**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 5 of 5 residents (Resident #s 1, 2, 3, 4, and 5) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was assessed for safety regarding hot liquids resulting in Resident #1 sustaining 1st and 2nd degree burns on 02/23/2024 when he spilled his coffee on himself and was not assessed for hot liquids safety after the incident. The facility failed to have a system in place to assess for hot liquid safety and to ensure Residents #2, #3, #4, and #5 were being served hot coffee with safety interventions assessment or potential interventions in place. The facility failed to follow its policy and ensure the resident was assessed upon admission to the facility to determine risk factors for consuming hot liquids safely (coffee, tea, soups, etc.) and failed to have a policy or a practice that was appropriate for resident consumption of hot liquids. Resident #1 received both 2nd and 1st degree burns on his shoulder, chest and right forearm. On 03/01/2024 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 03/03/2024 at 12:01 PM, the facility remained out of compliance at a scope of isolated and a severity level with no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This deficient practice placed residents at risk of scalding, burns, pain, infection, and hospitalization. The findings were: Record review of Resident #1's face sheet, dated 02/26/2024, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure, muscle weakness, and congestive heart failure. Review of Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 7, suggesting severe cognitive impairment. Record review of the care plan for Resident #1, dated 03/03/2023, reflected the following: Resident #1 had frail skin and may need assistance with activities of daily living completion with intervention to follow safety protocols for protection of injury. Review of order dated 02/23/2024 revealed NP wrote an order for Resident #1 to have a no spill cup with his meals. Record review of Resident #2's face sheet, dated 03/03/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included ankle contractures, age related debility, muscle weakness, other reduced mobility, and other lack of coordination. Review of the care plan for Resident #2, dated 12/21/23 revealed Resident #2 was at risk for impaired skin integrity. Review of Resident #2's MDS assessment dated [DATE] reflected a BIMS score of 2, suggesting severe cognitive impairment. Review of Resident #2's MDS dated [DATE] reflected lower extremity impairments (hip, knee, ankle, and foot) and used a wheelchair. Record review of Resident #3's face sheet, dated 03/03/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (disrupted blood flow to the brain), paralysis to one limb of the body, speech and language deficit, hemiplegia(paralysis) to the right dominant side of the body, muscle weakness, and unsteadiness on feet. Review of the care plan for Resident #3, dated 01/26/2024 revealed Resident #3 was at risk for bruising, skin breakdown and skin tears related to his decline in mobility, frail skin and his need for increased assistance with activities of daily living completion. Review of Resident #3's MDS assessment dated [DATE] reflected a BIMS score of 9, suggesting moderate cognitive impairment. Review of Resident #3's MDS assessment dated [DATE] reflected upper extremity impairments (shoulder, elbow, writs, and hand), used a wheelchair, and required supervision and touch assistance when eating. Record review of Resident #4's face sheet, dated 03/03/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Alzheimer's, muscle weakness, cognitive communication deficit, and mild cognitive impairment. Review of care plan for Resident #4, dated 11/20/2023 revealed Resident #4 had fragile skin and gets skin tears easily and Resident #4 has a diagnosis of dementia and will need to be re-oriented to person, place, time, and situation. Review of Resident #4's MDS assessment dated [DATE] revealed a BIMS score of 5 suggesting severe cognitive impairment. Record review of Resident #5's face sheet, dated 03/03/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, muscle weakness, cognitive communication deficit, and other psychotic disorder. Review of Resident #5's MDS assessment dated [DATE] reflected a BIMS score of NA - not applicable, suggesting moderate cognitive impairment. Review of the care plan for Resident #5, dated 03/07/2023 revealed Resident #5 had the potential for skin damage Resident #5 has a diagnosis of dementia and will need to be re-oriented to person, place, time, and situation. Review of Resident #5's MDS assessment dated [DATE] revealed she used a wheelchair. Review of NP progress note revealed on 02/23/2024 Resident #1 was seen this morning for an acute coffee burn. He was holding his coffee cup in the left hand and the left hand started shaking and he spilled the coffee over his far-right side of his chest, right auxiliary, right lower side, right shoulder, and right forearm. Second degree burn on the anterior right shoulder. Blistered skin. Blister posterior side right forearm. First degree burns on the right side, upper outer chest wall, and his right forearm. Observation and interview on 03/01/2024 with Resident #1 at 12:17 pm revealed that the resident said he was in his bed when he was served coffee in his room. He revealed he was not wearing a shirt and the coffee was placed on the bedside table in front of him. When asked if he was sitting up, he said he was lying as he was when the state surveyor observed him (slightly inclined in the bed). He said he picked up the coffee and his hand shook, and the coffee spilled on the right side of his body. The state surveyor observed an area on Resident #1's forearm about 3 inches in length and 3 inches in width red, dry, with white flaking skin and a scab in the center about 2 inches in length. Resident #1 revealed when the coffee spilled on him it hurt very badly and he yelled out. When the state surveyor asked Resident #1 to explain how it felt, he made a long expression in his face and a oh oh sound and grabbed his arm and said it hurt very badly. Observation on 03/01/2024 at 10:46 AM of coffee temperatures: Temperature when poured from the warmer into cup, temperature immediately taken - 164.3 degrees Fahrenheit. Coffee temperature taken after 5 minutes 150.02 degrees Fahrenheit. Coffee temperature taken 8 minutes after 144 degrees Fahrenheit. Observation on 03/01/2024 at 11:40 AM of Residents 2, 3, 4, and 5 being served coffee with no lid in the dining room. Interview on 03/01/2023 with CM A at 10:10 AM revealed she served Resident #1 coffee. She put it on his bed side table. As she left the room, she heard Resident #1 yell out in pain and saw that he had spilled his coffee on himself. Interview on 03/01/2024 with the NP at 10:30 AM revealed she was at the facility and assessed the resident at the time of the incident. She said Resident #1 did not have a history of involuntary hand movement or shaking. She said she wrote an order for Resident #1 to have a no spill cup with his meals. She said she had seen Resident #1 a lot of times with coffee. Interview on 03/01/2023 with the DM at 11:41 AM revealed there were not lids on coffee cups when they were serving in the dining room. The DM revealed that when a cup of coffee is taken to a residents' room, it has a lid, and it completely covers the top and has to be completely removed to drink the coffee. She said the facility began logging the temperature of the coffee after the incident with Resident #1. The DM revealed that the temperature was taken after it was brewed and in the coffee pot prior to serving. The DM revealed that when the state surveyor was in the dining room observing, she put ice cubes in the residents' coffee prior to it being served, but she did not take the temperature of the coffee in the cups when they were served to the residents. Interview on 03/01/2024 with the Administrator at 12:54 pm revealed she did not know at what temperature that hot liquids caused burns. She thought that hot liquids should be between served at a temperature between 140- and 150-degrees Fahrenheit. When shown the facility policy that reflected that one of the interventions to be implemented to minimize the risk from burns from hot liquids was to maintain a hot liquid serving temperature of not more than 180 Fahrenheit, the Administrator said she felt like this serving temperature was too high. After Resident #1 was injured by the coffee spill the Administrator revealed she did not conduct a hot liquids evaluation for Resident #1. The Administrator revealed no hot liquids safety evaluations were conducted for any of the residents in the facility. She did not conduct a hot liquids safety evaluation for Resident #1 or any other resident in the facility. Record review of a Google search revealed coffee and other hot beverages are usually served at 160 to 180 degrees Fahrenheit resulting in almost instantaneous burns that may require surgery. Facility policy safety of hot liquids dated October 2014 reflected: Policy Statement Residents will be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission and on change of condition. Appropriate precautions will be implemented to maximize choice of beverages while minimizing the potential for injury. Policy Interpretation and Implementation 1. The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. 2. Residents with these or other conditions may suffer from accidental burns and related complications stemming from thinner, more fragile skin that may burn quickly and severely and it take longer to heal. 3. Residents who prefer hot beverages with meals (i.e., coffee, tea, soups, etc.) will not be restricted from these options. Instead, staff will conduct regular hot liquids safety evaluations as indicated and document the risk factors for scalding and burns in the care plan. 4. Once risk factors for injury from both hot liquids are identified, appropriate interventions will be implemented to minimize the risk from burns. Such interventions may include: a. maintaining a hot liquid serving temperature of not more than 180°F. b. serving hot beverages in a cup with a lid; c. encouraging residents to sit at a table while drinking or eating hot liquids; d. providing protective lap covering or clothing to protect skin from accidental spills; and e. staff supervision or assistance with hot beverages. 