Health inspection·June 13, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Self-Reported Incident (SRI) and investigation, review of the facility's video surveillance, closed medical record review, review of the hospital records, staff interviews, and review of the facility policy, the facility failed to ensure a resident was free from neglect when the Director of Nursing (DON) and License Practical Nurse (LPN) #21 failed to adequately assess, monitor, and timely notify the physician of the resident's condition in accordance with professional standards of practice. This resulted in Immediate Jeopardy, serious life-threatening harm, and ultimate death when on 05/24/24 at 5:13 P.M., Resident #15 had a change in condition and at 5:54 P.M., State Tested Nursing Aides (STNA) #34 and #58 found Resident #15 grabbing at his chest, unresponsive to verbal commands, and in respiratory distress and alerted the DON to the resident's change of condition. There were no ongoing assessments during the evening shift and no notification to the physician for the need to alter treatments and/or send the resident out for evaluation, treatment or care. On 05/24/24 at 11:55 P.M., STNA #34 found the resident to be unresponsive and notified LPN #21 to come to the room and LPN #21 stated Resident #15 was dead. LPN #21 did not immediately initiate Cardiopulmonary Resuscitation (CPR) or contact the physician. There was a nine-minute delay in CPR being started and ten-minute delay to notify Emergency Medical Services (EMS). EMS responded and transported Resident #15 to the emergency room where he expired on 05/25/24 at 12:50 A.M. This affected one (Resident #15) of three (#15, #41, and #47) residents reviewed for neglect. The facility census was 47 residents. On 06/05/24 at 4:27 P.M., the [NAME] President of Operations #140 and Clinical Director #143 were notified Immediate Jeopardy began on 05/24/24 at 5:54 P.M. when Resident #15 was found by STNAs #34 and #58, grabbing at his chest, unresponsive to verbal commands and in respiratory distress. STNA #58 alerted the DON who was in the hall. STNA #58 and the DON entered the resident's room and proceeded to attempt to verbally stimulate Resident #15 to breathe. The DON attempted to obtain a blood pressure at 6:10 P.M. and was unable to get a blood pressure; however, oxygen saturation and heart rate were taken which was reported to be normal. At 6:00 P.M., STNA #58 ran back into Resident #15's room and told the DON that the resident was a full code. There was no notification to the physician, or activation of emergency services at that time. It was not until approximately 7:34 P.M. that a nurse (LPN #21/night shift) entered Resident #15's room and exited shortly afterwards after a brief discussion with the family about the resident being a full code and not on hospice. The next time LPN #21 entered the resident's room was at 11:55 P.M. after STNA #34 entered the room and noticed the resident had expired. At 11:56 P.M., LPN #21 left Resident #15's room, sat down at the nurse's station, and did not make any telephone calls immediately to notify the physician and/or EMS. On 05/25/24 at 12:00 A.M., LPN #21 notified the DON that Resident #15 was dead, and she did not complete CPR and refused to initiate the CPR. At 12:03 A.M., the DON had LPN #56 initiate CPR on Resident #15. At 12:04 A.M., LPN #21 notified EMS. The physician was never notified. EMS (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 18 Event ID: 365605 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365605 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milcrest Nursing Center 730 Milcrest Drive Marysville, OH 43040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)