**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure services were provided to meet quality professional standards. The facility failed to ensure physicians orders were obtained and clarified upon readmission from the hospital for 2 (#64, and #500) of 4 (#49, #64, #149, and #500) residents reviewed for hospitalizations. This deficient practice resulted in an Immediate Jeopardy situation on 03/16/2024 at 9:00 p.m., when Resident #500 returned to the facility without hospital discharge orders. Resident #500 was admitted to the hospital on [DATE] with symptoms including facial edema, tongue swelling, disoriented, and difficulty breathing. The hospital diagnoses was anaphylactic allergic reaction to Amiodarone. The facility failed to obtain records and orders from the hospital upon readmission on [DATE] and Amiodarone 200 mg BID remained on the eMAR. On 03/18/2024 at 8:00 a.m., S20LPN administered Amiodarone to Resident #500. S1ADM was notified of the Immediate Jeopardy situation on 03/19/2024 at 5:55 p.m. The Immediate Jeopardy was removed on 03/20/2024 at 2:12 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for any resident in the facility that returned from the hospital with new diagnoses and/or orders. Findings: Resident #500 Review of Resident #500's clinical record revealed a facility admission date of 06/20/2023. On 03/15/2024, Resident #500 was admitted to the hospital and diagnosed with an allergic reaction to Amiodarone and returned to the facility on [DATE]. Review of Resident #500's quarterly MDS with an ARD of 12/20/2023 revealed a BIMS of 15, which indicated she was cognitively intact. Review of Resident #500's Physician Orders dated March 2024 revealed an active order for Amiodarone 200 mg BID with a start date of 03/06/2024. Review of Resident #500's Nurses' Notes dated March 15, 2024 revealed, in part: 03/15/2024 at 6:45 a.m., S21LPN noted resident was stating that she could not breathe. Resident #500 had her O2 concentrator as high as it could go and was also on her portable tank set at 4 liters. BP 194/149, Pulse ranged from 88-127, Temperature 97.7, Respirations 32, O2 Saturation ranged from 78%-92%. Resident #500 continued stating I can't breathe! Gave resident a breathing treatment with the solution and she stated that it was not working. At 6:55 a.m. call placed to on call NP and verbal order was given to send resident to the hospital. Resident #500 refused to go to the hospital at that time. 03/15/2024 at 11:40 a.m., S22LPN entered room. Resident #500 found sitting in bed with facial edema. Upon assessment, Resident #500's tongue was swollen and she was disoriented. O2 Sats were 66% on room air. Resident #500's O2 Sats 86% on 3L. NP was called and notified of change. Resident #500 agreed to go to hospital. Review of Resident #500's hospital records dated 03/15/2024 to 03/16/2024 revealed the following, in part: Reason for hospitalization was facial edema and tongue swelling. Anaphylaxis likely secondary to Amiodarone. Discharge instructions included to use Epipen as needed for anaphylactic reactions and Do not take Amiodarone. Review of Resident #500's Nurses' Notes dated 03/16/2024 at 10:15 p.m.: Resident #500 returned from local hospital via ambulance at approximately 9:00 p.m. S23LPN received a prescription for an epi-pen from local hospital, which was faxed to the facility contracted pharmacy. Signed by S23LPN Review of Resident #500's eMAR dated March 2024, revealed Amiodarone 200 mg tablet BID was not discontinued upon readmission to the facility at 9:00 p.m. on 03/16/2024. Further review revealed the medication was documented as administered on 03/18/2024 at 8:00 a.m. An interview was conducted with Resident #500 on 03/18/2024 at 10:51 a.m. She reported she went to the hospital for having an allergic reaction to a medicine. She stated the hospital discontinued Amiodarone. An interview was conducted with S20LPN on 03/19/2024 at 2:18 p.m. She stated when a resident was readmitted to the facility, the receiving nurse was responsible for obtaining and entering new orders into the system. S20LPN reviewed Resident #500's physician's orders and eMAR and confirmed Amiodarone 200 mg BID was not discontinued on 03/16/2024 when the resident returned from the hospital. After further review of the eMAR, S20LPN she stated S23LPN attempted to administer Amiodarone 200 mg to Resident #500 on 03/17/2024 at 8:00 a.m. and 4:00 p.m., but the resident refused to take the Amiodarone. S20LPN stated on 03/18/2024 at 8:00 a.m., she put all of Resident #500's pills, including Amiodarone 200 mg, into one pill cup prior to entering the resident's room. She stated Resident #500 took all the medications in the pill cup at that time. She stated after the resident consumed the medications, Resident #500 asked if the Amiodarone was in the