**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 2 (Resident #2 and #3) of 6 residents reviewed for vehicle safety. -Maintenance Director failed to ensure Resident #2 and #3 were secured in the vehicle on 06/17/2024, while transporting residents back to the facility from dialysis visit, which resulted in falls with injuries. The noncompliance was identified as PNC. The IJ began on 06/17/2024 and ended on 06/18/2024. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of accidents and potential harm. Findings include: Resident #2: Review of Resident #2's Face Sheet dated 07/10/2024, revealed a [AGE] year-old female, with an admission date of 08/26/2016. Resident #2's diagnoses included: weakness, functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), end stage renal diseases (ESRD) (condition in which the kidneys lose the ability to remove waste and balance fluids), neuromuscular dysfunction of bladder (nerves and muscles don't work together very well causing lack of bladder control), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), unsteadiness on feet, pain, and history of falling. Review of Resident #2's quarterly MDS assessment dated [DATE], revealed resident had a BIMS score of 10 indicating moderate cognitive impairment. Section on Functional Abilities and Goals revealed Resident #2 with impairment to one side of the upper and lower extremities. Resident was dependent on staff assistance for oral hygiene, toileting, bathing, dressing, personal hygiene, and transfers. Review of Resident #2's comprehensive care plan dated 07/10/2024, revealed the resident is at risk for falls with injury related to weakness. Part of the interventions included, Uses wheelchair for long distance mobility; fall precautions. Review of Resident #2's physician orders dated 07/10/2024, reads in part an order for dialysis: Hemodialysis (treatment to filter wastes and water from your blood) every Monday, Wednesday, and Friday with transport time to dialysis at 1:00 p.m. Review of Resident #2's progress note dated 06/17/2024 at 7:03 p.m., written by LVN K reads while receiving oncoming report, this nurse received a phone call from facility driver that Resident #2 fell out of her chair onto the van floor while being transported back to the facility from dialysis. Driver unsure of any injury and called 911. The ambulance took resident to the hospital. An attempt to contact resident's RP was made with no success. Second RP was called and informed. Dr. and DON also notified. Review of Resident #2's progress note dated 06/18/2024 at 2:26 a.m., written by LVN K, reads (Resident #2) arrived back to the facility at 11:24 p.m., Her FM who was following the ambulance arrived approximately 5 minutes prior. She comes with a diagnosis of scalp hematoma (pool of mostly clotted blood that forms in an organ, tissue, or body space) and closed right fibula (outer and usually smaller of the two bones between the knee and the ankle in humans) fracture. A script for Tylenol 325 mg x 2 by mouth every 4 hours for fever and pain came with her. Upon assessment it was noted the hematoma to the back of her head, right side. No discoloration but pain to touch. She also has a cast on her right leg from her knee down to toes. When asked she stated a little pain to head. Tylenol given. It was effective. Review of Resident #2's progress noted dated 06/18/2024 at 12:07 p.m., written by SW, reads met with resident at bedside. FM also in room. SW inquired with resident about her recollection regarding the events that transpired the previous day. Resident verbalized not recalling what had occurred. SW inquired if she recalled being transferred and she stated she does not recall anything. SW asked if she was comfortable, and she verbalized she was. SW asked FM if he had any questions or concerns, and FM declined having any questions or concerns at the time. SW notified FM of on-going investigation. SW offered the number to the Complaint and Incident Intake number and Local Ombudsman and FM declined, stating he already had the information. Record review of EMS run record dated 06/17/2024 for Resident #2, reads R19 arrived with P24 already on scene to a 74 YOF who had suffered a fall from a sitting position. Patient was found lying supine on the floor of a transport van, alert and oriented, with (FM) present. Patient had stated that she had just finished her dialysis treatment and was being transported back home, when the van had taken a sharp left turn heading up [street name], and the patient fell out of her wheelchair and hit the back of her head on the floor of the van. Patient reported that she does not take any blood thinners or aspirin and that she did not lose consciousness. Patient was assisted by P24 and R19 crew members out of the van and onto the stretcher. Patient was placed onto R19 for further evaluation and treatment. Patient was placed on oxygen at 4LPM via nasal cannula, as reported she is on constant O2 and her SpO2 did drop to the high 80s when off oxygen. Patient was AO x4, a small bump to the back of her head was found, no bruising or bleeding present with no complaints of pain anywhere and vitals in normal range. Patient was transported code 1 to the hospital. Patient transfer was given to the hospital anursing staff and R19 departed the facility. Record review of hospital records for Resident #2 dated 06/17/2024, reads Patient completed dialysis and was in the back of the van when the van took a hard turn and patient fell from wheelchair. There are no complaints from her, but scalp hematoma was found. Patient is here for evaluation. Lab results interpretation: CT scan of cervical spine without contrast with no acute findings in head or cervical spine. CT of brain without contrast with no acute findings in the head or cervical spine. Radiology of right tibia/fibula revealed, Distal (situated away from the center of the body or from the point of attachment) tibial (large bone at the front of the lower leg) fracture associated with proximal (situated nearer to the center of the body or the point of attachment) and distal fractures of the fibula (outer and usually smaller of the two bones between the knee and the ankle in humans). Severe generalized demineralization of bones. During an interview on 07/03/2024 at 11:01 a.m., Resident #2 said she did not remember what happened on 06/17/2024 while in the facility vehicle. Resident #2 does not remember any details of the incident including who was driving the vehicle, who else was in the vehicle, was she secured to the vehicle, where the incident occurred, or what happened after the incident. During an interview on 07/03/2024 at 11:05 a.m., Resident #2's RP and FM said on the day of the incident he was with Resident #2 during her dialysis visit. RP said the facility Maintenance Director arrived sometime around 5:30 p.m., to pick up Resident #2 and #3 to transport back to the facility. RP said he wheeled Resident #2 to the lift ramp of the vehicle and walked away to go to his truck. RP said he did not see how the driver secured the residents in the vehicle prior to departure. RP said he followed the facility vehicle. RP said that while at the intersection of two streets he observed the facility vehicle making a protected left turn and that it seemed that the vehicle was experiencing mechanical issues and the driver pulled over to park. RP said when he got off the truck to see if they needed assistance, he saw inside the van that both residents were on the floor. RP said he did not see any cars cutting off the van during the turn and from his perspective the van was not going fast. RP said when he walked up to the vehicle, he did not see any seatbelts on the residents and the residents had fallen to their right side. The RP said he observed the wheelchairs were upright. RP said Resident #2's head was