**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to timely administer CPR for 1 of 3 sampled residents (#1) reviewed for CPR. This failure, determined to be an immediate jeopardy situation, resulted in Resident 1 receiving emergency CPR 13 to 20 minutes after Resident 1 was found unresponsive. This placed all residents at risk for not receiving timely CPR and constituted substandard quality of care. Findings include: The facility's [DATE] Policy and Procedure on Code Status and CPR stated in the event of a medical emergency where a resident is observed not breathing a staff member should initiate the following steps: - Call for help and bring crash cart to the area;- First CPR responder will verify code status of the resident in the EHR;- If the resident is full code, CPR will be initiated and 911 will be called. CPR will be continued until EMTs arrive to take over CPR.Resident 1 was admitted to the facility in 7/2025, with diagnoses including hemiparesis and tracheostomy. Resident 1's POLST status was identified as Full Code, which required CPR. Resident 1's [DATE] Care Plan identified the resident was at risk for complications of hypoxia related to acute and chronic respiratory failure, which included altered levels of consciousness.The facility's Investigation Report indicated that on [DATE] at around 9:30 AM, staff noticed Resident 1 was non-responsive and sought assistance from nursing. The nurse on scene indicated a response time of 10 to 20 minutes after the resident's initial assessment. Resident 1 was identified to be a full code status. The nurse's delay in initiating CPR resulted in an extensive delay of immediate lifesaving treatment for Resident 1.Per Resident 1's Progress Note dated [DATE] at 11:04 AM, Staff 5 (CNA) noted between 9:20 and 9:30 AM, Resident 1 was unresponsive to physical and verbal stimulation and reported the concern to Staff 4 (LPN). Staff 4, upon examination, declared Resident 1 dead at 9:33 AM. Staff 4 contacted Staff 2 (DNS) between 9:35 AM to 9:40 AM for further instruction, and from 9:40-9:45 AM, Staff 2 instructed Staff 4 to gather DNR status, start CPR, and call EMS. On [DATE] at 1:20 PM, Staff 4 (LPN) stated he did not initiate CPR lifesaving services due to his belief that the resident was already deceased . Staff 4 stated he determined Resident 1 deceased as of 9:33 AM due to the resident's lack of physical or verbal stimulation and yellowing of the skin near the resident's face. Staff 4 stated that around 9:42 AM, he received instructions from Staff 2 to check Resident 1's code status and initiate CPR. Staff 4 confirmed he began initiating CPR between 13 and 20 minutes after receiving direction from Staff 2 (DNS). Staff 4 further confirmed he did not call a Code Blue and did not check on Resident 1's code status because he declared Resident 1 had passed away. On [DATE] at 1:57 PM, Staff 5 (CNA) stated he was the care staff member who discovered Resident 1 was nonresponsive and had called for immediate assistance. Staff 5 stated he had noticed Resident 1 looked yellow and was nonresponsive. Staff 5 reported to Staff 4 of the event and further stated Code Blue and CPR was not initiated as Staff 4 believed Resident 1 was dead. Staff 5 stated he saw Resident 1 still conscious around 8:40 AM with no signs of concern. On [DATE] at 2:50 PM, Staff 6 (LPN) stated she was the additional nurse called to the emergency. Staff 6 stated at least 10 minutes or longer had passed between the time Resident 1 was assessed to when CPR services had begun. Staff 6 stated a Code Blue had not been called, but Staff 6 had contacted 911 for emergency services. On [DATE] at 3:07 PM, Staff 2 (DNS) stated that around 9:30 AM, Staff 4 contacted Staff 2 to request if law enforcement or if family needed to be contacted as Resident 1 had been determined by Staff 4 to be deceased . Staff 2 requested Staff 4 to begin CPR services after Resident 1's code status was determined. On [DATE] at 1:30 PM, Staff 1 (Administrator) confirmed the facility did not initiate CPR services in a timely manner to Resident 1. On [DATE] at 4:06 PM, the facility was notified of the Immediate Jeopardy (IJ) situation and immediacy removal plan was requested. On [DATE] at 5:19 PM, the facility submitted an acceptable immediacy removal plan.The deficient practice was identified as Past Noncompliance based on the following:On [DATE], the deficient practice was identified by the facility to be corrected when the facility completed a root causes analysis of the incident and determined there was a delay in initiating and conducting CPR. The Plan of Correction included:Re-educating LNs on the process of verifying code status, including POLST or physician orders when residents were observed with no pulse or respirations. All LNs were reeducated before their oncoming shift including float and agency LNs on emergency response.Medical records conducted audits on all new residents for a signed POLST or physician's order to determine resident's status until substantial compliance was met. Daily audits were immediately implemented to ensure proper initiation of emergency CPR services were provided during mock code blue for all shifts with no deficient practice found.