**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, review of emergency medical services (EMS) run report, staff interview, and facility policy review, the facility failed to initiate Cardiopulmonary Resuscitation or timely call EMS for Resident #13, a resident with advance directives for a Full Code status (indication for healthcare providers to perform all possible lift-saving measures in the event of a cardiac or respiratory arrest). This resulted in Immediate Jeopardy and Actual Harm/Subsequent Death on [DATE] at 5:40 P.M. when Resident #13 was found unresponsive and Licensed Practical Nurse (LPN) #521 failed to initiate CPR. EMS was not called until [DATE] at 6:23 P.M. and arrived at the facility at 6:32 P.M. Upon arrival, EMS determined Resident #13 was deceased , CPR was not in progress by facility staff and EMS were informed Resident #13 had been pronounced deceased in the facility at 5:40 P.M. This affected one resident (#13) of ten residents reviewed for death. The facility census was 53. On [DATE] at 1:27 P.M., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) #615 were notified Immediate Jeopardy began on [DATE] at 5:40 P.M. when Resident #13 was found unresponsive and Licensed Practical Nurse (LPN) #521 failed to initiate CPR or timely summon EMS services. The resident, who had advance directives for a Full Code status was subsequently pronounced deceased at the facility. The Immediate Jeopardy was abated on [DATE] when the facility implemented the following corrective actions: On [DATE] at 1:00 P.M. Managerial staff, Regional Director of Clinical Services (RDCS) #601, the Administrator, and the DON met and reviewed data collaboratively. A root cause analysis was conducted and system failure identified LPN #521 did not know Resident #13's code status and did not initiate CPR. On [DATE] at 2:00 P.M. the Administrator and DON received education from [NAME] President of Clinical Services (VPCS) #618 and [NAME] President of Operations (VPO) #617 on the following topics: where to locate advanced directives, CPR policy, Code Blue Flow Sheet, that hospice was not a code status and that advanced directives still need checked. The staff were educated to check the bed board, with a new process to add code status daily for staff and contracted service providers was also provided. Staff were educated to check the bed board, change of condition, communication during a code the crash cart, and staffing assignments. On [DATE] at 3:00 P.M. an Ad Hoc Quality Assurance and Performance Improvement (QAPI) was held. The meeting was held with the Administrator, the DON, Minimum Data Set (MDS) Coordinator #613, Medical Director (MD) #614, Dietary Director #602, Social Services Director #557, Medical Records #582, Activity Director #513, ADON #615, Human Resources Director (HRD) #520, Director of Rehabilitation (DoR) #565, Wound Care LPN #603, and Environmental Services Director (ESD) #550. The Administrator and the DON educated management on where to locate advanced directives, the facility CPR policy, Code Blue Flow Sheet, that hospice was not a code status and that advanced directives still needed checked, and new bed board process to add code status daily for staff. Contracted service providers would be educated to check the bed board, change of condition, communication during a code, crash cart, and staffing assignments. A Root Cause analysis was reviewed. The facility would give each service provider a memo upon entering the building that stated the facility's new process, they were to sign off on the sign off sheet that they were given the memo and had read and understood. In addition, the facility would be emailing all appropriate service providers the memo. On [DATE] at 3:30 P.M. 32 Certified Nurse Aides (CNAs), 19 LPNs, four Registered Nurses (RN), seven housekeepers, six receptionists,16 therapists, and 2 activity employees were educated on where to locate advanced directives, CPR policy, Code Blue Flow Sheet, that hospice is not a code status and advanced directives still need checked, and the new bed board process to add code status daily for staff. Contracted service providers will be educated to check the bed board, change of condition, communication during a code and crash cart, and staffing assignments by ADON #615 and the DON. On [DATE] at 4:00 P.M. a whole house audit for 58 residents' code status orders were reviewed for accuracy by ADON #615. This would be reviewed daily during clinical meetings, and the DON/designee would update and check the code status for new admissions. On [DATE] at 4:30 P.M. 58 resident care plans were reviewed for accuracy by MDS Coordinator #613. On [DATE], ADON #615 audited all current nurse's CPR certification records to ensure nursing staff had current CPR certification. No nurses were permitted to work until their active CPR certification was verified by Administration. On [DATE] at 8:00 A.M. Former Director of Nursing (FDON) #604 ran the 72-hour audit report on 58 residents to assess for change of condition that was not addressed. No issues were identified. The DON/designee would audit the 24 hour and 72-hour report. On [DATE] at 10:30 A.M. the DON and ADON #615 audited the three LPNs and four CNAs on duty and had them locate in the electronic medical record where the resident's code status was located. On [DATE] at 12:00 P.M. the DON/designee completed a mock code blue drill to identify areas of struggle. On [DATE] at 2:00 P.M. the Administrator, RDCS #601, and Regional Director of Operations (RDO) #599, administered a hands-on and written post-test for all nurses working. RDCS #601 and RDO #599 went to the units and demonstrated how to use the overhead page. RDCS #601 demonstrated how and where to look in the electronic medical record for code status. RDCS #601 and RDO #599 demonstrated how to use the walkie talkies. Shortly after the demonstration, ADON #615 had the staff perform a return demonstration of locating code status in the electronic medical record. Beginning on [DATE], an audit of the bed board code status would be reviewed and updated five times per week on an ongoing basis. This would be completed by the DON. Results of the audit would be reviewed through the facility's QAPI process. Beginning on [DATE], mock code blue drills would be conducted five times per week on alternating shifts for four weeks, then weekly on alternating shifts for four weeks. The mock code scenarios would be provided on a code response form. Staff participating in the mock codes would document on the code blue documentation nurses note form to record action taken and was the form the facility utilizes to document codes at the facility. The form included the time the code was called, time CPR was started, the time the squad arrived, whether the resident was transferred, and a notation on when and why resuscitative efforts were terminated with a notation on the form that resuscitation can only be terminated by a paramedic or doctor and that a nurse cannot stop a code. The mock