**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to have effective system in place to ensure residents' advanced directives were correctly initiated for 1 resident (#106), and ensure residents' medical records reflected the residents' wishes for emergency basic life support for 3 (#7, #103, and #106) of 32 (#7, #10, #11, #23, #36, #42, #43, #49, #51, #54, #58, #62, #65, #71, #79, #82, #84, #91, #92, #101, #103, #104, #106, #107, #306, #405, #406, #407, #408, #409, #410, and #411) sampled residents reviewed for Advance Directives. The deficient practice resulted in an Immediate Jeopardy situation on [DATE] for Resident #106 when she was found unresponsive, and CPR was not initiated by S5LPN as requested in Resident #106's Advanced Directive. The physical chart revealed a full code status, meaning this resident required CPR, while the electronic medical record revealed a DNR (Do Not Resuscitate) code status. S5LPN indicated she discovered and reported the discrepancy to S2DON on [DATE]. The facility failed to put corrective actions in place after the discrepancy in code status was discovered for Resident #106. The Immediate Jeopardy situation ended for Resident #106 when the resident expired on [DATE] but continued for Resident #7 and Resident #103 when their code statuses were also found with discrepancies. Resident #7, who had a diagnosis which included Acute and Chronic Respiratory Failure with Hypoxia, Atrial Fibrillation, and Chronic Diastolic Congestive Heart Failure, wished to have a DNR code status, but the electronic medical record revealed a full code status. Resident #103 who had a diagnosis which included Essential Hypertension and Atherosclerosis of Aorta, wished to have a full code status, but the electronic medical record revealed a DNR code status. S1ADMN was notified of the Immediate Jeopardy on [DATE] at 7:40 p.m. when record reviews revealed Resident #7 and Resident #103 had discrepancies related to code status. The Immediate Jeopardy was removed on [DATE] at 3:59 p.m. when the provider presented an acceptable plan of removal. Through interviews and record reviews, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. The Immediate Jeopardy Plan of removal included the following information: 1. Corrective actions taken for Residents #7 and #103 found to have been affected by the deficient practice are as follows: a. On [DATE], discrepancies of Residents #7 and #103 advanced directive were corrected to reflect current status. b. On [DATE], all current active residents' medical records were checked to ensure advanced directives, care plans, EMR, and physician orders were accurate. c. On [DATE], in-services were conducted with Medical Records Supervisor, Nurse Practitioner, and Admissions Coordinator related to accuracy of inputting resident advance directives into electronic medical record as well as verifying admission advanced directive orders. d. On [DATE], all residents' closed death records were audited from [DATE] to present, to verify physician orders related to code status for accuracy. e. On [DATE], facility educated all professional nursing staff of the process to verify code status of a resident by use of Consent for Cardiopulmonary Resuscitation, physician order, and patient face sheet. f. On [DATE], over bed care plans for all residents had been audited to ensure reflection of correct code status. g. On [DATE], audit of all current resident face sheets performed to ensure accurate code status. h. On [DATE], a root cause analysis was completed, and QA initiated with medical director notified. 2. Residents identified as having the potential to be affected by the deficient practice were identified. 3. The following measures were implemented in an effort to achieve substantial compliance: a. As of [DATE], upon admission of a new resident, a copy of Consent for Cardiopulmonary Resuscitation will be presented for verification. b. As of [DATE], DON or designee will review all current resident electronic medical records monthly to ensure the residents advanced directives and physician orders are accurate. c. As of [DATE], changed or revocated advanced directives must be submitted in writing to the administrator. 4. Quality Assurance measures put into place to ensure continued compliance are: a. As of [DATE], during facility daily stand up/QA meeting, NFA and/or DON will verify new admission code status was accurate per patient wishes. b. As of [DATE], monthly audit of all resident code status will be conducted by DON or designee. c. As of [DATE], any changes to a resident's advanced directive will be presented to the NFA in writing prior to DON or designee reviewing and updating the resident's chart. d. As of [DATE], DON or designee will monitor verification process upon admission and any changes of code status. e. As of [DATE], during facility stand up/QA meeting all new admissions advanced directive orders will be verified for accuracy. f. As of [DATE], results of audits will be reviewed with QA committed on a quarterly basis. 