**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure basic life support measures including cardiopulmonary resuscitation (CPR) were in place immediately, when needed, for a resident requiring emergency care for 1 of 2 residents (R35) reviewed during closed record review. R35 was a full code (wanted CPR). On [DATE], R35 stated she had chest pain rating at a 9/10 or 10/10. RN E (Registered Nurse) gave Tums and Tylenol which were not effective for R35's chest pain. R35's blood pressure was below R35's baseline. R35 continued to complain of chest pain. After 1 hour and 43 minutes from R35's initial complaint of chest pain, the facility called 911 for emergency medical services (EMS). The facility did not prepare to provide basic life support by failing to place R35 on a hard surface to initiate CPR, failing to have a crash cart in the room, and failing to provide supplemental oxygen. When EMS arrived, R35 was completely unresponsive to all stimuli, and was apneic (lack of breathing). RN E did not initiate basic life support, including CPR, when R35 presented with apnea. Upon arrival EMS initiated CPR. Resident was transported to hospital where she passed away. The facility's failure to provide basic life support, including cardiopulmonary resuscitation to a resident who wished to be full code created a finding of immediate jeopardy that began on [DATE]. Surveyors notified NHA A (Nursing Home Administrator), DON B (Director of Nursing), and VPCO D (Vice President of Clinical Operations) of the immediate jeopardy on [DATE] at 3:15 PM. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a severity/scope of D (Potential for Harm/Isolated) as the facility continues to implement its action plan. This is evidenced by: Per Centers for Medicare and Medicaid Services (CMS) Cardiopulmonary resuscitation (CPR) memo 14-01 revised [DATE], CPR refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased. When addressing full-code residents: If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition,) facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services. Facility policy titled, Code Status, implemented 7/2009 and last reviewed 2/2024, states in part: Purpose: To provide guidelines to staff with regards to determining and recording resident wishes related to code status and initiating cardiopulmonary resuscitation (CPR). Policy: It is the policy of this facility to properly identify and assess residents that are pulseless and unresponsive and provide timely and appropriate treatment. CPR will be initiated on all residents that have chosen CPR .When a cardiac arrest has been determined the following basic steps will be taken: .The facility staff is notified of the emergency by activating the emergency call light system/yelling for help by stating Code Blue. Verify the resident's code status .Designate someone to call 911. Staff begins CPR according to established standards of practice while designating someone to get AED (Automated External Defibrillator. A portable device that can be used to treat a person whose heart has suddenly stopped working.) and crash cart. Bare resident's chest and attach AED. Following the instructions as noted on the machine until EMS arrives. Other items that may be necessary to treat symptoms are available on the crash cart include ambu bag (a hand-held device commonly used to provide ventilation to a person who is not breathing or not breathing adequately), suction machine and supplemental oxygen. R35 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset, bulimia, hyperlipidemia, personal history of non-Hodgkin's lymphoma, and major depressive disorder. R35's Minimum Data Set (MDS) dated [DATE] indicates R35 has a Brief Interview for Mental Status (BIMS) of 4, indicating R35 had a severe cognitive impairment. R35 has an activated power of attorney (POA) which names her sister as the POA. R35's physician orders indicated that R35 chose to be a full code. R35's care plan states in part: .Focus: I am a Full code. Goal: My request will be honored during my stay at this facility. Interventions: Call 911 for transportation to the hospital. Initiate CPR in the absence of a pulse. Notify family and physician of changes in condition . R35's Weights and Vitals Summary Report indicates, in part, blood pressures on the following dates: [DATE] BP - 144/74 [DATE] BP - 138/76 [DATE] BP - 134/85 [DATE] BP - 114/71 Late entry Nurses Notes dated [DATE] at 20:30 (8:30PM), written by RN E (Registered Nurse) states: This writer went into the resident's room; resident is complaining of her chest hurting. Resident had family at the facility today visiting and everyone just left within the past few hours. Resident also complained of her stomach hurting. Asked if she ate anything unusual-she was not able to recall what she had to eat. Resident stated her pain is at a 9/10 or 10/10, with moaning and continuing to move her feet being unable to sit still at times because of pain. No pain in arm, neck, or jaw. 8:35pm: Resident had a loose stool and sat back down on couch, I elevated her legs on a pillow, and she stated that she felt some better. We have standing physician orders in the facility for tums 500mg-2 chewable tabs po (by mouth) q (every) 4hrs (4 hours) for indigestion prn (as needed). I asked resident if she would like to try the two tums first and go from there; she voiced understanding and agreed to try this first. I then followed up at 9:00pm- resident states she feels some better, but she is still hurting. We have standing physician orders in the facility for Tylenol 650mg po q 4hrs for pain or fever. Not to exceed 4,000mg daily. Resident voiced understanding and agreed to try a 650mg acetaminophen for the pain. I stayed with resident and assessed her every 10-15 minutes for an hour to monitor her vitals and pain: 8:35pm: 82/49-bp (blood pressure), 97.2-temp (temperature), 69-pulse, 96-O2 (oxygen saturation), rr-17 (respiratory rate) 8:40PM: 107/94-bp, 96.4-temp, 72-pulse, 97-O2, rr-17 8:55pm: 103/75-bp, 96.4-temp, 55-pulse, 98-o2, rr-17 9:10pm: 105/76-bp, 96-temp, 62-pulse, 96-o2, rr-17 9:25pm: 109/75-bp, 96.2-temp, 64-pulse, 96-o2, rr-18 9:40pm: 91/55-bp, 97.1-temp, 73-pulse, 98-O2, rr-18 9:55pm: 89/58-bp, 97.7-temp, 62-pulse, 97-O2, rr-17 I asked the resident to follow me down to the nurse's station if she was able to, and to sit on the bench, because I need to call (Sister's Name) and advise her of what is going on, and see what she wants to do, because resident needs to be seen at the hospital. Resident voiced understanding and agreed to follow me up to the nurse's station. She placed her shoes on but never made it up to the nurse's station; 2 minutes after leaving the resident's room, I was calling (Sister's Name) when I asked the CNAs (Certified Nursing Assistant) to check on resident and was notified that I needed to come to resident's room ASAP as she was not responsive. I tried to awake resident with a sternum rub, no response, Eyes-pupils were fixed and equally 4mm in size. Resident was breathing, her eyes were wide open, with BP of 82/45 pulse 44 then went to 22 right before rescue squad showed up, temp-97.7, O2-96 RR 22. Resident is a full code-notified rescue squad of this, printed off current med review list, and face sheet-handed this to rescue squad however they still left this behind in resident's room. 10:05pm: 82/45 (bp), 97.2-temp, 44-pulse went to 22, 100-o2, rr-17. 10:13am: [sic] As I continued to assess resident again, delegated to CNA to call (City Name) Rescue Squad and inform them that we have an emergency with resident not responding and vitals are faint and need their assistance asap. 10:20pm-Called resident's sister-(Sister Name) to inform her that resident is complaining of 9/10 10/10 chest pain and is showing signs of bradycardia (slow heart rate), and that resident has agreed to be sent out to the hospital to be evaluated and assessed. Resident stated that she wants her sister by her side as she trusts her with any decisions that are needed to be made on her behalf . Of note, according to National Heart, Lung, and Blood Institute from National Institute of Health (nhlbi.nih.gov), warning signs of cardiac arrest include belly pain, nausea, and chest pain. Of note, according to National Institute of Health, fixed pupils in cardiac arrest are a result of inadequate blood supply to the brain (pubmed.ncbi.mln.[NAME].gov). EMS report dated [DATE], states in part: . unit notified: [DATE] 22:13:41 (10:13PM) .arrived at Pt (patient): [DATE] 22:23:13 (10:23PM) Respirations 22:26:10 Apneic .Patient Care Report Narrative: (City Name) EMS paged to (Facility Name) for a patient that was breathing but not responsive. Crew responded to scene without delay. Once crew arrived on scene, they were met by a nursing home staff that pointed crew in the direction of the patients room. Once crew made it to patient side it was asked right away what the patients code status was. Patient was laying supine (laying face upward) on a couch completely unresponsive to all stimuli. Patient was immediately hooked up to vital monitor including a 4 lead (a machine that uses four electrodes to record the heart's electrical activity) while feeling for a pulse on the patient. While doing all this crew asked for a medical history on patient and all the nursing home staff stated was Alzheimer's but also stated patient had chest pain an hour before we called and another staff worker also stated, patient said they had bad chest pain and passed out. No pulses were palpable and 4 lead revealed asystole (no heartbeat) and with patient being a full code CPR was started immediately .Every 2 minutes rhythm was assessed as well as a pulse check. Patient remained in asystole while on scene . Of note, asystole is a type of cardiac arrest, which is when the heart stops beating entirely. This can cause someone to become unresponsive, not breathing or only gasping breaths (gasping breaths are not life sustaining) (American Heart Association, www.heart.org). Hospital records from the Emergency Department (ED) dated [DATE] at 10:54PM, states in part: .Chief Complaint: Cardiac Arrest .presented to ED today via EMS from (Facility Name) with ongoing CPR. Reported that patient was having chest pain .(facility) Staff then noted she became unresponsive, EMS (Emergency Medical Services) was called, reported they felt a weak pulse and patient was breathing, but quickly became pulseless. CPR started; airway was placed by EMS . On [DATE] at 8:14AM, Surveyor interviewed EMS H. EMS H indicated it took 10 minutes from the time the facility called 911 until EMS arrived at R35's side. Upon arrival to R35, she did not have a pulse and was apneic (lack of voluntary breathing). Surveyor asked EMS H about the hospital record stating felt a weak pulse and patient was breathing; Surveyor asked EMS H was the resident breathing upon your arrival. EMS H stated no, the resident was apneic, unresponsive, with no pulse. EMS H stated he would have expected facility staff to be performing CPR on R35 upon their arrival. EMS initiated CPR immediately. EMS H indicated the crew was not prepared to find R35 pulseless based on the call they received which was unresponsive but breathing. On [DATE] at 10:03AM, Surveyor interviewed CNA F (Certified Nursing Assistant). CNA F indicated she worked the evening shift on [DATE]. CNA F stated she worked on a different unit than R35. CNA F stated RN E was the nurse for the unit CNA F was working and was also the nurse for R35. CNA F indicated she needed RN E around 9:30PM on [DATE] because of a resident issue. CNA F indicated it took RN E about 15 minutes to come to the unit because RN E was dealing with R35. CNA F indicated at the end of her shift and after she had given report to the oncoming CNA, she left the unit and was walking by the nurse's station. CNA F saw RN E sitting at the nurse's station. CNA F saw another CNA from R35's unit coming up to the nurse's station to request RN E to come to R35's room because R35 was unresponsive. CNA F indicated the other nurse on duty called 911 and CNA F went down to assist with getting the room ready for EMS. CNA F indicated when she saw R35, R35 was laying on her couch, completely unresponsive, mouth agape. CNA F indicated staff attempted to obtain vital signs by using a blood pressure cuff and a pulse oximeter (device used to measure pulse and oxygen levels) and neither device could pick up a reading. CNA F indicated she was instructed to wait for EMS and direct EMS where to go when they arrived. CNA F indicated she waited for EMS at the front by the nurse's station and told them where to go. CNA F indicated after EMS had arrived, RN E instructed her to bring the crash cart and the other nurse told her where the crash cart was located. It should be noted despite R35 having recent known chest pain and being unresponsive with bradycardia, the facility did not provide