**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident had the right to be free of abuse for 1 of 8 residents reviewed for abuse. ( Resident #1) Resident #1 was intimidated, suffered pain and mental anguish, and forced to allow care against her will by CNA A on 3/11/24. CNA A refused to take no for an answer when Resident #1 told her she did not want to be transferred. CNA A pushed back at Resident #1's flailing hands and reached under her arms and transferred her against her will from her wheelchair to her bed. Resident #1 complained of back pain when she was transferred by CNA A. CNA A was hollering at Resident #1 and told her she was afraid for nothing. CNA A was close to Resident #1's face talking loudly in an intimidating manner. CNA A reached between Resident #1's legs to check if she was wet and the resident was begging her not to, but CNA A continued. The noncompliance was identified as past non-compliance (PNC). The IJ began on 3/11/24 and ended on 3/21/24. The facility had corrected the noncompliance before the survey began. The negative findings placed residents at risk of abuse, mental anguish, and pain. Findings included: Record review of Resident #1's face sheet with no date indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnose were heart failure, anxiety disorder, high blood pressure, and left lower quadrant pain. Record review of Resident #1's MDS assessment dated [DATE] indicated she had severe cognitive impairment. She required substantial/maximal assistance with bed to chair transfer and toilet transfer. During an interview on 4/5/24 at 11:45 a.m. the MDS nurse said Resident #1's MDS indicated the resident required two people for transfer. Record review of Resident #1's Care Plan dated 2/22/24 indicated a Problem of the resident required assistance with transfers due to decreased mobility, weakness and altered mentation. She used a wheelchair for ambulation. Some of the approaches were do not force the resident to perform a care activity, call the resident's family for assistance with ADL issues. Transfer resident per instructions on resident assistant guide. Record review of Resident #1's nursing note dated 3/11/24 at 8:15 p.m. indicated a grievance was brought to the nurse by a family member. Resident #1 was immediately assessed to ensure she was safe, skin showed no signs of bruising, the resident was calm and in no distress at this time. Resident #1 did ask for a pain pill but later declined it. The incident was immediately reported to administrative staff. Record review of Resident #1's nursing note indicated a note recorded as late entry on 3/12/24 at 11:32 a.m. indicated on 3/11/24 at 7:47 p.m. this nurse receive report from the charge nurse concerning an incident with CNA and reviewed the video with the family member. The Family member said CNA A was rude and handled Resident #1 roughly. Resident #1 said she was not fearful and had no new complaints of pain. Signed by ADON. Record review of a Provider Investigation Report indicated on 3/11/24 at 8:15 p.m. the family member reported CNA A approached Resident #1 and would not take no for an answer when attempting to put her to bed. Resident #1 said she was afraid the aide would drop her. The family member stated CNA A manhandled Resident #1. The family member said Resident #1 told her CNA A was rough with her and would not take no for an answer. The investigation findings were confirmed. The agency aide was blocked from returning to the facility. Record review of an email dated 3/12/24 from the administrator to HHSC Complaint and Incident Intake mailbox indicated . The Agency aide (CNA A) was terminated from our building meaning she was placed on a do not return list. In the conversation with the family and watching the video, it was determined that the aide was unnecessarily loud, and rude to the resident . Review of video provided by the family of Resident #1 dated 3/11/24 with a start time of 6:39 p.m. CNA A was seen in the room with Resident #1 sitting in the wheelchair adjacent to the bed. The aide told the Resident #1, Hold your arms up cause I'm not going to drop you. Resident #1 said, I do not want you to lift me, no, no, no. The aide was seen getting down in the resident's face saying, Hey, hey in a loud voice. CNA A was just about screaming at Resident #1 saying What's the problems? Resident #1 said, I don't want you to lift me. The aide said, Why? with hand gestures and her head was lowered down to the resident's face. Resident #1 said, I am afraid you will drop me. CNA A again loudly told Resident #1 I have never dropped you, I have put you in the bed before with no help. The aide told the Resident #1, Now don't start that today. You are fighting me. Resident #1 said repeatedly I am fighting you, I am fighting you, I am fighting you. The aide said, For what? Resident #1 and CNA A fumble back and forth a little, with CNA A moving her hands one way, and Resident #1 trying to block her hands another. Resident #1 begs her, Please don't do this to me. The resident is seen trying to flail her hands and CNA A pushed Resident #1's hands out of the way. CNA A reached under the resident's arms and lifted her to the bed. When the aide sits the resident on the bed she said, What was all of that for? You are in the bed honey. The resident said, You hurt my back. The aide turns Resident #1 around and put her legs in the bed, and told her that was uncalled for. The resident's knees are bent. CNA pulled Resident's house shoes off her feet. The back of the Resident #1's head was pressed into the headboard and the resident was on her bottom with her shoulders and in the air. The aide said, I don't have time for that, that was unnecessary, all of it, and walks out of the room. The aide came back in the room with a brief and gloves. The aide tells the resident ,You have cameras all in this room. I am not going to do anything to hurt you or me. Resident #1 asked her, What? the aide points to the camera and says loudly, You have cameras all over this room, I am not going to do anything to hurt you or me. So cut that out. CNA A was putting on her gloves. The video showed CNA A used gestures with lot of neck rolling back and forth, hand shaking, and shoulder jerking gestures as she gave her speech. The aide pulled Resident #1's legs apart and continued to do what she was doing as Resident #1 was saying, Please don't do that. CNA A told Resident #1, I am checking to see if you are wet. In a loud voice. CNA A put the brief on the table. Resident #1 asked, What is your name. The aide told her name. Resident # 1 asked, Why did you come in here and act that way? CNA A said, I did not come in here and act no way. I came in here to put you in the bed, and you started. She raised Resident #1's head up and told her to stretch her legs out, and the resident did so. The aide told her, You was doing all that hollering and screaming for no reason. Then she put a pillow