Azalea Gardens Nursing Center

Based on observation, staff interview, record review, and facility policy review, the facility failed to post the daily nursing staffing hours in a location readily accessible to residents and visitors and failed to update the posted staffing for three (3) of four (4) days of survey. This deficient practice had the potential to affect all 63 residents residing in the facility.
Findings included:
A review of the facility's Nurse Staffing Posting Information Policy, dated 10/2023, revealed, .It is the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines 1. The nurse staffing information will be posted on a daily basis .2. The facility will post the nurse staffing data at the beginning of each shift. 3. The information posted will be presented a. Presented in a clear and readable format. B. In a prominent place readily accessible to residents and visitors .
A record review of the facility's posted staffing information revealed that the last update was on 03/03/2025.
On 03/03/2025 at 10:00 AM, during an observation, the staffing information was located at the back of the facility near the vending machines. No residents or family members were observed near the area. This location was identified as the staff entryway, not a central location accessible to residents or visitors.
On 03/04/2025 at 9:55 AM, during an observation, the staffing information posted was dated 03/03/2025 and was not updated with current information. The posted form remained near the back door of the facility where there were no residents or family members observed.
On 03/04/2025 at 1:00 PM, during an interview with a family member of Resident #11, she stated that she had not seen the staffing information posted and did not know where it was located.
On 03/05/2025 at 3:15 PM, during an observation conducted with Licensed Practical Nurse (LPN) #1, the staffing information remained posted at the back door near the vending machines and was still dated 03/03/2025. No residents or family members were observed in the area.
On 03/05/2025 at 3:45 PM, during an interview, the Director of Nursing (DON) and Administrator confirmed that the staffing information had not been updated since Monday, 03/03/2025. The DON acknowledged that she had gotten sidetracked and forgot to update the staffing information. The Administrator stated that she believed family members and residents frequently visited the back area to get drinks and snacks from the vending machines. However, both the Administrator and the DON later confirmed that the staffing information was not centrally located, and that residents and family members typically did not enter through this door, as it was primarily used as a staff entrance.

Based on observation, staff interview, and facility policy review, the facility failed to use hand hygiene, discard overly ripe produce, and failed to calibrate a food thermometer prior to checking food temperatures, for two (2) of two (2) kitchen observations.
Findings included:
A review of the facility's Food Safety Policy, dated November 2023, revealed, Food will . be stored, prepared . with professional standards for food service safety. Policy Guidelines 1. Food safety practices shall be followed throughout the facility's entire food handing process .Elements of the process include the following .b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from the growth of microorganisms . 3. Facility shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage .7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. a. Staff shall wash hands according to facility procedures .
A review of the facility's Record of Food Temperatures Policy, dated November 2023, revealed, .It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled .Policy Guidelines .14. Food temperatures will be verified using a thermometer which is . calibrated to ensure accuracy .
On 03/03/2025 at 10:17 AM, during an observation of the kitchen and an interview with the Certified Dietary Manager (CDM), seven (7) sweet potatoes and one (1) onion with soft spots and white biological growth were observed in the pantry. Additionally, a bag of raisins was found open and exposed. Dietary Aide (DA) #2 was observed placing cartons of juice in the refrigerator and retrieved a plastic drink lid from the floor, discarded it, and continued placing five (5) juice cartons into the refrigerator without washing her hands. The CDM acknowledged that the staff member should have performed hand hygiene after retrieving the plastic drink lid from the floor and confirmed the presence of overly ripe produce and opened and exposed food items in the pantry. The CDM further stated that she and the Assistant Dietary Manager (ADM) were the only staff responsible for selecting produce from storage for the food preparation area, ensuring that no staff member would have mistakenly used the overly ripe produce.
On 03/03/2025 at 10:30 AM, during an interview, DA #2 confirmed that she retrieved the plastic drink lid from the floor and continued handling food items without performing hand hygiene. She acknowledged that she should have stopped and washed her hands before continuing food preparation. The Dietary Aide stated that staff receive monthly in-service training on infection control.
On 03/04/2025 at 11:00 AM, during an observation of the meal tray line and an interview the [NAME] was unable to explain how to properly calibrate a food thermometer before checking and recording food temperatures. The [NAME] stated that the thermometer should be calibrated to 22 degrees but did not use ice to calibrate the thermometer, despite the ADM providing ice for the process. The [NAME] acknowledged that she failed to properly calibrate the thermometer and stated that she was nervous. The [NAME] further stated that she normally would have calibrated the food thermometer using ice.
On 03/04/2025 at 11:20 AM, during an interview with the ADM, she confirmed that the [NAME] should have properly calibrated the food thermometer before use, which was why she had placed ice near her. The ADM emphasized the importance of ensuring thermometer accuracy to obtain correct food temperature readings. The ADM stated that her expectation was that all staff would correctly calibrate thermometers before use. The ADM also stated that staff receive monthly in-service training on infection control.
On 03/06/2025 at 10:24 AM, during an interview, the Administrator acknowledged that she was aware of the presence of overly ripe and opened and exposed food items in the pantry, the Dietary Aide's failure to use hand hygiene after retrieving an item from the floor, and the Cook's failure to calibrate the food thermometer. The Administrator stated that she expected staff to correctly monitor food temperatures for safety reasons and to ensure that food items were not stored in a deteriorated state. The Administrator confirmed that staff were expected to follow appropriate handwashing procedures to maintain food safety.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a nurse performed hand hygiene, changed gloves, and discarded a feeding tube syringe after it was dropped onto the floor during a medication administration observation for one (1) of three (3) residents reviewed for medication administration. (Resident #31)
Findings included:
A review of the facility's Infection Prevention and Control Program Policy, dated February 2024, revealed, .The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Guidelines .d. Standard Precautions .b. Hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures .d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies .p. Staff Education .a. Facility staff receive training relevant to their specific roles and responsibilities regarding the facility's infection prevention and control program, including policies and procedures related to their job function .
A record review of the facility's In-Service Attendance Record, dated 01/13/2025, 01/14/2025, and 01/17/2025, revealed that staff receiving training related to Infection Control Principles, including importance of hand hygiene .
On 03/04/2025 at 8:16 AM, during a medication administration observation for Resident #31, Licensed Practical Nurse (LPN) #2, while wearing gloves, retrieved the Percutaneous Endoscopic Gastrostomy (peg) tube syringe, which fell to the floor. LPN #2 picked up the syringe and proceeded to administer medications via the resident's peg tube without discarding the contaminated syringe, performing hand hygiene, or changing her gloves.
On 03/05/2025 at 8:20 AM, during an interview, LPN #2 confirmed she failed to change gloves, wash hands, or use a new syringe. LPN #2 stated the resident could develop an infection from using contaminated gloves and syringe. She explained that she should have removed the gloves, sanitized her hands, and used a new syringe. LPN #2 stated she was nervous and was not thinking clearly.
On 03/05/2025 at 1:00 PM, during an interview, the Director of Nursing (DON) stated that LPN #2 should have changed her gloves, sanitized her hands, and used a new syringe to prevent the resident from developing an infection.
On 03/06/2025 at 1:41 PM, during an interview, Registered Nurse (RN)#2/Infection Preventionist stated that the nurse should have changed her gloves, sanitized her hands, and used a new syringe. RN #2 also confirmed that LPN #2 had been trained regarding infection control practices.
On 03/06/2025 at 1:43 PM, during an interview, the Administrator stated that she expects staff to follow infection control policies to prevent residents from acquiring infections.
A record review of Resident #31's admission Record revealed the facility admitted the resident on 01/10/2024 with diagnoses including Unspecified Dementia.
A record review of Resident #31's Significant Change In Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/2024 revealed he had a Brief Interview for Mental Status (BIMS) score of 3, which indicated his cognition was severely impaired.

Based on observations, interviews, record review, and facility policy review, the facility failed to identify physical restraints related to the use of full-length bed rails and a lap buddy (type of chair restraint) for ten (10) of 19 sampled residents. Resident #1, Resident #10, Resident #13, Resident #19, Resident #41, Resident #45, Resident #54, Resident #58, Resident #60, and Resident #61.
Findings Include:
A record review of the facility's policy Physical Restraint Application Policy, dated January 2018, revealed Policy: The purpose of this procedure is to provide safety or postural support of a resident to prevent injury to the resident or others when the resident has medical symptoms that warrant the use of restraints . Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body . If a resident cannot mentally and physically self-release, then the device is considered a restraint .
Resident #1
On 06/19/23 at 01:17 PM, during an observation, Resident # 1 was lying in bed with head of bed elevated and there were two (2) full-length bed rails that were raised.
A record review of the admission Record revealed the facility admitted Resident #1 on 10/10/2007 with diagnoses including Unspecified Convulsions, Spastic Hemiplegia Affecting Right Dominant Side, and on 08/06/2021, a new diagnosis of Spastic Hemiplegia Affecting Left Nondominant Side.
A record review of the Order Review History Report revealed Resident #1 had a Physician's Order, dated 6/27/2016, for .full (length) padded side rails up x (times) 2 r/t (related to) convulsions and spastic hemiplegia .
Resident #10
On 06/19/23 at 11:03 AM, the SA observed Resident #10 lying in bed, with two (2) full-length side rails that were raised on both sides.
A record review of the admission Record revealed the facility admitted Resident #10 on 06/30/2010 with diagnoses including Epilepsy and Hemiplegia. A new diagnosis was added on 05/16/2016 of Conversion Disorder with Seizures or Convulsions.
A record review of the Order Summary Report with active orders as of 06/20/2023, revealed Resident #10 had a Physician's Order, dated 5/8/2018 for . full padded side rails up x2 for safety and seizure precautions .
Resident #13
On 06/19/23 at 11:15 AM, Resident #13 was observed lying in the bed with two (2) full-length side rails that were raised.
On 06/21/23 at 01:00 PM, during an interview and an observation, Resident #13 was lying in bed and both full-length side rails were raised. Resident #13 confirmed she could not release the rails on her own and that the bed rails were used to prevent her from falling out of bed.
A record review of the admission Record revealed the facility admitted Resident #13 on 02/09/2023 with diagnoses including Multiple Sclerosis and Other Muscle Spasm.
A record review of the Order Summary Report with active orders as of 06/22/2023, revealed Resident #13 had a Physician's Order, dated 2/9/2023, for . Full side rails up x 2 for safety per res (resident) request .
A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact.
Resident #19
On 06/21/23 at 02:25 PM, Resident #19 was observed lying in bed and he had two (2) raised full-length bed rails.
A record review of the admission Record revealed the facility admitted Resident #19 on 08/17/2019 and she had diagnoses including Unspecified Psychosis, Cerebrovascular Disease, and Dementia.
