Every finding on record at Laurels of Defiance the

Based on observation, staff interview, facility policy, and pharmacy documentation, the facility failed to store resident insulin in a safe and sanitary manner. This affected six of 17 residents (#14, #24, #25, #31, #34 #51) identified by the facility to receive insulin administration in a facility census of 93. Findings include: 1. Observation on [DATE] at 10:55 A.M. with Licensed Practical Nurse (LPN) #402 during observation of the 100 hall medication cart storage noted three open insulin pens. Resident #25 Fiasp insulin pen, Resident #14 Lantus insulin pen, and Resident #34 Basaglar insulin pen. No date was marked on the insulin pens indicated when they were opened. Interview with LPN #402 at the time of observation verified insulin pens, and vials are to be marked with the date when opened. According to facility pharmacy guidelines for Medications with Shortened Expiration dates indicated Fiasp, Lantus, and Basaglar insulins expire 28 after opening. 2. On [DATE] at 10:59 A.M. observation of the medication storage inside the 200 hall medication cart with LPN #457 discovered Resident #51 Novolog insulin pen open inside the cart. No date was marked on the pen indicating when opened. Interview with LPN #457 at the time of observation verified insulin pens and vials are to be marked with the date when opened. According to facility pharmacy guidelines for Medications with Shortened Expiration dates indicated Novolog insulins expire 28 after opening. 3. Observation with LPN #455 on [DATE] at 11:16 A.M. noted the medications stored inside the 300 hall medication cart. Resident #31 Lispro pen was observed to be dated as opened on [DATE]. A Toujeo pen was open without a name or date open marked on the insulin pen. Resident #24 Novolog insulin vial was marked as opened on [DATE]. An insulin vial containing Fiasp insulin was marked as opened on [DATE] without a resident name indicated on the container. Interview with LPN #455 at the time verified the insulin pens and vials lacking appropriate date marking and expired. According to facility pharmacy guidelines for Medications with Shortened Expiration dates indicated Novolog, Fiasp, Lispro insulin expired 28 days after opening. Toujeo insulin pens expire 42 days after opening. On [DATE] at 8:00 A.M. interview with the Director of Nursing (DON) during review of pharmacy guidelines for medications with shortened expiration dates verified insulins observed were to be discarded after 28 days. Facility identified 17 current residents that received insulin. Review of facility medication administration, insulin administration policy effective [DATE] revealed to follow the manufacturer's instruction for storage and expiration. Ensure the opened date is documented on the vial or pen. Check the expiration date prior to administration to ensure it is within the usage date. Expired insulin should be immediately discarded. Vials and pens without an open date recorded should be discarded.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure adequate infection control practices were carried out. This affected three residents (#82, #55, and #303) of five residents reviewed for infection control practices. The facility census was 93. Findings Include: 1. Review of Resident #82's medical record reveals an admission date of 05/13/25 Diagnoses included right femur fracture subsequent encounter, type II diabetes, heart disease, chronic obstructive pulmonary disease (COPD) and clostridium difficile (C-Diff). Review of Resident #82's physician orders revealed an order dated 06/04/25 for oxygen at two liters via nasal cannula to maintain greater than 92% and an order for contact isolation for C-Diff all services provided in room and in room by self. Observation on 06/09/25 at 12:20 P.M. of Resident #82 found her in bed in her room. A sign was posted announcing Resident #82 was on contact precautions. Personal protective equipment including gloves, gowns, and facemasks was available in a cart outside her room. Certified Nursing Assistant (CNA) #477 delivered Resident #82 her breakfast tray and set her food items. Resident #82 requested assistance with adjusting her oxygen tubing. CNA #477 was observed adjusting Resident #82's oxygen tubing in her nose and around her ears. CNA #477 did not don gloves when she came in contact with Resident #82. Interview on 06/09/25 at 12:25 P.M. with CNA #477 verified gloves were available and she should have worn them when she came in physical contact with Resident #82. Review of the facility policy titled, Contact Precautions, revised 10/14/22 revealed health care personnel caring for residents on Contact Precautions should wear gloves and a gown for all interactions that may involve contact with the resident. 2. Review of Resident #55's medical record revealed an admission date of 04/11/25. Diagnoses included hemiplegia and hemiparesis, dysphagia, chronic obstructive pulmonary disease, muscle weakness and cerebral infarction. Observation on 06/09/25 at 12:30 P.M. found CNA #482 delivering hall trays to the 400 hall. Observation on 06/09/25 at 12:35 P.M. found CNA #482 lifted her shirt collar with her left hand and coughed into her hand and shirt. CNA #482 did not use hand sanitizer and removed Resident #55's lunch tray from the meal delivery cart. CNA #482 delivered and set up Resident #55's lunch meal. Interview on 06/09/25 at 12:37 P.M. with CNA #482 verified she had not used hand sanitizer before delivering Resident #55's tray but had used the hand sanitizer in the room after setting up the meal. Review of the facility policy titled, Hand Hygiene, revised 05/08/25 revealed hand hygiene should be preformed after contact with body fluids and when contaminated with proteinaceous materials (phlegm or sputum). 3. Review of Resident #303's medical record revealed an admission date of 06/06/25. Diagnoses include nondisplaced fracture of seventh cervical vertebra, type two diabetes mellitus, history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. Review of Resident #303's physician orders dated 06/06/25 revealed an order for an indwelling urinary catheter. Observation on 06/10/25 at 08:50 A.M. of Resident #303's door and wall outside of the room revealed there was no enhanced barrier precaution sign posted. Interview on 06/10/25 at 08:52 A.M. with Licensed Practical Nurse (LPN) #404 verified an enhanced barrier precaution sign was not present on the door or the wall outside of Resident #303's room. Furthermore LPN #404 verified Resident #303 had an indwelling urinary catheter. Review of the policy titled Enhanced Barrier Precautions (EBP) with a revision date of 03/05/25 revealed to post signage for precautions on the door or wall outside of the residents room indicating the type of precautions and required personal protective equipment (PPE). Furthermore EBP were indicated for residents with indwelling medical devices which included central lines, urinary catheters, feeding tubes, and tracheotomies. This deficiency represents non-compliance investigated under Complaint Number OH00166459 and OH00165186.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure tracheostomy care was provided with approved technique to prevent cross contamination. This affected one (#191) of one residents reviewed for tracheostomy care and treatment. Facility census 93. Findings include: Resident #191 admitted to the facility on [DATE] with diagnoses including, chronic obstructive pulmonary disease, hypertension, anxiety disorder, atrial fibrillation, myocardial infarction, type 2 diabetes mellitus, bipolar disorder, panic disorder, malnutrition, coronary artery disease, anemia, peripheral vascular disease, tracheostomy, and gastrostomy. According to the nursing admission assessment dated [DATE] Resident #191 was assessed with impaired cognition, was dependent on staff for the provision of activities of daily living, received nutrition via feeding tube, and was incontinent of bowel and bladder. Review of physician orders revealed Tracheostomy (Trach) care to be performed every shift effective 05/28/25. Trach size 6 flex as needed for trach information effective 05/29/25. Change inner trach cannula as needed to maintain airway effective 05/29/25. Change inner tracheostomy (Trach) cannula size six (6) daily on night shift effective 05/30/25. Change trach ties weekly every night shift on every Saturday for infection control effective 05/31/25. On 06/09/25 a nursing plan of care was revised to address Resident #191 risk for respiratory distress, decannulation, infection related to Tracheostomy. Interventions were as indicated; Ensure that trach ties are secured at all times. Provide tracheostomy care/dressing change per order/facility protocol. Observation on 06/11/25 at 8:54 A.M. noted Licensed Practical Nurse (LPN) #406 at Resident #191 bedside and placed a Tracheostomy care kit on the overbed table. Multiple personal items were observed on the table and LPN #406 did not clean the table prior to the procedure. LPN #406 washed hands and proceeded to open the Tracheostomy kit. LPN #406 removed and donned sterile gloves from the kit and proceeded to open a bottle of saline which was contained inside the sterile kit. LPN #406 proceeded to open a separate individual disposable inner trach cannula. LPN #406 then handled Resident #191 tracheostomy soiled inner cannula and removed the inner cannula placing it to the trash receptacle. Without changing gloves or washing hands, LPN #406 took a cotton tipped applicator and placed the tip to the saline. LPN #406 cleansed the exterior of the remaining trach opening and inserted the tip into the trach opening. LPN #406 then handled the clean inner cannula with the soiled gloves, placed gloved fingers to the clean shaft of the cannula and subsequently into Resident #191 trach stoma. LPN #406 obtained a clean gauze dressing from the trach kit, dipped the dressing into the saline solution, cleansed the trach stoma and applied a clean/dry drain sponge to the stoma. LPN #406 then removed the existing trach ties and replaced with clean/new trach ties. On 06/11/25 at 9:08 A.M. interview with LPN #406 verified cross contamination had occurred during the tracheostomy cleaning procedure. Review of facility Tracheostomy tube cannula and stoma care procedure undated. Preparation of Equipment. Place equipment and supplies on a clean table or stand near the patient's bed. Open the tracheostomy care kit using sterile technique. Using sterile technique, pour sterile normal saline solution, sterile water, or other cleaning solution into one of the sterile solution containers. Then pour sterile normal saline solution or sterile water into the second sterile container for rinsing. For inner cannula care, you may use a third sterile solution container to hold the sterile gauze pads and sterile cotton-tipped applicators saturated with normal saline solution. If you must replace the disposable inner cannula, open the package containing the new inner cannula. Obtain or prepare new tracheostomy ties, if indicated. Implementation. Perform hand hygiene. Put on gloves and, as needed, other personal protective equipment (PPE). Assess the patient's respiratory status and need for suctioning. Remove the patient's tracheostomy dressing, inspect it for drainage, and then discard it. Remove and discard gloves. Caring for a disposable inner cannula. Perform hand hygiene. Put on clean gloves. Using your dominant hand, remove the patients inner cannula. After evaluating the secretions in the cannula, discard it properly. Pick up the new inner cannula, touching only the outer locking portion. Insert the cannula into the tracheostomy and lock it securely following the manufacturer's instructions. Remove and discard your gloves. Perform hand hygiene. Cleaning stoma and outer cannula. Put on clean gloves. With dominant hand, moisten a gauze pad with normal saline solution or water. The wipe the patients neck under the tracheostomy tube flanges and tracheostomy ties. Assess the stoma site and surrounding skin. Use a cotton tipped applicator and gauze pad to clean the stoma site and the tubes flanges. Wipe only once with each applicator or gauze pad and then discard it to prevent contamination of a clean area with a soiled applicator or pad. Loosen dried secretions with a sterile cotton-tipped applicator or gauze pad. Rinse debris with one or more gauze pads dampened with normal solution or water. Dry area thoroughly with additional gauze pads. Remove the tracheostomy ties and apply new ones. Apply a new tracheostomy dressing. Remove and discard gloves and other PPE. Perform hand hygiene. On 06/11/25 at 9:15 A.M. interview with the Director of Nursing verified LPN #406 did not follow tracheostomy care policy during tracheostomy care and resulted in cross-contamination during the procedure.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure an incontinent resident received timely interventions. This affected one (#191) of two residents reviewed for urinary and bowel incontinence care and services in a facility census of 93. Findings include: Resident #191 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, hypertension, anxiety disorder, atrial fibrillation, myocardial infarction, type 2 diabetes mellitus, bipolar disorder, panic disorder, malnutrition, coronary artery disease, anemia, peripheral vascular disease, tracheostomy, and gastrostomy. According to the nursing admission assessment dated [DATE] Resident #191 was assessed with impaired cognition, was dependent on staff for the provision of activities of daily living, received nutrition via feeding tube, and was incontinent of bowel and bladder. On 06/04/25 a nursing plan of care was revised to address Resident #191's incontinent of bladder and bowel related to mobility impairment. Interventions included; Resident uses disposable briefs. Change as needed (PRN). Check every two (2) hours and PRN for incontinence. Wash, rinse and dry perineum. Change clothing after incontinence care as needed. Observation on 06/09/25 at 8:53 A.M. noted Resident #191 in bed. Interview with Resident #191 at the time revealed he was experiencing loose stools and urinary incontinence. Resident #191 reported he frequently does not receive timely assistance with incontinence care. Review of Plan of Care Task documentation noted Resident #191 provided with incontinence care on 06/09/25 at 2:59 A.M. Resident #191 was documented with bowel and bladder incontinence. No further documentation recorded incontinence checks or associated care. Interview on 06/10/25 at 8:05 A.M. with Certified Nurse Aide (CNA) #438 revealed she assumed care of Resident #191 at 6:00 A.M. and was unaware when Resident #191 was last checked for incontinence. CNA #191 verified she had not checked Resident #191 since assuming care at 6:00 A.M. On 06/10/25 at 8:59 A.M. Resident #191 was noted in bed, awake and alert, and stated he had not been checked for incontinence by current shift and he was currently incontinent. On 06/10/25 at 9:02 A.M. observation with CNA #438 and CNA #482 noted Resident #191 in bed. Resident #191 stated he was incontinent and needed changed. CNA #438 and CNA #482 verified this was the first incontinence check with Resident #191 since assuming care at 6:00 A.M. CNA #482 removed Resident #191's adult incontinence brief and noted he was incontinent of a large amount of urine. CNA #482 provided perineal care and turned the resident to the left side. Resident #191 buttock was noted to be soiled with urine and tissue appeared slightly red. Both CNA's stated Resident #191 was a, heavy wetter and required frequent incontinence checks. On 06/11/25 at 11:04 A.M. interview with the Director of Nursing verified Resident #191 required two hour incontinence checks. Review of facility Nursing Rounds/Licensed Staff policy revised 02/15/24 revealed to check residents at least every two (2) hours. The routine check involves entering the residents room to determine if the residents needs are being met. If there has been a change in the resident's condition; or if the resident has any complaints. This deficiency represents non-compliance investigated under Complaint Number OH00165101.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure pharmacy recommendations were responded to in a timely manner. This affected two residents (#48 and #24) of five residents reviewed for unnecessary medications. The census was 93 residents. Findings Include: 1. Review of Resident #48's medical record revealed an admission date of 11/01/21. Diagnoses included dementia with behavioral disturbance, multiple sclerosis, impulsiveness, adjustment disorder with mixed anxiety and depression, and central nervous system disorder. Review of Resident #48's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating Resident #48 was moderately cognitively impaired. Resident #48 required maximal assistance with toilet use, bathing, personal hygiene. Resident #48 was independent with bed mobility and required supervision with transfer. Resident #48 displayed no behaviors during the review period. Review of Resident #48's Pharmacy Recommendations revealed on 12/17/24 the pharmacist reviewed Resident #48's Ability 5 milligrams (mg) daily for impulse disorder since 07/16/24, Paroxetine 40 mg daily, and Trazodone 25 mg daily and 100 mg at night, having been increased on 08/15/24. The pharmacist recommended a consideration of a gradual dose reduction, perhaps decreasing to Abilify 2 mg daily or document why a gradual dose reduction was clinically contraindicated. The pharmacist recommendation was not reviewed by the physician until 02/12/25. The physician declined the recommendation. Also reviewed by the pharmacist on 12/17/24 was Resident #48's nicotine patch for smoking cessation. Nicotine 21 mg patch since 08/16/24. Please consider a step down schedule based on the individuals body weight, recent cigarette use and cardiovascular disease. The physician did not review the recommendation until 02/12/25. The physician accepted the recommendation. Interview on 06/11/25 at 7:50 A.M. with the Director of Nursing (DON) verified Resident #48's December 2024 pharmacy recommendations were not reviewed by the physician until February 2025. 2. Review of Resident #24's medical record revealed an admission date of 10/18/24. Diagnoses include dementia, anxiety, type two diabetes mellitus, muscle weakness, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively intact. Review of Resident #24's monthly pharmacy review revealed the physician reviewed Resident #24's medication omeprazole 20 milligrams (mg) one capsule by mouth once daily. The pharmacy recommended to discontinue famotidine. The date of the recommendation was 12/18/24 and was signed by the physician on 02/12/25. The physician accepted the recommendations with the following modification: stop famotidine and monitor for worsening of reflux symptoms. Interview on 06/11/25 at 7:51 A.M. with the Director of Nursing (DON) verified the recommendation date was 12/18/24 and was not signed by the physician until 02/12/25. Review of the facility policy titled, Timeliness of Medication Regimen Review (MRR) Reports, with a last revised date of 09/07/23 revealed the attending physician is expected to review the resident's individual MRR and document and sign that he/she had reviewed the pharmacist's identified recommendations within 14 days of receipt.

Based on record review, interview and policy review, the facility failed to terminate employment for a State tested Nursing Assistant (STNA) who had a finding entered in the State Nurse Aide Registry concerning abuse, neglect, or misappropriation. This resulted in one employee, STNA #101, working at the facility while he was not eligible to work in a long-term care facility. This had the potential to affect all residents in the facility. The facility census was 85. Findings include: Review of the personnel file for STNA #101 revealed a hire date of 12/01/22. Review of the background check log revealed STNA #101's background check was submitted 11/22/22, completed 12/07/22 and received at the facility on 12/14/22. STNA #101 was hired to work. Review of the Ohio Department of Health Nurse Aide Registry form dated 11/23/22 revealed STNA #101 was eligible to work and his registry was in good standing. Review of the Criminal History Record Check dated 12/07/22 and stamped by the facility Received 12/14/22 revealed STNA #101 was arrested for theft and forgery 10/30/22 and the case was pending in the local county common pleas court. Review of a court document dated 11/23/22 revealed the defendant, STNA #101, withdrew his plea of not guilty and would apply for the diversion program. Review of the form Employee Disciplinary Record dated 01/09/23 revealed STNA #101 was suspended due to violating the Employee Handbook, Page 6: Rule 3 - your hiring is subject to receipt of a satisfactory criminal background check. STNA #101 would be allowed to return to work when the disqualifying item was removed from his background check. Review of an email correspondence dated 01/20/23 between the Administrator and the facility's corporate office revealed the Administrator requested guidance regarding STNA #101's background check and involvement in a diversion program. Review of the email correspondence dated 02/21/23 revealed a response from the Legal/HR department stating the use of a diversion program was fairly common and because there was no conviction (pending outcome of diversion program) it was okay for STNA #101 to work at the facility. Review of a letter dated 01/25/23 from the facility to the local county Probation Department revealed STNA #101 was hired on 12/01/22 and worked until 01/09/23. Review of the Ohio Department of Health Nurse Aide Registry form dated 02/21/23 revealed STNA #101 was eligible to work and his registry was in good standing. Review of the form titled Diversion Agreement, signed 03/24/23, revealed STNA #101 was accepted into a one-year Diversion Program and was overseen by a Probation Officer. Review of the personnel file for STNA #101 and the staff schedule revealed STNA #101 was scheduled and worked consistently in the facility from 02/22/23 through 11/03/23. Review of the Ohio Department of Health Nurse Aide Registry form dated 11/06/23 revealed STNA #101 was not eligible to work and his registry was not in good standing because STNA #101 was found to have committed abuse, neglect, or misappropriation and could not be employed by a long term care facility in any capacity. Review of the form Employee Disciplinary Record dated 11/06/23 revealed STNA #101 was suspended because the Nurse Aide Registry determined STNA #101 was not in good standing. STNA #101 would be suspended until his license was in good standing. Interview with Payroll/Accounts Payable (PAP) #501 on 11/06/23 at 12:00 P.M. confirmed STNA #101 worked in the facility between 12/01/22 and 01/09/23. PAP #501 confirmed the background check log identified the background check for STNA #101 was received on 12/14/22. Interview on 11/06/23 at 2:02 P.M. with the Director of Nursing (DON) confirmed the Nurse Aide Registry for STNA #101 revealed he was not eligible to work in the facility. The DON stated she became aware of the information on 11/06/23. Interview on 11/06/23 at 2:08 P.M. with the Administrator revealed STNA #101 explained to the facility during his interview about his situation with the court and his plan to be involved in the Diversion Program. The Administrator further stated STNA #101 was suspended while the facility requested guidance from Corporate regarding the Diversion Program. During interview on 11/06/23 at 2:48 P.M. with STNA #101 revealed he pled guilty to the charges brought against him (forgery and theft) on 11/23/22 in order to be allowed to participate in the Diversion Program. STNA #101 believed when he completed the Diversion Program his record would be clear. STNA #101 stated when he was pled guilty on 11/23/22, the court judge told STNA #101 as of today you were not convicted of anything and you can go back to work in healthcare. STNA #101 revealed he had no knowledge he was not in good standing and was not allowed to work in a long term care facility per the Nurse Aide Registry. STNA #101 stated the first time he was aware of it was when the Administrator called him on 11/06/23. During an interview on 11/06/23 at 2:58 P.M., the Administrator revealed STNA #101 returned to work at the facility on 02/22/23. During an interview on 11/06/23 at 5:00 P.M., the Administrator revealed STNA #101 should have been suspended on 12/14/22 when the results of his background check were received. STNA #101 was assigned to the 100 and 200 halls and did not work on the 300 and 400 halls. Review of an email correspondence from the Administrator on 11/07/23 at 9:05 A.M. revealed she believed the results of the background check dated 12/07/22 and stamped by the facility Received 12/14/22 was date-stamped in error and that was why STNA #101 was not suspended on 12/14/22. Review of the undated Employee Handbook revealed hiring was subject to the facility's receipt of a satisfactory criminal background check. Further, staff were required to report to their supervisor or the Administrator of the facility immediately upon being arrested for or convicted of any crime. Review of the policy Abuse Prohibition Policy, effective 10/14/22, revealed the facility shall not employ individuals who have been convicted of or have a finding entered into the State nurse aide registry concern, or have a disciplinary action in effect against his/her license by a state licensure body as a result of a finding of abuse, neglect, exploitation, misappropriation of property or mistreatment of individuals. Further review of the policy revealed the facility would ensure, without exception, all potential licensed and certified candidates must have their status confirmed with the appropriate boards to verify license/certification and to determine if any action has been taken against the license or certification. This deficiency represents non-compliance investigated under Complaint Number OH00147698.

