**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to perform life saving measures to a resident that was documented as a full code (When a person has no heartbeat and not breathing, CPR/cardiopulmonary resuscitation should be administered). This deficient practice resulted in an Immediate Jeopardy on [DATE] when nursing staff failed to perform CPR on R19 or call emergency services (911) when found with no heartbeat and was not breathing. This deficient practice placed all 95 residents at risk for the likelihood of serious injury, harm, and/or death from code status not being followed by staff. Findings include: Record review of R19's face sheet revealed admission into the facility on [DATE] with a pertinent diagnosis of benign neoplasm of meninges (tumors growing in membranes around the brain). According to the Minimum Data Set, dated [DATE], R19 had impaired cognition and was extensive assist with Activities of Daily Living (ADLS). Record review of Resident Code Status revealed a document that was signed by facility staff on [DATE]. The following choice was initialed and documented the following: Full Resuscitation and life sustaining treatment (Includes all treatment items outlined below under Selective Code Selective Resuscitation) as designated by facility because another code status cannot be designated due to incapacity of resident and/or lack of a healthcare legal decision maker or lack of authority of healthcare legal decision maker to designate another code. Record review of End Stage Illness care plan documented as an intervention Resident is Full Code initiated on [DATE]. Record review of physician orders revealed a full code (default) order. Record review of R19's Nursing Notes dated [DATE] at 8:49 AM, documented the following, Writer entered room to round on resident, resident was not responsive writer assessed, no breath sounds, no reading from v/s (vital sign) machine, sternum rub given, no response, writer called staff RN to assess and call time of death. Hospice team notified. Electronically signed by Licensed Practical Nurse (LPN) C. Record review of Nursing Notes dated [DATE] at 10:39 AM documented the following: Writer called to resident room; Writer unable to obtain v/s; Floor nurse and staff nurse also unable to obtain v/s; Time of death called at 0857 am by writer. Electronically signed by Registered Nurse (RN) D. During an interview on [DATE] at 1:30 PM with RN D, when asked actions that should be taken when a resident is found with no heartbeat and is not breathing, RN D said, You should check their code status. When asked if the resident is a full code or a full code by default what actions should take place, RN D said, CPR should be started and 911 called. When asked if she had pronounced the death of R19, RN D said, Yes. When asked why the code status was not checked first, RN D said, I was called to floor by (LPN B) and told that they needed an RN to pronounce R19's death. I was told she was a hospice patient. When asked if the code status was checked before pronouncing R19's death, RN D said, No. During an interview on [DATE] at 1:50 PM with LPN C, it was confirmed that R19 was under her care when she expired. When asked if a resident is a full code or a full code by default should CPR be performed, LPN C stated, Yes. When asked if CPR and 911 was called when R19 was found to have no heartbeat and not breathing, LPN C said, No, she was hospice. When asked if R19's code status was checked, LPN C said, No. During an interview on [DATE] at 01:56 PM with LPN B, it was confirmed that she was one of the unit managers. It was confirmed that R19 had been a full code. When asked what actions should be taken if a resident is a full code, LPN B said, You have to do CPR if there are no vital signs. When asked if CPR was performed and 911 was called for R19, LPN B said, Not to my knowledge, CPR was not performed. When asked should it have been performed on that resident, LPN B said, Yes. When asked did you call RN D and tell her to go pronounce R19's death, LPN B stated, I called and told (RN D) to go up and pronounce resident. I am not sure why they did not perform CPR. When (LPN C) called me, she said resident had passed and she needed someone to pronounce her death. I was not aware at the time she was a full code; I was aware she was hospice. During an interview on [DATE] at 2:15 pm with Hospice Registered Nurse (HN) E when asked if called when the resident had passed, HN E said, Yes. When asked if R19 was a full code, HN E said Yes. When asked if instructions were given to the facility not to perform CPR, HN E said, No, it would be the responsibility of the facility to follow their protocols. During an interview on [DATE] at 2:30 PM with Director of Nursing (DON) when asked if a resident is hospice and is a full code, should CPR be administered when the resident is found with no vital signs, DON said, Yes. After reviewing information with DON regarding R19 it was confirmed that CPR should have been administered and emergency services called. During an interview on [DATE] at 2:45 PM with Nursing Home Administrator (NHA), it was confirmed that CPR should have been administered at the time of R19's death. When asked if conversations should have been held with hospice addressing actions to be taken before the resident's death related to R19's code status, NHA, said, Yes. Record review of policy Death of a Guest/Resident last reviewed [DATE] documented the following, . if the guest/resident is Full Code status, CPR is started, and emergency 911 services are activated. On [DATE] 3:35 PM, the Nursing Home Administrator was notified of the Immediate Jeopardy (IJ) that began on [DATE] due to the facilities failure to provide life saving measures to R19. A written plan of removal for the immediate jeopardy was received and verified on [DATE]. The facility removal plan documented the following: (Facility Name) submits the following Credible Allegation of Compliance outlining the measures it has completed to remove the findings of immediate jeopardy for F678 regarding the facility's alleged failure to perform cardiopulmonary resuscitation (CPR) on resident (redacted resident facility number) (R 19), who was a full code. 1. Resident identified to be affected by the alleged deficient practice. (redacted resident facility number) (R19) no longer resides in the facility. 2. Residents with the potential to be affected by the alleged deficient practice. On 1-30-23, the 3 residents that resided in the facility that expired in the facility were reviewed to ensure CPR was performed in accordance with resident preferences. 3 out of 3 residents had a no CPR order. On 1-30-23 there are 95 residents currently residing in the facility and 95 out of 95 resident charts were reviewed to ensure the code status reflects the resident preferences. One resident is a full code hospice, his chart was reviewed, and licensed nurses are aware that he is full code hospice. 3. Systemic Measures The facility policy on Death of a Guest/Resident was reviewed and deemed appropriate on 1-30-23 and no changes were made to the policies. Licensed staff will be educated on checking code status on residents regardless of their payer source. There are currently 35 licensed Nurses on staff at the facility. The re-education began on 1-30-23 at 2:00 pm with staff that was in the facility regarding the Death of a resident and guest as of 3:30 pm on 1-30-23 there are 21 out 35 nurses educated. 7 of the 21 are flex and were notified via phone as well as mailing the policy, they will be educated upon return. The remaining licensed nurses will be re-educated prior to the start of their next shift scheduled. 4. Quality Assurance An Ad Hoc QA meeting was held on 1-30-23 with the Medical Director, Director of Nursing and Administrator to review the policies on Death of a guest or resident. The administrative nurses will review residents who have expired in the facility weekly for 4 weeks and monthly for 2 months to ensure CPR was performed in accordance with the resident's preferences. Any areas of non- compliance will be addressed immediately and will be reported to QAPI Committee for further recommendations. The Administrator is responsible for sustained compliance. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance had not yet been verified by the State Agency.