**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record reviews, and a review of the facility's policy titled Crash Cart Policy, and Emergency Crash Cart Checklist, the facility failed to ensure that emergency equipment for the crash cart was maintained and operational for one resident (R) (R1) on the [NAME] wing during Cardiopulmonary Resuscitation (CPR). This deficient practice resulted in staff being unable to perform (respirations) during CPR for R1, who went into cardiac arrest and displayed emesis (vomiting) in the airway. On April 22, 2025, at 10:36 a.m., a determination was made that the facility's noncompliance with one or more participation requirements caused or had the likelihood of causing serious harm. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on April 22, 2025, at 10:36 a.m. The noncompliance related to Immediate Jeopardy was determined to have existed on April 12, 2025. An Acceptable IJ Removal Plan was received on April 23, 2025. Based on observations, interviews, and record reviews outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on April 23, 2025. Findings include: A review of the facility's Crash Cart Policy (revised 4/1/2024) revealed the purpose of this policy is to ensure that all supplies critical to basic life support are readily available on the emergency cart. Compliance Guidelines: 1. Equipment/supplies used from the emergency crash cart are noted and replaced promptly. 3. The emergency crash cart is checked every 24 hours and after use. Missing or expired items are replaced, when applicable. 8. Nursing staff should be familiar with the contents located on and within the emergency crash cart. A review of the facility's document titled Emergency Crash Cart Checklist revealed suction equipment: Yankauer, suction kit, suction container, portable (suction) machine, and electrical cord (20 feet). Record Review of the face sheet revealed R1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Guillain-Barre Syndrome, dysphagia following cerebrovascular disease, gastrostomy status, dementia, pulmonary embolism without acute cor pulmonale, and gastroesophageal reflux disease (GERD). Record Review of the Minimum Data Set (MDS) Assessment for R1 dated 3/1/2025, revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderate cognitive impairment. The MDS further documented that R1 required extensive assistance with activities of daily living (ADLs), including eating, personal hygiene, and bed mobility. Record review of the care plan initiated on 10/10/2024, identified R1 as dependent on enteral feeding with gastrostomy tube (G-tube) and at risk for aspiration. Interventions included maintaining the head of bed elevation, monitoring for signs of aspiration, and providing a mechanical soft or pureed diet if consuming any foods orally. A review of the nursing Progress Notes for R1 dated 4/12/2025 at 12:06 p.m. revealed documentation that a code blue was initiated. The notes stated that staff entered room of R1 and found her unresponsive. Emergency measures, including CPR, were initiated. Documentation indicated that Emergency Medical Services (EMS) arrived and continued resuscitation efforts, but the resident was pronounced at 2:12 pm by EMS at the facility. During a simultaneous observation and interview on 4/14/2025 at 1:25 pm, the Unit Manager (UM) stated that upon the surveyors' arrival, she checked the crash cart on the [NAME] Wing and found that multiple essential emergency supplies were missing. She noted the following items were not present: Yankauer suction catheter, suction tubing, suction canister, 20-foot electric cord, CPR board, and tongue depressors. The UM stated that the items were missing because they had been previously used during a code event and were not replaced. The UM acknowledged that the crash cart was not properly stocked to respond to an emergency on the floor and confirmed that the April 2025 crash cart checklist was missing. The UM further revealed that the memory care unit crash cart checklist for March 2025 was present but had not been checked off for the entire month, indicating no documented verification of supplies. She further stated she had signed off on the [NAME] wing crash cart checklist for the previous night (4/14/2025) without verifying the cart's contents inside the cart. Interview on 4/15/2025 at 2:40 pm with Licensed Practical Nurse (LPN) W stated that on 4/12/2025, she was assigned to the [NAME] wing where R1 was located. The LPN W reported that she was the nurse who