Based on medical record review, staff interview, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidance for Coronavirus 2019 (COVID-19) vaccination and boosters, the facility failed to ensure residents were offered the COVID-19 vaccine booster in a timely manner. This affected six (#4, #11, #19, #20, #26, and #43) of nine residents reviewed for the COVID-19 vaccine. The census was 101. Findings include: 1. Review of Resident #4's medical record revealed an admitted [DATE]. Diagnoses included cutaneous abscess of the buttock, generalized idiopathic epilepsy and epileptic syndromes intractable, chronic obstructive pulmonary disease, dysphasia, muscle weakness, schizoaffective disorder, bipolar disorder, unspecified dementia, hypothyroidism, anxiety disorder, and insomnia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was moderately cognitively impaired. Review of the immunization record revealed Resident #4 last received a two-dose COVID-19 primary vaccine series on 06/07/22 with no documentation of a booster. Review of a Consent/Declination of COVID-19 Vaccination document dated 10/25/22 revealed Resident #4's guardian provided consent for Resident #4 to receive the vaccine booster. 2. Review of Resident #11's medical record revealed an admitted [DATE]. Diagnoses included heart failure, type two diabetes mellitus with diabetic chronic kidney disease, unspecified atrial fibrillation, hyperlipidemia, chronic kidney disease stage four, hypoxemia, and age related osteoporosis. Review of the MDS assessment dated [DATE] revealed Resident #4 was cognitively intact. Review of the immunization record revealed Resident #11 last received a two-dose COVID-19 primary vaccine series on 06/07/22 with no documentation of a booster. Further review of the medical record revealed no additional documentation showing Resident #4 was offered a COVID-19 booster from 06/07/22 to April 2023. 3. Review of Resident #19's medical record revealed an admitted [DATE]. Diagnoses included persistent vegetative state, type two diabetes mellitus, chronic conjunctivitis, filamentary keratitis, gastronomy status, and contracture unspecified joint. Review of the immunization record revealed Resident #19 last received a two-dose COVID-19 primary vaccine series on 06/07/22 with no documentation of a booster. Review of a Consent/Declination of COVID-19 Vaccination document dated 10/27/22 revealed Resident #19's guardian provided consent for Resident #19 to receive the vaccine booster. 4. Review of Resident #20's medical record revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominate side, type two diabetes mellitus without complications, cerebral palsy, hereditary and idiopathic neuropathy, essential (primary) hypertension, moderate intellectual disabilities, anxiety disorder, and muscle weakness. Review of the MDS assessment dated [DATE] revealed Resident #20 was cognitively intact. Review of the immunization record revealed Resident #20 last received a two-dose COVID-19 primary vaccine series on 06/07/22 with no documentation of a booster. Review of a Consent/Declination of COVID-19 Vaccination document dated 10/25/22 revealed Resident #20 provided consent to receive the vaccine booster. 5. Review of Resident #26's medical record revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified sequelae of cerebral infarction, anxiety disorder, major depressive disorder recurrent, essential (primary) hypertension, unspecified osteoarthritis, dysphasia oropharyngeal phase, muscle weakness, and hyperlipidemia. Review of the MDS assessment dated [DATE] revealed Resident #20 was moderately cognitively impaired. Review of the immunization record revealed Resident #26 last received a two-dose COVID-19 primary vaccine series on 06/07/22 with no documentation of a booster. Further review of the medical record revealed no additional documentation showing Resident #26 was offered an updated COVID-19 booster from 06/07/22 to April 2023. 6. Review of Resident #43's medical record revealed an admitted [DATE]. Diagnoses included Parkinson's disease, other neuromuscular dysfunction of bladder, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance psychotic disturbance, Alzheimer's disease with late onset, paroxysmal atrial fibrillation, hypertensive chronic kidney disease with stage five chronic kidney disease or end stage renal disease, hypertensive heart disease with heart failure, and essential primary hypertension. Review of the MDS assessment dated [DATE] revealed Resident #43 was rarely understood. Review of the immunization record revealed Resident #43 last received a two-dose COVID-19 primary vaccine series on 05/26/22 with no documentation of a booster. Review of a Consent/Declination of COVID-19 Vaccination document dated 10/25/22 revealed Resident #43 provided consent to receive the vaccine. Interview on 04/04/23 at 11:44 A.M. with the Director of Nursing #380 verified COVID-19 boosters were not offered timely for Resident #4, #11, #19, #20, #26, and #43. Review of facility policy titled, COVID Today Guidelines, effective 03/13/23, verified maintenance vaccine clinics must be scheduled weekly for current and new guests and residents who have not received the vaccine yet and would like to receive it. Facilities should administer the booster doses at the maintenance clinics. Review of the CDC guidance titled, Stay Up to Date with COVID-19 Vaccines Including Boosters, dated 03/02/23, revealed the CDC recommended people stay up to date with the COVID-19 vaccine for their age group. The CDC recommends one updated vaccine for everyone five years and older. Updated boosters are called updated because they protect against both the original virus that causes COVID-19 and the Omicron variant. Two COVID-19 vaccine manufacturers, Pfizer and Moderna, have developed updated COVID-19 boosters. Updated COVID-19 boosters became available on 09/22/22 for people aged [AGE] years and older.

Based on medical record review, observation, staff interview, and facility cleaning schedule, the facility failed to ensure resident wheelchairs were maintained in a clean and sanitary manner. This affected four (#12, #43, #48, #63) of four residents reviewed for clean equipment. The census was 101. Findings include: 1. Review of Resident #48's medical record revealed an admitted [DATE]. Diagnoses included benign neoplasm of the left choroid, hyperlipidemia, major depressive disorder recurrent, difficulty in walking, muscle weakness, benign prostatic hyperplasia without lower urinary tract symptoms, and essential primary hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of Resident #48's medical record revealed Resident #48 utilized a wheelchair. Observation on 04/03/23 at 5:00 P.M. of Resident #48's wheelchair revealed the wheelchair had a build up of grime and dirt along the metal bars along the side and under the wheelchair. Interview on 04/03/23 at 5:09 P.M. with Licensed Practical Nurse (LPN) #383 verified there was a regular cleaning scheduled for resident equipment and should be cleaned at least monthly. LPN #383 verified Resident #48's wheelchair was dirty and had not been cleaned in an unknown amount of time. 2. Review of Resident #63's medical record revealed was admitted on [DATE]. Diagnoses included cerebrovascular disease, unspecified dementia unspecified severity without behavioral disturbance, benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, anxiety disorder. Review of the MDS assessment, dated 02/11/23, revealed the resident was severely cognitively impaired. Review of the medical record revealed Resident #63 utilized a wheelchair. 44815 3. Review of the medical record for Resident #12 revealed a readmitted [DATE] with diagnoses of Alzheimer's disease, dementia, and history of falling. Review of the quarterly MDS assessment dated [DATE] revealed Resident #12 had severely impaired cognition and required a wheelchair for mobility. 4. Review of the medical record for Resident #43 revealed an admitted [DATE] with diagnoses of Parkinson's disease and dementia. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #43 was rarely understood and required a wheelchair for mobility. Observation and interview on 04/03/23 at 5:12 P.M. with LPN #396 confirmed Resident #63's wheelchair had clumps of dust hanging from the framework under his wheelchair, Resident #12's wheelchair had thick dust on the frame of her power wheelchair, and Resident #43's wheelchair wheels were splattered with a light brown substance that appeared to be chocolate milk, and the cog at the joint of the wheel and the spokes were coated in dust and debris. Continued interview with LPN #396 stated wheelchairs were expected to be cleaned during third shift. Review of an undated cleaning chore list revealed each hall was listed separately and then each day of the week up to two rooms were listed each day for a hall. Interview on 04/04/23 at approximately 11:30 A.M. with Director of Nursing (DON) #381, upon reviewing the cleaning chore list document, verified resident equipment, including resident wheelchairs, are to be cleaned by third shift staff on the designated days according to the chart.

Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure resident preference and choice for when to get up was honored. This affected two (#37 and #35) of five residents reviewed for choices. The census was 101. Findings include: 1. Review of Resident #37's medical record revealed a re-admitted [DATE] with an initial admitted d of 06/01/22. Diagnoses included Parkinson's disease, heart failure, syncope and collapse, cirrhosis of liver, major depressive disorder, diabetes mellitus type II, anxiety disorder, dysphagia, and personal history of COVID-19. Review of Resident #37's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #37 was cognitively intact. Resident #37 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #37 displayed no behaviors during the review period. Review of Resident #37's care plan revised 02/14/23 revealed supports and interventions for the risk for impaired skin integrity, risk for pain, risk for discomfort or adverse side effects of anti-Parkinson therapy, and self-care deficit. Interventions for self-care deficit included assistance of two staff members for transfers and a preference for morning showers. Observation on 04/03/23 at 10:20 A.M. of Resident #37 found him wearing a gown and lying in bed. Interview on 04/03/23 at 10:23 A.M. with Resident #37 found him to be alert and aware. Resident #37 stated he was not happy he was still in bed. Resident #37 stated the staff knew his preference to get up and ready after breakfast, but it was almost time for lunch and he had not gotten up yet. Interview on 04/04/23 at 1:18 P.M. with State tested Nursing Assistant (STNA) #411 stated Resident #37 was able to make his needs known and was cooperative with care. STNA #411 reported Resident #37 was able to participate in his care but required assistance. STNA #411 reported being aware of Resident #37's preference to be up and ready for the day before or shortly after breakfast. STNA #411 verified she had not gotten Resident #37 up and out of bed yesterday when he wanted. She reported she just did not have the time to get to him. 2. Review of Resident #35's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus type II, morbid obesity, major depressive disorder, chronic kidney disease, and lymphedema. Review of Resident #35's MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #35 was cognitively intact. Resident #35 required extensive assistance with bed mobility, dressing, and toilet use. Resident #35 was totally dependent on staff for transfers, personal hygiene, and bathing. Resident #35 displayed no behaviors during the review period. Review of Resident #35's care plan revised 04/06/23 revealed supports and interventions for risk for decline in cognition, risk for impaired skin integrity, potential for difficulty breathing, chronic pain, self-care deficit, and risk for falls. Observation on 04/03/23 at 10:00 A.M. of Resident #35 found him lying in bed. Interview on 04/03/23 at 10:01 A.M. with Resident #35 found him to be alert and aware. Resident #35 reported he was very unhappy. He stated the staff knew he wanted to get up around 8:00 A.M. and it was now 10:00 A.M. and he was still not gotten up. Resident #35 stated BINGO was supposed to be starting soon in the dining room area, and he was going to miss it because he was still in bed. Resident #35 reported it was his birthday and they were having a party for him in the afternoon. He stated he was really hoping to be up by then. Observation on 04/03/23 at 10:32 A.M. found a group of residents in the dining room area participating in BINGO and Resident #35 was observed to still be in bed. Observation on 04/03/23 at 1:34 P.M. found Resident #35 dressed, up in his wheelchair, and in the common area for his birthday celebration. The residents who were at the party were observed participating again in BINGO. Interview on 04/04/23 at 1:26 P.M. with State tested Nursing Assistant (STNA) #411 stated Resident #35 was able to make his needs know, was cooperative with care, and required staff assistance for getting up and ready in the morning. STNA #411 reported Resident #35 liked to get up out of bed early in the morning, usually right after breakfast. STNA #411 verified she had not gotten Resident #35 up yesterday until around 11:00 A.M. STNA #411 reported she was just not able to get to him. Review of the facility policy titled, Guest/Resident Rights, revised 04/28/22, revealed the resident had the right to a dignified existence and self-determination.

Based on medical record review, staff interview, review of an incident and accident log, and review of facility policy, the facility failed to ensure proper notifications were made following resident falls and transfers to the emergency room . This affected two (#16 and #77) of eight residents reviewed for notification. The census was 101. Findings include: 1. Review of Resident #16's medical record revealed an admitted [DATE]. Diagnoses included Parkinson's disease, schizoaffective disorder, muscle weakness, diabetes mellitus type II, anxiety disorder, major depressive disorder, hoarding disorder, morbid obesity, and osteoarthritis. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #16 was cognitively intact. Resident #16 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #16 was totally dependent on staff for bathing. Resident #16 displayed no behaviors during the review period. Review of Resident #16's care plan revised 02/18/23 revealed supports and interventions for risk for changes in mood, grief, self-care deficit, and risk for falls. Interventions for fall risk included anticipate needs, assess risk level for falls on admission and as needed, bed against the wall to increase functional space, fall risk protocol, encourage the resident to wear appropriate footwear as needed, keep the environment safe, keep the call light in reach, provide adequate lighting, keep commonly used item in reach, lock the wheels on the wheelchair prior to transfers, provide an adaptive wheelchair as needed, utilize a four wheeled walker, provide side rails, provide activities, and maintain non-skid strips to the floor in front of the bed. Review of Resident #16's fall risk assessment completed 02/16/23 revealed Resident #16 was at risk for falls. Review of the incident accident log from 11/04/22 through 04/03/23 revealed Resident #16 fell on [DATE], 12/31/22, 01/19/23, and 02/07/23. Review of Resident #16's fall investigations revealed Resident #16's responsible party was not notified of Resident #16's fall on 12/31/22, and Resident #16's physician was not notified of Resident #16's fall on 02/07/23. Interview on 04/04/23 at 1:09 P.M. with Resident #16 state she fell often, and reported sometimes staff were with her when she fell and sometime she was by herself. Interview on 04/06/23 at 2:29 P.M. with Director of Nursing (DON) #381 verified Resident #16's responsible party was not notified of Resident #16's 12/31/22 fall, and Resident #16's physician was not notified of Resident #16's 02/07/23 fall. 44815 2. Review of the medical record for Resident #77 revealed an admitted [DATE] with diagnoses of abnormalities of gait and mobility, dementia, and fracture of the neck of the right femur. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #77 had intact cognition and required extensive assistance of one person for transfers and locomotion. Further review revealed Resident #77 had a fracture related to a fall in the last six months. Review of the medical record for Resident #77 revealed a fall risk assessment was completed on admission. Review of the medical record for Resident #77 revealed he fell on [DATE], was assessed for injuries, and sent to the emergency room . Review of the progress notes dated 01/31/23 revealed no documentation Resident #77's family was notified of his transfer to the emergency room . Review of the fall investigation dated 01/31/23 revealed no documentation family was notified of Resident #77's transfer to the emergency room . Interview on 04/06/23 at approximately 4:00 P.M. with the DON #381 confirmed the medical record for Resident #77 did not include documentation his family was notified on 01/31/23 when he was transferred to the emergency room . Review of the facility policy titled Notification of Change, revised 12/19/22, revealed the facility must inform the resident, resident's physician and the resident's representative when there is a change in status. A change in status would include an accident involving the resident. Review of the facility policy titled, Fall Management, revised 08/18/22, revealed residents would be evaluated for their risk for falls and a plan of care would be developed and implemented based on the evaluation with ongoing review. Evaluations would be completed for fall risk upon admission, re-admission, quarterly, annually and with a significant change in condition. The licensed nurse would notify the attending physician and the responsible party of the fall and document the notification in the medical record.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure residents received appropriately thickened liquids. This affected one (#46) of two residents reviewed for thickened liquids. The census was 101. Findings include: Review of the medical record for Resident #46 revealed an admitted [DATE] with diagnoses of multiple sclerosis, morbid obesity, and dysphagia (difficulty swallowing). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had moderately impaired cognition and was independent with setup help only for eating. Review of the physician order dated 03/10/23 revealed Resident #46 received a mechanical soft diet with nectar thickened liquids. Observation on 04/05/23 at approximately 10:23 A.M. revealed Resident #46 in a wheelchair in her room with an overbed table within reach. Further observation of the overbed table revealed a large plastic cup with clear liquid and ice cubes in it. Interview at that time with Resident #46 verified she was able to reach her drink and could drink independently. Interview and observation on 04/05/23 at 10:39 A.M. with Licensed Practical Nurse (LPN) #395 confirmed Resident #46 had ice cubes in her water. Further interview with LPN #395 confirmed Resident #46 was on thickened liquids and should not have ice in her drinks. LPN #395 could not identify who provided the water to Resident #46. LPN #395 confirmed Resident #46 was on thickened liquids. Interview on 04/05/23 at 10:42 A.M. with LPN #383 stated she did not fill Resident #46's cup, but did ensure it was within reach when she repositioned Resident #46 prior to the observation on 04/05/23 at approximately 10:23 A.M. LPN #383 was unaware Resident #46 had a physician order for thickened liquids. Review of the facility policy titled, Diet Orders, reviewed 11/12/21, revealed the facility would adhere to therapeutic diet parameters.

Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents who required staff assistance with activities of daily living, received adequate and timely care to maintain good personal hygiene including shaving, nail care, and received timely and adequate assistance with meals. This affected three (#16, #29, and #71) of five residents reviewed for activities of daily living. The census was 101. Findings include: 1. Review of Resident #16's medical record revealed an admitted [DATE]. Diagnoses included Parkinson's disease, schizoaffective disorder, muscle weakness, diabetes mellitus type II, anxiety disorder, major depressive disorder, hoarding disorder, morbid obesity, and osteoarthritis. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #16 was cognitively intact. Resident #16 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #16 was totally dependent on staff for bathing. Resident #16 displayed no behaviors during the review period. Review of Resident #16's care plan revised 02/18/23 revealed supports and interventions for risk for changes in mood, grief, and self-care deficit. Interventions for bathing included to check nail length and trim and clean on bath days and as necessary with a bathing type listed as a shower. Observation on 04/03/23 at 3:24 P.M. of Resident #16 found her hair appeared unclean and she had facial hair on her chin and upper lip that was approximately one-half inch long. Interview on 04/03/23 at 3:26 P.M. with Resident #16 revealed she was alert and aware. Resident #16 reported she had not been getting bathed or shaven. She was supposed to be shaved when she got showers but she was not being showered and was only getting washed up in bed. Resident #16 reported she was supposed to get showers three times a week. Resident #16 stated she did not like having hair on her face. Review of Resident #16's shower schedule revealed she was supposed to receive a shower on first shift on Mondays, Wednesdays, and Fridays. Observation on 04/04/23 at 7:13 A.M. of Resident #16 found she still had facial hair and her hair appeared unclean. Observation on 04/04/23 at 11:24 A.M. of Resident #16 found her seated in the dining room with 12 other random residents. Resident #16 had observable facial hair on her upper lip and chin. Interview on 04/04/23 at 1:12 P.M. with State tested Nurse Aide (STNA) #411 verified Resident #16 was supposed to be showered and shaved on 04/03/23 on first shift, and verified she had not showered or shaved her. STNA #411 reported she ran out of time on 04/03/23, and she would make sure Resident #16 got showered and shaved on Wednesday. STNA #411 was not able to say when the last time Resident #16 was provided an actual shower and was shaven. STNA #411 verified Resident #16 had long facial hair. 2. Review of Resident #29's medical record revealed an admitted [DATE]. Diagnoses included cerebral infarction, Parkinson's disease, dysphagia, hemiplegia, major depressive disorder, contracture of muscle at multiple sites, muscle weakness, and personal history of COVID-19. Review of Resident #29's MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #29 was moderately cognitively impaired. Resident #29 was totally dependent on staff for bed mobility, transfers, personal hygiene and bathing. Resident #29 required extensive assistance with dressing, eating, and toilet use. Resident #29 displayed no behaviors during the review period. Resident #29 was not receiving therapy services at the time of the review. Resident #29 had limited range of motion impairment on both sides of his lower extremities and impaired on one side of his upper extremities. Review of Resident #29's care plan revised 03/12/23 revealed supports and interventions for impaired communication, risk for complications of left side hemiplegia and hemiparesis, risk for fluctuation in mood and self-care deficit. Interventions for self-care deficit included oral care after all oral intakes, staff extensive assistance to eat, between extensive assistance to dependent on staff assistance with personal hygiene, when bathed staff were to check his nail length and trim and clean his nails on the bath day and as necessary, and keep fingernails trimmed and clean. Observation on 04/03/23 at 1:30 P.M. found Resident #29 lying in bed. Resident #29's fingernails were long and his face was unshaven with about a quarter of an inch of hair growth. Interview on 04/03/23 at 1:32 P.M. found Resident #29 was alert, aware, and able to answer single word and yes and no questions. Resident #29 reported he was not able to shave himself or cut his fingernails. Resident #29 indicated he wanted his nails and facial hair trimmed, and the staff had not done it like he wanted. Observation on 04/04/23 at 11:32 A.M. of Resident #29 found him up in his wheelchair. Resident #29 continued to be unshaven and his fingernails were long. Interview on 04/04/23 at 1:22 P.M. with STNA #411 stated Resident #29 was totally dependent on staff for all his activities of daily living (ADLs). STNA #411 reported Resident #29 was bathed on third shift on Mondays, Wednesdays, and Fridays. STNA #411 reported when Resident #29 was bathed he was to be shaven and have his nails trimmed if needed. STNA #411 verified Resident #29 had not been shaven and his fingernails were long. Observation on 04/05/23 at 8:38 A.M. of Resident #29 found him up in his wheelchair in the dining room for breakfast. Resident #29 continued to not be shaven. His hands were under a blanket and his fingernails were not able to be observed. Interview on 04/05/23 at 8:39 A.M. with Physical Therapy Staff (PTS) #460 stated she was assisting residents with eating and getting them back to their rooms following breakfast on 04/05/23. PTS #460 uncovered Resident #29's hands and opened them. PTS #460 verified Resident #29 was unshaven and his fingernails were long. Interview on 04/05/23 at 3:05 P.M. with STNA #444 stated Resident #29 was not resistant to care but at times he would pull his face away when she was being shaven. Review of the facility policy titled, Routine Resident Care, revised 03/07/23, revealed residents were to receive the necessary assistance to maintain good grooming and personal hygiene. 41528 3. Review of Resident #71's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease with late onset, type two diabetes mellitus without complications, obstructive sleep apnea, mixed hyperlipidemia, essential (primary) hypertension, muscle weakness, hypokalemia, hypothyroidism, major depression recurrent mild, dysphagia, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the MDS assessment dated [DATE] revealed Resident #71 was rarely understood. Resident #71 was assessed to require extensive one person assistance with dressing and eating, extensive two person assistance with bed mobility, one person total dependence with locomotion on and off the unit, and two person total dependence with transferring, toileting, personal hygiene, and bathing. Resident #71 received a mechanically altered diet and was on hospice. Review of the care plan dated 08/24/22, and updated on 02/01/23, revealed Resident #71 was care planned for activities of daily living self care performance deficit and required assistance with activities of daily living and mobility. Interventions included Resident #71 required extensive assistance to eat. Observation on 04/03/23 at 11:22 A.M. revealed the meal cart arrived to Resident #71's hall and meal trays were passed. At 11:48 A.M., Resident #71 was observed laying down flat on his back in bed with his meal tray on the bedside table next to the bed but out of reach. The pureed lunch meal was uncovered. Subsequent interview with Resident #71 revealed he believed he had not received the lunch meal and when he saw the tray began to attempt to pull the meal tray from the bedside table to his lap. Interview on 04/03/23 at 11:51 A.M. with Licensed Practical Nurse (LPN) #383 verified Resident #71 required extensive assistance with eating. LPN #383 verified the meal trays had been passed approximately 30 minutes ago and other residents' trays in the hall were beginning to be picked up from residents finishing their meal. LPN #383 stated she could not verify the temperature because she did not have a thermometer but would guess that Resident #71's meal was no longer warm. Interview on 04/03/23 at 12:01 P.M. with LPN #383 and STNA #505 stated it was STNA #505's second day at the facility and when passing out trays she had just sat Resident #71's tray down not knowing he needed assistance eating.