leaning towards her right side and right leg was bent and left leg up on the armrest. The RP said Resident #3 was smaller than Resident #2 and he observed that Resident #3 was out of the wheelchair and lying on right side of head on floor. RP said the driver called 911 and emergency services showed up and assisted the residents to reposition, and then took both residents in ambulances. RP said the driver did not tell him anything about what happened. RP said Resident #2 had been transported in the vehicle regularly without any incident prior to the incident on 06/17/2024. Resident #3: Review of Resident #3's Face Sheet dated 07/03/2024, revealed a [AGE] year-old female, with an admission date of 12/22/2023. Resident #3's diagnoses included: abnormalities of gait and mobility, end stage renal disease (condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis, anxiety disorder (feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and lack of coordination. Review of Resident #3's quarterly MDS assessment dated [DATE], revealed resident had a BIMS score of 13 indicating she was intact cognitively. Section on Functional Abilities and Goals revealed Resident #3 was dependent on staff assistance for transfers and uses a manual wheelchair. Resident #3 had not had any other falls since admission. Review of Resident #3's comprehensive care plan dated 07/03/2024, revealed the resident is at risk for falls. Part of the interventions included, Uses wheelchair for long distance mobility; fall precautions. Review of Resident #3's physician orders dated 07/10/2024, reads in part an order for dialysis: Hemodialysis three times a week with transport time to dialysis at 1:00 p.m. Review of Resident #3's progress note dated 06/17/2024 at 7:05 p.m., written by LVN L, reads Driver contacted facility to advise that residents were on their way back from dialysis and informed nurses that on a turn that resident fell and tipped over. Driver contacted 911, as there was a hematoma to patient's head. EMS on scene and resident to be transported to the hospital. FM has been notified as well as MD and DON. Review of Resident #3's progress note dated 06/18/2024 at 1:35 a.m., written by LVN L, reads Resident returned from the hospital at 12:30 a.m., Resident alert and currently voice no pain. Resident with facial bruising to left eye, abrasion to left leg. RN at hospital said CT scan done and clear with no abnormalities. Review of Resident #3's progress note dated 06/18/2024 at 12:04 p.m., written by the SW, reads Met with resident at bedside, family present. Female FM stepped out and male FM and resident remained in the room. SW inquired with resident about her recollection of the events that transpired the previous day. Resident reports she was being brought back home when a turn was made, and she tilted to the right side. SW inquired with resident if she had any other recollection and male FM interjected and stated she was not buckled in. SW asked male FM to allow resident to provide information. Resident then stated that she recalls driver doing something at the bottom of her wheelchair but states she was not buckled from the top. DON and Administrator notified. Record review of EMS run record dated 06/17/2024 for Resident #3, reads Rescue 25 found the patient lying prone inside of a van. Patient was a [AGE] year-old female complaining of pain to the right wrist and face. She sustained a hematoma to the left eyebrow as well as an abrasion to the left knee. Patient had completed dialysis and was on her way to facility. Patient states that she was a passenger inside of the van when the driver took a sharp turn and knocked the patient off of her seat onto the floor of the van. Patient was moved to the stretcher and loaded into rescue 25. Her vitals were assessed while en route to the hospital. Patient was transported to the hospital code one level three trauma. Patient was transferred over to hospital staff and rescue 25 left without incident. Record review of hospital records for Resident #3 dated 06/17/2024, reads Patient completed dialysis and was on the van. The van took hard turn and patient on wheelchair fell. Patient has facial bruises and complaining of left knee pain and right-hand pain. Pain level is 5/10 pain. Patient did not lose consciousness. Lab results interpretation: Radiology right hand with no definitive areas of acute bony injuries. Radiology of left tibia fibula with no acute bony injuries were demonstrated. Minimal degenerative changes left knee joint. CT scan of facial bones without contrast: impression left anterior frontal scalp hematoma and left periorbital (eyelid or skin around the eye) soft tissue swelling. No maxillofacial fracture. CT scan of brain without contrast: No acute intracranial hemorrhage. During an interview on 07/03/2024 at 9:58 a.m., DON said the Maintenance Director was a designated driver for the facility's only transportation vehicle. DON said the Maintenance Director would pick up residents who were out of the facility at appointments after 4:00 p.m. before the 6/17/2024 incident. DON said she received a call on 06/17/2024 around 6:00 p.m. from the Maintenance Director who had contacted 911 prior to calling the DON. DON said the Maintenance Director reported that he picked up Residents #2 and #3 from dialysis, and while traveling back to the facility, while he was turning the facility vehicle, a car was crossing, and he had to brake hard. The DON said Residents #2 and #3 were on their wheelchairs and fell out of their wheelchairs and onto the floor. DON said the Maintenance Director pulled over and called 911. DON said the residents were transported to the hospital by ambulance. DON said Resident #2 had a left distal tibial fracture. Resident #3 did not sustain any fracture but had scratches and bruises to her face. DON said the Maintenance Director returned to the facility without any passengers and left for the day. DON said she and the former Administrator conducted the investigation. DON said they interviewed the Maintenance Director, who said that he strapped the wheelchairs of the residents and secured them with the vehicle seatbelts. DON said Residents #2 and #3 were interviewed. DON said Resident #2 said she did not remember the incident and that she only remembers flying. DON said Resident #3 FM were very upset. DON said the SW interviewed Resident #3 and FM was present during the interview saying that she was not strapped in. DON said Resident #3 then agreed that she was not strapped in. DON said Maintenance Director was suspended two days and given written disciplinary action. DON said all drivers had to re-do driver competency with return demonstration. DON said there is one Facility Driver and three other designated drivers. DON said a decision was made that only the Facility Driver will drive residents to outside appointments, or they will call for an ambulance transportation. During an interview on 07/08/2024 at 10:13 a.m., Resident #3 said she was being picked up from dialysis by the Maintenance Director. Resident #3 said the Maintenance Director did not put a seatbelt on her. Resident #3 said it was only she, Resident #2, and the Maintenance Director in the vehicle. Resident #3 said while turning a corner she fell from her wheelchair to right side and hit her head. Resident #3 said she fell on her arm and had a bruise to her leg. Resident #3 said she told the driver that her arm was hurting, and he told her the ambulance was on the way. Resident #3 said she sustained facial injuries of a bump on her left eyebrow and bruises. Resident #3 said she did not remember if her wheelchair was secured or if it moved. Resident #3 said Resident #2 was behind her and fell as well. During an interview on 07/03/2024 at 12:10 p.m., Facility Driver said he was not present for the incident that occurred on 