (measurement of the heart rate, breathing and blood pressure) were documented as follows: a. Blood pressure-00/00 (normal ranges between 120/80 to 100/60) b. Respirations indicated 0-(number of breaths per minute normal range is between 12 to 20) c. Pulse-indicated-0 (heart rate per minute, normal range is 60 to 100) d. Apical pulse indicated 0 (number of times the heart beats per minute, normal range is 60 to 100) e. Temperature-97.5 F (Fahrenheit, a unit of measuring temperature [normal range 97 F to 99 F]) f. Oxygen Saturation 65% (low) (oxygen level in the blood-normal range 90-100%) g. Blood sugar- 301 mg/dL (high) (milligrams per deciliter- normal range 70-100 mg/dL) A review of Resident 41's Emergency Department Report from GACH 1, dated [DATE], indicated the paramedics (an emergency personnel who performs CPR and other emergency care) was called by the facility staff on [DATE] at approximately 5:52 AM. The report indicated Resident 41 died on [DATE] at 6:50 AM. A review of Resident 41's GACH 1 Emergency Department (ED) Reports dated [DATE] timed at 7:14 PM, indicated Resident 41 was brought in by ambulance from the facility and found pulseless and not responsive. The GACH 1 ED report indicated the paramedics were called by the facility at approximately 5:52 AM and Resident 41 was last seen in her usual state of health 10 minutes prior. The GACH ED 1 report indicated paramedics were unable to obtain any return of spontaneous circulation in the field and were directed by base station to be transported. The report indicated Resident 41 arrived to GACH 1 ED with CPR in progress and Advanced Cardiac Life Support (ACLS, a set of clinical guidelines for the urgent and emergent treatment of life-threatening cardiovascular conditions that will cause or have caused cardiac arrest, using advanced medical procedures, medications, and techniques) in excess of 50 minutes, an additional dose of epinephrine (primary drug used in cardiac arrest, to increase cardiac output), sodium bicarbonate (medication used to treat metabolic acidosis [when acids build up in your body]), and calcium gluconate (medication used to manage cardiac arrest) were administered. The GACH 1 ED report indicated chest compressions continued with assisted ventilation (the movement of gas into and out of the lung by an external source connected directly to the patient) through endotracheal tube (a tube placed between the vocal cords through the airway to provide oxygen and inhaled gases to the lungs). The report indicated Resident 41 remained pulseless without cardiac activity on ultrasound and died on [DATE] at 6:50 AM. During an interview on [DATE] at 5:33 PM, the DON stated, there was no physician's order that indicated the code status for Resident 41. During a telephone interview on [DATE] at 6:04 PM, with the primary physician (Physician 1), Physician 1 stated he was notified by LVN 1 on [DATE] after Resident 41 was transferred to GACH 1. Physician 1 stated he could not recall the exact details of LVN 1's telephone notification on [DATE]. During a telephone interview with LVN 1 on [DATE] at 6:28 PM, LVN 1 stated on [DATE], at around 5:30 AM, while LVN 1 was putting away medications, (Resident 41) approached him and asked if LVN 1 could change her portable oxygen tank because Resident 41 believed her oxygen tank was empty. LVN 1 stated he observed Resident 41's oxygen tank gauge (a medical device designed to display the pressure level in an oxygen tank) and saw that the oxygen tank gauge was still half full. LVN 1 stated he checked Resident 41's oxygen saturation and vital signs but could not recall and did not document the oxygen saturation level and vital signs results on [DATE]. LVN 1 stated that he did not do any other assessments (respiratory) because he needed to finish his medication pass and go home. LVN 1 stated he left Resident 41 sitting in a chair by the Nursing Station and proceeded to finish putting away medication in Medication Cart 1. LVN 1 stated after leaving Resident 41 in the Nursing Station, he continued to administer medications to the residents in seven rooms before going to another Nursing Station by Medication Cart 2 to retrieve Resident 41's medications which were kept in Medication Cart 2. LVN 1 stated as he was approaching Medication Cart 2, he observed Resident 41 was not at the Nursing Station anymore but Resident 41's oxygen tank was left sitting by the Nursing Station. LVN 1 stated he proceeded to go to Medication Cart 2 to remove Resident 41's medications before he decided to go to Resident 41's room. During the same telephone interview, on 5 /4/2024 at 6:28 PM, LVN 1 stated as he entered Resident 41's room, LVN 1 observed Resident 41 lying in bed and not breathing. LVN 1 stated he went outside Resident 41's room to call for help and returned to Resident 41's bedside. LVN 1 stated when CNA 1 went to Resident 41's room, LVN 1 instructed CNA 1 to wait in the room, until he was able to review Resident 41's code status in the electronic medical records. LVN 1 stated he went outside Resident 41's room and went back to the Nursing Station and Medication Cart 2. LVN 1 stated he logged into the electronic medical records, but the electronic records did not indicate Resident 41's code status. LVN 1 stated he had to go to Nursing Station 