Based on medical record review, staff interview, review of an incident and accident log, and review of facility policy, the facility failed to ensure neurological checks were completed following unwitnessed falls. This affected one (#16) of five residents reviewed for falls. The census was 101. Findings include: Review of Resident #16's medical record revealed an admitted [DATE]. Diagnoses included Parkinson's disease, schizoaffective disorder, muscle weakness, diabetes mellitus type II, anxiety disorder, major depressive disorder, hoarding disorder, morbid obesity, and osteoarthritis. Review of Resident #16's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #16 was cognitively intact. Resident #16 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #16 was totally dependent on staff for bathing. Resident #16 displayed no behaviors during the review period. Review of Resident #16's care plan revised 02/18/23 revealed supports and interventions for risk for changes in mood, grief, self-care deficit, and risk for falls. Interventions for fall risk included anticipate needs, assess risk level for falls on admission and as needed, place the bed against the wall to increase functional space, fall risk protocol, encourage the resident to wear appropriate footwear as needed, keep the environment safe, maintained the call light in reach, provide adequate lighting, place commonly used items in reach, lock the wheels on the wheelchair prior to transfers, provide an adaptive wheelchair as needed, utilize a four wheeled walker, maintain side rails, provide activities, and place non-skid strips to the floor in front of the bed. Review of Resident #16's fall risk assessment completed 02/16/23 revealed Resident #16 was at risk for falls. Review of an incident and accident log from 11/04/22 through 04/03/23 revealed Resident #16 had falls on 11/13/22, 12/31/22, 01/19/23, and 02/07/23. Review of Resident #16's fall investigations revealed on 11/13/22 and 12/31/22 Resident #16 had unwitnessed falls in her room. No neurological checks were found as completed. Interview on 04/04/23 at 1:09 P.M. with Resident #16 stated she fell often, and reported sometimes staff were with her when she fell and sometimes she was by herself. Interview on 04/06/23 at 2:29 P.M. with Director of Nursing (DON) #381 verified Resident #16 did not have neurological checks completed following her unwitnessed falls on 11/13/22 and 12/31/22. Review of the facility policy titled, Fall Management, revised 08/18/22, revealed residents would be evaluated for their risk for falls and a plan of care would be developed and implemented based on the evaluation with ongoing review. Evaluations would be completed for fall risk upon admission, re-admission, quarterly, annually and with a significant change in condition. If a potential head injury was present complete the neurological record.

Based on medical record review and staff interview, the facility failed to ensure an as-needed anti-anxiety medication order had an end date. This affected one (#50) of five residents reviewed for unnecessary medications. The census was 101. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE] with medical diagnoses of anxiety and depression. Review of the quarterly Minimum Data Set (MDS) assessment revealed Resident #50 had intact cognition and was independent with setup help only for eating. Further review revealed Resident #50 received an anti-anxiety medication daily. Review of the current physician order dated 12/20/22 revealed Resident #50 received Xanax (an anti-anxiety medication) 0.25 milligrams (mg) up to three times daily as needed for 30 days. The end date on the order was marked indefinite. Review of a nursing note dated 12/20/22 revealed the order noted for no stop date on Xanax. Review of the physician progress notes dated 12/20/22 through 04/05/23 revealed no evaluation was completed to justify the continued use of the as-needed anti-anxiety medication. Review of the psychiatric notes completed on 02/01/23 and 03/08/23 revealed no evaluation was completed to justify the continued use of the as-needed anti-anxiety medication. Interview on 04/06/23 at 3:02 P.M., with the Director of Nursing (DON) #381 confirmed the as-needed order for Xanax did not have an end date and the facility could not provide documentation to verify a physician had evaluated Resident #50 for continued use of an as-needed order for an anti-anxiety medication.

Based on observation, staff interview, and facility policy review, the facility failed to properly store and secure medications. This affected one (#97) of one residents reviewed for medication storage. The census was 101. Findings include: Review of the medical record revealed Resident #97 was admitted on [DATE]. Diagnoses included hypo-osmolality and hyponatremia and delirium due to known physiological condition, encephalopathy, end stage renal disease, type two diabetes mellitus without complications, muscle weakness, hyperlipidemia, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 was cognitively intact. Review of Resident #97's physician order dated 03/14/23 revealed an order for the anti-nausea medication Zofran oral tablet four (4) milligrams (mg) give one tablet by mouth every eight hours as needed for nausea and vomiting and send to dialysis. Observation on 04/05/23 at 5:04 P.M. of the hemodialysis communication book revealed a hemodialysis communication document, dated 03/31/23, with a packaged Zofran tablet stapled to the top of the page. The hemodialysis book was maintained at the 100 and 200 hall nurse's station and was unsecured. Interview on 04/05/23 at 5:15 P.M. with Director of Nursing (DON) #381 verified the unsecure medication. Review of the medication administration policy, dated 10/14/22, revealed to ensure the medication cart is locked at all times when it is not in use or not within your contact vision. Store the locked medication cart in the appropriate storage area between medication passes.

Based on open and closed medical record reviews, staff interviews, physician interview, review of an emergency services run report, review of hospital documentation, review of a death certificate, review of a facility investigation, review of a facility facsimile (fax) transmittal binder, and review of facility policies regarding abuse, managing emergencies, and standards of nursing practice, the facility failed to ensure residents were free from neglect by providing on-going and timely assessments when there was an identified significant change in condition for one resident (Resident #12). This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #12 was complaining of abdominal pain and distention, difficulty breathing, and signs of gastrointestinal (GI) bleeding, and pleading to be sent to the hospital or be seen by a physician when the facility neglected to perform on-going or timely assessments nor seek appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#12) of four residents (#12, #15, #18, and #20) reviewed for appropriate assessments and timely treatment following a change in condition. The facility census was 97. On [DATE] at 4:44 P.M., the Administrator and Registered Nurse (RN) Regional Clinical Coordinator #100 were notified Immediate Jeopardy began on [DATE] when a staff member (Nurse Aide (NA) #399) noted Resident #12 complained of abdominal pain and distention, was eating very little, and had dark black tarry stools during incontinence care. There was no assessment or treatment completed for Resident #12 at that time. Resident #12 continued to have dark black tarry stools on [DATE], was not eating food, and complained of persistent abdominal pain without a treatment being sought or an assessment being completed. On [DATE], Resident #12 refused meals, complained of gas and abdominal pain, and was noted to have flushed and dry skin that was warm to the touch. The physician was notified via fax on [DATE] at 1:44 A.M., that medications offered to treat Resident #12's abdominal pain were not effective, and Resident #12 requested to see the physician or nurse practitioner as soon as possible. The fax was sent to a closed physician office and Resident #12 continued to complain of gas and abdominal pain. On [DATE], Resident #12 displayed pale color, shortness of breath and difficulty breathing, blue lips, was trembling, and had a large dark black tarry stool which was continuously flowing from the rectum. On [DATE], Licensed Practical Nurse (LPN) #444 obtained Resident #12's vital signs; however, no other assessment was completed. LPN #444 was instructed to fax the physician; however, the physician never received the fax, and no other attempts were made to notify the physician about Resident #12's physical condition or to seek further treatment. Resident #12's condition deteriorated and was sent to the emergency room (ER) after Resident #12 pleaded with Nurse Aide #415 to call emergency services using Resident #12's personal telephone. Resident #12 died on [DATE] at 12:11 P.M. at the hospital. The Immediate Jeopardy was removed on [DATE] at 10:48 A.M. when the facility implemented the following corrective actions: · On [DATE], Registered Nurse (RN) #200 and LPN #300 completed pain evaluations and summaries for change of condition on all current residents to determine if evaluations were completed and treatment provided. The evaluations and summaries were completed on [DATE] with no concerns identified. · On [DATE], Assistant Director of Nursing (ADON) #550 began education with all licensed nurses and nurse aides on abuse, neglect, and change in resident condition. On [DATE], the education was added to the general orientation for all newly hired licensed nurses. All 27 licensed nurses and all 38 nurse aides were educated by [DATE]. · On [DATE], ADON #550 began education with all licensed nurses that if a change in condition is identified in a resident, immediate action is needed, and the findings must be relayed to the physician immediately. All 27 nurses were educated by [DATE]. · On [DATE], ADON #550 began education with all licensed nurses on resident assessment techniques. All 27 nurses were educated by [DATE]. · On [DATE], ADON #550 began education with all nurse aides on identifying and notifying the licensed nurses immediately of resident changes in condition. All 38 nurse aides were educated by [DATE]. · On [DATE], ADON #550 began education with all licensed nurses regarding residents requesting to go to the hospital. All 27 nurses were educated by [DATE]. · On [DATE], ADON #550 began education with all licensed nurses regarding assessments of residents for constipation. All 27 nurses were educated by [DATE]. · On [DATE], RN Regional Clinical Coordinator #100 completed a chart audit of all current residents to review for bowel movements over the last three days. The audit was to identify any residents who had not had a bowel movement and if treatment was provided. The chart audit for all current residents concluded on [DATE] with no concerns identified. · On [DATE], ADON #550, RN #200, and LPN #300 completed head to toe assessments on all current residents including evaluation of lung sounds, bowel sounds, and pedal pulses with no concerns identified. · On [DATE], the Quality Assurance and Performance Improvement (QAPI) committee reviewed the facility policy for abuse and neglect and acute change in resident condition to determine content and appropriateness with no changes recommended to the policy. · On [DATE], review of the medical records for Resident #15, Resident #18, and Resident #20, revealed no concerns related to staff timely assessing and seeking treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] · On [DATE], the Director of Nursing (DON), or designee began audits of all current residents on the 24-hour report in the electronic health record, and review for documentation of acute changes in resident condition. The DON, or designee, will interview five nurses regarding identifying resident change in condition, the process to notify the physician, and ensure appropriate interventions and assessments were conducted in accordance with the policy. Audits will be completed five times weekly for four weeks, then weekly for four weeks, then monthly for three months. The audit will be reviewed by the QAPI committee monthly and the DON is responsible for sustained compliance. · On [DATE], the DON or designee will interview five nurse aides regarding the process to follow regarding notification to the nurse of a change in resident condition. Audits will be completed five times weekly for four weeks, then weekly for four weeks, then monthly for three months. The audit will be reviewed by the QAPI committee monthly and the DON is responsible for sustained compliance. · On [DATE], between 10:22 A.M. and 10:48 A.M., four nurses (LPN #221, LPN #470, LPN #427, LPN #674) and four nurse aides (NAs) (NA #415, NA #379, NA #632, NA #696) verified they were educated on resident abuse and neglect, resident assessments, reporting changes in resident condition to the licensed nurses, and timely notifying the physician of changes in resident condition. All staff members interviewed were knowledgeable of the content of each education provided by the facility. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #12's closed medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 was discharged on [DATE]. Review of the most recently completed Minimum Data Set (MDS) assessment completed [DATE] revealed Resident #12 had intact cognition. Resident #12 was assessed to be independent with eating and required an extensive two-plus persons assistance with toileting during the reference period. Resident #12 also received an anticoagulant medication (a blood thinning medication) seven days of the seven-day look back period. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #12's advance directives order was Full Code Resuscitation which meant resuscitative actions (including the use of powerful heart or blood pressure medications and/or cardiopulmonary resuscitation (CPR) to maintain life) were to be attempted if the resident went into cardio and/or pulmonary arrest. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #12 was ordered the anticoagulant medication [MEDICATION(S)] 5 milligrams (mg) by mouth twice daily. Review of Medication Administration Records (MARs) from February and [DATE] revealed Resident #12 received the anticoagulant medication as ordered. Review of a nursing progress note dated [DATE], documented by Licensed practical Nurse (LPN) #470, revealed Resident #12 complained of an upset stomach with no emesis. Review of a subsequent nursing progress note dated [DATE], documented by LPN #470, revealed Resident #12 continued to complain of nausea and vomiting and was explained to eat light and clear liquids. Resident #12 was noted to have drunk soda pop on this day. LPN #470 documented tried to raise Resident #12's head up to prevent aspiration and Resident #12 states she can't lay that way and the physician was notified. Review of a nursing progress note dated [DATE] at 5:33 P.M., documented by LPN #444, revealed Resident #12 still had nausea and vomiting and when staff walked into Resident #12's room, Resident #12 was putting her fingers down her throat. When questioned by staff, Resident #12 indicated she was trying to induce vomiting to help her feel better. Resident #12 was encouraged to have a clear liquid diet and eat light foods and was noted to have drunk more soda pop. Review of a nursing progress note dated [DATE], documented by LPN #470, revealed Resident #12 had no emesis but indicated her stomach still felt queasy. Review of a nursing progress note dated [DATE], documented by LPN #404, revealed the physician was notified via fax of Resident #12's continued refusal to eat or drink more than soda pop and a few sips of water with medications. Resident #12 reported pain across the epigastric region which radiated to her back, and the physician was also informed Resident #12 was afraid to eat due to the increased pain it caused. Further review of the progress note indicated Resident #12 was encouraged to take a pain medication ([MEDICATION(S)]) and an anti-nausea medication ([MEDICATION(S)]) to help with symptoms which were both ordered for Resident #12 as needed. Review of Nurse Practitioner (NP) #606's progress note dated [DATE] revealed Resident #12 had complaints of diarrhea, some nausea, and epigastric pain for almost one week. Resident #12 was not eating much but drinking at least 10 soda pops a day. Resident #12's abdomen was soft and non-tender on examination and vital signs were normal. NP #606 order laboratory (lab) values and an abdominal x-[CONDITION(S)] (x-ray). Review of lab values dated [DATE] revealed no critical or abnormal findings found for Resident #12 and hemoglobin and hematocrit levels were normal. Review of Resident #12's x-ray results dated [DATE] revealed a nonobstructive bowel gas pattern, no dilated loops of bowel, soft tissues without significant abnormality, and modest colonic fecal residual noted. Review of a nursing progress note dated [DATE], documented by LPN #404, revealed the results of Resident #12's x-ray and lab results were sent to physician, and Resident #12 continued to complain of pain across epigastric region radiating to the back. Review of a nursing progress note dated [DATE], documented by LPN #470, revealed staff encouraged Resident #12 to eat something, but Resident #12 indicated she felt full and could not eat and continued to drink soda pop. Review of a nursing progress note dated [DATE], documented by LPN #404, revealed Resident #12 drank soda pop with other intakes encouraged with no success. Review of nurse aide documentation on [DATE] at 4:18 A.M., documented by NA #517, revealed Resident #12 had a small loose bowel movement on this date and there was no documentation of any oral intakes. Further review of Resident #12's medical record revealed there was no documentation of Resident #12 being assessed by a licensed nurse on [DATE]. Review of nurse aide documentation on [DATE] revealed no oral intakes were recorded for Resident #12. Review of a nursing progress note dated [DATE] at 12:24 A.M., documented by LPN #404, revealed Resident #12 continued to complain of abdominal pain and bloating, but pain not radiating to the back. Resident #12 was offered pain medication but indicated it did not work and refused. Resident #12 was medicated with [MEDICATION(S)] for complaints of GI upset. Further review of the medical record revealed there was no documentation of a physical assessment being performed by the licensed nurse (LPN #404) on [DATE] after Resident #12 complained of abdominal pain, bloating, and refused pain medications because they were not effective to treat her pain. Review of a nursing progress note dated [DATE] at 11:15 P.M., documented by LPN #404, revealed Resident #12's skin was dry, flushed, and warm to the touch. Resident #12 complained of gas and epigastric pain that did not radiate to the back. Resident #12 was given [MEDICATION(S)] due to complaints of nausea and Resident #12 indicated she wanted to see a nurse practitioner or physician due to nausea. Resident #12 was instructed to take [MEDICATION(S)] and the nurse would fax a note to the physician. Review of nurse aide documentation dated [DATE] at 6:21 A.M., documented by NA #561, revealed Resident #12 refused meals on this date. Review of a nursing progress note dated [DATE] at 1:44 A.M., documented by LPN #404, revealed the physician was faxed regarding Resident #12's continued abdominal pain and gas; informed that Resident #12 refused [MEDICATION(S)] stating the medication did not relieve her pain; and Resident #12 wanted to see a nurse practitioner or physician as soon as possible. Review of a nursing progress note dated [DATE] at 5:37 A.M., documented by LPN #404, revealed Resident #12 was awake drinking soda pop and water, and when questioned, Resident #12 still reported epigastric pain and gas, but the area of pain was decreased in size and severity. Resident #12 was questioned if she wanted medications for nausea or pain and Resident #12 declined both. The progress noted indicated Resident #12 would continue to be monitored. Further review of the medical record revealed there was no documentation in the medical record of Resident #12 being assessed by a licensed nurse on [DATE] after 5:37 A.M. Review of a nursing progress note dated [DATE] at 1:27 P.M., documented by LPN #444, revealed the emergency services was at the facility at 9:45 A.M., to transfer Resident #12 to the hospital. Resident #12's vital signs were normal, report was given to the emergency services staff, and report was called to the hospital emergency room . Review of the Emergency Medical Services (EMS) run report dated [DATE] revealed they received a call at 9:29:09 A.M., about Resident #12 experiencing breathing problems and were enroute to the facility at 9:30:40 A.M. The EMS arrived at the facility at 9:33:51 A.M. Upon arrival to the facility, Resident #12 was lying in bed and was alert and oriented. Resident #12 was wearing a Continuous Positive Airway Pressure (C-PAP) machine, she usually wore at night and stating she could not breath. Nursing staff reported Resident #12 had been bloated and had dark tarry stools for the past two weeks and still had pain in her abdomen. Resident #12 was cool to the touch and very pale. The EMS assessment of Resident #12 reported gas pain and having melena (dark sticky feces containing partly digested food). At 9:45 A.M., the EMS assessment reported Resident #12 had a heart rate of 88 beats per minute (normal heart beats range from 60 to 100) that was irregularly irregular (having no pattern at all, with the intervals being haphazard and do not repeat, with an occasional, accidental exception); a cardiac rhythm of [CONDITION(S)] (an irregular and often very rapid heart rhythm); a blood pressure of ,d+[DATE] (a normal blood pressure is ,d+[DATE]); a respiratory rate of 21 breaths per minute (normal range from 12 to 16 breaths per minute); noted Resident #12 displayed rapid breathing; and oxygen saturation was 95% (a normal range is 95% to 100%). Resident #12 was alert, oriented, and responding appropriately to stimuli. At 9:54 A.M., the EMS reported Resident #12 had a heart rate of 129 beats per minute that was irregularly irregular; a cardiac rhythm of [CONDITION(S)]; a blood pressure of ,d+[DATE]; a respiratory rate of 23 breaths per minute; noted Resident #12 displayed rapid breathing; and oxygen saturation was 95%. Resident #12 remained alert and oriented. The EMS left the facility with Resident #12 on [DATE] at 9:51:00 A.M. and arrived at the hospital at 10:01:00 A.M. Review of hospital documentation dated [DATE] revealed Resident #12's history was obtained and revealed abdominal pain ongoing for two weeks and feelings of Resident #12 being bloated. Per the nurse from the facility and the EMS staff per the nurse, Resident #12 has had black tarry stools. Resident #12 reported to the EMS she could not sit up straight because of the pressure on her abdomen and complained of abdominal pain. The EMS found Resident #12's oxygen saturation rate was low and placed her on supplemental oxygen. Resident #12 was noted to have black tarry stools on [DATE] and unsure of episodes prior. Resident #12 was conversating with the EMS; complaining of shortness of breath when laid down; and complaining of abdominal discomfort when she sat up too far. By the time Resident #12 arrived at the hospital, Resident #12 was non-verbal and unable to give any information. Further review of the hospital documentation revealed on [DATE], Resident #12's skin was cool and dry; was lying with eyes open with some eye movement to her name but otherwise unresponsive. Resident #12's abdomen was firm and distended with ongoing leakage of black tarry stools smelling strongly. Resident #12's hemoglobin was 8.3 grams per deciliter (g/dL) (indicating a low level as normal values are between 11.7 and 15.5 g/dL); and Resident #12's hematocrit was 29.4%, (indicating a low level as normal values are between 35% and 47%). Review of hospital staff documentation revealed Resident #12 was obviously critically ill and strongly suspect an ischemic bowel with ongoing GI bleeding as the primary problem, though it seemed to have been potentially going on for a period of time and subsequently affecting all systems. At 11:46 A.M., Resident #12 blood pressure was not registering and at 12:01 P.M., Resident #12's heart rate was 57 beats per minutes with no palpable radial pulse, and Resident #12 had extensive gray black material emesis. At 12:04 P.M., Resident #12's heart rate was zero and a medication was given. At 12:06 P.M., another dose of medication was administered, and chest compressions were performed. CPR was started on Resident #12 and lot of black tarry drainage was coming from out of her mouth and nose during compressions. Hospital staff suctioned to try to clear drainage. At, 12:09 P.M., hospital staff were instructed to stop compressions with one visible heartbeat noted on the monitor. At 12:10 P.M., a physician was not able to visualize or palpate any pulse and at 12:11 P.M., Resident #12 was pronounced dead. Review of a death certificate, signed by the physician and dated [DATE], revealed Resident #12's date of death was [DATE] at 12:11 P.M., with an immediate cause of death of cardiopulmonary arrest due to gastrointestinal bleed. Interview on [DATE] at 9:42 A.M., with Nurse Aide (NA) #415 stated staff were already talking about Resident #12's condition when she got to work on [DATE] at 6:00 A.M., but NA #415 was not assigned to work on Resident #12's hall. NA #415 stated she observed Resident #12 on [DATE] in her room at approximately 9:20 A.M. and noted Resident #12's face was pale white, her lips were blue, she was tremoring, and Resident #12 told NA #415, the facility was trying to kill her. NA #415 stated Resident #12 was sitting up in bed with her C-PAP machine on and stating she could not breath. NA #415 stated Resident #12 had a brief on and material with a reddish tint was coming out of it and she could see bright red blood on the blue pad under Resident #12's buttocks while she was sitting up in bed. NA #415 stated two other nurse aides working with Resident #12 on [DATE] told her they reported Resident #12's condition to the nurse, and when NA #415 ask the nurse what was happening the nurse told her the physician was already contacted and there was nothing more they could do. NA #415 stated a staff member (NA #364) was also talking to Resident #12 and asked to be taken to the hospital. NA #415 stated Resident #12 unlocked her personal telephone and handed it to NA #415 and NA #415 called emergency services for Resident #12. NA #415 stated she was not with Resident #12 when EMS arrived at the facility and provided care. Interview on [DATE] at 10:01 A.M., with NA #326 stated NA #415 came to her on [DATE] and said something was wrong with Resident #12. NA #326 explained she provided care for Resident #12 ever since her admission to the facility and knew her well. NA #326 stated she went to see Resident #12 and she was freezing cold to the touch and stated she could not breath. NA #326 stated she went to Resident #12's assigned nurse aides on [DATE] and they told her Resident #12 was not herself, struggling to breath, and had black tarry stools. NA #326 stated on [DATE], when she observed Resident #12 lying in bed she had on a brief and could not physically see any bowel movement but could see through the brief and the contents inside the brief were black. Interview on [DATE] at 10:19 A.M., with NA #364 stated she worked with Resident #12 over the last two weeks and noted Resident #12 had abdominal pain, felt gassy, and had been asking to go to the hospital. NA #364 stated Resident #12 started drinking a lot of soda pop because she thought it could help her [NAME] and get rid of gas and at times would drink soda pop and milk at the same time in attempt to relieve gas. NA #364 stated when she reported to work on [DATE] at 2:00 A.M., she was told in report that the nurse aides reported Resident #12 had black bowel movements and the nurse was informed at that time. NA #364 stated on [DATE], Resident #12 was breathing hard, fast and she felt like she could not breath. NA #364 stated on [DATE] at approximately 7:00 A.M., she was trying to move Resident #12 around in bed to help her relieve gas; but NA #364 stated she had to tend to other residents on the hall including providing a resident with shower assistance and answering call lights. NA #364 stated a staff member came to her at approximately 8:00 A.M. on [DATE] and stated Resident #12 needed staff in her room right away. NA #364 stated Resident #12 looked pale and was ice cold to the touch. NA #364 stated LPN #444 was in Resident #12's room before her and the nurse told NA #364, she (LPN #444) did not have enough experience dealing with situations like Resident #12 was going through and wanted a second opinion. NA #364 stated once she was back in the room, Resident #12 had a dark black bowel movement that stained the pad under Resident #12. The stool appeared to be red and kept coming out of Resident #12 and the staff could not clean it fast enough. NA #364 stated Resident #12 kept repeating help me over and over. NA #364 stated she told LPN #444 about what was happening with Resident #12. LPN #444 told NA #364 she already spoke to the DON, who told her to fax the physician; but if NA #364 felt it was important, she could interrupt the meeting the DON was in. NA #364 stated she went to the meeting and told the DON; the nurse aides did not feel comfortable leaving Resident #12 alone and the DON needed to see Resident #12. NA #364 stated the DON told NA #364, the physician was notified, and Resident #12 would be okay. NA #364 stated the DON never did come see Resident #12 and NA #364 went back to Resident #12's room. NA #364 stated other staff members were in Resident #12's room at this time and around 9:20 A.M., Resident #12 asked staff to call the EMS for her. Interview on [DATE] at 10:53 A.M., with NA #328 stated Resident #12 had abdominal distention in the upper part of her abdomen and was uncomfortable for two weeks before [DATE]. NA #328 stated Resident #12 did not want to eat, and when she did eat, it was very little. NA #328 stated Resident #12 did drink a lot of soda pop and milk. NA #328 stated Resident #12's call light came on during morning shift report on [DATE] and when NA #328 responded to the call light Resident #12 told her she was uncomfortable and had abdominal discomfort. NA #328 stated Resident #12 looked pale and told NA #328 she had not slept at all the previous night. NA #328 stated she informed the nurse, and the nurse went to check on Resident #12. NA #328 stated the staff tried to get Resident #12 to lay on her side, but she could not stand it. NA #328 stated she left Resident #12's room to provide care for other residents and was later told Resident #12 called the facility telephone number and asked for staff to come to her room. NA #328 stated when she got back to Resident #12's room, at what NA #328 thought was between 7:30 A.M. or 8:00 A.M., Resident #12 indicated she was uncomfortable and when the staff sat Resident #12 up in bed, very loose black tarry bowel movement came from her rectum, it just kept coming out and stained the pad red under Resident #12. NA #328 stated Resident #12 was breathing very fast, was anxious, and kept saying help me over and over. NA #328 stated to another nurse aide she could not leave Resident #12 and the nurse aide tried to get the DON to look at Resident #12, but she never came. NA #328 stated Resident #12's nurse told her she did not feel comfortable with Resident #12's situation and wanted the DON's opinion on what to do. NA #328 stated she was in Resident #12's bedroom when EMS arrived, and she stated they put oxygen on her and the last thing she said to Resident #12 was she loved her, and Resident #12 said she loved her too before the EMS took her out of the bedroom. Interview on [DATE] at 11:17 A.M., with LPN #444 stated during her shift report on the morning of [DATE], the night shift nurse (LPN #404) reported to LPN #444 that Resident #12 wanted to go out to the hospital; but did not send her because she sent a fax to the physician and was waiting for a response. LPN #444 stated the physician did not always get faxes from the facility right away and copies of the fax transmittals were kept in a binder at the nurse's station. LPN #444 stated LPN #404 indicated Resident #12 was still complaining of GI issues; that Resident #12 refused medication to help with pain because it was not working; and Resident #12 wanted to see the physician or nurse practitioner as soon as possible. LPN #444 stated she began her medication pass right away on [DATE] and at approximately 7:00 A.M., she came to Resident #12's room. LPN #444 stated Resident #12 looked pale, so she checked her blood sugar, and based on those results administered sliding scale insulin, and continued to pass medications to other residents. LPN #444 stated she did not see Resident #12 again until around approximately 8:00 A.M., when Resident #12 called the facility and asked for staff to come to her room. LPN #444 stated Resident #12 stated she needed changed and LPN #444 got a set of vital signs, that were all normal for Resident #12; but stated Resident #12 was still pale and cold to the touch. LPN #444 stated Resident #12 had black stool but had not seen that prior to [DATE]. LPN #444 stated the DON was in a meeting, but she went in and told the DON about Resident #12's condition and what LPN #404 told her. LPN #444 stated she asked the DON to go look at Resident #12, at this time as well. LPN #444 stated the DON told her to send another fax to the physician, to send [MEDICATION(S)] (a medication used to treat gastroesophageal reflux disease) for Resident #12. LPN #444 left the meeting to send the fax requesting the medication. LPN #444 stated the DON was supposed to be her go to staff member, since she did not have a unit manager. LPN #444 stated the DON told LPN #444 she was not going to look at Resident #12 because she was in a meeting. LPN #444 stated she was not confident as a nurse related to assessing Resident #12's situation because she was not a nurse very long and wanted a second opinion, which was why she sought out the DON. LPN #444 stated she has been a nurse for seven years. LPN #444 stated at around 8:15 A.M., she sent the fax to the physician and a staff member came to her and told her a staff member had called the EMS. LPN #444 verified she did not go back to assess Resident #12 or seek treatment from the physician between when she took Resident #12's vital signs and when the EMS arrived at the facility on [DATE]. LPN #444 stated when the EMS arrived, she went back to Resident #12's room, at the time to get more vitals, but Resident #12 was moving too much, and she could not get them. LPN #444 stated it was not typical for her to contact the physician via fax because they answer the faxes slowly. LPN #444 stated she stayed in the facility to work on [DATE] until around 6:00 P.M. and she still had not heard back from the physician or the nurse practitioner. LPN #444 stated she never called the physician or nurse practitioner on [DATE], regarding Resident #12's condition. Review of the fax transmittal binder located at the nurse's station with LPN #444 for [DATE] at 11:40 A.M., revealed no evidence of faxes being sent to the physician or nurse practitioner regarding Resident #12 on [DATE]. Interview at time of this observation, with LPN #444, stated the faxes were in the binder and someone must have removed them. Interview on [DATE] at 11:43 A.M. with Staff Member #672 stated while assisting with resident room changes, Resident #12 was noted to have difficulty breathing. Staff Member #672 stated Resident #12 was lying in bed with the blankets down with her legs exposed and Staff Member #672 could see dark black on her bed sheets. Staff Member #672 informed LPN #444 of Resident #12's condition and returned to Resident #12's room. Staff Member #672 stated he observed Resident #12 ask another staff member to call the EMS for her. The staff member called using Resident #12's personal telephone after Resident #12 handed the phone to the staff member. Interview on [DATE] at 12:38 P.M. with Staff Member #785 stated Resident #12 called the facility telephone on [DATE] between 8:20 A.M. and 8:30 A.M., and stated she needed staff to her room immediately. Staff Member #785 stated it was not normal for Resident #12 to call the facility directly to ask for staff assistance. Staff Member #785 stated she went to find staff on the hall Resident #12 resided and observed both nurse aides were busy, so Staff Member #785 notified LPN #444 of Resident [TRUNCATED]