5. Food service staff will monitor and maintain foods temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. This was determined to be an Immediate Jeopardy (IJ) on 03/01/2024 at 3:29 PM. The Administrator was notified. The Administrator was provided with the IJ template on 03/01/2024 at 3:29 PM. The following POR was submitted by the facility and was accepted on 03/03/2024 at 9:10 AM. Plan of Removal for the Immediate Jeopardy F689 on 03.01.2024 On 03.01.2024 an abbreviated survey was initiated at the facility for an incident that occurred on 02.23.2024. On 03.01.2024 the state surveyor provided an Immediate Jeopardy (IJ) template notification that Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to the resident health and safety of 17 residents identified with the presence of risk factors on the hot liquids safety evaluation. The notification of immediate threat states as follows: The facility failed to provide hot liquids evaluation for resident #1. The deficient practice did result in harm to resident #1. Resident #1 was not evaluated at admission, nor at any other time, for hot liquid safety. Resident #1 was served hot coffee with unacknowledged risk factors present on 02.23.2024. He was served hot coffee without a lid, while in bed with no shirt or gown on, nor a clothing protector. These risk factors contributed to resident receiving burns from hot coffee and harm resulting from the deficient practice. The Medical Director, as well as the APRN , were notified on 02.23.2024, the date of the incident. The Medical Director, as well as the APRN, were notified of the deficient practice on 03.01.2024. Resident #1 will be reassessed with the hot liquid evaluation and updated in resident's plan of care, EMAR and paper chart. Initiated 03.01.2024 and completed by Assistant Director of Nursing on 03.01.2024. All staff in-serviced by the ADON and the MDS nurse for results of hot liquid assessment and interventions required for at risk residents. Initiated 03.01.2024 and completed 03.02.2024. Current and future residents will be assessed with the hot liquid evaluation and updated in residents plan of care, EMAR and paper chart. Initiated 03.01.2024 and completed by the Assistant Director of Nursing and the MDS Nurse on 03.01.2024. Seventeen at risk residents identified by hot liquid safety evaluations, and all staff in-serviced by the ADON and the MDS nurse for results of hot liquid assessment and interventions required for at risk residents. Initiated 03.01.2024 and completed 03.02.2024. Staff will be reeducated on the hot liquid evaluation, including but not limited to serving temperatures, fill capacity, placement, and identifying risk factors contributing to potential for spills. Initiated on 03.01.2024. The Administrator and the DON will continue reeducation with non-present/prn/agency staff and future staff. A posttest will be administered by the DON and the ADON to verify comprehension of the policy. Initiated on 03.02.2024 and will be completed for all scheduled staff 03.02.2024. Reeducation for current staff will be completed 03.02.2024. Reeducation for PRN/agency/future/non-present staff will be completed prior to staff starting their next shift and will be ongoing. Dietary supervisor in-serviced all dietary staff on safe holding and serving temperatures for hot beverages. Initiated 03.01.2024. Completed 03.02.2024. Dietary staff members will monitor safe temperature for beverages. Dietary staff will record hot beverage temperatures for every meal, and ensure they are within appropriate range of 140 to 155 degrees at service. Initiated on 03.02.2024 and will be an ongoing practice to ensure safety of residents with hot liquids. This task will be monitored by dietary supervisor daily to ensure compliance. Administrator will audit temperature logs daily ongoing. Ad Hoc QAPI meeting held 03.01.2024 with the Administrator, the ADON, the MDS nurse, and the Dietary Supervisor to discuss immediate jeopardy. This will be an ongoing discussion at monthly QAPI meetings indefinitely. A team of interdisciplinary professionals will review this policy and update as needed. Resident #1 will be reassessed with the hot liquid evaluation and updated in resident's plan of care, EMAR, and paper chart. Initiated 03.01.2024 and completed by Assistant Director of Nursing on 03.01.2024. Monitoring: Monitoring was initiated on 03/03/2024. Surveyor reviewed Resident #1's Hot Liquids Safety Evaluation dated 03/01/2024. Resident #1's plan of care was updated to include that hot liquids given to Resident #1 will have a lid, will be given while he is sitting up at a table, wearing a clothing/lap protector, and staff will assist him with eating. During interview with Resident #1, resident showed the state surveyor the insulated cup with lid that was provided to him for hot liquids. Reviewed staff in-services initialed by the ADON and the MDS nurse for results of hot liquid assessment and interventions required for at risk residents. Reviewed the facility hot liquids assessments conducted for all facility residents completed by the ADON and the MDS Nurse and the updates to the plan of care, EMAR, and paper chart for the seventeen residents identified by the hot liquid safety evaluations. Resident #1's Hot Liquids Safety Evaluation indicated risk factor other (2/23/24 hot liquid spill) and listed intervention for resident to use a cup with a lid. Resident #2's Hot Liquids Safety Evaluation indicated risk factors of cognition, mood and behavior, contractures, and mobility and listed interventions for resident to use a cup with lid, resident to drink hot liquids while sitting at table only and to wear clothing protective/lap protector. Resident #3's Hot Liquids Safety Evaluation indicated risk factors of strength, and mobility and listed interventions for resident to drink hot liquids while sitting at table only. Resident #4's Hot Liquids Safety Evaluation indicated risk factors of cognition, mood, and behavior and listed interventions for resident to use a cup with lid, resident to drink hot liquids while sitting at table only and to wear clothing protective/lap protector. Resident #5's Hot Liquids Safety Evaluation indicated risk factors of cognition and tremors and listed interventions for resident to drink hot liquids while sitting at table only and to wear clothing protective/lap protector. Reviewed Resident #s 1, 2, 3, 4, and 5 care plans to confirm Hot Liquids Safety Evaluation interventions are included in their care plans. Reviewed the staff in-services serving hot liquids that included serving temperatures, fill capacity, placement, and identifying risk factors contributing to potential for spills. Reviewed the post tests to verify comprehension of policy. Interviewed the Dietary supervisor who revealed she in-serviced all dietary staff on safe holding and serving temperatures for hot beverages and dietary staff members will monitor safe temperature for beverages. Dietary supervisor said dietary staff will record hot beverage temperatures for every meal and ensure they were within appropriate range of 140 to 155 degrees at service. Reviewed the current audit of dietary hot beverage temperature logs that revealed hot beverage temperatures for meals were served within the range of 140 to 155 degrees at service. The ADON and the MDS Nurse are responsible for conducting hot liquid safety evaluations as indicated in the POR and evidenced that the ADON and MDS Nurse conducted the hot liquids evaluation that revealed seventeen residents were identified with the presence of risk factors on the hot liquids safety evaluation. Observed on 03/03/24 at 11:45 am of 15 residents in the dining room. Several residents with interventions wearing thin plastic protective covering. Reviewed Ad Hoc QAPI meeting held 03.01.2024 with the Administrator, the ADON, the MDS nurse, and Dietary Supervisor to discuss immediate jeopardy. Interview on 03/03/2024 with KS B at 10:29 am revealed she was in-serviced on interventions for residents and hot liquids including which residents needed interventions and the procedures for serving hot liquids. She learned that hot liquids need to be between 140 and 155 degrees Fahrenheit and residents need to wear protective covering when drinking coffee. She needs to take the temperature of the coffee before it was served and if it was too hot it needs to sit and then the temperature taken again. Only a staff member should serve the resident coffee and the cups should only be ¾ full and placed on towards the center of the table on the resident's dominate side. Interview on 03/03/2024 with KS C at 10:42 who revealed he attended an in-service on interventions for residents and hot liquids including which residents needed interventions and the procedures for serving hot liquids. He learned that coffee temperatures have to be between 140 and 155 degrees Fahrenheit before it was taken to the resident. If it was higher than that that, they cannot serve it, it has to cool down. He was told to use a thermometer to measure the temperature. He revealed they were now charting coffee temperatures and there was a list of residents who needed assistance with hot liquids. He said it was important to only fill the cup ¾ full of hot drinks and it was not acceptable to leave hot beverages in an area where a resident was alone. When serving hot beverages, the hot beverages should be placed away from the edge of the table and close to the resident's dominant hand. He said try and offer iced tea or iced coffee instead of hot beverages. Interview on 03/03/2024 with CNA D at 10:54 who revealed she attended an in-service on interventions for residents and hot liquids including which residents needed interventions and the procedures for serving hot liquids. She revealed there was a list of all residents who needed interventions. She said hot beverages should be served to the residents at a temperature between 140 -155-degree Fahrenheit and to make sure it was not hotter. She will use a thermometer to check the temperature and make sure the temperature is correct before giving the beverage. She said that some residents have an intervention for clothing protectors and ice can be added to a beverage if it was too hot only if the resident