**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the drug regimen was free from unnecessary medication for 1 of 4 residents reviewed for antibiotic medications. (Resident #1.) The facility failed to: 1. Ensure Resident #1 was not given medications that caused him to experience a serious allergic reaction. 2. Ensure Resident # 1's physician orders and MAR were reviewed prior to administration of a new medication. 3. Ensure they followed their medication administration policy. Resident #1 experienced an adverse drug interaction to (Bactrim) a medication his clinical records indicated he was allergic to. An Immediate Jeopardy (IJ) situation was identified on 03/07/23 at 5:05 p.m. While the IJ was removed on 03/09/23 at 12;56 p.m., the facility remained out of compliance at actual harm with a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure caused a resident to have serious adverse allergic reaction to a medication and was hospitalized . Findings included: Record review of Resident #1's face sheet indicated he a [AGE] year-old male admitted to the facility on [DATE]. The sheet indicated he had allergies to Bactrim, Nexium, and Sulfate. Record review of Resident #1's Care Plan last revised 12/12/22 indicated he had allergies to of Bactrim, Sulfa, and Nexium. The Care Plan indicated a problem of requiring assistance with ADLs. The resident Required one person assist with bathing, bed mobility dressing, and sit up help with eating. He required one person assist with toileting and transfer as needed. Record review of Resident #1's quarterly MDS indicated he was moderately cognitively impaired. The MDS indicated he required supervision for bed mobility, transfer, locomotion on the unit, eating and toilet use. The MDS indicated he did not walk in the room or the corridor. However, there was no device noted. Observation on 03/07/23 of the outside of Resident #1's chart showed a bright orange sticker that said Allergies listed was Bactrim, Sulfa, and Nexium. Record review of Resident #1's computerized physician orders for 02/01/23 -02/28/23 indicated he had allergies to of Bactrim, Sulfa, and Nexium. His diagnoses were diabetes, anxiety, chronic obstructive pulmonary disease. Record review of Resident #1's nursing notes dated 02/13/23 at 8:55 a.m. indicated the resident complained of lethargy and shortness of breath on exertion with diarrhea and weakness. The resident was unable to hold bowels this AM and had an accident in his bed. New orders were received for labs, a urine analysis, and a chest X-ray with two views. Record review of Resident #1' s Complete Blood Count (CBC lab) dated 02/14/23 indicated platelets 112 low (range 142-424). Urine analysis indicated cloudy positive for catalase bacteria screen (Bacteria.) Record review of a Pathogens (bacteria) Detected report indicated the received date was 02/14/23. There was moderate Acinetobacter Baumannii (bacteria infection) that listed antibiotic treatment options. Record review of a nurse's note dated 2/20/23 at 7:30 p.m. indicated a call was received from the NP and received a new order for Bactrim DS. Give one by mouth every 12 hours for seven days for a diagnosis of urinary tract infection. Written by LVN C. Record review of a handwritten telephone order dated 02/20/23 indicated resident #1 was to receive Bactrim DS 1 by mouth every 12 hours times 7 days for diagnosis of UTI. Signed by LVN C Record review of Resident #3's MAR indicated on 02/21/23 at 10:00 p.m. Bactrim DS was given. Record review of Resident #1's nursing note dated 2/21/23 at 8:45 a.m. indicated blood sugar check was 202, the resident was lethargic with labored respirations of 22. His O2 stat was 72 and he was on 2.5 liters of oxygen via nasal cannula. Resident #1's blood pressure was 120 / 72, pulse was 94 and temperature was 98.9. The resident complained of nausea but refused medications for nausea. Upon assessment the resident had bruising and swelling to the left upper arm, bleeding to the gums was noted. There were red crested secretions noted to the left eye. The resident denied any recent falls. Resident #1 could not recall how he had obtained the bruising or swelling to his left arm. The DON was notified. Written by LVN E. Records review of a nursing note dated 2/21/23 at 9:00 a.m. indicated the pharmacy called to verify new order for Bactrim and said Resident #1 was allergic to Bactrim. A nurse questioned Resident #1 and he said when he took Bactrim his platelets depleted. EMS was called and the resident was transported to the hospital. Written by LVN E. Record review of a medication error report dated 02/21/23 at 8:30 a.m. indicated Resident #1 had a urinalysis with culture and sensitivity ordered on 02/14/23. The culture and sensitivity were received on 02/20/23 an order was given on the second shift from the NP to LVN C for Bactrim DS-1 tablet two times a day for seven days. LVN C wrote the order and RN D gave the initial dose. When the order was taken LVNC failed to verify allergies. Resident #1 was allergic to