**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy titled Care Plan, Comprehensive Person-Centered, and staff interviews, the facility failed to follow the care plan for skin assessments for one resident (R) (R145) of six residents reviewed for pressure ulcers. On 10/10/2024, 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, Regional Director of Operations, Regional Director of Clinical Operations, and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 10/10/2024 at 10:53 am. The noncompliance related to the IJ was identified to have existed on 2/16/2024. An Acceptable IJ Removal Plan was received on 10/11/2024. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/11/2024. Findings include: Review of the undated facility policy titled Care Plans, Comprehensive Person-Centered revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. R145 was admitted to the facility on [DATE] with diagnoses including encephalopathy due to subdural hematoma, chronic kidney disease and cerebrovascular accident with hemiplegia. R145 was discharged to the hospital on 4/5/2024. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R145 was cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 4 of 15, indicating severe cognitive impairment. The MDS documented R145 was at risk for pressure ulcers, but no ulcers present at the time of the assessment. R145 was dependent on staff for all activities of daily living. Review of the care plan for R145 dated 11/29/2023, documented R145 had potential for skin breakdown. Interventions included for staff to assess skin daily, keep dry, and monitor nutrition. Review of the Physician's Orders revealed an order with a start date of 10/27/2023 for skin assessments weekly on Fridays. However, the order was discontinued on 3/8/2024. Review of the Medication Administration Record (MAR) revealed skin assessments were signed off through 3/1/2024 as being completed. The 3/8/2024 skin assessment was not signed off. Review of the Certified Nursing Assistant (CNA) Bath Report dated 2/16/2024 documented an open area to the sacrum that was reported to the Licensed Practical Nurse (LPN). Further review of the medical record revealed no documented evidence of any additional bath skin assessments during the resident's stay at the facility. Review of the Skin Checks, which documented details of the skins assessments were not completed after 2/16/2024. The 2/16/2024 Skin Check revealed the weekly skin check, daily documentation of skin notes, and other skin assessments were reviewed as part of the skin care plan. However, there are no other Skin Checks after 2/16/2024 and the 2/16/2024 Skin Check does not include the area to the sacrum. Review of a Nurse's Progress Note dated 3/21/2024 documented R145 noted with open area on her tailbone related to pressure. Barrier cream applied. Review of the medical record revealed no documented evidence of any additional assessment or documentation of the wound until an unstageable wound to the sacrum measuring 7 cm x 7 cm x 0.1cm was identified on 3/27/2024 by the Wound Nurse Practitioner (NP). During an interview on 10/8/2024 at 2:34 pm, Corporate Wound Nurse (CWN) EE stated that during bathing the CNA is supposed to examine the skin and report any changes to the unit nurse right away. CWN EE further stated that the facility wound nurse should also complete a full body check for other wounds during rounds. During an interview on 10/15/2024 at 12:20 pm, MDS Coordinator RR revealed interventions are included in the care plan and should be followed. She stated it is a team effort to ensure all measures are completed that are documented in the care plans. Weekly skin assessments are done by nursing staff (LPN, RNs and Wound Care Nurse). CNA information is placed on bath sheets. The nursing staff should confirm any issues that the CNA observed on bath sheets. Cross Refer to F686. The facility implemented the following actions to remove the IJ: 1. R145 was discharged from the facility to the hospital on 4/4/2024 (sic) for a septic wound and did not return to the facility. 2. An AD-HOC meeting was held on 10/10/2024 with the Administrator, Director of Nursing (DON), Regional Director of Operations (RDO), Regional Director of Clinical Operations (RDCO), and Chief Medical Officer (CMO) to address the concerns identified related to the Immediate Jeopardy Citations. 3. On 10/10/2024, the RDO, RDCO, and CMO reviewed the center policy on Developing a Comprehensive Care Plan. No policy changes or recommendations were made because of this review. 4. On 10/10/2024, a Root Cause Analysis (RCA) of the wound management system breakdown was completed by RDO, RDCO, CMO, Administrator and DON. Documentation of analysis was put on the RCA Tool and was included in the Ad Hoc Quality Assurance Performance Improvement QAPI meeting. The Root Cause for the immediate jeopardy was identified as staff not following the center's policy for Pressure Ulcer Prevention and Management secondary to education deficit. 5. On 10/10/2024, all residents had a pressure ulcer risk assessment performed. Care plans were reviewed and updated by the MDS Coordinators for 139 of 140 (1 hospitalized ) residents to ensure that the weekly skin check was listed as an intervention under the at-risk skin care plan. 6. On 10/10/2024, the center MDS Coordinator, Wound Care Nurse, and Regional Wound Care Specialist (RWCS) conducted an audit for 5 of 5 residents with pressure ulcers/injuries to ensure that all residents have a comprehensive wound care plan that is being implemented. 