**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 (Resident #1) residents reviewed for quality of care.The facility failed to activate 911 emergency services response on 06/13/2025 for Resident #1 when he had a choking episode while eating resulting in his death. An IJ (Immediate Jeopardy) was identified on 07/08/2025. The IJ template was provided to the facility on [DATE] at 5:12 PM. While the IJ was removed on 07/10/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk of physical harm, pain, mental anguish, or death. Findings included:Record review of Resident #1s clinical resident profile reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis of diabetes type 2 (elevated blood sugar), vascular dementia (difficulty thinking and processing thoughts), major depressive disorder, and anxiety.Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS of 11, which indicating mild cognitive impairment. It also indicated Resident #1 did not have any swallowing disorders such as holding food in his mouth, coughing, or choking during meals or difficulty or pain with swallowing. Record review of Resident #1's care plan dated 01/17/2024 reflected: Receives Therapeutic and Mechanically soft Diet, Resident has decreased appetite with poor meal intake at times. Interventions included: Assist resident with meals as needed. Set up meal tray, open beverages, cut foods, provide assistance as needed.Record review of Resident #1's progress notes dated 06/13/2025 reflected At approximately 1720, CNA heard calling out for help. This nurse entered Dining room and noted resident gasping and coughing. CNA stated that resident was eating dinner and began choking on his food. Noted mech soft dinner tray in front of resident, consistent with resident's diet orders. This nurse assessed Resident's mouth and noted food in airway. Finger sweep attempted while visualizing food without success. This nurse started abdominal thrusts and sent CNA to alert another nurse for additional assistance. LVN B arrived, and this nurse and attempted abdominal thrusts several more times without success. Resident's respirations ceased and pulse was unobtainable. Code status confirmed as DNR. No signs of life noted. Notified PCP, RP, and DON. Signed by LVN [NAME] an interview on 07/08/2025 at 1:00 pm, The VA Nurse stated she reviewed the incident at her monthly visit to monitor the VA contract residents that reside at the nursing facility. She asked the facility DON why 911 was not notified. She stated the DON stated that the facility was honoring the residents DNR wishes. She stated that the facilities failure to activate emergency services by calling 911 during the choking episode was a reportable incident. The VA nurse stated that Resident #1 having a DNR on file did not mean that the facility should not treat him if he was choking. The facility stated they followed their policy they did not call 911 because the resident did not lose consciousness until the very end of the choking episode and at that time he had no pulse. She stated the ADM and DON told her it was not reportable because they were aware of the incident, and it was not under suspicious circumstances that followed their policy. In an interview on 07/08/2025 at 1:46 pm, LVN A stated on 6/13/25 she was passing the dinner trays out to the residents on the secure unit when the CNA working with her started yelling for help. Resident #1 was choking so she did a mouth sweep and a visual check on his mouth. LVN A stated Resident #1 continued to choke so she began chest thrust and was unsuccessful. She sent the CNA to get assistance and 2 more LVNs came to attempt the chest thrust. The Choking episode all happened so quickly no one initiated a 911 call. She stated the resident went limp and no longer was breathing. LVN A stated the nurses checked his code status, and it as DNR. They called their supervisor who told them to honor the DNR. LVN A stated an RN later came and pronounced the resident's time of death at the facility. LVN A stated their policy stated if the resident was a DNR, they did not have to call 911. Normally if choking were to happen, they would call 911, but staff were trying to get his airway clear. The DON showed the policy to staff that stated if a resident actively passes during emergency treatment, and they had a DNR, the nurse did not have call 911 emergency services. LVN A stated negative effects for not having 911 emergency services dispatched during an emergency such as choking could be that the resident could die. In an interview on 07/08/2025 at 1:57 pm, LVN B stated he was called to the secure unit with a suction machine and responded to Resident #1's choking. He took the suction machine to the secure unit and began assisting with the Heimlich maneuver. LVN B stated he was doing the chest thrust, so he was not aware of anyone calling 911. Anyone who was present during an emergency, could dial 911 for emergency response. LVN B stated negative effects of not activating 911/an emergency response for resident during a choking episode, could be death.In an interview on 07/08/2025 at 2:03 pm, LVN C stated she was notified by another nurse to get a suction machine and come to the secure unit. They set up the suction machine and attempted chest thrust on Resident #1. LVN C stated she was not aware of anyone calling 911. Resident #1 did not lose consciousness until the very end before he passed away. LVN C stated it was the first time she had encountered a resident choking. LVN C stated the negative effects to a resident for not calling 911 in an emergency response, depended on the situation. If it were something the staff could take care of within the facility, they would not call 911. LVN C stated the facility was honoring the resident's wishes with his DNR.In an interview on 07/08/2025 at 2:21 pm, the DON stated it was her