**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and interviews, the facility failed to comply with Resident #74's right to refuse or accept treatment regarding her wishes for no Cardiopulmonary Resuscitation (CPR) in the event if her heart stops beating or she stops breathing, no other medical treatment would be started or continued. Resident #74 had an elective Advanced Directive for a Do Not Resuscitate (DNR) code status and a Physician's Order for a DNR, dated [DATE]. On [DATE], the facility staff did not verify Resident #74's code status, before initiating Cardiopulmonary Resuscitation (CPR) when staff discovered the resident unresponsive with no evidence of a pulse or respirations. An Immediate Jeopardy (IJ) was determined to exist, on [DATE] at 7:28 PM, when facility staff found Resident #74 unresponsive, without a pulse or respirations. The facility's staff initiated Cardio-Pulmonary Resuscitation (CPR) on Resident #74 and continued to provide CPR for five (5) minutes until the Emergency Medical Services (EMS) was notified and the local Fire Department arrived and reviewed Resident #74's medical record and found Resident #74 was a Do Not Resuscitate (DNR) resident. The CPR was stopped, and Resident #74 was pronounced deceased at 7:42 PM. Resident #74 was never revived during the CPR. The facility's failure to identify Resident #74 as a DNR resident prior to initiating CPR resulted in the resident's decision for a DNR status not being honored or followed by the facility. The facility's failure to identify Resident #74's rights and Advance Directive for a DNR, placed Resident #74 and other DNR residents in a situation that was likely to cause serious injury, harm, impairment, or death. On [DATE] at 12:05 PM, the SA notified the facility's Administrator of the IJ and SQC. The facility submitted an Acceptable Immediate Jeopardy Removal Plan on [DATE], in which the facility alleged all corrective actions were completed on [DATE], and the IJ was removed on [DATE]. The SA validated the facility's Removal Plan on [DATE] and determined the IJ was removed on [DATE], prior to exit. Findings include: Review of the facility's policy titled, Advance Directives Policy, dated 11/2018, revealed the Advance Directive definition was a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care when the individual was incapacitated. The Do Not Resuscitate (DNR) definition indicated that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life sustaining treatments or methods are to be used. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Further review of the policy revealed information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Review of the facility's policy titled, Resident Rights, dated 01/2019, revealed: The facility will protect and promote the rights of the resident. A resident has the right to exercise his or her rights as a resident of the facility. Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR) Policy, dated 10/2018, revealed, it is the policy of this facility to adhere to resident's rights to formulate advance directives, and the facility will implement guidelines regarding cardiopulmonary Resuscitation (CPR). If a resident experiences a cardiac arrest, the facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and in accordance with the resident's advance directive. Review of Resident #74's Progress Notes-Nursing Notes, dated [DATE] at 9:18 PM, revealed a note at 7:28 PM stated the Charge Nurse, Medication (Med) cart nurse, Registered Nurse (RN) and three (3) Certified Nursing Assistants (CNAs) entered the room and Resident #74 was found unresponsive and no pulse. The resident was assisted to the floor via a sheet and Cardiopulmonary Resuscitation (CPR) was initiated per the American Heart Association protocol and 911 was called at 7:30 PM. The Fire Department arrived at 7:35 PM and the resident's chart was reviewed to discover the resident was a DNR. CPR was ceased at that time. Resident was pronounced at 7:42 PM. The Coroner arrived at 8:11 PM, and the resident's body was released to the funeral home at 8:32 PM. The Nurses Notes revealed CPR was performed for five (5) minutes, prior to the fire department's arrival. An interview, on [DATE] at 3:24 PM, with Registered Nurse (RN) #1/Supervisor, revealed she confirmed she did not ask anybody to get the chart until the Fire Department personnel asked for it. RN #1 said they received a call from the lab reporting a critically high Potassium level. RN #1 stated the Medical Doctor (MD) instructed them to send Resident #74 to the emergency room (ER) for evaluation and treatment. Resident #74 was left alone in the room with the Certified Nursing Assistant (CNA). RN #1 could not remember who the CNA was. RN #1 stated the CNA came to the door saying, I don't think she's breathing. RN #1 stated RN #5 and Licensed Practical Nurse (LPN) #2 initiated CPR. RN #1 said she entered the room and instructed another CNA to call 911. RN #1 said the next thing she knew was when she looked up and the Fire Department was at the facility, and that was when Resident #74's DNR status was identified. RN #1 said she did not know what happened, it happened so quick. RN #1 did say she had been in-serviced several times on where to look for a resident's code status to ensure it was identified and provided per the resident's request. Review of the Progress Notes-Nurses Notes, dated [DATE] at 7:17 PM, revealed a call was received from (Name of Hospital) lab reporting a critically high Potassium level of 8.7. Relayed to (Name of MD) who instructed to send resident to (Name of Hospital) to be evaluated and treated. (Names of Contact Persons) were notified and verbalized understanding. An interview, on [DATE] at 3:30 PM, revealed RN #5/Charge Nurse confirmed she did not ask anybody to get the chart to review Resident #74's code status. RN #5 said she did not ask anybody to get the chart because she thought RN #1/Supervisor had checked the chart for the code status. RN #5 said she was called into the room by a CNA. RN #5 said she provided chest compressions and LPN #2 provided mouth to mouth breathing. During an interview, on [DATE] at 3:59 PM, LPN #2 revealed she assisted RN #5 with resuscitating Resident #74. LPN #2 confirmed she did not ask anybody to get the chart. LPN #2 stated she has been trained where the code status was located in the chart. LPN #2 also stated she thought the supervisor had checked the chart for Resident #74's code status. Review of the facility's Advanced Care Planning form revealed Resident #74's printed name and her daughter's printed and signed name, dated [DATE], for an elected DNR code status. Resident #74's admission Record revealed the resident's daughters were the first and second contact persons. The resident's Advanced Directive was a Do Not Resuscitate. Review of Resident #74's Physician's Orders revealed an order, dated [DATE], for a DNR code status. During an interview, on [DATE] at 4:44 PM, Firefighter #1, revealed on [DATE], upon responding to the 911 call, the Chief obtained Resident #74's chart and discovered that Resident #74 was a DNR code status. Firefighter #1 stated that CPR was ceased at that time. An interview, on [DATE] at 12:22 PM, an interview with the Assistant Director of Nurses (ADON) revealed she was responsible for checking the residents code status and making sure there's a written order that is in the electronic record and on the Medication Administration Record (MAR). The ADON stated Resident #74's DNR order was in the chart Physician's Orders, and on the MAR. Resident #74's DNR code status was not honored due to the nurse's failure to check the Physician's Orders and MAR. During an interview, on [DATE] at 5:52 PM, the Director of Nursing (DON) confirmed Resident #74's code status was a Do Not Resuscitate (DNR), and when the resident was found unresponsive, on [DATE], the Charge Nurse initiated CPR. The DON stated after they found out the resident was a DNR, CPR was stopped. As a result, Resident #74's DNR code status choice was not honored. During an interview, on [DATE] at 4:46 PM, the Deputy Coroner stated the fire department had already pronounced the resident by the time he arrived. The Deputy Coroner said he was told the staff had performed CPR and the resident was never revived. An interview with the Medical Director, on [DATE] at 11:53 AM, revealed he was made aware of the staff initiating CPR after the EMS staff left the building. The Medical Director stated he was told the staff found the resident unresponsive and initiated CPR until the Fire Chief pulled the resident's chart and noted she was a DNR, and the Fire Chief stopped the CPR at that moment. The Medical Director stated the resident could have had a negative outcome of surviving with broken ribs or being placed on a ventilator. Review of the