**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, closed medical record review, resident, family, and staff interviews, review of the National Weather Service forecast, and review of the facility Elopement Policy and Procedure, the facility failed to provide adequate supervision and intervention to prevent Resident #33, who had a history of wandering, from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious harm, injury, or death when Resident #33 was seen (by camera footage) on 12/04/24 at 6:47 P.M. leaving the facility on foot with his rollator walker. The resident was missing from the facility for approximately one hour and 45 minutes without staff knowledge. The resident's whereabouts remained unknown until 12/05/24 at 12:07 A.M. when Resident #33's nephew found the resident approximately five miles from the facility in the garage of the home in the community where he had previously resided. On 12/04/24 temperatures were between 21 degrees and 37 degrees Fahrenheit with a severe winter weather warning in effect. Upon being found by his nephew, the resident was taken to the hospital for examination, admitted (to the hospital) and did not return to the facility. This affected one resident (#33) of six residents reviewed for elopement. The facility identified seven residents (#1, #9, #12, #20, #24, #27, and #32) who were at risk for elopement. The facility census was 34. On 12/18/24 at 4:37 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 12/04/24 at 6:47 P.M. when the facility failed to provide adequate supervision and intervention to prevent Resident #33 from eloping from the facility. Resident #33 exited the facility through the front door. At the time of the incident, a staff member reported hearing the door alarm sound but turned it off without investigation as the staff member assumed the alarm was activated by a person who had just delivered a food order. The Immediate Jeopardy was removed on 12/05/24 and deficiency corrected on 12/09/24 when the facility implemented the following corrective actions: • On 12/04/24 at 8:24 P.M. Resident #33 was noted to be missing by Licensed Practical Nurse (LPN) #237. A facility wide search of both the internal and external facility property and surrounding areas was initiated. The resident was located on 12/05/24 at 12:07 A.M. and did not return to the facility following the incident. • On 12/04/24 at 8:24 P.M. LPN #237 notified the Director of Nursing (DON) that Resident #33 was missing. The LPN then notified the police. The DON notified the Administrator and Resident #33's family. • On 12/04/24 at 8:30 P.M. the facility staff completed a head count and identified no other residents were missing. All other residents were accounted for in the facility. • On 12/04/24 at 9:45 P.M. alarms on all doors were validated by the Regional Director of Clinical Services (RDCS) #245 for proper function and sound including annunciation to the second- floor nursing unit. No annunciator panel was found on the third-floor nursing unit. • On 12/05/24 at 1:00 A.M. an Elopement Drill was conducted by the Administrator, the DON, and Assistant Director of Nursing (ADON) #240 and then conducted each shift for 72 hours by one of the following Leadership team members: the Administrator, the DON, LPN/ Minimum Data Set (MDS) #218, LPN/ Charge Nurse (CN) #237, or ADON #240 • On 12/05/24 at 9:30 A.M. an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review plan / progress with the Medical Director. The meeting was attended by the Medical Director via phone, the Administrator, DON, ADON #240, Dietary Director #229, Activity Director #226, RDCS #245, and Scheduler/Medical Records #205. • On 12/05/24 at 12:45 P.M. the Administrator conducted facility window checks to ensure all were secured with stop brackets to limit less than six-inch opening. No issues were identified. • On 12/05/24 at 1:00 P.M. RDCS in conjunction with the Administrator validated the function of the outside exits, front door, back door (employee entrance) extending inspection beyond what the security camera observations that were completed, to include the third floor East stairwell door, third floor [NAME] stairwell door, second floor East stairwell door, second floor [NAME] stairwell door, first floor [NAME] exit door, therapy exit Door (end of hallway across from employee entrance). Each door was checked for local alarm sound when activated and the sound of the alarm was readily audible via the annunciator panel on the second floor. All functioned appropriately. The first-floor East exit door in the stairwell does alarm locally