Bactrim. RN D was passing medications and gave the initial dose of Bactrim at 10:00 p.m. Bactrim was listed on the MAR as an allergy. On 02/21/23 at 10:18 a.m. the NP was contacted. When taking any orders for medication the nurse would check with another nurse to verify that the resident does not have an allergy to that medication. An in service was put out for nurses signed by LVN C and RN D and also the DON on 02/21/23. Record review of Resident #1s hospital records dated 3/7/23 indicated this [AGE] year-old male was admitted for acute chronic hypoxic (absence of enough oxygen) respiratory failures secondary to diffuse alveolar hemorrhage (life threating condition caused by a variety of disorders associated with hemoptysis (coughing up blood), anemia, diffuse lung infiltration, and acute respiratory failure. The patient was coughing up blood which had slowed and believed the underlying cause of his diffused alveolar hemorrhage is pneumonia in the setting of thrombocytopenia (low platelets in the blood can be cause by medication side effects). He underwent treatment with Octogam (used to treat chronic immune thrombocytopenia) 3 days of steroids. Platelets have recovered and he is currently on romiplostim (bone marrow stimulant and can be used to treat thrombocytopenia.) The main concern now is going to be respiratory failure and his hemoglobin was stable believed he is not currently bleeding. Hematology and oncology reported indicated a diagnosis thrombocytopenia, suspected drug induced thrombocytopenia platelets level was found to be 3 on admission. The patient is currently not actively bleeding, had some bruising present notably o his right upper quadrant chest and his left arm. He is not taking any anticoagulants or blood thinners. History significant of severe thrombocytopenia with Bactrim, history significant of patient given Bactrim on 02/20/23. During an interview on 03/07/23 at 9:43 LVN B said he worked as a medication nurse, he administered medications and had worked at the facility for about 21 years. He said Resident #1 was sent to the hospital because he had some bruising and bleeding. He said the staff on the evening shift gave Resident #1 Bactrim and he was allergic to the medications. LVN B said Resident #1 was currently in the hospital. During an interview on 03/07/23 at 10:16 a.m. the DON said Resident #1 had been confused and not his normal self. They had completed some labs to determine what was going on 02/14/23. Resident #1 had a UTI they received a culture and sensitivity test on 02/20/23. She said the NP prescribed Bactrim DS. The DON said the NP called with the order, LVN C took the order, and did not check for an allergy. She said LVN C put the order on the MAR. The DON said RN D gave the Bactrim and did not check the MAR for allergies. She said Resident #1 received one dose at 10 p.m. that night. The order was written for 10 p.m. and 10 a.m. Th DON said she saw Resident #1 before he was sent to the hospital on [DATE]. The DON said she saw a raised bruises on his arm and a blood blister inside his mouth on the top lip, and the eye had a red scab in the corner. She said the blood blister in his mouth busted on the way to the hospital. The DON said Resident #1 was diagnoses at the hospital with Thrombocytopenia (a platelet deficiency.) The DON said the medication administration procedure was the nurse giving the medication was supposed to check for allergies. She said on 02/20/23 the Bactrim was taken from the ER box and the first dose was given. The DON said the Pharmacy called on the morning just about the time they discovered the resident was allergic to Bactrim to report Resident #1 had an allergy to the medication. The DON said she called the NP and they spoke about what happened. She said the NP said when he talked to the nurse, he was not looking at Resident #1's profile, the nurse did not mention the allergy. The DON said she checked to make sure Resident #1 did not get a second dose of the medications. She did a medication error report and an in service on making sure nurses checked for allergies prior to administering medications. During an interview on 03/07/23 at 10:52 a.m. LVN E said she worked at the facility for a year. She said she was not the nurse that took the order for Resident #1. LVN E said when she came in on 02/21/23 she went to assess Resident #1. She said his blood sugar was fine but noticed a large bruise on his left arm. She said the bruise was raised and unusual looking. When she asked Resident #1 if he had fallen, he said no. LVN E said Resident #1 had what looked like a tear in corner of his eye that was blood. She said he was breathing a little fast. LVN E said Resident #1 said something was going on in his mouth, and it looked like a blood blister in his mouth. She said she got the DON to observe Resident #1. LVN E said his arm was huge and swollen. She said they were going to get Xray, his Oxygen stats was 76. She went back to desk, getting ready to send him out and was going to write the order. She