admission Record revealed Resident #74 was admitted by the facility, on [DATE], with the included diagnoses Cardiomyopathy, Heart Failure, Cardiomegaly, Tachycardia, Pulmonary Disease and Chronic Atrial Fibrillation. Review of Resident #74's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. This is the facility's accepted Immediate Jeopardy Removal Plan: Summary of events: The State Agency notified [NAME] Gardens Nursing Center on [DATE]th, 2020 at 12:05 P.M. of the immediate jeopardy and substandard quality of care for Residents #74, #31, and #64. The Facility failed to honor Resident #74's advance directive for a do not resuscitate (DNR) code status, failed to honor the Resident's Rights for Advance Directive, failed to follow the care plan for a DNR code status and failed to prevent a potential negative outcome by initiating Cardiopulmonary Resuscitation (CPR). Resident #74 was found pulseless on [DATE]th, 2019 at 7:28 PM by RN #1 who initiated Cardiopulmonary Resuscitation (CPR) for a total of five minutes. CPR was discontinued when emergency services arrived and notified RN #1 of Resident#74's DNR code status. RN #1 failed to follow the policy and procedures in place to identify Resident #74's code status. The State Agency notified the facility on [DATE]th, 2020 at 3:30 PM that Resident #31's code status was documented incorrectly on the Report Sheet and Resident #64's code status was not in the Electronic Health Record, according to their wishes which could have likely caused harm for Residents #31 and #64. The facility failed to follow policy and procedure to identify the correct code status for Residents #74, #31, and #64. Facility action plan: 1. The Director of Nursing (DON) conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with Registered Nurse (RN) #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. On [DATE]th, 2019 Care Plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. On [DATE]th, 2019 at 1:30 PM the Director of Nursing in serviced all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. On [DATE]th and 30th, 2020 the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. On [DATE] the Assistant Director of Nursing (ADON) reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. On [DATE]th, 2020 at 12:05PM, the State Agency identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. Care Plan Nurse found that Resident #64's order had been discontinued by Licensed Practical Nurse (LPN) #1 and the order was reentered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. No staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The facility alleges the immediate jeopardy was removed on [DATE]. On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through record review of the sign-in sheets and interview with the Director of Nursing (DON) that the facility conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with RN #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. The SA validated through record review of the in-service sign-in sheets and interview with the Care Plan Nurse that on [DATE]th, 2019 Care plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. The SA validated through record review of the sign-in sheets and interview with the DON that the facility conducted an in-service on [DATE]th, 2019 at 1:30 PM, by the Director of Nursing, to all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. The SA validated through record review of the in-service sign-in sheets and interview with the facility owner that on [DATE]th and 30th, 2020, the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. The SA validated by interview of the ADON that on [DATE] the ADON reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. The SA validated by record review and staff interviews, on [DATE]th, 2020 at 12:05 PM, the SA identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. The Care Plan Nurse found that Resident #64's order had been discontinued by LPN #1 and the order was re-entered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by the Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The SA validated by interviews the Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The SA validated through interviews with the Facility Administrator and the DON the Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. The SA validated through interviews with the Administrator and the DON that no staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and facility policy review, the facility failed to ensure Resident #74's Care Plan was implemented for a Do Not Resuscitate (DNR) code status, and to develop/implement Resident #22's Care Plan for pain medication administration as needed during wound care. These concerns were identified for two (2) of 30 care plans reviewed. Resident #74 had a Care Plan initiated and revised, on [DATE], for a DNR code status. The SA identified an Immediate Jeopardy (IJ) on [DATE] at 7:28 PM, when Resident #74 was found unresponsive and without a pulse or respirations by the facility staff. The facility staff failed to verify Resident #74's code status. Cardiopulmonary Resuscitation (CPR) was initiated by the facility staff until the local Fire Department arrived at 7:35 PM, and reviewed Resident #74's chart where the DNR code status was documented. The CPR was stopped after five (5) minutes, and Resident #74 was pronounced deceased at 7:42 PM. The facility staff did not follow Resident #74's Care Plan regarding her DNR code status. The facility's failure to follow Resident #74's Comprehensive Care Plan regarding her DNR code status placed Resident #74 and other residents with a DNR code status in situations that was likely to cause serious harm, injury, impairment or death. On, [DATE] at 12:05 PM, the State Agency (SA) notified the facility's Administrator of the Immediate Jeopardy (IJ). The facility submitted an Acceptable Immediate Jeopardy Removal Plan on [DATE], in which the facility alleged all corrective actions were completed on [DATE], and the IJ was removed on [DATE]. The SA validated the facility's Immediate Jeopardy Removal Plan on [DATE] and determined the IJ was removed on [DATE], prior to exit. Findings Include: Record Review of the facility's policy titled, Comprehensive Care Plans, dated 09/2018, revealed it is the policy of this facility to develop and implement a comprehensive person centered Care Plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #74 Review of Resident #74's Care Plan revealed the facility failed to follow the care plan regarding the resident's Do Not Resuscitate (DNR) code status. The Care Plan was initiated, on [DATE], for Resident #74's DNR code status. The goal was to honor the resident and family wishes. The interventions included: Ensure comfort measures are achieved without heroics. Ensure resident/family understands meaning of code status. Label the chart, Medication Administration Record (MAR) and Treatment Administration Record (TAR) to inform staff of DNR code status, obtain signed consent and Medical Doctors orders for DNR. Review of Resident #74's Progress Notes-Nursing Notes, dated [DATE] at 9:18 PM, revealed a note at 7:28 PM stated the Charge Nurse, Medication (Med) cart nurse, Registered Nurse (RN) and three (3) Certified Nursing Assistants (CNAs) entered the room and Resident #74 was found unresponsive and no pulse. The resident was assisted to the floor via a sheet and Cardiopulmonary Resuscitation (CPR) was initiated per the American Heart Association protocol and 911 was called at 7:30 PM. The local Fire Department arrived at 7:35 PM and reviewed Resident #22's chart to discover the resident was a DNR. CPR was ceased at that time. Resident was pronounced at 7:42 PM. The Coroner arrived at 8:11 PM, and the resident's body was released to the funeral home at 8:32 PM. The Nurses Notes revealed CPR was performed for five (5) minutes, prior to the fire department's arrival. During an interview, on [DATE] at 5:25 PM, RN #4/Care Plan Nurse revealed he looks at the residents advance directives to determine whether the resident is a full code or a DNR. LPN #4 said he normally does a care plan for the resident with a DNR code status and he expected the staff to follow the care plan. Review of the facility's Advanced Care Planning form revealed Resident #74's printed name and her daughter's printed and signed name, dated [DATE], for an elected DNR code status. Resident #74's admission Record revealed the resident's daughters were the first and second contact persons. The resident's Advanced Directive was a Do Not Resuscitate. Review of Resident #74's Physician's Orders revealed an order, dated [DATE], for a DNR code status. Review of the admission Record revealed Resident #74 was admitted by the facility, on [DATE], with the included diagnoses Cardiomyopathy, Heart Failure, Cardiomegaly, Tachycardia, Pulmonary