**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents and hazards, in that: Resident #1 was able to exit the facility without staff knowing on 08/13/2024. Staff were unaware that Resident #1 had walked out of the facility until they received a call from local police informing them Resident #1 was with the Police at a restaurant located .3 miles from the facility. An IJ was identified on 08/27/2024. The IJ template was provided to the facility on [DATE] at 06:45 PM. While the IJ was removed on 08/29/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because the facility needed to evaluate the effectiveness of their corrective actions. This failure could place residents at risk of accidents that could result in serious injury, harm, impairment, or death. Findings were: Record review of Resident #1's face sheet, dated 08/27/24, revealed Resident #1 was a [AGE] year-old female diagnosed with dementia originally admitted to the facility 03/01/2021. Record review of Resident #1's MDS assessment, dated 08/08/2024, revealed Resident #1 had a BIMS score of 5. Resident #1 used a walker when ambulating. Record review of Resident #1's care plan, dated 06/03/2024, revealed Resident #1 was identified as an elopement risk with no exit seeking behaviors. One intervention was identified as involve resident in group activities. Record Review of Resident #1's Elopement Risk Assessment, dated 06/12/2024, revealed Resident #1 was identified as At Risk for elopement with a score of 5. Resident #1's Elopement Risk Assessment was marked Yes for questions 1. Does the resident have a diagnosis of Dementia, OBS, Alzheimer's, Intellectual/ Developmental Disability, Delusions, Hallucinations, Anxiety Disorder, Depression, Bipolar, and/or Schizophrenia?, 2.Does the resident ambulate independently, with or without the use of an assistive device? (i.e. walker, cane or wheelchair)?, 3. Does the resident have any hearing, vision or communication problems?, 7. Is the resident cognitively impaired with poor decision-making skills (i.e. disorientation, cognitive deficits, disorganized thinking)?, 10. Does the resident display wandering without a sense of purpose (i.e. going in and out of other resident's rooms and explore their belongings, confused, aimless movements)?. The incident Record review of facility in-service training named Abuse & Neglect, Elopement/Wandering, and ensuring doors closed after letting visitors in/out, dated 8/13/2024, revealed 67 staff had signed the in-service. Record review of facility's employee roster revealed the facility had 75 employees. Record review of staff's clock-ins revealed 68 staff had worked from the time Resident #1 eloped from the facility on 08/13/2024 (around 9:00 PM) to morning shift (6 AM to 2 PM) on 08/27/2024. Out of the 68 staff who worked, 16 staff had not signed the in-service. Interview with DON on 08/27/2024 at 10:24 AM revealed Resident #1 eloped from the facility on 08/13/2024. DON stated that the medication aide passed Resident #1's medications about 9:00 PM and then asked resident if she wanted to go lay down. Resident #1 then walked to her room and entered. DON stated that Resident #1 was not seen leaving the facility and the staff were unaware that Resident #1 had left until the local police called the facility. Local police informed the facility that Resident #1 was with them at a restaurant .3 miles from the facility. Local police returned Resident #1 to the facility around 9:30 PM. DON stated that she completed a head-to-toe assessment on Resident #1 and then started to in-service on Abuse/Neglect, Elopement/wandering and ensuring doors are closed with all staff that were on shift. Interview with Administrator on 08/27/2024 at 10:34 AM revealed Resident #1 eloped from the facility on 08/13/2024 after receiving her 9:00 PM medications. Administrator stated the facility received a call from the local police informing them Resident #1 was at a restaurant .3 miles from the facility and would be escorted back to the facility. Administrator stated that resident was returned to the facility about 9:30 PM by local police. Administrator stated she was unsure how resident was able to elope from the facility but speculated that Resident #1 followed another resident's family out of the facility. Administrator stated that resident did not have exit seeking behaviors prior to her elopement. Interview with Resident #1's responsible party on 08/27/2024 at 11:30 AM revealed Resident #1 had been at the facility since 2021. Resident #1's responsible party stated Resident #1 had never had exit seeking behaviors. Resident #1's responsible party stated that Resident #1 was happy at the facility and had never expressed concerns with her care. Observation of all facility exit doors on 08/27/2024 starting at 11:45 AM revealed all exit doors were locked and unlocked with a keypad. All exit door alarms were working properly. Observation of Resident #1 on 08/27/2024 at 12:15 PM revealed resident sitting in the living room close to nursing station. Resident had a small band with a white square (wander guard) on her left ankle. Interview attempted with Resident #1 on 08/27/2024 at 12:16 PM revealed resident was confused and unable to answer surveyor's questions. Resident #1 was unable to tell surveyor the day of the week or what she had for breakfast. Interview with MA D on 08/27/2024 at 2:17 PM revealed Resident #1 received her medications on 08/13/2024 just after 9 PM and then went back to her room. MA D stated she did not see Resident #1 leave her room or the facility the night she eloped. Resident #1 was returned to the facility by local police around 9:30 PM. MA D stated the facility exit doors are locked and have an alarm when opened without being unlocked. MA D stated resident had no exit seeking behaviors prior to her elopement. This was determined to be an Immediate Jeopardy (IJ) on 08/27/2024 at 6:45 PM. Administrator was provided with the IJ template on 08/27/2024. The following Plan of Removal was accepted on 08/28/2024 at 1:13 PM. Plan of Removal: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On August 27, 2024 an investigation was initiated at [facility name and address]. At approximately 6:45p.m on August 27, 2024 a surveyor provided verbal notification that Texas Health and Human Services had determined the conditions at [the facility] constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F-0689 - Free of Accident Hazards/Supervision/Devices Immediate Corrections Implemented for Removal of Immediate Jeopardy. On August 13,2024 at approximately 9:20pm Resident#1 returned to the facility from the Emergency Department. Action: Resident #1 is a current resident and was brought back to facility on 8/13/2024. The director of nursing reassessed Resident #1 for Elopement risk and Wander guard was placed 8/15/2024 to monitor for resident exiting facility. IDT reviewed and interventions initiated, and care plan updated reflect elopement risk. On August 27, 2024, at approximately 7:00pm the following actions were taken; Action: Education initiated Elopement risk, Abuse/Neglect/Exploitation, Signs to watch for with residents exhibiting potential for elopement, increased wandering, exit seeking, increased behaviors. Education will be completed prior to staff working the next scheduled shift, and ongoing with general orientation for all new hires. Start Date: 8/27/2024 Completion Date: 8/27/2024 Responsible: Director of Nursing/designee Action: Administrator validated that exit doors are functioning with wander guard system for notification of opening doors and residents attempting to exit that have been identified as High risk of elopement. Start Date: 8/27/2024 Completion Date: 8/27/2024 Responsible: Administrator/Designee IDENTIFICATION OF OTHER AFFECTED: All residents have the potential to be affected. Action: Completed Elopement Risk Assessment on all residents and validated all residents at risk of elopement, score of 3 or greater, have appropriate interventions and plan of care in place per risk assessment. Start Date: 8/27/2024 Completion Date: 8/27/2024 Responsible: Director of nursing/designee SYSTEMIC CHANGES AND/OR MEASURES: Action: In-service and education was provided to facility staff regarding the process for residents who have been identified as an elopement risk and proper steps to take to assure residents remain safe without risk for elopement, including monitoring, care plan updates, wander guards as indicated. Start Date: 8/27/2024 Completion Date: Ongoing until all staff have received education prior to their next scheduled shift. Responsible Party: Director of Nursing/Designee Action: Signage to be placed at exit door to notify all persons exiting to watch for residents to assure they are not followed out by potentially wandering or unsafe residents. Start Date: 8/28/2024 Completion Date: 8/28/2024 Responsible Party: Administrator Action: Education was provided to all staff on Elopement policy, Abuse/Neglect/Exploitation. Start Date: 8/27/2024 Completion Date: 8/27/2024 and Ongoing until staff have received training prior to the start of their next shift. Responsible Party: Director of Nursing/Designee Action: Ad hoc QAPI meeting held with IDT team and MD