**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a Resident #4 received timely CPR per the physician's order when the resident was found unresponsive and without vital signs. The resident was pronounced deceased by EMS.On [DATE] at 11:26 a.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On [DATE] at 11:43 a.m., the administrator and DON were notified of the existence of the IJ situation and was provided the IJ template. On [DATE] at 4:28 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, [DATE] 3:58pm1.The facility failed to initiate CPR immediately when a resident with a full code status was found without signs of life.2. All residents residing in the facility who are full code status are at risk.3. Staff are in-serviced on policy and procedure of Medical Emergency Response and educated on locations of Code Status Identifiers for all residents residing in the facility. Signs are placed throughout facility for quick identification of how to respond to a resident without signs of life. DON updated code status sheets on [DATE].4. Plan will be completed [DATE] by 5:00pm.5. Staff present in building on [DATE] are in-serviced. Staff not present in building are contacted by phone call to provide verbal in-service on [DATE] with written documentation of date and time of contact for in-service. Signage posted throughout facility on [DATE].6. Changes to Code Status Document will be discussed in morning meeting to include Code Status changes, room changes, new admits or discharges. PIP will be initiated [DATE] for monitoring during 3 months for any changes needed to the system and will be added to QAPI [quality assurance and performance improvement]. New employees will be educated on Medical Emergency Response Policy and Procedure. A PIP will be initiated for the RN supervisor, [name withheld], [DATE] and monitored for the next 3 months.7. Medical Emergency Response Policy and Procedure provided with oral in-service, Signage posted throughout facility for quick identification of how to respond to a resident without signs of life with oral in-service for explanation of signage, and verbal education of locations of Code Status Identifiers for all residents residing in the facility. 8. The facility failed to initiate CPR immediately when a resident with a full code status was found without signs of lifeOn [DATE] at 9:11 a.m., after all staff members had been in-serviced, staff CPR training was verified, residents code status was verified for accuracy, and performance improvement projects were initiated with ongoing auditing, the immediacy was lifted, effective [DATE] at 5:00 p.m. The deficient practice remained at an isolated level with the potential for more than minimal harm.Based on observation, record review, and interview, the facility failed to initiate CPR to an unresponsive resident with a full code status for 1 (#4) of 1 sampled resident reviewed for emergency basic life support to include CPR.The administrator identified 47 residents resided in the facility and 31 Residents had a full code status.Findings: On [DATE] at 6:38 a.m., laminated code response/instructions were observed posted on shower doors, above nurse carts, and in the dining room. A Cardiopulmonary Resuscitation (CPR) policy, with a copyright date of 2024, read in part, If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. in accordance with the resident's advance directives, or b. in the absence of advance directives or a Do Not Resuscitate order; and c. if the resident does not show obvious signs of clinical death (e.g. [for example] rigor mortis, dependent lividity, decapitation, transection, or decomposition). CPR certified staff will be available at all times.The employee who first witnesses or is the first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance. CPR will continue unless: a. there is a DNR order in place. b. There are obvious signs of clinical death (rigor mortis, dependent lividity, decapitation, transection, or decomposition). c. initiating CPR could cause injury or peril to the rescuer.This will continue until emergency personnel arrive and resident is transported to the emergency room by the EMS. A Physician's order, dated [DATE] at 8:47 p.m., showed the resident was a full code and was admitted on [DATE]. An admission assessment, dated [DATE], showed Resident #4 had diagnoses which included bladder cancer, stage 3 kidney disease, and absence of kidney. A Nurse Progress Note, dated [DATE] at 3:27 p.m., showed LPN #1 received report from the night shift nurse at 7:00 a.m., Resident #4 had been anxious and attempting to get out of bed all night and that pain medication had been given at 6:30 a.m. The note showed at 8:00 a.m., LPN #1 completed the initial assessment, and vital signs were within normal limits. The note showed Resident #4 appeared anxious and was requesting more pain medication. The note showed Resident #4 was repositioned and the bed was lowered to the floor for safety. The note showed at