discovered the resident unresponsive after the family of R1 alerted the nursing station. LPN W stated that she called a code blue and called 911. LPN W further revealed that she did not perform CPR but observed LPN X start chest compressions when the crash cart was brought into the room. LPN W explained that she noticed suction supplies were not connected, and that a canister and tubing needed for suctioning were missing from the crash cart. LPN W stated that missing emergency supplies delayed the staff's response efforts. During a follow-up interview on 4/15/2025 at 3:20 pm with LPN W, she stated that a liquid substance resembling orange juice or food-like material was observed from the mouth of R1 during CPR. She confirmed that staff struggled to locate suction equipment and that the crash cart lacked necessary supplies. Interview on 4/15/2025 at 2:49 pm with Certified Nursing Assistant (CNA) U revealed that during the code, she retrieved a suction canister and tubing from the Memory Care crash cart because the [NAME] wing crash cart did not have what they needed. Interview on 4/15/2025 at 6:13 pm with LPN X stated that on 4/12 /2025, she responded to a code blue called for R1. Upon her arrival in R1's room, she found LPN W and other staff present and stated she immediately assumed the role of performing chest compressions on the resident. LPN X reported that during the code, she attempted to suction the R1's airway airway but could not because the crash carts suction machine was not working and the supplies, suction tubing, Yankauer and canister were missing from the cart. She stated that they (staff) were messing with it, but the suction would not function. LPN X stated that she attempted to use the Ambu bag but was unable to effectively ventilate R1 because of an obstruction in the airway caused by orange colored solid material, appearing to be vomit, resembling feeding tube formula mixed with food particles. LPN X further stated that CNA U left the unit to retrieve a suction canister and tubing from another crash cart. LPN X stated that proper suctioning equipment should have been immediately available on the crash cart to support emergency response efforts. A review of the Progress Notes dated 4/12/2025 at 1:28 pm noted that R1 had drinks (orange drink) and snacks visible at her bedside table to consume at her leisure. Interview on 4/16/2025 at 5:08 pm with the Medical Director (MD) stated that CPR is the priority during the code blue, and suction equipment should be immediately available. The MD revealed that the crash cart's missing suction components were unacceptable and represented a failure to meet Center for Medicare and Medicaid Services (CMS) requirements. The MD further revealed that the agency nurses had not been formally trained on the suction machine. Interview on 4/17/2025 at 3:10 pm with the Director of Nursing (DON) stated that no formal documentation existed showing that agency nurses had been trained on using the suction machine. The DON stated that she was unsure whether the orientation checklist included suction equipment. She confirmed that the suction machine was functional recently, but stated the nurse may not have known how to operate it properly. The DON confirmed that agency nurses should have been trained on the crash cart equipment. The DON revealed concern that RN X, who performed the code herself, acknowledged seeing white substances expelled from the resident's mouth, appearing as tube feed or cottage cheese-like, but had not documented it nor reported it initially. The DON further revealed RN W mentioned that she didn't get good suction and may have been missing a suction component after being retrieved from another unit. The DON stated the crash cart in the memory care unit is described as outdated and not actively used, functioning more like a supply reserve rather than a crash cart. She revealed that this older cart should be pulled from the memory care floor. The DON stated that she had not received full details of what was missing or the need to retrieve items from another unit. She also confirmed that the crash cart was restocked only after the survey team arrived. The DON revealed that central supply is responsible for stocking the crash cart, and equipment concerns are typically reported to the Assistant Director of Nursing (ADON), the UM, or the central supply. A review of the Progress Notes dated 4/12/2025 at 12:58 pm noted that R1 received her scheduled tramadol 50 milligrams (mg) through the gastric tube, confirmed with Medication Administration Record (MAR). The facility implemented the following actions to remove the IJ: 1. On 4/12/2025, Staff nurses performed CPR on resident #1 who expired. 