A record review of the Order Review History Report revealed Resident #19 had a Physician's Order, dated 8/17/2019, for Full side rails up x2 to define bed boundaries .
Resident #41
On 06/19/23 at 11:35 AM, during an observation, Resident #41 was sitting in the day room in a wheelchair. The wheelchair had a lap buddy (a form of chair restraint) with Velcro straps to the side of the chair. Resident #41 was confused and was not oriented.
On 06/19/23 at 02:06 PM, during an interview with Certified Nurse Aide (CNA) #1, she explained Resident #41 had Alzheimer's Disease and was unable to make her needs known. She confirmed that Resident #41 could not remove the lap buddy and that it was used to prevent Resident #41 from leaning forward and falling out of the wheelchair.
On 06/20/23 at 10:15 AM, during an interview with Licensed Practical Nurse (LPN) #1, she explained Resident #41 always wore the lap buddy when she was in her wheelchair for positioning and to prevent her from leaning forward out of the chair. She stated that without the lap buddy, Resident #41 would fall forward. She confirmed that Resident #41 was unable to remove the lap buddy due to her Dementia.
On 06/20/23 at 1:20 PM, Resident #41 was lying in bed with two (2) raised full-length padded bed rails.
On 06/20/23 at 1:50 PM, during an interview with CNA #2, she explained Resident #41 had the lap buddy and the padded bed rails in place for fall prevention. She explained that Resident #41 was unable to remove the lap buddy or the bed rails on her own.
A record review of the admission Record revealed the facility admitted Resident #41 on 02/25/2019 and she had diagnoses including Alzheimer's Disease and Vascular Dementia.
Record review of the Order Summary Report with active orders as of 06/22/2023, revealed Resident #41 had a Physician's Order, dated 10/6/2021, for May utilize lap buddy to w/c (wheelchair) as needed to assist with positioning r/t poor trunk control and a Physician's Order, dated 7/20/2021 for Full siderails up x 2 for bed mobility and safety .
Resident #45
On 06/19/23 at 11:20 AM, in an observation, there were two full-length bed rails on the resident's bed. The resident was not in the room at the time of the observation.
On 06/20/23 at 10:00 AM, during an interview with LPN #1, she explained Resident #45 had not had any recent falls and that he had full-length bed rails that were raised for bed mobility and safety.
On 06/20/23 02:22 PM, during an interview with CNA #3, she confirmed Resident #45 was unable to lower the bed rails on her own.
On 06/20/23 at 02:45 PM, observed Resident #45 lying in bed with full-length bed rails that were raised.
A record review of the admission Record revealed the facility admitted Resident #45 on 02/28/2018 and she had diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and Unspecified Dementia.
A record review of the Order Summary Report with active orders a of 06/20/2022, revealed Resident #45 had a Physician's Order, dated 3/24/2022, for . Full side rails up x2 for bed mobility and safety .
Resident #54
On 06/21/23 at 01:43 PM, during an observation and interview, Resident #54 was lying in bed with two raised full-length bed rails. Resident #54 explained staff pulled up both full-length bed rails to prevent him from falling. Resident #54 reported he could not lower the bed rails on his own if he wanted to.
A record review of the admission Record revealed the facility admitted Resident #54 on 01/25/2022 with a diagnosis of Metabolic Encephalopathy.
A record review of the Order Summary Report with active orders as of 06/20/2023, revealed Resident #54 had a Physician's Order, dated 6/19/2023 . Full side rails up x2 for bed mobility & (and) per resident request .
A record review of the Quarterly MDS with an ARD of 04/11/2023, revealed Resident #54 had a BIMS score of 13, which indicated he was cognitively intact.
Resident #58
On 06/19/23 at 11:50 AM, observed Resident #58 in his room sitting in a wheelchair. There were two raised full-length bed rails on his bed.
On 06/21/23 at 02:00 PM, during an interview with CNA #4, she explained bed rails are always used for safety when Resident #58 is in his bed. CNA #4 also confirmed that Resident #58 was unable to lower the bed rails on his own.
On 06/22/23 at 09:00 AM, during an interview with Resident #58, he explained the staff always raised the bed rails when he is in bed for safety and that he could not lower them if he wanted to. Resident #58 denied any recent falls or seizures.
A record review of the admission Sheet revealed the facility admitted Resident #58 on 12/07/2021, and he had diagnoses including Encounter for Orthopedic Aftercare Following Surgical Amputation, Acquired Absence of Right Leg Above Knee, Epilepsy, and Acquired Absence of Left Leg Above Knee.
A record review of the Order Summary Report with active orders as of 06/20/2023, revealed Resident #58 had a Physician's Order, dated 09/28/2022, for Full padded side rails up x2 for safety and seizure precautions.
A record review of the Quarterly MDS with an ARD of 05/06/2023 revealed Resident #58 had a BIMS score of 8, which indicated his cognition was moderately impaired.
Resident #60
On 06/19/23 at 11:29 AM, during an interview and observation, Resident #60 was lying in bed and had two (2) raised full-length bed rails. Resident #60 explained the bed rails were raised for safety for fear of falling out of bed.
On 06/20/23 at 10:00 AM, during an interview with LPN #1, she explained Resident #60 had full-length bed rails that were raised for safety but stated that Resident #60 could not lower the bed rails on her own.
A record review of the admission Record revealed the facility admitted Resident #60 on 03/06/2023 and she had diagnoses including Secondary Malignant Neoplasm of Brain and Hemiplegia Unspecified Affecting Left Nondominant Side.
A record review of the Order Summary Report with active orders as of 06/23/2023, revealed Resident #60 had a Physician's Order, dated 03/11/2023, for Full side rails up x 2 per resident request for bed mobility and fear of falling out of bed.
A record review of the Quarterly MDS with an ARD of 06/12/23 revealed Resident #60 had a BIMS score of 13, which indicated she was cognitively intact.
Resident #61
On 06/19/23 at 02:44 PM, during an observation, Resident #61 was lying in bed and had two (2) raised full-length bed rails.
A record review of the admission Record revealed the facility admitted Resident #61 on 03/23/2023 and she had diagnoses including of Heart Failure and Unspecified Psychosis.
A record review of the Order Summary Report with active orders as of 06/20/2023, revealed Resident #61 had a Physician's Order dated 6/19/2023, for Full assist rails on bed as requested by resident for bed mobility.
On 06/19/23 at 03:00 PM, during an interview with the Administrator, she explained the facility is a no restraint facility.
On 06/22/23 at 10:30 AM, during an interview with Administration and the Director of Nursing (DON), they confirmed the facility does use full bed rails per resident/family request and for safety measures. They explained they understand the definition of restraints and the residents cannot lower or remove the full bed rails on their own. They confirmed the lap buddy can not be removed by Resident #41. The facility did not try the least restrictive measures before implementing the full bed rails and did not assess residents for entrapment. The Administrator reported the owner advised the facility to remove all full-length bed rails on Monday 06/19/23 after the State Agency entered the facility but it was explained to the owner an assessment would need to be completed on the resident's prior to removing the bed rails.

Based on record review, staff interview, and facility policy review, the facility failed to develop a care plan for physical restraints related to the use of full length bed rails and a lap buddy (a form of chair restraint) for 10 of 19 residents sampled. Resident #1, Resident #10, Resident #13, Resident #19, Resident #41, Resident #45, Resident #54, Resident #58, Resident #60, and Resident #61.
Findings include:
A record review of the facility's policy Comprehensive Care Plans, dated September 2018, revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .
A record review of the medical record revealed there was no care plan developed related to the use of restraints for Resident #1, Resident #10, Resident #13, Resident #19, Resident #41, Resident #45, Resident #54, Resident #58, Resident #60, and Resident #61.
During an interview on 06/22/23 at 10:30 AM, with the Administrator and the Director of Nursing (DON), they confirmed the facility used full bed rails for Resident #1, Resident #10, Resident #13, Resident #19, Resident #41, Resident #45, Resident #54, Resident #58, Resident #60, and Resident #61 and these residents were unable to lower or remove the bed rails without assistance. They also confirmed that Resident #41 used a lab buddy for positioning and is unable to remove the devices without assistance. Both the DON and Administrator explained that a care plan should have been developed for restraints for Resident #1, Resident #10, Resident #13, Resident #19, Resident #41, Resident #45, Resident #54, Resident #58, Resident #60, and Resident #61.
On 06/22/23 at 11:10 AM, during an interview with Licensed Practical Nurse (LPN)#2/Minimum Data Set (MDS)-Care Plan Nurse, she confirmed she did not develop or initiate care plans related to restraints for Resident #1, Resident #10, Resident #13, Resident #19, Resident #41, Resident #45, Resident #54, Resident #58, Resident #60, and Resident #61. She stated that any residents with a restraint should have a care plan in place for the restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and facility policy review, the facility failed to assess or administer pain medication for Resident #22's gestures and verbalization of pain/comfort during wound care. Resident #22's wound care was observed, 11/26/2019 at 9:00 AM. Resident #22 exhibited gestures and verbalization of pain, such a pulling her left leg up and saying Owww twice during the treatment. The wound was located on the left heel. Resident #22 was not assessed by the Treatment Nurse neither time, and therefore no pain medication was offered or administered. Resident #22 had orders for a pain medication every (6) six hours as needed. As a result, the nurse's failure to assess and administer Resident #22's pain medication during the wound care observation, raised this concern to a harm level. This concern was identified for one of eight (1 of 8) residents reviewed for pain.
Findings include:
Review of the facility's policy titled, Pain Management, dated 11/2018, revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The facility utilizes a systematic approach for recognition, assessment, treatment and monitoring of pain. In order to help a resident, attain or maintain their highest practicable level of well-being and to prevent or manage pain, the facility should: a. Recognize when the resident's experiencing pain and identifies circumstances when the pain is anticipated; b. Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and with change in condition or status (e.g., after a fall with change in behavior or mental status). c. Manages or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences.
An observation, on 11/26/2019 at 9:00 AM, revealed Registered Nurse (RN) #3/Wound Care Nurse, failed to assess Resident #22's gestures and verbalization of pain/discomfort during the wound care. Registered Nurse (RN) #3/Wound Care Nurse, was assisted by Certified Nursing Assistant (CNA) #1. Resident #22 was initially observed lying comfortably in bed on her right side. When RN #3 began to clean the wound with NS, Resident #22 cried out OWWW and drew her left leg upward toward her chest, during the wound care. RN #3 confirmed Resident #22 did not receive pain medication prior to wound care. RN #3 continued to clean Resident #22's wound with NS. RN #3 measured the wound, washed her hands, applied gloves and cleaned the wound again. Resident #22 cried out OWWW a second time. RN #3 continued to preform the wound care until complete without assessing Resident #22's pain or providing pain medication. Resident #22's left heel wound measured 1.4 centimeter (cm) by 1.2 cm, with 50% slough, mild clear drainage, and no odor.