codes would be overseen by the DON or designee. The results of the audits would be reviewed through the facility's QAPI process. Beginning on [DATE], a code blue drill would be conducted five times per week on alternating shifts for four weeks, then weekly on alternating shifts for four weeks. These audits would be completed by the DON or designee using the code response form. Beginning on [DATE], the DON or designee would begin auditing 24-hour or 72-hour reports from the electronic medical record system to audit for any resident changes in condition, to ensure changes in condition were appropriately addressed. This would be completed five times per week on an ongoing basis. The results of the audits would be reviewed through the facility's QAPI process. Beginning on [DATE], interview questionnaires would be conducted with first floor staff on how to obtain help during emergency situations on alternating shifts five times per week for four weeks, then weekly for four weeks. These interviews would be conducted by the DON or designee. The results would be reviewed through the facility's QAPI process. Beginning on [DATE], the crash cart would be audited by the DON or designee to ensure all needed supplies are contained in the crash cart. The audits would take place on alternating shifts five times per week for four weeks, then weekly for four weeks. The results of the audits would be reviewed through the facility's QAPI process. Beginning on [DATE], the DON or designee would audit the first-floor staffing, to ensure scheduled staff members are present as scheduled, five times per week on random shifts for four weeks, then weekly on random shifts for four weeks. The results of the audits would be reviewed through the facility's QAPI process. On [DATE] at 4:00 P.M., RDCS #601 provided additional one-on-one education to LPN #521 regarding what the Code Blue form is and when to utilize it. LPN #521 verbalized understanding. Although the Immediate Jeopardy was removed on [DATE], the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include:Review of the closed medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, asthma, hemiplegia/hemiparesis after a stroke affecting the left nondominant side, congestive heart failure, atrial fibrillation, rectal cancer, and heart disease. Review of the physician's orders for Resident #13 revealed an order written on [DATE] for the resident to be a Full Code. Review of Resident #13's care plan revised on [DATE] revealed the resident had chosen to be a full code. Review of Resident #13's Hospice Care Hospice Services General Consents contract, dated [DATE], revealed the resident consented to hospice providing all services, supplies and medications related to his hospice diagnosis as ordered by his attending physician. The resident also selected he did not want to be a Do Not Resuscitate (DNR). Hospice services began as of [DATE]. An order was written on [DATE] to admit to hospice with a terminal diagnosis of hypertensive heart disease and chronic kidney disease with heart failure. Hospice was to be notified of all changes, falls, medication errors, equipment issues, and death. Record review revealed no changes to the resident's advance directive status on this date. Review of the comprehensive significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 was cognitively intact, rejected care daily, and had a life expectancy of less than six months. The assessment revealed the resident was receiving hospice services. Review of the resident's hospice notes dated [DATE] through [DATE] revealed no acute concerns were identified during this time period. The resident was assessed by the hospice nurse on [DATE] and [DATE]. The hospice note(s) identified the resident was a full code. Review of the hospice notes from Hospice Registered Nurse (HRN) #700 dated [DATE] revealed the following: Upon her arrival to the facility, she went to the second-floor nurses' station, and no staff were observed on the floor. HRN #700 went to Resident #13's room at approximately 5:35 P.M. LPN #521 and LPN #510 were in the resident's room along with facility aides. They were on speaker phone with the DON. LPN #521 reported she was unable to obtain the resident's blood pressure or oxygen level despite multiple attempts. HRN #700 noted the resident appeared to be actively transitioning. His pupils were fixed and dilated, respirations decreased to four to five breaths per minute, and his eyes were rolling to the back of his head. HRN #700 listened with her stethoscope to the resident's heart for three minutes but was unable to auscultate a heart rate. The resident was pronounced deceased at 5:40 P.M. The DON was notified via speaker phone. LPN #510 notified Medical Director (MD) #614 at approximately 5:43 P.M. who provided an order to release the resident's body to the funeral home. Hospice Director of Nursing (HDON) #701 was notified, and a death visit was initiated. Facility CNAs provided postmortem care. Multiple calls were made to Resident #13's emergency contacts but were unable to reach them. The crash cart was brought to the resident's room at approximately 6:15 P.M. and EMS arrived on scene approximately 20 minutes later at 6:35 P.M. HRN #700 asked the facility staff who had called EMS and why but received no answer from the facility staff. HRN #700 answered EMS's questions regarding Resident #13's health history and hospice eligibility. EMS voiced understanding and cleared the scene. HMD #702 was also updated on the resident's death. Review of the EMS run report for Resident #13, dated [DATE], revealed an unnamed facility staff called 911 at 6:23 P.M. for a cardiac/respiratory arrest with the priority listed as an emergency. EMS arrived at Resident #13's bedside on [DATE] at 6:32 P.M. The report indicated upon arrival a deceased male was found lying supine in bed after passing away at the facility at 5:40 P.M. per the facility staff. The report included Resident #13 was noted to be a hospice patient who had the facility staff and hospice personnel present at his passing. The narrative referenced there was confusion when contacting family and somehow 911 had been called at approximately 6:23 P.M., with contact made at 6:32 P.M., almost an hour after the patient had passed away. The nursing home managers apologized to EMS and stated they never should have been called. The narrative concluded by referencing the resident was DOA (dead on arrival) and left in the care of the facility and hospice staff. The section of the report indicating if CPR had been provided prior to EMS care was recorded as No. Review of a nursing progress note dated [DATE] at 8:20 P.M. (recorded as a late entry on [DATE] at 4:31 P.M.) revealed on [DATE] at 5:40 P.M., LPN #521 was notified by HRN #700 that Resident #13 was absent of vital signs. LPN #521 documented that, upon verification of the resident's code status of full code, emergency protocol was initiated. A Code Blue (a medical emergency signal indicating a cardiac or