said she saw the order right before hers was for Bactrim. LVN E said she knew Resident #1 was allergic to Bactrim. LVN E said she looked on his computer order and the front of the chart at the bright orange sticker and they said allergy to Bactrim. She said she asked someone to ask him what happened when he took Bactrim. LVN E said Resident #1 said his platelets deplete. She said at that time the ambulance was already in route. LVN E said right about that time the pharmacy called and said Resident #1 had an allergy to Bactrim. She said they were aware of how he was doing because the MDS coordinator was able to get updates daily. His platelets were better, but his oxygen was still low. During an interview on 03/07/23 at 11:40 a.m. the NP said he did not talk to Resident #1's physician about Resident #1 incident with receiving the Bactrim. The NP said most of the time he relied on the nurses to tell him what the allergies a resident had. When he talked to the nurse, he was not looking at Resident #1's profile. He said Resident #1 was sent to the hospital; his platelet count had dropped due to the Bactrim. The NP said Resident #1 always had chronic respiratory problems. The NP said in the future he would ask if the residents had allergies. During an interview on 03/07/23 at 11:59 a.m. RN D said she worked at the facility for 4 years and did a little bit of everything. She did staff development, taught aide classes, in services, immunizations, and currently passed medications. She said on 2/20/23 LVN C was the charge nurse and RN D said she was passing medications. She said LVN C told her she received an order to give Resident #1 Bactrim. RN D said she never looked at the order, or the MAR. RN D said she took the order verbally. She got the medication out of the Emergency Kit, gave the medication, and wrote medication administration on the MAR. RN D said she did not look at Resident #1's orders or MAR for allergies but should have. She said she knew he got sick and went to the hospital and she could not help but think it had something to do with the medications she gave. The RN said she had been a nurse for over 30 years. She said they did not really monitor a resident after giving a medication. She gave the medication about 10 p.m. and she had saw Resident #1 in the hallway around 11 p.m. RN D said she did not note any adverse reactions to the medications on the MAR or in the nursing notes. During an interview and record review on 03/07/23 at 2:25 the ADON said they monitor residents who received a new medication for 3 days, every shift. They put the monitoring on report or put in nurse notes. The ADON said Resident #1 received his first dose at 10 p.m. and should have been monitored on the next shift. However, review of the 24-hour report with the ADON only showed the medication was given, but no indication it was monitored. Also review of the nursing notes did not show any mention of the medication being monitored. During an interview on 03/07/23 at 2:55 p.m. the DON said they have not had QA meeting regarding Resident #'s Medication Error incident. She said they called the primary physician and the NP. The DON said she did not know if the Medical Director was informed or not. During a telephone interview on 03/07/23 at 2:57 p.m. LVN C said normally the NP would ask her what the allergies were for a Resident. She had faxed the lab to NP, he called to give an order for antibiotic. She said he called about 7:00 p.m. and she wrote the order in the chart and wrote it in on the MAR. LVN C said she never checked the chart for allergies. She said there was an orange sticker, on the front of the chart, it was listed on the computerized physician order, and the MAR. LVN C said RN D was passing medications and told RN D to give the medication. LVN C said the medication was ordered two times daily at 10 a.m. and 10 p.m. LVN C said she checked Resident #1's blood sugar after he received the Bactrim, and he was fine when she did the blood sugar check. LVN C said RN D got off the medication cart about 10 or 10:30 p.m. LVN C said after the incident she received an in services and write up for not checking the allergies. She said she had been a nurse for 32 years and had worked at the facility for two years. She said Resident #1would need help sometimes, but for the most part he was independent. During an interview on 03/07/23 at 3:58 p.m. the Regional Nurse, have not taken the incident with Resident #1 receiving medications he was allergic to QA. They had typed up something to address giving resident medications and allergies but was going to wait for the Medical Directors approval before initiating it. She said they did a cart review of other residents taking antibiotics, but had not taken Resident #1's issue to QA. During an interview on 03/07/23 at 4:05 p.m. the Medical Director said the facility staff made her aware Resident #1 received the Bactrim. They had discussed possible plans to ensure it did not happen again. The plans were for all residents to receive