**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and Responsible Person and staff interviews, the facility failed to ensure a resident's Do Not Resuscitate (DNR) goldenrod form (a portable physician's order printed on goldenrod colored paper that communicates an individual's wishes regarding resuscitation efforts for emergency responders) and Medical Orders for Scope of Treatment (MOST) form (outlines health care and end-of-life care instructions) stating DNR and Do Not Intubate (DNI) (intubation is a medical procedure where a tube is inserted into the airway to support breathing) were provided to Emergency Medical Services (EMS) upon emergent transfer to the hospital on Sunday 6/22/25. As a result of the resident having no advance directive information conveyed to the hospital, the resident was listed as a full code (all possible life saving measures), was intubated and placed on a mechanical ventilator (a machine that moves air in and out of the lungs) as part of his treatment. The resident's Responsible Person stated that Resident #101 was very specific about not wanting to be resuscitated or intubated and wished to have comfort measures only due to having to previously witnessed a family member intubated and not wanting that for himself. The facility later provided the hospital with resident's DNR and MOST form paperwork, he was extubated (medical procedure where the breathing tube is removed from the airway), and comfort measures were put into place as per his advance directive wishes. This deficient practice was evidenced for 1 of 3 residents reviewed for transfer and discharge (Resident #101).Findings included: Resident #101 was admitted to the facility on Friday 6/20/25 with diagnoses including dementia, history of falls, and muscle weakness. A physician order located in the electronic health record dated 6/20/25 revealed Resident #101's code status was DNR. A telephone interview conducted with the Director of Marketing on 8/19/25 at 9:10 PM revealed she reviewed Resident #101's completed and signed original portable DNR goldenrod form and MOST form showing he was a DNR and DNI inside the facility's medical records box on 6/22/25. A change in condition progress note written by Nurse #1 dated 6/22/25 revealed Resident #101 had a change in condition that included altered level of consciousness and a fall. Resident #101 was located on the floor at his bedside, lying face down with profuse bleeding from right forehead, pressure was applied to head, and Emergency Medical Services (EMS) was called to transport the resident to the hospital emergently. Attempted to contact Nurse #1 for interview and she was unable to be reached. The EMS record dated 6/22/25 revealed EMS was dispatched for emergency response related to a fall with possible head injury. EMS arrived on the scene to find Resident #101 lying face down on the floor with staff holding pressure to the resident's head with a towel. Facility staff advised that while they were passing trays to other residents outside Resident #101's room they heard him fall and went in to find him on the floor. Facility staff stated that when they first arrived Resident #101 was awake and speaking to them and as time progressed, he became less responsive to any stimuli. Resident #101 had equal and reactive pupils but were noted to be sluggish, he would open eyes to painful stimuli but had no other responses. Vital signs were obtained and were within normal limits. Facility staff handed the crew a packet of paperwork that had a face sheet and a medication list. EMS questioned the facility staff regarding code status of Resident #101 and any related paperwork. The facility staff on scene advised that Resident #101 was full code to the best of their knowledge as they had no other paperwork. EMS confirmed and facility staff advised they had not been told or given paperwork to suggest anything other than a full code status. Resident #101 was transferred to the stretcher and secured with assistance from facility staff on scene and without incident. The hospital was notified of incoming trauma patient and updates provided. Resident #101 was monitored throughout transport with no significant changes noted. Bleeding remained controlled with no changes noted. Vital signs were monitored throughout transport with no significant changes noted. Resident #101 was transferred into room with assistance from hospital staff on scene without incident. Report was given to hospital staff on scene and facility paperwork was copied by hospital registration for staff. Attempts to contact EMS for interviews were unsuccessful. Hospital records dated 6/22/25 revealed Resident #101 presented for evaluation after an unwitnessed fall at his rehabilitation living facility. Facility staff found Resident #101 unresponsive and not communicating. Upon EMS arrival, Resident #101 was responsive to pain only and had a large scalp laceration. On hospital arrival, Glasgow Coma Scale (clinical tool used to measure level of consciousness) was 4 (score of 8 or less indicates more severe injury) and Resident #101 was promptly intubated, placed on mechanical ventilation, and stabilized. However, later when the paperwork was brought from the facility it was realized that Resident #101 was a DNR and DNI. Resident #101 was extubated, family wishes were honored, and Resident #101 was made comfort care. A telephone interview was conducted with Resident #101's Responsible Person (RP) on 8/19/25 at 4:29 PM revealed Resident #101 was admitted to the facility on [DATE]. He stated on 6/22/25 he had just returned home from visiting with Resident #101 when he received a telephone call around 5:30 PM from Nurse #1 stating Resident #101 had fallen inside of his room, hit his head, and was bleeding from a cut on his head. He revealed Nurse #1 stated Resident #101 was being transported by EMS to the nearest hospital. The RP revealed that once he arrived at the hospital and was allowed back to see Resident #101, he observed the resident had been intubated and placed on a ventilator. He