The incident occurred when Resident #278 became unresponsive and had no pulse. Licensed Practical Nurse I began chest compressions without first confirming the resident's code status, which would have revealed the DNR order prohibiting such life-saving measures.
"LPN I performed CPR on him, which did result in Resident #278 regaining a heartbeat," Director of Nursing B told federal inspectors during a May interview.
The facility's own policy requires staff to "validate the resident is full code and there is no DNR order" before beginning CPR. But that didn't happen.
When Administrator A heard the code blue called, she ran to the nurses station to check Resident #278's status. She confirmed he had a DNR, then rushed back to his room to report it. By then, other staff were already there with the same information. The CPR had already been performed.
The administrator found out only after the event that the nurse had performed CPR on a patient with an active DNR order.
Director of Nursing B was working that evening when she heard staff yelling for help. She ran to Resident #278's room and found three staff members there: CNA H, CNA N, and LPN I. The resident was already beginning to wake up as she entered the room, and LPN I had stopped the chest compressions.
The director confirmed that Resident #278 had been unresponsive without a pulse before the CPR began.
Nobody filed an incident report.
The administrator thought the director of nursing had completed follow-up education with staff after the event. The director of nursing confirmed the facility completed no incident report and initiated no further education to improve the process of ensuring correct code status during emergencies.
Both the administrator and director of nursing told inspectors they expected staff to confirm a resident's code status before initiating CPR.
The facility's CPR policy, last reviewed in 2024, clearly states the first requirement: "Validate the resident is full code and there is no DNR order." Staff must maintain current CPR certification through providers whose training includes hands-on sessions in physical or virtual instructor-led settings with hands-on demonstration.
The violation represents a failure to honor the documented wishes of a resident who had chosen to decline life-sustaining measures. DNR orders reflect deeply personal decisions made by residents or their healthcare proxies about end-of-life care.
The successful resuscitation means Resident #278 received medical intervention they had specifically refused. The lack of an incident report or follow-up training suggests the facility treated the policy violation as routine rather than a serious breach of patient autonomy.
Federal inspectors cited the facility for failing to ensure staff followed established procedures for confirming code status before performing CPR. The violation was classified as causing minimal harm or potential for actual harm, affecting few residents.
The inspection took place on May 21, 2025, as part of routine federal oversight of nursing home operations. The Laurels of Sandy Creek is located at 425 E Elm Street in Wayland, Michigan.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Laurels of Sandy Creek from 2025-05-21 including all violations, facility responses, and corrective action plans.