Disease and Chronic Atrial Fibrillation. Review of Resident #74's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Resident #22 Review of Resident #22's Care Plan revealed the Care Plan did not address pain assessment/management for wound care. Further review of the Care Plan revealed the Focus for risk for skin breakdown secondary to decreased mobility and history (hx) of occasional urinary incontinence was initiated, on [DATE]. The Goal stated the resident would be free of skin breakdown with a Target Date of [DATE]. Further review of the care plan revealed an Intervention, dated [DATE], to cleanse the unstageable wound to the left heel with Normal Saline (NS), pat dry, apply Santyl to wound bed, apply sureprep to wound edges, apply adhesive dressing (dsy), wrap with kerlix, daily (dly) and as needed (PRN) until healed. The Interventions also included: Administer Ultram 50 milligrams (mg) by mouth (po) every (q) six (6) hours as needed (prn) for pain. Monitor effectiveness of prn medication and document. Notify Medical Doctor (MD) if medication not effective in helping relieve and/or control pain. An observation, on [DATE] at 9:00 AM, revealed Registered Nurse (RN) #3/Wound Care Nurse, did not follow Resident #22's Care Plan due to she did not assess the residents gestures and verbalization of pain/discomfort during the wound care observation, or administer pain medication. Registered Nurse (RN) #3/Wound Care Nurse, was assisted by Certified Nursing Assistant (CNA) #1. Resident #22 was observed lying comfortably in bed on her right side. When RN #3 began to clean the wound with NS, Resident #22 cried out OWWW and drew her left leg upward toward her chest, during the wound care. RN #3 confirmed Resident #22 did not receive pain medication prior to wound care. RN #3 continued to clean Resident #22's wound with NS. RN #3 measured the wound, washed her hands, applied gloves and cleaned the wound again. Resident #22 cried out OWWW a second time. RN #3 continued to preform the wound care until complete without assessing Resident #22's pain or providing pain medication. Resident #22's left heel wound measured 1.4 centimeter (cm) by 1.2 cm, with 50% slough, mild clear drainage, and no odor. An interview, on [DATE] at 11:00 AM, with RN #3/Wound Care Nurse, revealed Resident #22 did not receive pain medication prior to the wound care to the left heel. RN #3/Wound Care Nurse stated Resident #22 usually does not complain of pain. RN #3/Wound Care Nurse stated she should have stopped the treatment when the resident complained of pain. Review of Resident #22's Order Review Report revealed an order, dated [DATE], to cleanse the unstageable left heel wound with NS, pat dry, apply santyl to wound bed. Apply sureprep to wound edges. Apply adhesive foam dressing. Wrap with kerlix daily and PRN until healed, every day shift and as needed. Further review of the report revealed an order, dated [DATE], for Ultram Tablet 50 milligrams (mg), give one (1) tablet by mouth every six (6) hours as needed for pain. There also was an order, dated [DATE], to administer Tylenol tablet, give 1000 mg by mouth daily for pain. During an interview, on [DATE] at 5:33 PM, RN #4/Care Plan Nurse confirmed the facility failed to develop a care plan related to pain regarding Resident #22's left heel wound care. RN #4/Care Plan Nurse said he developed a care plan today, and he notified the doctor of Resident #22's wound care pain and received an order for pain medication routinely and as needed. An interview, on [DATE] at 5:58 PM, revealed the Director of Nurses (DON) stated, I would have stopped as soon as the resident cried out in pain during the wound care treatment and got her some pain medication. Review of the Face Sheet revealed Resident #22 was admitted by the facility, on [DATE], with the included diagnoses of Chronic Kidney Disease, Urinary Retention and Vascular Dementia with behavioral Disturbance. A review of Resident #22's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the presence of an unstageable pressure ulcer suspected of deep tissue injury evolution. Review of the resident's pain assessment revealed she received routine pain medication, but no as needed pain medication. The pain interview was not done. This is the facility's accepted Immediate Jeopardy Removal Plan: Summary of events: The State Agency notified [NAME] Gardens Nursing Center on [DATE]th, 2020 at 12:05 P.M. of the immediate jeopardy and substandard quality of care for Residents #74, #31, and #64. The Facility failed to honor Resident #74's advance directive for a do not resuscitate (DNR) code status, failed to honor the Resident's Rights for Advance Directive, failed to follow the care plan for a DNR code status and failed to prevent a potential negative outcome by initiating Cardiopulmonary Resuscitation (CPR). Resident #74 was found pulseless on [DATE]th, 2019 at 7:28 PM by RN #1 who initiated Cardiopulmonary Resuscitation (CPR) for a total of five minutes. CPR was discontinued when emergency services arrived and notified RN #1 of Resident#74's DNR code status. RN #1 failed to follow the policy and procedures in place to identify Resident #74's code status. The State Agency notified the facility on [DATE]th, 2020 at 3:30 PM that Resident #31's code status was documented incorrectly on the Report Sheet and Resident #64's code status was not in the Electronic Health Record, according to their wishes which could have likely caused harm for Residents #31 and #64. The facility failed to follow policy and procedure to identify the correct code status for Residents #74, #31, and #64. Facility action plan: 1. The Director of Nursing (DON) conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with Registered Nurse (RN) #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. On [DATE]th, 2019 Care Plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. On [DATE]th, 2019 at 1:30 PM the Director of Nursing in serviced all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. On [DATE]th and 30th, 2020 the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. On [DATE] the Assistant Director of Nursing (ADON) reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. On [DATE]th, 2020 at 12:05PM, the State Agency identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. Care Plan Nurse found that Resident #64's order had been discontinued by Licensed Practical Nurse (LPN) #1 and the order was reentered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. No staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The facility alleges the immediate jeopardy be removed on [DATE]. On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through record review of the sign-in sheets and interview with the Director of Nursing (DON) that the facility conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with RN #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. The SA validated through record review of the in-service sign-in sheets and interview with the Care Plan Nurse that on [DATE]th, 2019 Care plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. The SA validated through record review of the sign-in sheets and interview with the DON that the facility conducted an in-service on [DATE]th, 2019 at 1:30 PM, by the Director of Nursing, to all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. The SA validated through record review of the in-service sign-in sheets and interview with the facility owner that on [DATE]th and 30th, 2020, the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. The SA validated by interview of the ADON that on [DATE] the ADON reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. The SA validated by record review and staff interviews, on [DATE]th, 2020 at 12:05 PM, the SA identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. The Care Plan Nurse found that Resident #64's order had been discontinued by LPN #1 and the order was re-entered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by the Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The SA validated by interviews the Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The SA validated through interviews with the Facility Administrator and the DON the Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. The SA validated through interviews with the Administrator and the DON that no staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ was removed on [DATE], prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and facility policy review, the facility failed to honor Resident #74's Do Not Resuscitate (DNR) code status by initiating Cardio-Pulmonary Resuscitation (CPR) when the resident was found by the facility staff unresponsive and with no pulse or respirations, for one (1) of four (4) residents reviewed who had expired in the facility within the past six (6) months. The State Agency identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE]. Resident #74 had a Physician's Order and Advance Directive for a Do Not Resuscitate (DNR) code status dated [DATE] and was found by staff, on [DATE] at 7:28 PM, without a pulse or respirations. CPR was initiated by the facility's staff for five (5) minutes until the local Fire Department arrived. CPR was stopped due to the Fire Department staff reviewed the resident's chart and discovered the DNR code status. Resident #74 was never revived and was pronounced deceased at the facility. The facility's failure to honor Resident #74's DNR code status, placed this resident and other residents with a DNR code status, in a situation that was likely to cause serious harm, injury, impairment or death. The facility Administrator was notified of the IJ and SQC on [DATE]. The State Agency (SA) received an acceptable Immediate Jeopardy Removal Plan on [DATE], in which the facility alleged that all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE]. The SA determined the IJ was removed on [DATE] prior to the SA's exit on [DATE]. Findings Include: Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR), dated [DATE], revealed it is the policy of the facility to adhere to resident's rights to formulate the advance directives. In accordance to these rights, the facility will implement guidelines regarding Cardio-pulmonary Resuscitation (CPR). The facility will follow current American Heart Association (AHA) guidelines regarding CPR. If a resident experience a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and in accordance with the resident's advance directives, or in the absence of advance directives, or Do Not Resuscitate order and/ or if the resident does not show obvious signs of clinical death (e.g. rigor mortis, decapitation, transection, or decomposition). Review of the facility's policy titled, Advance Directives dated [DATE], revealed the Advance Directives will be respected in accordance with state law and facility policy. The policy guidelines stated that upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an Advance Directive if he or she chooses to do so. Information about whether the resident has executed an Advance Directive shall be displayed prominently in the medical record. If the resident indicates that he or she has not established Advance Directives, the facility staff should offer assistance in establishing advance directives. The resident has the right to refuse treatment, whether he or she has an Advance Directive. A resident will not be treated against his or her own wishes. The facility states the Advance Directive policy is a written instruction such as a living will or durable power of attorney for health care, recognized by state law, relating to the provisions of health care when the individual is incapacitated. The facility's Do Not Resuscitate (DNR) definition indicated, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life sustaining treatments or methods are to be used. Review of the facility's Resident Rights policy, dated [DATE], revealed the facility will inform the residents both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Prior to or upon admission the social service designee, or another designated staff member, will inform the resident and or the resident's representative of the resident's rights and responsibilities. The facility will protect and promote the rights of the resident. Review of the Progress Notes-Nursing Notes, dated [DATE] at 9:18 PM, revealed a note at 7:28 PM stated the Charge Nurse, Medication (Med) cart nurse, Registered Nurse (RN) and three (3) Certified Nursing Assistants (CNAs) entered the room and Resident #74 was found unresponsive and no pulse. The resident was assisted to the floor via a sheet and Cardiopulmonary Resuscitation (CPR) was initiated per the American Heart Association protocol and 911 was called at 7:30 PM. The local Fire Department arrived at 7:35 PM and the resident's chart was reviewed to discover the resident was a DNR. CPR was ceased at that time. Resident was pronounced deceased at 7:42 PM. The Coroner arrived at 8:11 PM, and the resident's body was released to the funeral home at 8:32 PM. The Nurses Notes revealed CPR was performed for five (5) minutes, prior to the fire department's arrival. Registered Nurse (RN) #1/Supervisor was interviewed on [DATE] at 3:24 PM. RN #1/Supervisor confirmed she did not ask anybody to get Resident #74's chart until the Fire Department personnel asked for it. RN #1/Supervisor said she did not know what happened, it happened so quick. RN #1/Supervisor stated RN #1 and LPN #5 initiated the CPR, and when she looked up the Fire Department was already there, and that's when they checked the chart for the code status. RN #1/Supervisor said they had received a call from the lab reporting a critically high Potassium level, and the Medical Doctor (MD) instructed them to send Resident #74 to the emergency room (ER) for evaluation and treatment. Resident #74 was left alone in the room with the Certified Nursing Assistant (CNA). RN #1/Supervisor said she could not remember who the CNA was. RN #1/Supervisor reported the CNA came to the door saying, I don't think she's breathing. RN #1/Supervisor stated RN #5 and Licensed Practical Nurse (LPN) #2 initiated CPR, and when she entered the room she instructed another CNA to call 911. RN #1/Supervisor said when she looked up the Fire Department was at the facility, and that was when Resident #74's DNR status was identified. RN #1 did say she had been in-serviced several times on where to look for a resident's code status. Review of the Progress Notes-Nurses Notes, dated [DATE] at 7:17 PM, confirmed a call was received from (Name of Hospital) lab reporting a critically high Potassium level of 8.7, which was reported to (Name of MD) who instructed to send resident to (Name of Hospital) to be evaluated and treated. (Names of Contact Persons) were notified and verbalized understanding. RN #5/Charge Nurse was interviewed, on [DATE] at 3:30 PM. RN #5/Charge Nurse said she did not ask anybody to get the chart to identify Resident #74's code status. RN #5/Charge Nurse said she provided chest compressions and LPN #2 provided mouth to mouth breathing. RN #5/Charge Nurse said she did not ask anybody to get the chart because she thought RN #1/Supervisor had checked the chart for the code status. RN #5 said she was called into the room by a CNA. An interview, on [DATE] at 3:59 PM, with LPN #2 revealed she had been trained where the code status was located in the resident's chart. LPN #2 confirmed she did not ask anybody to get the chart because she thought RN #5/Charge Nurse checked Resident #74's chart for the code status. LPN #2 said she did assist RN #5/Charge Nurse with resuscitating Resident #74. The Medical Director was interviewed, on [DATE] at 11:53 AM. The Medical Director stated Resident #74 could have had a negative outcome if she had survived with broken ribs or being placed on a ventilator. The Medical Director stated he was told the staff found Resident #74 unresponsive and initiated CPR. The Medical Director said CPR was performed until the Fire Chief pulled the resident's chart and noted she was a DNR, and the Fire Chief stopped the CPR at that moment. Review of the facility's Advanced Care Planning form revealed Resident #74's printed name and her daughter's printed and signed name, dated [DATE], for an elected DNR code status. Resident #74's admission Record revealed the resident's daughters were the first and second contact persons. The resident's Advanced Directive was a Do Not Resuscitate. Review of Resident #74's Physician's Orders revealed an order, dated [DATE], for a DNR code status. An interview, on [DATE] at 4:44 PM, revealed Firefighter #1 stated he responded to the call on [DATE] when Resident #74 was found pulseless. Fire Fighter #1 stated the Chief reviewed Resident #74's medical records and found Resident #74 was a DNR. CPR was stopped at that time once they identified Resident #74 as a DNR. Fire Fighter #1 also stated that the Resident #74 was pronounced by the Fire Department and the coroner was notified. An interview, on [DATE] at 12:22 PM, with the Assistant Director of Nurses (ADON) revealed Resident #74's DNR order was in the chart's Physician's Orders, and on the Medication Administration Record (MAR). The ADON stated she was responsible for checking the residents code status and making sure there's a written order that is in the electronic record and on the Medication Administration Record (MAR). The ADON revealed the orders for a DNR code status, and the resident's choice for a DNR code status was not followed by the nurses. An interview, on [DATE] at 5:52 PM, revealed the Director of Nursing (DON) confirmed Resident #74 was found unresponsive on [DATE], and Registered Nurse #5/Charge Nurse and Licensed Practical Nurse (LPN) #2 initiated CPR. The DON stated CPR ceased after Resident #74 was identified as a DNR by the local Fire Department when the chart was reviewed by them. The DON reported the nurses did not check the resident's code status, and as a result, Resident #74's DNR code status was not honored by the nurses who initiated the CPR. An interview, on [DATE] at 4:46 PM, with the Deputy Coroner revealed he was informed by the facility staff Resident #74 was never revived, and the fire department had already pronounced the resident by the time he arrived. Review of the admission Record revealed Resident #74 was admitted by the facility, on [DATE], with the included diagnoses Cardiomyopathy, Heart Failure, Cardiomegaly, Tachycardia, Pulmonary Disease and Chronic Atrial Fibrillation. Review of Resident #74's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. This is the facility's accepted Immediate Jeopardy Removal Plan: Summary of events: The State Agency notified [NAME] Gardens Nursing Center on [DATE]th, 2020 at 12:05 P.M. of the immediate jeopardy and substandard quality of care for Residents #74, #31, and #64. The Facility failed to honor Resident #74's advance directive for a do not resuscitate (DNR) code status, failed to honor the Resident's Rights for Advance Directive, failed to follow the care plan for a DNR code status and failed to prevent a potential negative outcome by initiating Cardiopulmonary Resuscitation (CPR). Resident #74 was found pulseless on [DATE]th, 2019 at 7:28 PM by RN #1 who initiated Cardiopulmonary Resuscitation (CPR) for a total of five minutes. CPR was discontinued when emergency services arrived and notified RN #1 of Resident#74's DNR code status. RN #1 failed to follow the policy and procedures in place to identify Resident #74's code status. The State Agency notified the facility on [DATE]th, 2020 at 3:30 PM that Resident #31's code status was documented incorrectly on the Report Sheet and Resident #64's code status was not in the Electronic Health Record, according to their wishes which could have likely caused harm for Residents #31 and #64. The facility failed to follow policy and procedure to identify the correct code status for Residents #74, #31, and #64. Facility action plan: 1. The Director of Nursing (DON) conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with Registered Nurse (RN) #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. On [DATE]th, 2019 Care Plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. On [DATE]th, 2019 at 1:30 PM the Director of Nursing in serviced all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. On [DATE]th and 30th, 2020 the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. On [DATE] the Assistant Director of Nursing (ADON) reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. On [DATE]th, 2020 at 12:05PM, the State Agency identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. Care Plan Nurse found that Resident #64's order had been discontinued by Licensed Practical Nurse (LPN) #1 and the order was reentered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. No staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The facility alleges the immediate jeopardy was removed on [DATE]. On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through record review of the sign-in sheets and interview with the Director of Nursing (DON) that the facility conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with RN #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. The SA validated through record review of the in-service sign-in sheets and interview with the Care Plan Nurse that on [DATE]th, 2019 Care plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. The SA validated through record review of the sign-in sheets and interview with the DON that the facility conducted an in-service on [DATE]th, 2019 at 1:30 PM, by the Director of Nursing, to all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. The SA validated through record review of the in-service sign-in sheets and interview with the facility owner that on [DATE]th and 30th, 2020, the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. The SA validated by interview of the ADON that on [DATE] the ADON reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. The SA validated by record review and staff interviews, on [DATE]th, 2020 at 12:05 PM, the SA identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. The Care Plan Nurse found that Resident #64's order had been discontinued by LPN #1 and the order was re-entered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by the Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The SA validated by interviews the Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The SA validated through interviews with the Facility Administrator and the DON the Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. The SA validated through interviews with the Administrator and the DON that no staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and facility policy review, the facility failed to ensure Resident #74's choice for a Do Not Resuscitate (DNR) code status was honored. This was identified for one of four (1 of 4) residents reviewed who expired in the facility over the past six (6) months. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE]. Resident #74 had a Physician's Order and an Advanced Directive, dated [DATE], for a DNR code status. On [DATE] at 7:38 PM, Resident #74 was found unresponsive, and without a pulse or respirations by the facility's staff. Cardiopulmonary Resuscitation (CPR) was initiated by the facility's staff and the Emergency Medical System (EMS) was notified. The local Fire Department was dispatched to the facility. Resident #74's chart was checked by the Fire Chief on arrival to the facility and it was discovered at that time Resident #74 was a DNR. CPR had been in progress five (5) minutes and was stopped by the Fire Chief at that time. Resident #74 was not revived during the CPR and was pronounced deceased at the facility. The facility's staff did not check Resident #74's chart to verify her choice of code status was a DNR, and CPR should not have been initiated. The facility's failure to honor Resident #74's choice for a DNR code status, placed Resident #74 and other residents with a DNR code status, in a situation that was likely to cause serious harm, injury, impairment or death. The SA notified the facility's Administrator of the IJ and SQC on [DATE]. Findings Include: Review of the facility's, Advance Directives Policy, dated 11/2018, revealed the Advance Directives will be respected in accordance with state law and facility policy. Information about whether the resident has executed an Advance Directive shall be displayed prominently in the medical record. A resident will not be treated against his or her own wishes. The facility's Do Not Resuscitate (DNR) definition indicated that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life sustaining treatments or methods are to be used. Review of the Progress Notes - Nurses Notes, revealed, on [DATE] at 7:28 PM, Resident #74 was found unresponsive and without a pulse. Resident #74 was assisted to the floor, and CPR was initiated by LPN #2 and RN #5. The Nurse's Notes stated 911 was called at 7:30 PM. The local Fire Department arrived at 7:35 PM and CPR was stopped at that time when the Fire Department staff checked Resident #74's code status on the medical record. Resident #74 was pronounced dead at 7:42 PM. The Nurse's Notes revealed Resident #74 was resuscitated for five (5) minutes, prior to the Fire Department's arrival. An interview with RN #1/Supervisor, on [DATE] at 3:24 PM, revealed she failed to follow the facility's policy for Resident #74's DNR code status. RN #1 confirmed she did not ask anybody to get the chart until the Fire Department requested it, which resulted in Resident #74's DNR code status not being recognized. RN #1 stated she didn't know what happened, everything happened so quick. During an interview on [DATE] at 3:30 PM, Registered Nurse (RN) #5 revealed she provided chest compressions and Licensed Practical Nurse (LPN) #2 provided the mouth to mouth breathing on [DATE] when Resident #74 was found unresponsive and with no pulse or respirations. RN #5 stated she did not ask anybody to get the resident's chart to verify the code status because she thought RN #1/Supervisor had done that. RN #5 revealed she was called into Resident #74's room by a Certified Nursing Assistant (CNA). RN #1/Supervisor was present at this time of the interview and stated she was in the room and they relieved each other until the Fire Department got there. Failure of the facility's staff to verify Resident #74's code status prior to initiating CPR