approximately 9:00 a.m., CNA #1 reported Resident #4 had refused to put on a gown. The note showed CNA #1 responded to the call light at 9:30 a.m. and Resident #4 was sitting up in bed complaining of feeling hot and still did not want a gown on. The note showed between 10:30 and 10:45 a.m., CNA #1 checked on Resident #4 again and the resident still refused a gown, but was sitting up in the bed. The note showed at 11:05 a.m., Resident #4's family member stepped into the hall and alerted CNA #1 Resident #4 was breathing weird. The note showed CNA #1 entered the room and found Resident #4 unresponsive, with one leg on the floor and one on the bed. The note showed CNA #1 called for help and LPN #1 and two other nurses, and three other CNA's responded. The note showed Resident #4 was not breathing and had no pulse. The note showed 911 was immediately called and CPR was initiated until EMS arrived and assumed CPR. The note showed EMS performed CPR for approximately 26 minutes and administered six rounds of epinephrine, when they pronounced Resident #4 dead at 12:03 p.m. The note showed the physician, administrator, and DON were notified. The note showed the resident's family member was assisted in notifying other family members, Resident #4 was put back into bed and cleaned up. The note showed the family was provided privacy and time to make arrangements. On [DATE] at 2:52 p.m., a phone interview was conducted with Resident #4's family member that was present during the incident. The family member stated Resident #4 was admitted on [DATE] at 6:20 p.m. The family member stated when they returned to the facility on [DATE] at 11:11 a.m., Resident #4 had both knees on the floor and was leaning to their right onto their lowered bed. The family member stated Resident #4's mouth and eyes were open, but they were not breathing. The family member stated they walked to the hall and told a nurse Resident #4 was not breathing. The family member stated CNA #1 walked into the room and back out and then within two minutes seven to eight staff arrived. The family member stated the staff picked Resident #4 off the floor and placed them into the bed where staff proceeded to clean Resident #4 up and make the bed. The family member stated when air came out of Resident #4, the staff then called 911, and moved Resident #4 to the floor and may have done three compressions before the fire department arrived. The family member stated it was probably seven to nine minutes before the staff called 911 after being aware the resident was not breathing. The family member stated, They did not do anything resuscitative all the way up until after they called 911. On [DATE] at 3:37 p.m., via a telephone interview, RN #1 stated LPN #1 and LPN #2 were the ones that responded. RN #1 stated, I was in the building, but was not aware of the situation. RN #1 stated they did not know anything about that resident. On [DATE] from 3:44 p.m. to 4:00 p.m., via a telephone interview, LPN #1 stated they had received report from night shift Resident #4 had been anxious. LPN #1 stated they did not have a lot of information, except the resident had been crying out in pain and was anxious during their assessment. LPN #1 stated they were in a different resident's room when CNAs were running towards Resident #4's room. LPN #1 stated CNA #1 had told them they were just in Resident #4's room [ROOM NUMBER] minutes prior to being called into the room by a family member. LPN #1 stated somebody was checking for a pulse or breathing, and when it was not found, the staff moved Resident #4 up into the bed and were cleaning the resident up. LPN #1 stated they thought it was weird Resident #4 did not have much bowel movement in their colostomy, but there was bowel movement coming from the rectum. LPN #1 stated One of the CNAs thought they heard a breath, so the supervisor (RN #1) instructed them to move Resident #4 to the floor. LPN #1 stated LPN #2 started CPR while they called 911. LPN #1 stated RN #1 was going to check for code status. LPN #1 stated they took over CPR for LPN #2, so that LPN #2 could go get the crash cart. LPN #1 stated CPR was continued until EMS arrived and took over. LPN #1 stated, I am not going to override my clinical nurse supervisor on when to start CPR, when they were asked why CPR was not initiated as soon as it was recognized there was no pulse or breathing. On [DATE] from 4:08 p.m. until 4:28 p.m., via a telephone interview, CNA #1 stated they had checked on and spoken with the resident when breakfast trays were dropped off, picked up, and at least twice while they were offering to assist Resident #4 to put on a gown. CNA #1 stated they had last observed Resident #4 sitting up in bed at approximately 10:55 a.m. CNA #1 stated they were coming out of a different resident's room when the family member told them Resident #4 was not breathing at approximately 11:05 a.m. CNA #1 stated they ran up the halls asking for a nurse. CNA #1 stated while the nurses