Inspection·March 4, 2024

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 02/20/24 at approximately 8:00 A.M. revealed Resident #33 and Resident #83 were roommates in a semi-private room. Further observations revealed the room had no privacy curtain in place to ensure resident privacy. Observation on 02/22/24 at 8:45 A.M. revealed Resident #33 and Resident #83's semi-private room continued to have no privacy curtain in place. Interview on 02/22/24 at 8:47 A.M. with STNA #156 verified there was no privacy curtain in place in Resident #33 and Resident #83's room to ensure they had a means for privacy in the room. This deficiency represents non-compliance investigated under Master Complaint Number OH00151169 and Complaint Number OH00150047. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365898 If continuation sheet Page 2 of 9 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 365898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Sylvania 5757 Whiteford Rd Sylvania, OH 43560 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)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on self-reported incident review, medical record review, staff interview, and review of a facility policy, the facility failed to submit the results of an investigation to the State Survey Agency in a timely manner. This affected one (#27) of one residents reviewed for neglect. The facility census is 79. Residents Affected - Few Findings include: Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included other hypertrophic osteoarthropathy, chronic obstructive pulmonary disease, type two diabetes mellitus with other diabetic arthropathy, and major depressive disorder recurrent. Review of the Minimum Data Set (MDS) assessment, dated 01/27/24, revealed the resident was significantly cognitively impaired. Review of a self-reported incident (SRI) created on 01/03/24 under the category of neglect, mistreatment, or abuse for Resident #27. Further review of the SRI revealed Resident #27 reported a staff member provided a shower that day, but Resident #27 did not want a shower. Review of the facility SRI revealed the investigation was not completed until 01/11/24, and the facility unsubstantiated the allegation. Interview on 02/26/24 at 3:25 P.M. with the Administrator verified the investigation was not completed in a timely manner and results were not reported to the State Survey Agency within five working days of the incident as required. Review of the policy titled, Abuse, Neglect, and Exploitation, dated 2023, revealed the Administrator will follow up with government agencies to confirm the initial report was received and report the results of the investigation when final within five working days of the incident. This deficiency represents an incidental finding discovered during investigation of Master Complaint Number OH00151169. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365898 If continuation sheet Page 3 of 9 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 365898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Sylvania 5757 Whiteford Rd Sylvania, OH 43560 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)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, review of the facility investigation, review of a personnel file, review of an emergency medical services (EMS) run report, review of the facility's policy for Emergency Procedure - Cardiopulmonary Resuscitation, review of the American Heart Association Journal, review of a job description for Licensed Practical Nurses (LPNs), and review of the cardiopulmonary resuscitation (CPR) certifications, the facility failed to timely initiate CPR for one resident (Resident #05) found unresponsive, without a pulse or blood pressure, and who was identified as a Full Code status. This resulted in Immediate Jeopardy and serious life-threatening harm, and/or death when Resident #05 did not receive timely CPR after she was discovered with no pulse or blood pressure. This affected one (#05) of three residents (#05, #06, #07) who expired unexpectedly at the facility. Additionally, the facility failed to ensure five [LPNs #101, #123, #134, #141, and Registered Nurse (RN) #138] of 31 nurses employed by the facility had a current CPR certification for Healthcare Providers. This placed all 39 current residents (#11, #12, #14, #15, #18, #22, #23, #24, #25, #28, #29, #31, #32, #35, #36, #38, #39, #40, #41, #44, #45, #48, #49, #52, #54, #56, #59, #60, #61, #64, #67, #70, #72, #74, #78, #80, #81, #83, and #86) designated with a Full Code resuscitation status at potential risk for more than minimal harm that is not Immediate Jeopardy. The facility census was 79. On [DATE] at 4:05 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 10:15 P.M. when Resident #05, who was a Full Code resuscitation status, was found unresponsive by State Tested Nurse Aide (STNA) #113. STNA #113 notified LPN #225 of Resident #05 being unresponsive, and EMS was notified at 10:22 P.M. LPN #225 assessed Resident #05 who was absent of vital signs and was pale. LPN #225 chose to exit the memory care unit and ran down the hall yelling for assistance from other staff members, passing a crash cart on the nearest unit. LPN #226 and Registered Nurse (RN) #147 went to Resident #05's room and she was found lying on the bed alone. No other staff were in the room and life-saving measures had not been initiated. RN #147 and LPN #226 placed Resident #05 on the floor and began chest compressions and staff followed with a crash cart. Resident #05 was left alone without CPR initiated for approximately two minutes per interview with RN #147. Through