Every finding on record at Milcrest Nursing Center

Based on record review, staff interview and policy review, the facility failed to ensure a resident or resident representative had timely access to their medical records upon request. This affected one (Resident #49) out of one resident reviewed for a records request. The facility census was 48. Findings include:Review of the medical record for Resident #49 revealed an admission date of 04/06/26 and discharge date of 05/05/26. Diagnoses included muscle weakness, dementia, anxiety, depression, edema, heart disease, and Alzheimer's disease.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 05 indicating impaired cognition.Review of an email correspondence dated 05/12/26 between the facility staff and the regional office revealed the request for medical records was approved. Review of an email correspondence dated 05/18/26 between the facility Administration staff and Resident #49's family revealed pricing was $206.32 for the resident's medical records and the regulations related to medical record request was provided to the family.Review of an email correspondence dated 05/26/26 revealed the medical records were emailed to the Resident's family. Interviews on 06/15/26 from 12:15 P.M. to 2:54 P.M. with the Regional Administrator #31 revealed the facility had no record of when Resident #49's family made the initial record request and verified the facility had no additional evidence of communication between the resident's family and the facility staff. She verified the facility policy stated records should be provided within 24 hours or paper copies shall be provided within two business days. She verified it was about a week before the family was provided the pricing information and two weeks for the documentation to be provided after the regional office gave approval. She verified the facility had no additional documentation or mentions of communication by phone and in person. Review of facility policy titled Medical Records Administrative Policy, dated 04/05/19 revealed the Administrator was responsible for maintaining and organizing records. The facility shall allow resident and representatives the right to access personal and medical records upon written or oral request in a format agreed upon within 24 hours (excluding weekdays and within two working days if copies are requested. Facility shall determine cost of supplies and postage if applicable. This deficiency represents non-compliance investigated under Complaint Number 3015021.

Based on record review, staff interview, and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for a fall with major injury. This affected one (Resident #49) out of three residents reviewed for falls. The facility census was 48. Findings include:Review of the medical record for Resident #49 revealed an admission date of 04/06/26 and discharge date of 05/05/26. Diagnoses included muscle weakness, dementia, anxiety, depression, edema, heart disease, and Alzheimer's disease.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 05 indicating impaired cognition and Resident #49 required partial to moderate assistance for activities of daily living and supervision/touching assistance with mobility. Review of the plan of care dated 04/13/26 revealed Resident #49 was at risk for falls and potential injury. Interventions included non-skid strips to be placed in front of the recliner left side of the bed and follow evening routine in bed by 7:00 P.M. to 7:30P.M. after toileting and ensure commonly used items were in reach.Review of the hospital paperwork dated 04/19/26 to 04/20/26 revealed Resident #49 arrived on 04/19/26 at 11:15 P.M. The History and Physical dated 04/20/26 with a time of service for 5:00 A.M. revealed the resident was seen after a fall with a laceration and found to have rib fractures at the 9th and 10th ribs.Review of the progress note dated 04/20/26 at 2:01 P.M. revealed Resident #49 was in her room with staff just outside the door when she fell. The resident was found sitting upright with her back against the bed and the cord to the recliner stretched across to a wheelchair about two feet from the recliner with the cord underneath resident. Blood was noted on the residents' clothing, on her knee, and elbow. The resident rated her pain 10 out of 10. The resident was confused but stated she did not hit her head and had both shoes on. The resident was taken to the hospital where and a skin tear was found at the knee and the elbow. The progress note dated 04/20/26 at 5:25 P.M. revealed Resident #49 returned to the facility from the hospital with new orders for sutures in place on right elbow. The Nurse practitioner note dated 04/20/26 verified Resident #49 was diagnosed with a 9th and 10th rib fracture from the fall on 04/20/26.Review of the progress note dated 05/04/26 revealed staff was notified by social services Resident #49 was on the floor. The staff had last interacted with Resident #49 two minutes prior. The resident was assessed and complained of pain in the right leg which was internally rotated and slightly shorter than the left leg and a laceration to the calf was observed and covered with a dry dressing. The resident was transferred to the hospital for evaluation. A progress note dated 05/05/26 revealed staff spoke with staff at the hospital who verified Resident #49 broke her hip. Review of the Minimum Data Set (MDS) discharge return not anticipated assessment dated [DATE] revealed one fall with major injury was documented on the MDS.Interview on 06/16/26 at 9:45 A.M. with Regional Director of Operations (RDO) #32 verified the MDS staff was not informed of the fracture and only did a look back of seven days for the discharge MDS assessment. She verified since the fall occurred about 15 days prior it was not captured. The RDO #32 verified the second fall was missed and the facility would be completing an amended MDS assessment to report the second fall with major injury after surveyor intervention. Review of the facility policy titled Charting and Documentation, dated 03/01/26 revealed the documentation should be complete and accurate. This deficiency represents non-compliance investigated under Complaint Number 3015021 and 3017937.

Based on record review and staff interview, the facility failed to ensure fall interventions were updated in the medical record and care plan after a fall. This affected one (Resident #41) of three residents reviewed for falls. The facility census was 48. Findings include Review of the medical record for Resident #41 revealed an admission date of 05/26/26. Diagnoses included dysphagia, cognitive communication deficit, respiratory failure diabetes, right femur fracture (prior to admission).Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact with a Brief Interview of Mental Status (BIMS) of 14 and was dependent with activities of daily living and required substantial and maximum assist with mobility. Review of the plan of care dated 06/05/26 revealed Resident #41 was at risk for falls and had interventions for therapy evaluations and treatment and have commonly used articles in reach. No interventions had been added to the fall care plan since 06/05/26. Review progress notes dated 06/13/26 revealed Resident #41 had a fall while standing in the bathroom. The Certified Nursing Aide (CNA) was present with resident during the witnessed fall. The resident was attempting to wash her hands and fell from a standing position. She reported pain to her back and right lower extremity and had a recent hip replacement so she was transferred to the hospital. A progress note dated 06/14/26 at 1:05 A.M. revealed the resident returned to the facility from the hospital with no injuries. No progress notes indicated new fall interventions implemented after the fall. Review of the fall investigation dated 06/13/26 revealed the CNA was with Resident #41 when she fell and she assisted resident in the fall and protected her head. Resident #41 was washing her hands at the sink when she became weak and fell. Interview on 06/16/26 at 12:35 P.M. with the Administrator revealed Resident #41's fall had new intervention of education since she was a BIMS of 14. The Administrator was unsure what type of education was provided and where was it documented and she reported she would need to find out. Interview on 06/16/26 at 1:35 P.M. with the Administrator and the Director of Clinical Operations(DCO) #32 verified Resident #41 was educated to use the call light. They verified the fall incident report was reviewed but DCO #32 verified she had not talked with staff and was not aware of the progress note stating staff was with the resident at the time of the fall. She reported after further review, the resident had gotten out of bed without staff assistance and the aide was returning with paper towels when the resident lost her balance. She reported the new intervention should be to educate the resident to use the call light. They verified this intervention was not in the medical record and was not added to the care plan. This deficiency represents non-compliance investigated under Complaint Number 3015021 and 3017937.

Based on record review, staff and resident interview and policy review, the facility failed to ensure showers were completed as scheduled. This affected one (Resident #20) out of three residents reviewed for Activities of Daily Living (ADL) care. The facility census was 48.Findings Included:Review of the medical record revealed Resident #20 admitted to the facility on [DATE]. Diagnoses included muscle weakness, anxiety disorder, benign neoplasm of the rectum, type two diabetes, hypokalemia, depression, hypertension, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had a Brief Interview for Mental Status score of 15 and normal cognitive function. Further review confirmed the resident required substantial/max assistance with tub/shower transfers.Review of Resident #20's Care Plan revised 05/05/26 revealed the resident required assistance from staff to meet Actives of Daily Living (ADL) related to cerebral vascular accident with left hemiparesis and weakness with interventions to assist the resident with bathing as needed and per resident's preference.Review of Resident #20's shower schedule dated June 2026 revealed a shower schedule of Monday and Thursdays with no documentation on the Treatment Administration Records (TAR) that showers occurred on 6/4/26 and 6/11/26 and that the resident was marked as non-applicable on 6/8/26.Interview on 6/15/26 at 2:53 P.M., Resident #20 verified they were scheduled to receive staff assisted showers on Monday and Thursday's and had not been receiving them but did receive a shower on Friday 6/12/26 because they were having their hair done.Interview on 6/16/26 at 10:39 A.M., with the Director of Nursing (DON) revealed Resident #20 was known to refuse showers and on 6/8/26 the resident refused their shower because they were going to have their hair done. Further interview revealed the facility had no documentation to support Resident #20 refused their scheduled showers on 06/04/26 and 06/11/26 and the facility documented non-applicable not refused for the shower on 6/8/26.Review of the facility policy titled ADLs, revised 03/04/26 revealed Support will be provided to meet care deficits related to ADL needs. This includes the resident's ability to bath, dress, groom, transfer and ambulate, toilet, and eat. and A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutritional, grooming and personal and oral hygiene.This deficiency represents non-compliance investigated under Complaint Number 3026793.

