**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide basic life support, including Cardiopulmonary Resuscitation (CPR, a lifesaving technique that is used in emergencies in which someone's breathing or heartbeat has stopped) in a timely manner for one of seven sampled residents who was a full code (all life saving measures to be performed) and found by staff without a pulse (Resident #1). Additionally, not all direct care staff were aware of the location of the code status documentation in residents' records (Residents #2 and #3). Also, the facility policy did not address the location of the code status documentation and how the information would be communicated throughout the facility so that staff would know immediately what action to take or not take when an emergency arises. The census was 114. The Administrator was notified on [DATE] at 3:00 P.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's Cardiopulmonary Resuscitation policy, dated [DATE], showed: -Policy: The facility will provide basic life support prior to the arrival of Emergency Medical Services (EMS), including initiation of CPR to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with the resident Advance Directives or a signed Do Not Resuscitate (DNR) order; -Charge nurse will initiate CPR unless: -Valid DNR is in place; -Clinical evaluation reveals obvious signs of clinical death (rigor mortis (stiffness of the muscles and joints of the body after the death of an individual), dependent lividity (bluish-purple discoloration of skin after death), decapitation (total separation of the head from the body), transection (to cut across something; to divide something by cutting it) or decomposition (the state or process of rotting or decay); -Initiating CPR could cause serious injury/immediate danger to the rescuer; -Responsibility: Licensed nurses, nursing administration and Director of Nursing (DON); -Procedure: -Full Code/CPR Upon resident assessment with absent vital signs; *Charge nurse will initiate a code blue; *Resident who is full code will have CPR initiated immediately; *CPR will continue until EMS arrives to take over CPR. -The policy did not address the location of the code status in the resident's medical record. 1. Review of Resident #1's medical record,showed: -admission date of [DATE]; -Full code; -Diagnoses included: Heart failure, Alzheimer's Disease, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), bradycardia (slow heart rate) and presence of a cardiac pacemaker (small electronic device, implanted in the chest to help regulate heart function). Review of the resident's electronic Physician's Order Sheet (ePOS), showed an order dated [DATE], for a full code. Review of the resident's care plan dated [DATE], showed: -Focus: Responsible party requests full code. Full code - initiate CPR; -Interventions/Tasks: Call for an ambulance. In event of cardiac arrest, do initiate cardiopulmonary resuscitation measures. Provide emergency measures as appropriate. Review code status routinely. Review of the resident's progress notes on [DATE], showed: -On [DATE] at 11:30 P.M., Licensed Practical Nurse (LPN) S saw the resident at approximately 11:30 P.M., lying on his/her back while in bed; -On [DATE] at 1:37 A.M., Certified Nurse's Aide (CNA) H called LPN D to the resident's room. LPN D observed the resident in bed unresponsive. CPR was immediately started and 911 was called. CPR was unsuccessful. Unknown staff called the resident's physician and he gave a death diagnosis of heart failure and coronary artery disease (CAD, a narrowing or blockage of the coronary arteries, which supply oxygen-rich blood to the heart). Review of a typed investigation report dated [DATE], showed: -On [DATE] between 12:15 A.M. and 12:30 A.M., during rounds, CNA H found the resident in a kneeling position on the mat beside his/her bed and called out for assistance; -LPN D and CNA J entered the room. The nurse assessed the resident and found his/her skin cool to the touch and no pulse present; -Code status was verified, a board was placed under the resident and CPR was initiated; -CNA R dispatched EMS requesting emergent transport; -EMS arrived and applied leads. Staff continued CPR until directive was given to discontinue at or around 12:30 A.M. Review of a written statement by CNA H dated [DATE], showed: -While doing rounds at 12:15 A.M., he/she noticed a patient on the floor in a praying position. His/Her face was face down on the mattress; -The CNA yelled for help to get the resident off the floor and LPN D and CNA J came in the room to help assist the resident off the floor; -LPN D along with LPN I started CPR. During an interview on [DATE] at 6:00 A.M., CNA H said he/she started work at 11:00 P.M., on [DATE]. The first time he/she saw the resident was at 12:15 A.M. on [DATE]. He/She had to pull the curtain back to see the resident. He/She observed the resident on the floor, beside his/her bed, on his/her knees in a praying position. His/Her hands were beside him/her, on the fall mat with his/her face pressed into the bed. The CNA immediately went to the door and yelled for help. LPN D and CNA J came into the room. The nurse told them to get the resident off the floor and into the bed, so he/she and the other CNA picked the resident up and placed him/her onto the bed. The resident did not look good, but he/she was warm to the touch. CNA H knew the resident was a full code, so he/she immediately ran to the nurse's station, to get the crash cart so they could perform CPR. When he/she got back to the room with the crash cart, LPN D told him/her to take it back because the resident was a DNR. The CNA explained he/she was sure the resident was a full code, but the nurse continued to say the resident was on hospice and was a DNR. The CNA pushed the crash cart out into the hall and ran to check the chart to verify the resident was a full code. He/She found the full code in the paper chart, but the nurse wanted to check it in the electronic record. It took them a little while to figure out the resident was actually a full code. Once they realized the resident was a full code, then staff called 911 and started CPR. Review of an undated written statement by CNA J, showed: -He/She was at the nurse's station around 12:15 A.M.-12:30 A.M., when CNA H came out of the resident's room and said he/she was on the floor; -LPN D and he/she entered the room and found the resident on the floor; -The nurse checked the resident's pulse and there was no pulse; -CPR was started. During an interview on [DATE] at 6:25 A.M., CNA J said CNA H was doing rounds and came and got him/her and LPN D when he/she found the resident on the floor. LPN D told him/her and CNA H to get the resident off the floor and into the bed. They were frantically trying to understand what would be the best course of action, as he/she did not know if the resident needed a lift to get into bed. He/She and CNA H decided to lift the resident under his/her arms and legs and put him/her into the bed. The resident was warm to the touch when he/she lifted him/her up into the bed. CNA H ran to get the crash cart. CNA J left the room after this. Review of a written statement by LPN D dated [DATE], showed: -At 12:15 A.M., he/she was called to the resident's room; -When he/she got to the room, he/she observed the resident on his/her knees, on his/her fall mat, in a praying position with his/her head on his/her bed; -LPN D called out the resident's name with no response; -CNA J and CNA H assisted the resident back into his/her bed so the nurse could assess him/her; -The resident's color was in normal limits, his/her skin was cool to the touch and he/she had no pulse; -Code status was verified, they placed a backboard under the resident and CPR was initially started; -LPN I arrived to assist with CPR; -CNA R called 911 and EMS arrived at approximately 12:33 P.M.; -LPN D and LPN I continued CPR until directive given to discontinue. During an interview on [DATE] at 6:15 A.M., LPN D said he/she heard CNA H call out and he/she and CNA J went into the resident's room. The resident was on his/her knees on the floor with his/her face in the bed. He/She looked dead. The resident's chest was not rising. LPN D felt for a pulse and could not find one. The two aides got the resident up into the bed so he/she could assess the resident better. The nurse believed the resident was on hospice and was a DNR. CNA H thought he/she was a full code and went to look in the resident's chart to verify. Usually the code could be found right in a resident's paper chart. It was confusing to find the code, and everything happened really fast. LPN D found it on the computer. Once they realized the resident was a full code, they called 911 and immediately started CPR. During interviews on [DATE] at 6:40 A.M. and on [DATE] at 5:51 P.M., LPN I said he/she was working on the other hall during the morning of the incident. CNA R came and got him/her and said a resident was nonresponsive and needed CPR. When he/she got to the resident's room, LPN D and CNA H were standing by the bed, there was a board under the resident and an oxygen mask on his/her face, but they had not started compressions. LPN D asked if they needed to do CPR since the resident had no pulse and looked deceased . LPN I said since the resident was warm to the touch and a full code they had to perform CPR. They started CPR. LPN D and CNA H continued CPR until the EMS arrived and told them to stop. Review of the EMS records, showed the facility called 911 at 12:26 A.M. During an interview on [DATE] at 11:50 A.M., the resident's physician said staff should have been able to verify code status immediately because the chances for survival increase if CPR is started within five minutes of a cardiac event. The longer the resident goes without CPR decreases the likelihood of survival. 