basic life support including placing R35 on a hard surface to initiate CPR, did not have a crash cart in the room, and was not providing supplemental oxygen. On [DATE] at 11:20AM, Surveyors interviewed DON B (Director of Nursing) and VPCO D (Vice President of Clinical Operations). DON B indicated if a resident complains of chest pain, the nurse should immediately notify the physician. DON B indicated an hour is too long to wait before notifying a physician or sending a resident out if they are complaining of chest pain. DON B indicated EMS can take up to 20 minutes to arrive to facility and RN E should have had the crash cart ready while waiting for EMS. DON B stated she could not speak to RN E's actions but obviously that is an unacceptable way to handle the situation and she should have started CPR. VPCO D indicated as soon as R35 was unresponsive they should have initiated CPR. VPCO D indicated she was not familiar with RN E since RN E was no longer working at the facility. VPCO D did agree there were inconsistencies with RN E's nurse's notes. VPCO D indicated a nurse consultant had completed an investigation on the event because it raised concerns about notifying a physician when there is a change in condition. VPCO D was not sure when the consultant completed the investigation. VPCO D shared a copy of the investigation report with the surveyors. The investigation report titled Investigation of Circumstances Surrounding Medical Transfer [DATE] is not dated or signed by the person completing the report. The report states, in part: .had clinical indications of a significant change in condition that RN E did not respond to adequately delaying the resident's [R35] discharge from the facility .issue with RN E's ability to make appropriate nursing decisions involving recognition of basic changes in resident condition . On [DATE] at 10:20AM, Surveyor called RN E to obtain an interview. Surveyor left a message on the voicemail but was unable to interview RN E. On [DATE] at 11:24AM, Surveyor interviewed MD G (Medical Doctor). MD G was the primary physician for R35. MD G indicated R35 should have notified a physician immediately upon R35's complaint of chest pain. Surveyor asked MD G what a physician's response would be if a nurse calls and states a resident is complaining of new onset of 9/10 or 10/10 chest pain with a blood pressure of 82/49. MD G indicated a physician would have ordered the resident to be seen. MD G agreed CPR should have been started because R35 was a full code. On [DATE] at 8:30PM, R35 complained of significant chest pain. RN E gave tums and Tylenol which were not effective. RN E monitored R35's vital signs for 1 hour and 43 minutes during which time R35's blood pressure remained abnormally low. RN E did not notify a physician. RN E did not provide basic life support when R35 became unresponsive and did not initiate CPR when RN E was apneic. The failure to ensure R35, a resident who had chosen to be full code, received basic life support when R35 presented with a change of condition created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when the facility completed the following: 1) RN E no longer employed at the center 2) Reeducation to nursing staff on CPR and competencies completed on [DATE] or prior to the start of their first shift 3) All residents at center records reviewed for care planning regards to code status 4) Education to staff provided by DON and VPCO on: 5) Immediate provider notification in acute change of condition 6) AMDA guidelines (American Medical Directors Association) 7) Location of crash cart and AED with emphasis on immediately bringing to patient bedside for immediate access if needed. 8) Detailed protocols and procedures for CPR 9) Automated external defibrillator use including policy review 10) Code sample procedures and drills 11) Adult basic life support including detailed assessment documentation 12) CPR drills completed on random shifts x 1 shift/week x 6 weeks then bimonthly x 2 months (random shifts) note work 12 hours shifts 13) Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting conducted to review current policies and procedures including CPR 14) All residents at center reviewed for valid code status On [DATE], facility held an ad hoc QAPI meeting and reviewed policy on CPR as well as events. CPR drills will be completed on random shifts once a week x 6 weeks then bimonthly x 2 months or until further reviewed by QAPI for substantial compliance. CPR drills will include randomized situations to provide various critical thinking scenarios.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 - the following examples are at a level 2. The State Agency received a complaint regarding abuse allegations involving RN U (Registered Nurse). The complaint alleged RN U was abusive toward residents and the staff reported these incidents to the former NHA (Nursing Home Administrator) however no investigation into the allegations occurred. R1 is a long-term resident of the facility in the locked memory care unit. R1 was admitted to the facility on [DATE]. R1's most recent MDS (Minimum Data Set) dated 6/12/23 of a significant change of condition, unscored on his BIMS (Brief Interview of Mental Status) which indicates R1's cognitive status is severely impaired. On 7/19/23 at 4:40 PM, Surveyor interviewed CNA W (Certified Nursing Assistant). Surveyor asked CNA W of any concerns with a staff member, she indicated about a month ago R1 was having one of his behaviors and RN U grabbed his hands and pushed R1 back. CNA W further indicated that R1 ran into the table when stumbling backwards, and he was a few feet from the table. Surveyor asked CNA W what R1 was doing at the time, she indicated R1 was just standing there and that R1 will get on edge if he is approached too quickly. CNA W further indicated that she was just starting her night shift and was working on that wing. Surveyor asked CNA W if she reported this incident, she indicated she did not until she was approached by the DON B (Director of Nursing) today. CNA W further indicated that she did not report the incident as she was thinking that nurses are supposed to know what they are supposed to do. Example 3 R14 is a long-term resident of the facility. R14 was admitted to the facility on [DATE]. R14's most recent quarterly MDS dated [DATE], scored at 14 on her BIMS which indicates R14's cognitive status is intact. On 7/20/23 at 12:00 PM, Surveyor interviewed CNA V. Surveyor asked CNA V if there have been any concerns with a staff member, she indicated there was incident with R14 with her CPAP (Continuous Positive Airway Pressure) machine. CNA V further indicated she went into R14's room to try to get the CPAP seal to R14's face. Due to unsuccessful attempts, CNA V called RN U for assistance. CNA V reports that RN U was yanking R14's head around, it was abusive, and tapping her face. R14 informed RN U that she was getting water on her face. RN U was tapping her face and told her there was no water on her face. Surveyor asked CNA V if the incident was reported, she indicated it was put in writing with another CNA and an RN and placed into the NHA's (Nursing Home Administrator) basket. Surveyor asked CNA V if there was any follow up, she indicated she did not have any follow up and that the DON is fully aware of these behaviors since she has started. On 7/20/23 at 9:54 AM, Surveyor attempted to contact RN U and did not receive a return phone call. On 7/20/23 at 11:12 AM, Surveyor interviewed RN E (Registered Nurse). Surveyor asked RN E if there have been any concerns with a staff member, she indicated there was a time when CNA V waived her down in the hallway to R14's room. RN E further indicated that she could tell there was something wrong, after RN U left R14's room, CNA V was almost shaking. Surveyor asked RN E the approximate time frame, RN E indicated she had trained RN U on night shift, and it was just after she started in April 2023. RN E indicated that this incident (CPAP incident with R14) has been talked about for months, DON B (Director of Nursing) reported to RN E things will get better and DON B stated this numerous times to RN E. Surveyor asked RN E if the incident was reported, she indicated she wrote a report and turned it in the former NHA. On 7/20/23 at 12:23 PM, Surveyor interviewed CNA X. Surveyor asked CNA X if there have been any concerns with a staff member, she indicated there was an incident with RN U and R14 with the CPAP machine. CNA X further indicated RN U grabbed R14's CPAP machine and was rough and tightening it. R14 reported feeling water on her face, RN U slapped R14's face and said there is not water on your face and that R14 is fine. Surveyor asked CNA X if the incident was reported, she indicated she wrote a report, provided it to the former NHA and did not receive any follow up. Surveyor reviewed RN U's personnel file and noted the following. RN U indicates she has a compact license based out of Iowa. According to NCSBN (National Council of State Boards of Nursing), RN U was ordered a cease and desist of her multi-state licensing privilege, in the state of Missouri initiated on 12/8/2016 and remains indefinite. The cease and desist was for substandard care or inadequate skill level. The following is a breakdown of the evidence recorded by the State Board of Nursing, State of Missouri, documents, in part: The Missouri State Board of Nursing has become aware of certain events that indicate that you are not safe and competent to practice nursing and that you have violated the Missouri Nurse Practice Act. The events in question involve your practice while working at [Hospital Name] from March 21, 2016, through April 19, 2016. You are licensed as a registered nurse by the Iowa Board of Nursing, a member of the Nurse Licensure Compact, which allowed you the privilege of practicing in member states. The Missouri State Board of Nursing is also a member of the Nurse Licensure Compact and you were utilizing your privilege to practice in Missouri off of your Iowa license. The evidence received is sufficient cause pursuant to sections 335.066, 225.320 and 335.325 of the Revised Statues of the State of Missouri to revoke your multi-state licensure privilege in the State of Missouri. The evidence received by the Board indicates that: You were originally hired by [Facility Name] to work in the cardiovascular intensive care unit (CVICU). Upon your hire date of March 21, 2016, you began a four (4) week orientation period in the CVICU and were assigned two (2) preceptors. You represented to [Facility Name] that you had twenty (20) years of experience as a nurse. During your orientation period, you were unable to unwilling to properly chart on patients despite being given guidance and training on how to do so and only being assigned one (1) patient to care for. You frequently needed reminders to properly chart, and you socialized too much rather than complete your charting despite being redirected on multiple occasions to cease socializing and take care of your patient, which includes proper charting. Your documentation was not entered until several hours after you completed care despite only having one (1) patient assigned to you. On your second day on the floor, you were assigned to a patient, M.B. The patient complained that you pulled on her NG tube roughly, turning her head. The patient also reported that you pushed the whole bottle of contrast that had been on ice down her NG tube at one time, which is not standard nursing practice. The patient and her daughter also complained that you engaged in inappropriate conversation that made them feel uncomfortable. That patient and her family requested that you never be assigned to the patient again based upon your actions and giving them the impression that you did not know how to care for her. On another occasion on April 4, 2016, a patient coded, and you failed to respond even though you were sitting right outside of the patient's room. Other nurses had to respond to the code. After precepting you for four (4) weeks, neither preceptor assigned to you felt comfortable leaving you alone with a patient. Pursuant to §335.310.3 RSMo, (State of Missouri Statutes) you are required to comply with the Missouri Nursing Practice Act in order to exercise your privilege to practice in this State. Your actions constitute incompetency in the performance of the functions or duties of a nurse, and, as such, violate §335.066.2(5) RSMo of the Nursing Practice Act of the State of Missouri. Your actions additionally violate professional trust or confidence with violates §335.066.2(13) of the Missouri Practice Act. This Board is allowed to take adverse action affecting the multi-state licensing privilege to practice in that party state §335.320(3) RSMo. The Board may also issue a cease-and-desist order to limit or revoke a nurse's authority to practice in the