Based on record review, staff interview and policy review, the facility failed to ensure the accuracy of the medical record. This affected one (Resident #49) out of three residents reviewed for falls. The facility census was 48. Findings includeReview of the medical record for Resident #49 revealed an admission date of 04/06/26 and discharge date of 05/05/26. Diagnoses included muscle weakness, dementia, anxiety, depression, edema, heart disease, and Alzheimer's disease.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 05 indicating impaired cognition and required partial to moderate assistance for activities of daily living and supervision /touching assistance with mobility. Review of the plan of care dated 04/13/26 revealed Resident #49 was at risk for falls and potential injury. Interventions included non-skid strips to be placed in front of the recliner left side of the bed and follow evening routine in bed by 7:00 P.M. to 7:30P.M. after toileting and ensure commonly used items were in reach. Review of the progress note dated 04/20/26 at 2:01 P.M. revealed Resident #49 was in her room with staff just outside the door when she fell. Resident was found sitting upright with her back against the bed and the cord to the recliner stretched across to a wheelchair about two feet from the recliner with the cord underneath the resident. Blood was noted on the resident's clothing, on her knee and elbow, and the resident rated her pain 10 out of 10. The resident was confused but stated she had not hit her head and had both shoes on. The resident was taken to the hospital where a skin tear was found on the knee and the elbow. The progress note dated 04/20/26 at 5:25 P.M. revealed the resident returned to the facility from the hospital with new orders for sutures in place on right elbow. Review of the Nurse Practitioner note dated 04/20/26 revealed Resident #49 was diagnosed with a 9th and 10th rib fracture from the fall on 04/20/26. Review of the fall investigation dated 04/19/26 revealed the fall occurred at 10:45 P.M. Resident #49 had a fall in her room after tripping over a cord and furniture. The resident reported pain and was transferred to the hospital. Review of the neurological check dated 04/19/26 revealed neurological checks were started on 04/19/26 at 10:45 P.M. and continued every 15 minutes for four checks, then every 30 minutes for four checks, then every hour for four checks, then every four hours for six checks and every 24 hours for three checks. Each timeslot was documented as being completed and with all areas documented as observed including temperature, pulse, respirations, blood pressure, pupils and bilateral grips and mental status. Review of the second set of neurological check dated 04/19/26 revealed neurological checks were started on 04/19/26 at 10:45 P.M. and were scheduled to continue every 15 minutes for four checks, then every 30 minutes for four checks, then every hour for four checks, then every four hours for six checks and every 24 hours for three checks. The time slots from 04/19/26 at 11:00 P.M. through 04/20/26 documented Resident #49 was at the hospital.Review of the hospital paperwork dated 04/19/26 to 04/20/26 revealed the Resident arrived on 04/19/26 at 11:15 P.M. The History and Physical dated 04/20/26 with a time of service for 5:00 A.M. revealed Resident #49 was seen after a fall with a laceration and found to have rib fractures at the 9th and 10th ribs. Interview on 06/16/26 at 8:48 A.M., with Regional Clinical Director #32 verified the medical record showed Resident #49 was hospitalized for several hours after her fall on 04/19/26. She also verified the facility documentation showed neurological checks were documented as being done while the resident was at the hospital. She verified this was inaccurate as the resident was not present to have neurological checks completed. She provided a different set of neuro checks completed at the same times which documented Resident #49 was hospitalized . Review of the facility policy titled Post fall medical care/suspected head injury, dated 08/01/17 revealed neurological assessments should be completed immediately and continue as per the schedule.Review of the facility policy titled Charting and Documentation, dated 03/01/26 revealed all services provided to the resident or changes in their condition shall be documented in the medical record, including changes in condition, observations and events or incidents involving the resident. The documentation should be complete and accurate.This deficiency represents non-compliance investigated under Complaint Number 3015021 and 3017937.

Based on observations, interviews, medical record review, and policy review, the facility failed to ensure a resident received appropriate incontinence care. This affected one (Resident #43) of three residents reviewed for incontinence care. The facility census was 44. Review of the medical record for Resident #43 revealed an admission date of 02/07/25. Diagnoses included transient ischemic attack, cerebral infarction, vascular dementia, and chronic respiratory failure with hypoxia.Review of his quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was cognitively impaired. Resident #43 required assistance with bed mobility. Review of the Care Plan dated 04/10/26 revealed Resident #43 was frequently incontinent. Interventions included care as needed, resident with be clean, dry, and odor free, and bed in the low position.Observation on 05/14/26 at 7:45 A.M. revealed Resident #43 was lying in bed with no sheets or pillow. His pajama top was wet and the room had a strong odor or urine. Certified Nursing Assistant (CNA) #200 explained she started her shift at 7:00 A.M. and was given report. She entered Resident #43's room to find him bed with his bed sheets, blankets, and clothing soaked in urine. CNA #200 was able to get the sheets and pillowcases off the bed, clean the resident's lower body, and place a dry pair of pant son him. Observation on 05/14/26 at 7:48 A.M. Resident #43's bed linins and pillows were bagged in his room to go to laundry. CNA #200 and CNA #202 was able to clean up Resident #43's upper body and place him in his wheelchair with a clean shirt. Resident #43's mattress smelled of urine and was replaced. Interview on 05/14/26 at 8:10 A.M. with Resident #43 verified he was lying in his bed, soaked in urine for a while. Review of the facility Activities of Daily Living (ADL) policy dated 03/04/26 revealed residents who are unable to carry out ADLs will receive necessary services to maintain functional abilities. This deficiency represents non-compliance investigated under Complaint Number 2999505.

Based on interviews, record review, and review of facility policy, the facility failed to ensure residents received their showers as scheduled. This deficient practice affected two (Resident #16 and Resident #37) of three residents reviewed for shower assistance. The facility census was 49.Findings Include: 1. Review of the medical record for Resident #16 revealed an admission date of 10/28/24 and diagnoses of muscle weakness, anxiety, dysarthria and anarthria, severe protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), tobacco use, and dementia.Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required partial to moderate assistance with showering and bathing.Review of Resident #16's care plan, last revised 02/09/26, revealed the resident required staff assistance to meet activities of daily living (ADL) needs related to dysarthria, COPD, malnutrition, and dementia, with interventions to assist the resident with bathing as needed and per resident preference.Review of Resident #16's shower schedule revealed the resident was scheduled to receive biweekly showers on Wednesdays and Saturdays.Review of Resident #16's shower documentation revealed no documentation of scheduled showers on 03/25/26 and 04/12/26.During an interview on 04/22/26 at 11:05 A.M., Resident #16 stated they had not received their scheduled showers on a regular basis.During an interview on 03/23/26 at 9:28 A.M., the Director of Nursing stated the facility had no documentation that Resident #16 received their scheduled showers on 03/25/26 and 04/12/26.2. Review of Resident #37's medical record revealed an admission date of 09/11/25 and diagnoses of muscle weakness, osteoarthritis, polyneuropathy, obesity, bipolar disorder, hypertension, heart failure, chronic obstructive pulmonary disease (COPD), body mass index (BMI) greater than 50 percent, and diabetes mellitus.Review of Resident #37's Minimum Data Set (MDS) assessment, last updated 04/08/26, revealed the resident required substantial to maximal assistance with showering and bathing.Review of Resident #37's care plan, last updated 04/06/26, revealed the resident required staff assistance to meet activities of daily living (ADL) needs related to diabetes, bipolar disorder, chronic pain, migraine, arthritis, neuropathy, obesity, COPD, and weakness, with interventions to assist the resident with bathing as needed and per resident preference.Review of Resident #37's shower schedule revealed the resident was scheduled to receive biweekly showers on Wednesdays and Saturdays.Review of Resident #37's shower documentation revealed no documentation of scheduled showers on 03/25/26, 03/29/26, 04/05/26, 04/08/26, and 04/12/26.During an interview on 04/22/26 at 11:10 A.M., Resident #37 stated they had missed showers during the previous two weeks and that they were upset when they missed their scheduled showers.During an interview on 03/23/26 at 9:28 A.M., the Director of Nursing confirmed the facility had no documentation showing that Resident #37 received their scheduled showers on the above dates.Review of the facility policy titled ADLs, last revised 03/04/26, revealed residents who are unable to carry out activities of daily living are to receive the necessary services to maintain grooming, personal hygiene, oral hygiene, and good nutrition.This deficiency represents non-compliance investigated under Complaint Number 2988246.

Base on observation, interview, and record review the facility failed to ensure linen and personal clothing was not soiled for one, (Resident #16). This affected one (Resident #16) of three residents reviewed for Activities of Daily Living (ADL). The facility census was 49.Findings Include:Review of Resident #16's medical record revealed an admission date of 04/25/25, diagnoses included acquired absence of right left below the knee, chronic venous hypertension with ulcer and inflammation of the left lower extremity, cellulitis, obesity, edema, anemia, hypothyroidism, bilateral blindness, hypertension, peripheral vascular disease, gastro-esophageal reflux, acquired absence of right and left fingers, muscle weakness, Type II Diabetes, and osteomyelitis.Review of Residents #16's care plan last revised on 01/16/26 revealed the resident required assistance from staff to meet ADLs needs due to a right below the knee amputation, diabetic neuropathy, complete bilateral blindness, and amputation of all fingers except of bilateral thumbs. Interventions include assisting the resident with bathing as needed, assisting the resident with clothing choices, and dressing as needed. Further review revealed an alteration in comfort related to the amputation of the right leg below the knee related to osteomyelitis, a history of amputation of all fingers except for bilateral thumbs. Interventions include check and document on wounds daily for signs and symptoms of infection, drainage, bleeding, any breakdown of the skin, and impaired circulation. Monitor for bleeding, document the amount of bloody draining on dressing and in drainage system, and wound care daily as ordered by the physician and rewrap the stump as ordered and as needed.Observation on 02/24/26 at 11:13 A.M. of Resident #16 revealed bilateral open wounds on the residents hand stumps and uncountable red smear marks on the resident ' s gown and bedding.Interview on 02/24/26 at 11:14 A.M. with Resident #16 revealed they were to have their bilateral hand stumps covered by a dressing and did not have a dressing on them. The resident further confirmed they were unaware of the red smear marks on their gown and bedding and wished to be cleaned up. The resident stated they were upset they were in a soiled gown and bedding.Interview on 02/24/26 at 1:05 P.M. with the Assistant Director of Nursing confirmed Resident #16's gown and bedding were soiled with red marks. Review of the undated facility policy, ALDs revealed residents who are unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene.Review of Resident #16's medical record revealed an admission date of 04/25/25, diagnoses included acquired absence of right left below the knee, chronic venous hypertension with ulcer and inflammation of the left lower extremity, cellulitis, obesity, edema, anemia, hypothyroidism, bilateral blindness, hypertension, peripheral vascular disease, gastro-esophageal reflux, acquired absence of right and left fingers, muscle weakness, Type II Diabetes, and osteomyelitis.Review of Residents #16's care plan last revised on 01/16/26 revealed the resident required assistance from staff to meet ADLs needs due to a right below the knee amputation, diabetic neuropathy, complete bilateral blindness, and amputation of all fingers except of bilateral thumbs. Interventions include assisting the resident with bathing as needed, assisting the resident with clothing choices, and dressing as needed. Further review revealed an alteration in comfort related to the amputation of the right leg below the knee related to osteomyelitis, a history of amputation of all fingers except for bilateral thumbs. Interventions include check and document on wounds daily for signs and symptoms of infection, drainage, bleeding, any breakdown of the skin, and impaired circulation. Monitor for bleeding, document the amount of bloody draining on dressing and in drainage system, and wound care daily as ordered by the physician and rewrap the stump as ordered and as needed.Observation on 02/24/26 at 11:13 A.M. of Resident #16 revealed bilateral open wounds on the residents hand stumps and uncountable red smear marks on the resident ' s gown and bedding.Interview on 02/24/26 at 11:14 A.M. with Resident #16 revealed they were to have their bilateral hand stumps covered by a dressing and did not have a dressing on them. The resident further confirmed they were unaware of the red smear marks on their gown and bedding and wished to be cleaned up. The resident stated they were upset they were in a soiled gown and bedding.Interview on 02/24/26 at 1:05 P.M. with the Assistant Director of Nursing confirmed Resident #16's gown and bedding were soiled with red marks. Review of the undated facility policy, ALDs revealed residents who are unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene.This deficiency represents non-compliance investigated under Complaint Number 2645121.

