**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a closed medical record, staff interview, policy review, Emergency Medical Services (EMS) run sheet, and review of staff statements, the facility failed to immediately start and continue Cardio-Pulmonary Resuscitation (CPR) until EMS were on scene for one resident (Resident #42) who was identified as a Full Code status and was found unresponsive without vital signs. This resulted in serious life-threatening harm and/or death when Resident #42 did not receive immediate and continuous CPR prior to EMS services arriving at the facility. This affected one (Resident #42) of three residents reviewed for code response. The facility identified 24 residents residing in the facility designated with Full Code status. The facility census was 40. On 05/07/25 at 2:30 P.M., the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 05/04/25 at 7:45 A.M. when Resident #42 was found without vital signs Registered Nurse (RN) #164 failed to initiate CPR immediately and stopped CPR prior to the arrival of EMS. Resident #42 expired at the hospital. The Immediate Jeopardy was removed on 05/05/24, when the facility implemented the following corrective actions: • On 05/04/25 at approximately 7:45 A.M., Resident #42 was found without vital signs. • On 05/04/25, the DON completed education on the CPR policy for all licensed nursing staff. • On 05/04/25, the licensed nurse (RN #164) who did not perform continuous CPR on the full code status resident (#42) was removed from the facility and the agency notified of the situation and investigation. • On 05/04/25, the Administrator and DON reviewed the policies and procedures related to code status. There was no revision to the policy made. • On 05/04/25, a Root Cause Analysis was performed using a fishbone diagram for the incident. This was completed by the Regional Director of Operation (RDO) #700, Regional Director of Clinical Operation (RDCO) #200, and the DON. • On 05/04/25, disciplinary actions were taken by the facility on the licensed nurse (RN #164) who did not initiate continuous CPR on a full code resident by notifying the board of nursing of the situation through filing a complaint and notifying the staff agency of the situation and marking the nurse as a do not return (DNR) on the facility profile. • On 05/04/25, additional training by the DON or designee was completed on the facility's policy and procedure for initiating CPR. • On 05/04/25, the DON or designee audited all residents advanced directives to the physician's orders and care plan for accuracy and listing in Electronic Medical Records (EMR). Findings are to be reviewed at the monthly Quality Assessment and Assurance (QAA) committee meeting. • On 05/04/25, the DON or designee performed a Code Blue drill with licensed practical nursing staff. Code Blue drills will continue to be completed three times per week for a period of three weeks including off shifts. Findings will be reviewed at the monthly QAA meetings. • On 05/04/25, the DON or designee audited all licensed staff files to verify all licensed staff have an active CPR certification. • On 05/04/25, the crash cart was audited to ensure all items were stocked and functional. Audits will continue for four weeks three times per week. • On 05/04/25, the facility notified the staffing agency of the CPR policy and has it uploaded as a read and sign prior to any staff picking up a shift at the facility through the agency. • On 05/04/25, an ad hoc Quality Assurance Performance and Improvement (QAPI) meeting was conducted to review the plan of correction and abatement including education and audits. Although the Immediate Jeopardy was removed on 05/05/25, 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 action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #42 revealed an admission date of 03/20/25. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, bipolar disorder and acute respiratory failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was independently ambulatory. Review of the physician's orders revealed the resident was a Full Code status indicating all resuscitative measures were to be done if she were to go into cardiac arrest. Review of the plan of care dated 03/27/25 revealed the resident chooses to be a full code. The goal is for CPR to be initiated in any event of arrest. Life sustaining measures will be implemented as needed to honor the resident's wishes. The interventions included the facility will implement CPR and life sustaining measures and the resident's advanced directives will be honored. Review of the nursing progress note dated 05/04/25 at 9:26 A.M. revealed at 8:00 A.M., upon the aide doing rounds, she found Resident #42 blue and unresponsive. Immediately the staff and this nurse, RN #164, ran to check the status of the resident. The resident had no pulse, and staff immediately began 30 compressions per 2 breaths continuously for 20 minutes. The resident remained unresponsive with no pulse. EMS arrived shortly after and began compressions. The DON was notified, and staff also made several attempts to contact the family. Review of Fire Department #1's EMS run report revealed they received the call on 05/04/25 at 8:05 A.M. and arrived at the facility at 8:11 A.M. The patient narrative of the incident was dispatched to location for a [AGE] year-old male, CPR in progress. Arrived on location to find patient on the floor, apneic, and pulseless. No CPR was being done upon arrival. EMS crew began CPR on this patient. Facility aides came into the room and were asked who initially started CPR. They advised the aides had begun CPR, followed by the nurse in charge of the patient's care. The nurse completed one cycle of CPR and made the statement, I am going to call this, and we are going to stop CPR. CPR was not being done on this patient for approximately five minutes prior to EMS arrival on scene. CPR was completed for two cycles and then placed on the LUCAS (automatic chest compression system) device for continuous CPR. Patient was lifted from the ground onto the cot and transported emergently to the hospital. Interview on 05/07/25 at 9:30 A.M. with Certified Nursing Assistant (CNA) #155 revealed the CNA worked on 05/04/25 from 6:00 A.M. to 6:00 P.M. The roommate of Resident #42 came out of the room and stated the resident is not eating and needed CNA #155 to go in and get him up to eat. Upon arrival to the room, the resident was unresponsive and lying on the right side. CNA #155 touched the resident's arm and face to get him to respond. The resident felt warm, so he was turned over onto his back and felt for a pulse. The resident was a bluish color and did not seem to be breathing. CNA #155 ran out of the room and told the agency nurse and other aides she needed help. The aides and nurse went to the room and got the other agency nurse. The nurse, RN #164, went to get the code status of the resident and Licensed Practical Nurse (LPN) #163 brought the crash cart. CNA#161 and CNA#155 lowered the resident to the floor because they did not have a back board on the crash cart. CNA #161 started compressions after knowing the resident was a full code status (unknown how long it was before CPR was initiated) and the agency nurse was doing breaths with a paper towel with a hole in it to cover the mouth due not having a mouthpiece for the Ambu bag. CNA#161 asked RN #164 to take over CPR and she did one round of compressions and stated, There is no pulse, stop CPR. LPN #163 stated she is just an LPN and RN #164 had authority over her. CNA #161 told RN #164, You cannot call a code you are not a doctor. RN #164 told her not to tell her how to do her job. It was about five to seven minutes before the EMS got on scene, and they were livid to find out that staff had stopped CPR. The EMS started CPR immediately upon arrival. Interview on 05/07/25 at 10:06 A.M. with RN #164 revealed she was notified around 7:30 A.M. to 8:00 A.M. Resident #42 was not responsive and went to the room. The resident was cyanotic and had no pulse. RN #164 left the room to check code status and found out the resident was a full code and yelled this down the hall to the nurse aides in the room. CNA #161 and LPN #163 took the crash cart to the room. The oxygen tank on the cart was empty and staff were unable to find any oxygen. A call was made to the DON and 911. RN #164 went to the room and took over CPR compressions. Then after one round, the resident did not have a pulse, was cyanotic and limp. Staff all just stopped doing the CPR, due to being in shock. RN #164 denied telling anyone to stop CPR. The facility made RN #164 write out a report and RN #164 had to leave the job around 11:19 A.M. When asked what they did wrong, the DON said, CPR should have continued until EMS arrived and not stopped. RN #164 agreed they should not have stopped CPR. Interview on 05/07/25 at 10:16 A.M. with CNA #161 revealed CNA #161 was in the hallway when CNA #162 was coming down the hallway saying something was wrong and Resident #42 was not breathing. CNA #161went to Resident #42's room at 7:50 A.M. and RN #164 came into the room and just looked at him and walked away to get the code status. LPN #163 brought down the crash cart and there was not a backboard on it, so staff placed the resident on the floor. At 8:00 A.M., code status was confirmed as full code and staff started CPR. The crash cart had an empty oxygen tank and the Ambu bag did not have a face mask, and no other face mask was found. LPN #163 had to use a paper towel with a hole in it to give