Based on open and closed medical record review, staff interviews, physician interview, review of an emergency services run report, review of hospital documentation, review of a death certificate, review of a facility investigation, review of a facility facsimile (fax) transmittal binder, and review of facility policy regarding a change in a resident ' s condition, the facility failed to timely notify the physician of a significant change in condition for one resident (Resident #12). This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #12 was complaining of abdominal pain and distention, difficulty breathing, and signs of gastrointestinal (GI) bleeding, and pleading to be sent to the hospital or be seen by a physician with no notification to the physician. The lack of notification resulted in Resident #12 not receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice affected one (#12) of four residents (#12, #15, #18, and #20) reviewed for change in condition. The facility census was 97. On [DATE] at 4:44 P.M., the Administrator and Registered Nurse (RN) Regional Clinical Coordinator #100 were notified Immediate Jeopardy began on [DATE] when a staff member (Nurse Aide (NA) #399) noted Resident #12 complained of abdominal pain and distention, was eating very little, and had dark black tarry stools during incontinence care. There was no assessment or treatment completed for Resident #12 at that time. Resident #12 continued to have dark black tarry stools on [DATE], was not eating food, and complained of persistent abdominal pain without a treatment being sought or an assessment being completed. On [DATE], Resident #12 refused meals, complained of gas and abdominal pain, and was noted to have flushed and dry skin that was warm to the touch. The physician was notified via fax on [DATE] at 1:44 A.M., that medications offered to treat Resident #12 ' s abdominal pain were not effective, and Resident #12 requested to see the physician or nurse practitioner as soon as possible. The fax was sent to a closed physician office and Resident #12 continued to complain of gas and abdominal pain. On [DATE], Resident #12 displayed pale color, shortness of breath and difficulty breathing, blue lips, was trembling, and had a large dark black tarry stool which was continuously flowing from the rectum. On [DATE], Licensed Practical Nurse (LPN) #444 obtained Resident #12 ' s vital signs; however, no other assessment was completed. LPN #444 was instructed to fax the physician; however, the physician never received the fax, and no other attempts were made to notify the physician about Resident #12 ' s physical condition or to seek further treatment. Resident #12 ' s condition deteriorated and was sent to the emergency room (ER) after Resident #12 pleaded with Nurse Aide #415 to call emergency services using Resident #12 ' s personal telephone. Resident #12 died on [DATE] at 12:11 P.M. at the hospital. The Immediate Jeopardy was removed on [DATE] at 10:48 A.M. when the facility implemented the following corrective actions: · On [DATE], RN Regional Clinical Coordinator #100 completed a chart audit of all current residents to review for any change of condition over the previous 14 days. The audit was to identify any residents with a change in condition and to verify if the physician or nurse practitioner was timely notified. The chart audit for all current residents concluded on [DATE] with no concerns identified. · On [DATE], the Quality Assurance and Performance Improvement (QAPI) committee reviewed the facility policy for change in resident condition to determine content and appropriateness with no changes recommended to the policy. · On [DATE], Assistant Director of Nursing (ADON) #550 began education with all licensed nurses on notifying the physician of laboratory results, x-[CONDITION(S)] (x-ray) results, and changes in resident condition via telephone notification. On [DATE], the education was added to the general orientation for all newly hired licensed nurses. All 27 licensed nurses were educated by [DATE]. · On [DATE], ADON #550 began education with all licensed nurses on evaluating and identifying resident pain, developing care plans for pain management, and notifying the physician immediately by telephone if pain was not managed. All 27 licensed nurses were educated by [DATE]. · On [DATE], ADON #550 began education with all nurse aides on identifying and notifying the licensed nurses immediately of resident changes in condition. All 38 nurse aides were educated by [DATE]. · On [DATE], ADON #550 began education with all licensed nurses that if a change in condition is identified in a resident, immediate action is needed, and the findings must be relayed to the physician immediately. All 27 nurses were educated by [DATE]. · On [DATE], review of the medical records for Resident #15, Resident #18, and Resident #20, revealed no concerns with physician notification. · On [DATE], the Director of Nursing (DON), or designee, began audits of all current residents on the 24-hour report in the electronic health record, and review documentation and diagnostics to ensure resident changes in condition are identified and physicians and nurse practitioners are notified timely of acute changes in resident condition. Audits will be completed five times weekly for four weeks, then weekly for four weeks, then monthly for three months. The audit will be reviewed by the QAPI committee monthly and the DON is responsible for sustained compliance. · On [DATE], between 10:22 A.M. and 10:48 A.M., four nurses (LPN #221, LPN #470, LPN #427, LPN #674) and four nurse aides (NA) (NA #415, NA #379, NA #632, NA #696) verified they were educated on reporting changes in resident condition to the licensed nurses, timely notifying the physician of changes in resident condition, and identifying and managing resident pain. All staff members interviewed were knowledgeable of the content of each education provided by the facility. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #12 ' s closed medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 was discharged on [DATE]. Review of the most recently completed Minimum Data Set (MDS) assessment completed [DATE] revealed Resident #12 had intact cognition. Resident #12 was assessed to be independent with eating and required an extensive two-plus persons assistance with toileting during the reference period. Resident #12 also received an anticoagulant medication (a blood thinning medication) seven days of the seven-day look back period. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #12 was ordered the anticoagulant medication [MEDICATION(S)] 5 milligrams (mg) by mouth twice daily. Review of a nursing progress note dated [DATE] revealed staff encouraged Resident #12 to eat something, but Resident #12 indicated she felt full and could not eat and continued to drink soda pop. Review of a nursing progress note dated [DATE] revealed Resident #12 drank soda pop with other intakes encouraged with no success. Review of nurse aide documentation on [DATE] revealed Resident #12 had a small loose bowel movement on this date and there was no documentation of any oral intakes. Further review of Resident #12 ' s medical record revealed there was no documentation of Resident #12 being assessed by a licensed nurse on [DATE]. Review of Medication Administration Records (MARs) from February and [DATE] revealed Resident #12 received the anticoagulant medication as ordered. Review of a nursing progress note dated [DATE], documented by LPN #404, revealed Resident #12 drank soda pop with other intakes encouraged with no success. Review of nurse aide documentation on [DATE] at 4:18 A.M., documented by NA #517, revealed Resident #12 had a small loose bowel movement on this date and there was no documentation of any oral intakes. Further review of Resident #12 ' s medical record revealed there was no documentation of Resident #12 being assessed by a licensed nurse on [DATE]. Review of nurse aide documentation on [DATE] revealed no oral intakes were recorded for Resident #12. Review of a nursing progress note dated [DATE] at 12:24 A.M., documented by LPN #404, revealed Resident #12 continued to complain of abdominal pain and bloating, but pain not radiating to the back. Resident #12 was offered pain medication but indicated it did not work and refused. Resident #12 was medicated with [MEDICATION(S)] for complaints of GI upset. Further review of the medical record revealed there was no documentation of a physical assessment being performed by the licensed nurse (LPN #404) on [DATE] after Resident #12 complained of abdominal pain, bloating, and refused pain medications because they were not effective to treat her pain. Review of a nursing progress note dated [DATE] at 11:15 P.M., documented by LPN #404, revealed Resident #12 ' s skin was dry, flushed, and warm to the touch. Resident #12 complained of gas and epigastric pain that did not radiate to the back. Resident #12 was given [MEDICATION(S)] due to complaints of nausea and Resident #12 indicated she wanted to see a nurse practitioner or physician due to nausea. Resident #12 was instructed to take [MEDICATION(S)] and the nurse would fax a note to the physician. Review of nurse aide documentation dated [DATE] at 6:21 A.M., documented by NA #561, revealed Resident #12 refused meals on this date. Review of a nursing progress note dated [DATE] at 1:44 A.M., documented by LPN #404, revealed the physician was faxed regarding Resident #12 ' s continued abdominal pain and gas; informed that Resident #12 refused [MEDICATION(S)] stating the medication did not relieve her pain; and Resident #12 wanted to see a nurse practitioner or physician as soon as possible. Review of a nursing progress note dated [DATE] at 5:37 A.M., documented by LPN #404, revealed Resident #12 was awake drinking soda pop and water, and when questioned, Resident #12 still reported epigastric pain and gas, but the area of pain was decreased in size and severity. Resident #12 was questioned if she wanted medications for nausea or pain and Resident #12 declined both. The progress noted indicated Resident #12 would continue to be monitored. Further review of the medical record revealed there was no documentation in the medical record of Resident #12 being assessed by a licensed nurse on [DATE] after 5:37 A.M. Review of a nursing progress note dated [DATE] at 1:27 P.M., documented by LPN #444, revealed the emergency services was at the facility at 9:45 A.M., to transfer Resident #12 to the hospital. Resident #12 ' s vital signs were normal, report was given to the emergency services staff, and report was called to the hospital emergency room . Review of the Emergency Medical Services (EMS) run report dated [DATE] revealed they received a call at 9:29:09 A.M., about Resident #12 experiencing breathing problems and were enroute to the facility at 9:30:40 A.M. The EMS arrived at the facility at 9:33:51 A.M. Upon arrival to the facility, Resident #12 was lying in bed and was alert and oriented. Resident #12 was wearing a Continuous Positive Airway Pressure (C-PAP) machine, she usually wore at night and stating she could not breath. Nursing staff reported Resident #12 had been bloated and had dark tarry stools for the past two weeks and still had pain in her abdomen. Resident #12 was cool to the touch and very pale. The EMS assessment of Resident #12 reported gas pain and having melena (dark sticky feces containing partly digested food). At 9:45 A.M., the EMS assessment reported Resident #12 had a heart rate of 88 beats per minute (normal heart beats range from 60 to 100) that was irregularly irregular (having no pattern at all, with the intervals being haphazard and do not repeat, with an occasional, accidental exception); a cardiac rhythm of [CONDITION(S)] (an irregular and often very rapid heart rhythm); a blood pressure of ,d+[DATE] (a normal blood pressure is ,d+[DATE]); a respiratory rate of 21 breaths per minute (normal range from 12 to 16 breaths per minute); noted Resident #12 displayed rapid breathing; and oxygen saturation was 95% (a normal range is 95% to 100%). Resident #12 was alert, oriented, and responding appropriately to stimuli. At 9:54 A.M., the EMS reported Resident #12 had a heart rate of 129 beats per minute that was irregularly irregular; a cardiac rhythm of [CONDITION(S)]; a blood pressure of ,d+[DATE]; a respiratory rate of 23 breaths per minute; noted Resident #12 displayed rapid breathing; and oxygen saturation was 95%. Resident #12 remained alert and oriented. The EMS left the facility with Resident #12 on [DATE] at 9:51:00 A.M. and arrived at the hospital at 10:01:00 A.M. Review of hospital documentation dated [DATE] revealed Resident #12 ' s history was obtained and revealed abdominal pain ongoing for two week and feelings of Resident #12 being bloated. Per the nurse from the facility and the EMS staff per the nurse, Resident #12 has had black tarry stools. Resident #12 reported to the EMS she could not sit up straight because of the pressure on her abdomen and complained of abdominal pain. The EMS found Resident #12 ' s oxygen saturation rate was low and placed her on supplemental oxygen. Resident #12 was noted to have black tarry stools on [DATE] and unsure of episodes prior. Resident #12 was conversating with the EMS; complaining of shortness of breath when laid down; and complaining of abdominal discomfort when she sat up too far. By the time Resident #12 arrived at the hospital, Resident #12 was non-verbal and unable to give any information. Further review of the hospital documentation revealed on [DATE], Resident #12 ' s skin was cool and dry; was lying with eyes open with some eye movement to her name but otherwise unresponsive. Resident #12 ' s abdomen was firm and distended with ongoing leakage of black tarry stools smelling strongly. Resident #12 ' s hemoglobin was 8.3 grams per deciliter (g/dL) (indicating a low level as normal values are between 11.7 and 15.5 g/dL); and Resident #12 ' s hematocrit was 29.4%, (indicating a low level as normal values are between 35% and 47%). Review of hospital staff documentation revealed Resident #12 was obviously critically ill and strongly suspect an ischemic bowel with ongoing GI bleeding as the primary problem, though it seemed to have been potentially going on for a period of time and subsequently affecting all systems. At 11:46 A.M., Resident #12 blood pressure was not registering and at 12:01 P.M., Resident #12 ' s heart rate was 57 beats per minutes with no palpable radial pulse, and Resident #12 had extensive gray black material emesis. At 12:04 P.M., Resident #12 ' s heart rate was zero and a medication was given. At 12:06 P.M., another dose of medication was administered, and chest compressions were performed. CPR was started on Resident #12 and lot of black tarry drainage was coming from out of her mouth and nose during compressions. Hospital staff suctioned to try to clear drainage. At, 12:09 P.M., hospital staff were instructed to stop compressions with one visible heartbeat noted on the monitor. At 12:10 P.M., a physician was not able to visualize or palpate any pulse and at 12:11 P.M., Resident #12 was pronounced dead. Review of a death certificate, signed by the physician and dated [DATE], revealed Resident #12 ' s date of death was [DATE] at 12:11 P.M., with an immediate cause of death of cardiopulmonary arrest due to gastrointestinal bleed. Interview on [DATE] at 9:42 A.M., with Nurse Aide (NA) #415 stated staff were already talking about Resident #12 ' s condition when she got to work on [DATE] at 6:00 A.M., but NA #415 was not assigned to work on Resident #12 ' s hall. NA #415 stated she observed Resident #12 on [DATE] in her room at approximately 9:20 A.M. and noted Resident #12 ' s face was pale white, her lips were blue, she was tremoring, and Resident #12 told NA #415, the facility was trying to kill her. NA #415 stated Resident #12 was sitting up in bed with her C-PAP machine on and stating she could not breath. NA #415 stated Resident #12 had a brief on and material with a reddish tint was coming out of it and she could see bright red blood on the blue pad under Resident #12 ' s buttocks while she was sitting up in bed. NA #415 stated two other nurse aides working with Resident #12 on [DATE] told her they reported Resident #12 ' s condition to the nurse, and when NA #415 ask the nurse what was happening the nurse told her the physician was already contacted and there was nothing more they could do. NA #415 stated a staff member (NA #364) was also talking to Resident #12 and asked to be taken to the hospital. NA #415 stated Resident #12 unlocked her personal telephone and handed it to NA #415 and NA #415 called emergency services for Resident #12. NA #415 stated she was not with Resident #12 when EMS arrived at the facility and provided care. Interview on [DATE] at 10:01 A.M., with NA #326 stated NA #415 came to her on [DATE] and said something was wrong with Resident #12. NA #326 explained she provided care for Resident #12 ever since her admission to the facility and knew her well. NA #326 stated she went to see Resident #12 and she was freezing cold to the touch and stated she could not breath. NA #326 stated she went to Resident #12 ' s assigned nurse aides on [DATE] and they told her Resident #12 was not herself, struggling to breath, and had black tarry stools. NA #326 stated on [DATE], when she observed Resident #12 lying in bed she had on a brief and could not physically see any bowel movement but could see through the brief and the contents inside the brief were black. Interview on [DATE] at 10:19 A.M., with NA #364 stated she worked with Resident #12 over the last two weeks and noted Resident #12 had abdominal pain, felt gassy, and had been asking to go to the hospital. NA #364 stated Resident #12 started drinking a lot of soda pop because she thought it could help her [NAME] and get rid of gas and at times would drink soda pop and milk at the same time in attempt to relief gas. NA #364 stated when she reported to work on [DATE] at 2:00 A.M., she was told in report that the nurse aides reported Resident #12 had black bowel movements and the nurse was informed at that time. NA #364 stated on [DATE], Resident #12 was breathing hard, fast and she felt like she could not breath. NA #364 stated on [DATE] at approximately 7:00 A.M., stated she was trying to move Resident #12 around in bed to help her relieve gas; but NA #364 stated she had to tend to other residents on the hall including providing a resident with shower assistance and answering call lights. NA #364 stated a staff member came to her at approximately 8:00 A.M., on [DATE] and stated Resident #12 needed staff in her room right away. NA #364 stated Resident #12 looked [NAME] and was ice cold to the touch. NA #364 stated LPN #444 was in Resident #12 ' s room before her and the nurse told NA #364, she (LPN #444) did not have enough experience dealing with situations like Resident #12 was going through and wanted a second opinion. NA #364 stated once she was back in the room, Resident #12 had a dark black bowel movement that stained the pad under Resident #12. The stool appeared to be red and kept coming out of Resident #12 and the staff could not clean it fast enough. NA #364 stated Resident #12 kept repeating help me over and over. NA #364 stated she told the LPN #444 about what was happening with Resident #12. LPN #444 told NA #364 she already spoke to the DON, who told her to fax the physician; but if NA #364 felt it was important, she could interrupt the meeting the DON was in. NA #364 stated she went to the meeting and told the DON; the nurse aides did not feel comfortable leaving Resident #12 alone and the DON needed to see Resident #12. NA #364 stated the DON told NA #364, the physician was notified, and Resident #12 would be okay. NA #364 stated the DON never did come see Resident #12 and NA #364 went back to Resident #12 ' s room. NA #364 stated other staff members were in Resident #12 ' s room at this time and around 9:20 A.M., Resident #12 asked staff to call the EMS for her. Interview on [DATE] at 10:53 A.M., with NA #328 stated Resident #12 had abdominal distention in the upper part of her abdomen and was uncomfortable for two weeks before [DATE]. NA #328 stated Resident #12 did not want to eat, and when she did eat, it was very little. NA #328 stated Resident #12 did drink a lot of soda pop and milk. NA #328 stated Resident #12 ' s call light came on during morning shift report on [DATE] and when NA #328 responded to the call light Resident #12 told her she was uncomfortable and had abdominal discomfort. NA #328 stated Resident #12 looked pale and told NA #328 she had not slept at all the previous night. NA #328 stated she informed the nurse, and the nurse went to check on Resident #12. NA #328 stated the staff tried to get Resident #12 to lay on her side, but she could not stand it. NA #328 stated she left Resident #12 ' s room to provide care for other residents and was later told Resident #12 called the facility telephone number and asked for staff to come to her room. NA #328 stated when she got back to Resident #12 ' s room, at what NA #328 thought was between 7:30 A.M. or 8:00 A.M., Resident #12 indicated she was uncomfortable and when the staff sat Resident #12 up in bed, very loose black tarry bowel movement came from her rectum, it just kept coming out and stained the pad under Resident #12 was red. NA #328 stated Resident #12 was breathing very fast, was anxious, and kept saying help me over and over. NA #328 stated to another nurse aide she could not leave Resident #12 and the nurse aide tried to get the DON to look at Resident #12, but she never came. NA #328 stated Resident #12 ' s nurse told her she did not feel comfortable with Resident #12 ' s situation and wanted the DON ' s opinion on what to do. NA #328 stated she was in Resident #12 ' s bedroom when EMS arrived, and she stated they put oxygen on her and the last thing she said to Resident #12 was she loved her, and Resident #12 said she loved her too before the EMS took her out of the bedroom. Interview on [DATE] at 11:17 A.M., with LPN #444 stated during her shift report on the morning of [DATE], the night shift nurse (LPN #404) reported to LPN #444 that Resident #12 wanted to go out to the hospital; but did not send her because she sent a fax to the physician and was waiting for a response. LPN #444 stated the physician did not always get faxes from the facility right away and copies of the fax transmittals were kept in a binder at the nurse ' s station. LPN #444 stated LPN #404 indicated Resident #12 was still complaining of GI issues; that Resident #12 refused medication to help with pain because it was not working; and Resident #12 wanted to see the physician or nurse practitioner as soon as possible. LPN #444 stated she began her medication pass right away on [DATE] and at approximately 7:00 A.M., she came to Resident #12 ' s room. LPN #444 stated Resident #12 looked pale, so she checked her blood sugar, and based on those results administered sliding scale insulin, and continued to pass medications to other residents. LPN #444 stated she did not see Resident #12 again until around approximately 8:00 A.M., when Resident #12 called the facility and asked for staff to come to her room. LPN #444 stated Resident #12 stated she needed changed and LPN #444 got a set of vital signs, that were all normal for Resident #12; but stated Resident #12 was still pale and cold to the touch. LPN #444 stated Resident #12 had black stool but had not seen that prior to [DATE]. LPN #444 stated the DON was in a meeting, but she went in and told the DON about Resident #12 ' s condition and what LPN #404 told her. LPN #444 stated she asked the DON to go look at Resident #12, at this time as well. LPN #444 stated the DON told her to send another fax to the physician, to send [MEDICATION(S)] (a medication used to treat gastroesophageal reflux disease) for Resident #12. LPN #444 left the meeting to send the fax requesting the medication. LPN #444 stated the DON was supposed to be her go to staff member, since she did not have a unit manager. LPN #444 stated the DON told LPN #444; she was not going to look at Resident #12 because she was in a meeting. LPN #444 stated she was not confident as a nurse related to assessing Resident #12 ' s situation because she was not a nurse very long and wanted a second opinion, which was why she sought out the DON. LPN #444 stated she has been a nurse for seven years. LPN #444 stated at around 8:15 A.M., she sent the fax to the physician and a staff member came to her and told her a staff member had called the EMS. LPN #444 verified she did not go back to assess Resident #12 or seek treatment from the physician; between when she took Resident #12 ' s vital signs and when the EMS arrived at the facility on [DATE]. LPN #444 stated when the EMS arrived, she went back to Resident #12 ' s room, at the time to get more vitals; but Resident #12 was moving too much and she could not get them. LPN #444 stated it was not typical for her to contact the physician via fax because they answer the faxes slowly. LPN #444 stated she stayed in the facility to work on [DATE] until around 6:00 P.M. and she still had not heard back from the physician or the nurse practitioner. LPN #444 stated she never called the physician or nurse practitioner on [DATE], regarding Resident #12 ' s condition. Review of the fax transmittal binder located at the nurse ' s station with LPN #444 for [DATE] at 11:40 A.M., revealed no evidence of faxes being sent to the physician or nurse practitioner regarding Resident #12 on [DATE]. Interview at time of this observation, with LPN #444, stated the faxes were in the binder and someone must have removed them. Interview on [DATE] at 11:43 A.M., with Staff Member #672 stated while assisting with resident room changes, Resident #12 was noted to have difficulty breathing. Staff Member #672 stated Resident #12 was lying in bed with the blankets down with her legs exposed and Staff Member #672 could see dark black on her bed sheets. Staff Member #672 informed LPN #444 of Resident #12 ' s condition and returned to Resident #12 ' s room. Staff Member #672 stated he observed Resident #12 asked another staff member to call the EMS for her. The staff member called using Resident #12 ' s personal telephone after Resident #12 handed the phone to the staff member. Interview on [DATE] at 12:38 P.M., with Staff Member #785 stated Resident #12 called the facility telephone on [DATE] at approximately between 8:20 A.M. and 8:30 A.M., and stated she needed staff to her room immediately. Staff Member #785 stated it was not normal for Resident #12 to call the facility directly to ask for staff assistance. Staff Member #785 stated she went to find staff on the hall Resident #12 resided and observed both nurse aides were busy, so Staff Member #785 notified LPN #444 of Resident #12 ' s request for staff assistance. Interview via telephone, on [DATE] at 1:52 P.M., with Physician #209 stated he only saw Resident #12 twice, once in [DATE] and again in February 2022. Physician #209 stated his Nurse Practitioner #606 saw Resident #12 as recently as [DATE]. Physician #209 stated Resident #12 had an abdominal x-ray and laboratory test performed on [DATE], with no abnormal results noted. Physician #209 stated he consulted with NP #606 and stated neither one received a telephone call, or anything related to Resident #12 ' s condition on [DATE]. Physician #209 verified he did receive a fax sent by the facility on [DATE] at 1:44 A.M., but it did not indicate anything other than Resident #12 wanted to see him or the nurse practitioner and contained no assessment of Resident #12 ' s condition. Physician #209 stated he nor his nurse practitioner would have seen the fax sent on [DATE] at 1:44 A.M., until much later in the day and stated there was always someone on call that could be contacted via telephone. Physician #209 stated the facility nurses where Resident #12 resided always call him via telephone and was not sure why they would send a fax given Resident #12 ' s situation. Interview via telephone on [DATE] at 3:18 P.M., with Physician #209 occurred when the physician called the surveyor. Physician #209 stated he had been reviewing the hospital documentation from [DATE]. Physician #209 stated he was never notified of Resident #12 having black tarry stools at any time and there was never any indication in the medical record at the facility that Resident #209 had black tarry stools before she was hospitalized on [DATE]. Physician #209 stated he just completed Resident #12 ' s death certificate and the cause of death was cardiac arrest due to gastrointestinal bleeding. Interview on [DATE] at 4:04 P.M. with NA #399 stated she worked with Resident #12 on [DATE], [DATE], and [DATE]. NA #399 stated on [DATE] she received in report from another nurse aide that Resident #12 had dark black stools and her abdomen was distended. NA #399 stated later that night, on [DATE], Resident #12 was not eating well having only eaten chicken broth. NA #399 stated Resident #12 had black dark tarry stools that night. NA #399 stated the stool was dark like coffee grounds in color and had the consistency of a slightly thick milkshake. NA #399 stated she informed the nurse on duty that night but was not sure if anything was done about it. NA #399 stated Resident #12 asked to go to the hospital that night and the nurse came in to check on Resident #12. NA #399 stated the nurse did not get Resident #12 ' s vital signs but felt her abdomen and Resident #12 did not go to the hospital that night. NA #399 stated the nurse was informed of Resident #12 ' s dark black bowel movement but did not ask to see it. NA #399 stated she came back to work on [DATE] and Resident #12 ' s abdomen was still distended. NA #399 stated Resident #12 had a bowel movement on her shift, and it had blood in it. Interview via telephone, on [DATE] at 8:30 A.M., with LPN #404 revealed she worked on the night shift between 10:00 P.M. ([DATE]) and 6:30 A.M. ([DATE]) and was assigned to Resident #12 on basically every day she worked. LPN #404 stated Resident #12 had complaints of abdominal pain for a while, but tests performed on Resident #12 came back with no concerns noted. LPN #404 stated on [DATE], she talked to Resident #12 during the night and Resident #12 asked to see the physician or nurse practitioner that day. LPN #404 informed Resident #12 she would send a fax. LPN #404 stated she normally sent faxes to the physician unless there was an emergency, and the physician typically responded to faxes during normal business hours. LPN #404 stated she saw Resident #12 around 5:00 A.M. on [DATE] and Resident #12 stated she still had abdominal pain, but the pain was not as bad and not affecting as big of an area. LPN #404 stated Resident #12 never asked her to go to the hospital at any time. LPN #404 stated she never knew Resident #12 had dark tarry stools and no one ever reported that to her. Interview via telephone, on [DATE] at 10:10 A.M., with the DON revealed on 0 [TRUNCATED]