expectation that when a resident was choking, the staff should have assessed the resident, visualized the oral cavity, removed the object if they are able, and started the Heimlich. The DON stated staff should have activated 91l. She stated Resident #1 was a DNR, so they did not proceed with any other intervention after he became unresponsive. She had not educated staff on the choking policy in writing; it was verbalized only when they discussed the event. The DON stated the negative effects for not issuing a 911 emergency response when a resident was choking was that the patient could die.In an interview on 07/08/2025 at 2:26, The ADM stated if a resident was choking, she expected the staff to follow choking guidelines. This included calling 911. DNR did not mean do not treat. The ADM stated she addressed the issue in an in service on 6/18/2025 at an all-staff meeting.In an interview on 07/08/2025 at 3:00 PM, the Medical Director stated the facility should have activated 911 emergency services response when Resident #1 was choking, and nurses were unable to clear the airway. He stated just because there was a DNR, did not mean not to treat the resident. Resident #1 was a fast eater and did have a diagnosis of dysphagia. the Medical Director stated the negative effects for a resident for not initiating 911 in an emergency such as choking could be death.Record review of the facility's policy Titled Policy for Choking / Foreign Body Obstructing Airway dated August 2021 and updated 6/18/2025 reflected: 1. Stand behind the resident.2. Wrap your arms around the resident's waist.3. Make a fist with one hand.4. Place the thumb side of your fist against the resident's upper mid-abdomen, below the ribcage and above the navel.5. Grasp your clenched fist with your other hand.6. Press your fist into the resident's upper abdomen with a quick upward thrust.7. Do not squeeze the ribcage. Contain the force of the thrust to your hands.8. Repeat the thrusts until the foreign body is expelled or the resident loses consciousness.9. If the airway is cleared immediately, report to nursing administration, resident's Physician for follow up as needed.10. If the airway does not clear immediately, and the resident becomes unresponsive, activate medical emergency response (ex. Code blue, call 91 1) and continue to attempt to the airway of the unresponsive resident.11. If at any time the resident is assessed to have no pulse and no respirations, follow goals of the resident's code status to determine if CPR should be initiated.12. Continue CPR if indicated until Emergency Personnel assume care of resident.13. Complete incident report and notification of responsible party & MAn Immediate Jeopardy was identified on 07/08/2025 at 5:12 PM. and an IJ template was provided to the ADM and DON. A plan of removal was requested at that time.The following Plan of Removal, submitted by the facility, was accepted on 07/10/2025 at 12:58 PM. On 7/8/2025 an abbreviated survey was initiated at center. On 7/8/2025 the surveyor provided Immediate Jeopardy (IJ template provided) that the regulatory services have determined that the conditions at the facility constitute an immediate threat to residents' health and safety. Notification of Immediate Jeopardy states as follows Tag F689 based on observation interview and record review failed to provide adequate supervision and devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents and supervision. The facility failed to ensure Resident #1 received 911 emergency services during a choking episode on 6/13/2025 at 5:20 PM. The resident expired at the facility. 1. Corrective Action Taken:On July 8, 2025, Corporate Clinical Specialist in serviced Administrator and ADON on facility's emergency response policy, including the requirement to call 911 during a choking incident regardless of DNR status. Competency verified by quiz, requiring 100% to pass.On July 8, 2025, Administrator and DON conducted a facility-wide in-service training regarding facility's emergency response policy, including the requirement to call 911 during a choking incident regardless of DNR status. Competency verified by quiz, requiring 100% to pass. No staff will be able to work until in-servicing and competency completed. This will be conducted to all staff and monitored by Administrator. Evidence will be kept in a binder in the administrator's office. On July 9, 2025, Corporate Clinical Specialist, in-serviced DON and ADON regarding proper performance of abdominal thrust or other measures during a choking incident. Competency verified by return demonstration and documented on the skills check off. This will be monitored by the Administrator. Evidence will be kept in a binder in the administrator's office. On July 9, 2025, DON and ADON in-serviced nursing staff regarding proper performance of abdominal thrust or other measures during a choking incident. Competency verified by return demonstration and documented on the skills check off. This will be monitored by the Administrator. Evidence will be kept in a binder in the administrator's office. 2. Identification of Other Residents: A review of all current residents with DNR orders was completed on July 8, 2025, to ensure that advanced directives are clearly documented in the medical record. Completed by CCS and ADON.No other residents were found to be at immediate risk.A review of all current residents with swallowing difficulties was completed on July 9, 2025, to ensure that care plans are clearly documented in the medical record. This review was conducted by the CCS and Director of Nursing (DON) No issues identified they were immediately corrected on 7/9/2025. 