**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, staff interviews, and policy review, the facility failed to provide basic life support (BLS), including Cardiopulmonary Resuscitation (CPR) to Resident #61 per the residents advanced directive for a full code status, when the resident was found unresponsive and absent of vital signs. This resulted in Immediate Jeopardy and serious life-threatening harm and the subsequent of death of Resident #61 beginning on [DATE] when Certified Nursing Assistant (CNA) #135 alerted Registered Nurse (RN) #142 Resident #61was absent of vital signs. Instead of providing immediate care (i.e. CPR) RN #142 assessed the resident to be absent of vital signs and contacted Licensed Practical Nurse (LPN) #136 who was working another unit to verify the resident ' s death. RN #142 pronounced the resident ' s time of death of 4:50 P.M. RN #142 notified the physician without indicating CPR was not initiated, and Physician #187 gave orders to release the resident to the funeral home. Resident #61 ' s family was notified of the resident's death but not of the fact CPR was never initiated. This affected one resident (#61) of 11 residents reviewed for death in the facility.On [DATE] at 3:54 P.M. the Administrator, Regional Director of Clinical Services (RDCS), Regional Director of Operations (DO) and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 4:50 A.M. when staff failed to provide basic life saving measures/CPR to Resident #61. Upon entering the resident ' s room CNA #135 observed Resident #61 to be absent of vital signs and not breathing. CNA #135 alerted RN #142 who assessed Resident #61 and found the resident was absent of vital signs and asked LPN #136 who was working on another unit to come and verify time of the resident ' s death and absence of vital signs. RN #142 did not notify LPN #136 or CNA #135 Resident #61 was a full code not was CPR attempted/provided. RN #142 notified Physician #187 of time of death but did not notify Physician #187 that CPR was not initiated.The immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 8:15 A.M. the Director of Nursing (DON) notified the Medical Director of the incident involving Resident #61. On [DATE] at 11:00 A.M. the facility implemented a plan for the DON to perform CPR Mock Code Evaluations via hands on demonstration with verbal discussion on day shiftand night shift on [DATE], [DATE], [DATE]. Additional mock code scheduled for [DATE], [DATE] and [DATE]. The DON/ADON then would perform random mockcodes for one week to capture all facility staff nurses to evaluate effectiveness and ensure competency. Once the random mock codes for one week were conducted by or on[DATE] the facility DON will audit the Mock CPR codes comparing an all-facility nurse staff roster to confirm all staff nurses have participated in a Mock CPR drill. If anurse was on vacation or unable to attend the drills, additional Ad Hoc Mock CPR drills will be provided prior to their next shift. On [DATE] at 11:48 A.M., Human Resources Employee audited all 16 facility nurses (4 RNs, 12 LPNs) and 11 agency nurses (3 RNs and 8 LPNs) files to ensure a valid CPRcard was on file. For additional measure the facility had an American Heart Association (AHA) CPR class scheduled to be completed in house on [DATE]. The facility wantedto offer a hands-on CPR class to include return demonstration that adheres to the AHA guidelines for all in-house licensed personnel due to facility policy and procedureguidance promotes/notes the AHA guidelines. On [DATE] the DON audited the facilities two crash carts to ensure proper supplies and equipment were available. Crash cart audits would be monitored for completion five toseven days a week by DON/ADON for four weeks. On [DATE] the DON re-audited 60/60 in-house resident records for code status according to residents ' preference/physicians ' orders. The review included care plans,DNR forms, PCC demographic bar on every resident and compared the advanced directives to the physician order for accuracy. On [DATE] an Ad Hoc QAPI meeting was held with the IDT including medical director, DON, Infection Preventionist, Administrator, Activities, BOM, Maintenance Director,Housekeeping Supervisor, Admissions Director, and the Therapy Director. Topics discussed included the CPR policy titled Emergency Procedure CardiopulmonaryResuscitation and Basic Life Support. The DON and/or ADON would audit new admissions to verify the advanced directives were as preferred/ordered. On [DATE] at 6:10 P.M. the DON re-educated all 16 licensed staff nurses (4 RNs, 12 LPNs) and identified 11 frequent agency nurses (3 RNs and 8 LPNs) to educate.Education provided included the facility ' s CPR policy titled Emergency Procedure Cardiopulmonary Resuscitation and Basic Life Support and the procedure for initiatingCPR. Licensed nurses were not permitted to work a shift until education was completed. On [DATE] per facility CPR policy all licensed staff nurses in any given shift were identified as part of the CPR team per policy. Reminder postings were placed by the timeclock, in the break room, and at the nurses ' stations by the DON and RDCS after receiving approval from the Administrator. The facility implemented a plan for the DON to audit new admissions to compare the residents ' advanced directives to the physician orders for accuracy. This audit wouldcontinue for all new admissions for three months. Findings would be reviewed at the monthly QAPI Committee meeting. The above would be discussed at the next QuarterlyQuality Assurance meetings.Although the Immediate Jeopardy was removed on [DATE] the deficiency remains at a 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 #61 revealed an initial admission date of [DATE] with diagnoses including atrial fibrillation, acute pulmonary edema, atherosclerotic heart disease, hypertension, malignant neoplasm of the pharynx, sepsis, and pleural effusion. Resident #61 was discharged to the hospital on [DATE] then readmitted to the facility on [DATE] with readmission diagnoses of aspiration pneumonia and acute respiratory failure with hypoxia. The resident expired in the facility on [DATE].Resident #61 was listed as his own responsible party and his sister was listed as the emergency contact. Resident #61 ' s code status in the event of cardiopulmonary arrest was a full code indicating he wanted all life sustaining measures provided to him if his heart stopped and he would stop breathing.Review of Resident #61 ' s care plan initiated on [DATE] revealed the Resident/Responsible Party wished for the resident to be a Full Code for their Advanced Directives. Care plan goals indicated the resident ' s wishes would be honored. Interventions included the facility would adhere to desired code status, they were to inform the resident ' s physician if code status changed, and the facility would review code status quarterly or as needed.Review of Resident #61 ' s physician orders dated [DATE] revealed the resident was a full code and desired basic life saving measures including CPR.Review of Physician and Nurse Practitioner (NP) assessments in the medical record revealed on [DATE] NP #189 assessed Resident #61 and documented Resident #61 was a full code.Review of Resident #61 ' s Medicare five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had some cognitive impairment, was to have nothing by mouth, required substantial (staff) assistance for oral hygiene and upper body dressing, required partial to moderate (staff) assistance with bed mobility, and was dependent on staff for toileting hygiene,showers, lower body dressing, personal hygiene and transfers with the use of a mechanical lift when not in therapy.Review of Resident #61 ' s Medication Administration Record (MAR) date [DATE] revealed on [DATE] at 4:00 A.M. RN #142 documented the administration of Levothyroxine Sodium tablet 125 micrograms (mcg) via peg tube to Resident #61.Review of Resident #61 ' s progress notes dated [DATE] at 4:50 A.M. authored by RN #142 stated CNA called RN #142 into Resident #61 ' s room, upon entering the room resident appeared to be deceased . Upon assessment it was confirmed that the resident had passed away. Other nurse came to verify time of death, family, Dr. and DON were notified. Waiting on call back from family message was left. There were no other details in RN #142 ' s note on [DATE] regarding Resident #61 coughing up phlegm or giving him a cup to spit into (as noted in the statement obtained as part of the facility investigation).Review of the facility investigation provided by Regional Director of Clinical Operations (RDCO) revealed the following incident reports and witness statements:Review of the facility document titled #152 (other) dated [DATE], timed 8:30 A.M. and authored by the DON revealed an incident description stating at approximately 4:50 A.M. on [DATE] the CNA called the resident ' s nurse into residents ' room. Upon entering the room the nurse documented resident appeared to be deceased . Upon assessment it was confirmed the resident has passed away. Residents ' nurse called for another nurse to verify resident was absent of vital signs. Nurse charted time of death 4:50 A.M. Family and on-call doctor (Physician #187) notified. DON notified via text message. The above incident was noted to be unwitnessed.Review of the facility document titled Employee Memorandum, dated [DATE] and signed by the DON and RN #142 revealed RN #142 violated a code of conduct rule by failure to follow doctor ' s orders and conduct self in a professional and ethical manner. The date of the violation was [DATE]. The corrective action was listed as follow doctor ' s orders. No further details werelisted on the form.Review of a typed witness statement, dated [DATE] with the first and last name of RN #142 typed