breaths. RN #164 came back to the room and was asked to take over CPR. RN #164 was doing compressions as CNA #161went into the hallway to look for EMS. CNA #161 heard RN #164 say, I'm stopping compressions, he is already gone. CNA #162 said, You are not supposed to stop CPR. RN #164 said, Do not tell me how to do my job. When EMS showed up about five to seven minutes later, they asked, What happened, why was CPR stopped? When the DON showed up and had all the staff write up statements, the DON was notified of the crash cart being empty of essential items, and by the time staff left for the day, the crash cart was full of those items. Interview on 05/07/25 at 2:45 P.M. with the Administrator and DON both confirmed Resident #42 was a full code and RN #164 called the code due to the resident having passed away. The Administrator and DON verified RN #164 should not have stopped the CPR. The DON removed RN #164 from the building and placed her on a DNR (do not return) with the agency. The DON, the Administrator, and supervisory staff immediately began in-servicing the nurses on code status of residents as well as beginning an audit of all charts for code status. All of the nurses had been in-serviced regarding code status. The agency was updated on DNR policy and all nurses who picked up a shift will sign before working at the facility. Interview on 05/07/25 at 3:55 P.M. with CNA#162 revealed the food trays came to the hall and Resident #42's tray was delivered to his room. At that time, around 7:30 A.M., Resident #42 was still lying in bed, and the tray was set on the bedside tray table beside the bed. A little bit later (before 8:00 A.M.), CNA#155 yelled she needed help and CNA #162 ran down the hall to Resident #42's room. There was a bruise on the left side of the resident's face and CNA #155 said something was wrong. They both tried to wake up Resident #42 and he did not respond. The resident's pulse was taken and could not be found. CNA #155 stayed in the room as CNA #162 ran to the nurse, RN#164. The nurse was told the resident does not have a pulse and was not breathing. The nurse was just standing there and stated, I do not know the code status. CNA #161 had gone down to the room waiting for a code status, which took around five to seven minutes. She went to the locked hall and got the nurse who grabbed the crash cart and ran to the room while waiting for the code status, but no one was doing CPR. The nurse still did not have the code status and went down to show where it was on the EMR, and she yelled at the staff the resident was a full code. CNA#162 went to the room, and CNA#161 started CPR and LPN #163 looked for a face mask, not present in crash cart and ended up using a paper towel for giving breaths. RN #164 came to the room and watched them doing CPR, when CNA #161 asked to be switched out. RN #164 took over compressions and completed one round, then stopped. RN #164 told all of the staff to stop, and she was calling the code. CNA# 162 said, Once CPR is started, it should not be stopped until the squad gets here. RN #164 stated, He does not have a pulse; he is gone and do not continue CPR. RN #164 also stated, I am a RN and do not tell me what my job is. RN #164 was threatening all staff with write ups if they touched Resident #42 to do any more CPR. He was making gurgling sounds and CNA #162 wanted to continue CPR and didn't because she had no authority. The squad got there after about five to seven minutes and was upset that no one was doing CPR. It was explained RN #164 called the code and she was at the medication cart on the phone. The EMS wanted to know the name of the nurse and stated she cannot call a code and stop CPR. Review of the 911 call from Fire Chief #2, revealed the call came in on 05/04/25 at 8:06 A.M. for Resident #42 who was a full code. When asked are you doing CPR? RN #164 replied, Yes we are. When asked how long have you been doing CPR? RN #164 replied, For about three minutes. Review of the written statement from RN #164 revealed on 05/04/25 she arrived at the facility and shortly after getting report, around 8:00 A.M. the aide informed her that Resident #42 was not responding. Upon arrival to the room, the resident had no pulse, face blue and was not responding. Staff did CPR for 20 minutes. The ambulance was called and were notified. The ambulance arrived five minutes before CPR was stopped. Review of CNA #161's statement given on 05/04/25 revealed CNA#155 came running up the front hall and said she thinks something is wrong with a resident. CNAs #161 and #155 went down to Resident #42's room. The resident was on his right side and his face was purple. Then RN #164 came into the room and just looked at the resident. CNA #161 asked for the resident's code status and a crash