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure a resident was safe from elopement for 1 of 1 sampled resident (#9) reviewed for elopement. This failure, determined to be an immediate jeopardy situation, resulted in Resident 9 leaving the facility without appropriate supervision and placed the resident at risk for serious injury or death. Findings include: Resident 9 admitted to the facility on [DATE] with diagnoses including stroke and dementia. The 7/30/24 hospital referral records indicated Resident 9 was withdrawn, and answered most questions with, I don't know. The record indicated, disorientation noted overnight and patient trying to leave, though was redirectable. The record also indicated, At this time the resident does not have the capacity to make decisions regarding leaving the hospital so [she/he] would be placed on elopement precautions. Resident 9's Elopement Risk Evaluations indicated the following: -8/20/24: the resident had poor impulse control and was at risk for elopement. -9/12/24: the resident had two attempts to get out of the side door unattended. -11/5/24: the resident eloped, did not communicate when leaving, and left to the community. The 9/12/24 care plan indicated Resident 9 had impaired cognitive function related to dementia and was an elopement risk due to impaired safety awareness. Progress Notes indicated the following: -8/27/24: Resident unable to communicate wants and needs, has a history of wandering and innocently wandered out of facility about 6:00 PM. -8/28/24: Resident wandered out of the facility about 6:00 PM. The note stated, Located 5 minutes at back entrance of facility. -9/12/24: Resident Care Manager notified by medication aide that the resident attempted to leave the building out the side door two times yesterday. The resident was easily redirected, but was confused with cognitive impairment. The resident's information was placed in elopement book. -11/3/24 at 1:30 PM: The note indicated staff were notified that Resident 9 absconded from the facility's property, local law enforcement was notified. Administrative staff were notified and were waiting for local law enforcement. -11/3/24 at 2:45 PM: Resident 9 returned to the facility unharmed, and stated, I'm cold. The resident was offered hot chocolate and a snack. -11/5/24: Resident 9 stated she/he would like to leave and go home, staff asked if she/he knew how to get there, and the resident stated, No. Later in the shift the resident was seen at the back door looking up in the doorway to show the nurse she/he knew the door code. The nurse told the resident it was dark and cold and she/he should not go outside. The resident stated, ok. The resident continued to walk around the building but no other attempts to get outside of the door were made. -11/10/24 at 11:56 AM: Resident 9 was found in the parking lot in the morning, was able to be redirected back to the facility, and then asked when she/he would be discharged . No facility investigations were found related to Resident 9's elopements on 8/27/24, 8/28/24, and 11/10/24. The 11/7/24 Facility Investigation of the 11/3/24 elopement indicated on 11/3/24 at 1:30 PM staff became aware Resident 9 was missing and the on duty nurse called local police to notify them that the resident was not able to be located. During this time the facility received a call from the off-duty Activities Director who reported she saw Resident 9 at a convenience store parking lot about ten minutes walking distance from the facility. The resident was quickly redirected back to the facility and was back inside the facility by 2:30 PM. No harm or injuries were noted at the time of her/his return. The resident was fully clothed in a long-sleeved shirt and jeans but did make a statement that she/he was cold. She/he was given a blanket and some hot chocolate to warm up and was content. During the time Resident 9 was gone, staff thought she/he was wandering around the facility or the outdoor courtyard per her/his usual routine. Observations on 11/13/24 from 10:54 AM through 3:06 PM revealed Resident 9 walked independently throughout the facility, participated in activities, and sat on the bed in her/his room. On 11/13/24 at 11:18 AM one of the facility's exit doors was observed to open without entering a code. The outside area led to a set of double gates that were open and led to the road. On 11/13/24 at 11:30 AM Staff 1 (Administrator) was observed to walk out of the identified exit door without entering a code. Staff 1 stated the door was supposed to shut and lock. Staff 1 acknowledged the door leading to the outside area was unlocked and the outside area led to the road and parking lot. On 11/13/24 at 11:36 AM Staff 3 (Maintenance Director) was observed to walk out the identified exit door without entering a code. Staff 3 acknowledged the door was not locked and stated a code should be entered to unlock the door. On 11/13/24 at 3:06 PM Resident 9 was alert but not oriented to place and time. Resident 9 stated she/he wanted to go home and started crying. During the interview the resident stated she/he was trapped here. Resident 9 stated she/he left the facility and went to a convenience store previously. Resident 9 stated she/he knew the numbers on the doors to get out of the facility and went to the window and stated she/he could exit out the window. The surveyor observed it appeared possible for the resident to exit through the window, but the resident did not attempt to go out the window at that time. Staff interviews from 11/13/24 at 11:30 AM to 11/14/24 at 12:28 PM indicated the following: -Staff 4 (CNA) stated Resident 9 wanted to go home and attempted to open the doors using the door codes. Staff 4 stated the identified door did not always lock and staff had to pull on the door to get it to lock and it was like that for a long time. Staff 4 stated she was unsure if it was reported to maintenance. Staff 4 further stated that several staff