2. On 4/17/2025, The Director of Nursing viewed the crash carts for [NAME] and East units and added NC cannula, various tubing, additional canisters, and tongue blades for both carts. The cart with supplies on the memory care unit was removed. 3. On 4/21/2025, The Director of Nursing initiated a new emergency crash cart checklist. 4. On 4/19/2025, The Director of Nursing completed suction machine set-up competencies on 15 licensed staff. 7 of 15 staff LPNs received a competency, 2 of 3 staff RNs and 1 of 1 DON received training by RNC. 5 of 8 agency LPNs received competency and O RN agency staff worked. 5. On 4/22/2025 The Director of Nursing completed suction machine set-up competencies on an additional 6 licensed staff. 13 of 15 total staff LPNs received competency, 2 of 3 total staff RNs received competency, 1/1 PA and 1/1 DON received competency. An additional 3 agency LPN for a total of 8 of 8 agency LPNs received competency and O RN agency staff worked. As of 04/22/2025 out of 28 (89%) of all staff and agency LPNs received competency training. Any staff who weren't present for education will receive education upon return prior to beginning the shift. Any agency staff will be educated prior to starting the shift. Any new hires will receive education during orientation. 6. On 4/22/2025, The Administrator conducted an ad hoc QAPI to address the supplies, competency of equipment for emergency events and routine re-assessment of the carts to replace supplies. Supplies on cart were verified using the checklist, and all supplies stocked on cart. 7. On 4/22/2025 The Director of Nursing initiated a lock numbered lock system for the crash cart. 8. On 4/17/2025 The Director of Nursing educated 7 of 15 staff LPN received education, 0 of 3 staff RNs, 1 of 1 PA received education, 2 of 8 agency LPNs and 0 of 2 agency RNs received education on supplies being stocked on the emergency crash cart, competency of suction machine, routine re assessment of the carts to replace supplies. 9. On 4/22/2025 The Director of Nursing educated an additional 6 staff LPNs for a total of 13 of 15 staff LPN, 2 of 3 staff RNs, 1 of 1 PA received education, an additional 6 agency LPNs for a total of 8 of 8 agency LPNs received education on where to locate supplies, competency of suction machine, routine re-assessment of the carts to replace supplies. As of 04/22/2025 out 28 (89%) of all staff and agency LPNs received competency. Any staff who weren't present for education will receive education upon return prior to beginning the shift. Any agency staff will be educated prior to starting the shift. Any new hires will receive education during orientation. 10. The Administrator and /or DON started an audit of emergency crash cart supplies and checklist and completed on 4/22/2025. 11. On 04/22/2025, the Administrator and Central Supply were educated by our supply company purchasing agent on how to order and maintain a par level of supplies. The facility has the ability to order supplies twice a week. 12. 4/22/2025 The Administrator, Director of Nursing, Assistant Director of Nursing, Medical Director, and Consultant staff reviewed the policies on emergency supplies, crash cart, and competency evaluation with no changes made. The facility implemented the following actions to remove the IJ: 1. Verified by record review. R1 expired on 4/12/2025. 2. Verified by observation and interview on 4/23/2025 at 12:43 pm with the DON. The DON and two surveyors went through the checklist and identified each item on carts, located on the east and west wings. The cart in the memory care unit was removed. 3. On 4/23/2025 at 12:43 p.m., the emergency crash cart checklist was verified and reviewed. The west and east wings have a clipboard of the new crash cart checklist; it is stored on top of the crash cart. 4. On 4/23/2025, verification through staff interviews and review of competency documentation confirmed that on 4/19/2025, the Director of Nursing completed suction machine set-up competencies on 15 licensed staff. Of those, 7 of 15 facility LPNs, 2 of 3 facility RNs, and 1 of 1 DON received documented competency training conducted by the Registered Nurse Consultant (RNC). Additionally, 5 of 8 agency LPNs completed the same competency training. No agency RNs were working on that date. Training records confirmed all listed staff were assessed for proper suction machine setup in accordance with the facility protocol. 