and without signature, revealed the following typed statement STNA notified this nurse at approximately 0450 to come to resident room. Upon entering the room I observed resident to have passed away. Vitals taken and there were no respirations or pulse. Resident was cold to the touch and pale, fingertips gray and bluish tent to lips and face cold and stiff. Rigor mortis was starting to take place. Resident appeared to have been deceased for some time. Nurse from the other unit came over to assess resident and confirmed time of death. Resident was last seen by this nurse at 0230. Resident was coughing and trying to bring up phylum (that had been present upon admission to the facility). This nurse elevated bed and gave resident a cup and he was able to expectorate in the cup. He stated he felt better and went to sleep.Review of a handwritten witness statement dated [DATE] authored by LPN #136 revealed LPN #136 was asked by RN #142 to confirm death of Resident #61 the morning of [DATE] at 4:45 A.M. with a CNA present in the room for assessment. Upon entering the room, the resident appeared cyanotic (blue) and cold to touch. No signs of life or respiratory effort. No palpable carotid pulse, heart or respiratory sounds for five minutes. Death confirmed at 5:00 A.M. and rigamortis was starting to set in.There was no witness statement from CNA #135 in the investigation.An interview on [DATE] at 10:40 A.M. with RN #142 revealed (on [DATE]) Resident #61 was last seen around 2:00 A.M. when CNA #135 came and got her due to the resident coughing up phlegm. In response, RN #142 went to check Resident #61 and gave him a cup to spit in and had him sitting up. RN #142 stated that it helped the cough, the resident was able to clear the phlegm, and the resident was laid back down. RN #142 stated around 4:40 A.M. to 4:45 A.M. CNA #135 came and got RN #142 due to the resident not breathing. Resident #61 was found to be absent of vital signs. RN #142 stated she had another nurse come in and verify absence of vital signs, and notified the physician, family and DON of the resident ' s death. RN #142 stated she did not discuss with the CNA or other nurse that Resident #61 was a full code, and stated she made the decision on her own not to do CPR because the resident was obviously dead. RN #142 also stated she did not tell the residents ' family nor the physician that CPR was not provided (as per the resident ' s advance directives/code status).An interview on [DATE] at 1:30 P.M. with Physician #187 revealed he was notified Resident #61 was deceased , but he was not informed CPR had not been provided to Resident #61. Physician #187 stated he had concerns as to why CPR was not initiated regardless of what condition the resident was found. Physician #187 stated his nurse practitioner notified him a few days later the resident was a full code, and he then spoke with the DON to find out why CPR was not initiated at time of death as it should have been.An interview on [DATE] at 3:13 P.M. with CNA #135 revealed she was assigned to Resident #61 for her shift which began on [DATE] through [DATE]. CNA #135 stated she had been checking on the resident every two hours and when she went to check him at 4:45 A.M. he appeared to be dead. CNA #135 stated Resident #61 was cold to touch but was not stiff, and she went to get RN #142. CNA #135 stated RN #142 went to get another nurse to confirm absence of vital signs and she was unaware of any conversation between the two nurses about Resident #61 ' s full code status. CNA #135 stated she completed postmortem care on Resident #61 and described his body as cold, not stiff, and rigor mortis (stiffening of the joints and muscles within two to six hours after death) had not set in when providing his postmortem care.A follow-up interview was conducted on [DATE] at 8:21 A.M. with RN #142 who stated and verified she administered Resident #61 Levothyroxine Sodium tablet via PEG tube on [DATE] at 4:00 A.M. The RN stated Resident #61 was alive at that time. When asked why she did not provide CPR on Resident #61, RN #142 stated take it easy. In my opinion he was dead andthere was no need for CPR.An interview on [DATE] at 10:30 A.M. with the Nurse Practitioner (NP) revealed she did not have any involvement with the situation regarding Resident #61 other than being notified CPR was not done and Resident #61 expired.An interview on [DATE] at approximately 4:45 P.M. with the RDCO revealed RN #142 was disciplined for not following physician orders related to Resident #61 passing away in the facility, as part of the facility ' s response to Resident #61 expiring in the facility as a full code and not receiving CPR. The RDCO verified RN #142 was still employed as a nurse at the facility as of this time. In addition, the RDCO verified the RN had not provided a written witness statement with her signature to verify her reported account of the