resulted in the resident's Advance Directive choice for a DNR code status not being honored. Review of the facility's Advanced Care Planning form revealed Resident #74's printed name and her daughter's printed and signed name, dated [DATE], for an elected DNR code status. Resident #74's admission Record revealed the resident's daughters were the first and second contact persons. The resident's Advanced Directive was a Do Not Resuscitate. Review of Resident #74's Physician's Orders revealed an order, dated [DATE], for a DNR code status. During an interview, on [DATE] at 3:59 PM, LPN #2, stated she did assist RN #5 with resuscitating Resident #74 on [DATE]. LPN #2 also confirmed she did not ask anybody to get the chart to review Resident #74's code status. LPN #2 also stated she thought the supervisor had checked the chart for Resident #74's code status. LPN #2 stated she has been trained several times on where the code status was located. Review of Resident #74's Care Plan, dated [DATE], revealed Resident #74's code status was Do Not Resuscitate (DNR). The goal is to honor the resident and family wishes. The interventions are to ensure comfort measures are achieved without heroics, ensure resident/family understands meaning of code status, label the chart, Medication Administration Record (MAR) and Treatment Administration Record (TAR) to inform staff of DNR code status, obtain signed consent and Medical Doctors order's for DNR. Fire Fighter #1's interview, on [DATE] at 4:44 PM, revealed he responded to the call the night Resident #74 died. Firefighter #1 revealed CPR was in process by the facility staff on arrival, and the Fire Chief reviewed the medical records and confirmed Resident #74 was a DNR code status and CPR was discontinued. The Director of Nurse's (DONs) interview, on [DATE] at 5:52 PM, confirmed RN #5/Charge Nurse found Resident #74 unresponsive, without a pulse and initiated CPR. The DON stated that CPR was stopped after the Fire Department found Resident #74 was a DNR code status on review of the resident's medical records. The DON confirmed Resident #74 was a DNR code status, and the CPR should not have been initiated. The DNR code status was located on the resident's medical record. The Medical Director's interview, on [DATE] at 11:53 AM, revealed he was informed staff found Resident #74 unresponsive and CPR was initiated. The Medical Director stated Resident #74 could have had a negative outcome of surviving with broken ribs or being placed on a ventilator. Review of the Admissions Record revealed Resident #74 was admitted by the facility, on [DATE], with the included diagnoses of Cardiomyopathy, Heart Failure, Cardiomegaly, Tachycardia, Pulmonary Disease and Chronic Atrial Fibrillation. A review of Resident #74's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. This is the facility's accepted Immediate Jeopardy Removal Plan: Summary of events: The State Agency notified [NAME] Gardens Nursing Center on [DATE]th, 2020 at 12:05 P.M. of the immediate jeopardy and substandard quality of care for Residents #74, #31, and #64. The Facility failed to honor Resident #74's advance directive for a do not resuscitate (DNR) code status, failed to honor the Resident's Rights for Advance Directive, failed to follow the care plan for a DNR code status and failed to prevent a potential negative outcome by initiating Cardiopulmonary Resuscitation (CPR). Resident #74 was found pulseless on [DATE]th, 2019 at 7:28 PM by RN #1 who initiated Cardiopulmonary Resuscitation (CPR) for a total of five minutes. CPR was discontinued when emergency services arrived and notified RN #1 of Resident#74's DNR code status. RN #1 failed to follow the policy and procedures in place to identify Resident #74's code status. The State Agency notified the facility on [DATE]th, 2020 at 3:30 PM that Resident #31's code status was documented incorrectly on the Report Sheet and Resident #64's code status was not in the Electronic Health Record, according to their wishes which could have likely caused harm for Residents #31 and #64. The facility failed to follow policy and procedure to identify the correct code status for Residents #74, #31, and #64. Facility action plan: 1. The Director of Nursing (DON) conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with Registered Nurse (RN) #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. On [DATE]th, 2019 Care Plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. On [DATE]th, 2019 at 1:30 PM the Director of Nursing in serviced all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. On [DATE]th and 30th, 2020 the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. On [DATE] the Assistant Director of Nursing (ADON) reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. On [DATE]th, 2020 at 12:05PM, the State Agency identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. Care Plan Nurse found that Resident #64's order had been discontinued by Licensed Practical Nurse (LPN) #1 and the order was reentered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. No staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The facility alleges the immediate jeopardy be removed on [DATE]. On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through record review of the sign-in sheets and interview with the Director of Nursing (DON) that the facility conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with RN #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. The SA validated through record review of the in-service sign-in sheets and interview with the Care Plan Nurse that on [DATE]th, 2019 Care plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. The SA validated through record review of the sign-in sheets and interview with the DON that the facility conducted an in-service on [DATE]th, 2019 at 1:30 PM, by the Director of Nursing, to all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. The SA validated through record review of the in-service sign-in sheets and interview with the facility owner that on [DATE]th and 30th, 2020, the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. The SA validated by interview of the ADON that on [DATE] the ADON reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. The SA validated by record review and staff interviews, on [DATE]th, 2020 at 12:05 PM, the SA identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. The Care Plan Nurse found that Resident #64's order had been discontinued by LPN #1 and the order was re-entered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by the Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The SA validated by interviews the Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The SA validated through interviews with the Facility Administrator and the DON the Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. The SA validated through interviews with the Administrator and the DON that no staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to monitor, review, and evaluate their Quality Assessment and Assurance (QAA) plan to identify and document the resident's Advance Directive choice for code status. During the initial recertification survey on [DATE] to [DATE], the State Agency (SA) identified the facility's failure to honor Resident #74's Do No Resuscitate (DNR) code status, on [DATE], when the resident was found unresponsive, and without a pulse and respirations. The facility staff initiated Cardiopulmonary Resuscitation (CPR), which continued for five (5) minutes until the Fire Department arrived and reviewed the resident's medical record which revealed the DNR code status. Resident #74 was never revived and announced deceased at the facility. The SA also identified inaccurate code status documented for Resident #31 and #64 on re-entrance on [DATE] to extend the survey to [DATE]. This concern was identified for three (3) of 78 (facility's census at time the SA re-entrance) resident code statuses reviewed. The SA identified an Immediate Jeopardy (IJ) on [DATE], due to the facility's failure to ensure accurate and consistent information regarding resident code status to use in emergency situations. The QAA review showed the QAA committee was not aware of this systemic issue, and the QAA committee was not monitoring facility practices related to accurate and consistent communication of resident's Advance Directives regarding code statuses. The facility's QAA met on [DATE] to discuss the facility's policy and procedure related to the code status for each resident. A plan of action was implemented to ensure all licensed nurses were in-serviced on honoring Resident's Rights and the right to choose a code status. The Director of Nurses (DON) provided an in-service, on [DATE], to all licensed nurses on honoring resident's rights, the right to choose a code status, and CPR