2. Review of Resident #3's medical record, showed: -admitted on [DATE]; -Full code. During an observation and interview on [DATE] at 11:00 A.M., Registered Nurse (RN) E said code status should be found in the resident's electronic medical record and paper chart. He/She was unable to locate the code status for Resident #3 in either place. He/She thought it might be because the resident had just been admitted over the weekend. An unidentified staff member came over and showed RN E where the code status could be found in the resident's electronic medical record in the physician's orders. 3. During an interview on [DATE] at 9:00 A.M., CNA K said if a resident was found unresponsive, code status could be found in a resident's paper chart. He/She was unable to locate a code status in Resident #2's paper chart. He/She said the nurses would know where to find the code status in an emergency. During an interview on [DATE] at 10:55 A.M., CNA N said if he/she found a resident unresponsive, he/she would let the nurse know. The nurse would have to check the code status because he/she did not have access to the resident's electronic medical records. If the nurse was not at the desk, it might take a little time to find the code status. During an interview on [DATE] at 3:00 P.M., the Director of Nursing said she would expect the staff to immediately verify the resident's code status and start CPR. Code status could be found in the resident's electronic medical records. Nurses and Certified Medication Technicians were the only staff who could access to the electronic medical records. The staff should know where to locate the code status. She was not told there was a delay in starting CPR on Resident #1 while staff tried to find his/her code status. She would have expected the nurse to have immediately verified the code status and started CPR. During an interview on at [DATE] at 3:05 P.M., the Administrator said she would expect staff to immediately verify the resident's code status and start CPR if the resident is a full code. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00231034

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain equipment in safe operating condition. On 11/18/22 at approximately 11:00 A.M., two staff noticed they could not turn down the packaged terminal air conditioner (PTAC) unit in a resident room (Resident #3 and Resident #10). The staff did not report the problem to maintenance staff. On 11/19/22 at approximately 12:30 A.M., a fire occurred in the residents' room. Review of the facility's investigation summary showed they determined the cause of the fire was the PTAC unit. Review of the fire marshal investigation showed the final hypothesis on the origin of the fire was the lower right side of the PTAC unit in the residents' room. Resident #3 sustained burns and smoke inhalation, which required intubation and admission to the intensive care unit. Seven residents were sent to the emergency room as a result of the fire. Of those seven, one had burns (Resident #3) and three had clinical indication of smoke inhalation (Residents #3, #1, #6). The census was 90. The administrator was notified on 12/16/22 at 12:41 P.M. of an Immediate Jeopardy (IJ) which began on 11/19/22. The IJ was removed on 12/16/22, as confirmed by surveyor onsite verification. 1. Review of the facility's building maintenance software (TELS), showed clean air filters, inspect condenser coils and clean as required for PTAC units documented as done on the following dates: 11/30/21, 2/28/22, 5/31/22, and 8/31/22. During an interview on 12/7/22 at 12:53 A.M., certified nurse's aide (CNA) R said he/she worked on the day shift 11/18/22 (prior to the fire). The heater (PTAC unit) was on in room [ROOM NUMBER] (Room where Resident #3 and Resident #10 resided). The room continued to become hotter. CNA R and the nurse were both in the room. The nurse turned off the heater, but it kept turning back on. The PTAC unit kept winding back up to heat. The nurse said he/she would report the problem to the maintenance director. The nurse did not ask CNA R to report it to maintenance. CNA R does not know if the unit was fixed that day. This was the first day CNA R noticed the problem with the heater in room [ROOM NUMBER]. During an interview on 12/2/22 at 4:35 P.M., Nurse S said he/she worked the day shift (11/18/22) prior to the fire. He/she is an agency employee. On the morning before the fire (11/18/22) between 11:00 A.M.-noon, staff could not get the PTAC unit in room [ROOM NUMBER] to turn down/off. Nurse S told the CNA to go tell the maintenance director about the problem. Nurse S saw the CNA head in the direction of the maintenance director, so he/she assumed it was done. Nurse S does not know if anyone in maintenance returned to work on the PTAC unit or not. During interviews on 12/2/22 at 11:50 A.M. and on 12/8/22 at 1:00 P.M., the maintenance director said maintenance staff conduct routine maintenance on the PTAC units on a quarterly basis, check the filters, look at the wiring and check for leaks. No one reported any problems to him about the PTAC unit in room [ROOM NUMBER]. He was not aware of any concerns. If the PTAC unit was not powering down, it could have been a thermostat issue. If he had been aware there was a problem with the PTAC unit, he would have had someone in maintenance check on it immediately. During an interview on 12/14/22 at 12:20 P.M., the administrator said he makes rounds in resident rooms daily, as does the maintenance director. They are in and out of the rooms all of the time, and they were not aware of any prior problems with the PTAC unit in room [ROOM NUMBER]. The PTAC units have generally been functioning well, and they do have extra units if one has a problem. The fire safety training they completed after the fire did not include education about reporting maintenance issues. Review of the facility's investigation summary, dated 11/23/22, included: -On 11/19/22 at approximately 12:30 A.M., the fire alarm sounded; -The fire was located in room [ROOM NUMBER], flames noted on the PTAC unit and bed near window; -Upon completion of the investigation the facility determined the PTAC unit was the cause of the fire in room [ROOM NUMBER]. During an interview on 11/19/22 at 12:35 P.M., Registered Nurse (RN) G said the residents who initially went to the hospital at the time of the fire were Residents #1, #2, #3, #4, #5, and #6. Resident #3 is in the intensive care unit (ICU). This was the resident who resided in the bed near the window in the room of the fire. During an interview on 11/21/22 at 8:30 A.M., the Director of Nursing (DON) said another resident (Resident #7) not initially reported, went to the hospital later in the day on 11/19/22, because he/she said he/she had smoke inhalation. Review of the fire marshal investigation report, dated 11/19/22, showed: -Upon arrival, fire suppression activities were completed and crews were in the process of removing residents from affected areas of the building; -No major fire damage to the structure, just contents in room [ROOM NUMBER], smoke deposits noted throughout portions of the building; -The exterior showed smoke and heat venting from the room of origin (room [ROOM NUMBER]) with the window completely gone; -Fire patterns indicated this fire originated and was contained in room [ROOM NUMBER] on the south wall. This is the location of the PTAC unit and its electrical connection to the building electrical system; -The final hypothesis of the cause of the fire is the right lower side of the PTAC unit located on the south wall of room [ROOM NUMBER]. The first material ignited was the wood board supporting the PTAC unit. 2. Observation of room [ROOM NUMBER] on 11/19/22 at 12:55 P.M., showed black soot coated the ceiling, walls and furniture. The window was knocked out and a board covered the hole in the wall. Burns were visible around the hole. A hole below the window where the PTAC unit formerly sat was open to the outside. The PTAC unit lay in pieces and scorched on the floor of the room. Two beds were in the room. Both beds were coated with dark soot. Observation in the hallway outside of the room, showed dark soot on the ceilings, walls and doors on the hall and at the nurse's station. 