incident. The RDCO voiced no awareness RN #142 had documented and administered Levothyroxine Sodium to Resident #61 at 4:00 A.M. on [DATE] which contradicted the typed and unsigned witness statement with RN #142 ' s name on it indicating she last saw the resident alive around 2:30 A.M. The RDCO stated RN #142 made a decision to not provide CPR without speaking to the physician about the full code status of Resident #61 and RN #142 did not provide CPR because the resident ' s conditiondid not indicate CPR should be provided according to the facility CPR policy because he had signs of rigor mortis.An interview on [DATE] at 9:06 A.M. with LPN #136 revealed upon entering Resident #61 ' s room to verify absence of vital signs the resident was visually starting to turn blue, he was cold to touch on his hands and arms but he had no signs of body stiffness at the time she attempted to obtain the resident ' s vital signs. LPN #136 stated there was no discussion with RN #142regarding Resident #61 ' s code status and she was instructed by RN #142 to verify the absence of vital signs.Review of the facilities policy titled Emergency Procedure-Cardiopulmonary Resuscitation and Basic Life Support, last revised on [DATE], revealed if an individual was found unresponsive and not breathing normally, a licensed staff member who was certified in CPR/BLS was to initiate CPR unless it was known that a DNR order that specially prohibited CPR and/or external defibrillation existed for that individual or if there were obvious signs of irreversible death (e.g., rigormortis). If the resident ' s DNR status was unclear, CPR was to be initiated until it was determined that there was a DNR or a physician ' s order not to administer CPR.This deficiency represents non-compliance investigated under Complaint Number OH00167051.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, facility policy and procedure review and interviews, the facility failed to provide timely, necessary and adequate care and services following an acute change in condition involving Resident #61 that started on [DATE]. The facility failed to ensure changes in the residents ' medical condition were comprehensively assessed, the residents change in condition, including abnormal vital signs and extreme loss of balance, was communicated to the medical provider, and individualized interventions were implemented. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on [DATE] when Resident #61 experienced hypotension (low blood pressure defined as a systolic pressure or top number below 90 millimeters of mercury (mm/Hg) and/or diastolic pressure or bottom number below 60 mm/Hg), dizziness, extreme loss of balance with his body going limp and eyes rolling back in his head while in physical therapy, as identified by the Physical Therapy Director (PTD) #172 who reported the incident to Licensed Practical Nurse (LPN) #132. LPN #132 did not comprehensively assess Resident #61 or notify the physician or Nurse Practitioner (NP). On [DATE] Resident #61 again presented with hypotension during physical therapy with blood pressures taken by PTD #172 noted as 82/55 millimeters of mercury (mm/Hg) and 94/59 mm/Hg while sitting and 72/50 mm/Hg and 75/48 mm/Hg while standing which was reported to Physician #187 by PTD #172 face-to-face in the facility hallway. Physician #187 failed to do a comprehensive medical assessment on Resident #61 on [DATE]. Resident #61 expired in the facility on [DATE] due to cardiopulmonary arrest. This affected one resident (#61) of eleven residents reviewed for change of condition.On [DATE] at 3:54 P.M. the Administrator, Regional Director of Operations (RDO), Regional Director of Clinical Services (RDCS) and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when therapy staff identified Resident #61 exhibited a change in condition which included abnormal vital signs, an extreme loss of balance caused by dizziness, body going limp and eyes rolling back in his head as recorded and reported by PTD #172. There was no evidence of timely or adequate interventions/medical treatment being provided. Resident #61 was not seen by Physician #187 nor by the Nurse Practitioner on [DATE]. Additionally, on [DATE] PTD #172 identified and documented Resident #61 again showed low blood pressures requiring therapy to be stopped. PTD #172 stopped Physician #187 in the hallway on [DATE] and notified him of low blood pressure. Physician #187 did not see Resident #61 on [DATE] or on [DATE]. On [DATE] Physician #187 gave verbal orders in the hallway to Registered Nurse (RN) #150 to decrease the residents Metoprolol (cardiac medication) from 25 milligrams (mg) daily to 12.5 mg daily and on [DATE] Physician #187 gave additional verbal orders to LPN #132 to discontinue the resident ' s Valsartan (cardiac medication) and to do orthostatic blood pressures every shift for three days. Resident #61 was subsequently found