respiratory arrest) was paged overhead. A second nurse and a certified nurse aide (CNA) came to assist with the emergency bringing the crash cart (a cart where lifesaving equipment is stored) with them. The second nurse went to call 911 and print out the paperwork needed. Approximately 10 minutes after calling 911, EMS arrived and took over CPR. EMS was not notified that the resident was on hospice but there was still a full code. LPN #521 documented after several rounds of CPR, the lead EMS called the emergency physician and confirmed the time of death. Interview with LPN #521 on [DATE] at 9:50 A.M. revealed she did not know much about Resident #13, but stated Certified Nursing Assistant (CNA) #593 would be able to provide more information. Interview with CNA #593 on [DATE] at 9:55 A.M. revealed she regularly provided care for Resident #13. CNA #593 said the resident was on hospice but still wanted to be a full code. The CNA stated the resident was alert and oriented and liked to go on leave of absence (LOA) from the facility in his motorized wheelchair. CNA #513 said she worked with Resident #13 two days before he died. She stated she had a hard time helping him get comfortable due to a wound on his buttocks but stated he rarely complained about anything. Interview with LPN #521 on [DATE] at 11:25 A.M. revealed she took over care of Resident #13 at 3:30 P.M. when the day shift nurse left. LPN #521 denied receiving report from off-going nurse LPN #506, as report was given to a different unidentified nurse. LPN #521 stated she did not know when HRN #700 arrived at the facility. LPN #521 said CNA #555 came to her and said Resident #13 did not look good, so she went to the resident's room to check on him. LPN #521 said she checked for a pulse and was able to feel a faint one. HRN #700 was also in the room and LPN #521 said HRN #700 said Resident #13 did not have a pulse. LPN #521 said she went into CPR mode and HRN #700 assisted her. LPN #521 was unable to provide a time she began CPR and stated she did not complete a Code Blue sheet. LPN #521 said someone brought the crash cart to the resident's room while someone else called 911. LPN #521 said when EMS arrived, they told her there was nothing to do as the resident was a hospice resident. LPN #521 told EMS the resident was a full code. EMS then took over care of Resident #13 and replaced LPN #521 from performing CPR. LPN #521 stated she did not know what time EMS arrived or at what time they took over CPR. LPN #521 stated the EMS personnel placed a big box-like piece of equipment on the resident's chest. She did not know what it was. LPN #521 stated she had worked for the facility for approximately a month and had just received her nursing license in [DATE]. Interview with Medical Director (MD) #614 on [DATE] at 2:25 P.M. revealed he had provided care to Resident #13 for many years and had been his physician prior to the resident being admitted to the facility. MD #614 said he examined the resident about a week before his death, and the resident had no complaints at that time. The MD revealed there was nothing indicating Resident #13 might be developing a potential problem between that time and when he passed away. Interview with Hospice Director of Nursing (HDON) #701 on [DATE] at 10:15 A.M. revealed HRN #700 arrived at the facility at approximately 5:20 P.M. At 5:43 P.M. HRN #700 went to Resident #13's room after being unable to locate any staff to provide an update for her. When she entered the resident's room, facility staff were at the bedside attempting to obtain vital signs. HRN #700 used her stethoscope to auscultate a heart rate and after three minutes was unable to obtain an apical pulse. HDON #701 confirmed CPR was never started on Resident #13 at any time by facility staff. HDON #701 said EMS arrive at the facility at 6:35 P.M. EMS did not attempt CPR or any other life saving measures as the resident had died at 5:40 P.M. Interview with MD #614 on [DATE] at 12:27 P.M. verified at the time Resident #13 he was a full code. MD #614 said he believed Resident #13 was not ready to accept that his desire to be a full code did not align with his not wanting to go to the hospital again, especially since he had just been discharged from the hospital recently. When the resident passed away, the facility did call and tell him, but he stated it was just notification of death and not a question regarding if the resident should be coded. MD #614 was unaware EMS had been called 50 minutes after Resident #13 was pronounced deceased . Interview with HRN #700 on [DATE] at 2:12 P.M. revealed the facility had contacted hospice around 1:00 P.M. to let them know Resident #13 had vomited. HRN #700 said she called the facility and was placed on hold and then the call was disconnected. HRN #700 said she called back a second time and spoke with LPN #521 who informed LPN #506 (the resident's assigned nurse) HRN #700 was on the phone, but LPN #506 was busy and unable to speak with HRN #700 and advised her to call back around 3:00 P.M. as that was change of shift. HRN #700 said she arrived at the facility at approximately 5:20 P.M. and remained at the nurses' station looking for a staff member to update her but did not see anyone. HRN #700 stated she then went to Resident #13's room and found LPN #521 and LPN #510 at the bedside attempting to obtain a blood pressure and pulse without success. HRN #700 took out her stethoscope and attempted to obtain an apical pulse for three minutes but was unable to auscultate one. HRN #700 told LPN #521 and LPN #510 Resident #13 was actively passing. LPN #521 and LPN #510 contacted MD #614 to notify him, and she contacted the hospice medical director. HRN #700 said she was unaware Resident #13 was a full code as LPN #521 and LPN #510 did not inform her of that. HRN #700 said Resident #13 had blood on his gown and his pillow from the earlier coffee ground emesis. During the interview, HRN #700 revealed after speaking to the funeral home, LPN #521 and LPN #510 approached HRN #700 and LPN #521 and asked her to lie and say she (LPN #521) and HRN #700 had provided CPR. HRN #700 stated she refused to lie and state CPR was provided when it was not. HRN #700 said she also spoke with the facility's DON on the phone and said the DON was upset with hospice and that Resident #13 should have had an advance directive of ‘do not resuscitate'. HRN #700 said the DON was upset but she also told the DON she would not lie and say CPR had been provided. The DON had stated she had already told their corporate personnel that CPR had been provided to Resident #13. Interview with LPN #506 on [DATE] at 3:21 P.M. revealed she was aware Resident #13 had a full code status even though he was on hospice services. A call was placed to CNA #519 on [DATE] at 3:37 P.M. as she worked the 3:00 P.M. to 11:00 P.M. on [DATE]. A message was received that the call could not be completed. A call was placed to CNA #555 on [DATE] at 3:58 P.M. as she worked on [DATE]. A recorded message