**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the residents right to be free from abuse for three (Residents #10, #52, and #32) of five residents reviewed for abuse, in that:On 7/28/25, Resident #10 was pushed by Resident #62 after the resident attempted to enter Resident #62's room without permission.On 8/07/25, Resident #52 and Resident #62 were engaged in a pushing match. Resident #62 pushed Resident #52. Resident #52 fell to the floor and hit her head. Resident #52 was sent to ER for evaluation and sustained no injuries.On 08/25/25, Resident #32 was pushed Resident #62 after the resident entered Resident #62's room without permission. Resident #32 fell to the floor and hit her head. Resident #32 was sent to ER for evaluation and sustained no injuries.On 8/26/25 at 6:45 PM, an IJ was identified. The facility was notified of the IJ on 8/26/2025. The IJ template was provide to the facility on 8/26/25 at 8:09 PM. While the IJ was removed on 08/28/25 at 5:56 PM, the facility remained out of compliance at a scope of pattern and a severity level of pattern due to the facility not providing interventions for Resident #62. This failure placed residents at risk of being abused and injured by Resident #62.Findings included: A record review of Resident #62's face sheet dated 8/26/2025 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted [DATE]. Diagnoses included Catatonic Schizophrenia (a mental health condition that affects thoughts, feelings and behavior), Major Depressive Disorder recurrent severe Psychotic Features (depression that causes low mood and lack of interest, loss of reality, delusional and irrational thoughts ), Generalized Anxiety Disorder (overwhelming fear and anxiety), Drug Induced Subacute Dyskinesia (uncontrollable movements caused by medication), Insomnia (inability to sleep) and UTI (infection of the urinary tract that may cause confusion).Record review of Resident #62's MDS, dated [DATE] reflected a BIMS score of 10, which indicated moderate cognitive impairment, with disorganized thinking that comes and goes, and changes in severity. Section E- Behavior reflected a score of 0 (zero), which indicated Behavior Not Exhibited, for A. Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually.A record review of Resident #62's Care Plan dated 7/29/25 and revised on 8/14/25 reflected the following: Focus: The resident has potential to demonstrate physical behaviors related to poor impulse control and paranoia/delusions. Interventions: Assess and address for contributing sensory deficits. Assess and anticipate resident needs: food, thirst, toileting needs, comfort, body positioning, pain, etc. Date initiated: 7/29/2025.Immediately separate residents and assess both residents. Provide 1:1 continuous monitoring. Continue to encourage resident to take medications to control behaviors. Psych visit with NP encouraging resident to take her medications. Refer resident to Behavior Health Hospital per order. Date initiated: 8/7/2025.Modify environment: move resident back to previous room where she resided alone. Date Initiated 7/29/2025, revision on 8/14/2025.Separate residents immediately in the event of resident-to-resident altercation. Encourage resident to accept PRN anxiety medication. Provide close supervision and safety checks every fifteen minutes for 72 hours. Psych tele-visit scheduled and performed. Head to toe assessment for injuries. Medication review. Date initiated 7/29/2025.Tele-visit with psych NP with medication review. New order for Risperdal started. Referral to crisis care team with onsite assessment of resident for placement. Date initiated 8/26/2025.Focus: The resident requires antidepressant medication (Zoloft and Trazodone) for diagnosis of depression.Interventions: Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement , agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant. Date Initiated: 12/6/2024.Focus: The resident uses anti-anxiety medications LORAZEPAM r/t anxiety disorder.Interventions: Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. ANTIANXIETY SIDE EFFECTS: Drowsiness, lack of energy, Clumsiness, slow reflexes, Slurred speech, Confusion and disorientation, Depression, Dizziness, lightheadedness, Impaired thinking and judgment, Memory loss, forgetfulness, Nausea, stomach upset, Blurred or double vision. PARADOXICAL SIDE EFFECTS: Mania, Hostility, and rage, Aggressive or impulsive behavior, Hallucinations. Monitor/record occurrence of target behavior symptoms: pacing, wandering inappropriate response to verbal communication and document per facility protocol. Date Initiated: 12/11/2024.Focus: The resident is non-compliant with medication administration related to paranoia and delusions.Interventions: Praise resident for a cooperative attitude towards her acceptance of meds. Talk to resident to determine reasons for refusal of care. Date initiated 7/29/2025.A record review of Resident #62's PCC orders initiated 8/20/2025 thru 8/26/2025 did not reflect a current order for anti-psychotic medication. Active prescriptions reflected Trazodone (for major depressive disorder), and Buspirone and Vistaril (for generalized anxiety). There were previous orders dated 5/31/2025 for Risperdal Consta Intramuscular Suspension Reconstituted ER 25mg; inject 25 mg intramuscularly one time a day every 14 days related to Catatonic Schizophrenia and Risperidone Oral Tablet Disintegrating 1 MG, give one tablet by mouth two times a day related to Catatonic Schizophrenia. A record review of Resident #62's discharge instructions dated 8/20/2025 from the behavior health hospital admission from 8/8/2025 thru 8/20/2025, reflected the following: Continue the following medications: Risperdal 2 MG (1 tablet) by mouth, twice a day for schizoaffective disorder. Risperdal 0.5 MG (1 tablet) by mouth, twice a day for schizoaffective disorderA record review of Resident #10's face sheet dated 8/28/2025 revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Alzheimer's Disease (process that causes the brain cells to die and the brain to shrink), Schizoaffective Disorder, Bipolar Type (mental disorder that includes delusions, hallucinations, disorganized thinking), anxiety disorder (overwhelming fear and anxiety), and Major Depressive Disorder, severe with psychotic symptoms (persistent depressive episodes).A record review of Resident #10's MDS dated [DATE] reflected a BIMS of 5, which indicated cognition was severely impaired. Section E0200. Behavioral Symptom - reflected a score of 0 (zero) which indicated Behavior Not Exhibited, for A. Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually.Section E0900. Wandering - reflected a score of 2 (two) which indicated this behavior occurred 4-6 days each week. A record review of Resident #10's Care Plan dated 8/22/2025 reflected the following: Focus: The resident is an elopement risk/wanderer, exit seeking.Intervention: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Focus: Resident involved in resident-to-resident altercation. Dated 7/28/2025.Interventions: Separate residents immediately in the event of resident-to-resident altercation. Provide increased supervision for the aggressor. Assess resident for injuries and emotional needs. Schedule Psychiatric NP tele-visit to assess for residual emotional trauma.Focus: Resident has a mood problem r/t Disease Process Alzheimer's dementia. Interventions:Monitor/record/report to MD prn risk for harming others: increased anger, labile mood, or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Focus: Resident is an elopement risk/wanderer exit seeking behavior. Interventions: Assess for fall risk. Assess for secure unit.Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Focus: Resident involved in resident-to-resident altercation. Interventions: Separate residents immediately in the event of a resident-to-resident altercation.Provide increased supervision to the aggressor. Assess resident for injuries or emotional needs. Schedule Psychiatric NP tele-visit to assess for residual emotional trauma. A record review of Resident #52's face sheet dated 8/27/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include Senile Degeneration of Brain (progressive deterioration of brain tissue), Dementia (symptoms that affect memory, thinking and social ability) and anxiety disorder (overly fearful or anxious). A record review of Resident #52's MDS dated [DATE] reflected a BIMS score of 3, which indicates cognition was severely impaired. Section E09.00. Wandering - Presence and Frequency. Has the resident wandered? The resident scored 0. Behavior not exhibited. A record review of Resident #52's Care Plan dated 7/11/2025 reflected the following: Focus: Resident has had aggressive behavior towards others. Interventions: 1:1 supervision for 72 hours Administer PRN anxiety medication for agitation. Identify trigger if possible and remove trigger. Medication review by Psychiatric NP - increased Depakote sprinkles to TID Psychiatric NP visit/evaluation Redirect and provide activities.Redirect resident during periods of agitation or aggression. Offer fluids/food in separate location within the secured unit. Assess for physical needs (bathroom privileges, comfort/pain).Provide activities for distraction. Separate residents during agitation. A record review of Resident #32's face sheet dated 8/27/2025 reflected a [AGE] year-old female admitted on [DATE]. Her diagnoses included Alzheimer's (common dementia where the brain shrinks) Major Depressive Disorder (depression, loss of self-esteem or low interest), and Lack of Coordination (unorganized movements and actions). A record review of Resident #32's MDS dated [DATE] reflected a BIMS of 4, indicated cognition is severely impaired. Section E0900. Wandering - Presence & Frequency, Has the resident wandered? Resident #32 scored a 2. Behavior of this type occurred 4-6 days, but less than daily. A record review of Resident #32's Care Plan dated 6/9/2025 reflected the following: Focus: The resident has a Skin Tear to right wrist from striking staff member while being redirected out of others' rooms. Interventions: Identify potential causative factors and eliminate/resolve when possible. Focus: Resident was involved in an altercation with another resident. Interventions: Administer PRN anxiety meds if resident is agitated and/or verbally instigating. Check for any physical needs - toileting, pain. Medication review by Psychiatric NP, initiated Vistaril BID Notify Psychiatric NP for med review r/t agitation/altercation. Nurse to assess for injuries and emotional trauma. Provide activities for distraction. Provide fluids and/or snack activity.Psychiatric NP visit to perform med review and evaluate for emotional adverse effects of altercations. A record review of the facility incident investigation dated 7/28/2025 reflected Resident #62 pushed Resident #10 who was attempted to enter the resident's room without permission. The other resident sustained no injury. Resident #62 was placed on 72 hour 1:1 monitoring, and no behaviors were exhibited during this period. A record review of the facility incident investigation dated 8/7/2025 reflected Resident #62 and Resident #52 were engaged in a pushing match. Resident #52 fell on the floor, hit her head, was sent to ER and CT scan revealed no injury. Resident #62 was placed on 72 hour 1:1 monitoring by the facility, evaluated by the NP, and referred and admitted to psychiatric facility, A record review of the facility incident investigation dated 8/25/2025 reflected Resident #62 and Resident #32. Resident #32 fell on the floor, hit her head, was sent to ER and CT scan revealed no injury. Resident #62 was placed on 1:1 monitoring by the facility. PRN medications were given for anxiety, consideration of readmission to behavioral health hospital (resident refused) and consult with the appointed guardian.An observation and interview on 8/26/2025 at 10:35 AM revealed Resident #62 lying on her bed, in her room. Clothing and hygiene were clean and appropriate. Resident interacted with surveyors by responding to assessment questions without hesitation. She stated she was doing okay. There were no visible marks or bruises.An observation and interview on 8/26/2025 at 10:40 AM revealed Resident #32 sitting in wheelchair, pulled up to a table in the main living area. Clothing and hygiene were clean and appropriate. There were no visible marks or bruises. Resident #32 said she does not remember falling or being shoved.During an interview on 8/26/2025 at 11:10AM the DON said Resident #62 was placed on immediate 1:1 monitoring beginning 8/25/2025 at 6:00 PM and would remain on monitoring until alternate placement could be identified for Resident #62. The DON stated the 1:1 monitoring checklist/form was blank from 8/25/2025 at 6:00 PM thru 8/26/2025 at 6:00 AM because the facility did not have the correct forms at the time the 1:1 monitoring was started. She said until about two weeks ago, Resident #62 (the aggressor) did not have a history of physical aggression, and she went to a behavioral health hospital on 8/8/2025 for delusional behaviors after she started refusing her injectable antipsychotic medication. She said, Regarding the incident last night, staff got them separated. We scheduled and conducted a tele-visit and medication review with NP and the preventions/interventions are for medication reviews and management. We are seeking a re-admission to the behavioral health hospital. A psych tele-visit has been planned.A record review of the facility's policy titled Abuse/Neglect, revision date 10/04/22 reflected the following: 1. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident-to-resident altercations will be reviewed as potential abuse not assumed as abuse. Resident-to-resident altercations must include any willful action that results in physical injury, mental anguish, or pain. 2. Adverse event: An adverse event in an untoward, undesirable, and usually unanticipated event that causes death or serious injury; or the risk thereof.Procedure: C. Prevention: The facility will provide residents, families, and staff an environment free from abuse and neglect.4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. F. Protection: The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, and exploitation, mistreatment of residents or misappropriation of resident property investigation.On 8/26/25 at 6:45 PM, an IJ was identified. The facility was notified of the IJ and provided the IJ Template 8/26/25 at 08:09 PM. Plan of Removal Version 4 was accepted/approved on 8/27/2025 at 5:39 PM and Version 5 was accepted/approved on 8/28/2025 at 5:45 PM. Immediate Jeopardy Plan of Removal The center Leaderships (Administrator and Director of Nursing) were notified on 8/26/2025 @7:45pm that an Immediate Jeopardy had been issued to the center related to F600 Abuse. Resident #32 attempted to go into Resident #62 room and Resident #62 pushed Resident #32 to the floor. Resident #32 was sent to the hospital on 8/25/2025 after being pushed by resident #62. The Hospital Physician/Staff assessed resident #10 on 8/25/2025 with no signs/symptoms of injury. She returned to the center with no new orders and has resumed her usual activities. Resident #62 being on 1:1 offers protection from abuse for Resident #32 and the other residents residing in the secure unit. The Director of Nursing and Assistant Director of Nursing conducted assessments/evaluations on the residents residing in the secure unit on 8/27/2025, no signs/symptoms of abuse were noted, since none of them can be interviewed. The assessments were documented in the resident electronic medical record. The Director of Nursing and Assistant Director of Nursing reviewed incident reports for the last 6 months on 8/27/2025 to validate incidents that occurred have appropriate interventions in place.Resident #62 was assessed by the Director of Nursing on 8/26/2025 with no signs/symptoms of injury/abuse/neglect. Her discharge orders were reviewed by the Director of Nursing on 8/26/2025 as a discrepancy was identified by a surveyor. Resident #62 had discharge orders for an antipsychotic medication from behavioral hospital on 8/20/2025 that were not implemented (Risperdal 2.5mg by mouth twice a day). The discrepancy was corrected by the Director of Nursing on 8/26/2025 and a medication error report was completed on 8/26/2025 by the Director of Nursing. The responsible party, Administrator, and Medical Director were made aware of the medication error. The center attending Nurse Practitioner assessed the resident on 8/26/2025 and made some antipsychotic medication changes that were implemented. Resident #62 remains on 1:1 monitoring, and this will continue until Resident #62 is discharged from the center or the interdisciplinary team determines discontinuation of the 1:1 monitoring is appropriate. The criteria includes discussion/consultation with the Medical Director, Attending Nurse Practitioner, and Psychiatric Nurse Practitioner. Review of resident behaviors for noted decreases in anxiety, agitation as confirmation of current medication effectiveness. The 1:1 monitoring will be provided by various nursing team members (licensed nurses, certified nursing assistants, certified medication aides, or hospitality aides). The center social worker contacted state hospital on 8/26/2025 and their Crises Care Team came to the center on 8/26/2025 and did an assessment on Resident #62. She is now on the waiting list to admit to state hospital and the center must fax requested documents every 3 days until resident #62 is accepted into the state hospital. The Director of Nursing will be responsible for that. The Psychiatric Nurse Practitioner will continue to provide onsite visits with the resident at least every two weeks until she discharges to state hospital. The attending Nurse Practitioner adjusted Resident #62 Risperdal order on 8/27/2025. The Director of Nursing contacted The Medical Director on 8/26/2025 and had no concerns related to this event and indicated that due to the resident's history and co-morbidities the medication error did not contribute to any behaviors.The Director of Nursing re-educated all staff (full-time, PRN) 8/27/2025 on interventions for Resident #62 including her being on 1:1, giving her opportunity to share her needs/wants, give her space as she is protective of her room/space, and to re-direct other residents away from her room. Those not present will receive the re-education prior to the start of their next shift.The Director of Nursing re-educated all staff (full-time, PRN) on addressing and responding to Resident #62 behavioral needs on 8/27/2025. Those not present will receive this re-education prior to the start of their next shift.The Director of Nursing and Assistant Director of Nursing did an audit of new admissions/re-admissions on 8/26/2025 with no negative findings. The audit consisted of new admissions/re-admissions since 8/1/2025. This was conducted to ensure medication orders were implemented.The Director of Nursing re-educated the Assistant Director of Nursing on the admission/readmission audit process on 8/26/2025. The Director of Nursing re-educated the licensed nurses on the admission/re-admission process related to medication orders on 8/26/2025 (full-time and part-time staff). Those not present will receive this re-education prior to the start of their next shift by the Director of Nursing.The Administrator, Director of Nursing, and Medical Director conducted an AD HOC Quality Assurance Meeting on 8/27/2025 to review the Immediate Jeopardy event.The Administrator/Director of Nursing will conduct random chart audits of readmissions weekly for four weeks to validate those returning from the hospital have their correct orders/order changes implemented. The Administrator/Designee will conduct random interviews/interactions with Resident #62 to validate behaviors are being managed. Negative findings will be addressed at the time of discovery and presented to the center Quality Assurance Program. Plan of Removal Monitoring Included:An observation of and interview on 8/28/2025 at 11:45am Resident #62 was in her room with CNA-A, who was providing 1:1 monitoring. Resident #62 stood by pleasantly, while CNA-A made her bed. Resident #62 spoke with the Surveyor and stated she wanted assistance being placed in a different facility. During an interview on 8/28/2025 at 11:15 AM, the DON stated she in-serviced all staff providing 1:1 monitoring for Resident #62. She stated overnight staff were in-serviced via telephone on 8/27/2025 at 2:30 AM, and they signed documents left at the facility. She stated the in-service included resident-to-resident altercation preventions and how to manage residents who required 1:1 monitoring/supervision.During an interview on 8/28/2025 at 11:38 AM, LVN-H stated the most recent in-service on ANE covered 1:1 monitoring and de-escalation. She stated methods of prevention for resident-to-resident altercations included providing personal space to