cart. It took RN #164 seven to 10 minutes to get the code status. CNA #161 and #155 placed Resident #42 on the floor and started the code. LPN #163 came into the room and was looking through the crash cart looking for stuff. The oxygen tanks were empty. LPN #163 was doing the breaths and CNA #161 was doing compressions, which was started at 8:00 A.M. RN #164 came back to the room and was asked to do the compressions. RN #164 started doing compression and CNA #161 was leaving the room to check for the EMS. CNA #161 heard RN #164 stop the code and say he is already gone. Once the EMS showed up, CNA #161 went back to the unit. Review of the statement given by CNA #162 around 8:00 A.M., revealed CNA#155 came to get help because she found Resident #42 not breathing. Resident #42 was lying on his right side, and he had a bruise on the left side of his face. CNAs #155 and #162 immediately got the nurse. Upon getting the nurse, she was trying to find his code status (which took several minutes). CNAs #155 and #161 moved the resident off his bed to the floor. The nurse did not start compressions, CNA#161 started the CPR. CNA#162 went to get the other nurse, LPN #163, who grabbed the crash cart and proceeded to the room. When entering the room, CNA #161 was doing compressions. RN #164 stated she was calling the code. CNA #162 stated, You cannot cancel the code. CNA#162 went to get all the residents away from the door of his room. The squad arrived and wanted to know why CPR was stopped, and CNA #155 told them RN #164 had called the code. The EMS stated she was not allowed to do that, and they started life saving measures again immediately. The EMS stated they needed to report the nurse and wanted to know her name. Review of the statement on 05/04/25 from CNA#155 revealed at approximately 8:00 A.M., a resident came to her and told her his roommate (Resident #42) was not eating and requested that CNA #155 wake him up. When CNA #155 entered the room, Resident #42 was lying in his bed completely covered up with a blanket. The resident was on his right side and the left side of his face was bruised. CNA #155 called his name, shook his arm, tapped his cheek and got no response. CNA #155 ran down the hall and yelled for help. Two aides (CNA #161 and CNA #162) and the two nurses (RN #164 and LPN #163) came to help. CNAs #161 and #155 moved the resident to the floor and CNA #161 started CPR. LPN #163 came in and started doing breaths. RN #164 came to the room with the crash cart. CNA #161 requested for RN #164 to take over compressions. RN #164 did one round of compressions while LPN #163 was doing breaths. RN #164 then stated she was, Calling the code, told staff to stop CPR. From the time CPR was stopped until the EMS arrived was about five minutes. The EMS questioned why CPR was stopped and CNA #155 explained that RN #164 had, Called the code and told staff to stop. RN #164 was the highest authority in the building at the time. The EMS immediately started life saving measures again. The EMS stated that they were reporting RN #164 for stopping CPR. Review of the statement on 05/04/25 from LPN #163 revealed at 8:00 A.M., the nurse was doing morning medication pass when an aide called the nurse to run down to Resident #42's room. While running to the room, the resident was on the bed, the resident's face was purple, and he was unresponsive. While waiting for RN #164 to get the code status, LPN #163 ran to get the crash cart. After six minutes, RN#164 told staff Resident #42 was a full code. CNA #161 started doing 30 compressions and LPN #163 gave two breaths. LPN #163 heard the bones crack and while giving breaths, she heard gurgling sounds. The crash cart was not properly stocked, no backboard, and the oxygen tank was empty. While doing CPR for twenty minutes, RN #164 told CNA #161 that she is doing compressions now. RN #164 only did one set of compressions and after LPN #163 gave two breaths, RN#164 stopped the code and said, I'm calling it, he is gone. RN #164 stayed in the room and LPN #163 left the room because she was upset with what happened and waited for EMS to arrive. Review of the facility's policy, Cardiopulmonary Resuscitation (CPR), dated 04/28/25 revealed that it is the policy of the facility to adhere to residents' rights to formulate advanced directives. In accordance with these rights, this facility will implement guidelines regarding CPR. This deficiency represents non-compliance investigated under Master Complaint Number OH00165420 and Complaint Numbers OH00165380 and OH00165034.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a closed medical record, review of hospital documentation, review of an emergency medical services (EMS) run detail report, review of a facsimile (fax) document, staff interviews, and review of facility policy, the facility failed to ensure a resident (#30) was provided appropriate and timely treatment, care, and services when the resident was assessed with changes in condition. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when Resident #30 was ordered supplemental oxygen and a non-invasive ventilator (NIV) for use to aid the resident's respiratory status. Resident #30 was noted to refuse the NIV without notification to the physician and subsequently was assessed with low blood pressure and a low oxygen saturation rate on [DATE] which were not timely or appropriately reassessed, reported to the physician, or rechecked prior to providing medications to the resident. The lack of timely and appropriate care, services, and notification to the physician contributed to Resident #30's untimely death when she was found in her room with blue lips, removing her shirt and supplemental oxygen, was unable to answer questions, and her eyes were rolled in the back of her head. Resident #30 became unresponsive and absent of vital signs and was sent to the hospital where the resident was placed on a ventilator in the intensive care unit (ICU) and subsequently died. This affected one (#30) of three residents reviewed for appropriate care and services. The facility census was 30. On [DATE] at 3:19 P.M., the facility Administrator and Interim Director of Nursing (IDON) #600 were notified Immediate Jeopardy began on [DATE] at 6:42 A.M. when staff failed to provide Resident #30 with appropriate and timely treatment, care, and services after being assessed with a change in condition. Resident #30 was assessed as hypotensive (low blood pressure) on [DATE] at 6:42 A.M. and had low oxygen saturation levels at 2:42 P.M. with no recheck of the resident's blood pressure, no follow up assessments completed, no notification to the physician regarding the low oxygen saturation levels was made, and no recheck of the oxygen saturation level or respiratory assessment was completed. Resident #30 was then given antianxiety and narcotic pain medications at 4:15 P.M. and subsequently was found in her room with blue lips, removing her shirt and supplemental oxygen, was unable to answer questions, and her eyes were rolled in the back of her head. Resident #30 became unresponsive and absent of vital signs which required the facility staff to initiate cardiopulmonary resuscitation (CPR). Resident #30 was sent to the hospital via EMS where the resident was placed on a ventilator in the ICU and subsequently died on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 4:00 P.M., an interdisciplinary team (IDT) Quality Assessment and Assurance (QAA) meeting was held to discuss and develop a plan with Medical Director #800. The plan was reviewed through discussion with the Administrator, Regional Director of Operations (RDO) #700, IDON #600, and the [NAME] President Director of Clinical Services (VPDCS) #707. • On [DATE] at 4:00 P.M., MD #800 was notified of the Immediate Jeopardy and review of the facility change in condition policy and plan for corrective action was reviewed with no changes made. • On [DATE] at 4:00 P.M., the change in condition policy was reviewed by the Administrator and IDON #600 with no changes made. • On [DATE] at 4:00 P.M., IDON #600 and Assistant Director of Nursing (ADON) #500 provided education to all Licensed Practical Nurses (LPNs) and Registered Nurses (RNs), including managers, on the facility change in condition policy and staff response to a change in condition. All nurses were educated by 9:50 P.M. with a plan for no nurses on leave and no agency nurses would be able to work without receiving the education. • On [DATE] at 4:30 P.M., all resident medical records were reviewed by IDON #600 and ADON #500 to review vital signs, oxygen saturation, and the resident's physical condition. The focus of the medical review reviews was to determine if the resident was within their normal baseline and if not, notification to the physician would be made. • On [DATE] at 7:00 P.M., all resident medical records were reviewed by IDON #600 and ADON #500 to review for change in condition. All identified changes in resident condition were notified to the physician. • On [DATE], an audit tool was implemented to monitor resident charts relating to any change in condition, adverse effects, and specifically, assessments for changes in condition as it related to change in condition notification. IDON #600 and/or ADON #500 will review documentation of at least 20 percent (%) of the total resident census utilizing the audit tool to ensure notification of change was made and proper care and services were implemented. The audits will continue daily for two weeks, then three times a week for the third week, and then twice a