to review policy on Elopement, Abuse and neglect, and Plan of removal/response to Immediate Jeopardy Citation on 8/27/2024 Start Date: 8/27/2024 Completion Date: 8/27/2024 Responsible: Administrator/Designee Tracking and Monitoring Director of Nursing/Designee will review residents with At Risk for wandering or elopement identified or newly admitted with history of elopements to assure appropriate interventions and plan of care are in place 5 times per week beginning 8/28/2024 for 12 weeks or until sufficient compliance if found. This will be documented in daily clinical meeting with use of electronic log and reviewed monthly in QAPI meeting. Director of Nursing/Designee will complete audits for those residents who wear a wander guard to ensure electronic monitoring device is functioning every shift for 7 days beginning 8/28/2024 then will monitor electronic monitoring devices daily 5 times per week for 12 weeks or until sufficient compliance if found. This will be documented in daily clinical meeting with use of electronic log and reviewed monthly in QAPI meeting. Administrator/designee will complete random audit every shift for 7 days, beginning 8/28/2024 for appropriate staff response to wandering or potentially exit seeking residents, immediate education will be provided, if necessary, then will monitor random shifts, 5 times a week for 12 weeks or until sufficient compliance if found. This will be documented on log to be reviewed in QAPI Meeting Monthly. Administrator/designee will complete audit of exits for proper functioning of doors, alarms and wander guard system for proper functioning every shift for 7 days, beginning 8/28/2024 then will monitor random shifts, 5 times a week for 12 weeks or until sufficient compliance if found. This will be documented on log to be reviewed monthly in QAPI. Any trends or concerns were/will be addressed with Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review Verification: Interview with Administrator on 08/28/2024 at 1:25 PM revealed the facility started in-servicing its staff on 08/27/24. Administrator stated the facility would continue to in-service its staff prior to the start of their shifts until all staff have been in-serviced. Administrator also stated the DON started to re-assess all residents on their elopement risk and would be complete on 08/29/2024. Administrator stated she hung signs on all exit doors instructing anyone exiting to ensure that residents do not follow them out. Administrator stated she tested all exit doors to ensure the alarms and wander guards worked properly. Observation of the facility's exit doors on 08/28/2024 starting at 1:45 PM revealed all 8 exit doors had a sign that read Caution For the safety of our residents please ensure doors properly close behind you. All exit doors were locked, and alarm sounded when release bar was pressed. Interview with Administrator on 08/29/2024 at 9:54 AM revealed DON and Administrator worked on re-assessing the residents to identify those at risk for elopement. Administrator stated she was reviewing care plans for residents identified as at risk for elopement and ensuring care plans included interventions to prevent elopement. Interview with LPN A on 08/29/2024 at 9:24 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. LPN A was able to demonstrate an understanding of the in-service materials. Interview with RN B on 08/29/2024 at 9:35 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. RN B was able to demonstrate an understanding of the in-service materials. Interview with CNA C on 08/29/2024 at 9:52 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA C was able to demonstrate an understanding of the in-service materials. Interview with MA D on 08/29/2024 at 10:17 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. MA D was able to demonstrate an understanding of the in-service materials. Interview with CNA E on 08/29/2024 at 10:32 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA E was able to demonstrate an understanding of the in-service materials. Interview with LPN F on 08/29/2024 at 10:36 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. LPN F was able to demonstrate an understanding of the in-service materials. Interview with LPN G on 08/29/2024 at 10:52 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. LPN G was able to demonstrate an understanding of the in-service materials. Interview with MA H on 08/29/2024 at 11:08 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. MA H was able to demonstrate an understanding of the in-service materials. Interview with RN I on 08/29/2024 at 11:17 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. RN I was able to demonstrate an understanding of the in-service materials. Interview with CNA J on 08/29/2024 at 11:22 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA J was able to demonstrate an understanding of the in-service materials. Interview with CNA K on 08/29/2024 at 11:22 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA K was able to demonstrate an understanding of the in-service materials. Interview with CNA L on 08/29/2024 at 11:28 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA L was able to demonstrate an understanding of the in-service materials. Interview with CNA M on 08/29/2024 at 11:31 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA M was able to demonstrate an understanding of the in-service materials. Interview with Housekeeping N on 08/29/2024 at 11:32 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. Housekeeping N was able to demonstrate an understanding of the in-service materials. Interview with Housekeeping O on 08/29/2024 at 11:36 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. Housekeeping O was able to demonstrate an understanding of the in-service materials. Interview with DA P on 08/29/2024 at 11:42 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. DA P was able to demonstrate an understanding of the in-service materials. Interview with [NAME] Q on 08/29/2024 at 11:42 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. [NAME] Q was able to demonstrate an understanding of the in-service materials. Interview with DS R on 08/29/2024 at 11:43 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. DS R was able to demonstrate an understanding of the in-service materials. Interview with [NAME] S on 08/29/2024 at 11:46 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. [NAME] S was able to demonstrate an understanding of the in-service materials. Interview with Housekeeping T on 08/29/2024 at 11:48 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. Housekeeping T was able to demonstrate an understanding of the in-service materials. Interview with Human Resources Director U on 08/29/2024 at 11:50 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. Human Resources Director U was able to demonstrate an understanding of the in-service materials. Interview with CNA V on 08/29/2024 at 11:52 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA V was able to demonstrate an understanding of the in-service materials. Interview with LPN W on 08/29/2024 at 11:54 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. LPN W was able to demonstrate an understanding of the in-service materials. Interview with Activities Director X on 08/29/2024 at 11:57 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. Activities Director X was able to demonstrate an understanding of the in-service materials. Interview with PT Assistant Y on 08/29/2024 at 12:00 PM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. PT Assistant Y was able to demonstrate an understanding of the in-service materials. Interview with [NAME] Z on 08/29/2024 at 12:04 PM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. [NAME] Z was able to demonstrate an understanding of the in-service materials. Interview with LPN AA on 08/29/2024 at 12:10 PM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. LPN AA was able to demonstrate an understanding of the in-service materials. Observation of the facility's wander guard system on 08/29/2024 at 3:02 PM revealed alarm sounds when resident got about 5 feet from the front door in the living room. The alarm turned off when resident moved closer to the nurse's station at the end of the living room. Record review of in-service training on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out, dated 08/27/2024, on 08/29/2024 revealed 63 out of 69 staff have signed the in-service training. Record review of all resident's Elopement Risk assessments on 08/29/2024 revealed the facility re-assessed each resident's risk of eloping starting 08/27/2024. The facility completed the re-assessments on 08/29/2024. Record review of facility's monitoring logs on 08/29/2024 revealed DON/Designee reviewed resident's identified as elopement risk care plans for appropriate interventions on 08/28/2024 and 08/29/224. Record review of facility's monitoring logs on 08/29/2024 revealed DON/Designee completed audits for residents wearing wander guards on 08/28/2024 on all shifts and 08/29/2024 6 AM-2 PM shift. Record review of facility's monitoring logs on 08/29/2024 revealed Administrator/Designee completed random audits of staff's response to resident's wandering on 08/28/24 on each shift and on 08/29/2024 on the 6 AM-2 PM shift as well as the 2 PM- 10 PM shift. Record review of facility's monitoring logs on 08/29/2024 revealed Administrator/Designee reviewed completed audits of exit for proper functioning of door alarms and wander guard system on 08/28/2024 and 08/29/2024. The Administrator was informed the Immediate Jeopardy was removed on 08/29/2024 at 3:29 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to 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 (Resident #61) of 29 residents reviewed for CPR, in that; Resident #61 was discovered unresponsive, assessed as full code, and provided CPR for 9 minutes without the use of an available an AED prior to 911 EMS's arrival at the resident's side. An IJ was identified on [DATE]. The IJ template was provided on [DATE] at 11:05 am. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not Immediate Jeopardy because the facility is still monitoring their effectiveness of their plan of removal. This failure placed residents at risk for harm up to and including death by the denial of all life saving measures as trained. The findings included: A record review of Resident #1's admission record dated, [DATE], revealed an admission date of [DATE] and a death discharge date of [DATE], with diagnoses which included altered mental status, extended spectrum beta lactamase resistance [a bacteria that can't be killed by many of the antibiotics that doctors use to treat infections, like penicillin's and some cephalosporins for urinary tract infections], and urinary tract infection. A record review of Resident #1's admission MDS dated [DATE] revealed Resident #61 was an [AGE] year-old male admitted from an acute care hospital for support and rehabilitation related to a urinary tract infection. A record review of Resident #61's physician's order dated [DATE] revealed RN R documented a physician's order for Resident #61 to receive care as Full Code. A record review of Resident #61's care plan dated [DATE], revealed, [Resident #61] has an advance Directive as evidenced by: Full code status Date Initiated: [DATE] [ .] wishes will be honored, Date Initiated: [DATE] [ .] CPR will be performed as ordered. A record review of Resident #61's SBAR document dated [DATE] revealed, Situation [ .] the change in condition, symptoms, or signs observed, and evaluated is/are: cardiac arrest, respiratory arrest. This started on: [DATE]. Since this started it has gotten: stayed the same [ .] Resident/Patient Evaluation [ .] mental status evaluation: unresponsiveness [ .] Code Status: Full Code [ .] Appearance, summarize your observations and evaluation: CNA notified this nurse of resident being unresponsive assessed resident not responsive no pulse RN supervisor notified initiated CPR crash cart access notified 911 CPR performed until paramedics arrived emergency medical technicians continued with CPR resident transfers out with Pulse unconscious accompanied by three emergency medical technicians [ .]. A record review of the EMS TripTix EMS Patient Care Record dated [DATE] revealed, CPR was performed by the facility staff for 9 minutes from 09:38 AM to 09:47 AM as evidenced by, Incident Date / Times [ .] unit notified by dispatch [DATE] 09:41 [AM] [ .] Unit En Route [DATE] 09:43 [AM] [ .] Unit Arrived on Scene [DATE] 09:45 [AM] [ .] Arrived at patient [DATE] 09:47 [AM] [ .] Unit left scene [DATE] 10:04 [AM] [ .] complaints and impressions; cardiac arrest, onset date and time [DATE] 09:38 [AM], [ .] AED used prior to EMS NO [ .] Further review revealed a summary which reflected the facility had performed CPR chest compressions and oxygenated rescue breathing but had not used the AED. The EMTs provided medications and applied the EMS AED and revealed Resident #61 had regained an irregular heartbeat after EMS care and medications administered intraosseous [directly into the bone marrow]. During an interview and observation on [DATE] at 02:28 PM the DON stated sometime in [DATE] Resident #61 was discovered unresponsive and was provided emergency CPR care. The DON stated she was not certain if the AED used. The DON proceeded to demonstrate the AED to the surveyor. The AED was stored on the facility's emergency crash cart along with CPR equipment such as an oxygen tank, and oxygen delivery equipment and included a suction pump with accessories. The DON demonstrated the AED as functional and stated the AED had not been used and could not recall the last time it had been used. The DON stated she believed LVN A, LVN B, and RN C were directly involved with Resident #1's CPR care. During an interview on [DATE] at 07:10 PM the DON provided updated information and stated she recalled the [DATE] CPR event for Resident #61 and stated the AED was not utilized, and EMS services arrived at the facility after the 911 call, approximately 4-5 minutes. The DON stated she did not know why the AED was not utilized and further stated EMS arrived quickly. The DON was asked to provide any further documentation to the event and did not provide further documentation. The DON stated LVN A, LVN B , and RN C were involved in the CPR event for Resident #61. During an interview on [DATE] at 07:40 PM LVN A stated on [DATE] around 09:30 AM to 10:00 AM CNAs AB and AC reported to her Resident #61 was unresponsive. LVN A stated she told the CNAs to get RN C and immediately arrived at Resident #61's bed side. LVN A stated she assessed Resident #61 as a full code and without a pulse and not breathing. LVN A stated she began emergency CPR with chest compressions and RN C arrived at the bedside quickly. LVN A stated RN C assumed chest compressions and told her to get the crash cart and call 911. LVN A stated she ran to retrieve the crash cart and along the way told LVN B to call 911. LVN A stated she returned to Resident #61 with the crash cart and resumed chest compressions while RN C administered oxygen with rescue breaths. LVN A stated 911 EMTs were at the bedside quickly around 4-7 minutes maybe. LVN A stated EMS took over and Resident #61 was assessed with a pulse and left for the hospital with EMS. LVN A stated she was trained for CPR by the American Heart Association . LVN A stated the AED was stored on the crash cart and was immediately available upon arrival at Resident #61's bedside. LVN A stated the AED was never opened, removed from the case, or from the crash cart. LVN A stated she was so involved in providing CPR chest compressions and rescue breaths she did not think about the AED. LVN A stated her training included the use of an AED during CPR as soon as the AED was available. During an interview on [DATE] at 06:00 AM RN C stated on [DATE] she worked from 06:00 AM to 02:00 PM. RN C stated she was providing patient care when CNAs AB and AC told her LVN A needed her, and Resident #61 was unresponsive. RN C stated she ran to Resident #61's bedside and assessed Resident #61 as unresponsive and told LVN A to get the crash cart and call 911. RN C stated she began CPR chest compressions. RN C stated LVN A returned with the crash-cart, and they switched CPR roles and LVN A continued chest compressions while RN C administered oxygenated rescue breaths. RN C stated 911 EMS arrived quickly and continued CPR. RN C stated the facility's AED was stored on the facility's crash-cart and was immediately available when the crash-cart arrived but she nor LVN A gave it a thought due to the high stress of providing CPR. RN C stated she and LVN A provided CPR for maybe 5 minutes and 911 arrived quickly. RN C stated she was CPR trained by the American Heart Association . RN C stated her training included the use of an AED during CPR as soon as the AED is available. A record review of the facility's Emergency Procedure Cardiopulmonary Resuscitation policy dated February 2018, revealed, Policy Statement; personnel have completed training on the initiation of cardiopulmonary resuscitation and basic life support including Defibrillation for victims of sudden cardiac arrest; general guidelines; the chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. Early delivery of a shock with a defibrillator plus CPR within 3 to 5 minutes of collapse can further increase chances of survival [ .] emergency procedure; cardiopulmonary resuscitation; [ .] when the AED arrives assess for need and follow AED protocol as indicated [ .]. A record review of the facility's Automatic External Defibrillator, Use and Care of, dated [DATE], revealed, Policy Interpretation and Implementation: The automatic external defibrillator (AED) will be used to try to restore normal cardiac rhythm when arrhythmia is strongly suspected .remove the device from its case .check the battery cartridge to ensure it is in place .remove the film seals from the pads .turn on the device and follow the prompts . A record review of the American Heart Association's website Part 3: Adult Basic and Advanced Life Support; 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-and-advanced-life-support, accessed [DATE], revealed, Top 10 take home messages for adult cardiovascular life support: [ .] On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR). Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions. Early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest [ .] Defibrillation is most successful when administered as soon as possible [ .]. A record review of the facility's in-service train the trainer, revealed, In-service Description: Rapid Response Policy, date: [DATE], Instructor Corp RN, in-service time: 1 hour.; the Administrator; the DON received CPR / AED training. Further review of the attached printed training revealed, [ .] the chances of surviving a sudden cardiac arrest maybe increased if CPR is initiated immediately upon collapse [ .] Early delivery of a shock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival [ .] Provide periodic mock codes for training purposes [ .] instruct a staff member to retrieve the automatic external defibrillators [ .] when the AED arrives, assess for need and followed protocols as indicated [ .] continue with CPR/BLS until emergency medical personnel arrive [ .] This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 11:05 AM. ADMN AA was notified. ADMN AA was provided with the IJ template on [DATE]. The following Plan of Removal was accepted on [DATE] at 10:27 AM. Plan of Removal Date [DATE] PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On [DATE] an annual survey was initiated at [Facility name and address]. On [DATE], a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F678 Quality of Life CPR The facility failed to provide Quality of life CPR care for Resident #61 in that it did not follow and provide basic life support, including CPR, to a resident requiring such emergency care prior to arrival of emergency medical personnel. Problem The Facility's Deficient practice revealed facility failed to provide basic life support, including CPR, to a resident requiring emergency care prior to the arrival of emergency medical personnel. Immediate Corrections Implemented for Removal of Immediate Jeopardy. Once the facility was made aware of the deficient practice, the Director of Nursing/designee conducted an in-service with all staff on Mock Code, Rapid Response, AED, and CPR Training with emphasis on the expectation that the AED is retrieved immediately after checking for pulse and respirations. Residents identified at risk are those with Advanced Directives of Full Code status. The facility Director of Nursing/designee completed a 100% audit of residents advanced directive. This audit was completed on [DATE]. Residents who did not have a proper advanced directive were corrected immediately. Director of Nursing/Designee initiated education with clinical staff on [DATE] on proper protocol and procedure during a rapid response event and including timely retrieval and proper use of AED. This education was completed on [DATE]. The education was completed as a mock drill and monitored with DONs direct supervision and guidance to validate staff competency and understanding. Staff completed in-service training sheet. Identification of Others: Residents identified with full code status have the potential to be impacted by the alleged deficient practice. Director of nursing/designee completed mock code reviews with clinical staff to ensure adequate knowledge of resuscitation protocol. Systemic Changes The Director of Nursing/ designee initiated immediate training on Mock Codes, Rapid Response, AED, CPR and documentation of code process training to nursing staff on [DATE]. All education is at 100% completion as of [DATE]. The Director of Nursing/designee completed all education and training was started on [DATE] and will continue until all clinical staff have received training prior to the start of their work shift. The facility Director of Nursing, Corporate Clinical Director and Administrator met on [DATE] to evaluate the facility policy and procedures regarding Quality of Life and CPR Care. The Director of nursing/designee will complete education and training with all clinical staff on [DATE] and newly hired clinical staff over Mock Codes, Rapid Response, AED, CPR protocols and documentation of code process. The education will be provided by DON or designee with the necessary skill set related to CPR/ Rapid Response and proper documentation. The Administrator, DON, and designee will develop and ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in F678. Monitoring will include a system to ensure deficient practice is prevented. The monitoring and oversight system will ensure clinical staff are adequately trained to meet requirements of safe practice. Concerns identified will be provided by the DON or designee to the QAPI committee monthly, for a minimum of 6 months, for the discussion of sustaining compliance or correction of concerns identified. Monitoring The DON or designee will develop a short-term monitoring system for all areas of deficient practice identified for this deficiency. Monitoring will include a system to observe all clinical staff's adequate understanding of rapid response protocols on all shifts. Monitoring will be completed through direct observation, when possible, as well as through observation of mock codes. The monitoring will be documented on educational in-service forms and mock drills with staff's acknowledgment. The Director of Nursing/ designee will also conduct a chart review of any resident who has coded to validate that charting has been completed adequately and according to the education provided. This monitoring system will begin [DATE]. Data gathered will be measurable and monitoring will occur at least monthly and include weekend days and alternate shifts over the next 3 months and quarterly following. All concerns identified during the monitoring process will be addressed timely and documented for correction. The monitoring process, findings, and corrections will be presented to the facility QAPI committee each month for a minimum of 6 months for this plan of correction. Administrator will be responsible for monitoring DON compliance with system monthly. System compliance will be documented and discussed. The Administrator/designee will develop or ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in F678. Clinical Director of Operations will in-service Admin and DON over Rapid Response Policy and Procedure on [DATE]. Monitoring will be conducted monthly for 3 months to determine if compliance is being sustained. Sustained compliance or corrective actions will be discussed and documented in QAPI Meeting. The QAPI committee will meet monthly, and facility interdisciplinary team will meet daily to review the ongoing status of the corrections for this deficiency with the purpose to identify, evaluate, plan, implement, and address concerns or deficient practices identified as it relates, or to determine if compliance is being sustained. All corrections or steps taken and identified by QAPI will be documented and addressed immediately. Ad Hoc QAPI meeting will be held on [DATE] with the Medical Director, Administrator, Director of Nursing, and IDT to review and validate the plan of removal. Involvement of Medical Director The Director of Nursing notified the facility's Medical Director, of the Immediate Jeopardy tag on [DATE]. The Administrator will be responsible for implementation of ensuring the adequate process regarding Mock Code Monitoring. The new process/system was initiated on [DATE]. Please accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued [DATE]. Plan Of Removal Verification Clinical Director of Operations will in-service Admin and DON over Rapid Response Policy and Procedure on [DATE]. Monitoring will be conducted monthly for 3 months to determine if compliance is being sustained. Sustained compliance or corrective actions will be discussed and documented in QAPI Meeting. A record review of the facility's in-service train the trainer, revealed, In-service Description: Rapid Response Policy, date: [DATE], Instructor Corp RN, in-service time: 1 hour.; the Administrator; the DON received CPR/AED training. Further review of the attached printed training revealed, .the chances of surviving a sudden cardiac arrest maybe increased if CPR is initiated immediately upon collapse .Early delivery of a shock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival .Provide periodic mock codes for training purposes .instruct a staff member to retrieve the automatic external defibrillators .when the AED arrives, assess for need and followed protocols as indicated .continue with CPR/BLS until emergency medical personnel arrive . The Director of Nursing/designee conducted an in-service with all nursing staff n Mock Code, Rapid Response, AED, and CPR Training with emphasis on the expectation that the AED is retrieved immediately after checking for pulse and respirations. Residents identified at risk are those with Advanced Directives of Full Code status. The Director of Nursing/designee initiated immediate training on Mock Codes, Rapid Response, AED, CPR and documentation of code process training with nursing staff on all shifts on [DATE]. All education was at 100% completion as of [DATE]. The Director of Nursing/designee-initiated education with clinical on all shifts on [DATE] on proper protocol and procedure during a rapid response event and including timely retrieval and proper use of AED. This education