Resident #62. She also stated redirection of other residents away from Resident #62's room. She stated 1:1 monitoring for Resident #62 meant always being with her, everywhere she went.During an interview on 8/28/2025 at 11:43 AM LVN-G stated she was in-serviced on 1:1 monitoring and ANE. She stated de-escalation for Resident #62 included giving her space while redirecting other residents. She stated additional tactics were offering Resident #62 activities and checking on her personal needs, i.e., hunger or thirst. She stated abuse was physical, mental, sexual and/or verbal, and was to be reported immediately to the abuse coordinator.During an interview on 8/28/2025 at 11:45 AM CNA-A stated she was in-serviced on signs of Resident #62's agitation. She stated signs of agitation included Resident #62 walking fast with her head down. She stated staff walked with Resident #62, but did not force anything on her (direction or location). She stated she was in-serviced on ANE, and added it was either physical, mental, or sexual. She denied witnessing it, and added she would make a report to the Administrator or would call HHSC.During an interview on 8/28/2025 at 11:50 AM CNA-B stated she received in-services on how to manage 1:1 resident monitoring. She stated staff were to always stay with Resident #62. She stated withdrawal was a sign of Resident #62's agitation and/or aggression. She stated medication refusal was also a sign of upcoming agitation. She stated actions to keep residents safe from abuse meant paying close attention to and redirecting them. She stated activities helped all residents to remain calm.During an interview on 8/28/2025 at 12:04 PM SC/MA stated she was in-serviced on signs of aggression for Resident #62. She stated signs included facial expressions, movement, isolation, speedy walking. She stated prevention of resident-to-resident altercations included separation, offering activities, providing personal space, and redirection. During an interview on 8/28/2025 at 12:09 PM CNA-C stated she was in-serviced on ANE, 1:1 monitoring and Resident #62's behaviors. She stated when Resident #62, or any resident, became agitated, she has asked them what was needed to calm them. She stated if the resident did not respond, she would leave the resident alone for a few minutes, then return. She stated if the resident escalated, she would back off and get a nurse for assistance. She stated resident-to-resident altercations required resident separation and additional staff assistance. She stated she was also in serviced on ANE and to whom to make a report.During an interview on 8/28/2025 at 12:12 PM CNA-D stated she received an in-service on ANE, proper procedures for resident-to-resident altercations and de-escalation. She stated resident-to-resident altercations were managed by separation, and added she would remove the resident who was less aggressive. She stated she paid close attention to resident behaviors, specifically an agitated resident, and she would move the other residents away from the area ahead of an incident. She stated all aides should know residents, and added if any resident seemed off behaviorally, staff intervened beforehand. During an interview on 8/28/2025 at 12:15 PM CNA-E stated he was in-serviced on Resident #62. He stated in-service training included respecting her space and redirecting other residents away from her room. He stated during resident-to-resident altercations, the residents were separated. He stated he would find an activity to offer the agitated resident, like walking or watching television. He stated Resident #62's trigger was her room; of which she was very territorial. During a phone interview on 8/28/2025 at 1:30 PM the NP stated Resident #62 had a recent change in condition with three behavioral episodes in the last month. She said the medication changes conducted prior to admission to the behavioral health hospital failed, thus requiring an inpatient stay. She said, The inpatient stay was not long enough. They do not make a pill for behavior. She said, According to my assessment of the care provided at the facility, they did everything they could have done to prevent future behavioral occurrences. She said the interdisciplinary team was currently trying to stabilize Resident #62 with additional medication adjustments. During an interview on 8/28/2025 at 12:18pm CNA-F stated she was in-serviced on 8/25/25 on abuse, resident rights, to whom she would make a report, and resident to resident altercations. She stated she would separate the resident, as altercations were resolved by separation. She stated prevention methods were dependent upon each resident as they had unique needs. She stated 1:1 monitoring with Resident #62 was conducted day and night, and if necessary other residents were redirected away from Resident #62's room. Record review of the medication audit sheets for six residents for admission/re-admission orders compliance. The orders were cross-referenced in the EMR to verify accuracy. Record Review of the assessments/evaluations in the EMR conducted on all residents in the secure unit.Record review of the in-service sheet dated 8/27/2025 and verified via interviews with licensed nurses understanding of medication reconciliation. Record review of the ad hoc QAPI Meeting sign-in sheet dated 8/27/25 reflected signatures of the Medical Director, Administrator, and Director of Nursing. Record review of in-service titled, Resident Specific In-Service - Resident #62, conducted by DON on 8/27/2025 reflected: Please remember these things when caring for Resident #62: 1. Please respect her space, she likes to spend time alone in her room. 2. Please redirect other residents from wandering into her room. 3. Allow her to express herself. 4. Offer activities that interest Resident #62. 5. If she appears anxious or agitated, please try to determine if she needs anything (hungry, thirsty, toileting, discomfort) and report this behavior to the charge nurse. 6. Report ALL refusals to the charge nurse immediately. Thirty-nine staff signatures were included on the in-service.Record review of 1:1 Monitoring Log for Resident #62, dated 8/27/25 and 8/28/25 reflected staff initials in 15-minute intervals to indicate continuous monitoring of Resident #62. Record review of Attestations for 1:1 Monitoring for Resident #62, dated 8/28/2025 and signed by two CNA's verifying they both provided 1:1 monitoring/supervision for Resident #62 during the shifts 6:00 PM - 10:00 PM on 8/25/2025 and 10:00 PM - 6:00 AM on 8/26/2025.Record review of Resident #62's orders in PCC reflected an order dated 8/26/25 for Risperdal Oral Tablet 0.5 MG to be administered 1 tablet by mouth, two times daily for preventative related to major depressive disorder, recurrent severe without psychotic features for three days; Risperdal Oral Tablet 1 MG dated 8/30/25 to be administered 1 tablet by mouth two times a day for Preventative related to major depressive disorder, recurrent severe without psychotic features. On 8/28/2025 at 5:39 PM the ADM, DON, and [NAME] President of Clinical Services were notified the IJ was removed.While the IJ was removed on 08/28/25 at 5:56 PM, the facility remained out of compliance at a scope of pattern and a severity level of pattern due to the facility not providing interventions for Resident #62.

Deficiency Text Not Available

