**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #2588471 and #2594155.Based on interview and record review, the facility failed to ensure residents received care in accordance with professional standards and advance directives were honored in 1 resident (Resident #101) of 4 residents reviewed for quality of care, resulting in an immediate jeopardy when, beginning on [DATE] at approximately 3:00 PM the resident had a serious acute change of condition (shortness of breath) and staff failed to assess, monitor and act promptly by notifying emergency services, resulting in death from cardiac arrest. This deficient practice placed all residents at risk for serious harm, injury and/or death.Findings include:The facility failed to assess, monitor and promptly notify emergency services for Resident #101, who was a full code and reported by Certified Nursing Assistant (CNA) J to be experiencing respiratory difficulties on [DATE] beginning at approximately 3:00 PM. Resident #104 was identified by Registered Nurse (RN) C at approximately 9:00 PM unresponsive and displaying agonal breathing (gasping for air that sound like snoring or gurgling). RN C contacted hospice services at 9:04 PM, who returned the call at 9:24 PM and instructed RN C to call 911 due to Resident #101's full code status. EMS arrived to transport Resident #101 to the hospital at 9:28 PM, and the resident was pronounced dead 1 hour later in the hospital.The Immediate Jeopardy began on [DATE] when the facility failed to assess, monitor and act promptly, by notifying emergency services when Resident #101 complained of respiratory difficulties and was found unresponsive approximately 6 hours later. The Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on [DATE] at 12:15 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at a scope of isolated and severity of actual harm that is not immediate jeopardy due to sustained compliance has not been verified by the State Agency.Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes and heart failure. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #13 was cognitively intact. Review of the Functional Abilities revealed that Resident #13 was dependent on staff to transfer out of bed. Review of Resident #101's Advance Directive dated and signed on [DATE] by Resident #101 and a physician indicated Code Status: Full code.Treatment Options: Intubation, IV fluids, Antibiotics, Feeding tube, Hospitalization, Dialysis. All options were marked Yes. Review of Resident #101's Care Plan revealed, Advanced Directives.date initiated: [DATE] Interventions: Nursing will honor my code status by initiating CPR. Full Code. Intubation, antibiotics, hospitalization, IV fluids, Feeding tube, Dialysis.Review of Resident #101's Hospital Records dated [DATE] revealed, .At 9:47 PM: BIBA (brought in by ambulance) unresponsive, IGEL (artificial airway inserted through the mouth) in place with bag mask ventilation. No pulse per EMS (emergency medical services), pulse check completed, no pulse, CPR (cardiopulmonary resuscitation) initiated. Per EMS has been unresponsive for over 1 hour.Time of death: 10:25 PM.In an interview on [DATE] at 1:04 PM EMS Responder (MM) reported that they arrived to the facility on [DATE] at 9:28 PM and received report from a Registered Nurse (RN). EMS MM reported that the RN could not tell them anything except for Resident #101 had been unresponsive and demonstrated agonal breathing for 45-60 minutes, and there had not been any reports that he was having any issues earlier that day. EMS MM reported that the RN kept saying that she was not familiar with Resident #101 because she had not worked the day before, but that he was on hospice and a full code (wanted all necessary life-saving medical treatment). When EMS MM assessed Resident #101, he was completely unconscious, his skin was pale and cool, he had no response to stimuli or sternal rub, he had a weak pulse, and he was taking sporadic (infrequent, irregular) agonal breaths.In an interview on [DATE] at 1:01 PM, RN-Hospice (RN-H) O reported that she had received a message from her hospice on-call triage nurse on [DATE] at 9:17 PM to notify her that RN C had called hospice requesting a nurse visit due to Resident #101 being unresponsive and in respiratory distress. RN-H O reported that she returned the call to RN C at 9:24 PM and explained that she would be arriving in about an hour; RN C responded frantically and stated, (Resident #101) is a full code.he will be dead by then! RN-H O replied by instructing RN C to call 911 immediately. RN-H O reported that when a hospice resident has full code advance directives and is in acute respiratory distress, they would expect that the facility staff implement their own emergency polices and procedure prior to calling hospice.In an interview on [DATE] at 10:21 AM, RN C reported on [DATE] around 9:00 PM she went to administer medications to Resident #101 and noticed he was unresponsive, and his breathing sounded like he was snoring. RN C reported that she had not been in the room prior to 9:00 PM because Resident #101's room was at the end of the 400 hall and he was one of the last residents on her medication