but was not alarming nor was it listed on the annunciator panel on the second floor. The first-floor [NAME] exit door in the stairwell does alarm locally but was not alarming on the annunciator panel on the second floor, where it is listed. A contracted company was contacted to obtain quote for connecting these exit doors with the annunciator panel on the second floor or other intervention. A door monitor was initiated. • On 12/05/24 at 2:48 P.M. ADON #240 completed updated elopement observations for current residents, reviewed plan of care and updated as indicated for risk and interventions. • On 12/05/24 at 3:00 P.M. the Administrator and ADON #240 completed the audit and update of the Elopement binders to reflect residents that are currently identified as risk for elopement (#1, #12, #20, #24, #27, #32, #34). • On 12/05/24 the DON completed review of current residents Leave of Absence (LOA) orders, updated as indicated, reviewed plan of care and updated as indicated. • On 12/05/24 DON and ADON #240 completed updated smoking observations for the current residents who smoked (#2, #7, #8, #10, #17, #18, #27, #32, #35, and #36), reviewed each resident's plan of care and updated as indicated. In addition, the facility posted lists on nursing units identifying supervised or independent smokers. • On 12/05/24 at 4:40 P.M. the Administrator and DON completed staff education related to resident safety including elopement risk and interventions, and importance of alarm response and investigation. Staff who were not present at the facility were educated via phone. Newly hired staff would receive education as part of the orientation process. • On 12/05/24 the Administrator completed the education of the Admissions Director related to the review of hospital paperwork prior to admission to identify special needs/safety concerns and communicate special needs with facility team. • On 12/05/24 the Administrator and DON completed education of staff on what to do if a resident was stating they want to go home or leave the facility, or if they observe exit seeking behaviors. • On 12/05/24 The Administrator and DON completed educating staff on how to identify resident smoking status if they had a resident state they were going outside to smoke. • On 12/05/24 at 5:00 P.M. residents with a Brief Interview for Mental Status (BlMS) score 12 or above were educated that if they hear another resident making statements that they wanted to get out of the facility/[NAME] Manor they report to a staff member so that they could implement interventions for resident safety and determine if discharge planning was appropriate. The education was initiated by RDCS #245 and completed by LPN/Charge Nurse #207 43 and LPN/Charge Nurse #243 • On 12/05/24 the Administrator contacted the contracted provider (Alta Protection Services) requesting service for the rear door staff entrance and front door due to the identified sensitivity related to the winds setting off the door alarms when no human activity taking place at the doors. Additionally requested a quote for the instillation of an annunciator panel on the third-floor nursing unit. • Beginning 12/05/24 second floor staffing distribution, beginning night shift, would assign one team member to remain at the nursing station desk to be available to respond to door alarms. Nursing staff educated on this by the Director of Nursing and indication listed on the daily assignment sheet posting. • On 12/09/24 the Administrator purchased audible monitors to be placed in the stairwell by first floor east and first-floor west outside exits, as it was determined that when the hallway door was closed the alarm sounding by the outside exit in the stairwell cannot be heard midway down the hall where the door monitor was located. • Beginning 12/05/24 at 1:00 A.M. the Administrator, DON, or Designee would conduct an elopement drill on every shift for 72 hours beginning day shift, then weekly for four weeks, then monthly for two months. Results of the drills would be submitted to the QAPI Committee for further review and recommendations. • Beginning 12/05/24 Administrator, DON, or Designee would conduct elopement/ door alarm drills five times per week on various shifts for four weeks then monthly for two months for validation of appropriate staff response to triggered alarms and to ensure that staff are fluent with the alarm response process. Results of the drills would be submitted to the QAPI Committee for further review and recommendation. • Beginning 12/05/24 Admissions/ re-Admissions referral information would be reviewed by the Director