5. On 4/23/2025, verification through interview and documentation review confirmed that on 4/22/2025, the Director of Nursing completed suction machine set-up competencies on an additional six licensed staff. This brought the total number of trained staff to 13 of 15 facility LPNs, 2 of 3 facility RNs, 1 of 1 Physician Assistant (PA), and 1 of 1 Director of Nursing (DON). An additional three agency LPNs were trained, completing the full 8 of 8 agency LPNs. No agency RNs were present on shift. As of 4/22/2025, 25 out of 28 total staff and agency LPNs (89%) had completed and documented competency training. It was confirmed that staff not present for education will receive training upon return prior to beginning their shift, and all agency and new hires will be educated before assignment. Verified competencies with staff interviews conducted on 4/23/2025, at 2:35 pm Licensed Practical Nurse (LPN) B, at 2:36 pm LPN HHH, at 2:40 pm LPN LL, at 2:48 pm LPN H, at 2:49 pm LPN N, at 2:50 pm LPN T, at 3:07 pm Assistant Director of Nursing (ADON), at 3:13 pm Physician Assistant (PA) A1, at 3:10 pm Registered Nurse (RN) K, at 3:17 pm LPN P, at 3:19 pm LPN O, at 3:19 pm LPN M, at 3:28 pm LPN EEE, at 3:28 pm LPN D, at 3:31 pm LPN E, at 3:37 pm LPN F, at 3:43 pm LPN YYYY, at 3:45 pm Central Supply, at 3:50 pm LPN J. 6. Verified by record review. A facility document Quality Assessment and Performance Improvement Plan dated 4/22/2025 revealed the problem statement as the crash cart was missing the necessary supplies for emergency events. Lack of documentation is needed to routinely check stock. Lack of staff competencies to effectively manage the equipment. Goal: have on hand the necessary supplies for emergency events, document routine checks and staff knowledge of equipment in use. Baseline Data: the crash cart on the [NAME] wing lacked necessary supplies for an emergency event. The supplies were not checked on a routine basis. Staff didn't have knowledge of the equipment use. Root causes: lack of education and process failure. Barrier: staff are not routinely checking crash cart to re-stock supplies, staff do not know how to use equipment. Tasks: assess the crash cart and add needed supplies, completed by DON on 4/17/2025. Educate staff where additional supplies are located. Obtain a par level for needed supplies, completed on 4/18/2025, perform suction machine competency checks with licensed staff completed on 4/18/2025, update crash cart checklist, completed on 4/21/2025, and add visual check system to alert staff when crash cart opened on 4/21/2025. The team members that were present were Administrator, DON, Assistant Director of Nursing (ADON), MDS, Social Worker, Medical Director, and regional staff. 7. Verified by observation on 4/23/2025 at 12:43 pm a locked number locking system has been applied to 2 crash carts on west wing and east wing. Verified by interview on 4/23/2025 at 12:43 pm with DON that revealed that the lock numbered system will ensure that when the cart is used the lock is broken and the crash cart will be easily identified when items have been used on the crash cart. Further, the crash cart will be restored, and a new number is given to replace the old lock. The nurse will write a new number on the check list and initial that they have verified and replaced equipment back on crash cart. 8. Verified staff education on supplies being stocked on the emergency crash cart, competency of suction machine, routine reassessment of the carts to replace supplies by reviewing sign-in sheets and education sheets. In addition, Verified education with staff interviews conducted on 4/23/2025, at 2:35 pm Licensed Practical Nurse (LPN) B, at 2:36 pm LPN HHH, at 2:40 pm LPN LL, at 2:48 pm LPN H, at 2:49 pm LPN N, at 2:50 pm LPN T, at 3:07 pm Assistant Director of Nursing (ADON), at 3:13 pm Physician Assistant (PA) A1, at 3:10 pm Registered Nurse (RN) K, at 3:17 pm LPN P, at 3:19 pm LPN O, at 3:19 pm LPN M, at 3:28 pm LPN EEE, at 3:28 pm LPN D, at 3:31 pm LPN E, at 3:37 pm LPN F, at 3:43 pm LPN YYYY, at 3:45 pm Central Supply, at 3:50 pm LPN J. 9. Verified staff education on supplies being stocked on the emergency crash cart, competency of suction machine, routine reassessment of the carts to replace supplies by reviewing sign-in sheets and education sheets. In addition, Verified education with staff interviews conducted on 4/23/2025, at 2:35 pm Licensed