agrees. She revealed the beverage cup should be filled to 75% capacity and hot beverages should be removed from the dining rooms or other areas where residents have accessibility without supervision. Residents could also be offered an insulated mug with a lid but only if the resident agrees. Interview on 03/03/2024 with CNA E at 11:05 am who revealed he attended an in-service on interventions for residents and hot liquids including which residents needed interventions and the procedures for serving hot liquids. He said hot liquid temperatures should be 140 - 155-degree Fahrenheit and residents need to have protective apron if they were on the list of residents with interventions. He revealed the kitchen staff were to make sure the temperature was cool enough for the residents to drink the beverage. He said do not place coffee close to the resident and hot drinks can't be left in or around where the residents were not supervised. Residents who have cognitive issues or physical issues need to be offered assistance and supervised while consuming hot beverages. Interview on 03/03/2024 with RN F at 11:18 AM revealed she attended an in-service on interventions for residents and hot liquids including which residents needed interventions and the procedures for serving hot liquids. She learned that hot liquids can't be served to residents if they were hotter than 140 - 155-degrees Fahrenheit and do not place hot drinks too close to the edge of the table but have them within residents' reach. She said some residents will wear protective clothing and they have already begun using the protective clothing with the resident. Interview on 03/03/2024 with LVN G at 11:20 AM revealed he attended an in-service on interventions for residents and hot liquids including which residents needed interventions and the procedures for serving hot liquids. He said he was going to use the thermometer from the kitchen to check that hot drinks were not hotter than 140 - 155-degrees Fahrenheit and serving mugs should be only filled to 75% capacity. Resident can have an insulated cup and lid. He was aware that there was a list of residents who need interventions for hot beverages and what those interventions are. Interview on 03/03/2024 at 11:27 AM with the DM revealed the dietitian in-serviced her on interventions for residents and hot liquids including which residents needed interventions and the procedures for serving hot liquids. She revealed that the kitchen will be taking the temperature of all hot liquids to confirm they were served at a temperature between 140- 155-degrees Fahrenheit. She said that if the resident agrees, staff can drop a piece of ice to cool the beverage. She revealed hot drinks need to be placed away from the edge of the table but in resident's reach when it was served. Some residents have an intervention for protective clothing when they have been served hot drinks and some residents will have a lid on their beverages. She revealed that the list of residents who have hot liquid intervention was in the kitchen. The ADM was informed the Immediate Jeopardy was removed on 03/03/2024 at 12:01 PM. The facility remained out of compliance at a scope of isolated and at a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and record review, the facility failed to protect the resident right to request, refuse and/or discontinue treatment for 1 (Resident #1) of 34 residents reviewed for advance directives. The facility failed to ensure Resident's # 1 OOHDNR was processed and updated in EMR and care plan when signed by physician on [DATE]. The resident had a seizure on [DATE] that resulted in life saving measures being given, as the EMR showed resident was a full code, AED was applied and shock given, CPR was started, and resident was transferred to the hospital . An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated. This failure placed residents at risk of not having their wishes known, respected, and a potential of prolonged suffering, pain, physical injury and psychosocial harm due to receiving CPR against their wishes. Findings Include: Review of Resident # 1's face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnosis that include Progressive supranuclear ophthalmoplegia (an inability to look down and focus) Brain Stem Stroke syndrome (when blood supply to the base of the brain is interrupted or stopped.), other symptoms and signs involving cognitive functions and awareness ( Mild mental impairment that can include memory loss, mood swings and behavioral changes ) and palliative care. Review of Resident # 1's admission MDS was in progress with a start date of [DATE]. Review of Resident # 1's discharge BIMs completed on [DATE] reflect a score of 10 out of 15 reflecting Moderate cognitive impairment. Review of Resident #1 's Base line care plan dated [DATE] revealed full code status. No updated on [DATE] with change of code status to OOH-DNR Review of Resident # 1's Comprehensive care plan updated [DATE] revealed DNR status. Review of Resident # 1's Physicians orders revealed admission order on [DATE] of full code status. Physicians order written on [DATE] and signed by the physician on [DATE] change status to OOH-DNR. Review of Resident # 1's Out of hospital do-not-resuscitate on chart signed by resident on [DATE] and physician on [DATE]. Reflecting that as of [DATE] the resident wishes were to not have advanced life saving measures during a medical emergency. Review of Resident #1's progress notes dated [DATE] at 5:20 PM written by DON, revealed resident was in dining room when he had a seizure, staff call the DON, CMA pulled up EMR, to obtain code status. EMR information screen showed full code status, resident was given respiratory support, transferred to room and 911 was called. Staff followed emergency operator's instructions, applied AED which advised shock. Shock given as instructed and CPR initiated per instruction. Interview [DATE] at 09:30 am with SW, she stated that the resident's RR came to her on [DATE] in the morning requesting resident be made a DNR, the social worker gave her an OOHDNR. Several hours later (no sure of the time but it was the same day) the RR brought the document back completed, requesting a notary, the SW found one who discovered that Resident #1 had signed in the incorrect spot. The RR, SW and Notary then went to the room and witnessed Resident #1 sign the document in the correct place. The charge nurse was notified, and the document was placed in the folder for the physician to sign when she came in. Interview [DATE] at 10:00 am with DON, she was at the facility the day of the incident and responded to yells from the dining room. Upon arriving she saw Resident # 1 having a seizure, an CMA pulled up the code status in the EMR as a Full code. Resident # 1 was per DON agonal breathing (insufficient breathing that often sounds like snoring, snorting, gasping or labored breathing), he was given respiratory support, transferred to his room. 911 was contact, assessment by RN given over the phone, instructed to place AED and follow instructions until paramedics arrived. AED applied, shock advised and given, after shock CPR was started per AED instructions. Paramedics arrived and took over CPR. Upon review of chart while making transfer packet it was discovered that an OOHDNR was on the chart, signed by the resident and the Physician. A signed physician's order dated [DATE] and signed [DATE] was also located in the paper chart. Updated information given to paramedics; resident was transported to hospital. Per conversation with Resident #1's RR on [DATE] resident had survived, no updates since then. Per DON nurse the worked that day and was on duty the day the order was signed, resigned the day after the incident with no notice. Interview [DATE] 11:45 am ADM stated she was not in the building when the incident occurred, but she was made aware of it and the IDT met the next morning to evaluate the event and identify the root causes, Review [DATE] 1:00 PM Review of Policy Medication and treatment orders dated [DATE] revealed All orders must be charted and made part of the resident medical record and plan of care. Review [DATE] 1:10 PM review of Policy Advanced Directive Revised [DATE] 20. The Director of Nursing services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 02:50 PM and the administrator was notified at 02:50 PM. The Administrator was provided with the IJ Template on [DATE]. The following Plan of Removal was accepted on [DATE] at 02:44 PM. POR Preparation and submission of this Plan of removal does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of removal is prepared and submitted solely because of requirements under state and federal laws. On [DATE] an abbreviated survey was initiated. On [DATE] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of immediate threat states as follows: The facility failed to ensure Resident #1 has the right to formulate an advance directive and determine the choice to receive or not CPR (cardiopulmonary resuscitation). The deficient practice did result in harm to resident #1. The medical Director has been notified of the deficient practice on 02.15.2024. The resident #1 Code Status has been updated on Electronic Medical Records System (EMR) and on the paper chart to reflect that the resident is OOHDNR. The resident's care plan has been reviewed and updated. Implementation date is 02.16.2024 by DON. Completed on 02.16.2024. The Divisional Director of Nursing, Director of Nursing, Social Worker, and MD have done a full facility wide audit to make sure that all the residents at the facility have accurate Code Status on both the EMR and the Paper chart. Residents' care plans were reviewed during the audit. Every resident's code status is accurately documented and accurately reflected on the care plans. Implementation date is 02.16.2024 by DDRC, DON, SW. Completed on 02.16.2024 and will be ongoing. The DON has created a Code Status Binder with updated code status for every resident and made available at the nurses' stations for easy access by the staff. Changes will be reported to the DON, Administrator and ADON, and will be updated immediately by the DON or designee. Implementation Date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. Each resident's code status and Advance Directives will be reviewed daily for 30 days by