During an interview, on 11/26/2019 at 11:00 AM, RN #3 confirmed she did not stop to assess Resident #22's pain level during the wound care. RN #3 stated Resident #22 did not receive any pain medication prior to the wound care treatment. RN #3 stated Resident #22 normally does not complain of pain. RN #3 confirmed she should have stopped the treatment when Resident #22 complained of pain to assess her pain and administer pain medication. RN #3 said she thought the State Agency (SA) would have a problem with her stopping the treatment.
During an interview, on 11/26/2019 at 10:00 AM, CNA #1 stated Resident #22 only complains of pain when the nurses does the wound care.
Review of Resident #22's Order Review Report revealed an order, dated 10/24/2019, to cleanse the unstageable left heel wound with NS, pat dry, apply santyl to wound bed. Apply sureprep to wound edges. Apply adhesive foam dressing. Wrap with kerlix daily and PRN until healed, every day shift and as needed. Further review of the report revealed an order, dated 9/16/2019, for Ultram Tablet 50 milligrams (mg), give one (1) tablet by mouth every six (6) hours as needed for pain. There also was an order, dated 6/28/2019, to administer Tylenol tablet, give 1000 mg by mouth daily for pain.
During an interview, on 11/26/2019 at 5:58 PM, the Director of Nursing (DON) stated residents are assessed prior to wound care treatments. The DON stated, I would have stopped as soon as the resident cried out in pain during the wound treatment and got her some pain medication.
Review of Resident #22's Medical Record revealed she was hospitalized [DATE] to 6/15/2019 after a fall. Resident #22 returned to the facility on 6/15/2019 status post a left hip replacement and was identified with soft heels. Sureprep was ordered to both heels as well as off loading. Further review of Resident #22's wound/skin assessments revealed: On 6/29/2019, the left heel was staged a Deep Tissue Injury (DTI) measuring 3.7 cm x 3.2 cm dark purple area with treatment continued. On 7/25/2019 the left heel measured 2.2 cm x 2.7 cm, black and firm. On 8/29/2019, the left heel measured 1.8 cm x 1.7 cm. On 9/26/2019 the left heel measured 1.5 cm x 1.5 cm with treatment continuing. On 10/31/2019 the left heel measured 1.5 cm x 2.0 cm. On 11/21/2019 the left heel measured 1.4 cm x 1.2 cm with continued treatment. Gradual slow healing.
An interview, on 11/26/2019 at 9:45 AM, revealed the Director of Nurses (DON) stated Resident #22's heels were soft on return to the facility from the hospital on 6/15/2019 due to a left hip replacement. The DON stated the Wound Care Nurse put treatments into place. The DON stated we are seeing improvement, but it is a slow gradual healing.
Review of the admission Record revealed the facility admitted Resident #22, on 4/30/2012, with the included diagnoses of Unstagable Left Heel Wound, Alzheimer's Disease, Osteoarthritis, Chronic Kidney Disease and Atherosclerotic Heart Disease.
Review of Resident #22's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/22/19, revealed Resident #22 had a Brief Interview of Mental Status (BIMS) score 3, which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the presence of an unstageable pressure ulcer suspected of deep tissue injury evolution. Review of the resident's pain assessment revealed she received routine pain medication, but no as needed pain medication. The pain interview was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to assist three (3) of six (6) residents, who attended the Resident Group Interview meeting, on 11/25/2019, to participate in the Gubernatorial election on 11/6/2019. The residents who voiced their concern regarding their voting rights were Resident #20, Resident #44 and Resident #54.
Finding include:
Review of the facility's policy titled, Residents Right To Vote, dated 9/2018, revealed that prior to an election, the social worker, social service designee, or assigned staff member should identify the residents who choose to vote, and identify the residents who need to register.
In an interview, on 11/25/2019 at 3:00 PM, during the Resident Group Interview meeting, three (3) of the six (6) residents, Resident # 20, Resident #44, and Resident #54 stated they did not get to vote in the general Gubernatorial election on 11/6/2019. They expressed the desire to vote.
In an interview, on 11/25/2019 at 3:25 PM, the Social Worker revealed she had a list of the three (3) residents who voted, and the others did not vote because they did not say they wanted to.
In an interview, on 1/29/2020 at 11:15 AM, the Administrator revealed before the survey in November, the residents were asked in Resident Council if they wanted to vote. Since the survey in November, the facility now asks the residents on admission if they would like to vote. Since November 2019, residents with a Brief Interview for Mental Status (BIMS) of 13 or higher are asked on admission and every month in resident council meetings if they would like to vote. The Administrator did state before the survey in November 2019, they did not check with all residents with a BIMS of 13 or higher about voting, but now they do. The administrator confirmed there have been no other elections since the November 2019 Governor's election. The Administrator stated the facility does provide transportation for the residents who want to go vote, and if the resident wants to vote by absentee, or wanted to register we assist them with that also. The Administrator stated if the resident is not registered to vote, the resident will be assisted to register on admission and when the elections come up. The Administrator stated the Social Services staff are responsible to oversee the resident's voting rights. The Administrator confirmed the residents who do not attend the council meetings will be addressed individually about their voting rights. The Administrator stated when an election comes up it will be posted for the residents to see, and discussed in the resident council meetings. The Administrator stated, this may not cause harm to a resident, but it does violate their right to vote.
Review of the Resident Council minutes from July 2019 to November 2019 revealed there was no documentation the residents had been offered the opportunity to vote.
Review of the Quarterly Minimum Data Sets (MDS), dated [DATE], revealed Resident #44 had a BIMS score of 15, which indicated no cognitive impairment.
Review of the most recent Quarterly MDS, dated [DATE], revealed Resident #54 had BIMS score of 15, which indicated no cognitive impairment.
Review of the Annual MDS, dated [DATE], revealed Resident #20 had BIMS score of 15, which indicated no cognitive impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to monitor, review, and evaluate their Quality Assessment and Assurance (QAA) plan to identify and document the resident's Advance Directive choice for code status. During the initial recertification survey on [DATE] to [DATE], the State Agency (SA) identified the facility's failure to honor Resident #74's Do No Resuscitate (DNR) code status, on [DATE], when the resident was found unresponsive, and without a pulse and respirations. The facility staff initiated Cardiopulmonary Resuscitation (CPR), which continued for five (5) minutes until the Fire Department arrived and reviewed the resident's medical record which revealed the DNR code status. Resident #74 was never revived and announced deceased at the facility. The SA also identified inaccurate code status documented for Resident #31 and #64 on re-entrance on [DATE] to extend the survey to [DATE]. This concern was identified for three (3) of 78 (facility's census at time the SA re-entrance) resident code statuses reviewed.
The SA identified an Immediate Jeopardy (IJ) on [DATE], due to the facility's failure to ensure accurate and consistent information regarding resident code status to use in emergency situations. The QAA review showed the QAA committee was not aware of this systemic issue, and the QAA committee was not monitoring facility practices related to accurate and consistent communication of resident's Advance Directives regarding code statuses. The facility's QAA met on [DATE] to discuss the facility's policy and procedure related to the code status for each resident. A plan of action was implemented to ensure all licensed nurses were in-serviced on honoring Resident's Rights and the right to choose a code status. The Director of Nurses (DON) provided an in-service, on [DATE], to all licensed nurses on honoring resident's rights, the right to choose a code status, and CPR policies. On, [DATE], the Assistant Director of Nurses (ADON) reviewed all resident code status records in each resident's paper chart and compared that review to all of the resident's electronic health records, for a total of 77 records. The result was 55 residents were DNRs, and 22 were full code status. On [DATE], the SA identified inaccurate code statuses for Resident's #31 and #64.
The facility's failure to monitor the QAA's corrective plan to ensure the residents' Advance Directive regarding code status was accurate, placed Resident #74, #31, #64 and other residents with a DNR code status at risk for serious injury, harm, impairment or death.
The facility Administrator was notified of the IJ on [DATE] at 12:05 PM.
The State Agency (SA) received an acceptable Immediate Jeopardy Removal Plan on [DATE], in which the facility alleged that all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE].
The SA determined the IJ was removed on [DATE], prior to the SA's exit on [DATE].
Findings include:
Review of the facility's Quality Assessment & Assurance (QAA) policy, dated 01/2019, revealed it is this facility's policy to develop, implement, and maintain an effective, comprehensive, data-driven QAA program that focuses on outcomes of care, promotes individual choice and the improvement in quality of life. The QAA Committee shall be interdisciplinary and shall consist at a minimum of: The Administrator, The Medical Director, The Director of Nursing, Infection Control Prevention Officer, two facility staff. The QAA Committee will: Conduct scheduled monthly meeting. Develop and implement appropriate plans of action to correct identified quality concerns and deficiencies. Participate in development, implementation and monitoring of the facilities written QAPI Plan. Regularly review and analyze performance data, including data collected under the QAPI (Quality Assurance and Performance Improvement) program, Infection Reports, Pharmacy, Psychological Reports, and recommendations. Identify issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program are necessary. Act on available data to make corrections or improvements. Review and evaluate all filed and completed grievances. Adverse events will be monitored in accordance with established procedures based on the type of adverse event. The data related to adverse events will be used to develop activities to prevent them.
On [DATE] at 2:39 PM, an interview with the Administrator revealed the facility held monthly QAA meetings. The Administrator stated new areas of concern are identified and a plan of correction is established. The Administrator stated the plan of correction included goals for resolutions. The Administrator stated old concerns are discussed for current status and if changes are needed. The Administrator revealed the concerns are identified from complaints/grievances, nursing reports, and general reporting by families, staff, and/or residents.
Resident #74
The facility failed to monitor a plan of correction established by the facility's QAA regarding the resident's Advanced Directives regarding their code status was honored and documented correctly in the medical record. As a result per review of Resident #74's Progress Notes-Nursing Notes, dated [DATE] at 9:18 PM, revealed a note at 7:28 PM documented Resident #74 was found by staff unresponsive and without a pulse or respirations. The staff initiated CPR. (Resident #74 was a Do Not Resuscitate (DNR) code status). The Emergency Medical System (EMS) was notified at 7:30 PM. The Fire Department arrived at 7:35 PM and checked the resident's chart and it was discovered at that time the resident was a DNR. The CPR was performed for five (5) minutes, until the Fire Department instructed the CPR to be stopped. Resident #74 was not revived and was pronounced deceased at 7:42 PM. The facility staff failed to check Resident #74's code status prior to initiating CPR.
