Health inspection·February 21, 2019

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 medical record review and staff interview the facility failed to ensure residents had the right to refuse or discontinue treatment when they failed to have matching cardiopulmonary resuscitation code status documentation. This affected three (#3, #5 and #7) of 16 residents reviewed for code status. The facility census was 27. Findings include: 1. Medical record review of Resident #5 revealed an admission date of: [DATE] with pertinent diagnoses of: fracture of lumbar vertebrae, muscle weakness, dementia without behaviors, insomnia, hypertension glaucoma, vitamin deficiency, and depressive episodes. Review of a paper Do Not Resuscitate (DNR) comfort care form dated [DATE] revealed the resident was requesting a Do No Resuscitate Comfort Care-Arrest (DNR-CCA) code status. Review of Resident #5's electronic medical record on [DATE] at 5:02 P.M. revealed a current Physicians Order for the Resident to be a full code and receive cardiopulmonary resuscitation (CPR). Interview with the Director Of Nursing (DON) on [DATE] at 5:34 P.M. verified the code status was different on the Physician Order and the Paper form. 2. Medical record review for Resident #3 revealed an admission date of [DATE] with pertinent diagnoses including: paralytic ileus, hemiplegia and hemiparesis affecting right dominant side, muscle weakness, and diabetes mellitus type two. Review of a paper DNR comfort care form dated [DATE] revealed the resident was requesting a DNR-CCA code status. Record review of a Physician Order on [DATE] revealed the Resident was requesting a DNRCC code status. Interview with the DON on [DATE] at 5:34 P.M. verified the code status was different on the Physician Order and the Paper form. 3. Medical record review of Resident # 7 revealed an admission date of [DATE] with pertinent diagnoses of: diabetes mellitus type two, muscle weakness, hypertension, hypothyroidism, and hyperlipidemia. (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 7 Event ID: 366415 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 366415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Cape May 175 Cape May Drive Wilmington, OH 45177 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)