pill cup. S20LPN said she told the resident yes, and Resident #500 stated she did not want to take that medication again. S20LPN confirmed she did not know Resident #500 had an allergic reaction to Amiodarone 200 mg and the medication should have been discontinued upon return from the hospital on [DATE]. An interview was conducted with S23LPN on 03/19/2024 at 2:56 p.m. S23LPN confirmed he readmitted Resident #500 to the facility on [DATE] and did not contact the hospital or facility physician to obtain or clarify orders for Resident #500. An interview was conducted with S8NP on 03/19/2024 at 2:29 p.m. S8NP reviewed Resident #500's discharge orders and stated Resident #500 had an allergic reaction to Amiodarone on 03/15/2024 that required hospital admission. S8NP stated the facility staff should have followed the discharge orders from the hospital and discontinued Amiodarone upon the resident's return on 03/16/2024. An interview was conducted with S24RPH on 03/20/2024 at 3:40 p.m. S24RPH stated the facility should notify the pharmacy when a medication was discontinued. She stated if a resident had an allergic/anaphylactic reaction to a medication it should be immediately discontinued, he confirmed that the half-life of Amiodarone was 26 to 107 days, and a resident could have a reaction at any time to a medication. S24RPH confirmed a medication reaction could occur within the first dose or 24 hours or at any time after the medication is administered. Resident #64 Review of clinical record for Resident #64 revealed was readmitted to the facility on [DATE] with an indwelling urinary catheter. Review of Resident #64's Quarterly MDS with an ARD of 01/31/2024 revealed Resident #64 was incontinent of bladder with an indwelling catheter. Review of Resident #64's local hospital discharge records dated 01/22/2024 revealed no orders for catheter care. Review of Resident #64's current Physician Orders revealed no orders for an indwelling catheter from 01/22/2024 until 03/19/2024. On 03/18/2024 at 9:30 a.m., an observation was made of Resident #64 lying in bed with an indwelling catheter. On 03/19/2024 at 2:45 p.m., an interview was conducted with S18LPN. S18LPN stated a physician's order was required for resident catheter changes and care. S18LPN stated S3WNC was responsible for changing resident's catheters. After reviewing Resident #64's active orders, S18LPN confirmed there was not an order for catheter care and catheter changes prior to 03/19/2024. On 03/20/2024 at 9:06 a.m., an interview was conducted with S3WCN. She stated she was responsible for completing catheter changes. She stated she was not aware Resident #64 had a catheter. After reviewing Resident #64's active orders, S3WCN confirmed there was not an order for indwelling catheter changes or daily catheter care. On 03/20/2024 at 10:45 a.m., an interview was conducted with S30LPN. She stated she was the nurse on duty when Resident #64 returned from the hospital on [DATE]. S30LPN stated Resident #64 had a catheter when he returned to the facility. She stated Resident #64 did not return to facility with discharge paperwork. S30LPN stated she did not call the on call nurse practitioner to obtain or clarify orders related to the urinary catheter. On 03/20/2024 at 11:58 a.m., an interview was conducted with S2ADON. She stated an order was required for catheter changes and catheter care. After reviewing Resident #64's current orders January to March 2024, S2ADON confirmed there was not an order for catheter care and catheter changes prior to 03/19/2024. She stated if a resident did not have orders for needed care she expected her staff to call the on call nurse practitioner to obtain orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure an effective system was in place for advanced directives. The facility failed to ensure: 1. Advanced directives were correctly implemented for 1 (#143) of 4 (#143, #344, #345, and #346) residents reviewed that expired; and 2. Resident's medical records accurately reflected the residents' wishes for emergency basic life support for 3 (#81, #112, and #136) of the 30 sampled and 3 random residents reviewed for Advanced Directives. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 5:45 a.m., when S8LPN stopped performing CPR on Resident #143 due to a discrepancy in the resident's code status. S8LPN performed CPR for 5 minutes before stopping after a facility staff discovered Resident #143 had conflicting advance directive wishes that designated both DNR and full code status. Death was pronounced for Resident #143 on [DATE] at 6:30 a.m. Further record review revealed Resident #81, Resident #112, and Resident #136 had discrepancies with their documented code statuses and interviews confirmed staff did not know which code status to follow in case of an emergency. S1ADM was notified of the Immediate Jeopardy situation on [DATE] at 4:00 p.m. The Immediate Jeopardy Plan of removal included the following information: 1. Corrective actions for alleged deficient practice were accomplished for Resident #81, Resident #112, Resident #136, Resident #394, by the following: a. Resident #81, order clarification written for DNR to match Advance Directive, completed [DATE] b. Resident #112, order clarification written for DNR to match Advance Directive, completed [DATE] c. Resident #136, order clarification written for DNR to match Advance Directive, completed [DATE] d. Resident #394, order clarification written for DNR to match Advance Directive, completed [DATE] e. Staff Developer, will In-service Nursing staff regarding CPR policy, initiated [DATE], to be completed by [DATE]. Staff will not be allowed to work until signed off. f. Regional Director or Corporate QI Nurse will in-service Staff Developer, who will be presenting in-services to nursing staff, completed [DATE]. g. Corporate QI Nurse, will in-service Social Services that Advanced directives must be changed in the event of a change in physician order, initiated [DATE], completed [DATE]. h. Staff Developer will in-service Nursing Staff to contact MD or NP for termination of CPR, initiated [DATE], to be completed [DATE]. Staff will not be allowed to work until signed off. i. Corporate QI Nurse will in-service Administrator and Assistant Administrator regarding Advanced Directive policy and procedure and CPR policy and procedure. j. Audit of all Code Status orders to ensure they match what is in resident chart, completed [DATE]. k. Audit of all Code Status orders to ensure they match Advance Directives, [DATE]. 2. All residents have the potential to be affected by this alleged deficient practice 3. The measures put into place to prevent this alleged deficient practice from re-occurring a. Staff Developer will in-service Nursing Staff regarding CPR policy, initiated [DATE], to be completed by [DATE]. Staff will not be allowed to work until signed off. b. Corporate QI Nurse will in-service Social Services that Advanced directives must be changed in the event of a change in physician order, initiated [DATE], and completed [DATE]. c. Staff Developer will in-service Nursing Staff to contact MD or NP for termination of CPR, initiated [DATE], to be completed [DATE]. Staff will not be allowed to work until signed off. d. Corporate QI Nurse will in-service Administrator and Assistant Administrator regarding Advanced Directive policy and procedure and CPR policy and procedure. e. Audit of all Code Status orders to ensure they match what is in resident chart, completed [DATE] f. Audit of all Code Status orders to ensure they match Advance Directives, completed [DATE] g. Follow up CPR and Code Status test for nursing staff to review understanding, initiated [DATE] and to be completed [DATE]. h. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each new admission and ensure physician orders match advance directive, beginning [DATE], to be completed [DATE], expected 100% compliance. i. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident hospital return and ensure physician orders match advance directive beginning [DATE], to be completed [DATE], expected 100% compliance. j. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident quarterly care plan and ensure physician orders match advance directive beginning [DATE] to be completed [DATE], expected 100% compliance. k. Administrator or designee will review discharged residents charts and ensure resident code status was carried out according to policy and procedure, twice per week, ending [DATE]. 4. Facility will monitor its performance to ensure sustained compliance by the following a. Follow up CPR and Code Status test for nursing staff to review understanding, initiated [DATE] and to be completed [DATE]. b. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each new admission and ensure physician orders match advance directive, beginning [DATE], to be completed [DATE], expected 100% compliance. c. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident hospital return and ensure physician orders match advance directive beginning [DATE], to be completed [DATE], expected 100% compliance. d. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident quarterly care plan and ensure physician orders match advance directive beginning [DATE] to be completed [DATE], expected 100% compliance. e. Administrator or designee will review discharged residents charts and ensure resident code status was carried out according to policy and procedure, twice per week, ending [DATE]. f. Administrator of designee will review advance directive audit twice per week for compliance, ending [DATE]. g. Regional Director or Corporate QI Nurse will review audits once per week for compliance, ending [DATE]. h. Additional in-servicing and or progressive disciplinary action will occur if further non-compliance is noted Through interviews and record reviews, the surveyor confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. The Immediate Jeopardy was removed on [DATE] at 3:26 p.m. The deficient practice continued at a potential for more than minimum harm for all 149 residents currently residing in the facility. Findings: Review of facility's Advance Directive Policy and Procedure revealed the following: Upon admission, the facility will: IV. Determine whether the resident has an advanced directive, and if not determine whether the resident wishes to formulate an advanced directive. a. If the resident or resident's legal representative has executed one or more advance directives, or executes upon admission, the facility will incorporate and maintain a copy in the residents medical record readily retrievable by any facility staff, and desired wishes be communicated to the resident's direct care staff and physician. Quarterly as needed the facility will: II. Identify, clarify, and periodically review, as part of the comprehensive care planning process, the existing care instructions on whether the resident wishes to change or continue these instructions. Review of the facility's Cardiopulmonary Resuscitation (CPR) Policy and Procedure revealed, in part, the following: 7. If the resident is unresponsive, apneic, and or only gasping and has elected CPR on his/her advanced medical directives begin basic life support. 8. Continue uninterrupted basic life support measures until you are relieved by another person knowledgeable about CPR, emergency life medical personnel (paramedics, EMT's, etc.) arrives to assume emergency medical care, or a physician pronounces the resident expired. Resident #143 Review of Resident #143's Clinical Record revealed she was admitted to the facility on [DATE] and expired on [DATE]. Review of Resident #143's Advanced Directives revealed, in part, the following: On [DATE], the resident's daughter indicated Resident #143 should be a Full Code. On [DATE], the resident's daughter indicated Resident #143 should be both a Full Code and DNR. Review of Resident #143's Physician Orders revealed, in part, the following: [DATE] - Code Status: Full Code. Review of Resident #143's Nurses Notes revealed [DATE] at 5:30 a.m., S8LPN had been called to Resident #143's room where she found her unresponsive and began CPR. Another nurse was getting paperwork together when she noticed DNR was marked on Advanced Directive Consent. CPR was stopped. Resident's daughter was notified and arrived at the facility. Coroner arrived at 6:15 a.m., assessed resident and called 6:30 a.m. as time of death. On [DATE] at 8:55 a.m., an interview was conducted with S6LPN. She confirmed in the event a resident coded, a nurse would be expected to locate and confirm the resident's code status. She then confirmed the Code status could be found in multiple locations; the hard chart and the physician's orders. She stated she would look in the EHR on the resident's face sheet or MAR to find the code status. She stated if she were in the nurse's station, she would look in the resident's hard chart. On [DATE] at 9:24 a.m., an interview was conducted with S9AC. She stated upon admission, either the resident or their responsible party would fill out the Advance Directive Consent. She stated the completed consent would then be scanned and emailed to S3ADON, S8LPN, S7LPN and S12AADM. She stated S7PN was responsible for entering the order into the resident's medical record. She confirmed any changes made to a resident's code status should be updated immediately throughout the medical record. On [DATE] at 9:43 a.m., an interview was conducted with S7LPN. She stated Advanced Directives were completed by S9AC upon admission then emailed to her to enter as Physician's Orders into the EHR. She stated for current residents, any changes made to their Advanced Directives or Physician's orders would be brought to her to update them in the EHR. She confirmed she was the only person responsible for entering a resident's Advance Directive and Code Status into their medical record as a Physician's Order. She also confirmed she had been expected to perform chart audits weekly to ensure accuracy of Advanced Directives but had not conducted them as she should have. She confirmed she was directed by Administration to change the Physician's Orders for Resident #112 and Resident #136 to a DNR on the morning of [DATE] to match their signed Advanced Directive. She then confirmed prior to making those changes, both Resident #112 and Resident #136 had a Physician's Order for Full code status. She then confirmed Resident #81's February 