06/17/2024. Facility Driver said following the incident where residents had fallen, he is the only person who was authorized to drive the vehicle. He said that he had been the Facility Driver for several years and conducts training of other designated drivers. He said the former Administrator did not want him to work overtime and he would work until 2-2:30 p.m. He said that he arrives at work at 5:00 a.m., to drive residents to outside appointments. He said that the facility is now working on scheduling outside appointments within the time that he was scheduled to work, or he flexes his schedule to accommodate late evening appointments and pickups. He said that he inspected the vehicle on 06/18/2024 and found no mechanical issues with the equipment in the vehicle. He said that it was the neglect of the Maintenance Director who did not put the seatbelt on the residents. He said he trained the three other designated drivers and required that they performed a return demonstration around 3 months ago. He said that he had not experienced any issues with the securement devices while he had been driving. During an observation on 07/03/2024 at 12:20 p.m., Facility Driver was observed individually lifting three residents on the vehicle and securing each resident to go to an outside appointment. Facility Driver secured the frames of the wheelchairs with four-point anchors to the floor rail. He then secured residents by running a seatbelt across the residents and pulled each piece of equipment to ensure all belts and attachments were secured. There were no defects, or any other issues noted with vehicle equipment. Facility Driver found to be proficient at use of safety equipment. During an interview on 07/03/2024 at 2:00 p.m., the Maintenance Director said he had been in his position at the facility for two years. The Maintenance Director said he was a designated transporter up to 06/17/2024, in case of evacuations or emergencies. The Maintenance Director said he had been driving the facility vehicle for about a year without incident. The Maintenance Director said he was in-serviced on safe transportation by the Facility Driver back in July 2023. The Maintenance Director said the in-service covered the importance of buckling up residents, seatbelts, and putting on manual brakes. The Maintenance Director said he was trained to use floor anchors to secure the wheels and use the seatbelt that goes over the chest of passengers. He said there are two anchors used in front and two in the back that are attached to the frame of a wheelchair and adjusted to size. He said he was trained to double check to make sure the passenger was secured and there was no movement. The Maintenance Director said on 06/17/2024 during the evening he picked up Resident #2 and #3 from a dialysis appointment. He said he was driving about 30-40 MPH. He said that he waited at the intersection of two streets and waited for the protected left green light. He said that Resident #2's RP was following the vehicle. The Maintenance Director said the green light came on and he started turning left onto the farthest right lane of the three-lane road. He said he saw a white sedan facing the opposite direction that appeared to possibly turn into his lane. The Maintenance Director said he hit the brake and turned more left. He said he heard a hit on the floor and noticed that both Resident #2 and #3 fell to the right side. He said he stopped in the non-passing lane and called 911. He said that both wheelchairs were anchored to the floor. He said he could not explain what happened. He said he did not see any defects in the seatbelts or anchors. He said the seatbelts were off and he did not know if it was because of the hard braking. He said he was not in any rush to be anywhere. He said an ambulance arrived and they had to wait for a second ambulance. He said Resident #3 complained of pain to her arm and had a bump/bruise to her forehead. He said Resident #2's FM was present at the scene and that Resident #2 had landed on her back on the floor and had one of her legs stuck in the seatbelt. The Maintenance Director said after the residents were transported to the hospital he drove back to the facility. He said the following day the Facility Driver checked the van to make sure nothing snapped and re-in-serviced the Maintenance Director on properly securing passengers during transport having to do a return demonstration. The Maintenance Director said he then had to leave because he was suspended on 06/18/2024. He said he came back to the facility on [DATE] and had not driven the vehicle anymore. Review of vehicle manufacturer operation manual undated, reads in part, Safety belts must be worn by all occupants. Passengers can dramatically reduce their risk of being killed or seriously injured by wearing their safety belts. Organizations that own vans and wagons should have a written safety belt use policy. Drivers should be responsible for enforcing the policy. Review of the facility provided Safe Transportation policy dated 05/2023, reads in part When transportation is the responsibility of the facility, staff will assist in transporting, handling, and transferring individuals. The purpose of this policy is to ensure the safety of individuals served as well as staff during transportation and include the provisions for handling emergency situations. Interpretation: 1. Vehicles must meet federal, state, local and manufacturer's safety and mechanical operating and maintenance standards for the vehicle. The Administrator and/or Director of Maintenance will ensure the safety of vehicles equipment, supplies, and materials owned or leased by the company and will maintain these in good condition during times of providing services. 5) Before allowing transportation staff to drive unsupervised, transportation staff must be trained and able to demonstrate the following: Operation of wheelchair lift, restraining devices and other special equipment; passenger assistance and securement; awareness and handling of unsafe conditions, emergencies, and security threats; and procedures for reporting abuse and neglect. 6) Transportation staff will receive training on each individual's transferring or handling requirements for the individual and/or equipment prior to transferring or transporting individuals. All transfers and handling of individuals served will be done in a manner that ensures safe transportation, dignity, and privacy. 12) In accordance with state laws, anyone riding in a moving vehicle must wear seatbelts and/or child safety restraints. To this end, every vehicle used to conduct facility business shall have a safety belt installed for each seating position. No vehicle shall be operated while carrying more passengers than available safety belts. Each motor vehicle operator and all occupants shall be secured with the safety belt or child safety seat whenever the motor vehicle is under power or in motion. The driver of the vehicle shall ensure that each occupant is properly restrained before beginning any trip, regardless of the length or duration, until the motor is shut off. Under no circumstances will any person be allowed to drive, ride, or otherwise be transported without such devices in use. 17) Residents using wheelchairs will be transported according to manufacturer's safety guidelines. This includes, but is not limited to, safe operation and regular maintenance of lift equipment, checks of straps to secure the wheelchair to the floor of the vehicle, and use of adaptive seating equipment when appropriate. Transportation staff who are transporting residents and who complete tie-downs of wheelchairs will receive training on how to do so and will be required to demonstrate competency prior to transporting individuals using wheelchairs. Review of employee records revealed Maintenance Director