of Nursing/Designee to ensure risks were identified and interventions implemented. The reviews would continue for four weeks then monthly for two months with the results submitted to the QAPI Committee for further review and recommendation. • Beginning 12/05/24 Administrator or Designee would audit scheduled smoking breaks two times per day, five times per week for four weeks then monthly for two months to ensure that residents assessed to smoke with supervision are being supervised during smoke breaks. The results of the audits would be submitted to the QAPI Committee for further review and recommendation. • Beginning 12/05/24 Administrator or Designee would interview three residents two times per week for four weeks then monthly for two months to determine if they have heard another resident making statements that they want to get out of the facility/[NAME] Manor and if it was reported to facility staff. The results of the interviews would be submitted to the QAPI Committee for further review and recommendation. • Beginning 12/05/24 Administrator or Designee would interview three staff members two times per week for four weeks then monthly for two months related to what they would do in response to door alarms, residents saying they are going smoking and if a resident makes a statement they want to get out of the facility/[NAME] Manor. The results of the interviews would be submitted to the QAPI committee for further review and recommendation. Findings Include: Review of the closed medical record for Resident #33 revealed an admission date of 12/02/24 with diagnosis including muscle weakness, other symbolic dysfunctions, encephalopathy, and abnormalities of gait and mobility. The resident was discharged on 12/05/24 and did not return to the facility. Review of a progress note dated 12/02/24 at 1:53 P.M. revealed Resident #33 arrived at the facility from the hospital with a past medical history of heart failure, hypertension and memory loss. The resident had his natural teeth, ambulated with a rollator and had a steady gait. Review of the physician's orders dated 12/02/24 revealed Resident #33 was not to go on leave of absence (LOA) without supervision. Review of the admission assessment dated [DATE] at 2:20 P.M. revealed Resident #33 was attentive, oriented, generally normal to person, place and time, with an intact memory. Review of the Functional Abilities assessment dated [DATE] at 4:43 P.M. revealed Resident #33 required supervision or touching assistance for sit to stand, transfers, and to walk 150 feet. Partial to moderate assistance was needed to go up or down 12 stairs. Review of the baseline care plan dated 12/02/24 revealed Resident #33 would be monitored to minimize risk of wandering and/or elopement and interventions put in place as needed. There were no additional interventions listed. Review of the Elopement assessment dated [DATE] at 9:43 AM revealed Resident #33 was not identified as an elopement risk. Review of the admission Minimum Data Set (MDS) 3.0 assessment revealed it had not been completed and was in progress. Review of a progress note dated 12/04/24 at 8:30 P.M. authored by Licensed Practical Nurse (LPN) #243 revealed LPN #243 went to obtain vital signs for the resident, he was noted to not be in his room or bathroom, staff looked on the unit and within the facility and it was determined that he was not in the facility. Staff searched the surrounding parking lot area. The Director of Nursing (DON) and Administrator were notified. Resident #33's niece was called and asked if they had taken the resident out, and notified the resident was not at the facility. The Cleveland Police were contacted and informed. The resident's physician was notified. Review of the facility LOA sign-out book revealed Resident #33 did not sign-out when he left the faciity on [DATE]. Review of the National Weather Service forecast at www.weather.gov revealed the weather in the Cleveland area on 12/04/24 included a high temperature of 37 degrees Fahrenheit (F) and low of 21 degrees F. Review of the Self-Reported Incident and related facility investigation, dated 12/04/24, revealed Resident #33 was admitted on [DATE] to a room on the third floor. Per the hospital paperwork he had a history of wandering which was not reflected in the initial elopement observation. Following dinner Resident #33 got on the elevator with a Certified Nursing Assistant (CNA) #217 and they had a normal conversation riding down the elevator. Resident #33 made a statement that he was going out to smoke. CNA #217 primarily worked on the second floor and had not