**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure prescribed therapeutic diet of dysphagia mechanical soft consistency was followed for 1 of 8 sampled residents, (#1). This failure resulted in resident #1 consuming the wrong consistency snack, causing her to choke, and turn blue until she was transferred and admitted to the hospital Intensive Care Unit (ICU) and treated for acute respiratory failure with hypoxia. On 12/20/24 at 11:00 AM, resident #1, who was on a mechanical soft consistency diet, was allowed to consume a peanut butter and jelly (PB&J) sandwich from a tray of snacks left on a table in the dayroom by Certified Nursing Assistant (CNA) A. The CNA was aware resident #1 was on a mechanical soft diet but allowed the resident to eat the sandwich because she had seen her eat bread in the past. The CNA recalled she was called back into the dayroom by CNA B who told her resident #1 did not look good. She said resident #1 was sitting up in a chair with her mouth open and tongue sticking out. Licensed Practical Nurse (LPN) C and LPN D immediately responded, and LPN C attempted to administer the Heimlich maneuver but the resident was unresponsive. The resident was lowered to the floor and suctioned with some food removed from her airway. The resident remained unconscious with a pulse when the paramedics arrived and removed food from the back of the resident's airway. The resident was transported to the hospital and admitted to the Intensive Care Unit with admitting diagnoses of acute respiratory failure with hypoxia. The facility's failure to follow the prescribed therapeutic diet resulted in substandard quality of care at the Immediate Jeopardy level, starting on 12/20/24. The facility implemented actions to remove the immediacy as of 1/14/25. Findings: Cross reference F726 Resident #1 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included Parkinson's disease, unspecified psychosis, dysphagia oropharyngeal phase, history of cerebral infarction (stroke), unspecified dementia, generalized anxiety disorder, and major depressive disorder. Review of resident #1's physician orders for December 2024 revealed an order for a dysphagia mechanical soft texture diet since 8/29/23. Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status score of 10 out of 15, which indicated moderate cognitive impairment. The assessment indicated resident #1 had no upper or lower extremity limitations, was independent for eating, and required set up or clean-up assistance for other Activities of Daily Living (ADLs). The assessment did not document any symptoms of a swallowing disorder but showed she was on a mechanically altered diet which required a change in food texture or liquids. Dysphagia is defined as difficulty swallowing that could, in some cases, make it almost impossible to swallow. Oropharyngeal phase dysphagia can be caused by neurological conditions such as Parkinson's disease. Not being able to swallow correctly can lead to complications such as aspiration pneumonia due to food entering the lungs and choking due to food getting stuck in the throat. When food gets stuck in the throat it can block the airway and lead to death if not attended to promptly (retrieved on 01/21/25 from the mayoclinic.org). The National Foundation of Swallowing Disorders, following the recommendations of The American Dietetic Association, described dysphagia mechanical soft texture diet included foods such as pureed breads but advised all other bread textures should be avoided. The recommendations included other foods to be avoided included sandwiches and peanut butter, (retrieved on 1/23/25 from swallowingdisorderfoundation.com). A progress note written by the Director of Nursing (DON) on 12/20/24 at 11:28 AM, revealed that at 11:10 AM, a hospice CNA and floor CNA were in the dining room of the memory care unit passing snacks. The floor CNA was called to assist on the floor and within seconds the hospice CNA alerted the floor CNA that the resident didn't look like she felt well. The note described the floor CNA stated that the resident had her mouth open and tongue sticking out, so she called the nurse immediately. The DON documented the LPN started the Heimlich maneuver and soggy bread material came out, then she was laid on the floor on her side and suctioned. The APRN, Physician Assistant (PA), and another LPN also responded. She detailed the resident's oxygen saturation was 71% on room air so oxygen was applied, and the oxygen saturations came up to 92%. The DON detailed that Emergency Medical Service (EMS) arrived and used a laryngoscope (a small tool to look in your throat) to remove the remaining object from blocking the airway. Resident #1 was transferred to the hospital for possible aspiration and the family was notified. Normal oxygen saturation levels should be between 95% and 100% for most people. Oxygen is essential to all body functions so low oxygen levels are concerning and may lead to many serious conditions and damage to individual organ systems, especially your heart and brain. If your level is lower than 88% you should get emergency treatment, (retrieved on 1/27/25 from www.myclevelandclinic.org). Review of a nursing progress note revealed a change in condition note entered on 12/20/24 at 1:30 PM, that indicated resident #1 had respiratory arrest. The note revealed resident #1's vital signs at that time were, blood pressure 85/56, pulse 44, no respirations, oxygen saturation 71% on room air, and mental status was unresponsive. The LPN documented that she responded immediately and noticed the resident had something in her mouth and her face was discolored. She started the Heimlich maneuver and soggy bread material was expelled from her mouth, so they lowered her to the floor on her side and suctioned. EMS was called, oxygen was applied on the resident, and the APRN gave the order to transfer the resident to the hospital. At 2:34 PM, the LPN documented she spoke with the resident's son who said he was at the hospital with the resident. A nursing progress note dated 12/24/24 at 11:02 PM, indicated resident #1 returned to the facility from the hospital with orders for a diet change. On 12/25/24 at 10:25 AM, the Respiratory Therapist (RT) assessed the resident and documented she was awaiting orders from the APRN. The Registered Dietician (RD) evaluated the resident on 12/26/24 and noted resident #1's diet order was changed to a regular diet with pureed texture and thin liquids. She also documented the resident required supervision with meals due to her history of attempting to take food from others. On 12/26/24 a change in condition note was documented by a nurse that the resident had abnormal lung sounds (rales, rhonchi, wheezing) and the doctor ordered a chest X-ray due to chest congestion. Review of a physician progress note dated 12/29/24, revealed resident #1 was evaluated for resumption of care after a hospitalization from 12/20/24 to 12/24/24 due to choking resulting in intubation (a tube in her throat to breath) as per hospital records with administration of multiple Intravenous antibiotics in the ICU setting. She returned to the facility on antibiotic therapy for five days. Review of resident #1's hospital records with admission date 12/20/24, revealed she was seen due to a choking incident where she was unresponsive. The admission summary indicated the resident choked on her meal and became unresponsive, so EMS were called. Upon arrival to the hospital emergency room (ER), she remained