1 to get Resident 41's paper chart to look for the POLST. LVN 1 stated Resident 41's POLST indicated Resident 41 was a full code (full support which includes cardiopulmonary resuscitation (CPR) if the patient has no heartbeat and is not breathing). LVN 1 stated after reviewing Resident 41's paper chart, LVN 1 returned to Resident 41's room to initiate CPR. LVN 1 stated that after completing about two full sets (consisting of 2 rescue breaths and 15 chest compressions) of CPR, LVN 1 instructed CNA 1 and CNA 2 to take over CPR, as he went outside Resident 41's room to the Nursing Station to call 911. LVN 1 stated he was the only licensed nurse during the shift (11 Pm to 7 AM) for the entire facility on [DATE]. During an interview on [DATE] at 7:31 PM with CNA 1, CNA 1 stated on [DATE] she was working inside another resident's room when she heard LVN 1 calling for help. CNA 1 stated LVN 1 initiated the CPR to Resident 41 after checking the code status of Resident 1. During a telephone interview on [DATE] at 7:58 PM with CNA 3, CNA 3 stated she did not hear LVN 1 called for Code Blue while she was in the restroom. CNA 3 stated when she got out of the restroom, she went to Resident 41's room and saw CNA 1, CNA 2, and CNA 7 performing CPR while LVN 1 was on the phone in the Nursing Station, calling 911. CNA 3 stated she touched Resident 41's hand and felt that Resident 41 was still warm. During a second telephone interview on [DATE] at 2:01 PM with Physician 1, Physician 1 stated facility staff should immediately initiate CPR when a resident is found to be unresponsive and without a pulse. Physician 1 stated a resident's code status should be entered into the resident's records upon admission. Physician 1 stated Resident 41 was under his care and was very frail. During another interview on [DATE] at 1:56 PM with LVN 1, LVN 1 stated on [DATE] he saw CNA 1 in the hallway when he came out of Resident 41's room after finding Resident 41 unresponsive and not breathing. LVN 1 stated he instructed CNA 1 don't start anything because he stated he needed to find out Resident 41's code status first. LVN 1 stated he went to the medication cart and logged into the electronic records but was not able to find Resident 1's code status in the electronic records. Then LVN 1 stated he went to the Nursing Station and looked through Resident 41's paper chart to look for the resident's code status. LVN 1 stated he found Resident 1's POLST that indicated Resident 1 was a Full Code (attempt to provide CPR). LVN 1 stated when he learned of Resident 1's code status, he went back to the resident's room and initiated CPR. LVN 1 stated everyone was on standby and did not perform CPR until he found out the resident's code status. During a second interview on [DATE] at 4:07 PM with CNA 1, CNA 1 stated CNA 2 and CNA 7 were in the room when she arrived in Resident 1's room. CNA 1 stated CNA 3 arrived in the room sometime after. CNA 1 stated when she went into the room, she helped CNA 2 and CNA 7 place the backboard (a flat piece of platform that is placed under a person's body for the purpose of providing effective CPR) under Resident 1's body. CNA 1 stated LVN 1 started CPR after they put the backboard (a board designed to provide rigid support during movement of a person during CPR and to provide support to residents with suspected spinal or limb injuries). During a telephone interview on [DATE] at 2:06 PM with Resident 41's Family Member (FM 1), FM 1 stated the resident was in good spirits on [DATE]. FM 1 stated Resident 1 was planning on going home on [DATE]. FM 1 stated she talked to Resident 41 on [DATE], then on [DATE] at around 7 AM, she was informed by GACH 1 physician that Resident 41 passed away. During a concurrent interview and record review of the facility's policy and procedure (P&P) titled, Medical Emergency Response, revised on [DATE], on [DATE] at 6:11 PM, the DON stated the staff who first witnessed a medical emergency, such as finding an unresponsive and pulseless resident, should initiate immediate action, including CPR and calling for assistance. The DON stated the P&P indicated the CPR will only be stopped if a Do Not Resuscitate (DNR, instruction to not perform CPR on a resident) order is found to be in place in the resident's record. The DON stated staff should initiate CPR then have someone else verify the resident's code status. The DON stated delaying the CPR could result in a resident's death. During the same interview and record review on [DATE] at 6:11 PM with the DON, the facility's P&P titled, Cardiopulmonary Resuscitation (CPR), revised [DATE], the DON stated the P&P indicated facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and in the absence of advance directives or a Do Not Resuscitate order. DON stated staff should initiate CPR right away even without knowing the resident's code status. DON stated staff should perform CPR right away and should not delay CPR by searching for the code status. DON stated CPR can always be stopped if staff eventually find the code status as DNR. During a telephone interview on [DATE] at 6:15 PM with CNA 2, CNA 2 stated she saw Resident 41 near the Nursing Station on [DATE] at around 5:30 AM. CNA 2 stated she went to another resident's room and sometime later, she heard LVN 1 call for code blue. CNA 2 stated as she was going into Resident 1's room, LVN 1 was coming of the room to check for the code status. CNA 2 stated that CNA 2, CNA 1 and CNA 4 did not start CPR as instructed by LVN 1. CNA 2 stated that when LVN 1 came back to the room, that was when LVN 1 started CPR. CNA 2 stated she does not remember how long it took LVN 1 to find Resident 41's code status in the resident's records. 