met Resident #33 given he was only at the facility for two days and was unaware that he did not smoke. The CNA got off the elevator on the second floor and Resident #33 remained on the elevator which was going down to the first floor. When the night shift nurse went to obtain vital signs for Resident #33 at 8:24 P.M. it was determined he was not in the room. Facility staff immediately began to search, internally, externally on property by foot and in personal cars searching the surrounding area. Facility administration and regional staff were notified and responded to the facility for support. The Administrator pulled the security camera footage, and determined the resident exited the front door with his rollator at 6:47 P.M. wearing plaid flannel pajama pants, a zip up sweatshirt and a ball cap. He began walking down the street, sat on his rollator at the corner for approximately two minutes then continued walking down the street and out of camera view. Efforts to find the resident continued through the night until the resident was located by his nephew at the resident's own home where he previously resided, in the garage with the garage door closed 12:07 A.M. on 12/05/24. The family alleged that the resident was jumped while he was out indicating that he had a broken nose, all his teeth knocked out and his face all cut up. The recommendation to transport him to the emergency room (ER) for evaluation was made to the family by facility staff. The nephew drove back to the facility with the resident to pick up the resident's niece to go to the emergency room. When facility staff requested to see the resident, the family refused and made threats towards the staff making a statement 38 and hot which was interpreted as a reference to a gun. So, the facility staff was unable to determine if the resident had any injuries and/or the extent of any injuries. Resident #33's niece was given a copy of the face sheet and physician orders to take to the emergency room, and the Director of Nursing called report into the hospital emergency room (ER) related to the situation and family transporting to them. The following morning 12/05/24 at 7:30 A.M. the Director of Nursing called the hospital for a status update on the resident and was told that he was admitted with a diagnosis of dementia, x-rays were negative, there were no fractures identified, and a computed tomography (CT) scan was completed with no findings. The facility was unable to validate if any serious injury resulted, but the resident was not safe when he exited the facility due to the cold, windy and rainy weather on that day. Further review of the facility investigation revealed that based on review of the camera footage, there was a Door Dash delivery car visible on the camera footage, approximately 10 minutes prior to the resident exiting the facility. The Door Dash driver came up the elevator and delivered the food to a resident on the second floor, then left the facility. A staff member that was on the second floor at the time of the food delivery returned to the first floor approximately five to 10 minutes following the door dash driver. When they got to the first floor they heard the front entrance alarm sounding. The staff member reset the front door alarm but did not investigate the reason for it sounding. The facility substantiated that resident neglect did occur. Review of the witness statement dated 12/04/24 and authored by LPN #237 revealed she identified Resident #33 as missing around 7:30 P.M. to 7:45 P.M., initiated the search, called code, contacted the DON and called 911 emergency services. Review of the witness statement dated 12/05/24 and authored by CNA #217 revealed on 12/04/24 she got on the elevator on the third floor with Resident #33. She had a short conversation with him about going out to smoke a cigarette. The elevator opened on the second floor and the CNA got out. She did not remember hearing an alarm sound after that. Interview on 12/17/24 at 11:21 A.M. with the Administrator, DON and RDCS #245 revealed Resident #33 didn't have a designated power of attorney (POA) or guardian. There had not been an evaluation by a Nurse Practitioner (NP) or physician because Resident #33 was only at the facility for a little over 48 hours. The administrative staff revealed the resident's hospital admission record showed history of wandering but stated this was missed on the elopement assessment. Corrective action and education were done with admission Director, and the facility was currently auditing all admissions for any risk. The facility currently had a staff member