5. Proposed substantial compliance will be achieved on or before [DATE]. Findings: Review of the facility's policy, Advance Directives, revealed the following, in part: Information about whether or not the resident had executed an advance directive shall be displayed prominently in the medical record. A resident will not be treated against his or her own wishes. Review of the facility's policy, Emergency Procedure-Cardiopulmonary Resuscitation, revealed the following, in part: If the resident's DNR status was unclear, CPR will be initiated until it was determined there was a DNR. Resident #106 Review of Clinical Records for Resident #106 revealed she was admitted to the facility on [DATE] with diagnoses, which included Aftercare Following Joint Replacement Surgery. Review of the MDS with an ARD of [DATE] revealed Resident #106 had a BIMS of 15, which indicated she was cognitively intact. Record review revealed Resident #106 had an advanced directive dated [DATE] which stated CPR should be done on this resident in case of extreme emergency. Review of the physician's orders for Resident #106 revealed an order, which stated Do Not Resuscitate and was initiated on [DATE]. In addition, a review of Miscellaneous Document Tab in the electronic medical record revealed the Resident/Family Consent for CPR was signed by the resident representative on [DATE] for the resident to be a Full Code was labeled as a DNR. Review of Progress/Nurses Notes for Resident #106 dated [DATE] revealed S5LPN stated Resident was found this morning at 3:20 a.m. by nurse unresponsive. Vital signs unable to be established. Resident was listed DNR as of August of 2022. Protocols were followed thereafter. An interview was conducted on [DATE] at 4:15 p.m. with S10CNA. She stated she went into Resident #106's room at 1:30 a.m. to assist the resident to the bathroom. S10CNA stated Resident #106 stated she was ok, and there were no concerns noted. She stated at 3:20 a.m. S5LPN called her into Resident #106's room. She stated S5LPN listened to Resident #106's heart with her stethoscope, and tried to obtain vital signs. She stated CPR was not initiated and a code was not called because Resident #106 was a DNR. She stated she checked the electronic medical record to verify the resident's code status. An interview was conducted on [DATE] at 4:30 p.m. with S5LPN. She stated on [DATE] at 3:20 a.m. she went into Resident #106's room and found her unresponsive. She stated she was unable to obtain vital signs on the resident. She stated the electronic medical record indicated Resident #106 was a DNR. She stated she did not call a code and did not initiate CPR. She stated while charting, she found the physical chart had a code status of full code, and the electronic medical record had a code status of DNR, which was her normal process. She stated she checked with S2DON about the discrepancy and S2DON recommended not initiating CPR because she believed the resident was a DNR. She confirmed she did not return to initiate CPR. An interview was conducted on [DATE] at 5:39 p.m. with S6LPN, a floor nurse. She verified her name was located on Resident #106's physician orders as verified, but could not recall this resident's accurate code status. She stated when a resident was admitted , she would activate a resident's code status order in the electronic medical record without checking the accuracy on the physical chart. An interview was conducted on [DATE] at 5:43 p.m. with S2DON. She confirmed Resident #106 should had been a full code status, and verified the physician orders and care plan stated the resident was a DNR. She stated on [DATE], she reviewed the call from S5LPN regarding Resident #106's death. She stated she asked S5LPN what the resident's code status was, and was told she was a DNR. She stated she did not know Resident #106 was a full code until [DATE]. Resident #7 Review of current Clinical Records for Resident #7 revealed she was admitted to the facility on [DATE] with diagnoses, which included Acute and Chronic Respiratory Failure with Hypoxia, Atrial Fibrillation, and Chronic Diastolic Congestive Heart Failure. Review of the MDS with an ARD of [DATE] revealed Resident #7 had a BIMS of 13, which indicated she was cognitively intact. Review of Resident #7's Advanced Directive titled Resident/Family Consent for Cardiopulmonary Resuscitation form located on the resident's physical chart stated the resident was to receive CPR in case of extreme emergency. This was signed by Resident #7's Responsible Party on [DATE]. Review of the facesheet located on the electronic medical record revealed Resident #7 had a DNR status. Review of the Physician orders for Resident #7 revealed an order for a DNR code status dated [DATE]. Review of Resident #7's current Care Plan revealed resident had a DNR code status. An interview was conducted on [DATE] at 11:15 a.m. with S12LPN. She stated to find a resident's code status she would locate it in the physical chart. She stated Resident #7 was Full Code status per documentation in the physical chart. She stated she was responsible for Resident #7's admit orders. She stated when a resident was admitted , orders are cued from administration, and then she was responsible for activating the orders. She confirmed she did not double check the orders with the resident's advance directive. An interview was conducted on [DATE] at 5:43 p.m. with S2DON. S2DON stated an incorrect code status was brought to her attention on [DATE] for Resident #7, and the facility started to conduct chart audits on all residents residing in the facility. An interview was conducted on [DATE] at 9:52 a.m. with Resident #7. When asked about her code status wishes, she stated her wishes for her code status were to be a DNR. Resident #103 Review of current Clinical Records for Resident #103 revealed she was admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes, Essential Hypertension, and Atherosclerosis of Aorta. Review of the MDS with an ARD of [DATE] revealed Resident #103 had a BIMS of 15, which indicated she was cognitively intact. Record review revealed Resident #103 had an advanced directive dated [DATE], which stated CPR should be done on this resident in case of extreme emergency, located in the resident's physical chart. Review of Resident #103's physician orders revealed an order which stated Do Not Resuscitate and was initiated on [DATE]. On [DATE], a revision was made to the physician orders to initiate Full Code status. An interview was conducted on [DATE] at 10:00 a.m. with Resident #103. She stated she was a full code, and wished for CPR to be initiated. An interview was conducted on [DATE] at 11:28 a.m. with S8MR. She stated she was responsible for entering all residents' code status and advanced directives. She stated S9AC completed all new admit packets in the facility's computer system. Once the packet was completed, S8MR opened the document titled CPR Patient Family Consent, and then saved the document into the resident's EMR (Electrical Medical Record). She stated she made the physical chart and placed the code status on the chart. She stated she then added orders under the physician orders for the resident, which includes the resident's code status. She stated the orders were placed in the order section on the EMR for the nurse to verify the order. She stated verification should include looking at the physician order and comparing it to the resident's advanced directive to make sure it was accurate. She stated if it was inaccurate, the nurse should not activate the order, and it should be brought to S8MR's attention for change. She stated she entered Resident #103's code status as a DNR on [DATE], and revised it on [DATE]. She stated a chart audit was conducted on [DATE], when the facility realized Resident #103's code status was incorrect. She confirmed Resident #103's code status should had been Full Code. She confirmed Resident #7 and Resident #106's code statuses were also incorrect and put in by error by herself. S8MR verified her credentials did not include any certifications of nursing. An interview was conducted on [DATE] at 5:02 p.m. with S9AC. She stated she was responsible for all admissions, which included documentation of Advanced Directives. She stated when a resident was admitted , she spoke with the resident or the resident representative in regards to their code status. She stated she explained to them what each code status meant, and once the decision was made, she had the resident representative or resident to sign the advanced directive. She stated she signed as a witness on the advanced directive. An interview was conducted on [DATE] at 5:33 p.m. with S7NP. She stated when she saw an order for a code status for her to sign, she did not check the advance directive to ensure the order and the advanced directive matched for accuracy. She stated she signed the order without questioning if it was correct. She could not verify if she was responsible for verifying orders on Residents #7, #103, #106. An interview was conducted on [DATE] at 5:43 p.m. with S2DON. She stated S9AC was in charge of contacting the family, and explaining to them the difference between full code and DNR status. She stated once the family or resident had made the decision on what code status they wished