Review of Resident #74's Care Plan, dated [DATE], revealed the resident was a DNR code status.
Review of Resident #74's Physician's Orders revealed an order, dated [DATE], for a DNR code status.
Review of Resident #74's Advance Directive, dated [DATE], revealed the resident and her daughter had elected a DNR code status.
An interview with Registered Nurse (RN) #1/Supervisor, on [DATE] at 3:24 PM, revealed she did not ask anyone to get Resident #74's chart to check the code status. RN #1/Supervisor confirmed the code status was not identified until the Fire Department personnel asked for the chart. RN #1 said she had been in-serviced regarding the location of the residents' code status, but everything happened so fast, and before she knew it the Fire Department was there. RN #1/Supervisor stated RN #5 and Licensed Practical Nurse (LPN) #2 initiated CPR, and when she entered the room, she instructed another Certified Nursing Assistant (CNA) to call 911.
An interview with RN #5/Charge Nurse, on [DATE] at 3:30 PM, revealed she did not ask anybody to get the chart to identify Resident #74's code status. RN #5/Charge Nurse said she did not ask anybody to get the chart because she thought RN #1/Supervisor had checked the chart for the code status. RN #5 said she was called into the room by a CNA. RN #5/Charge Nurse said she provided chest compressions and LPN #2 provided mouth to mouth breathing.
Licensed Practical Nurse (LPN) #2 was interviewed on [DATE] at 3:59 PM. LPN #2 revealed she did not ask anybody to get the chart because she thought RN #5/Charge Nurse checked Resident #74's chart for the code status. LPN #2 confirmed she did assist RN #5/Charge Nurse with resuscitating Resident #74. LPN #2 revealed she had been trained where the code status was located in the resident's chart.
On [DATE] at 5:52 PM, an interview with the Director of Nursing (DON), confirmed, on [DATE], Resident #74 was found unresponsive and with no pulse or respirations. The DON confirmed Resident #74 was a DNR, and CPR was initiated by the facility staff until the Fire Department arrived and discovered the resident was a DNR. The DON revealed CPR was performed for five (5) minutes until the Fire Department's discovery of the DNR code status. The facility staff did not check the resident's chart to ensure the code status was identified and honored.
Review of the facility's Quality Assessment and Assurance (QAA) sign in sheets dated [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] revealed the Medical Director, Administrator, Director of Nurses, Quality Assurance Nurse, Activity Director, Dietary Manager, Infection Preventionist, Social Worker, Minimum Data Set and Assistant Director of Nursing attended the QA meetings. The meeting on [DATE] had a typed note attached stating, Discussed policy and procedure related to code status. Discussed implementation and in-serving staff on policy and procedure related to code status. The [DATE] notes addressed the discussion of (citation tag number), in-services conducted on resident code status, mock code drill with no issues identified. Discussed policy and procedure related to communication of code status, with no changes made. Discussed the facility's action plan to include audits of residents' code status, and all findings will be reported to QAPI.
Review of the facility's In-Service Attendance Record, dated [DATE], revealed the staff was trained on honoring Resident/family right to choose CPR and code status. Further review of the facility's In-Service Attendance Records revealed the facility provided a training titled, Initiating CPR/Code Status to the licensed nurses, on [DATE].
An interview, on [DATE] at 11:53 AM, revealed the Administrator confirmed the QAA committee failed to monitor their corrective actions to make sure all the resident's code status was correct. The Administrator also stated the system failed because their checks and balances did not work. The Administrator confirmed the system the QAA interdisciplinary team put in place was not successful. The Administrator stated the facility had a QAA meeting, on [DATE], and discussed Resident #74's DNR code status. The Administrator stated the QAA committee considered this as a high risk situation and should be taken care of immediately. The Administrator stated the only thing the disciplinary team implemented during the meeting was to in-service the supervisors on where to locate the resident's code status and to perform a mock code. The Administrator stated the Quality Assurance (QA)/Infection Nurse schedules the QAA meetings monthly and as needed. The Administrator also stated the RN supervisors were in-serviced immediately on all shifts on how to locate the resident's code status in the chart, computer and Kiosk. The Administrator reported the RNs involved in the incident with Resident #74 did not receive any disciplinary actions from the facility. The Administrator stated the Assistant Director of Nursing (ADON) was responsible for checking the Physician's Orders, Quick Reference Sheet and the Medication Administration Records (MARS) to make sure the code statuses matched. The ADON was also responsible for monitoring all resident's code status. The Administrator said LPN #5 was the acting QA/Infection Control Nurse, and was responsible for checking behind the ADON to make sure the resident's code status was updated.
Review of the facility's In-Service Attendance Record, dated [DATE], revealed the signatures of RN #1 and #5, regarding Code Status Simulation.
On [DATE] at 12:22 PM, an interview with the ADON revealed Resident #74's DNR status was not honored due to the nurses did not check her code status which was on the chart, the physician's orders, and the Medication Administration Record (MAR).
Review of the admission Record revealed Resident #74 was admitted by the facility, on [DATE], with the included diagnoses of Cardiomyopathy, Cardiomegaly, Tachycardia, Pulmonary Disease, Heart Failure, and Chronic Atrial Fibrillation.
A review of Resident #74's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.
Resident #31
Review of Resident #31 Quick Reference Sheet revealed Resident #31 was a Full Code. Review of the chart and current Electronic Physician's Orders revealed Resident #31 had elected to have a DNR code status.
On [DATE] at 12:16 PM, an interview with LPN #5/Interim QA Nurse, revealed she did not know what happened with Resident #31's DNR code status not being on the Quick Reference Sheet. LPN #5 confirmed Resident #31 was a DNR, and should have been identified as such. LPN #5 stated she had only checked the new admissions since the last survey because all of the other charts had been checked.
Resident #64
Review of Resident #64's Quick Reference Guide report sheet, revealed Resident #64 was listed as a DNR code status. Review of the current Physician's Orders revealed there was no code status order for a DNR. Further review revealed there was no code status on the Medication Administration Record (MAR). This is an additional check for code status for the facility. The MAR did not indicate a DNR because the nurse deleted it on the Physician's Orders which could have resulted in CPR being initiated instead of a DNR.
An interview, on [DATE] at 11:53 AM, revealed the Administrator confirmed Resident #64's DNR code status was deleted from the electronic record by mistake. The Administrator stated LPN #1 deleted the DNR order instead of a medication. The Administrator confirmed this was not found until the SA discovered it and reported the finding to them on [DATE]. The Administrator reported the facility ran a report of discontinued orders and found that LPN #1 discontinued the DNR order for Resident #64 on [DATE]. A medication order should have been discontinued instead of Resident #64's code status.
An interview, on [DATE] at 11:45 AM, with LPN #1, revealed she clicked on the wrong thing in the computer. LPN #1 confirmed she clicked on DNR instead of a medication she was trying to delete. LPN #1 did not realize the mistake until LPN #4 revealed it to her.
On [DATE] at 12:16 PM, an interview with Licensed Practical Nurse (LPN) #5 revealed she didn't know what happened with Resident #64's code status being incorrect. LPN #5 stated she missed it. Resident #64's DNR code status was deleted on the Electronic Record.
During an interview, on [DATE] at 4:20 PM, LPN #6 revealed the nurses were trained to find the resident's code status on their Quick Reference Sheet, on the MARs, the bright red sheet at the nurse's station and crash cart. LPN #6 also said the ADON updates them monthly and with new admits or changes in the resident's code status.
During an interview with LPN #7, on [DATE] at 4:45 PM, she revealed the nurses are trained to find the resident's code status on top of the MARs, Quick Reference Sheet, the red sheet at the nurses' station and crash cart. LPN #7 also said she thought the ADON updated them. LPN #7 stated the nurses write changes on their report sheet and turn it in at the end of the shift.
An interview, on [DATE] at 12:22 PM, revealed the ADON said she was responsible for checking the resident's code status and making sure there's a written order in the Electronic Record and on the MAR. The ADON also confirmed the facility was not aware of the nurse deleting the resident's Code status until the SA discovered it. The ADON also stated if Resident #31 and Resident #64 conditions would have changed, both residents potentially could have had Cardiopulmonary Resuscitation (CPR) done, which could possibly cause pain from broken ribs and or resident being placed on a ventilator.
This is the facility's accepted Immediate Jeopardy Removal Plan:
Summary of events:
The State Agency notified [NAME] Gardens Nursing Center on [DATE]th, 2020 at 12:05 P.M. of the immediate jeopardy and substandard quality of care for Residents #74, #31, and #64. The Facility failed to honor Resident #74's advance directive for a do not resuscitate (DNR) code status, failed to honor the Resident's Rights for Advance Directive, failed to follow the care plan for a DNR code status and failed to prevent a potential negative outcome by initiating Cardiopulmonary Resuscitation (CPR). Resident #74 was found pulseless on [DATE]th, 2019 at 7:28 PM by RN #1 who initiated Cardiopulmonary Resuscitation (CPR) for a total of five minutes. CPR was discontinued when emergency services arrived and notified RN #1 of Resident#74's DNR code status. RN #1 failed to follow the policy and procedures in place to identify Resident #74's code status. The State Agency notified the facility on [DATE]th, 2020 at 3:30 PM that Resident #31's code status was documented incorrectly on the Report Sheet and Resident #64's code status was not in the Electronic Health Record, according to their wishes which could have likely caused harm for Residents #31 and #64. The facility failed to follow policy and procedure to identify the correct code status for Residents #74, #31, and #64.
Facility action plan:
1. The Director of Nursing (DON) conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with Registered Nurse (RN) #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred.
2. On [DATE]th, 2019 Care Plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status.
3. On [DATE]th, 2019 at 1:30 PM the Director of Nursing in serviced all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies.
4. On [DATE]th and 30th, 2020 the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses.
5. On [DATE] the Assistant Director of Nursing (ADON) reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status.
6. On [DATE]th, 2020 at 12:05PM, the State Agency identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. Care Plan Nurse found that Resident #64's order had been discontinued by Licensed Practical Nurse (LPN) #1 and the order was reentered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes.
7. The Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status.
8. The Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record.
No staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member.
The facility alleges the immediate jeopardy was removed on [DATE].
On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ:
1. The SA validated through record review of the sign-in sheets and interview with the Director of Nursing (DON) that the facility conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with RN #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred.
2. The SA validated through record review of the in-service sign-in sheets and interview with the Care Plan Nurse that on [DATE]th, 2019 Care plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status.
3. The SA validated through record review of the sign-in sheets and interview with the DON that the facility conducted an in-service on [DATE]th, 2019 at 1:30 PM, by the Director of Nursing, to all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies.
