**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure personnel provide 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 of 4 (#1) residents in that: Resident #1 was administered CPR, 2 compressions which caused Resident #1 to moan in pain, by LVN A after found unresponsive. Resident #1 was a DNR. Resident #1 had an OOH-DNR. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6 PM. While the IJ was removed on [DATE] at 1:26 PM. The facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to evaluate the plan of removal. This facility failure could place residents at risk of not having their rights honored; experiencing worsening of condition; severe injury, and hospitalization. The findings included: A record review of complaint investigation #546794, dated [DATE], revealed Resident #1 had to go to the emergency room, the addendum stated Resident #1 was unresponsive and 911 was called. The complainant stated RN A said she was sorry; I was completely unaware that Resident #1 had a DNR and I administered CPR. The complainant, not realizing that Resident #1 had no pulse and wasn't breathing which complainant took to mean unconscious, sat speechless. complainant then said, You mean she (Resident #1) didn't have a pulse? The RN A replied No. She wasn't breathing, and she did not have a pulse. When I got in there, I assessed for breath and pulse, didn't find either one, and jumped on her and yelled Starting CPR and gave her 2 compressions. At that point her chest came off the bed and she made a loud groaning sound. The nurse went on to explain that she never checked the binder on the crash cart and that there is no protocol for the order things should be done when the crash cart is needed. RN A told complainant she only knew about the DNR because the Dr called over from the hospital to discuss what happened and when the nurse got to the part about the CPR, he stated to her You realize she has a DNR. The nurse said it was after that phone call that she went and checked the binder and saw the non-hospital DNR was in there. The RN A stated that she had called her Director of Nursing, but she wanted us to hear it from her what had happened. A record review of Resident #1's admission Record dated [DATE] was documented, a [AGE] year-old, she was admitted on [DATE] with diagnoses of multiple rib fractures, dementia) (a decline in mental ability severe enough to interfere with daily life), Parkinson's disease (a progressive neurological disorder that affects movement, primarily due to a decline in dopamine-producing brain cells, leading to symptoms like tremors, stiffness, and slow movement, but also impacting non-motor functions like sleep and mood.) and cognitive communication deficit. Resident #1 was at facility for 24 days and was discharged on [DATE]. A record review of Resident #1's electronic chart was documented an OOH-DNR dated [DATE]. A record review of Resident #1's consolidated physician orders for [DATE] revealed she had a code status order for DNR. A record review of Resident #1 admission MDS dated [DATE] was documented her BIMs score was 8/15 (moderate cognitive impairment), she had impairment on lower extremity on both sides, she used a walker/wheelchair to mobilize, she required supervision for self-care for eating, oral hygiene, persona hygiene, and maximum/moderate assistance with toileting, showers, and dressing. Resident #1 was incontinent of bowel/bladder, she had diagnoses of fractures, dementia, and Parkinson's. A record review of Resident #1 baseline care plan dated [DATE] was documented her code status was DNR. A record review of Resident #1's care plan conference dated [DATE] was documented her code status was OOH-DNR. A record review of Resident #1's Transfer/Discharge Report dated [DATE] at 5:15 PM was documented she was unresponsive and was transferred to hospital. A record review of Resident #1's progress note dated [DATE] by MD was documented Admitting Diagnosis: Right sided rib fractures Chief Complaint: Impaired mobility and self-care. Medical coverage provided by: MD. Interval History: The patient is undergoing rehabilitation at the skilled nursing facility and since the last visit, the patient is participating well in the therapy program. The patient is reporting any pain. New issues since last visit: The patient was assessed while sitting up in the chair with [family member] at her side. The patient reports moderate pain but tolerable with Tylenol and Lidoderm patches, per [family member] Oxycodone attempted and made the patient nauseous requiring Zofran. Patient's [family member] requesting continuation of Zofran PRN with nursing. A record review of Resident #1's progress note dated [DATE] at 4:41 PM was documented Resident #1 presents with weakness and tremors. Request labs for UTI, UA and were ordered. A record review of Resident #1's progress notes dated [DATE] at 4:48 PM Zofran ODT Tablet Dispersible 4 MG, give 1 tablet by mouth every 8 hours as needed for nausea. A record review of Resident #1's progress notes dated [DATE] at 5:43 PM was documented Zofran ODT Tablet Dispersible 4 MG, give 1 tablet by mouth every 8 hours as needed for nausea. PRN Administration was: Effective. A