investigation, it was discovered LPN #225 refused to perform chest compression on Resident #05 due to a shoulder issue; however, no such shoulder issue was noted in LPN #225's personnel file. EMS arrived at 10:31 P.M. and took over life-saving interventions. The EMS physician called the time of death at 11:09 P.M. The physician and Resident #05's family were notified of the resident's death and notified the funeral home, who picked up Resident #05 on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE], LPN #225, who did not perform CPR on Resident #05, was suspended pending investigation. LPN #225 was informed she could not return to work until further notice. • On [DATE], disciplinary action was taken with LPN #225 for not initiating CPR for a resident with a Full Code resuscitation status. LPN #225 was called on [DATE] by Human Resources (HR) #192, the DON, and the Administrator, with the intention of terminating employment. LPN #225 would not answer the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365898 If continuation sheet Page 4 of 9 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 365898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Sylvania 5757 Whiteford Rd Sylvania, OH 43560 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)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety phone or return the calls. LPN #225 then texted the facility on [DATE] after hours and resigned without notice. • On [DATE], the Administrator notified Medical Director #300 of the incident. Residents Affected - Few • On [DATE], the DON and the Administrator reported LPN #225 to the Ohio Board of Nursing. • On [DATE], the DON/Designee completed an audit of all residents that expired in the past six months to ensure that their Code Status was followed with no concerns identified. • On [DATE], the DON/Designee completed an audit of all current residents and compared the advance directives to the physician order for accuracy with no concerns noted. • On [DATE], the DON/Designee completed an audit of all licensed nurses to ensure CPR certifications were current. The facility identified five (LPNs #101, #123, #134, #141, and RN #138) nurses did not have current CPR certifications for Healthcare Providers as a result of the audit. • On [DATE], the DON/Designee completed an audit of all current staff to ensure all are available and able to perform job duties. • On [DATE], the DON/Designee completed all staff education on abuse/neglect and misappropriation. All staff were educated in person or via telephone and all education was completed on [DATE]. • On [DATE], the DON/Designee completed all staff education on the importance of initiating CPR immediately on full code residents. All staff were educated in person or via telephone and all education was completed on [DATE]. • On [DATE], the DON/Designee completed all staff education on the necessity of informing management in the event you cannot fully perform job duties. All staff were educated in person or via telephone and all education was completed on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365898 If continuation sheet Page 5 of 9 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 365898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Sylvania 5757 Whiteford Rd Sylvania, OH 43560 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)

F 0678 • Level of Harm - Immediate jeopardy to resident health or safety On [DATE], a Code Blue drill was conducted with no concerns identified. Residents Affected - Few On [DATE], a Quality Assurance Performance Improvement (QAPI) meeting was held, and a Performance Improvement Plan (PIP) was implemented following notification of Medical Director #300 via phone by the Administrator. The Administrator, Social Service Director (SSD) #194, the DON, Minimum Data Set (MDS) Coordinator #197, Unit Manager LPN #166, Unit Manager RN #148, Unit Manager RN #136, Business Office Manager (BOM) #193, Maintenance Director (MD) #196, admission Director (AD) #191, HR #192, Physical Therapy Director (PTD) #251, and Chief Operating Officer (COO) #500 were present for the meeting. • • The DON will monitor for code status compliance by interviewing licensed nurses about the facility's CPR policy and procedure, as well as requesting return demonstration of the CPR process. Compliance checks will be conducted on three nurses two times weekly for three months. The findings will be reviewed at the monthly QAPI committee meeting. • The DON/Designee will audit all new admissions to compare the resident's advance directives to the physician orders for accuracy. This audit will be conducted four to five times a week for three months. The findings will be reviewed monthly at the QAPI committee meeting. • The DON/Designee will perform Code Blue drills three times a month for three months and will cover all shifts. The findings will be reviewed at the monthly QAPI committee meeting. • On [DATE], the medical records for Resident #06 and Resident #07, who expired unexpectedly at the facility, were reviewed and staff responded appropriately. • On [DATE], between 7:15 A.M. to 12:00 P.M., interviews with LPN #108, LPN #134, LPN #141, LPN #159, STNA #109, STNA #137, STNA #150, and STNA #156 verified all were educated on the facility's abuse and neglect policy, the CPR policy and importance of initiating CPR timely, and importance of notifying the facility if unable to fully perform job duties. Interview with all staff members confirmed each possessed adequate knowledge and retention of the policies, procedures, and expectations of the education provided. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365898 If continuation sheet Page 6 of 9 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 365898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Sylvania 5757 Whiteford Rd Sylvania, OH 43560 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)