2023 Physician's Order for Full Code status was incorrect based on the presence of a signed Advanced Directives indicating DNR status. On [DATE] at 10:25 a.m., an interview was conducted with S8LPN. She stated she was called to Resident #143's room where she found her unresponsive. She stated she reviewed Resident #143's paper chart, noted the resident was a Full Code then began CPR. She stated while performing CPR, S5LPN brought an Advanced Directive indicating the resident was a DNR. She explained after the second advance directive was brought in and indicated the resident was a DNR, she and S5LPN made the determination to terminate CPR efforts on [DATE] at 5:35 a.m. She confirmed the coroner arrived on [DATE] at 6:15 a.m., and called time of death at 6:30 a.m. On [DATE] at 2:18 p.m., an interview was conducted with S5LPN. She confirmed she responded to the code for Resident #143 on [DATE]. She denied locating or entering the resident's room with an Advanced Directive of DNR. She also confirmed she did not receive an order from S17NP to stop the CPR efforts for Resident #143. On [DATE] at 2:24 p.m., an interview was conducted with S16LPN. She confirmed she responded to a code for Resident #143 on [DATE]. She explained she was in the room with S8LPN when CPR was initiated. She stated while S8LPN was performing CPR, S5LPN entered the room with an Advanced Directives which indicated Yes to CPR and Yes to DNR. S16LP confirmed CPR was stopped at that time. On [DATE] at 2:09 p.m., an interview was conducted with Resident #143's daughter. She stated prior to admission, she completed and electronic advanced directive consent for her mother which should have indicated a Full Code status. She confirmed she had filled out a second Advance Directive on [DATE] over the phone with S9AC. She confirmed S9AC was made aware Resident #143 was to be a Full Code with CPR initiated in the event of cardiac or respiratory arrest. On [DATE] at 1:05 p.m., an interview was conducted with S17NP. She confirmed she was familiar with Resident #143. She explained the residents advanced directive should indicate CPR should be initiated or not in the event of cardiac arrest or respiratory arrest. She confirmed she never gave a telephone/verbal order to discontinue CPR for Resident #143. She then confirmed she would never give a telephone order to discontinue CPR on any resident. On [DATE] 01:45 p.m. an interview was conducted with S3ADON. She stated that S2DON would review all resident's code status prior to S9AC submitting to the electronic chart. She stated the code status could be located under the code status tab in the paper chart or on the face sheet of the electronic chart. On [DATE] at 2:32 p.m., an interview was conducted with S1ADM. S1ADM reviewed both versions of Resident #143's Advanced Directives and stated he interpreted both to mean Resident #143 was a full code status and staff should have continued CPR until further clarification could be made. He confirmed staff began CPR on Resident #143 and then stopped prior to the resident being pronounced dead by an appropriate entity. On [DATE] at 2:41 p.m., an interview was conducted with S14CQIN. She confirmed S1ADM made her aware of the discrepancies with Resident #143's Advanced Directive on [DATE] after she expired. She confirmed the facility swapped to an electronic Advanced Directive several months ago and family members had difficulty understanding and completing the new form to correctly reflect their wishes regarding code status. S14CQIN reviewed both of Resident #143's Advance Directive consents and stated she interpreted both to mean Resident #143 was a full code status and staff should have continued CPR until further clarification could be made. On [DATE] at 11:27 a.m. and interview was conducted with S15RCN. S15CRN reviewed both of Resident #143's Advance Directive Consents. S15RCN stated the Resident #143's daughter marked both CPR and DNR on the form. She confirmed the resident's wishes were unclear and she would expect staff to refer to the physician's order for further clarification. Resident #81 Review of Resident #81's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #81's LaPOST, signed by the resident on [DATE], revealed the resident indicated she would like to be a DNR. Review of Resident #81's Physician Orders revealed, in part, the following: [DATE] - Code Status: Full Code. On [DATE] at 8:55 a.m., an interview was conducted with S6LPN. She reviewed Resident #81's EHR and confirmed their code status per physician's orders was a Full Code and CPR should be initiated in the events of an emergency. Resident #112 Review of Resident #112's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #112's Advanced Directives, signed by the resident's daughter on [DATE], revealed the resident indicated