indicated CNA #555's mailbox was full, and a message could not be left. A call was placed to CNA #621 on [DATE] at 4:06 P.M. as she worked the 3:00 P.M. to 11:00 P.M. on [DATE]. A message was received that the call could not be completed. Interview with CNA #566 on [DATE] at 4:21 P.M. revealed she worked the 3:00 P.M. to 11:00 P.M. on [DATE]. CNA #566 said she was in a room with another resident when a code was called. She stated she took the crash cart to Resident #13's room. She stated she did not remember if anyone was performing CPR. CNA #566 did not how long the code lasted or who called 911. CNA #566 revealed she was not certified in CPR. An interview was conducted on [DATE] at 1:16 P.M. with LPN #510 who revealed she was working in the facility at the time Resident #13 had a change of condition, but she was not his nurse. When asked if chest compressions or breaths were performed on Resident #13, LPN #510 stated she was not sure. She stated she was at the resident's bedside, left the room, and passed the hospice nurse who was just walking into the room. LPN #510 stated she checked Resident #13's code status, called 911 and the DON, but did not recall what time. LPN #510 stated she got the crash cart, set the crash cart in the doorway of Resident #13's room, and left. She stated she did not know what happened after that. A follow up interview on [DATE] revealed LPN #510 clarified she had taken the crash cart to the room then started getting the paperwork together that EMS would need when they arrived. She stated she did not participate in a code. LPN #510 stated she believed the resident was a full code and checked the electronic medical record to confirm that. LPN #510 said when someone codes, she always checks the resident's code status before starting CPR. LPN #510 said no one directly asked her to lie and say CPR was started on the resident. Review of the facility policy Emergency Procedure-Cardiopulmonary Resuscitation (CPR) last revised [DATE] revealed the facility would 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 was responsible for coordinating the rescue effort and directing other team members during the rescue effort. The CPR team in this facility shall include at least one nurse, one LPN and two CNAs. If an individual was found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest was likely, begin CPR. Instruct a staff member to activate the emergency response system (EMS) and call 911. Instruct a staff member to retrieve the automatic external defibrillator (AED). Verify the code status of the resident. Continue with CPR until EMS arrives. Review of the facility policy Charting and Documentation last revised [DATE] revealed documentation of procedures and treatments would include care-specific details, including: the date and time the procedure/treatment was provided; the name and title of the individual(s) who provided the care; the assessment data and/or any unusual findings obtained during the procedure/treatment; how the resident tolerated the procedure/treatment; whether the resident refused the procedure/treatment; notification of family, physician, or other staff, if indicated; and the signature and title of the individual documenting. This deficiency represents noncompliance investigated under Master Complaint Number 2612264 and Complaint Numbers 2578214 and 1381901.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, closed record review, review of emergency medical services (EMS) run reports, review of the facility assessment and floor plan, review of facility staffing, policy review and interview, the facility failed to accurately assess and provide timely and necessary medical intervention for residents identified to have an acute change in condition. In addition, the facility failed to provide basic life support (BLS) and Cardiopulmonary Resuscitation (CPR) in accordance with BLS/CPR standards of practice, failed to maintain adequate staffing resources to allow for efficient and effective emergency response to residents' with cardiopulmonary arrest, and failed to have effective systems in place for staff to obtain timely assistance during a CPR code. This resulted in Immediate Jeopardy and Actual Harm/Subsequent Death for Resident #13, #58 and #74. This affected three residents (#13, #58, and #74) of 22 residents reviewed for change in condition. The facility census was 53. Immediate Jeopardy began on [DATE] at approximately 12:30 A.M. when Resident #74 was assessed to have shortness of breath with a low oxygen saturation (71%). The nurse on duty failed to notify the physician or provide adequate intervention. The resident's oxygen saturation remained low (85% and 89%) when checked following the administration of aerosol treatment and application of Bilevel Positive Airway Pressure (BiPAP) (a noninvasive ventilation system to administer supplemental oxygen) with no evidence of physician notification or medical intervention. At approximately 2:10 A.M. the resident was found on the floor of his room. Licensed Practical Nurse (LPN) #532 began CPR per the resident's advance directives; however, the LPN did not check to see if the resident had a pulse prior to implementation. The other nurse on duty (LPN #633) took over 30 minutes to call 911 causing a delay in emergency medical services (EMS) response/assistance. EMS arrived at the facility at 2:57 A.M. and transported Resident #74 to a local hospital where he was pronounced deceased on arrival at the emergency room (ER) at 3:33 A.M. The Immediate Jeopardy continued on [DATE] when Resident #58 told Registered Nurse (RN) #511 she was having respiratory distress. RN #511 did not check the resident's vital signs before administering treatment and then left the resident unattended to get oxygen. When RN #511 returned, Resident #58 was unresponsive. Without assessing the resident's vital signs, RN #511 again left the resident to go to another floor to get help. Upon return to the resident's room, CPR was initiated without first assessing to see if the resident had a pulse and without use of a backboard (a necessary component to CPR which provides a firm, non-compressible surface and reduces mattress displacement allowing for effective compressions). EMS arrived onsite and took over CPR at 3:10 A.M. Resident #58 was subsequently pronounced deceased on arrival at the emergency room (ER) at 3:45 A.M. The unit Resident #58 resided on at the facility had just opened in [DATE] with single occupancy rooms for skilled residents. There was no staffing plan for this unit in the facility assessment. In addition, there was no communication system in place for emergent situations and staff working on the unit had to physically leave the unit to go to the second floor to get additional staff assistance when/if needed. The Immediate Jeopardy continued on [DATE] at 1:04 P.M. when LPN #506 failed to notify Medical Director (MD) #614 or provide medical intervention when Resident #13, (who had advance directives for a Full Code status) was assessed