the DON, the Administrator after which there will be weekly audits for 90 days. The facility will review each resident's code status and Advance Directives during monthly QAPI meetings. Implementation Date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. New Admits charts will be reviewed daily during morning meetings by the IDT team led by DON, Social Worker, and the Administrator. Implementation date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. The DON will include code status reviews at the weekly Risk Meeting to ensure that every resident's code status will remain up to date. The Risk Meeting will be attended by the IDT team, the DON, Staff Development Coordinator, the director of Rehab, and the MDS coordinator. Implementation date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. Staff In-service on Code Status and Advanced Directives are ongoing and being conducted by the Staff Development Nurse at the facility. Implementation date is 02.16.2024. Initial In-service was 02.16.2024, with SW, DON, Admin, MDS. The Staff Development Nurse was in-service by the Administrator on 02.16.2024. The Administrator and DON will continue in-service with non-present/prn/agency staff and future staff, which will be on-going. Inservice will be completed by 02.21.2024 and ongoing. The Administrator, DON, ADON and/or the Social Worker will immediately document discussions with all residents and/or resident representative(s) regarding the residents' rights. Including but not limited to the residents' decision on code status. Implementation date is 02.17.2024 In-service on 02.17.2024 In-serviced the Administrator, DON, SW and MDS, regarding residents' rights and immediate documentation of such discussions, and this will be on-going. In-service done by DDRC and RDO on 02.17.2024. Completed on 02.17.2024 and will be ongoing. The Social Worker will review and verify code status during all care plan meetings. If the resident and/or resident representative(s) elect to change code status, Social Worker will immediately document the discussion, and inform the Administrator, DON and ADON and verify paper chart and EMAR updated accurately. Implementation date is 02.17.2024. Completed on 02.17.2024 and this will be on-going. The Administrator, DON, ADON and/or Social Worker will chart all orders and make part of the residents' medical records and care plan. Implementation 02.17.2024 The DON, ADON and any other Licensed Nurse can accept phone orders and are responsible for charting phone orders once received and accepted. Completed on 02.17.2024 and will be ongoing. Staff In-service on abuse, neglect, and exploitation with all staff. Implementation date is 02.16.2024 The Administrator in-service staff on abuse, neglect, and exploitation. The Administrator and DON will continue in-service with non-present/prn/agency staff and future staff, which will be on-going. The DDRC in-service the Administrator and DON on 02.17.2024. Inservice will be completed by 02.21.2024 and will be ongoing. .The DON, MDS, and the Social Worker were educated on 02.17.2024 by the administrator on IJ. There was an Ad Hoc Qapi meeting regarding the IJ on 02.17.2024 with the Administrator, DON, Social worker and MDS. This will be an on-going discussion at QAPI meetings indefinitely. The Medical Director was notified of the IJ on 02.17.2024 by the administrator. Verification Plan of Removal: 6. Corporate Nurse completed Inservice training to Adm, DON, and MDS nurse, who immediately started training staff on Advance directive, order transcription, Code book, and resident rights and abuse and neglect. b. Staff training was performed on [DATE] and plan for staff not on duty was developed with completion date of [DATE]. 7. The Administrator was unable to confirm the current status of the resident on [DATE], but an update from the wife on [DATE] stated he was in stable condition with no anticipated discharge date . 8. DON Validated all Residents code status was up to date per paper chart, red binder with code status was created and placed at nurses' station verified as up to date, EMR was up to date, including care plans on [DATE]. Daily audits preformed on 2/18,2/19, and [DATE] verified. Random audit of 4 residents with Full code status and 4 residents with DNR status were completed and verified as correct. 9. Verified thru sign in sheets that all facility staff reporting for duty from [DATE] at 6 am thru [DATE] at 6 am had completed in-services on Abuse/neglect, Advance Directives, The new red binder at the nurse's station with code status, resident rights and transcribing physician's orders. Interview with ADM on [DATE] at 10:00 she stated that the corporate compliance nurse educated her on Abuse/neglect, advance Directives, the red binder for code status, resident rights and who is responsible for transcribing physician's orders. Interview with SW on [DATE] at 09:30 am she stated that the corporate nurse and the DON educated her on the following in services, abuse/neglect, advance directives, the red binder at the nurse's station, resident rights and the process for transcribing orders. Interview with the DON on [DATE] at 11:30 am stated that the corporate nurse educated her on the following in-service abuse/neglect, resident rights, code book at the nurse's station, and transcribing order so that she could educate her staff and be a resource for questions. c. Interviews were conducted with staff across multiple shifts on [DATE] 06:00 am Thru [DATE] 06:00 am, including Maintenance Director, Culinary Director, Culinary Associate, Lead Housekeeper revealed they had all been in-serviced by the DON/ADON. Staff stated they were educated on abuse, neglect and exploitation, who to report abuse to, types of abuse, residents' rights and where to find the resident rights posted in the facility and what to do in a medical emergency. d. Interviews were conducted with staff across all shifts on [DATE] 06:00 am thru [DATE] at 06:00 am including 8 RCA's, 3 Agency RCA, 3 Med Techs, 1 Agency LVN, 2 LVN's and 1 RN revealed they had all been in-serviced by DON/ADON stated they were educated on abuse, neglect and exploitation, who to report abuse to, types of abuse, residents rights and where to find the resident rights posted in the facility, advance directives, where to find code status, and how to transcribe physician's order. The Nurses all stated that the information on who is responsible to enter the advance directive orders was new to them, and the rest of the information was a good reminder. 10. Ad hoc QAPI meeting held with IDT team and MD on [DATE] at 3:45pm to review policy on Abuse, Neglect and exploitation, resident status, Advance Directives and Code Status, and Plan of removal/response to immediate Jeopardy Citation. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying the POR had been initiated and or completed. The Administrator was informed the immediate jeopardy was removed on [DATE] at 10:45 am. While the IJ was removed the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated. due to the facility was still monitoring the effectiveness of the Plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan to include the minimum healthcare information necessary to properly care for a resident for 1 of 24 residents (Resident #1) reviewed for baseline care plans. The facility failed to update Resident #1 baseline care plan on [DATE] when his code status changed from Full code to DNR, resulting in Resident #1 receiving CPR and the use of an AED which delivered a shock on [DATE] the Resident # 1 suffered a seizure and stopped breathing. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy at a scope of isolated. This failure could place residents at risk of not receiving appropriate care to meet their current needs, prolonged suffering, pain, physical injury and psychosocial harm due to receiving CPR against their wishes. Findings Include: Review of Resident # 1's face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnosis that include Progressive supranuclear ophthalmoplegia (an inability to look down and focus) Brain Stem Stroke syndrome (when blood supply to the base of the brain is interrupted or stopped.), other symptoms and signs involving cognitive functions and awareness ( Mild mental impairment that can include memory loss, mood swings and behavioral changes ) and palliative care. Review of Resident #1's admission MDS was in progress, and undated. Review of Resident # 1's discharge BIMs dated [DATE] reflected a score of 10 out of 15 reflecting Moderate cognitive impairment. Review of Resident #1's Base line Care plan dated [DATE] revealed full code status. Review of Resident #1's Comprehensive care plan updated [DATE] revealed DNR status. Review of Resident #1's Physicians orders revealed admission order on [DATE] of full code status. Physicians order written on [DATE] and signed on [DATE]. Review of Resident #1's Out of hospital do-not-resuscitate on chart signed by resident on [DATE] and physician on [DATE]. Review of Resident #1's progress notes dated [DATE] at 5:20 p.m., written by the DON, revealed resident was in dining room when he had a seizure, staff call the DON, CMA pulled up EMR, to obtain code status. EMR information screen showed full code status, resident was given respiratory support, transferred to room and 911 was called. Staff followed emergency operator's instructions, applied AED which advised shock. Shock given as instructed and CPR initiated per instruction. Interview [DATE] at 09:30 a.m. with SW, she stated that the Resident #1's RR came to her on [DATE] in the morning requesting resident be made a DNR, the social worker gave her an OOHDNR. Several hours later (no sure of the time but it was the same day) the RR brought the document back completed, requesting a notary, the SW found one who discovered that Resident # 1 had signed in the incorrect spot. The RR, SW and Notary then went to the room and witnessed Resident #1 sign the document in the correct place. The Charge nurse was notified, and the document was placed in the folder for the physician to sign when she came in. Interview [DATE] at 10:00 a.m., the DON said she was at the facility the day of the incident and responded to yells from the dining room. Upon arriving she saw Resident #1 having a seizure, a CMA pulled up the code status in the EMR