were checking for vital signs, the CNAs put Resident #4 on the bed and put a gown, and a brief on Resident #4. CNA #1 stated, It felt like an eternity, but was probably four to five minutes before CPR was initiated. CNA #1 stated, while RN #1 was looking for the code status one of the CNAs thought they heard a breath, so when RN #1 returned, they were instructed to move the resident to the floor and initiate CPR. CNA #1 stated LPN #2 started CPR, but then LPN #1 took over compressions while LPN #2 went to get the crash cart. CNA #1 stated they did not remember when 911 was called, but it started quickly once they were told to start CPR. CNA #1 stated the electronic health record system could be logged into from their phones within 60 seconds if they have good wireless internet. On [DATE] at 8:39 a.m., CNA #4 stated resident code statuses were kept in a binder. They showed the surveyor the binder in the linen closet by room [ROOM NUMBER] that showed resident names with a red column for DNR and a green column for full code. They stated every hall had a binder. They stated the DON was responsible for entering the code status. They stated the nurse would probably be the person to determine when to initiate CPR on a resident. CNA #4 stated they had not been involved in a code and would try to help in any way. On [DATE] at 8:44 a.m., CNA #5 showed the surveyor a binder in the linen closet by room [ROOM NUMBER]. They stated it identified each resident’s code status. They stated the nurses put the information in. They stated if a resident appeared to not be breathing, they would get the nurse. CNA #5 stated when a resident dropped to the floor, if staff were right there, they could not leave the resident by themselves. They stated if the resident started turning a color, they would start CPR. They stated their role in a code was to make sure everyone was out of the way. On [DATE] at 8:49 a.m., CNA #6 stated if a resident appeared to not be breathing, they would get the nurse and call for help. They stated they guessed they could initiate CPR if needed. On [DATE] at 8:52 a.m., CNA #3 stated staff would check to see if a resident was unresponsive. They stated if they did not respond they would start CPR. They stated their role could vary from chest compressions or swapping out breathing depending on what the person running the code instructed them to do. On [DATE] at 8:55 a.m., ACMA #2 stated resident code statuses were located in the MAR. They stated if a resident was unconscious or lethargic with a slow response, not moving, or not responding when their name was called, they would notify the nurse before beginning CPR. They stated their role was to assist the nurse when needed during a code. On [DATE] at 9:01 a.m., ACMA #3 stated there was a code sheet in both the linen closet on the hall and in their MAR. They stated when a resident appeared to not be breathing, they would check for a pulse, check their oxygenation, and call for a nurse. They stated they believed the nurse decided when to initiate CPR. They stated they would assist the nurse in whatever they needed. On [DATE] at 9:05 a.m., ACMA #4 stated if a resident appeared to not be breathing, they would stay with the resident, get the nurse, look at the code book to make sure they were a full code, call 911, and complete CPR until the paramedics arrived. On [DATE] at 9:08 a.m., LPN #4 stated if a resident appeared to not be breathing, they would get their stethoscope, watch for their chest to rise and fall, if it did not, they would do a sternal rub. They stated if the resident continued to not respond, they would check their code status if they were not breathing. They stated if they were a full code, depending on the bed, they would either deflate the bed or pull the resident to the ground and start chest compressions while calling for help. On [DATE] at 9:13 a.m., RN #2 stated the DON was the person responsible for putting resident code statuses in. They stated if a resident appeared to not be breathing, they would check their airway, circulatory status, and heart rate. They stated they would call for help, call 911, and initiated CPR if they did not have a pulse. RN #2 stated they would likely be the person running the code. On [DATE] at 9:10 a.m., RN #1 was re-interviewed via telephone. RN #1 stated, They came to get me, [Resident #4] wasn't responding. I went down there, [their] [family member] was sitting by the bed. [Resident #4] was already gone. RN #1 stated when one of the CNAs heard spontaneous breathing they found the code status on the electronic health record and instructed staff to initiate CPR and call 911. On [DATE] at 9:25 a.m., the DON stated, CPR should be initiated when you find a resident with the absence of vital signs and you find out they are a full code. The DON stated, Staff should assume CPR is necessary unless there is a DNR on file. I put [Resident #4's] orders in, and I know [Resident #4] was a full code. The DON stated the RN #1 