stated Resident #101 had completed his advance directives paperwork prior to being admitted to the facility and was very specific about not wanting to be resuscitated or intubated and wished to have comfort measures only due to having to watch a family member be intubated and not wanting that for himself. He (the RP) revealed they asked the hospital staff about Resident #101's DNR form and MOST form stating that he did not want to be resuscitated or intubated and the hospital staff stated they did not receive any paperwork from the facility regarding Resident #101's advance directives and as a result he was being treated as a full code (all life save measures). The RP was familiar with the Director of Marketing from the facility, so he called her (the Director of Marketing) to see if there was a way to have the facility to send over Resident #101's advance directive paperwork. The RP indicated the Director of Marketing went to the facility herself and picked up the original paperwork and brought it over to the hospital. He revealed once the hospital received the advance directive paperwork, they discussed with him (the RP) and his family if they still wanted to proceed with Resident #101's advance directive wishes. They all agreed to proceed as the resident wished, and Resident #101 was then extubated. The RP stated seeing anyone be intubated and then having to be extubated would be awful enough but having to watch his mother sit and cry while his father was being put through the procedure was something he would not wish for anyone. He revealed he did not understand why the facility did not send the advance directive paperwork for Resident # 101, especially since those had been completed prior to his admission to the facility and were his wishes. A telephone interview conducted with the facility Director of Marketing on 8/19/25 at 9:10 PM revealed she was familiar with Resident #101 and his family. She stated on the evening of 6/22/25 she had received a telephone call from Resident #101's RP stating the facility did not send the advance directive paperwork to the hospital that stated Resident #101 was a DNR and DNI and that because the hospital had not received the paperwork they had to treat Resident #101 as a full code, had intubated him, and placed him on a ventilator. She revealed Resident #101's RP stated he had tried to call the facility several times with no answer and asked if she could locate Resident #101's advance directives paperwork and have it sent to the hospital to show Resident #101's advance directive wishes. The Director of Marketing stated she attempted to call the facility with no answer, so she drove to the facility to locate Resident #101's advance directive paperwork and take it to the hospital herself. The Director of Marketing revealed when she arrived at the facility she did speak with Nurse #1 who stated she had sent the facility transfer paperwork with Resident #101 but did not include his advance directives paperwork as she was not able to locate them. The Director of Marketing stated after locating Resident #101's advance directives paperwork she was able to take the original forms to the hospital herself. She revealed once the hospital received the original advance directive forms, they were able to discuss Resident #101's wishes with his family and Resident #101 was extubated and placed on comfort care. The Director of Marketing revealed that to her knowledge original advance directive forms were to be placed inside of the advance directive books located at each nurse station and she did not know why the originals for Resident #101 had been placed inside of the medical record box. An interview conducted with the Administrator on 8/20/25 at 11:06 AM revealed she was familiar with Resident #101 and the incident that occurred on 6/22/25. She stated she believed Nurse #1 did send transfer paperwork with Resident #101 but was aware she did not include the advance directives. The Administrator stated Nurse #1 could not locate Resident #101's advance directives paperwork prior to him leaving for the hospital which caused Resident #101 to be treated as a full code until the facility was able to locate the paperwork and provide it to the hospital. She revealed typically when the facility had a new admission, and the advance directive was completed at the facility then the paperwork would be placed inside of the physician notebook to be signed. She stated once the advance directive paperwork was signed by the physician the paperwork was placed into the medical records box to be scanned into the resident's electronic health record, and the original was then placed inside of the advance directive notebook located at the nurse's desk. The Administrator revealed she believed Resident #101's advance directives were completed and signed prior to his admission to the facility and were placed into the medical records box to be scanned into Resident #101's electronic health record (EHR) instead of being placed inside the advance directive notebook. She stated she would expect advance directive forms to be placed inside of the advance directive notebook by the licensed nursing staff so they can be accessed. Licensed nursing staff should also make sure advance directives were sent with residents to appointments, transfers, or discharges. The Administrator stated Nurse #1 should have reviewed EHR to ensure Resident #101's code status and if she had any questions she should have contacted her supervisor. The facility was notified of immediate jeopardy on 8/20/25 at 7:04 PM. The facility provided the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: The facility failed to ensure that Resident #101's Do Not Resuscitate (DNR) goldenrod and Medical Order of Scope of Treatment (MOST) form was sent with him upon emergent transfer to the hospital on 6-22-25 between 5:30pm and 6:00pm. He had a fall earlier in the day that resulted in a laceration to his head and had to be sent out to the hospital. The family was notified of the need to send Resident #101 