pass. RN C reported that she had not been notified of any concerns during report that day and/or from CNA's (Certified Nursing Assistant). RN C reported that she did not ask for assistance from other facility staff; RN C obtained vital signs and when they were abnormal, she gave Resident #101 oxygen and then called hospice to inform them of the resident's condition. RN C reported that Resident #101's blood pressure was very low and his blood oxygen level was 70%. RN C reported that she knew Resident #101 was full code, but thought she needed to contact hospice first for guidance with his care. RN C reported that she waited about 15 minutes for hospice to call back and then was instructed by the hospice nurse to call 911 due to Resident #101 being a full code. RN C reported that she had discussed the situation afterwards with other facility nurses and was told that she did the right thing by calling hospice first.In an interview on [DATE] at 1:25 PM, CNA J reported that Resident #101 put his call light on at the beginning of the shift around 3:00 PM on [DATE], he looked very tired, and complained of not feeling well and being short of breath; CNA J notified RN C and RN C said that she would give him a breathing treatment. CNA J reported that she had checked on him from the doorway several times before dinner; Resident #101 was snoring, and his chest was rising and falling. CNA J thought that the resident needed to rest, so she did not bother him. CNA J reported that Resident #101 would not wake up after dinner, and again CNA J reported that to RN C. CNA J reported that she was busy for the rest of the night and did not know anything until she saw Resident #101 leaving with EMS towards the end of the shift.In an interview on [DATE] at 10:48 AM, CNA AA reported that she remembered that Resident #101 was always putting his call light on and hollering to get up in his chair. CNA AA reported that Resident #101required the assistance of two people so she would turn the call light off and then tell his CNA. CNA AA reported that most of the time Resident #101 requested to get up during the busy meal time. CNA AA reported that call lights for Resident #101's hall could be heard but not seen from other halls.In an interview on [DATE] at 3:01 PM, Licensed Practical Nurse (LPN) F reported that RN C never asked for her help with Resident #101 on [DATE]. LPN F did not even know anything was wrong until the EMS arrived.Review of Resident #101's EMS report dated [DATE] revealed, .Call received at 9:24 PM.On scene: 9:28 PM.Chief Complaint: Unconscious. Duration: 1 hour. Arrived on scene, nurse met EMS at the door and let us in. Nurse advised that the patient was laying in his bed, unconscious but breathing. Nurse was not able to provide EMS with any medical history about the patient. Nurse stated that she was unsure of anything. Inside the patient room, patient was laying in bed. Patient was unconscious. Patient respiratory rate was 8-10 times a minute. Patient skin was pale, cool and cyanotic. Nurse stated that he has been in this state for 45-60 minutes now. Nurse also advised that his SpO2 (measurement of oxygen in the blood) level was reading very low, along with his blood pressure. When nurse was asked why the patient was on hospice, she replied with I'm not sure, but I'm sure it's on my other computer. Nurse was asked as to what his medical history was she again replied with I'm not sure, I didn't work yesterday. Nurse was also asked if there was any complaints from 1st shift or even 2nd shift and she stated I'm not too sure, not that I was told. Nurse stated that the patient was normally awake and talking to staff .When EMS asked the nurse any question, she would respond with many times with I'm not sure as I didn't work yesterday. Initial blood pressure was 68/30 - manually obtained. Nurse then left the room. Nurse was asked to come back and help move the patient from the facility bed to EMS cot.Patient did have a palpable carotid pulse at this time. Patient was agonal breathing with a rate of 6-8 breaths a minute.Arrived at (hospital).Patient still had a palpable carotid pulse but was getting weaker. Patient was sheet lifted from the cot and placed onto the hospital bed where he lost his pulse. They began CPR. Patient was full code per the nursing home.Review of Resident #101's Hospice report dated [DATE] revealed, .XXX[DATE] at 9:04 PM (RN C) Caller.requesting PRN (as needed) visit by (hospice nurse) at this time d/t (due to) change in pt (patient) condition; Caller states pt is unresponsive to stimuli, BP 87/43.O2 sat 60% on 4L (liters) (supplemental oxygen) via simple mask with noted terminal secretions; Caller denies any s/s (signs and symptoms) of acute respiratory distress or discomfort at this time;.offered support, reviewed comfort measures/medications.attempted to provide education on s/s to expect in EOL (end of life) and disease progression to the caller. (hospice triage nurse) inquired if the caller understood and was satisfied with the plan of care;.XXX[DATE] at 9:24 PM Call to (facility) by (RN-H O) Spoke with (RN C) regarding patients status and patient would probably pass soon and to inform