7. On 10/10/2024, nursing employees, 6 of 7 RN's, 27 of 29 LPN's and 43 of 46 CNA's were educated by the RWCS, Staff Development Coordinator (SDC), and DON on implementation of the care plan for pressure ulcer prevention and management including location of the care plan in the electronic health record and viewing the care plan prior to the start of the shift. LPNs were educated regarding following physicians orders and the person-centered care plan. Any staff not educated during the initial education will have the education prior to the start of their shift or during the orientation period. The facility implemented the following actions to remove the IJ: 1. Record review showed R145 was discharged from the facility to the hospital on 4/5/2024 with a septic wound and did not return to the facility. 2. A review of the facility QAPI sign in sheet showed facility held an ad-hoc meeting on 10/10/2024, a total of twenty staff signed off as attendees, which included, the Administrator, DON, Social [NAME] Director (SSD), Rehabilitation Director (RD), CMO, Maintenance Director, RDO, Dietary Manager (DM) and Unit Managers. 3. Review of the facility policy Care Plans, Comprehensive Person-Centered showed the policy was signed and dated on 10/10/2024 by RDO, RDCO and the CMO with no changes to the policy. 4. Review of the root cause analysis showed LPNs and CNAs were educated to ensure weekly skin assessments will be completed on a weekly basis and documented. DON will ensure the completion of assessments in a timely manner. Interview on 10/15/2024 at 1:03 pm, the DON verified the DON in-serviced staff along with RN PP. The DON stated CNAs were re-educated on how to fill out shower sheets (and give a copy to the charge nurse and DON), as soon as a skin condition was identified and to notify the nurse immediately. Interview on 10/15/2024 at 5:37 am, CNA GG revealed she attended an in-service training hosted by the DON. CNA GG stated the in-service focused on reporting and documentation of skin changes for all residents. 5. Review of a Daily Census dated 10/10/2024 revealed 139 of 140 residents were reassessed for risk for pressure ulcers and that residents had a care plan to include weekly skin assessments. This was verified by review of the pressure ulcer risk assessments and care plans for R12, R395, R400 R402 and R403. 6. Review of the pressure Ulcer/Injury Care Plan Update Tool revealed 5 of 5 residents care plans were reviewed for accuracy of wound location and care plan reflective of care provided. Review of five residents, R12, R395, R400, R402 and R403, showed the residents had comprehensive care plans for pressure ulcers. 7. Review of in-service sign in sheets revealed 27 of 29 LPNs, 43 of 46 CNA's and 6 of 7 RN's were in-serviced by the RWCS on 10/10/2024 on care plans for pressure ulcer prevention and management. Also verified via the following staff interviews on 10/15/2024 at 5:37 am with CNA GG, 5:59 am with LPN JJ, 6:29 am with CNA HH, 6:39 am with CNA II, 6:59 am with LPN LL, 7:19 am with LPN MM, 11:27 am with LPN OO, 11:39 am with RN PP, 12:04 pm with RN QQ, and 12:20 pm with RN RR, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. There were no new hires. 9. All corrections were made by 10/10/2024. 10. The immediacy of the IJ was removed on 10/11/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of facility policy titled Pressure Injury Prevention and Management, and staff interviews, the facility failed to provide the necessary care and services to prevent the development and worsening of pressure ulcers for one of six residents (R) (R145) reviewed for pressure ulcers. Specifically, the facility failed to ensure weekly skin assessments and wound observations were completed for R145 and failed to provide the recommended treatment for a sacral pressure ulcer. On 10/10/2024, 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, Regional Director of Operations, Regional Director of Clinical Operations, and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 10/10/2024 at 10:53 am. The noncompliance related to the IJ was identified to have existed on 2/16/2024. An Acceptable IJ Removal Plan was received on 10/11/2024. Based on observations, record review, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/11/2024. Findings include: Review of the facility policy titled Pressure Injury Prevention and Management last reviewed 10/10/2024 revealed the facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment . Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries will be performed by a licensed nurse and documented on the Weekly Wound Observation Tool. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task. Review of a Face Sheet revealed R145 was admitted to the facility on [DATE] with diagnoses including encephalopathy due to subdural hematoma, chronic kidney disease and cerebrovascular accident with hemiplegia. R145 was discharged to the hospital on 4/5/2024. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R145 was cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 4 of 15, indicating severe cognitive impairment. The MDS documented R145 was at risk for pressure ulcers, but no ulcers present at the time of the assessment. R145 was dependent on staff for all activities of daily living. Review of the Certified Nursing Assistant (CNA) Bath Report dated 2/16/2024 documented an open area to the sacrum that was reported to the Licensed Practical Nurse (LPN). Further review of the medical record revealed no documented evidence of any additional bath assessments during the resident's stay at the facility. Skin Assessments ordered weekly with start date of 10/27/2023 to be checked off as completed on the Medication Administration Record (MAR). However, no skin assessment was ordered after 3/8/2024, with the last skin assessment checked off on 3/1/2024, with no documentation of a sacral wound. Review of a Wound Consult Note dated 2/21/2024 documented R145 was seen for a left elbow unstageable wound measuring 4 centimeters (cm) x 6 cm x 0.1 cm. The responsible party was notified of the wound to the left elbow. There was no documentation of a sacral wound. Review of Wound Weekly Observation Forms dated 2/29/2024, 3/19/2024, and 3/25/2024 revealed no documentation of the resident's sacral wound. Review of physician orders, treatment records and progress notes revealed no documentation of any care provided to the sacral wound. R145 was seen by a physician for an elbow wound on 3/20/2024 with no sacral wound documented. Review of a Nurse's Progress Note dated 3/21/2024 documented R145 noted with open area on her tailbone related to pressure. Barrier cream applied, will notify wound care. Review of the medical record revealed no documented evidence of any additional assessment or documentation of the wound until an unstageable wound to the sacrum measuring 7 cm x 7 cm x 0.1cm was identified on 3/27/2024 by the Wound Nurse Practitioner (NP). Review of R145 Progress Note dated 3/27/2024, revealed Wound NP SSS documented an unstageable wound measuring 7 cm x 7 cm x 0.1 cm with odor and drainage with a planned treatment of Medihoney and calcium alginate dressing three times per week. There was no order written for the planned treatment. Review of the Treatment Administration Record (TAR) for R145 revealed orders dated 3/26/2024 which instructed staff to cleanse R145's left buttock and right buttock wounds with saline and cover with colloidal dressing every three days. The treatment was followed from 3/27/2024 to discharge on [DATE]. There were no other documented wound treatments for R145. The NP recommendation for Medihoney and calcium alginate dressing three times per week was never implemented. Review of a Wound Physician Progress Note dated 4/3/2024 documented the sacral wound measured 13 cm x 11 cm x 1.5 cm. The note also documented there was a heavy amount of foul purulent (consisting of, containing, or discharging pus) drainage noted which has a strong odor. Review of R145 Progress Note dated 4/3/2024, NP (JJJ) documented R145 was seen with an unstageable sacral wound, and wound culture ordered. Review of the wound culture results revealed it was collected on 4/4/2024, and results received after R145 was already hospitalized showing multiple bacteria. Review of R145 Weekly Wound Assessment Form dated 4/3/2024 documented the sacral wound was acquired on 3/28/2024 and the resident's responsible party was made aware of the wound. Review of R145 Physician's Order dated 4/4/2024 documented staff to cleanse the wound with Dakins' solution. There was no documented evidence this was started prior to R145 being transferred to hospital on 4/5/2024. Review of NP (JJJ) Note dated 4/4/2024 documented she was alerted to resident condition change by family members of R145 who were visiting. NP JJJ documented R145 was dehydrated and gave an order for normal saline 1/2 liter at 100 milliliters (ml) /hour (hr). The Medication Administration Record documented the intravenous (IV) fluid was administered before transferring R145 to hospital on 4/5/2024. Review of R145 Progress Note dated 4/5/2024, revealed a change of condition note documenting that R145 was not eating or drinking and was transferred to hospital. Review of the Hospital Transfer Form dated 4/5/2024 revealed no documentation of a sacral wound. Review of the hospital record revealed R145 presented on 4/5/2024 with a decline and was refusing to eat or drink over the past few days. A significant pressure ulcer was noted with active purulent foul-smelling drainage. R145 was diagnosed with septic shock secondary to pressure injury of deep tissue of sacral region with necrotizing soft tissue infection. R145 was intubated and had debridement of the sacral wound on 4/6/2024 and 4/13/2024. R145 had a diverting colostomy placed on 4/13/2024. The hospital record also documented on 4/20/2024, R145 was transitioned to comfort care, compassionate extubation, and consult with inpatient hospice. During a telephone interview on 10/8/2024 at 1:10 pm, LPN TTT stated the CNA should report any skin conditions directly to the floor nurse who reports to the unit manager. LPN TTT stated they were the nurse on record who signed the CNA bath sheet but did not recall being told about the opening