behind the resident's head and then two. The resident said that was too many. The aide took one pillow out, rolled her bedside table over the bed. Walked out and turned off the light. Total time of the video 3 minutes and 4 seconds. During an interview on 4/3/24 at 1:15 p.m. in Resident #1's room the family member of Resident#1 said she was very upset by the things she saw on the video regarding CNA A and the treatment of Resident #1. She said she had brought that video to the attention of the facility staff and the aide was let go. During that interview Resident #1 said she remembered the incident and did not want to talk about it at all. During an interview on 4/5/24 at 11:07 a.m. the ADON said she saw the video regarding Resident #1. She said when CNA A walked in the room she was agitated, a little upset, and was working that hall by herself. The ADON said Resident #1 asked her if she was going to go and get help to transfer her. She said CNA A told her no. The ADON said Resident #1 wanted two people to transfer her but did not require two. She said Resident #1 told CNA A she needed go and get someone else because she did not want to fall. The ADON said CNA A told Resident #1 she had transferred her alone before. She said the aide proceeded to put Resident #1 on the bed without help and without incident. The ADON said when CNA A laid Resident #1 down there was no pillow, and she looked uncomfortable. She said CNA A left the room and came back. She said then CNA A put the pillow under Resident #1's head. The DON said it was not so much what the aide said to the resident, it was her tone of voice and her agitation. She said CNA A was in a disagreement with the resident and did not use a pleasant voice. The ADON said she had never seen any behaviors like that from CNA A before. She said during the incident CNA A told Resident #1 there was a camera in the room, so she was aware it was there. The ADON said when the family member talked to her initially there was no mention of abuse. The ADON said the family member said CNA A was rough and condescending. She said on the next day when the family member came back, the family member told the former DON it was abuse. During an interview on 4/5/24 at 11:40 a.m. Administrator said she watched the video and did substantiate abuse regarding Resident #1. She said in her opinion the CNA was disparaging or offensive. She did not have a statement from CNA A. The Administrator said she took everything to the QA committee and spoke to the Medical Director regarding the abuse. She said she also completed in services on abuse and the resident's right to refuse. During an interview on 4/5/24 at 12:08 p.m. the RNC said she had watched the video regarding Resident #1 and it was abuse. She said they had in serviced staff to make sure if a resident said no then the staff were to honor their request and leave them alone. Record review of the facility Abuse policy dated April 2021 indicated Abuse of any kind against residents was strictly prohibited. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes, but is not limited to hitting, slapping, biting, punching, or kicking. Corporal ( physical) punishment used to control behavior is recognized as a form of abuse. Record review of the facility Quality Assurance Performance Improvement Committee Meeting dated 3/21/24 indicated during the meeting they spoke of abuse involving an agency staff, and on in service of staff when a resident says no they mean no. They spoke of resident rights and monitoring. All staff agreed to Inservice staff on Resident Rights and Reporting abuse. The form was signed by department heads and the Medical Director. Record review of the facility Provider investigation report dated 3/18/24 had the attached in services that indicated staff were in serviced on resident rights to refuse care, right to refuse medications, baths, eating, changing brief, and incontinent care. The in service indicated if a resident said no then walk away and get the nurse. Encouraging and coaxing the resident was acceptable to the point the resident said no. Do not argue with the resident. Also, an in service on abuse that indicated timely reporting of abuse, when to report, and who to report to. Interviews were conducted with facility staff regarding in services on abuse neglect and resident rights of when a resident says no it means on 4/5/24 between 12:56 p.m. through 1:45 p.m. with 8 CNAs and 4 LVNs. The staff interviewed were: At 12:56 p.m. CNA F At 12:59 p.m. CNA L At 1:10 p.m. LVN J At 1:04 p.m. CNA H At 1:07 p.m. CNA N At 1:17 p.m. LVN C At 1:23 p.m. CNA E At 1:27 p.m. LVN K At 1:34 p.m. CNA G At 1:32 p.m. LVN M At 1:38 p.m. CNA I At 1:45 p.m. CNA O Interviews indicated theses facility staff were knowledgeable about the facility abuse policy. They said they were in serviced on resident rights and when a resident said no that means do not force the resident to do something they did not want to do. They were also familiar with abuse, reporting in a timely manner, and who to report abuse to. The noncompliance was identified as PNC. The IJ began on 3/11/24 and ended on 3/21/24. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident had the right to be free from neglect for 1 of 7 (Resident #1) residents reviewed for neglect. The facility failed to ensure staff performed CPR for resident #1 until emergency services arrived. The facility failed to ensure the AED was utilized when Resident #1 was found unresponsive. These failures resulted in an identification of an Immediate Jeopardy (IJ) On [DATE] at 1:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy 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. These failures could place residents at risk for neglect by not receiving appropriate life saving measures resulting in a decline in health or death. Findings Included: 1. Record review of the face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including end stage renal disease (the last stage of long-term kidney disease), diabetes, hypertension (elevated blood pressure), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). The face sheet indicated Resident #1 was a full code (in the event of cardiac arrest, CPR will be initiated). Record review of MDS dated [DATE] indicated Resident #1 was understood by others and usually understood others. The MDS indicated Resident #1 had a BIMS score of 15 and was cognitively intact. The MDS did not indicate Resident had a DNR advanced directive in place. Record review of the care plan last revised [DATE] did not indicate Resident #1's code status. Record review of the physician orders dated [DATE] through [DATE] indicated Resident #1 had an order for code status of full code starting [DATE]. Record review of the nursing progress note dated [DATE] written by LVN WWW indicated that Nurse WWW received report from a CNA of Resident #1 not breathing. The progress note indicated Nurse WWW transported the crash