assigned as a door monitor 24 hours a day because two exit doors were not connected to the enunciator panel. The facility believed Resident #33's ability to elope was partially caused when there was a food delivery to the second floor, and the delivery person was known to exit. Staff turned off the alarm without investigation assuming it had been the food delivery person. After reviewing the Self-Reported Incident (SRI) the Administrator, DON and RDCS #245 verified the elopement had occurred, they had substantiated the incident had occurred and had developed a plan to prevent it happening again. An interview on 12/17/24 at 11:39 A.M. with LPN/MDS #218 revealed she was on the second floor on 12/04/24 when a Door Dash delivery arrived. When she came back down, the (door) alarm was ringing. LPN #218 stated she knew Door Dash had just left so she turned off the alarm. The LPN/MDS nurse revealed if the release bar (on the door) was held it alarmed and after 15 seconds, it released. She stated a lot of delivery people didn't want to go back up to the second floor and look for someone to let them out. LPN/MDS #218's office was downstairs so some days it happened a lot. Currently the facility had a staff member serving as a door monitor. They monitored if a resident was trying to leave and helped visitors exit. Staff were now expected to investigate, go outside to do a quick check of the perimeter, and call upstairs for staff to do a headcount. An interview on 12/18/24 at 10:00 A.M. with Resident #33's niece revealed the family was unaware the resident had cognitive issues until 11/2024 when he was taken to the hospital after he was found wandering a long way from his house in the middle of the night. The family of Resident #33 decided he wasn't safe living alone, so they moved him into the facility on [DATE]. On 12/04/24 the resident's niece received a call from the facility at 8:34 P.M. asking if she had taken the resident out, as he was not at the facility. She stated she called her mom and brother and then went to the facility. She stated the family searched the facility along with the staff. Resident #33's nephew went out to search the area. There was a severe Winter weather warning going on for Cleveland. The niece watched the video surveillance with the administrator. Resident #33 exited the front door of the facility at 6:47 P.M. without a jacket or gloves. He walked across the street, sat down on his rollator for a couple minutes and then went on down the street and out of sight. A little after midnight the nephew found Resident #33 at his previous address in the garage. The resident's niece stated the resident had been assaulted, his teeth were knocked out and knuckles scraped. The niece stated her brother got Resident #33 in his car, came back to the facility to pick her up at the facility and they took him to the hospital ER. The resident's niece stated the physician said the resident's injuries were consistent with an assault. The niece stated the admission person was aware of her uncle's dementia and stated the facility where the resident had been admitted to was a locked facility, residents were to be monitored and if an alarm went off staff would check. Attempts to obtain the hospital records during the complaint investigation for Resident #33 related to this incident were unsuccessful. On 12/18/24 at 3:39 P.M. interview with LPN #243 revealed she was in the facility on 12/04/24, the day Resident #33 eloped but worked on the second floor. LPN #243 remembered the door alarm went off that evening but then stated it was silenced. After LPN #243 punched out and left the facility another employee called a little after 7:30 P.M. and told her they couldn't find Resident #33. She started driving around the area looking for the resident. Other staff were doing the same. Interview on 12/18/24 at 4:30 P.M. with CNA #217 revealed on 12/04/24 she was assisting staff on the third floor and got on the elevator to go back to her own assignment on the second floor. Resident #33 was already on the elevator when she got on. The CNA stated they (she and the resident) made small talk, and the resident mentioned he was going out to smoke. CNA #217 got off the elevator at the second floor and Resident #33 went down to first. It was the first time the CNA had met Resident #33. The CNA stated she wasn't even sure he was one of the facility residents or a visitor. Interview on 12/19/24 at 10:56 A.M. with LPN #237 revealed on 12/04/24 at around 7:35 P.M. the LPN went to obtain Resident #33's vital signs and then realized the resident was missing. She stated she checked all the rooms on the third floor and then called a code. All staff started looking around the facility for the resident. When he was not found in the building, she stated she called the DON and 911. Review of the facility Elopement Unauthorized Absence Policy dated 08/02/24 revealed the purpose of the policy was to identify a resident's risk for elopement, prevent a resident from exiting the facility without the knowledge of the staff and to delineate the reporting process if an elopement occurs. This deficiency represents non-compliance investigated under Control Number OH00160618.