3. Review of Resident #3's hospital record, showed: -Arrived 11/19/22 at 1:21 A.M.: -Unknown resident presented with burns and inhalation injury after fire in nursing home. Per emergency medical services (EMS) the patient was in the room the fire started in and was pulled out of the fire through the window. They think they fire may have started from his/her furnace. Patient presented with soot around his/her mouth and to the face, superficial burns to face, partial thickness burns to right arm and left knee with approximately 1% total body surface area. He/she was given Cyanokit (can be used to treat multiple sources of cyanide poisoning, including smoke inhalation and ingestion) by EMS in-route. He/she arrived to the emergency room (ER) on a non-rebreather (a device used in medicine to assist in the delivery of oxygen therapy. Allows for delivery for higher concentration of oxygen) and unresponsive and per EMS they were unable to intubate due to the resident's jaw being clenched. Heart rate was in the 40's (normal 60 through 100) and oxygen saturation (percent of oxygen in the blood) in the 60s (normal 95% through 100%), so the patient was emergently intubated. Patient became hypotensive (low blood pressure) with systolic blood pressure (SBP, top number, normal is 90 through 120) in the 30s and was given a total of 3 liters of crystalloid (water-soluble electrolytes including sodium and chloride) which stabilized his/her pressure. He/she was briefly on levophed (used to treat low blood pressure and heart failure) but was then able to be stopped. He/she was also given 1 ampule of bicarb (used to lower acidosis, high acidity level in the blood); -Patient unable to provide history, but nursing staff from the nursing home later called and provided the resident's name; -Primary survey: Airway absence of airway protection, airway not patent, frothy sputum present, soot in airway; -Partial thickness burn to right inner elbow; -Partial thickness burn to left knee -Head/face: Soot to head. Superficial burns to face; -Oral cavity: Oropharynx (the part of the throat behind the mouth) with soot. Superficial burns to lips; -admitted to the medical surgical intensive care unit (ICU) form the ER; -Physical examination on 11/19/22 at 11:30 A.M., blood pressure high at 194/74 (normal 90/60 through 120/80), temperature low at 96.1 degrees Fahrenheit (F, normal 97.8 through 99.1). Sedated on vent. Some redness to face/burns; -A chest x-ray obtained on 11/19/22, showed central consolidation in glass density with interior lobular septal thickening. Findings are likely related to pulmonary edema (swelling). Bilateral (both sides) dependent consolidation may represent a combination of atelectasis (complete or partial collapse of the entire lung or area (lobe) of the lung) and/or aspiration. Review of the resident's progress notes, showed: -On 11/21/22 at 1:54 A.M., called hospital for an update on the resident's condition. Spoke to the nurse who said the resident is still intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their airway. The tube keeps the airway open so that air can get through. The tube can connect to a machine that delivers air or oxygen) and sedated. Burns noted to his/her right forearm and blisters to the left knee. During an interview on 12/1/22 at 9:25 A.M., the resident's family member said the resident is now out of the ICU, but remains in critical condition. It was not so much the burns that is causing the problems, but the smoke inhalation. Due to the burns, smoke inhalation and long term ventilator use, the resident's kidneys are failing. Review of the resident's Certificate of Death, showed: -Actual or presumed date of death : December 11, 2022; -Immediate cause of death: End stage renal (kidney) disease. 4. Review of Resident #1's progress notes, showed on 11/19/22 at 1:20 A.M., charge nurse noted to send resident to hospital via EMS related to smoke inhalation. Resident was exposed to smoke inhalation. Resident sent out for prophylactic (prevention). Family and physician aware. Resident at the hospital under observation. Review of the resident's hospital records, dated 11/19/22, showed: -The resident originally admitted as an unknown patient until later identified as Resident #1; -Resident here for smoke exposure. Per EMS, patient from a nurse home that caught fire. Patient was in the room next to the one that caught fire. Patient exposed to black smoke. -In the emergency department, patient was yelling and agitated. He/she was found to have elevated carboxyhemoglobin (a stable complex of carbon monoxide that form in red blood cells when carbon monoxide is inhaled. Elevated levels can indicate carbon dioxide poisoning. Can be caused by smoke inhalation) and placed on a nonrebreather (mask that delivers high levels of oxygen and prevents the rebreathing of exhaled carbon dioxide). Patient is admitted for further management. 5. Review of Resident #6's progress notes, showed: -On 11/19/22 at 3:11 A.M., confirmed the resident is at the hospital, is stable and will be returning; -On 11/19/22 at 2:16 P.M., patient sent to the emergency room for further evaluation. Patient crying noted hand was burned, nose and lip was burned. Review of the resident's hospital records, dated 11/19/22 at 9:42 A.M., showed: -Chief complaint: Smoke inhalation: From a nursing home fire eight hours prior. Staff noticed soot around his/her nose. Wanted him/her to be checked out. Patient was across the hall from the fire; -Clinical impression: Smoke inhalation; -Carboxyhemoglobin 4.7 (normal is typically lower than 2, can but up to 5 in individuals who smoke), will plan discharge. Nursing home states understanding the patient should return for any other concerns about his/her health. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the G level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one resident (Resident #3) when staff failed to evacuate a bed ridden resident from a room that was on fire. On [DATE] at approximately 12:30 A.M., a fire occurred in the resident's room. Staff responded to the room, but were unable to remove the resident from the room. Staff interviewed said the bed did not fit through the doorway and there was insufficient number of staff who responded to the room with the fire to remove the resident from the bed. In addition, staff in the facility failed to follow their fire plan by not responding appropriately to the fire alarm. One staff finished providing care before responding to the fire and at that time, the smoke was too thick to enter the affected area. Another staff left the facility upon identifying there was a fire and did not assist with evacuation. Because Resident #3 remained in the room, staff did not close the door, so the containment of the smoke from the room of fire origin was delayed. This delay placed all other residents in danger. The resident was not evacuated until first responders evacuated him/her through the first-story window. The resident sustained burns and smoke inhalation, which required intubation and admission to the intensive care unit. The resident expired 22 days later. Seven residents were sent to the emergency room as a result of the fire. Of those seven, one had burns (Resident #3) and three had clinical indication of smoke inhalation (Residents #3, #1, #6). The census was 90. The administrator was notified on [DATE] at 4:35 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. 1. Review of the facility's Fire Plan Initial Actions, undated, included: -If fire is suspected to be within closed spaces, check the door to the room suspected of being involved in the fire: -If heat is detected, sound the alarm and clear the immediate area around the affected room; -Only if victims are suspected to be in affected rooms, rescue anyone in immediate danger while protecting the safety of the rescuing staff member(s). Follow the facility's procedure for [NAME] (Alert, Rescue, Alarm, Contain/Confine, Extinguish/Evacuate); -Alert residents and staff members by announcing Code Red and the location three times loud and clear on the overhead paging system. Pull the nearest fire alarm; -Call 911 immediately; -Contain the fire if possible without undue risk to personal safety; -In a large-scale fire, the local fire department may order evacuation of the facility. In which case, evacuate residents from the building as quickly and as safely as time permits; -If time permits, a good rule of thumb is to evacuate ambulatory residents first; -Facility should evacuate the triangle of rooms (examples provided). It should always be the room next to and across the hall for the triangular zone; -Residents and staff should be moved out according to each smoke zone (examples provided); -No mention of how to evacuate bed-ridden residents or residents who have beds which do not fit through the doorframes; -Emergency contact information for administrator, director of nursing and maintenance director not consistent through the emergency plan. 2. Review of Fire Department O's run report, dated [DATE], showed: -Department was dispatched to a fire at the facility; -Call received at 12:34 A.M.; -On scene at 12:39 A.M.; -Upon arrival, nursing home staff was waving us through the front door stating the fire was through the doors and pointed in several different directions. They informed us the fire was in a resident's room and that room had two residents. No fire was seen, but heavy smoke conditions were met upon entry to the facility. Nursing home staff pointed towards the [NAME] side. (Generally speaking, [NAME] is the back of the structure of the building so that is where the search began.) Fire department O was married with Fire Department P who informed us they were at the fire room and beginning to extinguish. Fire Department O told Fire Department P they would split off and cover the other wings, either beginning evacuation or deeming if it was acceptable for the residents to shelter in place. Residents being evacuated from their rooms were sent to the day room on the [NAME] side where Lieutenant Q made transportation decision. Once all residents were accounted for and deemed to be in a safe space Fire Department O was instructed to retrieve the fans off a the fire truck and bring one to the [NAME] and Alpha side to begin ventilation. Review of the fire marshal investigation report, dated [DATE], showed: -Upon arrival, fire suppression activities were completed and crews were in the process of removing residents from affected areas of the building; -No major fire damage to the structure, just contents in room [ROOM NUMBER], smoke deposits noted throughout portions of the building; -The exterior showed smoke and heat venting from the room of origin (room [ROOM NUMBER]) with the window completely gone; -Fire patterns indicated this fire originated and was contained in room [ROOM NUMBER] on the south wall. This is the location of the Packaged Terminal Air Conditioner (PTAC) unit and its electrical connection to the building electrical system; -The final hypothesis of the cause of the fire is the right lower side of the PTAC unit located on the south wall of room [ROOM NUMBER]. The first material ignited was the wood board supporting the PTAC unit. During an interview on [DATE] at 10:00 A.M., the local fire marshal said they received a call at approximately 1:00 A.M. on [DATE] of a fire in the building. Upon arrival, facility staff waved the emergency services toward the new area of the building. The fire was extinguished from the exterior. The crew could not immediately evacuate one resident out of the room because his/her bed would not fit through the doorframe. They wanted to evacuate all residents on the 200 hall to other areas of the building due to the amount of smoke. The fire marshal's main concern was the size of the bed in the room of the fire's origin. If staff were able to remove the resident in the bed more quickly, they could have immediately closed the room door and contained the fire and smoke. 