unresponsive, so they intubated her for hypoxic (low oxygen) respiratory failure and admitted her to the ICU. The discharge summary on 12/24/24 showed the discharge diagnosis of acute hypoxic respiratory failure and noted that speech and swallow tests had been done, and her diet was adjusted. On 1/13/25 at 1:56 PM, the DON stated she served as the facility's Risk Manager. She confirmed that on 12/20/24 around 11:00 AM, CNA A alerted staff that resident #1 was choking on a snack in the memory care unit day room. The DON stated the facility found the root cause of the event was staff were not familiar with the approved snacks per diet texture orders and snacks being placed unsecured in the dementia unit. In a joint interview on 1/13/25 at 4:15 PM, with the Director of Rehabilitation (DOR) and the Speech Therapist (ST), the DOR stated resident #1's most recent Speech evaluation was completed on 8/27/24 and showed a decline in cognitive and swallowing function which required a mechanical soft/chopped textured diet. The DOR explained resident #1 also required supervision during meals and cues for swallowing. The ST stated their goal was for resident #1 to implement compensatory strategies to increase safety during meals. She explained that a mechanical soft diet consisted of foods like pudding, applesauce, Jello, and pureed bread but would not include peanut butter and jelly sandwiches. On 1/14/25 at 9:24 AM, in a telephone interview CNA A said she had worked at the facility since July 2024 and had no prior experience as a CNA. She recounted that on 12/20/24 she was assigned to work the secure memory care unit and had worked with resident #1 before. CNA A stated she was aware resident #1 required a dysphagia mechanical soft texture diet and said around 11:00 AM she went to the nourishment room, outside of the secured unit, to get snacks for the residents. She recalled she grabbed a tray that contained labeled snacks with resident's names and other unlabeled snacks such as peanut butter sandwiches and cookies. She returned to the memory care unit's dayroom and saw resident #1 sitting at a table by herself, next to the door. CNA A said she placed the tray of snacks on a table across from resident #1 and saw her grab the peanut butter and jelly sandwich from the tray. She confirmed she allowed resident #1 to have the sandwich because she had seen her eating bread before, thought the sandwich was soft, and ok for her to eat. CNA A explained she was then called away by another CNA that needed help and left the dayroom. She recalled there was a hospice CNA in the dayroom that was attending to another resident who called her back into the dayroom a few moments later to say that resident #1, didn't look good. CNA A explained she returned to the dayroom and saw resident #1, who was turning blue, had her mouth open and tongue sticking out. She said she immediately called for help and LPN C and LPN D arrived to provide emergency care for resident #1. CNA A remembered resident #1 was unresponsive and they gave her supplemental oxygen until EMS arrived and transferred her to the hospital. CNA A explained she had not been educated about which foods were appropriate for a dysphagia mechanical soft diet and had not asked anyone if a peanut butter and jelly sandwich was appropriate for resident #1. On 1/14/25 at 9:35 AM, LPN C stated that she was assigned to the memory care unit on 12/20/24 and around the time of the incident she was out of the secured unit making copies at the nurse's station. She recalled at approximately 11:00 AM, CNA A came out of the secured unit saying she needed help right away. When she entered the dayroom, she saw resident #1 sitting up in a chair with her mouth open, tongue sticking out, and a creamy substance in her mouth. LPN C said she immediately started the Heimlich maneuver, and some food came out, but the resident was unresponsive. She recounted that LPN D came to the room with portable suction and assisted her to lower resident #1 to the floor, place her on her side and suction her mouth. LPN C explained some food came out of resident #1's moth, but she was still unresponsive, and her oxygen saturation was low at 71%. She said at that time that they gave her supplemental oxygen and waited for EMS to arrive. LPN C said when EMS arrived they used the laryngoscope to get more food out of her mouth and then transported her to the hospital. She confirmed that resident #1 had known behaviors of grabbing food from others and ate very fast. LPN C stated resident #1 required a mechanical soft texture diet and therefore a peanut butter and jelly sandwich would not be appropriate for her because it was very sticky and hard to swallow. On 1/14/25 at 9:40 AM, the Certified Dietary Manager (CDM) confirmed that resident #1 was prescribed a dysphagia mechanical soft texture diet on 12/20/24. He stated that prescribed snacks were served around 10:00 AM and 2:00 PM daily but resident #1 did not get a prescribed snack. The CDM explained resident #1 was offered a daily snack because she liked them so extra snacks were always added to the tray. He related that the dietary aides were directed to place the snack trays in the 400-hall nourishment room and not in the memory care unit's dayroom, to prevent memory care residents from grabbing foods not prescribed for their diet. He explained some of the snacks offered were peanut butter sandwiches, applesauce, pudding, and cookies. He confirmed that resident #1 had behaviors of grabbing foods from others, so trays should not be left unattended. The CDM said pureed bread was okay, but peanut butter and jelly sandwiches were not acceptable or safe for a resident who needed a dysphagia mechanical soft texture diet. On 1/14/25 at 1:46 PM, LPN D explained he had not worked on the secured memory care unit, but on 12/20/24 he was at the nurses' station outside the secured unit when he heard CNA A calling for help. He recounted that when he entered the dayroom, resident #1 was sitting in a chair making gasping sounds and appeared to be having trouble breathing. He explained LPN C was administering the Heimlich maneuver to resident #1 when she went unconscious but had a pulse. He said they lowered her to the floor on her side and suctioned her mouth with some food coming out. On 1/14/25 at 2:24 PM, in a telephone interview CNA B confirmed she worked for an outside hospice and was at the facility on 12/20/24 to provide care to hospice residents in the building. She explained that on that day at approximately 11:00 AM, she was visiting a resident in memory care unit and was working with a resident in the dayroom when she noticed that resident #1 did not look good. Hospice CNA B said she did not see CNA A bringing the snack tray in to the room and had not seen resident #1 take the peanut butter and jelly sandwich. She explained that CNA A had left the room and CNA B ran out to get her back when she saw resident #1 looking ill. Hospice CNA B said CNA A arrived immediately and went to call for help. She reported that because she was not directly observing resident #1 when CNA A left the room, she could not say how long she had been choking before she noticed. On 1/15/25 at 2:05 PM, the APRN said that around lunch time on 12/20/24, she was called to the memory care unit by a nurse who told her a resident was choking. She recounted when she arrived in the dayroom she saw resident #1 sitting up in a chair and a nurse was behind her performing the Heimlich maneuver. The APRN described the