to R145's sacrum. LPN TTT further stated that the resident should have been examined and the wound nurse made aware. LPN TTT also stated the wound nurse worked Monday to Friday and the weekend supervisor would have been responsible to notify them during the weekends. The wound should have been documented in a progress note and the treatment orders would have been up to the wound care nurse. During an interview on 10/8/2024 at 2:32 pm, CNA HH revealed that if they see a skin issue during bathing it is reported to the nurse right away by filling out the bath sheet and handing it to the nurse who signs it right away. CNA HH also stated sometimes, she reported directly to the wound nurse if they are in the facility. During an interview on 10/8/2024 at 2:34 pm, Corporate Wound Nurse (CWN) EE stated that during bathing the CNA is supposed to examine the skin and report any changes to the unit nurse right away. CWN EE further stated that the facility wound nurse also does a full body check for other wounds during rounds. CWN EE continued to state when a nurse is notified, they are supposed to inform the floor manager or the wound nurse to examine the resident. Once a facility acquired wound is identified, a change of condition, Braden scale, and a care plan should be initiated. CWN EE also stated that if a resident has co-morbities such as poor appetite or circulation issues, the facility completes an unavoidable wound document which is then uploaded in the electronic record. CWN EE was not able to find any such document for R145. CWN EE also stated that the Wound Care NP made rounds on residents on Mondays and Thursday. On other days, the unit nurse should write a progress note and obtain interim treatment orders which change would be revised by the wound nurse as needed. During an interview on 10/9/2024 at 9:15 am, Wound Care Nurse, LPN FF, revealed the bath sheet is completed by the CNA and given to the nurse. The nurse would be responsible for obtaining and administering treatment orders until the resident was seen by the Wound Care NP. During an interview on 10/9/2024 at 10:08 am, the Medical Records Clerk revealed she was responsible for uploading the bath sheets and other paper documents to the electronic health record (EHR) and would provide requested copies. On 10/9/2024 at 11:00 am, the Medical Records Clerk returned stating there were no additional bath skin assessment records for R145. During a follow-up interview on 10/9/2024 at 11:30 am, LPN FF stated that hydrocolloidal dressings were suitable for protection and not for large open wounds. LPN FF stated updating the orders to include the Wound NP's planned treatment of Medihoney and calcium alginate dressing would have been the responsibility of the then wound care nurse. During a telephone interview on 10/9/2024 at 1:40 pm, the former Wound Care Nurse VVV stated the Wound NP was responsible for entering orders and she just followed what was written. During an interview on 10/9/2024 at 3:20 pm, the DON stated she had no specific knowledge of the concerns regarding R145. The DON further stated the wound care nurse was responsible for obtaining and reviewing treatment orders for any new wounds. The DON also stated skin changes should be discussed during morning clinical meetings and monthly quality meetings and she was not aware of any problem with wounds. The facility implemented the following actions to remove the IJ: 1. R145 was discharged from the facility to the hospital on 4/4/2024 (sic) with a septic wound and did not return to the facility. 2. An Ad-Hoc meeting was held on October 10/10/2024 with the Administrator, Director of Nursing (DON), Regional Director of Operations (RDO), Regional Director of Clinical Operations (RDCO), and Chief Medical Officer (CMO) to address the concerns identified related to the Immediate Jeopardy Citations. 3. On 10/10/2024, the RDO, RDCO, and CMO reviewed the facility policy regarding Pressure Ulcer Prevention and Management. Facility did not make any policy changes or recommendations on this review. 4. On 10/10/2024, a Root Cause Analysis (RCA) regarding the pressure ulcer prevention and skin management system was completed by RDO, RDCO, CMO, Administrator and DON. Documentation of the RCA was put on the RCA Tool and was included in the Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting. The Root Cause for the immediate jeopardy was identified as staff not following the center's policy for Pressure Ulcer Prevention and Management secondary to education deficit. 5. The facility Unit Managers and Wound Care Nurse conducted skin assessments on 131 of 140 (One in hospital and eight refused) residents residing in the center on 10/10/2024. Audit revealed no new in-house acquired pressure ulcers/injuries. 6. On 10/10/2024, five of five residents residing in the center identified with pressure ulcers/injuries were reassessed including measurements and documented on by the wound care nurse practitioner. 