3. Review of the facility's investigation summary, dated [DATE], included: -On [DATE] at approximately 12:30 A.M., the fire alarm sounded; -The fire was located in room [ROOM NUMBER], flames noted on the PTAC unit and bed near window; -Upon completion of the investigation the facility determined the PTAC unit was the cause of the fire in room [ROOM NUMBER]. During an interview on [DATE] at 12:35 P.M., Registered Nurse (RN) G said the residents who initially went to the hospital at the time of the fire were Resident's #1, #2, #3, #4, #5, and #6. Resident #3 is in the intensive care unit (ICU). This was the resident who resided in the bed near the window in the room of the fire and the resident who was not evacuated from the room. Observation of the affected areas of facility, on [DATE] at 12:55 P.M., with the administrator and maintenance director, showed when walking from the front lobby into the nursing station area, there are 4 halls in a wagon wheel formation. Soot and debris was visible on the ceiling and on the floor in the nurse's station areas. Approximately 8 feet down each hall is a fire door. Some soot was visible on the ceiling that lead to the fire doors on each hall. No soot noted past the fire doors. The affected hall was to the immediate right when entering the unit. The ceiling, walls and equipment on this hall observed to have a layer of debris and soot. The room [ROOM NUMBER] was taped off with caution tape. When opening the room door, the ceilings and walls were covered with black debris and soot. The window unit lay on the floor, charred, and broken into pieces. The window had a board over it and the hole in the wall where the PTAC unit had been was open to the outside. The administrator said they are allowing that to air out for a while. The bed that would have been by the window was pulled to the middle of the room. The room, hall, and nurse's station smelled very smoky. Mid-way down the 200 hall was a fire door. There was no visible soot past the fire door. The administrator said the dampers all shut and fire doors all shut. The sprinklers only in the affected area went off. Staff immediately removed the residents from that room and called 911. During an interview on [DATE] at 1:00 P.M., the maintenance director said he just started at the facility in September. The PTAC unit is what caused the fire. He was aware of no issues with this unit before the fire. He got a call from the alarm company when the fire alarm went off. It was about 12:40 A.M., that he got the call. When they called they said the fire alarm was going off and staff were evacuating. By the time he arrived to the facility, the fire department was already at the facility and had blocked off the street. There is no routine maintenance required for the PTAC units. They are not made to be worked on, if they stop working, a new one is installed. During an interview on [DATE] at 3:38 P.M., the Director of Nursing (DON) said when emergency medical services (EMS) was taking residents out during the fire, they were just taking them and bringing them to local hospitals in the area. The facility did not even know who all was taken until they were allowed back in the building to do a head count. A total of seven residents went to the hospital as a result of the fire. 4. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated [DATE], showed: -Resident is rarely/never understood; -Extensive assistance of two persons required for bed mobility and transfer; -Total dependence of one staff required for locomotion on and off the unit; -Surface to surface transfer: Not steady, only able to stabilize with human assistance; -Used a wheelchair; -Primary medical condition category: Other neurological conditions; -Diagnoses included: High blood pressure, diabetes, stroke, aphasia (loss of ability to understand or express speech), and hemiplegia or hemiparesis (one sided weakness or paralysis); -Weight: 177 pounds; -Had a feeding tube. Review of the resident's care plan, showed: -Focus: Activity of daily living (ADL) function: Requires assistance with ADL care needs, mobility. Here for a long-term stay and is at risk for functional decline: -Goal: Have needs met daily; -Interventions included: Staff of one or two for safe positioning in bed and wheelchair. Use a Hoyer lift (mechanical lift) for transfers. Staff of one or two to assist with ADL needs; -Focus: Limited physical mobility related to stroke: -Goals: Demonstrate the appropriate use of adaptive devise(s) to increase mobility. Remain free of complications related to mobility, including contractures (loss of range of motion caused by muscle and tendon rigidity), skin breakdown, and fall related injury; -Interventions included: Total dependence on staff for locomotion with the use of the wheelchair. Provide supportive care, assistance with mobility as needed. Review of Fire Department O's run report, dated [DATE], showed the following for the resident: -Primary impression Burn; -Secondary complaint: Smoke inhalation; -Injury: Burns- burn of unspecified degree, nursing home [DATE]; -Mechanism of injury: Burn; -Medical/trauma: Trauma; -Barriers of care: Physical barrier (unable to access patient); -At 12:51 A.M.: -Mental status: Patients eyes are open and follows verbal commands with his/her eyes. No verbal response; -Skin: Patient's skin is wet and cold form fire suppression efforts; -Head, eyes, ears, nose, and throat (HEENT): Black soot note around nose and mouth. No swelling to areas noted. Jaw is noted to be clinched shut; -Chest: Course lung sounds noted upon initial assessment. Does not appear to have labored breathing. Lunch sounds rhonchi (rattling or whistling respiratory sound resembling snoring, caused by secretions in the airway) to all lobes; -Extremities: Two separate third degree burns (extended into the fat layer that lies beneath the skin) noted to right arm. First wound is on lateral (to the side) forearm, approximately 3 inches long and 1 inch wide. Second is on lateral upper arm, approximate 2 inches in diameter. Patient does not move his/her extremities or follow commands with extremities. Unknown patient's normal baseline condition; -At 1:16 A.M.: -Mental Status: Patients eye responses are beginning to become sluggish and patient is more difficult to arouse; -Chest: Pink frothy sputum noted coming from mouth just prior to arrival at receiving facility. Oxygen saturation beginning to drop along with heart rate; -Chief complaints of this patient is burns and smoke inhalation. First alarm units are on scene performing fire attack operations and search and rescue. This patient was found in a fire room and was extracted through a window. This patient was placed on a stretcher and brought to transport upon arrival on scene. Patient was extracted through window of facility and secured to stretcher in supine position with safety straps. Patient is transported to the hospital without compilations. Patient is moved to the emergency room (ER) room via stretcher. Patient care is transferred to ER nursing staff with a decline in patient's condition. Review of the resident's hospital record, showed: -Arrived [DATE] at 1:21 A.M.: -Unknown resident presented with burns and inhalation injury after fire in nursing home. Per EMS the patient was in the room the fire started in and was pulled out of the fire through the window. They think they fire may have started from his/her furnace. Patient presented with soot around his/her mouth and to the face, superficial burns to face, partial thickness burns to right arm and left knee with approximately 1% total body surface area. He/she was given Cyanokit (can be used to treat multiple sources of cyanide poisoning, including smoke inhalation and ingestion) by EMS in-route. He/she arrived to the ER on a non-rebreather (a device used in medicine to assist in the delivery of oxygen therapy. Allows for delivery for higher concentration of oxygen) and unresponsive and per EMS they were unable to intubate due to the resident's jaw being clenched. Heart rate was in the 40's (normal 60 through 100) and oxygen saturation (percent of oxygen in the blood) in the 60s (normal 95% through 100%), so the patient was emergently intubated. Patient became hypotensive (low blood pressure) with systolic blood pressure (SBP, top number, normal is 90 through 120) in the 30s and was given a total of 3 liters of crystalloid (water-soluble electrolytes including sodium and chloride) which stabilized his/her pressure. He/she was briefly on levophed (used to treat low blood pressure and heart failure) but was then able to be stopped. He/she was also given 1 amp of bicarb (used to lower acidosis, high acidity level in the blood); -Patient unable to provide history but nursing staff