4. The SA validated through record review of the in-service sign-in sheets and interview with the facility owner that on [DATE]th and 30th, 2020, the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses.
5. The SA validated by interview of the ADON that on [DATE] the ADON reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status.
6. The SA validated by record review and staff interviews, on [DATE]th, 2020 at 12:05 PM, the SA identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. The Care Plan Nurse found that Resident #64's order had been discontinued by LPN #1 and the order was re-entered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by the Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes.
7. The SA validated by interviews the Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status.
8. The SA validated through interviews with the Facility Administrator and the DON the Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record.
The SA validated through interviews with the Administrator and the DON that no staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member.
The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and interviews, the facility failed to comply with Resident #74's right to refuse or accept treatment regarding her wishes for no Cardiopulmonary Resuscitation (CPR) in the event if her heart stops beating or she stops breathing, no other medical treatment would be started or continued. Resident #74 had an elective Advanced Directive for a Do Not Resuscitate (DNR) code status and a Physician's Order for a DNR, dated [DATE]. On [DATE], the facility staff did not verify Resident #74's code status, before initiating Cardiopulmonary Resuscitation (CPR) when staff discovered the resident unresponsive with no evidence of a pulse or respirations.
An Immediate Jeopardy (IJ) was determined to exist, on [DATE] at 7:28 PM, when facility staff found Resident #74 unresponsive, without a pulse or respirations. The facility's staff initiated Cardio-Pulmonary Resuscitation (CPR) on Resident #74 and continued to provide CPR for five (5) minutes until the Emergency Medical Services (EMS) was notified and the local Fire Department arrived and reviewed Resident #74's medical record and found Resident #74 was a Do Not Resuscitate (DNR) resident. The CPR was stopped, and Resident #74 was pronounced deceased at 7:42 PM. Resident #74 was never revived during the CPR.
The facility's failure to identify Resident #74 as a DNR resident prior to initiating CPR resulted in the resident's decision for a DNR status not being honored or followed by the facility. The facility's failure to identify Resident #74's rights and Advance Directive for a DNR, placed Resident #74 and other DNR residents in a situation that was likely to cause serious injury, harm, impairment, or death.
On [DATE] at 12:05 PM, the SA notified the facility's Administrator of the IJ and SQC.
The facility submitted an Acceptable Immediate Jeopardy Removal Plan on [DATE], in which the facility alleged all corrective actions were completed on [DATE], and the IJ was removed on [DATE].
The SA validated the facility's Removal Plan on [DATE] and determined the IJ was removed on [DATE], prior to exit.
Findings include:
Review of the facility's policy titled, Advance Directives Policy, dated 11/2018, revealed the Advance Directive definition was a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care when the individual was incapacitated. The Do Not Resuscitate (DNR) definition indicated that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life sustaining treatments or methods are to be used. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Further review of the policy revealed information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.
Review of the facility's policy titled, Resident Rights, dated 01/2019, revealed: The facility will protect and promote the rights of the resident. A resident has the right to exercise his or her rights as a resident of the facility.
Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR) Policy, dated 10/2018, revealed, it is the policy of this facility to adhere to resident's rights to formulate advance directives, and the facility will implement guidelines regarding cardiopulmonary Resuscitation (CPR). If a resident experiences a cardiac arrest, the facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and in accordance with the resident's advance directive.
Review of Resident #74's Progress Notes-Nursing Notes, dated [DATE] at 9:18 PM, revealed a note at 7:28 PM stated the Charge Nurse, Medication (Med) cart nurse, Registered Nurse (RN) and three (3) Certified Nursing Assistants (CNAs) entered the room and Resident #74 was found unresponsive and no pulse. The resident was assisted to the floor via a sheet and Cardiopulmonary Resuscitation (CPR) was initiated per the American Heart Association protocol and 911 was called at 7:30 PM. The Fire Department arrived at 7:35 PM and the resident's chart was reviewed to discover the resident was a DNR. CPR was ceased at that time. Resident was pronounced at 7:42 PM. The Coroner arrived at 8:11 PM, and the resident's body was released to the funeral home at 8:32 PM. The Nurses Notes revealed CPR was performed for five (5) minutes, prior to the fire department's arrival.
An interview, on [DATE] at 3:24 PM, with Registered Nurse (RN) #1/Supervisor, revealed she confirmed she did not ask anybody to get the chart until the Fire Department personnel asked for it. RN #1 said they received a call from the lab reporting a critically high Potassium level. RN #1 stated the Medical Doctor (MD) instructed them to send Resident #74 to the emergency room (ER) for evaluation and treatment. Resident #74 was left alone in the room with the Certified Nursing Assistant (CNA). RN #1 could not remember who the CNA was. RN #1 stated the CNA came to the door saying, I don't think she's breathing. RN #1 stated RN #5 and Licensed Practical Nurse (LPN) #2 initiated CPR. RN #1 said she entered the room and instructed another CNA to call 911. RN #1 said the next thing she knew was when she looked up and the Fire Department was at the facility, and that was when Resident #74's DNR status was identified. RN #1 said she did not know what happened, it happened so quick. RN #1 did say she had been in-serviced several times on where to look for a resident's code status to ensure it was identified and provided per the resident's request.
Review of the Progress Notes-Nurses Notes, dated [DATE] at 7:17 PM, revealed a call was received from (Name of Hospital) lab reporting a critically high Potassium level of 8.7. Relayed to (Name of MD) who instructed to send resident to (Name of Hospital) to be evaluated and treated. (Names of Contact Persons) were notified and verbalized understanding.
An interview, on [DATE] at 3:30 PM, revealed RN #5/Charge Nurse confirmed she did not ask anybody to get the chart to review Resident #74's code status. RN #5 said she did not ask anybody to get the chart because she thought RN #1/Supervisor had checked the chart for the code status. RN #5 said she was called into the room by a CNA. RN #5 said she provided chest compressions and LPN #2 provided mouth to mouth breathing.
During an interview, on [DATE] at 3:59 PM, LPN #2 revealed she assisted RN #5 with resuscitating Resident #74. LPN #2 confirmed she did not ask anybody to get the chart. LPN #2 stated she has been trained where the code status was located in the chart. LPN #2 also stated she thought the supervisor had checked the chart for Resident #74's code status.
Review of the facility's Advanced Care Planning form revealed Resident #74's printed name and her daughter's printed and signed name, dated [DATE], for an elected DNR code status. Resident #74's admission Record revealed the resident's daughters were the first and second contact persons. The resident's Advanced Directive was a Do Not Resuscitate.
Review of Resident #74's Physician's Orders revealed an order, dated [DATE], for a DNR code status.
During an interview, on [DATE] at 4:44 PM, Firefighter #1, revealed on [DATE], upon responding to the 911 call, the Chief obtained Resident #74's chart and discovered that Resident #74 was a DNR code status. Firefighter #1 stated that CPR was ceased at that time.
An interview, on [DATE] at 12:22 PM, an interview with the Assistant Director of Nurses (ADON) revealed she was responsible for checking the residents code status and making sure there's a written order that is in the electronic record and on the Medication Administration Record (MAR). The ADON stated Resident #74's DNR order was in the chart Physician's Orders, and on the MAR. Resident #74's DNR code status was not honored due to the nurse's failure to check the Physician's Orders and MAR.
During an interview, on [DATE] at 5:52 PM, the Director of Nursing (DON) confirmed Resident #74's code status was a Do Not Resuscitate (DNR), and when the resident was found unresponsive, on [DATE], the Charge Nurse initiated CPR. The DON stated after they found out the resident was a DNR, CPR was stopped. As a result, Resident #74's DNR code status choice was not honored.
During an interview, on [DATE] at 4:46 PM, the Deputy Coroner stated the fire department had already pronounced the resident by the time he arrived. The Deputy Coroner said he was told the staff had performed CPR and the resident was never revived.
An interview with the Medical Director, on [DATE] at 11:53 AM, revealed he was made aware of the staff initiating CPR after the EMS staff left the building. The Medical Director stated he was told the staff found the resident unresponsive and initiated CPR until the Fire Chief pulled the resident's chart and noted she was a DNR, and the Fire Chief stopped the CPR at that moment. The Medical Director stated the resident could have had a negative outcome of surviving with broken ribs or being placed on a ventilator.
Review of the admission Record revealed Resident #74 was admitted by the facility, on [DATE], with the included diagnoses Cardiomyopathy, Heart Failure, Cardiomegaly, Tachycardia, Pulmonary Disease and Chronic Atrial Fibrillation.
Review of Resident #74's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.
This is the facility's accepted Immediate Jeopardy Removal Plan:
Summary of events:
The State Agency notified [NAME] Gardens Nursing Center on [DATE]th, 2020 at 12:05 P.M. of the immediate jeopardy and substandard quality of care for Residents #74, #31, and #64. The Facility failed to honor Resident #74's advance directive for a do not resuscitate (DNR) code status, failed to honor the Resident's Rights for Advance Directive, failed to follow the care plan for a DNR code status and failed to prevent a potential negative outcome by initiating Cardiopulmonary Resuscitation (CPR). Resident #74 was found pulseless on [DATE]th, 2019 at 7:28 PM by RN #1 who initiated Cardiopulmonary Resuscitation (CPR) for a total of five minutes. CPR was discontinued when emergency services arrived and notified RN #1 of Resident#74's DNR code status. RN #1 failed to follow the policy and procedures in place to identify Resident #74's code status. The State Agency notified the facility on [DATE]th, 2020 at 3:30 PM that Resident #31's code status was documented incorrectly on the Report Sheet and Resident #64's code status was not in the Electronic Health Record, according to their wishes which could have likely caused harm for Residents #31 and #64. The facility failed to follow policy and procedure to identify the correct code status for Residents #74, #31, and #64.
Facility action plan:
1. The Director of Nursing (DON) conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with Registered Nurse (RN) #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred.
2. On [DATE]th, 2019 Care Plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status.
3. On [DATE]th, 2019 at 1:30 PM the Director of Nursing in serviced all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies.
4. On [DATE]th and 30th, 2020 the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses.
5. On [DATE] the Assistant Director of Nursing (ADON) reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status.
6. On [DATE]th, 2020 at 12:05PM, the State Agency identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. Care Plan Nurse found that Resident #64's order had been discontinued by Licensed Practical Nurse (LPN) #1 and the order was reentered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes.
7. The Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status.
8. The Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record.
No staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member.
The facility alleges the immediate jeopardy was removed on [DATE].
On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ:
1. The SA validated through record review of the sign-in sheets and interview with the Director of Nursing (DON) that the facility conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with RN #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred.
2. The SA validated through record review of the in-service sign-in sheets and interview with the Care Plan Nurse that on [DATE]th, 2019 Care plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status.