the care and serviced needed to make sure they did not get medications they were allergic to. Record review of the facility policy on Medication Utilization and Prescribing- Clinical Protocol last revised July 2016, indicated the physician and staff will identify situation in which a resident is taking medications associated with potentially significant medication related problems such as allergies and adverse drug reactions. This was determined to be an Immediate Jeopardy (IJ) on 03/07/23 at 5:05 p.m. The facility Administrator, DON, ADON, and MDS coordinator. The Administrator was provided with the IJ template on 03/07/23 at 5:05 p.m. During an observation and interview on 3/9/23 at 8:00 a.m. of Resident #1 in the hospital showed he was sitting up in bed. He was on oxygen and seemed to have some difficulty breathing and talking. He said to come to the right side of the bed because he was hard of hearing. He said he could hear nothing out of his left ear and the right side appeared to be getting worse. He said he trusted the people at the facility to make sure he was taken care of and treated right. Resident #1 said some of the staff knew he was allergic to Bactrim because he had told them what it did to him in the past. He said the nurse came in that night and said she was going to give him some medication for the kidney infection. He did not hear her say Bactrim. His daughter was in the room and said she might have heard the nurse say Bactrim, but it did not register with her at the time. Observation showed he had a pan in the bed with him, he said it was there in case he coughed up blood. Resident said he was still coughing up blood, but it was not bright red like it was. He also said they had not talked to him about discharge at this time. During an interview on 03/09/23 at 9:07 a.m. Regional Nurse said they had a written counseling on LVN C and RN D. They had made some addendums to the facility Policy of Medication Utilization and prescribing. She said on 03/08/23 at 12:30 p.m. a QA meeting was held, and the medical director attended by phone. The Regional nurse said per the POR an audit was conducted and everyone on antibiotics were rechecked for allergies. She said they were ensuring the resident responses to the medications were noted on 24-hour report. They were also making sure resident assessments were completed for adverse reactions and noted in nurse's notes, and to put on the MAR. During a telephone interview on 03/09/23 at 12:09 p.m. RN D said she did tell Resident #1 what medications she was giving him. She said she knew he was hard of hearing and tried to talk loudly when speaking to him. RN D said she thought he heard what she said when he took the medication. The plan of removal was accepted on 03/08/23 at 10:05 a.m. [Residents Who have suffered, or are Likely to suffer, A serious Adverse outcome as a result of the non-compliance. The failure to ensure that residents did not receive medications that were identified as allergies created a finding of immediate jeopardy. Resident #1 received one dose of a medication he had a known allergy to. Negligent practice had the potential to affect all residents. Actions the facility will take. Regional nurse provided in-service to DON and Administrator. Areas covered include the importance of identifying all allergies of residents. The importance of clearly documenting allergies for staff to assess and also shall keep medical record current as new allergies are identified. Facility is expected to have a system in place that ensures nursing receiving orders are verifying the resident is not allergic. Started 03/07/23 5:30 pm completed 03/07/23 6pm. All nurses and medication aides will be in-service prior to their next shift, no nurse or cma will be allowed to work until in-service is complete. In-service will cover the importance of verifying all known allergies prior to receiving an order. All nurses will communicate allergies to physician when obtaining new orders. All nurses will be in serviced on policy change, two nurses to verify medication pulled from emergency kit. This will ensure the correct medication is pulled and that it is not contraindicated due to allergy. All nurses will be in serviced on updated policy that all residents will be assesses every shift during the duration of antibiotic therapy by a licensed nurse to monitor for adverse reaction. Assessment will be documented on MAR, nurses notes and noted on facility 24-hour report. In servicing will be conducted by DON or designee. Started 03/07/23 5:30 pm completed on 03/08/23 11:55 pm. All residents receiving an antibiotic were audited to ensure no other residents were affected. Audit performed by DON. Started 03/07/23 5:40 pm Completed 6:15 pm. Don and admin audited to ensure all residents charts have known allergies clearly identified on chart and MAR. Started 03/07/23 5:40 pm completed 7pm. Administrator verified both nurses that administered the medication have written counseling on file and were provided with education on