to the hospital due to the fall, as well as the Medical Provider by Nurse #2. Nurse # 1 communicated to the Emergency Medical Service (EMS) staff he was a DNR but could not produce the actual DNR document for EMS staff, who then treated him as a full code. When he was treated at the hospital, initially he was treated as a full code and was intubated. The Director of Marketing later found the DNR/goldenrod and took it to the hospital around 11:30 pm when it was located. We were unable to determine who actually put the documents in the medical records box, however only licensed nursing staff receive and process the admission packet. The DNR had been put in the medical records box to scan into the record, but because of the patient being admitted around 6:15PM on Friday the 20th, it was not scanned into the medical record and then placed in the DNR binder at the nurses' station therefore at the time of the emergent need, it was not available. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents with a code status of Do No Resuscitate and Do Not Intubate were at risk with this deficient practice. All residents with code status were audited by reviewing the Physician's order for the patient's code status in the electronic medical record against the documents contained in the DNR book located at each nurses' station on 7-10-25. This was completed by the Director of Nursing (DON) to ensure that the DNR/goldenrod and MOST Form is available in the DNR book. No negative findings noted upon completion of the audit for code status. An Audit for advance directives including FULL CODE/ DNR and/or MOST forms was completed on 7-10-25 by the Director of Nursing and ongoing with any new admissions /readmissions/ significant changes. The audit was performed by checking the current patient charts in the facility for advance directive orders for FULL CODE/ DNR and MOST form. If it was indicated for the resident to have a DNR and/or MOST form, there was an audit of the original forms that are kept in DNR book to ensure that the orders and the DNR and/or MOST forms matched. No other discrepancies were found. All orders for DNR and/ or a MOST form matched with the resident order indicated. The DNR/MOST Book contains the DNR and/ or MOST form and are located at each nurses station. All Advance Directives are also scanned in the Medical Records under the Document Tab by the Medical Records Coordinator. Code status for each patient whether DNR or Full Code are in the electronic Physician orders and is visible under the information bar on the electronic Medication Administration Record (eMAR) and the electronic Kardex. The medical record box was checked and there were no DNRs and/ or MOST forms in the box waiting to be uploaded to the medical record by the Director of nursing on 6-23-25 and continues daily. The Director of Nursing or designee also checks this box on the weekends and after hours by coming in or calling the facility. All new admissions/readmissions/ significant changes after the 100% audit completed on 7-10-25 were audited for compliance by the DON from 7-11-25 onward and continues at this time. Director of Nursing also completed an audit of all admissions/re-admissions/significant changes from the last 30 days (6-11-25 to 7-10-25) to identify any issues with the DNR and/or MOST form not being available. Quality Assurance and Process Improvement (QAPI) determined that the root cause was placing the original copy of the DNR in the Medical Record Box instead of placing the original in the DNR/MOST book when reviewed on 6-26-25 during QAPI. Therefore, the new process of copying the original DNR and / or MOST form to put in the Medical Records Box instead of the original will alleviate not having the original readily available to be sent for any transfers.No other emergent transfers were affected as evidenced by no issues reported to the facility and documents in the eMAR. An audit of all emergent transfers to the hospital was completed for the last 30 days to validate there were no issues was also completed by the Director of Nursing on 7-10-25. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Education will be completed by 7-10-25 by Director of Nursing for all licensed nurses to ensure that if a patient comes in with a DNR/Goldenrod and /or a MOST form upon admission, it is immediately placed in the DNR book, and a copy is provided to medical records. If a patient transfers out of the facility for a medical need, the original Goldenrod and/or MOST form must accompany that patient to the hospital. The Director of Nursing used the following education based on nursing policy and procedure #303. The DON provided the following education to all licensed nurses: 1. If a resident admits with a signed DNR and /or MOST, a copy of the DNR is to be made and placed in the medical record box for uploading instead of the original form. 2. The ORIGINAL DOCUMENT is to then be placed in the DNR book immediately located at each nurse's station.3. If the patient is transferred out for any reason, the ORIGINAL DOCUMENT will be sent with the patient Based on #1 education listed above, the process of having a copy of the DNR and/ or MOST form to be placed in the medical record box for uploading will ensure having the DNR and/ or MOST form also noted in the medical record aside from the original being in the DNR book located at each nurses' station. Not putting the original copy in the medical record box for uploading will ensure that the original is not lost and is readily available in the DNR Book for any transfers. The code status will be placed on the 24- hour report sheet by the admitting licensed nurse upon admission/ readmission or any significant changes. The licensed nurse will verify the DNR and / or MOST status, then update the physician order in the medical record. The licensed nurse will then place the original copy in the DNR Book at the nurses' station and update the 24- hour report sheet that nurses utilize when giving shift reports. Licensed nursing staff were educated by the