to have an acute change in medical condition. The resident had coffee ground emesis, was hypotensive (blood pressure of 87/60 (normal ranges from 120/80)), tachycardic (pulse of 114 (normal ranges from 60 to 100 beats per minute (bpm)), and an oxygenation level of 93 percent (%) (normal ranges from 95 to 100%) on room air. At 5:40 P.M., Resident #13 was found unresponsive with no intervention provided. EMS were not contacted until [DATE] at 6:23 P.M. and arrived at the facility at 6:32 P.M. Upon arrival, EMS determined Resident #13 was deceased , CPR was not in progress by facility staff, and EMS was informed that Resident #13 had been pronounced deceased at the facility at 5:40 P.M. On [DATE] at 4:20 P.M. the Director of Nursing (DON), Administrator, Regional Director of Clinical Services (RDCS) #601, and Regional Director of Operations (RDO) #559 were notified Immediate Jeopardy began on [DATE] at 2:10 A.M., when the facility failed to ensure comprehensive systems were in place to timely identify and provide necessary intervention to Resident #74 who experienced an acute change in condition resulting in the resident's death. The Immediate Jeopardy continued on [DATE] and [DATE] when the facility continued to ensure comprehensive systems were in place to timely identify and provide necessary intervention to residents (#58 and #13) who experienced an acute change in condition resulting in resident death. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 4:30 P.M. during a TEAMS (virtual) call with [NAME] President of Operations (VPO) #617, [NAME] President of Clinical Services (VPCS) #618 educated the Administrator, DON, RDCS #601, and RDO #599, on the facility CPR policy, emergency response processes, and code blue flow sheets related to how to respond to emergency situations and to notify others for help by use of walkie-talkie or overhead paging system. On [DATE] at 5:00 P.M., RDCS #601 and the Administrator provided education to Activities Director (AD) #513, Housekeeping Services Director (HSD) #550, the DON, the Assistant Director of Nursing (ADON) #615, Medical Records Director (MRD) #582, Maintenance Director #538, Director of Social Services (DSS) #557, Minimum Data Set Director (MDSD) #613, Dietary Manager (DM) #602, Human Resources Director (HRD) #520, and Wound Care Nurse (WCN) #603, on the CPR policy, emergency response processes, and code blue flow sheets related to how to respond to emergency situations and to notify others for help by use of walkie-talkie or overhead paging system. On [DATE] at 5:45 P.M. an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was led by RDCS #601 and the Administrator who identified the root cause analysis to be lack of education on the facility CPR policy and emergency response/notification protocols. The members in attendance were identified to be AD #513, HSD #550, the DON, ADON #615, MRD #582, Maintenance Director #538, DSS #557, MDSD #613, DM #602, HRD #520, WCN #603 and Medical Director (MD) #614 via the telephone. On [DATE] at 6:45 P.M. RDCS #601 and RDO #599 educated all staff (32 Certified Nursing Assistants (CNAs), 19 LPNs, four RNs, seven housekeeping staff, six receptionists, 16 therapists, and two activities staff) on the facility CPR policy, emergency response processes, and code blue flow sheets related to how to respond to emergency situations and to notify others for help. On [DATE] by 5:30 P.M. all 58 residents were assessed by the DON, WCN #603, and ADON #615 for any acute changes in condition. On [DATE] starting at 5:00 P.M., Corporate RN Basic Life Support Instructor #619 and Corporate LPN Basic Life Support Instructor provided CPR recertification to nine nurses (LPN #551, ADON #615, the DON, LPN #521, LPN #559, LPN #510, WCN #603, LPN #607, and LPN #504). All nurses who did not attend were removed from the schedule until they were able to provide updated CPR recertification. On [DATE] at 4:30 P.M., RDCS #601 conducted an audit on crash carts to ensure they were stocked and readily available for an emergency situation. On [DATE] at 6:00 P.M. all clinical staff (32 CNAs, 19 LPNs, and 4 RNs), received education by RCDS #601 and Former DON (FDON) #604 validating that code statuses were updated. Three resident orders (Resident #87, Resident #60, and Resident #23) were updated for code statuses. On [DATE] at 6:15 P.M., VPO #617, VPC #618, RDCS #601, RDO #599, the Administrator, and the DON met to discuss future staffing for when closed units opened. Beginning on [DATE], RDCS #601 initiated education to all clinical staff, also to include scheduler/HR, DON and the Administrator, to ensure there was always a minimum of one staff member on the first floor. On [DATE], the DON/Designee would perform mock code blues on alternating shifts five times a week for four weeks, then weekly on alternating shifts for four weeks. Audits would be documented on the code blue flow sheet. All audits performed would be recorded and reviewed during the weekly QAPI. Beginning on [DATE], CPR policy training would be conducted during new hire orientation and every six months with staff. The DON would be responsible to ensure that all new hires received the information during new hire orientation and would monitor the education (related to the CPR policy, emergency response processes, and code blue flow sheets on how to respond to emergency situations and to notify others for help) every six months. Beginning on [DATE], education topics were added to all new hire orientation training. The DON would ensure that if any employee received orientation at a sister facility, they would ensure all education topics were completed prior to starting on the floor. On [DATE] at 4:30 P.M. 58 resident care plans were reviewed for accuracy by MDS Coordinator #613. On [DATE] at 8:00 A.M. FDON #604 ran the 72-hour audit report on 58 residents to assess for change of condition that was not addressed. The DON/designee would audit the 24-hour and 72-hour report. On [DATE] at 12:00 P.M. the DON/designee completed a mock code blue drill to identify areas of struggle. On [DATE] at 2:00 P.M. the Administrator, RDCS #601, and RDO #599, administered a hands-on and written post-test for all nurses working. RDCS #601 and RDO #599 went to the units and demonstrated how to use the overhead page. RDCS #601 demonstrated how and where to look in the electronic medical record for code status. RDCS #601 and RDO #599 demonstrated how to use the walkie talkies. Shortly after the demonstration, ADON #615 had the staff perform a return demonstration of locating code status in the electronic medical record. Beginning on [DATE], an audit of the bed board code status would be reviewed and updated five times per week on an ongoing basis. This would be completed by the DON. Results of the audit would be reviewed through the facility's QAPI process. Beginning on [DATE], the DON or designee would begin auditing 24-hour or 72-hour reports from the electronic medical record system to audit for any resident changes in