state §335.325(3) RSMo. For the reasons stated above, the Missouri State Board of Nursing orders you to CEASE AND DESIST from the practice of nursing in Missouri. You must immediately CEASE AND DESIST from the practice of nursing in Missouri based on your compact privileges granted through your home state of Iowa . On 7/20/23 at 2:12 PM, Surveyor interviewed DON B. Surveyor asked DON B if she has ever received any verbal or written statements from staff concerning any incidents, she indicated she has not received anything. DON B further indicated she was aware that the former NHA did receive information and the NHA would not divulge that information as it was a conflict due to the relationship with DON B and RN U. On 7/20/23 at 3:00 PM, Surveyor interviewed NHA A. Surveyor asked NHA if she has ever received any concerns from staff of staff behaviors, she indicated she did not and has not found any notes or an investigation. Surveyor asked NHA A if these incidents should be reported, she indicated they would immediately be reported and investigated. (It is important to note that the previous NHA left the position at the beginning of June 2023, the current NHA A has started her position in July 2023.) On 7/20/23 at 3:14 PM, Surveyor interviewed RCN C (Regional Clinical Manager). Surveyor asked RCN C if he has been informed of concerns with nurse behaviors with residents, he indicated he did not. The facility was aware staff reported concerns regarding RN U. RN U's personnel file included concerns from another state including rough treatment of patients. The facility failed to investigate allegations RN U was abusive toward residents and failed to ensure residents were protected from abuse. Based on observation, interview, and record review the facility failed to protect residents right to be free from verbal and physical abuse by Resident (R1). This has the potential to affect all 12 residents who reside on the 100 unit with R1. The facility failed to protect residents right to be free from physical abuse by Registered Nurse (RN U) for 2 of 3 residents reviewed for abuse. R1 has a history at the facility of resident-to-resident incidents including slapping a resident, shaking a resident, grabbing the shirt of a resident, and yelling and swearing at other residents. In addition, R1 has grabbed arms and throat of staff, threw staff against the wall, and punched and hit staff during cares and when walking in the hallway. Supervision for R1 was not increased to prevent further incidents. On 6/3/23 at 4:55 AM R1 entered R4's room and grabbed R4's forearms while R4 was sitting in her recliner. R4 was screaming. R1 was monitored 1:1 (one on one) from 6/3/23 at 5:00 AM through 6/6/23 at 12:00 AM. On 6/10/23, he became agitated in the dining room and wielded a knife back and forth toward a staff member. On 6/30/23 at 9:15 AM R1 went over to R9's room, while staff members attempted to intervene, R1 grabbed a staff member by both arms and proceeded to punch/strike R9 in the face with a closed fist. The facility was aware R1's behaviors of hitting, punching, grabbing, yelling, and swearing at other residents and staff. The facility's failure to increase supervision resulted in R1 abusing R4 and R9 created a finding of Immediate Jeopardy (IJ) that began on 6/3/23. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the Immediate Jeopardy on 7/6/23 at 4:08 PM. The Immediate Jeopardy was removed on 7/6/23. However, the deficient practice continues at a scope/severity of E (no actual harm with potential for more than minimal harm, pattern) as the facility continues to implement their action plan. Evidenced by: The facility's Abuse, Neglect and Exploitation policy, revised 5/1/23, includes, in part, the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. III. Prevention of Abuse, Neglect and Exploitation B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms. C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment. D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. IV. Identification of Abuse, Neglect and Exploitation B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff, or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on a resident's body 5. Verbal abuse of a resident overheard 6. Physical abuse of a resident observed IV. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: C. Increased supervision of the alleged victim and residents D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator R1 was admitted [DATE]. R1's diagnoses include dementia with agitation, anxiety, restlessness, insomnia, and depression. R1's MDS (Minimum Data Set), dated 6/12/23, indicates R1 has severe cognitive impairment, has delusions, is physical toward others, is verbal towards others, has other behaviors, rejects cares and wanders. R1 ambulates with supervision, R1's Care Plan includes, in part, the following: Focus: Resident does not usually stay in a group activity long. He will participate more when it is 1:1 or with just 1 or 2 other people. Resident enjoys spending time outdoors and his wife visits him frequently. Date Initiated: 6/24/22, Revised on 6/26/23. Interventions: Provide 1:1 visits weekly, Provide with leisure materials for room such as magazines. Take resident outside, with another staff, if he is having behaviors. When resident is agitated attempt to provide a lower stimulating activity in a quiet area. Date Initiated: 6/26/23. Focus: The resident is an elopement risk/wanderer r/t (related to) disoriented to place. History of attempts to leave facility unattended, impaired safety awareness, dementia. Date Initiated: 6/23/22. Interventions: At HS (hour of sleep) and through the night shift, observe resident q (every) 2 hours. If resident is awake restless, or wandering, offer toileting and return to bed. Date Initiated: 10/20/22. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (please note there is nothing after this) Date Initiated: 6/23/22. Provide structured activities toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date Initiated: 6/23/22. Focus: The resident has a behavior problem r/t agitation. Physical aggression to others. Resident may require 1:1's with behaviors PRN (as needed). Lashing out at staff and resident unprovoked. Date Initiated: 6/23/22. Revision on: 7/3/23. Interventions: Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Date Initiated: 6/23/22. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 6/23/22. Loud noises, patients yelling trigger me. Please redirect me to a lesser stimuli environment. Date Initiated: 7/3/23. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential causes. Date Initiated: 6/23/22. Provide program of activities that is of interest and accommodates residents' status. Date Initiated: 6/5/23. Focus: The resident is/has potential to be physically aggressive towards staff r/t dementia, hallucinations, and delusions. Date Initiated: 6/26/23. Interventions: Administer medications as ordered. Analyze times of day, places, circumstances, triggers and what de-escalates behavior and document. Anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Modify environment as needed. Encourage to go to his room or Serenity room (if unoccupied) where there is less stimulation. When the resident becomes agitated: Intervene before agitation escalates.; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Date Initiated: 6/26/23. Focus: I use anti-anxiety medication r/t anxiety disorder secondary to dementia. Date Initiated: 6/22/23. Interventions: Monitor occurrence of for (sic) target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc. and document per facility protocol. Date Initiated: 6/23/22. The facility's Misconduct Incident Report includes, in part the following: Date occurred: 6/1/23. Briefly Describe the incident: CNA was walking past R1's room when she heard a noise, CNA went to room immediately to see what had happened. CNA noticed (residents' wife/visitor) was laying on the floor next to bed. CNA asked if she was ok and not to move that she was going to go get a nurse. Before CNA left, she had another CNA remove R1 from the room until wife was able to be assessed by nurse. Nurse went to room and check on (wife). Nurse checked vitals and range of motion to make sure that there were no injuries. Vitals were good and (wife) was able to move all extremities without any pain. Nurse asked wife if she had hit her head, and she stated No Nurse asked (wife) if she could recall what happened. she stated I was standing in front of R1's chair and he was reaching for the show (sic) box to put his old shoes in, and he pushed me to get out of the way and I tripped on the mat on the floor. I know that he didn't mean anything by this. Describe the Effects: This did have a little effect on wife as she got teary eyed as she stated that I know that he doesn't realize what he has done, and it is just hard for me to see him like this. The facility implemented the following after the incident: Fifteen-minute checks implemented and will continue until midnight (6-1-23), then 30- minute checks till 6am (6-2-23), 45-minute checks until 12pm (6-2-23) and then 1-hour checks till midnight (6-2-23). Staff informed of this, and forms given to staff to fill out and return to the administrator when completed. The facility's Misconduct Incident Report includes, in part the following: Date occurred: 6/3/23. Briefly describe the incident: Staff member was talking to resident (R1) in the hallway, resident took off down the hallway and before staff member could get caught up with (R1) he had entered another resident's room (R4) and grabbed her forearms. Staff entered (R4's) room and seem (sic) that (R1) had grabbed (R4's) forearms. Staff member was able to get (R1) away from (R4), than (sic) (R1) grabbed staff members arms and was pushing the staff member and trying to hit staff member in the face. Another staff member came to help and was able to get (R1) redirected and back to his room. One on one intervention in place, staff interviews and investigation have all started. Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct: Residents were separated immediately. 1 on 1 initiated for resident (R1). MD (Medical Doctor) was notified of incident and behaviors. Medications were adjusted and will continue to monitor for effect. Educational session for all clinical staff on how to appropriately approach dementia residents was initiated. NHA (Nursing Home Administrator) or designee to complete ongoing training with all staff on dementia behaviors. Licensed nurse to be present in the dementia wing during AM and PM shifts along with CNA and HA (Hospitality Aide) staff to monitor behaviors and assist with ensuring resident and staff safety and intervene appropriately to (R1's) behaviors. Contact to local psychiatric providers for referral to additional support for resident (R1) in progress. (sic) Resident's care plan will be reviewed and modified appropriately. Continue with non-pharmacological approaches as appropriate. Continue to work with MD, staff, and residents POA (Power of Attorney) for additional resources and approaches to resident (R1) behaviors. CNA N's (Certified Nursing Assistant's) statement, dated 6/3/23, includes, in part, the following: As I was walking towards the top of the hall, I noticed (R1) leaning against the med room door. (R1) has been very unsteady and has a swollen lf (left) ankle. So, I asked him if he'd like to go and sit in a chair in his room. He said no, I then tried to start a conversation with him, asking him if his ankle hurt. He then became angry and very aggressive. He quickly took off down the hall. He entered (R4's) room before I could get there. As I entered her room, (R1) had leaned over her and grabbed her forearms. (R4) was sitting in her recliner at that time. (R4) was screaming. I radioed for help as (R1) had a hold of my arms and was pushing me and trying to hit me in the face. (CNA H) came and helped. He was pushing both of us up the hall. (CNA H) was able to get (R1) to his room and calm him down. R1's Progress Notes include, in part, the following: 6/3/23, 4:55 AM, Called to memory unit by CNA over walkie talkie for help. Upon entering unit noted (R1) had a strong hold upon (CNA N) wrist and was pulling her backwards, resident eventually calmed down. Was informed by staff the (sic) this resident had a hold of another resident, grabbed both wrists and (R4) was sitting in her recliner chair crying emotional support given, resident returned to his room without further incident. Tylenol given for pain scale of 5. Snack given and drank 2 cans of pop, residents separated and taken to room, redirected by CNA, and calmed down and let go of CNA. Assessed other resident (R4) very faint bruising noted to right arm. Resident denied pain or discomfort, resident resting quietly at this time DON (Director of Nursing), Administrator notified will notify wife and Dr. in the AM. Resident placed on 1:1 supervision. Of note, a dependent person would likely experience extreme fear and anxiety when someone enters their living space unprovoked and grabs them to the point of bruising. R4 was emotionally upset and crying after the incident. R1's Resident One to One Supervision Record shows that R1 was on one to one from 6/3/23, 5:00 AM - 6/6/23, 12:00 AM. There is no other evidence of increased supervision after this incident, On 7/6/23 at 9:20 AM Surveyor interviewed CNA H (Certified Nursing Assistant) via telephone. CNA H stated on 6/3/23, early morning, CNA N radioed for assistance on the 100 wing. CNA H observed R1 in R4's room. R1 was in front of R4 holding CNA N's wrists. R1 refused to let CNA N's wrists go. CNA H assisted with guiding R1 and CNA N out of R4's room while R1 held onto CNA N's wrists. Once R1 was outside R4's room he switched to being calm and let go of CNA N's wrists. CNA H stated R4 was very upset. 