policies. On, [DATE], the Assistant Director of Nurses (ADON) reviewed all resident code status records in each resident's paper chart and compared that review to all of the resident's electronic health records, for a total of 77 records. The result was 55 residents were DNRs, and 22 were full code status. On [DATE], the SA identified inaccurate code statuses for Resident's #31 and #64. The facility's failure to monitor the QAA's corrective plan to ensure the residents' Advance Directive regarding code status was accurate, placed Resident #74, #31, #64 and other residents with a DNR code status at risk for serious injury, harm, impairment or death. The facility Administrator was notified of the IJ on [DATE] at 12:05 PM. The State Agency (SA) received an acceptable Immediate Jeopardy Removal Plan on [DATE], in which the facility alleged that all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE]. The SA determined the IJ was removed on [DATE], prior to the SA's exit on [DATE]. Findings include: Review of the facility's Quality Assessment & Assurance (QAA) policy, dated 01/2019, revealed it is this facility's policy to develop, implement, and maintain an effective, comprehensive, data-driven QAA program that focuses on outcomes of care, promotes individual choice and the improvement in quality of life. The QAA Committee shall be interdisciplinary and shall consist at a minimum of: The Administrator, The Medical Director, The Director of Nursing, Infection Control Prevention Officer, two facility staff. The QAA Committee will: Conduct scheduled monthly meeting. Develop and implement appropriate plans of action to correct identified quality concerns and deficiencies. Participate in development, implementation and monitoring of the facilities written QAPI Plan. Regularly review and analyze performance data, including data collected under the QAPI (Quality Assurance and Performance Improvement) program, Infection Reports, Pharmacy, Psychological Reports, and recommendations. Identify issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program are necessary. Act on available data to make corrections or improvements. Review and evaluate all filed and completed grievances. Adverse events will be monitored in accordance with established procedures based on the type of adverse event. The data related to adverse events will be used to develop activities to prevent them. On [DATE] at 2:39 PM, an interview with the Administrator revealed the facility held monthly QAA meetings. The Administrator stated new areas of concern are identified and a plan of correction is established. The Administrator stated the plan of correction included goals for resolutions. The Administrator stated old concerns are discussed for current status and if changes are needed. The Administrator revealed the concerns are identified from complaints/grievances, nursing reports, and general reporting by families, staff, and/or residents. Resident #74 The facility failed to monitor a plan of correction established by the facility's QAA regarding the resident's Advanced Directives regarding their code status was honored and documented correctly in the medical record. As a result per review of Resident #74's Progress Notes-Nursing Notes, dated [DATE] at 9:18 PM, revealed a note at 7:28 PM documented Resident #74 was found by staff unresponsive and without a pulse or respirations. The staff initiated CPR. (Resident #74 was a Do Not Resuscitate (DNR) code status). The Emergency Medical System (EMS) was notified at 7:30 PM. The Fire Department arrived at 7:35 PM and checked the resident's chart and it was discovered at that time the resident was a DNR. The CPR was performed for five (5) minutes, until the Fire Department instructed the CPR to be stopped. Resident #74 was not revived and was pronounced deceased at 7:42 PM. The facility staff failed to check Resident #74's code status prior to initiating CPR. Review of Resident #74's Care Plan, dated [DATE], revealed the resident was a DNR code status. Review of Resident #74's Physician's Orders revealed an order, dated [DATE], for a DNR code status. Review of Resident #74's Advance Directive, dated [DATE], revealed the resident and her daughter had elected a DNR code status. An interview with Registered Nurse (RN) #1/Supervisor, on [DATE] at 3:24 PM, revealed she did not ask anyone to get Resident #74's chart to check the code status. RN #1/Supervisor confirmed the code status was not identified until the Fire Department personnel asked for the chart. RN #1 said she had been in-serviced regarding the location of the residents' code status, but everything happened so fast, and before she knew it the Fire Department was there. RN #1/Supervisor stated RN #5 and Licensed Practical Nurse (LPN) #2 initiated CPR, and when she entered the room, she instructed another Certified Nursing Assistant (CNA) to call 911. An interview with RN #5/Charge Nurse, on [DATE] at 3:30 PM, revealed she did not ask anybody to get the chart to identify Resident #74's code status. RN #5/Charge Nurse said she did not ask anybody to get the chart because she thought RN #1/Supervisor had checked the chart for the code status. RN #5 said she was called into the room by a CNA. RN #5/Charge Nurse said she provided chest compressions and LPN #2 provided mouth to mouth breathing. Licensed Practical Nurse (LPN) #2 was interviewed on [DATE] at 3:59 PM. LPN #2 revealed she did not ask anybody to get the chart because she thought RN #5/Charge Nurse checked Resident #74's chart for the code status. LPN #2 confirmed she did assist RN #5/Charge Nurse with resuscitating Resident #74. LPN #2 revealed she had been trained where the code status was located in the resident's chart. On [DATE] at 5:52 PM, an interview with the Director of Nursing (DON), confirmed, on [DATE], Resident #74 was found unresponsive and with no pulse or respirations. The DON confirmed Resident #74 was a DNR, and CPR was initiated by the facility staff until the Fire Department arrived and discovered the resident was a DNR. The DON revealed CPR was performed for five (5) minutes until the Fire Department's discovery of the DNR code status. The facility staff did not check the resident's chart to ensure the code status was identified and honored. Review of the facility's Quality Assessment and Assurance (QAA) sign in sheets dated [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] revealed the Medical Director, Administrator, Director of Nurses, Quality Assurance Nurse, Activity Director, Dietary Manager, Infection Preventionist, Social Worker, Minimum Data Set and Assistant Director of Nursing attended the QA meetings. The meeting on [DATE] had a typed note attached stating, Discussed policy and procedure related to code status. Discussed implementation and in-serving staff on policy and procedure related to code status. The [DATE] notes addressed the discussion of (citation tag number), in-services conducted on resident code status, mock code drill with no issues identified. Discussed policy and procedure related to communication of code status, with no changes made. Discussed the facility's action plan to include audits of residents' code status, and all findings will be reported to QAPI. Review of the facility's In-Service Attendance Record, dated [DATE], revealed the staff was trained on honoring Resident/family right to choose CPR and code status. Further review of the facility's In-Service Attendance Records revealed the facility provided a training titled, Initiating CPR/Code Status to the licensed nurses, on [DATE]. An interview, on [DATE] at 11:53 AM, revealed the Administrator confirmed the QAA committee failed to monitor their corrective actions to make sure all the resident's code status was correct. The Administrator also stated the system failed because their checks and balances did not work. The Administrator confirmed the system the QAA interdisciplinary team put in place was not successful. The Administrator stated the facility had a QAA meeting, on [DATE], and discussed Resident #74's DNR code status. The Administrator stated the QAA committee considered this as a high risk situation and should be taken care of immediately. The Administrator stated the only thing the disciplinary team implemented during the meeting was to in-service the supervisors on where to locate the resident's code status and to perform a mock code. The Administrator stated the Quality Assurance (QA)/Infection Nurse schedules the QAA meetings monthly and as needed. The Administrator also stated the RN supervisors were in-serviced immediately on all shifts on how to locate the resident's code status in the chart, computer and Kiosk. The Administrator reported the RNs involved in the incident with Resident #74 did not receive any disciplinary actions from the facility. The Administrator stated the