Based on closed medical record review, staff interviews, review of an emergency services run report, review of hospital documentation, and review of a facility policy, the facility failed to completely and accurately document a resident condition and reason for transfer from the facility in the medical record. This deficient practice affected one (#12) of four residents reviewed for documentation following a change in condition. The facility census was 97. Findings include: Review of Resident #12's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 was discharged on [DATE]. Review of a nursing progress note dated 03/16/22 at 1:27 P.M., revealed emergency services were at the facility at 9:45 A.M. to transfer Resident #12 to the hospital. Resident #12's vital signs were as followed: blood pressure 107/79 millimeters of mercury (mm/Hg), heart rate was 69 beats per minute, respirations were 16 breaths per minute, temperature was 98.6 degrees Fahrenheit (F), and oxygen saturation rate was 95% on room air. Report was given to emergency services as well as the accepting hospital Resident #12 went to. The nursing progress note was electronically signed by Licensed Practical Nurse (LPN) #444. The nursing progress note on 03/16/22 at 1:27 P.M., was the last entry in Resident #12's medical record. There was no documentation related to Resident #12's physical appearance or condition nor any documentation related to complaints of abdominal discomfort and pain, shortness of breath, difficulty breathing, or black tarry stools. Review of an emergency medical services (EMS) run report dated 03/16/22 revealed they received a call at 9:29:09 A.M. about Resident #12 experiencing breathing problems and were enroute to the facility at 9:30:40 A.M. EMS arrived at the facility at 9:33:51 A.M. Upon arrival to the facility, Resident #12 was lying in bed and was alert and oriented. Resident #12 was wearing a continuous positive airway pressure (C-PAP) she wore at night and stating she could not breath. Nursing staff reported Resident #12 had been bloated and had dark tarry stools for the past two weeks and still had pain in her abdomen. Resident #12 was cool to the touch and very pale. The EMS assessment of Resident #12 reported gas pain and melena (dark sticky feces containing partly digested food). EMS left the facility with Resident #12 on 03/16/22 at 9:51:00 A.M. and arrived at the hospital at 10:01:00 A.M. Review of hospital documentation dated 03/16/22 revealed Resident #12's history was obtained and revealed abdominal pain ongoing for two week and feelings of Resident #12 being bloated. Per the nurse from the facility and EMS staff per the nurse, Resident #12 has had black tarry stools. Interview on 03/21/22 at 9:42 A.M. with Nurse Aide (NA) #415, at 10:19 A.M. with NA #364, and at 10:53 A.M. with NA #328, all stated Resident #12 was pale, cold to the touch, complaining of not being able to breath, complaining of abdominal pain, and had a black tarry stool on 03/16/22 before being sent to the hospital. Interview on 03/21/22 at 11:17 A.M. with LPN #444 verified she was the staff member who wrote the progress note about Resident #12's discharge on 03/16/22. LPN #444 verified Resident #12 did look pale and expressed concerns about her abdominal pain and discomfort her. LPN #444 verified the progress note she documented about Resident #12 on 03/16/22 did not contain a full and accurate description of what was happening with Resident #12 at the time she left the facility. Review of the policy titled, Documentation Expectations, last revised 11/01/17, revealed all facts and pertinent information related to an event, course of treatment, resident condition, response to care, and deviation from standard treatment (including the reason for the deviation) must be documented. This deficiency represents an incidental finding discovered during the investigation for Master Complaint Number OH 110, Complaint Number OH 107, and Complaint Number OH 103.