6/4/23, 19:53 (7:53 PM): Resident was up in room, voided on floor, CNA came in to clean up the floor and try and help the resident change his brief and clothes. Resident became angry, yelling at CNA to get out of his room and using profane language. Resident holding arms out and clenched, but never struck staff. CNA was able to get the floor cleaned but not successful in changing resident's shirt. Resident calmed down on his own. 6/5/23, 14:30 (2:30 PM): Resident was resistive to cares. Was incontinent and staff attempted to change clothes and resident was striking out at staff became angry and agitated. Resident left safely alone with a staff member in close range. Unable to sit still and pacing in hallway, snack and activity provided and was helpful. 6/6/23, 09:19: CNA reported resident became agitated and was swinging at CNA he tripped on a chair in the hallway and fell. When the nurse arrived on 100 hall resident was observed standing up from the floor. No injuries noted, but unable to look under the resident's clothes or to obtain vitals d/t (due to) resident's mood behaviors. This nurse was able to direct resident back to his room, give him something to drink, have him sit in his chair, and was calm prior to me leaving the hall. Of note, per Misconduct Report Dated 6/3/23 the facility had an intervention including a licensed nurse to be present in the dementia wing during AM and PM shifts along with CNA and HA (Hospitality Aide) staff to monitor behaviors and assist with ensuring resident and staff safety and intervene appropriately to (R1's) behaviors. Per progress note date 6/6/23 a nurse was called to the 100 wing and not present on the wing. 6/10/23, 09:53: Resident's mood/behavior continue to be monitored d/t changes in medication. He did have some behaviors while trying to change his pants. He was striking out, but with two assist we were able to change pants. No behaviors noted after that. 6/13/23, 12:33: Called to 100 wing for assistance. Entered dining room and resident was yelling out and very agitated. Staff moving other residents from his table for safety. Attempted to keep resident back away from others and keep both him, staff, and residents safe. Resident then picked up his knife and began to wield it back and forth towards me. I continued to reinforce he needed to put the knife down, he finally did put it on table (sic) but then started to push chairs toward another table of residents and I attempted to stop him when he grabbed both of my wrists and hurt me. I looked straight on and asked him to stop that he is hurting me, he as quick as he started, stopped, looked at me and became very calm. He stated I won't hurt you, at this time I was able to lead resident to his room and he was then calm all the way. 6/15/23, 18:07 (6:07 PM): Med tech (Medication Technician) walked into the dining room to check in on the CNA's working on 100. CNA reported that (R1) was swinging and chased her out of the room. CNA then reapproached resident (R1) to have him to move another seat. (R1) then grabbed CNA by the neck. CNA continued to scream and yell. Resident let go and was removed of the dining room. CNA was assessed for injury, she is ok. (sic) Resident assessed for injury, no injury. DON called; administrator called. Family updated and doc (doctor) faxed, police coming to assess the situation further. 6/16/23, 12:09: Spoke to (R1 spouse) about incident that occurred 6/15/23. Stated she is not sure what is triggering him to have these behaviors. Spouse is hoping we can figure out what is causing these issues. DON also part of call. 6/16/23, 20:01 (8:01 PM): Writer attempting to do v/s (vital signs) at time of fall resident was swearing and looked at CNA present in room and stated I will kill you. Resident grabbed CNA by scrub top and was punching CNA in stomach. Resident has been pushing chairs and going in and out of other rooms and refusing to leave. At this time is sitting in another resident's recliner and will not come out. 1-1 redirected, activity, left safely alone, food, drink and attempted to toilet. All ineffective and some attempts make aggression worse. PRN (as needed) Risperdal given. DON is aware of incident. 6/16/23, 21:34 (9:34 PM): Called to 100 wing by CNA stated resident slid from chair. Resident was already up and sitting in a chair as was restless and not wanting to stay on floor. Resident went to sit in chair and did not sit back far enough causing a slide to floor. CNA assisted rest of way to floor. Notified DON, notified wife, (R1's Physician) updated. Resident refused v/s and skin assessment. Resident has been agitated and aggressive. Of note, per Misconduct Report Dated 6/3/23 the facility had an intervention including a licensed nurse to be present in the dementia wing during AM and PM shifts along with CNA and HA (Hospitality Aide) staff to monitor behaviors and assist with ensuring resident and staff safety and intervene appropriately to (R1's) behaviors. Per progress note date 6/16/23 a nurse was called to the 100 wing and not present on the wing. 6/17/23, 10:49: Pt (patient) continues to have reported increased behaviors. Pts behaviors including trying to swing or hit staff. Being resistive to cares. Exit seeking. Yelling/shouting. Pt has given PRN Ativan and Risperdal this AM and was very effective. Pt later was resting in bed. No look of restlessness or anxiety noted when sleeping. Pt then awoke and is starting to get anxious and restless and agitated easily. Pt gave another dose of Risperdal and Lorazepam to assist with these behaviors' d/t limited nonpharmacological options available that help aid in pts increased behaviors. 6/17/23, 16:19 (4:19 PM): Pts wife came in around 1430 (2:30 PM). Pts wife began to try and get Pt to change his wet clothes d/t urinary incontinence and not letting staff assist with cares d/t aggression. After several attempts (R1's spouse) did get (R1) changed. (R1's spouse) began to cry when husband began to get angry at her and is upset that husband has been having increased behaviors. Pt was given PRN Risperdal and Ativan x2 (times two) today d/t increased aggression towards others. Pt is one on one with staff 24/7. Pt did appear to have unsteady gait when trying to get him back into his room to lie down. Pt is sound asleep at this time. Staff sitting next to him in his room. Talked with (R1's spouse) again that he is probably exhausted d/t being up for 2 days straight and with the medication kicking in is what is making him tired and unsteady gait. Reassured her that staff with be with him (sic) all evening. Scheduled medications were not given this evening d/t increased lethargy. Of note there is no evidence R1 was on 1:1 24/7. R1 was on 1:1 as needed. 6/18/23, 05:43: Lorazepam Oral Tablet 0.5 mg (milligrams), Give 0.5 mg by mouth every 4 hours as needed for aggression/behaviors. Recommended that resident gets medication every 4 hours exactly. Resident woke up in aggravations, hitting, kicking, and yelling out. (sic) Resident is unsafe to environment and residents surrounding them. 6/18/23, 21:30 (9:30 PM): Lorazepam Oral Tablet 0.5 mg (milligrams), Give 0.5 mg by mouth every 4 hours as needed for aggression/behaviors. Moderate behavioral outburst with mild forms of aggression. Resident received a lorazepam and will be monitored for residual effects of tiredness. Attempts to be made so resident doesn't continue to sleep constantly. 6/19/23, 21:59 (9:59 PM): Resident stated his scrotum hurt, he did spill coffee this AM on his lap and has refused being changed all shift. Staff assisted resident per his request to have it looked at. Due to resident becoming agitated quickly staff didn't have much time to look but no redness or blisters were observed. Resident did swing, kick, and pull at scrubs toward both staff members who were assisting resident. Resident pulled pants up and refused a brief, staff let resident be. Staff did get both incontinent b[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) to a resident requiring emergency care for 1 of 3 Residents (R3) reviewed for code status. Additionally, the facility does not have a process for ensuring a CPR certified staff member is available on each shift. This has the potential to affect 10 full code residents that reside in the facility. R3 was a full code (wanted cardiopulmonary resuscitation) and was found pulseless and nonbreathing on [DATE]. An LPN (Licensed Practical Nurse) failed to initiate CPR when R3 was found to be cyanotic in the face, pulseless and not breathing. Facility failure to begin cardiopulmonary resuscitation, and its failure to ensure CPR-certified staff on each shift, created a finding of immediate jeopardy that began on [DATE]. Surveyors notified DON B (Director of Nursing) and RCN C (Regional Clinical Nurse) of the immediate jeopardy on [DATE] at 11:50 AM. The immediate jeopardy was removed on [DATE]. However, the deficient practice continues at a severity/scope of E (Potential for Harm/Pattern) as the facility continues to implement its action plan. This is evidenced by: Per CMS (Centers for Medicare and Medicaid Services) Cardiopulmonary resuscitation (CPR) memo 14-01 revised [DATE] CPR refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased. When addressing full-code residents: If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition,) facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services. Facility policy titled, Cardiopulmonary Resuscitation (CPR), implemented [DATE], states in part, .Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). Police Explanation and Compliance Guidelines: 1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. 2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or . c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition. 3. CPR certified staff will be available at all times. 4. Staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain certification or recertification is also acceptable. Facility policy titled Medical Emergency Response, dated [DATE], states in part .Policy: 1. It is the policy of this facility to respond to medical emergencies for residents, staff, and visitors. Policy Explanation and Compliance Guidelines: 1. The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance. 2. CPR will continue unless: a. There is a DNR order in place. b. There are obvious signs of clinical death (rigor mortis, dependent lividity, decapitation, transection, or decomposition). 8. If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or c. if the resident does not show obvious signs of clinical death. 11. The facility will ensure that CPR certified staff are available at all times. 12. Current certified staff must maintain CPR-Certification for Healthcare Providers through a CPR provider whose training includes hands-on skills practice and in-person assessment and demonstration of skills. Online certification is not acceptable. 