Health inspection·September 25, 2023

F 0678 Level of Harm - Immediate jeopardy to resident health or safety 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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on closed medical record review, review of a facility self-reported incident (SRI), review of the facility Cardiopulmonary Resuscitation (CPR) policy and interviews, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) for Resident #37, who was found unresponsive, without a pulse/heartbeat and identified as a full code status. This resulted in Immediate Jeopardy that was actual harm on [DATE] when Resident #37 did not receive CPR, EMS were not contacted for medical services and the resident subsequently expired. This affected one resident (#37) of two residents reviewed for death in the facility. The facility census was 34 residents. On [DATE] at 10:07 P.M. the Administrator, Mobile Director of Nursing (DON)/Registered Nurse (RN) #152 and Regional Director of Clinical Services (RDCS) were notified that Immediate Jeopardy began on [DATE] at approximately 1:30 P.M. when Licensed Practical Nurse (LPN) #150 found Resident #37, who had advanced directives for a full code status, not breathing. Prior to the incident, LPN #150 last saw Resident #37 alive between 11:30 A.M. and 12:45 P.M. when she provided a wound treatment and fed the resident lunch. LPN #150 confirmed the absence of Resident #37's vital signs but failed to initiate CPR or call 911. LPN #150 indicated she did not think to check Resident #37's medical record to determine code status, initiate CPR or call 911 due to Resident #37 having passed away. The Immediate Jeopardy was removed and corrected on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 10:00 A.M., the facility Administrator, Regional [NAME] President of Operations, (RVPO), Regional Director Clinical Services (RDCS) and Clinical Quality Specialist (CQS) were made aware of CPR not being initiated at the time of the occurrence during a facility meeting. • On [DATE] at 10:15 A.M., LPN #150, the nurse on duty at the time of the occurrence, was removed from the unit. The facility completed an interview and obtained a statement from the LPN related to the situation. At 10:30 A.M. LPN #150 was suspended pending further investigation. • Page 1 of 6 366110 366110 09/25/2023 Crawford Manor Healthcare Center 1802 Crawford Rd Cleveland, OH 44106

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On [DATE] at 11:00 A.M., the facility obtained statements from the State Tested Nursing Assistants (STNAs) who were on duty at the time of the occurrence. • On [DATE] at 11:30 A.M., the Interim Director of Nursing (IDON) initiated immediate in-house education for all licensed nurses on the facility policies and procedures for identifying a change of condition, initiating CPR and crash cart validation. Those staff not on duty were contacted via telephonic means. This education was completed on [DATE] at 12:45 P.M. • On [DATE] at 12:00 P.M., all staff were in serviced by the Administrator and Mobile DON, on Abuse, Neglect and Misappropriation, monitoring and reporting, the overhead paging policy, the phone system, the use of walkie talkies for urgent situations. Staff not on duty were serviced by telephonic means. This was completed on [DATE] at 8:00 P.M. • On [DATE] the facility identified the phone system did not have overhead paging capability. The phone system was fixed on [DATE] at 1:30 P.M. • On [DATE] all current resident medical records were audited by the Social Service Designee (SSD) to ensure appropriate documentation of current code status and advance directive status. This was completed on [DATE] at 2:30 P.M. • On [DATE] at 2:30 P.M., the RDCS in-serviced the Administrator, IDON, Mobile Director of Nursing, Minimum Data Set (MDS) nurse, SSD and the Assistant Director of Nursing (ADON) on validation of code status at the time of expiration notification. • On [DATE] at 2:42 P.M. the facility administrator purchased six walkie talkies for nurses and managers to utilize to communicate to staff as needed. They arrived at the facility on [DATE] at 3:41 P.M. • On [DATE] at 3:30 P.M., the attending physician was notified Resident #37 had a full code status and CPR was not initiated. • On [DATE] at 3:40 P.M., the IDON and Administrator notified Resident #37's wife that the resident's full code status was not honored or initiated on [DATE]. 366110 Page 2 of 6 366110 09/25/2023 Crawford Manor Healthcare Center 1802 Crawford Rd Cleveland, OH 44106