her of ETA (estimated time of arrival), (RN C) stated But he's a full code. Instructed (RN C) to send patient to ER (emergency room) due to full code status and her concerns about patients declining vitals and being unresponsive. (RN C) voiced understanding and that she would call 911.Review of Resident #101's Progress Note dated [DATE] at 9:28 PM revealed, Found non-responsive, BP 87/43.oxygen in the 70s. Breath sounds adventitious. Placed on oxygen with mask. Hospice, 911 called.Picked up by EMS.The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy.Resident no longer resides at the facility.Nurse (RN C) was removed from the facility schedule on [DATE].On [DATE] 51 of 51 residents that reside in the facility had a head-to-toe assessment completed by a licensed nurse to ensure the residents had not experienced a change in condition. Any change in condition noted will be documented in the medical record and communicated to the attending physician. No change of condition with current residents were identified.On [DATE] the facility completed an audit of hospital transfers since [DATE]. Two other residents were transferred out and there were no concerns identified with the hospital transfers.A Facility Call List was placed at each nurse's station to ensure they know who to contact for emergencies in the facility, [DATE].On [DATE], education was initiated for Licensed Nurses, CENAs, Dietary and Housekeeping, Activities, Maintenance and Administrative staff members. Education will be completed by the DON or a designated nurse manager and included the following topics: Change of Condition, Life Threatening Change, Change of Condition- Monitoring, Change of Condition- Reporting, Alert Charting Process, Stop and Watch, Facility Call List, Rounding- beginning of shift and periodically throughout the shift, DNR/Advance Directives [DATE]. (As of [DATE] 6 out of 15 Licensed Nurses have been educated. Any staff member who has not received the education, will receive before the start of their next shift. They will not be allowed to work until education has been completed), EMS/Hospital Transfer (As of [DATE] at 430PM, 27 out of 71 staff members have received the education. Any staff member who has not received the education, will receive before the start of their next shift. They will not be allowed to work until education has been completed.)Medical Director was notified of these findings on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This pertains to intake #2592743.Based on observation, interview and record review the facility failed to prevent an elopement and ensure safety in 1 resident (Resident #104) of 4 residents reviewed for safety/supervision, resulting in an Immediate Jeopardy when on 8/15/25 at approximately 7:00 P.M., Resident #104 (who was a known elopement risk) exited the facility unbeknownst to facility staff through an emergency exit door and was discovered outside by another resident and EMS (emergency medical services) who notified facility staff. Resident #104 was approximately 350 feet from the facility driveway walking alongside the main road, when he was first attended by facility staff at approximately 7:15 PM. This deficient practice placed 6 residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include:The facility failed to provide adequate supervision to prevent elopement for an exit seeking resident, Resident #104, who had been actively exit seeking for 2 days, and ensure that door alarms are functioning as intended for the wanderguard system (a device that triggers an alarm when near a restricted area). Resident #104 was found by another resident and EMS approximately 350 feet away from the facility driveway, walking on the side of a 30 MPH (miles per hour) road. The Immediate Jeopardy began on 8/15/25 when the facility failed to supervise Resident #104 and he eloped from the facility between 7:00 PM-7:15 PM. Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on 8/19/25 at 9:00 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 8/20/25, but noncompliance remains at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance has not been verified by the State Agency.Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia. Review of Resident #104's Wandering Risk Scale Assessment dated 8/12/25 at 3:43 PM revealed a score of 14, indicating a high risk for wandering. Further details were that Resident #104 cannot follow instructions, is ambulatory, has a history of wandering, has a medical diagnosis of dementia/cognitive impairment; diagnosis impacting gait/mobility or strength. Review of Resident #104's Social Services Note dated 8/13/25 revealed, Resident admitted to facility on 8/12/25 for long term care placement. Resident has severe complications with comprehension and memory.Resident's cognition assessed scoring a 03 on the BIMS Brief Interview for Mental Status exam. Resident assessed for wandering and confirmed an elopement risk. Wander guard placed. A BIMS score of 3, out of a total possible score of 15, indicated Resident #104 was severely cognitively impaired. Review of Resident #104's Progress Note dated 8/13/25 at 9:08 PM revealed, .No exit-seeking this