was hired on 09/28/2022. On 07/06/2023 the Maintenance Director received competency training on being a Van Driver-Transporter PRN. Maintenance Director was found to be competent in numerous tasks to include administrative functions which included reporting all incidents such as falls and change of condition to the DON immediately; personnel functions, transportation functions, staff development, safety and sanitation which included following established safety regulations in use of equipment; equipment and supply functions, and resident rights. The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering: On 6/18/2024 Facility Maintenance Director given disciplinary action of write up with two-day suspension. Review of employee timecard verified that employee was suspended 6/18/2024 and did not return to work until 6/24/2024. On 6/18/2024 Driver competencies were performed for one Facility Driver and three other staff members designated as drivers. On 6/18/2024 Facility restrictions put in place regarding who was able to drive residents on the vehicle allowing only the Facility Driver to drive residents. On 6/18/2024 Facility Driver verified functionality of seatbelt and safety straps finding no defects. On 6/18/2024 Facility in-service on teaching additional drivers properly how to strap residents on the wheelchairs to van when transporting. On 06/18/2024 Facility in-service on and abuse and neglect. After entry of investigator on 07/03/2024: Random sample residents (Resident #10, #12, #13, and #14) who had been transported by the facility vehicle were interviewed. Resident #10 was interviewed on 07/10/2024 at 8:59 a.m., Resident #12 as interviewed on 07/10/2024 at 8:54 a.m., Resident #13 was interviewed on 07/10/2024 at 9:02 a.m., and Resident #14 was interviewed on 07/10/2024 at 9:06 a.m. None of the residents reported any concerns with being secured when being transported in the vehicle. None of the residents reported any fall or near fall incidents in the vehicle. On 07/03/2024, observation made of Facility Driver performance on using securement safety devices in the vehicle. There was no evidence of any defects of safety equipment. Facility Driver found to be proficient at use of safety equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents in the facility were free from neglect for 1 (Resident #1) of 14 residents reviewed for neglect in that: Resident #1 was found unresponsive on [DATE] around 7:25 AM by CNA C who immediately notified RN A. RN A who was responsible for Resident #1 did not know the process and procedures that were to be followed when a full-code resident was found unresponsive, resulting in the resident not being provided CPR. An IJ was identified on [DATE] at 10:25 AM. The IJ template was provided to the facility on [DATE] at 10:25 AM. While the IJ was removed on [DATE] at 6:55 PM the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm, because all staff had not been trained on Emergency Response Procedure and Calling a Code. These failures could place residents at risk for serious injury, hospitalization and/or death. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed he was [AGE] years old, was admitted to the facility on [DATE] and discharged on [DATE] due to death in the facility. The face sheet did not indicate his code status. Record review of Resident #1's history and physical dated [DATE] revealed he had diagnoses including coronary artery disease (damage or disease of the hearts major blood vessels), osteomyelitis (infection in the bone), Diabetes mellitus with hyperglycemia (Diabetes with high blood sugar), hypertension (high blood pressure, vascular dementia (dementia caused by blood clots in the brain) and hemiparesis affecting left side as late effect of cerebrovascular accident (Stroke affecting his left side). Record review of Resident #1's admission MDS dated [DATE] revealed he had a BIMS score of 8 (moderate cognitive impairment). He had symptoms of delirium including fluctuating periods of inattention and disorganized thinking. He had symptoms of psychosis including hallucinations (seeing something that is not actually there). He had no symptomatic behaviors. He was dependent on staff for toileting, bathing, dressing, personal hygiene, sitting up, and transferring between surfaces. Record review of Resident #1's care plan dated [DATE] revealed he was a full code status, that the facility would honor his wishes regarding code status and attempt to resuscitate him should arrest occur. His physician would be contacted, emergency services would be notified, and family would be notified. Record review of Resident #1's physician's orders dated [DATE] revealed no orders concerning his code status. Record review of Resident #1's Advance Directives information in his electronic record accessed [DATE] revealed his CPR (Resuscitation) Status was Attempt CPR. Record review of Resident #1's progress note dated [DATE] at 10:53 AM by RN A documented the following Resident found unresponsive by this nurse, initially attempted vitals but was unsuccessful, CPR initiated immediately, code cart brought to room, AED in place with commands initiated, 911 called, CPR continued till EMS arrived and took over. DON, Administrator, and MD notified. Family called and updated. All questions and concerns addressed. Record review of the fire department's Hospital Care Report for Resident #1 dated [DATE] beginning at 7:55:12 AM revealed that paramedics were dispatched to the facility at 7:56 AM and arrived at the resident's bedside at 8:07 AM. The resident was pale and cold, pulseless and apneic (not breathing) and facility staff were performing compressions. Facility staff reported to the paramedics they noticed the resident was not breathing at around 7:20 AM and had called 911 around 7:55 AM. The paramedics took over compressions, established IV (needle in a vein) access, placed oxygen on the resident and administered epinephrine (adrenaline) and normal saline. The patient (Resident #1) was found in asystole (without a heartbeat) and remained in the same cardiac rhythm. The paramedics contacted physician (unidentified) who gave permission to discontinue ALS (Advance Life Support) interventions. CPR was discontinued on [DATE] at 8:17 AM. The paramedics advised the nurse at the facility of the doctor's orders, and the paramedics left. The resident was not transported from the facility. Record review of the facility's self-report Intake Investigation Worksheet dated [DATE] revealed an allegation of neglect because RN A found Resident #1 unresponsive on [DATE] at 7:38 AM but did not initiate CPR until 16 minutes later at 7:55 AM. In an interview on [DATE] at 8:31 AM, the ADON revealed she received a telephone call at 7:40 AM on [DATE] from the DON that RN A had texted the DON at 7:38 AM that Resident #1 had expired. The DON asked the ADON to go to the facility to initiate CPR and call 911. The ADON stated she arrived at the facility at 7:54 AM and found RN A at the nurse's station at the front of the building. Per the ADON she asked RN A who was with Resident #1 and RN A said No one. The ADON stated she then ran to Resident #1's room with RN A and when she arrived the crash cart was in the resident's room but there were no staff members there. The ADON said she called 911 at 7:55 AM while RN A initiated CPR assisted by LVN D, and CNAs C and E who had arrived at the room by then. Per the ADON, CNA C had gone into Resident #1's room to get him up for breakfast, found him unresponsive, and notified RN A. The ADON stated she asked RN A why CPR was not initiated, and RN A said that he was already cold and grey, and that she (RN A) did not know what to do, that this type of situation was handled differently in the hospital where she had worked before. [RN A date of hire [DATE]]. The ADON stated that RN A