Assistant Director of Nursing (ADON) was responsible for checking the Physician's Orders, Quick Reference Sheet and the Medication Administration Records (MARS) to make sure the code statuses matched. The ADON was also responsible for monitoring all resident's code status. The Administrator said LPN #5 was the acting QA/Infection Control Nurse, and was responsible for checking behind the ADON to make sure the resident's code status was updated. Review of the facility's In-Service Attendance Record, dated [DATE], revealed the signatures of RN #1 and #5, regarding Code Status Simulation. On [DATE] at 12:22 PM, an interview with the ADON revealed Resident #74's DNR status was not honored due to the nurses did not check her code status which was on the chart, the physician's orders, and the Medication Administration Record (MAR). Review of the admission Record revealed Resident #74 was admitted by the facility, on [DATE], with the included diagnoses of Cardiomyopathy, Cardiomegaly, Tachycardia, Pulmonary Disease, Heart Failure, and Chronic Atrial Fibrillation. A review of Resident #74's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Resident #31 Review of Resident #31 Quick Reference Sheet revealed Resident #31 was a Full Code. Review of the chart and current Electronic Physician's Orders revealed Resident #31 had elected to have a DNR code status. On [DATE] at 12:16 PM, an interview with LPN #5/Interim QA Nurse, revealed she did not know what happened with Resident #31's DNR code status not being on the Quick Reference Sheet. LPN #5 confirmed Resident #31 was a DNR, and should have been identified as such. LPN #5 stated she had only checked the new admissions since the last survey because all of the other charts had been checked. Resident #64 Review of Resident #64's Quick Reference Guide report sheet, revealed Resident #64 was listed as a DNR code status. Review of the current Physician's Orders revealed there was no code status order for a DNR. Further review revealed there was no code status on the Medication Administration Record (MAR). This is an additional check for code status for the facility. The MAR did not indicate a DNR because the nurse deleted it on the Physician's Orders which could have resulted in CPR being initiated instead of a DNR. An interview, on [DATE] at 11:53 AM, revealed the Administrator confirmed Resident #64's DNR code status was deleted from the electronic record by mistake. The Administrator stated LPN #1 deleted the DNR order instead of a medication. The Administrator confirmed this was not found until the SA discovered it and reported the finding to them on [DATE]. The Administrator reported the facility ran a report of discontinued orders and found that LPN #1 discontinued the DNR order for Resident #64 on [DATE]. A medication order should have been discontinued instead of Resident #64's code status. An interview, on [DATE] at 11:45 AM, with LPN #1, revealed she clicked on the wrong thing in the computer. LPN #1 confirmed she clicked on DNR instead of a medication she was trying to delete. LPN #1 did not realize the mistake until LPN #4 revealed it to her. On [DATE] at 12:16 PM, an interview with Licensed Practical Nurse (LPN) #5 revealed she didn't know what happened with Resident #64's code status being incorrect. LPN #5 stated she missed it. Resident #64's DNR code status was deleted on the Electronic Record. During an interview, on [DATE] at 4:20 PM, LPN #6 revealed the nurses were trained to find the resident's code status on their Quick Reference Sheet, on the MARs, the bright red sheet at the nurse's station and crash cart. LPN #6 also said the ADON updates them monthly and with new admits or changes in the resident's code status. During an interview with LPN #7, on [DATE] at 4:45 PM, she revealed the nurses are trained to find the resident's code status on top of the MARs, Quick Reference Sheet, the red sheet at the nurses' station and crash cart. LPN #7 also said she thought the ADON updated them. LPN #7 stated the nurses write changes on their report sheet and turn it in at the end of the shift. An interview, on [DATE] at 12:22 PM, revealed the ADON said she was responsible for checking the resident's code status and making sure there's a written order in the Electronic Record and on the MAR. The ADON also confirmed the facility was not aware of the nurse deleting the resident's Code status until the SA discovered it. The ADON also stated if Resident #31 and Resident #64 conditions would have changed, both residents potentially could have had Cardiopulmonary Resuscitation (CPR) done, which could possibly cause pain from broken ribs and or resident being placed on a ventilator. This is the facility's accepted Immediate Jeopardy Removal Plan: Summary of events: The State Agency notified [NAME] Gardens Nursing Center on [DATE]th, 2020 at 12:05 P.M. of the immediate jeopardy and substandard quality of care for Residents #74, #31, and #64. The Facility failed to honor Resident #74's advance directive for a do not resuscitate (DNR) code status, failed to honor the Resident's Rights for Advance Directive, failed to follow the care plan for a DNR code status and failed to prevent a potential negative outcome by initiating Cardiopulmonary Resuscitation (CPR). Resident #74 was found pulseless on [DATE]th, 2019 at 7:28 PM by RN #1 who initiated Cardiopulmonary Resuscitation (CPR) for a total of five minutes. CPR was discontinued when emergency services arrived and notified RN #1 of Resident#74's DNR code status. RN #1 failed to follow the policy and procedures in place to identify Resident #74's code status. The State Agency notified the facility on [DATE]th, 2020 at 3:30 PM that Resident #31's code status was documented incorrectly on the Report Sheet and Resident #64's code status was not in the Electronic Health Record, according to their wishes which could have likely caused harm for Residents #31 and #64. The facility failed to follow policy and procedure to identify the correct code status for Residents #74, #31, and #64. Facility action plan: 1. The Director of Nursing (DON) conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with Registered Nurse (RN) #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. On [DATE]th, 2019 Care Plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. On [DATE]th, 2019 at 1:30 PM the Director of Nursing in serviced all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. On [DATE]th and 30th, 2020 the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. On [DATE] the Assistant Director of Nursing (ADON) reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. On [DATE]th, 2020 at 12:05PM, the State Agency identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. Care Plan Nurse found that Resident #64's order had been discontinued by Licensed Practical Nurse (LPN) #1 and the order was reentered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. No staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The facility alleges the immediate jeopardy was removed on [DATE]. On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through record review of the sign-in sheets and interview with the Director of Nursing (DON) that the facility conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with RN #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. The SA validated through record review of the in-service sign-in sheets and interview with the Care Plan Nurse that on [DATE]th, 2019 Care plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. The SA validated through record review of the sign-in sheets and interview with the DON that the facility conducted an in-service on [DATE]th, 2019 at 1:30 PM, by the Director of Nursing, to all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. The SA validated through record review of the in-service sign-in sheets and interview with the facility owner that on [DATE]th and 30th, 2020, the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. The SA validated by interview of the ADON that on [DATE] the ADON reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. The SA validated by record review and staff interviews, on [DATE]th, 2020 at 12:05 PM, the SA identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. The Care Plan Nurse found that Resident #64's order had been discontinued by LPN #1 and the order was re-entered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by the Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The SA validated by interviews the Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The SA validated through interviews with the Facility Administrator and the DON the Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. The SA validated through interviews with the Administrator and the DON that no staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.