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of a facility self-reported incident (SRI), review of the facility Cardiopulmonary Resuscitation (CPR) policy and interviews, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) for Resident #37, who was found unresponsive, without a pulse/heartbeat and identified as a full code status. This resulted in Immediate Jeopardy that was actual harm on [DATE] when Resident #37 did not receive CPR, EMS were not contacted for medical services and the resident subsequently expired. This affected one resident (#37) of two residents reviewed for death in the facility. The facility census was 34 residents. On [DATE] at 10:07 P.M. the Administrator, Mobile Director of Nursing (DON)/Registered Nurse (RN) #152 and Regional Director of Clinical Services (RDCS) were notified that Immediate Jeopardy began on [DATE] at approximately 1:30 P.M. when Licensed Practical Nurse (LPN) #150 found Resident #37, who had advanced directives for a full code status, not breathing. Prior to the incident, LPN #150 last saw Resident #37 alive between 11:30 A.M. and 12:45 P.M. when she provided a wound treatment and fed the resident lunch. LPN #150 confirmed the absence of Resident #37's vital signs but failed to initiate CPR or call 911. LPN #150 indicated she did not think to check Resident #37's medical record to determine code status, initiate CPR or call 911 due to Resident #37 having passed away. The Immediate Jeopardy was removed and corrected on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 10:00 A.M., the facility Administrator, Regional [NAME] President of Operations, (RVPO), Regional Director Clinical Services (RDCS) and Clinical Quality Specialist (CQS) were made aware of CPR not being initiated at the time of the occurrence during a facility meeting. • On [DATE] at 10:15 A.M., LPN #150, the nurse on duty at the time of the occurrence, was removed from the unit. The facility completed an interview and obtained a statement from the LPN related to the situation. At 10:30 A.M. LPN #150 was suspended pending further investigation. • On [DATE] at 11:00 A.M., the facility obtained statements from the State Tested Nursing Assistants (STNAs) who were on duty at the time of the occurrence. • On [DATE] at 11:30 A.M., the Interim Director of Nursing (IDON) initiated immediate in-house education for all licensed nurses on the facility policies and procedures for identifying a change of condition, initiating CPR and crash cart validation. Those staff not on duty were contacted via telephonic means. This education was completed on [DATE] at 12:45 P.M. • On [DATE] at 12:00 P.M., all staff were in serviced by the Administrator and Mobile DON, on Abuse, Neglect and Misappropriation, monitoring and reporting, the overhead paging policy, the phone system, the use of walkie talkies for urgent situations. Staff not on duty were serviced by telephonic means. This was completed on [DATE] at 8:00 P.M. • On [DATE] the facility identified the phone system did not have overhead paging capability. The phone system was fixed on [DATE] at 1:30 P.M. • On [DATE] all current resident medical records were audited by the Social Service Designee (SSD) to ensure appropriate documentation of current code status and advance directive status. This was completed on [DATE] at 2:30 P.M. • On [DATE] at 2:30 P.M., the RDCS in-serviced the Administrator, IDON, Mobile Director of Nursing, Minimum Data Set (MDS) nurse, SSD and the Assistant Director of Nursing (ADON) on validation of code status at the time of expiration notification. • On [DATE] at 2:42 P.M. the facility administrator purchased six walkie talkies for nurses and managers to utilize to communicate to staff as needed. They arrived at the facility on [DATE] at 3:41 P.M. • On [DATE] at 3:30 P.M., the attending physician was notified Resident #37 had a full code status and CPR was not initiated. • On [DATE] at 3:40 P.M., the IDON and Administrator notified Resident #37's wife that the