record review of Resident #1's progress note dated [DATE] at 6:13 PM by RN A, was documented, resident was last seen well at 1630 (4:30 PM) when I administered her evening medications. I was notified at 1705 (5:05 PM) that resident was unresponsive. when assessed resident was not breathing and did not respond to sternal chest rub. 911 was called, CPR was initiated after 1 pump of CPR resident moaned out and was now breathing. vitals where 139/78 02 88 heart rate 52. resident still would not open eyes and would not verbally respond. EMS arrived and resident was sent to hospital for further evaluation. A record of Resident #1's hospital record dated [DATE] was documented Resident #1 had an unresponsive episode at her nursing home. Resident #1 was fond by nurse the started 1 chest compression and Resident #1 started moaning so compressions were stopped. Resident #1 was more responsive and CT scan to chest showed a large pleural effusion. Resident #1 had been able to answer questions, began to moan and moving and these were stopped, EMS administer Narcan per report Resident #1 was on narcotics. Resident #1 was at her baseline status and was weaned off oxygen. CT scan was negative and was stable and read for discharge to another facility. During an interview on [DATE] at 4:47 PM, via email, the complainant stated She (LVN A) was also the one who told me she did CPR without knowing there was a DNR in place. She spoke directly to the hospital and was in charge of the ambulance upon its arrival. The last stay at hospital was a severe UTI. Attempted interview on [DATE] at 12:30 PM, [DATE] at 1:26 PM, [DATE] at 12:02 PM with RN A left a voicemail and did not return call before the exit. During an interview on [DATE] at 1:07 PM with CNA B stated that day, she was not sure of exact date, Resident #1 was not breathing, called CNA C on phone and asked her to get nurse, RN A. CNA B stated she automatically grabbed the crash cart, with code status book and went to tell RN A to go to Resident #1's room. CNA B stated RN A started CPR and did 2 compressions, and Resident #1 opened her eye. CNA B stated during the compression, she had opened the code book to Resident #1's code status and told RN A that Resident #1 was a DNR. CNA B stated she had stepped out on the hall to return to her hall, saw EMS and let them know Resident #1's room number, and she left on the stretcher awake. CNA B stated later that day, RN A stated she had looked at Resident #1's admission record and her code status was a DNR. CNA B had stated to RN A that she had told her Resident #1 was a DNR, but she did not listen. CNA B stated that RN A did not hear her. CNA B stated RN A, CNA C were in Resident #1's, but was not sure of the other staff. CNA B stated she was trained for CPR at hospital that she worked at and not at the facility. During an interview on [DATE] at 1:47 PM with LVN AE stated Resident #1 was fine and did not have a change of condition, the night before the incident with the code status. LVN AE stated she worked nights and was not involved with the code status incident with Resident #1. LVN AE stated she knew Resident #1 was a DNR. LVN AE stated she would look at the crash cart, on top had a code status log of all residents with their code states. LVN AE stated the code status was printed out every night. LVN AE stated she was not sure if she was trained at facility for code status. During interview on [DATE] at 2:56 PM with MD stated she was not aware that a CNA, had told LVN A Resident #1 was a DNR, and the LVN A continued to do compressions. During an interview on [DATE] at 11:52 AM with the current DON stated her expectations of nursing would be to document more, document a change of condition, and notify the state agency. The current DON stated the MD had access to resident labs via software system. The current ADON started working after this incident. During an interview on [DATE] at 12:23 PM with ADON stated she was not present for the incident with Resident #1. ADON stated the family had not shared any complaints and Resident #1 family member visited her daily. The ADON stated every night the residents code status's get printed by night staff and placed in a binder, on top of crash cart. The ADON stated RN A should have looked at the code status binder. The ADON stated the previous DON did educate her on the code status incident but had no documentation and she did not remember signing anything for code status training. The ADON stated she was not the boss and did not report this incident to the state agency. During an interview/observation on [DATE] at 10:51 AM with the DON showed the surveyor where they kept the code status of residents in binder, on top of the crash cart near the nurse's station. During an interview on [DATE] at 12:01 PM with the previous DON stated she worked from [DATE] through [DATE]. The previous DON stated she did not remember Resident #1 at this time. The previous DON stated she would expect a nurse to respond to an unresponsive resident, by looking at the binder with all resident code status, call 911. The previous DON stated if resident was a DNR, do not do CPR on resident and call 911. If resident a full code she