shift, however resident was wandering up to doors stating he needs to leave and find his dad.Alarms are not functioning even though bracelet is in good working order.Review of Resident #104's Progress Note dated 8/15/25 at 2:55 PM revealed, .Resident is agitated and wants to see his son.Review of Resident #104's Progress Note dated 8/15/25 at 4:59 PM revealed, Resident ambulates independently on unit. Resident very anxious on shift and repeats that he is getting tire (sic) of this he has things to do and he is walking out of here. Staff redirected resident and ensured that his family is returning tomorrow, for family visited resident earlier and stated that they will be back tomorrow. Resident attempted to be redirected with activities, which is short lived.Review of Resident #104's Event Note dated 7:30 PM revealed, Resident wandering the halls of the facility. Resident baseline is confused. Resident is ambulate without assistive device. Ambulance personal (sic) came back into the building and stated that one of the residents is outside that is not supposed to be outside. The writer of this note exited the building and ran into one of the alert residents out on loa (leave of absence) in the parking lot that stated that the resident went down that why (sic) pointing to the left of the facility. The writer of this note followed after the resident. The writer of this note followed behind the resident and redirected and assisted the resident back into the building. In an interview on 8/18/25 at 3:01 PM, Licensed Practical Nurse (LPN) F reported that Resident #104 had dementia and in the evening it got worse; he talked about going home and pushed on doors. LPN F reported that she had noticed a while back that the doors did not alarm when the wanderguard bracelets were near them, and she was told by other staff that the managers were already aware of the issue. In an interview and observation on 8/18/25 at 3:52 PM, Maintenance Director (MD) LL reported that he had not checked doors or alarms since 8/15/25 because there were no extra wanderguard bracelets to use to engage the alarms. MD LL reported that prior to 8/15/25 he checked every door, every day, and was not aware of any issues. Review of logs for the past 3 months revealed, new sheets of paper, perfectly dated and checked for every day; there were zero issues noted. An observation was then made, along with DON B; where a resident that was wearing a wanderguard bracelet was walked up to and through the main entrance and there was no alarm sound observed. DON B reported that it was supposed to sound when the resident was near the doorway. MD LL reported that he was not aware that the door was not alarming with the wanderguard bracelets. All other doors (4) were checked and none of them alarmed when the wanderguard was in the area.In an interview on 8/19/25 at 3:23 PM, Registered Nurse (RN) H reported that she was the nurse assigned to Resident #104 the night he left the building. RN H reported that the resident was wandering a lot, talking about his family and wondering when they were coming to get him. RN H reported that staff tried to redirect the resident and encouraged him to participate in an activity earlier in the evening, but that it did not work. RN H reported that she had last saw Resident #104 standing at the nurse's station when the EMS (emergency medical services) were leaving the building. RN H reported that she had gone to administer medication to another resident, and all other staff were down halls and/or in rooms when she left Resident #104 at the nurse's station. RN H reported that she did not hear any alarms but when she returned to the nurse's station a few minutes later, there was an EMT (emergency medical technician) from the EMS standing at the nurse's station. RN H reported that the EMT informed her of Resident #104 being outside of the building. RN H reported that she then exited the building and found Resident #104 walking on the side of the road. RN H reported that Resident #104's wanderguard bracelet did not alarm when he exited the building and that she was not aware of a device that was supposed to be used to check that the wanderguard was functioning properly. In an interview on 8/19/26 at 10:26 AM, EMT W reported that the EMS were in the building on 8/15/25 around 7:00 PM and when they went to leave the facility, they waited at the door to be let out. EMT W reported that a staff member outside of the door yelled the code so that they could open the door; the staff member came in and the EMT's went out. EMT W reported that while cleaning the ambulance and preparing for their next run, a man (Resident #104) came up to the door and started talking to them, then walked away and down the street. EMT W reported that shortly after that another man (Resident #106) told them the resident was not supposed to be outside, so they went back into the facility to inform staff.In an interview on 8/19/25 at 4:30 PM, EMT Y reported that when they left the building on 8/15/25 there was no staff around to let them out the door, and they waited at the nurse's station for a few minutes, until finally a facility staff member told them the code to the