Resident #61's hands had turned purple and his face was pale when LPN #341 found him without a pulse on the toilet. The licensed practical nurse told inspectors she called 911 but couldn't perform CPR because staff were unable to get the resident off the toilet.
The death occurred during a night shift when the audible signal to the facility's call light system had been disconnected. CNA #368 discovered when she arrived for work that Resident #61's call light was illuminated but making no sound. She checked the call panel and found his light had been on for more than 30 minutes.
"The cord from the annunciator panel at the desk had been disconnected," CNA #368 told inspectors during interviews following a complaint investigation.
LPN #341 was working the third floor that night with two certified nursing assistants when CNAs heard a sound on the wall and entered Resident #61's room. The licensed nurse followed them in and found the resident on the toilet, slumped forward with no pulse.
"His hands were purplish, face was pale, and his skin was warm," LPN #341 told inspectors.
She immediately called for help from LPN #346, who was working downstairs on another unit. When LPN #346 arrived on the third floor to assess Resident #61, she asked staff for the resident's medical chart to determine his code status.
Nobody could find it.
LPN #346 checked for pulses and observed that the resident was mottled. When emergency medical services arrived, they declared Resident #61 dead on arrival and left the facility. No code was called during the emergency.
The facility's own Emergency Procedure-Cardiopulmonary Resuscitation policy required staff to initiate CPR for any unresponsive resident not breathing normally, unless a do-not-resuscitate order specifically prohibited CPR or there were obvious signs of irreversible death like rigor mortis.
If a resident's DNR status was unclear, the policy mandated that CPR be initiated until staff could determine whether a DNR order existed.
LPN #341 eventually accessed a computer and discovered that Resident #61 was designated as a "full code," meaning CPR should have been attempted. But by then, emergency responders had already declared him dead.
In a follow-up interview, LPN #341 confirmed she was uncertain who eventually located the resident's chart, but said "it was nowhere to be found on the third floor" during the emergency.
CNA #368 provided additional details about the moments before the resident's death. She had entered his room and found Resident #61 on the toilet with yellowish hands. Another CNA, #329, asked if he was okay.
"Resident #61 mumbled," CNA #368 told inspectors.
LPN #341 moved in and out of the room several times during this period. CNA #368 checked the resident's pulse and found it was faint initially, but disappeared entirely within minutes.
"Resident #61 was not taken off the toilet and CPR was not completed," she told inspectors.
The unit manager, LPN #307, later confirmed to inspectors that resident code status information was available in the electronic medical record and that nurses always had computer access. This contradicted the emergency response, where staff claimed they couldn't determine Resident #61's code status without his physical chart.
The inspection revealed a cascade of failures during the medical emergency. The disconnected call light system meant Resident #61 could have been in distress for an extended period without staff knowledge. When CNAs finally discovered him in medical crisis, the facility's response violated its own emergency procedures.
Staff failed to immediately initiate CPR on a full-code resident, instead spending critical time searching for a missing chart when the information was accessible electronically. The inability to move the resident from the toilet became the rationale for not attempting life-saving measures.
LPN #341 called the director of nursing after EMS declared the resident dead, and the DON subsequently contacted Resident #61's sister to notify her of his death.
The Ohio Department of Health investigation found the facility in immediate jeopardy violation, the most serious category of nursing home deficiency. This classification indicates conditions that caused or were likely to cause serious injury, harm, impairment or death to residents.
The complaint investigation documented how multiple system failures converged during a single resident's final moments. The silent call light system eliminated an early warning mechanism. Missing charts created confusion about care directives. Staff unfamiliarity with electronic records delayed critical decision-making.
Most significantly, the facility's own emergency procedures were abandoned when staff encountered a logistical challenge, leaving a resident to die without attempted resuscitation despite his full-code status.
The inspection report provides no information about how long Resident #61 may have been in distress before staff discovered him, or whether earlier intervention could have changed the outcome. What remains clear is that Highland Square's emergency response system failed at multiple critical points when a resident needed immediate life-saving care.
Federal inspectors concluded their investigation without identifying any corrective actions taken by the facility to prevent similar emergency response failures in the future.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Square Nursing and Rehabilitation from 2025-05-21 including all violations, facility responses, and corrective action plans.
Additional Resources
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