for, the Resident/Family Consent for Cardiopulmonary Resuscitation form was signed by the Resident Representative or resident, and then witnessed by S9AC with her signature. S2DON stated after the form was completed, it was uploaded to the electronic medical record, where S8MR then saw the form, and put in an order under physician orders stating the resident's code status. She stated the order showed up on the nurses' computers to check for accuracy. She stated nurses were responsible for checking the advance directive and the order to make sure it was accurate. She stated the nurse then verified the order if accurate, and should report to S8MR if inaccurate. She stated the doctor or nurse practitioner would see the verified order by the nurse. She stated the doctor or nurse practitioner would then verify the order matched the advance directive prior to signing the order. S2DON stated an incorrect code status was brought to her attention on [DATE] for Resident #7, and the facility started to conduct chart audits on all residents residing in the facility. She stated she was aware of Resident #103's code status being incorrect in the system. She confirmed this could have had the potential for harm. An interview was conducted on [DATE] at 6:30 p.m. with S1ADMN. He stated the advanced directive process started with S8MR entering the orders. He stated the floor nurses were responsible for verifying the orders. He stated the orders for code status then go to the doctor or nurse practitioner to sign after they also verify the accuracy of the orders. He confirmed there were discrepancies with Resident #7, #103, and #106 related to code status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to be administered in a manner which enabled it to use its resources effectively and efficiently to ensure an effective system was in place to ensure advance directives were followed for 3 (#7, #103, and #106) of 32 (#7, #10, #11, #23, #36, #42, #43, #49, #51, #54, #58, #62, #65, #71, #79, #82, #84, #91, #92, #101, #103, #104, #106, #107, #306, #405, #406, #407, #408, #409, #410, and #411) sampled residents reviewed for Advanced Directives. The deficient practice resulted in an Immediate Jeopardy situation on [DATE] for Resident #106 when she was found unresponsive, and CPR was not initiated by S5LPN as requested in Resident #106's Advanced Directive. The physical chart revealed a full code status, meaning this resident required CPR, while the electronic medical record revealed a DNR (Do Not Resuscitate) code status. S5LPN indicated she discovered and reported the discrepancy to S2DON on [DATE]. The facility failed to put corrective actions in place after the discrepancy in code status was discovered for Resident #106. The Immediate Jeopardy situation ended for Resident #106 when the resident expired on [DATE] but continued for Resident #7 and Resident #103 when their code statuses were also found with discrepancies. Resident #7, who had a diagnosis which included Acute and Chronic Respiratory Failure with Hypoxia, Atrial Fibrillation, and Chronic Diastolic Congestive Heart Failure, wished to have a DNR code status, but the electronic medical record revealed a full code status. Resident #103 who had a diagnosis which included Essential Hypertension and Atherosclerosis of Aorta, wished to have a full code status, but the electronic medical record revealed a DNR code status. S1ADMN was notified of the Immediate Jeopardy on [DATE] at 7:40 p.m. when record review revealed Resident #7 and Resident #103 had discrepancies related to code status. The Immediate Jeopardy was removed on [DATE] at 3:59 p.m. when the provider presented an acceptable plan of removal. 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 Plan of removal included the following information: 1. Corrective actions taken for Residents #7 and #103 found to have been affected by the deficient practice are as follows: a. On [DATE], discrepancies of Residents #7 and #103 advanced directive were corrected to reflect current status. b. On [DATE], all current active resident's medical record were checked to ensure advanced directives and physician orders matched related to code status in resident electronic record as well as chart. c. On [DATE], in-service conducted with Medical Records Supervisor, Nurse Practitioner, and Admissions Coordinator related to accuracy of inputting resident advance directives into electronic medical record as well as verifying admission advanced directive orders. d. On [DATE], all resident's closed death records were audited back to [DATE], to verify physician orders related to code status for accuracy. e. On [DATE], over bed care plans for all residents have been audited to ensure reflection of correct code status. f. On [DATE], audit of all current resident face sheets performed to ensure accurate code status. g. On [DATE], a root cause analysis was completed, and QA initiated with medical director notified. 