**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 6 Residents (Resident #1) reviewed for cardio-pulmonary resuscitation. RN A and LVN B failed to continue to perform CPR, until the arrival of emergency medical personnel, to Resident #1 who was a full code status. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 5:05 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope identified as isolated with actual 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 required. Findings include: Review of the the facility 3613-A revealed that on [DATE] at 2:10 PM Resident #1 was found unresponsive by LVN C, in her bed. Review of Resident #1's admission Record revealed she was admitted to the facility on [DATE] diagnosis of Acute Respiratory Failure with Hypoxia (inadequate oxygen supply), Unspecified A-Fib, HTN (hypertension - high blood pressure), and Unspecified Dementia. Review of Resident #1's MDS dated , [DATE], revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Section O reflected that she did not receive hospice services. Resident #1 had a BIMS score of 15. Review of Resident #1's consolidated physician orders for the dates of [DATE] through [DATE] reflected the following: CPR Full Code, Start Date of [DATE], End Date was blank Admit to [Hospice Name], Start Date was blank, End Date: [DATE] Review of Resident #1's care plan, dated [DATE], last revised [DATE], reflected: Focus: The resident has a terminal prognosis r/t chronic resp. failure and was on hospice services through [Hospice Name]. Date Initiated: [DATE]. Goal: The resident's comfort will be maintained through the review date Review of Resident #1's care plan, dated [DATE], last revised [DATE], reflected: Focus: Full code CPR order in place. Date Initiated: [DATE] Goal: Request for CPR To be initiated will be followed Intervention/Task: Review medical record to ensure proper documents are signed, consult with nursing staff on changes in health. Review of Nurses Notes for the dates on [DATE] reflected: At aprox 1410 this nurse was notified by [LVN C] that resident was pale, unresponsive, had no respirations and was cold to touch. crash cart was taken to residents room and [RN B] assessed for signs of life, she noted no response, no pulse, no respirations, hands and feet were discolored, and jaw was tight. @ 1412 I instructed [CNA D] to start cpr and [LVN B] to get the ambu bag, while I called 911 and notified hospice nurse who states she is on her way. at approx 1416 ems arrived. ems staff worker {Name] called [Hospital Name] ER doctor who gave him the order to stop aggressive tx and Dr. pronounced resident deceased at 1422. post mortom [sic] care was provided by staff pending arrival of hospice nurse who is calling residents [family member]and funeral home. don notified. will report to oncoming shift. In an interview on [DATE] at 3:34 PM LVN A stated Resident #1 was on Hospice for a short period of time. She stated around 2 PM, the resident was fine, and respirations were present. She stated LVN C alerted her that she was needed to Resident #1, and crash cart was obtained. She stated RN B had the stethoscope and Resident #1 was not breathing or showing signs of life. She stated they agreed to start CPR. LVN A stated she called 911 and Hospice Nurse. She stated they were switching in and out and doing compressions on Resident #1. She stated, it felt gruesome to do compressions on [Resident #1] - she was pale, rigor was present, and they could barely open her jaw to use Ambu bag. She stated she was taught that an RN could call Time of Death (ToD). ToD was called and shortly after, EMS arrived. She stated EMS assessed and called their doctor who called Resident #1's ToD. She stated she was taught that the RN calling ToD while in school. She stated it was important to continue compressions until EMS arrive to ensure they have done everything they can do to save [a resident's] life.? In an interview on [DATE] at 3:13 PM RN B stated Resident #1 was in respiratory distress and had been placed on Hospice care. She stated on [DATE], Hospice had visited her that morning and provided medication. RN B stated LVN C discovered Resident #1 was not breathing. She stated when they discovered her, she was pale - no breaths or pulse were present. She stated they agreed to initiate CPR - the scheduler was present, the other nurse and another aide. She stated she has always been taught that if there was not a DNR, they needed to do CPR. She stated the other nurse on duty (LVN A) kept insisting that she (RN B) needed to go ahead and pronounce Resident #1's Time of Death (ToD). She stated she doubted herself and they agreed to stop CPR. She stated to her understanding, they should have done CPR until EMS arrived to take over, unless specified in a certain directive. She stated they should have continued the CPR because it was the rule. She stated they should have continued CPR to do what they can to restart the heart and get it pumping again. In an interview on [DATE] at 2:37 PM, the DON stated her expectation was for the nurses to continue with CPR until EMS arrived, because Resident #1 was a full code. Review of a report completed by the police department dated [DATE] reflected the police department having received a report of a resident (identified as Resident #1) being found without signs of life. The report reflected that upon EMS arrival, CPR was not underway. The report reflected that LVN A questioned RN B about pronouncing the ToD, which prompted RN B to request the time, calling the ToD at 1416 (2:16 PM). Further, it reflected that EMS staff called the doctor and the doctor pronounced Resident #1 deceased at 1422 (2:22 PM). The report concluded with a statement that Resident #1 was a full code with a signed DNR pending and set up for [DATE]. Review of facility policy, titled Self Determination End of Life Measures, last revised [DATE], reflected .the facility will respect the wishes of the resident as outlined in the advanced directive. Review of resident report Code status dated [DATE], reflected the facility had 31 residents who had a Full Code Status. Review of facility in-services included Residet Rights and Change in Condition, dated [DATE], Abuse & Neglect and Hospice Residents w/ Full Code Status and What to Do In Case of Emergency, dated [DATE], How to Determine When to Use Your AED, undated, Abuse & Neglect, dated [DATE], Emergency Response - Code Blue - Documentation, undated, CPR Drills/Types of Code Scenarios/Using Dummy & Practicing AED, dated [DATE], and Required Daily Checklist for Emergency Response Code Blue, undated. The ADM and DON were notified of the Immediate Jeopardy (IJ) on [DATE] at 5:05PM PM due to the above failures. The ADM and DON were provided with the Immediate Jeopardy (IJ) template on [DATE] at 5:36 PM The following Plan of Removal submitted by the facility was accepted on [DATE] at 11:20 AM and indicated: Action: Audit of ALL Residents Code Status to include accurate orders, Out of Hospital DNR is on file if resident is a DNR, and care plans reflects current orders. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing Action: Re-Education of Abuse/Neglect Policy to all staff (staff not present, agency, and PRN staff will be re-educated prior to working their next scheduled shift, newly hired staff will be educated within their first 3 days of employment), with special attention to: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident to resident altercations will be reviewed as potential abuse not assumed as abuse. Resident to resident altercations must include any willful action that results in physical injury, mental anguish or pain. Adverse event: An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Neglect is 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. Mistreatment means inappropriate treatment or exploitation of a resident. Training: the facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. New Employee orientation will consist of educational resources to identify abuse, neglect, exploitation, and misappropriation of resident property. Ongoing in-services (Staff not present, PRN, agency staff will be re-educated prior to the start of their next shift, this will be tracked by the Administrator/Director of Nursing/Designee beginning [DATE]) will be conducted to educate staff regarding; Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, recognizing signs of burnout/stress/frustration and how to manage those feelings, how to report suspected abuse, neglect, exploitation, or the misappropriation of resident property without fear of reprisal, interventions for aggressive behavior of residents, and dementia management and resident abuse prevention. Prevention the facility will provide the residents, families, and staff an environment free from abuse and neglect. The facility will post in a public area easily accessible to residents, visitors, and staff members information on how to report concerns, incidents, and grievances without fear of retribution. The facility will post the Abuse Preventionist/Task 5G Coordinator and Co-Coordinator of the facility. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator and per policy. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse. All occurrences of potential abuse or criminal behavior will be investigated by the Abuse Preventionist and/or designee. The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. Investigation comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property will be investigated. The administrator, in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC. The administrator in consultation with the Risk Management Department will report any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care form, the facility to local law enforcement. Abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property of residents by employees of any facility will be grounds for immediate termination. With an allegation of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, the employee(s) will immediately be suspended pending an investigation. The employee will have an opportunity to present a written statement to answer the allegation(s) of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. The employee will have the opportunity to be advised of the outcome of the investigation in the determination of disciplinary action and/or reinstatement. Protection the facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, and exploitation, mistreatment of residents or misappropriation of resident property investigation. Allegations of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property will remain confidential. If fear of reprisal cannot be relieved, an individual who reports suspected abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property may not be required to identify himself. All allegations will be investigated regardless of identification of caller. Harassment and interfering with an investigation will result in disciplinary action up to and including termination. Prosecution of civil offenses will be pursued to the fullest extent of the law. Start Date: [DATE] Completion Date: Started [DATE] and all staff (including agency personnel) will receive this education prior to the start of the next shift and all new hires will receive this education upon hire. The Administrator and Director of Nursing were re-educated on the components of abuse and neglect (as indicated above) on [DATE], Corporate Compliance Nurse. Responsible: Corporate Compliance Nurse, Administrator & Director of Nurses Action: Re-education of ALL nursing staff addressing current resident Code Status, in the event of a resident change of condition/unresponsive, to include to never stop CPR until EMS arrives and takes over care of the resident. Start Date: [DATE] Completion Date: Started [DATE] and all nursing staff including agency personnel will receive this education prior to the start of the next shift, and all new hire nursing staff will receive it upon hire. Licensed Vocational Nurse A and Registered Nurse B were re-educated by Director of Nursing on [DATE] regarding residents that are on hospice can be a full code, use of an AED, Education on CPR, when to stop CPR- not until EMS arrives. The Administrator and Director of Nursing were re-educated on the components of addressing resident Code Status (as indicated above) on [DATE] by [NAME], Corporate Compliance Nurse. Responsible Corporate Compliance Nurse, Administrator & Director of Nurses This Plan of Removal will be monitored by the Director of Nursing or designee beginning [DATE] by two code status audits to include accurate orders, accurate care plans weekly x4 weeks any issues will be addressed at time of discovery and reviewed with the QAPI team monthly during the center monthly scheduled QAPI team meeting. This plan of removal will be reviewed with the QAPI team monthly x3 and re-evaluated if needed. Director of Nursing or designee will perform two 1:1 documented coaching conversations with a nursing staff member regarding CPR process weekly x4 weeks and any issues will be addressed at time of discovery and reviewed with the QAPI team. This plan of removal will be reviewed with the QAPI team monthly x3 and re-evaluated if needed. A QAPI meeting was held on [DATE] to discuss Plan of Removal and the incident. A QAPI meeting was held [DATE] with Administrator, Director of Nursing, and the Medical Director to review the incident and to discuss how the plan of removal will be monitored. Monitoring of the facility plan of removal is as follows: During an interview on [DATE] at 12:18 PM, LVN E stated she has been at the facility