week for the fourth week to ensure compliance. The audit tools will be presented in weekly QAA committee meetings for four weeks to determine the need to continue the plan, make any changes to the plan, or stop the audits if compliance has been achieved. • On [DATE], two (#20 and #25) additional resident medical records were reviewed for appropriate care and services with a change in condition with no concerns identified. • On [DATE], between 9:00 A.M. and 4:00 P.M., LPN #203, LPN #206, ADON #500, and IDON #600, verified they were educated on the facility's polices related to treatment of a change in condition, physician notification of a change in condition, and to document all assessments, including follow up assessments, of all abnormal vital signs. All staff members interviewed were knowledgeable about the education content and felt confident the information could be applied during their work tasks. 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 action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #30 revealed an admission date of [DATE]. Diagnoses included bipolar disorder, respiratory failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus, fatigue, chronic pain syndrome, dependence on respirator, cocaine abuse, schizoaffective disorder, and non-compliance with medication regimen. The resident was discharged to the hospital on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #30 from [DATE] revealed the resident was assessed with modified independence in regard to decision-making. Resident #30 was assessed to utilize supplemental oxygen or NIV with no refusal of care assessed during the review period. Review of Resident #30's care plan for potential for alteration in respiratory function related to COPD, pneumonia, and sleep apnea, dated [DATE] and reviewed [DATE], revealed interventions which included to administer medications as ordered, administer supplemental oxygen and may use a portable oxygen tank, notify the physician of changes in respiratory status, and observe for signs or symptoms of dyspnea (shortness in breath). Review of Resident #30's care plan for chronic pain, dated [DATE] and reviewed [DATE], revealed interventions which included to administer analgesics per order, anticipate need for pain relief and respond immediately to complaints of pain, evaluate effectiveness of pain interventions, and identify and record side effects and impact on function. Review of the physician orders for Resident #30 revealed an order dated [DATE] for the narcotic pain medications Tramadol 50 milligrams (mg) to give two tablets by mouth four times a day and an ordered Percocet 5-325 mg to give one tablet by mouth four times a day for pain on [DATE]. Resident #30 was ordered the antianxiety medication Lorazepam one (1) mg to give one tablet by mouth once every 24 hours as needed on [DATE]. Resident #30 was ordered the blood pressure medication Metoprolol 50 mg to give one tablet by mouth daily with instructions to hold for systolic blood pressure less than 110 millimeters of mercury (mmHg) or heart rate less than 60 beats per minute on [DATE]. Resident #30 was ordered the antianxiety medication Clonazepam 1 mg by mouth three times daily. Resident #30 was ordered the combination drug for treatment of COPD Ipratropium 0.5 mg - albuterol three (3) mg (2.5 mg base) per milliliter (ml) to inhale 3 mls orally every four hours as needed for shortness of breath on [DATE]. Further review of Resident #30's physician orders revealed an order dated [DATE] that Resident #30 may use a portable oxygen concentrator with activity at two (2) liters via nasal cannula to maintain saturation greater than 90% every shift related to COPD. Resident #30 also had an order dated [DATE] for nursing to notify the physician if the resident's systolic blood pressure was less than 100 mmHg or greater than 175 mmHg, the diastolic blood pressure was less than 60 mmHg or greater than 100 mmHg, and heart rate was less than 50 beats per minute every day shift related to hypertension and every night shift for NIV with use completed nightly. The order contained specific settings for the NIV for nighttime use and as needed for naps and could be titrated for the resident's comfort every night. If abnormalities are noted, staff are to notify the physician and document notifications and abnormalities. Review of Resident #30's vital signs between [DATE] and [DATE] revealed the resident's vital signs were within normal limits except on [DATE] when the residents blood pressure was 95/65 mmHg. Review of the vital signs for Resident #30 revealed on [DATE] at 6:42 A.M. the resident had a blood pressure of 82/71 mmHg with a heart rate of 55 beats per minute. Further review of Resident #30's vital signs revealed Resident #30 had no other