7. On 10/10/2024, orders were verified for five of five Residents with pressure injuries by the Regional Skin Management Specialist to ensure orders in the electronic medical administration record (E-MAR) matched the recommendations of the wound care nurse practitioner. The facility implemented an audit conducted by the DON after each wound care nurse practitioner visit to ensure the orders match the recommendations of the wound care nurse practitioner. This audit will be conducted once a week. 8. On 10/10/2024, Nursing employees 6 out of 7 registered nurses (RN's), 27 out of 29, licensed practical nurses (LPN's) and 43 out of 46 certified nursing assistants (CNA's) were educated by the Regional Wound Care Specialist (RWCS) Staff Development Coordinator (SDC), and DON on the pressure ulcer prevention and treatment. Specifically, CNAs received education to notify the licensed nurse anytime a new skin area was identified and to document the findings on the body sheet. The LPNs/RN's received education on conducting weekly skin assessments and notifying the Medical Provider or Wound Care Nurse Practitioner NP anytime a new skin area is identified as well as following physician orders and plan of care for wound care treatments. Anyone that was not educated during the Initial education sessions will be educated prior to start of their shift or during the orientation process. 9. The Regional Skin Management Specialist (RSMS) educated three of three wound care nurses on ensuring pressure wounds are measured weekly and are assessed on the Weekly Wound Assessment Tool. 10. On 10/10/2024, 139 of 140 (One in hospital) residents' charts were audited the DON will ensure staff have an order to perform a weekly skin check. 11. On 10/10/2024, the facility implemented a process to ensure that skin checks are monitored daily to ensure completion. The DON will conduct daily audits to ensure skin checks are completed daily and to ensure any newly identified pressure ulcer was reported to the MD or Wound Care Provider and an appropriate treatment ordered. 12. All corrections were made by 10/10/2024. 13. The immediacy of the IJ was removed on 10/11/2024. The facility implemented the following actions to remove the IJ: 1. R145 was discharged from the facility to the hospital on 4/5/2024 with a septic wound and did not return to the facility. 2. A review of the facility QAPI sign in sheet showed facility held an ad-hoc meeting on 10/10/2024, a total of twenty staff signed off as attendees, which included, the Administrator, DON, Social [NAME] Director (SSD), Rehabilitation Director (RD), CMO, Maintenance Director, RDO, Dietary Manager (DM) and Unit Managers. 3. Review of the facility policy Pressure Ulcer Prevention and Management showed the policy was signed and dated on 10/10/2024 by RDO, RDCO and the CMO with no changes to the policy. 4. Review of the root cause analysis showed LPNs and CNAs were educated to ensure weekly skin assessments will be completed on a weekly basis and documented. DON will ensure the completion of assessments in a timely manner. Interview on 10/15/2024 at 1:03 pm, the DON verified the DON in-serviced staff along with RN PP. The DON stated CNAs were re-educated on how to fill out shower sheets (and give a copy to the charge nurse and DON), as soon as a skin condition was identified and to notify the nurse immediately. Interview on 10/15/2024 at 5:37 am, CNA GG revealed she attended an in-service training hosted by the DON. CNA GG stated the in-service focused on reporting and documentation of skin changes for all residents. 5. Facility Unit Managers, LPN 00, LPN MM, LPN LL and LPN JJ verified skin assessments were completed for 131 of 140 residents. Review of four sampled residents revealed R36, R104, R68 and R89's skin assessments were completed on 10/10/2024. 6. Review of the Pressure Ulcer/Injury Order Audit Update Tool revealed five of five residents with pressure ulcers and documented, R12, R395, R400, R402 and R403 skin assessments were completed, and pressure ulcer measurements were verified by the NP and correctly documented. 7. Review of the electronic medical records (e-MAR) showed orders for R12, R395, R400, R402 and R403 matched the recommendations of the wound care nurse practitioner. During an interview on 10/15/2024 at 1:03 pm, the DON confirmed she will continue to audit following each Wound Care NP visit to ensure recommendations are followed for wound treatments. 8. Review of in-service sign in sheets revealed 27 of 29 LPNs, 43 of 46 CNA's and 6 of 7 RN's were in-serviced by the RWCS on 10/10/2024 on pressure ulcer prevention and treatment. Also verified via the following staff interviews on 10/15/2024 at 5:37 am with CNA GG, 5:59 am with LPN JJ, 6:29 am with CNA HH, 6:39 am with CNA II, 6:59 am with LPN LL, 7:19 am with LPN MM, 11:27 am with LPN OO, 11:39 am with RN PP, 12:04 pm with RN QQ, and 12:20 pm with RN RR, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. There were no new hires. 9. Review of in-service sign in sheets revealed LPN FF, LPN LL, and RN VV were educated by RSMS regarding timely skin assessments and timely documentation of pressure wounds. Interview on 10/15/2024 at 11:27 am LPN- FF revealed she was the wound care nurse. LPN FF completed in-service and stated education focused on skin impairment and timely notification of the physician. 10. Review of resident charts showed 139 of 140, residents' charts were audited by the DON and documented the DON will ensure staff completed and documented weekly skin checks. Review of four sampled residents revealed R36, R104, R68 and R89's had a Physician's Order for weekly skin assessments. 