identified failure. Started 03/07/23 5:40 pm- completed 6pm. Resident #1 remains in the hospital. Administrator notified medical director of immediate jeopardy on 03/07/23 At 5:45 pm. Facility will hold QA on 03/08/23 to address identified failures. Start 03/07/23 completed 03/08/23 12:30 pm Systems, Polices and procedures Facility updated policy and procedure titled medication utilization. Update includes two nurses to verify all medications obtained from pharmacy emergency kit. Two nurses will verify the medication is correct and not contraindicated due to allergies. Residents receiving antibiotic therapy will be assessed every shift during the duration of therapy to monitor for adverse reaction. Assessment will be documented on MAR, nurses notes and noted on facility 24-hour report. In servicing will be conducted by DON or designee. Started 03/07/23 7pm completed 03/08/23 11:55 pm.] The facility noted in their plan of removal some areas would not be completed until 03/08/23 at 11:55 p.m. On 03/09/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews on 03/09/23 between 9:40 a.m. and 12:48 p.m. facility staff: LVN F/MDS nurse- worked as nurse on the floor sometimes mostly day shift. LVN A- worked 7:00 a.m. to 3:00 p.m. also took on call and worked all 3 shifts. LVN G- worked 7:00 a.m. to 3:00 p.m. LVN E -worked 11:00 p.m. to 7:00 a.m. and 7:00 a.m. to 3:00 p.m. RN H/treatment nurse- worked as a nurse on the floor on occasion. Normally worked 8:00 a.m. to 5:00 p.m. also worked on call and worked had worked all 3 shifts. LVN B/ Medication nurse-worked 7:00 a.m. to 3:00 p.m. RN D/ Medication nurse- worked 3:00 p.m. to 11:00 p.m. ADON/RN - worked 7:00 a.m. to 5:00 p.m.- also worked on call and worked all 3 shifts. LVN I/MDS nurse - worked 7:00 a.m. to 3:00 p.m. LVN J- worked 3:00 p.m. to 11:00 p.m. LVN K/Medication nurse- worked 7a to 3:00 p.m. Record review of in services and staff interviews indicated they were knowledgeable regarding checking documentation to ensure residents did not have allergies to medications prior to administration. The staff indicated they were to check the physician orders, and MAR when receiving the order from the physician for any allergies to medications. They were to check the physician order and MAR prior to administration of medications. They said if the initial dose of medications needed to be given from the ER kit two nurses were to sign and verify there were no allergies. The staff said they would ensue the residents were monitored for adverse side effects to the medications, and the monitoring would be noted in the nurses' notes, on the 24 hour report, and on the MAR. They were able to provide information and refer to policies they were educated on during the in-services they received. The administrative staff to include the DON and ADON were knowledgeable as well. Record reviews were completed on two charts to ensure nursing notes contained documentation about adverse reactions to medications. The MARs of those residents were reviewed to ensue documentation about adverse reactions to mediations. The 24-hour report was also reviewed to ensue documentation was noted about adverse reactions to medications. The residents' allergies were also checked to ensure residents were not receiving medications listed that they were allergic to. There were no issues identified. During an interview and observation on 03/9/23 at 11:08 a.m. the DON said she was also in serviced. She was educated on the importance of checking documentation. She said right now she was checking charts to make sure nurses had documented in the nursing notes, MAR and on the 24-hour report. Observation verified the DON checking her records of antibiotics against the 24-hour report and nursing notes. The Administrator, DON, Corporate Nurse, MDS coordinator, and ADON, were informed the Immediate Jeopardy was removed on 03/09/23 at 12:56 p.m. The facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy with a scope of isolated 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 observation, interview, and record review, the facility failed to provide basic life support, including CPR, to residents requiring emergency care prior to the arrival of emergency medical personnel. There were no staff on the 11p-7a shift certified to provide CPR on 5 of 25 dates reviewed from [DATE] through [DATE]. ([DATE], [DATE], [DATE], [DATE], and [DATE]) On [DATE] at 8:30 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could result in failure to treat cardiac arrest, delayed care during cardiac arrest, or death for residents who wished to be resuscitated in the event of cardiac arrest. Findings included: Record review of a daily census report dated [DATE], provided by the Administrator, indicated there were 42 residents who wished to be resuscitated in the event of cardiac arrest. During an interview on [DATE] at 2:50 p.m., RN C said she had been the Staff Development Nurse for approximately one month. RN C said she taught CNA classes, worked on incident reports, and provided