1. R3 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, diabetes mellitus type 2, chronic kidney disease, old myocardial infarction, history of venous thrombosis and embolism on anticoagulation therapy, coronary angioplasty, occlusion, and stenosis of right coronary artery. R3's most recent Minimum Data Set (MDS) dated [DATE] states that R3 has a Brief Interview for Mental Status (BIMS) of 15, indicating that R3 is cognitively intact. The MDS also indicates that R3 requires supervision and set up help only for transfers, supervision of one staff for bed mobility, limited assistance of one staff for dressing and toileting and extensive assistance of one staff member for hygiene. R3 is always continent of bowel and bladder. R3's Advance Directives dated [DATE] state that R3 chose to remain a full code. R3's care plan, initiated [DATE], states in part . Focus: I am a Full Code. Interventions: Call 911 for transportation to the hospital. Initiate CPR in the absence of a pulse. Provide privacy during code. Nurse's note dated [DATE] at 13:41 PM (1:41 PM) states in part, Note Text: resident was going to go out with a friend when he passed out. Friend was able to get him back into chair. Resident was pale, jerking in wheelchair, unresponsive, with low O2 (Oxygen) at 84% and high heart rate at 96, blood sugar 141. Irregular heart rate and slurring words. O2 applied at 3L (Liters). O2 measured 94% with O2 on. Resident sent out via ambulance. ER called. family called . Nurse's note dated [DATE] at 17:50 PM (5:50 PM) states in part, Late Entry: Note Text: Call placed to [Hospital Name] ER (emergency room) and requested update on resident. Nurse stated resident had a vasovagal response they did a CT scan (x-ray to look at internal organs) which was fine, urinalysis and other tests on him and everything seems good, mentioned Lasix (diuretic) and push fluids. Nurse's note dated [DATE] at 18:30 PM (6:30 PM) states in part, Late Entry: Condition: laughing, talking, mobile via ambulation. Resident was witnessed getting up from ambulance cot and ambulated into their room with the assistance of their walker. Resident was provided supper meal in their room, and then proceeded to go on with the rest of the day. Resident was joking and kidding with staff members throughout the night. Per hospital, via phone communication, Resident was seen, and labs were drawn as well as monitoring of vitals. Hospital then proceeded to deem resident fit to return. Transferring resident back to facility via Ambulance. Hospital stated that resident had no signs of medical issues. No paperwork was received about resident. Note Text: Resident returned back to facility per ambulance. Ambulance staff came in dropped (Resident Name) off and then left absent of giving handoff report. Resident upon initial evaluation upon return appeared to be in normal . Nurse's note dated [DATE] at 01:53 AM (1:53 AM) states in part, Note Text: During rounds performed by CNAs, Resident was discovered to be displaying no respirations. CNA staff reported to nurse, that something was wrong with resident. Nurse went down and observed no respirations, no pulse felt, no O2 obtained, and skin to be cyanotic. Director of Nursing notified, family notified, fax sent out to doctor, ER called for pronunciation of death. Administrator notified per DON . Of note, there is no documentation to indicate CPR should not be started. Cyanotic skin is not an indicator to not initiate CPR. There is no contemporaneous documentation of rigor mortis or lividity. Nurse's note dated [DATE] at 02:45 AM (2:45 AM) states in part, Late Entry: Note Text: ER contacted, they stated, I should contact the coroner due to the circumstances of the untimely death and the ER visitation of the resident falling with less than 24 hours . Nurse's note dated [DATE] at 04:45 AM (4:45 AM) states in part, Note Text: Coroner contacted due to unexpected death at 0249. Coroner arrived at facility at around 0330 and left at around 0430. Coroner is going to gather information from (Hospital Name) in the morning and will fax information back to the facility. (Funeral Home) was contacted by Coroner to remove the body. Body has been removed; belongings left in the room. (Funeral Home) will contact family and discuss funeral arrangements and stated that he will let the family know that resident's belongings are still located in their room and that they can come and sort through them when they are ready. More information to follow after coroner gathers information from hospital . On [DATE] at 6:42 AM, Surveyor interviewed HA G (Hospitality Aide). Surveyor asked HA G about incident on [DATE] and if she could walk Surveyor through what she observed and knew about the incident. HA G stated, I was passing water around 1:00 AM and noticed R3's lower body was off the bed, and he had, had a BM. I couldn't find CNA F. Around 1:25 AM a light was going off and I saw CNA F and asked her to check on R3, so he didn't fall out of bed. R3 had one leg straight like he sat on the edge of the bed then laid over to the side with his head resting on the bed. One hand was still holding his cane. On [DATE], HA G's written statement to the facility states, At 1:00 AM, I HA G was passing out water, when I passed water to R3 I noticed his legs were over the bed while sitting in bowel. I notified the CNA, CNA F, about the bowel. CNA F went to help R3 with cares and found resident non-responsive. CNA F asked me to go get the nurse in charge, LPN D (Licensed Practical Nurse). LPN D asked CNA F to prep resident for the morgue once clarified he was decreased. As CNA F was cleaning up the resident, she found an IV was left in the resident's right forearm. CNA F also found what could possibly be saliva on the bedding where his face [sic]. I noticed that the resident had blood coming from his mouth. While CNA F was cleaning the bowel, I noticed there was blood in his stool. CNA F finished cleaning up resident and positioned him in bed. CNA F notified the nurse of the finding, and that the resident was ready for the morgue. Resident was found unresponsive around 1:30 AM on [DATE]. On [DATE] at 5:57 AM, Surveyor interviewed CNA F. Surveyor asked CNA F if CNAs are allowed to perform CPR in the facility and if she has a current CPR certification. CNA F stated, I need to renew my CPR certification. I have no clue if a CNA can perform CPR here in this facility. Surveyor asked CNA F to talk through what she remembers and saw from R3's death on [DATE]. CNA F stated, HA G reported to me that R3 was sitting on the edge of the bed, R3 was lying to the side with head on the mattress and feet up due to head of the bed being flat and R3 smelled of BM. I went down to R3's room and turned on the light. I had HA G go get the LPN. R3 was purple in the face, had had a bowel movement with blood in stool, and puddle of saliva which appeared to have blood in it. It appeared as if R3 had bit his tongue. This all happened around 1:15 AM or 1:30 AM. I had saw R3 last around midnight. I did not know R3 was a full code, but LPN D indicated that he was aware. I think that is why they now put dots on the doors. That should have been done before this happened. LPN D checked R3 for a pulse then told me to get R3 ready for the funeral home. I did note he still had an IV from ER visit in the right arm, which I removed. On [DATE], CNA F's written statement to the facility states, HA G passed water for the night. She notified me, CNA F, that the resident was lying in bed with feet and legs off bed. She also stated the resident was laying in bowel. I CNA F went to help the resident with cares and found the resident non-responsive with HA G shadowing me. I immediately asked HA G to get the nurse on shift, LPN D. LPN D asked that I prep the resident for the morgue once clarified he was deceased . As I was cleaning up the resident, I found an IV was left in the resident's right forearm. I also found what appeared to possibly be saliva on the bedding where his face was laying. The resident also had blood at the corner of his mouth, I then examined his tongue was clenched between his teeth. I finished cleaning the resident's body, positioned him in bed and notified the nurse of findings and that he was ready for when the morgue would be arriving. Resident was found unresponsive around 1:30 AM on [DATE]. On [DATE] at 9:25 AM, Surveyor interviewed LPN D. Surveyor asked LPN D to walk through the incident with R3 from [DATE]. LPN D stated, on the previous shift R3 was sent out to the ER (emergency room); he returned to the facility between 6:00 PM and 6:30 PM. When I saw him come back, he appeared fine. Later that night I called for the discharge paperwork from the hospital, including labs and images. I did notice his Troponin was high on initial draw as well as his D-dimer. I did call the DON (Director of Nursing) about discharge paperwork after R3 was expired. I did look at it earlier for medication changes but that was all. Earlier in the evening I talked with ambulance driver who took R3 to his room. R3 was able to walk into his room using a walker at his normal gait. I then got R3 a tray for supper. From 6:00 PM until 6:00 AM I am the only nurse here. The day shift nurses were here that day until 6:30 PM or 7:00 PM. R3 was independent in his room, and he does not get night medications. At night he will call for staff to take his hearing aids, but he normally is up until 1:00 AM or 2:00 AM. At about 11:00 PM or 11:30 PM staff were passing water and CNA walked out the room next to R3's and noted he was still up watching TV at that time. At about 1:00 AM staff walked by R3's room and noted something was off. R3 was in the fetal position and had bowel on the bed. The CNA noted that R3 was blue in the face, cold to the touch and stiff. Staff yelled for me, and I went down to R3's room. R3 was in BM, cold to the touch, and blue in the face. I called the DON right away. DON told me to get paperwork. It was at that time that it dawned on me that I needed to call the coroner due to unexplained death. Coroner got the facility around 2:30 AM. I asked the coroner some questions. R3 still had the IV in his arm from the hospital. The IV was removed and placed next the R3's arm. During conversation with the DON, I informed her that R3 was cold to the touch, was in fecal matter, was in the fetal position, and blue in the face. The DON told me to fill out forms, call ER, family and she would contact the NHA (Nursing Home Administrator). R3 was a full code, and they are giving me a warning for this. That is what I was told. Of note: Per CNA F (Certified Nursing Assistant) statement and interview R3 was last seen at midnight alive and well. During interview with HA G (Hospitality Aide) she indicates that she was passing water at 1:00 AM and noted R3 smelled of BM (bowel movement) and alerted CNA G of this between 1:15 AM and 1:30 AM at which time CNA G entered R3's room and found him unresponsive, approximately 1 ¼ to 1 ½ hours after last seen alive and well. According to the National Institute of Health, Rigor mortis appears approximately 2 hours after death in the muscles of the face, progresses to the limbs over the next few hours, completing between 6 to 8 hours after death. Rigor mortis then stays for another 12 hours (till 24 hours after death) and then disappears. Of note: LPN D indicates that the CNA noted R3 to blue in the face, cold to the touch, and stiff, but only indicates that he noted R3 to be cold to the touch and blue in the face. A CNA is unable to assess a resident for rigor mortis. There is no mention of R3 being stiff or in rigor mortis. On [DATE] at 2:50 PM, Surveyor again interviewed LPN D. Surveyor asked LPN D if he was aware of R3's code status prior to entering his room. LPN D stated, I did know his code status. Surveyor asked LPN D about calls placed to DON B. LPN D stated, The first time I called her I only told her that R3 was found dead, but I did not get into the nitty gritty until after I talked with the hospital and family. On [DATE] at 9:59 AM, Surveyor interviewed DON B. Surveyor asked DON B if she could walk through her conversation with LPN D the morning of [DATE] following R3's death. DON B stated, LPN D called me about 1:30 AM and told me they had went into R3's room and found resident gone - passed away. He said that when he went to check on R3 he was cold, stiff and had no pulse. LPN D then told me he had already called the ER for R3's hospital paperwork from the previous day and notified the family of R3's passing. LPN D had called me immediately following the incident but did not give me any details, just said resident was found expired and that he had to go someone was at the door and he would call back. He called me back 15 minutes later to inform me of what happened and that he was going to call the coroner or that he had called the coroner, I am not sure which. He told me he had just found him, but it could not have been just. Of note: DON B's statement of He told me he had just found him, but it could not have been just indicates that DON B believed that R3 had been deceased for some time prior to LPN D calling her. Surveyor asked DON B what her expectation was for finding a resident pulseless and non-breathing. DON B stated, LPN D should have known R3's code status and started CPR, that is my expectation. Nurse's note dated [DATE] at 12:54 PM (12:54 PM) states in part, Late Entry: Note Text: Spoke with Coroner this am. Corner (Name), about whether autopsy was going to be performed. Per Coroner report: Due to the significant medical history pertaining to heart issues there will be no autopsy performed. The coroner spoke with the family, and they understood their rights and refused the procedure. The family told the coroner that they knew it was coming due to the way he wanted to live. Corner and Medical examiner /pathologist examined body and reviewed medical records, and these were their