door. EMT Y reported that there were no residents nearby when they exited the facility, but then a few minutes later Resident #104 walked up to the back door of the ambulance and started conversing with them; EMT Y did not know he was a resident until she heard someone outside in a wheelchair start yelling, hey, he's not supposed to be out here! EMT Y went back into the facility to let staff know that there was a resident outside.In an interview on 8/19/25 at 10:15 AM, Resident #106 reported that he was outside on 8/15/25 when the EMS left the building. Resident #106 reported that he spotted Resident #104 outside after the EMS had walked out; he tried to alert the EMS and was about to go get Resident #104 himself had EMS not done something. Resident #106 reported that he wasn't sure if Resident #104 walked out with EMS or just afterwards.In an interview on 8/20/25 at 9:00 AM, Activities Aide (AA) II reported that she had tried to encouraged Resident #104 to participate in activities on 8/15/25 prior to the end of her shift (5:00 PM) but he was not interested and continued to wander around the facility. AA II reported that the facility does not offer activities after 5:30 PM.In an interview on 8/19/25 at 12:34 PM, DON B reported that she was not aware that the wanderguard alarms were not working properly until they were tested with this surveyor on 8/18/25. DON B reported that it was her understanding that EMS personnel must have known the door code and opened it themselves on 8/15/25 allowing Resident #104 to exit. DON B reported that all facility staff she interviewed had said they did not give EMS the door code, but she had not interviewed anyone from the EMS about the incident.In an interview on 8/20/25 at 9:11 AM, Human Resources staff (HR) P reported that the facility normally had 4 CNA's on second shift, but that there was a call in on 8/15/25 which left only 3 CNA's, a nurse and DON B who was filling in as a floor nurse. HR P reported that the activities staff clocked out at 5:00 PM, and there were no housekeepers working after 5:00 PM. In an interview and observation on 8/19/25 at 1:28 PM, Door Security Company (DSC) NN reported that the main entrance to the facility (the door that Resident #104 exited) did not have sufficient sensitivity to engage the alarm system when the wanderguard bracelets were near the door. DSC NN reported that he had suggested the facility replace the system 4 years ago due to the system frequently failing to work properly. Observed the wanderguard alarm now sound loudly when the wanderguard bracelet was within 2 feet of the main entrance door. DSC NN reported that the wanderguard bracelet will not make the other doors in the facility alarm, unless the bracelet goes through the doorway. Review of Resident #104's Baseline Care Plan revealed, RESOLVED: I am an elopement risk from the facility based upon the elopement risk assessment and secondary to confusion, disorientation, history of wandering, and an actual elopement on 8/15/25. Dated initiated: 8/12/25. Resolved Date: 8/15/25.Interventions: RESOLVED: Nursing to check wanderguard placement each shift. Date initiated: 8/12/25, Resolved Date: 8/15/25. Resident placed on 1:1 d/t (due to) elopement for 72 hours. Date initiated: 8/15/25. Resolved Date: 8/15/25. This plan of care had been deleted and was not active. Review of Resident #104's current Care Plan revealed, .is an elopement risk and/or exhibits wandering behavior r/t (related to) dementia, mental and behavioral disturbances. Date initiated: 8/16/25, Created on 8/15/25.Interventions: 8/15/25 Resident to be monitored by one-to-one staff member due to elopement risk increase/attempt. Date initiated: 8/16/25.Distract resident when increased wandering by offering pleasant diversions, structured activities, food, conversation, television, book, etc. per resident preferences. Date initiated: 8/15/25., May wander or attempt to leave facility unattended: triggers for wandering/eloping are watching visitors & family enter and leave building, wanting to go home. De-escalate by redirection, giving simple tasks to do . Date initiated: 8/15/25., Resolved: Wander alert: check for placement q (every) shift and function per policy. Date initiated: 8/15/25, Resolved Date: 8/16/25 (by DON B). This was Resident #104's active care plan.In an interview on 8/20/25 at 12:03, DON B reported that Resident #104 should have the wanderguard/wander alert bracelet as an active intervention on his care plan; DON B reported that it was not showing up. DON B then found the intervention resolved (removed) from the care plan and could not explain why. DON B reported that a resolved intervention is not available for staff to view.In a subsequent interview on 8/20/25 at 12:21 PM, DON B and Corporate Nurse Consultant (CNC) U reported that the wanderguard intervention was on Resident #104's current care plan and they did not see what the concern was. This surveyor reviewed a copy of Resident #104's care plan that revealed, DON B had created a new intervention on 8/20/25 that indicated, Check Wander guard for placement q shift and function per policy. CNC U acknowledged the discrepancy/error and reported that the intervention for Resident #104's wanderguard alert bracelet had accidentally been removed from his care plan on 8/16/25 and had been recreated on 8/20/25 to reflect the resident's current status. The Immediate Jeopardy that began on 8/15/25 was removed on 8/20/25 when the facility took the following actions to remove the immediacy.1. Resident #104:8/15/2025 Resident returned to the facility.8/15/2025 Skin assessment completed and no injuries noted.8/15/2025 Neuro check completed and resident remains at baseline.8/15/2025 Wander Risk Scale UDA completed.8/20/2025 Resident #104's Care plan reviewed and updated.8/15/2025 Physician notified of event and order for one on one supervision. 