cart to Resident #1's room and assessed resident for code status. The progress note indicated a CNA called 911. The progress note indicated Resident #1 was without respirations and CPR was initiated. The progress note indicated when EMS arrived, they took over. The progress note indicated the nurse practitioner was contacted and gave an order for 2 LVNs to pronounce death. The progress note indicated LVN WWW and LVN AAA pronounced Resident #1 deceased . Record review of the ambulance report dated [DATE] indicated, .Arrived to the facility and was directed to [Resident #1's room] by staff. [Resident #1] was found lying supine in bed upon our arrival with no staff in room. No evidence of CPR or Basic Life support noted. An LVN directed us to the room with [Resident #1] when we accidentally walked by it. [LVN WWW] stated We rounded on her at 3 am and she was sleeping. [LVN WWW] states that they found her unresponsive and not breathing at 0507, so they called us. Patient has medical history as noted, is on medications as noted, and has NKDA as noted. 803 arrived on the scene to the patient laying in the room with no nursing home staff tending to her and no equipment such as crash cart, AED, or BVM as well as no staff noted anywhere near the room. All staff were at desk in the center of the Nursing home when attempted to contact for patient information leading up to time of calling us. [Resident #1] was laying supine in the bed upon our arrival covered with the three blankets with head upon a pillow. Patient was unresponsive and breathing was apneic (cessation of breathing). No pulse was found to carotid or femoral area. [Resident #1] was attached to monitor as CPR was about to be started, but obvious signs of death were noted including pooling of blood on majority of posterior portion of body, and slight rigor-mortis noted to arms when they were attempted to be moved for pad placement and CPR. Obvious signs of death were noted as mentioned above. Monitor had asystole (when the heart stops beating entirely) noted in all three leads as noted in attached picture. Skin was cold and dry to touch. Nursing home staff was found sitting at station and asked if they had performed CPR prior to our arrival. [LVN WWW] states We seen her clearly dead when approached her earlier, so we didn't even attempt. Nurse informed me the patient did not have a DNR and was full code status . During an interview on [DATE] at 2:02 p.m. LVN AAA said she remembered the incident with Resident #1. LVN AAA said she was not Resident #1's charge nurse on the night shift from [DATE]-[DATE]. LVN AAA said a CNA came to the nurse's station and grabbed the other nurse. LVN AAA said they were gone for some time and when the other nurse returned, she said Resident #1 was unresponsive. LVN AAA said she looked up Resident #1's code status, grabbed the crash cart, went to Resident #1's room and initiated CPR. LVN AAA said she did not stop CPR until EMS arrived. LVN AAA said they received an order from the physician for 2 LVNs to pronounce death. When asked if it was in her scope of practice to pronounce death LVN AAA said it was in the facility's policy. During an interview on [DATE] at 8:10 a.m. LVN WWW said she worked the overnight shift on [DATE]. LVN WWW said she was an agency nurse. LVN WWW said she had been Resident #1's nurse that night. LVN WWW said at approximately 5:00 am a CNA came to get her to go to Resident #1's room. LVN WWW said when she entered Resident #1's room, she noticed her facial color was pale. LVN WWW said after she assessed Resident #1, she went to the nurse's station and told LVN AAA she thought Resident #1 was deceased . LVN WWW said she had hospice training in the past. LVN WWW said LVN AAA grabbed the crash cart, and they went to Resident #1's room. LVN WWW CPR was initiated. LVN WWW said she did a couple of chest compressions on Resident #1. LVN WWW said when they pulled the sheet down it was noted Resident #1's body was cool to the touch, she had slight mottling on her legs, her fingers were purple, and her blood was pooling. LVN WWW said at that point CPR was stopped. LVN WWW said when EMS arrived, they questioned why CPR was not being performed. LVN WWW said she had informed EMS the resident was deceased . LVN WWW said she had always been told an LVN cannot pronounce death. LVN WWW said the DON told them to call the physician to get an order to pronounce death. LVN WWW said she reached the physician via text messages and was given the order for 2 LVNs to pronounce death. When asked if this was in her scope of practice LVN WWW said it was what the facility told her to do. During an interview on [DATE] at 10:17 a.m. LVN WWW said the AED was not turned on or used when CPR was initiated on Resident #1. Record review of the facility's Automatic External Defibrillator (AED) policy dated [DATE] indicated, The facility will use the Automatic External Defibrillator (AED) to treat victims who experience sudden cardiac arrest. It is only applied to victims who show all signs of cardiac arrest such as: unconscious, unresponsive, not breathing normally, and have no pulse. Procedure: Active EMS by calling 911 Bring AED to the resident location Press On button Follow the prompts as given by the AED Prepare the resident by removing any clothing from the resident's chest Wipe away any excess moisture from chest Quickly shave excess chest hair if necessary Pull pads from storage slot Remove pads from packaging Pads may only be used once Apply pads Continue to follow the prompts given by the AED Continue CPR as directed by the AED until EMS arrives . Record review of the facility's Identifying Types of Abuse policy dated [DATE] indicated, As part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents. Abuse of any kind against residents is strictly prohibited. Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur .Having the knowledge and ability to provide care and services, but choosing not to, constitutes abuse . Record review of the facility's Cardiopulmonary Resuscitation (CPR)-Basic Life Support (BLS) policy dated [DATE] indicated, The objective of the CPR policy is to provide basic life support based until emergency medical services arrives, consistent with the resident advanced directives, in the absence of an advance directive or Do Not Resuscitate Order and if the resident does not show clinical signs of death. The facilities strive to assure all clinicians are certified on BLS-Cardiopulmonary Resuscitation through programs approved by the American Heart Association and/or American Red Cross .CPR will be initiated unless: decision not to initiate CPR has previously been made by the resident/patient, CPR will be initiated for any resident/patient, visitor, or staff member who experience cardiopulmonary arrest while in the facility. Residents presents with obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present . Record review of the facility's