Based on observations, staff interviews, and policy review, the facility failed to ensure safe storage of food in the kitchen. This had potential to affect all facility residents as they all ate food from the kitchen. The facility census was 44. Findings include: Observation and interview on 04/07/25 at 10:21 A.M. of the freezer with Kitchen Manager (KM) #66 revealed a bag of tater tots and a bag of crinkle fries were open and left undated. A bag of hot dogs had a hold in it and was left open to air. A box of garlic bread was left open to air and uncovered. In the fridge two undated carry out boxes with leftovers were present. One contained cake and another had breakfast food. In the dry storage are there were two cans with dents near the seals, including apple pie filling and apple sauce. KM #66 confirmed findings and acknowledged food should be dated and sealed/covered after opening. KM #66 stated the facility uses dented cans of food. Observation and interview on 04/09/25 at 11:51 A.M. with Kitchen Consultant (KC) #504 confirmed a container of shredded cheese was in the service line refrigeration and dated 03/23/25 to 03/29/25. KC #504 confirmed the cheese was outdated and should have been removed 03/29/25. Review of facility policy titled Food Storage Dry Goods, dated 06/20/17, revealed dietary shall ensure all packaged and canned food items would be kept cleaned, dry and properly sealed. All can goods will be inspect for dents, rust or bulges. All damaged cans would be placed in a designated area for vendor return. Review of facility policy titled Food Storage Cold, dated 08/01/17, revealed dietary would ensure all refrigerated food items would be stored properly, labeled and dated and stored in a manner that would prevent cross contamination.

Based on observation, resident and staff interview, and record review, the facility failed to ensure a resident's bathroom door opened and closed properly. This affected one (#08) resident out of sixteen residents reviewed for environment. The facility census was 44. Findings include: Review of the medical record revealed Resident #08 admitted to the facility on [DATE]. Diagnoses included anxiety disorder and fibromyalgia. Review of Resident #08's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact,. Resident #08 was independent with personal hygiene. Resident #08 required supervision with toilet transfers and walking ten feet. Observation of Resident #08's room on 04/07/25 at 1:59 P.M. revealed Resident #08's sliding door to her bathroom was difficult to open and close because it was stuck on the track. Interview with Resident #08 on 04/07/25 at 1:59 P.M. revealed she could not open and close her bathroom door because it would get stuck. Observation of Resident #08's room on 04/09/25 at 3:41 P.M. revealed Resident #08's sliding door to her bathroom remained stuck on the track and difficult to open and close. Interview with Corporate Registered Nurse (CRN) #500 on 04/09/25 at 3:41 P.M. verified Resident #08's sliding door to her bathroom was difficult to open and close because it was stuck on the track.

Based on observation, staff interview, and policy review, the facility failed to ensure a resident had a care plan for elopement and the use of a Wanderguard. This affected one (#25) out of one residents reviewed for elopement. The facility census was 44. Findings include: Review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, high blood pressure, diabetes and depression. Review of an elopement risk assessment dated [DATE] identified the resident to be at risk for elopement. An interventions on the assessment included the use of a Wanderguard. Review of the care plan dated 02/06/25 did not identify the resident to be at risk for elopement or identify the us of the Wanderguard. Observation of Resident #25 on 04/07/25 at 02:17 P.M. revealed she was wearing a Wanderguard on her leg. Review of policy titled Wanderguard Devices, dated 06/19/17, revealed a potential for elopement plan of care will be implemented including Wanderguard as an intervention. Interview on interview 04/10/25 at 2:13 P.M. with Corporate Registered Nurse (RN) #500 verified Resident #25 did not have a care plan identifying her risk for elopement and use of a Wanderguard.

Based on review of the medical record, staff interviews, and policy review, the facility failed to ensure care conferences were completed quarterly and included participation of the interdisciplinary team and the resident/responsible party. This affected two (#1 and #13) residents reviewed for care conferences. The facility census was 44. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included vascular dementia, anxiety disorder, major depressive disorder, and chronic kidney disease stage three. Review of Significant Change Data Set Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had cognitive impairment. This resident was assessed to be independent with eating, require substantial assistance with toileting and transfers, and partial assistance with bathing and dressing. Review of the care conferences for the last 12 months revealed Resident #1 received a care conference on 03/10/24, 06/14/24, and 09/24/24 with no documentation of the meeting, no evidence of the resident/representative participating and no evidence of members of the interdisciplinary team participating. There was no evidence of any quarterly care conferences after 09/24/24. Review of facility policy titled Plan of Care Meeting, dated 01/26/17, revealed facility shall establish a procedure for care conferences. Facility shall hold care conference meetings within 72 hours of admission and at least quarterly to review and revise the care plan. This shall include members of the interdisciplinary team, resident and family. Interview on 04/09/25 at 10:05 A.M. with Social Services Designee (SSD) #26 verified all department heads should be attending the care conference, including the resident and resident representatives. SSD #26 verified the 03/10/24, 06/14/24 and 09/24/24 contained no evidence of any staff or resident participation and there were no quarterly care conferences held after 09/24/24. 2. Review of the medical record for Resident #13 revealed an admitted [DATE]. Diagnoses included dysphasia, dementia, Alzheimer's, insomnia, cognitive communication deficit, and Crohn's disease. Review of the MDS assessment dated [DATE] revealed Resident #13 was cognitively intact. Review of care conference dated 09/26/24 revealed it was completed by the admissions director and did not name any staff or resident/family attendance and was left blank without any details about discussion. There was no evidence of any quarterly care conferences after 09/24/24. Interview 04/09/25 at 10:05 A.M. with SSD #26 and Corporate Registered Nurse (RN) #500 confirmed facility did not have any evidence of care conferences for Resident #13 since 09/24/24. SSD #26 confirmed the care conference on 09/24/24 contained no evidence of any staff or resident participation. Corporate RN #500 revealed facility identified the problem of missing care conferences and was including this as a Quality Improvement plan, but was unable to provide evidence of having recent quarterly care conferences.

Based on record review, staff interview, and review of the facility policy, the facility failed to maintain hospice documentation for one (#11) of one resident reviewed for Hospice. The facility identified three residents receiving hospice care (#11, #14 and #37). The facility census was 44. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE]. Diagnoses included adult failure to thrive, malnutrition, muscle weakness Parkinson's disease, atrial fibrillation, and chronic kidney disease. Review of Hospice election and admission paperwork dated 02/10/25 revealed Resident #11 was admitted to hospice care. Review of the hospice communication binder for Resident #11 contained no documentation from hospice visits. Interview on 04/10/25 at 9:36 A.M. with Unit Manager (UM) #511 confirmed the hospice communication binder for Resident #11 had no documentation from visits. UM #511 revealed they had blank communication forms in the binder. The electronic medical record and paper medical record were reviewed and found no documented communication from hospice visits. Interview on 04/10/25 at 9:40 A.M. with Registered Nurse (RN) #68 confirmed she had never seen communication forms completed for Resident #11 and reported it was difficult to get a binder from hospice. Interview on 04/10/25 at 9:45 A.M., Medical Records #52 revealed she did not have any record of hospice notes. Review of facility policy titled Hospice Services, dated 11/20/17, revealed facility shall establish a procedure for hospice services. The policy revealed the facility shall maintain hospice communication.