3. The SA validated through record review of the sign-in sheets and interview with the DON that the facility conducted an in-service on [DATE]th, 2019 at 1:30 PM, by the Director of Nursing, to all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies.
4. The SA validated through record review of the in-service sign-in sheets and interview with the facility owner that on [DATE]th and 30th, 2020, the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses.
5. The SA validated by interview of the ADON that on [DATE] the ADON reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status.
6. The SA validated by record review and staff interviews, on [DATE]th, 2020 at 12:05 PM, the SA identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. The Care Plan Nurse found that Resident #64's order had been discontinued by LPN #1 and the order was re-entered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by the Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes.
7. The SA validated by interviews the Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status.
8. The SA validated through interviews with the Facility Administrator and the DON the Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record.
The SA validated through interviews with the Administrator and the DON that no staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member.
The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and facility policy review, the facility failed to ensure Resident #74's Care Plan was implemented for a Do Not Resuscitate (DNR) code status, and
to develop/implement Resident #22's Care Plan for pain medication administration as needed during wound care. These concerns were identified for two (2) of 30 care plans reviewed.
Resident #74 had a Care Plan initiated and revised, on [DATE], for a DNR code status. The SA identified an Immediate Jeopardy (IJ) on [DATE] at 7:28 PM, when Resident #74 was found unresponsive and without a pulse or respirations by the facility staff. The facility staff failed to verify Resident #74's code status. Cardiopulmonary Resuscitation (CPR) was initiated by the facility staff until the local Fire Department arrived at 7:35 PM, and reviewed Resident #74's chart where the DNR code status was documented. The CPR was stopped after five (5) minutes, and Resident #74 was pronounced deceased at 7:42 PM. The facility staff did not follow Resident #74's Care Plan regarding her DNR code status.
The facility's failure to follow Resident #74's Comprehensive Care Plan regarding her DNR code status placed Resident #74 and other residents with a DNR code status in situations that was likely to cause serious harm, injury, impairment or death.
On, [DATE] at 12:05 PM, the State Agency (SA) notified the facility's Administrator of the Immediate Jeopardy (IJ).
The facility submitted an Acceptable Immediate Jeopardy Removal Plan on [DATE], in which the facility alleged all corrective actions were completed on [DATE], and the IJ was removed on [DATE].
The SA validated the facility's Immediate Jeopardy Removal Plan on [DATE] and determined the IJ was removed on [DATE], prior to exit.
Findings Include:
Record Review of the facility's policy titled, Comprehensive Care Plans, dated 09/2018, revealed it is the policy of this facility to develop and implement a comprehensive person centered Care Plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
Resident #74
Review of Resident #74's Care Plan revealed the facility failed to follow the care plan regarding the resident's Do Not Resuscitate (DNR) code status. The Care Plan was initiated, on [DATE], for Resident #74's DNR code status. The goal was to honor the resident and family wishes. The interventions included: Ensure comfort measures are achieved without heroics. Ensure resident/family understands meaning of code status. Label the chart, Medication Administration Record (MAR) and Treatment Administration Record (TAR) to inform staff of DNR code status, obtain signed consent and Medical Doctors orders for DNR.
Review of Resident #74's Progress Notes-Nursing Notes, dated [DATE] at 9:18 PM, revealed a note at 7:28 PM stated the Charge Nurse, Medication (Med) cart nurse, Registered Nurse (RN) and three (3) Certified Nursing Assistants (CNAs) entered the room and Resident #74 was found unresponsive and no pulse. The resident was assisted to the floor via a sheet and Cardiopulmonary Resuscitation (CPR) was initiated per the American Heart Association protocol and 911 was called at 7:30 PM. The local Fire Department arrived at 7:35 PM and reviewed Resident #22's chart to discover the resident was a DNR. CPR was ceased at that time. Resident was pronounced at 7:42 PM. The Coroner arrived at 8:11 PM, and the resident's body was released to the funeral home at 8:32 PM. The Nurses Notes revealed CPR was performed for five (5) minutes, prior to the fire department's arrival.
During an interview, on [DATE] at 5:25 PM, RN #4/Care Plan Nurse revealed he looks at the residents advance directives to determine whether the resident is a full code or a DNR. LPN #4 said he normally does a care plan for the resident with a DNR code status and he expected the staff to follow the care plan.
Review of the facility's Advanced Care Planning form revealed Resident #74's printed name and her daughter's printed and signed name, dated [DATE], for an elected DNR code status. Resident #74's admission Record revealed the resident's daughters were the first and second contact persons. The resident's Advanced Directive was a Do Not Resuscitate.
Review of Resident #74's Physician's Orders revealed an order, dated [DATE], for a DNR code status.
Review of the admission Record revealed Resident #74 was admitted by the facility, on [DATE], with the included diagnoses Cardiomyopathy, Heart Failure, Cardiomegaly, Tachycardia, Pulmonary Disease and Chronic Atrial Fibrillation.
Review of Resident #74's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.
Resident #22
Review of Resident #22's Care Plan revealed the Care Plan did not address pain assessment/management for wound care. Further review of the Care Plan revealed the Focus for risk for skin breakdown secondary to decreased mobility and history (hx) of occasional urinary incontinence was initiated, on [DATE]. The Goal stated the resident would be free of skin breakdown with a Target Date of [DATE]. Further review of the care plan revealed an Intervention, dated [DATE], to cleanse the unstageable wound to the left heel with Normal Saline (NS), pat dry, apply Santyl to wound bed, apply sureprep to wound edges, apply adhesive dressing (dsy), wrap with kerlix, daily (dly) and as needed (PRN) until healed. The Interventions also included: Administer Ultram 50 milligrams (mg) by mouth (po) every (q) six (6) hours as needed (prn) for pain. Monitor effectiveness of prn medication and document. Notify Medical Doctor (MD) if medication not effective in helping relieve and/or control pain.
An observation, on [DATE] at 9:00 AM, revealed Registered Nurse (RN) #3/Wound Care Nurse, did not follow Resident #22's Care Plan due to she did not assess the residents gestures and verbalization of pain/discomfort during the wound care observation, or administer pain medication. Registered Nurse (RN) #3/Wound Care Nurse, was assisted by Certified Nursing Assistant (CNA) #1. Resident #22 was observed lying comfortably in bed on her right side. When RN #3 began to clean the wound with NS, Resident #22 cried out OWWW and drew her left leg upward toward her chest, during the wound care. RN #3 confirmed Resident #22 did not receive pain medication prior to wound care. RN #3 continued to clean Resident #22's wound with NS. RN #3 measured the wound, washed her hands, applied gloves and cleaned the wound again. Resident #22 cried out OWWW a second time. RN #3 continued to preform the wound care until complete without assessing Resident #22's pain or providing pain medication. Resident #22's left heel wound measured 1.4 centimeter (cm) by 1.2 cm, with 50% slough, mild clear drainage, and no odor.
An interview, on [DATE] at 11:00 AM, with RN #3/Wound Care Nurse, revealed Resident #22 did not receive pain medication prior to the wound care to the left heel. RN #3/Wound Care Nurse stated Resident #22 usually does not complain of pain. RN #3/Wound Care Nurse stated she should have stopped the treatment when the resident complained of pain.
Review of Resident #22's Order Review Report revealed an order, dated [DATE], to cleanse the unstageable left heel wound with NS, pat dry, apply santyl to wound bed. Apply sureprep to wound edges. Apply adhesive foam dressing. Wrap with kerlix daily and PRN until healed, every day shift and as needed. Further review of the report revealed an order, dated [DATE], for Ultram Tablet 50 milligrams (mg), give one (1) tablet by mouth every six (6) hours as needed for pain. There also was an order, dated [DATE], to administer Tylenol tablet, give 1000 mg by mouth daily for pain.
During an interview, on [DATE] at 5:33 PM, RN #4/Care Plan Nurse confirmed the facility failed to develop a care plan related to pain regarding Resident #22's left heel wound care. RN #4/Care Plan Nurse said he developed a care plan today, and he notified the doctor of Resident #22's wound care pain and received an order for pain medication routinely and as needed.
An interview, on [DATE] at 5:58 PM, revealed the Director of Nurses (DON) stated, I would have stopped as soon as the resident cried out in pain during the wound care treatment and got her some pain medication.
Review of the Face Sheet revealed Resident #22 was admitted by the facility, on [DATE], with the included diagnoses of Chronic Kidney Disease, Urinary Retention and Vascular Dementia with behavioral Disturbance.
A review of Resident #22's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the presence of an unstageable pressure ulcer suspected of deep tissue injury evolution. Review of the resident's pain assessment revealed she received routine pain medication, but no as needed pain medication. The pain interview was not done.
This is the facility's accepted Immediate Jeopardy Removal Plan:
Summary of events:
The State Agency notified [NAME] Gardens Nursing Center on [DATE]th, 2020 at 12:05 P.M. of the immediate jeopardy and substandard quality of care for Residents #74, #31, and #64. The Facility failed to honor Resident #74's advance directive for a do not resuscitate (DNR) code status, failed to honor the Resident's Rights for Advance Directive, failed to follow the care plan for a DNR code status and failed to prevent a potential negative outcome by initiating Cardiopulmonary Resuscitation (CPR). Resident #74 was found pulseless on [DATE]th, 2019 at 7:28 PM by RN #1 who initiated Cardiopulmonary Resuscitation (CPR) for a total of five minutes. CPR was discontinued when emergency services arrived and notified RN #1 of Resident#74's DNR code status. RN #1 failed to follow the policy and procedures in place to identify Resident #74's code status. The State Agency notified the facility on [DATE]th, 2020 at 3:30 PM that Resident #31's code status was documented incorrectly on the Report Sheet and Resident #64's code status was not in the Electronic Health Record, according to their wishes which could have likely caused harm for Residents #31 and #64. The facility failed to follow policy and procedure to identify the correct code status for Residents #74, #31, and #64.
Facility action plan:
1. The Director of Nursing (DON) conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with Registered Nurse (RN) #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred.
2. On [DATE]th, 2019 Care Plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status.
3. On [DATE]th, 2019 at 1:30 PM the Director of Nursing in serviced all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies.
4. On [DATE]th and 30th, 2020 the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses.
5. On [DATE] the Assistant Director of Nursing (ADON) reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status.
6. On [DATE]th, 2020 at 12:05PM, the State Agency identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. Care Plan Nurse found that Resident #64's order had been discontinued by Licensed Practical Nurse (LPN) #1 and the order was reentered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes.
7. The Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status.
8. The Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record.
No staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member.
The facility alleges the immediate jeopardy be removed on [DATE].
On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ:
1. The SA validated through record review of the sign-in sheets and interview with the Director of Nursing (DON) that the facility conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with RN #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred.