resident as looking ashen and not responding but having a pulse. She said during the Heimlich some food came out, but the resident was still unresponsive. The APRN directed the staff to lower the resident to the floor on her side and a male nurse started suctioning. She recalled that oxygen was applied until EMS arrived and proceeded with additional life saving measures. The APRN said the resident's color started improving and EMS transported her to the ER. She explained that prior to the incident she had not worked with resident #1 and was unaware of her dysphagia diagnosis or food texture order. but was told by staff that the resident had ingested some type of bread, and which caused her to choke. The APRN indicated she did not believe bread was part of a mechanical soft texture diet and it was her expectation for staff to be knowledgeable on the types of textures and foods appropriate for each diet. She said that a resident with swallowing difficulties could potentially choke, aspirate, or become unresponsive if they ingested food not suitable for their diet texture. The Immediate Jeopardy was determined to be removed on 1/14/24 after verification of the immediate actions implemented by the facility. The scope and severity of the deficiencies was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy. The resident sample was expanded to include seven additional residents who required dysphagia diets. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *CNA A received a teachable moment regarding appropriate snacks according to diet texture with the DON on 12/20/24. * On 12/20/24 an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the action plan. The Medical Director reviewed and approved the plan. * On 12/20/24 the RD completed a quality review on residents diet orders and validated with the CDM against the kitchen's meal ticket identifiers to ensure that diets were being served as prescribed. Orders were clarified as needed. * On 12/20/24 resident diet orders were posted in pantry rooms and dining rooms. Print outs listing approved snacks for regular texture, dysphagia advanced, dysphagia mechanical soft, and dysphagia pureed were posted to dining rooms, nursing stations, and med carts. The CDM validated that snacks were delivered to the secured pantry. * Education for staff started on 12/20/24 and continued through 1/3/25. They educated staff on appropriate snacks based on resident diet texture order and the procedure to validate the resident's diet order if needed. Training also included Abuse/Neglect training and supervision during snack pass. Newly hired staff would receive education during orientation regarding appropriate snacks to be offered based on diet texture orders. * On 12/23/24 the CDM completed 100% training with dietary staff regarding meal ticket accuracy and procedures for snacks. New diet orders would be reviewed during morning clinical meeting. *On 12/23/24 Unit Managers began weekly audits to ensure appropriate snacks were being passed, meal tickets matched what was being served, and staff was able to verbalize where to find correct diet information. Audits were done 12/23/24, 12/30/24, and 1/06/25 with no discrepancies noted. *On 12/24/24 a facility wide quality review was begun by Speech Language Pathologist to verify that residents with dysphagia diagnosis were on the correct texture diets. The audit was completed on 1/14/25 with no discrepancies noted. *Resident #1 returned to the facility on [DATE] from the hospital with diet texture downgraded to puree. Orders and care plans were updated accordingly to reflect the texture change. The RD followed up with resident #1 on 12/26/24 with no new recommendations. * On 12/24/24 NHA and Interdisciplinary Team (IDT), including Medical Director, met for monthly QAPI meeting and to review the progress made. They determined that all plans that had been put in place were effective. *On 12/30/24 the RD completed the second quality review to ensure diet orders in the electronic medical record matched the meal tracker. There were no issues noted. Interviews conducted from 01/15/25 through 01/16/25 with 21 total facility staff who represented the dietary and nursing departments revealed they were knowledgeable of the facility's policy and procedure for dysphagia diet orders, and appropriate snacks. Interviews conducted with nursing staff, including 9 CNAs, 2 Registered Nurses, and 3 Licensed Practical Nurses, revealed they received education between 12/20/24 and 12/25/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had the knowledge, skill sets, and competencies to provide foods/snacks to residents in accordance with their plan of care and physician orders for 1 of 8 sampled residents, (#1). This failure resulted in the resident being allowed to consume the wrong consistency snack which resulted in the resident choking and being transferred to a higher level of care where she was admitted to the Intensive Care Unit (ICU) and treated for acute respiratory failure with hypoxia. On 12/20/24 at 11:00 AM, resident #1, who was on a mechanical soft consistency diet, was allowed to consume a peanut butter and jelly (PB&J) sandwich from a tray of snacks left on a table in the dayroom by CNA A. The CNA was aware resident #1 was on a mechanical soft diet but allowed the resident to eat the sandwich because she had seen her eat bread in the past. The CNA recalled she was called back into the dayroom by CNA B who told her resident #1 did not look good. CNA A said resident #1 was sitting up in a chair with her mouth open and tongue sticking out. Licensed Practical Nurse (LPN) C and LPN D immediately responded, and LPN C attempted to administer the Heimlich maneuver but the resident was unresponsive. The resident was lowered to the floor and suctioned with some food removed from her airway. The resident remained unconscious with a pulse when the paramedics arrived and removed food from the back of the resident's airway. The resident was transported to the hospital and admitted to the Intensive Care Unit with admitting diagnoses of acute respiratory failure with hypoxia. The facility's failure to follow the prescribed therapeutic diet resulted Immediate Jeopardy starting on 12/20/24. The facility implemented actions to remove the Immediate Jeopardy as of 1/14/25. Findings: Cross reference F692 Resident #1 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included Parkinson's disease, dysphagia oropharyngeal phase (trouble swallowing in the mouth or throat), history of cerebral infarction (stroke), and unspecified dementia. Review of resident #1's physician orders for December 2024 revealed orders for a dysphagia mechanical soft texture diet since 8/29/23. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 10 out of 15, which indicated moderate cognitive impairment. She had no upper or lower extremity limitations, was independent for eating, and required set up or clean-up assistance for other Activities of Daily Living (ADLs). She was not identified as having any symptoms of a swallowing disorder but was on a mechanically altered diet which required a change in food texture or liquids. Review of resident #1's care plan, with revision date 11/20/24, identified she had a potential nutritional problem related to the need for mechanically altered diet texture and past medical history of Parkinson's disease, dysphagia, dementia, and Gastro Esophageal Reflux Disease. The interventions included staff to monitor/document/report as needed any signs or symptoms of dysphagia but failed to include interventions for staff to serve diet as ordered. According to the National Foundation of Swallowing Disorders, which followed the recommendations from the American Dietetic Association, a dysphagia mechanical soft texture included foods such as soft pancakes, and pureed breads but all other bread textures should be avoided. Other foods that should be avoided included sandwiches and peanut butter, (retrieved on 1/23/25 from Swallowingdisorderfoundation.com). On 1/13/25 at 1:56 PM, the facility's Reportable and Adverse incident log from December 2024 was reviewed with the Director of Nursing (DON) who was also the Risk Manager. She said that on 12/20/24 at around 11:00 AM, CNA A alerted staff that resident #1, who at the time was in the day room of the memory care unit, was choking on a snack. The Heimlich maneuver was performed, and the resident was suctioned but ultimately, was transferred via Emergency Medical Services (EMS) to the hospital. The DON recalled she responded to the scene along with two nurses, the Advance Practice Registered Nurse (APRN), and the Physician Assistant (PA). According to the DON, the root cause was staff not being familiar with the approved snack list based on diet texture orders and snacks being placed unsecured on a dementia unit. On 1/14/25 at 9:24 AM, during a telephone interview, CNA A stated she had worked at the facility since July 2024 and had no prior CNA experience. She reported on 12/20/24 she was assigned to work on the secure memory care unit. She noted she had worked with resident #1 before and was aware she was on a dysphagia mechanical soft texture diet. She recalled at about 11:00 AM, she went to the nourishment room, located outside of the secured unit, to get snacks for the residents. She said she picked up a tray with labeled snacks with resident names and other snacks such as peanut butter sandwich and cookies, that had no resident names. She stated she went back to the memory care unit's dayroom where resident #1 was seated at a table by herself next to the door. She said she placed the tray of snacks on a table across from resident #1 and then saw the resident grab a peanut butter and jelly sandwich. She said she allowed the resident to have the sandwich because she had seen her eating bread before, and the sandwich was soft. She remembered she was called away by another CNA that needed help and left the dayroom. She noted she was called back to the dayroom by a hospice CNA a few seconds later as resident #1 didn't look good. She said the resident was turning blue, had her mouth open and tongue sticking out. She recalled she immediately called for help and LPN C administered the Heimlich maneuver and LPN D assisted with suctioning the resident's airway. She reported resident #1 was unresponsive and was given supplemental oxygen until paramedics arrived and transferred the resident to the hospital. She said she was not trained on what foods were appropriate for a dysphagia mechanical soft diet and did not ask anyone if a peanut butter and jelly sandwich was appropriate for the resident. Review of the nursing progress notes revealed a change in condition note entered on 12/20/24 at 1:30 PM, by an LPN that noted the resident went into respiratory arrest. The note revealed resident #1's vital signs at the time of the incident were, blood pressure 85/56, pulse 44, respirations 0, oxygen saturation 71% on room air, and mental status was unresponsive. The LPN documented that she responded immediately and noticed the resident had something in her mouth and her face was discolored. She started the Heimlich maneuver and soggy bread material was expelled from her mouth. The note showed they lowered the resident on to the floor on her side and suctioned. The note read that EMS arrived, applied oxygen and the APRN gave the order to transfer the resident to the hospital. At 2:34 PM the LPN noted she spoke with the resident's son who said he was at the hospital with the resident. According to resident #1's hospital records with admission date 12/20/24, noted she was seen due to the choking incident and resident being unresponsive. The admission summary showed the resident was having her meal, started to choke and became unresponsive. On arrival to the emergency room (ER), she remained unresponsive, was intubated for hypoxic respiratory failure and admitted to the ICU. The Discharge summary dated [DATE] showed the discharge diagnosis of acute hypoxic respiratory failure and noted that speech and swallow tests were done, and diet was adjusted. Review of resident #1's modified Quarterly MDS completed on 12/27/24, post readmission from an acute care hospital, revealed she required setup assistance for eating, had a new behavior of rejecting care, had difficulty swallowing due to coughing or choking during meals, and continued on mechanically altered diet. Review of a physician progress note dated 12/29/24, noted resident #1 was evaluated for resumption of care after hospitalization from 12/20/24 to 12/24/24 due to choking resulting in intubation as per hospital record with administration of multiple intravenous antibiotics in the ICU setting. She returned to the facility on antibiotic therapy for five days. Review of CNA A's personnel file revealed she was hired on 7/09/24 and had received her CNA certification in 2024. The facility's Job Description for CNAs noted CNAs were entrusted to provide responsible healthcare and were responsible to provide each of their assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan. Other duties and responsibilities included providing direct care in accordance with treatment plans and attending scheduled facility in-services, orientations, and educational classes. According to the job requirements, CNAs must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. On 1/14/25 at 4:34 PM, the Assistant Director of Nursing (ADON) was interviewed with the Regional Nurse Consultant (RNC) and DON present. The ADON confirmed she was the Staff Educator and stated staff received orientation with general nursing topics that included nutrition but not specific to diet types and appropriate food textures. Review of CNA A's education file revealed she completed the new hire orientation packet and skills competency assessment for eating support on 7/10/24. There were no documented competencies or in-services related to caring for dysphagia residents, food textures, or appropriate foods/snacks for each diet type. On 1/15/25 at 12:43, CNA E said that prior to the choking incident she had not been educated on diet types or food textures. She worked with resident #1 regularly and said she preferred not giving resident #1 a snack because she was at risk for choking. On 1/15/25 at 1:10 PM, CNA A stated she had not received training related to diet types or food textures when she was hired, and she did not remember attending any in-services prior to the choking incident. On 1/15/25 at 1:46 PM, LPN D reported he had worked at the facility for a total of two years. He said he had never received education during orientation related to diet types and food textures but had received education at a prior facility. On 1/15/25 at 3:21 PM, interviews were conducted with five CNAs from the first and second shift, who said they did not receive education regarding diet types or food textures prior to the choking incident. They confirmed they were responsible for passing out meal trays, handing out snacks, assisting with feeding residents, and monitoring residents during meals. A review of the Facility Assessment revised 8/01/24, noted the facility provided resident services such as eating assistance and nutritional services including individualized dietary plans and specialized diets. The assessment lacked an explanation of how the facility would educate their staff to ensure these services were provided safely and appropriately. According to section 3.4, Staff training/education and competencies, in-service trainings for nursing aides must address areas of weakness as determined in nurse aides' performance reviews and may address the special needs of residents as determined by the facility staff. According to the Consistency Census Report printed on 1/14/25 at 2:51 PM, 31 out of 175 residents in the facility required a mechanically altered texture diet (mechanical soft, pureed, thickened liquids) related to a dysphagia diagnosis. In the memory care unit six residents required a mechanically altered texture diet. The resident sample was expanded to include seven additional residents who required dysphagia diets. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *CNA A received a teachable moment regarding appropriate snacks according to diet texture with DON on 12/20/24. * On 12/20/24 an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the action plan. The Medical Director reviewed and approved the plan. * On 12/20/24 the RD completed a quality review on resident diet orders and validated with the Certified Dietary Manager (CDM) against the kitchen's meal ticket identifiers to ensure that diets were being served as prescribed. Orders were clarified as needed. * On 12/20/24 resident diet orders were posted in pantry rooms and dining rooms. Print outs listing approved snacks for regular texture, dysphagia advanced, dysphagia mechanical soft, and dysphagia pureed were posted to dining rooms, nursing stations, and med carts. CDM validated that snacks were delivered to the secured pantry. * Education for staff started on 12/20/24 and continued through 1/3/25 with 98% trained. Education included recognizing the different diet types and food textures, appropriate snacks for each diet type, and procedure to validate the resident's diet order as needed. Training also included Abuse/Neglect training and supervision during snack pass. Newly hired staff would receive education during orientation regarding appropriate snacks to be offered based on diet texture orders. * On 12/23/24 CDM completed 100% training with dietary staff regarding meal ticket accuracy and procedure for snacks. New diet orders would be reviewed during morning clinical meeting. *On 12/23/24 Unit Managers began weekly audits to ensure appropriate snacks were being passed, meal tickets matched what was being served, and staff was able to verbalize where to find correct diet information. Audits were done 12/23/24, 12/30/24, and 1/6/25 with no discrepancies noted. *On 12/24/24 a facility wide quality review began by Speech Language Pathologist verifying that residents with dysphagia diagnosis were on the correct texture diets. The audit was completed on 1/14/25 with no discrepancies noted. *Resident #1 returned to the facility on [DATE] from the hospital with diet texture downgraded to puree. Orders and care plan were updated accordingly to reflect the texture change. Registered Diet (RD) followed up with resident on 12/26/24 with no new recommendations. * On 12/24/24 the Administrator and Interdisciplinary Team (IDT), including Medical Director, met for monthly QAPI meeting and to review the progress made. They determined that all plans that had been put in place were effective. *On 12/30/24 the RD completed the second quality review to ensure diet orders in the electronic medical record matched the meal tracker. There were no issues noted. Interviews conducted from 01/15/25 through 01/16/25 with 21 total facility staff who represented the dietary and nursing departments revealed they were knowledgeable of the facility's policy and procedure for dysphagia diet orders, and appropriate snacks. Interviews conducted with nursing staff, including 9 CNAs, 2 Registered Nurses, and 3 Licensed Practical Nurses, revealed they received education between 12/20/24 and 12/25/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to honor the right to refuse treatment related to implementing a Do Not Resuscitate Order (DNRO) to prohibit aggressive resuscitation measures at the end of life for 1 of 7 residents reviewed for advance directives, (#1). On [DATE] at approximately 5:00 AM, Licensed Practical Nurse (LPN) A discovered resident #1 in bed, unresponsive and without a pulse. She directed staff to use the facility's overhead paging system to announce a Code Blue while she called 911. Registered Nurses (RNs) B and C responded from another unit and asked about the resident's resuscitation status. LPN A informed them resident #1 had Full Code or full resuscitation status, which meant she should receive Cardiopulmonary Resuscitation (CPR) procedures including chest compressions, intubation, and defibrillation to keep her alive. RNs B and C entered resident #1's room and initiated CPR. LPN D responded from another unit and joined the resuscitation effort. The three nurses took turns doing chest compressions and manually forcing air into her lungs with a bag valve mask as they continued aggressive measures to revive resident #1. When Emergency Medical Services (EMS) personnel arrived at approximately 5:10 AM, they found resident #1 still had no pulse or respirations, so they took over CPR. Continued resuscitation efforts in the hospital Emergency Department (ED) were unsuccessful, and resident #1 was pronounced dead at 5:55 AM. On [DATE] at approximately 9:45 AM, during review of resident #1's medical record, the Unit Manager (UM) discovered a Do Not Resuscitate Order (DNRO) form and realized the resident received CPR against her wish for a natural, peaceful, and dignified death. The facility's failure to honor the right to choose DNR status to promote a natural death contributed to resident #1 suffering unwanted, aggressive resuscitation efforts for approximately one hour, and placed all residents who had DNROs at risk for serious injury/impairment/prolonged death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's removal of immediacy. Findings: Cross reference F678. Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on [DATE]. Her diagnoses included Coronary Artery Disease, Hypertension, Hyperlipidemia, Dementia, and Schizophrenia. The hospital record included a history and physical progress note dated [DATE] that described resident #1's neurological status as awake, alerted oriented [to] person place situation. The note indicated the resident's resuscitation status was Full Code. Resident #1's medical record was updated on [DATE] to include a State of Florida DO NOT RESUSCITATE ORDER that was signed by the resident and her attending physician. The document showed the resident's signature under the statement, Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld. The physician's statement read, I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation.in the event of the patient's cardiac or respiratory arrest. The resident's revised advance directive related to DNR status was reflected in the Order Review Report for February and [DATE]. The DNRO was transcribed to the electronic medical record (EMR) on [DATE] and remained an active physician order until the date of resident #1's death. Review of resident #1's paper chart revealed the canary yellow-colored DNRO form was displayed prominently as the first page of the chart. Review of the Quarterly Minimum Data Set (MDS) assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 11 out of 15, which indicated she had moderately impaired cognition. The MDS assessment showed the resident had clear speech, was usually able to make herself understood and usually understood others. A Change in Condition form dated [DATE] at 6:23 AM, was completed by LPN A. The document revealed resident #1 was found unresponsive at 5:00 AM, CPR was started, and 911 was called for assistance. LPN A inaccurately documented resident #1's code status as Advance Care Planning Information (the resident/patient has orders for the following advance care planning) Full Code. An associated Nursing Progress Note dated [DATE] at 9:06 AM revealed LPN A discovered resident #1 unresponsive in bed at 5:00 AM when she attempted to administer the resident's medication. The note indicated nurses initiated CPR and 911 was contacted. The progress note indicated EMS personnel arrived ten minutes later and continued resuscitation efforts in the facility until 5:30 AM, after which they transported resident #1 to the hospital. On [DATE] at 10:01 AM, in a telephone interview, LPN A stated she was familiar with resident #1 as she was often on her assignment on the 200 Unit. She recalled on [DATE] at approximately 5:00 AM, she was passing morning medications and found resident #1 unresponsive in bed. LPN A stated she instructed the CNAs to page Code Blue over the intercom while she called 911 and printed the resident's face sheet with demographic information. When asked if she informed the nurses who responded to the Code Blue announcement that resident #1 had Full Code status, she said, I don't recall the other nurses asking me anything. LPN A explained later that morning, the UM of the 300 Unit discovered a DNRO form in resident #1's chart. LPN A said, I did not check the code status. It happened so fast; I didn't check the chart. I didn't check the chart. I'm sorry this happened. It was a mistake. On [DATE] at 10:19 AM, in a telephone interview, RN B recalled on [DATE] at approximately 5:00 AM, he was working on the 300 Unit. He stated he was about to administer medications when he heard the Code Blue announcement. RN B explained he and RN C, the other nurse on the 300 Unit, responded to the 200 Unit where LPN A informed them resident #1 had Full Code status. He stated RN C accompanied him to resident #1's room where they assessed the resident and determined she did not have a pulse and was not breathing. He confirmed they initiated and continued CPR until EMS personnel arrived. RN B explained he returned to work later that day on the afternoon shift of [DATE] and was informed resident #1 had a DNRO. RN B said, In hindsight, yes. I should have looked in the medical record for the resident's code status myself. He indicated if he had seen the DNRO form in the medical record, he would not have initiated CPR. On [DATE] at 10:49 AM, in a telephone interview, RN C recalled the events of [DATE]. She verified she was assigned to residents on the 300 Unit and was starting medication administration when she heard the Code Blue announcement at about 5:00 AM. She stated on arrival at the 200 Unit nurses' station, resident #1's assigned nurse told her the resident had Full Code status. RN C confirmed she participated in CPR efforts with RN B and another LPN who responded to the room. RN C described resident #1's assigned nurse as a veteran nurse and said, She had been at the facility ten-plus years. That's why they believed her when she said resident was a Full Code. RN C stated the following morning, the Director of Nursing (DON) informed her resident #1 had a DNRO. RN C acknowledged she should have checked resident #1's code status before performing CPR. On [DATE] at 5:04 PM, the facility's Social Services Director (SSD) explained she discussed advance directives with residents and/or their representatives upon admission. She stated during these discussions she reviewed the implications of both CPR and DNR status and includes information on the potential adverse consequences of CPR. The SSD said, Advance directives including DNROs are a matter of life and death. They are very important, and they should be honored by all staff. A DNRO is the resident's wish to go in peace. On [DATE] at 3:09 PM, in a telephone interview, resident #1's son described his mother's medical history as including multiple hospitalizations, a heart valve replacement and recent early signs of Parkinson's Disease or dementia. He recalled a telephone call from the facility on [DATE], when a staff member informed him that his mother was found unconscious and had been sent to the hospital. Resident #1's son stated the facility never informed him staff performed CPR on his mother. He explained when he arrived at the ED, hospital staff told him his mother already passed away. Resident #1's son stated his mother made her own decisions and might had been upset that she got CPR because it was against her wishes. He verified the DNRO was his mother's choice and said, If she had chosen that; that's what they should do. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *From [DATE] to [DATE], the SSD completed an audit of the code status for all 144 current residents of the facility and no discrepancies were found. *On [DATE], the facility initiated education for licensed nurses, including agency nurses, on policies and procedures for Advanced Directives, CPR, the Nurse Practice Act, and Florida DNROs. Licensed nurses who scored less than 80% on the post-test received re-education until a passing score was achieved. *On [DATE], all staff, including licensed and non-licensed personnel, received educated on the Abuse/Neglect prohibition policy and procedure and Resident Rights. *On [DATE], mock Code Blue drills were initiated for all three nursing shifts, 7am to 3pm, 3pm to 11pm, and 11pm to 7am. As of [DATE], five Code Blue drills have been completed. Mock Code Blue drills will continue twice weekly on all shifts to include weekends. *As of [DATE], staff members who did not receive education related to Advanced Directives, CPR, the Nurse Practice Act, Florida DNROs, Abuse/Neglect prohibition, and Resident Rights were notified by telephone that they may not return to work until education is received. Newly hired staff will receive education at the time of new hire orientation. *As of [DATE], the facility educated 91% of licensed staff. Review of in-service attendance sheets validated the participation of licensed staff in education on the above topics. The attendance sheets contained the signatures of 29 of 32 nurses, 14 RNs and 15 LPNs. Review of the code status audits with the SSD revealed no concerns. On [DATE], interviews were conducted with two RNs, seven LPNs, and one CNA who represented all three shifts, and weekend and weekday schedules. The nurses were able to demonstrate the ability to locate residents' code status in the paper medical chart and EMR, and all verbalized it was necessary for two nurses to verify code status prior to the initiation of CPR. All staff interviewed verbalized understanding of the education provided. The resident sample was expanded to include six additional residents. Interviews and record reviews revealed residents #2, #3, and #4 had Full Code status, and there were no concerns related to