findings. Resident in the past had refused to go see a Cardiologist. Resident stating I feel fine and refusing treatment. He was advised by his primary physician (Physician Name) in the past to see a cardiologist for which he refused. He also has a history of coronary artery disease, CVA, atrial fibrillation, type 2 diabetes, hypertension, and chronic kidney disease. This nurse explained to coroner that resident had an unresponsive episode earlier and was sent to the emergency room to be evaluated. This nurse explained to coroner, per staff reporting that resident was unresponsive for 2-5 minutes. Coroner and Medical pathologist both agreed that resident threw a clot which would explain the increase troponin and d-dimer. D-dimer 674 and troponin 81 were both elevated. (Labs completed D-dimer which indicates possible clot formation and troponin muscle damage). The coroner asked this nurse if the resident was taking any medications such as coumadin or Eliquis. The nurse told the medical examiner that the resident was currently on Eliquis 2.5mg BID (twice a day). The coroner examined the body and found blood in his stool, and blood coming from mouth, which indicates bleeding noted. Coroner stated that the blood in the mouth was caused by resident gritting his teeth in his mouth, due to the pain from another clot, possibly coming from the lungs due the pulmonary edema, that lodged in his heart which stopped it immediately. He called it a type of seizure caused by clots that go to the heart. Coroner also stated, that even if resident was at the hospital or at the facility, there would have been nothing anyone could have done to prevent his death. No type of resuscitation would have brought the resident back especially after rigor mortis already present . Of note: Nurses Notes indicate the coroner was called to come to the facility at approximately 2:45 AM and arrived at approximately 3:30 AM. Per interview with LPN D and review of progress notes there was no indication CPR was not started due to rigor mortis but only that the resident was cold and blue. Cold and blue is not an indication not to start CPR. The coroner did not arrive to the facility until 2 plus hours after resident expired and one would expect some rigor mortis at this point. 2. On [DATE], Surveyor reviewed nursing staff CPR certifications and noted that the facility employs 15 Nurses and Med Tech's, which includes the DON and Nurse Managers. Of those 15 Nurses and Med Tech's only 6 have current up to date and appropriate CPR certifications. Nursing Schedules reviewed showed that on [DATE] from 10:00 PM to 6:00 AM the only staff in the building with a valid CPR certification was CNA H. Of note: Facility staff are unaware of whether a CNA can perform CPR in the facility and Nurses interviewed indicate that they had been told that CNAs cannot perform CPR in the facility. On [DATE] at 4:30 PM, Surveyor interviewed CNA K. Surveyor asked CNA K if she was CPR certified. CNA K stated, I don't have a current CPR certification. Surveyor asked CNA K if she was aware whether a CNA could perform CPR in the facility. CNA K stated, Nurses have to do CPR. On [DATE] at 4:40 PM, Surveyor interviewed CNA L. Surveyor asked CNA L if she was CPR certified. CNA L stated, I don't have a CPR certification. Surveyor asked CNA L if she was aware whether a CNA could perform CPR in the facility. CNA L stated, I am not sure if CNA's can-do CPR or not. I would have to ask. On [DATE] at 5:57 AM, Surveyor interviewed CNA F. Surveyor asked CNA F if CNAs are allowed to perform CPR in the facility and if she has a current CPR certification. CNA F stated, I need to renew my CPR certification. I have no clue if a CNA can perform CPR here in this facility. On [DATE] at 6:22 AM, Surveyor spoke with RN E (Registered Nurse). RN E stated that DON B and RCN C (Regional Clinical Nurse) told her that CNA's can only do CPR on the street. In this facility they say CNAs can't do CPR. On [DATE] at 6:25 AM, Surveyor again spoke with LPN D. Surveyor asked LPN D if he knew or was aware whether CNAs could do CPR in this facility. LPN D stated, I was not aware this facility did not allow CNAs to do CPR until my conversation with RNC C. RNC C and I discussed CNAs doing CPR and RNC C stated No, No, they can't do that. Surveyor asked HA G if she was aware whether the facility allowed CNAs to do CPR. HA G indicated she was not aware whether they could or not. On [DATE] at 7:37 AM, Surveyor interviewed CNA/Med Tech J. Surveyor asked CNA/Med Tech J whether she was able to perform CPR in the facility. CNA/Med Tech J stated, As a CNA, no I cannot do CPR but as a Med Tech I can. On [DATE] at 7:40 AM, Surveyor interviewed LPN I. Surveyor asked LPN I if she was aware whether a CNA could perform CPR in this facility. LPN, I stated, DON B told us CNAs can't do CPR. On [DATE] at 9:15 AM, Surveyor interviewed CNA H. Surveyor asked CNA H is she knew whether she was allowed to perform CPR in the facility. CNA H stated that yes, she was able to perform CPR as a CNA. RCN C called me yesterday to educate me and inform me that I would be the only person CPR certified in the building at times that could do CPR, so I took that as I can do CPR. On [DATE] at 9:48 AM, Surveyor interviewed DON B. Surveyor asked DON B prior to Surveyors coming into the building who was able to perform CPR. DON B stated, Nurses only. I did tell the Nurses that CNAs are not allowed to perform CPR in the facility. On [DATE] at 9:52 AM, Surveyor interviewed RNC C. Surveyor asked RNC C if prior to Surveyors coming into the building who was able to perform CPR. RNC C stated, Certified staff. We do prefer Nurses to do it. This was related to a licensed staff member so that is who we educated, licensed staff. Surveyor asked RNC C if he had informed Nursing staff that CNAs were not able to perform CPR in the building prior to Surveyors entering the building. RNC C stated, Not sure I said that exactly, but yes. The failure to ensure R6's wishes were accurately and consistently identified in the medical record and the failure to ensure CPR-certified staff worked each shift created a reasonable likelihood that serious harm could occur, thus creating a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when it had completed the following: On 6/23.23 the facility recognized the concern and completed the following: Education by DON or designee to all licensed clinical staff on Medical Emergency Response policy by [DATE]. Competency evaluation conducted of all licensed clinical staff no later than [DATE] by DON or designee. Verbal verification of 3 licensed staff random shifts per week x6 weeks on CPR competency Audit conducted monthly for 12 months by HE director of designee that all staff have annual CPR training. Audit completed on crash cart/AED update items as necessary by DON or designee by [DATE]. Audit conducted by DON or designee not later than [DATE] and weekly x6 weeks. SSD to audit new admission Code status from [DATE] by [DATE]. Present to QAPI team on [DATE]. The facility did not identify on [DATE] the need to educate all staff on CPR and did not have a system in place to ensure a CPR certified staff member was always working until [DATE] when the facility implemented the following . 1. A system was put into place to ensure a CPR certified staff is on duty each shift: - The NHA and/or DON will review the nursing schedule daily to ensure there is a CPR certified staff on schedule (Marked with a capital C) after their name. - The facility created a master list of current licensed employees noting Certified CPR expiration dates with the DON in conjunction with the HR Director to monitor monthly. - The facility reviewed employees creating a list of employees that are CPR certified in the facility as alternatives if there shall be a call in. - The Scheduler and Nurse's station was provided a list of Certified CPR employees to utilize if a call in occurs, the nurse on duty and/or scheduler will alert the DON for replacement options. - The DON and/or HR Director will review any new hire for Certification in CPR noting expiration date if applicable. - The Facility has set up Mandatory CPR Certification for 7-8-23 and 7-13-23 to ensure adequate staffing that are certified in CPR. - The Facility will continue to offer Certification in CPR on an annual basis. 2. Education was provided to all staff Certified in CPR that they may perform CPR when directed by a licensed nurse. 3. Education was provided to all staff to report to nurse if a resident is found PNB 4. Education was provided to the NHA, DON and Scheduler on providing adequate staff certified in CPR for every shift and the list of employees Certified in CPR to utilize for replacement in case of a call in. 5. Education was provided to the licensed nurses on replacing a staff member who was Certified in CPR with another employee Certified in CPR for after hour shifts (Pm's, Nights, Weekends) and will alert the DON 6. The DON and/or designee will audit: - Five random employees' random shifts with verbal validation on who may perform CPR per week x 6 weeks to ensure understanding. - The nursing schedule to ensure a CPR certified staff is on duty each shift per week to ensure compliance. - The Certified CPR list monthly to ensure compliance with valid Certification in CPR - Mock codes with the involvement of all staff are conducted weekly x 6 weeks - Competency for CPR were completed on all staff who are Certified in CPR

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure 1 (R1) of 2 supplemental residents on specialized diets received food in an assessed consistency so as not to create a hazardous environment and received supervision to prevent a choking accident. Facility staff did not follow the care plan for 1 of 1 supplemental residents (R26), which led to a fall that resulted in a fractured hip, and did not review and revise the care plans of 2 of 15 sample residents (R20 and R10) after they had multiple falls. R1 has Parkinson's disease and dysphagia and is at risk for choking. R1 is to receive a pureed diet and is to be cued while eating. On 2/9/22 and 2/10/22 R1 was given meals that were not pureed. In addition, R1 was left alone in his room to eat. The facility's failure to ensure R1 received the appropriate diet consistency and supervision during meals created a finding of IJ (Immediate Jeopardy) beginning on 2/9/22. The NHA (Nursing Home Administrator) NHA A was informed of the IJ finding on 2/10/2022 at 4:34 PM. The facility removed the immediate jeopardy on 2/12/22. The IJ continues at a scope severity of G as the facility continues to implement their action plan and as evidenced by the following: R26 has severe cognitive impairment. R26 had two falls. During the first fall the facility did not put interventions into place post fall. During the second fall staff did not follow R26's care plan by having a bed/chair alarm correctly placed under R26 while in bed. This second fall resulted in a right hip fracture. R20 and R10 each had multiple falls. The facility did not always immediately assess the circumstances leading to the fall and, when appropriate, implement changes to the care plan to prevent further falls. This is evidenced by: Example 1 R1 was admitted on [DATE] with diagnoses of Parkinson's disease (a progressive neuro-system disorder that affects movement) and dysphagia in the oropharyngeal phase. Dysphagia is the medical term for swallowing problems. People with dysphagia may have difficulty forming a food bolus in their mouth or experience a delay when they try to swallow it. This increases their risk of choking or breathing in food while they're eating. It also makes it more difficult to eat enough, in turn increasing their risk of not getting enough nutrients. . many healthcare professionals recommend a puréed diet to patients with dysphasia to reduce their risk of choking and potentially breathing food into their lungs while ensuring they meet their nutritional needs. https://www.healthline.com/nutrition/pureed-food#basics People with dysphagia are also at risk for aspirating food into their lungs. 