3. Systemic Changes: The facility's choking and emergency response policy was revised on 7/9/2025 by Regional Director of Operations in consultation with Corporate Nurse. The statement Repeat thrust until the foreign body is expelled or the resident loses consciousness was revised to Repeat the thrust until the foreign body is expelled. The statement if the airway does not clear immediately, and the resident becomes unresponsive, activate medical emergency response (ex. Code blue, call 911) and continue to attempt to clear the airway of the unresponsive resident was removed. The new revisions states that If the airway does not clear immediately activate medical emergency response and continue to attempt to clear the airway. On July 8, 2025, the Administrator and Director of Nursing conducted a facility-wide in-service training on the facility's emergency response policy. Staff were educated that during any choking incident, 911 must be called immediately once the Heimlich maneuver is initiated, regardless of the resident's DNR status. Competency was verified through a mandatory quiz, with a required passing score of 100%. No employee will be permitted to work until both the in-service and competency have been successfully completed. This training will be provided to all staff and overseen by the Administrator. Documentation of completion and competency will be maintained in a binder located in the Administrator's office.All new hires will receive mandatory training by the DON, or designee, on emergency response protocols related to choking, incidents, and emergency responses during orientation. These drills will consist of Mock Drills with different choking-based scenarios.A competency quiz has been implemented to assess staff understanding of emergency procedures quarterly, requiring 100% to pass.CCS and DON are auditing diets to ensure correct completed 7/9/2025. 4. Monitoring and Quality Assurance: The Corporate Clinical Specialist educated the DON and ADON regarding emergency protocols and response.The Director of Nursing (DON) or designee will conduct random audits of staff knowledge and response by conducting medical emergency drills (i.e., choking episode) weekly for 8 weeks, then monthly for 4 months. Results of audits will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings.Any deficiencies will result in immediate re-education.Medical Director notified 7/9/2025, and reviewed Plan of Removal and approved. 5. Responsible Party: The Administrator and Director of Nursing are responsible for implementing and monitoring this Plan of Correction. 6. Completion Date: All corrective actions will be completed by July 9, 2025.On 07/10/2025 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:1. Record review of in-service education dated 07/08/2025 for the ADM, DON, ADON and all staff reflected they had been educated over the policy on choking/relief of foreign body obstructing the airway. Verified with 4 signatures. Education provided on always calling 911 in an emergency no matter what the DNR status of the resident is. Understanding was verified by receiving 100% on post education quiz. Verified with 73 signatures.2. Record review of an audit dated 07/08/2025 reflected all residents with DNR orders to ensure that advanced directives were clearly documented in the medical record had been completed. Record review of an audit dated 07/08/2025 reflected A review of all current residents with swallowing difficulties was completed on July 9, 2025, to ensure that care plans are clearly documented in the medical record. This review was verified by an audit of 5 random residents medical records. The medical records reflected DNR / advanced directives were clearly documented and diet orders were correct. Medical record review of care plans reflected that resident with swallowing difficulties had interventions within the care plan. 3. Record review the facility's Choking and Emergency Response Policy was revised on 7/9/2025 by Regional Director of Operations in consultation with Corporate Nurse and again on 07/10/2025. The statement Repeat thrust until the foreign body is expelled or the resident loses consciousness was revised to Repeat the thrust until the foreign body is expelled. The statement if the airway does not clear immediately, and the resident becomes unresponsive, activate medical emergency response (ex. Code blue, call 911) and continue to attempt to clear the airway of the unresponsive resident was removed. The new revisions states that If the airway does not clear immediately activate medical emergency response and continue to attempt to clear the airway. On July 10, 2025, the Administrator and Director of Nursing conducted a facility-wide in-service training on the facility's emergency response policy. To clarify the policy revision, the facility contacted each employee and instructed them on the policy revision. Verified through sign-in sheet with 73 signatures and DON and ADM interview. 4. Record review of QAPI meeting held on 07/08/25 at 5:15pm revealed the meeting was attended by the Medical Director, Administrator, and DON.Interviews conducted on 07/10/2025 between 1:45 pm - 2:45 pm CNA C, CNA D, CNA E, CNA F, CNA G, MA H, CNA I, CNA J, Social Worker, LVN K, CNA L, LVN M, LVN N, LNV O, RN P, Business Office Manager, Activities Director, Activities assistant Director, Housekeeper, Dietary cook, Dietary Manager, and Laundry Supervisor, revealed that all verbalized if a resident were to have a choking episode, 911 emergency response should be activated. They stated that any staff member could dial 911. They stated they did not wait for a resident to become unconscious prior to calling 911. They stated 911 should be activated immediately if chocking was not cleared with coughing. They were able to demonstrate the chest thrust to dislodge objects obstructing the airway. The staff stated DNR did not mean do not treat. On 07/10/2025 at 3:04 pm, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure personnel provided basic life support, which included CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 5 residents (Resident #82) reviewed for cardio-pulmonary resuscitation. LVN B failed to initiate CPR when she found Resident #82, who was full code status, unresponsive and not breathing. Resident #82 was declared deceased . An Immediate Jeopardy (IJ) situation was identified on 09/26/24 at 4:42 PM. While the IJ was removed on 09/27/24 at 12:57 PM, the facility remained out of compliance at a scope of isolated identified as no actual harm with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of death from not receiving life-saving measures if needed. Findings included: Record review of Resident #82's admission Record dated 9/27/24 revealed she was an [AGE] year-old female admitted to the facility on [DATE]. The area of the document under the title Advanced Directives was blank. Record review of Resident #82's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 12 indicating she had moderately impaired cognition. She required supervision during eating, maximum assistance for toileting and bathing, and was totally dependent on staff for bed to chair transfers. Her diagnoses included dementia with agitation (loss of memory or other thinking abilities that interferes with daily life); cognitive communication deficit (difficulty with communication caused by disruption in cognition); anemia (lack of red blood cells needed to carry oxygen throughout the body); hypertension (high blood pressure), anxiety disorder and depression. Record review of Resident #82's care plan reflected the following entry dated initiated 3/2/21, I and/or responsible party have been provided the information explaining the Advanced Directive process and following the education have decided that I am a FULL CODE .Goal: My Full Code will be honored by my family and staff .Interventions/Tasks: My family and staff are aware of my FULL CODE status .Review my Advanced Directive options and Resident Rights quarterly and PRN with me and my family . An entry initiated 9/10/24 reflected the following: admitted to [hospice company name] Hospice for dx of Dementia .Goal: I will have all needs met, over the next 90 days .Interventions/Tasks: Staff will monitor and report any changes to RP, hospice and physician . Record review of Resident #82's Order Recap Report dated 9/26/24 reflected the following orders: Full code status with a start date of 11/29/20. Admit patient to [hospice company name] .call [hospice company name and phone number] for change in condition, falls, labs, Xray, transfer to hospital or in the event of death. Start date 9/10/24. Record review of Resident #82's Progress notes reflected the following entries: Entry dated 9/3/24 at 11:12 AM: Spoke with resident RP [name] via telephone and informed him of resident's decline over the last two weeks. resident has had a loss of appetite, not eating meals normally, she requires more assistance from staff with eating, and now has pressure wounds to her ankles. resident expresses she is in pain lately as well. RP wishes to speak to brother regarding resident's decline so a decision may be made about a possible referral to hospice. social worker verbalized understanding and RP to reach back out once a decision is made. Signed by Social Worker. Entry dated 9/9/24 at 9:55 AM: Patient refuses to be fed by CNA for breakfast. Patient is lying peacefully with eyes closed unlabored breathing noted. No distress noted. Signed by LVN A. Entry dated 9/9/24 at 1:38 PM: family requesting hospice eval. social worker to send hospice referral to .hospice agency. Signed by Social Worker. Entry dated 9/10/24 at 12:38 PM: Patient admitting to hospice. Call [hospice company name and phone number] for change in condition, falls, labs, XRAY, transfer to hospital or in the event of death. PCP notified. Signed by LVN A. Entry dated 9/13/24 at 9:23 AM: [Hospice company name] hospice nurse visited patient this AM. Patient is gurgling, possible aspiration. Will change diet to pureed and thicken liquids for next meal. Patient is showing signs of swallowing issues. Patient is showing signs of pain PRN morphine given at 9:20AM. Signed by LVN A. Entry dated 9/13/24 at 6:35 PM: Residents medications were held this evening as she was unable to swallow medications. Resident had audible wet/congestion this afternoon. When resident was checked on prior to dinner resident was breathing, with increased secretions. After dinner resident had no respirations. DON notified. Hospice notified, awaiting response from Hospice Nurse at this time. Signed by LVN B. Entry dated 9/13/24 at 7:51 PM: Resident passed, awaiting hospice arrival Signed by LVN B. Entry dated 9/13/24 at 9:13 PM: Hospice nurse in facility for resident. Emergency contact [RP name] Notified of residents passing. MD Notified. Resident to be picked up by [transportation company name] services and taken to funeral home. Awaiting arrival. Signed by LVN B. Entry dated 9/13/24 at 9:58 PM: Resident taken by [company name] transportation services going to the funeral home. Signed by LVN B. Record review of Resident #82's hospice documentation-Visit Note Report dated 9/10/24 reflected the following: Visit Type: RN Hospice Start of Care. Narrative: [Resident #82] is an [AGE] year-old female who is being admitted to hospice services on 09/10/2024 with a primary diagnosis of dementia under the care of medical director, [Hospice MD name]. patient's additional diagnoses include: cognitive communication deficit, htn, anemia, mdd [major depressive disorder], mood disorder, muscle weakness, unspecified abnormalities of gait and mobility [difficulty with walking], muscle wasting, insomnia, anxiety, abnormal uterine and vaginal bleeding, pain, rls [restless leg syndrome-an irresistible urge to move the legs], atrial fibrillation [abnormal heart rhythm], osteoarthritis. Patient