8/15/2025 D.O.N and Administrator were notified.8/15/2025 Attempted to notify emergency contact #1 and #2, message was left 8/15/2025 All doors/alarms were checked to ensure they are properly secured and functioning. It was determined all doors were properly secured and functioning at that time.8/16/2025 Facility has contacted Securitas to come out and service wanderguard system.8/18/2025 Facility will have a staff member at the nursing station monitoring the facility doors that go outside during non-business hours to ensure any resident at risk for wandering with a wanderguard in place do not exit the doors to the outside. During business hours the receptionist will monitor doors. This will be in place until the wanderguard system is serviced.8/19/2025 service was completed- it determined all doors were properly secured and were functioning and in working order. The front door needed the sensitivity increased, which was completed by the technician during his visit.8/16/2025 Signage was placed at door for family and visitors to stop at nursing station for assistance.2. On 8/15/2025 the facility completed a head count of residents to ensure no other residents were affected. 52 out of 52 residents were accounted for.3. 8/16/2025 All residents were reviewed to ensure a wander assessment was completed in the last 90 days and residents at risk for wander/elopement were reviewed to ensure resident safety and proper plan of care in place.4. On 8/15/2025, education was initiated for All Staff which includes Licensed Nurses, CENAs, Dietary, Housekeeping, Activities, Maintenance and Administrative staff members.a. Education will be completed by the DON or a designated nurse manager and included the following topics: 1. Elopement Policy and Procedures, Door Alarm and Wanderguard Alarm. 2. Verbal education provided on redirecting residents with exit seeking behaviors. 8/19/2025 facility added additional education on exit seeking behaviors- redirection includes offering snacks, walking with resident, calling family, seeing if personal needs are met (i.e. need to use bathroom, ensuring they are not too warm or cold, tired, looking for their room etc.), place on 15 minute supervision to keep in line of sight.b. As of 8/19/2025 at 1000AM, 47 out of 62 staff members have received the education.Any staff member who has not received the education, will receive before the start of their next shift. They will not be allowed to work until education has been completed.5. Medical Director was notified of these findings on 8/15/2025.6. 8/18/2025 QAA Committee has reviewed the plan and will continue to review the audits to ensure adherence to scope of practice, specifically elopement policy and procedures.7. On 8/20/2025 Errors were identified for resident 104, therefore, all residents at risk for elopement had care plans reviewed and updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00132852. Based on interview and record review, the facility failed to follow and implement their CPR (cardiopulmonary resuscitation) policy regarding AED use for 1 of 1 resident (Resident #143) reviewed for events surrounding death, resulting in an immediate jeopardy when beginning on [DATE] at approximately 9:20 AM, the facility failed to ensure that staff had access to a working AED (automated external defibrillator) per facility policy and Resident #143 was found unresponsive with no pulse or respirations and CPR was initiated. Resident #143 was pronounced dead at the hospital. This deficient practice placed all residents who were full code status (15 residents on [DATE]) at risk for serious harm, injury, and/or death. Findings include: Review of an admission Record revealed Resident #143 admitted to the facility on [DATE] with pertinent diagnoses which included kidney disease, congestive heart failure, type II Diabetes, and cardiomyopathy. Review of a Minimum Data Set (MDS) assessment for Resident #143, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #143 was cognitively intact. Review of Resident #143's active orders on [DATE] at 3:21 PM revealed that Resident #143 was full code status. Review of a current Care Plan focus for Resident #143, initiated [DATE], revealed that Resident #143 had elected full code status. Review of Nursing Progress Note, dated [DATE] at 12:03 PM, revealed LPN (Licensed Practical Nurse) R was called to Resident #143's room at approximately 9:20 AM and assisted another nurse with CPR as resident was unresponsive with no