undated Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy indicated, Residents have the right to be free from abuse, neglect misappropriation of resident property and exploitation . The Administrator was notified on [DATE] at 1:55 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The DON was provided the Immediate Jeopardy template on [DATE] at 2:02 p.m. The facility's Plan of Removal was accepted on [DATE] at 4:25 p.m. and included: In-service to all staff about life saving measures were provided on [DATE] and on [DATE] with a post test. The in-service was specifically about: verification of code status in the resident's medical chart, that advance directive orders cannot be accepted verbally and can only be accepted on the proper OOH form which must be dated and signed by the physician, about who can order a DNR, and that CPR cannot be stopped once started until EMS arrives and takes over the CPR process. Presenter of in-service: ADON Abuse and neglect prevention in-service was given to all staff at the facility on [DATE] and on [DATE] with a post test. The in-service was specifically about: About the type of abuse and neglect, prohibition of abuse and neglect of residents, reporting all potential occurrences of abuse and neglect, about who the abuse and neglect facility coordinator was, and illustrations of potential cases of abuse and neglect were given as well. Presenter of in-service: ADON and RN regional consultant. In-service was completed on [DATE] for all nursing staff regarding CPR regulations, code status orders, and advance directive related care. The in-service was specifically about: verification of code status in the resident's medical chart, advance directive orders cannot be accepted verbally and can only be accepted on the proper OOH form which must be dated and signed by the physician, about who can order a DNR, that CPR cannot be stopped once started until EMS arrives and takes over the CPR process. Presenter of in-service: ADON Pronouncement of death regulations - in-service started on [DATE] and continued [DATE] for all licensed nursing staff. The in-service was specifically about: RN's and licensed physicians are the only ones that can pronounce a resident's death, the role LVN's have in pronouncing a residents death per the board of nursing (that LVN's cannot pronounce), that a nurse cannot verbally accept DNR orders and must have an OOH form signed and dated by the licensed physician, documentation of occurrence that must include, date, time of death, and the name and title of the person pronouncing the death of the resident. Presenter of in-service: Regional Nurse Consultant Hospice nurse and hospice administrator were in-serviced on [DATE] by the facility administrator, including facility nurses, that they will not accept verbal CPR stop orders from a hospice nurse and about the need to provide the correct and appropriate care related to their advance directive. On [DATE] and [DATE], all nursing staff were educated about the requirement to document events accurately and to report any irregularities to the administrator. Presenter of in-service: ADON. On [DATE], the DON was in-serviced in depth on the importance of documentation and including everything that had occurred accurately. Presenter of in-service: the Administrator, the Medical Director, with RN nursing consultant and the facility management present. Use of AED in-service started and was completed on [DATE] for all licensed nursing staff. A posttest on use of AED was given and completed by the licensed staff on [DATE]. Presenter of in-service: Regional Nurse Consultant and ADON. CPR certifications were audited on [DATE], and nurses were in-serviced on not initiating CPR if certification is not current. Audit completed by: ICP Director and Staffing coordinator. The facility policy was revised on [DATE]. Regarding current staff, as of today ([DATE]), every licensed nurse at the facility was CPR certified. For new hires, they will be required to provide the facility with CPR certification within a week of hire. A status code audit was completed on [DATE] and [DATE] to ensure no discrepancies regarding code status exist and that the corresponding forms on the chart matched the orders. The audit was completed by: ICP, LVN, and Staffing coordinator. All residents on hospice with DNR orders were checked to ensure their ordered code on the chart matched the signed paperwork in the chart. The audit was completed by: ICP, LVN and Staffing coordinator. For staff not currently at the facility, including agency staff, PRN staff and new hires, in-services and a post test will be provided prior to them working their shift. Start Date: [DATE] Completion Date: [DATE] Responsible: the Administrator, RN Consultant, the ADON or designee Regarding nurse # 1, the CPR check off was completed on [DATE] and nurse # 2, was CPR certified at the facility by a CPR instructor on [DATE]. Action 2: After an internal investigation, the Medical Director was notified by the administrator about the deficient practice on [DATE]. The Medical Director provided education to the Administrator, the DON, and the ADON about CPR guidelines, the need to follow CPR guidelines and regulations, MD orders, with a posttest to validate that participants fully understood the discussed topic. The Administrator, the DON, and the ADONs have passed the test with 100%. Start Date: [DATE] Completion Date: [DATE] Responsible: The Medical Director and RN Regional Nurse Consultant QA Involvement On [DATE] an Ad Hoc QAPI meeting was held with the Medical Director, the Facility Administrator, the Director of Nursing, to review and update policy and protocols in regard to CPR and advance directive orders and care. On [DATE], the Medical director was notified by the administrator of IJ and for the review of the plan of removal. Action 3: The Administrator, the RN Consultant, the DON, and the ADON will monitor all residents with code status, to ensure the order and the paperwork required does match. Process: The administrator and the ADON or designee will review all new or any new changes in code status - daily (M through F) during morning meeting. The Administrator or designee will check on a weekly basis nursing practices when CPR should have occurred to ensure staff was following CPR protocol during morning meeting. The Administrator or designee will also check weekly for signed paperwork, hospice residents with potential DNR codes, their orders for DNR, and for a signed OOH DNR. Monitoring: On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review on [DATE] of a random selection of 13 LVN and RN's CPR certifications indicated nurses reviewed had a current and appropriate CPR certification. Record review on [DATE] of a random selection of 36 resident charts indicated residents reviewed had code status that matched on the face sheet and orders and had DNR's on file for residents who had chosen to be a