2. During a concurrent observation of the completeness of the emergency cart and interview with the DON on [DATE] at 10:57 AM, the DON stated the following were missing from the facility's emergency cart: a. Ambu-bag (a type of device known as a bag valve mask, which is commonly used to provide respiratory support to patients who are not breathing or not breathing adequately) b. Glucometer (device used to check blood sugar levels) c. Pulse Oximeter (device used to check oxygen saturation levels in the blood) d. 20 Gauge Intravenous Catheter (IV, a thin plastic tube that is inserted to a person's vein for the purpose of giving medications, blood, etc.) e. Kerlix (a type of gauze) f. Nebulizer kit (device used to provide treatment to the lungs) g. First Aid Kit that had missing items. On [DATE] at 10:57 AM, the facility's document titled, Emergency Cart Checklist, revised 5/2020, was reviewed with the DON. The DON stated the Emergency Cart Checklist was the current checklist used by the facility staff to check the completeness of the Emergency Cart. The DON stated the form was completed by the LVN (LVN 4) from the 11 PM to 7 AM shift on [DATE]. The DON stated she did not know why the checklist was checked off if some items are missing. During a concurrent interview and record review of Emergency Cart Checklist on [DATE] at 5:03 PM with LVN 4, dated 5/2020, LVN 4 stated he completed the checklist on the night of [DATE]. LVN 4 stated he knew that there were missing supplies in the EC. LVN 4 stated he used to write an X if a supply was missing but was instructed by a former staff member of the facility to put a check instead. LVN 4 stated he was also instructed to report the missing items using a group chat in his cellphone. LVN 4 stated the group chat members included the facility Administrator, DON, Director of Staffing Development (DSD), and nurses from the 11:00 PM to 7:00 AM shift. During an interview on [DATE] at 5:45 PM with the DSD, the DSD stated licensed nurses were tasked and were trained to complete the Emergency Cart Checklist. The DSD stated the nurses were instructed to write an 'X' if an item is missing or write a line or check when the item is in the EC. The DSD stated staff are expected to notify the DSD via phone call or text message if an item or items are missing. The DSD stated nurses are also able to refill the EC and do not have to wait for the DSD's reply. The DSD further stated none of the nurses have informed him of any of the missing items in the EC. During an interview on [DATE] at 6:11 PM with the DON, the DON stated the EC is used in the case of an emergency such as a code blue. The DON stated the EC should be always restocked after use and ready for use. The DON stated not having the proper equipment in the EC could result in the delay of care, such as CPR, to residents that are experiencing a medical emergency. The DON stated Ambu-bags are used during a CPR procedure and should always be stocked in the EC. A review of the facility's Emergency Cart Checklist, unidentifiable, revision date, indicated the following must be present in the EC: a. First Drawer: Oxygen Sign and Gloves b. Second Drawer: Glucometer, Glucose Strips (a small piece of plastic that is used with a glucometer), thermometer (device used to check body temperature, pulse oximeter, lancets (a device used to prick a person's finger with an enclosed needle for the purpose of withdrawing a small amount of blood), alcohol pads, blood pressure cuff (device used to check blood pressure), and stethoscope (device used to listen to a person's heart, lungs, etc.) c. Third Drawer: Insulin syringe (a small cylindrical tube that is connected to a needle and a plunger), IV Catheter, Normal Saline (a liquid solution), Tapes, torniquet (an elastic band that is usually tied to a person's limb to facilitate insertion of an IV catheter), scissors, gauze, and kerlix. d. Fourth Drawer: [Nasal Cannula], non-rebreather mask (a mask that is connectable to an oxygen-delivery source to provide supplemental oxygen to a patient), oxygen tubing, Nebulizer, and Nebulizer kit. e. Fifth Drawer: Isolation gown (disposable gown that is worn to protect a person's clothing), face mask (a small piece of paper-like material that is worn to cover a person's nose and mouth), zip locks, trash bag, infectious waste bag, Ambu-bag, first aid kit, flashlight, and extension cord. A review of the facility's P&P titled, Medical Emergency Response, revised [DATE], indicated the employee who first witness or is first on site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance. The P&P also indicated a nurse will stay with the resident and designate a staff member to announce a Code Blue, if necessary, notify the physician and call 911 as needed. The P&P indicated Night shift supervisor or nurse will ensure that all emergency carts and equipment are inventoried and ready to use. The P&P