Practical Nurse (LPN) B, at 2:36 pm LPN HHH, at 2:40 pm LPN LL, at 2:48 pm LPN H, at 2:49 pm LPN N, at 2:50 pm LPN T, at 3:07 pm Assistant Director of Nursing (ADON), at 3:13 pm Physician Assistant (PA) A1, at 3:10 pm Registered Nurse (RN) K, at 3:17 pm LPN P, at 3:19 pm LPN O, at 3:19 pm LPN M, at 3:28 pm LPN EEE, at 3:28 pm LPN D, at 3:31 pm LPN E, at 3:37 pm LPN F, at 3:43 pm LPN YYYY, at 3:45 pm Central Supply, at 3:50 pm LPN J. 10. On 4/23/2025, an audit titled Emergency Crash Cart Audit was conducted, starting on 4/22/2025 at 8:00 am and 5:00 pm. On 4/23/2025, an audit was completed at 8:00 am. No issues were found. Supplies were present on the west and east wings, and the checklist was completed and initialed by the night shift nurse. 11. An interview on 4/23/2025 at 2:00 pm with the Administrator confirmed she received training on ordering and maintaining par level of supplies. Interview on 4/23/2025 at 2:03 pm with Central Supply revealed she received training on how to order supplies. Training /Onboarding checklist from the supply company. It gives step-by-step directions on how to log in, how to search, and how to order supplies. 12. Verified by record review that the policy titled, Clinical Supplies in Case of Emergency, Competency Evaluation, and Crash Cart were reviewed by the Administrator, DON, ADON, MD, and Consultant staff on 4/22/2025 and no changes were made. All corrective actions were completed on 04/22/2025. The facility is alleging that the IJ will be removed on 04/23/2025.

Based on staff interviews, record review, and review of Job descriptions for the Administrator and Director of Nursing (DON) the facility failed to provide oversight to ensure the facility crash carts were equipped with the emergency equipment for one resident (R) (R1), failed to ensure the crash carts maintained a checklist for March and April 2025, In addition Administration failed to ensure staff were trained on the operation of using a suction machine. On April 22, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and corporate staff were informed of the Immediate Jeopardy on April 22, 2025, at 10:36 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on April 12, 2025. Findings included: A review of the Administrator's job description revealed the position's purpose: leads, guides, and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards, and established facility policies and procedures to provide appropriate care and services to residents. Major duties: Plans, develops, organizes, implements, evaluates, and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. Plans, develops, organizes, implements, evaluates, and directs the facility's programs and activities in accordance with guidelines issued by the governing body. A review of the DON's job description revealed section major duties- Plans, develops, organizes, implements, evaluates and directs the overall operations of the Nursing Services department, as well as its programs and activities, in accordance with current state and federal laws and regulations. Interprets and communicates policies and procedures to nursing staff, and monitors staff practices and implementation. Performs rounds to observe residents and ensure nursing needs are being met. Conducts observations of nursing care and supervises development of in-service education to ensure nursing staff is competent in current knowledge and skills. Oversees resident incidents and concerns daily to identify any unusual occurrences and reports them promptly to the Administrator and/or state agency for appropriate action. The facility failed to ensure that emergency equipment for the crash cart was maintained and operational for one resident (R) (R1) on the [NAME] wing during Cardiopulmonary Resuscitation (CPR). Cross reference: F678 A review of the nursing Progress Notes for R1 dated 4/12/2025 at 12:06 p.m. revealed that a code blue was initiated. The notes stated that staff entered the room of R1 and found her unresponsive. Emergency measures, including CPR, were initiated. Documentation indicated that Emergency Medical Services (EMS) arrived and continued resuscitation efforts, but the resident was pronounced expired at 2:12 pm by EMS at the facility. Interview on 4/15/2025 at 6:13 pm with LPN X stated that on 4/12 /2025, she responded to a code blue called for R1. LPN X further revealed that she attempted to suction the R1's airway but found that the crash cart's suction machine was not working because supplies were missing from the cart. LPN