as a Full code. The DON said Resident #1 was agonal breathing (insufficient breathing that often sounds like snoring, snorting, gasping or labored breathing), he was given respiratory support, transferred to his room, and 911 was contacted. The DON said assessment by RN given over the phone, instructed to place AED and follow instructions until paramedics arrived. AED applied, shock advised and given, after shock CPR was started per AED instructions. Paramedics arrived and took over CPR. Upon review of chart while making transfer packet it was discovered that an OOHDNR was on the chart, signed by the resident and the Physician. A signed physician's order dated [DATE] and signed [DATE] was also located in the paper chart. Updated information given to paramedics; resident was transported to hospital. The DON said per conversation with Resident # 1 RR on [DATE] resident had survived, no updates since then. The DON said the nurse who worked that day was on duty the day the order was signed, resigned the day after the incident with no notice. Interview on [DATE] at 11:45 a.m. with the ADM, her expectation is that when a physician signs an order, no matter if he wrote it, or it was a verbal or telephone order it be processed per policy which to her understanding in to place the order in the EMR. She stated that not placing orders in the EMR, can result in a potential negative outcome for the residents. She stated her expectation is the policy on advance directive and care plans be followed by staff and they are unfamiliar with what to do they ask the DON or MDS nurse for clarification. She stated not having a resident's orders and needs reflected can put the residents at risk of not receiving the care they need. Policy Care plans, comprehensive person-centered revised [DATE] 11. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's conditions change. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 02:50 p.m., and the administrator was notified at 02:50 PM. The Administrator was provided with the IJ Template on [DATE]. The following Plan of Removal was accepted on [DATE] at 02:44 PM and indicated the following. POR Preparation and submission of this Plan of removal does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of removal is prepared and submitted solely because of requirements under state and federal laws. On [DATE] an abbreviated survey was initiated. On [DATE] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of immediate threat states as follows: The facility failed to provide basic life support and CPR per the physician's order and Resident #1's advance directives. The deficient practice did result in harm to resident #1. The Medical Director has been notified of the deficient practice on 02.15.2024. The resident #1 Code Status has been updated on Electronic Medical Records System (EMR) and on the paper chart to reflect that the resident is OOHDNR. The resident's care plan has been reviewed and updated. Implementation date is 02.16.2024 by DON. The Divisional Director of Nursing, Director of Nursing, Social Worker, and MD have done a full facility wide audit to make sure that all the residents at the facility have accurate Code Status on both the EMR and the Paper chart. Residents' care plans were reviewed during the audit. Every resident's code status is accurately documented and accurately reflected on the care plans. Implementation date is 02.16.2024 Completed on 02.16.2024 and will be ongoing. The DON has created a Code Status Binder with updated code status for every resident and made available at the nurses' stations for easy access by the staff. Changes will be reported to the DON, Administrator and ADON, and will be updated immediately by the DON or designee. Implementation Date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. Each resident's code status and Advance Directives will be reviewed daily for 30 days by the DON and the Administrator after which there will be weekly audits for 90 days. The facility will review each resident's code status and Advance Directives during monthly QAPI meetings. Implementation Date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. New Admits charts will be reviewed daily during morning meetings by the IDT team led by DON, Social Worker, and the Administrator. Implementation date is 02.16.2024. Completed on 02.16.2024 and will be on-going. The DON will include code status reviews at the weekly Risk Meeting to ensure that every resident's code status will remain up to date. The Risk Meeting will be attended by the IDT team, the DON, ADON, the director of Rehab, and the MDS coordinator. Implementation date is 02.16.2024. Completed on 02.16.2024 and will be on-going. Staff In-service on Code Status and Advanced Directives are ongoing and being conducted by the DON and/or the ADON. Implementation date is 02.16.2024. Initial in-service was on 02.16.2024 with SW, DON, Admin, MDS. The Staff Development Nurse was in-service by the Administrator on 02.16.2024. The Administrator and DON will continue in-service with non-present/prn/agency staff and future staff, which will be on-going. In-service will be completed by 02.21.2024 and ongoing. The Administrator, DON, ADON and/or the Social Worker will immediately document discussions with all residents and/or resident representative(s) regarding the residents' rights. Including but not limited to the residents' decision on code status. Implementation date is 02.17.2024 In-service on 02.17.2024 In-serviced the Administrator, DON, SW and MDS, regarding residents' rights and immediate documentation of such discussions, and this will be on-going. In-service done by DDRC and RDO on 02.17.2024. Completed on 02.17.2024 and will be ongoing. Staff In-service on abuse, neglect, and exploitation with all staff. Implementation date is 02.16.2024 The Administrator and DON will continue in-service with non-present/prn/agency staff and future staff, which will be on-going. The DDRC in-service the Administrator and DON on 02.17.2024. Inservice will be completed by 02.21.2024 and ongoing. The DON, MDS, and the Social Worker were educated on 02.17.2024 by the administrator on IJ. There was an Ad Hoc QAPI meeting regarding the IJ on 02.17.2024 with the Administrator, DON, Social worker and MDS. This will be an on-going discussion at QAPI meetings indefinitely. The Medical Director was notified of the IJ on 02.17.2024 by the administrator. Verification Plan of Removal: 1. Corporate Nurse completed Inservice training to Adm, DON, and MDS nurse, who immediately started training staff on Advance directive, order transcription, Code book, and resident rights and abuse and neglect. a. Staff training was performed on [DATE] and plan for staff not on duty was developed with completion date of [DATE]. 2. The Administrator was unable to confirm the current status of the resident on [DATE], but an update from the wife on [DATE] stated he was in stable condition with no anticipated discharge date . 3. DON Validated all Residents code status was up to date per paper chart, red binder with code status was created and placed at nurse's station verified as up to date, EMR was up to date, including care plans on [DATE]. Daily audits preformed on 2/18, 2/19, and [DATE] verified. Random audit of 4 residents with Full code status and 4 residents with DNR status were completed and verified as correct. 4. Verified thru sign in sheets that all facility staff reporting for duty from [DATE] at 6 am thru [DATE] at 6 am had completed in-services. a. Interviews were conducted with staff across multiple shifts on [DATE] from 06:00 am thru [DATE] at 06:00 am, including Maintenance Director, Culinary Director, Culinary Associate, Lead Housekeeper revealed they had all been in-serviced by the DON/ADON. Staff stated they were educated on abuse, neglect and exploitation, who to report abuse to, types of abuse, residents' rights and where to find the resident rights posted in the facility, and what to do in a medical emergency. b. Interviews were conducted with staff across all shifts on [DATE] from 06:00 am thru [DATE] at 06:00 am including 8 RCAs, 3 Agency RCAs, 3 Med Techs, 1 Agency LVN, LVNs and 1 RN revealed they had all been in-serviced by the DON/ADON. Staff stated they were educated on abuse, neglect and exploitation, who to report abuse to, types of abuse, residents' rights and where to find the resident rights posted in the facility, advanced directives, where to find code status, and how to transcribe physician's orders. 5. Ad hoc QAPI meeting held with IDT team and MD on [DATE] at 3:45pm to review policy on Abuse, Neglect and exploitation, resident status, Advance Directives and Code Status, and Plan of removal/response to immediate Jeopardy Citation. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying the POR had been initiated and or completed. The Administrator was informed the immediate jeopardy was removed on [DATE] at 10:45 am. While the IJ was removed the facility remained out of compliance at a severity level of no Actual harm that was not immediate jeopardy and scope was isolated, due to the facility was still monitoring the effectiveness of the Plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow physician orders and the resident's advance directives for 1 of 35 residents (Resident #1) whose records were reviewed for DNR code status. The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff did not provide Resident #1, who had a DNR in place, CPR started after the resident had a seizure and stopped breathing, according to professional standards of practice. On [DATE] Resident # 1 had a seizure and stopped breathing, was listed as a full code in the EMR. Life saving measures were initiated. Upon review of the medical record order signed by the physician on [DATE] out-of- hospital do not resuscitate. Resident #1 had an out of hospital do not resuscitate singed on [DATE] and signed by the physician on [DATE] in the medical record. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated. These deficient practices could contribute to a resident's prolonged suffering, pain, physical injury and psychosocial harm due to receiving CPR against their wishes. Findings Include: Review of Resident #1's face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnoses that include Progressive supranuclear ophthalmoplegia (an inability to look down and focus) Brain Stem Stroke syndrome (when blood supply to the base of the brain is interrupted or stopped), other symptoms and signs involving cognitive functions and awareness, (Mild mental impairment that can include memory loss, mood swings and behavioral changes), and palliative care. Review of Resident #1's admission MDS was in progress, and undated. Review of Resident # 1's discharge BIMs dated [DATE] reflected a score of 10 out of 15 reflecting Moderate cognitive impairment. Review of Resident #1's Base line Care plan dated [DATE] revealed full code status. and was not updated to reflect the physician's order of [DATE] for OOH-DNR Review of Resident #1's Comprehensive care plan updated [DATE] revealed DNR status. Review of Resident #1's Physicians orders revealed admission order on [DATE] of full code status. Physicians order written on [DATE] and signed on [DATE]. Review of Resident #1's Out of hospital do-not-resuscitate on chart signed by resident on [DATE] and physician on [DATE]. Review of Resident #1's progress notes dated [DATE] at 5:20 p.m., written by the DON, revealed resident was in dining room when he had a seizure, staff call the DON, CMA pulled up emr, to obtain code status. EMR information screen showed full code status, resident was given respiratory support, transferred to room and 911 was called. Staff followed emergency operator's instructions, applied AED which advised shock. Shock given as instructed and CPR initiated per instruction. Interview on [DATE] at 09:30 a.m., the SW stated that the Resident #1's RR came to her on [DATE] in the morning requesting resident be made a DNR, the social worker gave her an OOHDNR. Several hours later (not sure of the time but it was the same day) the RR brought the document back completed, requesting a notary, the SW found one who discovered that Resident #1 had signed in the incorrect spot. The RR, SW and Notary then went to the room and witnessed Resident #1 sign the document in the correct place. The charge nurse was notified, and the document was placed in the folder for the physician to sign when she came in. Interview [DATE] at 10:00 a.m., the DON said she was at the facility the day of the incident and responded to yells from the dining room. Upon arriving she saw Resident #1 having a seizure, a CMA pulled up the code status in the EMR as a Full code. The DON said Resident #1 was agonal breathing (insufficient breathing that often sounds like snoring, snorting, gasping or labored breathing), he was given respiratory support, transferred to his room, and 911 was contacted. The DON said assessment by RN given over the phone, instructed to place AED and follow instructions until paramedics arrived. AED applied, shock advised and given, after shock CPR was started per AED instructions. Paramedics arrived and took over CPR. Upon review of chart while making transfer packet it was discovered that an OOHDNR was on the chart, signed by the resident and the Physician. A signed physician's order dated [DATE] and signed [DATE] was also located in the paper chart. Updated information given to paramedics; resident was transported to hospital. The DON said per conversation with Resident #1's RR on [DATE] resident had survived, no updates since then. The DON said the nurse who worked that day was on duty the day the order was signed, resigned the day after the incident with no notice. Interview [DATE] 11:45 am She was not in the building when the incident occurred, but she was made aware of it and the IDT met the next morning to evaluate the event and identify the root causes, Review of Policy Medication and treatment orders [DATE] 12:30 PM dated [DATE] revealed All orders must be charted and made part of the resident medical record and plan of care. Review of Policy Advanced Directive [DATE] at 12:45 PM Revised [DATE] 20. The Director of Nursing services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 02:50 p.m., and the administrator was notified at 02:50 PM. The Administrator was provided with the IJ Template on [DATE]. The following Plan of Removal was accepted on [DATE] at 02:44 PM and indicated the following. POR Preparation and submission of this Plan of removal does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of removal is prepared and submitted solely because of requirements under state and federal laws. On [DATE] an abbreviated survey was initiated. On [DATE] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of immediate threat states as follows: The facility failed to provide basic life support and CPR per the physician's order and Resident #1's advance directives. The deficient practice did result in harm to resident #1. The Medical Director has been notified of the deficient practice on 02.15.2024. The resident #1 Code Status has been updated on Electronic Medical Records System (EMR) and on the paper chart to reflect that the resident is OOHDNR. The resident's care plan has been reviewed and updated. Implementation date is 02.16.2024 by DON. The Divisional Director of Nursing, Director of Nursing, Social Worker, and MD have done a full facility wide audit to make sure that all the residents at the facility have accurate Code Status on both the EMR and the Paper chart. Residents' care plans were reviewed during the audit. Every resident's code status is accurately documented and accurately reflected on the care plans. Implementation date is 02.16.2024 Completed on 02.16.2024 and will be ongoing. The DON has created a Code Status Binder with updated code status for every resident and made available at the nurses' stations for easy access by the staff. Changes will be reported to the DON, Administrator and ADON, and will be updated immediately by the DON or designee. Implementation Date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. Each resident's code status and Advance Directives will be reviewed daily for 30 days by the DON and the Administrator after which there will be weekly audits for 90 days. The facility will review each resident's code status and Advance Directives during monthly QAPI meetings. Implementation Date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. New Admits charts will be reviewed daily during morning meetings by the IDT team led by DON, Social Worker, and the Administrator. Implementation date is 02.16.2024. Completed on 02.16.2024 and will be on-going. The DON will include code status reviews at the weekly Risk Meeting to ensure that every resident's code status will remain up to date. The Risk Meeting will be attended by the IDT team, the DON, ADON, the director of Rehab, and the MDS coordinator. Implementation date is 02.16.2024. Completed on 02.16.2024 and will be on-going. Staff In-service on Code Status and Advanced Directives are ongoing and being conducted by the DON and/or the ADON. Implementation date is 02.16.2024. Initial in-service was on 02.16.2024 with SW, DON, Admin, MDS . The Staff Development Nurse was in-service by the Administrator on 02.16.2024. The Administrator and DON will continue in-service with non-present/prn/agency staff and future staff, which will be on-going. In-service will be completed by 02.21.2024 and ongoing. The Administrator, DON, ADON and/or the Social Worker will immediately document discussions with all residents and/or resident representative(s) regarding the residents' rights. Including but not limited to the residents' decision on code status. Implementation date is 02.17.2024 In-service on 02.17.2024 In-serviced the Administrator, DON, SW and MDS, regarding residents' rights and immediate documentation of such discussions, and this will be on-going. In-service done by DDRC and RDO on 02.17.2024. Completed on 02.17.2024 and will be ongoing. Staff In-service on abuse, neglect, and exploitation with all staff. Implementation date is 02.16.2024 The Administrator and DON will continue in-service with non-present/prn/agency staff and future staff, which will be on-going. The DDRC in-service the Administrator and DON on 02.17.2024. Inservice will be completed by 02.21.2024 and ongoing. The DON, MDS, and the Social Worker were educated on 02.17.2024 by the administrator on IJ. There was an Ad Hoc QAPI meeting regarding the IJ on 02.17.2024 with the Administrator, DON, Social worker and MDS. This will be an on-going discussion at QAPI meetings indefinitely. The Medical Director was notified of the IJ on 02.17.2024 by the administrator. Verification Plan of Removal: 1. Corporate Nurse completed Inservice training to Adm, DON, and MDS nurse, who immediately started training staff on Advance directive, order transcription, Code book, and resident rights and abuse and neglect. a. Staff training was performed on [DATE] and plan for staff not on duty was developed with completion date of [DATE]. 2. The Administrator was unable to confirm the current status of the resident on [DATE], but an update from the wife on [DATE] stated he was in stable condition with no anticipated discharge date . 3. DON Validated all Residents code status was up to date per paper chart, red binder with code status was created and placed at nurse's station verified as up to date, EMR was up to date, including care plans on [DATE]. Daily audits preformed on 2/18, 2/19, and [DATE] verified. Random audit of 4 residents with Full code status and 4 residents with DNR status were completed and verified as correct. 