Based on observation, interview and record review, the facility failed to provide pressure reducing interventions as recommended to aide in the healing of a pressure ulcer for one (#08) out of four residents reviewed for pressure ulcers. The facility census was 44. Findings include: Review the medical record revealed Resident #08 admitted to the facility on [DATE]. Diagnoses included pressure ulcer of sacral regional stage three, pressure ulcer of left hip stage three, adult failure to thrive, malignant neoplasm of right female breast, polyneuropathy, anxiety disorder, iron deficiency anemia, type two diabetes mellitus, and fibromyalgia. Review of Resident #08's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #08 required supervision with rolling left and right, sitting to lying, lying to sitting, sitting to standing, and transfers. Resident #08 had one stage three pressure ulcer that was present upon admission to the facility. Review of Resident #08's skin care plan dated 12/27/24 revealed Resident #08 was at risk for skin integrity related to fragile skin, impaired mobility, incontinence and resisting care. Resident #08 had a stage three pressure ulcer to the left hip. Interventions included a pressure reducing mattress to bed. Review of Resident #08's initial wound evaluation and management summary signed by Wound Care Physician (WCP) #501, dated 12/13/24, revealed Resident #08 had a stage three pressure wound of the right hip full thickness. The wound was 7 centimeters (cm) by 1.5 cm by 0.1 cm. Recommendations included a low air loss mattress. Review of Resident #08's wound evaluation and management summary signed by WCP #501, dated 04/09/24, revealed Resident #08 had a stage three pressure wound of the right hip full thickness. The wound was 2.5 cm by 0.8 cm by 0.1 cm. The wound was listed as healing. Recommendations included a low air loss mattress. Review of Resident #08's physician orders dated 12/10/24 to 04/09/25 revealed Resident #08 did not have an order for a low air loss mattress. Review of Resident #08's progress notes from 12/10/24 to 04/09/25 revealed no information related to Resident #08 having a low air loss mattress. Observations of Resident #08's room on 04/07/25 at 1:59 P.M. and 04/09/25 at 3:41 P.M. revealed Resident #08 was lying in bed on her right hip. Resident #08 did not have a low air loss mattress in place. Interview with Corporate Registered Nurse (RN) #500 on 04/09/25 at 3:41 P.M. verified Resident #08's was lying in bed on her right hip and Resident #08 did not have a low air loss mattress. Review of the facility policy titled Wound and Skin Care Program, dated 12/20/24, revealed residents will be assessed for risk of skin breakdown and appropriate interventions will be initiated. Wound treatments and dressings will be supported by a physician's order.

Based on medical record review, observation, staff and resident interviews, and policy review, the facility failed to ensure nail care was provided for one (#30) of three residents reviewed for activities of daily living. The facility census was 44. Findings include: Review of the medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included vascular dementia,, stage three kidney disease, anxiety, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact and required assistance from staff for activities of daily living (ADLs). Review of the care plan dated 02/02/25 revealed Resident #30 needs assistance from staff for ADL needs with interventions to assist with bathing as needed. The care plan did not specify assistance with nail care. Review progress notes dated 02/01/25 to 04/10/25 revealed no notes related to toe nail care or podiatry services. Review of skin and shower sheets from 02/01/25 to 04/08/25 revealed no mention of nail care being offered or refused. Observation and interview on 04/07/25 at 10:56 A.M. with Resident #30 revealed her toenails were long, thick and the left foot big toenail was torn. Resident #30 revealed she was interested in seeing the podiatrist and would like to have her toenails cut. Interview on 04/09/25 at 10:05 A.M. with Social Service Designee (SSD) #26 revealed residents were on the list for podiatry. The facility identified several residents that had been missed for consents and were working to get consents signed and services provided as needed and desired. Observation and interview on 04/09/25 at 3:40 P.M. with Licensed Practical Nurse (LPN) #510 confirmed Resident #30's nails were long and thick with the small toe nails wrapping around the tips of the toes. The left big toenail was split about half way down and jagged. LPN #510 confirmed the nails were long and the left toenail was broken. LPN #510 stated She definitely needs to see the podiatrist. Resident #30 informed LPN #510 she was agreeable to the podiatrist. Interview 04/10/25 at 4:00 P.M. with SSD #26 revealed she may have had consents for podiatry from Resident #30, but was unable to provide evidence of offering or scheduling a podiatrist to the resident. Review of the undated facility policy titled ADLs revealed the facility shall establish a procedure to ensure the level of care and services of each resident. Residents unable to carry out ADL abilities shall shall be assisted.

Based on review of the medical record and staff interviews, the facility failed to implement interventions in a timely manner after a significant weight loss. This affected one (#29) of four residents reviewed for nutrition. The facility census was 44. Findings include: Review of the medical record for Resident #29 revealed an admitted [DATE]. Diagnoses included with fracture of superior rim of right pubis, major depressive disorder, anxiety disorder, and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had severe cognitive impairment. The resident was assessed to be independent with eating. Review of the care plan dated 04/04/25 revealed Resident #29 was at risk for altered nutrition related to medical diagnoses including Alzheimer's disease. Interventions included administer medications as ordered, encouraged intake as needed, obtain and monitor laboratory work as needed, obtain weight as ordered, provide and serve diet as ordered, and provide nutritional supplements as ordered. Review of the weights recorded for Resident #29 revealed on 08/02/24 a weight of 107.5 pounds (lbs). On 09/03/24 the resident weighed 98.9 lb for an 8.6-pound loss, which equaled an eight percent weight loss in 30 days. Review of the progress note dated 09/05/24 at 3:20 P.M. revealed due to a significant weight variance, re-weight requested. Review of the weights record for Resident #29 revealed no re-weight was completed until 10/02/24 when the resident was identified to weigh 101 lbs. With no interventions implemented. Review of the resident's weight on 12/10/24 revealed a weight of 99.5 lbs. This was an eight pound loss, or 7.4 percent weight loss in four months. On 12/28/24 and 01/06/25 the resident's weight was documented as 99.5 lbs. No interventions were implemented from August 2024 until January 2025. Review of the physician order dated 01/23/25 revealed Resident #29 was ordered a magic cup in the afternoon for supplement. The resident's weight on 02/05/25 was 96 lbs, a loss of 11.5 lbs or 10.6 percent loss in six months. Review of the physician order dated 02/10/25 revealed Resident #29 was ordered house supplement two ounces three times a day for to monitor stability related to significant weight loss. Review of the physician order dated 02/10/25 revealed Resident #29 was ordered to obtain weekly weight times four weeks for weight loss. Review of the weights on 02/18/25 and 0/25/25 revealed the resident weighed 94 lbs. On 03/05/25 the resident weighed 91.5 lb, down eight lbs, or eight percent in three months. The resident's weight on 04/03/25 was 96.5 pounds. Interview on 04/08/25 at 2:48 P.M. with Registered Dietician (RD) #503 verified a re-weight was not completed on Resident #29 after requested in September 2024. RD #503 verified no interventions were put into place until January 2025 after a significant weight loss of eight percent in September 2024.

Based on review of the medical record, pharmacy recommendations, interviews, and policy review, the facility failed to timely implement pharmacy recommendations for one (#29) of five residents reviewed for medications. The facility census was 44. Findings include: Review of the medical record for Resident #29 revealed an admitted [DATE]. Diagnoses included with fracture of superior rim of right pubis, major depressive disorder, anxiety disorder, and alzheimer's disease. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had cognitive impairment. Review of the monthly medication review (MMR) dated May 2024 revealed Resident #29 was recommended laboratory (lab) tests of magnesium, complete metabolic panel (CMP), thyroid stimulation hormone (TSH), and complete blood count (CBC). Review of the physician orders revealed no order was placed for the magnesium, CMP, TSH, or CBC for Resident #29 per the recommendation of the MMR. Review of the physician order dated 08/13/24 revealed Resident #29 was ordered a CBC, CMP, and urinalysis (UA) with culture and sensitivity (C&S) related to back and left flank pain. Review of the MMR dated November 2024 revealed Resident #29 was to have TSH levels checked. Review of the physician order dated 01/15/25 revealed Resident #29 was ordered TSH levels next lab draw. Interview on 04/09/25 at 1:44 P.M. with the Corporate Registered Nurse (RN) #503 verified labs were not completed per recommendations.

Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure a resident received dental care after breaking a tooth. This affected one (#05) resident out of two residents reviewed for dental care. The facility census was 44. Findings include: Review of the medical record revealed Resident #05 admitted to the facility on [DATE]. Diagnoses included muscle weakness, protein calorie malnutrition, iron deficiency anemia, constipation, anxiety disorder, and dysphagia. Review of Resident #05's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. Resident #05 was independent with eating and required set up assistance with oral hygiene. Resident #05 had obvious or likely cavities or broken natural teeth. Review of Resident #05's census information dated 04/10/25 revealed Resident #05 was on Medicaid. Review of Resident #05's oral cavity assessment dated [DATE] revealed Resident #05 had her own teeth. Resident did not have any broken, loose or carious teeth noted on the assessment. Review of Resident #05's dental care plan dated 08/11/24 revealed Resident #05 had the potential for oral and dental health problems related to natural teeth with likely cavities. Interventions included administer medications as ordered, assist with oral care as needed, and monitor, document and report to the physician as needed of signs and symptoms of oral and dental problems needing attention including broken teeth. Review of Resident #05's undated dental visit history revealed Resident #05 had no history of dental visits while at the facility. Observation of Resident #05 on 04/07/25 at 2:15 P.M. revealed Resident #05 had a front left tooth that appeared to be broken in half with the bottom half of the tooth missing. Interview on 04/07/25 at 2:15 P.M. Resident #05 stated she broke her front left tooth while she resided at the facility and she had not seen the dentist. Interview with Corporate Registered Nurse (CRN) #500 on 04/09/25 at 5:15 P.M. revealed staff at the facility had reported Resident #05 had broken her tooth at the facility but CRN #500 did not know the date when the tooth was broken. CRN #500 verified Resident #05 had not been seen by the dentist since she had broken her front tooth. Interview with Registered Nurse (RN) #502 on 04/10/25 at 10:41 A.M. revealed she completed an oral assessment for Resident #05's 03/28/25 MDS on 03/25/25 and Resident #05 was noted to have cavities. RN #502 stated she did not observe any broken teeth. Interview with Certified Nursing Assistant (CNA) #36 on 04/10/25 at 11:44 A.M. revealed she was not aware Resident #05 had a broken front tooth until 04/09/25 when staff asked her if her broken front tooth was a change. CNA #36 stated Resident #05 was admitted with no broken front teeth, but CNA #35 noticed Resident #05 had a broken front tooth on the left side when asked about it by management on 04/09/25. CNA #36 stated she frequently cares for Resident #05 and she never noticed the broken tooth. Resident #05 never had any complaints about the tooth. Review of the facility's policy titled Ancillary Services, revised 03/28/24, revealed the nurse will contact the resident's physician immediately when any resident has a perceived change in condition. An assessment will be made by the nurse prior to the phone call so that the nurse is prepared to discuss condition changes. The facility will refer to ancillary services as needed.