X stated she could not locate the suction tubing, Yankauer, and canister. She stated that they (staff) were messing with it, but the suction would not function. LPN X revealed that she attempted to use the Ambu bag but could not effectively ventilate R1 because of an obstruction in the airway caused by orange- colored solid material, which appeared to be vomit, resembling feeding tube formula mixed with food particles. Interview on 4/15/2025 at 4:25 pm with the DON stated she was unaware of the specific crash cart issues during the code involving R1. The DON revealed she later learned from Nurse X that white, cottage cheese-like material was expelled during CPR, yet this was never documented in the clinical record. She further revealed that CNA U informed her that she had retrieved a suction canister and tubing from another unit because the [NAME] wing crash cart was missing supplies. The DON stated these are communication failures and revealed, If it's not documented, it didn't happen. She confirmed that staff had not been appropriately trained to use the suction machine and that agency nurses were operating without verification of suction equipment competency. The DON revealed that moving forward, she would initiate training, mock codes, and disciplinary action against staff who signed crash cart checklists without verifying supplies. Interview on 4/22/2025 at 10:04 am with the Administrator confirmed that she had not been made aware of the crash cart's missing equipment until after the code occurred. The Administrator stated that she did not receive a completed incident report until several days after the incident and had not been informed by her DON of the deficiencies. The Administrator stated that policies were not followed, the checklist was incorrectly signed, and she had since removed access to the Memory Care cart due to its outdated condition. The Administrator further revealed that a complete overhaul of the crash cart management had been initiated, including education and implementing zip tie security measures on carts. The facility implemented the following actions to remove the IJ: 1. On 4/12/2025 R1 received CPR from staff nurses and expired. 2. On 4/22/2025 The Administrator, Director of Nursing, Assistant Director of Nursing, Medical Director and Consultant staff reviewed the policies on emergency supplies, crash cart and competency evaluation with no changes made. 3. On 4/22/2025, The Regional Operations Director educated the facility administrator of job duties to include but not limited to managing daily operations, coordinate and oversee department heads, providing education and compliance training, ensure licensure staff have appropriate education, competency checks, and infection control practices are maintained. 4. On 4/22/2025, The Administrator conducted an ad hoc QAPI to address the supplies for emergency events. Findings included lack of knowledge about equipment and use. Lack of routine checks, and documentation of checks for emergency cart supplies. 5. The Administrator, DON or ADON observed crash carts on [NAME] and East wings daily x3 to determine if the updated process is effective by observing supplies in crash cart, and checklist documentation complete for that day. Completed on 04/22/2025 with no negative outcome. 6. On 4/19/2025, The Director of Nursing completed suction machine set-up competencies on 15 licensed staff. 7 of 15 staff LPNs received a competency, 2 of 3 staff RNs and 1 of 1 DON received training. 5 of 8 agency LPNs received competency, and O RN agency staff worked. 7. On 4/22/2025 The Director of Nursing completed suction machine set-up competencies on an additional 6 licensed staff. 13 of 15 total staff LPNs received competency, 2 of 3 total staff RNs received competency, 1/1 PA and 1/1 DON received competency. An additional 3 agency LPN for a total 8 of 8 agency LPNs received competency, and O RN agency staff worked. As of 04/22/2025 out 28 (89%) of all staff and agency LPNs received competency. Any staff who weren't present for education will receive education upon return prior to beginning the shift. Any agency staff will be educated prior to starting the shift. Any new hires will receive education during orientation. 8. On 4/17/2025 The Director of Nursing educated 7 of 15 staff LPN received education, 0 of 3 staff RNs, 1 of 1 PA received education, 2 of 8 agency LPNs and O of 2 agency RNs received education on supplies being stocked on the emergency crash cart, competency of suction machine, routine re-assessment of the carts to replace supplies. 