would expect the nurse to start CPR until EMS came. In regard to this incident, she as a DON would train on code status and what to do, and report to the state agency. During an interview on [DATE] at 2:15 PM with Resident #1's family member/ MPOA stated he was in the room the day Resident #1 went to the hospital. Resident #1's spouse stated he was with Resident #1 in the morning, and at lunch. Family member stated Resident #1 went to lay down and she was unresponsive to him, he called out for a staff, staff grabbed the crash cart, and did see the nurse doing compressions, and went outside room, so staff can care for Resident #1. Family member of Resident #1 stated at the time it happened so fast he did not think about the code status of DNR. Family member stated EMS was able to get Resident #1 stabilized and Resident #1 went to hospital. Family member of Resident #1 stated at the hospital Resident #1 did not have any broken bones and changed her blood pressure medications due to low blood pressure. Family member stated Resident #1 was well and was taking a nap at the time. During an interview on [DATE] at 2:18 PM the previous DON stated she was the DON at the facility until mid-[DATE] when she resigned. The previous DON stated she was unaware of Resident #1's CPR event and could not recall any details of the incident. The DON stated she was employed as the DON during the month of [DATE] but was not the DON effectively stating the administrator and the ADON had cut her out of the loop and the ADON was as a result the DON. The DON stated had she known of the incident she would have reported the incident and investigated the incident. The DON stated if Resident #1 had wished to be a DNR status they should have not provided CPR. During an interview on [DATE] at 2:25 PM with CNA C stated RN A did do compressions, she was not sure who found Resident #1. CNA C stated she did not recall if Resident #1 was in pain. CNA C stated the resident code status were in a binder on the crash cart. CNA C stated she was following the nurses' instructions, and she was not sure of Resident #1's code status. During an interview on [DATE] at 5:59 PM the SW stated the residents last right/choice was to have their code status honored and staff should respect a resident choice. During interview in [DATE] at 4:17 PM with LVN L stated she was the overnight nurse that maintained the DNR binder and ensured the binder was accurate nightly and last night [DATE] at 1 AM, he printed out a new page for the binder and placed on crash cart. During an interview on [DATE] at 5:02 PM the Administrator stated he was not the administrator at the time of the allegation on behalf of Residents #1 and the previous Administrator was responsible for ensuring those allegations were heard, documented, and satisfactorily resolved for Residents #1. The Administrator stated he was the current abuse, neglect, and exploitation prevention coordinator. The Administrator stated the failure to recognize and report allegations of ANE could place residents at risk for not having their allegations of ANE reported. The Administrator stated he had begun training for his team and all the staff to ensure they all understood the ANE prevention recognizing and reporting process and expected increased documentation and recognition of allegations of ANE with reports to the state agency. Record review of Policy, Communication of Code Status dated 7/22 was documented, It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. 4. The resident's code status should be entered into the resident physician orders in the EMR. 5. Additional means of communication of code status include: Code status will appear at the top of the resident home screen in EMR. 9. The resident's code status will be reviewed at least quarterly and documented in the medical record. The Administrator was notified of an IJ on [DATE] at 6 PM and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on [DATE] at 1:26 PM and included the following: Plan of Removal (POR) for Immediate Jeopardy, dated [DATE] was documented: To Whom it may concern, Summary of Details which lead to outcomes. On [DATE], an abbreviated survey was initiated at 10 am. On [DATE], A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the facility constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F678 The facility failed to implement a resident's advance directive on Resident #1. Identify residents who could be affected. All Residents with an advance directive have the potential to be affected. Facility census on [DATE]. Identify responsible staff/ what action taken: . Regional VPO and Regional Nurse Consultant provided education on CPR and Advance Directives honoring resident rights to Administrator and Director of Nursing on [DATE]. Director of Nursing and Assistant Director of Nursing conducted education on CPR and Advance Directives for all nurses. A mock code was performed for am and pm shifts on [DATE], with documentation on a Mock Code form. Advance Directive Binder on the crash cart was reviewed and verified to ensure residents code status were listed and correct on [DATE], by the DON. The Regional VPO educated the Administrator and Director