for 2 years and worked Monday - Friday, from 6 AM - 2 PM. She stated the (2) types of code status are full code and DNR. She stated full code means to initiate life saving measures and DNR means do not start CPR. She stated staff can access code status information in the resident hard charts; she stated a red sheet means DNR and a green sheet means DNR . She stated it can also be found in the computer and in the crash cart binder. She stated she got recent training on this topic in the form of an in-service and a CPR training class. She stated abuse can be physical, verbal, mental or financial and if witnessed, she would report it to the facilities Abuse Coordinator, adding that this is the ADM. She stated if she were responding to an Unresponsive Resident, she would yell out the Code, which she later identified as Code Blue. She stated she would check [the resident's] code status and retrieve the crash cart. If they are full code, she stated she would drop the HOB and begin CPR while waiting for staff to arrive with the crash cart to place a backboard. She stated she would not stop compressions until EMS arrived. She stated she would not provide CPR if the resident were DNR. She stated if hospice resident were to be found unresponsive, she would act in accordance with their code status, adding that hospice doesn't mean DNR. She stated that it is important to honor a resident's wishes regarding code status because this is their Resident Rights and their personal choice which must be respected. During an interview on [DATE] at 12:28 PM, CNA F stated she works Monday through Friday, 6 AM to 2 PM and has been here since [DATE]. She stated the two code statuses are full code and DNR. She stated full code means to attempt to resuscitate [the resident] and retrieve crash cart and defibrillator if necessary, and that DNR is Do Not Resuscitate. She stated this information can be found in the resident charts in the nursing station or in the notebook on the crash cart. She stated she was recently re-educated by the DON on resident code status. She stated abuse can be willful or intentional and that there are several types, adding that if she witnessed abuse, she would report this to her ADM as she is the Abuse Coordinator. She stated she if she found a resident unresponsive, she would inform the DON and Charge Nurse. She stated she would check their code status and if they were full code, she would get the crash cart and defibrillator. She stated she would start CPR and not stop until EMS arrived to take over. She stated if a resident was on hospice and was found unresponsive, she would contact the hospice nurse and take the same steps - she wouldn't assume the resident was DNR. She stated it is important to honor a resident's wished regarding code status because residents have rights, and their code status is one of them. During an interview on [DATE] at 12:41 PM, ADON stated that she has been with the company for 6 years and works the 6 PM - 6 AM shift. She stated the types of code status are DNR and full code, adding that DNR is Do Not Resuscitate, which means do not perform CPR, and full code means to perform CPR and continue until EMS arrives. She stated this information can be found in the binder on the crash cart, the resident charts or on the computer, and that all staff were recently on this topic via written and verbal in-servicing and was completed by her and the DON. She said abuse can be sexual, physical, or mental and should be reported to the ADM, the Abuse Coordinator. She stated when responding to an unresponsive resident, staff should announce Code Blue and respond with a crash cart. She stated they should call 911 and initiate CPR after they have checked resident's code status. She stated if staff provide CPR, they should not stop until EMS arrives; if a resident is DNR, they should not be provided CPR. She stated that just because a resident is on Hospice, they are not automatically a DNR; they can be full code. She stated if a hospice resident is found unresponsive, staff should review their charts to confirm their code status. She stated it is important to honor a resident's wishes regarding code status because you would want to honor anyone's wishes regarding code status. During an interview on [DATE] at 1:00 PM, LVN A stated she has been here since [DATE] and normally works the 6 AM - 6 PM shift. She stated the types of code status are DNR and a full code, adding that DNR is Do Not Resuscitate and full code means to do CPR if they are unresponsive without a pulse. LVN A stated code status information can be found in resident charts or on the crash cart. She stated she has recently received re-education which included online training modules that cover code status and CPR. She stated she was also in-serviced on code status, Abuse and Neglect and the AED and these trainings were conducted by the DON and CCN J. She stated abuse is intentional harm to a resident which can be emotional, sexual, physical or verbal and if witnessed, should be reported to the ADM who she identified as the Abuse Coordinator. She stated when responding to an Unresponsive Resident, she would announce the Code and retrieve the crash cart and AED. She stated she would inform everyone and request help from staff and identified this incident as a Code Blue. She stated if a pulse was absent, she wouldn't provide CPR. She stated if a pulse was present, she would provide CPR until EMS arrives. If a resident was on hospice, she stated she would check their code status and respond accordingly and be sure to call the hospice nurse. She stated it is important to honor a resident wishes regarding code status because it is their right to either be full code or DNR. During an interview on [DATE] at 1:23 PM, CNA G stated she has been at the facility a little over a month and works the 2 PM - 10 PM shift. She recalled that there are (2) different types of code status, DNR and another one, adding that DNR means Do Not Resuscitate and the other one is when you grab the crash cart and AED and take it to the unresponsive residents. She stated then, you would provide CPR until the ambulance. CNA G stated resident code status information can be found behind the desk, in binders; she stated she does not know where else the information can be found. She stated she has not seen the crash cart in years but knows where to find it and when to retrieve it. She stated she was recently provided a walk-through and in-service on code status and the crash cart. She stated abuse can be emotional, verbal, sexual and physical and if witnessed, should be reported to the ADM and the DON. She stated the protocol for responding to an unresponsive resident is to yell for help. She stated she would provide not provide CPR if the resident was DNR but would provide CPR if the resident was not breathing, no pulse was present and if the resident was full code; she wouldn't stop CPR until EMS arrived. CNA G stated that if a resident on hospice was found