absent of all vital signs on [DATE] at 4:50 A.M. and pronounced deceased .The Immediate Jeopardy was removed on [DATE] when the facility implemented the followingactions: On [DATE] the Regional Director of Clinical Services (RDCS) notified the Medical Director of the Immediate Jeopardy involving quality of care for Resident #61. On [DATE] an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held and attended by the Administrator, Medical Director, Regional Director ofClinical Services (RDCS), Director of Nursing (DON), Therapy Director, Infection Preventionist, Activities Director, Business Office Manager (BOM), MaintenanceDirector, Housekeeping Supervisor, and Admissions Director (AD) to discuss the incident involving Resident #61. On [DATE] the DON, RDCS and LPNs interviewed/assessed 60 of 60 in house residents to identify any unreported changes in condition. Skin sweeps were done for 16 residentswho were unable to be interviewed due to cognitive deficits. 44 residents were interviewed related to unreported changes in their health status. On [DATE] the DON educated 16 of 16 licensed facility nurses, 11of 11 frequently used agency nurses, 14 of 14 therapy staff and 32 of 32 nurse aides on the facility ' s change incondition policy titled Change in a Resident ' s Condition or Status which included physician notification and documentation requirements. Staff members were notpermitted to work a shift until education was completed [DATE]. Newly hired (licensed nurses and nurse aides) would be educated on the change of condition policy includingphysician notification regulations during orientation by the DON/ADON. Beginning [DATE] the facility implemented a plan for the DON and Assistant Director of Nursing (ADON) to review the 24-hour report to identify documented changes inconditions to ensure any change of condition identified is properly reported to the resident, physician and the family/resident representative per policy/procedure. Thiswould occur for five to seven days a week for five weeks then randomly thereafter. The reviews would be discussed at the next QAPI meeting.Although the Immediate Jeopardy was removed on [DATE] the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not ImmediateJeopardy) 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 #61 revealed an initial admission date of [DATE] with diagnoses including atrial fibrillation, acute pulmonary edema, atherosclerotic heart disease, hypertension, malignant neoplasm of the pharynx, sepsis, and pleural effusion. Resident #61 was discharged to the hospital on [DATE] then re-admitted to the facility on [DATE] with a readmission diagnosis of aspiration pneumonia and acute respiratory failure with hypoxia. The resident expired in the facility on [DATE].Record review revealed Resident #61 was listed as his own responsible party and his sister was listed as the emergency contact. Resident #61 ' s code status in the event of cardiopulmonary arrest was a full code indicating he wanted all life sustaining measures provided to him if his heart stopped and he would stop breathing. There was no evidence in the medical record to indicate a change in the full code status at any time during the stay.Review of Resident #61 ' s care plan initiated on [DATE] revealed the resident/responsible party wished for the resident to be a full code for their advanced directives. Care plan goals indicated the resident's wishes would be honored. Interventions included the facility would adhere to desired code status, they were to inform the resident ' s physician if code status changed, and thefacility would review code status quarterly or as needed.Further review of Resident #61's care plan revealed a plan for the resident ' s desire to return home with home health care when able.Review of physician orders revealed on [DATE] there was an order for Metoprolol Succinate Extended Release (ER) 25 milligrams (mg) daily via peg tube and an order dated for Valsartan 40 mg via peg tube daily for hypertension.Record review revealed Resident #61 had a plan of care initiated on [DATE] regarding the diagnosis of hypertension (high blood pressure) with goals and interventions including the resident would remain free from signs and symptoms of hypertension. Interventions included nursing staff to administer hypertensive medications per physician orders and monitor for side effects such as orthostatic hypotension (low blood pressure) and increased heart rate, monitor for and document any edema (swelling), and staff were to report any significant changes to the physician.Review of Resident #61 ' s Physician and Nurse Practitioner assessments revealed the last assessment was completed on [DATE] by Nurse Practitioner (NP) #189 indicating Resident #61 had an improvement in conditions since last visit. The resident denied any issues or concerns at the time of the visit. Active issues included hypertension managed with