11. Review of the Daily Audit Skin Assessments and New Skin Issues revealed daily audits from 10/11/2024 through 10/18/2024 ensuring all ordered skin assessments were completed and provider notification and treatment ordered for any new skin issues identified. There were no new skin issues identified. During an interview on 10/16/2024 at 12:03 pm the RDO CC revealed she is monitoring audits on a weekly basis. 12. All corrections were made by 10/10/2024. 13. The immediacy of the IJ was removed on 10/11/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the policy titled Cardiopulmonary Resuscitation (CPR) the facility failed to honor one of nine sample residents (R) (R#7) advanced directive to be a full code by failing to provide cardiopulmonary resuscitation when R#7 was found without a pulse or respiration. R#7 experienced a change in condition, was unresponsive, CPR was not initiated, the resident expired at the hospital. On [DATE], 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 and Interim Director of Nursing were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:07 a.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. An acceptable Removal Plan (Credible Allegation of Compliance) related to 483.24(a)(3) - Personnel provide basic life support, including cardiopulmonary resuscitation was received on [DATE]. The removal plan included in-service training for licensed nurses on Resident Rights related to Advanced Directives, CPR and performing resuscitation for residents experiencing cardiopulmonary arrest; and in-service training for all additional staff on CPR policy, Advanced Directives, Code Blue, and how to find a resident's code status. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). Findings include: Review of the policy titled Cardiopulmonary Resuscitation (CPR) reviewed [DATE] indicated the policy of the facility is to adhere to residents' rights to formulate advance directives. In accordance to these rights, the facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). Policy Explanation and Compliance Guidelines: 1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. 2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives. Review of the clinical record for R#7 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to pneumonia, respiratory failure, systolic (congestive) heart failure, and tachycardia. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as two which indicated severe cognitive impairment. Section O revealed resident was receiving speech therapy and respiratory therapy. Review of the care plan initiated [DATE] revealed that R#7 has an upper respiratory infection. Intervention to be implemented included monitor heart rate and difficulty breathing. The Order Recap Report revealed an order dated [DATE], for full code status. Review of the Advance Directive Check list for R#7, revealed the statement I have not executed an advance directive or Physician Order for Life-Sustaining Treatment (POLST) and do not wish to discuss advance directives further at this time. The document was signed by R#7's sister and was dated [DATE]. Review of Health Status Note dated [DATE] at 12:16 a.m., written by Registered Nurse (RN) AA, revealed a Late Entry for [DATE] at 11:50 p.m. The note indicated Nurse alerted by the certified nursing assistant (CNA) that resident had a change in respirations. Alerted other staff to room and 911 called and given resident history. Review of the document titled Emergency Medical Service (EMS) [Agency name] revealed dispatch was notified on [DATE] at 11:53 p.m. that resident in room [room] staff advised that patient was decreasing breaths and decreasing pulse. Upon arrival, EMS entered facility and room to find no nursing staff. Nursing staff was noted sitting in a lounge room across from the resident's room. Staff advised that I watched him take his last breath, but no resuscitation efforts were attempted, and patient was still in bed with no staff in the room. EMS asked nursing staff if patient was a DNR (do not resuscitate) and nursing staff advised patient was a full code. The medical crew began CPR and transferred patient to stretcher and transferred to the hospital. Review of the hospital encounter HPI dated [DATE] revealed chief complaint patient present with cardiac arrest. [AGE] year-old male with history of CVA has been brought to the emergency room for cardiac arrest. The EMS brought him to the emergency room with a King airway and Advanced Cardiovascular Life Support (ACLS) protocol. Patient's blood sugar was noted to be 59 and corrected. ACLS protocol was continued for another 20 minutes there was no response with patient continued to be in Pulseless electrical activity (PEA). Patient's pupils are fixed and dilated; further resuscitation efforts were stopped. Per the hospital documentation R#7 was declared dead on [DATE] at 12:45 a.m. Interview on [DATE] at 3:05 p.m. with RN AA, indicated that she is certified in Basic Life Support (BLS) and CPR. She stated residents code status are documented in the Electronic Medical Record (EMR) dashboard section. RN AA stated upon seeing a resident experiencing a change condition she would call out their name and check