Health inspection·March 26, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and interviews, the facility failed to ensure advanced directives were readily available and followed during a medical emergency for Resident #66. This affected one resident (Resident #66) of three residents reviewed for advance directives. The facility census was 64. Findings included: Review of the medical record revealed Resident #66 was admitted to the facility on [DATE]. Diagnoses included heart failure, respiratory failure, atrial fibrillation, congestive heart failure, nonrheumatic aortic stenosis, atherosclerotic heart disease, cardiomyopathy, hypertension, major depressive disorder, transient ischemic attack, and thoracic aortic ectasia. Resident #66 expired in the facility on [DATE]. Review of the physician's orders revealed Resident #66 had an order for Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) dated [DATE]. Review of the DNR identification form revealed Resident #66 requested a code status of Do-Not-Resuscitate Comfort Care Arrest (DNRCCA). It was signed by the resident. The physician signed on [DATE]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #66 had intact cognition. Review of the plan of care dated [DATE] revealed Resident #66 has a DNRCCA code status. Interventions included to adhere to his desired code status, inform the residents physician if there was a code status change, and review the code status quarterly or as needed. Review of the progress notes revealed no documentation of him expiring. The last health status note was dated [DATE] at 9:09 A.M. There was a psychiatric progress note dated [DATE]. Review of the facility document titled Code Blue Bedside Documentation, dated [DATE] at 10:30 A.M., revealed the housekeeper witnessed Resident #66 drop to the floor to the ground. The bedside nurse went into assess due to he had an absence of vital signs. Cardiopulmonary resuscitation (CPR) was initiated, oxygen was placed on the resident. A nursing assistant called 911. Resident #66 had a return of his pulse then his pulse was lost and CPR was initiated, Emergency Medical Service (EMS) arrived and CPR continued. They were unable to return his vitals and the time of death was called at 10:45 A.M. (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 6 Event ID: 365667 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 365667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Center for Rehabilitation and Nursing 555 Springbrook Dr Medina, OH 44256 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)