**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review, it was determined that the facility failed to ensure: 1.) the emergency response system was activated to call a code, 2.) 911 was enacted, 3.) the automatic external defibrillator (AED) was utilized for a resident who was found unresponsive (Resident #7) and was a full code status (all resuscitation procedures will be provided when a person stops breathing or heart stops beating). This deficient practice occurred for 1 of 3 residents (Resident #7) reviewed for unexpected deaths and 4.) failed to ensure a system was in place to appropriately track and maintain cardiopulmonary resuscitation (CPR) certifications to ensure that staff maintain the appropriate CPR certification. The facility's system wide failure to appropriately track and maintain appropriate cardiopulmonary resuscitation certifications, and provide the required emergency response, posed a serious and immediate threat to the health, safety, and wellbeing of all residents who resided in the facility. A serious adverse outcome had occurred and was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on [DATE] at 1:50 PM. The IJ situation began on [DATE] at 8:00 AM when Resident #7 was found unresponsive and was identified by the survey team during an on-site survey on [DATE]. The facility submitted an acceptable removal plan on [DATE] at 8:30 AM. The removal plan was verified, as implemented, by the survey team on [DATE] at 9:30 AM. Evidence as follow: On [DATE] at 12:51 PM, the surveyor reviewed the closed medical record for Resident #7, which revealed: A Licensed Practical Nurse (LPN #1) documented a Nurse's Note (NN) on [DATE] at 16:05 (4:05 PM). The NN revealed that during rounds at 7:00 AM, Resident #7 was awake and verbal. Then by 8:00 AM, LPN #1 went to give Resident #7 medications, and the resident was unresponsive, no pulse, body a little cold CPR was done and no response, body was getting cold [SIC]. The RN PP (Director of Nursing) pronounced dead. The admission record for Resident #7 revealed the resident was admitted to the facility with diagnoses which included but were not limited to hyperkalemia (high potassium level) and malignant neoplasm of the prostate (prostate cancer). A Living Will Declaration signed by Resident #7 on [DATE] revealed there was no life-sustaining procedures that may be withheld or withdrawn indicated if the resident had an illness, disease, or injury, or experienced extreme mental deterioration, such that there was no reasonable expectation of recovering or regaining a meaningful quality of life. The Annual Minimum Data Set (MDS, assessment tool), dated [DATE], revealed under the Prognosis section that the resident was not checked off having a chronic disease that may result in a life expectancy of less than 6 months. The Care Plan for Resident #7 was reviewed. A Problem listed was Advance Directives - Resident had an Advance Directive/Proxy dated [DATE]. The Goal was Resident #7 will continue to be informed and educated of the rights to make Advance Directives/Proxy, change it as needed, and their wishes will be followed and respected, Dated [DATE]. The Physician's Order, signed by the Physician on [DATE], did not reveal an order for 'do not resuscitate.' On [DATE] at 9:07 AM, the surveyor interviewed LPN #1, the nurse assigned to care for Resident #7 on [DATE]. LPN #1 confirmed she was assigned to Resident #7 on [DATE]. LPN #1 stated the resident was okay, and then in the next twenty minutes, the resident went bad and that the resident was unresponsive. When she went to see Resident #7 prior, she stated that she had spoken with the resident, and Resident #7 said they were going to eat breakfast. The surveyor inquired as to what was she did when the resident was found unresponsive and asked if 911 was activated. LPN #1 stated, we did not call 911, that she went in to give the resident medications, and the resident was already gone. LPN #1 stated she was shocked, she called for help from another nurse (LPN #2), and she stated, I did everything I was supposed to do. LPN #1 stated to refer to her NN; all the information was in her notes. On [DATE] at 9:38 AM, the surveyor interviewed the DON regarding the process that is to be followed if a resident was found unresponsive. The DON stated that if a person was unresponsive, the nurse would check the resident and complete a nursing evaluation. The DON stated that if the resident was a full code, 911 would be called. The DON stated she remembered Resident #7 and that she was called in on the weekend to pronounce (confirm death) Resident #7. The DON stated she was told that Resident #7 had no vital