8 Signs of Dying from Aspiration Pneumonia notes that Mortality estimates for aspiration pneumonia vary. At least 5 percent of people who are hospitalized for aspiration will die .Among geriatric populations, mortality skyrockets. A 2013 study of elderly patients put 30-day mortality at 21 percent. First responders, doctors, nurses, and other healthcare providers must always treat aspiration pneumonia as a medical emergency with a high mortality risk .In the immediate aftermath of aspiration, a patient may be unable to breathe or swallow, presenting a medical emergency. After the risk of hypoxia has passed, the dangers of aspiration pneumonia have not. Aspiration pneumonia can cause numerous complications, including: Sepsis Respiratory failure Acute respiratory distress syndrome (ARDS) Bacterial pneumonia https://blog.sscor.com/8-signs-of-dying-from-aspiration-pneumonia R1 had a speech therapy (ST) evaluation on 4/17/2020 which states in part .the resident has been on a NDD (National Dysphagia Diet) level 3 diet with ground meats. Referral now is due to a recent coughing episode witnessed by staff. This is likely due to his progression of PD (Parkinson's Disease) or decreased memory of swallow safety strategies. Per facility records, R1 had physician orders dated 9/29/2020 for a Regular diet, Level 2 with pureed meats and slurried, soaked bread. R1 had another ST evaluation on 12/15/2020 which states in part .R1's skills had declined with oral residue and prolonged chew time for meats. Downgraded to a NDD#2 which includes slurried, soaked bread and pureed meats. Resident best tolerates-in terms of safety-as well as without prolonged oral transmit times, ground meats with NDD#2. On 6/21/2021, R1 had another ST evaluation which states in part, R1's current speech production and intelligibility: Moderate/severe-25% intelligible, limited mainly to words or phrases. Diet: NDD 2, mechanical altered; swallowing .safe only in structured settings .reinforce safe swallowing strategies. R1's care plan includes in part, identified needs and interventions as follows in regards to diet and speech: *Resident has potential for communication problems related to slow, garbled speech: Ask yes/no questions, if appropriate. Praise all response efforts. *Resident has an ADL (activities of daily living) self-care performance deficit related to (R/T) Parkinson's: Resident is able to feed self and use a right handed curved spoon. Resident is not to eat grapes without supervision. Resident is to go down to meals early to give enough time to eat. Resident can have clothing protector on for drooling and for meals. If resident is eating in room; ensure he is in good postural alignment in the wheel chair; face the TV with tray table in front with feet over lower bar on table to prevent the table from sliding away. Lipped plate, cups with lids and straws pointing toward resident, food cut up if needed, silverware on right side, drinks on left side, napkin tucked into shirt. Oral care: Assist with set up after each meal to clear any food residue. *The resident is risk for potential nutritional problem R/T Parkinson's disease .dysphagia, history of pocketing food. Choking hazard. Can feed self. Very slow eater: Avoid foods that are hard for resident to chew and monitor for pocketing and chewing or swallowing problems. Diet as ordered, Regular Level 2-Mechanical texture, regular/thin fluid consistency, pureed meat and slurried, soaked bread .Plate guard, bent spoon, built up utensils, straws, beverages in plastic cups with lid. Resident able to feed self with adaptive equipment; staff provide assistance as needed. Resident preferences for meal times/patterns honored. 1. Decreased rate of feeding, small bites. 2. Must be seated at 90 degrees for eating/drinking. 3. Staff assist if needed. Provide resident with reminders/verbal cues to do liquid swish every 2 bites to clear residue. Provide supervision and assist as needed. Of note; R1's plan of care states to provide resident with reminders/verbal cues to do a liquid swish every 2 bites to clear residue. This cannot occur without direct supervision at meals. On 2/9/22, at 11:47 AM, Surveyor observed R1 sitting in a wheelchair in R1's room eating ground beef meat loaf that had been served. R1 did not have staff supervision. On 2/09/22, at 11:47 AM, Surveyor interviewed Licensed Practical Nurse (LPN) R and asked what diet is ordered for R1. LPN R stated, Ground meat. Surveyor asked LPN R, has there been any recent changes to R1's diet? LPN R indicated 'No. On 2/09/22, at 11:56 AM, Surveyor asked Registered Nurse (RN) U, what type of diet is ordered for R1? RN U looked at the physician's order and indicated mechanical texture, pureed meats, and slurried/soaked bread. On 2/10/22, at 11:25AM, Surveyor observed R1 alone in R1's room sitting in a wheel chair eating chili. The chili had chunks of tomatoes and ground beef. R1 did not have staff supervision. On 2/10/2022, at 4:35PM, Surveyor observed R1 sitting in a wheelchair in R1's room eating pureed casserole. Surveyor took some of the very thick and sticky casserole from R1's spoon and turned the spoon upside down. The casserole slowly plopped off. R1 did not have staff supervision. On 2/14/22, at 1:00 PM, Surveyor asked Registered Dietician (RD) H, what diet is R1 currently on? RD H stated, Mechanical soft with pureed meats. R1 can have soft foods like mashed potatoes, soft cooked vegetables, and soft foods. Surveyor asked RD H, is chili considered a pureed food? RD H stated, No chili should be pureed because there is meat in it. Surveyor asked RD H, is ground beef meat loaf a pureed meat? RD H replied, No ground meat loaf should be pureed. On 2/10/22, at 12:05, Surveyor interviewed Maintenance Manager (MM) L. MM L is the maintenance manager for the facility and has been cooking in the kitchen due to lack of dietary staff. Surveyor asked MM L, how do you know what diet is ordered for residents? MM L stated, I look at the resident's dietary card along with the attached white menu slip for that day. Surveyor asked MM L, what diet is ordered for R1? MM L looked at R1's dietary card and responded, Pureed meat with soaked bread. Surveyor asked MM L, is chili considered pureed? MM L stated, I was informed by [NAME] E that all soups and chili are considered pureed. Surveyor asked MM L, is ground beef meat loaf considered pureed? MM L pointed at a food processor and stated, All pureed meat goes through the machine. R1 is the only resident on pureed meat. The facility did not have a backup system to catch errors in food consistency because there was minimal information on the card that is on the food tray that is served to residents. Consequently, a person serving the food would not be aware if the food was the wrong consistency, as evidenced below. On 2/7/2022 at 11:45, Surveyor observed resident meal tray line. [NAME] E was plating food and passed it to DA I who then covered foods. After the food is plated by [NAME] E, it is covered and placed on a transport cart by Dietary Aide (DA) I. There isn't a resident tray card present which identifies who the tray belongs to, what type of diet and consistency of food and liquids and any allergies or special precautions on any of the meal trays. There was a small label on the transport cart that had each resident's name and minimal information (such as [NAME] Doe, NAS (no added salt)). There were no further instructions on the cart for staff to follow. A carafe of coffee sat on top of the cart. The cart is taken to the nursing units for delivery by staff including office, administrative, and nursing staff. On 2/8/22 at 7:50 AM, Surveyor observed tray line. DA G received a meal from [NAME] E and placed the food tray on the service cart. Surveyor asked DA G, how do you know which resident the tray belongs to? DA G stated, I guess because the cook tells me. Surveyor asked DA G, have you ever seen a tray card on the resident tray that identifies the resident, what diet and consistency the diet and fluid should be? DA G stated, No, I haven't. Surveyor asked DA G, have you ever put the tray in the wrong place on the delivery cart? DA G replied, I don't think so. On 2/9/2022 at 8:10 AM, Surveyor asked Certified Nursing Assistant (CNA) D, how do you know which tray goes to which resident? CNA D stated, By the label on the cart. Surveyor asked CNA D, what if the dietary staff put the wrong tray in the wrong slot? CNA D stated, I don't know. Surveyor asked CNA D, how would a new staff or an agency staff know if a resident was receiving the wrong tray? CNA D stated, Well, usually one of us old gals are with the new ones. Surveyor asked CNA D, how would I know if someone needed thickened liquids and they asked for coffee (the coffee sits in a carafe on top of the service cart in regular thin liquid form)? CNA D responded, I guess you wouldn't. Surveyor asked, have you ever seen tray cards with the resident name, diet and consistency listed on the resident meal trays? CNA D replied, I have seen that before, but not for a long time. On 2/9/22 at 8:15, Surveyor asked Registered Dietician (RD) H, how long have you been at the facility? RD H stated, I have been supporting the facility since October 2021. Surveyor asked RD H, does the facility use meal tray cards? RD H stated, No, the carts are labeled with the resident name. On 2/9/22 at 3:32 PM, Surveyor asked Interim Nursing Home Administrator (INHA) A, How do staff know residents are receiving the correct meal upon tray pass? INHA A stated, By the labeling identifier on the service cart. Surveyor asked INHA A, what about the coffee on top of the service carts; would a new CNA know if a resident should have thickened liquids by the current system? INHA A stated, I don't know. Failure to ensure R1's environment was free of accident hazards (i.e., R1 was served food in a consistency that would not create a choking hazard) and that R1 received care-planned supervision while eating created a reasonable likelihood that serious harm could occur. This led to a finding of immediate jeopardy. The facility removed the immediate jeopardy on 2/12/21 when it implemented the following: 1. On 2/10/22 at 4:50 PM, the facility immediately checked to ensure that the identified resident (R1) had received the correct altered textured dinner tray and confirmed and validated INHA/Director of Nursing B (DON). 2. On 2/10/22 at 4:50 PM, R1 was provided supervision during meal by DON B. 3. On 2/11/22 the physician and power of attorney (POA) were notified that R1 had potentially received incorrect therapeutic meal two times 2/12/22 by DON B. 4. Chest X-ray was ordered and obtained to ensure that the identified resident PB did not show any signs of aspirations and X-ray validated that the lungs were clear with no abnormalities noted on 2/10/22. 5. Respiratory assessment was completed on the identified resident and no issued identified by the RN charge nurse on 2/10/22. 6. Respiratory assessments were completed on the other like residents who receive altered textured diets by the RN Charge Nurse and no issues were identified on 2/10/22. 7. Corporate Dietician reviewed Dietary orders for all residents who receive altered texture diets. Orders were verified and updated as deemed appropriate on 2/11/22 by 9/pm. 8. Physician orders were obtained for Speech Therapy to evaluate & treat 17 other residents with potential to be affected by the DON on 2/11/22. 9. Dietary care plans were reviewed for accuracy and updated to reflect any new orders and recommendations for all residents by the DON on 2/11/22. 10. Speech Therapy recommendations were updated on meal tray tickets, Two (2) residents were downgraded 2/11/22. II. EDUCATION 11. All staff education initiated on 2/11/22 to ensure that physician order, including appropriate dietary recommendations are in place for all residents. Staff will receive education prior to starting their next working shift by DON/Administrator. 12. All staff educated initiated on the procedure on tray ticket system for resident meal delivery and appropriate diet 2/11/22. Competency and validation will be completed on staff to ensure that tray ticket is present on meal tray, that the meal validates what the tray ticket indicates is the appropriate diet for the resident. Staff will receive education prior to starting their next working shift by Dietician/DON/ or Administrator. Education will also include what to do if there is no ticket or if the tray ticket does not match what is on the actual resident plate or tray. 13. All staff educated initiated regarding immediate steps to take if the tray ticket does not match the meal on the tray and what immediate steps to ensure that resident receives appropriate therapeutic diet on 2/11/22. Staff will receive education prior to starting their next working shift Administrator/DON. 14. All staff educated on two step validation for proper therapeutic diet for meal delivery for residents; first at tray line with plating food per the resident meal ticket and secondly at the point of delivery of staff prior to being received by resident. Staff will be educated prior to starting their next shift by Administrator/DON. 15. All staff educated initiated on definition and oversite of Direct Supervision and Intermittent Supervision for residents during mealtime. Staff will be educated prior to starting their next shift by Administrator/DON. 16. Dietician and Dietary Manger educated on importance of tray ticket system and requirement of updating tickets for any changes to resident diet orders 2/11/22 17. Dietary staff educated on menus and recipes to properly make any altered textured diets per the physician orders by the Dietician 2/11/22 18. All staff educated initiated on 2/11/22 on resident care plan to include resident current dietary order and resident required level of supervision during mealtime. Staff will be educated prior to starting their next shifty DON/Administrator. 