had not alerted other nurses in the facility about Resident #1's condition. She said that an investigation was done, with RN A being suspended and later terminated in response to the investigation. In an interview on [DATE] at 12:39 PM, the DON revealed that when CNA C told RN A that Resident #1 was unresponsive and the RN found the resident unresponsive, the RN should have started the code. She said the Code Blue procedure involved the nurse getting help from other staff in announcing Code Blue on the intercom, taking the crash cart and AED to the resident's room, and calling 911 while responding nurses and other responding staff would place a back board under the resident, start chest compressions, place and use the ambu-bag (bag used to help a patient's breathing), place the AED pads on the patient's chest and follow instructions from the AED machine. The DON said that that these compressions, use of the ambu-bag and following instructions from the AED should continue until paramedics arrived to take over the situation. She said that RN A was suspended pending investigation of the incident, and later was terminated. In an interview on [DATE] at 4:59 PM the DON revealed that the facility had not done any training about how to respond to this type of emergency [an unresponsive patient who is full-code], because nothing like this had happened before. She stated that nurses learned about CPR in outside classes when they got their CPR cards renewed. Telephone attempts to reach RN A were made on [DATE] at 9:34 AM, and on [DATE] at 8:15 AM, 9:21 AM, and 11:24 AM with no response although requests for a return call were left in her digital mailbox. Record review of RN A's personnel file revealed she was hired on [DATE]. She initialed a New Hire Orientation Acknowledgement that included location and information about the AED on [DATE]. In an interview on [DATE] at 8:31 AM, LVN D said she became aware of the incident involving Resident #1 before breakfast on [DATE] when RN A came to her asking what the procedure was when a resident was found with no vital signs. LVN D said RN A was not sure if Resident #1 had a DNR order or had a full code status. LVN D said she went to the nurse's station and found a green sheet of paper in his file [denotes full code status] and then looked in his electronic chart which also showed he had a full code status. LVN D said when she discovered Resident #1 had a full-code status she ran to get the crash cart and AED, took them to Resident #1's room. LVN D stated when she arrived at Resident #1's room the room was empty. LVN D said she and RN A arrived at the resident's room together and put the board under his back, opened the AED and placed patches on the resident, started CPR. LVN D said the AED did not shock him. At some point the ADON arrived and was using the ambu-bag. LVN D was not able to state when the ADON arrived. In an interview on [DATE] at 8:56 CNA E revealed that the morning of [DATE] around 7:25 AM, she was walking down the 400 hall when CNA C came out of Resident #1's room and said he was not moving. CNA E said she looked at Resident #1 who looked grey and was cold to the touch. CNA E said she and CNA C stepped outside the room where RN A had her cart and told the RN that she needed to go into the room because Resident #1 was gone. CNA E said the RN went into Resident #1's room, touched the resident, and pulled the sheet over his head. CNA E said she told the RN Don't do that and the RN pulled the sheet back down. CNA E said the RN then left the room and once outside asked the CNA (CNA E) what the procedure was. CNA E said she did not respond to the RN's question but instead told CNA C what the CNAs did when told by a nurse that a resident had died (wash the body, change the linens, use a towel to close the mouth). In a telephone interview on [DATE] at 10:52 AM, CNA C revealed she arrived for work on [DATE] around 6:00 AM and began her work. After readying several residents for breakfast, she asked RN A what she needed to for Resident #1. RN A told her to get him up for breakfast, but when CNA C entered Resident #1's room to begin getting him ready, she saw that the resident's face and hands were discolored, and his mouth was wide open. The CNA said she looked at the resident's chest and did not see him breathing. CNA C said she walked out of room and told RN A something was wrong with Resident #1, that he was not breathing and was not ok. CNA C said she went with RN A into Resident #1's room and saw the RN check the resident's pulse and breathing. The CNA followed the RN out of the resident's room where RN A was heard asking CNA E what the procedure was because it was different in different states. CNA C stated she was later going to the dining room to help with breakfast when she saw the ADON, RN A and LVN D go to Resident #1's room with the crash cart. She followed them to the resident's room where she observed the three nurses place the back board, start chest compressions, attach the AED to the resident, and begin use of the ambu-bag. In an interview on [DATE] at 4:22 PM, LVN F revealed that on [DATE] before breakfast (was not able to give specific time) she heard unidentified staff members saying that Resident #1 had expired. LVN F said she was surprised because no one had called a Code Blue. LVN F said she went to Resident #1's room where LVN D, RN A and CNA C were beginning to place the back board under the resident and to start compressions. Record review of the facility's policy Emergency Procedure - Cardiopulmonary Resuscitation dated 02/2018 revealed that if an individual is found unresponsive and not breathing normally a licensed staff member who is certified in CPR/BLS (cardiopulmonary resuscitation/Basic life support) shall initiate CPR unless it is know that a DNR order that specifically prohibits CPR and/or external defibrillation exists for the individual. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR order or a physician's order to not administer CPR. Record review of the facility's policy Abuse and Neglect - Clinical Protocol dated [DATE] revealed that the definition of neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The physician and staff will help identify risk factors for abuse within the facility such as those related to staffing such as poor preparation, training, and lack of knowledge or skills that might affect how the residents are being cared for. Staff and management will help identify situations that might constitute or could be construed as neglect such as inattention to advance directives. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 10:25 AM. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 10:25 AM. The Plan of Removal was accepted on [DATE] at 12:12 PM: [DATE] Employee was interview and statement taken. This was completed by [DON name] RN, DON and [ADON name] LVN, ADON on [DATE]. Met with Administrator and decision was made to suspend employee same day on [DATE]. This was completed by [DON name] RN, DON and [Administrator name], Administrator on [DATE]. Investigation begin by interviewing staff members and taking written statements. This was completed by [DON name] RN, DON on [DATE]. [DATE] Full code and DNR audit were completed to ensure, physician order, code status icon and correct colored paper (green or red) is in chart for all residents. This was completed by [LVN B Name] LVN, Medical records on [DATE]. Continued to take statements from staff members. This was completed by [DON name] RN, DON on [DATE]. Audit CPR certification for nurses completed This was completed by [DON name] RN, DON on [DATE]. CPR certification class was scheduled for Thursday [DATE] at 1:30pm. This was completed by [ADON name] LVN, ADON on [DATE]. In-service on where to find a residents' code status provided to staff. This was completed by [DON name] RN, DON on [DATE]. [DATE] In-services on ''Emergency response procedure, calling a code'' provided to staff. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. Continue investigation by taking staff statements. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. [DATE] In-services continued on ''Emergency response procedure, calling a code'' This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. Continue investigation by taking staff statements. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. [DATE] Continue investigation by taking staff statements. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. [DATE] In-serviced nurses about what to do when a patient is full code or DNR and found with no signs of life. This was completed by [DON name] RN, DON on [DATE]. Facilities Plan to ensure compliance quickly [DATE] Staff in-service on ''Abuse and neglect'' and ''Emergency response procedure, calling a code: verification of code status, instructing staff to activate emergency response system code, call 911, and initiate basic life support''. Staff members will not assume any job responsibilities until training has been received by DON/designee This was completed by [DON name] RN/DON on [DATE]. This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards to knowledge about abuse and neglect and how to reach/do in a code blue situation. DON/designee will report monthly to QAPI [DATE] and ongoing CPR certification class and emergency mock drill training provided on [DATE] at 1:30pm. Will be completed by [Business owner's name] (Owner of [Business name and location]). This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards how to react/do in a code blue situation. DON/designee will report monthly to QAPI Ongoing Emergency mock drills training quarterly. Will be completed by [Business owner's name] (Owner of [Business name and location]). This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards how to react/do in a code blue situation. DON/designee will report monthly to QAPI Plan of Removal was verified a follows: - Confirmed through interview and record review (DON, [DATE] 4:59 PM; HR Manager [DATE], 9:43 AM) that alleged perpetrator was interviewed, suspended and terminated. - Through interview with 3 LVNs from 6 AM to 6 PM shift and two LVNs from 6 PM to 6 AM shift confirmed understanding of training regarding response to resident without signs of life (LVN F, [DATE] 4:22 PM; LVNs - [DATE] 9:04AM, [DATE] 2:22 PM, 5:08 PM, 5:16 PM.) - Confirmed through interview (Medical Records Director, [DATE] at 3:11 PM) that an audit was performed on all resident records to ensure accuracy of resident code status; confirmed through record review of residents physical and electronic charts ([DATE] at 4:04 PM) the accuracy of resident code status for 12 sample residents (Census of 75). - Confirmed through record review (audit listing with nurse's names and CPR expiration dates) and interview (DON [DATE], 5:05 PM) that nurses' CPR training status was audited, and that the facility has taken action to train one nurse whose CPR training was expired. - Confirmed through observation (Group trainings observed [DATE], at 2:07 PM, 2:50 PM, 3:58 PM), interview (DON [DATE] at 5:05 PM) and documentation (Inservice sign-ins dated [DATE], [DATE], [DATE], [DATE]) that trainings regarding calling a code and regarding determining a resident's code status as identified in the plan of removal were provided. - Confirmed through interview (Administrator [DATE] 3:30 PM) and record review (Service Agreement dated [DATE]) that the facility entered into a service agreement with a provider of BLS and First aid/CPR/AED courses. - Confirmed through interview and record review that ANE training is provided to employees and through interviews with 13 staff (RN (DON [DATE] 5:05 PM; RN [DATE] 2:03 PM), LVN (LVN F, [DATE] 4:22 PM; LVNs [DATE], 5:08 PM, 5:16 PM, CNAs - [DATE] at 10:52, [DATE], 1:52 PM, 1:59 PM, 2:33 PM, 2:57 PM, 3:07 PM, 3:30 PM; 3:40 PM), Restorative Aide ([DATE], 2:11 PM), Activities Director ([DATE], 2:16 PM) understanding of the concept of neglect. - Confirmed through interview that employees (DON [DATE] 5:05 PM) who have not completed Emergency response procedure, calling a code: verification of code status, instructing staff to activate emergency response system code, call 911, and initiate basic life support training will not assume job responsibilities until training has been done. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 6:55 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**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, including 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 (Resident #1) of 14 residents reviewed for physician's orders for provision of basic life support in that: Resident #1 was found unresponsive on [DATE] around 7:25 AM by CNA C who immediately notified RN A. RN A went to the resident's room and checked him for signs of life but did not know how to respond when she did not find a pulse, and did not immediately start CPR or other life-sustaining measures, resulting in Resident #1's wishes to be resuscitated not being honored. An IJ was identified on [DATE] at 10:25 AM. The IJ template was provided to the facility on [DATE] at 10:25 AM. While the IJ was removed on [DATE] at 6:55 PM the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm, because all staff had not been trained on Emergency Response Procedure and Calling a Code. These failures could place residents at risk for serious injury, hospitalization and/or death. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed he was [AGE] years old, was admitted to the facility on [DATE] and discharged on [DATE] due to death in the facility. The face sheet did not indicate his code status. Record review of Resident #1's history and physical dated [DATE] revealed he had diagnoses including coronary artery disease (damage or disease of the hearts major blood vessels), osteomyelitis (infection in the bone), Diabetes mellitus with hyperglycemia (Diabetes with high blood sugar), hypertension (high blood pressure), vascular dementia (dementia caused by blood clots in the brain) and hemiparesis affecting left side as late effect of cerebrovascular accident (Stroke affecting his left side). Record review of Resident #1's admission MDS dated [DATE] revealed he had a BIMS score of 8 (moderate cognitive impairment). He had symptoms of delirium including fluctuating periods of inattention and disorganized thinking. He had symptoms of psychosis including hallucinations (seeing something that is not actually there). He had no symptomatic behaviors. He was dependent on staff for toileting, bathing, dressing, personal hygiene, sitting up, and transferring between surfaces. Record review of Resident #1's care plan dated [DATE] revealed he was a full code status, that the facility would honor his wishes regarding code status and attempt to resuscitate him should arrest occur. His physician would be contacted, emergency services would be notified, and family would be notified. Record review of Resident #1's physician's orders dated [DATE] revealed no orders concerning his code status. Record review of Resident #1's Advance Directives information in his electronic record accessed [DATE] revealed his CPR (Resuscitation) Status was Attempt CPR. Record review of Resident #1's progress note dated [DATE] at 10:53 AM by RN A documented the following Resident found unresponsive by this nurse, initially attempted vitals but was unsuccessful, CPR initiated immediately, code cart brought to room, AED in place with commands initiated, 911 called, CPR continued till EMS arrived and took over. DON, Administrator, and MD notified. Family called and updated. All questions and concerns addressed. Record review of the fire department's Hospital Care Report