4. Verified thru sign in sheets that all facility staff reporting for duty from [DATE] at 6 am thru [DATE] at 6 am had completed in-services on Abuse/neglect, Advance Directives, The new red binder at the nurse's station with code status, resident rights and transcribing physician's orders. Interview with ADM on [DATE] at 10:00 she stated that the corporate compliance nurse educated her on Abuse/neglect, advance Directives, the red binder for code status, resident rights and who is responsible for transcribing physician's orders. Interview with SW on [DATE] at 09:30 am she stated that the corporate nurse and the DON educated her on the following in services, abuse/neglect, advance directives, the red binder at the nurse's station, resident rights and the process for transcribing orders. Interview with the DON on [DATE] at 11:30 am stated that the corporate nurse educated her on the following in-service abuse/neglect, resident rights, code book at the nurse's station, and transcribing order so that she could educate her staff and be a resource for questions. a. Interviews were conducted with staff across multiple shifts on [DATE] from 06:00 am thru [DATE] at 06:00 am, including Maintenance Director, Culinary Director, Culinary Associate, Lead Housekeeper revealed they had all been in-serviced by the DON/ADON. Staff stated they were educated on abuse, neglect and exploitation, who to report abuse to, types of abuse, residents' rights and where to find the resident rights posted in the facility, and what to do in a medical emergency. b. Interviews were conducted with staff across all shifts on [DATE] from 06:00 am thru [DATE] at 06:00 am including 8 RCAs, 3 Agency RCAs, 3 Med Techs, 1 Agency LVN, LVNs and 1 RN revealed they had all been in-serviced by the DON/ADON. Staff stated they were educated on abuse, neglect and exploitation, who to report abuse to, types of abuse, residents rights and where to find the resident rights posted in the facility , advanced directives, where to find code status, and how to transcribe physician's orders The Nurses all stated that the information on who is responsible to enter the advance directive orders was new to them, and the rest of the information was a good reminder. 5. Ad hoc QAPI meeting held with IDT team and MD on [DATE] at 3:45pm to review policy on Abuse, Neglect and exploitation, resident status, Advance Directives and Code Status, and Plan of removal/response to immediate Jeopardy Citation. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying the POR had been initiated and or completed. The Administrator was informed the immediate jeopardy was removed on [DATE] at 10:45 am. While the IJ was removed the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated. Due to the facility was still monitoring the effectiveness of the Plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure basic life support, including CPR, would be provided to a resident requiring such emergency care subject to related physician orders and the resident's advance directives for 1 of 17 residents (Resident #8), reviewed for advanced directives. 1. Resident #8's EMR reflected her code status was Do Not Resuscitate (DNR) while her wishes were to have a full code status and to receive life saving measures in the event of a life-threatening medical emergency. 2. LVN O and LVN P did not have current CPR certification and were working night shifts together as the only licensed staff in the facility. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of an untimely death, not having their wishes known, respected and implemented in a medical emergency. Findings included: 1. Review of face sheet for Resident #8 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of congestive heart failure (A progressive heart disease that affects pumping action of the heart muscles, causing fatigue and shortness of breath), atherosclerosis of coronary artery bypass graft (a narrowing of the arteries that can significantly reduce the blood supply to vital organs), stage 3 chronic kidney disease (A condition characterized by a gradual loss of kidney function), chronic obstructive pulmonary disease (disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), long term (current) use of anticoagulants (blood thinners), metabolic encephalopathy (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function), infarction (heart attack), peripheral vascular disease (narrowing or occlusion by atherosclerotic plaques of arteries outside of the heart and brain), Type 2 diabetes mellitus with diabetic chronic kidney disease, diabetic nephropathy, and peripheral angiopathy without gangrene, asthma with status asthmaticus (severe lung disorder characterized by narrowing of the airways, the tubes which carry air into the lungs, that are inflamed and constricted, causing shortness of breath, wheezing and cough unresponsive to repeated courses of beta-agonist therapy such as inhaled albuterol, levalbuterol, or subcutaneous epinephrine), and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Review of Quarterly MDS Assessment for Resident #8 dated [DATE] reflected a BIMS score of 10, indicating a moderate cognitive impairment. Review of the care plan for Resident #8 dated [DATE] the Advanced Directives section heading reflected DO NOT RESUSCITATE, FULL CODE. A care plan item related to code status reflected the following: (Resident #8) is Full Code. (Resident #8) will have request honored during facility stay. Family/MD will be notified of Change in Condition. If Code Status changes, the clinical record will be updated to reflect change. Nursing Staff will provide chest compressions/respirations when the residents heart stops and call ambulance to transfer to hospital. Staff will honor resident with privacy during CPR. Review of physician orders for Resident #8 reflected an order for Full Code Status dated [DATE]. Review of paper medical record and EMR for Resident #8 reflected no current DNR form. Review on [DATE] at 11:29 a.m. of the EMR reflected a consistent heading featured on every page of the record that included the resident name, photograph, PCP, room number, and code status. The code status reflected DNR in bright yellow lettering. A link titled, Advanced Directive to the right of the heading linked to a page of the same title which had both Do Not Resuscitate and Full Code listed. Review of the paper medical record for Resident #8 reflected that the first page in the binder was a green sheet of paper with the words FULL CODE in large letters and placed inside a sheet protector. Review of nursing progress notes for Resident #8 dated [DATE] reflected the following: Goals of care meeting held with resident and her two daughters. MD explained to resident and daughters are terminal cardiac disease with reference to recent visit to physician cardiologist. Resident and daughters were given an opportunity to ask questions. Explained resident currently has an out of hospital DNR on file signed in January twenty1 x 2 physicians at the hospital; went over meeting/purpose of this form and since resident number eight is still capable of making her own decisions determined it would be best for her to sign this form since she's cognitively intact. Resident number eight ultimately decided that she does wish to remain full code. She is having a difficult time making decisions toward comfort versus palliative versus hospice care, and says she just doesn't know what to say. Currently resident does not wish to sign out of hospital DNR bus her out of hospital DNR was revoked during this meeting and orders were written for full code status. During an interview on [DATE] at 12:34 p.m., LVN F stated if she were close to the nurse's station, she would look at the paper medical chart for the resident's code status, but if she were down the hall, she would probably just look at the EMR in the computer. During an interview on [DATE] on 12:37 p.m., the MDSN stated she would look in the EMR for code status. She stated that she was aware of the implications of incorrectly implementing CPR if a resident was a full code or vice versa but did not elaborate. During an interview on [DATE] on 12:38 p.m. CNA I stated that she would look in the computer at the EMR to determine a resident code status. During an interview on [DATE] on 12:39 p.m. CNA J stated she would look in the computer at the EMR to determine a resident code status. During an interview on [DATE] at 2:49 p.m., LVN E stated she would look in the resident's chart for code status. When asked which chart, she stated the code status was on the paper medical record at the nurse's desk and also in the computer, and she would look at whichever one was faster. During an interview on [DATE] at 2:50 p.m. CNA L stated she would look in the computer at the EMR to determine a resident code status. During an interview on [DATE] at 2:51 p.m. CNA M stated she would look in the computer at the EMR to determine a resident code status. During an interview on [DATE] at 2:53 p.m. CNA N stated he would look either in the paper medical record or in the computer at the EMR to determine a resident code status, whichever was closer. During an interview on [DATE] at 2:54 p.m. RN D stated she would look in the computer at the EMR to determine a resident code status. During an interview on [DATE] at 3:13 p.m., the DON stated their process related to code status was for residents to have a full code status on admission until all the paperwork was together establishing otherwise. She stated it was the responsibility of nursing and social work departments to enter code status into the EMR and into the paper medical record. She stated that she was the nursing department head, so it was her responsibility. She stated if a resident arrived with a DNR form from the hospital, they did not honor that because it was not an Out of Hospital DNR order. She stated it was her responsibility to complete the OOH-DNR, obtain the required signatures, and get the red sheet filed into the resident's paper chart. She stated the red sheet had the words Do Not Resuscitate printed on it. She stated that once the order for the DNR was entered into the EMR, a yellow tag showed up at the top of all screens in the resident electronic chart saying DNR. She stated if the resident wanted to have a full code status, which meant they would receive CPR in the event that they were found unresponsive or without a pulse, the full code order was entered, a green sheet with the words Full Code on it was placed in the resident's paper chart, and the words Full Code showed up at the top of all the pages of the resident's electronic chart. She stated the EMR for Resident #8 should not have said DNR in the heading. She stated staff were trained to look in the paper chart for the code status in an emergency. She was asked to provide a written record of this training but did not as of exit on [DATE]. She stated the EMR timed out often, and if the staff were charting or passing medications and the page timed out, it was probably quicker to look at the paper chart. She stated it was, however, possible the staff would get the information from the heading of the EMR if they had recently refreshed the page. She stated she believed the likely outcome if staff checked the EMR and saw the DNR