condition, to ensure changes in condition were appropriately addressed. This would be completed five times per week on an ongoing basis. The results of the audits would be reviewed through the facility's QAPI process. Beginning on [DATE], interview questionnaires would be conducted with first floor staff on how to obtain help during emergency situations on alternating shifts five times per week for four weeks, then weekly for four weeks. These interviews would be conducted by the DON or designee. The results would be reviewed through the facility's QAPI process. Beginning on [DATE], the crash cart would be audited by the DON or designee to ensure all needed supplies are contained in the crash cart. The audits would take place on alternating shifts five times per week for four weeks, then weekly for four weeks. The results of the audits would be reviewed through the facility's QAPI process. Beginning on [DATE], the DON or designee would audit the first-floor staffing, to ensure scheduled staff members are present as scheduled, five times per week on random shifts for four weeks, then weekly on random shifts for four weeks. The results of the audits would be reviewed through the facility's QAPI process. On [DATE] at 4:00 P.M., RDCS #601 provided additional one-on-one education to LPN #521 regarding what the Code Blue form was and when to utilize it. LPN #521 verbalized understanding. Although the Immediate Jeopardy was removed on [DATE] the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the closed medical record revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), schizophrenia, depression, dependence on supplemental oxygen, heart disease, and a history of a stroke without residual effects from the stroke. Review of the physician's orders for Resident #74 revealed the following: An order dated [DATE] for one puff of a Ventolin inhaler every six hours as needed for asthma, and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 milligrams (mg) per 3 milliliters to be inhaled every six hours as needed for wheezing. An advance directive order dated [DATE] for a Full Code (attempt all life-saving treatment) if his heart were to stop beating. An order dated [DATE] for oxygen to be administered continuously at four liters per minute via nasal cannula. An order written [DATE] to apply Bilevel Positive Airway Pressure (BiPAP) (a noninvasive ventilation system to administer supplemental oxygen) 45 minutes intermittently as often as possible throughout the day, every three hours for low oxygen levels. Review of the Medicare five-day comprehensive Minimum Data Set (MDS) 3.0 assessment for Resident #74 dated [DATE] revealed the resident was severely cognitively impaired, became short of breath when lying flat, and received oxygen as well as non-invasive ventilation. Review of the care plan related to Advance Directives for Resident #74, last revised on [DATE] revealed to implement full code measures per the resident's request. Review of a nursing progress note for Resident #74 dated [DATE] at 4:00 A.M. revealed LPN #532 documented at the start of her shift the resident was alert and oriented. At approximately 12:30 A.M., Resident #74 was lying flat. LPN #532 elevated the resident's head of the bed and checked his oxygen level. The resident's oxygen level was 71% (abnormal low). LPN #532 had Resident #74 use his as needed Ventolin and Ipratropium aerosol for shortness of breath. Upon completion of the breathing treatment, LPN #532 re-checked the resident's oxygen level, and it had increased to 85% (which remained below normal range). The note included LPN #532 applied the resident's BiPAP around 1:00 A.M. then re-checked his oxygen level after using it for a short while, and his oxygen level increased to 89% (remained below normal range). There was no evidence the physician was notified or evidence of adequate intervention to address this change in the resident's condition. Continued review of the nursing progress note authored by LPN #532 revealed at 2:10 A.M., LPN #532 went to check on Resident #74 and was met in the hallway by Resident #74's roommate who informed the nurse that Resident #74 was on the floor. The progress note revealed LPN #532 immediately began CPR with CNA #610 assisting with the code. The CNA re-applied Resident #74's oxygen. The note included at 2:38 A.M., 911 (EMS) was called to transport the resident to the hospital. CPR continued until EMS arrived and took over care. LPN #532 notified the Director of Nursing (DON), the Assistant Director of Nursing (ADON) the Medical Director (MD), and the resident's next of kin regarding what happened and his transport to the local emergency room (ER). LPN #532 documented on [DATE] at 4:28 A.M. that she contacted the ER and was informed Resident #74 had passed away. Review of the EMS Run Report, dated [DATE], revealed EMS received a call from the facility at 2:44 A.M. and arrived at the facility at 2:57 A.M. Resident #74 was found by EMS with CPR being performed on the floor by facility staff. After EMS arrived, they confirmed asystole (no pulse) on a monitor, they took over CPR and transported Resident #74 to the local hospital emergency room where he was pronounced dead on arrival at 3:33 A.M. An interview with LPN #532 on [DATE] at 4:09 P.M. revealed she always worked the night shift from 11:00 P.M. to 7:00 A.M. and she was typically assigned to work on the second floor. She verified she was the nurse assigned to care for Resident #74 on ([DATE]) the night the resident coded and passed away. LPN #532 stated on this night she had the resident sit up on the edge of his bed, she gave him his inhaler and then breathing treatment for shortness of breath. LPN #532 stated she felt Resident #74 was feeling better after his breathing treatment. LPN #532 said about an hour later she went to see how the resident was feeling and was informed by Resident #74's roommate that the resident was on the floor. LPN #532 said she yelled for help immediately and CNA #610 said she was CPR certified and offered to help. LPN #532 said she did not check to see if Resident #74 had a pulse, she just started CPR. LPN #532 stated that LPN #633 called 911 but it took LPN #633 30 minutes before she called 911 for emergency services. LPN #532 stated she did not know why it took LPN #633 so long to call 911. LPN #532 stated she later contacted the hospital and was told Resident #74 had expired. LPN #532 stated she was orienting LPN #633 that shift, and LPN #633 brought the crash cart to Resident #74's room. During the interview LPN #532 stated LPN #633 and CNA #610 no longer worked at the facility but did not provide any additional information related to why. An interview on [DATE] at 11:35 A.M. with Medical Director (MD) #614 revealed EMS should be called immediately for any resident who goes into cardiac arrest. Medical Director #614 also stated the nurse should check for a pulse before starting CPR. A telephone interview with LPN #633 on [DATE] at 6:49 P.M. revealed she had only worked for the facility for a few weeks. During the interview, she stated she remembered the night of [DATE] when Resident #74 coded as stated it was very frightening. LPN #532 had yelled for help after the LPN had found the resident on the floor. CNA #610 was assisting LPN #532, so LPN #633 stated she went back to the nurses' station to try and find information about the resident so she could call for help. LPN #633 said she tried to call 911 but was unable to figure out how to use the facility phone. LPN #633 said she finally used her personal phone to call 911. LPN #633 said she did not know the address of the facility to provide to EMS. LPN #633 then said she printed off a copy of the face sheet for EMS and then had to go downstairs to get the copy. She stated she did not know the code to allow the squad to enter the facility. LPN #633 stated after the incident she changed her status to as needed and had not worked at the facility since. 