Based on medical record reviews, observations, staff interviews, and policy review, the facility failed to ensure infection control measures were followed during medication administration. This affected one (#197) of four residents reviewed for medication administration. The facility census was 44. Findings include: Review of the medical record for Resident #197 revealed an admitted [DATE]. Diagnoses included bacteremia, end stage renal disease (ESRD), and atrial fibrillation. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #197 had intact cognition. Review of the care plan dated 04/08/25 revealed Resident #197 was at risk for infection related to indwelling medical device, open wound and central vein catheter (CVC). Interventions included to wear gown and gloves when providing high-contact resident care activities. Review of the physician order date 04/05/25 revealed Resident #197 was ordered enhanced barrier precautions (EBP) related to indwelling devices every shift for monitoring. Review of the physician order dated 04/07/25 revealed Resident #197 was ordered the antibiotic meropenem-sodium chloride intravenous solution reconstituted one gram per 50 milliliters (ml), use 1000 milligrams (mg) intravenously (IV) one time a day for bacteremia. Observation on 04/08/25 at 4:23 P.M. of medication administration revealed Registered Nurse (RN) #68 popped medications into her hands without gloves on and placed them into medication cup. RN #68 administered those medications to Resident #197. At 4:20 P.M. RN #68 administered IV antibiotics through Resident #197's central venous catheter (CVC) on the left side of chest. RN #68 did not wear a gown for enhanced barrier precautions (EBP) during the administration of the IV. Interview on 04/08/25 at 4:25 P.M. with RN #68 verified she placed medications into her hands and then into the medication cup. RN #68 verified she administered those medications to Resident #197. RN #68 verified she did not wear a gown for EBP when administering the resident's IV. Review of the facility policy titled Enhanced Barrier Precautions, revealed the policy of the facility was to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs). Enhanced barrier precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). High-contact resident activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care.

Based on review of Resident Council minutes, resident interview, and staff interview, the facility failed provide ongoing communication to residents about their rights. This had potential to affect all residents. The facility census was 44. Findings include: Review of Resident Council meeting minutes dated 04/29/24, 05/27/24, 06/20/24, 07/24/24, 08/2024, 09/30/24, 10/29/24, 11/27/24, 12/30/24, 01/27/25, 02/26/25, and 03/26/25 revealed no resident right was documented as being discussed. Interview on 04/10/25 at 11:30 A.M. with Resident #36 revealed staff does not review any resident rights at the Resident Council meetings. Interview on 04/10/25 at 11:49 A.M. with Activity Director #42 confirmed she was not discussing resident rights during Resident Council meetings. She revealed she had been running the meetings since 09/2024 and was informed in March 2025 of the need to discuss the rights with the residents.