was completed on [DATE]. The education was completed as a mock drill and monitored with the DON's direct supervision and guidance to validate staff competency and understanding. Staff completed in-service training sheet. The Director of Nursing/designee completed all education and training was started on [DATE] and will continue until all clinical staff on all shifts have received training prior to the start of their work shift. A record review of the facility's nursing roster revealed 22 nurses were employed by the facility over all 3 shifts, 06:00 AM to 02:00 PM, 02:00 PM to 10:00 PM, and 10:00 PM to 06:00 AM. 22 of the 22 nurses on all shifts were interviewed for AED CPR training. And were able to identify and use of AED. During an observation of a mock CPR AED event on [DATE] at 01:06 p.m., revealed the ADMN AA called out to DON that a resident was unresponsive. The DON yelled out Code Blue and instructed RN R, LVN G, LVN Q and LVN E to follow her to the unresponsive mock resident's room. The DON then delegated responsibilities to each nurse and one nurse to go get the crash cart. The DON then proceeded to place a backboard under the mock resident while communicating out load he importance of the backboard and if there was no backboard then to place the unresponsive resident on the floor. The DON began compressions while counting out load to 30, followed by using the AMBU bag for the two breaths. The crash cart arrived during this time. The DON showed staff, while doing it, how to remove the AED from its case, opened the AED cover, which automatically began the verbal AED prompt protocols. The DON removed the AED pads from the case, attached the electrical pad leads to the AED, and placed the pads on the CPR mannequin, and continued to follow the AED verbal prompts. The DON stated to the mock CPR AED participants, Continue CPR with the AED until EMS arrives. During an interview on [DATE] at 01:08 AM LVN K stated she had received in person training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED was presented. LVN K stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. Interviews done on [DATE] During an interview on [DATE] at 1:15 p.m., LVN E stated she worked 6-2 and 2-10 shifts. LVN E stated she had received training on [DATE], to include instructions, for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN E stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:16 p.m., LVN G stated she worked 6-2 and 2-10 shifts. LVN G stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN K stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:18 p.m., RN C stated she worked 6-2 shifts. RN C stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN C stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:19 p.m., LVN Q stated she worked 6-2 and 2-10 shifts. LVN Q stated she had received training on [DATE], to include instructions, for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN Q stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:20 p.m., RN R stated she worked 6-2 and 2-10 shifts. RN R stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN R stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 01:33 PM LVN P stated she had received in-person training for CPR with the use of an AED during a mock CPR code event on [DATE]. LVN P stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. LVN P stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. During an interview on [DATE] at 1:55 p.m., LVN I stated he worked weekends and just started the previous weekend. LVN I stated he had received training on [DATE], to include instructions, for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN I stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:56 p.m., RN K stated she was one of the ADONs. RN K stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN K stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:57 p.m., LVN L stated she worked on weekends. LVN L stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN L stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:58 p.m., RN O stated she was one of the ADONs. RN O stated she had received training on [DATE], to include instructions, for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN O stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 2:01 p.m., LVN J stated she worked 10-6 shift. LVN J stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. LVN J stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. During an interview on [DATE] at 2:12 p.m., RN D stated she worked 10-6 shift. RN D stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN D stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 2:17 p.m., RN N stated she worked 6-2 shifts. RN N stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN N stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 2:21 p.m., LVN H stated she was the MDS Coordinator. LVN H stated she worked weekends. LVN U stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. LVN H stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. During an interview on [DATE] at 2:33 p.m., LVN A stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN A stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 2:47 p.m., LVN M stated she worked 10-6 shift. LVN M stated she had received training on [DATE], to include instructions, for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN M stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 2:50 p.m., LVN U stated she worked weekends. LVN U stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. LVN U stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. The facility DON/designee completed a 100% audit of residents advanced directive. The audit was completed on [DATE]. Residents who did not have a proper advanced directive were corrected immediately. A record review of the facility census revealed 29 residents requested they receive CPR (CardioPulmonary Resuscitation) care and had full code orders signed by a physician. A record review of Resident #2's code status revealed Resident #2 was a full code. A record review of Resident #7's code status revealed Resident #7 was a full code. A record review of Resident #33's code status revealed Resident #33 was a full code. A record review of Resident #53's code status revealed Resident #53 was a full code. A record review of Resident #257's code status revealed Resident #257 was a full code. ADMN AA, DON, and designee will develop and ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in F678. Monitoring will include a system to ensure deficient practice is prevented. The monitoring and oversight system will ensure clinical staff are adequately trained to meet requirements of safe practice. Concerns identified will be provided by the DON or designee to the QAPI committee monthly, for a minimum of 6 months, for the discussion of sustaining compliance or correction of concerns identified. The DON or designee will develop a short-term monitoring system for all areas of deficient practice identified for this deficiency. Monitoring will include a system to observe all clinical staff's adequate understanding of rapid response protocols on all shifts. Monitoring will be completed through direct observation, when possible, as well as through observation of mock codes. The monitoring will be documented on educational in-service forms and mock drills with staff's acknowledgment. The Director of Nursing/ designee will also conduct a chart review of any resident who has coded to validate that charting has been completed adequately and according to the education provided. This monitoring system will begin [DATE]. Data gathered will be measurable and monitoring will occur at least monthly and include weekend days and alternate shifts over the next 3 months and quarterly following. All concerns identified during the monitoring process will be addressed timely and documented for correction. The monitoring process, findings, and corrections will be presented to the facility QAPI committee each month for a minimum of 6 months for this plan of correction. Administrator will be responsible for monitoring DON compliance with system monthly. System compliance will be documented and discussed. A record review of the facility's undated, F678 Quality of Care Life Support monitoring worksheet revealed, Administrator will conduct monitoring to ensure rapid response Mock drills are conducted once a month for 3 months and once a quarter for six months; a form designed to document and follow CPR Mock Codes to include corrective actions. A record review of the facility's [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 3 of 29 (Resident #61) residents reviewed for CPR care and 2 of 21 nurses (LVN A and RN C) reviewed for competencies and skill sets for CPR care to include an AED, in that; The facility failed to ensure all nursing staff had competent skills in performing actual CPR, to include using the AED, as a result of Resident #61 being found unresponsive on [DATE] and the responding nurse staff (LVN A and RN C) not using the AED during the actual CPR process for this resident. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:10 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not Immediate Jeopardy because the facility is still monitoring the effectiveness of their Plan of Removal. This failure placed residents at risk for harm up to and including death by the denial of all life saving measures as trained. The findings included: A record review of Resident #1's admission record dated, [DATE], revealed an admission date of [DATE] and a death discharge date of [DATE], with diagnoses which included altered mental status, extended spectrum beta lactamase resistance [a bacteria that can't be killed by many of the antibiotics that doctors use to treat infections, like penicillin's and some cephalosporins for urinary tract infections], and urinary tract infection. A record review of Resident #1's admission MDS dated [DATE] revealed Resident #61 was an [AGE] year-old male admitted from an acute care hospital for support and rehabilitation related to a urinary tract infection. A record review of Resident #61's physician's order dated [DATE] revealed RN R documented a physician's order for Resident #61 to receive care as Full Code. A record review of Resident #61's care plan dated [DATE], revealed, [Resident #61] has an advance Directive as evidenced by: Full code status Date Initiated: [DATE] [ .] wishes will be honored, Date Initiated: [DATE] [ .] CPR will be performed as ordered A record review of Resident #61's SBAR document dated [DATE] revealed, Situation [ .] the change in condition, symptoms, or signs observed, and evaluated is/are: cardiac arrest, respiratory arrest. This started on: [DATE]. Since this started it has gotten: stayed the same [ .] Resident/Patient Evaluation [ .] mental status evaluation: unresponsiveness [ .] Code Status: Full Code [ .] Appearance, summarize your observations and evaluation: CNA notified this nurse of resident being unresponsive assessed resident not responsive no pulse RN supervisor notified initiated CPR crash cart access notified 911 CPR performed until paramedics arrived emergency medical technicians continued with CPR resident transfers out with Pulse unconscious accompanied by three emergency medical technicians [ .]. A record review of the EMS TripTix EMS Patient Care Record dated [DATE] revealed, CPR was performed by the facility staff for 9 minutes from 09:38 AM to 09:47 AM as evidenced by, Incident Date / Times [ .] unit notified by dispatch [DATE] 09:41 [AM] [ .] Unit En Route [DATE] 09:43 [AM] [ .] Unit Arrived on Scene [DATE] 09:45 [AM] [ .] Arrived at patient [DATE] 09:47 [AM] [ .] Unit left scene [DATE] 10:04 [AM] [ .] complaints and impressions; cardiac arrest, onset date and time [DATE] 09:38 [AM], [ .] AED used prior to EMS NO [ .] Further review revealed a summary which reflected the facility had performed CPR chest compressions and oxygenated rescue breathing but had not used the AED. The EMTs provided medications and applied the EMS AED and revealed Resident #61 had regained an irregular heartbeat after EMS care and medications administered intraosseous [directly into the bone marrow]. During an interview and observation on [DATE] at 02:28 PM the DON stated sometime in [DATE] Resident #61 was discovered unresponsive and was provided emergency CPR care. The DON stated she was not certain if the AED used. The DON proceeded to demonstrate the AED to the surveyor. The AED was stored on the facility's emergency crash cart along with CPR equipment such as an oxygen tank, and oxygen delivery equipment and included a suction pump with accessories. The DON demonstrated the AED as functional and stated the AED had not been used and could not recall the last time it had been used. The DON stated she believed LVN A, LVN B, and RN C were directly involved with Resident #1's CPR care. During an interview on [DATE] at 07:10 PM the DON provided updated information and stated she recalled the [DATE] CPR event for Resident #61 and stated the AED was not utilized, and EMS services arrived at the facility after the 911 call, approximately 4-5 minutes. The DON stated she did not know why the AED was not utilized and further stated EMS arrived quickly. The DON was asked to provide any further documentation to the event and did not provide further documentation. The DON stated LVN A, LVN B, and RN C were involved in the CPR event for Resident #61 AND reported to her Resident #61 was unresponsive. LVN A stated she told the CNAs to get RN C and immediately arrived at Resident #61's bed side. LVN A stated she assessed Resident #61 as a full code and without a pulse and not breathing. LVN A stated she began emergency CPR with chest compressions and RN C arrived at the bedside quickly. LVN A stated RN C assumed chest compressions and told her to get the crash cart and call 911. LVN A stated she ran to retrieve the crash cart and along the way told LVN B to call 911. LVN A stated she returned to Resident #61 with the crash cart and resumed chest compressions while RN C administered oxygen with rescue breaths. LVN A stated 911 EMTs were at the bedside quickly around 4-7 minutes maybe. LVN A stated EMS took over and Resident #61 was assessed with a pulse and left for the hospital with EMS. LVN A stated she was trained for CPR by the American Heart Association. LVN A stated the AED was stored on the crash cart and was immediately available upon arrival at Resident #61's bedside. LVN A stated the AED was never opened, removed from the case, or from the crash cart. LVN A stated she was so involved in providing CPR chest compressions and rescue breaths she did not think about the AED. LVN A stated her training included the use of an AED during CPR as soon as the AED was available. During an interview on [DATE] at 06:00 AM RN C stated on [DATE] she worked from 06:00 AM to 02:00 PM. RN C stated she was providing patient care when CNAs AB and AC told her LVN A needed her, and Resident #61 was unresponsive. RN C stated she ran to Resident #61's bedside and assessed Resident #61 as unresponsive and told LVN A to get the crash cart and call 911. RN C stated she began CPR chest compressions. RN C stated LVN A returned with the crash-cart, and they switched CPR roles and LVN A continued chest compressions while RN C administered oxygenated rescue breaths. RN C stated 911 EMS arrived quickly and continued CPR. RN C stated the facility's AED was stored on the facility's crash-cart and was immediately available when the crash-cart arrived but she nor LVN A gave it a thought due to the high stress of providing CPR. RN C stated she and LVN A provided CPR for maybe 5 minutes and 911 arrived quickly. RN C stated she was CPR trained by the American Heart Association. RN C stated her training included the use of an AED during CPR as soon as the AED is available. RN C stated she had not documented her role in Resident #61's CPR care to include times and details of care such as the use of an AED, RN C stated she believed the DON and / or LVN A had documented the CPR care. A record review of the facility's Emergency Procedure Cardiopulmonary Resuscitation policy dated February 2018, revealed, Policy Statement; personnel have completed training on the initiation of cardiopulmonary resuscitation and basic life support including Defibrillation for victims of sudden cardiac arrest; general guidelines; the chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. Early delivery of a shock with a defibrillator plus CPR within 3 to 5 minutes of collapse can further increase chances of survival [ .] emergency procedure; cardiopulmonary resuscitation; [ .] when the AED arrives assess for need and follow AED protocol as indicated [ .]. A record review of the American Heart Association's website Part 3: Adult Basic and Advanced Life Support; 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-and-advanced-life-support, accessed [DATE], revealed, Top 10 take home messages for adult cardiovascular life support: [ .] On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR). Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions. Early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest [ .] Defibrillation is most successful when administered as soon as possible [ .]