status first was that the entire staff was familiar with Resident #8 and aware of her code status, so they would know to perform CPR. She stated she would hope all the nurses were aware of Resident #8's code status. During an interview on [DATE] at 4:07 p.m., LVN E stated she thought Resident #8 had a DNR status, but she would have to look it up. She stated she could not remember every resident's code status and would have to look them up if she needed to know in an emergency. During an interview on [DATE] at 4:07 p.m., LVN G stated she thought Resident #8 had a DNR status, because she was on hospice at one time. During an interview on [DATE] at 4:53 p.m., Resident #8 was asked how she would feel if staff did not start CPR on her if she stopped breathing or if her heart stopped. She stated Well, if I died, then I would never know. But I do want CPR started because I want to be around a long time, and I would want them to at least try. During an interview on [DATE] at 3:22 p.m., the ADM stated she oversees the code statuses of residents in a loose way, but she expected the nursing department to maintain the program. She stated the DON was responsible for ensuring that all facility nurses were CPR certified. She stated she did not know the exact process the nursing department had developed to ensure compliance with resident code status. She stated she expected them to make sure the code status was consistent with the with the physician orders. She stated she did see it as a problem that the EMR had a code status of DNR reflected when she should actually have a full code status. She stated the outcome could be they would not follow the resident's wishes and that they would either to do CPR when it was not something the resident wanted or the flip side. When asked what the flip side was, she stated they would fail to provide CPR. When asked what the outcome of that could be, she stated it could be death. 2. Review of CPR certification for facility nurses reflected that proof of certification was not available for two of the facility's overnight nurses, LVN O and LVN P. Review of the nursing schedule for [DATE] reflected that LVN O and LVN P were the only two nurses on the schedule that night. A telephone interview was attempted on [DATE] at 3:45 p.m. with LVN O, but she did not answer or call back. A telephone interview was attempted on [DATE] at 3:47 p.m. with LVN P, but she did not answer or call back. During an interview on [DATE] at 10:00 a.m., the DON stated that LVN O and LVN P had worked the night shift together the night before and neither of them had produced legitimate verification that they had been recertified in CPR. Review of facility's policy, Advance Directives dated [DATE] reflected the following: Advanced directives will be respected in accordance with state law and facility policy. Information about whether or not the resident has executed advance directive shall be displayed prominently in the medical record. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist in the residence decision to accept or decline assistance. The Administrator and DON were notified on [DATE] at 5:13 p.m. of the IJ due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on [DATE] at 1:42 p.m. Plan of Removal for the Immediate Jeopardy on [DATE] The alleged deficient practice has the potential to result in harm to all residents. The medical Director has been notified of the alleged deficient practice on [DATE]. On [DATE], the Director of Nursing, Social Worker, and MD have done a full facility wide audit to make sure that all the residents at the facility have accurate Code Status on both the banner page of the EMR and the Paper chart. Residents' care plans were reviewed during the audit. Every resident's code status is accurately documented and accurately reflected on the care plans. On [DATE], the DON has created a Code Status Binder with updated code status for every resident and on [DATE] the Code Status binder was made available at the nurses' station (facility has one nursing station only) for easy access by the staff. Any changes in Code Status for any resident will be reported to the DON, administrator or ADON and the Code Status Binder will be updated immediately by the DON or designee. On [DATE], our nurses were trained by our Director of Nursing and our Staff Education Nurse - [facility name] - on the information contained and the location - nurses' station - of the Code Status Binder for residents of [facility name]. Staff not on duty on [DATE] will be trained prior to the beginning of their next shift by Staff Education Nurse, DON, ADON, or Administrator. Newly hired staff members will receive training on Code Status and Advance Directives and the presence of a Code Status Binder prior to working their first shift. Training will be on-going. On [DATE], each resident's code status and Advance Directives were reviewed and Code Status review for each resident will continue daily for 30 days. At the end of 30 days, Code Status review will continue weekly for 90 days. Conducting these 30 day and 90 days reviews will be the DON, ADON, MDS Nurse, or the Administrator. The facility will review each resident's code status and Advance Directives during monthly QAPI meetings. QAPI team review of residents' code status will be on-going. Beginning [DATE], during daily morning stand up meeting (held on weekdays - Monday through Friday) the IDT team lead by DON, Social worker, and the administrator, the Code Status of all new admits will be reviewed. Code status review for new admits began [DATE] and will continue indefinitely. On [DATE], the DON completed this training on Advance Training/Code Status for IDT team members including social worker, MDS Nurse, Staff Education Nurse, and the administrator. On [DATE], the DON will include code status reviews at the weekly Risk Meeting to ensure that every resident's code status will remain up to date. The Risk Meeting will be attended by the IDT team: the DON, ADON, Staff development coordinator, the director of Rehab, Social Worker, Activity Director, Dining Director, and the MDS coordinator. On [DATE], DON received training on this process by Administrator using facility policy based upon regulation. On [DATE], staff In-service on Code Status and Advanced Directives began for all current staff and will be ongoing for all staff members. Training on Code Status and Advance Directives is provided by the Staff Development Nurse at [facility name]. Newly hired staff members will complete the training on Code Status and Advanced Directives prior to their first shift worked. Staff members who were absent during the initial training will be required to complete the training on Code Status and Advance Directives upon returning to work. Training to be provided by Staff Education Nurse, DON, ADON, or Administrator. On [DATE], the DON or ADON for [facility name], will ensure that there is at least one licensed nurse (RN or LVN) with CPR certification for each shift effective immediately. All licensed nurses will be required to be CPR certified 90 days from [DATE]. The facility plan of removal was monitored by the survey team in the following ways: Review on [DATE] of the EMR reflected a consistent heading featured on every page of the record that included the resident name, photograph, PCP, room number, and code status. The code status reflected FULL CODE in bright green lettering. Review of newly-created code status binder kept at the nurse's station reflected that all resident code status sheets were updated and included. They correctly matched resident orders, care plans, and code status reflected in the EMR. During an interview on [DATE] at 9:49 a.m., the SW stated anytime she visited with a new resident, she had a packet that she went over, and they discussed Resident Rights and code status. She stated there were often times that residents were confused about the difference between the hospital DNR and the DNR they needed here, so they went over that specifically. She stated they discussed with the family as well. She stated the code status conversation was the initial introduction before she went back the following day to complete the MDS assessment. She stated any residents who were already there and wanted to change their code status would have a meeting with her and start the process with them. She stated she and the DON would be keeping track of code status and ensuring accuracy in EMR and code status binder during their risk meeting weekly and any time in between, as situations arise. Review of an in-service titled Advance Directives and Code Status reflected 41 staff signatures. Review of CPR certificates for LVNs O and P reflected they were provided the training at an area hospital by an accredited trainer on [DATE]. During interviews on [DATE] between 9:50 a.m. and 11:00 a.m., 3 CNAs, 2 LVNs, 1RN, and 1MA all reported they had been in-serviced with the new process to check the code status binder to determine code status. During interviews on [DATE] between 4:00 p.m. and 5:00 p.m., 4 CNAs, 1 MA, and 2LVNs reported they had been in-serviced with the new process to check the code status binder to determine code status. Observation on [DATE] at 5:00 p.m. revealed the code status binder was at the nurse's station in full view of anyone passing by. Review on [DATE] of five randomly selected EMR records reflected three DNR and two Full Code status; this information was reflected on the resident's initial screens, care plans, physician orders, and face sheets. Review of the paper medical records for the above sample selected reflected that all were consistent with the EMR. Observation revealed a separate red binder at the nurse's station labeled Advanced Directives. Enclosed was an excel spread sheet with a list of residents who were full code reflected in the color green and residents with a DNR reflected red. Review of a resident code status audit dated [DATE] reflected that all residents in the facility had been audited to ensure code status was listed correctly in all locations. During interviews on [DATE], one RN and one LVN were on the floor and were able to explain the facility's new Advance Directives process. The ADM was notified on [DATE] the IJ was removed, and the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with a scope identified as isolated.