Health inspection·February 13, 2019

F 0578 Level of Harm - Minimal harm or potential for actual harm 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. Based on record review and staff interview the facility failed to comply with Resident #51's code status This affected one of 19 sampled residents. Residents Affected - Few Findings include: Review of the closed record for Resident #51 revealed a re-admission date of 03/26/18. Diagnoses included paranoid schizophrenia, idiopathic epilepsy, and peripheral vascular disease. Physician orders for December 2018 revealed a code status of Do Not Resuscitate Comfort Care Arrest (DNRCC- Arrest) dated 07/18/18. DNRCC- Arrest indicated the resident did not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. Review of the DNRCC form signed by both the physician and Resident #51's responsible party dated 07/19/18 revealed Resident #51's code status was DNRCC-Arrest. Review of the care plan dated 07/31/18 revealed Resident #51 and family had chosen a DNR status and CPR measures would not be attempted during a cardiac arrest. Review of nursing notes dated 12/18/18 at 7:07 P.M. revealed at 6:25 P.M. Licensed Practical Nurse (LPN) #11 was notified Resident #51 was leaning in his chair and something was wrong. LPN #11 observed Resident #51 leaning to the right in his chair, unresponsive and absent of all vital signs. CPR was started and emergency medical services ( 911) was called. LPN #11 and another nurse continued CPR until emergency medical services (EMS) arrived and took over. Review of the facility's investigation dated 12/19/18 revealed on 12/18/19 at 6:15 P.M. Resident #51 was found slumped over in the chair seated at the table, leaning over the right arm rest. Resident #51 was found to have food in his mouth and LPN #11 suctioned out some liquid, and noted the resident had pieces of bread in his mouth. Resident #51 did not have a pulse and was removed from his chair by staff members and placed on the ground. CPR was initiated and 911 was called. EMS arrived and they took over care of Resident #51 and indicated that there was nothing more they could do. The coroner was called, visited the facility and released the body to the funeral home. Interview on 02/12/19 at 9:18 A.M. with LPN #11 revealed she was aware Resident #51 had orders for DNRCC-Arrest but performed CPR on the resident anyway. Review of the facility policy titled, Advanced Care Planning, revised July 2018 revealed the resident's preference for advanced directives would be recorded in their medical record and further used in the development of the resident's plan of care. 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 5 Event ID: 366183 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 366183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seasons Nursing and Rehab 456 Seasons Rd Stow, OH 44224 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)