signs, and prior, the resident was alert and oriented, and ambulatory. On [DATE] at 9:50 AM, the surveyor interviewed LPN #2. LPN #2 stated she was told by LPN #1 that Resident #7 had a problem. LPN #2 stated the resident was not on her assignment, and she had been across from Resident #7's room at the nurses' station. LPN #2 stated that LPN #1 called her into the room, and they both started CPR on Resident #7. The surveyor inquired to LPN #2 if she would call 911, and she stated, of course I would call 911. The surveyor asked LPN #2 if either nurse utilized an AED. LPN #2 stated, no, we did not use the AED because no one went and got it. LPN #2 stated she did as much CPR as she could because she was tired and had a shoulder problem. The surveyor inquired to LPN #2 if there was any documentation or a form filled out to record what was happening with Resident #7. LPN #2 stated that no form was filled out and the resident did not have a pulse, but they were still a a little warm. The surveyor inquired again about the AED. LPN #2 stated she went into Resident #7's room, and there was no AED. It was located on the first floor. LPN #2 stated that LPN #1 called her in and that there were only three nurses in the whole building. LPN #2 stated she did not know if LPN #1 had called a code overhead and stated that she and LPN #1 were the only nurses there during the code. On [DATE] at 9:59 AM, the surveyor interviewed a Registered Nurse, Nursing Supervisor (RN#1), at the first-floor nurses station. The surveyor asked RN #1 about the small red machine enclosed in a glass case and attached to the wall. RN #1 stated it is an AED, and it is used when a resident codes or was in distress. She stated we should have one on each floor but that the facility only had one. RN #1 stated that the staff would page code overhead if a resident codes or was in distress. RN #1 stated that all the nurses would go to the code, and the first floor nurse would bring the AED to the code. On [DATE] at 11:00 AM, the LHNA provided the surveyor a copy of the facility's Emergency Procedure-Cardiopulmonary Resuscitation' policy, Revised 10/2021. The Policy revealed: Policy Statement: Personnel have completed training on initiating cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for sudden cardiac arrest. General Guidelines: 1. Sudden cardiac arrest [SCA] is a loss of heart function due to abnormal heart rhythms (arrhythmias). Cardiac arrest occurs soon after symptoms appear. It is a leading cause of death among adults. 2. A heart attack refers to impaired blood flow to the heart which leads to damage of the heart muscle. A heart attack can cause sudden cardiac arrest. Typically heart attacks are less sudden than SCA. 3. Victims of cardiac arrest may initially have gasping respirations or may appear to be having a seizure. Training in BLS includes recognizing presentations of SCA. 4. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 5. Early delivery of a shock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase the chances of survival. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g., rigor mortis). 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. 8. If the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives. Preparation for Cardiopulmonary Resuscitation: 1. Obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. 2. The facility's procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care of facility BLS training material. 3. Provide periodic Mock Codes (simulations of an actual cardiac arrest) for training purposes. 4. Select and identify a CPR Team for each shift in the case of an actual cardiac arrest. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort directing other team members during the rescue effort. 5. The CPR Team in this facility shall include at least one nurse, one LPN/Licensed Vocational Nurse (LVN), and two CNAs who have received training and certification in CPR/BLS. 6. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times . Emergency Procedure-Cardiopulmonary Resuscitation: 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR. a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events . 6. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with compression-ventilation ratio of 30:2. 7. When the AED arrives, assess for need and follow AED protocol as indicated. 