Metoprolol ER (a medication used to decrease blood pressure) 25 milligrams (mg) daily, Lasix (diuretic) 20 mg daily, Valsartan (a medication used to decrease blood pressure) 40 mg daily and Spironolactone (diuretic) 12.5 mg daily. The resident was seen for a stabilization visit after being hospitalized for pneumonia and paroxysmal atrial fibrillation (abnormal heart rhythm). The resident was noted to be a full code. The note included the resident appeared chronically ill, received continuous oxygen and was alert and oriented to person, place and time with forgetfulness. There was no evidence in the assessment to indicate hypotension/low blood pressure was an expected or normal baseline finding for Resident #61.Vital signs were noted as within normal limits for the resident and were noted as vital signs reviewed from the date of [DATE] at 2:47 P.M. which included a blood pressure of 127/75 millimeters of mercury (mm/Hg).Review of Resident #61's Medicare five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had some cognitive impairment, was to have nothing by mouth, required substantial assistance for oral hygiene and upper body dressing, required partial to moderate assistance with bed mobility, and was dependent on staff for toileting hygiene, showers, lower body dressing, personal hygiene and transfers with the use of a mechanical lift when not in therapy.Review of Resident #61's Physical Therapy Daily Treatment Note authored by Physical Therapy Director (PTD) #172 dated [DATE] revealed Resident #61 performed sit to stand and stand pivot transfers from bed to wheelchair with minimal assist to contact guard assist, Resident #61 also performed Pressure Releaving Exercises (PREs) to lower extremities with verbal and visual cues for technique. An additional remark by PTD #172 stated the resident experienced extreme loss of balance (LOB) on first and only ambulation attempt caused by dizziness, the resident's body went limp with eyes rolling back requiring maximal assistance to prevent fall. Resident was immediately taken to the nurses ' station; nursing reported a low blood pressure and then resident was assisted to bed.Further review of Resident #61 ' s medical record revealed the Medication Administration Record, Treatment Administration Record and record of blood pressures for [DATE] showed no bloodpressures had been recorded by nursing on [DATE] and not since [DATE]. Additionally, review of the nursing progress notes and assessments showed no evidence the nurse documented the change of condition which was brought to nursing ' s attention by PTD #172 on [DATE] and there were no notes or assessments from the physician or NP to indicate Resident #61 had been assessed on [DATE]. The last nursing assessment completed on Resident #61 was a skin assessment on [DATE].Review of a Physical Therapy note dated [DATE] authored by PTD #172 and signed at 1:51 P.M. revealed Resident #61 ambulated approximately 50 feet using a front wheeled walker with minimal assistance along with pre-gait standing task. Resident #61 experienced a drop in blood pressure with each attempt. PTD. #172 spoke with Physician #187 regarding this situation. Gait training was paused for the remainder of the day. Noted under the additional remarks sections were Resident #61 ' s blood pressure readings ranging from 82/55 mm/Hg to 94/59 mm/Hg sitting to 72/50 mm/Hg to 75/48 mm/Hg standing which were obtained in therapy. Standing task was put on hold on this date.Review of Resident #61's nursing progress note dated [DATE] at 10:59 A.M. authored by Registered Nurse (RN) #150 revealed RN #150 was given a verbal order from the physician to decrease Resident #61 ' s Metoprolol to 12.5 mg every day. Additionally, on [DATE] at 2:48 P.M. a progress note authored by Licensed Practical Nurse (LPN) #128 revealed the physician gave a verbal order to discontinue Resident #61 ' s Valsartan and to do orthostatic blood pressures (blood pressure conducted lying, sitting, and standing) every shift for three days.Review of physician orders dated [DATE] revealed new orders for Metoprolol 12.5 mg daily, Valsartan was discontinued and the physician ordered orthostatic blood pressures every shift forthree days.Review of documented vital signs dated [DATE] for Resident #61 revealed RN #142 recorded the following blood pressures: 108/64 mm/Hg while lying at 8:31 P.M., 101/60 mm/Hg whilesitting at 8:32 P.M. and 84/57 mm/Hg while standing at 8:33 P.M.Further review of Resident #61 ' s progress notes revealed there were no additional progress notes authored after [DATE] at 2:48 P.M. until the resident ' s death on [DATE] at 4:50 A.M.An interview on [DATE] at 1:30 P.M. with Physician #187 revealed he had not been notified of any concerns with Resident #61 on [DATE], but on [DATE] he was caught in the hallway byPhysical Therapy Director (PTD) #172 who indicated during treatments Resident #61 became hypotensive