also indicated staff will ensure emergency medications and equipment are inventoried and restocked. A review of Basic Life Support Provider Manual by American Heart Association, dated 2020, indicated: High-quality CPR (proper hand position and depth of chest compression) with minimal interruptions and early defibrillation (administering a controlled electric shock to allow restoration of the normal rhythm) are the actions most closely related to good resuscitation outcomes. High quality CPR if started immediately after cardiac arrest combined with early defibrillation can double or triple the chances of survival. These time-sensitive interventions can be provided both by members of the public and by healthcare providers. By standers who are not trained in CPR should at least provide chest compressions. Even without training, bystanders can perform chest compressions with guidance from emergency telecommunicators over the phone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess, identify interventions, and services for Resident 41, who had diagnoses of respiratory failure with hypoxia (condition in which tissues of the body are starved of oxygen), pneumonia (lung inflammation) and chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and who was receiving continuous oxygen therapy by failing to: 1. Monitor and conduct respiratory assessment for complications associated with the use of oxygen and notify the primary physician (Physician 1). On [DATE] at 5:30 AM, Resident 41 verbalized not feeling well and asked the Licensed Vocational Nurse (LVN) 1 for her oxygen tank to be replaced because the resident, felt it was empty. 2. Evaluate and assess the need to obtain a physician's order for the use of oxygen therapy from the date of admission to the facility on [DATE], for Resident 41 who had a diagnosis of COPD and respiratory failure with hypoxia. 3. Notify and obtain a physician's order to administer Resident 41's oxygen at 3 liters per minute, via nasal cannula (NC-a medical device that consists of a small, flexible tube with two prongs that sit inside a patient's nostrils) and titrate (continuously measure and adjust the balance) to keep oxygen saturation (measures the percentage of oxygen in the blood) equal to or above 92% on [DATE] (3 days after admission to the facility). LVN 2 stated he did not obtain and clarify Resident 41's oxygen therapy orders from Physician 1 on [DATE]. 4. Develop and implement a resident- centered care plan (a formal process that correctly identifies existing needs and recognizes resident's potential needs or risks) to address and identify interventions based upon the resident's assessment and orders, for resident's history of respiratory distress (a serious lung condition that causes low blood oxygen) with hypoxia and need for oxygen therapy, as indicated in the facility's policy and procedures on Oxygen Administration and Comprehensive Care Plans. 5. Notify the physician of any changes in the resident's respiratory condition, including changes in vital signs (blood pressure, temperature, pulse, heart rate), oxygen concentrations, or evidence of complications associated with the use of oxygen, in accordance with the facility's policy and procedures on Oxygen Administration. 6. Ensure LVN 1 initiated immediate action, and performed cardiopulmonary resuscitation (CPR- involves chest compressions and mouth to mouth [rescue breaths with the aim to circulate blood and oxygen in the body), after finding Resident 41, unresponsive and not breathing, on [DATE], as indicated in the facility's policy and procedure titled Medical Emergency Response and Resident 41's Portable Orders for Life Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency). These failures resulted in the delay in assessment, care, and physician notification of Resident 41's respiratory condition when the resident verbalized her concern to LVN 1 that the resident felt her oxygen tank being empty and not feeling well, on [DATE] around 5:30 AM. As a result, Resident 41 was transferred to the General Acute Care Hospital (GACH) 1 Emergency Department (ED) on [DATE]. The GACH 1 ED report indicated Resident 41 was brought in by ambulance from the facility and found pulseless and not responsive. The GACH 1 ED report indicated 911 paramedics were called by the facility at approximately 5:52 AM. Resident 41 passed away at GACH 1 on [DATE] at 6:50 AM with a diagnosis of cardiac arrest. On [DATE] at 11:44 AM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility's failure to conduct respiratory assessment, identify interventions, and services for Resident 41, who had diagnoses of respiratory failure with hypoxia, pneumonia and COPD, and who was receiving continuous oxygen therapy. The survey team notified the Director of Nursing (DON), the Administrator (ADM) and the Regional Consultant (RC) of the IJ situation due to the facility's failure to ensure Resident 41 received respiratory assessment, treatments, and services when Resident 41 verbalized to LVN 1 the resident was not feeling well and asked for her oxygen tank to be replaced because the resident felt it was empty. On [DATE] at 6:13 PM, while onsite at the facility, the survey team removed the IJ, in the presence of the ADM, and the DON after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified/confirmed onsite the facility's implementation of the IJ Removal Plan and the IJ situation was no longer present. The IJ Removal Plan dated [DATE] at 6:03 PM, included the following: 1. Administrator notified the facility Medical Director of Immediate Jeopardy incident on [DATE]. 