is a full code . Patient has been a resident of [nursing facility name] since 2019. Patient is disoriented and unaware of time, place, and situation. Neurological deficits noted as follows: nonverbal, unable to make eye contact, incontinent of bowel and bladder, contractures (permanent or temporary tightening of muscles and tendons causing limited movement of a joint) of bilateral legs, patient unable to make needs known. lung sounds clear to auscultation. respirations even and unlabored. bowel sounds active in all quadrants. Bilateral legs contracted with noted redness to outer left ankle and inner right ankle due to pressure. Area being cleansed with skin prep and monitored. Patient nonambulatory [sic] and is max assist with transfers. six months ago, patient was able to get out of bed and participate with activities and sit up in wheelchair. Per staff, decline has been rapid. appetite is poor as currently patient is consuming 2-3 bites of 3 meals a day. Three months ago, patient was consuming 50% of three meals a day. Patient has lost 2 lbs in the past two weeks. Patient is bedbound and no longer getting out of bed. Patient has no history of falls . The document was signed by Hospice RN C. During an interview on 9/27/24 at 8:55 AM, LVN A stated she had worked at the facility for 2 years any worked the 7 AM to 2 PM shift. She stated she had cared for Resident #82 during the day shift on 9/13/24. She stated a hospice nurse had been in to see Resident #82 that morning and she appeared to be very uncomfortable. She stated Resident #82 had been grimacing and yelling out. She stated Resident #82 had been declining for a while and her family had decided to place her on hospice services. LVN A stated she did not do a full assessment or get vital signs because the hospice nurse was with her. She stated she never checked the resident's code status because, when on hospice, you think DNR. When shown her progress note and asked about her possibly aspirating, LVN A stated she asked the hospice nurse about it and she wanted to try Resident #82 on a pureed diet. She stated she administered some morphine to the resident and she had slept a lot the remainder of her shift. She stated Resident #82 would not accept any food when the CNAs had attempted to feed her lunch. LVN A stated she knew how to locate the resident's code status by checking their electronic medical records or the binder at the nurse's station. LVN A stated she never checked the status for Resident #82 because she assumed she was DNR because she was on hospice. She stated the risk of not knowing a resident's code status was failing to do CPR which would result in death and not following the resident's rights. LVN A stated facility management had called her on 9/26/24 and she had received in-service training. She stated they added a binder to the crash cart that included a list of all resident's code status that would be updated daily. She stated, if a resident was DNR, she was supposed to check the documentation to ensure it was complete. If the resident had no code status or was full code, they should initiate CPR immediately and call emergency services. During an interview on 9/27/24 at 10:27 AM with MA D, she stated she had worked at the facility for the past 2 and a half years and had known Resident #82 for a while. She stated Resident #82's health had been declining and she had not been eating or drinking as much and she had begun to crush some of her medications for her. MA D stated, on 9/13/24, she thought she recalled the resident was able to take her meds that morning and she had seen her again around lunchtime. She stated she had opened her eyes and was able to reply, hey when greeted but did not speak any more than that. She stated that was the last time she had seen her before she passed away. MA D stated she could tell a resident's code status because it was in the computer and on their Medication Administration Records. She stated she did not know Resident #82's code status the day she passed, did not recall looking for it and was not present when she had stopped breathing. MA D stated she had received in-service training that day related to code status. She stated, she should always get the nurse if there was a change in a resident's condition. She stated, if a resident was unresponsive-they should yell for help, check the code status on the computer, in a binder at the nurse's station and on the crash chart. She stated CPR should be initiated immediately for any resident who was a full code or unknown status. MA D stated she was CPR certified and should assist the nurse as needed in emergency situations. She stated the risk of not knowing a resident's code status was not honoring the resident's wishes and death. On 9/26/24 at 4:10 PM, an attempt to reach LVN B via telephone was unsuccessful. During a telephone interview on 9/27/24 at 8:32 AM, LVN B stated she had worked for the facility for about 6 months and usually worked the 2 PM to10 PM shift. She stated she understood how to check a resident's code status and it could be found in the electronic medical record as well as a binder which was kept at the nurse's station. She stated, if a resident was DNR, they were to also check the document for the appropriate signatures. When asked about Resident #82's care on 9/13/24, she stated she arrived for work around 3:30 PM that day and it had been about 3 weeks since she had worked at the facility. She stated she checked Resident #82 during her initial rounds and noticed she had changed condition. LVN B stated she asked the CNAs and Medication Aide about her and learned Resident #82 was on hospice and had been declining. She stated she checked her vital signs and could not recall if she had documented them but remembers they were stable. She stated the resident would open her eyes and follow her with her