unresponsive, she would call the hospice nurse to inform them of the resident status, then check their code status prior to providing CPR. She stated it is important to honor a residents wished regarding code status because some residents are ready to go, adding that it is their choice. During an interview on [DATE] at 1:35 PM, CNA H stated she has been here over a year and works the night shift - 10 PM to 6 AM. She stated the types of code status are DNR and full code, adding that DNR is Do Not Resuscitate and full code is running CPR until EMS arrives. CNA H stated resident information on their code status can be found on the crash cart and in the paper charts at the nurse's station, adding that she was recently re-trained on this information verbally and via in-service. She stated she has been trained on abuse, and abuse can be verbal, physical, emotional, or sexual; if witnessed, she stated this should be reported to the ADM or the DON. She stated the protocol for responding to an Unresponsive Resident, which she identified as a Code Blue, includes informing the nurse, beginning compressions. and grabbing the crash cart. She stated if the resident is a DNR, she wouldn't begin CPR compressions. If they were a full code, she would begin CPR and not stop until EMS arrives to take over. She stated if a resident on hospice was found unresponsive, she would check their code status to confirm rather they were full code or DNR, and inform their respective [hospice] nurse. She stated it is important to honor a resident wishes regarding code status because it is important to respect them, and their end of life wishes, and it is their right to choose. During an interview on [DATE] at 1:41 PM, RN B stated she has been working with the facility for 1 year and works the weekend shift from 6 AM - 2 PM. She stated full code status can be either DNR or full code. She stated DNR is Do Not Resuscitate and full code means the patient wants to be resuscitated if their heart stops or they stop breathing, and this information can be found in their charts and on the crash cart in a folder. She stated she her recent re-training for code status was via Healthcare Academy and via in-services provided by the DON. She stated when responding to an Unresponsive Resident, if there is an absence of pulses or breathing, or resident in distress, they would notify the nurse, retrieve the crash cart and call 911. She called this a Code Blue. She stated she would not provide life saving measures if a resident was a DNR. If a resident was full code, they would provide the response mentioned above, including CPR, and wouldn't stop CPR until the emergency team arrived to take over. She stated it is important to honor a resident wishes regarding code status because it is their right to be resuscitated or have life saving measures provided. She stated she has been a nurse for 40 years and takes accountability for the incident involving Resident #1. During an interview on [DATE] at 2:13 PM, CCN J stated she has worked with the company since 2012. She stated considering the IJ there has been 1:1 re-education with LVN A and RN B which included Abuse and Neglect, Code Status, CPR when initiated and not stopping, DNR, and hospice resident code status rights. She stated there was also retraining on licensed nursing staff, unresponsive residents, and CPR. She added that all staff were educated on Abuse and Neglect. The DON and ADM were in-service by her [CCN J]. She stated they did an audit of code status for ALL residents to ensure everyone had a code status on file and that all DNR residents have OOHDNR documentation on file and updated. She stated that her monitoring of the facilities POR includes reporting to the facility to audit the DON's audits of code status. She stated the DON will provide What would you do? scenarios for nursing staff. She stated she will physically be on-site, at the facility, to speak with staff and review information regarding code status and will ensure new hires receive the same information. CCN J stated her monitoring responsibilities will be done at minimum of weekly, and more often as necessary; at least for the next 4 weeks. She added that the components of the POR will be reviewed in their monthly QAPI meetings for the next 2 months. Observation of the facility's crash cart revealed signage alerting staff to retrieve the AED if they are retrieving the crash cart. Observation of the crash cart revealed a binder that included all residents' code status in an emergency. Review of (2) Employee Roster's revealed documentation of the DON's contact to ALL staff (either in-person or via telephone). The documentation reflected that nursing staff were re-trained on Responding to a Code, Code Blue, CPR, Crash Cart/AED, and Abuse and Neglect, and direct care staff were re-trained on Abuse and Neglect. Review of CPR Process 1:1 Conversation with Nursing Staff, completed by the DON, reflected a 1:1 conversation was had with LVN A on [DATE] at 8:40 AM and with LVN E on [DATE] at 8:41 AM. The conversations include scenarios for What do you do? regarding an unresponsive resident who may be DNR or full code. Review of Abuse and Neglect Policy, last revised [DATE] revealed highlighted portions in the areas of Abuse, Neglect and Mistreatment, Training, Prevention, Identification, Investigation and Protection were acknowledged via an in-service dated [DATE]. Record Review of an In-Service for LVN A titled, Code Blue - When to Stop CPR - Never Until EMS Arrives, AED, Hospice Res. Can be Full Code was completed by the DON, and dated [DATE]. Record Review of an In-Service for RN B titled, Code Blue - When to Stop CPR - Never Until EMS Arrives, AED, Hospice Res. Can be Full Code was completed by the DON and dated [DATE]. Review of facility in-service titled Code Status/Resident Change of Condition, Unresponsiveness, responding to a Code, Abuse and Neglect, Code Blue - When to Stop CPR, Never Until EMS Arrives, AED, Hospice Patients can be Full Code, all dated [DATE] - [DATE] reflected these trainings were started and completed by all nursing staff. Review of [facility]Audit of Resident Code Status dated [DATE] at 7:15 PM reflected the facility census to be 37. The record reflected that All residents had either full code or DNR identified in their care plan and has an order for their status All residents who were DNR have appropriate documents in their charts. Review of Code Status audit dated [DATE] noted the DON will audit resident charts for code status order and accuracy; DON will audit resident chart for care plan accuracy related to code status. An audit completed on [DATE] reflected no changes from the previous audit, which was completed on [DATE] and revealed all residents have a red sheet in their charts if they are DNR, and a green sheet if they are Full Code. Review of QAPI Meeting Sign-In Sheet titled Plan of Removal Monitoring, dated [DATE], revealed the attendance to include the ADM, DON, (2) corporate nurses, and the CO[TRUNCATED]