2. On [DATE], licensed nurses identified was in-serviced by the DON regarding Physician notification when there is a change of condition focusing on respiratory system, respiratory assessment, and management of disease such as COPD, respiratory failure with hypoxia and oxygen therapy. Identified license nurse was suspended on [DATE] pending investigation. 3. On [DATE], the DON and Registered Nurse (RN) Supervisor reviewed the 13 residents with oxygen therapy orders, COPD diagnosis and respiratory distress with hypoxia for signs of respiratory distress or change of condition. 4. On [DATE], the Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) nurse reviewed in-house residents with diagnosis of COPD and respiratory failure with hypoxia for the implementation of resident centered care plans. 5. Starting [DATE], licensed nurses will check that residents are receiving the appropriate oxygen therapy as ordered at the start of their shift. When placing residents from oxygen concentrators to oxygen tanks, licensed nurses will verify the oxygen order to ensure that the liters per minute being administered matches the order. Cross reference F678 Findings: During review of GACH 1 Pulmonology (a branch of medicine that specializes in diagnosing and treating diseases of the lungs and other parts of the respiratory system) Progress Notes dated [DATE] timed at 12:14 PM, indicated Resident 41 was previously admitted to GACH 1 on [DATE], with diagnoses including acute on chronic systolic heart failure (one or two main types of heart failure), severe aortic stenosis, end stage renal disease (final, permanent stage of kidney disease) on dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to), dyspnea (shortness of breath), and hypoxia. The GACH 1 Pulmonology Progress Notes indicated Resident 41 felt weak and tired and was receiving 4 Liters (L, unit of measure) of Oxygen via Nasal Cannula (a small, flexible tube that contains two open prongs intended to sit just inside the nostrils to deliver supplemental oxygen). The progress note indicated Resident 41's chest x-ray results indicated small bilateral pleural effusions (buildup of excess fluid between the layers of the pleura [part of the respiratory tract that cushions the lung and reduces any friction that may develop between the lung, rib cage, chest cavity] outside the lungs). A review of GACH 1 Cardiology Progress Notes dated [DATE] timed at 8:21 AM, indicated Resident 41 was on 4 liters per minute of oxygen therapy during that time ([DATE]) and Resident 41 stated that breathing was stable at this level of oxygen. A review of Resident 41's admission Record indicated the facility originally admitted the resident on [DATE], and was readmitted back to the facility on [DATE], with diagnoses that included acute on chronic systolic heart failure, acute respiratory failure with hypoxia, and COPD. A review of Resident 41's Clinical admission dated [DATE] timed at 3:18 PM, indicated Resident 41 was on Oxygen at 3 liters per minute. The Clinical admission indicated Resident 41's pulse oximetry (pulse oximetry is a painless, noninvasive method of measuring the saturation of oxygen in a person's blood) reading during admission to the facility was at 95% (a resting oxygen saturation level between 95% and 100% is regarded as normal for a healthy person) using oxygen administered via nasal cannula. The Clinical admission indicated Resident 41's discharge goal was to return home. A review of Resident 41's History and Physical (H&P) dated [DATE], indicated the resident had the capacity to understand and make decisions. The H&P indicated one of Resident 41's diagnosis included pneumonia. A review of Resident 41's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) with assessment reference date of [DATE], indicated the resident had moderate cognitive (thought process) impairment. The MDS indicated Resident 41 required partial/moderate assistance (helper does less than half the effort) in walking up to 10 feet. The MDS indicated Resident 41 required supervision (helper provides verbal cues) on task such as oral hygiene, upper body dressing, sit to stand and bed mobility. The MDS indicated Resident 41 required partial/moderate assistance with toileting, shower and lower body dressing. A review of Resident 41's POLST signed and dated by Physician 1 on [DATE], indicated to attempt and perform CPR, if the resident was found with no pulse and is not breathing. A review of Resident 41's physician's order dated [DATE], authored by LVN 2, indicated to administer oxygen via NC at 3 liters (unit of measurement) per minute, may titrate oxygen to maintain oxygen saturation greater or equal to 92% every shift for shortness of breath. A review of Resident 41's care plan dated [DATE], indicated the resident was at risk for rehospitalization due to COPD . and hypertension (high blood pressure). The care plan interventions included to notify the physician if resident presents with signs and symptoms of respiratory distress . such