2. Residents identified as having the potential to be affected by the deficient practice were identified. 3. The following measures were implemented in an effort to achieve substantial compliance: a. As of [DATE], upon admission of a new resident, a copy of Consent for Cardiopulmonary Resuscitation will be presented to NFA for verification. b. As of [DATE], DON or designee will review all current resident electronic medical records monthly to ensure the residents advanced directives match current physician orders. c. As of [DATE], changes or revocations of advanced directives must be submitted in writing to the administrator. d. As of [DATE], during facility stand up/QA meeting all new admission advanced directive orders will be verified for accuracy. e. As of [DATE], results of audits will be reviewed with QA committed on a quarterly basis. 4. Quality Assurance measures put into place to ensure continued compliance are: a. As of [DATE], during facility daily stand up/QA meeting, NFA and/or DON will verify new admission code status was accurate per patient wishes. b. As of [DATE], monthly audit of all resident code status will be conducted by DON or designee. c. As of [DATE], any changes to a resident's advanced directive will be presented to the NFA in writing prior to DON or designee reviewing and updating the resident's chart. d. As of [DATE], DON or designee will monitor verification process upon admission and any changes of code status. 5. Proposed substantial compliance will be achieved on or before [DATE]. Findings: Cross Reference F678 Review of the facility's policy, Advance Directives, revealed the following, in part: Information about whether or not the resident had executed an advance directive shall be displayed prominently in the medical record. A resident will not be treated against his or her own wishes. Review of the facility's policy, Emergency Procedure-Cardiopulmonary Resuscitation, revealed the following, in part: If the resident's DNR status was unclear, CPR will be initiated until it was determined there was a DNR. An interview was conducted on [DATE] at 4:15 p.m. with S10CNA. She stated she went into Resident #106's room at 1:30 a.m. to assist the resident to the bathroom. S10CNA stated Resident #106 stated she was ok, and there were no concerns noted. She stated at 3:20 a.m. S5LPN called her into Resident #106's room. She stated S5LPN listened to Resident #106's heart with her stethoscope, and tried to obtain vital signs. She stated CPR was not initiated and a code was not called because Resident #106 was a DNR. She stated she checked the electronic medical record to verify the resident's code status. An interview was conducted on [DATE] at 4:30 p.m. with S5LPN. She stated on [DATE] at 3:20 a.m. she went into Resident #106's room and found her unresponsive. She stated she was unable to obtain vital signs on the resident. She stated the electronic medical record indicated Resident #106 was a DNR. She stated she did not call a code and did not initiate CPR. She stated while charting, she found the physical chart had a code status of full code, and the electronic medical record had a code status of DNR, which was her normal process. She stated she checked with S2DON about the discrepancy and S2DON recommended not initiating CPR because she believed the resident was a DNR. She confirmed she did not return to initiate CPR. An interview was conducted on [DATE] at 5:39 p.m. with S6LPN, a floor nurse. She verified her name was located on Resident #106's physician orders as verified, but could not recall this resident's accurate code status. She stated when a resident was admitted , she would activate a resident's code status order in the electronic medical record without checking the accuracy on the physical chart. An interview was conducted on [DATE] at 11:15 a.m. with S12LPN. She stated to find a resident's code status she would locate it in the physical chart. She stated Resident #7 was Full Code status per documentation in the physical chart. She stated she was responsible for Resident #7's admit orders. She stated when a resident was admitted , orders are cued from administration, and then she was responsible for activating the orders. She confirmed she did not double check the orders with the resident's advance directive. An interview was conducted on [DATE] at 11:28 a.m. with S8MR. She stated she was responsible for entering all residents' code status and advanced directives. She stated S9AC completed all new admit packets in the facility's computer system. Once the packet was completed, S8MR opened the document titled CPR