F 0678 non-compliance due to five nurses working at the facility that had expired CPR certification. Level of Harm - Immediate jeopardy to resident health or safety Findings included: Residents Affected - Few Review of Resident #05's medical record revealed an original admission date of [DATE] and a readmission date of [DATE]. Diagnoses included chronic obstructive pulmonary disease, dementia, bipolar disease, and fibromyalgia. Review of a physician order dated [DATE] revealed Resident #05 had a Full Code resuscitation status. Review of Resident #05's care plan dated [DATE], revised on [DATE], revealed the resident had a Full Code resuscitation status. An intervention included to initiate CPR in the absence of a pulse. Review of a progress note dated [DATE] revealed Resident #05's code status was reviewed during a care conference and Resident #05's family wished for the resident to remain a Full Code resuscitation status at that time. Review of nursing progress notes dated [DATE] at 2:10 P.M. revealed Resident #05 was very anxious and agitated during the shift. Staff members attempted to provide redirection activities with little success. A nurse practitioner was notified and provided new orders that were implemented. At 3:36 P.M., an antianxiety medication was administered due to continued anxiousness and agitation and was noted as ineffective at 4:28 P.M. A nurse practitioner with psychiatric services was contacted and provided new orders. At 5:19 P.M., Resident #05 was administered an antipsychotic medication due to continued behaviors. At 6:15 P.M., Resident #05 was noted to continue with the same behaviors of yelling out, restlessness, and anxiousness. Resident #05 complained of being short of breath, but continuously took her nasal cannula off which supplied supplemental oxygen, and the resident was reminded several times to keep the oxygen on. Resident #05's lung sounds were clear throughout, and oxygen saturation levels were at 94 percent (%). A nurse practitioner was contacted and gave orders for a chest x-radiation (x-ray) diagnostic image and a urinalysis to be obtained. Resident #05's responsible party was made aware of the resident's behavior and the new orders. Review of a progress note dated [DATE] revealed on [DATE] Resident #05 was checked on between 9:30 P.M. and 10:00 P.M. and was last seen with her nasal cannula on watching television in bed. A nurse aide (STNA #113) noticed Resident #05 looked pale and noticed her nasal cannula was not in her nose and she was holding it in her hand. The nurse aide notified the nurse (LPN #225) of Resident #05's condition and found Resident #05 was unresponsive and vital signs were absent. The nurse told the nurse aide to contact EMS and CPR was started immediately until EMS staff arrived and took over life saving measures. Resident #05 expired at 11:09 P.M., and notifications were made to the on-call physician, unit manager, family, and funeral home. Review of the facility investigation initiated on [DATE] revealed the DON obtained a statement via an interview from LPN #225 regarding Resident #05's death who resided on the locked memory care unit. Further review of the investigation revealed LPN #225 instructed STNA #113 to call EMS. LPN #225 then left the memory care unit, running and yelling down the hall, and passed a crash cart on the nearest unit. RN #147 and LPN #226, from another unit, ran a crash cart back to the memory care unit to Resident #05's room. Chest compressions were started on Resident #05 by LPN #226 and RN #147 while LPN #225 refused to complete chest compressions. LPN #225 informed the DON she could not do chest compressions due to shoulder issues. It was determined there was no documentation in LPN #225's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365898 If continuation sheet Page 7 of 9 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 365898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Sylvania 5757 Whiteford Rd Sylvania, OH 43560 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)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few personnel file indicating any restrictions to performing regular or essential job duties. The investigation determined chest compressions were not immediately started on Resident #05 when she was found absent vital signs, was unresponsive, pale, and had a Full Code resuscitation status in place. Review of an EMS run report dated [DATE] revealed Resident #05 experienced cardiac arrest at 10:20:00 P.M. on [DATE]. EMS received the telephone call from the facility at 10:24:37 P.M., the call was dispatched at 10:25:20 P.M., and EMS staff were enroute to the facility at 10:27:04 P.M. EMS staff arrived at the facility at 10:29:03 P.M. and reached Resident #05 at 10:31:00 P.M. Further review of the EMS run report revealed staff indicated the last known time Resident #05 was well was at 9:30 P.M. and facility staff found Resident #05 unresponsive at 10:20 P.M. When EMS staff arrived, Resident #05 was laying on the floor with staff performing chest compressions when EMS staff took over life-saving measures. Resident #05 was noted to be pulseless, and the resident was not breathing. EMS continued with life saving measures for approximately 30 minutes and Resident #05 continued to have no heartbeat. A physician was contacted to request life-saving efforts be