Based on closed medical record review, staff interviews, physician interview, review of an emergency services run report, review of hospital documentation, review of a death certificate, review of a facility investigation, and review of a facility policy, the facility failed to follow their abuse policy relating to reporting an incident of resident neglect to the State Survey Agency. This deficient practice affected one (#12) of four residents reviewed for potential neglect. The facility census was 97. Findings include: Review of Resident #12's closed medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 was discharged on [DATE]. Review of the most recently completed Minimum Data Set (MDS) assessment completed [DATE] revealed Resident #12 had intact cognition. Resident #12 was assessed to be independent with eating and required an extensive two-plus persons assistance with toileting during the reference period. Resident #12 was also received an anticoagulant medication seven days of the seven-day look back period. Review of a nursing progress note dated [DATE] at 12:24 A.M. revealed Resident #12 continued to complain of abdominal pain and bloating, but pain not radiating to the back. Resident #12 was offered pain medication but indicated it did not work and refused. Resident #12 was medicated with [MEDICATION(S)] for complaints of GI upset. There was no documentation of a physical assessment being performed by the licensed nurse on [DATE] after Resident #12 complained of abdominal pain bloating and refused pain medications because they were not effective to treat her pain. Review of a nursing progress note dated [DATE] at 11:15 P.M. revealed Resident #12's skin was dry, flushed, and warm to the touch. Resident #12 complained of gas and epigastric pain that did not radiate to the back. Resident #12 was given [MEDICATION(S)] due to complaints of nausea and Resident #12 indicated she wanted to see a nurse practitioner or physician due to nausea. Resident #12 was instructed to take [MEDICATION(S)] and the nurse would fax a note to the physician. Review of nurse aide documentation dated [DATE] revealed Resident #12 refused meals on this date. Review of a nursing progress note dated [DATE] at 1:44 A.M. revealed the physician was faxed regarding Resident #12's continued abdominal pain and gas, informed that Resident #12 refused [MEDICATION(S)] and the medication did not relieve her pain, and Resident #12 wanted to see a nurse practitioner or physician as soon as possible. Review of a nursing progress note dated [DATE] at 5:37 A.M. revealed Resident #12 was awake drinking soda pop and water, and when questioned, Resident #12 still reported epigastric pain and gas, but the area of pain was decreased in size and severity. Resident #12 was questioned if she wanted medications for nausea or pain and Resident #12 declined both. The progress noted indicated Resident #12 would continue to be monitored. There was no documentation in the medical record of Resident #12 being assessed by a licensed nurse on [DATE] after 5:37 A.M. Review of a nursing progress note dated [DATE] at 1:27 P.M., revealed emergency services was at the facility at 9:45 A.M. to transfer Resident #12 to the hospital. Resident #12's vital signs were normal, report was given to the emergency services staff, and report was called to the hospital emergency room . Review of an emergency medical services (EMS) run report dated [DATE] revealed they received a call at 9:29:09 A.M., about Resident #12 experiencing breathing problems and were enroute to the facility at 9:30:40 A.M. The EMS arrived at the facility at 9:33:51 A.M. Upon arrival to the facility, Resident #12 was lying in bed and was alert and oriented. Resident #12 was wearing a continuous positive airway pressure (C-PAP) machine, she usually wore at night and stating she could not breath. Nursing staff reported Resident #12 had been bloated and had dark tarry stools for the past two weeks and still had pain in her abdomen. Resident #12 was cool to the touch and very pale. The EMS assessment of Resident #12 reported gas pain and having melena (dark sticky feces containing partly digested food). At 9:45 A.M., the EMS assessment reported Resident #12 had a heart rate of 88 beats per minute (normal heart beats range from 60 to 100) that was irregularly irregular (having no pattern at all, with the intervals being haphazard and do not repeat, with an occasional, accidental exception); a cardiac rhythm of [CONDITION(S)] (an irregular and often very rapid heart rhythm); a blood pressure of ,d+[DATE] (a normal blood pressure is ,d+[DATE]); a respiratory rate of 21 breaths per minute (normal range from 12 to 16 breaths per minute); noted Resident #12 displayed rapid breathing; and oxygen saturation was 95% (a normal range is 95% to 100%). Resident #12 was alert, oriented, and responding appropriately to stimuli. At 9:54 A.M., the EMS reported Resident #12 had a heart rate of 129 beats per minute that was irregularly irregular; a cardiac rhythm of [CONDITION(S)]; a blood pressure of ,d+[DATE]; a respiratory rate of 23 breaths per minute; noted Resident #12 displayed rapid breathing; and oxygen saturation was 95%. Resident #12 remained alert and oriented. The EMS left the facility with Resident #12 on [DATE] at 9:51:00 A.M. and arrived at the hospital at 10:01:00 A.M. Review of hospital documentation dated [DATE] revealed Resident #12's history was obtained and revealed abdominal pain ongoing for two week and feelings of Resident #12 being bloated. Per the nurse from the facility and the EMS staff per the nurse, Resident #12 has had black tarry stools. Resident #12 reported to the EMS she could not sit up straight because of the pressure on her abdomen and complained of abdominal pain. The EMS found Resident #12's oxygen saturation rate was low and placed her on supplemental oxygen. Resident #12 was noted to have black tarry stools on [DATE] and unsure of episodes prior. Resident #12 was conversating with the EMS; complaining of shortness of breath when laid down; and complaining of abdominal discomfort when she sat up too far. By the time Resident #12 arrived at the hospital, Resident #12 was non-verbal and unable to give any information. Further review of the hospital documentation revealed on [DATE], Resident #12's skin was cool and dry; was lying with eyes open with some eye movement to her name but otherwise unresponsive. Resident #12's abdomen was firm and distended with ongoing leakage of black tarry stools smelling strongly. Resident #12's hemoglobin was 8.3 grams per deciliter (g/dL) (indicating a low level as normal values are between 11.7 and 15.5 g/dL); and Resident #12's hematocrit was 29.4%, (indicating a low level as normal values are between 35% and 47%). Review of hospital staff documentation revealed Resident #12 was obviously critically ill and strongly suspect an ischemic bowel with ongoing GI bleeding as the primary problem, though it seemed to have been potentially going on for a period of time and subsequently affecting all systems. At 11:46 A.M., Resident #12 blood pressure was not registering and at 12:01 P.M., Resident #12's heart rate was 57 beats per minutes with no palpable radial pulse, and Resident #12 had extensive gray black material emesis. At 12:04 P.M., Resident #12's heart rate was zero and a medication was given. At 12:06 P.M., another dose of medication was administered, and chest compressions were performed. CPR was started on Resident #12 and lot of black tarry drainage was coming from out of her mouth and nose during compressions. Hospital staff suctioned to try to clear drainage. At, 12:09 P.M., hospital staff were instructed to stop compressions with one visible heartbeat noted on the monitor. At 12:10 P.M., a physician was not able to visualize or palpate any pulse and at 12:11 P.M., Resident #12 was pronounced dead. Review of a death certificate, signed by the physician and dated [DATE], revealed Resident #12's date of death was [DATE] at 12:11 P.M., with an immediate cause of death of cardiopulmonary arrest due to [CONDITION(S)]. Interview on [DATE] at 9:42 A.M., with Nurse Aide (NA) #415 stated staff were already talking about Resident #12's condition when she got to work on [DATE] at 6:00 A.M., but NA #415 was not assigned to work on Resident #12's hall. NA #415 stated she observed Resident #12 on [DATE] in her room at approximately 9:20 A.M. and noted Resident #12's face was pale white, her lips were blue, was tremoring, and Resident #12 told NA #415, the facility was trying to kill her. NA #415 stated Resident #12 was sitting up in bed with her C-PAP machine on and stating she could not breath. NA #415 stated Resident #12 had a brief on and material with a reddish tint was coming out of it and could see bright red blood on the blue pad under Resident #12's buttocks while she was sitting up in bed. NA #415 stated two other nurse aides working with Resident #12 on [DATE] told her they reported Resident #12's condition to the nurse, and when NA #415 ask the nurse what was happening the nurse told her the physician was already contacted and there was nothing more they could do. NA #415 stated a staff member was also taking to Resident #12 and asked to be taken to the hospital. NA #415 stated Resident #12 unlocked her personal telephone and handed it to NA #415 and NA #415 called emergency services for Resident #12. NA #415 stated she was not with Resident #12 when EMS arrived at the facility and provided care. Interview on [DATE] at 10:01 A.M., with NA #326 stated NA #415 came to her on [DATE] and said something was wrong with Resident #12. NA #326 explained she provided care for Resident #12 ever since her admission to the facility and knew her well. NA #326 stated she went to see Resident #12 and she was freezing cold to the touch and stated she could not breath. NA #326 stated she went to Resident #12's assigned nurse aides on [DATE] and they told her Resident #12 was not herself, struggling to breath, and had black tarry stools. NA #326 stated on [DATE], when she observed Resident #12 lying in bed she had on a brief and could not physically see any bowel movement but could see through the brief and the contents inside the brief were black. Interview on [DATE] at 10:19 A.M., with NA #364 stated she worked with Resident #12 over the last two weeks and noted Resident #12 had abdominal pain, felt gassy, and had been asking to go to the hospital. NA #364 stated Resident #12 started drinking a lot of soda pop because she thought it could help her [NAME] and get rid of gas and at times would drink soda pop and milk at the same time in attempt to relief gas. NA #364 stated when she reported to work on [DATE] at 2:00 A.M., she was told in report that the nurse aides reported Resident #12 had black bowel movements and the nurse was informed at that time. NA #364 stated on [DATE], Resident #12 was breathing hard, fast and she felt like she could not breath. NA #364 stated on [DATE] at approximately 7:00 A.M., stated she was trying to move Resident #12 around in bed to help her relieve gas; but NA #364 stated she had to tend to other residents on the hall including providing a resident with shower assistance and answering call lights. NA #364 stated a staff member came to her at approximately 8:00 A.M., on [DATE] and stated Resident #12 needed staff in her room right away. NA #364 stated Resident #12 looked [NAME] and was ice cold to the touch. NA #364 stated LPN #444 was in Resident #12's room before her and the nurse told NA #364, she (LPN #444) did not have enough experience dealing with situations like Resident #12 was going through and wanted a second opinion. NA #364 stated once she was back in the room, Resident #12 had a dark black bowel movement that stained the pad under Resident #12. The stool appeared to be red and kept coming out of Resident #12 and the staff could not clean it fast enough. NA #364 stated Resident #12 kept repeating help me over and over. NA #364 stated she told the LPN #444 about what was happening with Resident #12. LPN #444 told NA #364 she already spoke to the DON, who told her to fax the physician; but if NA #364 felt it was important, she could interrupt the meeting the DON was in. NA #364 stated she went to the meeting and told the DON; the nurse aides did not feel comfortable leaving Resident #12 alone and the DON needed to see Resident #12. NA #364 stated the DON told NA #364, the physician was notified, and Resident #12 would be okay. NA #364 stated the DON never did come see Resident #12 and NA #364 went back to Resident #12's room. NA #364 stated other staff members were in Resident #12's room at this time and around 9:20 A.M., Resident #12 asked staff to call the EMS for her. Interview on [DATE] at 10:53 A.M., with NA #328 stated Resident #12 had abdominal distention in the upper part of her abdomen and was uncomfortable for two weeks before [DATE]. NA #328 stated Resident #12 did not want to eat, and when she did eat, it was very little. NA #328 stated Resident #12 did drink a lot of soda pop and milk. NA #328 stated Resident #12's call light came on during morning shift report on [DATE] and when NA #328 responded to the call light Resident #12 told her she was uncomfortable and had abdominal discomfort. NA #328 stated Resident #12 looked pale and told NA #328 she had not slept at all the previous night. NA #328 stated she informed the nurse, and the nurse went to check on Resident #12. NA #328 stated the staff tried to get Resident #12 to lay on her side, but she could not stand it. NA #328 stated she left Resident #12's room to provide care for other residents and was later told Resident #12 called the facility telephone number and asked for staff to come to her room. NA #328 stated when she got back to Resident #12's room, at what NA #328 thought was between 7:30 A.M. or 8:00 A.M., Resident #12 indicated she was uncomfortable and when the staff sat Resident #12 up in bed, very loose black tarry bowel movement came from her rectum, it just kept coming out and stained the pad under Resident #12 was red. NA #328 stated Resident #12 was breathing very fast, was anxious, and kept saying help me over and over. NA #328 stated to another nurse aide she could not leave Resident #12 and the nurse aide tried to get the DON to look at Resident #12, but she never came. NA #328 stated Resident #12's nurse told her she did not feel comfortable with Resident #12's situation and wanted the DON's opinion on what to do. NA #328 stated she was in Resident #12's bedroom when EMS arrived, and she stated they put oxygen on her and the last thing she said to Resident #12 was she loved her, and Resident #12 said she loved her too before the EMS took her out of the bedroom. Interview on [DATE] at 11:17 A.M., with LPN #444 stated during her shift report on the morning of [DATE], the night shift nurse (LPN #404) reported to LPN #444 that Resident #12 wanted to go out to the hospital; but did not send her because she sent a fax to the physician and was waiting for a response. LPN #444 stated the physician did not always get faxes from the facility right away and copies of the fax transmittals were kept in a binder at the nurse's station. LPN #444 stated LPN #404 indicated Resident #12 was still complaining of GI issues; that Resident #12 refused medication to help with pain because it was not working; and Resident #12 wanted to see the physician or nurse practitioner as soon as possible. LPN #444 stated she began her medication pass right away on [DATE] and at approximately 7:00 A.M., she came to Resident #12's room. LPN #444 stated Resident #12 looked pale, so she checked her blood sugar, and based on those results administered sliding scale insulin, and continued to pass medications to other residents. LPN #444 stated she did not see Resident #12 again until around approximately 8:00 A.M., when Resident #12 called the facility and asked for staff to come to her room. LPN #444 stated Resident #12 stated she needed changed and LPN #444 got a set of vital signs, that were all normal for Resident #12; but stated Resident #12 was still pale and cold to the touch. LPN #444 stated Resident #12 had black stool but had not seen that prior to [DATE]. LPN #444 stated the DON was in a meeting, but she went in and told the DON about Resident #12's condition and what LPN #404 told her. LPN #444 stated she asked the DON to go look at Resident #12, at this time as well. LPN #444 stated the DON told her to send another fax to the physician, to send [MEDICATION(S)] (a medication used to treat gastroesophageal reflux disease) for Resident #12. LPN #444 left the meeting to send the fax requesting the medication. LPN #444 stated the DON was supposed to be her go to staff member, since she did not have a unit manager. LPN #444 stated the DON told LPN #444; she was not going to look at Resident #12 because she was in a meeting. LPN #444 stated she was not confident as a nurse related to assessing Resident #12's situation because she was not a nurse very long and wanted a second opinion, which was why she sought out the DON. LPN #444 stated she has been a nurse for seven years. LPN #444 stated at around 8:15 A.M., she sent the fax to the physician and a staff member came to her and told her a staff member had called the EMS. LPN #444 verified she did not go back to assess Resident #12 or seek treatment from the physician; between when she took Resident #12's vitals signs and when the EMS arrived at the facility on [DATE]. LPN #444 stated when the EMS arrived, she went back to Resident #12's room, at the time to get more vitals; but Resident #12 was moving too much and she could not get them. LPN #444 stated it was not typical for her to contact the physician via fax because they answer the faxes slowly. LPN #444 stated she stayed in the facility to work on [DATE] until around 6:00 P.M. and she still had not heard back from the physician or the nurse practitioner. LPN #444 stated she never called the physician or nurse practitioner on [DATE], regarding Resident #12's condition. Review of the fax transmittal binder located at the nurse's station with LPN #444, on [DATE] at 11:40 A.M., revealed no evidence of faxes being sent to the physician or nurse practitioner regarding Resident #12 on [DATE]. Interview at time of this observation, with LPN #444, stated the faxes were in the binder and someone must have removed them. Interview on [DATE] at 11:43 A.M., with Staff Member #672 stated while assisting with resident room changes, Resident #12 was noted to have difficulty breathing. Staff Member #672 stated Resident #12 was lying in bed with the blankets down with her legs exposed and Staff Member #672 could see dark black on her bed sheets. Staff Member #672 informed LPN #444 of Resident #12's condition and returned to Resident #12's room. Staff Member #672 stated he observed Resident #12 asked another staff member to call the EMS for her. The staff member called using Resident #12's personal telephone after Resident #12 handed the phone to the staff member. Interview on [DATE] at 12:38 P.M., with Staff Member #785 stated Resident #12 called the facility telephone on [DATE] at approximately between 8:20 A.M. and 8:30 A.M., and stated she needed staff to her room immediately. Staff Member #785 stated it was not normal for Resident #12 to call the facility directly to ask for staff assistance. Staff Member #785 stated she went to find staff on the hall Resident #12 resided and observed both nurse aides were busy, so Staff Member #785 notified LPN #444 of Resident #12's request for staff assistance. Interview via telephone, on [DATE] at 1:52 P.M., with Physician #209 stated he only saw Resident #12 twice, once in [DATE] and again in February 2022. Physician #209 stated his Nurse Practitioner #606 saw Resident #12 as recently as [DATE]. Physician #209 stated Resident #12 had an abdominal x-ray and laboratory test performed on [DATE], with no abnormal results noted. Physician #209 stated he consulted with NP #606 and stated neither one received a telephone call, or anything related to Resident #12's condition on [DATE]. Physician #209 verified he did receive a fax sent by the facility on [DATE] at 1:44 A.M., but it did not indicate anything other than Resident #12 wanted to see him or the nurse practitioner and contained no assessment of Resident #12's condition. Physician #209 stated he nor his nurse practitioner would have seen the fax sent on [DATE] at 1:44 A.M., until much later in the day and stated there was always someone on call that could be contacted via telephone. Physician #209 stated the facility nurses where Resident #12 resided always call him via telephone and was not sure why they would send a fax given Resident #12's situation. Interview via telephone on [DATE] at 3:18 P.M., with Physician #209 occurred when the physician called the surveyor. Physician #209 stated he had been reviewing the hospital documentation from [DATE]. Physician #209 stated he was never notified of Resident #12 having black tarry stools at any time and there was never any indication in the medical record at the facility that Resident #209 had black tarry stools before she was hospitalized on [DATE]. Physician #209 stated he just completed Resident #12's death certificate and the cause of death was cardiac arrest due to gastrointestinal bleeding. Interview on [DATE] at 4:04 P.M., with NA #399 stated she worked with Resident #12 on [DATE], [DATE], and [DATE]. NA #399 stated on [DATE] she received in report for another nurse aide that Resident #12 had dark black stools and her abdomen was distended. NA #399 stated later that night, on [DATE], Resident #12 was not eating well having only eaten chicken broth. NA #399 stated Resident #12 had black dark tarry stools that night. NA #399 stated the stool was dark like coffee grounds color and had the consistency of a slightly thick milkshake. NA #399 stated she informed the nurse on duty that night but was not sure if anything was done about it. NA #399 stated Resident #12 asked to go to the hospital that night and the nurse came in to check on Resident #12. NA #399 stated the nurse did not get Resident #12's vital signs; but felt her abdomen and Resident #12 did not go to the hospital that night. NA #399 stated the nurse was informed of Resident #12 dark black bowel movement but did not ask to see it. NA #399 stated she came back to work on [DATE] and Resident #12's abdomen was still distended. NA #399 stated Resident #12 had a bowel movement on her shift and it had blood in it. Interview via telephone, on [DATE] at 8:30 A.M., with LPN #404 revealed she worked on the night shift between 10:00 P.M. ([DATE]) and 6:30 A.M. ([DATE]) and was assigned to Resident #12 on basically everyday she worked. LPN #404 stated Resident #12 had complaints of abdominal pain for a while, but tests performed on Resident #12 came back with no concerns noted. LPN #404 stated on [DATE], she talked to Resident #12 during the night and Resident #12 asked to see the physician or nurse practitioner that day. LPN #404 informed Resident #12 she would send a fax. LPN #404 stated she normally sent faxes to the physician unless there was an emergency, and the physician typically responded to faxes during normal business hours. LPN #404 stated she saw Resident #12 around 5:00 A.M. on [DATE] and Resident #12 stated she still had abdominal pain, but the pain was not as bad and not affecting as big of an area. LPN #404 stated Resident #12 never asked her to go to the hospital at any time. LPN #404 stated she never knew Resident #12 had dark tarry stools and no one ever reported that to her. Interview via telephone, on [DATE] at 10:10 A.M., with the DON revealed on [DATE] she was in a meeting when LPN #444 came in and showed her Resident #12's vital signs, and LPN #444 told her Resident #12 kept saying she did not feel good. The DON stated she told LPN #444 to contact the physician to see what he wanted to do. The DON stated she could not remember if she told LPN #444 to call of fax the physician. The DON stated they usually contacted the physician via fax. The DON stated later during the meeting on [DATE], NA #364 interrupted the meeting and told her Resident #12 was having a hard time breathing. The DON stated she told NA #364 she already talked to LPN #444 and told her to contact the physician. The DON stated she did not go to see Resident #12 before the EMS arrived at the facility. Once the EMS was in the facility, she went to Resident #12's room. The DON stated there were a lot of people in Resident #12's room so she did not stay long and did not see Resident #12 leave the facility. The DON stated she investigated the incident and the investigation included review of Resident #12's medical record and staff interviews. Review of an undated facility investigation revealed NA #555 was interviewed and verified she worked with Resident #12 on the night on [DATE]. NA #555 stated Resident #12 asked to go to the hospital and NA #555 informed LPN #404. Further review of the facility investigation revealed LPN #404 was interviewed and verified on [DATE] at 10:00 P.M., at the start of her shift, NA #555 informed her Resident #12 requested to go to the hospital. LPN #404 stated she assessed Resident #12 and verified Resident #12 was her normal self and vital signs were within her normal limits. LPN #404 stated Resident #12 never asked her to be sent to the hospital, and Resident #12 remained unchanged throughout the night. LPN #444 was interviewed as part of the investigation and verified she spoke with the DON about Resident #12 condition. LPN #444 stated the DON directed LPN #444 to notify the physician to see if the facility could give Resident #12 something for excess gas. LPN #444 notified the physician and was waiting for a response. Interview on [DATE] at 1:13 P.M., with the Administrator verified the facility did not submit the investigation of the incident with Resident #12 on [DATE] to the State Survey Agency. The Administrator stated she was not aware what was going on with Resident #12 on [DATE] and did not know what her condition was until the EMS showed up at the facility. The Administrator stated the facility did not suspect any neglect occurred after conducting their investigation. The Administrator verified the policy. Review of the policy titled, Abuse Prohibition, Investigation, and Reporting, revised [DATE], revealed it is the policy of the facility to prohibit mistreatment, neglect, and abuse of residents and/or misappropriation of resident property or resources. Neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The person(s) observing an incident of guest abuse or suspected guest abuse must immediately report such incidents/suspicions to the Administrator. Upon receiving a report of abuse, the charge nurse will immediately examine the guest. The Administrator will appoint a representative to investigate the incident. A copy of the findings will be provided to the Administrator within five working days of the occurrence of the incident. The findings of the investigation must be submitted to the state agency within five working days of the allegation. This deficiency represents an incidental finding discovered during the investigation for Master Complaint Number OH 110, Complaint Number OH 107, and Complaint Number OH 103.