eyes but did not speak. LVB B stated she checked on Resident #82 again before dinner and there had been no change. LVN B stated she then went to the dining room to feed residents. She stated she checked on Resident #82 after dinner, and she was very pale and was not breathing. She stated she reported it to the DON and Administrator who had told her to call the hospice company. LVN B stated she called the hospice company and believed it was the answering service. She stated they told her they would contact Resident #82's family and send a nurse out to pronounce death. LVN B stated she did not initiate CPR or call emergency services because she assumed, because Resident #82 was on hospice services, she was DNR status and had not looked for the information. LVN B stated she received a call from facility management on 9/26/24 and they conducted an in-service over the phone. She stated in-service included the importance of checking the resident's code status and contacting emergency services and initiating CPR for residents who were full-code status. She the facility was implementing an additional binder with all the resident's code status to be kept with the crash cart. LVN B stated the risk of not knowing a resident's code status was, like this, I messed up. I should have coded her and potentially brought her back. She stated the risk was death and not following the resident's wishes. During an interview with the Social Worker on 9/26/24 at 2:57 PM, she stated Resident #82's family was provided advanced directive information upon admission. She stated, if a resident does not have a DNR order, they typically review the advance directive information with them and provide a copy of the information for their review. The information is periodically reviewed again during subsequent care plan meetings. If no signed advanced directives are provided by a resident or their responsible party (RP), they resident is considered a full code. The Social Worker stated Resident #82 had begun to physically decline and she had conversations with her RP about the possibility of hospice services. She stated, initially, the RP wanted to send a family member to visit the resident first. She stated the family came to see Resident #82 and decided to place her on hospice services so she set up the referral. The Social Worker stated she did not bring up the issue of Advanced Directives or a Do Not Resuscitate order at that time because they had always opted out of the idea in the past. She stated she asked the hospice company to discuss it with her family during admission. The Social Worker stated she knew the hospice company was working toward getting a DNR order in place but she had not received any information from them. During an interview on 9/26/24 at 3:40 PM, Hospice RN C stated she was the nurse who admitted Resident #82 to hospice services and pronounced her death. She stated the resident had just come on hospice services three days before she died. Hospice RN C stated they were in the process of getting her DNR orders signed, and her RP had verbalized his wishes for a DNR verbally to her stating he knew she had stopped eating, was declining and losing weight. Hospice RN C stated Resident #82's RP was homebound and unable to physically travel to the facility. An employee of their company had travelled to his home to have him sign her admission documents and was planning another trip to have him sign the DNR documents, but the resident passed away before getting the paperwork done. She stated the physician would not enter an order for DNR without the signed document from the patient's RP. When asked about their protocol for a resident who was possibly aspirating (breathing food or fluids into the lungs) as noted in the nurse's notes on 9/13/24, she stated there was another Hospice nurse there that morning who had reported those concerns to her and she advised to administer hyoscyamine (a medication to decrease secretions such as excess saliva) and try pureed food or thick liquids. Hospice Nurse C stated she was contacted later that evening about Resident #82's passing and went to the facility to pronounce her death. She stated she contacted the resident's family and physicians. She stated she would not have advised the facility to call 911 because she knew the wishes of her family and she thought the resident had likely been deceased a while before they found her. During an interview on 09/26/2023 at 4:42 PM the DON stated she was notified by LVN B after Resident #82 had passed away. She stated she knew Resident #82 was on hospice services but was unaware at the time the resident was a full code. She stated she was leaving the facility for the day when the nurse notified her, and she did not pronounce the resident's death because she was told the hospice nurse was on her way to the facility. She stated she told LVN B to call her if there was any delay and she would come right back. The DON stated she asked LVN B if the family had been notified and she said no. She stated she directed her to check with the hospice nurse to determine whether they had contacted the family. She stated she did not communicate with the hospice company when they were at the facility earlier the same day. The DON stated the risk of failure to perform CPR when it was appropriate to do so was death. In an interview on 9/27/24 at 12:59 PM, the Administrator stated she did not recall a nurse telling her Resident #82 had died while she was at the facility. She stated she had gone home sometime after dinner and learned later that she had passed away. She had previously been unaware Resident #82 was a full code at the time she died. Record review of the facility's policy titled CPR-AED Policy dated revised 8/15/24 reflected the following: 1. In the event of cardiopulmonary arrest of a resident/patient without DNR