from the nursing home later called and provided the resident's name; -Primary survey: Airway absence of airway protection, airway not patent, frothy sputum present, soot in airway; -Partial thickness burn to right inner elbow; -Partial thickness burn to left knee -Head/face: Soot to head. Superficial burns to face; -Oral cavity: Oropharynx (the part of the throat behind the mouth) with soot. Superficial burns to lips; -admitted to the medical surgical intensive care unit (ICU) form the ER; -Physical examination on [DATE] at 11:30 A.M., blood pressure high at 194/74 (normal 90/60 through 120/80), temperature low at 96.1 degrees Fahrenheit (F, normal 97.8 through 99.1). Sedated on vent. Some redness to face/burns; -A chest x-ray obtained on [DATE], showed central consolidation in glass density with interior lobular septal thickening. Findings are likely related to pulmonary edema (swelling). Bilateral (both sides) dependent consolidation may represent a combination of atelectasis (complete or partial collapse of the entire lung or area (lobe) of the lung) and/or aspiration. Review of the resident's progress notes, showed: -On [DATE] at 1:54 A.M., called hospital for an update on the resident's condition. Spoke to the nurse who said the resident is still intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their airway. The tube keeps the airway open so that air can get through. The tube can connect to a machine that delivers air or oxygen) and sedated. Burns noted to his/her right forearm and blisters to the left knee. Observation of the resident's room on [DATE] at 12:55 P.M., showed black soot coated the ceiling, walls and furniture. The window missing and a board covering the hole in the wall. Burns visible around the hole. A hole below the window where the PTAC unit formerly sat, open to the outside. The PTAC unit was in pieces and burnt up on the floor of the room. Two beds were in the room. The roommate's bed positioned was up against the wall on the side of the room closest to the door. The resident's bed was positioned in the middle of the room with side rails up on both sides of the bed. Both beds had dark soot that coated them. Observation in the hallway outside the residents room, showed dark soot on the ceilings, walls and doors on the hall and at the nurse's station. Observation of the exterior of the building on [DATE] at 2:21 P.M., showed a feeding pump pole lay on the ground and appeared charred. Other debris, to include what appeared to be the window frame lay on the ground. Plywood was positioned into the window and there was a hole in the wall below the window where the PTAC unit had been. Observation on [DATE] at 11:38 A.M., showed the resident's bed frame measured 42 inches wide. The bed measured 43 inches wide to the edges of the side rails, from side to side. The inner part of the door frame measured 42 inches. During an interview on [DATE] at 9:25 A.M., the resident's family member said the resident is now out of the intensive care unit (ICU), but remains in critical condition. It was not so much the burns that is causing the problems, but the smoke inhalation. Due to the burns, smoke inhalation and long term ventilator use, the resident's kidneys are failing. The emergency room staff said the resident was taken out the window of the room and was concerned as to why they took the resident out the window and not out the door. Review of the resident's Certificate of Death, showed: -Actual or presumed date of death : [DATE]; -Immediate cause of death: End stage renal (kidney) disease. 5. Review of Resident #1's quarterly MDS, dated [DATE], showed: -Rarely/never understood; -Extensive assistance required for bed mobility, transfer, and locomotion on and off the unit; -Diagnoses included schizophrenia and muscle weakness. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Impaired mobility related to impaired range of motion; -Goals: Participate in mobility needs to the limit of ability; -Interventions included: Maintain upper body alignment, perform actions to maintain optimal joint mobility and muscle function during periods of immobility, provide for therapy consult if indicated. Review of the resident's progress notes, showed on [DATE] at 1:20 A.M., charge nurse noted to send resident to hospital via EMS related to smoke inhalation. Resident was exposed to smoke inhalation. Resident sent out for prophylactic (prevention). Family and physician aware. Resident at the hospital under observation. Review of the fire department emergency transport run sheet for an unidentified resident, later identified as Resident #1, dated [DATE], showed: -Chief complaint: Possible smoke inhalation; -Duration: 15 minutes; -Signs and symptoms: Generalized symptoms- other general symptoms; -Barriers of care: psychologically impaired, uncooperative; -Vital signs at 1:02 A.M.: Blood pressure 140/101, pulse 120, respirations 16, oxygen saturation 96%; -Vital signs at 1:15 A.M.: Blood pressure 139/99, pulse 118, respirations 20, oxygen saturation 98%; -Narrative: 911 was called for a possible fire in a local nursing home. We responded to ambulance staging and were immediately given a patient for transport. The patient had no demographic or medical history upon transfer. The patient was in the room next to the fire. The patient did not have any visible smoke or burn injuries. Patient answered some question but was combative and would not answer most. Lungs clear bilaterally (both sides). We attempted oxygen and the patient fought us and would not allow the mask on his/her face. The emergency room made aware. Review of the resident's hospital records, dated [DATE], showed: -The resident originally admitted as an unknown patient until later identified as Resident #1; -Resident here for smoke exposure. Per EMS, patient from a nurse home that caught fire. Patient was in the room next to the one that caught fire. Patient exposed to black smoke. Upon evaluation, patient agitated, yelling; -In the emergency department, patient was yelling and agitated. He/she was found to have elevated carboxyhemoglobin (a stable complex of carbon monoxide that form sin red blood cells when carbon monoxide is inhaled. Elevated levels can indicate carbon dioxide poisoning. Can be caused by smoke inhalation) and placed on a nonrebreather (mask that delivers high levels of oxygen and prevents the rebreathing of exhaled carbon dioxide). Patient is admitted for further management. During an interview on [DATE] at 8:30 A.M., the DON said Resident #1 is still at the hospital, but is due to come back. 6. Review of Resident #6's quarterly MDS, dated [DATE], showed: -Resident rarely/never understood; -Independent with bed mobility and transfer; -Supervision required with locomotion on and off the unit; -Diagnoses included high blood pressure and Alzheimer's disease. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Activity of daily living self-care performance deficit; -Goal: Maintain current level of function; -Interventions included: Able to reposition self in the bed, requires one staff participation to dress. Review of the resident's progress notes, showed: -On [DATE] at 3:11 A.M., confirmed the resident is at the hospital, is stable and will be returning; -On [DATE] at 2:16 P.M., patient sent to the emergency room for further evaluation. Patient crying noted hand was burned, nose and lip was burned. Review of the resident's hospital records, dated [DATE] at 9:42 A.M., showed: -Chief complaint: Smoke inhalation: From a nursing home fire 8 hours prior. Staff noticed soot around his/her nose. Wanted him/her to be checked out. Patient was across the hall from the fire; -Clinical impression: Smoke inhalation; -Carboxyhemoglobin 4.7 (normal is typically lower than 2, can but up to 5 in individuals who smoke), will plan discharge. 7. Review of the facility census report at the time of the fire, dated [DATE], showed Resident #10 resided in the room the fire began in the bed closest to the door. Review of Resident #10's annual MDS, dated [DATE], showed: -Can make self-understood and understands; -Moderately impaired cognition; -Independent with bed transfers and locomotion; -Used a walker and a wheelchair; -Diagnoses included dementia, anxiety, depression, and asthma, chronic obstructive pulmonary disease (COPD, lung disease), or chronic lung disease. During an observation and interview on [DATE] at 12:43 P.M., showed the resident sat in a wheelchair in his/her new room at the facility. The resident said he/she remembers the fire. He/she saw the light, like a candle flickering. Someone came in and got him/her and took him/her out of the room. 8. Review of the list of staff on duty at the time of the fire, provided by the facility, showed: -Two nurses: Licensed Practical Nurses (LPN) A and LPN B; -Six certified nursing assistants (CNA): CNA C, CNA D, CNA E, CNA F, CNA H, and CNA I; -No ancillary staff at the facility at the time of the fire. During an interview on [DATE] at 2:40 P.M., the Director of Nursing (DON) said the schedule showed 7 staff on duty, but there was also someone there on light duty not listed on the schedule, CNA I. Also, CNA H was in orientation. 