and dizzy when standing. Physician #187 stated he did not see the resident to physically assess him but did review his medications to address the symptoms reported by PTD #172. Physician #187 stated he decreased Resident #61 ' s Metoprolol to 12.5 mg daily. Physician #187 stated he then made additional changes to discontinue the residents Valsartan that day and ordered orthostatic blood pressures every shift for three days. Physician #187 stated he was not notified by the facility of the orthostatic blood pressures taken on [DATE] between 8:31 P.M. to 8:33 P.M. Physician #187 stated he was notified Resident #61 expired but stated he was not informed that no CPR was initiated. Physician #187 stated he had concerns as to why CPR was not initiated, and regardless of what condition the resident was found in the nurses should have performed CPR on the resident as he was a full code resident. Physician #187 stated his Nurse Practitioner notified him a few days later that the resident was a full code yet no CPR was initiated. Physician #187 stated he brought it to the attention of the Director of Nursing (DON) his concerns with CPR not being initiated at time of death for Resident #61.An interview on [DATE] at 1:48 P.M. with PTD #172 confirmed PTD #172 spoke to Physician #187 in the hallway on [DATE] regarding Resident #61 becoming orthostatic in therapy and would complain of dizziness with standing. PTD #172 stated this also occurred on [DATE] and verified he witnessed Resident #61 have an extreme loss of balance with dizziness and body went limp with eyes rolled back in his head. PTD #172 stated Resident #61 had to be held to prevent a fall at that time. PTD #172 stated it was not abnormal for Resident #61 to feel dizzy when standing, but it was not Resident #61's norm or baseline to go limp as if he was going to pass out. PTD #172 stated he had told LPN #132 about Resident #61 ' s symptoms in therapy on [DATE]. PTD #172 stated he thought that was the nurse assigned to Resident #61 on that day.An interview on [DATE] at 2:26 P.M. with RN #150 revealed on [DATE] the RN was assigned to be the float nurse in the facility and Physician #187 stopped him in the hallway and gave averbal order to decrease Resident #61 ' s Metoprolol from 25 milligrams (mg) daily to Metoprolol 12.5 mg daily.An interview on [DATE] at 10:30 A.M. with the Nurse Practitioner (NP) revealed she did not have any involvement with the situation regarding Resident #61 (on [DATE] or [DATE]) othe than being notified CPR was not done on [DATE] and Resident #61 expired. The NP stated she was unaware of the change in condition the resident had on [DATE] during therapy and the day prior to his death.An interview on [DATE] at 11:36 A.M. with LPN #132 revealed the LPN was on orientation and RN #150 was teaching him. LPN #132 stated therapy indicated Resident #61 became dizzy, had an extreme loss of balance, complained of being dizzy, and had moderated changes in blood pressure. Therapy staff indicated the resident went limp and eyes rolled back in head. LPN #132stated they assisted the resident to his room and to bed but did not complete an assessment and did not notify the physician or NP.An interview on [DATE] at 11:51 A.M. with RN #150 revealed on [DATE] the RN was at the nurses ' station on the [NAME] unit when PTD #172 brought Resident #61 to him. RN #150 stated PTD #172 said Resident #61 was done in therapy due to weakness, dizziness and almost falling during therapy. RN #150 stated the resident appeared tired but was alert and oriented per baseline. RN #150 stated his actions included taking the resident to his room, checking vital signs and blood sugar, and assisted the resident to bed. RN #150 stated he did not notify Physician #187 nor a Nurse Practitioner of Resident #61 ' s acute change in condition in therapy because RN #150 felt the symptoms described were not lingering. RN #150 verified he did not document the vitals he took, what was reported by PTD #172 nor complete a change of condition assessment in the medical record.Review of the facility policy titled Change in a Resident ' s Condition or Status, last revised February 2021, revealed it was the policy of the facility to promptly notify the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and /or status. The policy included the facility must inform the resident, consult with the resident ' s medical practitioner and/or notify the resident ' s representative, authorized family member, or legal power of attorney/guardian when there is a change requiring such notification. Circumstances requiring notification included but were not limited to significant change in the resident ' s physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status including but not limited to life threatening conditions or clinical complications.This deficiency represents non-compliance investigated under Complaint Number OH00167051.