status, life support measures will be initiated according to either the American Heart Association/American Red Cross guidelines or per State Guidelines. According to the 2001 American Heart Association, BLS (Basic Life Support) for Healthcare Providers, prompt initiation of CPR remains the standard of care except when rigor mortis, lividity, tissue decomposition or obvious fatal trauma are present. Rescuers who initiate BLS should continue until one of the following occurs: o Restoration of effective spontaneous circulation and ventilation. o Transfer of care to emergency medical responders or other trained personnel who continue BLS or initiate advanced life support. o Transfer of care to a physician who determines that resuscitation should be discontinued. o Inability to continue resuscitation because of exhaustion, because environmental hazards endanger the rescuer, or because continued resuscitation would jeopardize the lives of others. o Recognition of reliable criteria for determination of death; or o Presentation of a valid no-CPR order to the rescuers. 2. At least one person at the scene of the arrest will remain with the victim and initiate the Code Blue [code used when someone has no heartbeat or stops breathing] procedure. (see guidelines below) 3. Any clinical employee trained in Basic Life Support may initiate CPR. 4. The Emergency Medical System (911 or local number) will be activated immediately. Additional Advanced Life Support functions will be instituted by paramedics with the EMS system. 5. EMS will transport resident/patient to the emergency room of the transfer agreement hospital. Guidelines: .B. Person who discovers arrest: 1. Calls for help while placing the resident/patient in flat position on back. C. Nurses Responding: .c. Begin CPR . The Administrator, DON, and Regional RN were notified of the IJ on 09/26/2023 at 4:42 PM due to the above failures. The Administrator was provided with the IJ template on 9/26/24 at 4:52 PM. The following Plan of removal submitted by the facility was accepted on 9/27/24 at 12:57 PM and reflected the following: POR [LVN B] who was the nurse on duty did not perform CPR on a patient who she believed was a DNR. [Resident #82's RP] had not executed the DNR paperwork as Hospice was working out logistics to get the paperwork over to him. [LVN B] was inserviced by DON on 9/26/2024 regarding CPR policy that included education on full code status, when to initiate a full code, and following physicians' orders in regard to code status. Competency was verified via quiz. Immediately on September 26, 2024, CCS [Regional RN] inserviced Administrator and DON on CPR policy to included education on full code status, when to initiate a full code, and following physicians' orders in regard to code status. Competency was verified via quiz. On September 26, 2024, DON/Designee initiated inserviced [sic] with the licensed nurses on CPR policy to include education on full code status, when to initiate a full code, and following physician orders regarding code status. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed on September 26, 2024. At this time, we do not use agency. However, the above content was incorporated into new hire orientation by Administrator effective 9/26/2024. On September 26, 2024, an audit was completed of all resident code status by DON/Designee. The audit did not find any additional concerns. Medical Director was notified on September 26, 2024. In order to monitor current residents for potential risks, SW/designee will audit the code status of all residents weekly x4 weeks and monthly thereafter to ensure accuracy. Any negative findings will be corrected and reported to the QAPI committee to ensure continued compliance. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Record review of the attached in-service content dated 9/26/24 revealed it included a copy of the facility's CPR-AED Policy dated revised 8/15/24 as well as the following: *CODE STATUS TO BE PRINTED NIGHTLY AND PLACED IN BINDER ON CRASH CART-BY NIGHT SHIFT (10-6) *CPR MUST BE INITIATED ON ANY RESIDENT THAT DOES NOT HAVE AN OUT OF HOSPITAL DNR. THIS INCLUDES RESIDENTS THAT ARE ON HOSPICE *PHYSICAN ORDERS MUST BE FOLLOWED- FULL CODE/DNR *CODE STATUS IS ON THE PROFILE PAGE- IF YOU CLICK ON HYPERLINK YOU WILL VIEW THE DNR *THE CPR/AED POLICY MUST BE FOLLOWED- EACH NURSE WILL BE EDUCATED AND GIVEN A COPY *IF THE DNR IS NOT SIGNED BY A PHYSICIAN IT IS NOT COMPLETE-AND RESIDENT IS CONSIDERED A FULL CODE *IF FAMILY STATES THEIR LOVED ONE IS A DNR BUT NO DNR HAS BEEN FILLED OUT, CPR MUST BE INNITIATED [sic] *A RESIDENT THAT HAS A COMPLETE OUT OF HOSPITAL DNR AND PHYSICIAN ORDER FOR DNR. THE DNR MUST BE FOLLOWED AND NO CPR PROVIDED An attached Attendance/In-service Record dated 9/26/24 reflected the training had been conducted by the DON, ADON, and Regional RN and had been completed by 22 nursing staff with completed competency quizzes. Monitoring of the facility's Plan of Removal included the following: Observation on 9/27/24 at 4:35 PM, the facility's crash cart (a cart that contains emergency supplies to be used during CPR) revealed a binder that contained an Order Listing Report for Advanced Directives dated 9/27/24. The report reflected there were 36 residents in the facility who had Full Code status. During an interview on 9/27/24 at 1:40 PM, the ADON stated she knew Resident #82's health had been declining but had been unaware of her placement on hospice services. She stated she was working in the facility on 9/13/24 and thought she left sometime around 6:00 PM that day. She stated she learned later in the evening Resident #82 had passed away. The ADON stated she knew Resident #82 had been full code status in the past but did not know whether anything had changed. She stated she was out of the facility a lot that week due to a personal family