2. Review of the closed medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including pneumonia, chronic obstructive pulmonary disease (COPD), diabetes, high blood pressure, congestive heart failure (CHF), major depressive disorder, and altered mental status. Review of the physician's orders dated [DATE] for Resident #58 revealed the following orders: skilled level of care and skilled assessment and monitoring every shift, full code status, head of the bed should be elevated to 45 degrees or higher to ease her breathing, use of an Albuterol inhaler one puff every six hours as needed for shortness of breath, Ipratropium Bromide 0.02% solution aerosol four times a day for asthma, and Albuterol-Budesonide aerosol 90-80 micrograms every six hours as needed for wheezing. Review of Resident #58's care plan (initiated [DATE]) revealed on [DATE] the care plan was updated to include the resident was known to refuse her oral inhaler, and the physician should be notified on refusals. There was no code status listed on the care plan. Review of the progress notes for Resident #58 dated [DATE] through [DATE] revealed Resident #58 had no complaints of respiratory distress or other complaints. There were no progress note entries made by nursing on [DATE]. Review of the comprehensive Minimum Data Set (MDS) 3.0 admission assessment, dated [DATE], revealed Resident #58 was severely cognitively impaired, required moderate to maximum assistance for all activities of daily living, had shortness of breath when lying flat, and was a smoker. The resident received speech therapy, occupational therapy, and physical therapy. Review of a progress note documented on [DATE] at 3:44 A.M. and authored by RN #511 revealed Resident #58 had activated her call light. RN #511 responded to the call light and the resident complained of being short of breath. RN #511 gave the resident her Albuterol inhaler and elevated the head of the resident's bed. The inhaler and elevating the head of the resident's bed was ineffective. RN #511 then initiated a breathing treatment and left the resident sitting on the edge of her bed. A few minutes later Resident #58 activated her call light again and told the nurse she needed oxygen. RN #511 left the room to get an oxygen concentrator. When RN #511 returned to the room, Resident #58 was laying across her bed and was unresponsive. The note revealed RN #511 then left the resident again and went up to the second floor to get another nurse, LPN #532. The note documented the nurses immediately started CPR while an unidentified CNA called 911 at 2:51 A.M. The progress note revealed the resident's heart rate was documented to be 188 beats per minute and oxygen was 57% (abnormal low). EMS arrived at 3:10 A.M. CPR was performed then by EMS. Resident #58 was transported to the ER, and the physician, DON and emergency contact were notified. Review of the EMS run report dated [DATE] revealed 911 received a call at 2:53 A.M. that Resident #58 needed emergency assistance and they arrived at the resident at 3:04 A.M. The resident was found lying in bed with facility staff performing CPR. Per staff, the resident was complaining of respiratory distress and staff left to get a breathing treatment and when they returned the resident was unresponsive, apneic and pulseless. Staff stated they then called EMS and started compression only CPR. EMS arrived and took over CPR. The resident was transported to the hospital with continuous CPR being provided but remained in asystole during transport. Review of the progress note dated [DATE] at 4:15 A.M. authored by RN #511 revealed the nurse called the hospital to get Resident #58's status and was told Resident #58 passed away at 3:45 A.M. An observation conducted on [DATE] at 2:40 P.M. revealed no staff were present on the first-floor nursing unit and no staff were observed in any of the resident occupied rooms on the unit. Six residents were present on the unit at the time of the observation (Resident #22, #26, #31, #35, #46, and #61). An interview with CNA #579 on [DATE] at 3:00 P.M. revealed she was assigned to care for the residents on the first floor today ([DATE]), but she came up to the second floor. When asked why she was on the second floor instead of her assignment on the first floor she stated I don't remember why she had come up to the second floor. CNA #579 confirmed she was not CPR certified and was unaware the facility had a CPR team. CNA #579 then went to the elevator and returned to the first floor. CNA #579 verified the first floor had been left without a staff member while she was on the second floor. On [DATE] at approximately 2:00 P.M. observation of the room Resident #58 had occupied revealed it was at the very end of the hallway farthest away from the elevator. In order for RN #511 to get help from the second floor, she walked 137.5 feet from the resident's bed to the first floor elevator, pushed the button to call the elevator, waited (an unknown amount of time) for the elevator to arrive, ascend to the second floor and locate the staff for help, then return to the resident's room. This distance was verified by Administrator #600 and Regional Director of Clinical Services #601 during an interview on [DATE] at 12:15 P.M. LPN #532, who was the nurse assigned to the second floor during interview as part of the on-site investigation stated she would estimate it would have taken two to three minutes for RN #511 to obtain assistance for Resident #58. Interview with the Director of Nursing (DON) on [DATE] at 11:25 A.M. revealed she had worked for the facility for several years as a night shift supervisor but had only been the DON for a few weeks. She stated the nurse assigned to the first floor also had residents assigned to her on the second floor and the facility recently (date not provided) changed staffing to always have a CNA working on the first floor. If an emergency were to occur, the CNA would call for help. The CNA could overhead page for help but most likely they would run to the second floor for help. Interview with RN #517 on [DATE] at 2:50 P.M. revealed she had worked for the facility for approximately one month. RN #517 was not aware the facility was supposed to have a code team consisting of one nurse and two CNAs and she was not aware the facility had a code blue documentation sheet. She further stated she received no information during orientation regarding mock code exercises. Interview with LPN #521 on [DATE] at 2:55 P.M. revealed she had worked for the facility for approximately one month. LPN #521 was not aware the facility was supposed to have a code team consisting of one nurse and two CNAs and she was not aware the facility had a code blue documentation sheet. She further stated she received no information during orientation regarding mock code exercises. Interviews with CNA #563 and CNA #523 on [DATE] at 3:05 P.M. revealed neither one was aware that there was a CPR team on each shift or that they were to be assigned to it. CNA #563 said she was certified in CPR for another facility and CNA #523 said she used to be CPR certified through the facility when they offered it, but it expired a few years ago. Interview with Former DON (FDON) #604 on [DATE] at 3:10 P.M. revealed she was unaware the facility was supposed to have a CPR team on each shift and revealed the CNA staff were not CPR certified. FDON #604 stated the facility did not have a crash cart policy and she had never seen a code blue documentation sheet. FDON #604 stated the facility had not yet come up with a plan regarding how the first-floor staff were to obtain help since the incident with Resident #58 had just occurred and they had not had time to determine how to fix the problem. The FDON stated they always had the capability of overhead paging and thought everyone knew how to do that. FDON further revealed that RN #511 should not have had to leave an unresponsive resident to obtain help. Interview with RDO #599 on [DATE] at 3:30 P.M. revealed she was unaware of the facility's CPR policy indicating there was a code team assigned to each shift consisting of one nurse and two CNAs and that the CNAs were not certified in CPR. She was unable to provide any information on mock code in-services. Interview with RN #511 on [DATE] at 4:30 P.M. revealed she was assigned to the first floor on [DATE]. She stated she preferred to be the one assigned to the first floor as opposed to an aide as she felt a nurse should be the first line of defense for the building. RN #511 confirmed she was also assigned residents on the second floor as well. During the interview, RN #511 revealed on [DATE] Resident #58 had activated her call light, and she went to her room to see what the resident needed. The resident said she was short of breath. RN #511 elevated the head of the resident's bed then went to the medication cart and brought the resident's Albuterol inhaler to use. The resident inhaled two puffs. Before RN #511 was able to leave the room, Resident #58 stated the inhaler was not helping and requested an aerosol treatment. RN #511 obtained the resident's Albuterol-Budesonide aerosol 90-80 micrograms and started the aerosol treatment. Resident #58 then requested oxygen be obtained. There was no evidence the RN conducted a comprehensive assessment (including vital signs or physical respiratory assessment) of the resident during this time Continued interview with RN #511 revealed she then left the first floor, went up to the second floor, and retrieved an oxygen concentrator and oxygen tubing which she then took back down to the resident's room. RN #511 stated she had left Resident #58 sitting up in bed when she went to get the oxygen and when she returned to the room, RN #511 found the resident lying on the bed. RN #511 said she nudged the resident, but nothing happened, and the resident did not respond. RN #511 said she was the only person working on the floor, so she had to leave the resident's room, go to the elevator, push the button for the elevator, take the elevator to the second floor then yell for help. The RN revealed LPN #532 and an unidentified aide came to RN #511's assistance and they returned to the first floor. When asked if there was any other way to obtain help, RN #511 reported no, she was not able to overhead page and stated staff had had requested walkie talkies in order to obtain assistance from the second floor, but nothing had come from it. RN #511 also revealed the facility did not have an AED to use on a resident who went into cardiac arrest. RN #511 said she and LPN #532 took the crash cart to Resident #58's room and the unidentified aide called 911. Upon entering Resident #58's room, RN #511 stated she and LPN #532 began CPR with the resident. The RN revealed they did not place a backboard under the resident. RN #511 stated prior to initiating CPR she did not check for a pulse, and the facility did not have an AED to determine if a resident required a shock to restart her heart. RN #511 said she and LPN #532 continued CPR until EMS arrived at which time the resident was transferred to the local ER. RN #511 said the evening shift nurse, LPN #544, had not reported anything unusual about Resident #58 at the earlier change of shift. Interview with LPN #532 on [DATE] at 4:09 P.M. revealed she was typically assigned to work on the second floor. During the interview LPN #532 revealed she remembered when Resident #58 coded. LPN #532 said the resident was in respiratory distress and RN #511 gave her an inhaler, then an aerosol treatment, then had to retrieve oxygen the resident wanted from the second floor. LPN #532 said the next thing she knew RN #511 returned to the second floor calling for help. LPN #532 said she and an unidentified aide went back to the first floor with RN #511. RN #511 and LPN #532 grabbed the crash cart and went to the resident's room while the aide called 911. LPN #532 said she thought Resident #58 had a pulse still as the pulse oximeter was picking up an oxygenation level. She stated RN #511 did not check for a pulse before starting CPR. LPN #532 said CPR continued until EMS arrived and took over. They transported Resident #58 to the ER where she was pronounced expired. Interview with DoR #565 on [DATE] at 10:50 A.M. revealed he had worked with Resident #58 on [DATE] and denied the resident had any concerns, complaints of shortness of breath, not feeling well, or chest pain. The DoR revealed the resident presented as per her normal and there was nothing out of the ordinary with the resident. The DoR revealed he was surprised when he heard the next day the resident had passed away. Interview with LPN #510 on [DATE] at 11:15 A.M. revealed she recalled Resident #58. The LPN revealed the resident was on the first floor in the new unit that opened sometime in [DATE]. LPN #510 said the resident was alert, independently mobile, and knew what she wanted. Resident #58 never complained about being short of breath, not feeling well, or chest pain. Interview with MD #614 on [DATE] at 11:35 A.M. revealed he was the only physician for the [TRUNCATED]