as adventitious lung sounds (any sounds that occur in addition to normal breathing sounds), shortness of breath . A review of Resident 41's care plan dated [DATE], indicated the resident has pneumonia. The care plan interventions included to auscultate (listening to the sounds of the body during a physical examination) lung sounds, listen for crackles and diminished breath sounds due to atelectasis (the collapse of part or all of a lung, is caused by a blockage of the air passages). During the review of Resident 41's Progress Notes dated [DATE] timed at 5:30 AM, authored by Licensed Vocational Nurse (LVN) 1 indicated Resident 41 approached LVN 1 at the Nursing Station asking for another oxygen tank (a container with oxygen inside it, used for helping people to breathe). The Progress Notes indicated LVN 1 advised Resident 41 that Resident 41 still had half a tank left and will change (the oxygen tank) when it is lower. The Progress Notes indicated Resident 41 understood and just waited outside Nursing Station until staff finished with rounds. During the same review of Resident 41's Progress Notes dated [DATE] timed at 5:30 AM, the Notes indicated Noted Resident 41's oxygen tank outside Nursing Station. The Progress Notes indicated LVN 1 went inside Resident 41's room to ask if the resident still wanted her oxygen tank. The Progress Notes indicated Resident 41 was found unresponsive in bed with eyes slightly open, no pulse, no rise of chest, [Resident 41] was still warm, blood sugar 301, unable to get blood pressure. The Progress Notes indicated 911 [paramedics] was called while staff (unknown) did CPR The Progress Notes indicated Resident 41 was transferred to the GACH on [DATE] at 6:25 AM, and family and Physician 1 was notified. A review of Resident 41's Change of Condition (COC) note dated [DATE] timed at 6:23 AM, indicated Found [Resident 41] unresponsive lying in bed with eyes slightly open. Called code blue (a declaration of or a state of medical emergency and call for medical personnel and equipment to attempt to resuscitate a patient) and started CPR. 911 was called and noted patient was full code, did CPR for 10 minutes before paramedics arrived and took over patient care. No pulse, and after 25 minutes of CPR and resident was transferred to GACH. The COC indicated Resident 41's oxygen saturation was 65% and blood sugar of 301. The COC indicated Physician 1 was notified on [DATE] at 6:42 AM. A review of Resident 41's Medication Administration from [DATE] to [DATE] indicated an order to administer ipatropium-albuterol (made up of two different bronchodilators (a drug that relaxes and opens the airways, used to treat COPD) inhalation solution 0.5 - 2.5 milligrams (mg) / 3 milliliters (ml). Inhale 3 ml orally, every 6 hours as needed for shortness of breath. The MAR indicated X marks from [DATE] to [DATE], indicating no inhalation solution was signed out and provided to Resident 41. A review of Resident 41's GACH 1 Emergency Department (ED) Reports dated [DATE] timed at 7:14 PM, indicated Resident 41 was brought in by ambulance from the facility and found pulseless and not responsive. The GACH 1 ED report indicated the paramedics were called by the facility at approximately 5:52 AM and Resident 41 was last seen by facility staff (LVN 1) in her usual state of health 10 minutes prior. The GACH 1 ED report indicated paramedics were unable to obtain any return of spontaneous circulation in the field and were directed by base station to be transported. The report indicated Resident 41 arrived to GACH 1 ED with CPR in progress and Advanced Cardiac Life Support (ACLS, a set of clinical guidelines for the urgent and emergent treatment of life-threatening cardiovascular conditions that will cause or have caused cardiac arrest, using advanced medical procedures, medications, and techniques) in excess of 50 minutes, an additional dose of epinephrine (primary drug used in cardiac arrest, to increase cardiac output), sodium bicarbonate (medication used to treat metabolic acidosis [when acids build up in your body]), and calcium gluconate (medication used to manage cardiac arrest) were administered. The GACH 1 ED report indicated chest compressions continued with assisted ventilation (the movement of gas into and out of the lung by an external source connected directly to the patient) through endotracheal tube (a tube placed between the vocal cords through the airway to provide oxygen and inhaled gases to the lungs). The report indicated Resident 41 remained pulseless without cardiac activity on ultrasound (an imaging test that uses sound waves to make pictures of organs) and died on [DATE] at 6:50 AM. During an interview and concurrent record review of Resident 41's Clinical admission notes and Physician Orders with the DON on [DATE] at 5:33 PM, the DON stated Resident 41 was admitted to the facility on [DATE] with oxygen being administered via NC. The DON stated Resident 41's Oxygen therapy order was initiated on [DATE]. The DON stated after reviewing all of Resident 41's care plans developed from [DATE] to [DATE], the resident's care plans did not indicate care plans were developed for Resident 41's use of oxygen, history of hypoxia, and shortness of breath. During the same concurrent interview and record review of Resident 41's COC