resident's full code status was not honored or initiated on [DATE]. • On [DATE], two crash carts were checked to ensure all supplies were available for CPR by the IDON and Mobile DON. There were several missing items that were replaced. A shift-to-shift sign off sheet for CPR cart validation was initiated on [DATE] at 4:00 P.M. • On [DATE] at 5:10 P.M., the Human Resource (HR) Director audited all licensed nursing staff files to ensure current CPR certification. • Beginning on [DATE] the facility implemented a plan for the Mobile DON or Charge Nurse to conduct a mock code blue drill every shift for three days, then once weekly for four weeks, and once monthly for two months. Mock drills were completed on [DATE] at 6:19 P.M., [DATE] at 9:35 P.M., [DATE] at 5:38 P.M., [DATE] at 9:20 P.M., [DATE] at 5:58 P.M., [DATE] at 9:45 P.M., [DATE]/ at 5:10 P.M. • On [DATE] at 7:40 P.M., the RDCS completed an audit of all in-house deaths from [DATE] to current date to ensure resident advance directives were followed. Audits would continue monthly for three months. • Beginning on [DATE] the facility implemented a plan for the Administrator/designee to conduct three resident interviews for neglect twice weekly for four weeks. Interviews were completed on [DATE], [DATE], [DATE]. • Interviews on [DATE] between 10:01 A.M. and 11:04 A.M. and on [DATE] at 4:09 P.M. with two Registered Nurses (RN), RN #136 and RN #138, and State Tested Nursing Assistants (STNAs) #108, #113, #118, #121, and #151, revealed no concerns related to advance directives and/or code status. Each staff member interviewed revealed they were trained on the facility's policy for advance directive, change of condition and CPR. Findings include: Review of the closed medical record for Resident #37 revealed an admission date of [DATE] with diagnoses including chronic viral hepatitis C, pressure ulcer of sacral region, acquired absence of left leg above the knee. The record indicated Resident #37 passed away on [DATE] at 1:30 P.M. The resident was in his room unresponsive and absent of vital signs. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment for Resident #37, dated [DATE], revealed the resident had intact cognition. The assessment indicated the resident did not have a condition or chronic disease that would result in a life expectancy of less than six months. Review of the plan of care for Resident #37 revealed the resident had advanced directives that indicated a Full Code. Interventions included involving the physician in advanced directives conversations and reviewing advanced directives with the resident/family. Review of a hospital discharge summary paper dated [DATE] revealed Resident #37 was a full code status and was discharged to a skilled facility with diagnosis of sepsis and an order for an antibiotic, Levofloxacin for three days. Review of the resident's re-admission physician orders, dated [DATE] revealed the resident did not have a physician order related to advance directives. Review of the admission progress note dated [DATE] at 5:41 P.M. revealed Resident #37 was re-admitted from the hospital with a full code status. Review of a note dated [DATE] at 2:17 P.M. revealed at 1:30 P.M. LPN #150 found Resident #37 unresponsive and absent of vital signs. The note indicated postmortem care was provided by STNAs. At 1:35 P.M. the Administrator, family and physician were notified Resident #37 expired. At 2:00 P.M. the family visited. At 2:15 P.M. the family notified the facility of the funeral home arrangements. Review of the nursing progress note revealed no evidence the resident exhibited dependent lividity, rigor mortis, decapitation, or transaction. Review of progress note dated [DATE] at 4:45 P.M. revealed the funeral home removed the resident's body. Review of a progress note dated [DATE] at 9:06 P.M. revealed Resident #37 expired and full code status was not followed. No CPR was initiated. Notification was made to the medical director, physician, and family that CPR was not initiated. Review of a facility self-reported incident (SRI) report, tracking number 239053 dated [DATE] at 2:06 P.M. revealed the facility reported an allegation of neglect involving Resident #37. The SRI noted based on the comprehensive investigation that was completed by the facility which included resident record review, hospital record review and staff interviews the allegation of neglect was verified when Resident #37 was identified without vital signs and designated full code directives which were not followed, and CPR was not initiated. Review of the SRI investigation revealed a statement