The training gap emerged during a federal inspection following an incident involving resident 52. Inspectors found that while the facility had policies requiring staff to know which residents wanted resuscitation attempts, managers had performed no auditing or monitoring to ensure workers understood these critical distinctions.
CNA J told inspectors she had watched orientation training videos but received no specific education about resident code statuses. She knew the information was available in the electronic medical record and on hall sheets that staff carried while working, but had not been taught how to use it in emergencies.
The facility's October 2025 resuscitation policy stated that staff should initiate medical emergency procedures for any resident needing resuscitation "unless there is a 'Do Not Resuscitate' order documented in the resident's electronic medical record." The policy required providing basic life support and CPR "prior to the arrival of emergency medical services, subject to physician order and resident choice indicated in the resident's advance directives."
Two licensed practical nurses demonstrated better understanding during interviews. LPN L, who started working at the facility in an unspecified month, explained she would not start CPR on a resident with a DNR code status if the resident was unresponsive with no pulse or respirations. She said she had received general education regarding advance directives and code status.
LPN D, who also started in an unspecified month, told inspectors she would check a resident's code status before beginning CPR in an emergency. She had received mandatory education about advance directives and code statuses.
The facility's advance directive policy, reviewed during the inspection, stated: "It is the policy of this facility will provide basic life support, including CPR Cardiopulmonary Resuscitation, when a resident requires such emergency care." The policy specified that nurses were educated to initiate CPR as recommended by the American Heart Association "unless: A valid Do Not Resuscitate order is in place."
Director of Nursing B could not provide signed documentation showing which nursing staff attended a meeting held after resident 52's incident. The meeting was intended to address the code status confusion that had emerged from the emergency.
Managers acknowledged they had not audited whether staff members were aware of expectations regarding life-sustaining measures according to residents' code statuses. They also admitted performing no monitoring to ensure residents' code statuses were properly identified after the incident with resident 52.
The inspection revealed that while the facility provided education on advance directives and resident code statuses during new hire orientation and annual training, the system had failed for at least one worker. CNA J's case demonstrated how a certified nursing assistant could begin working in direct patient care without understanding when to attempt resuscitation.
Hall sheets containing resident information were supposed to travel with staff as they worked, providing immediate access to code status information during emergencies. However, the lack of specific training meant workers might not know how to interpret or act on this critical information when seconds mattered.
The facility's policies appeared comprehensive on paper, requiring staff to distinguish between residents who wanted full resuscitation efforts and those with do-not-resuscitate orders. But the implementation gap left at least one worker unprepared to make life-or-death decisions during her first week on the job.
Federal inspectors cited the facility for failing to ensure staff received adequate training on advance directives and code statuses, finding minimal harm or potential for actual harm affecting few residents. The violation occurred despite written policies that seemed to address the training requirements.
The case highlighted how policy compliance on paper does not guarantee real-world preparedness when nursing assistants face medical emergencies involving residents with different wishes about end-of-life care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunset Manor Avera Health from 2025-12-31 including all violations, facility responses, and corrective action plans.