Resident 2 died 41 minutes later.
Federal inspectors determined the facility placed residents in immediate jeopardy when staff failed to perform complete CPR with respirations. The violation began the day Resident 2 stopped breathing and continued until the facility corrected its emergency response system through staff retraining and equipment verification.
Resident 2 had been admitted with a fractured left femur, chronic obstructive pulmonary disease and high blood pressure. Her physician's order for life-sustaining treatment specifically requested full resuscitation attempts, including CPR, intubation, mechanical ventilation and transfer to intensive care if needed. She was alert and oriented, requiring staff assistance with daily activities.
Staff C, the certified nursing assistant, delivered Resident 2's breakfast tray that morning and found her unresponsive. She ran to the hallway and yelled for help, then went to the nurse's station to check the resident's code status and retrieve the emergency cart.
Licensed practical nurse Staff D was passing medications when Staff C reported that Resident 2 wasn't breathing. Staff D found the resident lying on her back sideways in bed, not breathing and without a pulse. The resident's skin had turned bluish-gray but remained warm to touch.
Staff D and registered nurse Staff E began CPR while Staff C brought the crash cart. The three staff members continued chest compressions until paramedics arrived at 8:12 AM and took over. Paramedics pronounced Resident 2 dead at 8:26 AM.
None of the responding staff provided rescue breathing.
Staff C acknowledged during an interview that staff "did not administer respirations during CPR." She said "the cart was missing stuff, like the breathing tube." Staff D confirmed they initiated chest compressions but did not give respirations "because the ambu bag was not on the cart."
The facility's own policy required licensed nurses to maintain current CPR certification. Standard CPR protocol, according to the nursing manual inspectors referenced, calls for 30 chest compressions followed by two rescue breaths, continuing at a 30:2 ratio. The manual specifies that rescuers should take no more than 10 seconds to open the airway and deliver the two breaths.
All three staff members who responded to the emergency had expired CPR certifications.
Staff C's certification expired months before the incident. Staff D's certification had also lapsed. Staff E, the registered nurse who called 911, was working with an expired certification as well.
The administrator and director of nursing acknowledged during interviews that the facility had experienced several staff changes and became aware that numerous employees had expired CPR certifications. They confirmed that CPR consists of both rescue breathing and chest compressions, provided to residents based on their physician orders and advance directives.
The director of nursing acknowledged that staff are expected to provide respirations if a resident is not breathing, using an ambu bag, barrier mouthpiece or mouth-to-mouth if no other equipment is available. Both administrators confirmed that Resident 2 died at the facility.
Federal regulations require nursing homes to ensure that residents receive proper emergency care. The facility's failure to maintain current CPR certifications and properly equipped emergency carts violated these requirements. The immediate jeopardy determination reflected inspectors' finding that the deficient care placed residents at risk for serious injury, harm or death.
The facility removed the immediate jeopardy status after inspectors verified that staff had obtained active CPR certifications, emergency equipment was properly maintained, and staff had been re-educated on CPR policies and procedures. The corrective measures ensured an effective system was in place to protect residents requiring CPR.
Inspectors also found that the facility failed to ensure timely physician visits for residents after hospital readmissions. Two residents went 112 days and 50 days respectively without required physician visits within 30 days of returning from the hospital.
Resident 11, who had diabetes, chronic kidney disease and an amputated lower leg, was readmitted in November but never saw a physician during a 112-day period through the inspection date. Resident 14, who had chronic heart failure, returned from the hospital in January but went 50 days without a required physician visit.
The administrator and director of nursing explained that their facility physician had been on leave and they were unable to secure physician coverage during that time. Residents were seen by nurse practitioners or physician assistants instead, but these visits did not meet the regulatory requirement for face-to-face physician contact within 30 days of admission or readmission.
The facility policy, last updated in 2008, required residents to be seen by a physician at least every 30 days for the first 90 days after admission. The administrators acknowledged that physician visits were not completed within the required timeframe for either resident.
Resident 2's death occurred during a period when the facility's emergency response capabilities were compromised by expired staff certifications and inadequate equipment maintenance. Her physician's orders had specifically requested full resuscitation efforts, but the staff who responded to her emergency were unable to provide complete CPR due to their lapsed training and missing equipment.
The incomplete CPR response lasted from 7:45 AM, when Staff C found Resident 2 not breathing, until 8:12 AM, when paramedics arrived and took over resuscitation efforts. During those 27 minutes, Resident 2 received only chest compressions without the rescue breathing that could have helped restore oxygen to her brain and vital organs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shelton Health and Rehabilitation from 2025-03-06 including all violations, facility responses, and corrective action plans.
Additional Resources
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