notes, Progress Notes, vital signs records, and assessment notes from [DATE] to [DATE] with the DON, on [DATE] at 5:33 PM, the DON stated there was no documented evidence found indicating a respiratory assessment and treatment was performed on [DATE], by LVN 1, when Resident 41 verbalized to LVN 1 that Resident 41 was not feeling well and felt her oxygen tank was empty. During a telephone interview on [DATE] at 6:04 PM, with Physician 1, Physician 1 stated Resident 41 was on continuous oxygen therapy due to her medical condition of cancer, systolic heart failure and pneumonia. Physician 1 stated he would expect the licensed nurse assigned to care for Resident 41, to conduct a respiratory assessment of Resident 41 when she verbalized to LVN 1 on [DATE] that Resident 41 felt like her oxygen tank was empty, because Resident 41 might not be feeling well. Physician 1 stated that LVN 1 should have checked Resident 41's vital signs and respiratory assessment because of Resident 41's respiratory diagnoses (pneumonia, COPD, hypoxia) and notified Physician 1 immediately. Physician 1 stated he was notified by LVN 1 on [DATE] after Resident 41 was transferred to GACH 1. Physician 1 stated he could not recall the exact details of LVN 1's telephone notification on [DATE]. During a telephone interview with LVN 1 on 5 /04/2024 at 6:28 PM, LVN 1 stated on [DATE], at around 5:30 AM, while LVN 1 was putting away medications, Resident 41 came up to LVN 1 and asked if LVN 1 could change her portable oxygen tank because Resident 41 believed her oxygen tank was empty. LVN 1 stated he observed Resident 41's oxygen tank gauge (a medical device designed to display the pressure level in an oxygen tank) and saw that the oxygen tank gauge was still half full. LVN 1 stated he checked Resident 41's oxygen saturation and vital signs but could not recall and did not document the oxygen saturation level and vital signs results on [DATE]. LVN 1 stated that he did not do any other assessments (respiratory) or treatment to Resident 41, because he needed to finish his medication pass on [DATE] and go home. LVN 1 stated he left Resident 41 sitting in a chair by the Nursing Station and preceded to finish putting away medications in Medication Cart 1. LVN 1 stated after leaving Resident 41 in the Nursing Station, he continued to administer medications to other residents in seven rooms before going to another Nursing Station by Medication Cart 2, to retrieve Resident 41's medications which were kept in Medication Cart 2. LVN 1 stated as he was approaching Medication Cart 2, he observed Resident 41 was not at the Nursing Station anymore but Resident 41's oxygen tank was left by the Nursing Station. LVN 1 stated he proceeded to go to Medication Cart 2 to remove Resident 41's routine medications before he decided to go to Resident 41's room. During the same telephone interview, on 5 /04/2024 at 6:28 PM, LVN 1 stated as he entered Resident 41's room on [DATE], LVN 1 observed Resident 41 lying in bed and not breathing. LVN 1 stated he went outside Resident 41's room to call for help and return to Resident 41's bedside. LVN 1 stated when Certified Nurse Assistant (CNA) 1 came to Resident 41's room, LVN 1 instructed CNA 1 to wait in the room, until he was able to review Resident 41's code status in the electronic medical records. LVN 1 stated he went outside Resident 41's room back to the Nursing Station and Medication Cart 2. LVN 1 stated he logged into the electronic medical records, but the electronic records did not indicate Resident 41's code status. LVN 1 stated he had to go to Nursing Station 1 to get Resident 41's paper chart to look for the POLST. LVN 1 stated Resident 41's POLST indicated Resident 41 was a full code (full support which includes cardiopulmonary resuscitation (CPR), if the patient has no heartbeat and is not breathing). LVN 1 stated after reviewing Resident 41's paper chart, LVN 1 returned to Resident 41's room to initiate CPR. LVN 1 stated that after completing about two full sets (consisting of 2 rescue breaths and 15 chest compressions) of CPR, LVN 1 instructed CNA 1 and CNA 2 to take over CPR, as he went outside Resident 41's room to the Nursing Station to call 911. LVN 1 stated he was the only licensed nurse during the shift (11 PM to 7 AM) for the entire facility on [DATE]. During an interview on [DATE] at 7:31 PM, with CNA 1, CNA 1 stated that in the morning of [DATE], between 5:30 AM to 6 AM, CNA 1 stated she was sitting by the Nursing Station and recalled observing Resident 41 walking up to the Nursing Station and verbalized not feeling well to LVN 1. CNA 1 stated seeing LVN 1 leaving the Nursing Station after talking to Resident 41 and LVN 1 continued passing medications on his assigned residents. CNA 1 stated that on [DATE], she heard LVN 1 shouting for help. CNA 1 stated she went to Resident 41's room, where she found LVN 1 standing right by the resident. CNA 1 stated LVN 1 instructed her to wait and remain at Resident 41's bedside, while LVN 1 went out to check Resident 41's code status. During the same interview on [DATE] at 7:31 PM, with CNA 1, CNA 1 stated LVN 1 returned to Resident 41's bedside and initiated chest compressions while CNA 2 used the Ambu bag (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing) to give Resident 41 