Based on review of the facility's Self-Reported Incident (SRI) and investigation, review of the facility's video surveillance, closed medical record review, review of the hospital records, staff interviews, and review of the facility policy, the facility failed to ensure a resident was free from neglect when the Director of Nursing (DON) and License Practical Nurse (LPN) #21 failed to adequately assess, monitor, and timely notify the physician of the resident's condition in accordance with professional standards of practice. This resulted in Immediate Jeopardy, serious life-threatening harm, and ultimate death when on [DATE] at 5:13 P.M., Resident #15 had a change in condition and at 5:54 P.M., State tested Nursing Aides (STNA) #34 and #58 found Resident #15 grabbing at his chest, unresponsive to verbal commands, and in respiratory distress and alerted the DON to the resident's change of condition. There were no ongoing assessments during the evening shift and no notification to the physician for the need to alter treatments and/or send the resident out for evaluation, treatment or care. On [DATE] at 11:55 P.M., STNA #34 found the resident to be unresponsive and notified LPN #21 to come to the room and LPN #21 stated Resident #15 was dead. LPN #21 did not immediately initiate Cardiopulmonary Resuscitation (CPR) or contact the physician. There was a nine-minute delay in CPR being started and ten-minute delay to notify Emergency Medical Services (EMS). EMS responded and transported Resident #15 to the emergency room where he expired on [DATE] at 12:50 A.M. This affected one (Resident #15) of three (#15, #41, and #47) residents reviewed for neglect. The facility census was 47 residents. On [DATE] at 4:27 P.M., the [NAME] President of Operations #140 and Clinical Director #143 were notified Immediate Jeopardy began on [DATE] at 5:54 P.M. when Resident #15 was found by STNAs #34 and #58, grabbing at his chest, unresponsive to verbal commands and in respiratory distress. STNA #58 alerted the DON who was in the hall. STNA #58 and the DON entered the resident's room and proceeded to attempt to verbally stimulate Resident #15 to breathe. The DON attempted to obtain a blood pressure at 6:10 P.M. and was unable to get a blood pressure; however, oxygen saturation and heart rate were taken which was reported to be normal. At 6:00 P.M., STNA #58 ran back into Resident #15's room and told the DON that the resident was a full code. There was no notification to the physician, or activation of emergency services at that time. It was not until approximately 7:34 P.M. that a nurse (LPN #21/night shift) entered Resident #15's room and exited shortly afterwards after a brief discussion with the family about the resident being a full code and not on hospice. The next time LPN #21 entered the resident's room was at 11:55 P.M. after STNA #34 entered the room and noticed the resident had expired. At 11:56 P.M., LPN #21 left Resident #15's room, sat down at the nurse's station, and did not make any telephone calls immediately to notify the physician and/or EMS. On [DATE] at 12:00 A.M., LPN #21 notified the DON that Resident #15 was dead, and she did not complete CPR and refused to initiate the CPR. At 12:03 A.M., the DON had LPN #56 initiate CPR on Resident #15. At 12:04 A.M., LPN #21 notified EMS. The physician was never notified. EMS responded and transported Resident #15 to the emergency room where he expired on [DATE] at 12:50 A.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], Staffing Agency #500 was made aware of the neglect allegations involving LPN #21. LPN #21 was placed on the Do Not Return list. On [DATE], the Administrator and [NAME] President of Operations #140 suspended the DON. On [DATE], the DON was terminated as an employee from the facility. On [DATE], all 56 employees at the facility were educated on the facility's abuse policy including identification of neglect and reporting an allegation of neglect. On [DATE] at 10:33 A.M., the facility initiated an investigation. On [DATE], an Ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to determine the root cause of the Immediate Jeopardy. On [DATE], LPN #93 and Registered Nurse (RN) #177 educated all 16 licensed nursing staff regarding identification of change in condition, the components of a comprehensive assessment, monitoring of the change in condition as well as timely notification of the physician according to professional standards of practice. In addition, all staff were educated regarding the prevention, identification and reporting of abuse to include neglect according to facility policy. On [DATE], 50 residents were interviewed regarding abuse. There were no concerns about any allegations of abuse/neglect made known as a result of the interviews. On [DATE], the facility submitted the initial SRI. On [DATE], the Local Police and the Ohio Board of Nursing were made aware of the neglect allegation involving the DON. On [DATE], Quality Assurance Director (QAD) #180 completed an audit of nurse's progress notes to identify any resident that experienced a change in condition without being appropriately assessed, monitored and reported timely to the physician. A comprehensive assessment was performed for any resident identified as experiencing a change in condition not appropriately assessed, monitored and timely report made to the physician. The audit was conducted for the timeframe of [DATE] to [DATE]. On [DATE], QAD #180 completed an audit on 50 residents' progress notes to identify any documentation indicating an incident of abuse including neglect, as well as any other category of reportable incident according to the Centers for Medicare and Medicaid Services (CMS) regulation, had occurred. No documentation was identified indicating a reportable incident occurred. On [DATE], Clinical Director #143 educated the facility's 13 Directors and Supervisors regarding the investigation and reporting requirements according to CMS regulation for all reportable events including neglect. Beginning on [DATE], the facility will complete questionnaires to evaluate licensed nursing staffs' understanding of the components of a comprehensive assessment, monitoring of the change in condition, and timely notification of the physician according to professional standards of practice as well as audits also in the form of questionnaires consisting of staff understanding of abuse identification and reporting specifically neglect. This will be conducted six times per week each for four weeks to include all shifts. Beginning on [DATE], the facility will complete audits in the form of questionnaires which will be conducted by the facility Directors and Supervisors to evaluate understanding of incident investigation and reporting requirements. The audits will be conducted six times per week for four weeks. Beginning on [DATE], the facility will complete audits consisting of review of nurse's progress notes to determine completion of a comprehensive assessment, monitoring of a change in condition and timely notification of the physician according to professional standards of practice. The audits will be performed three times a week for four weeks. Beginning on [DATE], the facility will submit their audit findings to the QAPI Committee weekly for recommendations. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included atrial fibrillation, mesothelioma (an aggressive and rare form of cancer that usually occurs in the thin layer of tissue that lines the lungs or the abdomen), and respiratory failure with hypoxia. Resident #15 died on [DATE] at 12:50 A.M. at the emergency room . Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively intact and required substantial/maximal assistance from staff for toileting. Review of the physician orders for Resident #15 revealed an order dated [DATE] for the resident to be a full code. Review of Resident #15's medical record revealed there was no documentation of a blood pressure reading or the inability to obtain blood pressure. There was no documentation that the physician was notified of Resident #15's change in condition. There was no documentation of a respiratory assessment, neurological assessment, pain assessment, or cardiac assessment completed after the DON was alerted by STNAs #34 and #58 of Resident #15's change of condition at 6:00 P.M. Review of the progress note dated [DATE] at 7:00 P.M. revealed LPN #21 documented Resident #15 was in respiratory distress when this nurse arrived to report for shift. The DON was in the room with the resident. The DON reported all vitals within normal limits and does not see any need to send the resident out to the hospital when the day shift nurse recommended to send him to the hospital. There was no documentation of vital signs, notification of physician, no documentation of respiratory assessment, neurological assessment, pain assessment, or cardiac assessment completed by LPN #21. The progress note dated [DATE] at 11:40 P.M. (the facility's video surveillance shows actual time was 11:55 P.M.) revealed LPN #21 was notified by STNA #34 to assess Resident #15. Resident #15 was found in bed and unresponsive. There was no documentation that CPR was initiated, or the physician was notified. Review of Resident #15's hospital records revealed on [DATE] at 12:50 A.M., Resident #15 was pronounced dead. Review of the facility's SRI revealed the facility concluded the allegation of neglect was substantiated on [DATE]. The facility's review of video and video audio on [DATE] from 5:00 P.M. to midnight showed the DON failed to assess, monitor, and timely notify the physician of Resident #15's change in condition. The DON stated, He is transitioning and discusses the inability to obtain blood pressure and he was shaking. The facility substantiated the allegation of neglect and concluded the DON did not adequately assess, monitor, and timely notify the physician of Resident #15's change of condition which led to his death. Interview with STNA #34 on [DATE] at 10:30 A.M. revealed during the change of shift at approximately 6:00 P.M. on [DATE], she and STNA #58 found Resident #15 in severe distress, eyes wide open, grabbing at his chest, and he looked like he was having trouble breathing. They both went to the hall to get help and found the DON and she went into Resident #15's room. STNA #34 stated she found Resident #15 unresponsive and cold during the 11:00 P.M. to 11:30 P.M. rounds (the facility's video surveillance shows actual time was 11:54 P.M.) and alerted LPN #21 of Resident #15's condition. STNA #34 was unable to remember the last time she provided care to Resident #15 prior to finding Resident #15 unresponsive. Interview with Nurse Practitioner (NP) #75 on [DATE] at 1:30 P.M. confirmed there was no communication from the facility regarding Resident #15's change of condition at 6:00 P.M. or when staff found him unresponsive at 11:55 P.M. NP #75 confirmed any change of condition, including inability to obtain blood pressure, low oxygen saturation levels, difficulty breathing, or any signs of distress would indicate a need for notification of a physician. She would expect a nurse to provide an assessment of the condition of the resident if they were unable to obtain blood pressure, or if a concern for respiratory distress in a patient. Interview with the DON on [DATE] at 10:20 A.M. revealed that on [DATE] at around 6:00 P.M., she was called into Resident #15's room by STNAs because of concerns for respiratory distress. The DON verified she was unable to obtain blood pressure on Resident #15, using manual and automatic cuff after multiple attempts. The DON verified she did not perform a respiratory, neurological, cardiac, or pain assessment at that time. The DON verified she did not call the physician regarding Resident #15's change of condition and further verified that she did