A Minnesota nursing home has been cited for neglect after four nurses failed to perform CPR on a resident, even though the resident appeared to have been dead for several hours.

The incident occurred in May, when four caregivers came upon an unresponsive resident in bed at the Chris Jensen Health and Rehabilitation Center, in Duluth, MN. The resident had a physician’s order for lifesaving treatment, directing for resuscitation if there was no pulse or breathing, the Minneapolis Star Tribune reported.

But the nurses failed to act, the state found, with one assuming that the patient did not request CPR, another nurse determining it was “too late,” and a third becoming “too upset to do anything,” according to the report. A nurse practitioner ordered staffers not to resuscitate, investigators found, after assessing that the resident was “cold, stiff and had been dead for a while.”

Minnesota officials also determined the 170-bed skilled care provider lacked systems to ensure that residents’ medical wishes were followed when they were found unresponsive, the Tribune noted. Another 45 residents at the facility who have CPR requests were deemed to be at risk by the state.

Chris Jensen Health and Rehab, which is managed by Health Dimensions Group, is reported to have corrected violations by educating nurses on CPR and emergency response measures. It also ran staff drills and reviewed residents’ records.

“We are committed to providing patient-centered care to our residents in a comfortable and respectful environment. At all times, the health, safety and privacy of our residents and staff are our first priority. Should a situation occur, it is thoroughly investigated and any issues addressed,” Amy Porter, executive director of the facility, said in a statement to McKnight’s.

Whether to perform CPR has been an ongoing issue for nursing homes in recent years. An Illinois nursing home employee was charged in March after failing to deliver CPR to a resident who later died. In January, a Syracuse, NY, nursing facility was called out by state surveyors after ­five nurses failed to consult a resident’s chart, which contained a do-not-resuscitate order, and saved her life by using CPR and other measures