2. The SA validated through record review of the in-service sign-in sheets and interview with the Care Plan Nurse that on [DATE]th, 2019 Care plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status.
3. The SA validated through record review of the sign-in sheets and interview with the DON that the facility conducted an in-service on [DATE]th, 2019 at 1:30 PM, by the Director of Nursing, to all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies.
4. The SA validated through record review of the in-service sign-in sheets and interview with the facility owner that on [DATE]th and 30th, 2020, the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses.
5. The SA validated by interview of the ADON that on [DATE] the ADON reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status.
6. The SA validated by record review and staff interviews, on [DATE]th, 2020 at 12:05 PM, the SA identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. The Care Plan Nurse found that Resident #64's order had been discontinued by LPN #1 and the order was re-entered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by the Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes.
7. The SA validated by interviews the Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status.
8. The SA validated through interviews with the Facility Administrator and the DON the Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record.
The SA validated through interviews with the Administrator and the DON that no staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member.
The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ was removed on [DATE], prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and facility policy review, the facility failed to honor Resident #74's Do Not Resuscitate (DNR) code status by initiating Cardio-Pulmonary Resuscitation (CPR) when the resident was found by the facility staff unresponsive and with no pulse or respirations, for one (1) of four (4) residents reviewed who had expired in the facility within the past six (6) months.
The State Agency identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE]. Resident #74 had a Physician's Order and Advance Directive for a Do Not Resuscitate (DNR) code status dated [DATE] and was found by staff, on [DATE] at 7:28 PM, without a pulse or respirations. CPR was initiated by the facility's staff for five (5) minutes until the local Fire Department arrived. CPR was stopped due to the Fire Department staff reviewed the resident's chart and discovered the DNR code status. Resident #74 was never revived and was pronounced deceased at the facility.
The facility's failure to honor Resident #74's DNR code status, placed this resident and other residents with a DNR code status, in a situation that was likely to cause serious harm, injury, impairment or death.
The facility Administrator was notified of the IJ and SQC on [DATE].
The State Agency (SA) received an acceptable Immediate Jeopardy Removal Plan on [DATE], in which the facility alleged that all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE].
The SA determined the IJ was removed on [DATE] prior to the SA's exit on [DATE].
Findings Include:
Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR), dated [DATE], revealed it is the policy of the facility to adhere to resident's rights to formulate the advance directives. In accordance to these rights, the facility will implement guidelines regarding Cardio-pulmonary Resuscitation (CPR). The facility will follow current American Heart Association (AHA) guidelines regarding CPR. If a resident experience a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and in accordance with the resident's advance directives, or in the absence of advance directives, or Do Not Resuscitate order and/ or if the resident does not show obvious signs of clinical death (e.g. rigor mortis, decapitation, transection, or decomposition).
Review of the facility's policy titled, Advance Directives dated [DATE], revealed the Advance Directives will be respected in accordance with state law and facility policy. The policy guidelines stated that upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an Advance Directive if he or she chooses to do so. Information about whether the resident has executed an Advance Directive shall be displayed prominently in the medical record. If the resident indicates that he or she has not established Advance Directives, the facility staff should offer assistance in establishing advance directives. The resident has the right to refuse treatment, whether he or she has an Advance Directive. A resident will not be treated against his or her own wishes. The facility states the Advance Directive policy is a written instruction such as a living will or durable power of attorney for health care, recognized by state law, relating to the provisions of health care when the individual is incapacitated. The facility's Do Not Resuscitate (DNR) definition indicated, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life sustaining treatments or methods are to be used.
Review of the facility's Resident Rights policy, dated [DATE], revealed the facility will inform the residents both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Prior to or upon admission the social service designee, or another designated staff member, will inform the resident and or the resident's representative of the resident's rights and responsibilities. The facility will protect and promote the rights of the resident.
Review of the Progress Notes-Nursing Notes, dated [DATE] at 9:18 PM, revealed a note at 7:28 PM stated the Charge Nurse, Medication (Med) cart nurse, Registered Nurse (RN) and three (3) Certified Nursing Assistants (CNAs) entered the room and Resident #74 was found unresponsive and no pulse. The resident was assisted to the floor via a sheet and Cardiopulmonary Resuscitation (CPR) was initiated per the American Heart Association protocol and 911 was called at 7:30 PM. The local Fire Department arrived at 7:35 PM and the resident's chart was reviewed to discover the resident was a DNR. CPR was ceased at that time. Resident was pronounced deceased at 7:42 PM. The Coroner arrived at 8:11 PM, and the resident's body was released to the funeral home at 8:32 PM. The Nurses Notes revealed CPR was performed for five (5) minutes, prior to the fire department's arrival.
Registered Nurse (RN) #1/Supervisor was interviewed on [DATE] at 3:24 PM. RN #1/Supervisor confirmed she did not ask anybody to get Resident #74's chart until the Fire Department personnel asked for it. RN #1/Supervisor said she did not know what happened, it happened so quick. RN #1/Supervisor stated RN #1 and LPN #5 initiated the CPR, and when she looked up the Fire Department was already there, and that's when they checked the chart for the code status. RN #1/Supervisor said they had received a call from the lab reporting a critically high Potassium level, and the Medical Doctor (MD) instructed them to send Resident #74 to the emergency room (ER) for evaluation and treatment. Resident #74 was left alone in the room with the Certified Nursing Assistant (CNA). RN #1/Supervisor said she could not remember who the CNA was. RN #1/Supervisor reported the CNA came to the door saying, I don't think she's breathing. RN #1/Supervisor stated RN #5 and Licensed Practical Nurse (LPN) #2 initiated CPR, and when she entered the room she instructed another CNA to call 911. RN #1/Supervisor said when she looked up the Fire Department was at the facility, and that was when Resident #74's DNR status was identified. RN #1 did say she had been in-serviced several times on where to look for a resident's code status.
Review of the Progress Notes-Nurses Notes, dated [DATE] at 7:17 PM, confirmed a call was received from (Name of Hospital) lab reporting a critically high Potassium level of 8.7, which was reported to (Name of MD) who instructed to send resident to (Name of Hospital) to be evaluated and treated. (Names of Contact Persons) were notified and verbalized understanding.
RN #5/Charge Nurse was interviewed, on [DATE] at 3:30 PM. RN #5/Charge Nurse said she did not ask anybody to get the chart to identify Resident #74's code status. RN #5/Charge Nurse said she provided chest compressions and LPN #2 provided mouth to mouth breathing. RN #5/Charge Nurse said she did not ask anybody to get the chart because she thought RN #1/Supervisor had checked the chart for the code status. RN #5 said she was called into the room by a CNA.
An interview, on [DATE] at 3:59 PM, with LPN #2 revealed she had been trained where the code status was located in the resident's chart. LPN #2 confirmed she did not ask anybody to get the chart because she thought RN #5/Charge Nurse checked Resident #74's chart for the code status. LPN #2 said she did assist RN #5/Charge Nurse with resuscitating Resident #74.
The Medical Director was interviewed, on [DATE] at 11:53 AM. The Medical Director stated Resident #74 could have had a negative outcome if she had survived with broken ribs or being placed on a ventilator. The Medical Director stated he was told the staff found Resident #74 unresponsive and initiated CPR. The Medical Director said CPR was performed until the Fire Chief pulled the resident's chart and noted she was a DNR, and the Fire Chief stopped the CPR at that moment.
Review of the facility's Advanced Care Planning form revealed Resident #74's printed name and her daughter's printed and signed name, dated [DATE], for an elected DNR code status. Resident #74's admission Record revealed the resident's daughters were the first and second contact persons. The resident's Advanced Directive was a Do Not Resuscitate.
Review of Resident #74's Physician's Orders revealed an order, dated [DATE], for a DNR code status.
An interview, on [DATE] at 4:44 PM, revealed Firefighter #1 stated he responded to the call on [DATE] when Resident #74 was found pulseless. Fire Fighter #1 stated the Chief reviewed Resident #74's medical records and found Resident #74 was a DNR. CPR was stopped at that time once they identified Resident #74 as a DNR. Fire Fighter #1 also stated that the Resident #74 was pronounced by the Fire Department and the coroner was notified.
An interview, on [DATE] at 12:22 PM, with the Assistant Director of Nurses (ADON) revealed Resident #74's DNR order was in the chart's Physician's Orders, and on the Medication Administration Record (MAR). The ADON stated she was responsible for checking the residents code status and making sure there's a written order that is in the electronic record and on the Medication Administration Record (MAR). The ADON revealed the orders for a DNR code status, and the resident's choice for a DNR code status was not followed by the nurses.
An interview, on [DATE] at 5:52 PM, revealed the Director of Nursing (DON) confirmed Resident #74 was found unresponsive on [DATE], and Registered Nurse #5/Charge Nurse and Licensed Practical Nurse (LPN) #2 initiated CPR. The DON stated CPR ceased after Resident #74 was identified as a DNR by the local Fire Department when the chart was reviewed by them. The DON reported the nurses did not check the resident's code status, and as a result, Resident #74's DNR code status was not honored by the nurses who initiated the CPR.
An interview, on [DATE] at 4:46 PM, with the Deputy Coroner revealed he was informed by the facility staff Resident #74 was never revived, and the fire department had already pronounced the resident by the time he arrived.
Review of the admission Record revealed Resident #74 was admitted by the facility, on [DATE], with the included diagnoses Cardiomyopathy, Heart Failure, Cardiomegaly, Tachycardia, Pulmonary Disease and Chronic Atrial Fibrillation.
Review of Resident #74's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.
This is the facility's accepted Immediate Jeopardy Removal Plan:
Summary of events:
The State Agency notified [NAME] Gardens Nursing Center on [DATE]th, 2020 at 12:05 P.M. of the immediate jeopardy and substandard quality of care for Residents #74, #31, and #64. The Facility failed to honor Resident #74's advance directive for a do not resuscitate (DNR) code status, failed to honor the Resident's Rights for Advance Directive, failed to follow the care plan for a DNR code status and failed to prevent a potential negative outcome by initiating Cardiopulmonary Resuscitation (CPR). Resident #74 was found pulseless on [DATE]th, 2019 at 7:28 PM by RN #1 who initiated Cardiopulmonary Resuscitation (CPR) for a total of five minutes. CPR was discontinued when emergency services arrived and notified RN #1 of Resident#74's DNR code status. RN #1 failed to follow the policy and procedures in place to identify Resident #74's code status. The State Agency notified the facility on [DATE]th, 2020 at 3:30 PM that Resident #31's code status was documented incorrectly on the Report Sheet and Resident #64's code status was not in the Electronic Health Record, according to their wishes which could have likely caused harm for Residents #31 and #64. The facility failed to follow policy and procedure to identify the correct code status for Residents #74, #31, and #64.