Patient Family Consent, and then saved the document into the resident's EMR (Electrical Medical Record). She stated she made the physical chart and placed the code status on the chart. She stated she then added orders under the physician orders for the resident, which includes the resident's code status. She stated the orders were placed in the order section on the EMR for the nurse to verify the order. She stated verification should include looking at the physician order and comparing it to the resident's advanced directive to make sure it was accurate. She stated if it was inaccurate, the nurse should not activate the order, and it should be brought to S8MR's attention for change. She stated she entered Resident #103's code status as a DNR on [DATE], and revised it on [DATE]. She stated a chart audit was conducted on [DATE], when the facility realized Resident #103's code status was incorrect. She confirmed Resident #103's code status should had been Full Code. She confirmed Resident #7 and Resident #106's code statuses were also incorrect and put in by error by herself. S8MR verified her credentials did not include any certifications of nursing. An interview was conducted on [DATE] at 5:02 p.m. with S9AC. She stated she was responsible for all admissions, which included documentation of Advanced Directives. She stated when a resident was admitted , she spoke with the resident or the resident representative in regards to their code status. She stated she explained to them what each code status meant, and once the decision was made, she had the resident representative or resident to sign the advanced directive. She stated she signed as a witness on the advanced directive. An interview was conducted on [DATE] at 5:33 p.m. with S7NP. She stated when she saw an order for a code status for her to sign, she did not check the advance directive to ensure the order and the advanced directive matched for accuracy. She stated she signed the order without questioning if it was correct. She could not verify if she was responsible for verifying orders on Residents #7, #103, #106. An interview was conducted on [DATE] at 5:43 p.m. with S2DON. She stated S9AC was in charge of contacting the family, and explaining to them the difference between full code and DNR status. She stated once the family or resident had made the decision on what code status they wished for, the Resident/Family Consent for Cardiopulmonary Resuscitation form was signed by the Resident Representative or resident, and then witnessed by S9AC with her signature. S2DON stated after the form was completed, it was uploaded to the electronic medical record, where S8MR then saw the form, and put in an order under physician orders stating the resident's code status. She stated the order showed up on the nurses' computers to check for accuracy. She stated nurses were responsible for checking the advance directive and the order to make sure it was accurate. She stated the nurse then verified the order if accurate, and should report to S8MR if inaccurate. She stated the doctor or nurse practitioner would see the verified order, verified with the advance directive and order to make sure it was correct, and then signed the order. S2DON stated an incorrect code status was brought to her attention on [DATE] for Resident #7, and the facility started to conduct chart audits on all residents residing in the facility. She stated she was aware of Resident #103's code status being incorrect in the system. She confirmed this could have had the potential for harm. S2DON confirmed Resident #106 should had been a full code status, and verified the physician orders and care plan stated the resident was a DNR. She stated on [DATE], she reviewed the call from S5LPN regarding Resident #106's death. She stated she asked S5LPN what the resident's code status was, and was told she was a DNR. She stated she did not know Resident #106 was a full code until [DATE]. She stated it was the responsibility of Medical Records, the nurses, and the Nurse Practitioner and/or Physician to verify accuracy of all orders including Code Status. S2DON confirmed the facility failed to ensure all staff members who were responsible for entering, verifying, and signing Code Status orders were comparing both the physical signed Advanced Directive with the EMR for accuracy. An interview was conducted on [DATE] at 6:30 p.m. with S1ADMN. He stated the advanced directive process started with S8MR entering the orders. He stated the floor nurses were responsible for verifying the orders. He stated the orders for code status then go to the doctor or nurse practitioner to sign after they also verify the accuracy of the orders. He confirmed there were discrepancies with Resident #7, #103, and #106 related to code status.