9. Review of LPN A's hand written statement, dated [DATE], showed around 12:30 A.M., he/she sat at the nurse's station charting when he/she heard someone call out for help. Upon entering the resident's room, he/she saw flames by the window at the bottom of the air conditioning unit. He/she grabbed Resident #10 out of the room. The fire alarm started to alarm and he/she ran to call 911. By now, the other staff was available, he/she grabbed the 200 hall fire extinguisher, pulled the pin and sprayed the base of the fire, backed up and sprayed again. He/she did this three times before he/she was unable to keep doing it due to inhaling the smoke. He/she and a second nurse tried to pull the resident (Resident #3) out in his/her bed, but was unsuccessful. The smoke grew and became black and the staff were unable to see and breathe. The staff then started moving other residents behind fire doors. He/She noticed emergency lights and ran outside to meet the fire department and showed them the area of the fire and was told to stay behind the 100 hall fire doors. During an interview on [DATE] at 11:10 A.M., LPN A said he/she worked at the facility through an agency. Upon arrival, about 10:45 P.M. on [DATE], the nurse manager showed him/her the emergency call list. LPN A found other needed lists and supplies on his/her own. They figured out staffing for the shift, and he/she began making rounds and charting. At 12:22 A.M. on [DATE], he/she heard yelling for help. He/she followed the sound and smelled smoke. When he/she arrived to the room (room [ROOM NUMBER]), he/she removed one resident (Resident #10) from the room, but could not remove the other resident (Resident #3) who was in the bed in the room. Resident #3's bed was too big to fit through the door. He/she does not know if the bed had parts that could be removed to fit through the door. He/she wondered about a sheet lift, but did not think there were enough people. Also, for staff to enter the room, they would have had to push Resident #3's bed back toward the fire. He/she called 911 and then heard the fire alarm sound. Other staff did not respond right away. CNA C asked if this was a drill. LPN A said No, I'm on the phone with 911. LPN A grabbed a fire extinguisher and pulled the pin, but it didn't work. He/she used another extinguisher and swept the fire three time, but it bounced back in his/her face. The nurse from the 600 hall arrived, and LPN A tried sweeping the fire with the extinguisher again, but the fire remained. He/she attempted three times to put out the fire with the extinguisher, but the fire kept going. Staff started evacuating other residents around the room and closing the resident room doors as they were evacuated. LPN A could see the emergency lights and directed EMS to the side door. They said they would take over from there. LPN A did not think there was enough staff. One CNA left the building while he/she was on the phone with the 911 operator. Review of the staff statements provided by the facility as part of their investigation, showed no statement provided for LPN B. During an interview on [DATE] at 9:13 A.M., LPN B said he/she has been a nurse at the facility for about one month, and works night shift on the 600 hall. On the night of the fire, he/she arrived a little before 11:00 P.M. and received report. He/she gathered supplies and helped with a dressing change of a resident. He/she heard the fire alarm sound and the fire doors closed. He/she went to the fire panel on 600 and saw it said the fire was on the 200 hall. LPN B and a CNA went over to the 200 hall. It looked like a vent was on fire. The one resident's bed was caught on the other resident's bed. The bed was blocking the door. Smoke was billowing. They could have done a sheet transfer, but the bed was blocked and they couldn't enter the room. CNA F went outside to see if he/she could extinguish the fire from there. LPN B tried to find other staff, but it was smoky and hard to see. The light-duty aide gave him/her an extinguisher, but it was not firing correctly, when he/she pulled the pin, it did not seem pressurized. The area was getting so black from the smoke so fast, she had to back up. The police arrived before the fire department. They helped move residents out of the way of the fire, in case a total evacuation was needed. There was another CNA on 600 at the back of the hall, CNA E. LPN B did not see CNA E anymore that night after the fire alarm sounded. CNA E did not say anything to him/her before leaving, LPN B said they had enough staff that night but not everyone was knowledgeable, they had a lot of agency and new people and one person was on light duty. The facility has a code alert for fire, to alert everyone overhead, but no one did the overhead page. LPN B thinks the other nurse called 911. Review of the staff statements provided by the facility as part of their investigation, showed no statement provided for CNA F. During an interview on [DATE] at 11:05 P.M., CNA F said he/she has worked at the facility for about 3 months and was working on the 600 hall side. He/she clocked in and started doing rounds. He/she was finishing up in room [ROOM NUMBER] when he/she heard the fire alarm. He/she and LPN B went to the 200 hall. There was a resident still in the room with the fire. They tried to get him/her out, but the first bed was blocking the way. LPN B came with a fire extinguisher. The bed was too big. There were smoke and flames and he/she thinks it was from the PTAC unit. The window was already busted, he/she went outside to see if he/she could extinguish the fire from there. He/she did not have any problems with his/her extinguisher, but was not able to put out the fire. When the fire department arrived, they helped get the residents on that side of the building out of the way. One staff member named CNA E left the facility, he/she did not tell anyone. They could have used more staff. He/she does not remember fire safety from orientation, but knew how to use a fire extinguisher from past jobs. Review of CNA C's handwritten statement, dated [DATE], showed on [DATE] night shift, the fire alarm went off when he/she was orientating, doing round. He/She instantly stared checking rooms, closing doors and then went through double doors. There was a lot of smoke to where he/she could not see, so he/she reacted and started getting people out of their rooms, behind the fire doors. Then EMS and police showed up. During an interview on [DATE] at 6:07 P.M., CNA C said he/she did not find the fire. At the time he/she found out there was a fire, he/she was doing rounds and heard the alarm going off. He/she started checking rooms on his/her assigned hall, hall 400. He/she was on the opposite side of the fire doors as the fire. Once done with those rooms, he/she went out past the double doors and could see smoke on a different hall. He/she started getting people out of that area. He/she did not evacuate the residents on the hall with the fire. Then police and fire department came. They started to come in the front door, so she showed them the side door, the door closest to the affected area but behind the smoke doors. It was too smoky in the hall with the fire to go to that area, it was black smoke. The fire department got the bed bound residents out. No one on 200 [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff were able to provide emergency basic life support immediately when needed, including cardio-pulmonary resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to restore spontaneous blood circulation and breathing in a person in cardiac arrest), to any resident requiring such care in accordance with physician's orders and the resident's advanced directives. The facility failed to have a system to ensure residents' code statuses are obtained timely upon admission, updated when changed and documented congruently through the medical record. Staff identified the hard chart (the paper medical record/chart) as the first place they would look for a resident's code status. For one resident with an incongruent code status, staff would have been directed not to do CPR when the resident desired CPR based on the documentation in the hard chart (Resident #435). Three residents had no ordered code status or signed code status sheets available to staff (Residents #535, #190 and #235). Two residents had incongruently documented code statuses (Residents #535 and #19). Three residents had no ordered code status and no signed code status sheet in the medical record until [DATE] (Residents #186, #187 and #77). Two residents had a signed code status sheet but no ordered code status (Residents #188 and #189). These failures put residents who wished not to receive CPR at risk for receiving CPR against their wishes and residents who wished to receive CPR at risk for not receiving CPR per their wishes. The census was 90. Of those 90 residents, 69 had physician orders for a full code, 13 had physician orders for do not resuscitate (DNR, CPR will not be initiated) and eight had no ordered code status in the electronic physician order sheet. The administrator was notified on [DATE] at 12:54 P.M., of an Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. 