9. On 4/22/2025 The Director of Nursing educated an additional 6 staff LPNs for a total of 13 of 15 staff LPN, 2 of 3 staff RNs, 1 of 1 PA received education, an additional 6 agency LPNs for a total of 8 of 8 agency LPNs received education on where to locate supplies, competency of suction machine, routine reassessment of the carts to replace supplies. As of 04/22/2025 25 out 28 {89%) of all staff and agency LPNs received competency. Any staff who weren't present for education will receive education upon return prior to beginning the shift. Any agency staff will be educated prior to starting the shift. Any new hires will receive education during orientation. 10. The Administrator and /or DON started an audit of emergency crash cart supplies and checklist and completed on 4/22/2025. 11. On 04/22/2025 The Administrator and Central Supply were educated by our supply company purchasing specialist on how to order and maintain a par level of supplies. The facility has the ability to order supplies twice a week. All corrective actions were completed on 04/22/2025. The facility is alleging that the IJ will be removed on 04/23/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Verified by record review. Resident expired on 4/12/2025. 2. On 4/23/2025 at 2:03 pm verified by record review that the policy titled, Clinical Supplies in Case of Emergency, Competency Evaluation, and Crash Cart was reviewed by the Administrator, DON, Assistant Director of Nursing (ADON), MD, and Consultant staff and there will not be any changes. 3.Verified by record review of the Administrator's job description that was provided to the Administrator on 4/22/2025. The job duties included managing daily operations, major duties and responsibilities, personal skills and traits desired/ physical requirements/ working conditions, and compliance as a condition of employment. Reviewed and verified the Administrators' signatures of employee acknowledgement date on 4/22/2025. 4.Verified by record review. A facility document, Quality Assessment and Performance Improvement Plan (QAPI) dated 4/22/2025, revealed the problem statement as the crash cart was missing the necessary supplies for emergency events. Lack of documentation is needed to routinely check stock. Lack of staff competencies to effectively manage the equipment. Goal: have on hand the necessary supplies for emergency events, document routine checks, and staff knowledge of equipment in use. Baseline Data: The crash cart on the [NAME] wing lacked necessary supplies for an emergency event. The supplies were not checked on a routine basis. Staff didn't have knowledge of the equipment use. Root causes: lack of education and process failure. Barrier: staff are not routinely checking crash carts to re-stock supplies, staff do not know how to use equipment. Tasks: assess the crash cart and add needed supplies, completed by DON on 4/17/2025. Educate staff where additional supplies are located. Obtain a par level for needed supplies, completed on 4/18/2025, perform suction machine competency checks with licensed staff completed on 4/18/2025, update crash cart checklist, completed on 4/21/2025, and add visual check system to alert staff when crash cart opened on 4/21/2025. The team members that were present were Administrator, DON, ADON, Minimum Data Set (MDS) staff, Social Worker, Medical Director, and regional staff. 5.Verified by observation on 4/23/2025 at 12:43 pm, a locked number locking system has been applied to 2 crash carts on [NAME] wing and East wing. Verified by interview on 4/23/2025 at 12:43 pm with DON that revealed that the lock numbered system will ensure that when the cart is used, the lock is broken, and the crash cart will be easily identified when items have been used on the crash cart. Further, the crash cart will be restored, and a new number is given to replace the old lock. The nurse will write a new number on the checklist and initial that they have verified and replaced the equipment back on crash cart. 6.On 4/23/2025, it was verified through staff interviews and documentation review that the Director of Nursing had completed suction machine set-up competencies for 15 licensed staff as of 4/19/2025. Seven of 15 in-house LPNs, 2 of 3 RNs, and 1 of 1 DON had documented competency validation. Additionally, 5 of 8 agency LPNs received training, with no agency RNs present on shift during that time. Verified education with staff interviews conducted on 4/23/2025 