F 0678 • Level of Harm - Immediate jeopardy to resident health or safety On [DATE], two crash carts were checked to ensure all supplies were available for CPR by the IDON and Mobile DON. There were several missing items that were replaced. A shift-to-shift sign off sheet for CPR cart validation was initiated on [DATE] at 4:00 P.M. Residents Affected - Few • On [DATE] at 5:10 P.M., the Human Resource (HR) Director audited all licensed nursing staff files to ensure current CPR certification. • Beginning on [DATE] the facility implemented a plan for the Mobile DON or Charge Nurse to conduct a mock code blue drill every shift for three days, then once weekly for four weeks, and once monthly for two months. Mock drills were completed on [DATE] at 6:19 P.M., [DATE] at 9:35 P.M., [DATE] at 5:38 P.M., [DATE] at 9:20 P.M., [DATE] at 5:58 P.M., [DATE] at 9:45 P.M., [DATE]/ at 5:10 P.M. • On [DATE] at 7:40 P.M., the RDCS completed an audit of all in-house deaths from [DATE] to current date to ensure resident advance directives were followed. Audits would continue monthly for three months. • Beginning on [DATE] the facility implemented a plan for the Administrator/designee to conduct three resident interviews for neglect twice weekly for four weeks. Interviews were completed on [DATE], [DATE], [DATE]. • Interviews on [DATE] between 10:01 A.M. and 11:04 A.M. and on [DATE] at 4:09 P.M. with two Registered Nurses (RN), RN #136 and RN #138, and State Tested Nursing Assistants (STNAs) #108, #113, #118, #121, and #151, revealed no concerns related to advance directives and/or code status. Each staff member interviewed revealed they were trained on the facility's policy for advance directive, change of condition and CPR. Findings include: Review of the closed medical record for Resident #37 revealed an admission date of [DATE] with diagnoses including chronic viral hepatitis C, pressure ulcer of sacral region, acquired absence of left leg above the knee. The record indicated Resident #37 passed away on [DATE] at 1:30 P.M. The resident was in his room unresponsive and absent of vital signs. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment for Resident #37, dated [DATE], revealed the resident had intact cognition. The assessment indicated the resident did not have a condition or chronic disease that would result in a life expectancy of less than six months. 366110 Page 3 of 6 366110 09/25/2023 Crawford Manor Healthcare Center 1802 Crawford Rd Cleveland, OH 44106

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the plan of care for Resident #37 revealed the resident had advanced directives that indicated a Full Code. Interventions included involving the physician in advanced directives conversations and reviewing advanced directives with the resident/family. Review of a hospital discharge summary paper dated [DATE] revealed Resident #37 was a full code status and was discharged to a skilled facility with diagnosis of sepsis and an order for an antibiotic, Levofloxacin for three days. Review of the resident's re-admission physician orders, dated [DATE] revealed the resident did not have a physician order related to advance directives. Review of the admission progress note dated [DATE] at 5:41 P.M. revealed Resident #37 was re-admitted from the hospital with a full code status. Review of a note dated [DATE] at 2:17 P.M. revealed at 1:30 P.M. LPN #150 found Resident #37 unresponsive and absent of vital signs. The note indicated postmortem care was provided by STNAs. At 1:35 P.M. the Administrator, family and physician were notified Resident #37 expired. At 2:00 P.M. the family visited. At 2:15 P.M. the family notified the facility of the funeral home arrangements. Review of the nursing progress note revealed no evidence the resident exhibited dependent lividity, rigor mortis, decapitation, or transaction. Review of progress note dated [DATE] at 4:45 P.M. revealed the funeral home removed the resident's body. Review of a progress note dated [DATE] at 9:06 P.M. revealed Resident #37 expired and full code status was not followed. No CPR was initiated. Notification was made to the medical director, physician, and family that CPR was not initiated. Review of a facility self-reported incident (SRI) report, tracking number 239053 dated [DATE] at 2:06 P.M. revealed the facility reported an allegation of neglect involving Resident #37. The SRI noted based on the comprehensive investigation that was completed by the facility which included resident record review, hospital record review and staff interviews the allegation of neglect was verified when Resident #37 was identified without vital signs and designated full code directives which were not followed, and CPR was not initiated. Review of the SRI investigation revealed a statement provided by LPN #150 on [DATE] which revealed at approximately 12:45 P.M. she administered a treatment and assisted Resident #37 with lunch. At 1:30 P.M. Resident #37 was observed without vital signs. Two STNAs came into the room to perform postmortem care, LPN #150 notified the physician, family, Administrator, and IDON of Resident #37 death. LPN #37 arranged with the funeral home to pick up the resident's body. A follow up phone interview on [DATE] with LPN #150 by the RDCS revealed she did not check Resident #37's code status. LPN #150 had re-admitted the resident (from the hospital) three days prior and remembered he was a full code. LPN #150 told the RDCS she was rushed and forgot to follow protocol. Interview on [DATE] at 10:22 A.M., with STNA #118 revealed she provided care to Resident #37 on [DATE], the morning he passed. The STNA stated Resident #37 was at his normal baseline status. The STNA revealed later that day, LPN #150 asked her and STNA #121 to provide postmortem care for the resident. STNA #118 stated she had informed LPN #150 Resident #37 was a full code. LPN #150 responded to her that the resident had passed. 366110 Page 4 of 6 366110 09/25/2023 Crawford Manor Healthcare Center 1802 Crawford Rd Cleveland, OH 44106