honoring advance directives for residents #5, #6, and #7 who had DNROs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, licensed nurses failed to follow the facility's policy and procedure for Cardiopulmonary Resuscitation (CPR) related to verification of resuscitation or code status in an emergency for 1 of 7 residents reviewed for advance directives, (#1). On [DATE] at approximately 5:00 AM, Licensed Practical Nurse (LPN) A discovered resident #1 in bed, unresponsive and without a pulse. She directed staff to use the facility's overhead paging system to announce a Code Blue while she called 911. Registered Nurses (RNs) B and C responded from another unit and asked about the resident's resuscitation status. LPN A informed them resident #1 had Full Code or full resuscitation status, which meant she should receive Cardiopulmonary Resuscitation (CPR) procedures including chest compressions, intubation, and defibrillation to keep her alive. RNs B and C entered resident #1's room and initiated CPR. LPN D responded from another unit and joined the resuscitation effort. The three nurses took turns doing chest compressions and manually forcing air into her lungs with a bag valve mask as they continued aggressive measures to revive resident #1. None of the nurses verified the resident's code status prior to implementing CPR. When Emergency Medical Services (EMS) personnel arrived at approximately 5:10 AM, they found resident #1 still had no pulse or respirations, so they took over CPR. Continued resuscitation efforts in the hospital Emergency Department (ED) were unsuccessful, and resident #1 was pronounced dead at 5:55 AM. On [DATE] at approximately 9:45 AM, during review of resident #1's medical record, the Unit Manager (UM) discovered a Do Not Resuscitate Order (DNRO) form and realized the resident received CPR against her wish for a natural, peaceful, and dignified death. The facility's failure to ensure staff followed procedures related to honoring an advance directive to withhold CPR contributed to resident #1 suffering unwanted, aggressive resuscitation efforts for approximately one hour, and placed all residents who had valid DNROs at risk for serious injury/impairment/prolonged death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's removal of immediacy. Findings: Cross reference F578. Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on [DATE]. Her diagnoses included Coronary Artery Disease, Hypertension, Hyperlipidemia, Dementia, and Schizophrenia. Resident #1's medical record revealed a State of Florida DO NOT RESUSCITATE ORDER dated [DATE] that was signed by the resident and her attending physician. The document showed the resident's signature under the statement, Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld. The physician's statement read, I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation.in the event of the patient's cardiac or respiratory arrest. Review of the Order Review Report for February and [DATE] revealed resident #1 had an active physician DNRO at the time of her death. The resident's electronic medical record (EMR) showed the advance directive DNR was noted on the ribbon of the resident information screen. Review of resident #1's paper chart revealed the canary yellow-colored DNRO form was displayed prominently as the first page of the chart. A Nursing Progress Note dated [DATE] at 9:06 AM revealed LPN A discovered resident #1 unresponsive in bed at 5:00 AM when she attempted to administer the resident's medication. The note indicated nurses initiated CPR and 911 was contacted. The progress note indicated EMS personnel arrived ten minutes later and continued resuscitation efforts in the facility until 5:30 AM, after which they transported resident #1 to the hospital. Review of the facility's policy and procedure Cardiopulmonary Resuscitation (CPR) revised [DATE] read, Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a valid Do Not Resuscitate (DNR) order. The procedure directed staff to first call for assistance immediately, and then two staff members are to verify the current physician order for code status. The documented indicated if there was no DNRO, nurses would initiate CPR. On [DATE] at 1:02 PM, the facility's the Director of Nursing (DON) and the Administrator discussed the incident investigation and Root Cause Analysis related to resident #1 receiving CPR despite documentation of a DNRO. They provided the facility's policy and procedure for CPR and the DON explained the document included the instruction for two nurses to verify a resident's code status prior to the initiation of CPR. The DON and Administrator were informed the document indicated two staff, not two nurses, needed to verify code status. The DON stated the facility staff had been educated that the code status verification had to be done by two licensed nurses, and this protocol had existed for a while. The DON explained on [DATE], during the investigation of incident, the UM of the 300 Unit discovered resident #1's DNRO form in the medical record. The DON explained DNRO forms were printed on yellow paper to ensure they were easily visible, and resident #1's DNRO form was found on the first page in her paper chart. The DON recalled the UM for the 300 Unit opened resident #1's paper chart and said, It was right there, the first page you see. The Administrator and DON stated during the investigation, LPN A acknowledged she never checked resident #1's medical record after she found her unresponsive. They stated they tried to get her to elaborate, but LPN A could not explain why she did not check the resident's medical record for her code status. Review of the facility's investigation showed a focus on LPN A's failure to check resident #1's code status, but it did not fully address the other three nurses who initiated and performed CPR without verification of the resident's code status. When asked if staff were required to bring the resident's paper chart to the bedside for proof of code status during a Code Blue situation, the DON stated the facility had no such requirement. She acknowledged if the chart was brought to the room for a Code Blue, all nurses who responded would be able to view the resident's code status to ensure the circumstances required provision of CPR. On [DATE] at 10:01 AM, in a telephone interview, LPN A explained she had been on staff at the facility for over 20 years. She confirmed she had received education regarding necessary actions if a resident was found unresponsive, not breathing, and/or without a pulse. LPN A explained the resident's code status must be verified by two licensed nurses prior to the initiation of CPR. She stated that protocol had been in place for as long as she could remember. LPN A confirmed she was aware resident who elected DNR status had a DNRO form placed in the paper chart and a copy was scanned into the EMR. She recalled on [DATE] at approximately 5:00 AM, she was passing morning medications and found resident #1 unresponsive in bed. LPN A stated she instructed the CNAs to page Code Blue over the intercom while she called 911 and printed the resident's face sheet with demographic information. When asked if she informed the nurses who responded to the Code Blue announcement that resident #1 had Full Code status, she said, I don't recall the other nurses asking me anything. LPN A explained later that morning, the UM of the 300 Unit discovered a DNRO form in resident #1's chart. LPN A said, I did not check the code status. It happened