told them Resident #4 had an absence of vital signs and they stated yes when they asked if we were doing a full code. The DON stated, CPR should be initiated quickly within a couple minutes at the most and should be continued until someone says they are a DNR or EMS takes over. The DON stated they did an in-service and placed the code status of every resident on the insides of the closets, on the nurses' carts, crash cart book, and the electronic health record. The DON stated staff should be able to get logged into the electronic health record within 60 seconds usually, and it should not take more than three to four minutes to find a resident's code status. On [DATE] at 10:47 a.m., the administrator was present, while the DON stated the code status list was updated for any new admissions, changes in room, or code status. The DON stated the ADON and administrator had access and would be able to update the list if the DON was not available. The DON stated they had completed CPR in-service on the weekend of [DATE], and then again with the weekly staff the following Monday. The DON stated the inaccuracies of residents being listed, or incorrect room numbers being listed, were found by surveyors were because one resident had just recently passed, one was recently discharged , and two had just had their rooms changed. The DON stated they were planning on updating the code status sheet that day. On [DATE] at 7:29 a.m., CNA #2 stated they were CPR certified, but that they had not received in-service in the past two weeks. On [DATE] at 7:44 a.m., performance improvement projects in regard to CPR initiation, were provided to state surveyors. They had been initiated on [DATE]. On [DATE] at 8:35 a.m., the administrator stated all of the staff had now been in-serviced, except one of the staff members who was in the intensive care unit, but they would in-service them when and if they returned to work. The administrator also stated that CNA #2 had been in-serviced that morning at 8:32 a.m. On [DATE] at 8:49 a.m., the updated code status sheet was provided and verified to be accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A past noncompliance immediate Jeopardy (IJ) situation was determined to exist effective [DATE] related to the facility's failure to immediately perform Cardio Pulmonary Resuscitation (CPR) on a Resident (Res) with full code status who was found not breathing and without a detectable heart beat. Res #42 was found by an unidentified Certified Nurse Aide (CNA) in bed and appeared not to be breathing. The unidentified CNA reported the findings to the Licensed Practical Nurse (LPN) immediately at approximately 6:00 a.m., who then assessed the resident and found him to have no signs of life. The LPN then notified the resident's family member, the administrator, the Director of Nursing (DON), and the Police. The LPN did not initiate CPR on Res #42 who had on file an order for full code. Approximately 53 minutes later, EMSA and the fire department arrived to initiate CPR. The fire department and EMSA were unable to revive Res #42. On [DATE] at 1:02 p.m., the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facilities failure to ensure staff members initiated CPR on a resident who was deemed full code in the event a resident was found to be without a pulse or respirations. The past noncompliance IJ was removed, effective [DATE] at 3:00 p.m., after the facility put measures in place to prevent recurrence. A staff training of American Heart Association Basic Life Support was conducted on [DATE]. An additional in-service, dated [DATE] at 2:00 p.m. to 3:00 p.m., was conducted with the nursing staff regarding how to check Do Not Resuscitate (DNR) and full code status and when to perform CPR. On [DATE], interviews were conducted with facility staff and they voiced knowledge of what to do in an event a resident was found in cardio-pulmonary arrest. Based on interview and record review, the facility failed to provide basic life support, including CPR, to one (#42) of two residents sampled for closed record review due to death. The administrator identified 31 residents in the facility with full code status. Findings: An undated facility policy, titled Cardiopulmonary Resuscitation (CPR) read in parts If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: . In the absence of advance directives or a Do Not Resuscitate order; . Res #42 had diagnoses which included chronic obstructive pulmonary disease, chronic respiratory failure, dementia, severe protein-calorie malnutrition, and depression. A review of Res #42's clinical record did not document a DNR form. A physician order, dated [DATE], documented Res #42 was a full code. A care plan, created on [DATE], read in parts Code status: I prefer to be a DNR, or I prefer to have CPR. I have an advanced directive that says it is empowered once 2 doctors determine I am incompetent to make my own decisions. I do not have an Advance Directive. An admission MDS assessment, dated [DATE], documented Res #42 was severely impaired in cognition, required extensive assistance with bed mobility, transfer, locomotion, dressing, toilet use, bathing, hygiene, and did not walk. The assessment documented Res #42 had shortness of breath when lying flat and during exertion, and utilized oxygen. A nurse note, dated [DATE] at 6:15 a.m., documented LPN #1 was notified at 6:00 a.m., that Res #42 was in bed and an unidentified CNA came to let her know that she did not think Res #42 was breathing. The note documented LPN #1 assessed Res #42 and his pupils were fixed and dilated and he had no pulse. The noted documented LPN #1 was unable to obtain a blood pressure on Res #42. The note documented LPN #1 notified a family member of Res #42 who stated they were on their way to the facility. The note documented LPN #1 notified the police, administrator, and the director of nursing. The note documented LPN had last visualized Res #42 at 5:15 a.m., when LPN #1 had put Res #42's oxygen cannula back in his nares. The note documented Res #42 was speaking at that time. The note did not document CPR had been initiated. The next nurse note entry, dated [DATE] at 6:53 a.m. by LPN #1, documented the fire department and EMSA had arrived to do CPR and Res #42's family member was at the bedside. The note documented the family member's statement of not attempting CPR on Res #42 and documented LPN #1 informing her that a DNR would have had to been signed and on file in the facility in order for the EMSA and fire department to not initiate CPR. A nurse note, dated [DATE] at 7:11 a.m., documented the fire department and EMSA were unable to revive Res #42 and the facility was waiting for the arrival of the medical examiner. On [DATE] at 5:15 p.m., the administrator was asked if the staff had initiated CPR for Res #42. The administrator stated she did not know as she was not in the building when Res #42 expired. When asked if the staff were CPR certified, the administrator stated the nurses were CPR knowledgeable but she did not know if they were all certified. On [DATE] at 5:32 p.m., the administrator provided documentation RN #1, who was working evening and night shift on [DATE], was CPR certified. On [DATE] at 8:29 a.m., a family member of Res #42 was interviewed and confirmed Res #42 did not have a DNR and was a full code. The family member stated they had received information on formulation of an advanced directive and DNR and had requested the facility assist them to complete the forms but had not done so before Res #42 had expired. [DATE] at 9:37 a.m., LPN #1 was interviewed and stated she was not assigned to care for Res #42 on the night shift of [DATE] onto [DATE], but had put his oxygen back on a few times during the night shift. LPN #1 stated at around 6:00 a.m. on [DATE], she heard a staff member yelling down the hall and went down to check on Res #42 then checked the chart and found was there was no DNR documented. LPN #1 stated she called the family member listed and was told by her/him they did not want Res #42 to be resuscitated as he would not want CPR. LPN #1 stated she told the family member they were required to start CPR since he did not have a DNR and he was a full code. LPN#1 stated she did not start CPR as she was trying to honor the family's request. LPN #1 stated CPR was not started until EMSA got to the facility and when the family member came in CPR was in progress. LPN #1 stated she knew the policy of the facility in the event of cardio-pulmonary arrest was to check the residents chart for code status and CPR was to be started if a DNR was not on file. LPN #1 stated she did not do that with Res #42. On [DATE] at 10:15 a.m., the social service (SS) director reported the family had told him the resident did have a DNR and advanced directive during the admission paperwork but did not have the documents with them. The SS director stated he told Res #42's family member the facility would be required to perform CPR on Res #42 if he experienced cardio-pulmonary arrest until a DNR on was on file with the facility. The SS director stated he made sure the family member understood this. On [DATE] at 11:05 a.m., the administrator stated the facility always asked for advanced directives and DNR's on admission and if they don't have one they are encouraged to complete one at that time. The administrator stated they are told if they had a DNR or advanced directives, they need to bring a copy to the facility as soon as possible as the resident will be resuscitated as a full code until the documents are in the building. The administrator stated she would contact the DON for additional information related to Res #42's cardio-pulmonary arrest. On [DATE] at 11:30 a.m., the administrator stated she spoke with the DON by phone and was told the BLS/CPR training and in-service in [DATE] were conducted due to the response of the facility staff when Res #42 experienced cardio-pulmonary arrest and subsequently expired.