of Nursing on reporting guidelines per PL 2014-14 dated [DATE], on [DATE]. Social Worker/designee will be responsible for updating the Advance Directive binder when there is a change in code status. New staff and agency staff (if applicable) will be educated in Advance Directives and the location of the code status binder which is located on the emergency cart by the DON/designee prior to starting their shift. Implementation of Changes Nurses can easily identify and locate the code status for residents, as the advanced directive binder is clearly marked and located on the crash cart. The location of the advance directive binder is documented in the in-service provided to the nursing staff. Nurses will only perform CPR if the resident is designated as a Full Code. Training initiated and completed on [DATE], and after the education sessions, nurses will have a better understanding of code status and the situations in which CPR should or should not be performed. Any new hires and or agency staff (if applicable) will be educated prior to the start of their shift. The Director of Nursing will conduct monthly mock code scenarios for 3 months. Monitoring Administrator, Director of Nursing, or designated staff will monitor the code status of residents daily for 4 weeks, including any changes upon admission and thereafter. Social Worker/designee will be responsible for updating the Advance Directive binder when there is a change in code status. Any negative outcomes will be reported to the QAPI Committee. Involvement of Medical Director Ad hoc QAPI held at 7:35 pm on [DATE], with the Medical Director, Director of Nursing and Administrator for discussion of Immediate Jeopardy and the plan of removal. The Medical Director, 6:28 pm was notified about the immediate Jeopardy on [DATE]. Who is responsible for the implementation of the process? Director of Nursing and/or Designee. POR verification was started on [DATE] was documented: Identify residents who could be affected. Record review of Resident list revealed 71 residents in the building During an interview on [DATE] at 1:13 PM on [DATE] the DON stated prior to [DATE] the entire census of 71 had the potential for their code statuses not being reviewed if a potential event of a resident being discovered unresponsive. Identify responsible staff/ what action taken: Record Review of CPR/Advanced Directive in-service training dated [DATE] was documented the Regional VPO and Regional Nurse Consultant provided education on CPR and Advance Directives to the Administrator and DON. During an interview on [DATE] at 1:18 PM Regional VPO stated he provided education on CPR and Advance Directives honoring resident rights to the Administrator and the Director of Nursing on [DATE],[DATE] and that the Director of Nursing and the Assistant Director of Nursing conducted education on CPR and Advance Directives for all nurses. A mock code was performed for am and pm shifts on [DATE],[DATE] with documentation on a Mock Code form. Record review of in-service training CPR code status mock code, summary: in the event of code blue, immediately delegate for a staff member to retrieve resident code status form binder on crash cart before beginning CPR. Code status binder is updated nightly by nursing staff. (mock code initiated) dated [DATE] included, LVN H, LVN P, CNA Q, PT R, CNA S, CNA T, CNA U, CNA V, and CNA W. The following staff LVN H, LVN P, CNA Q, PT R, CNA S, CNA T, CNA U, CNA V, and CNA W, who received training for supporting a residents' wishes for a code status and participated in the facility's initial Mock Code event on [DATE] training were interviewed as follows: During an interview on [DATE] at 1:46 PM LVN H stated on [DATE] she was trained by the DON for a Mock Code event designed to augment the staffs' in-service regarding a potential CPR event if a Resident was discovered unresponsive. LVN H stated the protocol in the training would have a focus in the training for the staff to identify the Resident in the DNR Binder which was maintained accurately on the cart, and to communicate the information to one and another to specify if the Resident had wishes to receive or not to receive CPR. During interviews on [DATE] from 5:45 PM to 6:33 PM LVN P, CNA Q, PT R, CNA S, CNA T, CNA U, CNA V and CNA W stated she they had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident #1'sSmith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. LVN PThey stated she arrived to discover CNA Q was on her way with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. LVN PThey stated if it were a real CPR event she they would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. During an interview on [DATE] at 5:56 PM CNA Q stated she had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident Smith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. CNA Q stated she arrived at the 100-hall with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. CNA Q stated if it were a real CPR event she would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. During an interview on [DATE] at 6:33 PM PT R stated he had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident Smith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. PT