Facility action plan:
1. The Director of Nursing (DON) conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with Registered Nurse (RN) #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred.
2. On [DATE]th, 2019 Care Plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status.
3. On [DATE]th, 2019 at 1:30 PM the Director of Nursing in serviced all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies.
4. On [DATE]th and 30th, 2020 the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses.
5. On [DATE] the Assistant Director of Nursing (ADON) reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status.
6. On [DATE]th, 2020 at 12:05PM, the State Agency identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. Care Plan Nurse found that Resident #64's order had been discontinued by Licensed Practical Nurse (LPN) #1 and the order was reentered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes.
7. The Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status.
8. The Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record.
No staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member.
The facility alleges the immediate jeopardy was removed on [DATE].
On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ:
1. The SA validated through record review of the sign-in sheets and interview with the Director of Nursing (DON) that the facility conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with RN #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred.
2. The SA validated through record review of the in-service sign-in sheets and interview with the Care Plan Nurse that on [DATE]th, 2019 Care plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status.
3. The SA validated through record review of the sign-in sheets and interview with the DON that the facility conducted an in-service on [DATE]th, 2019 at 1:30 PM, by the Director of Nursing, to all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies.
4. The SA validated through record review of the in-service sign-in sheets and interview with the facility owner that on [DATE]th and 30th, 2020, the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses.
5. The SA validated by interview of the ADON that on [DATE] the ADON reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status.
6. The SA validated by record review and staff interviews, on [DATE]th, 2020 at 12:05 PM, the SA identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. The Care Plan Nurse found that Resident #64's order had been discontinued by LPN #1 and the order was re-entered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by the Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes.
7. The SA validated by interviews the Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status.
8. The SA validated through interviews with the Facility Administrator and the DON the Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record.
The SA validated through interviews with the Administrator and the DON that no staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member.
The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and facility policy review, the facility failed to ensure Resident #74's choice for a Do Not Resuscitate (DNR) code status was honored. This was identified for one of four (1 of 4) residents reviewed who expired in the facility over the past six (6) months.
The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE]. Resident #74 had a Physician's Order and an Advanced Directive, dated [DATE], for a DNR code status. On [DATE] at 7:38 PM, Resident #74 was found unresponsive, and without a pulse or respirations by the facility's staff. Cardiopulmonary Resuscitation (CPR) was initiated by the facility's staff and the Emergency Medical System (EMS) was notified. The local Fire Department was dispatched to the facility. Resident #74's chart was checked by the Fire Chief on arrival to the facility and it was discovered at that time Resident #74 was a DNR. CPR had been in progress five (5) minutes and was stopped by the Fire Chief at that time. Resident #74 was not revived during the CPR and was pronounced deceased at the facility. The facility's staff did not check Resident #74's chart to verify her choice of code status was a DNR, and CPR should not have been initiated.
The facility's failure to honor Resident #74's choice for a DNR code status, placed Resident #74 and other residents with a DNR code status, in a situation that was likely to cause serious harm, injury, impairment or death.
The SA notified the facility's Administrator of the IJ and SQC on [DATE].
Findings Include:
Review of the facility's, Advance Directives Policy, dated 11/2018, revealed the Advance Directives will be respected in accordance with state law and facility policy. Information about whether the resident has executed an Advance Directive shall be displayed prominently in the medical record. A resident will not be treated against his or her own wishes. The facility's Do Not Resuscitate (DNR) definition indicated that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life sustaining treatments or methods are to be used.
Review of the Progress Notes - Nurses Notes, revealed, on [DATE] at 7:28 PM, Resident #74 was found unresponsive and without a pulse. Resident #74 was assisted to the floor, and CPR was initiated by LPN #2 and RN #5. The Nurse's Notes stated 911 was called at 7:30 PM. The local Fire Department arrived at 7:35 PM and CPR was stopped at that time when the Fire Department staff checked Resident #74's code status on the medical record. Resident #74 was pronounced dead at 7:42 PM. The Nurse's Notes revealed Resident #74 was resuscitated for five (5) minutes, prior to the Fire Department's arrival.
An interview with RN #1/Supervisor, on [DATE] at 3:24 PM, revealed she failed to follow the facility's policy for Resident #74's DNR code status. RN #1 confirmed she did not ask anybody to get the chart until the Fire Department requested it, which resulted in Resident #74's DNR code status not being recognized. RN #1 stated she didn't know what happened, everything happened so quick.
During an interview on [DATE] at 3:30 PM, Registered Nurse (RN) #5 revealed she provided chest compressions and Licensed Practical Nurse (LPN) #2 provided the mouth to mouth breathing on [DATE] when Resident #74 was found unresponsive and with no pulse or respirations. RN #5 stated she did not ask anybody to get the resident's chart to verify the code status because she thought RN #1/Supervisor had done that. RN #5 revealed she was called into Resident #74's room by a Certified Nursing Assistant (CNA). RN #1/Supervisor was present at this time of the interview and stated she was in the room and they relieved each other until the Fire Department got there. Failure of the facility's staff to verify Resident #74's code status prior to initiating CPR resulted in the resident's Advance Directive choice for a DNR code status not being honored.
Review of the facility's Advanced Care Planning form revealed Resident #74's printed name and her daughter's printed and signed name, dated [DATE], for an elected DNR code status. Resident #74's admission Record revealed the resident's daughters were the first and second contact persons. The resident's Advanced Directive was a Do Not Resuscitate.
Review of Resident #74's Physician's Orders revealed an order, dated [DATE], for a DNR code status.
During an interview, on [DATE] at 3:59 PM, LPN #2, stated she did assist RN #5 with resuscitating Resident #74 on [DATE]. LPN #2 also confirmed she did not ask anybody to get the chart to review Resident #74's code status. LPN #2 also stated she thought the supervisor had checked the chart for Resident #74's code status. LPN #2 stated she has been trained several times on where the code status was located.
Review of Resident #74's Care Plan, dated [DATE], revealed Resident #74's code status was Do Not Resuscitate (DNR). The goal is to honor the resident and family wishes. The interventions are to ensure comfort measures are achieved without heroics, ensure resident/family understands meaning of code status, label the chart, Medication Administration Record (MAR) and Treatment Administration Record (TAR) to inform staff of DNR code status, obtain signed consent and Medical Doctors order's for DNR.
Fire Fighter #1's interview, on [DATE] at 4:44 PM, revealed he responded to the call the night Resident #74 died. Firefighter #1 revealed CPR was in process by the facility staff on arrival, and the Fire Chief reviewed the medical records and confirmed Resident #74 was a DNR code status and CPR was discontinued.
The Director of Nurse's (DONs) interview, on [DATE] at 5:52 PM, confirmed RN #5/Charge Nurse found Resident #74 unresponsive, without a pulse and initiated CPR. The DON stated that CPR was stopped after the Fire Department found Resident #74 was a DNR code status on review of the resident's medical records. The DON confirmed Resident #74 was a DNR code status, and the CPR should not have been initiated. The DNR code status was located on the resident's medical record.
The Medical Director's interview, on [DATE] at 11:53 AM, revealed he was informed staff found Resident #74 unresponsive and CPR was initiated. The Medical Director stated Resident #74 could have had a negative outcome of surviving with broken ribs or being placed on a ventilator.
Review of the Admissions Record revealed Resident #74 was admitted by the facility, on [DATE], with the included diagnoses of Cardiomyopathy, Heart Failure, Cardiomegaly, Tachycardia, Pulmonary Disease and Chronic Atrial Fibrillation.
A review of Resident #74's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.
This is the facility's accepted Immediate Jeopardy Removal Plan:
Summary of events:
The State Agency notified [NAME] Gardens Nursing Center on [DATE]th, 2020 at 12:05 P.M. of the immediate jeopardy and substandard quality of care for Residents #74, #31, and #64. The Facility failed to honor Resident #74's advance directive for a do not resuscitate (DNR) code status, failed to honor the Resident's Rights for Advance Directive, failed to follow the care plan for a DNR code status and failed to prevent a potential negative outcome by initiating Cardiopulmonary Resuscitation (CPR). Resident #74 was found pulseless on [DATE]th, 2019 at 7:28 PM by RN #1 who initiated Cardiopulmonary Resuscitation (CPR) for a total of five minutes. CPR was discontinued when emergency services arrived and notified RN #1 of Resident#74's DNR code status. RN #1 failed to follow the policy and procedures in place to identify Resident #74's code status. The State Agency notified the facility on [DATE]th, 2020 at 3:30 PM that Resident #31's code status was documented incorrectly on the Report Sheet and Resident #64's code status was not in the Electronic Health Record, according to their wishes which could have likely caused harm for Residents #31 and #64. The facility failed to follow policy and procedure to identify the correct code status for Residents #74, #31, and #64.
Facility action plan:
1. The Director of Nursing (DON) conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with Registered Nurse (RN) #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred.
2. On [DATE]th, 2019 Care Plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status.
3. On [DATE]th, 2019 at 1:30 PM the Director of Nursing in serviced all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies.
4. On [DATE]th and 30th, 2020 the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses.
5. On [DATE] the Assistant Director of Nursing (ADON) reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status.
6. On [DATE]th, 2020 at 12:05PM, the State Agency identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. Care Plan Nurse found that Resident #64's order had been discontinued by Licensed Practical Nurse (LPN) #1 and the order was reentered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes.
7. The Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status.
8. The Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record.
No staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member.
The facility alleges the immediate jeopardy be removed on [DATE].
On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ:
1. The SA validated through record review of the sign-in sheets and interview with the Director of Nursing (DON) that the facility conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with RN #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred.
2. The SA validated through record review of the in-service sign-in sheets and interview with the Care Plan Nurse that on [DATE]th, 2019 Care plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status.
3. The SA validated through record review of the sign-in sheets and interview with the DON that the facility conducted an in-service on [DATE]th, 2019 at 1:30 PM, by the Director of Nursing, to all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies.
4. The SA validated through record review of the in-service sign-in sheets and interview with the facility owner that on [DATE]th and 30th, 2020, the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses.
5. The SA validated by interview of the ADON that on [DATE] the ADON reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status.
6. The SA validated by record review and staff interviews, on [DATE]th, 2020 at 12:05 PM, the SA identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. The Care Plan Nurse found that Resident #64's order had been discontinued by LPN #1 and the order was re-entered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by the Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes.
7. The SA validated by interviews the Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status.
8. The SA validated through interviews with the Facility Administrator and the DON the Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record.
The SA validated through interviews with the Administrator and the DON that no staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member.
The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.