DNR. Staff interviewed on [DATE] and [DATE] between 8:00 a.m. and 9:50 p.m. (CNA B, CNA C, CNA D, CNA E, CNA F, CMA G, LVN H, LVN J, the Treatment Nurse, CNA K, LVN L, CNA M, RN X, LVN Y, RN Z, CMA AA, ADON BB, ADON CC, CNA DD, CNA EE, CNA FF, RN GG, LVN HH, CMA KK, LVN LL, CNA MM, CNA NN, CNA QQ, CNA VV, LVN WW, the MDS Nurse, CNA XX, CNA YY, CMA ZZ, LVN AAA, LVN BBB, LVN CCC, MA DDD, LVN EEE, CNA FFF, CNA GGG, MA HHH, CNA JJJ, CNA KKK, LVN LLL, LVN MMM, LVN NNN, CNA PPP, LVN QQQ, RN RRR, CNA SSS, LVN TTT, LVN VVV, and LVN WWW) were able to name where to find the code status for a resident, said code status could not be accepted as a verbal order, and a DNR had to be on the appropriate form with a physician's signature. Staff interviewed said an LVN could not pronounce a resident's death, only a physician or a RN could pronounce death. Staff interviewed said documentation must be accurate without any omissions. Staff interviewed on [DATE] and [DATE] between 8:00 a.m. and 9:50 p.m. (CNA B, CNA C, CNA D, CNA E, CNA F, CMA G, LVN H, LVN J, the Treatment Nurse, CNA K, LVN L, CNA M, RN X, LVN Y, RN Z, MA AA, ADON BB, ADON CC, CNA DD, CNA EE, CNA FF, RN GG, LVN HH, CMA KK, LVN LL, CNA MM, CNA NN, CNA QQ, CNA VV, LVN WW, the MDS Nurse, CNA XX, CNA YY, MA ZZ, LVN AAA, LVN BBB, LVN CCC, CMA DDD, LVN EEE, CNA FFF, CNA GGG, CMA HHH, CNA JJJ, CNA KKK, LVN LLL, LVN MMM, LVN NNN, CNA PPP, LVN QQQ, RN RRR, CNA SSS, LVN TTT, LVN VVV, and LVN WWW, Housekeeper A, [NAME] N, Dishwasher P, Dishwasher Q, Dishwasher R, Assistant Kitchen Manager, Dietary Helper S, Dietary Manager, Housekeeper T, Floor Technician, Housekeeper V, Housekeeper W, Assistant Activity Director, DOR, OT PP, Housekeeper RR, ST SS, Laundry Aide TT, Human Resources Manager, Transportation Driver) were able to name all types of abuse and neglect including physical, mental, sexual, and misappropriation of property. Staff were able to name the Abuse Coordinator as the Administrator. Staff said witnessed or reported abuse should be reported to the Abuse Coordinator immediately. During an interview on [DATE] at 3:28 p.m. the Medical Director said he attended a QAPI meeting regarding the failure. The Medical Director said he educated the Administrator, the DON, and the ADON's not to accept any verbal orders for a DNR. The Medical director said a DNR needed to be well marked in the chart and if not, CPR needed to be performed until the EMS arrived. The Medical Director said he thought the facility had relied on the hospice company to have the DNR in the charts. The Medical Director said the hospice facility had it and there was some breakdown in the hospice system. The Medical Director said either an MD or RN can pronounce a death. The Medical Director said he thought they have drilled it in the staffs' minds now. The Medical Director said he thought after this IJ, staff had a greater understanding and going forth should have the proper education on what they needed to do for the residents. During an interview on [DATE] at 12:10 p.m. the DON said she was in-serviced regarding CPR. The DON said she was in-serviced regarding pronouncing death and only an RN, MD, and JP can pronounce death. The DON said you could not stop CPR until the EMS resumed care. The DON said CPR must be started if a resident did not have a DNR. The DON said if a resident was a full code, then CPR should be started. The DON said CPR could be administered as an AED was being set up. The DON said the AED was located by the exit towards the memory. The DON said a DNR was ordered by the physician. The DON said the facility must have the physical DNR. The DON said staff could look in the EMR and chart to see a resident's code status. The DON said staff should document everything on their shift. The DON said she thought a communication error occurred because of incompetence. The DON said after the in-services, she felt they are compliant to perform their assigned duties correctly, and we will continue to have in-services. The DON said they had a QAPI (Quality Assurance and Performance Improvement) meeting where the topics of documentation and a system for our code status to be in place and available to staff were discussed. During an interview on [DATE] at 12:21 p.m. the Administrator said staff had been in-serviced regarding CPR, AED, Pronouncement of Death, and Abuse/neglect. The Administrator said the CPR in-service addressed the requirement of having an up-to-date CPR certification to perform CPR. The Administrator said staff could look in the chart to see a resident's code status. The Administrator said once a person starts CPR they can only stop when EMS physically takes over. The Administrator said staff cannot take a verbal DNR order over the phone. The Administrator said there had to be a hard copy of the resident's DNR on the chart. The Administrator said the only people who can pronounce death are a physician, justice of the peace, or RN. The Administrator said the AED was located by the time clock and should be used in a code situation. The Administrator said she thought this failure occurred due to incompetence. The Administrator said she felt after the in-services staff have the equipment and knowledge, they need to perform their duties in a code. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided 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 2 of 7 (Resident #1 and Resident #2) residents reviewed for CPR. The facility failed to ensure staff performed CPR for resident #1 until emergency services arrived. CPR was initiated and then stopped prior to emergency services arrival. The facility failed to ensure staff utilized the AED when Resident #1 was found unresponsive. The facility failed to ensure Resident #2 advance directive was accurate. CPR was initiated on Resident #2 and stopped upon verbal confirmation by hospice agency of Resident #2's DNR. The facility failed to ensure staff were current with CPR training. The facility failed to follow their policy and procedure for Pronouncing death. The facility failed to properly document initiation of CPR for Resident #2. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 1:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy 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. These failures could place residents at risk of not receiving necessary life-saving measures, decline in health, and death. Findings include: 1. Record review of the face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including end stage renal disease (the last stage of long term kidney disease), diabetes, hypertension (elevated blood pressure), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). The face sheet indicated Resident #1 was a full code (in the event of cardiac arrest, CPR will be initiated). Record review of MDS dated [DATE] indicated Resident #1 was understood by others and usually understood others. The MDS indicated Resident #1 had a BIMS of 15 and was cognitively intact. The MDS did not indicated Resident had a DNR advanced directive in place. Record review of the care plan last revised [DATE] did not indicated Resident #1's code status. Record review of the physician orders dated [DATE] through [DATE] indicated Resident #1 had an order for code status of full code starting [DATE]. Record review of the nursing progress note dated [DATE] written by LVN WWW indicated that Nurse WWW received report from a CNA of Resident #1 not breathing. The progress note indicated Nurse WWW transported the crash cart to Resident #1's room and assessed resident for code status. The progress note indicated a CNA called 911. The progress note indicated Resident #1 was without respirations and CPR was initiated. The progress note indicated when EMS arrived, they took over. The progress note indicated the nurse practitioner was contacted and gave an order for 2 LVNs to pronounce death. The progress note indicated LVN WWW and LVN AAA pronounced Resident #1 deceased . Record review of the ambulance report dated [DATE] indicated, .Arrived to the facility and was directed to [Resident #1's room] by staff. [Resident #1] was found lying supine in bed upon our arrival with no staff in room. No evidence of CPR or Basic Life support noted. An LVN directed us to the room with [Resident #1] when we accidentally walked by it. [LVN WWW] stated We rounded on her at 3 am and she was sleeping. [LVN WWW] states that they found her unresponsive and not breathing at 0507, so they called us. Patient has medical history as noted, is on medications as noted, and has NKDA as noted. 803 arrived on the scene to the patient laying in the room with no nursing home staff tending to her and no equipment such as crash cart, AED, or BVM as well as no staff noted anywhere near the room. All staff were at desk in the center of the Nursing home when attempted to contact for patient information leading up to time of calling us. [Resident #1] was laying supine in the bed upon our arrival covered with the three blankets with head upon a pillow. Patient was unresponsive and breathing was apneic (cessation of breathing). No pulse was found to carotid or femoral area. [Resident #1] was attached to monitor as CPR was about to be started, but obvious signs of death were noted including pooling of blood on majority of posterior portion of body, and slight rigor-mortis noted to arms when they were attempted to be moved for pad placement and CPR. Obvious signs of death were noted as mentioned above. Monitor had asystole (when the heart stops beating entirely) noted in all three leads as noted in attached picture. Skin was cold and dry to touch. Nursing home staff was found sitting at station and asked if they had performed CPR prior to our arrival. [LVN WWW] states We seen her clearly dead when approached her earlier, so we didn't even attempt. Nurse informed me the patient did not have a DNR and was full code status . During an interview on [DATE] at 2:02 p.m. LVN AAA said she remembered the incident with Resident #1. LVN AAA said she was not Resident #1's charge nurse on the night shift from [DATE]-[DATE]. LVN AAA said a CNA came to the nurse's station and grabbed the other nurse. LVN AAA said they were gone for some time and when the other nurse returned, she said Resident #1 was unresponsive. LVN AAA said she looked up Resident #1's code status, grabbed the crash cart, went to Resident #1's room and initiated CPR. LVN AAA said she did not stop CPR until EMS arrived. LVN AAA said they received an order from the physician for 2 LVNs to pronounce death. When asked if it was in her scope of practice to pronounce death LVN AAA said it was in the facility's policy. During an interview on [DATE] at 8:10 a.m. LVN WWW said she worked the overnight shift on [DATE]. LVN WWW said she was an agency nurse. LVN WWW said she had been Resident #1's nurse that night. LVN WWW said at approximately 5:00 am a CNA came to get her to go to Resident #1's room. LVN WWW said when she entered Resident #1's room, she noticed her facial color was pale. LVN WWW said after she assessed Resident #1, she went to the nurse's station and told LVN AAA she thought Resident #1 was deceased . LVN WWW said she had hospice training in the past. LVN WWW said LVN AAA grabbed the crash cart, and they went to Resident #1's room. LVN WWW CPR was initiated. LVN WWW said she did a couple of chest compressions on Resident #1. LVN WWW said when they pulled the sheet down it was noted Resident #1's body was cool to the touch, she had slight mottling on her legs, her fingers were purple, and her blood was pooling. LVN WWW said at that point CPR was stopped. LVN WWW said when EMS arrived, they questioned why CPR was not being performed. LVN WWW said she had informed EMS the resident was deceased . LVN WWW said she had always been told an LVN cannot pronounce death. LVN WWW said the DON told them to call the physician to get an order to pronounce death. LVN WWW said she reached the physician via text messages and was given the order for 2 LVNs to pronounce death. When asked if this was in her scope of practice LVN WWW said it was what the facility told her to do. During an interview on [DATE] at 10:17 a.m. LVN WWW said the AED was not turned on or used when CPR was initiated on Resident #1. 2. Record review of the face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including anxiety disorder, hypokalemia (decreased potassium), shortness of breath, Alzheimer's, and hypertension. The face sheet indicated Resident #2 was a full code. Record review of the MDS dated [DATE] indicated Resident #2 was usually understood by others and usually understood others. The MDS indicated Resident #2 had a BIMS of 00 and was severely cognitively impaired. The MDS did not indicate Resident #2 had a DNR advanced directive. Record review of the care plan last revised [DATE] indicated Resident #2 was receiving hospice services with interventions including assure advance directives were in place per resident and responsible party request. Record review of the physician's orders dated [DATE] through [DATE] indicated Resident #2 had an order for code status: full code starting [DATE]. Record review of the progress noted dated [DATE] written by LVN NNN indicated Resident #2 was sitting in her Geri chair (large, padded chair with wheeled base designed to assist seniors with limited mobility) in front of the nurse's station. The progress note indicated Resident #2 turned pale and was having seizure like activity. The progress note indicated LVN NNN sat Resident #2 up and began to assess her vital signs. The progress note indicated LVN NNN notified the hospice nurse of the change in condition. The progress note indicated Resident #2 had a code status of DNR. The progress note indicated Resident #2 took a gasp and then no respirations were noted. The progress note indicated the hospice nurse pronounced Resident #2 deceased . Record review of LVN NNN's Basic Life Support (CPR and AED) card issued [DATE] indicated her CPR certification expired 10/2023. During an interview on [DATE] at 1:57 p.m. LVN NNN said she was working the morning of [DATE]. LVN NNN said she was called to the nurse's station due to Resident #2 sitting up in her Geri-chair and turning pale. LVN NNN said Resident #2 started shaking like she was having a seizure. LVN NNN said she called EMS and checked the resident's code status. LVN NNN said CPR was initiated. LVN NNN said she called hospice at 8:15 a.m. to obtain Resident #2's code status as she was trying to get into her computer at the time to determine code status. LVN NNN said the hospice nurse called her back at 8:17 a.m. and informed her Resident #2 was a DNR. LVN NNN said she notified the DON and the hospice nurse that CPR was initiated. LVN NNN said she was told by the DON not to document in Resident #2's chart that she had initiated CPR. LVN NNN said there was not a DNR in Resident #2's chart. During an interview on [DATE] at 1:43 p.m. the DON said she remembered Resident #2 expiring. The DON said she was not at the facility but was given report regarding Resident #2's death. The DON said she had been informed CPR was initiated on Resident #2. The DON said she told LVN NNN not to document the initiation of CPR. The DON said she did not know why she told the nurse not to document the initiation of CPR and that it was a mistake on her part. During an interview on [DATE] at 10:26 a.m. The Patient Care Manager (hospice for Resident #2) said she had no documentation prior to the date of death showing the facility had been given Resident #2's DNR. The Patient Care Manager said the documentation indicated the facility was provided the DNR for Resident #2 on [DATE] at approximately 2:30 pm. The Patient Care Manager said the hospice company's procedure was to fax or email the DNR as soon as they had it completed and signed. The Patient Care Manager said she was unsure why the DNR was not at the facility prior to Resident #2's date of death . During an interview on [DATE] at 11:26 a.m. the SW said she had started at the facility in [DATE]. The SW said after she started at the facility, she did a complete audit of all residents' code status to ensure accuracy in the EMR. The SW said she did weekly scheduled assessments with residents and verified their code statuses at that time. The SW clarified she did not perform weekly assessments on every resident in the facility. The SW said when a resident admits the admissions coordinator usually got the advance directive at that time. The SW said when it came to a resident on hospice that hospice communicated with the nurses, and it was the nurse's responsibility to update the code status, and obtain appropriate paperwork if hospice notified them of a code status change. Record review of the facility's Cardiopulmonary Resuscitation (CPR)-Basic Life Support (BLS) policy dated [DATE] indicated, The objective of the CPR policy is to provide basic life support based until emergency medical services arrives, consistent with the resident advanced directives, in the absence of an advance directive or Do Not Resuscitate Order and if the resident does not show clinical signs of death. The facilities strive to assure all clinicians are certified on BLS-Cardiopulmonary Resuscitation through programs approved by the American Heart Association and/or American Red Cross .CPR will be initiated unless: decision not to initiate CPR has previously been made by the resident/patient, CPR will be initiated for any resident/patient, visitor, or staff member who experience cardiopulmonary arrest while in the facility. Residents presents with obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present . Record review of the facility's Do Not Resuscitate DNR Orders guideline dated [DATE] indicated, .DNR order-means that, while the resident/patient will receive medically appropriate care, cardiopulmonary resuscitation will not be initiated . Record review of the facility's Automatic External Defibrillator (AED) policy dated [DATE] indicated, The facility will use the Automatic External Defibrillator (AED) to treat victims who experience sudden cardiac arrest. It is only applied to victims who show all signs of cardiac arrest such as: unconscious, unresponsive, not breathing normally, and have no pulse. Procedure: Active EMS by calling 911 Bring AED to the resident locations Press On button Follow the prompts as given by the AED Prepare the resident by removing any clothing from the resident's chest Wipe away any excess moisture from chest Quickly shave excess chest hair if necessary Pull pads from storage slot Remove pads from packaging Pads may only be used once Apply pads Continue to follow the prompts given by the AED Continue CPR as directed by the AED until EMS arrives . Record review of the facility's Death of a Resident, Documenting policy revised [DATE] indicated, Appropriate documentation shall be made in the clinical record concerning the death of a resident. A resident may be declared dead by a licensed physician or registered nurse with physician in accordance with state law . Record review of the facility's Narrative policy dated [DATE] indicated, Narrative documentation will reflect the status of the resident/patient or the situation. Each entry will include the actual date and time of the entry .Narrative documentation will be completed during the following circumstances including but not limited to: admission, change in condition, death, discharge, exception to established care plan, physician/family notification, resident/patient or family expressed concern or dissatisfaction, response to treatment. Narrative documentation will include on factual and objective information . The Administrator was notified on [DATE] at 1:55 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The DON was provided the Immediate Jeopardy template on [DATE] at 2:02 p.m. The facility's Plan of Removal was accepted on [DATE] at 4:25 p.m. and included: Inservice was completed on [DATE] for all nursing staff regarding CPR regulations, code status orders and advanced directive related care. The in services were specifically about: verification of code status in the resident's medical chart, and that advanced directives orders cannot be accepted verbally and can only be accepted on the proper OOH form, dated, and signed by the physician. Presenter of in-service: Infection Preventionist. Pronouncement of death regulations - in-service started on [DATE] and continued [DATE] for all nursing staff. The in services were specifically about: RN's and licenses physicians are the only ones that can pronounce a resident's death, the role of the LVN's in pronouncing a residents death per the board of nursing status (that LVN's cannot pronounce), that a nurse cannot verbally accept DNR orders and must have a OOH form signed and dated by the