two rescue breaths. CNA 1 stated LVN 1 instructed to check for Resident 41's vital signs. CNA 1 stated she remembered the pulse oximeter (an electronic device that measures the saturation of oxygen in the blood) not reading and the blood pressure machine showing an error result. CNA 1 stated LVN 1 instructed CNA 1 to take over the chest compressions while LVN 1 went back to the Nursing Station to call 911. CNA 1 stated she recalled LVN 1 returning to Resident 41's room and continued to perform CPR to Resident 41, until the paramedics arrived and took over the CPR. During a telephone interview on [DATE] at 7:49 PM with LVN 2, LVN 2 stated that on [DATE], she noted in Resident 41's previous ([DATE] to [DATE]) GACH 1 records that the resident should be on oxygen therapy. LVN 2 stated that on [DATE], LVN 2 entered the physician order for oxygen at 3 liters per minute via NC in Resident 41's electronic records but did not inform or verify the oxygen orders with Physican 1. LVN 1 stated she assumed that the admitting licensed nurse just forgot to put in the oxygen orders for Resident 41 upon admission to the facility on [DATE]. During another interview on [DATE] at 1:56 PM with LVN 1, LVN 1 stated he saw CNA 1 on [DATE] upon finding Resident 41 unresponsive and not breathing. LVN 1 stated he instructed CNA 1 and stated, don't start anything because LVN 1 needed to find out Resident 41's code status first. LVN 1 stated he went to the medication cart and logged into the electronic records but was not able to find Resident 41's code status. LVN 1 stated he went to the Nursing Station and looked through Resident 41's paper chart to look for the resident's code status. LVN 1 stated he found Resident 41's POLST that indicated Resident 41 was a Full Code (attempt to provide CPR). LVN 1 stated when he learned of Resident 41's code status, he went back to the resident's room and initiated CPR. LVN 1 stated that on [DATE], everyone was standing by for CPR because we did not know the code status yet. During a concurrent interview and record review of the facility's policy and procedure (P&P) titled, Medical Emergency Response, revised on [DATE], on [DATE] at 6:11 PM, the DON stated the staff who first witnessed a medical emergency, such as finding an unresponsive and pulseless resident, should initiate immediate action, including CPR and calling for assistance. The DON stated the P&P indicated the CPR will only be stopped if a Do Not Resuscitate (DNR, instruction to not perform CPR on a resident) order is found to be in place in the resident's record. The DON stated staff should initiate CPR then have someone else verify the resident's code status. The DON stated delaying the CPR could result in a resident's death. During a telephone interview on [DATE] at 2:06 PM with Resident 41's Family Member (FM 1), FM 1 stated the resident was in good spirits on [DATE]. FM 1 stated Resident 41 was planning on going home on [DATE]. FM 1 stated she talked to Resident 41 on [DATE], then on [DATE] at around 7 AM, she was informed by GACH 1 physician that Resident 41 passed away. During a telephone interview on [DATE] at 6:15 PM with CNA 2, CNA 2 stated she saw Resident 41 near the nursing station on [DATE] at around 5:30 AM. CNA 2 stated she went to another resident's room and sometime later, she heard LVN 1 call for code blue. CNA 2 stated as she was going into Resident 41's room, LVN 1 was coming of the room to check for the code status. CNA 2 stated that CNA 2, CNA 1 and CNA 4 did not start CPR as instructed by LVN 1. CNA 2 stated that when LVN 1 came back to the room, that was when LVN 1 started CPR. CNA 2 stated she does not remember how long it took LVN 1 to find Resident 41's code status in the resident's records. A review of the facility's policy and procedure titled Notification of Changes, with a revision date of [DATE], indicated the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident representative when there is a change of condition requiring notification. A review of the policy and procedure titled Oxygen Administration dated [DATE] indicated oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The policy indicated the resident's care plan shall identify interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: the type of oxygen delivery system, when to administer, such as continuous or intermittent and /or when to discontinue, equipment setting for the prescribed flow rates, monitoring of oxygen saturation levels and/or vital signs as ordered, and monitoring for complications associated with the use of oxygen. The policy indicated staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. A review of the facility's policy and procedure titled Comprehensive Care Plans, dated [DATE], indicated the facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. A review of the facility's policy and procedure titled, Medical Emergency Response, revised on [DATE], indicated The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid . The policy indicated, a nurse will assess the situation and determine the severity of the emergency, stay with the resident, designate a staff member to announce a Code Blue, if necessary, and call 911 as needed. The policy further indicated, CPR will continue unless there is a DNR (do not resuscitate) order in place .