Based on closed medical record review, staff interviews, physician interview, review of an emergency services run report, review of hospital documentation, review of a death certificate, review of a facility investigation, and review of a facility policy, the facility failed to report an incident of resident neglect to the State Survey Agency. This deficient practice affected one (#12) of four residents reviewed for potential neglect. The facility census was 97. Findings include: Review of Resident #12's closed medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 was discharged on [DATE]. Review of the most recently completed Minimum Data Set (MDS) assessment completed [DATE] revealed Resident #12 had intact cognition. Resident #12 was assessed to be independent with eating and required an extensive two-plus persons assistance with toileting during the reference period. Resident #12 was also received an anticoagulant medication seven days of the seven-day look back period. Review of a nursing progress note dated [DATE] at 12:24 A.M. revealed Resident #12 continued to complain of abdominal pain and bloating, but pain not radiating to the back. Resident #12 was offered pain medication but indicated it did not work and refused. Resident #12 was medicated with [MEDICATION(S)] for complaints of GI upset. There was no documentation of a physical assessment being performed by the licensed nurse on [DATE] after Resident #12 complained of abdominal pain bloating and refused pain medications because they were not effective to treat her pain. Review of a nursing progress note dated [DATE] at 11:15 P.M. revealed Resident #12's skin was dry, flushed, and warm to the touch. Resident #12 complained of gas and epigastric pain that did not radiate to the back. Resident #12 was given [MEDICATION(S)] due to complaints of nausea and Resident #12 indicated she wanted to see a nurse practitioner or physician due to nausea. Resident #12 was instructed to take [MEDICATION(S)] and the nurse would fax a note to the physician. Review of nurse aide documentation dated [DATE] revealed Resident #12 refused meals on this date. Review of a nursing progress note dated [DATE] at 1:44 A.M. revealed the physician was faxed regarding Resident #12's continued abdominal pain and gas, informed that Resident #12 refused [MEDICATION(S)] and the medication did not relieve her pain, and Resident #12 wanted to see a nurse practitioner or physician as soon as possible. Review of a nursing progress note dated [DATE] at 5:37 A.M. revealed Resident #12 was awake drinking soda pop and water, and when questioned, Resident #12 still reported epigastric pain and gas, but the area of pain was decreased in size and severity. Resident #12 was questioned if she wanted medications for nausea or pain and Resident #12 declined both. The progress noted indicated Resident #12 would continue to be monitored. There was no documentation in the medical record of Resident #12 being assessed by a licensed nurse on [DATE] after 5:37 A.M. Review of a nursing progress note dated [DATE] at 1:27 P.M., revealed emergency services was at the facility at 9:45 A.M. to transfer Resident #12 to the hospital. Resident #12's vital signs were normal, report was given to the emergency services staff, and report was called to the hospital emergency room . Review of an emergency medical services (EMS) run report dated [DATE] revealed they received a call at 9:29:09 A.M., about Resident #12 experiencing breathing problems and were enroute to the facility at 9:30:40 A.M. The EMS arrived at the facility at 9:33:51 A.M. Upon arrival to the facility, Resident #12 was lying in bed and was alert and oriented. Resident #12 was wearing a continuous positive airway pressure (C-PAP) machine, she usually wore at night and stating she could not breath. Nursing staff reported Resident #12 had been bloated and had dark tarry stools for the past two weeks and still had pain in her abdomen. Resident #12 was cool to the touch and very pale. The EMS assessment of Resident #12 reported gas pain and having melena (dark sticky feces containing partly digested food). At 9:45 A.M., the EMS assessment reported Resident #12 had a heart rate of 88 beats per minute (normal heart beats range from 60 to 100) that was irregularly irregular (having no pattern at all, with the intervals being haphazard and do not repeat, with an occasional, accidental exception); a cardiac rhythm of [CONDITION(S)] (an irregular and often very rapid heart rhythm); a blood pressure of ,d+[DATE] (a normal blood pressure is ,d+[DATE]); a respiratory rate of 21 breaths per minute (normal range from 12 to 16 breaths per minute); noted Resident #12 displayed rapid breathing; and oxygen saturation was 95% (a normal range is 95% to 100%). Resident #12 was alert, oriented, and responding appropriately to stimuli. At 9:54 A.M., the EMS reported Resident #12 had a heart rate of 129 beats per minute that was irregularly irregular; a cardiac rhythm of [CONDITION(S)]; a blood pressure of ,d+[DATE]; a respiratory rate of 23 breaths per minute; noted Resident #12 displayed rapid breathing; and oxygen saturation was 95%. Resident #12 remained alert and oriented. The EMS left the facility with Resident #12 on [DATE] at 9:51:00 A.M. and arrived at the hospital at 10:01:00 A.M. Review of hospital documentation dated [DATE] revealed Resident #12's history was obtained and revealed abdominal pain ongoing for two week and feelings of Resident #12 being bloated. Per the nurse from the facility and the EMS staff per the nurse, Resident #12 has had black tarry stools. Resident #12 reported to the EMS she could not sit up straight because of the pressure on her abdomen and complained of abdominal pain. The EMS found Resident #12's oxygen saturation rate was low and placed her on supplemental oxygen. Resident #12 was noted to have black tarry stools on [DATE] and unsure of episodes prior. Resident #12 was conversating with the EMS; complaining of shortness of breath when laid down; and complaining of abdominal discomfort when she sat up too far. By the time Resident #12 arrived at the hospital, Resident #12 was non-verbal and unable to give any information. Further review of the hospital documentation revealed on [DATE], Resident #12's skin was cool and dry; was lying with eyes open with some eye movement to her name but otherwise unresponsive. Resident #12's abdomen was firm and distended with ongoing leakage of black tarry stools smelling strongly. Resident #12's hemoglobin was 8.3 grams per deciliter (g/dL) (indicating a low level as normal values are between 11.7 and 15.5 g/dL); and Resident #12's hematocrit was 29.4%, (indicating a low level as normal values are between 35% and 47%). Review of hospital staff documentation revealed Resident #12 was obviously critically ill and strongly suspect an ischemic bowel with ongoing GI bleeding as the primary problem, though it seemed to have been potentially going on for a period of time and subsequently affecting all systems. At 11:46 A.M., Resident #12 blood pressure was not registering and at 12:01 P.M., Resident #12's heart rate was 57 beats per minutes with no palpable radial pulse, and Resident #12 had extensive gray black material emesis. At 12:04 P.M., Resident #12's heart rate was zero and a medication was given. At 12:06 P.M., another dose of medication was administered, and chest compressions were performed. CPR was started on Resident #12 and lot of black tarry drainage was coming from out of her mouth and nose during compressions. Hospital staff suctioned to try to clear drainage. At, 12:09 P.M., hospital staff were instructed to stop compressions with one visible heartbeat noted on the monitor. At 12:10 P.M., a physician was not able to visualize or palpate any pulse and at 12:11 P.M., Resident #12 was pronounced dead. Review of a death certificate, signed by the physician and dated [DATE], revealed Resident #12's date of death was [DATE] at 12:11 P.M., with an immediate cause of death of cardiopulmonary arrest due to [CONDITION(S)]. Interview on [DATE] at 9:42 A.M., with Nurse Aide (NA) #415 stated staff were already talking about Resident #12's condition when she got to work on [DATE] at 6:00 A.M., but NA #415 was not assigned to work on Resident #12's hall. NA #415 stated she observed Resident #12 on [DATE] in her room at approximately 9:20 A.M. and noted Resident #12's face was pale white, her lips were blue, was tremoring, and Resident #12 told NA #415, the facility was trying to kill her. NA #415 stated Resident #12 was sitting up in bed with her C-PAP machine on and stating she could not breath. NA #415 stated Resident #12 had a brief on and material with a reddish tint was coming out of it and could see bright red blood on the blue pad under Resident #12's buttocks while she was sitting up in bed. NA #415 stated two other nurse aides working with Resident #12 on [DATE] told her they reported Resident #12's condition to the nurse, and when NA #415 ask the nurse what was happening the nurse told her the physician was already contacted and there was nothing more they could do. NA #415 stated a staff member was also taking to Resident #12 and asked to be taken to the hospital. NA #415 stated Resident #12 unlocked her personal telephone and handed it to NA #415 and NA #415 called emergency services for Resident #12. NA #415 stated she was not with Resident #12 when EMS arrived at the facility and provided care. Interview on [DATE] at 10:01 A.M., with NA #326 stated NA #415 came to her on [DATE] and said something was wrong with Resident #12. NA #326 explained she provided care for Resident #12 ever since her admission to the facility and knew her well. NA #326 stated she went to see Resident #12 and she was freezing cold to the touch and stated she could not breath. NA #326 stated she went to Resident #12's assigned nurse aides on [DATE] and they told her Resident #12 was not herself, struggling to breath, and had black tarry stools. NA #326 stated on [DATE], when she observed Resident #12 lying in bed she had on a brief and could not physically see any bowel movement but could see through the brief and the contents inside the brief were black. Interview on [DATE] at 10:19 A.M., with NA #364 stated she worked with Resident #12 over the last two weeks and noted Resident #12 had abdominal pain, felt gassy, and had been asking to go to the hospital. NA #364 stated Resident #12 started drinking a lot of soda pop because she thought it could help her [NAME] and get rid of gas and at times would drink soda pop and milk at the same time in attempt to relief gas. NA #364 stated when she reported to work on [DATE] at 2:00 A.M., she was told in report that the nurse aides reported Resident #12 had black bowel movements and the nurse was informed at that time. NA #364 stated on [DATE], Resident #12 was breathing hard, fast and she felt like she could not breath. NA #364 stated on [DATE] at approximately 7:00 A.M., stated she was trying to move Resident #12 around in bed to help her relieve gas; but NA #364 stated she had to tend to other residents on the hall including providing a resident with shower assistance and answering call lights. NA #364 stated a staff member came to her at approximately 8:00 A.M., on [DATE] and stated Resident #12 needed staff in her room right away. NA #364 stated Resident #12 looked [NAME] and was ice cold to the touch. NA #364 stated LPN #444 was in Resident #12's room before her and the nurse told NA #364, she (LPN #444) did not have enough experience dealing with situations like Resident #12 was going through and wanted a second opinion. NA #364 stated once she was back in the room, Resident #12 had a dark black bowel movement that stained the pad under Resident #12. The stool appeared to be red and kept coming out of Resident #12 and the staff could not clean it fast enough. NA #364 stated Resident #12 kept repeating help me over and over. NA #364 stated she told the LPN #444 about what was happening with Resident #12. LPN #444 told NA #364 she already spoke to the DON, who told her to fax the physician; but if NA #364 felt it was important, she could interrupt the meeting the DON was in. NA #364 stated she went to the meeting and told the DON; the nurse aides did not feel comfortable leaving Resident #12 alone and the DON needed to see Resident #12. NA #364 stated the DON told NA #364, the physician was notified, and Resident #12 would be okay. NA #364 stated the DON never did come see Resident #12 and NA #364 went back to Resident #12's room. NA #364 stated other staff members were in Resident #12's room at this time and around 9:20 A.M., Resident #12 asked staff to call the EMS for her. Interview on [DATE] at 10:53 A.M., with NA #328 stated Resident #12 had abdominal distention in the upper part of her abdomen and was uncomfortable for two weeks before [DATE]. NA #328 stated Resident #12 did not want to eat, and when she did eat, it was very little. NA #328 stated Resident #12 did drink a lot of soda pop and milk. NA #328 stated Resident #12's call light came on during morning shift report on [DATE] and when NA #328 responded to the call light Resident #12 told her she was uncomfortable and had abdominal discomfort. NA #328 stated Resident #12 looked pale and told NA #328 she had not slept at all the previous night. NA #328 stated she informed the nurse, and the nurse went to check on Resident #12. NA #328 stated the staff tried to get Resident #12 to lay on her side, but she could not stand it. NA #328 stated she left Resident #12's room to provide care for other residents and was later told Resident #12 called the facility telephone number and asked for staff to come to her room. NA #328 stated when she got back to Resident #12's room, at what NA #328 thought was between 7:30 A.M. or 8:00 A.M., Resident #12 indicated she was uncomfortable and when the staff sat Resident #12 up in bed, very loose black tarry bowel movement came from her rectum, it just kept coming out and stained the pad under Resident #12 was red. NA #328 stated Resident #12 was breathing very fast, was anxious, and kept saying help me over and over. NA #328 stated to another nurse aide she could not leave Resident #12 and the nurse aide tried to get the DON to look at Resident #12, but she never came. NA #328 stated Resident #12's nurse told her she did not feel comfortable with Resident #12's situation and wanted the DON's opinion on what to do. NA #328 stated she was in Resident #12's bedroom when EMS arrived, and she stated they put oxygen on her and the last thing she said to Resident #12 was she loved her, and Resident #12 said she loved her too before the EMS took her out of the bedroom. Interview on [DATE] at 11:17 A.M., with LPN #444 stated during her shift report on the morning of [DATE], the night shift nurse (LPN #404) reported to LPN #444 that Resident #12 wanted to go out to the hospital; but did not send her because she sent a fax to the physician and was waiting for a response. LPN #444 stated the physician did not always get faxes from the facility right away and copies of the fax transmittals were kept in a binder at the nurse's station. LPN #444 stated LPN #404 indicated Resident #12 was still complaining of GI issues; that Resident #12 refused medication to help with pain because it was not working; and Resident #12 wanted to see the physician or nurse practitioner as soon as possible. LPN #444 stated she began her medication pass right away on [DATE] and at approximately 7:00 A.M., she came to Resident #12's room. LPN #444 stated Resident #12 looked pale, so she checked her blood sugar, and based on those results administered sliding scale insulin, and continued to pass medications to other residents. LPN #444 stated she did not see Resident #12 again until around approximately 8:00 A.M., when Resident #12 called the facility and asked for staff to come to her room. LPN #444 stated Resident #12 stated she needed changed and LPN #444 got a set of vital signs, that were all normal for Resident #12; but stated Resident #12 was still pale and cold to the touch. LPN #444 stated Resident #12 had black stool but had not seen that prior to [DATE]. LPN #444 stated the DON was in a meeting, but she went in and told the DON about Resident #12's condition and what LPN #404 told her. LPN #444 stated she asked the DON to go look at Resident #12, at this time as well. LPN #444 stated the DON told her to send another fax to the physician, to send [MEDICATION(S)] (a medication used to treat gastroesophageal reflux disease) for Resident #12. LPN #444 left the meeting to send the fax requesting the medication. LPN #444 stated the DON was supposed to be her go to staff member, since she did not have a unit manager. LPN #444 stated the DON told LPN #444; she was not going to look at Resident #12 because she was in a meeting. LPN #444 stated she was not confident as a nurse related to assessing Resident #12's situation because she was not a nurse very long and wanted a second opinion, which was why she sought out the DON. LPN #444 stated she has been a nurse for seven years. LPN #444 stated at around 8:15 A.M., she sent the fax to the physician and a staff member came to her and told her a staff member had called the EMS. LPN #444 verified she did not go back to assess Resident #12 or seek treatment from the physician; between when she took Resident #12's vitals signs and when the EMS arrived at the facility on [DATE]. LPN #444 stated when the EMS arrived, she went back to Resident #12's room, at the time to get more vitals; but Resident #12 was moving too much and she could not get them. LPN #444 stated it was not typical for her to contact the physician via fax because they answer the faxes slowly. LPN #444 stated she stayed in the facility to work on [DATE] until around 6:00 P.M. and she still had not heard back from the physician or the nurse practitioner. LPN #444 stated she never called the physician or nurse practitioner on [DATE], regarding Resident #12's condition. Review of the fax transmittal binder located at the nurse's station with LPN #444, on [DATE] at 11:40 A.M., revealed no evidence of faxes being sent to the physician or nurse practitioner regarding Resident #12 on [DATE]. Interview at time of this observation, with LPN #444, stated the faxes were in the binder and someone must have removed them. Interview on [DATE] at 11:43 A.M., with Staff Member #672 stated while assisting with resident room changes, Resident #12 was noted to have difficulty breathing. Staff Member #672 stated Resident #12 was lying in bed with the blankets down with her legs exposed and Staff Member #672 could see dark black on her bed sheets. Staff Member #672 informed LPN #444 of Resident #12's condition and returned to Resident #12's room. Staff Member #672 stated he observed Resident #12 asked another staff member to call the EMS for her. The staff member called using Resident #12's personal telephone after Resident #12 handed the phone to the staff member. Interview on [DATE] at 12:38 P.M., with Staff Member #785 stated Resident #12 called the facility telephone on [DATE] at approximately between 8:20 A.M. and 8:30 A.M., and stated she needed staff to her room immediately. Staff Member #785 stated it was not normal for Resident #12 to call the facility directly to ask for staff assistance. Staff Member #785 stated she went to find staff on the hall Resident #12 resided and observed both nurse aides were busy, so Staff Member #785 notified LPN #444 of Resident #12's request for staff assistance. Interview via telephone, on [DATE] at 1:52 P.M., with Physician #209 stated he only saw Resident #12 twice, once in [DATE] and again in February 2022. Physician #209 stated his Nurse Practitioner #606 saw Resident #12 as recently as [DATE]. Physician #209 stated Resident #12 had an abdominal x-ray and laboratory test performed on [DATE], with no abnormal results noted. Physician #209 stated he consulted with NP #606 and stated neither one received a telephone call, or anything related to Resident #12's condition on [DATE]. Physician #209 verified he did receive a fax sent by the facility on [DATE] at 1:44 A.M., but it did not indicate anything other than Resident #12 wanted to see him or the nurse practitioner and contained no assessment of Resident #12's condition. Physician #209 stated he nor his nurse practitioner would have seen the fax sent on [DATE] at 1:44 A.M., until much later in the day and stated there was always someone on call that could be contacted via telephone. Physician #209 stated the facility nurses where Resident #12 resided always call him via telephone and was not sure why they would send a fax given Resident #12's situation. Interview via telephone on [DATE] at 3:18 P.M., with Physician #209 occurred when the physician called the surveyor. Physician #209 stated he had been reviewing the hospital documentation from [DATE]. Physician #209 stated he was never notified of Resident #12 having black tarry stools at any time and there was never any indication in the medical record at the facility that Resident #209 had black tarry stools before she was hospitalized on [DATE]. Physician #209 stated he just completed Resident #12's death certificate and the cause of death was cardiac arrest due to gastrointestinal bleeding. Interview on [DATE] at 4:04 P.M., with NA #399 stated she worked with Resident #12 on [DATE], [DATE], and [DATE]. NA #399 stated on [DATE] she received in report for another nurse aide that Resident #12 had dark black stools and her abdomen was distended. NA #399 stated later that night, on [DATE], Resident #12 was not eating well having only eaten chicken broth. NA #399 stated Resident #12 had black dark tarry stools that night. NA #399 stated the stool was dark like coffee grounds color and had the consistency of a slightly thick milkshake. NA #399 stated she informed the nurse on duty that night but was not sure if anything was done about it. NA #399 stated Resident #12 asked to go to the hospital that night and the nurse came in to check on Resident #12. NA #399 stated the nurse did not get Resident #12's vital signs; but felt her abdomen and Resident #12 did not go to the hospital that night. NA #399 stated the nurse was informed of Resident #12 dark black bowel movement but did not ask to see it. NA #399 stated she came back to work on [DATE] and Resident #12's abdomen was still distended. NA #399 stated Resident #12 had a bowel movement on her shift and it had blood in it. Interview via telephone, on [DATE] at 8:30 A.M., with LPN #404 revealed she worked on the night shift between 10:00 P.M. ([DATE]) and 6:30 A.M. ([DATE]) and was assigned to Resident #12 on basically everyday she worked. LPN #404 stated Resident #12 had complaints of abdominal pain for a while, but tests performed on Resident #12 came back with no concerns noted. LPN #404 stated on [DATE], she talked to Resident #12 during the night and Resident #12 asked to see the physician or nurse practitioner that day. LPN #404 informed Resident #12 she would send a fax. LPN #404 stated she normally sent faxes to the physician unless there was an emergency, and the physician typically responded to faxes during normal business hours. LPN #404 stated she saw Resident #12 around 5:00 A.M. on [DATE] and Resident #12 stated she still had abdominal pain, but the pain was not as bad and not affecting as big of an area. LPN #404 stated Resident #12 never asked her to go to the hospital at any time. LPN #404 stated she never knew Resident #12 had dark tarry stools and no one ever reported that to her. Interview via telephone, on [DATE] at 10:10 A.M., with the DON revealed on [DATE] she was in a meeting when LPN #444 came in and showed her Resident #12's vital signs, and LPN #444 told her Resident #12 kept saying she did not feel good. The DON stated she told LPN #444 to contact the physician to see what he wanted to do. The DON stated she could not remember if she told LPN #444 to call of fax the physician. The DON stated they usually contacted the physician via fax. The DON stated later during the meeting on [DATE], NA #364 interrupted the meeting and told her Resident #12 was having a hard time breathing. The DON stated she told NA #364 she already talked to LPN #444 and told her to contact the physician. The DON stated she did not go to see Resident #12 before the EMS arrived at the facility. Once the EMS was in the facility, she went to Resident #12's room. The DON stated there were a lot of people in Resident #12's room so she did not stay long and did not see Resident #12 leave the facility. The DON stated she investigated the incident and the investigation included review of Resident #12's medical record and staff interviews. Review of an undated facility investigation revealed NA #555 was interviewed and verified she worked with Resident #12 on the night on [DATE]. NA #555 stated Resident #12 asked to go to the hospital and NA #555 informed LPN #404. Further review of the facility investigation revealed LPN #404 was interviewed and verified on [DATE] at 10:00 P.M., at the start of her shift, NA #555 informed her Resident #12 requested to go to the hospital. LPN #404 stated she assessed Resident #12 and verified Resident #12 was her normal self and vital signs were within her normal limits. LPN #404 stated Resident #12 never asked her to be sent to the hospital, and Resident #12 remained unchanged throughout the night. LPN #444 was interviewed as part of the investigation and verified she spoke with the DON about Resident #12 condition. LPN #444 stated the DON directed LPN #444 to notify the physician to see if the facility could give Resident #12 something for excess gas. LPN #444 notified the physician and was waiting for a response. Interview on [DATE] at 1:13 P.M. with the Administrator verified the facility did not submit the investigation of the incident with Resident #12 on [DATE] to the State Survey Agency. The Administrator stated she was not aware what was going on with Resident #12 on [DATE] and did not know what her condition was until EMS showed up at the facility. The Administrator stated the facility did not suspect any neglect occurred after conducting their investigation. Review of the policy titled, Abuse Prohibition, Investigation, and Reporting, revised [DATE], revealed it is the policy of the facility to prohibit mistreatment, neglect, and abuse of residents and/or misappropriation of resident property or resources. Neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The person(s) observing an incident of guest abuse or suspected guest abuse must immediately report such incidents/suspicions to the Administrator. Upon receiving a report of abuse, the charge nurse will immediately examine the guest. The Administrator will appoint a representative to investigate the incident. A copy of the findings will be provided to the Administrator within five working days of the occurrence of the incident. The findings of the investigation must be submitted to the state agency within five working days of the allegation. This deficiency represents an incidental finding discovered during the investigation for Master Complaint Number OH 110, Complaint Number OH 107, and Complaint Number OH 103.