Director of Nursing began on 6-30-25 with completion by 7-10-25. The orders are reviewed by the nursing leadership team (consisting of the DON, SDC, Unit Manager #1 and Unit Manager #2) during the Monday to Friday clinical morning meeting and update the DNR Book and the report sheets at that time as needed. The Night Supervisor and Weekend Supervisor and On-call Nurse will review and report to DON as needed for any off hours and weekend admissions/readmissions / significant changes. The Regional Director Clinical services (RDCS) provided this education on 6-30-25. Licensed floor nursing staff, including any nurse manager or nurses assigned to a cart who has not received education by 07/10/25 will not be allowed to work until education is completed. Education will be provided by the Director of Nursing or designee. A roster of all licensed staff maintained by the Director of Nursing are checked off as they are educated. Any PRN (as needed by licensed staff) or agency licensed nurse working within the building must acknowledge understanding prior to working their shift as evidenced by being able to state the location of the DNR Binder and awareness of sending the DNR and /or MOST form with any transfers. The education will be completed by the Director of Nursing or designee prior to their first shift.New licensed floor nursing staff will receive education within the orientation process by the Staff Development Coordinator (SDC) or designee. The Director of Nursing informed the SDC of the need to include this in orientation class for any licensed nurse on 7-9-25 to start with the next orientation class. Any PRN (as needed licensed staff) and agency licensed nurse working within the building must acknowledge understanding before working. Each new licensed employee will be able to state their awareness of following process #1 to #3:1. If a resident admits with a signed DNR and /or MOST, a copy of the DNR is to be made and placed in the medical record box for uploading instead of the original form. 2. The ORIGINAL DOCUMENT is to then be placed in the DNR book immediately located at each nurse's station.3. If the patient is transferred out for any reason, the ORIGINAL DOCUMENT will be sent with the patient Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The Quality Assurance and Process Improvement (QAPI) meeting was held on 6-26-25 with the Interdisciplinary Team (IDT) that consists of the Administrator, Medical Director, Director of Nursing, Discharge Director, Medical Records Director, Dietary Manager, Director of Rehabilitation, Minimum Data Set (MDS) Nurse, Human Resource Manager, Activities Director). The IDT team determined that a Plan of Correction was needed and developed the Plan of Correction for approval to follow for QAPI to ensure monitoring and compliance. The IDT team decided to audit and monitor FULL CODE /DNR /MOST documents in the DNR/MOST book and in the Electronic Medical Record for all new admissions/readmission / significant changes daily for 4 weeks, then 5 times per week for 4 weeks, then 3 times per week for 4 weeks for 4 weeks to ensure ongoing compliance. The audit will be completed by matching the Physician order for all code status to the electronic medical record and the DNR/MOST book located at each nurse's station. The DON or designee will complete the required audits as outlined above. Results will be reviewed upon completion of audits with QAPI team monthly for the next 3 months minimum to determine success and potential need for continuation or until substantial compliance is achieved. Alleged Date of Immediate Jeopardy Removal and Compliance: 7/11/25 The facility's corrective action plan was validated on 8/25/25 by the following: Interviews with licensed nursing staff, admissions coordinator, Director of Marketing, Social Worker, and medical records revealed they had received education on resident advanced directives paperwork. They stated when a new admission arrived at the facility with completed advanced directive paperwork, a copy of the paperwork was to be placed inside the medical records box to be scanned into the resident's electronic health record (EHR) and the original was to be placed inside of the advanced directive notebook located at each nurse desk. They revealed if a resident completed their advanced directive paperwork upon their arrival to the facility or anytime during their stay at the facility the original paperwork was to be placed inside the physician notebook located at each nurse desk and then once signed by the physician the original would then be placed inside the advanced directive notebook and a copy of the paperwork placed inside the medical records box to be scanned into the resident's EHR. They stated the original advanced directive was to be sent as part of the facility packet anytime a resident was leaving the facility for an appointment, transfer to the hospital, or discharged from the facility. They were able to demonstrate the process, and observations were made of all residents original advanced directive forms located in the advanced directive notebook at each nurse desk and copies of advanced directives were located inside the medical records box waiting to be scanned into the resident's EHR. Review of facility orientation education for new hires and contract staff included education on advanced directive process. Reviewed the audit and monitoring tools with no issues noted. Interviews with the Administrator and the DON revealed they had received training from their corporate regarding the advanced directive process and making sure all original advanced directives were placed inside the advanced directive notebooks, copies were placed inside the medical records box for scanning, only advanced directives that needed a physician signature were placed inside the physician notebook, and original advanced directive was included with facility paperwork for any resident appointments, transfers, or discharges. The facility's immediate jeopardy removal date and compliance date of 7/11/25 was validated.