. A record review of the facility's in-service train the trainer, revealed, In-service Description: Rapid Response Policy, date: [DATE], Instructor Corp RN, in-service time: 1 hour.; the Administrator; the DON received CPR / AED training. Further review of the attached printed training revealed, [ .] the chances of surviving a sudden cardiac arrest maybe increased if CPR is initiated immediately upon collapse [ .] Early delivery of a shock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival [ .] Provide periodic mock codes for training purposes [ .] instruct a staff member to retrieve the automatic external defibrillators [ .] when the AED arrives, assess for need and followed protocols as indicated [ .] continue with CPR/BLS until emergency medical personnel arrive [ .] This was determined to be an Immediate Jeopardy (IJ) on 08/072023 at 4:10 p.m. The Administrator was notified. The Administrator was provided with the IJ template on [DATE]. The following Plan of Removal was accepted on [DATE] at 2:10 p.m. Plan of Removal Verification Date [DATE] PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, POR - Plan of Removal for Immediate Jeopardy dated [DATE] at 12:32 PM with the DON and ADMN Y: Summary of details which leads to outcomes. On [DATE] an annual survey was initiated at the Facility. On [DATE], a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F726 COMPETENT NURSING STAFF The facility failed to have sufficient nursing staff with the appropriate competencies and skills set to provide nursing and related services to assure resident and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident Problem The Facility's Deficient practice revealed facility staff failed to demonstrate competency related to providing basic life support, including CPR including the timely application and use of an AED to a resident requiring emergency care prior to the arrival of emergency medical personnel. Immediate Corrections Implemented for Removal of Immediate Jeopardy. o Once the facility was made aware of the deficient practice, the Director of Nursing/ designee conducted an in-service with all staff on Mock Code, Rapid Response, AED, and CPR Training with emphasis on staff competencies to include all licensed staff all shifts, with return demonstration. The facility Director of Nursing/designee completed a 100% training in person with return demonstration of all licensed staff began on [DATE] and completed on [DATE] o Director of Nursing/Designee initiated education with clinical staff on [DATE] on proper protocol and procedure during a rapid response event and including timely retrieval and proper use of AED. This education was completed on [DATE]. The education was completed as a mock drill and monitored with DONs direct supervision and guidance to validate staff competency and understanding completed began mock code Competency in-service training sheet. Identification of Others: o Residents identified with full code status have the potential to be impacted by the alleged deficient practice. o Director of nursing/designee completed mock code reviews with clinical staff to ensure adequate knowledge of resuscitation protocol. Systemic Changes o the DON/designee initiated immediate training on Mock Codes, Rapid Response, AED, CPR and documentation of code process training to nursing staff on [DATE]. All education is at 100% completion as of [DATE]. o the DON/designee completed all education and training to all clinical staff and all clinical staff upon hire and added to new hire checklist. o the facility DON, Corporate Clinical Director and Administrator met on [DATE] to evaluate the facility policy and procedures regarding Quality of Life and staff competencies. o the DON/designee will complete education and training with all clinical staff on [DATE] and newly hired clinical staff over Mock Codes, Rapid Response, AED, CPR protocols and documentation of code process. The education will be provided by DON or designee with the necessary skill set related to CPR/ Rapid Response, including AED use and proper documentation. Education will include return demonstration and routine mocks to validate understanding and competency of all clinical staff. o The Administrator, DON/designee will develop and ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in F726. Monitoring will include a system to ensure deficient practice is prevented. The monitoring and oversight system will ensure clinical staff are adequately trained to meet requirements of safe practice. Concerns identified will be provided by the DON or designee to the QAPI committee monthly, for a minimum of 6 months, for the discussion of sustaining compliance or correction of concerns identified. Monitoring o The DON or designee will develop a short-term monitoring system for all areas of deficient practice identified for this deficiency by [DATE]. Monitoring will include a system to observe all clinical staff's verbalization of comprehension and return demonstration of rapid response protocols on all shifts through return demonstration q month for 3 months and quarterly for 12 months. o Monitoring will be completed through direct observation, when possible, and observation of mock codes. DON/Designee will retain record of all written mock competencies' routine and PRN. Mock codes will be run monthly for all clinical staff q month for 3 months on various shifts, then quarterly for 12 months. The monitoring will be documented on educational in-service forms and mock drills with staff's acknowledgment. o The Administrator/ designee will develop or ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in F726 o The QAPI committee will meet monthly, and facility interdisciplinary team will meet daily to review the ongoing status of the corrections for this deficiency with the purpose to identify, evaluate, plan, implement, and address concerns or deficient practices identified as it relates, or to determine if compliance is being sustained. All corrections or steps taken and identified by QAPI will be documented and addressed immediately. o An Ad Hoc QAPI meeting was held on [DATE] with the Medical Director, Administrator, Director of Nursing, and IDT to review and validate the plan of removal. Involvement of Medical Director The DON notified the facility's Medical Director, of the Immediate Jeopardy tag on [DATE]. The Administrator will be responsible for implementation of ensuring the adequate process regarding Monitoring of staff competency related to the provision of CPR including the use of an AED. The new process/system was initiated on [DATE]. Please accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued [DATE]. Plan of Removal Verification Once the facility was made aware of the deficient practice, the DON/designee conducted an in-service with all staff on Mock Code, Rapid Response, AED, and CPR Training with emphasis on staff competencies to include all licensed staff all shifts, with return demonstration. The facility Director of Nursing/designee completed a 100% training in person with return demonstration of all licensed staff began on [DATE] and completed on [DATE] DON/Designee initiated education with clinical staff on [DATE] on proper protocol and procedure during a rapid response event and including timely retrieval and proper use of AED. This education was completed on [DATE]. The education was completed as a mock drill and monitored with DON's direct supervision and guidance to validate staff competency and understanding completed began mock code Competency in-service training sheet. Identification of Others: Residents identified with full code status have the potential to be impacted by the alleged deficient practice. Director of nursing/designee completed mock code reviews with clinical staff to ensure adequate knowledge of resuscitation protocol. Systemic Changes The DON/designee initiated immediate training on Mock Codes, Rapid Response, AED, CPR, and documentation of code process training to nursing staff on [DATE]. All education is at 100% completion as of [DATE]. The DON/designee completed all education and training to all clinical staff and all clinical staff upon hire and added to new hire checklist. The facility DON, Corporate Clinical Director and Administrator met on [DATE] to evaluate the facility policy and procedures regarding Quality of Life and staff competencies. The DON/designee will complete education and training with all clinical staff on [DATE] and newly hired clinical staff over Mock Codes, Rapid Response, AED, CPR protocols and documentation of code process. The education will be provided by DON or designee with the necessary skill set related to CPR/ Rapid Response, including AED use and proper documentation. Education will include return demonstration and routine mocks to validate understanding and competency of all clinical staff. During and observation of a mock CPR AED event on [DATE] at 01:51 p.m., revealed the DON called out to that a resident was unresponsive. The DON yelled out Code Blue and instructed RN O, RN K, RN N and LVN P to follow her to the unresponsive mock-Resident's room. The DON then delegated responsibilities to each nurse and one nurse to go get the crash cart. DON then proceeded to place a backboard under mock resident while communicating out load the importance of this backboard and if no backboard to then place the Unresponsive resident on the floor. The DON began compressions while counting outloud to 30, followed by using the AMBU bag for the two breaths. The crash cart arrived during this time. The DON showed staff, while doing it, how to remove the AED from its case, open the AED cover, which automatically begins the verbal AED Prompts protocols, the DON removed the AED pads from the case, attached the electrical pad leads to the AED, and placed the pads on the CPR mannequin, and continued to follow the AED verbal Prompts. The DON stated to the Mock CPR AED participants, continue CPR with the AED until EMS arrives. Interview on [DATE] at 2PM the DON stated 2 nurses, LVN M and LVN J were called at first and came in for mock CPR code training. Interview on [DATE] at 2:13 PM with LVN P, T, TH doubles, Fridays 6-2PM, worked for SNF for 8 yrs. Worked all halls. DON -over weekend had a mock code, in-service, documentations, designate duties, implement AED, can participate call 911, call