she would like to be a DNR. Review of Resident #112's current Physician Orders revealed, in part, the following:[DATE] - Code Status: Full Code. Review of Resident #112's Physician Progress Notes, dated [DATE], [DATE], and [DATE], indicated the resident was Full Code status. Resident #136 Review of Resident #136's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #136's most recent MDS, with an ARD of [DATE], revealed the resident was assessed to have a BIMS of 10, which indicated the resident had moderate cognitive impairment. Review of Resident #136's LaPOST, signed by the resident on [DATE], revealed the resident indicated he would like to be a DNR. Review of Resident #136's current Physician Orders revealed both of the following active orders: An order for Code Status: Full Code; and An order for Code Status: Do Not Resuscitate DNR. Review of Resident #136's Hospice Records Binder with the local hospice company indicated, in part, Resuscitation Status: DNR per LaPOST. On [DATE] at 11:30 a.m., an interview was conducted with Resident #136. He confirmed he signed the paperwork to become a DNR in [DATE] and his wishes had not changed since that time. On [DATE] at 12:58 p.m., an interview was conducted with S1ADM. He confirmed the facility opened the QA process for Advance Directives as of [DATE] and all charts were audited by S12AADM following the incident to ensure accuracy. He then confirmed there were current discrepancies present for Resident #81, Resident #112 and Resident #136.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to be administered in a manner which enabled the effective and efficient use of resources to ensure an effective system was in place to ensure Advance Directives would be followed appropriately for 4 (#81, #112, #143, and #136) of the 30 sampled and 3 random residents reviewed for Advanced Directives. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 5:45 a.m., when S8LPN stopped performing CPR on Resident #143 due to a discrepancy in the resident's code status. S8LPN performed CPR for 5 minutes before stopping after a facility staff discovered Resident #143 had conflicting advance directive wishes that designated both DNR and full code status. Death was pronounced for Resident #143 on [DATE] at 6:30 a.m. Further record review revealed Resident #81, Resident #112, and Resident #136 had discrepancies with their documented code statuses and interviews confirmed staff did not know which code status to follow in case of an emergency. S1ADM was notified of the Immediate Jeopardy on [DATE] at 4:00 p.m. The Immediate Jeopardy Plan of Removal included the following information: 1. Corrective actions for alleged deficient practice were accomplished for Resident #81, Resident #112, Resident #136, Resident #394, by the following: a. Resident #81, order clarification written for DNR to match Advance Directive, completed [DATE] b. Resident #112, order clarification written for DNR to match Advance Directive, completed [DATE] c. Resident #136, order clarification written for DNR to match Advance Directive, completed [DATE] d. Resident #394, order clarification written for DNR to match Advance Directive, completed [DATE] e. Staff Developer, will In-service Nursing staff regarding CPR policy, initiated [DATE], to be completed by [DATE]. Staff will not be allowed to work until signed off. f. Regional Director or Corporate QI Nurse will in-service Staff Developer, who will be presenting in-services to nursing staff, completed [DATE]. g. Corporate QI Nurse, will in-service Social Services that Advanced directives must be changed in the event of a change in physician order, initiated [DATE], completed [DATE]. h. Staff Developer, will in-service Nursing Staff to contact MD or NP for termination of CPR, initiated [DATE], to be completed [DATE]. Staff will not be allowed to work until signed off. i. Corporate QI Nurse will in-service Administrator and Assistant Administrator regarding Advanced Directive policy and procedure and CPR policy and procedure. j. Audit of all Code Status orders to ensure they match what is in resident chart, completed [DATE]. k. Audit of all Code Status orders to ensure they match Advance Directives, [DATE]. 2. All residents have the potential to be affected by this alleged deficient practice 3. The measures put into place to prevent this alleged deficient practice from re-occurring a. Staff Developer, will In-service Nursing staff regarding CPR policy, initiated [DATE], to be completed by [DATE]. Staff will not be allowed to work until signed off. b. Corporate QI Nurse, will in-service Social Services that Advanced directives must be changed in the event of a change in physician order, initiated [DATE], completed [DATE]. c. Staff Developer, will in-service Nursing Staff to contact MD or NP for termination of CPR, initiated [DATE], to be completed [DATE]. Staff will not be allowed to work until signed off d. Corporate QI Nurse will in-service Administrator and Assistant Administrator regarding Advanced Directive policy and procedure and CPR policy and procedure. e. Audit of all Code Status orders to ensure they match what is in resident chart, completed [DATE] f. Audit of all Code Status orders to ensure they match Advance Directives, completed [DATE] g. Follow up CPR and Code Status test for nursing staff to review understanding, initiated [DATE] and to be completed [DATE]. h. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each new admission and ensure physician orders match advance directive, beginning [DATE], to be completed [DATE], expected 100% compliance. i. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident hospital return and ensure physician orders match advance directive beginning [DATE], to be completed [DATE], expected 100% compliance. j. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident quarterly care plan and ensure physician orders match advance directive beginning [DATE] to be completed [DATE], expected 100% compliance. k. Administrator or designee will review discharged residents charts and ensure resident code status was carried out according to policy and procedure, twice per week, ending [DATE]. 4. Facility will monitor its performance to ensure sustained compliance by the following a. Follow up CPR and Code Status test for nursing staff to review understanding, initiated [DATE] and to be completed [DATE]. b. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each new admission and ensure physician orders match advance directive, beginning [DATE], to be completed [DATE], expected 100% compliance. c. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident hospital return and ensure physician orders match advance directive beginning [DATE], to be completed [DATE], expected 100% compliance. d. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident quarterly care plan and ensure physician orders match advance directive beginning [DATE] to be completed [DATE], expected 100% compliance e. Administrator or designee will review discharged residents charts and ensure resident code status was carried out according to policy and procedure, twice per week, ending [DATE]. f. Administrator of designee will review advance directive audit twice per week for compliance, ending [DATE]. g. Regional Director or Corporate QI Nurse will review audits once per week for compliance, ending [DATE]. g. Additional in-servicing and or progressive disciplinary action will occur if further non-compliance is noted. Through interviews and record reviews, the surveyor confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. The Immediate Jeopardy was removed on [DATE] at 3:26 p.m. The deficient practice continued at a potential for more than minimum harm for all 149 residents currently residing in the facility. Findings: Review of facility's Advance Directive Policy and Procedure revealed the following: Procedure: Upon admission, the facility will: IV. Determine whether the resident has an advanced directive, and if not determine whether the resident wishes to formulate an advanced directive. a. If the resident or resident's legal representative has executed one or more advance directives, or executes upon admission, the facility will incorporate and maintain a copy in the residents medical record readily retrievable by any facility staff and desired wishes be communicated to the resident's direct care staff and physician. Quarterly as needed the facility will: II. Identify, clarify, and periodically review, as part of the comprehensive care planning process, the existing care instructions on whether the resident wishes to change or continue these instructions. Review of the facility's Cardiopulmonary Resuscitation (CPR) Policy and Procedure reveals: 7. If the resident is unresponsive, apneic, and or only gasping and has elected CPR on his/her advanced medical directives begin basic life support. 8. Continue uninterrupted basic life support measures until you are relieved by another person knowledgeable about CPR, emergency life medical personnel (paramedics, EMT's, etc.) arrives to assume emergency medical care, or a physician pronounces the resident expired. On [DATE] at 10:25 a.m., an interview was conducted with S8LPN. She stated she was called to Resident #143's room where she found her unresponsive on [DATE] at 5:30 a.m. She stated she reviewed Resident #143's paper chart, noted the resident was a Full Code then began CPR. She stated while performing CPR, S5LPN brought an Advanced Directive indicating the resident was a DNR. She explained after the second advance directive was brought in and indicated the resident was