for Resident #1 dated [DATE] beginning at 7:55:12 AM revealed that paramedics were dispatched to the facility at 7:56 AM and arrived at the resident's bedside at 8:07 AM. The resident was pale and cold, pulseless and apneic (not breathing) and facility staff were performing compressions. Facility staff reported to the paramedics they noticed the resident was not breathing at around 7:20 AM and had called 911 around 7:55 AM. The paramedics took over compressions, established IV (needle in a vein) access, placed oxygen on the resident and administered epinephrine (adrenaline) and normal saline. The patient (Resident #1) was found in asystole (without a heartbeat) and remained in the same cardiac rhythm. The paramedics contacted physician (unidentified) who gave permission to discontinue ALS (Advance Life Support) interventions. CPR was discontinued on [DATE] at 8:17 AM. The paramedics advised the nurse at the facility of the doctor's orders, and the paramedics left. The resident was not transported from the facility. Record review of the facility's self-report Intake Investigation Worksheet dated [DATE] revealed an allegation of neglect because RN A found Resident #1 unresponsive on [DATE] at 7:38 AM but did not initiate CPR until 16 minutes later at 7:55 AM. In an interview on [DATE] at 8:31 AM, the ADON revealed she received a telephone call at 7:40 AM on [DATE] from the DON that RN A had texted the DON at 7:38 AM that Resident #1 had expired. The DON asked the ADON to go to the facility to initiate CPR and call 911. The ADON stated she arrived at the facility at 7:54 AM and found RN A at the nurse's station at the front of the building. Per the ADON she asked RN A who was with Resident #1 and RN A said No one. The ADON stated she then ran to Resident #1's room with RN A and when she arrived the crash cart was in the resident's room but there were no staff members there. The ADON said she called 911 at 7:55 AM while RN A initiated CPR assisted by LVN D, and CNAs C and E who had arrived at the room by then. Per the ADON, CNA C had gone into Resident #1's room to get him up for breakfast, found him unresponsive, and notified RN A. The ADON stated she asked RN A why CPR was not initiated, and RN A said that he was already cold and grey, and that she (RN A) did not know what to do, that this type of situation was handled differently in the hospital where she had worked before. [RN A date of hire [DATE]]. The ADON stated that RN A had not alerted other nurses in the facility about Resident #1's condition. She said that an investigation was done, with RN A being suspended and later terminated in response to the investigation. In an interview on [DATE] at 12:39 PM, the DON revealed that when CNA C told RN A that Resident #1 was unresponsive and the RN found the resident unresponsive, the RN should have started the code. She said the Code Blue procedure involved the nurse getting help from other staff in announcing Code Blue on the intercom, taking the crash cart and AED to the resident's room, and calling 911 while responding nurses and other responding staff would place a back board under the resident, start chest compressions, place and use the ambu-bag (bag used to help a patient's breathing), place the AED pads on the patient's chest and follow instructions from the AED machine. The DON said that that these compressions, use of the ambu-bag and following instructions from the AED should continue until paramedics arrived to take over the situation. She said that RN A was suspended pending investigation of the incident, and later was terminated. In an interview on [DATE] at 4:59 PM the DON revealed that the facility had not done any training about how to respond to this type of emergency [an unresponsive patient who is full-code], because nothing like this had happened before. She stated that nurses learned about CPR in outside classes when they got their CPR cards renewed. Telephone attempts to reach RN A were made on [DATE] at 9:34 AM, and on [DATE] at 8:15 AM, 9:21 AM, and 11:24 AM with no response although requests for a return call were left in her digital mailbox. Record review of RN A's personnel file revealed she was hired on [DATE]. She initialed a New Hire Orientation Acknowledgement that included location and information about the AED on [DATE]. In an interview on [DATE] at 8:31 AM, LVN D said she became aware of the incident involving Resident #1 before breakfast on [DATE] when RN A came to her asking what the procedure was when a resident was found with no vital signs. LVN D said RN A was not sure if Resident #1 had a DNR order or had a full code status. LVN D said she went to the nurse's station and found a green sheet of paper in his file [denotes full code status] and then looked in his electronic chart which also showed he had a full code status. LVN D said when she discovered Resident #1 had a full-code status she ran to get the crash cart and AED, took them to Resident #1's room. LVN D stated when she arrived at Resident #1's room the room was empty. LVN D said she and RN A arrived at the resident's room together and put the board under his back, opened the AED and placed patches on the resident, started CPR. LVN D said the AED did not shock him. At some point the ADON arrived and was using the ambu-bag. LVN D was not able to state when the ADON arrived. In an interview on [DATE] at 8:56 CNA E revealed that the morning of [DATE] around 7:25 AM, she was walking down the 400 hall when CNA C came out of Resident #1's room and said he was not moving. CNA E said she looked at Resident #1 who looked grey and was cold to the touch. CNA E said she and CNA C stepped outside the room where RN A had her cart and told the RN that she needed to go into the room because Resident #1 was gone. CNA E said the RN went into Resident #1's room, touched the resident, and pulled the sheet over his head. CNA E said she told the RN Don't do that and the RN pulled the sheet back down. CNA E said the RN then left the room and once outside asked the CNA (CNA E) what the procedure was. CNA E said she did not respond to the RN's question but instead told CNA C what the CNAs did when told by a nurse that a resident had died (wash the body, change the linens, use a towel to close the mouth). In a telephone interview on [DATE] at 10:52 AM, CNA C revealed she arrived for work on [DATE] around 6:00 AM and began her work. After readying several residents for breakfast, she asked RN A what she needed to for Resident #1. RN A told her to get him up for breakfast, but when CNA C entered Resident #1's room to begin getting him ready, she saw that the resident's face and hands were discolored, and his mouth was wide open. The CNA said she looked at the resident's chest and did not see him breathing. CNA C said she walked out of room and told RN A something was wrong with Resident #1, that he was not breathing and was not ok. CNA C said she went with RN A into Resident #1's room and saw the RN check the resident's pulse and breathing. The CNA followed the RN out of the resident's room where RN A was heard asking CNA E what the procedure was because it was different in different states. CNA C stated she was later going to the dining room to help with breakfast when she saw the ADON, RN A and LVN D go to Resident #1's room with the crash cart. She followed them to the resident's room where she observed the three nurses place the back board, start chest compressions, attach the AED to the resident, and begin use of the ambu-bag. In an interview on [DATE] at 4:22 PM, LVN F revealed that on [DATE] before breakfast (was not able to give specific time) she heard unidentified staff members saying that Resident #1 had expired. LVN F said she was surprised because no one had called a Code Blue. LVN F said she went to Resident #1's room where LVN D, RN A and CNA