family, Call MD, give report to ER implement skills and continue use of AED. Interview on [DATE] at 2:18 PM- ADON K, worked for [DATE], works the floor if coverage is needed, all shifts -Did mock codes- 6 time, staff that would work different shifts, she made sure to cover all component, directed staff to do different task, call 911, call family, call MD, give report to ER, especially documentation, QAPI- monthly-don't recall talking about Resident #61, had 2 ADHOC mtg- nursing competency, areas of improvement all related to investigations management team DM, pharmacies, DON, Admin. Interview on [DATE] at 2:23 PM with RN O, ADON, m-f 8-5, prn, worked the floor, worked all halls, worked as LVN, trained on Mock code by DON-process and delegate task, call 911, family, MD and DON. Learned the delegating of task. QAPI-not sure if it was brought up, recent member to QAPI, had a emergency QAPI mtg, called MD, pharmacist, Admin, DON, department heads-discussed the incident with resident and interventions and POR. Interview on [DATE] at 2:33 PM with RN N, worked for 7 yrs. ago, worked all halls, worked days and evenings, DON mock codes-2nd, refreshes CPR training, CPR certified, process- go to resident, assess, pulse, delegate, check if resident code status, work as a team to assist resident. Make sure to sue board or on floor, make sure resident is positioned and can with out with other team member, utilize ED, document, wait for EMS. Did go to QAPI trainings. Interview on [DATE] at 2:46 PM with LVN J, worked the prn, all shifts, all halls, (nights) worked for 2 yrs., was out of town, called her on phone, yesterday did demonstration - DON in-service, CPR, all staff have a role, check pt., make sure environment after, assess, check code status, process, CNA can be involved- calling 911, family, DON explained for nursed and CNA in detail of training, CPR, AED, QAPI-not sure. Interview on [DATE] at 2:51 PM with LVN M, night shift, worked here for 1 yr., DON-called first, then came in yesterday for mock code-going over code and procedures and react to situation, go to room, res not breathing, initiated emergency response, call 911, cart c rt, AED, document time, delegate task, document on PCC. QAPI-had training. Interview on [DATE] at 2:57 PM with LVN F, Med nurse Charge nurse, m-f 6-2, worked for 2 yrs., worked all halls, in-service - was at SNF, mock code and in-service-find resident responsive, if code does not get verbal, check pulse, assess, delegate task, check res code status, crash cart, back board, AED, start on CPR and wait for EMS to come, QAPI-not sure. Interview on [DATE] at 3:16 PM with LVN E, shifts doubles 6-10pm, worked for 3 months, worked E, F B hall (left side), -DON in-service mock code-demonstrated mock code, trained, res assesses, get res code status, 30 compressions to 2 rest, AED, call 911, etc, documentation and who helped you and wait for EMS. QAPI- no A record review of the facility's nursing roster revealed 21 nurses were employed by the facility over all 3 shifts, 06:00 AM to 02:00 PM, 02:00 PM to 10:00 PM, and 10:00 PM to 06:00 AM. 21 of the 21 nurses were interviewed for AED CPR training. A record review of the facility's nursing roster revealed 2 nurses, LVN J and LVN M were not in serviced in person as of [DATE] and have since [DATE] received in person CPR, AED, Documentation, training. During an interview on [DATE] at 02:13 PM LVN P stated she had received in person training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN P stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. LVN P stated the training was documented on a training competency checkoff form which she signed, and the DON signed. LVN P stated she currently works 3-4 time a week doubles from 06:00 AM to 02:00 PM and continues on 02:00 PM to 10:00 PM. During an interview on [DATE] at 02:18 PM RN K stated she had received training on [DATE] to include instructions for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN K stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. RN K stated her training with return demonstration was recorded on a CRP AED competency checkoff form signed by the DON and herself. RN K stated she had attended the QAPI meeting on [DATE]. RN K stated she works Monday thru Friday 06:00 AM to 06:00 PM. During an interview on [DATE] at 02:23 PM RN O stated she had received in-person training for CPR with the use of an AED during a Mock CPR code event on [DATE]. RN O stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. RN O stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. RN O stated the DON signed her CPR AED competency checkoff list in approval of her CPR AED competency training. RN O stated she works Monday thru Friday 06:00 AM to 06:00 PM. During an interview on [DATE] at 02:33 PM RN N stated she had received in person training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN N stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. RN N stated the training was documented on a training competency checkoff form which she signed, and the DON signed. RN N stated she received in-service training for QAPI reporting. RN N stated she currently works 3-4 time a week doubles from 06:00 AM to 02:00 PM and continues on 02:00 PM to 10:00 PM. During an interview on [DATE] at 02:50 PM LVN J stated she had received training on [DATE] to include instructions for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN J stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. LVN J stated her training with return demonstration was recorded on a CRP AED competency checkoff form signed by the DON and herself. LVN J stated she was in serviced on the QAPI review process. LVN J stated she is PRN and works all shifts. During an interview on [DATE] at 02:51 PM LVN M stated she had received in-person training for CPR with the use of an AED during a Mock CPR code event on [DATE]. LVN M stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. LVN M stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. LVN M stated the DON signed her CPR AED competency checkoff list in approval of her CPR AED competency training. LVN M stated she works the night shift 10:00 PM to 06:00 AM. During an interview on [DATE] at 02:57 PM LVN F stated she had received in person training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN F stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. LVN F stated the training was documented on a training competency checkoff form which she signed, and the DON signed. LVN F stated she received in-service training for QAPI reporting. LVN F stated she worked the 06:00 AM to 02:00 PM shift. During an interview on [DATE] at 03:16 PM LVN E stated she had received training on [DATE] to include instructions for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN E stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. LVN E stated her training with return demonstration was recorded on a CPR AED competency checkoff form signed by the DON and herself. LVN E stated she had attended the QAPI meeting on [DATE]. LVN E stated she works Monday thru Friday 06:00 AM to 06:00 PM. LVN E stated she currently works 3-4 time a week doubles from 06:00 AM to 02:00 PM and continued 02:00 PM to 10:00 PM. Identification of Others: Residents identified with full code status have the potential to be impacted by the alleged deficient practice. A record review of the facility census revealed 29 residents requested they receive CPR care and had Full Code orders signed by a physician. A record review of Resident #2's code status revealed Resident #2 was a full code. A record review of Resident #7's code status revealed Resident #7 was a full code. A record review of Resident #33's code status revealed Resident #33 was a full code. A record review of Resident #53's code status revealed Resident #53 was a full code. A record review of Resident #257's code status revealed Resident #257 was a full code. Monitoring The DON or designee will develop a short-term monitoring system for all areas of deficient practice identified for this deficiency by [DATE]. Monitoring will include a system to observe all clinical staff's verbalization of comprehension and return demonstration of rapid response protocols on all shifts through return demonstration q month for 3 months and quarterly for 12 months. Monitoring will be completed through direct observation, when possible, and observation of mock codes. DON/Designee will retain record of all written mock competencies' routine and PRN. Mock codes will be run monthly for all clinical staff q month for 3 months on various shifts, then quarterly for 12 months. The monitoring will be documented on educational in-service forms and mock drills with staff's acknowledgment. The Administrator/ designee will develop or ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in F726 A record review of the facility's, F726 Staffing, Sufficient and Competent Nursing policy, dated [DATE] revealed, Policy Statement: Our Facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. policy interpretation and implementation: . competent staff: competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. staff must demonstrate the skills and techniques necessary to care for residents needs