training for the nurses on the Automated External Defibrillator (AED). RN C said nurses were not required to be CPR certified when hired, and when the facility hired a nurse that did not have a CPR certification, the facility tried to get them certified within a month. RN C said she did not know who was responsible for checking CPR certifications. During an interview on [DATE] at 3:23 p.m., the DON said it was the responsibility of the Staff Development Nurse (RN C) to check CPR certifications, but RN C was new in that position and had not had time to get it done. The DON said nurses were not required to have a CPR certification when they were hired. The surveyor asked the DON if the facility had a responsibility to ensure that at least one staff was certified to perform CPR on each shift. The DON said CPR was covered under the nurse's scope of practice, and the facility did not have a policy that required staff to be certified to perform CPR on each shift. During an interview on [DATE] at 3:50 p.m., the Administrator said he had been an Administrator for 36 years and had never heard that the facility was required to have staff certified to perform CPR on each shift. The Administrator said the facility knew who CPR was certified but did not say how the facility knew which staff had current certifications to perform CPR. During an interview on [DATE] at 5:07 PM, the DON said the facility was contacting staff in an attempt to get documentation of staff CPR certifications. The DON said the facility did not have copies of staff CPR certifications, and that the night shift staff were not answering their phones. The DON said someone from the facility would have to go to each staff members home to request the certifications. A review of staffing schedules indicated there were no staff on the 11p-7a shift certified to provide CPR on 5 of 25 dates reviewed for the month of [DATE]. ([DATE], [DATE], [DATE], [DATE], and [DATE]) Review of records provided by the Administrator on [DATE] included all CPR certifications the facility could provide, and staff sign in sheets from [DATE] thru [DATE]. The records indicated there were five dates the facility did not have staff certified to perform CPR on the 11p-7a shift ([DATE], [DATE], [DATE], [DATE], and [DATE]). Record review of a facility audit of licensed nursing staff CPR certifications, dated [DATE], indicated 13 of 27 licensed nurses did not have current training in performing CPR. Staffing records indicated there were five dates the facility did not have staff certified to perform CPR on the 11p-7a shift ([DATE], [DATE], [DATE], [DATE], and [DATE]). During an interview on [DATE] at 9:00 a.m., the Administrator said the facility audit of CPR certifications was completed on [DATE] and included all licensed staff. The Administrator indicated 13 licensed staff did not have current CPR certifications. Record review of an e-mail from RN F, dated [DATE] at 9:38 p.m., indicated the regional nurse consultant had conducted an in service with the Administrator and DON. The email indicated the in-service was related to requirements for long term care in regard to CPR certification. The in-service indicated the facility must have current CPR certification on nursing staff and ensure availability of certified staff every shift. Systems were discussed for future oversight and maintenance to ensure deficient practice does not reoccur. The in-service was signed by the Administrator and DON. During an interview on [DATE] at 8:50 a.m., RN F said the facility had reviewed the regulations and that she had provided an in-service to the Administrator and the DON regarding the requirement to have someone in the facility who was CPR certified on each shift, and that an online refresher alone was not adequate. RN F said, I can't apologize enough that this has happened. RN F said there would be a CPR class in the facility at 10:00 a.m. During an interview on [DATE] at 9:00 a.m., the Administrator said LVN L worked on the 11p to 7a shift. The Administrator said LVN L told the facility her CPR certification was valid, but the facility did not receive a copy of it when she was hired. The administrator said, we should have. He said when the facility requested a copy of her certification on [DATE] LVN L told them it had expired. The administrator said the HR staff should have obtained a copy of LVN L's CPR certification when she was hired, and that the person who does that now knows to make sure that is done when nurses are hired. The administrator said the facility had been trying to arrange for someone to teach a CPR class, but it hasn't happened yet. The administrator said, It should have already been done. During an interview [DATE] at 9:58 a.m., RN F said at one time there was a system in place to ensure CPR certifications were tracked. She said the facility had experienced turnover in management and that tracking CPR certifications had falling through the cracks, and that has led to this system failure. RN F said usually the HR staff