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on [DATE] at 1:23 P.M., with LPN #150 revealed on [DATE] at approximately 11:30 A.M. she administered Resident #37's wound treatment and fed him some lunch. The LPN revealed Resident #37 was alert and smiling. At 1:30 P.M., LPN #150 stated she went back into Resident #37's room and found him unresponsive and without vital signs. LPN #150 did not initiate CPR; however, she did tell STNA #118 and #121 to provide postmortem care. LPN #150 provided notification to the physician, Administrator and family and she arranged for removal of the body. LPN #150 stated she panicked and did not think about full code status or initiating CPR. She stated Resident #37 had passed and his body was cool. LPN #150 stated she did remember re-admitting Resident #37 from the hospital and seeing the full code status on the discharge summary. LPN #150 stated she notified the IDON of the resident's death and was told to write a good nurse's note. The LPN revealed the IDON did not mention to check for the resident's code status. Interview on [DATE] at 3:36 P.M., with STNA #121 revealed she delivered Resident #37's lunch tray and he appeared to be sleeping. At approximately 1:30 P.M. LPN #150 informed her Resident #37 passed away and postmortem care needed to be provided. STNA #121 stated she assisted to provide postmortem care to Resident #37. Interview on [DATE] at 9:21 A.M., with Resident #37's physician, Physician #155 revealed he did not recall addressing any change in the resident's code status (following his re-admission to the facility on [DATE]). He verified LPN #150 had notified him Resident #37 had no pulse and was absent of breath sounds. Interview on [DATE] at 2:00 P.M., with the Mobile DON, revealed [DATE] was his first day of employment. The Mobile DON revealed in the morning meeting on this date, he reviewed Resident #37's full code status and identified CPR was not initiated. Interview on [DATE] at 5:00 P.M., with the Administrator revealed it was unfortunate LPN #150 did not follow Resident #37's advanced directives. The Administrator verbalized the measures the facility had taken following the incident to ensure they had a good system in place to prevent a similar reoccurrence. Interview on [DATE] at 9:26 A.M., with IDON #154 revealed LPN #150 had notified her of Resident #37 death on [DATE]. IDON #154 stated she did not ask about code status but assumed LPN #150 took the appropriate actions according to the resident's advanced directives. Interview on [DATE] at 8:28 A.M., with the medical director (MD), MD #156 revealed facility had very few resident deaths. He stated he was notified Resident #37 did not receive CPR and indicated he expected staff to follow each residents' code status. The MD stated he was involved in developing a corrective action plan for the facility following the incident. Review of the facility policy titled Cardiopulmonary Resuscitation (CPR), revised [DATE] revealed CPR would be provided to all residents who experience cardiopulmonary arrest unless one or more of the following is present. • A valid advance directive requesting withholding of CPR. • 366110 Page 5 of 6 366110 09/25/2023 Crawford Manor Healthcare Center 1802 Crawford Rd Cleveland, OH 44106

F 0678 A properly executed ad witness Do Not Resuscitate (DNR) order. Level of Harm - Immediate jeopardy to resident health or safety • Documented verbal wishes by the resident/surrogate decision maker indicating the desire to be DNR but physical order pending. Residents Affected - Few • Dependent lividity, rigor mortis, decapitation, or transaction. This deficiency represents non-compliance investigated under Control Number OH00146486. 366110 Page 6 of 6