1. Review of the nursing policy and procedure binder, located at the long-term care nurse's station, reviewed on [DATE], that contained a policy titled Cardio-Pulmonary Resuscitation, revised [DATE], showed: -Upon determination that a resident is in cardio-pulmonary or respiratory arrest, CPR will be initiated by a CPR certified staff member and 911 called for advanced cardiac life support, unless one of the exceptions applies: -When the resident or surrogate has indicated that resuscitation is not desired and the attending physician has issued a written DNR order that is maintained in the facility's clinical record; -When attempts to perform CPR would place the rescuer at risk of personal injury; -Each resident code status will be maintained in the clinical record; -The policy did not identify the process to obtain and document a resident's code status upon admission or when the code status is changed. During an interview on [DATE] at 9:24 A.M., the administrator said he was not sure where staff would look if they needed to know a resident's code status. He will provide the policy. [DATE] was his first day at the facility. The Regional Director of Operations was the administrator prior to that. Review of the facility's Advanced Directives policy, dated as last reviewed on [DATE] and provided by the administrator, showed: -It is the policy of the facility to respect the resident's right of self-directed care including the right to issue advance directives on health care, to refuse or accept treatment, to make informed decisions, and/or appoint a health care agent to make decision on the behalf of the resident when the resident lacks the capacity to do so; -Upon admission, the facility will provide each resident medically deemed competent or resident's representative, who does not have an existing advance directive, with written information and instruction regarding the right to make advance directives prior to the initiation of care or at any requested time: -The resident may revise or revoke an advance directive at any time; -If the resident cannot communicate whether an advance directive exists and no advance directive is produced, the resident will be treated as if an advance directive does not exist; -The resident's instructions, the resident's receipt of written information, and the existence or non-existence of the resident's advance directive must be documented in the resident's record; -If the facility makes a determination that no advance directives exist, the facility will explore options for financial and health care decision-making on behalf of the resident, i.e. appointment of a guardian if necessary; -The facility employees will be educated regarding the resident's right to self- determination; -The facility shall make a determination if resident's advance directive is valid. If so, the facility shall honor such directive; -The policy did not identify the process to obtain and document a resident's code status upon admission or when the code status is changed. During an interview on [DATE] at 9:59 A.M., with the administrator and Regional Nurse Consultant, they said staff would check the physician orders, order profile and paper chart when determining a resident's code status. The first place they would look in the event of an emergency would be the hard chart. Staff would respond according to the documentation found in the hard chart. They would expect code statuses to be congruent throughout the medical record. There should be conversations with the resident or resident representative about the decision to be a full code (CPR to be initiated) or DNR. Social Services is responsible through audits to ensure all residents have a code status. 2. Review of Resident #435's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -The resident admitted to the facility from an acute care hospital on [DATE]; -Moderately impaired cognition; -Diagnoses included heart failure, high blood pressure, kidney disease, diabetes and anxiety disorder; -Primary medical condition category: Medically complex conditions. Review of the resident's electronic medical record, showed: -An order dated [DATE], for full code; -A face sheet, showed full code; -No documentation to show staff discussed with the resident or resident representative the resident's desired code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A red sheet of paper, showed DNR; -An unsigned and undated purple DNR sheet. During an interview on [DATE] at 11:12 A.M., the resident said he/she believed he/she was a full code but wanted no extreme measures. 3. Review of Resident #535's entry MDS, dated [DATE], showed the resident admitted from another nursing home on [DATE]. Review of the resident's electronic medical record, showed: -Diagnoses included dementia with behavioral disturbances and Alzheimer's disease; -A baseline care plan, dated [DATE], showed the advanced directives/code status section, blank; -No ordered code status; -A face sheet did not identify the resident's code status; -No documentation to show staff discussed with the resident or resident representative the resident's desired code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -No green, red, or purple color-coded paper in the front of the chart; -No code status sheet. 4. Review of Resident #190's entry MDS, dated [DATE], showed the resident admitted from the community on [DATE]. Review of the resident's electronic medical record, showed: -No ordered code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -No color-coded paper in the front of the chart; -No code status sheet. 5. Review of Resident #235's entry MDS, dated [DATE], showed the resident admitted from another nursing home on [DATE]. Review of the resident's electronic medical record, reviewed on [DATE] at 12:15 P.M., showed: -No ordered code status; -No documentation to show staff discussed with the resident or resident representative the resident's desired code status. Review of the hard charts at the nurse's station on [DATE], showed no hard chart available for the resident. During an interview on [DATE] at 9:59 A.M., with the administrator and Regional Nurse Consultant, they said if there was no code status to refer to, staff should default to full code. During an interview on [DATE] at 11:30 A.M., Licensed Practical Nurse (LPN) C provided the resident's hard chart and said the facility had been looking for the hard chart for the resident for days. The hard chart contained the hospital record, but there is no other documentation. He/she would expect the chart to contain more information, such as the code status sheet. Review of the resident's hard chart, showed: -No color-coded paper in the front of the chart; -No code status sheet. During an interview on [DATE] at 12:02 P.M., the Regional Nurse Consultant provided the hospice folder for the resident and said the folder was located in the MDS office. Review of the information located in the folder, showed an outside of the hospital DNR sheet, dated [DATE]. The Regional Nurse Consultant said she would have expected the hospice folder to be at the nurse's station, where it could be accessed by all staff. 6. Review of Resident #534's admission MDS, dated [DATE], showed the resident admitted from an acute care hospital on [DATE]; -Moderately impaired cognition; Review of the resident's electronic medical record, reviewed on [DATE], showed: -A face sheet, code status: Full code; -An order dated [DATE], for full code; -No documentation to show staff discussed with the resident or resident representative the resident's desired code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A red sheet of paper, showed DNR; -A signed code status sheet in the hard chart, dated [DATE] for DNR. During an interview on [DATE] at 9:20 A.M., it was explained to the resident what it meant to be a full code and to receive CPR or a DNR and not to receive CPR, and he/she was asked which code status would he/she prefer to be. The resident said he/she wanted to be a full code. During an interview on [DATE] at 9:59 A.M., the administrator and Regional Nurse Consultant, said if staff followed the directions in the paper chart for the resident's DNR, staff would not be following the resident's wishes. Regarding the resident, the most recent order, which would be the full code physician order dated [DATE], would be considered the actual code status and following the directions for the resident in the paper chart would put the resident at risk of not receiving CPR per his/her wishes. Further review of the resident's electronic medical record, showed: -The resident's order dated [DATE] for full code discontinued on [DATE] and a new ordered for DNR dated [DATE]. The order entered by the Nurse Manager/MDS Coordinator; -No documentation to show staff discussed with the resident or resident representative the resident's desired code status. Further review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A red sheet of paper, showed DNR; -A signed code status sheet in the hard chart, dated [DATE] for DNR. During an interview on [DATE] at 10:22 A.M., the Nurse Manager/MDS Coordinator said if a resident had an incongruent code status, she would expect staff to talk with the resident before changing the order. She talked to the resident about his/her wishes as it related to code status, not long ago today ([DATE]) and the resident said he/she wanted to be a DNR. At 10:23 A.M., the Nurse Manager/MDS Coordinator and the surveyor entered the resident's room. The Nurse Manager/MDS Coordinator told the resident that she was just in to talk to the resident a little bit ago. She then explained to the resident what it was to be a full code and to receive CPR or a DNR and not to receive CPR, and the resident was asked which code status he/she would prefer. The resident said he/she wanted to be a full code. The resident added that he/she talked to the social worker the other day and said that is what he/she wanted. The Nurse Manager/MDS coordinator then left the room and the resident said that person never came in to talk to him/her today about his/her code status, only the surveyor did. Further review of the resident's electronic and paper chart, on [DATE], showed the resident still listed as a DNR in both locations. The code status not changed to full code per the resident's wishes. During an interview on [DATE] at 10:43 A.M., the administrator said he would follow up regarding the resident's code status. During an observation an interview on [DATE] at approximately 11:00 A.M., the social worker, administrator, Nurse Manager/MDS Coordinator and Regional Nurse Consultant were at the nurses station. The social worker held up the resident's signed DNR, dated [DATE] as they discussed the resident's code status. The social worker and Regional Nurse Consultant then walked down the hall and entered the resident's room. The social worker held up the signed code status sheet to the resident and said look you signed this don't you want to be a DNR? The resident replied, oh yes, DNR. It was not explained to the resident the difference between a full code and DNR at this time. 7. Review of Resident #19's quarterly MDS, dated [DATE], showed: -admitted from an acute care hospital on [DATE]; -Severe cognitive impairment. Review of the resident's electronic medical record, showed: -A progress note dated [DATE], the resident arrived to the facility family is very involved in the care. The resident is a full code status; -No further documentation of discussion of the resident's code status; -An order dated [DATE], for DNR; -A face sheet, showed DNR. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A green paper in from of chart, showed full code; -A code status for full code, signed [DATE]. During an interview on [DATE] at 9:59 A.M., the administrator and Regional Nurse Consultant, said regarding the resident, the most recent order would supersede the older order. The resident would be a DNR. They would expect there to be documentation with the family regarding the change in code status. During an interview on [DATE] at 8:46 A.M., LPN P said he/she was not sure how to know a resident's code status, possibly on the back of the room door. If not there, he/she was not sure. Observation on [DATE] at 8:57 A.M., of the resident's room, showed no code status listed on the back of the door to the room, closet or bathroom. 8. Review of Resident #186's entry MDS, dated [DATE], showed the resident admitted from an acute care hospital on [DATE]. Review of the resident's electronic medical record, reviewed on [DATE], showed: -No ordered code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A green piece of paper, with full code; -Full coded status sheet, dated [DATE]; -No documentation a code status was obtained prior to [DATE]. 9. Review of Resident #187's entry MDS, dated [DATE], showed the resident admitted from an acute care hospital on [DATE]. Review of the resident's electronic medical record, reviewed on [DATE], showed: -No ordered code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A green piece of paper, with full code; -Full coded status sheet, dated [DATE]; -No documentation a code status was obtained prior to [DATE]. 10. Review of Resident #77's admission MDS, dated [DATE], showed: -The resident admitted from the community on [DATE]; -Moderately impaired cognition. Review of the resident's electronic medical record, showed: -No ordered code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A green piece of paper, with full code; -Full code status sheet, dated [DATE]; -No documentation a code status was obtained prior to [DATE]. 11. Review of Resident #188's entry MDS, dated [DATE], showed the resident admitted from the community on [DATE]. Review of the resident's electronic medical record, showed: -No ordered code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A green piece of paper, with full code; -Full code status sheet, dated [DATE] 12. Review of Resident #189's admission MDS, dated [DATE], showed: -The resident admitted from an acute care hospital on [DATE]; -Resident is rarely/never understood. Review of the resident's electronic medical record, showed: -No ordered code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A green piece of paper, with full code; -Full code status sheet, dated [DATE]. 13. During an interview on [DATE] at 8:43 A.M., the staffing coordinator said in the event of an emergency, staff should look in the front of the hard chart to determine a resident's code status. 14. During an interview on [DATE] at 8:50 A.M., Social Services said the process to obtain a resident's codes status on admission is, the admission coordinator and concierge get the initial code status signed. If a code status changes during a resident's stay, she will take the old signed code status sheet from the chart and add the new code status sheet. Nurses are then notified so they can change the order in the electronic medical record. Signed code status sheets are also kept in the business chart. 15. During an interview on [DATE] at 8:57 A.M., Certified Nursing Assistant (CNA) O said he/she works for a nursing agency and does not know where to look for a resident's code status, he/she would find facility staff in the event he/she needed to know a resident's code status in an emergency. 16. During an interview on [DATE] at 9:06 A.M., CNA A said he/she would look in the hard chart, located at the nurse's station, for a resident's code status. If it was not there, he/she would ask the nurse. 17. During an interview on [DATE] at 9:07 A.M., CNA N said if he/she found someone expired and needed to know their code status, he/she would look in the hard chart at the nurse's station. If nothing was there, he/she would ask the charge nurse. 18. During an interview on [DATE] at 9:09 A.M., Certified Medication Technician (CMT) M said if he/she entered a resident's room and saw that the resident had expired and he/she needed to know their code status, he/she would look in the hard chart at the nurse's station. If nothing was there, then he/she would get the nurse. 19. During an interview on [DATE] at 9:44 A.M., LPN L said the first place he/she would look for code status is in the electronic medical record. Hard copies are also kept in the hard chart. 20. During an interview on [DATE] at 10:28 A.M., the admission coordinator said the facility has an admission packet that is provided to the residents upon admission, but to her understanding, it is the responsibility of the concierge to get the signed code status orders. The facility identified that it was not being done in a timely manner, so now she will go down the room and make sure it gets signed. When she does this, she will talk to the resident and have them sign. If they are not able to talk, she will call the family. She is not a nurse and cannot enter orders into the computer, she works the front desk. After getting the paperwork signed, she will put the paperwork in the hard chart with the corresponding red or green paper. She does not tell the resident's nurse anything after getting the code status signed, because all she has to do is put the information in the chart. She was not sure what the nurses do from there. She started employment at the facility on [DATE], went on leave [DATE] and just got back yesterday. 21. During an interview on [DATE] at 10:32 A.M., LPN H said he/she had never done an admission at the facility, but would put the ordered code status in the system if he/she did have to admit a resident. If he/she found a resident unresponsive, he/she would start CPR and have another staff check the orders. If they say the resident was a DNR, he/she would stop CPR. 22. During an interview on [DATE] at 10:36 A.M., the Assistant Director of Nursing (ADON) said the admitting nurse transcribes the orders, including code status. The ADON or Director of Nursing (DON) then audits the admission orders within 24 hours. Code statuses are being entered in the electronic medical record and in the hard chart. A red paper/sheet with big/bold letters DNR will be placed in the chart's first page, then a purple sheet signed consent will be placed in back of the red sheet. If full code, a green sheet will be used. If a code sheet is not found in the resident chart, she would look in the electronic medical record. If orders are not found during her audit, she will refer to the hospital medical records. 23. During an interview on [DATE] at 10:43 A.M., LPN K said he/she thinks the admission coordinator gets the resident's code status orders. In the event he/she needed to know a resident's code status urgently, he/she would look in the hard chart. 24. During an interview on [DATE] at 11:01 A.M., LPN J said the nurses are responsible to obtain resident code statuses. In the event a resident were to stop breathing, staff would follow the resident's code status in the hard chart. 25. During an interview on [DATE] at 11:05 A.M., the Concierge/CNA said she had been employed by the facility since 2008. When a new admission arrives, she is responsible to do the admission paperwork. She will greet the resident then get them to the bed and situated. The code status sheet is completed with the family and resident at the same time because it is very important. The signed code status sheets are then brought to the admission coordinator, she does not give them to the nurse. CNAs are not able to enter orders, but she can add a colored sheet into the front of the chart. [NAME] for full code and red for DNR. She does not give the signed code status to the nurses. The code status sheet is given to the admission coordinator. 26. During an interview on [DATE] at 10:44 A.M., LPN C said the charge nurse is responsible for transcribing orders, including the resident's code status. Orders are then entered into the electronic medical record and hard chart. The ADON or DON audit the orders within 24 hours. If there is no code status in the admission records, she will ask or clarify with the resident, and if resident is non-verbal, she will talk or call the family or responsible person. If code sheets are missing in the electronic medical record or hard chart, she would immediately notify the DON or ADON. 28. During an interview on [DATE] at 1:34 P.M., the Regional Director of Operations said the facility had a mock survey around the week of [DATE]. Issues were identified with resident code statuses at that time. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).