a DNR, she and S5LPN made the determination to terminate CPR efforts on [DATE] at 5:35 a.m. She confirmed the coroner arrived on [DATE] at 6:15 a.m., and called time of death at 6:30 a.m. On [DATE] at 2:24 p.m., an interview was conducted with S16LPN. She confirmed she responded to a code for Resident #143 on [DATE]. She explained she was in the room with S8LPN when CPR was initiated. She stated while S8LPN was performing CPR, S5LPN entered the room with an Advanced Directives which indicated Yes to CPR and Yes to DNR. S16LPN She confirmed CPR was stopped at that time. On [DATE] at 2:09 p.m., an interview was conducted with Resident #143's daughter. She stated prior to admission, she completed and electronic advanced directive for the resident which should have indicated a Full Code status. She confirmed she had filled out a second Advance Directive on [DATE] over the phone with S9AC. She confirmed S9AC was made aware Resident #143 was to be a Full Code with CPR initiated in the event of cardiac or respiratory arrest. On [DATE] at 1:05 p.m., an interview was conducted with S17NP. She confirmed she never gave a telephone/verbal order to discontinue CPR for Resident #143. On [DATE] at 2:32 p.m., an interview was conducted with S1ADM. S1ADM reviewed both versions of Resident #143's Advanced Directives and stated he interpreted both to mean Resident #143 was a full code status and staff should have continued CPR until further clarification could be made. He confirmed staff began CPR on Resident #143 and then stopped prior to the resident being pronounced dead by an appropriate entity. On [DATE] at 11:27 a.m. and interview was conducted with S15RCN. S15CRN reviewed both of Resident #143's Advance Directive Consents. S15RCN stated the Resident #143's daughter marked both CPR and DNR on the form. She confirmed the resident's wishes were unclear and she would expect staff to refer to the physician's order for further clarification. On [DATE] at 9:24 a.m., an interview was conducted with S9AC. She stated upon admission, either the resident or their responsible party would fill out the Advance Directive Consent. She stated she would then scan the completed consent email it to S3ADON, S8LPN, S7LPN and S12AADM. She stated S7LPN was responsible for entering the order into the resident's medical record. She confirmed any changes made to a resident's code status should have been updated immediately throughout their medical record. On [DATE] at 9:43 a.m., an interview was conducted with S7LPN. She stated Advanced Directives were completed by S9AC upon admission then emailed to her to enter as Physician's Orders into the EHR. She stated for current residents, any changes made to their Advanced Directives or Physician's orders would be brought to her to update the EHR. She confirmed she was the only person responsible for entering a residents' Advance Directive and Code Status into their medical record as a Physician's Order. She also confirmed she had been expected to perform chart audits weekly to ensure accuracy of Advanced Directives but had not conducted them. She then confirmed she was directed by S1ADM to change the Physician's orders for Resident #112 and Resident #136 to DNR on the morning of [DATE] to match their signed Advanced Directive. She stated prior to making those changes, both Resident #112 and Resident #136 had a physician's order for a full code in their EHR. She further confirmed Resident #81's February 2023 Physician's Order for Full Code status was incorrect because the resident signed an Advanced Directive indicating DNR status. On [DATE] at 2:41 p.m., an interview was conducted with S14CQIN. She confirmed S1ADM made her aware of the discrepancies with Resident #143's Advanced Directive on [DATE] after she expired. She confirmed the facility swapped to an electronic Advanced Directive several months ago and family members had difficulty understanding and completing the new form to correctly reflect their wishes regarding code status. S14CQIN reviewed both of Resident #143's Advance Directive consents and stated she interpreted both to mean Resident #143 was a full code status and staff should have continued CPR until further clarification could be made. On [DATE] at 12:58 p.m., an interview was conducted with S1ADM. He confirmed following Resident #143's death on [DATE], he found discrepancies regarding her Advanced Directive. He stated he also identified CPR had been initiated for her then stopped without a physician's order or the presence of EMS assuming her care. He confirmed the facility opened the QA process for Advance Directives as of [DATE] and all charts were audited by S12AADM to ensure accuracy. He then confirmed there were current discrepancies present for Resident #81, Resident #112 and Resident #136. Cross Reference 678