Based on medical record review, staff interview, review of the facility incident log, review of the facility incident report, review of the facility investigation, and policy review, the facility failed to ensure one resident's (#82) fall interventions were in place. This resulted in actual harm when Resident #82 fell from the bed, when she was left unattended, while the bed was in the highest position which resulted in a [MEDICAL CONDITION]. This affected one resident (#82) out of four reviewed for falls. The facility census was 81. Findings included: Review of the medical record revealed Resident #82 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care dated 12/29/20 revealed the resident was at risk for falls. Interventions included encouraging the resident to wear appropriate footwear as needed, keep the resident's environment safe and free from clutter, adequate lighting, keep the call light within reach, ensure commonly used items within reach, and keep the bed in an appropriate position. Review of the Minimum Data Set 3.0 Assessment (MDS) dated , 01/05/21, revealed a Brief Interview for Mental Status (BIMS) Score of three, which indicated the resident had impaired cognition. The resident required extensive assistance with bed mobility, transfers, locomotion, dressing, eating, toileting, and maintaining hygiene. The resident had falls prior to and after admission to the facility. Review of the progress notes dated from December 2020 to January 2021 revealed on 01/07/21 the resident was found lying on the floor with her head on the tray table support and complained of hip pain. An X-ray was ordered, the results were reported to the doctor, and the resident was sent to the hospital. Review of X-ray results dated 01/07/21 revealed Resident #82 had a intertrochanteric left femoral fracture ([MEDICAL CONDITION]). Review of the facility incident log dated January 2021 revealed on 01/07/21 Resident #82 was found on the floor laying parallel to the bed with her head resting on the tray table legs. The resident was on the bed pan in bed and rolled off. The bed was in the high position. There was redness noted on the left hip. Review of the facility incident report dated 01/07/21 revealed Resident #82 was found on the floor and had hip tenderness. Review of the facility incident and accident investigation form dated 01/07/21 revealed Resident #82 was placed on the bed pan in bed and she rolled off and out of the bed. The bed had been left in the high position. Interview on 03/05/21 at 1:41 P.M., the Licensed Practical Nurse (LPN) #524 verified if the care plan listed a fall intervention for the bed to be in the appropriate position, would mean for the bed to be in a lowered position. Interview on 03/05/21 at 1:58 P.M., the Director of Nursing (DON) verified Resident #82 had a fall on 01/07/21. The DON verified Resident #82's care plan had a fall intervention in place for the bed to be in the appropriate position, meaning the bed was to be in the lowered position. The DON verified Resident #82's bed was in the highest position when she fell on [DATE], resulting in a broken hip. The DON reported the State tested Nursing Assistant (STNA) #700 involved in the incident was educated. Interviews on 03/05/21 from 2:55 P.M. to 3:45 P.M., LPN #524, STNA #500, #567, #579, and #581, Registered Nurse (RN) #542, and RN #555 verified they had not received training regarding the positioning of beds for residents identified as fall risks anytime after 01/07/21. Interview on 03/09/21 at 9:02 A.M., the STNA #700 verified she was on the hall providing care when she heard Resident #82 call out. She went to the residents room, the bed was already raised to a higher position, and placed the resident on the bed pan. STNA #700 left the room without lowering the bed, finished assisting another resident she had previously been caring for. She further reported she should have lowered the bed prior to leaving the room. Review of facility policy titled Fall Management revised October 2019 revealed the facility would identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls. This deficiency substantiates Complaint Number OH 066.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of the hospital report, review of the written statements, review of the employee education, review of an employee personnel file, and review of the facility ' s audits, the facility failed to safely transfer a resident as care planned. This resulted in actual harm when Resident #50 suffered a fractured tibia and fibula following an improper transfer by facility staff. This affected one (#50) of one resident reviewed for accidents. The facility census was 96. Findings include: Review of Resident #50's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/11/19, revealed Resident #50 had severe cognitive impairment. Resident #50 required an extensive two person assist for bed mobility and was totally dependent with a two person assist for transfers. Review of the care plan, dated 01/21/19, revealed Resident #50 had an Activities of Daily Living (ADL) self-care performance deficit and required assistance with ADLs and mobility related to a [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Intervention included the resident required dependent assistance with transfers with two staff assistance and a mechanical lift. Review of an undated nursing care card revealed Resident #50 was dependent on staff for transfers and required a two person assist with a mechanical lift. Review of a progress note, dated 05/21/19 at 7:00 [NAME]M., revealed Resident #50 had a change in condition. Further review of the progress notes revealed on 05/21/19 at 8:14 [NAME]M., Resident #50's right leg was [MEDICAL CONDITION] with pain noted. Resident #50's right knee to the foot was swollen with bruising noted on the front and back of the calf just below the knee. Resident #50's calf was firm to the touch, with no warmth noted, and Resident #50 complained of discomfort with movement. The progress note dated 05/21/19 at 9:54 [NAME]M., revealed physician orders [REDACTED].#50's right leg. Review of the radiology report, dated 05/21/19, revealed a proximal tibia and fibula (bones of the lower leg) fracture with malalignment, mild soft tissue swelling, and joint space narrowing. Review of a progress note, dated 05/21/19 at 2:47 P.M., revealed Resident #50's guardian was notified of the tibia and fibula fractures and informed Resident #50 was sent to the emergency room . Review of an emergency room provider progress note revealed Resident #50 presented with leg swelling and was sent to the emergency room for an evaluation following an x-ray that revealed a [MEDICAL CONDITION] tibia and fibula. The progress notes further revealed the emergency room was initially told there was no history of trauma or injury, but later were told there was a possibility of a nurse aide transferring Resident #50 without a mechanical lift, but details were unclear. Interview on 12/04/19 at 9:30 [NAME]M. with Licensed Practical Nurse (LPN) #200 revealed Resident #50 needed a two person assist with a mechanical lift for transfers. LPN #200 verified it was the policy of the facility that two staff members be present when using the mechanical lift. Review of a hand-written note, dated 05/21/19 at approximately 5:00 P.M., revealed a State tested Nurse Aide (STNA #300) reported to the Director of Nursing (DON) that she heard another STNA (#310) transferred Resident #50 by herself and Resident #50 fell . Review of STNA #310's personnel file revealed an employee disciplinary record document, dated 05/22/19, and indicated STNA #310 transferred a resident (#50) with one assist that was care planned for a two person assist and a mechanical lift. This action resulted in Resident #50 sustaining a fractured leg. STNA #310 was terminated from employment as a result. Interview on 12/04/19 at 11:18 [NAME]M. with the DON stated on 05/21/19, it was reported to her there was a fracture in the facility of unknown origin. The DON stated she came to the facility to initiate an investigation and called all the staff that had any interaction with Resident #50 for the past 24 hours. The DON stated Resident #50 was unable to communicate what happened and said STNA #300 reported to her that STNA #310 was taking care of Resident #50 and transferred him by herself and dropped Resident #50 to the floor. The DON stated she was told STNA #310 got another STNA to help her get Resident #50 up and never told the nurse what happened. The DON stated on 05/22/19, STNA #310 was terminated from employment at the facility. Interview on 12/04/19 at 4:48 P.M. with STNA #300 revealed she reported to the DON on 05/21/19 she heard Resident #50 was dropped the previous evening. STNA #300 stated she saw another aide, who was not working in her area, and the other aide told her she was helping STNA #310 transfer Resident #50. STNA #300 asked the nurse aide if she actually assisted with the transfer, and the nurse aide denied assisting STNA #310 stating Resident #50 was already on the ground because STNA #310 transferred him by herself. As a result of the incident, the facility took the following action to correct the deficient practice by 06/13/19: 1. On 05/21/19, the facility interviewed 19 staff members who provided care for Resident #50, and during the interviews it was discovered Resident #50 was transferred by one staff member (STNA #310). 2. On 05/22/19, STNA #310 was terminated from employment as a result of not following Resident #50 ' s care card intervention to utilize two staff members when performing a mechanical lift transfer which resulted in a fractured leg. 3. On 05/31/19, all staff members were educated on utilizing a two person assist for transfers when there were care plan interventions for a two person assist with transfers. Staff were also instructed that an assessment must be completed for the resident before the resident can be moved after a fall. 4. The facility completed audits of three resident transfers each day on 05/23/19, 05/27/19, 05/29/19, 05/31/19, 06/03/19, 06/05/19, 06/07/19, 06/09/19, 06/13/19, 06/14/19, 06/16/19, 06/19/19, and 06/21/19. All transfers were completed using the appropriate level of assistance with no resident injuries noted.

Based on medical record review, observations, interviews with staff and a witness, review of the facility's Wander Guard/Secure Care Device Assessment policy, review of the facility's incident investigation, review of the manufacturer's instructions for placement of the Secure Care transmitter device, and review of the Secure Care door alarm audits, the facility failed to ensure adequate supervision was provided to prevent the elopement of a resident who was assessed as being at risk for elopement. This resulted in Immediate Jeopardy when Resident #1 left the facility without staff knowledge and was found unattended in his wheelchair in the middle of the state highway in front of the facility by a person driving by on the highway placing the resident at risk for serious injury and/or death. This affected one (#1) of six residents (#2, #3, #4, #5, #6) reviewed for being at risk for elopement. The facility identified a total of eleven residents assessed as being at risk for elopement. On 09/13/16 at 2:40 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 07/30/16 at approximately 8:55 A.M. when Resident #1 left the facility through the 300 corridor exit door without supervision and was subsequently discovered by a passerby in the middle of the state highway in his wheel chair. Resident #1 propelled his wheelchair through a delayed egress locking exterior door which failed to activate or sound an audible alarm for the Secure Care transmitter on the resident's wheelchair. The facility was unaware Resident #1 was missing until approximately 9:15 A.M. Resident #1 independently propelled his wheelchair approximately seventy-five yards into the middle of the state highway in front of the facility. Resident #1 was returned to the facility at approximately 9:15 A.M. by the passerby. The resident was assessed by nursing staff and no injury was discovered. The Immediate Jeopardy was removed on 08/01/16 when the Wander Guard/Secure Care Device was relocated from Resident #1's wheelchair to the resident's right ankle, and all door alarms were checked to ensure they were functionally operational. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility had not reassessed other residents for risk of elopement and proper placement of Wander Guards/Secure Care Devices and provide in-service education to staff on the appropriate placement of Wander Guards/Secure Care Devices and elopement prevention despite no further elopements from the facility. Additionally, the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. The facility implemented the following corrective actions: · On 07/30/16 at 10:15 A.M., Resident #1's Wander Guard/Secure Care Device was relocated from the resident's wheelchair to the resident's right ankle. · On 08/01/16, all door alarms were checked utilizing the Secure Care testing device by Maintenance Director #1 for proper function. · On 09/13/16 by 8:00 P.M., all residents were assessed for risk of elopement and proper placement of Wander Guards/Secure Care Devices by nursing staff and the DON. · On 09/13/16 as of 8:00 P.M., all facility staff were educated on the appropriate placement of Wander Guards/Secure Care Devices and elopement prevention by the designated department manager for each department. Two staff were currently on leave of absence and will be educated by the department manager prior to returning to work. · On 09/13/16, the facility relocated all Wander Guards/Secure Care Devices secured to wheelchairs to Residents #4, #5 and #6's right ankles. · On 09/13/16 at 1:30 P.M., Maintenance Director #1 completed the sensitivity adjustment of all alarmed doors to the highest possible activation level. · On 09/14/16, the facility received information from a Wander Guard/Secure Care technician that the transmitter device is able to be placed in an upright position on the rod/leg above the wheel of the wheelchair. If the resident is assessed to be unable to utilize the right ankle Guard, the DON/designee and Maintenance Director #1 will evaluate the wheelchair for proper placement of the transmitter. If the transmitter is applied to the wheelchair, the DON will educate all staff on the placement of the transmitter and monitoring of placement. · On 09/14/16, random interviews with State tested Nurse Aides (STNA) #201 and #203 and Licensed Practical Nurse (LPN) #306 verified attendance and content of the provided elopement in-service. · On 09/14/16, monitoring for on-going compliance was initiated and will be completed five times a week for four weeks by the clinical management team. Team meetings will include review of new orders, review of 24 hour reports, and review of behavior management meetings through the facility Quality Assurance program. The Quality Assurance program review will provide additional education and monitoring for any identified non-compliance. · On 09/14/16, review of five (#2, #3, #4, #5 and #6) additional residents' medical records revealed no concerns with elopement and placement of a Wander Guard/Secure Care Device. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the current Minimum Data Set (MDS) assessment, dated 07/27/16, identified the resident with moderate cognitive impairment and dependent on staff for the completion of activities of daily living. Additionally, the resident utilized a wheelchair for mobility. Review of the nurses notes dated 06/27/16 at 5:18 P.M. revealed the resident was displaying wandering behaviors. Review of the physician order dated 06/29/16 revealed an order to apply a Wander Guard/Secure Care Device (transmitter) to guest with staff to check the function every shift. Review of the nursing plan of care for elopement risk related to wandering and attempts to leave the facility, with an initiation date of 07/22/16, revealed interventions which included to observe whereabouts frequently, ensure Wander Guard/Secure Care Device is on each shift and working daily, redirect away from exit doors as needed, redirect to activities as able, and approach in a slow, calming manner when redirecting away from doors. Review of nurses notes dated 07/30/16 at 9:31 A.M. documented the resident got out of the facility without the alarm sounding. The resident was found in the middle of the road and a passerby called the facility asking if the facility was missing a resident. The resident was brought back into the facility by a second passerby (traveling in the same vehicle) safely and taken to his room. The Wander Guard/Secure Care Device was intact and working. When the resident was asked where he was going, he stated a local establishment. The alarm was noted to sound when the resident was brought back into the facility. Review of the Summary of Clinical Event document, dated 07/30/16, revealed the DON determined the application of the Wander Guard/Secure Care Device, located under the resident's wheelchair, may have been blocked from activating the alarm. The Wander Guard/Secure Care Device was then removed from the wheelchair, placed on the resident's ankle and checked for appropriate function. The summary did not contain any statement from or interview with the second passerby who returned the resident to the facility. The summary was acknowledged and signed on 08/01/16 by the DON and the Administrator. Review of weekly Secure Care Door Alarm testing forms revealed the exit egress doors were checked for operation utilizing the testing device on 07/25/16 and 08/01/16. Observation on 09/13/16 at 7:50 A.M. during interview with Resident #1 revealed the resident was in the dining room sitting in a wheelchair with a Wander Guard/Secure Care Device to the right ankle and a fall prevention alarm fastened to the seat back. The resident did not recall the event and indicated he enjoys sitting outside daily. Observation on 09/13/16 at 11:55 A.M. with Assistant Director of Nursing (ADON) #1, the DON and Maintenance Director #1 revealed ADON #1 placed the Wander Guard/Secure Care Device to the underside of Resident #1's wheelchair on the left side metal frame. The location of the Wander Guard/Secure Care Device antenna was to the right of the door, six inches from the floor and seven inches from the threshold. Observation of the Wander Guard/Secure Care Device revealed the transmitter was applied in a horizontal position. ADON #1 propelled Resident #1 through the door approximately 10 feet from the threshold and the Wander Guard/Secure Care Device alarm failed to sound. Interview with the DON revealed when the Wander Guards/Secure Care Devices are placed on residents or utilized on ambulation equipment (wheelchair, walkers), the placement of the transmitters are not verified at application for appropriate operation and initiation of an alarm. Observation on 09/13/16 at 12:30 P.M. of the road in front of the facility revealed a posted 35 mile per hour speed limit and identified the road as a state highway. Interview with the Administrator on 09/13/16 at 1:30 P.M. verified, during a review of the manufacturer's instructions for Secure Care Transmitter Placement (dated 03/20/15), to ensure proper operation of the transmitter, it must be in an upright or vertical position on the ankle. Interview on 09/13/16 at 1:45 P.M. with the DON revealed three (#4, #5 and #6) additional residents were identified with Wander Guards/Secure Care Devices affixed to their wheelchairs on 09/13/16 and the facility was in the process of removing them from the wheelchairs and applying the devices to the residents' ankle. Interview on 09/14/16 at 9:15 A.M. with Maintenance Director #1 revealed he is responsible for maintenance of the Wander Guard/Secure Care Device (delay egress) exit doors. The doors are checked for proper operation once weekly utilizing the Secure Care testing device. Maintenance Director #1 stated he was not made aware of the incident with Resident #1 until Monday 08/01/16 and then all delay egress doors were assessed for proper operation. On 09/14/16 at 10:10 A.M., a telephone interview with the passerby driving on the state highway (Witness #1) stated on 07/30/16 at approximately 8:45 A.M., Resident #1 was observed at the drive way (south end of the facility) and access to state highway 66 on the side of the road sitting in a wheelchair. Witness #1 turned the vehicle around and Witness #2 (Spouse of Witness #1 traveling in the same vehicle) exited the car in the direction of Resident #1. By that time, Resident #1 had propelled himself into the center of the state highway into traffic. Witness #2 asked Resident #1 where he was going and the resident replied, away from there. Witness #2 then propelled the resident away from the state highway and returned the resident to the front of the facility. Witness #1 went into the facility and reported to a nurse at the nursing station the resident was discovered outside in front of the facility. The nurse (name unknown to Witness #1) then proceeded to the front door and propelled the resident inside. Witness #1 stated the resident was dressed in sweat pants, a T-shirt with a flannel shirt covering, one slipper and one sock. Review of the facility policy titled Wander Guard/Secure Care Device Assessment, dated March 2005, directed staff to place the device on the guest (resident) when the risk for elopement is determined. Staff is to check the security of the device on the resident's extremity. This deficiency substantiates Complaint Number OH 849.