for a pulse and respiration. She stated if the person did not respond and had no pulse or respiration, she would call for assistance or call 911, open the persons airway, and start chest compressions. During continued interview, RN AA revealed that around 11:30 p.m. CNA VV came to the desk and informed her that R#7 was not looking good, that his skin color and breathing had changed. RN AA stated when she and CNA VV arrived at R#7's room, she placed a pulse oximetry on his finger, but could not obtain an oxygen saturation or a pulse reading. RN AA stated she called 911 from the resident's bedside and informed them there was resident that had a decrease in breathing and heartbeat. She stated she left R#7's room to verify code status in the EMR. She revealed the information in the EMR identified R#7 was a full code. At this time, RN AA stated she called RN DD on the phone, who was taking a break, and asked her to come inside and help her with a resident that was not doing good. RN AA, RN DD, and Licensed Practical Nurse (LPN) EE returned to R#7's room and assessed the resident. RN AA stated no one started CPR or chest compressions for R#7, when he was assessed as not breathing and without a pulse. RN AA was asked why she or her co-workers did not start chest compressions and her answer was I do not know. I should have. She stated EMS arrived within three to four minutes and started CPR and transported R#7 to the hospital. Phone interview on [DATE] at 10:16 a.m. with EMS Provider stated he responded to a call at the facility on [DATE] at 12:01 a.m. where a resident was found with decreased heart rate and decreased respiration. He stated upon arrival, staff were noted sitting at the nurse's station. They directed EMS personnel to the room where R#7 resided. He stated there were no staff members present in the resident's room. He stated he asked a staff member who was sitting in the dayroom if she was the nurse caring for the resident and she stated No, I watched him take his last breath ten minutes ago. He was then directed to the nursing station, while the crew prepared the resident for CPR. The staff members sitting at the nursing station informed EMS that the resident was a full code. He revealed that CPR was started, and the resident was transferred to the Hospital. Interview on [DATE] at 12:18 p.m. with CNA VV indicated she is certified in BLS and CPR. She stated if a person is unresponsive, she would check for pulse, look for rise and fall of the chest, call for help, and start CPR. She stated on [DATE] on the 7:00 p.m. to 7:00 a.m. shift, she noticed R#7 breathing was rapid and labored. She stated that she checked on the resident every 30 minutes because his breathing was different than usual. During further interview, she stated she checked R#7 around 11:18 p.m. and noticed his chest was not rising or falling. She stated she informed the nurse I do not think R#7 is breathing. She stated she went back to the residents' room with the nurse, and the nurse looked at R#7 and told her to wait and left the room. She stated RN DD and LPN EE came to the doorway of R#7 room and ask how the resident was doing. She stated, I informed the two nurses R#7 had passed, and their response was oh my goodness. She stated she informed the paramedics that R#7 had stopped breathing and was deceased . During further interview, she stated she heard the nurse tell the paramedics that R#7 was a full code and then the paramedics started CPR. She stated the reason she did not start CPR on R#7 was because the nurse never returned to the room to inform her of R#7 code status. Interview on [DATE] at 12:23 p.m. with the Administrator, revealed the incident with R#7 has been reported to the State Survey Agency and the police department. She further stated an in-house investigation is in progress. She stated the nurse in charge of R#7 care was terminated and reported to the state board of nursing. Interview on [DATE] at 9:20 a.m. with the Medical Director, revealed the facility has policies and procedures in place regarding resident advance directives and code status. He stated the incident with R#7 happened because the nurse made a choice not to follow the policies and procedures that the facility has in place. The facility implemented the following actions to remove the Immediate Jeopardy: On the evening shift (7 p.m.-7 a.m.) of [DATE]-17, 2022, CNA#1 discovered resident #7 with a change in condition and that he had coded, she informed the Charge Nurse. Charge Nurse (RN#1) failed to perform CPR, per resident #7 Advanced Directive. On [DATE], the Medical Director was notified of the incident by Administrator. An ADHOC QAPI Meeting with a root cause analysis, was held on [DATE], to review the incident that occurred on the evening shift of [DATE]-17, 2022. Members present for the ADHOC QAPI meeting include the Medical Director, Administrator, Interim Director of Nursing, MDS Coordinator, Social Services Director, CNA Supervisor, Staffing Supervisor, and owner. Root Cause Analysis outcome was that RN#1 failed to perform her duties to perform CPR for resident #7 per resident #7 Advanced Directive. On [DATE], the QAPI committee reviewed the facility CPR Policy, and the committee determined the policy did not need to be changed, but education to be provided to licensed personnel regarding the policy. On [DATE], the Social Services Director, conducted an audit of all residents to compare the Advance Directives to the Physician orders for accuracy. Audit tool Advance Directive Audit was used to complete the audit. 