C were beginning to place the back board under the resident and to start compressions. In an interview and record review on [DATE] at 3:45 PM with the Administrator and the DON, the Administrator revealed that nurses are given a one-day orientation to the facility policies, and three days of orientation on the floor with experienced nurses regarding protocol to make sure nurses are ready to work the floor. The DON then signs the paperwork regarding orientation. The Administrator stated that that the orientation with experienced nurses on the floor included the AED, the Crash Cart and how to determine code status. When asked when the crash cart and determining code status were not included on the orientation check list, the Administrator stated that the AED is on the orientation check list, and the Crash Cart was in the same area as the AED. Record review of the facility's policy Emergency Procedure - Cardiopulmonary Resuscitation dated 02/2018 revealed that if an individual is found unresponsive and not breathing normally a licensed staff member who is certified in CPR/BLS (cardiopulmonary resuscitation/Basic life support) shall initiate CPR unless it is know that a DNR order that specifically prohibits CPR and/or external defibrillation exists for the individual. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR order or a physician's order to not administer CPR. Record review of the facility's policy Abuse and Neglect - Clinical Protocol dated [DATE] revealed that the definition of neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The physician and staff will help identify risk factors for abuse within the facility such as those related to staffing such as poor preparation, training, and lack of knowledge or skills that might affect how the residents are being cared for. Staff and management will help identify situations that might constitute or could be construed as neglect such as inattention to advance directives. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 10:25 AM. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 10:25 AM. The Plan of Removal was accepted on [DATE] at 12:12 PM: [DATE] Employee was interview and statement taken. This was completed by [DON name] RN, DON and [ADON name] LVN, ADON on [DATE]. Met with Administrator and decision was made to suspend employee same day on [DATE]. This was completed by [DON name] RN, DON and [Administrator name], Administrator on [DATE]. Investigation begin by interviewing staff members and taking written statements. This was completed by [DON name] RN, DON on [DATE]. [DATE] Full code and DNR audit were completed to ensure, physician order, code status icon and correct colored paper (green or red) is in chart for all residents. This was completed by [LVN B Name] LVN, Medical records on [DATE]. Continued to take statements from staff members. This was completed by [DON name] RN, DON on [DATE]. Audit CPR certification for nurses completed This was completed by [DON name] RN, DON on [DATE]. CPR certification class was scheduled for Thursday [DATE] at 1:30pm. This was completed by [ADON name] LVN, ADON on [DATE]. In-service on where to find a residents' code status provided to staff. This was completed by [DON name] RN, DON on [DATE]. [DATE] In-services on ''Emergency response procedure, calling a code'' provided to staff. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. Continue investigation by taking staff statements. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. [DATE] In-services continued on ''Emergency response procedure, calling a code'' This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. Continue investigation by taking staff statements. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. [DATE] Continue investigation by taking staff statements. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. [DATE] In-serviced nurses about what to do when a patient is full code or DNR and found with no signs of life. This was completed by [DON name] RN, DON on [DATE]. Facilities Plan to ensure compliance quickly [DATE] Staff in-service on ''Abuse and neglect'' and ''Emergency response procedure, calling a code: verification of code status, instructing staff to activate emergency response system code, call 911, and initiate basic life support''. Staff members will not assume any job responsibilities until training has been received by DON/designee This was completed by [DON name] RN/DON on [DATE]. This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards to knowledge about abuse and neglect and how to reach/do in a code blue situation. DON/designee will report monthly to QAPI [DATE] and ongoing CPR certification class and emergency mock drill training provided on [DATE] at 1:30pm. Will be completed by [Business owner's name] (Owner of [Business name and location]). This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards how to react/do in a code blue situation. DON/designee will report monthly to QAPI Ongoing Emergency mock drills training quarterly. Will be completed by [Business owner's name] (Owner of [Business name and location]). This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards how to react/do in a code blue situation. DON/designee will report monthly to QAPI Plan of Removal was verified a follows: - Confirmed through interview and record review (DON, [DATE] 4:59 PM; HR Manager [DATE], 9:43 AM) that alleged perpetrator was interviewed, suspended and terminated. - Through interview with 3 LVNs from 6 AM to 6 PM shift and two LVNs from 6 PM to 6 AM shift confirmed understanding of training regarding response to resident without signs of life (LVN F, [DATE] 4:22 PM; LVNs - [DATE] 9:04AM, [DATE] 2:22 PM, 5:08 PM, 5:16 PM.) - Confirmed through interview (Medical Records Director, [DATE] at 3:11 PM) that an audit was performed on all resident records to ensure accuracy of resident code status; confirmed through record review of residents physical and electronic charts ([DATE] at 4:04 PM) the accuracy of resident code status for 12 sample residents (Census of 75). - Confirmed through record review (audit listing with nurse's names and CPR expiration dates) and interview (DON [DATE], 5:05 PM) that nurses' CPR training status was audited, and that the facility has taken action to train one nurse whose CPR training was expired. - Confirmed through observation (Group trainings observed [DATE], at 2:07 PM, 2:50 PM, 3:58 PM), interview (DON [DATE] at 5:05 PM) and documentation (Inservice sign-ins dated [DATE], [DATE], [DATE], [DATE]) that trainings regarding calling a code and regarding determining a resident's code status as identified in the plan of removal were provided. - Confirmed through interview (Administrator [DATE] 3:30 PM) and record review (Service Agreement dated [DATE]) that the facility entered into a service agreement with a provider of BLS and First aid/CPR/AED courses. - Confirmed through interview and record review that ANE training is provided to employees and through interviews with 13 staff (RN (DON [DATE] 5:05 PM; RN [DATE] 2:03 PM), LVN (LVN F, [DATE] 4:22 PM; LVNs [DATE], 5:08 PM, 5:16 PM, CNAs - [DATE] at 10:52, [DATE], 1:52 PM, 1:59 PM, 2:33 PM, 2:57 PM, 3:07 PM, 3:30 PM; 3:40 PM), Restorative Aide ([DATE], 2:11 PM), Activities Director ([DATE], 2:16 PM) understanding of the concept of neglect. - Confirmed through interview that employees (DON [DATE] 5:05 PM) who have not completed Emergency response procedure, calling a code: verification of code status, instructing staff to activate emergency response system code, call 911, and initiate basic life support training will not assume job responsibilities until training has been done. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 6:55 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm, and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.