8. Continue with CPR/BLS until emergency medical personnel arrive. The facility did not call a code, contact 911 or utilize the AED per the facility policy. On [DATE] at 11:27 AM, the surveyor, in the presence of the survey team, interviewed the DON about completing mock codes per the facility policy. The DON stated they have not mock codes recently, and she did not provide any further information related to mock codes. The DON stated the facility educated staff on CPR, and the surveyor requested copies of LPN #1 and LPN #2's CPR certification. On [DATE] at 11:53 AM, the surveyor conducted an additional interview with LPN #2 in the presence of the survey team. The surveyor inquired about the facility process if a resident is found unresponsive. LPN #2 stated when someone is unresponsive, you would start CPR and call 911. The surveyor inquired if LPN #1 had called 911. LPN #2 stated that she didn't know if LPN #1 called 911. LPN #2 stated if they have a code, they would call a code STAT overhead. Furthermore, LPN #2 stated there were only three nurses on staff in the building that day and no Registered Nurse, I didn't hear her call. LPN #2 stated, we do mock fire drills, but not mock codes. LPN #2 stated when a code occurred that, the nurses were supposed to document it in the nurses' notes. LPN #2 stated she had CPR certification and knew how to use it. LPN #2 stated that Resident #7 had no pulse when she went into Resident #7's room, and then LPN #1 exited Resident #7's and LPN #2 began CPR completed a blood pressure and there was no reading, and stated LPN #1 talked to the DON and decided to stop CPR. LPN #2 stated they didn't have enough staff, and there was no supervisor on that weekend. On [DATE] at 12:00 PM, the DON provided the surveyor with a Community & Workplace Certification, Basic Life Support, Adult, Child & Infant CPR, and AED for LPN #1, and the DON did not provide a CPR certification for LPN #2. The surveyor inquired as to the CPR training at the facility. The DON stated the facility does a CPR class at the facility, American Heart Association (AHA). The DON reviewed the CPR card provided to the surveyor for LPN #2, and the surveyor inquired how the certification met the American Heart Association training standards. The DON did not provide an explanation and stated she didn't have LPN #2's CPR card. On [DATE] at 1:42 PM, the surveyor interviewed the LNHA and DON in the presence of the survey team. The surveyor informed the DON and LHNA regarding the findings; 911 was not activated, a code was not called, and the AED was not utilized for Resident #7 when the resident became unresponsive. The DON confirmed that the staff should have utilized the AED and called 911. The DON further stated that three nurses were working that day, and the process should have been enacted. The surveyor asked the DON regarding the ability of LPNs to assess a resident or are LPNs able to pronounce death. The DON acknowledged the LHNA and stated that LPNs could not pronounce death or assess a resident. On [DATE] at 8:59 AM, the LHNA and DON were interviewed by the surveyor, in the presence of the team, regarding the facility's process of tracking the nursing staff CPR certifications. The DON stated the in-service coordinator should be tracking the CPR certifications, but she was unsure if it was up to date. The DON provided a copy of 7 Employee BLS certifications. The CPR cards provided to the surveyors included 5 AHA Provider Basic Life Support cards, including a copy of LPN #2's card. A second copy of the Community & Workplace Certification, Basic Life Support, Adult, Child & Infant CPR and AED for LPN #1, and two cards for National CPR Foundation, Provider Card. The survey team requested to see the tracking system at that time. The DON stated the In-service Coordinator/Assistant Director of Nursing (IC/ADON) would provide it. Furthermore, the DON added, there had not been CPR training because of COVID. On [DATE] at 9:31 AM, the IC/ADON provided the surveyor, in the presence of the survey team, a Plaza Healthcare and Rehab Center BLS (Basic Life Support) Log, with 20 names listed and 18/20 of the names had an X next to it. The surveyor inquired about the list provided by the IC/ADON and how the IC/ADON would know when the CPR certification expired. The IC/ADON stated she did not have expiration dates on it, and she just knew when they expired, and she would put an X next to the staff's name if they had the CPR certification. She stated that was how she tracked it, and she knew if they had the certification by when the facility offered the CPR training. She stated that some staff would forward a card if they had the training elsewhere. There were 12 more employee names on the Plaza Healthcare and Rehab Center BLS (Basic Life Support) Log than copies of CPR cards provided by the facility. On [DATE] at 10:03 AM, the surveyor interviewed the receptionist/staff coordinator (R/SC) in the presence of another surveyor. She stated her