including agency staff were unaware the door did not close and had to be pulled shut. Staff 4 stated Resident 9 was exit-seeking on a daily basis. -Staff 5 (CNA) stated Resident 9 got bored, wanted to go outside and asked a couple of times for the door code. Staff 5 stated the resident sought outside activities but the resident was not safe to go outside alone. -Staff 6 (CNA) stated today was her first day working here and she was unaware of any residents who were at risk for elopement, and nobody told her of residents who were an elopement risk. -Staff 7 (NA) stated there was one resident who was exit-seeking but he could not remember the resident's name. -Staff 8 (CNA) stated Resident 9 was an elopement risk and the resident eloped to the front parking lot on two occasions. Staff 8 stated Resident 9 was the only resident who was an elopement risk. -Staff 9 (CNA) stated he worked at the facility for a month and was not aware of residents who were at risk for elopement. -Staff 10 (CNA) stated Resident 9 attempted to leave the facility multiple times by using the door codes and was able to figure out the codes no matter how many times they were changed. Staff 10 stated on one occasion about a week or week and half ago the resident's roommate reported the resident was down by the street and brought Resident 9 back inside the facility. Staff 10 stated she reported the incident to the charge nurse but could not remember the nurse's name. -Staff 11 (LPN) stated Resident 9 had dementia and was able to go outside the facility on multiple occasions. Staff 11 stated on one occasion the resident went to a convenience store and police were notified and the resident arrived back to the facility by her/himself. Staff 11 stated the resident was out in the parking lot at least two weeks prior to going to the convenience store. Staff 11 stated on one occasion when the resident was in the parking lot a dietary staff made him aware the resident was outside. Staff 11 stated the door codes were changed multiple times, but the resident was able to figure out the codes. -Staff 12 (LPN Resident Care Manager) stated Resident 9 eloped on one occasion to a convenience store and on another occasion was found in the parking lot. Staff 12 stated she read a progress note by Staff 11 that indicated the resident got out to the parking lot and the resident should not be alone. Staff 12 stated an investigation was not completed for the incident when the resident got out to the parking lot and was unsure if the resident was unattended in the parking lot. On 11/13/24 at 1:35 PM and 3:40 PM Staff 1 and Staff 2 stated Resident 9 eloped to a convenience store on 11/3/24 and the off-duty activity person stopped there and talked to her/him. The resident stated she/he was out for a walk. The staff told the resident to return to the facility and she contacted the nurse at the facility. Staff 1 stated after the resident was found at the convenience store, she/he was determined to be an elopement risk. Staff 1 and Staff 2 stated after the elopement to the convenience store the resident was placed on 1:1 supervision until the door codes could be changed the following day. Staff 1 and Staff 2 were asked about the 11/10/24 progress note that indicated Resident 9 was found in the parking lot by nursing staff. Staff 1 and Staff 2 acknowledged an investigation was not completed for the 11/10/24 incident when Resident 9 was found outside the facility unattended. Staff 1 and Staff 2 stated they were unaware of any other elopement attempts by Resident 9. The staff indicated the facility had other residents who were also at risk for elopement. On 11/13/24 at 4:22 PM Staff 1 and Staff 2 were notified of the Immediate Jeopardy (IJ) situation and provided a copy of the IJ template related the to facility's failure to ensure individualized care planned interventions to prevent elopement were implemented. On 11/13/24 at 6:12 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: *11/13/24 at 5:15 PM the facility immediately placed Resident 9, who was at the highest risk for elopement, on one-to-one supervision and was care planned accordingly to prevent any possibility of elopement. This would be indefinite until the resident's discharge. *The facility would perform a full facility chart audit to identify any other residents at risk for elopement and their care plans would be updated. *A facility wide inspection would be conducted immediately by the environmental services team and nursing staff to identify any doorways that may not be properly secured. All doors would be inspected to ensure locking mechanisms are functional. Any issues identified would be resolved. *A staff-wide education had begun and all staff would be in-serviced on the elopement policy, elopement binder, and all residents at risk for elopement and their care plans. Alerting administration of attempted or actual elopements, ensuring doors remain locked. All staff would sign off on this education prior to beginning their next shift. Any agency or outside staff would be alerted prior to their entering the facility regarding the elopement procedures and policy and would be shown at entry where the elopement binder was and associated policies were located. *The administrator or designee would audit all doors to ensure locking mechanisms were functioning and doors were locked daily x 7, biweekly x 2 weeks, weekly x 1 month, and results would be taken to QAPI to identify any further trends and concerns. The immediacy was removed on 11/14/24 after verifying the plan of correction was sufficiently implemented.