R stated he arrived to discover CNA Q was on her way with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. PT R stated if it were a real CPR event he would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. During an interview on [DATE] at 5:49 PM CNA S stated she had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident Smith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. CNA S stated she arrived to discover CNA Q was on her way with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. CNA S stated if it were a real CPR event she would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. During an interview on [DATE] at 5:50 PM CNA T stated she had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident Smith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. CNA T stated she arrived to discover CNA Q was on her way with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. CNA T stated if it were a real CPR event she would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. During an interview on [DATE] at 5:47 PM CNA U stated she had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident Smith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. CNA U stated she arrived to discover CNA Q was on her way with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. CNA U stated if it were a real CPR event she would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. During an interview on [DATE] at 5:45 PM CNA V stated she had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident Smith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. CNA V stated she arrived to discover CNA Q was on her way with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. CNA V stated if it were a real CPR event she would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. During an interview on [DATE] at 5:47 PM CNA W stated she had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident Smith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. CNA W stated she arrived to discover CNA Q was on her way with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. CNA W stated if it were a real CPR event she would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. Record review of list of nurses provided by the DON revealed at total of 10 nursing staff working in the facility. Interview on [DATE] at 12:15 PM with ADM/DON/Regional nurse stated they had 10 full time nurses working at facility with no agency staff. Record of staffing schedule for [DATE] was documented 7 nursing staff that worked on the AM and PM schedule. The Advance Directive Binder on the crash cart was reviewed and verified to ensure residents code status were listed and correct on [DATE]/4/25, by the DON. Record review of statement from DON dated [DATE] was documented, Reviewed and verified advanced directrices binder on crash cart to ensure all code status were correct. Record review of the Advance Directive Binder on the crash cart was reviewed and verified to and included 71 residents. The Regional VPO educated the Administrator and Director of Nursing on reporting guidelines per PL 2014-14 dated [DATE], on [DATE]. Record review of In-service training dated [DATE] by the Regional VPO was documented ADM and or DON will enforce state/Federal guidelines on state reporting. In addition, the ADM and/or DON will report all significant events to the Regional [NAME] President which included signatures of DON/RN, ADM and ADON. Record review of the LTC provider letter, dated [DATE]. 2024 (PL 2014-14) was attached to in-service. Social Worker/designee will be responsible for updating the Advance Directive binder when there is a change in code status. Record review of statement dated [DATE] was documented I, SW understand that it is my responsibility to update advanced directive binder when there are changes in code status. Upon each admission it will be explained to family and residents their right to make medical decisions, including the right to formulate and have respected advance directives that may be updated and changed anytime at their request, signed and dated by SW. New staff and agency staff (if applicable) will be educated in Advance Directives and the location of the code status binder which is located on the emergency cart by the DON/designee prior to starting their shift. During an interview on [DATE] at 1:13 PM the DON stated new staff and agency staff (if applicable) will be educated about Advance Directives and the location of the code status binder which was located on the emergency cart, prior to starting their shift. Implementation of Changes Record review of in-service training on Code Status/Advanced Directive, where and how do you know what code status they have, and Binder is located on the crash cart with list of resident code status dated [DATE] which included 13 nursing staff. A record review of the facility's full time nursing roster revealed 11 nurses: 1. The DON 2. LVN D 3. ADON LVN E 4. LVN F 5. LVN G 6. LVN H 7. LVN I 8. LVN J 9. LVN K 10. LVN L 11. LVN O A record review of the facility's PRN nursing roster revealed 3 nurses: 1. LVN M 2. RN N Of the facility's' 13[TRUNCATED]