licensed physician, documentation of occurrence that must include, date, time of death, name and title of person pronouncing the death of the resident. Presenter of in-service: Regional Nurse Consultant. Hospice nurse and hospice administrator were in-serviced on [DATE] by the facility administrator, including facility nurses, that they will not accept verbal CPR stop orders from a hospice nurse and about the need to provide the correct and appropriate care related to their advanced directive. On [DATE] and [DATE], all nursing staff were educated about the requirement to document events accurately and to report any irregularities to the administrator. Presenter of in-service: ADON. On [DATE], the DON was in-serviced in depth on the importance of documentation and including everything that had occurred accurately. Presenter of in-service: Administrator, Medical Director, with RN nursing consultant and facility management present. Use of AED in-service started and was completed on [DATE] for all licensed nursing staff. A posttest on use of AED was given and completed by the licensed staff on [DATE]. Presenter of in-service: Regional Nurse Consultant and ADON. CPR certifications were audited on [DATE], and nurses were in serviced on not initiating CPR if certification is not current as per reviewed and revised facility policy - dated [DATE]. Regarding current staff, as of today [DATE], every licensed nurse at the facility is CPR certified. For new hires, they will be required to provide the facility with CPR certification within a week of hire. Audit completed by: ICPC and Staffing coordinator. A status code audit was completed on [DATE] and [DATE] to ensure no discrepancies regarding code status exist and that the corresponding forms on the chart are matching orders. The audit was completed by: ICPC, LVN and Staffing coordinator, LVN. All residents on hospice with DNR orders were checked to ensure their ordered code on the chart matched the signed paperwork in the chart. The audit was completed by: ICPC, LVN and Staffing coordinator, LVN. For staff not currently at the facility, PRN staff and new hires, in services and a post test will be provided prior to them working their shift. Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator, RN Consultant, ADON or designee Monitoring: On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review on [DATE] of a random selection of LVN and RN's CPR certifications indicated nurses reviewed had a current and appropriate CPR certification. Record review on [DATE] of a random selection of resident charts indicated residents reviewed had code status that matched on the face sheet and orders and had DNR's on file for residents who had chosen to be a DNR. Staff interviewed on [DATE] and [DATE] between 8:00 a.m. and 9:50 p.m. (CNA B, CNA C, CNA D, CNA E, CNA F, CMA G, LVN H, LVN J, the Treatment Nurse, CNA K, LVN L, CNA M, RN X, LVN Y, RN Z, CMA AA, ADON BB, ADON CC, CNA DD, CNA EE, CNA FF, RN GG, LVN HH, CMA KK, LVN LL, CNA MM, CNA NN, CNA QQ, CNA VV, LVN WW, the MDS Nurse, CNA XX, CNA YY, CMA ZZ, LVN AAA, LVN BBB, LVN CCC, CMA DDD, LVN EEE, CNA FFF, CNA GGG, CMA HHH, CNA JJJ, CNA KKK, LVN LLL, LVN MMM, LVN NNN, CNA PPP, LVN QQQ, RN RRR, CNA SSS, LVN TTT, LVN VVV, and LVN WWW) were able to name where to find the code status for a resident and said code status could not be accepted as a verbal order and an DNR had to be on the appropriate form with a physician's signature. Staff interviewed said an LVN could not pronounce a resident's death, only a physician or RN could pronounce death. Staff interviewed said documentation must be accurate without any omissions. During an interview on [DATE] at 3:28 p.m. the Medical Director said he attended a QAPI meeting regarding the failure. The Medical Director said he educated the Administrator, DON, and ADON's not to accept any verbal orders for a DNR. The Medical director said a DNR needed to be well marked in the chart and if not CPR needed to be performed until the EMS arrives. The Medical Director said he thought the facility had relied on the hospice company to have the DNR in the charts. The Medical Director said the hospice facility had it and there was some breakdown in the hospice system. The Medical Director said either an MD or RN can pronounce a death. The Medical Director said he thought they have drilled it in the staffs' minds now. The Medical Director said he thought after this IJ staff had a greater understanding and going forth should have the proper education on what they needed to do for the residents. During an interview on [DATE] at 12:10 p.m. the DON said she was in-serviced regarding CPR. The DON said she was in-serviced regarding pronouncing death and only an RN, MD, and JP can pronounce death. The DON said you could not stop CPR until the EMS resumes care. The DON said CPR must be started if a resident did not have a DNR. The DON said if a resident was a full code, then CPR should be started. The DON said CPR could be administered as AED was being set up. The DON said the AED was located by the exit towards the memory. The DON said a DNR was ordered by the physician. The DON said the facility must have the physical DNR. The DON said staff could look in the EMR and chart to see a resident's code status. The DON said staff should document everything on their shift. The DON said she thought a communication error occurred because of incompetence. The DON said after the in-services, she felt they are compliant to perform their assigned duties correctly and we will continue to have in-services. The DON said they had a QAPI (Quality Assurance and Performance Improvement) meeting where the topics of documentation and a system for our code statutes to be in place and available to staff were discussed. During an interview on [DATE] at 12:21 p.m. the Administrator said staff had been in-serviced regarding CPR, AED, Pronounce of Death, and Abuse/neglect. The Administrator said the CPR in-service addressed the requirement of having an up-to-date CPR certification to perform CPR. The Administrator said staff could look in the chart to see a resident's code status. The Administrator said once a person starts CPR they can only stop when EMS physically takes over. The Administrator said staff cannot take a verbal DNR order over the phone. The Administrator said there had to be a hard copy of the resident's DNR on the chart. The Administrator said the only people who can pronounce death are a physician, justice of the peace, or RN. The Administrator said the AED was located by the time clock and should be used in a code situation. The Administrator said she thought this failure occurred due to incompetence. The Administrator said she felt after the in-services staff have the equipment and knowledge, they need to perform their duties in a code. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy 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.