responsibilities included putting staffing out, doing the state nursing report, room rosters, and updating admission and discharge charts. She stated she had to schedule a nurse on each shift that was CPR certified. The surveyor inquired how the R/SC would know what nurses were CPR certified. The R/SC stated the IC/ADON had a list of CPR certified staff and stated if the CPR certification was done outside of the building, the staff would bring it in. The surveyor showed the R/SC the undated list of BLS certifications provided by the IC/ADON and inquired to the R/SC if that was the list she utilized. The R/SC stated she utilized a different list with the staff name and the expiration date. The surveyor inquired to the R/SC if a specific type of CPR certification was required. The R/SC stated she was unaware of the type of CPR certification required for nursing staff. She completed a schedule every four weeks and did not look at the CPR certified list every time she completed a schedule; she looked at it every few months. The R/SC provided the surveyors with a list of all Active Employees, Nursing, which included 12 LPNs, 41 Certified Nursing Assistants (CNA), and 8 Registered Nursed (RN). On [DATE] at 10:28 AM, the IC/ADON provided the surveyor with two more CPR cards. Her AHA Provider Basic Life Support CPR card included one AHA Provider Advanced Cardiovascular Life Support Card. There were 10 more names on the Plaza Healthcare and Rehab Center BLS Log than CPR cards provided. The DON was not listed on the list. On [DATE] at 11:11 AM, the surveyor interviewed the DON in the presence of another surveyor. The surveyor asked the DON why she was listed as the 7:00 AM- 3:00 PM (day shift) RN on the day that Resident #7 became unresponsive. She stated she was not in the building that day, and she was on call. The DON stated that the facility did not have a charge nurse on the schedule that day. She stated that they usually would, but she would be on call if they don't have enough staff. Asked why she was not in the building on 2/12 since she was scheduled from 7-11, the DON stated that she was on call that day and confirmed that she was on the list as the RN. On [DATE] at 12:01 PM, the R/SC provided the surveyor with a copy of an undated Plaza Healthcare and Rehab Center BLS (Basic Life Support) Log (Log) that she would utilize to make the schedule. The Log revealed 19 nursing staff with an X next to 18/19 nursing staff. In the column next to the X was an Issue Date, and next to that, Renew By. Five out of the nineteen nursing staff did not have a date listed in the Issue Date and Renew By columns. The surveyor reviewed the Log provided by the DON on [DATE] at 12:00 PM and compared it to the nursing staff schedule for the date Resident #7 required CPR. Both LPN #1 and LPN #2 were on the R/SC's list as having had BLS training. The LPN (only nurse) assigned to the 1st floor on the same date was not listed as having BLS training. On the day Resident #7 coded, five out of thirty-four nursing staff scheduled were listed on the R/SC's list as having had BLS training. On [DATE] at 1:32 PM, the surveyor, in the presence of two other surveyors, conducted a telephone interview with the Medical Director (MD), who was also the attending Physician for Resident #7. The surveyor inquired if she was aware that all of the nursing staff were not CPR certified. She stated she was not aware and assumed that the supervisors knew CPR. The surveyor asked the MD if it was important for nursing staff to have current, appropriate CPR certification. The MD responded, yes, they should, and all nurses should have CPR certification. The MD stated that she was not aware that all staff did not have appropriate or current CPR certification. Review of the Unit Coordinator/Charge Nurse (Registered Nurse/LPN) Job Description indicated that it is the Unit Coordinator/ Charge Nurse responsibility to direct, monitor, and supervise all staff assigned to the unit, to ensure Quality of Care and Quality Life for each resident, to exercise good judgment and to respect confidential matters. The direction of staff will ensure that care and services will be delivered in compliance with all Federal, State, and local requirements and facility policies and procedures. Evaluates emergencies and determine the immediate measures to be implemented according to standards of practice. Communicated all emergencies to the Director of Nursing/ADON and/or designee. Scope of Supervision: Responsible for all nursing staff assigned to the unit and coordinate quality of care and quality of life for every resident residing on the units all shifts. NJAC 8:39-4.1 (31)iii, 9.6 (g)