98 out of 98 resident charts were audited and all orders were correct. There have been no residents that have experienced a code since the audit was performed. On [DATE], RN#1, who did not perform CPR on the full code status resident was suspended, license was reported to the State Board of Nursing by Administrator, the agency she was employed by was notified by Staffing Supervisor, Facility Reported Incident for Neglect was submitted to HFRD by Administrator. Administrator filed a police report with the Police Department. On [DATE], an audit was conducted for residents that experienced cardiopulmonary arrest in the last 30 days was completed and no other issues were identified. Audit was conducted by the Administrator. There have been no codes since this incident. On [DATE] and 18, 2022, 100% of licensed nursing staff, 5 out of 5 Registered Nurses and 13 out of 13 Licensed Practical Nurses, received education related to Resident's Rights related to Advanced Directives, CPR and performing resuscitation efforts on a resident experiencing cardiopulmonary arrest. The CNA (CNA#1) that discovered R#7 with a change of condition was in-serviced on CPR policy, Advanced Directives and Code Blue. This education includes how to verify a resident's code status. On [DATE] and 18, 2022, 18 out of 20 CNA's received education related to CPR policy, Advanced Directives and Code Blue. Education includes how to find a resident's code status by utilizing the red dots located on resident doors and the resident's chart in Point Click Care. The CNA's that did not receive education will be educated prior to their next scheduled shift. All agency Licensed Nurses were also in-serviced prior to their shift starting. Licensed staff were in-serviced by Staffing Supervisor and Interim Director of Nursing. On [DATE] and 18, 2022, all other staff received education related to Resident's Rights related to Advanced Directives, Code Blue, and CPR policy. Education includes how to find a resident's code status by utilizing the red dots located on resident doors and the resident's chart in Point Click Care. This staff includes the following: 6 out of 10 Therapy staff, 2 out of 2 Activity staff, 2 out of 2 Social Services staff, 1 out of 1 Medical Records staff, 5 out of 5 Administrative staff, 15 out of 15 Housekeeping/Maintenance staff, 7 out of 9 Dietary staff. Any staff not educated is either on leave or PRN. Those staff will be educated prior to starting their next scheduled shift. Staff were in-serviced by Staffing Supervisor, Interim Director of Nursing, Administrator, or Social Services Director. On [DATE] and 18, 2022, 100% of Licensed Nurses, 5 out of 5 Registered Nurses and 13 out of 13 Licensed Practical Nurses, completed a competency related to performing CPR according to a resident's directive orders and all were deemed competent by the licensed instructor, Staffing Supervisor, and Interim Director of Nursing. All agency staff will complete a competency prior to starting their shift. On [DATE], the facility initiated a process that all new admission Advance Directives and Code status will be audited using the Advance Directive Audit Tool, completed by Social Services Director. On [DATE], the facility initiated a process that all new Licensed Nurses employed by facility, or by an agency will be in-serviced on CPR and Code status prior to starting their shift providing direct patient care. Education will be provided by Staffing Supervisor or Interim Director of Nursing. All corrections were completed on [DATE]. The facility alleges that IJ was removed [DATE]. Survey Agency validated removal of the Immediate Jeopardy as follows: The IJ was removed on [DATE], after the survey team performed onsite verification to verify that the Removal Plan had been implemented. A chart audit, which included 100% of residents, was performed to ensure each resident's code status matched the resident's advanced directive. Twenty-six interviews were conducted with staff to ensure staff had received training related to advanced directives and review of code status, including that CPR must be initiated when a resident was a full code. The staff that were interviewed included the Administrator, Interim DON, Staff Supervisor, Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Physical Therapist, Social Services Director, Office Assistant, Housekeeping, Dietary staff, Activities Director, and Human Resources Manager. The staff interviewed revealed knowledge on advanced directives and code status and performing CPR. In-service training records were reviewed, and the records verified that 45 facility staff and 18 contract staff received in-service training. Staff training was ongoing and those staff that were unavailable would receive education upon their return to work and prior to starting his/her duties, including contract agency staff. A monitoring system had been implemented and would be presented to the Quality Assurance and Performance Improvement Committee each month.