provided by LPN #150 on [DATE] which revealed at approximately 12:45 P.M. she administered a treatment and assisted Resident #37 with lunch. At 1:30 P.M. Resident #37 was observed without vital signs. Two STNAs came into the room to perform postmortem care, LPN #150 notified the physician, family, Administrator, and IDON of Resident #37 death. LPN #37 arranged with the funeral home to pick up the resident's body. A follow up phone interview on [DATE] with LPN #150 by the RDCS revealed she did not check Resident #37's code status. LPN #150 had re-admitted the resident (from the hospital) three days prior and remembered he was a full code. LPN #150 told the RDCS she was rushed and forgot to follow protocol. Interview on [DATE] at 10:22 A.M., with STNA #118 revealed she provided care to Resident #37 on [DATE], the morning he passed. The STNA stated Resident #37 was at his normal baseline status. The STNA revealed later that day, LPN #150 asked her and STNA #121 to provide postmortem care for the resident. STNA #118 stated she had informed LPN #150 Resident #37 was a full code. LPN #150 responded to her that the resident had passed. Interview on [DATE] at 1:23 P.M., with LPN #150 revealed on [DATE] at approximately 11:30 A.M. she administered Resident #37's wound treatment and fed him some lunch. The LPN revealed Resident #37 was alert and smiling. At 1:30 P.M., LPN #150 stated she went back into Resident #37's room and found him unresponsive and without vital signs. LPN #150 did not initiate CPR; however, she did tell STNA #118 and #121 to provide postmortem care. LPN #150 provided notification to the physician, Administrator and family and she arranged for removal of the body. LPN #150 stated she panicked and did not think about full code status or initiating CPR. She stated Resident #37 had passed and his body was cool. LPN #150 stated she did remember re-admitting Resident #37 from the hospital and seeing the full code status on the discharge summary. LPN #150 stated she notified the IDON of the resident's death and was told to write a good nurse's note. The LPN revealed the IDON did not mention to check for the resident's code status. Interview on [DATE] at 3:36 P.M., with STNA #121 revealed she delivered Resident #37's lunch tray and he appeared to be sleeping. At approximately 1:30 P.M. LPN #150 informed her Resident #37 passed away and postmortem care needed to be provided. STNA #121 stated she assisted to provide postmortem care to Resident #37. Interview on [DATE] at 9:21 A.M., with Resident #37's physician, Physician #155 revealed he did not recall addressing any change in the resident's code status (following his re-admission to the facility on [DATE]). He verified LPN #150 had notified him Resident #37 had no pulse and was absent of breath sounds. Interview on [DATE] at 2:00 P.M., with the Mobile DON, revealed [DATE] was his first day of employment. The Mobile DON revealed in the morning meeting on this date, he reviewed Resident #37's full code status and identified CPR was not initiated. Interview on [DATE] at 5:00 P.M., with the Administrator revealed it was unfortunate LPN #150 did not follow Resident #37's advanced directives. The Administrator verbalized the measures the facility had taken following the incident to ensure they had a good system in place to prevent a similar reoccurrence. Interview on [DATE] at 9:26 A.M., with IDON #154 revealed LPN #150 had notified her of Resident #37 death on [DATE]. IDON #154 stated she did not ask about code status but assumed LPN #150 took the appropriate actions according to the resident's advanced directives. Interview on [DATE] at 8:28 A.M., with the medical director (MD), MD #156 revealed facility had very few resident deaths. He stated he was notified Resident #37 did not receive CPR and indicated he expected staff to follow each residents' code status. The MD stated he was involved in developing a corrective action plan for the facility following the incident. Review of the facility policy titled Cardiopulmonary Resuscitation (CPR), revised [DATE] revealed CPR would be provided to all residents who experience cardiopulmonary arrest unless one or more of the following is present. • A valid advance directive requesting withholding of CPR. • A properly executed ad witness Do Not Resuscitate (DNR) order. • Documented verbal wishes by the resident/surrogate decision maker indicating the desire to be DNR but physical order pending. • Dependent lividity, rigor mortis, decapitation, or transaction. This deficiency represents non-compliance investigated under Control Number OH00146486.