issue. The ADON stated she had received in-service training for her corporate management on 9/26/24 and had assisted with providing in-service training to the facility staff afterward. She stated, if a resident was found unresponsive, staff should call for help, have someone check code status and retrieve the crash cart, and call emergency services. If a resident is DNR and on hospice, they should contact the hospice company. She stated they added a list of residents along with their code status to the crash cart and the list would be updated daily. The ADON stated the risk of not knowing a resident's code status included death if the resident was full-code status and performance of CPR against the wishes of someone who desired DNR status. During a telephone interview on 9/27/24 at 2:47 PM, the Medical Director stated he had cared for Resident #82 for more than three years. He stated she had deteriorated quickly and had been transferred to hospice services. He stated he did not contract with the particular hospice company used by Resident #82 and he had been notified by the facility of Resident #82's death. The Medical Director stated he had been notified by the facility Administration about the IJ. He stated he had a huge ethical issue if they had done CPR on someone in [Resident #82's] state because of the trauma it would have caused her. When asked about the risk of failure to perform CPR on a resident who was full code status, the Medical Director stated, as a general rule, not taking into account anything else-you should initiate CPR or the resident could pass. The Medical Director stated he had spoken with the Administrator and her superiors about addressing this and other issues on a weekly basis. He stated he believed the nurses should not be placed in a position such as the one that had occurred. He stated he planned to have the issue addressed with the Quality Assurance committee. In an interview with CNA E on 9/27/24 at 3:39 PM, she stated she worked at the facility for 2 years and typically worked the 2 PM to 10 PM shift. She stated Resident #82 had declined over the previous weeks before she died and needed to be fed. She stated she worked with Resident #82 on the day she passed away and recalled checking on her and changing her. She stated she appeared to be sleeping during the shift and would not accept any dinner when she attempted to feed her. She stated she attempted to place a straw in her mouth and she would not take it and she did not want to push her to drink. She stated she thought she had possibly received some morphine and was on hospice. CNA E stated she had informed LVN B that Resident #82 would not accept any food or drinks. She stated she recalled LVN B checking her after dinner and she had died. CNA E stated she could check a resident's code status on the computer. She stated she had received in-service training. CNA E stated if a resident was found unresponsive, they should call for help, get the nurse, get the crash cart and follow any of the nurse's instructions to assist. She stated the resident's code status could be found in the computer, and in binders at the nurse's station and on the crash cart. During an interview with the Social Worker on 9/27/24 at 4:09 PM, she stated she had received in-service training related to Advanced Directives and had been assisting with the facility's Plan of Removal. The Social Worker demonstrated the binder kept at the nurse's station which included face sheets and copies of the DNR documents for all residents as applicable. She stated a full audit of all facility residents had been completed the binder was found to be up-to-date and accurate. The Social Worker stated resident status in the computer must never be changed unless all documents were in order and properly signed. She stated she and the MDS Nurse worked together to ensure any changes to a resident's code status was immediately addressed, and both ensured physician orders and properly signed documents were obtained. The Social Worker stated she would be auditing all resident records weekly for the next four weeks then monthly thereafter to ensure accuracy and ongoing compliance. She stated, if she was unable to complete the audit, the MDS Nurse or nursing administrative staff would complete the audit. The Social Worker stated the QA committee would be meeting weekly for the next 8 weeks to review the process and ensure compliance. Interviews were conducted with facility staff across all three shifts on 9/27/24 from 11:21 AM through 4:43 PM. The staff included, LVN A, CNA M, CNA N, RN F, LVN G, LVN H, LVN I, CNA E, LVN J, LVN K, and CNA L. The interviews revealed they had all received in-service training and could accurately describe how to determine the resident's code status, how to determine whether DNR documentation was complete, how and when to initiate CPR, and how long they should continue CPR. During an interview with the Administrator on 9/27/24 at 4:30 PM, she stated the IJ occurred because the charge nurse failed to check code status for a resident who was on hospice and initiate CPR and call 911 when she was found unresponsive. She stated the hospice company failed to ensure they received the proper documentation timely from Resident #82's RP when he expressed his desire for a DNR order. She stated the risk to residents included failure to honor the resident's wishes and death if no CPR was initiated. During an interview on 9/27/24 at 4:38 PM, the Regional RN stated the IJ occurred due to a failure to check and act upon the code status of a resident and assumed they were DNR because they were on hospice. She stated the risk for failure to initiate CPR was death and failure to honor a resident's wishes. The Administrator was informed the IJ was removed on 9/27/24 at 6:30 PM. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.