so fast; I didn't check the chart. I didn't check the chart. I'm sorry this happened. It was a mistake. On [DATE] at 10:19 AM, in a telephone interview, RN B recalled on [DATE] at approximately 5:00 AM, he was on the 300 Unit with RN C when the Code Blue announcement was made. He stated they arrived at the 200 Unit nurses' station, and LPN A told them resident #1 had Full Code status. RN B stated he and RN C entered resident #1's room and found she had no pulse and was not breathing. RN B stated as the staff at bedside tried to decide who would go first, RN C started chest compressions and he grabbed the bag valve mask. He recalled there was a third nurse present, LPN D, and he said, They did a couple of rounds of CPR, apiece. RN B recalled LPN A did not do participate in the resuscitation efforts but she came in and out of the room three to four times while resident #1 received CPR. RN B stated when EMS personnel arrived, they asked for the resident's code status and LPN A said, Full Code. He stated the resident's paper chart was not in the room while they performed CPR. RN B said, In hindsight, yes. I should have looked in the medical record for the resident's code status myself. He indicated if he had seen the DNRO form in the medical record, he would not have initiated CPR. On [DATE] at 10:49 AM, in a telephone interview, RN C confirmed she responded to the 200 Unit nurses' station with RN B. She stated she asked LPN A about the resident's code status and LPN A told her the resident had Full Code status. RN C recalled when she arrived in the room, another nurse was already performing CPR, then RN B took over. She stated when he was tired, he called for relief, and she took over. RN C recalled LPN A came back and forth to the room, and repeated resident #1 had Full Code status. RN C acknowledged she did not verify resident #1's code status in the medical record because LPN A was an experienced nurse. RN C said, All the time I thought the resident was a Full Code because [name of the assigned nurse] said so. But it's my bad too, because I did not check the chart. On [DATE] at 11:15 AM, in a telephone interview, LPN D stated she was on the 100 Unit when she heard the Code Blue paged on the intercom system. She stated when she arrived in resident #1's room, CPR was already in progress. LPN D stated she did not ask anyone about the resident's code status. She recalled she performed two to three rounds of CPR and said, It seemed like it took forever for 911 to arrive. She stated she was the last nurse to do a round of chest compressions before EMS personnel took over. LPN D emphasized the resident's assigned nurse was responsible for verification of the code status but added, I could have looked in the medical record too, but it was not my unit. It was not my resident. On [DATE] at 3:09 PM, in a telephone interview, resident #1's son described his mother's medical history as including multiple hospitalizations, a heart valve replacement and recent early signs of Parkinson's Disease or dementia. He stated his mother made her own decisions and the DNRO was her choice. The resident's son said, If she had chosen that; that's what they should do. On [DATE] at 5:04 PM, the facility's Social Services Director (SSD) explained she discussed advance directives with residents and/or their representatives upon admission. She stated during these discussions she thoroughly explained the differences between Full Code and DNR status. The SSD stated a resident's code status can be revised at any time, and if a new DNRO was obtained, several copies of the document were made. She stated one copy was placed directly in the resident's paper chart, and another added to the designated Red Binder for DNRO forms that was located at the nurses' stations on all units. The SSD stated a copy of the DNRO was also scanned into the resident's EMR and a physician's order for the new code status was entered into the EMR. She explained a DNRO would be reflected in the resident's the care plan for Advance Directives. The SSD explained prior to staff performing CPR on resident #'1 she had conducted twice weekly audits to ensure each resident's code status was accurately reflected in the paper chart, the EMR, all Red Binders, physician orders and care plans. She validated no discrepancies were noted during the audits for resident #1's advance directives related to her code status. The SSD said, Advance directives including DNROs are a matter of life and death. They are very important, and they should be honored by all staff. A DNRO is the resident's wish to go in peace. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *From [DATE] to [DATE], the SSD conducted an audit of all 144 current residents' advance directives to include DNROs and Full Code status. *On [DATE], the Human Resources Coordinator reviewed all nurses' CPR certification and found none to be expired. *On [DATE], all staff, licensed and non-licensed staff were educated the policies and procedures for Abuse/Neglect prohibition and Resident Rights. *From [DATE] to [DATE], the facility's licensed nurses, to include licensed agency nurses, were educated by the DON with regards to Advanced Directives, CPR policy and procedure, and the Nurse Practice Act related to Unprofessional Conduct. *As of [DATE], licensed nurses, including nurses from staffing agencies, completed post-tests on the topic of Florida DNROs. Nurses who scored less than 80% received re-education by the Regional Director of Clinical Services and re-tested until they demonstrated understanding with a score of 80% or above. *On [DATE], mock Code Blue drills were initiated for all three nursing shifts, 7am to 3pm, 3pm to 11pm, and 11pm to 7am. As of [DATE], five Code Blue drills have been completed. Mock Code Blue drills will continue twice weekly on all shifts to include weekends. *As of [DATE], the facility educated 91% of licensed staff. Any staff members who did not receive education related to CPR, Advanced Directive, Abuse/Neglect prohibition, and Resident Rights were notified by phone and informed they may not return to work until the education was received. The nurses who performed CPR for resident #1 on [DATE] were removed from the schedule. Newly hired staff will receive education at new hire orientation. Review of in-service attendance sheets validated the participation of licensed staff in education on the above topics. The attendance sheets contained the signatures of 29 of 32 nurses, 14 RNs and 15 LPNs. Review of the code status audits with the SSD revealed no concerns. On [DATE], interviews were conducted with two RNs, seven LPNs, and one CNA who represented all three shifts, and weekend and weekday schedules. The nurses were able to demonstrate the ability to locate residents' code status in the paper medical chart and EMR, and all verbalized it was necessary for two nurses to verify code status prior to the initiation of CPR. All staff interviewed confirmed they were made aware of the incident that involve a resident who selected DNR status receiving CPR. They verbalized understanding the education provided and verified they were required to pass a post-test. Each staff member verified participation in at least one mock Code Blue drill. The resident sample was expanded to include six additional residents. Interviews and record reviews revealed residents #2, #3, and #4 had Full Code status, and there were no concerns related to honoring advance directives for residents #5, #6, and #7 who had DNROs.