would check CPR certifications when nurses were hired, but in this facility, they intended to assign that task to the RN C, but they didn't, and the system failed. During an interview on [DATE] at 11:02 a.m., LVN H said she worked 8a-5p shift and had worked at the facility for about 3 weeks. She said her CPR certification was current, but the facility never asked to see it when she was hired. During an interview on [DATE] at 11:15 a.m., LVN I said she worked the 3p-11p shift. LVN I said her CPR certification had expired, but she was not sure when. She said the last class she had taken was in 2020. LVN I said when her CPR certification expired the facility did not prompt her to renew it. During an interview on [DATE] at 11:20 a.m., LVN J said she had worked on the 11p-7a shift for about 5 years. She said her CPR certification had expired in [DATE]. LVN J said she did not recall the facility prompting her to renew her CPR certification. During an interview on [DATE] at 11:30 a.m., LVN K said she worked 8a-5p. LVN K said her CPR certification had expired in [DATE]. She said the facility told her once in June or [DATE] to renew her certification, but that was the only time. During an interview on [DATE] at 12:15 p.m., LVN L said she had worked at the facility for about a month on the 11p-7a shift. She said the facility had asked whether she was certified to perform CPR when she was hired and she told them yes. LVN L said the facility did not ask to see documentation of her CPR certification nor ask for a copy of it when she was hired. LVN L said she discovered her CPR certification had expired a couple of days ago when she cleaned out her purse. LVN L said she did not recall the date her certification had expired and that she had thrown the card away. During an interview on [DATE] at 2:49 the administrator said the failure of the facility to ensure there was someone certified to perform CPR on each shift was a system failure related to not understanding who was responsible for keeping records. He said there had been changes in staff and a lack of knowledge on the part of quite a few people who were unnamed. During a telephone interview on [DATE] at 11:00 a.m., the Human Resources manager said she became responsible for ensuring CPR certifications were valid upon hire after the survey ended on [DATE]. The HR manager said that task was previously assigned to the staffing coordinator, who's last day to work at the facility was [DATE]. The HR manager said she did not know who was responsible for the task between [DATE] and [DATE]. During a telephone interview on [DATE] at 1:57 p.m., the DON said the facility did not provide training on how to perform CPR, other than a CPR class. Record review of a facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation, revised [DATE], included a policy statement indicating personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of cardiac arrest. The policy also indicated: The chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. Select and identify a CPR Team for each shift in the case of an actual cardiac arrest. To the extent possible designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. The CPR team in this facility shall include at least one nurse, one LVN and two CNA's all of whom have received training and certification in CPR Continue with CPR until emergency medical personnel arrive This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 8:30 p.m. The Administrator was notified on [DATE] at 8:30 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The Administrator was provided with the IJ template on [DATE] at 8:30 p.m. The following Plan of Removal was submitted by the facility. The plan of removal was accepted on [DATE] at 3:15 p.m., and included the following: I. RESIDENTS WHO HAVE SUFFERED, OR ARE LIKELY TO SUFFER, A SERIOUS ADVERSE OUTCOME AS A RESULT OF THE NON-COMPLIANCE THE FAILURE TO ENSURE THAT EMPLOYEES HAD THE APPROPRIATE TRAINING AND COMPENTENCAY IN CPR CREATED A FINDING OF IMMEDIATE JEOPARDY. THIS HAD THE POTENTIAL TO IMPACT ALL 42 FULL CODE RESIDENTS WHO DID NOT HAVE AN OOH DNR AND HAD ELECTED TO BE RESUCCIATED IN THE EVENT OF AN CARDIAC ARREST. II. ACTIONS THE FACILITY WILL TAKE ADMINISTRATOR AND DON WERE INSERVICED ON [DATE] AT 9:15 PM BY REGIONAL NURSE ON THE POLICY AND PROCEDURE FACILITIES CPR POLICY AND TRAINING REQUIREMENTS ON THE REGULATION OF F678 WHICH INCLUDES FACILITIES MUST ENSURE THAT PROPERLY TRAINED PERSONNEL (AND CERTIFIED IN CPR FOR HEALTHCARE PROVIDERS) ARE AVAILABLE IMMEDIATELY (24 HOURS PER DAY) TO PROVIDE BASIC LIFE SUPPORT, INCLUDING CARDIOPULMONARY RESUSCITATION (CPR), TO RESIDENTS REQUIRING EMERGENCY CARE PRIOR TO THE ARRIVAL OF EMERGENCY MEDICAL PERSONNEL, AND SUBJECT TO ACCEPTED PROFESSIONAL GUIDELINES, THE RESIDENT'S ADVANCE DIRECTIVES, AND PHYSICIAN ORDERS. INTIATED: [DATE] COMPLETED: [DATE] 10:00 A.M. IN-SERVICES ON THE ON CPR POLICY WERE STARTED ON [DATE] AT 9:20PM BY DON FOR ALL FACILITY STAFF, INCLUDING: DIRECT NURSING STAFF, CHARGE NURSES, DIETARY