documented blood pressure obtained on [DATE]. Further review of Resident #30's vital signs record between [DATE] and [DATE] revealed the resident's oxygen saturation rates were obtained as ordered and were within normal limits except on [DATE] at 2:42 P.M. which revealed an 80% oxygen saturation rate with no further documentation of oxygen saturation rates obtained on [DATE]. It was also noted Resident #30's oxygen saturation rates obtained on [DATE], [DATE], and [DATE] were the only entries that indicated Resident #30 utilized the NIV at night as ordered. Review of Resident #30's nursing progress notes from [DATE] to [DATE] revealed multiple entries related to the resident not using her NIV as ordered and the nurses provided education to Resident #30. There was no documentation in the progress notes of the physician or nurse practitioner being notified of Resident #30 not wearing the NIV. Further review of the progress notes revealed on [DATE], Resident #30 was educated by a previous director of nursing that serious bodily injury, including death, was possible if poisonous gases reached a level in the resident's body at night if she did not wear her oxygen as ordered. Review of a nurse practitioner progress note dated [DATE] revealed Resident #30 was non-compliant with wearing oxygen, following a fluid restriction, and wearing compression stockings. The nurse practitioner documented the resident was compliant with wearing NIV at bedtime due to resident's chronic respiratory condition to reduce risk if resident developing significant adverse medical complications and frequent hospitalizations. Review of nursing progress notes between [DATE] and [DATE] revealed no significant issues with Resident #30's blood pressure or oxygen saturation rates, and no identification of any changes in condition. Review of a fax document sent to Medical Director #800 on [DATE] at 6:47 A.M. revealed LPN #207 sent a notification that Resident #30 had a blood pressure of 82/71 mmHg and a heart rate of 55 beats per minute. LPN #207 documented Resident #30 had her blood pressure medication held. Further review of a return fax document from Medical Director #800 revealed no instructions to the nurse for continued assessment, treatment, or care of Resident #30 following the low blood pressure reading. The only documentation from Medical Director #800 on the returned fax document was an illegible mark on the bottom right corner of the document. Review of Resident #30's [DATE] medication administration record (MAR) revealed on [DATE] the resident received an as needed breathing treatment of Ipratropium albuterol solution 3 mls inhaled for shortness of breath at 1:06 P.M. at which time the resident's oxygen saturation rate was 97%. At 2:07 P.M., Resident #30 received as needed Lorazepam for anxiety. Further review of the [DATE] MAR revealed Resident #30 received scheduled Tramadol 50 mg and Clonazepam 1 mg by mouth both at 3:00 P.M. as ordered. Resident #30 was also administered both Percocet 5-325 mg and Clonazepam 1 mg at 4:15 P.M. A review of nursing progress notes on [DATE] revealed a note entered at 1:06 P.M. which revealed Resident #30 received a breathing treatment due to the resident stating she could not breathe. Review of a progress note entered at 9:04 P.M. revealed Resident #30 was given Clonazepam 1 mg and Percocet 5-325 mg at 4:15 P.M. on [DATE]. State Tested Nurse Aide (STNA) #124 entered the resident's room to answer the resident's call light. STNA#124 entered the room to find Resident #30 removing her shirt and oxygen tubing, and STNA #124 noticed Resident #30's lips were blue. STNA #124 asked Resident #30 what she needed but when the resident tried to respond, she was not able to talk and continued to remove her shirt and oxygen tubing. LPN #208 went to assess the situation and the nurse discovered Resident #30's eyes were rolled back in her head. Resident #30 was moved to the floor and staff began CPR. EMS were called while staff continued CPR until EMS arrival. Resident #30 was sent to a local hospital and at last report was on a ventilator and moved to the ICU. Further review of progress notes from [DATE] revealed no documented evidence of staff reassessing the resident's respiratory status, oxygen saturation levels, or notification to the physician regarding the resident's change in condition until Resident #30 left the facility via EMS. Review of an EMS run detail report dated [DATE] at 4:26 P.M. revealed dispatch was initiated for an unresponsive but breathing female (Resident #30). Upon response, dispatch was advised CPR was being initiated by nurses. EMS arrived on scene to find Resident #30 supine on the floor with CPR in progress. Resident #30 was unresponsive, apneic (not breathing), and had no pulse upon EMS arrival