19. Competencies and education will be conducted by Dietician and/or Administrator and DON who have passed the competency education and has been designated to provide education. Staff will be able to verbalize where the menus are located and where they can obtain the recipe for making therapeutic altered diets such at Pureed or Mechanical Soft (Dental Soft). They will additionally state how to validate a tray for accuracy and what to do if the tray is not correct. Lastly, staff will explain where they can obtain this information for a resident and describe what Supervision verses Intermittent Supervision means. Ill. System Policy and Procedures 20. Tray ticket system has been created to reflect current diet orders for all residents by facility Dietician 2/11/22 21. Facility Policies and procedures including: (Acceptance of Therapeutic Diet) reviewed by Corporate Dietician on 2/12/22 and remain up to date. 22. Facility meal textures have been revised by Corporate Dietician and approved by facility Medical Director on 2/11/22 to improve consistency of meal preparation on 2/12/22. 23. Facility care plan template was reviewed on 2/11/22 to update approaches related to level of supervision required for a resident during mealtime. 24. Facility Recipes and meal preparation reviewed by the facility Dietician and updated to reflect instructions on altered texture diet preparation per the recipes on 2/11/22. 25. QAPI Committee including facility Medical Director reviewed and approve plan on 2/11/2022 IV. Monitoring and Audits 26. Two step validation for proper altered diet meal delivery for residents was implemented for every meal beginning breakfast on 2/11/22. The audit includes 100% verification of accuracy at tray line with plating food per the resident meal ticket and secondly at the point of delivery by staff prior to resident receiving food tray. This shall continue every meal for the next 30 days than 10 meals per week for two weeks. 27. One (1) staff interview shall be conducted daily for the next 30 days to assure understanding of immediate facility changes implemented and staff responsibility with changes. 28. QAPI for cooks to understand how to follow the recipes specific to altered textured diets and where they would obtain those recipes. Audit three (3) times per week to ensure correct consistency for altered diets 29. Staff will be able to verbalize understanding of what Supervised versus Intermittent Supervision means and where they can obtain this information of which residents require this. 30. Ongoing frequency and duration of the monitoring shall be reviewed and determined by the facility QAPI Committee On 2/14/22 at 7:30 AM, Surveyors observed all residents with altered diets to ensure the residents received the correct diet and consistency per the resident tray card and dietary order provided to Surveyors on 2/7/2022. The diets and consistency appeared appropriate. On 2/14/2021 at 8:20 AM, Surveyor observed meal pass at breakfast and lunch to ensure meal tray cards were present on each resident tray and that diets with specialized consistencies were being followed. The deficient practice continues at a scope/severity of G (actual harm/isolated) as evidenced by: Example 4 R10 was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease, dementia with behavioral disturbances, anxiety disorder, and muscle weakness. R10's care plan dated 4/1/21 states, in part: Focus: The resident is at risk for falls r/t (related to) gait/ balance problems. Goal: The resident will be free from falls through the review date. Interventions: Ensure that the resident is wearing appropriate footwear (non-slip shoes or gripper socks) when ambulating or transferring. Follow facility fall protocol. R10 had a fall on 11/22/21. R10 was found on the floor in her bathroom. R10 was not assessed by a RN (Registered Nurse) and her care plan was not updated with new interventions. R10 had a fall on 1/12/22. R10 was found on the floor in her room. R10's care plan was not updated with new interventions. R10 had a fall on 2/4/22. R10's daughter was assisting her to the bathroom and R10 fell and hit her head. R10's care plan was not updated with new interventions and there was no documentation that education was provided to R10's daughter. New fall interventions were added to R10's care plan on 2/8/22, after Surveyors entered the facility. The new interventions include: anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: ambulation with walker and other activities instructed by therapy. Pt [sic] (Physical therapy) to evaluate and treat as ordered and PRN (as needed). Example 2 The facility's policy entitled, Comprehensive Resident Centered Care Plans, undated, states, in part: Intent- .It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident .The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident . It is our purpose to ensure that each resident is provided with individualized, goal-directed care, which is reasonable, measurable and based on resident needs. A resident's care should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care . Developing the Care Plan: . 3a) The intervention statements describe those measures performed by the staff to help the resident achieve the expected outcomes . The facility's policy entitled, Falls and Fall Risk, Managing, with a revision date of March 2018, states, in part: Policy Statement- Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling . Resident- Centered Approaches to Managing Falls and Fall Risk- 1) The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls .5) If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . 7) In conjunction with the attending physician, staff will identify and implement relevant interventions .to try to minimize serious consequences of falling . The facility's policy entitled, Assessing Falls and Their Causes, with a revision date of March 2018, states, in part: .Documentation- When a resident falls, the following information should be recorded in the resident's medical record: .6) Appropriate interventions taken to prevent future falls . R26 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease, Type 2 Diabetes Mellitus with Hyperglycemia and Mild Cognitive Impairment. R26's MDS (Minimum Data Set) Quarterly Assessment, dated 12/22/21, indicates R26's BIMS (Brief Interview of Mental Status) is 00 indicating severe cognitive impairment. Section G Functional Status, Transfers: Extensive two assist, Toileting: Extensive two assist, Mobility Devices: walker Walk in Room: Limited one assist. Section J indicates R26 had one fall without injury since admission. R26's Care Plan, dated 8/25/21, with a target date of 03/29/22, states in part: . Focus: The resident is high risk for falls r/t Confusion, Gait/balance problems, Incontinence, Unaware of safety needs, Wandering, History of falls and fall with major injury (left 8-9 rib fractures) Goal: The resident will be free of falls through the review date. Interventions: .The resident uses bed and chair electronic alarms. Ensure the devices are in place as needed . Fall Report dated 12/01/2021, states in part: .PT was found lying on right side in front of the bathroom in fetal position with head resting on a pillow .RN assessed, no injuries .neuro(neurological) checks initiated .ROM (range of motion) without signs of pain . Note: No intervention added to R26's care plan in regards to this fall . On 2/10/22 at 08:50, Surveyor interviewed Director of Nursing (DON) B in regards to R26's fall on 12/1/21. Surveyor asked DON B to recall cause and DON B indicated R26 had moved onto the 400 unit due to COVID and he was unfamiliar with surroundings, confused, very ill, not cooperative with cares, and restless. Surveyor asked DON B what intervention was put into place after fall and DON B indicated checking on R26 more often. DON B was unable to find this documented or care planned. DON B then indicated no intervention was added to care plan or put in documentation. Nurse Progress Note dated 2/5/22 at 07:55 states in part: .Note Text: Was called to res room as he was found in the middle on his room on the floor lying on his right side. Res stated he was heading to the bathroom. Vitals WNL (Within Normal Limits), Small abrasion to the right wrist, no other injury noted. Res states he isn't hurt at all. Res was gotten up off the floor using a total lift with assist of 2. Res does have a bed and chair alarm however the bed alarm did not sound as it was plugged into the chair alarm still. Fall Report dated 2/5/2022 07:55, states in part: . Resident: R26 Incident Location: Resident room Person Preparing Report: LPN R . [Licensed Practical Nurse] Notes: 2/9/2022: 2/5/2022 07:55 AM resident was found on floor by his bed on his right side. Legs toward bathroom, head toward bed. He was not wearing his glasses. He had gripper socks on. Resident was noted to be restless, and he was not using any assistive devices. He was last seen minutes prior when CNA [certified nursing assistant] walked by his room. He was last toileted @ 06:44 am and was incontinent of urine at that time and at time of fall. Resident had not used call light for assistance, does at times. Alarm was not sounding. A/O [alert and oriented] to self, confused & forgetful. Resident had laxative in 8 hours prior to fall. Last BM [bowel movement] Resident only noted injury at time of fall was abrasion on right wrist. Resident was assisted to bed via Hoyer and assist of 2. Approximately 1130am CNA reported resident was c/o [complaining of] right hip pain. Resident had been lying in bed since eating breakfast and had no c/o until now. Was having facial grimacing and wanted to go to ER [Emergency Room]. (son/POA) was notified of change. Ambulance was called for transfer. Report called to [GRHC]. It was determined that he had fractured his right hip and required surgery. The surgery will be done on Monday at [GRHC] . Predisposing Physiological Factors .Incontinent (checked) . Predisposing Situation Factors .Alarm did not sound (checked) . Immediate Action Taken: Description: .Res does have a bed and chair however the bed alarm did not sound as it was plugged into the chair alarm still . Witness Statement, signed and dated by CNA T 2/5/22 at 07:55, states in part: .Any alarms: type- yes; Was it sounding - no . Hospital History and Physical, dated 2/5/202, at 4:12 PM, states in part: . [R26] is an [AGE] year old male who fell at the nursing home today and unfortunately has a right hip fracture .Principal Problem: Closed displaced fracture of right femoral neck (HCC) (2/5/2022) . Hospital Discharge summary, dated [DATE], states, in part: .Diagnosis: Principal Problem: Closed displaced fracture of right femoral neck .02/10- Surgery, right hip endoprosthesis (Right), cemented utilizing a [NAME] cemented Summit stem size 7, with a 53 bipolar head with a 1.5 neck length . On 2/10/22, at 08:40 AM, Surveyor interviewed LPN R about R26's fall on 2/05/22. LPN R indicated CNA T found R26 on the floor when passing breakfast trays. LPN R indicated CNA T called out to LPN R indicating R26 was on the floor. LPN R indicated R26 had an alarm but it was not sounding. LPN R indicated R26 was observed lying on right hip on the floor in R26's room. LPN R indicated LPN R had asked R26 to roll over and then assessed range of motion and vital signs on R26. LPN R indicated R26 was able to move all limbs and indicated he had no pain and was fine. LPN R indicated the Hoyer lift was used to get R26 up off the floor and into the recliner in his room. LPN R indicated R26 then ambulated into bathroom with assist with no complaints of pain. LPN R indicated all that morning R26 had no complaints of pain up until 11:10 AM. LPN R indicated at that time LPN S was called over to assist. It was at that time R26's right leg was observed to be slightly shorter than the left leg. LPN R indicated LPN S called the hospital and completed the paperwork to send R26 out. Surveyor asked LPN R if a registered nurse assessed R26 at the time of the fall and LPN R indicated no. LPN R indicated R26 and family agreed to have R26 sent to emergency room. On 2/10/22 at 08:50, Surveyor asked Director of Nursing (DON) B about R26's fall on 2/5/22 resulting in right hip fracture. Surveyor asked DON B if there was an intervention put into place post fall. DON B looked over documentation and indicated R26 was to be alarmed and the alarm did not sound. DON B indicated the intervention was to check on the alarms more often. DON B could not find documentation for this. DON B then indicated no there was not. Surveyor asked DON B if a new intervention should be put i[TRUNCATED]