STAFF, SOCIAL WORKER, MDS NURSES, MAINTENANCE, AND THE RECEPTIONIST.NO EMPLOYEE WILL BE ALLOWED TO WORK UNTIL THEY HAVE BEEN IN-SERVICED ON THE POLICY AND REQUIREMENTS OF ADEQUATELY CPR TRAINED STAFF COVERAGE IN BUILDING AND THE REQUIREMENTS OF CPR TRAINING TO INCLUDE A SKILLS CHECKOFF. ALL IN-SERVICE TRAINING TO BE COMPLETED BY EMPLOYEES NEXT WORKING SHIFT. INITIATED: [DATE] COMPLETED: [DATE] 11:00 P.M. ADMINISTRATOR VERIFIED THAT A CERTIFIED CPR TRAINED LVN, PER REGULATORY REQUIREMENTS INCLUDING RETURN DEMONSTRTATION, WILL BE ON SHIFT AT 11:00P.M. ON [DATE] AND WILL STAY ON SHIFT UNTIL 7:00 A.M ON [DATE]. INITIATED: [DATE] COMPLETED: [DATE] 11:00 P.M. AN AUDIT OF ALL EMPLOYEES FOR CPR CERTIFICATION AND TRAINING WAS COMPLETED BY ADMINISTRATOR ON [DATE] FOR CPR COMPLIANCE. INITIATED: [DATE] COMPLETED: [DATE] 11:00 P.M. ADMINISTRATOR HAS ARRANGED A BLS CERTIFIED INSTRUCTOR TO APPLY TRAINING AND CERTIFICATION FOR 10 EMPLOYEES ON [DATE] AT 10:00A.M. THIS TRAINING WILL INCLUDE A SKILLS CHECK-OFF. EMPLOYEES INCLUDED IN TRAINING CONSIST OF 1 CHARGE NURSE LVN 11 P.M.- 7:00 A.M SHIFT, 4 CHARGE NURSE LVNS 7:00 A.M. - 3:00 P.M. SHIFT, 1 CHARGE NURSE LVN 3:00 P.M. - 11:00 P.M. SHIFT, 1 R.N - DIRECTOR OF NURSES, 1 RN - ASSISTANT DIRECTOR OF NURSES, 1 RN - WOUND CARE NURSE, AND 1 CHARGE NURSE RN 3:00 P.M. - 11:00 P.M. SHIFT. ALL 11:00 P.M. - 7:00 A.M. ARE NOW CPR CERTIFIED - INITIATED: [DATE] COMPLETED: [DATE] 2:00 P.M. III. SYSTEMS, POLICIES, AND PROCEDURES FACILITIES POLICY AND PROCEDURE TITLED EMERGENCY PROCEDURE- CARDIOPULMONARY RESUCITTATION WAS REVIEWED AND UPDATED BY ADMINISTRATOR AND REGIONAL NURSE ON [DATE] TO ENSURE THAT CURRENT POLICY MEETS THE STANDARDS OF PRACTICE AND REGULATORY REQUIREMENTS ON PROPERLY TRAINED STAFF ARE IN THE BUILDING 24/7. INITATED: [DATE] COMPLETED: [DATE] 12:00 P.M. IV. MONITORING, AUDITS, AND QAPI ONGOING SYSTEMATIC CHANGE TO ENSURE CPR TRAINED STAFF ARE ON ALL SHIFTS IS THAT ALL LICENSED PERSONELL WILL NOW BE REQUIRED TO OBTAIN CPR CERTIFICATION. A BINDER WITH ALL CERTIFICATIONS AND CARDS WILL BE KEPT IN THE HUMAN RESOURCE DEPARTMENT AND AUDITED MONTHLY BY HUMARN RESOURCE DIRECTOR TO ENSURE THAT CARDS ARE CURRENT AND NOT EXPIRED. HUMAN RESOURCE DIRECTOR HAS BEEN TRAINED ON HER DUTIES, CPR REQUIREMENTS, AND WHICH CPR CLASSES ARE ACCEPTABLE PER REGULATORY REQUIREMENTS. SHE WILL POST AND NOTIFY SUPERVISORS 60 DAYS BEFORE CPR CERTIFICATION EXPIRES. BINDER WILL BE SEPERATED BY DIVIDERS FOR EACH SHIFT TO ENSURE THAT EACH SHIFT HAS PROPERLY TRAINED PERSONELL. THE ADMINISTRATOR AND OR REGIONAL NURSE WILL MONITOR FOR COMPLIANCE MONTHLY. INITIATED: [DATE] COMPLETED [DATE] 2:30 P.M. THE QAPI TEAM, LED BY THE ADMINISTRATOR, WILL MEET WEEKLY FOR 3 WEEKS TO DISCUSS COORDINATION OF COMPLETION OF ALL IN-SERVICES, ASSESSMENTS, AND INTERVENTIONS ARE UTILIZED AND COMPLETED TO ENSURE THAT APPROPRIATE CPR TRAINED STAFF ARE ON DUTY FOR EACH SHIFT. THE MEDICAL DIRECTOR WAS NOTIFIED ON [DATE] OF THE IMMEDIATE JEOPARDY CALLED ON FACILITY. INITIATED: [DATE] COMPLETED: [DATE] 12:00 P.M. The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Record review of the staffing schedule for [DATE] indicated LVN G had been scheduled to work the 11p-7a shift to ensure staff certified to perform CPR were available. Documentation for LVN G's CPR certification was reviewed. Record review of an email from RN F, dated [DATE] at 9:38 p.m., indicated the administrator and DON had received an in-service on [DATE] regarding the requirement that the facility must provide staff who are certified to perform CPR on each shift, and that an online only certification was not sufficient to meet the requirement. Observation on [DATE] at 10:00 a.m. indicated the facility had provided an instructor lead CPR class which included return demonstration of skills Record review of an invoice, dated [DATE] and given to the facility by a CPR instructor, indicated 10 staff members had attended a CPR class on that date. Review of the CPR class roster indicated the following nurses by position and shift had completed the CPR certification: of 1 LVN charge nurse on the 11p-7a shift, 4 LVN charge nurses on the 7a-3p shift, 1 LVN charge nurse on the 3p to 11p shift, the DON, 1 RN ADON, 1 RN Wound Care Nurse, and 1 RN charge nurse on the 3p-11p shift. An additional LVN charge nurse on the 11p-7a shift completed a CPR certification outside the facility and provided documentation to the facility. During interviews on [DATE] between 10:00 am and 12:15 p.m., 1 RN and 8 LVNs, representing all shifts, indicated they were CPR certified and could correctly identify the rate of compressions, depth of compressions, and ratio of compressions to rescue breaths (ADON, LVN M, LVN G, LVN H, LVN I, LVN J, LVN N, LVN O, LVN L) All nurses interviewed indicated they were aware the facility was required to ensure staff certified to provide CPR were available on each shift. The administrator was informed the Immediate Jeopardy was removed on [DATE] at 4:00 p.m. The facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.