at the facility. Resident #30's skin was pale, dry, and cool to the touch. EMS continued CPR while the resident was transported to the hospital; however, the resident remained in asystole (no heart activity) throughout the transport. Resident #30's nurse advised that she came to check on the resident and noticed she was unresponsive and barely breathing. The nurse checked for a pulse, but no pulse was found. Review of hospital documentation revealed Resident #30 was examined on [DATE] with a chief complaint of pulseless electrical activity (PEA). Per the nursing facility, Resident #30 stated she was not feeling well, was given three different medications, then suddenly collapsed without a pulse. Resident #30 was transported to the hospital via EMS. A computed tomography scan of the resident's chest revealed there was not a pulmonary embolism but identified severe pneumonia bilaterally with infectious agents of extended-spectrum beta-lactamase (ESBL) and Methicillin-Resistant Staphylococcus Aureus (MRSA) which was highly suspicious for an aspiration event resulting in pneumonia, likely from the facility. Resident #30 was diagnosed were PEA, anoxic brain injury, sepsis with shock, acute chronic hypoxia hypercapnic respiratory failure with aspiration pneumonia, new onset of atrial flutter with rapid ventricular rate (RVR), acute kidney injury, renal failure, and subacute T6 mildly commuted fracture. Interview on [DATE] at 2:00 P.M. with ADON #500 revealed the residents, including Resident #30, who are supposed to wear their NIV at night are not compliant with using them. ADON #500 stated the facility staff educated the residents on the importance of using the devices but verified she had not notified the physician of the residents' non-compliance with the NIV. Interview on [DATE] at 10:11 A.M. with Medical Director #800 revealed he was not notified of Resident #30's low blood pressure or low oxygen level on [DATE]. MD #800 stated he did not receive any notifications about the resident until after she left the facility via EMS. MD #800 stated, after reviewing the events of [DATE], he would have probably had the nursing staff observe Resident #30. MD #800 stated he was not specifically notified of Resident #30's refusals to wear her NIV, but verified he knew the resident was non-compliant with her supplemental oxygen at times. MD #800 notified the surveyor that Resident #30 died on the morning of [DATE]. Interview on [DATE] at 11:44 A.M. with LPN #222 revealed she worked on [DATE] from 2:00 P.M. to 10:00 P.M. LPN #222 verified she received shift report from the nurse working the previous shift but did not receive information that Resident #30 had a low blood pressure. LPN #222 stated she was the staff member who found Resident #30 without her supplemental oxygen on and stated she put the oxygen back on the resident. LPN #222 stated Resident #30's oxygen saturation rate at that time was 80%, and verified she did not recheck the resident's oxygen levels after that. LPN #222 stated she just figured the resident's oxygen saturation rate would go up since she put the supplemental oxygen back on the resident. LPN #222 verified she would not have administered Resident #30 her narcotic pain medications and antianxiety medications on her shift if she had known the resident's blood pressure was so low earlier in the morning. LPN #222 explained the medications she gave Resident #30 would suppress her respiratory system. LPN #222 confirmed she gave Resident #30 Clonazepam 1 mg and Percocet 5-325 one tablet by mouth at 4:15 P.M. on [DATE] and Resident #30 took them without any issues. LPN #222 stated around 4:20 P.M., STNA #124 told her she was needed in Resident #30's room as she was found unresponsive. LPN #222 stated she and STNA #124 moved Resident #30 to the floor and initiated CPR until EMS arrived at the facility. Interview on [DATE] at 4:40 P.M. with LPN #224 revealed she faxed the doctor about Resident #30's low blood pressure on [DATE]. LPN #224 stated she had Resident #30 elevate her feet and stated she rechecked the resident's blood pressure but could not remember what the blood pressure was or if she documented it. LPN #224 stated she informed the oncoming nurse about Resident #30's low blood pressure because the physician had not faxed back yet. LPN #224 verified she did not update the physician about Resident #30's ongoing low blood pressure. Review of the facility policy titled, Change in Residents Condition, dated 08/23, revealed the facility shall notify the resident, his or her representative of changes in the residents medical or mental condition. The nurse supervisor or charge nurse will notify the residents attending physician or on call physician when there has been a change in the resident's condition.