not call the responsible party regarding Resident #15. The DON verified that on the facility's video surveillance, she was the one at 6:10 P.M. speaking to LPN #21 and RN #62 regarding Resident #15 and stated, He's breathing almost like someone who is transitioning, that he is a full code, she did not have a reason to send to hospital, because he would come right back. Interview with STNA #58 on [DATE] at 1:00 P.M. revealed that on [DATE] at approximately 5:15 P.M., Resident #15 was complaining of coughing, to which she helped him set up in bed, provided water, and his meal tray, and he began to eat at that time. During change of shift on [DATE] at approximately 6:00 P.M. with oncoming STNA #34, they entered Resident #15's room to find him grasping at his chest with his hands, his eyes wide open, unresponsive to verbal stimulation and irregular breathing/holding breath. STNAs #34 and #58 immediately exited the room to find the DON, outside of his room. The DON began to talk to Resident #15 to which he did not respond. The DON directed STNA #58 to find his code status in the medical record. STNA #58 went to the nurses' station, found his medical record, and found his code status was a full code, and ran back to tell the DON. STNA #58 told the DON he was a full code and proceeded to find vital sign equipment. The pulse oximeter was applied to the finger of Resident #15 and his oxygen saturation was 76 percent (%). STNA #58 stated the resident's oxygen saturation never was normal (normal is 96 to 100%) and it stayed in the 70's range. Resident #15 had oxygen on via nasal cannula and they were unable to obtain blood pressure with wrist cuff. STNA #58 left the room shortly after, around the same time as the DON, and continued walking rounds with STNA #34. Interview with RN #62 on [DATE] at 1:30 P.M. revealed she was giving report to LPN #21 on [DATE] at approximately 6:00 P.M. when she was told Resident #15 was in distress and the DON was handling it. RN #62 stated she was under the understanding it was an emergency with Resident #15. The DON came to the nursing desk shortly after beginning shift report and was told Resident #15 was having respiratory issues and was unable to obtain blood pressure. RN #62 stated she asked the DON if Resident #15 needed to be sent to the hospital and was told by the DON the hospital will send him right back because his oxygen saturation was 97%. RN #62 verified she did not call the physician or assess Resident #15 at that time because she was transferring care to LPN #21. Attempts to interview LPN #21 during the investigation were unsuccessful. Interview with VPO #140 on [DATE] at 9:30 A.M. verified LPN #21 would not cooperate with the facility's investigation, and LPN #21 refused to provide a statement on [DATE] and would not return any of the facility's telephone calls to provide a statement. VPO #140 also verified LPN #21 worked for a staffing agency and the staffing agency reported LPN #21 would not return their telephone calls either and was uncooperative with the staffing agency's investigation. Review of the facility's video surveillance outside of Resident #15's room revealed the following events occurred beginning on [DATE] at 5:00 P.M. and ending on [DATE] at 12:17 A.M.: From 5:02 P.M. to 5:13 P.M., a male's voice is heard coughing/yelling with inaudible communication. At 5:14 P.M., a male's voice is heard coughing with inaudible communication. STNA #58 is seen bringing food trays down the hall and states, [Resident #15's first name] calm down, hold on then proceeds to deliver a food tray to another resident's room. Then STNA #58 proceeded to walk into Resident #15's room and Resident #15 stated Can't stop coughing. STNA #58 states I am going to pull you up, then there is inaudible conversation, then states, Do you want a drink, breath through your nose to get that oxygen. STNA #58 walks out of Resident #15's room at 5:17 P.M. At 5:18 P.M., STNA #58 enters Resident #15's room with a food tray. STNA #58 tells Resident #15 that a nurse will come check on you and states she is not a nurse. STNA #58 leaves Resident #15's room and proceeds to deliver food trays to surrounding rooms until 5:20 P.M. and then leaves the hall with the food cart. At 5:40 P.M., a male's voice is heard coughing with inaudible communication, and this is the last time that the male's voice is heard. At 5:58 P.M., STNAs #34 and #58 can be seen entering Resident #15's room and parts of a conversation are heard including a female's voice asking Resident #15 You, ok?' and tells him to breathe through his nose multiple times. No male voice is heard. At 5:59 P.M., STNA #34 enters a room across the hall from Resident #15 and the DON exits the same room and proceeds into Resident #15's room. At 6:00 P.M., STNA #58 exits Resident #15's room and walks down to the nurses' station. STNA #58 is seen running from the nurses' station to Resident #15's room, and a female's voice is heard saying, he does not have a Do Not Resuscitate (DNR) order and form. At 6:01 P.M., the DON leaves Resident #15's room and goes to the nurse's station. At 6:01 P.M., STNA #58 removes the tray from Resident #15's room and states I don't know what's happening. At 6:02 P.M., the DON and STNA #58 are seen outside Resident #15's room, and the DON states he has mesothelioma and lung cancer. STNA #58 leaves Resident #15's room, enters room across the hall, then leaves and proceeds to walk down to the nurse's station. At 6:03 P.M., STNA #58 returns to Resident #15's room with a blood pressure cuff in her hand. At 6:06 P.M., the DON and STNA #58 are seen exiting Resident #15's room. At 6:07 P.M., the DON is seen entering Resident #15's room with a blood pressure cuff in her hand. At 6:10 P.M., the DON is seen exiting Resident #15's room with a blood pressure cuff in her hand, and a female's voice is heard saying, I can't get blood pressure. At 6:12 P.M., the DON is seen leaving off unit. From 6:10 P.M. to 7:33 P.M., no staff enter Resident #15's room. At 7:34 P.M., LPN #21 enters Resident #15's room and talks to the two family members that arrived at 7:32 P.M. At 7:37 P.M., LPN #21 leaves Resident #15's room. From 7:38 P.M. to 11:55 P.M., LPN #21 did not enter Resident #15's room. At 11:54 P.M., STNA #34 enters Resident #15's room and remains in the room for a full minute before exiting and stands at the door and waits for LPN #21. LPN #21 reaches STNA #34 at Resident #15's door and states I don't know why he's so cold. LPN #21 states The room is cold? They both enter Resident #15's room at 11:55 P.M. STNA #34 is heard stating He's dead and LPN #21 states Yeah. At 11:55:59 P.M., LPN #21 exits Resident #15's room stating, And he is a full code and no hospice. LPN #21 walks to the nurse's station and you can hear the bed in Resident #15's room being moved. At 11:56 P.M., LPN #21 reaches the nurse's station and sits there. At 11:57 P.M., STNA #34 exits Resident #15's room carrying a gown and states something to LPN #21 that was inaudible. LPN #21, STNA #34 and STNA #103 have a conversation at the nurse's station. At 11:59 P.M., STNA #103 leaves the nurse's station. At 12:00 A.M., LPN #21 makes a telephone call (to the DON) and states Our guy just passed away. I wanted to send him out but .he is a full code .I can't even get him out of the bed. He is dead weight. I can't get him on the floor. Okay, I'm calling to let you know .I will start CPR and I will yell across the room for the next nurse to call [DATE]. LPN #21 got louder and said I already verified [DON's name]. You knew his situation when you left here. I already verified he was dead, and I called you .Why are you yelling at me .I was at the assisted living (AL) unit, you had me working at AL .I will go in and do CPR. You call the other nurse. LPN #21 is off the telephone and makes comments to STNA #34 before she leaves the nurses station stating Don't act like it's an emergency now. You knew the situation. At 12:02 A.M., LPN #21 sends STNA #34 to tell the long-term care (LTC) nurse (LPN #56) to call 911. LPN #21 then starts down the hall walking. She turns back around towards the nurse's station and sits down again. At 12:03 A.M., LPN #56 arrives at the nurse's station and enters Resident #15's room at 12:03 A.M. LPN #56 can be heard doing compressions as the bed squeaks with each compression. At 12:04:34 A.M., LPN #21 is seen walking up to Resident #15's room with the crash cart. As she enters the room, LPN #21 asks LPN #56 Do we have a backboard?. The backboard can be seen on the back of the crash cart by the camera. STNA #34 states I don't know. LPN #56 asks LPN #21 if she has called 911. LPN #21 replies Yeah. LPN #56 asks LPN #21, Has the responsible parties been notified? LPN #21's replies You don't have to do all that. LPN #56 states, He is a full code. Yes, we do. LPN #21 states, I'm not saying you don't have to do CPR. I'm saying doing it in the bed its ineffective. LPN #21 asks Where is the backboard? LPN #56 yells back, I don't know. We don't have one. You are in a nursing home. Noises can be heard coming from the room but not distinguishable. LPN #56 states Help me get him on the floor. LPN #21 states There should be a backboard. LPN #56 repeats, I need some help. Are you kidding me? This is someone's life here. Give me the attitude later. LPN #21 is heard stating, I need to start my rounds. From 12:10 A.M. to 12:17 A.M., EMS arrives, takes over CPR for Resident #15, and transports Resident #15 to the hospital. Review of the facility's video surveillance of the nurse's station revealed the following events occurred beginning on [DATE] at 6:00 P.M. and ending on [DATE] at 6:10 P.M.: At 6:00 P.M., a female's voice is heard saying Oh my goodness. STNA #58 is seen looking at a resident's chart, and places it on the desk. At 6:01 P.M., the DON is seen looking at the same chart on the desk. At 6:05 P.M., RN #62 picks up the telephone and states there was an emergency down the hall, someone will be down. STNA #34 and STNA #148 at the nurses' station have conversations. At 6:06 P.M., RN #62 is heard talking to a female voice. The voice stated He is moving, he is twitching, he is not (inaudible conversation); he is wide eyed. Multiple conversations are heard at the nurse's station. STNA #58 is now at the nurse's station. From 6:06 P.M. to 6:10 P.M., multiple conversations at the nurse's station are heard, with STNAs #34, #58, #148, RN #62 and LPN #21. At 6:10 P.M., a female voice is heard saying Can't get a blood pressure ., (inaudible conversation); He is wide eyed, he's almost like someone who is transitioning, that's what it is, he is a full code. RN #62 says Send him, and the DON says, He will come right back. Review of the facility policy titled Resident Condition Changes dated [DATE] revealed the nurse will contact the resident's physician immediately when any resident has perceived a change in condition. An assessment will be made by the nurse prior to the phone call so the nurse is prepared to discuss condition change. A change of condition includes but is not limited to changes in physical or mental status. The nurse will document condition change and physical/responsible party contact information in nurses' notes. Review of the facility policy titled Abuse dated [DATE] revealed residents have the right to be free from abuse, neglect, exploitation and misappropriation of resident property. It is the facility policy to investigate all alleged violations involving abuse, neglect, exploitation or mistreatment. The policy further defines neglect as the failure of the facility, its employee, or facility service to provide goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility policy defines abuse to include the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This deficiency represents non-compliance investigated under Complaint Number OH00154334.