pulse or respirations until EMT's (Emergency Medical Technicians) arrived. Resident #143 was then transferred to the local Emergency Department. In a telephone interview on [DATE] at 10:24 AM, CNA (Certified Nursing Assistant) X reported that she walked past Resident #143's room that morning and saw Resident #143 sitting up in bed facing the window. CNA X reported that she came back a minute or two later and Resident #143 was slumped onto her back with blue lips, not breathing. CNA X reported that Resident #143 was not eating at the time. CNA X reported that she called for help and two nurses responded and initiated CPR, performing chest compressions and giving her air. CNA X reported that the nurses looked for the AED (automated external defibrillator) and could not find it. In a telephone interview on [DATE] at 4:01 PM, LPN (Licensed Practical Nurse) R reported that she was called to the room of Resident #143 along with another nurse by CNA X because Resident #143 was not breathing. LPN R reported that she yelled to the desk to call 911. LPN R reported that the other nurse had already begun chest compressions when she arrived to Resident #143's room. LPN R reported that she grabbed the crash cart and continued CPR with the other nurse for about 5 minutes until EMT's (Emergency Medical Technicians) arrived. LPN R reported that there was no AED in the crash cart or able to be found. LPN R reported that EMT's worked on Resident #143 for approximately 15 minutes before leaving the facility to transport Resident #143 to the local hospital. In an interview on [DATE] at 4:44 PM, NHA (Nursing Home Administrator) A reported that the facility AED was locked in the Director of Nursing's office on [DATE] when CPR was being performed on Resident #143 and not available for responding staff. NHA reported that she did not know why the AED was locked in the Director of Nursing's office. Review of facility policy/procedure CPR Policy, effective [DATE], revealed .CPR sequence . Check patient for responsiveness . If unresponsive, call for help and activate EMS, or direct others to do so . Obtain AED and emergency equipment or direct others to do so . Check for breathing and pulse . if no pulse and not breathing, begin CPR cycle . Use AED as soon as it is available . On [DATE] at 9:48 AM, NHA (Nursing Home Administrator) A was notified of an Immediate Jeopardy that began on [DATE] and was identified on [DATE] when Resident #143 was found unresponsive without a pulse or respirations and staff were unable to fully implement the CPR Policy including use of an AED (automated external defibrillator). On [DATE], this surveyor verified the facility completed the following to remove the Immediate Jeopardy. 1- Resident #143 expired. 2- A facility wide audit was conducted to define which residents had the Advanced Directive of desiring to be a FULL CODE, as far as their documented wishes, orders and care plans. All residents with Full Code status were reviewed [DATE] by Social Service Director and DON. 3- On [DATE], the AED was assessed and all necessary supplies needed to perform a FULL CODE were available in the crash cart. 4- Beginning [DATE], the charge nurse on each shift will check for the accessibility of the AED. This will be ongoing. This will be documented. This will be done on a checklist and given to DON. 5- On [DATE], the CPR policy was reviewed by the Administrator, the DON, and the RNC. 6- Beginning [DATE], the DON/ADON/Nurse Manager will monitor 7 days weekly on various shifts to include some weekend shifts. This monitoring will go on for 4 weeks. After that the monitoring will be done 3 days weekly on various shifts, to include some weekend days for a period of not less than 6 months for ongoing compliance. After that, random checks will be conducted. Any concerns with any of the monitoring will be immediately addressed by the Administrator and DON. 7- Beginning [DATE], as additional oversight, the Regional Nurse Consultant will monitor the AED accessibility weekly. 8- Beginning [DATE], all nurses were in-serviced on the use of the AED and CPR/Advanced Directives. The in-servicing was conducted by the DON And MDS Coordinator with input from the Regional Nurse Consultant. Knowledge was measured by a POST TEST requiring 100% of the answers to be correct to pass. No staff will work after [DATE] until they have successfully completed and passed the test. This includes agency staff, prn staff, staff on any leave of any kind to include vacation or FMLA. The topics of the in-service include: 1- CPR/Advanced Directives, 2- What is an AED? Who can use it? When is it used? When should it be available? Where is it kept? Who keeps it ready to go?, 3- What is MY ROLE in my position, during a FULL CODE?, 4- What is a CRASH CART? When is it used? What is on it? Any staff who fail to comply with the points of the in-service will be further educated and/or progressively disciplined as indicated. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of actual harm that is not immediate jeopardy, and severity of isolated due to not all education had been completed and sustained compliance had not yet been verified by the State Agency.