discontinued, and time of death was given at 11:09 P.M. Interview on [DATE] at 9:51 A.M., with the Administrator and the DON revealed on [DATE] Resident #05 was found unresponsive, and LPN #225 refused to perform CPR. LPN #225 instructed STNA #113 to call EMS and then left the unit to get assistance from other nurses. Two nurses from other units responded and began CPR. The DON was not aware how long it took the staff to respond to Resident #05 and CPR to be initiated. The DON confirmed CPR was delayed by LPN #225's refusal to begin chest compressions. Telephone interview with RN #147 on [DATE] at 1:25 P.M. revealed, on [DATE], she was assigned to the [NAME] unit of the facility, and LPN #226 was assigned to the Evergreen unit. RN #147 stated she saw LPN #225 coming down the hall and heard LPN #225 yelling for assistance on the secured memory care unit. RN #147 stated a nurse aide from [NAME] unit got the crash cart, and when the staff arrived at Resident #05's room on the memory care unit, the resident was alone in the room lying in the bed. RN #147 stated she and the nurse aide placed Resident #05 on the floor and began CPR while STNA #113 was on the telephone with EMS. RN #147 stated LPN #225 stood in the doorway of the room and refused to assist with CPR. RN #147 estimated it took the staff two minutes to reach Resident #05's room after being alerted of the incident. Review of STNA #113's written statement, obtained through interview with the DON, dated [DATE] revealed STNA #113 entered Resident #05's room and noticed the resident looked very pale. STNA #113 and LPN #225 both could not get Resident #05 to respond to them, so LPN #225 told STNA #113 to call EMS. STNA #113 indicated LPN #225 then left the memory care unit and would be heard yelling for help. Two different nurses returned to the memory care unit and began life-saving measures on Resident #05 while LPN #225 left the unit to talk to EMS and let them in the door. Review of LPN #225's personnel file revealed a hire date of [DATE]. Further review revealed LPN #225 had a current basic life support (BLS) certification on file with an expiration date of [DATE]. There was no documentation in LPN #225's personnel file related to work restrictions or changes to job duties because of shoulder issues. Review of a disciplinary action document dated [DATE] revealed LPN #225 was terminated based on the facility policy to begin procedures for a resident that was in need of medical attention right away, as being charge nurse of a whole unit. Further review revealed a resident (#05) was unresponsive on the memory care unit where LPN #225 was the charge nurse. LPN #225 instructed STNA #113 to call EMS, but LPN #225 left the unit yelling and calling for help while passing a crash cart on the nearest unit. A crash cart was taken to the memory care unit and two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365898 If continuation sheet Page 8 of 9 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 365898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Sylvania 5757 Whiteford Rd Sylvania, OH 43560 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)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few different staff members began chest compressions while LPN #225 refused to perform chest compressions citing shoulder issues. There was nothing in LPN #225's personnel file indicting any job restrictions preventing LPN #225 from performing essential job duties. LPN #225 was noted to be BLS certified, and the facility determined LPN #225 did not immediately start chest compressions on Resident #05. Review of the facility policy titled, Cardiopulmonary Resuscitation, revised [DATE], revealed it is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, this facility will implement guidelines regarding CPR. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to arrival of emergency medical services, and in accordance with the resident's advance directives. CPR certified staff will be available at all times. Staff will maintain current CPR certification for healthcare providers through CPR provided who evaluates proper technique through in-person demonstration of skills. CPR certification which included an online knowledge component yet still requires in-person demonstrations to obtain certification or recertification is also acceptable. Review of the American Heart Association Journal, Vol. 122, No.18, found at https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.110.970905, revealed the goals of resuscitation are to preserve life. Criteria for not starting CPR would include: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril; Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition); or a valid, signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated do not resuscitate order. 2. Review of the documentation provided by the facility revealed 31 nurses were currently employed by the facility. Of those 31 nurses, four LPNs (#101, #123, #134, #141) and one RN (#138) had expired CPR certification for Healthcare Providers. Interview on [DATE] at 12:54 P.M., with the DON verified five facility-employed nurses (LPNs #101, #123, #134, #141, and RN #138) had expired CPR certification. Review of the undated facility job description for Licensed Practical Nurses (LPNs) revealed LPNs must identify resident problems and emergency situation and initiate emergency care and lifesaving measures in the absence of a physician. This deficiency represents non-compliance investigated under Master Complaint Number OH00151169. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365898 If continuation sheet Page 9 of 9