Based on closed medical record review, review of the facility's video surveillance, staff interviews, review of the facility's Self-Reported Incident (SRI) and investigation, review of the Emergency Medical Services (EMS) run report, review of the facility policy, and review of the American Heart Association (AHA) guidelines, the facility failed to timely initiate Cardiopulmonary Resuscitation (CPR) or contact EMS timely for one resident (#15), who was found unresponsive, without a pulse or respirations, and who was identified as a Full Code status. In addition, once initiated, the facility failed to provide adequate CPR techniques for Resident #15. This resulted in Real and Present Danger, serious life-threatening harm, and ultimate death when Resident #15 did not receive CPR for nine minutes after he was discovered with no vital signs, EMS was not contacted for assistance until ten minutes after the resident was discovered, and when CPR was initiated, staff performed chest compressions while Resident #15 remained in the bed, without a backboard present, which lessoned the overall effectiveness of chest compressions. This affected one (Resident #15) of three (#15, #55, and #56) residents reviewed for death in the facility. The facility census was 47. On [DATE] at 4:47 P.M., the Administrator, the Director of Nursing (DON), [NAME] President of Operations #140 and Clinical Director #143 were notified Real and Present Danger began on [DATE] at 11:55 P.M. when the facility failed to immediately initiate CPR for Resident #15 who was a full code and was found unresponsive and without vital signs. State tested Nursing Aide (STNA) #34 and Licensed Practical Nurse (LPN) #21 found Resident #15 dead on [DATE] at 11:55 P.M. LPN #21 was heard stating Resident #15 was a Full Code and not hospice services on the facility's video surveillance. At 11:56 P.M., LPN #21 leaves Resident #15's room and sits at the nursing station and does not make any telephone calls until 12:00 A.M. On [DATE] at 12:00 A.M., LPN #21 telephones the DON to report Resident #15 has deceased , and LPN #21 is reluctant to initiate CPR. At 12:03 A.M., LPN #56 initiates CPR on Resident #15 and completes CPR on Resident #15's bed without a backboard present. At 12:04 A.M., EMS were contacted by LPN #21. LPN #56 continued with CPR until EMS arrives at 12:10 A.M. The Real and Present Danger was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 12:17 A.M., EMS transported Resident #15 to the hospital and the emergency room pronounced Resident #15 dead at 12:50 A.M. On [DATE], Clinical Director #143 submitted their initial SRI. On [DATE], the facility held an ad-hoc Quality Assurance and Performance Improvement (QAPI) committee meeting to discuss and identify the problem and complete a root cause analysis. On [DATE], the DON and LPN #93 educated all 16 licensed nurses regarding verification of the resident's code status and when the nurse should complete CPR. Education will be provided to all agency licensed nurses upon their next scheduled shift by the DON/designee. The education included advance directive specifics (Full Code, Do Not Resuscitate Comfort Care Arrest (DNRCCA), and Do Not Resuscitate Comfort Care (DNRCC)), physician required pronouncement of death and steps to performing a code/providing CPR according to AHA guidelines as well as location of crash carts and the supplies/equipment necessary to perform resuscitative measures. On [DATE], the DON and LPN #93 verified all 16 licensed nurses had active CPR certification. On [DATE], the DON, LPN #93 and Clinical Director #143 conducted an audit on all 46 residents' advance directive. The Advance Directive state forms, physician orders, and care plans were audited to ensure all were consistent throughout the medical record. On [DATE], the DON and LPN #93 completed an audit of the facilities crash carts. The equipment and supplies were present on the two crash carts in the facility. Beginning on [DATE], mock codes will be conducted to ensure staff proficiency as well as CPR is performed according to AHA guidelines. Mock codes will be conducted three times weekly to include both licensed nurse shifts as well as nine staff questionnaires weekly regarding understanding of the Advanced Directive policy. Mock codes and questionnaires will be coordinated to include licensed nurses provided by the staffing agency. Both mock codes and questionnaires will be performed at minimum for four weeks by the DON and/or designee. Audit findings will be presented to the QAPI Committee weekly for recommendations. On [DATE], Clinical Director #143 educated all 14 therapists (physical, occupational, and speech) regarding advance directive specifics (Full Code, DNRCCA, and DNRCC) as well as the required response to identifying a resident experiencing a potential life-threatening event. Education was also provided regarding potential for participation in code events whether CPR certified or not. On [DATE], the facility reported LPN #21 to the Ohio Board of Nursing and to the local police for failure to initiate CPR on a resident whose code status was Full Code. Although the Real and Present Danger was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Real and Present Danger) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included atrial fibrillation, mesothelioma, and respiratory failure with hypoxia. Resident #15 died at the emergency roiagnom on [DATE] at 12:50 A.M. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. Review of the physician orders for Resident #15 revealed an order dated [DATE] for the resident to be a full code. Review of Resident #15's progress notes dated [DATE] at 11:40 P.M. (per video surveillance the time was 11:54 P.M.) revealed LPN #21 was notified by State tested Nurse Aide (STNA) #34 to come to the residents' room to assess. Resident #15 was found laying in bed unresponsive. No signs of breathing noted. LPN #21 attempted to move the resident from the bed to the floor but was unable to. The DON was notified. The crash cart was moved from behind the nurses' station to the resident's room. Staff nurse (LPN #56) continues CPR, with no back board noted. LPN #21 expressed concern of doing ineffective CPR. CPR continues until EMS arrived on scene. Review of the facility's video surveillance outside of Resident #15's room revealed the following events occurred beginning on [DATE] at 11:54 P.M. and ending on [DATE] at 12:17 A.M.: At 11:54 P.M., STNA #34 enters Resident #15's room and remains in the room for a full minute before exiting and stands at the door and waits for LPN #21. LPN #21 reaches STNA #34 at Resident #15's door and states I don't know why he's so cold. LPN #21 states the room is cold? They both enter Resident #15's room at 11:55 P.M. STNA #34 is heard stating He's dead and LPN #21 states yeah. At 11:55:59 P.M., LPN #21 exits Resident #15's room stating, And he is a full code and no hospice. LPN #21 walks to the nurse's station and you can hear the bed in Resident #15's room being moved. At 11:56 P.M., LPN #21 reaches the nurse's station and sits there. At 11:57 P.M., STNA #34 exits Resident #15's room carrying a gown and states something to LPN #21 that was inaudible. LPN #21, STNA #34 and STNA #103 have a conversation at the nurse's station. At 11:59 P.M., STNA #103 leaves the nurse's station. At 12:00 A.M., LPN #21 makes a telephone call (to the DON) and states Our guy just passed away. I wanted to send him out, but .he is a full code .I can't even get him out of the bed. He is dead weight. I can't get him on the floor. OK I'm calling to let you know .I will start CPR and I will yell across the room for the next nurse to call [DATE]. LPN #21 got louder and said I already verified [DON's name]. You knew his situation when you left here. I already verified he was dead, and I called you .Why are you yelling at me .I was at the assisted living (AL) unit, you had me working at AL .I will go in and do CPR. You call the other nurse . LPN #21 is off the telephone and makes comments to STNA #34 before she leaves the nurses station stating Don't act like it's an emergency now. You knew the situation. At 12:02 A.M., LPN #21 sends STNA #34 to tell the long-term care (LTC) nurse (LPN #56) to call 911. LPN #21 then starts down the hall walking. She turns back around towards the nurse's station and sits down again. At 12:03 A.M., LPN #56 arrives at the nurse's station and states He is a full code honey as she is talking on the telephone and asking where the crash cart is. We need to do CPR, and someone needs to call 911. STNA #34 returns and is talking to LPN #21 while she is sitting at the nurse's station. LPN #56 is still on the telephone, asks, Where is he at? STNA #34 follows and states, that one and points to Resident #15's room. LPN #56 enters Resident #15's room at 12:03 A.M. LPN #56 is heard saying I am. I am. I am. LPN #56 can be heard doing compressions as the bed squeaks with each compression. At 12:04 A.M., STNA #34 enters Resident #15's room. LPN #56 is heard saying His name is [First name of Resident #15] what? STNA #34 steps out of the room and looks at the name plate and states [Resident #15's first and last name]. STNA #34 asks LPN #56 You called 911, right?. LPN #56 states, We still have to do CPR. At 12:04:34 A.M., LPN #21 is seen walking up to Resident #15's room with the crash cart. As she enters the room, LPN #21 asks LPN #56 Do we have a backboard?. The backboard can be seen on the back of the crash cart by the camera. STNA #34 states I don't know. LPN #56 asks LPN #21 if she has called 911. LPN #21 replies Yeah. LPN #56 asks LPN #21, Has the responsible parties been notified? LPN #21's replies You don't have to do all that. LPN #56 states, He is a full code. Yes, we do. LPN #21 states, I'm not saying you don't have to do CPR. I'm saying doing it in the bed its ineffective. LPN #21 asks Where is the backboard? LPN #56 yells back, I don't know. We don't have one. You are in a nursing home. Noises can be heard coming from the room but not distinguishable. LPN #56 states Help me get him on the floor. LPN #21 states There should be a backboard. LPN #56 repeats, I need some help. Are you kidding me? This is someone's life here. Give me the attitude later. LPN #21 is heard stating, I need to start my rounds. At 12:10 A.M, EMS arrives and STNA #34 escorts EMS to Resident #15's room. Code verification asked of nurses. Both nurses respond, He is a full code. At 12:17 A.M., EMS is seen transporting Resident #15 out of the room. Review of the facility submitted SRI revealed an allegation of neglect was made known on [DATE]. The involved resident was identified as Resident #15, and the alleged perpetrator was LPN #21. The date of occurrence was indicated to be [DATE] and the SRI's initial report was noted to have been submitted on [DATE]. The SRI's summary of the incident revealed on [DATE] at 12:00 A.M., LPN #21 contacted the DON to inform her Resident #15 had expired. The DON questioned LPN #21 if CPR had been conducted and LPN #21 stated no. The DON directed LPN #21 to initiate CPR in which the LPN was reluctant to initiate. The DON hung up the telephone and called LPN #56 to initiate CPR on Resident #15. The facility's investigation determined there was a delay and reluctancy to initiate CPR on Resident #15. Review of LPN #56's undated witness statement revealed on [DATE] at 12:02 A.M., LPN #56 was notified by the DON to go to the skilled unit because Resident #15 was in cardiac arrest and a full code. LPN #56 immediately went to the skilled unit and LPN #21 was sitting at the nurse's station. LPN #56 went into Resident #15's room, and Resident #15 was gray, no sign of rise and fall from chest, mouth open and no verbal/non-verbal response when she spoke his name. LPN #56 started CPR and shouted out for the nurse (LPN #21) to assist with CPR. LPN #21 entered the room and began to argue regarding the position of the resident that he was in a bed and that CPR would be ineffective. LPN #56 stated CPR should have been started until the resident could be placed on a flat/firm surface and continued to provide CPR compressions after a count of 20 compressions. Review of STNA #34's undated witness statement revealed on [DATE] at about 11:00 to 11:30 P.M. (actual time was 11:54 P.M. per video surveillance), STNA #34 found Resident #15 unresponsive and called LPN #21. LPN #21 called the DON and EMS. LPN #21 asked STNA #34 to call the other nurse, LPN #56. LPN #56 and STNA #34 got Resident #15 on the floor and the nurses did CPR before the squad came. Review of the DON's witness statement dated [DATE] revealed she received a telephone call from LPN #21 at midnight on [DATE] stating Resident #15 had died . The DON asked for a statement of her involvement in the code. LPN #21 stated she had not initiated the code. The DON stated Resident #15 was a full code and she needed to get off the telephone and initiate CPR. The DON repeated to LPN #21 to get off the telephone. LPN #21 continued to argue with the DON. The DON raised her voice and told LPN #21 to get off the telephone and go do CPR. The DON immediately called LPN #56 on the long-term hall and told LPN #56 there was a code in the building in [Resident #15]'s room and needed her to help as LPN #21 had not initiated the code. The DON was on the telephone until LPN #21 was in the room initiating compressions. Review of the EMS run report dated [DATE] revealed EMS received the call on [DATE] at 12:04 A.M. Resident #15 was transported to the local hospital and provided with advanced life support interventions by EMS. Interview with STNA #34 on [DATE] at 10:30 A.M. revealed she found Resident #15 cold and non-responsive and alerted LPN #21 of his status. STNA #34 verified LPN #21 did not initiate any life saving measures including CPR, and CPR was initiated by LPN #56 once she arrived on the unit. Interview with the DON on [DATE] at 1:00 P.M. confirmed she received a telephone call on [DATE] at 12:00 A.M. from LPN #21. LPN #21 told her Resident #15 had died . The DON stated she told LPN #21 to go start CPR and call 911, to which LPN #21 refused. LPN #21 continued to refuse to start CPR, so the DON hung up the telephone, and she called LPN #56 at 12:02 A.M. to go to the skilled unit and start CPR on Resident #15. Interview with Nurse Practitioner (NP) #75 on [DATE] at 1:30 P.M. confirmed there was no communication from the facility regarding Resident #15's change of condition, emergency services, CPR and/or Resident #15's death. NP #75 confirmed she met Resident #15 on [DATE] and during Resident #15's assessment, Resident #15 requested to be a full code. NP #75 confirmed CPR should have been initiated immediately when LPN #21 found Resident #15 unresponsive without vital signs. Interview with the DON on [DATE] at 10:30 A.M. verified that facility policy and standard adult CPR was 30 compressions to two breaths ratio, and LPN #56 did compressions of 20 and a pulse check which were not within the guidelines of the correct performance of CPR. The DON verified the backboard was present on the crash cart on [DATE] at 12:04 A.M. and LPN #56 should have utilized the backboard when completing CPR on Resident #15. Interview with LPN #56 on [DATE] at 11:43 A.M. revealed she received a telephone call from the DON on [DATE] at 12:02 A.M to go start CPR on Resident #15 who was a full code because LPN #21 refused to start CPR. When she arrived at the skilled unit, both LPN #21 and STNA #34 were at the nurse's station. LPN #56 was directed to the residents' room at approximately 12:04 A.M., where she found Resident #15 and he was gray, he had no sign of rise and fall from his chest, mouth open and no verbal/non-verbal response when she spoke his name. LPN #56 verified she began compressions on Resident #15 while in bed with no backboard and no backboard was used for the entirety of CPR. LPN #56 verified she provided CPR to Resident #15 with 20 compressions and then would check for a pulse. LPN #56 verified she provided CPR to Resident #15 until the medics arrived and took over. Attempts to interview LPN #21 during the investigation were unsuccessful. Interview with the [NAME] President of Operations (VPO) #140 on [DATE] at 9:30 A.M. verified LPN #21 would not cooperate with the facility's investigation, and LPN #21 refused to provide a statement on [DATE] and would not return any of the facility's telephone calls to provide a statement. VPO #140 also verified LPN #21 worked for a staffing agency and the staffing agency reported LPN #21 would not return their telephone calls either and was uncooperative with the staffing agency's investigation. Review of the facility policy titled Adult CPR dated [DATE] revealed to provide high-quality CPR per AHA Basic Life Support guidelines, a licensed staff member who was certified in CPR/BLS (basic life support) shall initiate two rescue breaths after 30 compressions, continue at 30 to two ratio. Review of the AHA guidelines dated [DATE] revealed the AHA urged all potential rescuers to immediately start CPR unless a valid DNR order was in place or there were obvious clinical signs of irreversible death present (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) or initiating CPR could cause injury or peril to the rescuer. This deficiency represents non-compliance investigated under Complaint Number OH00154334.