at 2:35 pm Licensed Practical Nurse (LPN) B, at 2:36 pm LPN HHH, at 2:40 pm LPN LL, at 2:48 pm LPN H, at 2:49 pm LPN N, at 2:50 pm LPN T, at 3:07 pm Assistant Director of Nursing (ADON), at 3:13 pm Physician Assistant (PA) A1, at 3:10 pm Registered Nurse (RN) K, at 3:17 pm LPN P, at 3:19 pm LPN O, at 3:19 pm LPN M, at 3:28 pm LPN EEE, at 3:28 pm LPN D, at 3:31 pm LPN E, at 3:37 pm LPN F, at 3:43 pm LPN YYYY, at 3:45 pm Central Supply, at 3:50 pm LPN J. 7. On 4/23/2025, further verification confirmed that the Director of Nursing completed suction machine competencies on an additional six staff members by 4/22/2025. Documentation supported that a total of 13 of 15 facility LPNs, 2 of 3 facility RNs, 1 Physician Assistant (PA), and 1 of 1 DON had received competency. Three additional agency LPNs were verified, completing the full 8 of 8 agency LPNs trained. As of 4/22/2025, 25 out of 28 licensed staff and agency LPNs (89%) had documented competencies. Any staff not present will be trained prior to their next shift, and all new agency or hired staff will be trained prior to assignment. Verified education with staff interviews conducted on 4/23/2025 at 2:35 pm Licensed Practical Nurse (LPN) B, at 2:36 pm LPN HHH, at 2:40 pm LPN LL, at 2:48 pm LPN H, at 2:49 pm LPN N, at 2:50 pm LPN T, at 3:07 pm Assistant Director of Nursing (ADON), at 3:13 pm Physician Assistant (PA) A1, at 3:10 pm Registered Nurse (RN) K, at 3:17 pm LPN P, at 3:19 pm LPN O, at 3:19 pm LPN M, at 3:28 pm LPN EEE, at 3:28 pm LPN D, at 3:31 pm LPN E, at 3:37 pm LPN F, at 3:43 pm LPN YYYY, at 3:45 pm Central Supply, at 3:50 pm LPN J. 8. On 4/23/2025, interviews and documentation confirmed that on 4/17/2025, the Director of Nursing educated 7 of 15 in-house LPNs, 1 of 1 PA, and 2 of 8 agency LPNs on emergency crash cart stocking procedures, suction machine use, and routine cart reassessment. At that time, none of the three facility RNs or the two agency RNs had received the training. Verified education with staff interviews conducted on 4/23/2025 at 2:35 pm Licensed Practical Nurse (LPN) B, at 2:36 pm LPN HHH, at 2:40 pm LPN LL, at 2:48 pm LPN H, at 2:49 pm LPN N, at 2:50 pm LPN T, at 3:07 pm Assistant Director of Nursing (ADON), at 3:13 pm Physician Assistant (PA) A1, at 3:10 pm Registered Nurse (RN) K, at 3:17 pm LPN P, at 3:19 pm LPN O, at 3:19 pm LPN M, at 3:28 pm LPN EEE, at 3:28 pm LPN D, at 3:31 pm LPN E, at 3:37 pm LPN F, at 3:43 pm LPN YYYY, at 3:45 pm Central Supply, at 3:50 pm LPN J. 9.On 4/23/2025, it was verified that on 4/22/2025, the Director of Nursing conducted follow-up education with an additional six in-house LPNs and six agency LPNs, bringing the totals to 13 of 15 facility LPNs, 2 of 3 RNs, 1 PA, and 8 of 8 agency LPNs. Staff were instructed on locating supplies, suction machine competency, and routine reassessment procedures. By 4/22/2025, 25 of 28 total LPNs (including agency) had received training. Staff absent at the time of training will be educated upon return, and new and agency hires will receive this education prior to beginning their shift. Verified education with staff interviews conducted on 4/23/2025 at 2:35 pm Licensed Practical Nurse (LPN) B, at 2:36 pm LPN HHH, at 2:40 pm LPN LL, at 2:48 pm LPN H, at 2:49 pm LPN N, at 2:50 pm LPN T, at 3:07 pm Assistant Director of Nursing (ADON), at 3:13 pm Physician Assistant (PA) A1, at 3:10 pm Registered Nurse (RN) K, at 3:17 pm LPN P, at 3:19 pm LPN O, at 3:19 pm LPN M, at 3:28 pm LPN EEE, at 3:28 pm LPN D, at 3:31 pm LPN E, at 3:37 pm LPN F, at 3:43 pm LPN YYYY, at 3:45 pm Central Supply, at 3:50 pm LPN J. 10.Verified by record review on 4/23/2025 of an audit titled, Emergency Crash Cart Audit that began on 4/22/2025 an audit was conducted on 4/22/2025 at 8 am and 5 pm. On 4/23/2025 an audit was completed at 8 am no issues found supplies were present on west and east wing and check list was completed and initialed by night shift nurse. 11. Verified by interview and record review. An interview on 4/23/2025 with the Administrator at 2:00 pm confirmed she received the training on how to order and maintain par level of supplies. Interview on 423/2025 at 2:03 pm with the Central Supplies Clerk revealed she received training on how to order supplies. Record review revealed a Training /Onboarding checklist by {Company Name}. It gives step by step directions on how to login, how to search and order supplies. All corrective actions were completed on 04/22/2025. The facility is alleging that the IJ will be removed on 04/23/2025.